Geraldo Luiz de Figueiredo

Predictors of restenosis after percutaneous coronary intervention using bare-metal stents: a comparison between patients with and without dysglycemia

The objective of this study was to identify intravascular ultrasound (IVUS), angiographic and metabolic parameters related to restenosis in patients with dysglycemia. Seventy consecutive patients (77 lesions) selected according to inclusion and exclusion criteria were evaluated by the oral glucose tolerance test and the determination of insulinemia after a successful percutaneous coronary intervention (PCI) with a bare-metal stent. The degree of insulin resistance was calculated by the homeostasis model assessment of insulin resistance (HOMA-IR). Six-month IVUS and angiogram follow-up were performed. Thirty-nine patients (55.7%) had dysglycemia. The restenosis rate in the dysglycemic group was 37.2 vs 23.5% in the euglycemic group (P = 0.299). The predictors of restenosis using bivariate analysis were reference vessel diameter (RVD): pound2.93 mm (RR = 0.54; 95%CI = 0.05-0.78; P = 0.048), stent area (SA): <8.91 mm(2) (RR = 0.66; 95%CI = 0.24-0.85; P = 0.006), stent volume (SV): <119.75 mm(3) (RR = 0.74; 95%CI = 0.38-0.89; P = 0.0005), HOMA-IR: >2.063 (RR = 0.44; 95%CI = 0.14-0.64; P = 0.027), and fasting plasma glucose (FPG): < or =108.8 mg/dL (RR = 0.53; 95%CI = 0.13-0.75; P = 0.046). SV was an independent predictor of restenosis by multivariable analysis. Dysglycemia is a common clinical condition in patients submitted to PCI. The degree of insulin resistance, FPG, RVD, SA, and SV were correlated with restenosis. SV was inversely correlated with an independent predictor of restenosis in patients treated with a bare-metal stent.

In-Lab Upfront Use of Tirofiban May Reduce the Occurrence of No-Reflow During Primary Percutaneous Coronary Intervention. A Pilot Randomized Study

Background Despite successful opening of culprit coronary artery, myocardial reperfusion does not always follows primary percutaneous coronary intervention (PPCI). Glycoprotein IIb/IIIa inhibitors are used in the treatment of no-reflow (NR), but their role to prevent it is unproven. Objective To evaluate the effect of in-lab administration of tirofiban on the incidence of NR in ST-elevation myocardial infarction (STEMI) treated with PPCI. Methods STEMI patients treated with PPCI were randomized (24 tirofiban and 34 placebo) in this double-blinded study to assess the impact of intravenous tirofiban on the incidence of NR after PPCI according to angiographic and electrocardiographic methods. End-points of the study were: TIMI-epicardial flow grade; myocardial blush grade (MBG); resolution of ST-elevation < 70% (RST < 70%) at 90min and 24h after PPCI. Results Baseline anthropometric, clinical and angiographic characteristics were balanced between the groups. The occurrence of TIMI flow < 3 was not significantly different between the tirofiban (25%) and placebo (35.3%) groups. MBG ≤ 2 did not occur in the tirofiban group, and was seen in 11.7% of patients in the placebo group (p=0.13). RST < 70% occurred in 41.6% x 55.8% (p=0.42) at 90min and in 29% x 55.9% (p=0.06) at 24h in tirofiban and placebo groups, respectively. Severe NR (RST ≤ 30%) was detected in 0% x 26.5% (p=0.01) at 90 min, and in 4.2% x 23.5% (p=0.06) at 24h in tirofiban and placebo groups, respectively. Conclusion This pilot study showed a trend toward reduction of NR associated with in-lab upfront use of tirofiban in STEMI patients treated with PPCI and paves the way for a full-scale study testing this hypothesis.

Avaliação a médio prazo do controle de fatores de risco de doença cardiovascular em coorte prospectiva de pacientes de alto risco tratados por intervenção coronária percutânea

