Fernando Mendes Sant'Anna

Estudo randomizado e comparativo da intervenção coronária percutânea com stents recobertos por titânio-óxido nítrico ou de aço inoxidável em pacientes com doença arterial coronária: estudo RIO

BACKGROUND: Stent coating with titanium-nitride oxide (Titan) has been shown to reduce neointimal hyperplasia in both animals and humans. A prospective, randomized, clinical study was designed to compare the incidence of major adverse cardiac events (MACE) after two years in patients with the Titan stent versus the stainless steel stent. METHODS: Two hundred patients (228 stenosis) submitted to stent implantation between October 2005 and May 2006 were randomized into two groups: I) Bare metal stent (100); II) Titan (100) and followed clinically. MACE was defined as a composite of death, acute myocardial infarction or clinically driven revascularization of target lesion. MACE and angina free survival after 2 years were compared between the two groups. RESULTS: All procedures were successful in both groups. Baseline clinical and angiographic characteristics were similar in both groups. Mean follow-up period was 482 ± 264 days. After 30 days, MACE was 2% in group I and 1% in group II (P = 0.32). MACE free survival at 2 years was significantly better in the Titan group than in the bare metal stent group (93.6% vs. 82.4%; P = 0.036) as well as angina free survival (84% vs. 71%; P = 0.02). CONCLUSIONS: Revascularization with Titan stent in chronic coronary artery disease is safe, effective, and reduces the incidence of MACE and angina after two years when compared with the bare metal stent.

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.

Desfechos hospitalares em pacientes submetidos a intervenção coronária percutânea na vigência de síndromes coronárias agudas atendidos em Unidades de Pronto Atendimento (UPAs): resultados de um Centro de Cardiologia Terciário

ABSTRACT In-Hospital Outcomes in Patients with AcuteCoronary Syndromes Undergoing CoronaryPercutaneous Intervention Primarily Assisted inthe Emergency Care Units (ECUs) – Resultsfrom a Tertiary Cardiology Center Background: Emergency Care Units (ECUs) were createdto meet an urgent need of the Brazilian government toimprove health care to low-income population. ECUs quicklybecame reference centers to treat chest pain in this po-pulation, due to their ability to provide prompt medicalcare, availability of last generation drugs and well trainedstaff. This study is aimed at describing the profile and in-hospital follow-up of patients with acute coronary syndromesseen in these units and later referred to a tertiary hospital,where they were treated by percutaneous coronary inter-vention with stent implantation. Method: Three hundredpatients were referred from ECUs to Santa Helena Hos-pital (Cabo Frio, RJ) from July to December, 2009. Onehundred and sixty four patients (202 lesions) were treatedby percutaneous intervention with stent and were dividedin two groups: group I included 86 patients with acutecoronary syndromes with ST segment elevation and groupII included 78 patients with acute coronary syndromeswithout ST segment elevation. Clinical and angiographiccharacteristics and in-hospital major adverse cardiac eventswere compared between the two groups.

Enzimas miocárdicas na cirurgia de revascularização sem circulação extracorpórea

BACKGROUND: CABG surgery on the beating heart (off-pump) is increasingly used to lessen injury to the brain, kidneys and other organs. However, the perioperative incidence of myocardial injury and its effect on outcome vs conventional CABG (on-pump) remains unclear. MATERIAL AND METHODS: Retrospective study of 303 patients (122 off-pump, 181 on-pump) after isolated CABG from Feb/97-Feb/99. CPK and EKG were obtained pre and post-op, MB fraction and troponin T levels were measured postoperatively. Complications were also recorded. The groups were comparable in terms of age (65 ± 10 vs 65 ± 9 yr), CCS and NYHA class. RESULTS: Mean number of grafts was 3.10 on-pump vs 2.26 off-pump. Perioperative myocardial infarction, morbidity and mortality (7/181 vs 6/122) were also comparable. There were higher postoperative CK levels in the on-pump group compared to the off-pump (548 ± 420 vs 236 ± 365). MB fraction was slightly higher in the on-pump group, but not significantly different (62 ± 197 vs 29 ± 46) nor was troponin T levels (3.5 ± 16 vs 3.5 ± 17) were An inverse correlation between the number of grafts and troponin T release in the off-pump group occurred early during our off-pump experience. There was no correlation between graft location and the incidence of infarcts or troponin T release. CONCLUSION: The higher troponin T release during our initial experience subsequently decreased. This suggests that improvements in operative technique (e.g. better exposure allowing more posterior grafts without surface trauma) may be responsible. Current techniques make off-pump CABG a safe alternative for revascularization.

