Gerardo Nau

Exaggerated inflammatory response following sirolimus-eluting stent fracture

A 46-year-oldmanwith a history of recurrent right coronary artery (RCA) in-stent restenosiswas admitted because of stable angina. Three months earlier, a 3.0×33-mm Cypher stent (Cordis Corp., Warren, New Jersey) was implanted, with optimal angiographic results. On admission, a roundedmyocardialmasswas found (Fig. 1A) encircling a fractured stent (Fig. 1B, D). Coronary angiogram revealed in-stent restenosis and confirmed stent fracture (Fig. 1E–F). We proceeded with cardiac surgery in order to further clarify the nature of the mass and by-pass the RCA. Microscopic sample evaluation of the excised mass demonstrated dense fibrosis coupled with mononuclear cell infiltration, while there were no neoplastic cells (Fig. 1C). Following an uneventful surgical recovery, the patient was discharged home at postoperative day 4. Drug-eluting stent fracture can lead to complications such as restenosis [1], thrombosis [2,3], aneurismal formation [4] and even perforation with catastrophic consequences. In the current case, the presence of increased vessel rigidity (i.e. long overlapping stented segments and the use of stent with closed-cell design) and angulation may have caused stent fracture [5,6]. In addition, animal and human data indicate that chronic coronary vessel exposure to either paclitaxel or sirolimus-eluting stent is associated with a whole host of local detrimental effects such as inflammation, endothelial dysfunction and inappropriate vessel remodeling. It is conceivable that the development of severe drug-eluting stent fracture created an ideal scenario for an amplify vessel exposure to all drug-eluting stent components and hence, provoke an exaggerated inflammatory response. To the best of

Gradientes intraventriculares e qualidade de vida no acompanhamento a longo prazo da redução não-cirúrgica do septo intraventricular na cardiomiopatia hipertrófica obstrutiva

BACKGROUND: About 30% of patients with hypertrophic obstructive cardiomyopathy (HOCM) have dynamic obstruction of the left ventricular outflow tract (LVOT). Symptomatic patients are treated with negative inotropic agents, however, some patients do not respond to medical therapy. Surgical myectomy was the standard therapy for these patients until the nineties. Percutaneous alcohol septal ablation (ASA) was introduced as a less invasive alternative therapy. This study was aimed at assessing the clinical course of patients undergoing ASA at our center METHOD: Seven patients with HOCM were included and intraventricular gradients and quality of life before and after ASA were evaluated. Mean follow-up was 3.3 ± 1.8 years RESULTS: There was a significant improvement in the New York Heart Association (NYHA) class during the followup. The mean LVOT gradient before ASA at rest was 67 ±22 mmHg and 131 ± 27 mmHg with Valsalva maneuver. In the late follow-up, the mean LVOT gradient at rest was 33 ± 37 mmHg and 37 ± 47 mmHg with Valsalva maneuver. Peak oxygen uptake was 14.7 ml/min prior ASA, increasing to 25.4 ml/min during the follow-up CONCLUSION: In our study, ASA was a safe and effective treatment for HOCM providing substantial relief of symptoms, outflow tract obstruction and improvement of exercise capacity and quality of life with low complication rates.

Efficacy and Safety of Transfemoral Transcatheter Aortic Valve Replacement under General Anesthesia versus Local Anesthesia with Conscious Sedation

Background: Currently, there is no consensus about the most adequate anesthetic management in transfemoral transcatheter aortic valve replacement. Although it has been shown that local anesthesia (LA) with or without conscious sedation is feasible, clinical results are controversial. Objective: The aim of this study was to evaluate the safety and efficacy of transfemoral transcatheter aortic valve replacement performed under general anesthesia versus local anesthesia with conscious sedation. Methods: This was a single-center, retrospective study of high risk patients with severe aortic stenosis undergoing transfemoral transcatheter aortic valve replacement between March 2009 and December 2016. The population was divided according to anesthetic management. Safety and efficacy outcomes were evaluated at 30-days and were classified according to definitions of the Valve Academic Research Consortium-2. In addition, key times during hospitalization were evaluated. Results: A total of 121 patients undergoing transfemoral transcatheter aortic valve replacement under general anesthesia (n=55, 45.5%) or local anesthesia with conscious sedation (n=66, 54.5%). were included in this analysis. Mean age was 83.2±5.7 years and 48.8% were men. There were no differences in either the procedural result or in the 30-day efficacy and safety outcomes. The rate of death at 30-days was 7.3% in the group with general anesthesia and 3% in the local anesthesia with conscious sedation group (log-rank p 0.28). The need of conversion to general anesthesia was 3% (2 patients), in all cases due to major vascular complications during the procedure. In the local anesthesia with conscious sedation group shorter procedural time, intensive care unit and hospital length of stay were observed. Conclusions: Transfemoral transcatheter aortic valve replacement performed under local anesthesia with conscious sedation seems to be a safe and effective alternative to the use of general anesthesia.

