Expedito Eustáquio Ribeiro da Silva

Doença aterosclerótica difusa desmascarada pela avaliação fisiológica invasiva da circulação coronária

It is known that coronary atherosclerosis is a diffuse process, very little visible at angiography. This article describes a stable angina patient, three months after acute myocardial infarction (AMI), and a severe lesion in anterior descending artery (ADA), evinced by coronariography. Myocardial fractional flow reserve (FFR), obtained through intracoronary pressure measurements, was 0.37 during maximum hyperemia, clearly showing the presence of ischemia. A stent was implanted in ADA and, despite the excellent angiographic result, post-stent FFR was only 0.75, the minimum limit, below which there is ischemia. When the pressure wire (PW) was slowly drawn back from the distal portion of ADA to its proximal portion, a continuous and gradual increase in intracoronary pressure was noted, which clearly indicates diffuse atherosclerosis and not focal stenosis. A gradient was not observed at the stent place. The patient was kept under medical treatment and has been asymptomatic so far.

Dissecção Espontânea de Artéria Coronária: Abordagem Terapêutica e Desfechos de Uma Série Consecutiva de Casos

Background: Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and diagnosis is made by necropsy in more than 70% of the cases. Optimal treatment is still uncertain, and the treatment options are percutaneous coronary intervention, coronary artery bypass surgery and medical therapy. The objective of this study was to evaluate the clinical characteristics, treatment modalities and outcome of a series of cases with spontaneous coronary artery dissection. Methods: Retrospective, single-center study, based on the analysis of the database at a high-complexity cardiology service. Results: We identified 25 patients with spontaneous coronary artery dissection, 56% were female, with a mean age of 48.8 ± 10 years. Only 24% had no risk factor for atherosclerosis and in 92% of the cases, the clinical presentation was of acute coronary syndrome. The left anterior descending artery was the most commonly affected vessel (48,1%) and there was only one case involving multiple vessels. The conservative approach was used in 56%, percutaneous coronary intervention in 40% and coronary artery bypass grafting in 4%. The in-hospital and late event-free survival was 92% and 84.2%, respectively. Conclusions: Spontaneous coronary artery dissection predominated in young women, with at least one risk factor for coronary artery disease. The choice of different therapeutic strategies confirms the still controversial nature of the optimal approach for spontaneous coronary artery dissection. We believe that individualized therapy is still the optimal modality.

Angiographic geometric predictors of myocardial infarction are not associated with ultrasonographic markers of plaque vulnerability

OBJECTIVE Some angiographic geometric features of coronary lesions have recently been described as independent predictors of myocardial infarction. The purpose of this study was to correlate these geometric markers with intravascular ultrasound findings known to be associated with greater vulnerability to plaque rupture. METHODS A total of 30 patients with stable coronary syndromes and de novo lesions (31 lesions) underwent coronary angiography and intravascular ultrasound (IVUS). For each lesion, angiographic geometric features (degree of symmetry, degree of stenosis, lesion length, and outflow angle) were correlated with the following ultrasound variables: type of plaque (soft, fibrous, mixed, or calcified), plaque burden and remodeling index. RESULTS Mean lesion length was 9.2 +/- 4.4 mm, percent stenosis was 50.0% to 89.0% (mean 67.7 +/- 12.1%), inflow angles ranged from 8.48 degrees to 48.78 degrees (mean 24.0 +/- 11.4 degrees), outflow angles ranged from 8.30 degrees to 53.03 degrees (mean 23.8 +/- 11.7 degrees), and the symmetry index ranged from 0 to 1 (mean 0.56 +/- 0.32). On ultrasound evaluation, frequency of soft or calcified plaques, positive remodeling, and magnitude of plaque burden were not associated with any angiographic geometric feature (p > 0.05 for all analysis). CONCLUSION Angiographic geometric features that predispose to acute occlusion do not correlate with IVUS morphologic and quantitative findings associated with plaque vulnerability.

Biomarker release after percutaneous coronary intervention in patients without established myocardial infarction as assessed by cardiac magnetic resonance with late gadolinium enhancement: VIEIRA DE MELO et al.

This study aimed to evaluate the amount and pattern of cardiac biomarker release after elective percutaneous coronary intervention (PCI) in patients without evidence of a new myocardial infarction (MI) after the procedure as assessed by cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE).

Early Removal of the Arterial Sheath After Percutaneous Coronary Intervention Using the Femoral Approach: Safety and Efficacy Study

ABSTRACT Introduction We evaluated the safety and efficacy of protamine administration, guided by activated clotting time, for the immediate femoral arterial sheath removal in patients undergoing percutaneous coronary intervention with unfractionated heparin in order to propose an algorithm for clinical practice. Methods Prospective study with consecutive patients with stable angina or low-to-moderate risk acute coronary syndrome. We compared patients with an early removal of the arterial sheath to those whose sheath removal was based on a standard protocol. Results The early removal group (n = 149) had lower access manipulation time than the conventional group (58.3 ± 21.4 minutes vs. 355.0 ± 62.9 minutes; p p p = 0.49). There was no stent thrombosis during hospitalization and no significant differences in the incidence of major vascular or bleeding events. The incidence of other bleeding events leading to a prolonged in-hospital length of stay was lower in the early removal group (1.3% vs. 5.1%; p = 0.05). Conclusions: The selective use of an approach for immediate femoral sheath removal, based on activated clotting time guidance and protamine administration, is a safe and effective option in patients undergoing percutaneous coronary intervention by femoral access.

