Gilberto Marchiori

Stent dislodgement in the treatment of left main coronary artery dissection

Correspondencia: George Cesar Ximenes Meireles • Rua Sena Madureira, 1265/102, Vila Clementino, CEP 04021-051, Sao Paulo, SP – Brasil E-mail: gcxm@cardiol.br, george.ximenes@terra.com.br Artigo recebido em 17/09/12, revisado em 21/12/12, aceito em 08/01/13. Palavras-chave Arterias Coronarias, Disseccao, Angioplastia Coronaria com Balao, Stents. Introducao A disseccao acidental do tronco da arteria coronaria esquerda (TCE) e uma das complicacoes mais temidas pelo cardiologista intervencionista, cuja ocorrencia pode ter consequencia grave se nao diagnosticada e tratada prontamente com a revascularizacao miocardica. A incidencia da disseccao ocasionada pelo cateter e menor que 0,1%, elevando-se para 1,05% em pacientes com lesao obstrutiva do TCE1-4. A realizacao de intervencao percutânea imediata com implante de stent parece ser a medida apropriada para tratamento de disseccao acidental do TCE de moderada/ grande extensao, como demonstrado no presente caso.

Evolução hospitalar de pacientes submetidos a assistência circulatória com balão intra-aórtico durante intervenção coronária percutânea de alto risco: registro InCor

ABSTRACT In-Hospital Outcomes of Patients Submitted toCirculatory Support with Intra-Aortic BalloonPump During High Risk Percutaneous CoronaryIntervention: InCor Registry Background: The intra-aortic balloon pump (IABP) has beenused for decades as a circulatory support device, beingrecommended in most guidelines, despite poor evidence ofmortality reduction. The purpose of this study was to evaluatethe use of IABP as an adjunct therapy in percutaneouscoronary intervention (PCI). Methods: Single center registryanalyzing in-hospital outcomes of 134 consecutive patientssubmitted to IABP during high risk PCI or in the presenceof cardiogenic shock. Results: Mean age was 64.7 + 12.5years and 67.9% were males. The population presentedhigh-risk features, with 33.5% of diabetic patients, 73.1%treated in the presence of myocardial infarction, 68.6%with three-vessel disease and left ventricular ejection fractionof 38.6 + 16.1%. TIMI 2/3 flow was obtained in 86.4% ofthe cases and 1.6 + 0.6 lesion/patient was treated. Therewere 18 (13.4%) reinfarctions, of which 9 (6.7%) were dueto stent thrombosis, 2 (1.4%) patients were referred forCABG and 16 (11.9%) for a new PCI. Hospital mortalitywas 61.2% and the major adverse cardiac events (MACE)rate was 67.2%. By multivariate analysis, predictors ofmortality were: age > 65 years, prior PCI, need of dialysisand three-vessel disease. Predictors of survival were: normalventricular function, TIMI 2/3 flow at the end of the procedureand IABP utilization > 72 hours.

Caracterização e impacto clínico tardio do no-reflow associado a intervenção coronária percutânea primária vs. eletiva

INTRODUCAO: Apesar dos grandes avancos alcancados pela cardiologia intervencionista, o fenomeno do no-reflow ainda ocorre durante as intervencoes coronarias percutâneas (ICP) e esta associado a pior prognostico. O objetivo deste estudo foi caracterizar os perfis clinico, angiografico e do procedimento de pacientes com no-reflow, alem de avaliar seu impacto clinico tardio. METODOS: Analisamos, no periodo de janeiro de 2004 a fevereiro de 2009, todos os pacientes submetidos a ICP no Instituto do Coracao (InCor), que em qualquer momento da intervencao apresentaram no-reflow, mesmo que transitoriamente. Os pacientes foram divididos em dois grupos: no-reflow de reperfusao (associado a ICP primaria) e no-reflow de intervencao (associado a ICP eletiva). A probabilidade de obito foi estimada pelo metodo de Kaplan-Meier e a regressao de Cox foi utilizada para identificar seus preditores. RESULTADOS: Foram avaliados 132 pacientes consecutivos, 81 no grupo no-reflow de reperfusao e 51 no grupo no-reflow de intervencao. O sucesso do procedimento foi obtido em 83,5% da populacao total (80,2% vs. 90,2%, respectivamente; P = 0,149). A probabilidade de mortalidade tardia foi estimada em 38,6%, sendo maior no grupo de no-reflow de reperfusao (55,8% vs. 11,1%; P = 0,005). Na analise multivariada, somente o sexo feminino [hazard ratio (HR) 2,5, intervalo de confianca de 95% (IC 95%) 1,22-5,14; P = 0,027) e a doenca pulmonar obstrutiva cronica (HR 9,3, IC 95% 1,45-60,14; P = 0,027) foram preditores independentes de mortalidade, enquanto o uso previo de estatina foi um fator de protecao (HR 0,15, IC 95% 0,05-0,48; P = 0,002). CONCLUSOES: O fenomeno de no-reflow foi associado a elevados indices de insucesso do procedimento e mortalidade tardia, principalmente quando associado a angioplastia primaria.