INTRODUCAO: A prevencao secundaria apos intervencao coronaria percutânea (ICP) e fundamental para melhorar a sobrevida livre de eventos e consiste principalmente no controle de fatores de risco. Analisou-se a prevencao secundaria de pacientes de alto risco, incluidos prospectivamente no estudo Sequence Variation in Platelet Aggregation in Response to Clopidogrel and aspirin (SPARC). METODOS: Foram arrolados 187 pacientes consecutivos entre dezembro de 2009 e fevereiro de 2011, tratados por ICP com stent e avaliados em retornos ambulatoriais de 30 dias, 3 meses, 6 meses e 12 meses quanto ao controle de hipertensao arterial, disglicemia, dislipidemia e tabagismo, e medidas terapeuticas respectivas. RESULTADOS: Houve aumento significativo de pacientes com controle pressorico (29%; P = 0,02), que cessaram tabagismo (18%; P = 0,003), e que receberam hipolipemiantes (19%; P < 0,0001) entre a internacao para ICP e o primeiro retorno apos o procedimento. Esse melhora do controle de fatores de risco refletiu-se em reducao do escore de risco de Framingham medio observado no mesmo periodo (9,9%; P < 0,0001). Durante seguimento de ate 12 meses o ganho atingido na internacao para ICP se manteve para todos os fatores de risco. CONCLUSOES: Observou-se efeito importante relativamente a internacao indice para ICP, com aumento da prescricao de medicamentos para controle de fatores de risco e alcance de metas. Esse estudo identifica relevante janela de oportunidade para priorizacao do controle de fatores de risco na internacao inicial, quando ganhos expressivos sao observados e mantidos. Mas tambem explicita que esforcos adicionais sao necessarios para expandir o beneficio da prevencao secundaria no seguimento a medio prazo de pacientes tratados por ICP.

Discinergia Ventricular Esquerda Reversível Identificada por Potenciação Pós-Extrassistólica em Miocardiopatia Chagásica Crônica Não é Causada por Hibernação Miocárdica

BACKGROUND: Regional left ventricular segmental wall motion impairment is an early marker of chronic Chagas cardiomyopathy. We have recently shown that dysynergy may be reversed in some ventricular regions by post-extrasystolic potentiation. Despite normal epicardial coronary arteries, patients with Chagas cardiomyopathy have perfusion defects, raising the possibility that myocardial hibernation could be responsible for the wall motion abnormalities reversed during post-extrasystolic potentiation. METHOD: Twentytwo consecutive patients with chronic Chagas cardiomyopathy underwent coronary angiography, left ventricular contrast angiography and stress-redistribution-reinjection thallium-201 myocardial scintigraphy for the assessment of the perfusion status in left ventricular segments showing the presence of post-extrasystolic potentiation. RESULTS: No significant coronary artery stenosis was seen in any of the patients. Post-extrasystolic potentiation was seen in at least one left ventricular segment in 14 of the 22 patients. It occurred in ventricular areas with baseline moderate to intense wall motion disorders, but not with dyskinesis. These patients showed an improvement in the average myocardial wall motion scores of 1.49 ± 0.73 to 1.36 ± 0.76 from the baseline to the post-extrasystolic beat (P < 0.05). In these areas, myocardial perfusion was normal or only mildly impaired, and ischemia was not induced by exercise or pharmacological stress. CONCLUSION: The present results do not support the hypothesis of hibernating myocardium caused by microvascular perfusion disorders in chronic Chagas cardiomyopathy.

Oclusão percutânea de comunicação interatrial tipo ostium secundum com prótese memopart

BACKGROUND: The authors report their initial experience with the Memopart™ device (Shanghai Shape Memory Alloy Co Ltd, Shanghai, China) for the occlusion of secundum atrial septal defect (ASD). METHODS: This was a prospective observational study of a series of patients undergoing percutaneous occlusion of ASD with right ventricle volume overload and favorable anatomic characteristics. The procedure was performed by percutaneous femoral approach. The mean follow-up was 10.3 ± 5 months, with clinical and 24-hour echocardiographic evaluations (or before hospital discharge), 1, 3, 6, and 12 months after implantation. RESULTS: From February/2012 to April/2013, 21 patients, 16 females, mean age 33.1 ± 18.7 years, were submitted to percutaneous occlusion of an ASD. The average diameter of the defect was 19.04 ± 6.25 mm and the device size was 21.42 ± 6.73 mm (8 to 34 mm). Total occlusion of the defect was observed in all cases before hospital discharge. During follow-up, all patients were asymptomatic and without residual shunt. There was no deaths or any other complications in the series. CONCLUSIONS: The percutaneous closure of ASD using a Memopart™ device is an effective and safe procedure within the limits of this investigation. The device is user-friendly and has a high rate of immediate occlusion, even in large defects.

