Faustino Miranda-Guardiola

Perfil clínico, pronóstico y variabilidad en el tratamiento del síndrome coronario agudo sin elevación del segmento ST. Datos del registro PEPA

Objectives. To assess the clinical characteristics and inter-hospital variability in the treatment and prognosis of patients with non-ST-segment elevation acute coronary syndromes. Patients and method. Data from the PEPA study, a prospective registry that enrolled 4,115 patients in 18 Spanish hospitals, were analyzed. Results. The mean age of the patients enrolled was 65 years, 33% were women, and 26% had diabetes. Large differences were observed in the clinical profile of patients admitted to different centers, especially relative the history of previous disease, prior coronary revascularization, and co-morbidity. Antiplatelet treatment was used in 93% of patients, heparin in 45%, beta-blockers in 42%, nitrates in 67%, and calcium antagonists in 46%. During hospitalization, exercise stress testing was performed in 37% of patients, coronary angiography in 32%, coronary angioplasty in 9%, and coronary surgery in 4%. Inter-hospital variability was minimal for the use of antiplatelet agents, wide for the use of heparin and betablockers, and huge for the use of revascularization procedures. Mortality and the incidence of death or myocardial infarction were 2.6% and 4.4% during hospitalization, and 4.6% and 8% at 3 months, with wide interhospital variability. These differences were not significant once adjusted for clinical characteristics and the treatment received at admission. Conclusions. Patients with non-ST-segment elevation acute coronary syndromes represent an heterogeneous

Bench top evaluation and clinical experience with the Szabo technique: new questions for a complex lesion.

Background: The Szabo technique has been described as a method to ensure accurate ostial stent placement. We sought to investigate this novel technique in detail both in vitro and in vivo. Methods and Results: The technique was subjected to bench testing and also undertaken in 26 patients. Each step was recorded with cine angiography and the stents imaged by microcomputed tomography. The ostial LAD was treated in 81% and a DES was implanted in 92%. Angiographic success was 88.5% (one case of stent dislodgement). Repeat angiography was performed in 78% and restenosis observed in two patients. MACE rate at 15.5 ± 5.1 months was 13% (1 TLR, 1 MI, 1 cardiac death). Despite a seemingly excellent immediate angiographic result, we report one case of restenosis at follow up and one case of IVUS examination (performed in four patients) in which significant stent protrusion, into the proximal main vessel, was observed. In vitro bench testing confirmed a significant and asymmetric (carina side) stent protrusion into the main branch, with the last cell of the stent undergoing significant deformation. Conclusions: The Szabo technique is not a precise technique to implant a stent at the level of the ostium. The proximal end of the stent undergoes significant and asymmetric deformation, protruding into main branch. Additional concerns with this complex technique include the potential for stent damage or contamination before implantation and the risk of stent dislodgement. We conclude that there are more disadvantages than benefits to this technique which only partially addresses the difficulties encountered in the treating ostial lesions.