Femoral Pseudoaneurysm Treatment by Local Thrombin Injection

Objetivos. El objetivo de este estudio ha sido evaluar la seguridad y eficacia del cierre del pseudoaneurisma femoral iatrogenico mediante la inyeccion de trombina local guiada por ecografia Doppler. Metodos y resultados. Entre Marzo 2007 y Junio 2016 se incluyeron para tratamiento un total de 32 pacientes con inyeccion de trombina. La edad media fue 64,3±10,2 anos. La mayoria de los pseudoaneurismas estuvieron asociados a la realizacion de cateterismos coronarios diagnosticos o terapeuticos (59,3%). Siete pacientes habian recibido tratamiento anticoagulante y 21 doble antiagregacion plaquetaria. En todos los casos se intento previamente cierre por compresion manual. La media del diametro mayor de los pseudoaneurismas fue de 38 mm. Luego del tratamiento la trombosis inmediata del saco ocurrio en 28 pacientes (87,5%), mientras que 4 pacientes requirieron de una segunda inyeccion, determinando un exito del 96,8%. En un solo paciente este tratamiento no fue efectivo, con posterior conversion a reparacion quirurgica programada. La dosis media de trombina fue de 450 Unidades. Un unico paciente presento complicacion trombotica venosa que requirio terapia anticoagulante con buena evolucion clinica. Conclusion . El tratamiento del pseudoaneurisma con inyeccion local de trombina guiado con eco-Doppler es una alternativa terapeutica segura y eficaz para pacientes con pseudoaneurisma femoral refractarios a la compresion manual.

TCT-504 Bleeding risk in Acute Coronary Syndrome submitted to PCI with new oral antiplatelet agents

nos: 507-508

Sobrevivência a médio prazo e estado funcional de pacientes com estenose valvar aórtica grave submetidos a implante transcateter da válvula aórtica

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a treatment option for patients with aortic valve stenosis (AS) and high or prohibitive surgical risk. We report our experience using the Medtronic CoreValveTM self-expending system. METHODS: From 2009 to 2013, 51 consecutive patients with severe symptomatic AS and high or prohibitive surgical risk were submitted to TAVI. Results were analyzed according to the criteria of the Valve Academic Research Consortium (VARC) -2. RESULTS: Mean age was 82 ± 6 years, 49% were female, 19% were diabetic, 21% had renal failure and the logistic EuroScore was 17.4 ± 11.4%. The success rate of the device was 84.3%. All of the patients had a significant decrease of transaortic gradients, which was maintained over time. Hospitalization time was 6 days (interquartile range: 5-8,8). In-hospital mortality at 30 days was 7.8% and 9.8%, respectively. Permanent pacemaker implantation was required in 32.6% of the cases, ischemic stroke was observed in 3.9% and major vascular complications in 6% of the patients. Survival at 6 months and 1 year was 86.3% and 84.4%, respectively. NYHA functional class improved significantly after TAVI and remained low in the medium-term follow-up. CONCLUSIONS: In this preliminary experience, the treatment of patients with AS and high or prohibitive surgical risk with TAVI, using the CoreValveTM self-expanding system was feasible and safe and led to sustained improvement of cardiac symptoms. After overcoming the initial risks of death and stroke, the procedure guaranteed good long-term clinical outcomes.

Letter by Albertal et al Regarding Article “Interventional Therapy of Bifurcation Lesions: A TIMI Flow-Guided Concept To Treat Side Branches in Bifurcation Lesions—A Prospective Randomized Clinical Study (Thueringer Bifurcation Study, THUEBIS Study as Pilot Trial)”

To the Editor: We read with great interest the article by Korn et al1 that compared a mandatory versus a bailout treatment strategy at the side branches (SBs) during bifurcation percutaneous coronary interventions (PCIs). The authors concluded that a bailout strategy for treating the SB stenosis in patients …

Uso de tromboaspiração em angioplastia coronária primária no mundo real: registro multicêntrico argentino de infarto agudo do miocárdio com supradesnivelamento do segmento ST

ABSTRACT Real World Use of Thrombus-Aspiration DuringPrimary Angioplasty. Argentinean MulticenterRegistry of ST-Elevation Myocardial Infarction Background: Manual thrombus-aspiration has proven toimprove myocardial reperfusion during primary percu-taneous coronary intervention. However, the adequatepopulation for this approach has not been well established.The aim of this study was to determine the frequency andpatient selection for thrombus-aspiration during primarypercutaneous coronary intervention. Method: From July2008 to February 2009, we included 183 patients submittedto primary percutaneous coronary intervention from eightArgentinean centers in a prospective ST-segment elevationmyocardial infarction (STEMI) registry. Baseline characte-ristics as well as clinical and angiographic outcomes werecompared among patients treated with and withoutthrombus-aspiration. Results: Manual thrombus-aspirationwas used in 20.8% of the patients. Baseline clinical cha-racteristics were similar among patients treated with andwithout thrombus-aspiration. However, thrombus-aspirationtreatment was associated with worse baseline renal functionand greater baseline ST-segment elevation (thrombus-as-piration: 12.2 ± 7.7 mm vs. 10.2 ± 8.6 mm; P = 0.06). Thethrombus-aspiration group had a higher rate of patients withgrade 4-5 thrombus (86.8% vs. 49%; P < 0.01) and baselineTIMI flow 0 (thrombus-aspiration 63.2% vs. 40.7%; P = 0.03),greater vessel diameter (3.46 ± 0.5 mm vs. 3.12 ± 0.5 mm;P = 0.01), use of distal filter (13.1% vs. 0.7%; P = 0.04)