Use of the pressure wire method for measuring pulmonary arterial pressures in patients with pulmonary atresia

OBJECTIVE The objective of the study was to analyse the use of the pressure wire for the acquisition of intravascular pulmonary pressures in the presence of pulmonary atresia and systemic-dependent pulmonary blood flow. METHODS In this study, we included patients with pulmonary atresia and systemic-dependent pulmonary circulation referred for diagnostic catheterisation for evaluation of pulmonary pressures during the period from April, 2012 to April, 2013. The systemic-pulmonary collateral arteries were selectively catheterised, and in the absence of a critical stenosis angiographically determined; the pressure wire was introduced in these arteries to reach the main pulmonary artery, and/or lobar, and segmental branches. Aortic and pulmonary pressures were simultaneously obtained. We evaluated the feasibility and safety of the method. RESULTS We studied 10 patients (age 21 days to 11 years). In all of them, the pressures of pulmonary circulation - main artery, and/or lobar, and segmental branches - were successfully measured with the pressure wire. Of eight patients with indication for Rastelli surgery, the pulmonary pressures were considered normal in five, and slightly increased in three. In two patients requiring univentricular correction - total cavopulmonary anastomosis - the diastolic pressure was increased (20 mmHg). All procedures were performed without haemodynamic instability, cardiac arrhythmia, systemic saturation reduction, death, or any other complication. CONCLUSION Measurement of pulmonary vascular pressures using the pressure wire in small patients with pulmonary atresia is safe and effective. It allows the acquisition of reliable pressure curves, even in the presence of small vessels, bending and tortuosity, without the risk usually associated with the use of conventional diagnostic catheters.

Rationale and design of a prospective study to assess the effect of microcirculatory antiplatelet and vasodilation therapy in patients with chronic chagas heart disease and coronary microvascular disease

Background: Studies on Trypanosoma cruzi infections and histopathologic studies in individuals with Chagas disease suggest that ischaemia plays a role in the pathogenesis of myocardial lesions in the chronic phase of the disease. These ischaemic disorders are caused by microcirculatory deregulation. Atypical angina is a common symptom in patients in the chronic phase of Chagas disease. In a large number of patients, despite the absence of significant angiographic coronary obstructions, the occurrence of perfusion abnormalities is documented by myocardial scintigraphy during stress, which is reversible after rest. Methods: This will be a single-centre, prospective, single cohort study with a therapeutic intervention followed by a late quantitative re-evaluation of myocardial perfusion defects initially detected in patients with Chagas disease and angiographically normal coronary arte ries. Myocardial perfusion single-photon emission computed tomography (SPECT) will be performed before and 90 days after therapeutic intervention using Technetium ( 99m Tc) sestamibi as a radiotracer and physical stress or vasodilation stimulation with dipyridamole. Therapeutic intervention will consist of acetylsalicylic acid (single daily dose of 100 mg) with verapamil (80 mg b.i.d.; a total daily dose of 160 mg). The primary endpoint of the study is a > 50% reduction of the area of ischaemic myocardium calculated by the polar scintigraphic map. Conclusions: This will be the first study of a therapeutic approach to attenuate or reverse ischaemic

Base racional e plano de estudo prospectivo para avaliar o efeito de terapêutica antiplaquetária e vasodilatadora microcirculatória em pacientes com cardiopatia chagásica crônica e distúrbios microvasculares coronários

BACKGROUND: There is evidence based on experimental models studies in infections by Trypanosoma cruzi, as well as histopathologic studies in individuals with Chagas heart disease, suggesting that ischemia plays a role in the pathogenesis of myocardial lesions in the chronic phase of the disease. These ischemic disorders are caused by microcirculatory dysregulation. Atypical angina is a common symptom in patients in the chronic phase of Chagas heart disease. In a large number of patients, despite the absence of significant angiographic coronary obstructions, the occurrence of perfusion abnormalities is documented by myocardial scintigraphy during stress, which is reversible after rest. METHODS: This is a single center, prospective, single cohort study, with a therapeutic intervention, followed by a late quantitative reevaluation of the myocardial perfusion defects, initially detected in patients with Chagas heart disease and angiographically normal coronary arteries. Myocardial perfusion single-photon emission computed tomography (SPECT) will be performed before and 90 days after the therapeutic intervention, using sestamibi-Tc99m as a radiotracer and physical exercise or vasodilation stimulation with dipyridamole as stressors. Therapeutic intervention will consist of acetylsalicylic acid (single daily dose of 100 mg) associated to verapamil (80 mg bid and a total daily dose of 160 mg). The primary endpoint of the study is a reduction > 50% of the area of ischemic myocardium calculated by the polar scintigraphic map. CONCLUSIONS: This is the first study of a therapeutic approach to attenuate or revert ischemic myocardial perfusion abnormalities of microvascular origin in patients with chronic Chagas heart disease.