Evolución hospitalaria y pronóstico actual de la angina inestable

Introduccion y objetivos El pronostico de los pacientes con angina inestable ha mejorado en los ultimos anos, lo que ha conducido a una progresiva reduccion de la estancia y el tratamiento hospitalarios. El objetivo de este estudio fue conocer el pronostico actual de la angina inestable en una poblacion no seleccionada seguida durante un periodo de 3 meses. Pacientes y metodos Se estudiaron 478 pacientes consecutivos con angina inestable, que fueron tratados siguiendo una pauta de tratamiento guiada por los sintomas y los resultados de una prueba de esfuerzo o de estres farmacologico realizada antes del alta. Resultados La edad media fue de 66 ± 11 anos, un 30% eran mujeres, un 35% tenian antecedentes de infarto, un 61% presentaban cambios isquemicos en el ECG de ingreso y un 16% tuvieron elevacion de las CK-MB. Se practico un ecocardiograma al 80% de los pacientes, prueba de esfuerzo al 62% y coronariografia al 51%, siendo revascularizados el 27%. Durante la hospitalizacion, la incidencia de mortalidad o infarto, angina refractaria o complicaciones isquemicas fue del 3,6%, 11% y 13%, respectivamente. Despues del alta, la incidencia de estas complicaciones fue del 3,3%, 9% y 10% (NS respecto a la fase hospitalaria). Globalmente, desde el ingreso hasta los 3 meses de seguimiento un 4,2% de los pacientes fallecieron, un 7% fallecieron o tuvieron un infarto, un 20% presento angina refractaria y un 26% tuvo alguna complicacion isquemica. Conclusiones El pronostico actual de la angina inestable durante la fase hospitalaria es relativamente bueno. Sin embargo, los pacientes dados de alta una vez estabilizados presentan una elevada incidencia de complicaciones isquemicas durante los primeros 3 meses de seguimiento, similar a la presentada durante la fase aguda por todos los pacientes.

Remodelado ventricular izquierdo tras ablación septal percutánea con alcohol en pacientes con miocardiopatía hipertrófica obstructiva: estudio ecocardiográfico

Evaluamos el impacto de la reduccion de la obstruccion en el tracto de salida del ventriculo izquierdo tras la ablacion septal percutanea con alcohol sobre la hipertrofia y el remodelado del ventriculo izquierdo (VI). Pacientes y metodo. Se incluyo a 20 pacientes con miocardiopatia hipertrofica tratados con ablacion septal percutanea. Se realizo ecocardiograma Doppler en situacion basal, inmediatamente despues de la ablacion septal percutanea y a los 3 y 12 meses de seguimiento, en el que se midieron los diametros y grosores del VI y del gradiente de presion en el tracto de salida del ventriculo izquierdo. Resultados. Inmediatamente despues de la ablacion septal percutanea, el gradiente de presion en el tracto de salida del VI disminuyo de 63,0 ± 27,7 a 28,2 ± 24,7 mmHg (p < 0,001), sin que se apreciaran cambios significativos en las dimensiones del VI. Doce meses despues se observo un incremento en los diametros telediastolico (de 47,1 ± 4,9 a 50,8 ± 4,5 mm; p < 0,01) y telesistolico del VI (de 27,1 ± 3,0 a 33,7 ± 4,6 mm; p < 0,01) y una reduccion en los grosores del septo (de 19,5 ± 4,0 a 15,5 ± 2,7 mm; p < 0,01) y de la pared posterior del VI (de 14,0 ± 2,2 a 12,9 ± 1,3 mm; p < 0,01). Los volumenes telediastolico y telesistolico del VI aumentaron (de 106,4 ± 26,9 a 123,1 ± 28,7 ml; p < 0,01, y de 50,2 ± 17,3 a 56,7 ± 18,3 ml; p < 0,01, respectivamente), sin que se observaran cambios en la fraccion de eyeccion del VI. La reduccion del gradiente de presion en el tracto de salida del ventriculo izquierdo observada a los 12 meses de la ablacion septal percutanea se correlaciono de manera significativa con el incremento del diametro telesistolico del VI (r = 0,63; p < 0,01). Conclusiones. La reduccion de la obstruccion en el tracto de salida del ventriculo izquierdo en pacientes con miocardiopatia hipertrofica tratados con ablacion septal percutanea se acompana de un incremento de los diametros y volumenes del VI en el seguimiento. Esto indica el desarrollo de un remodelado cardiaco y de una regresion en la hipertrofia del VI de estos pacientes que podria contribuir a su mejoria sintomatica

IVUS-guided treatment strategies for definite late and very late stent thrombosis