Trends in the Use of the Transradial Approach in More Than a Decade: The InCor's Experience

ABSTRACT Background : The use of the radial approach for diagnostic cardiac catheterization and percutaneous coronary interventions varies among different interventional cardiology centers in the world. We describe the trends in the use of this approach over the past 14 years at a tertiary hospital. Methods : Consecutive coronary procedures performed from 1999 to 2013 at a single center, in patients aged ≥ 35 years were identified. Age, gender, resource provider (Public or Private Healthcare System) and the complexity of the procedure (diagnostic or therapeutic) were retrospectively analyzed. Results : 103,253 procedures were included. The Brazilian Public Healthcare Service (SUS – Sistema Unico de Saude ) was the resource provider in 77% of the cases. Mean age of patients was 62.2 ± 11.3 years and 58% were male. The radial approach was used in 6,402 (6.2%) procedures, showing a significant rise over time, which was more evident when analyzed comparatively for the six timepoints of service experience: 0.2%; 0.6%; 3.1%; 2.1%; 6.9%, and 24.4% respectively (p Conclusions : We demonstrated progressive changes in the profile of the use of access routes for diagnostic cardiac catheterization and percutaneous coronary interventions at a large center over time. These data are consistent with the global trend and are significantly robust, especially when the last sextile is analyzed. RESUMO Tendencias da Utilizacao da Via de Acesso Transradiai em Mais de Uma Decada: A Experiencia do InCor Introduco : A utilizacao da via radial para a realizacao de cateterismo cardiaco diagnostico e intervencao coronaria percutânea varia entre os diversos centros de hemodinâmica. Descrevemos as tendencias do uso dessa via de acesso ao longo dos ultimos 14 anos num servico terciario. Metodos : Foram identificados procedimentos coronarianos consecutivos realizados de 1999 a 2013, em um unico centro, em pacientes com idade ≥ 35 anos. Dados como idade, sexo, fonte provedora de recursos (Sistema de Saude Publico ou Saude Suplementar/Privado) e complexidade do procedimento (diagnostico ou terapeutico) foram retrospectivamente analisados. Resultados : Foram incluidos 103.253 procedimentos, dos quais o Sistema Unico de Saude (SUS) foi o provedor de recursos em 77% dos casos. A media de idades dos pacientes foi 62,2 ± 11,3 e 58,8% eram do sexo masculino. A via radial foi utilizada em 6.402 (6,2%) dos procedimentos, apresentando ascenSao significativa ao longo do tempo, mais evidente quando analisada comparativamente nos seis periodos de experiencia do servico: 0,2%, 0,6%, 3,1%, 2,1%, 6,9% e 24,4%, respectivamente (p Conclusoes : Demonstramos a progressiva modificacao do perfil de utilizacao das vias de acesso para a realizacao de cateterismo cardiaco diagnostico e intervencao coronaria percutânea de um centro de grande porte ao longo do tempo. Esses dados sao condizentes com a tendencia mundial e de significativa robustez, principalmente quando analisado o ultimo sextil.

Injeção de trombina guiada por ultrassom no tratamento de pseudoaneurisma da artéria femoral após procedimento percutâneo em pacientes com síndrome coronária aguda

BACKGROUND: Ultrasound-guided thrombin injection (TI) is an option for the treatment of femoral artery pseudoaneurysm. Nevertheless, the result of this technique in patients with acute coronary syndrome (ACS) may be compromised by the use of antithrombotic drugs. In addition, thrombin extravasation to systemic circulation could potentially cause an increase in thromboembolic events. METHODS: Patients admitted with ACS who developed femoral artery pseudoaneurysm after a percutaneous procedure and treated by TI between January 2007 and July 2011 were included. Clinical and laboratory characteristics, treatment results and complications were evaluated. RESULTS: We evaluated 23 patients with mean age of 67.1 ± 14.2 years, 60.9% were women, with body mass index of 28.4 ± 4.7 kg/m² and 52.2% were diabetics. At presentation, 87% had non-ST elevation ACS and the remaining had ST elevation myocardial infarction. Of the evaluated patients, 70% were submitted to percutaneous coronary intervention. All patients were receiving aspirin, 78.3% used P2Y12 inhibitors and 39.1% used glycoprotein IIb/IIIa inhibitors. TI was successful in occluding the pseudoaneurysm in 100% of cases (96.7% after the first injection), without distal embolization, local infection or need of surgical correction. There were no cases of myocardial infarction, stroke or unscheduled revascularization. There was one death due to cardiogenic shock 22 days after TI, on the second post-operative day after an elective coronary artery bypass graft surgery. CONCLUSIONS: Treatment of femoral artery pseudoaneurysm by TI is a safe and effective procedure in patients with ACS.

