Eulógio E. Martinez

Physiologic multivalvular regurgitation during pregnancy: a longitudinal Doppler echocardiographic study☆

Valvular function, assessed by Doppler technique, has not been extensively investigated during normal pregnancy. To prospectively study this feature, 18 normal pregnant women were followed during their pregnancies and puerperium, with serial clinical and pulsed-continuous Doppler echocardiographic examinations. In four gestational periods and the puerperium, we analysed: (a) ventricular and atrial dimensions, as well as valve annular diameters; (b) prevalence and characteristics of trivial valvular regurgitations. During pregnancy, slight but significant increases of the four cardiac chamber dimensions and valve annular diameters were observed, except for the aortic ring. The prevalence of physiologic valvular regurgitation in early pregnancy (mitral, 0%; tricuspid, 38.9%; pulmonary, 22.2%; aortic, 0%), was similar to a control group of 18 healthy non-pregnant women. As pregnancy evolved, there was a progressive and significant increase of multivalvular regurgitation, maximal at full-term (mitral, 27.8%; tricuspid, 94.4%; pulmonary, 94.4%, P < 0.05 vs. early pregnancy). Aortic regurgitation was not detected in any stage of pregnancy. In the puerperium, mitral regurgitation resolved, but tricuspid and pulmonary regurgitation were still significantly prevalent (83.3% and 66.7%, respectively, P < 0.05 vs. early pregnancy). It is concluded that physiologic multivalvular regurgitation is frequent in pregnancy, mainly involving right-sided valves in late gestational periods, occasionally persisting in the early puerperium. Chamber enlargement, valve annular dilatation, and increased prevalence of trivial valve regurgitation are time-related events during normal pregnancy, resulting from a reversible cardiac remodeling process induced by physiologic volume overload. These aspects should be considered for a correct interpretation of Doppler echocardiographic findings in pregnant women with suspected heart disease.

A New Paradigm for Plaque Stabilization

The concept of plaque stabilization was developed to explain how lipid lowering could decrease adverse coronary events without a substantial reduction in the regression of atherosclerosis. Plaques were stabilized by reducing serum cholesterol leading to several favorable pathobiological changes in the vessel wall of lipid-rich plaques responsible for a majority of acute coronary events. However, this concept is limited for several reasons including that it does not incorporate strategies directed against either plaques that have already destabilized or non-lipid-rich plaques, which are the substrate for at least one third of major coronary thrombi and may or may not be stabilized by lipid lowering. For the destabilized plaque with overlying thrombus, either percutaneous intervention, long-term antithrombotic and/or anticoagulant therapy, or possibly aggressive lipid lowering stabilizes lesions by reducing subsequent thrombosis at the lesion site and, at least with lipid lowering, by improving endothelial function and possibly reducing inflammation. Short-term, in-hospital antithrombotic approaches alone with agents like the GP platelet IIb/IIIa inhibitors have not been effective in this situation. For other plaques not presently destabilized, the main goal of therapy is reducing future acute coronary events. Several classes of drugs, including ACE inhibitors, &bgr;-blockers, and antithrombotic agents in addition to lipid-lowering agents, reduce events, and this may be attributable, at least in part, to plaque-stabilizing effects.

Coronary Revascularization (Surgical or Percutaneous) Decreases Mortality After the First Year in Diabetic Subjects but not in Nondiabetic Subjects With Multivessel Disease An Analysis From the Medicine, Angioplasty, or Surgery Study (MASS II)

Background— It is currently unknown whether revascularization procedures are associated with an improvement in mortality among diabetic subjects, as compared with a more conservative medical treatment. Methods and Results— In MASS II, a total of 611 patients with stable multivessel coronary disease were randomly assigned to medical treatment, surgery, or angioplasty. From these, 190 patients had diabetes (medical, 75 patients; angioplasty, 56 patients; surgery, 59 patients) and comprised the present study population. Mortality rates were analyzed for the entire 5 years of follow-up. Separate analyzes were also performed for mortality at 2 time intervals: during the first year and after the first year of follow-up. We calculated the probability of death conditional on surviving to the start of the interval analyzed. The cumulative 5-year mortality as well as the mortality during the first year of follow-up was not significantly different among treatment groups, both for diabetic and for nondiabetic subjects. Also, during years 2 to 5, the mortality of the 3 treatment groups was not different for nondiabetic subjects. Among diabetic subjects, however, patients randomized to angioplasty or surgery had a significantly lower mortality between years 2 and 5 than those allocated to medical treatment (P=0.039). Conclusion— Surgery, angioplasty, and medical treatment appear to be associated with similar mortality rates for non-diabetic subjects. For diabetic subjects, however, coronary revascularization (percutaneous or surgical) significantly decreased the risk of death after the first year and up to 5 years, compared with medical treatment alone.