AIMS Our aim was to describe the intravascular ultrasound (IVUS) findings of patients with late stent thrombosis (ST) undergoing percutaneous intervention, and to compare the pre- and post-intervention IVUS findings of patients treated with balloon angioplasty (BA) vs. additional stent implantation (ASI). METHODS AND RESULTS A total of 117 patients with late ST imaged with IVUS were included (51.2% had drug-eluting stent ST). Treatment was left to the operators discretion: BA was performed in 53.8% and ASI in 46.2%. Pre-intervention, incomplete stent apposition (ISA) was observed in 69.8% vs. 63.0% (p=0.43), underexpansion in 33.3% vs. 18.5% (p=0.07) and restenosis in 15.9% vs. 27.8% (p=0.12), respectively. Post-intervention, persistent ISA was observed in 37.2% vs. 60.9% (p=0.03) and malapposition volume decreased by 43.6% vs. 2.6% (p=0.03). Persistent underexpansion was observed in 9.3% vs. 17.4% (p=0.26); however, the stent expansion index was largely increased with BA (from 0.75 to 0.88) compared to ASI (from 0.80 to 0.82); p=0.046. At two years, recurrent ST was observed in one (1.7%) vs. four (7.7%) patients, respectively; p=0.09. CONCLUSIONS Non-optimal IVUS criteria of stent implantation are often observed in patients with late ST. Treatment of late ST with BA leads to a larger reduction of malapposition and underexpansion with respect to ASI and is associated with favourable outcomes.

Pronóstico a largo plazo de las mujeres con síndrome coronario agudo sin elevación del segmento ST

Antecedentes y objetivos. Las mujeres con infarto y elevacion del segmento ST tienen un peor pronostico que los varones. Sin embargo, existe poca informacion sobre el pronostico de las mujeres con sindrome coronario agudo sin elevacion del segmento ST (SCASEST). El objetivo del estudio fue conocer si el pronostico a largo plazo de las mujeres con SCASEST es diferente al de los varones. Pacientes y metodo. De un total de 300 pacientes consecutivos ingresados por SCASEST con cambios isquemicos en el ECG, se compararon las caracteristicas clinicas y la evolucion de las 95 mujeres con las de 95 varones seleccionados por tener la misma edad, prevalencia de diabetes mellitus e hipertension arterial.

[Differences in the management and prognosis of patients with non-ST segment elevation acute coronary syndrome according to the department of initial admission].

OBJECTIVES To assess the influence of the department of initial admission on the hospital management and 3-month prognosis of patients with non-ST elevation acute coronary syndromes. PATIENTS AND METHOD The data for the 4115 patients admitted to 18 hospitals in the PEPA study were compared according to the department of initial admission. RESULTS Twenty-six percent of the patients were admitted to the coronary care unit, 53% to the cardiology department, 9% to the internal medicine department, and 12% were discharged from the emergency ward. The baseline risk profile was high in patients admitted to the coronary care unit and decreased progressively in patients admitted to the cardiology, internal medicine and emergency departments (P<.00001). The intensity of medical management was progressively lower in these departments, but not in parallel to their different baseline lower risk profile. Beta blockers were administered to 50%, 45%, 27% and 21% of the patients, respectively; an exercise test was performed in 34%, 44%, 35% and 12%; coronary angiography in 46%, 34%, 19% and 0%; and coronary revascularization in 22%, 12%, 9% and 0% (P<.00001). The 3-month incidence of mortality or myocardial infarction was 12.2%, 6.4%, 8.7% and 3.8%, respectively (P<.00001), differences that became nonsignificant after adjustment for risk profile on admission. CONCLUSIONS Patients with non-ST elevation acute coronary syndrome admitted to the coronary care unit or cardiology department have a profile of higher risk on admission than patients admitted to the internal medicine department. Also, these patients more frequently receive pharmacological treatments and diagnostic and therapeutic procedures of proven efficacy but not in a manner that parallels their different risk profile on admission. However, these differences in the intensity of in-hospital management do not seem to lead to differences in the 3-month prognosis.