Qual o erro da angiografia na definição de isquemia miocárdica durante intervenções coronarianas percutâneas

BACKGROUND: The angiography has been used as a reference standard to define coronary artery disease (CAD), although its limitations are well-known. The significance of the myocardial fractional flow reserve (FFR) in the assessment of CAD is well established. OBJECTIVE: The aim of this study was to evaluate the accuracy of angiography when defining ischemic lesions and its correlation with FFR. METHODS: Two hundred and fifty consecutive patients (471 arteries) were included in this study. All stenoses > 50% at the angiography visual estimate (AVE) were assessed by FFR measurements. When FFR was 0.75, no interventional treatment was carried out. Offline quantitative coronary angiography (QCA) was performed in all stenoses, which were divided in intermediate (< 70% - 327) and severe (125). The correlation coefficients between the diameter of the stenosis (%DS) and FFR and the accuracy of VA of the angiography when assessing ischemia were determined. RESULTS: FFR could be obtained in 452 lesions (96%). Mean %DS and FFR were 56 ± 8% and 0.74 and 76 ± 6% and 0.48 for moderate and severe stenoses, respectively. Concordance between QCA and FFR was poor, especially in intermediate stenoses (Spearmans rho = - 0.33, p<0.0001). Visual assessment resulted in an accuracy of 57% and 96% in intermediate and severe lesions, respectively. CONCLUSION: Neither the visual assessment of an angiogram nor QCA can accurately predict the significance of most intermediate coronary stenoses, which emphasizes the importance of associating it to a functional evaluation of the coronary circulation, resulting in an adequate treatment of these stenoses.

Utilização do fluxo fracionado de reserva do miocárdio para identificar variáveis preditoras de pior prognóstico após intervenções coronárias percutâneas

INTRODUCAO: Varios estudos foram realizados para definir preditores de eventos adversos pos-intervencao coronaria percutânea (ICP). Pacientes cujo fluxo fracionado de reserva do miocardio (FFR) pos-procedimento e < 0,90 apresentam indice de eventos cardiacos adversos maiores em 6 meses pelo menos 3 vezes maior do que aqueles cujo FFR e ≥ 0,90. Este estudo teve por objetivo identificar fatores clinicos, angiograficos e do procedimento associados a FFR pos-ICP < 0,90. METODOS: Foram incluidos 193 pacientes (256 lesoes) tratados entre 2004 e 2005, e o FFR foi medido antes e depois da ICP em todos os vasos tratados. Os pacientes foram divididos nos grupos FFR < 0,90 e FFR ≥ 0,90. Analise multivariada por regressao logistica foi utilizada para determinar as razoes de chances (odds ratio - OR) ajustadas. RESULTADOS: Foi possivel obter o FFR em todas as lesoes. Nao se observou diferenca nos parâmetros clinicos entre os dois grupos de pacientes. Houve diferenca em alguns parâmetros angiograficos e do procedimento, porem, ao aplicarmos o modelo de regressao logistica, a unica variavel que se associou com FFR pos-ICP < 0,90 foi o tratamento da arteria descendente anterior (OR = 12,1; IC 95% 6,4-22,9; P < 0,01). CONCLUSOES: A unica variavel preditora de FFR pos-ICP < 0,90 foi o tratamento da arteria descendente anterior.

Tratamento cirúrgico de paciente adulto com origem anômala da artéria interventricular anterior do tronco da artéria pulmonar

From all congenital cardiopathies, anomalous origin of anterior interventricular artery occurs once per 300,0000 live births, reporting high mortality in the first year after birth. However, if good collateral circulation is available for the artery related to the abnormality, the patient may be kept asymptomatic until mature age. This is the report on a rare case of a 43-year-old patient who was oligosymptomatic, with normal ventricular function in this pathology presentation. The patient was submitted to surgical treatment with no extracorporeal circulation.

Angiografia versus fluxo fracionado de reserva na avaliação do grau de importância das estenoses coronárias

INTRODUCTION: In complex coronary artery disease, it is sometimes difficult to determine which lesions are associated with reversible ischemia. Despite this, the selection of lesions to be stented is often based on the subjectively interpreted angiogram alone. Fractional flow reserve (FFR) is an established objective methodology to indicate which lesions are ischemia-producing. OBJECTIVE: The aim of this study, in patients admitted for elective percutaneous coronary intervention (PCI), was to evaluate the accuracy of angiography in defining culprit lesions, taking FFR as the gold standard, and also its correlation with FFR METHODS: Two hundred and fifty consecutive patients (471 arteries) scheduled for PCI were included in this study. All stenoses > 50% by visual estimation, initially selected to be stented by 3 independent reviewers were assessed by measurement of the FFR. When the FFR was 0.75, no interventional treatment was given. Offline quantitative coronary angiography (QCA) was performed for all stenoses, divided into intermediate (< 70% - 327) and severe (125). The correlation coefficient between the degree of stenosis (%DS) and FFR was determined as was the accuracy of the visual assessment of angiography in evaluating ischemia taking FFR as the gold standard. RESULTS: Optimal FFR readings were obtained in 452 lesions (96%). %DS and FFR were 56 ± 8% and 0.74 for moderate and 76 ± 6% and 0.49 for severe stenosis. Concordance between QCA and FFR was poor especially in intermediate stenosis (Spearmans rho = -0.33, p<.0001). Visual assessment resulted in accuracies of 57% and 96% for intermediate and severe lesions, respectively. CONCLUSIONS: Thus, neither visual assessment of an angiogram nor QCA can accurately predict the significance of most intermediate coronary stenoses, stressing the importance of associating these to a functional evaluation of the coronary circulation which can correctly guide treatment of stenosis.