Extrinsic compression of the left main coronary artery by a dilated pulmonary artery: Clinical, angiographic, and hemodynamic determinants

Extrinsic compression of the left main coronary artery (LMC) by the pulmonary artery (PA) is a very unusual and poorly understood entity, usually associated with the presence of adult congenital heart disease. We identified 12 patients (age range, 6 months to 55 years) with LMC stenosis (≥ 50%) presumably secondary to compression by a dilated main PA and related to various forms of heart disease (11 congenital, 1 pulmonary hypertension). In all cases, the main PA was dilated with the main PA/aortic root diameter increased (mean, 2.0; normal value, ≤ 1.0), and in all but two, PA pressures were increased (> 30 mm Hg systolic). Left coronary trunk stenosis was usually visualized in only one angiographic view (best seen in 45° left anterior oblique, 30° cranial projection). The LMC also appeared to be inferiorly displaced and in close contact with the left aortic sinus (mean angle between sinus and LMC was 23° ± 13°, a control group was 70° ± 15°). In one patient, surgical correction of the dilated PA was associated with a reduction in LMC stenosis from 85% to < 50% and less inferior left main displacement (from 25° to 50°). Patients with a dilated main PA may exhibit extrinsic LMC compression leading to significant eccentric narrowing and downward displacement of the LMC. In the presence of significant dilatation of the main PA from any etiology, functional and/or anatomic studies should be performed to exclude significant LM obstruction. Cathet Cardiovasc Intervent 2001;52:49–54.

TCF7L2 Polymorphism rs7903146 Is Associated with Coronary Artery Disease Severity and Mortality

Background TCF7L2 polymorphisms have been consistently associated with type 2 diabetes mellitus in different populations and type 2 diabetes mellitus is a major risk factor for cardiovascular disease, especially coronary artery disease. This study aimed to evaluate the association between TCF7L2 polymorphism rs7903146 and coronary artery disease in diabetic and non-diabetic subjects. Methods and Results two populations were studied in order to assess severity of coronary artery disease and cardiovascular events incidence. Eight-hundred and eighty nine subjects who were referred for cardiac catheterization for coronary artery disease diagnosis were cross-sectionally evaluated for coronary lesions (atherosclerotic burden) and 559 subjects from the MASS-II Trial were prospectively followed-up for 5 years and assessed for major cardiovascular events incidence. As expected, rs7903146 T allele was associated with diabetes. Although diabetic patients had a higher prevalence of coronary lesions, no association between TCF7L2 genotype and coronary lesions was found in this subgroup. However, non-diabetic individuals carrying the T allele were associated with a significantly higher frequency of coronary lesions than non-diabetic non-carriers of the risk allele (adjusted OR  = 2.32 95%CI 1.27–4.24, p = 0.006). Moreover, presence of multi-vessel coronary artery disease was also associated with the CT or TT genotypes in non-diabetics. Similarly, from the prospective sample analysis, non-diabetics carrying the CT/TT genotypes had significantly more composite cardiovascular end-points events than CC carriers (p = 0.049), mainly due to an increased incidence of death (p = 0.004). Conclusions rs7903146 T allele is associated with diabetes and, in non-diabetic individuals, with a higher prevalence and severity of coronary artery disease and cardiovascular events. name of registry site (see list below), registration number, trial registration URL in brackets. Clinical Trial Registration Information Medicine, Angioplasty, or Surgery Study (MASS II): Unique identifier: ISRCTN66068876.

Randomized evaluation of two drug-eluting stents with identical metallic platform and biodegradable polymer but different agents (paclitaxel or sirolimus) compared against bare stents: 1-year results of the PAINT trial.

Objectives: We tested two novel drug‐eluting stents (DES), covered with a biodegradable‐polymer carrier and releasing paclitaxel or sirolimus, which were compared against a bare metal stent (primary objective). The DES differed by the drug, but were identical otherwise, allowing to compare the anti‐restenosis effects of sirolimus versus paclitaxel (secondary objective). Background: The efficacy of novel DES with biodegradable polymers should be tested in the context of randomized trials, even when using drugs known to be effective, such as sirolimus and paclitaxel. Methods: Overall, 274 patients with de novo coronary lesions in native vessels scheduled for stent implantation were randomly assigned (2:2:1 ratio) for the paclitaxel (n = 111), sirolimus (n = 106), or bare metal stent (n = 57) groups. Angiographic follow‐up was obtained at 9 months and major cardiac adverse events up to 12 months. Results: Both paclitaxel and sirolimus stents reduced the 9‐month in‐stent late loss (0.54–0.44 mm, 0.32–0.43 mm, vs. 0.90–0.45 mm respectively), and 1‐year risk of target vessel revascularization and combined major adverse cardiac events (P < 0.05 for both, in all comparisons), compared with controls. Sirolimus stents had lower late loss than paclitaxel stents (P < 0.01), but similar 1‐year clinical outcomes. There were no differences in the risk of death, infarction, or stent thrombosis among the study groups. Conclusion: Both novel DES were effective in reducing neointimal hyperplasia and 1‐year re‐intervention, compared to bare metal stents. Our findings also suggest that sirolimus is more effective than paclitaxel in reducing angiographic neointima, although this effect was not associated with better clinical outcomes.© 2009 Wiley‐Liss, Inc.