In-hospital outcomes and predictors of mortality in acute myocardial infarction with cardiogenic shock treated by primary angioplasty: data from the InCor registry

Background: Cardiogenic shock is the leading cause of death in patients with ST-segment elevation myocardial infarction (STEMI). The present study evaluated patients with STEMI and cardiogenic shock undergoing primary percutaneous coronary intervention, in order to establish their profile and predictors of in-hospital mortality. Methods: A single centre registry, including 100 patients evaluated from 2001 to 2009, was used to compile clinical, angiographic and procedure-related characteristics and in-hospital outcomes. The independent predictors of in-hospital mortality were determined by multivariate analysis. Results: A high prevalence of risk factors was observed. The angiographic success rate was 92%, despite the lesion complexity (83.1% were type B2/C). The left anterior descending artery was the most affected artery (45%), and 73% of the patients had multivessel disease. The mortality rate was 45%, and its independent predictors were multivessel disease (odds ratio [OR] 2.62; 95% confidence interval [95% CI] 1.16–5.90) and TIMI flow < 3 at the end of the procedure (OR 2.11; 95% CI 1.48–3.02). Conclusions: Patients with STEMI complicated by cardiogenic shock presented high-risk clinical and angiographic characteristics, and despite the high angiographic success rate of the procedure, mortality rates were high. The presence of multivessel disease and TIMI flow < 3 at the end of the procedure were independent predictors of mortality.

Comparação de segmentos angiograficamente normais e com estenose luminal significativa avaliados pelo ultrassom intracoronário com histologia virtual: análise piloto

INTRODUCAO: A doenca arterial coronaria (DAC) e sabidamente difusa, podendo acometer multiplos segmentos arteriais. No entanto, quando se analisa a angiografia coronaria, e comum a concomitância, em um mesmo paciente, da presenca de lesao em um segmento e da ausencia de obstrucao em outros. Por se tratar de um luminograma, a angiografia apresenta limitacoes para o diagnostico da DAC. Neste estudo utilizou-se o ultrassom intracoronario com histologia virtual (USIC-HV) para avaliar a presenca e a composicao de placas ateroscleroticas em segmentos angiograficamente normais e com lesoes em pacientes com DAC estabelecida. METODOS: No total, 17 pacientes com DAC obstrutiva encaminhados para realizacao de angioplastia foram submetidos a USIC-HV dos tres grandes vasos epicardicos. Apos analise minuciosa da angiografia, foram selecionados 32 segmentos angiograficamente normais, os quais foram comparados a outros 19 segmentos coronarios com estenose luminal > 70%. RESULTADOS: A carga de placa media em segmentos sem lesao angiografica foi de 47,3 ± 15,1%, enquanto em segmentos com estenose angiografica foi de 76,2 ± 8,8% (P < 0,01). A composicao da placa diferiu entre os segmentos. Placas nos segmentos angiograficamente normais apresentavam maior componente fibrolipidico (17 ± 11% vs. 11,4 ± 12%; P = 0,045) e menor componente necrotico (13,1 ± 13% vs. 20,2 ± 12%; P = 0,03). CONCLUSOES: Nesta analise piloto, em pequeno grupo de pacientes portadores de DAC, observou-se que segmentos angiograficamente normais frequentemente apresentam placa aterosclerotica. A composicao da placa em segmentos angiograficamente normais, entretanto, diferiu daquela em segmentos com lesao, sugerindo a coexistencia de estagios distintos do processo aterosclerotico em um mesmo paciente.

When is the Best Time for the Second Antiplatelet Agent in Non-St Elevation Acute Coronary Syndrome?

Dual antiplatelet therapy is a well-established treatment in patients with non-ST elevation acute coronary syndrome (NSTE-ACS), with class I of recommendation (level of evidence A) in current national and international guidelines. Nonetheless, these guidelines are not precise or consensual regarding the best time to start the second antiplatelet agent. The evidences are conflicting, and after more than a decade using clopidogrel in this scenario, benefits from the routine pretreatment, i.e. without knowing the coronary anatomy, with dual antiplatelet therapy remain uncertain. The recommendation for the upfront treatment with clopidogrel in NSTE-ACS is based on the reduction of non-fatal events in studies that used the conservative strategy with eventual invasive stratification, after many days of the acute event. This approach is different from the current management of these patients, considering the established benefits from the early invasive strategy, especially in moderate to high-risk patients. The only randomized study to date that specifically tested the pretreatment in NSTE-ACS in the context of early invasive strategy, used prasugrel, and it did not show any benefit in reducing ischemic events with pretreatment. On the contrary, its administration increased the risk of bleeding events. This study has brought the pretreatment again into discussion, and led to changes in recent guidelines of the American and European cardiology societies. In this paper, the authors review the main evidence of the pretreatment with dual antiplatelet therapy in NSTE-ACS.