Análisis y características de los stents farmacoactivos disponibles en la actualidad. Futuros desarrollos

Los stents metalicos se desarrollaron para combatir el retroceso elastico, las complicaciones agudas y la reestenosis de la angioplastia con balon, pero crearon una nueva entidad, la restenosis intra-stent, ligada a multiples factores. Entre ellos, las caracteristicas clinicas del paciente y el tipo de lesion son inmodificables. Sin embargo, la tecnica de implante y, muy particularmente, el diseno del stent han experimentado una gran transformacion que ha desembocado en la nueva era de los stents recubiertos, stents liberadores de farmacos o el termino que mejor los define, stents farmacoactivos. Estos nuevos stents son dispositivos muy complejos que involucran tecnologia y diseno de la plataforma o stent, investigacion y desarrollo en el terreno de los polimeros que actuan como transportadores y liberadores de los farmacos, y el propio farmaco que debe inhibir la proliferacion neointimal. Si bien los primeros disenos, con 5 anos de seguimiento clinico a sus espaldas, han mostrado una reduccion significativa y sostenida de la reestenosis y las nuevas revascularizaciones frente a los stents metalicos convencionales, tambien han mostrado debilidades y sombras, que deben irse corrrigiendo en las proximas generaciones de stents farmacoactivos. En esta revision se lleva a cabo un analisis detallado de la importancia del diseno del stent, se hace una incursion breve en el mundo de los polimeros, sus tipos y su funcionamiento, y se describen los farmacos empleados en los stents farmacoactivos. Se analizan las caracteristicas y los resultados clinicos y angiograficos de los stents actualmente disponibles o en fase de estudio, y se abre una ventana hacia los futuros desarrollos.

TCT-206 Incidence and clinical impact of Side Branch Occlusion After Bioresorbable Vascular Scaffold Implantation for Chronic Total Occlusions: Insight from the CTO-ABSORB pilot study

Background: The thicker strut of metallic stents potentially contributes to a higher incidence of side branch occlusion (SBO). This study sought to assess the incidence and clinical impact of SBO after bioresorbable vascular scaffold (BVS) implantation in percutaneous CTO revascularization. Methods: 35 consecutive true CTOs lesions (Euro-CTO club definition) treated with BVS were included in this prospective study. Target lesions were scaffold after mandatory pre-dilatation and IVUS analysis. Side branch occlusion (SBO) was defined as a reduction in TIMI flow to grade 0 or 1. Accordingly, side branches (SB) with pre-BVS implantation TIMI flow grade 0 or 1 were excluded. Visible SB were classified in two groups: really small (< 0.5mm) or not ( 0.5mm). Results: The most frequent lesions treated were the RCA (46%) and LAD (40%). According to the Japanese-CTO score of complexity most of lesions were classified as intermediate (49%) or difficult-very difficult (26%). 34% were moderate-severe calcified lesions. Pre-dilatation was 100% by cutting balloon in 71%. The total scaffold length implanted per lesion was of 52.5 22.9mm. All the scaffolds were delivery and deployment successfully. Post-dilatation was done in 63%. The total number of visible SB covered by BVS was 109 (3.2 1.4 per lesion). SBO after BVS implantation was described in (7/109) 6.4%. Really small SB (SB< 0.5mm), were slightly more frequently occluded (4) 3.7% compared to SB 0.5mm (3) 2.8%. In 4 of 7 of cases of SBO, a significant dissection after balloon dilatation and before BVS implantation was observed. However, dissection was reported in 1/4 (25%) of really small SB and in 3/3 (100%) of bigger SB 0.5mm. Post-procedural SBO was not related with an increased incidence of in-hospital myocardial infarction. At a median of 10.2 (6.2-11.9) months, no MACE was reported and all the devices were patent by MSCT. Conclusions: In our study with long complex lesions covered by BVS we report a relatively slow rate of SBO after BVS implantation, including all visible SB. Moreover it seemed that SBO had not a significant impact in in-hospital or midterm adverse events. Further investigation is required in a pivotal randomized trial.