Diagnosis of fetal arrhythmias using echocardiographic and Doppler techniques

Fetal echocardiography is the most practical method for diagnosing prenatal arrhythmias. Because some prenatal tachyarrhythmias have been shown to respond to antiarrhythmic drugs, correctly diagnosing fetal arrhythmias has assumed new importance. With the aid of two-dimensional echocardiographic imaging, an M-mode cursor can be aligned to record atrial and ventricular wall motion--either independently or simultaneously. A consistent feature in the fetus is prominent atrial wall contractions that can be readily recorded on the M-mode tracing. By matching atrial and ventricular wall contractions with assumed P waves and QRS complexes, the fetal electrocardiogram can be reconstructed. In 57 fetuses studied, recurrent atrial and ventricular ectopic beats were the most common prenatal arrhythmias. However, atrial flutter, ventricular tachycardia, atrial and ventricular bigeminy and atrial and ventricular bradyarrhythmias have been correctly identified and in some instances appropriately treated. Marked fetal bradycardia in the midtrimester of pregnancy is shown for the first time to be caused by transducer pressure on the maternal abdominal wall.

Comparison between Percutaneous Balloon Valvuloplasty and Open Commissurotomy for Mitral Stenosis

Eighty patients with tight and pliable mitral stenosis were randomized in a prospective trial comparing percutaneous balloon valvuloplasty and open commissurotomy. Mitral valve area increased significantly in both groups immediately after the procedures. However, a decrease in mitral valve area occurred in both groups at 6, 12 and 24 months during the follow-up. There was no death in either group. Two patients had significant mitral regurgitation after percutaneous balloon valvuloplasty. After 24 months, all patients in the commissurotomy group and 97.4% of the patients in the balloon valvuloplasty group were in New York Heart Association functional class I or II.

High versus low-pressure balloon inflation during Multilink™ stent implantation: Acute and long-term angiographic results

We compared the impact of low and high‐pressure balloon inflation on acute and late angiographic results of Multilink™ stent. Low‐pressure balloon inflation (9.5 ± 1.9 atm) was used in 43 stents and high pressure (17.1 ± 1.5 atm) in 44. A larger immediate luminal gain was achieved in stents with high‐pressure balloon inflation (1.80 ± 0.26 vs. 1.47 ± 0.62; P = 0.002), resulting in a larger mean diameter in this group (2.71 ± 0.37 vs. 2.48 ± 0.47; P = 0.017). At follow‐up, a larger luminal diameter was achieved in the high pressure group (1.93 ± 0.72 vs. 1.45 ± 0.66; P = 0.002) and a trend to a lower rate of angiographic restenosis (15% vs. 38%, P = 0.08). Cathet. Cardiovasc. Intervent. 50:398–401, 2000.

Stent coronário de liga cobalto-cromo concebido no Brasil: achados histológicos preliminares em modelo experimental porcino

SUMMARY Cobalt-Chromium Coronary Stent Conceivedin Brazil: Preliminary Histologic Findings inan Experimental Porcine Model Background: This study aims to evaluate, in an experimen-tal porcine model, a new and pioneer cobalt-chromiumthin-strut coronary stent conceived in Brazil. Also, it aimsto report the initial experience of a Brazilian center forpre-clinical validation of endovascular devices. Method: The new bare Cobalt-Chromium stent (Scitech ProdutosMedicos Ltda) was implanted in the coronary arteries oftwelve domestic pigs. The stent was designed in short rings(for increased homogeneity of vessel scaffolding), thin struts(75 µm) and inter-strut angle engineered to optimize theradial strength. The inter-ring connection was made by ashort and very thin link (65 µm) in a curved format, witha circumferential diameter of 6 mm for side branch access.Another two animals received conventional bare metalstents as controls (Driver®, Medtronic Inc., e Matrix®,Sahajanand Medical Technologies). After one month, theimplanted stents were excised for microscopic analysis.