A Inibição da Via Final Comum da Agregação Plaquetária Reduz o Fenômeno de Não Reperfusão Durante a Intervenção Coronária Percutânea Primária? Tirofiban no Infarto Agudo do miocárdio e a não ReperfusÃo (TIARA)

Introducao: A intervencao coronaria percutânea primaria e hoje o metodo preferencial de reperfusao na abordagem de pacientes com infarto agudo do miocardio com supradesnivelamento do segmento ST. Em boa parte desses casos, ocorre o fenomeno de nao reperfusao, que e a incapacidade de se reperfundir uma regiao do miocardio apos o restabelecimento da patencia de uma arteria coronaria epicardica previamente ocluida. O beneficio de inibidores da glicoproteina IIb/IIIa, bloqueando a via final comum da agregacao plaquetaria, tem sido sugerido em estudos de sindromes coronarias agudas, mas persistem pontos obscuros quanto a sua real eficacia, no contexto da nao reperfusao, em pacientes tratados com intervencao coronaria percutânea primaria. Metodos: Investigacao multicentrica que avaliou o impacto da administracao precoce do inibidor da glicoproteina IIb/IIIa de baixo peso molecular tirofiban, em forma duplo-mascarada, controlada por placebo, sobre a ocorrencia de nao reperfusao, empregando metodos angiograficos e eletrocardiografico para documentar (1) os fluxos coronario epicardico, pelo escore TIMI, e microcirculatorio, pelo escore MBG de opacificacao e escoamento miocardicos; (2) a resolucao do supradesnivelamento do segmento ST, como indice final do sucesso da reperfusao. Conclusoes: Se comprovada reducao da incidencia de nao reperfusao tanto 90 minutos como 24 horas apos a intervencao coronaria percutânea primaria, este estudo-piloto, deve nortear a implementacao de estudo mais abrangente, para investigar o possivel impacto do bloqueio sistematico da via final comum da agregacao plaquetaria, sobre a mortalidade de pacientes com infarto agudo do miocardio com supradesnivelamento do segmento ST.

Fase Piloto do Estudo SPECTRUM. Reserva de Fluxo Fracionada Versus Angiografia para Avaliação e Conduta em Pacientes com Lesões Obstrutivas Coronárias de Grau Moderado: Racional e Desenho do Estudo

Introducao: A despeito de suas reconhecidas limitacoes, a angiografia coronaria invasiva e o metodo mais usado (muitas vezes unico) para a adocao de estrategias terapeuticas em pacientes submetidos a cateterismo cardiaco diagnostico. A mensuracao de reserva de fluxo fracionada (FFR) tem sido empregada em diversos estudos, fundamentalmente no contexto de pacientes em que a avaliacao angiografica per se indica a necessidade de intervencao sobre as lesoes coronarias. No entanto, o metodo praticamente nao foi ainda testado em condicoes opostas, no cenario clinico em que as obstrucoes, angiograficamente, nao indicariam intervencoes. O proposito deste trabalho, a ser realizado de forma piloto em dois centros, e testar a hipotese de que tambem para lesoes intermediarias, nas quais a angiografia nao demonstra necessidade de intervencao coronaria, a medida de FFR resultaria em alteracao da conduta terapeutica baseada em angiografia. Metodos: Serao incluidos pacientes consecutivos e clinicamente estaveis, com doenca coronaria em segmento proximal e/ou medio de um ou mais vasos epicardicos (diâmetro > 2,5 mm), apresentando obstrucoes entre 40 e 70%, por estimativa visual. Em seguida, a conduta terapeutica (clinica ou intervencionista) baseada em angiografia, relativamente a essas lesoes, sera definida de maneira independente por consenso de dois observadores. A partir dai, os pacientes, em ambos os grupos, serao randomizados para dois subgrupos: (1) manutencao de conduta baseada na angiografia; e (2) realizacao de FFR para decisao terapeutica. Os pacientes com lesoes em que se obtiver FFR < 0,80 serao tratados com revascularizacao percutânea ou cirurgica, enquanto os portadores de lesoes com FFR ≥ 0,80 serao tratados clinicamente. Conclusoes: O presente estudo visa avaliar se a medida de FFR em lesoes intermediarias nao consideradas necessarias de tratamento intervencionista pela angiografia resulta em mudanca de conduta.