Desfechos tardios da intervenção coronária percutânea com stent farmacológico em pontes de veia safena: dados do registro InCor

BACKGROUND: The safety and efficacy of drug-eluting stents in the treatment of saphenous vein graft (SVG) lesions remains controversial. This study assessed the late follow-up of patients with SVG lesions treated with drug-eluting stents. METHODS: Single center registry including patients undergoing SVG interventions using drug-eluting stents (n = 82), without clinical or angiographic exclusion criteria, from 2003 to 2009. The rates of major adverse cardiac events (MACE), death, acute myocardial infarction (AMI), target vessel revascularization (TVR) and stent thrombosis were evaluated. RESULTS: Mean age was 67.8 ± 10.2 years, most of them were male (85.4%), 40.2% were diabetic and 52.4% had stable angina. An average of 1.45 ± 0.5 stents per patient were implanted and CypherTM was the stent used in most of the cases (61%). Stent diameter was 3.22 ± 0.39 mm and stent length was 20.1 ± 7.3 mm. Angiographic success rate was 96.3%. In the 4.1-year follow-up, the rate of MACE was 28%, death 6%, AMI 19.5% and TVR 18.2%. There were two cases of definitive or probable stent thrombosis (2.4%) within the follow-up period. CONCLUSIONS: Long-term follow-up showed high MACE rates in patients with SVG lesions treated with drug-eluting stents, probably due to the accelerated atherosclerosis that develops within the grafted vein conduits.

Perfil de segurança dos stents farmacológicos nas síndromes coronárias agudas: dados do Registro INCOR

BACKGROUND: Drug-eluting stents are a great advance in the treatment of coronary disease. However, their use in patients with acute coronary syndromes has been the subject of intense scientific debate. METHODS: 910 consecutive patients treated with at least one drug-eluting stent between May 2002 and September 2006 were enrolled in the present analysis. The patients were assigned to 2 groups according to their clinical condition at the time of admission: 1) Stable group (635 patients with stable angina) and 2) Acute group (275 patients with NSTEMI). We analyzed the clinical and angiographic characteristics as well as the occurrence of late adverse events. RESULTS: The clinical characteristics of the groups were similar, except for the highest incidence of smokers in the acute group and previous percutaneous intervention in the stable group. After 588 days (median follow-up period), the stable and acute groups had similar rates of re-infarction (2.8 vs. 5.0%; p = 0.1), target vessel revascularization (6.0 vs. 7.7%; p = 0.4), death (4.5 vs. 6.5%; p = 0.2) and composite major adverse cardiac events (9.9 vs. 11.9%; p = 0.4), respectively. However, the occurrence of in-stent thrombosis was more frequent in patients with acute coronary diseases (1.4 vs. 4.4%; p = 0.02), mainly due to the occurrence of thrombosis within the first year after implantation (1.1 vs. 4.4%; p = 0.01). CONCLUSION: Drug-eluting stents have shown a good safety profile in patients with acute coronary syndromes compared to those with chronic coronary disease, despite the higher incidence of late in-stent thrombosis.

Clinical performance of a novel ultrathin strut, low-dose, sirolimus-eluting stent with abluminal-only biodegradable polymeric coating for patients undergoing percutaneous coronary intervention in the daily practice

BACKGROUND The present study aimed to evaluate the clinical performance, in the daily practice of a busy catheterization laboratory, of a novel drug-eluting stent (DES) built with an ultra-thin-strut metallic platform, eluting sirolimus at low doses, abluminal coated with biodegradable polymers, and mounted in a low-compliant delivery system. METHODS Prospective, single-arm study, comprising all consecutive patients undergoing percutaneous coronary intervention (PCI) with the Inspiron™ sirolimus-eluting stent (SES) (Scitech, Aparecida de Goiania, Brazil). The primary endpoint was the occurrence of major adverse cardiac events (MACE) [cardiac death, non-PCI related myocardial infarction (MI), or target vessel revascularization (TVR)]. RESULTS A total of 470 patients were included, from which 51.3% were diabetics, 33.8% had triple-vessel disease, 15.3% had heart failure, 38.9% had at least one bifurcation treated, 19.8% were treated for a bare metal stent restenosis, and 61.9% had at least one type C lesion; one or more of these features were found in 96.0%. At 300 days, the rate target lesion revascularization was 5.4% and the rate of MACE was 8.1%. The incidence of definite or probable stent thrombosis was 0.4%, with no cases between 30 and 300 days. CONCLUSIONS The novel stent is associated with excellent short and mid-term clinical outcomes in patients treated with PCI in the daily practice.

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.

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.

Modificações evolutivas da necessidade de cirurgia de revascularização miocárdica de emergência em indivíduos submetidos a intervenção coronária percutânea: análise de 9.938 pacientes

BACKGROUND: Percutaneous coronary interventions (PCI) in centers without cardiac surgery represent a real option in the current context of interventional cardiology. The purpose of this study was to evaluate changes in the incidence and indications for coronary artery bypass grafting in patients undergoing PCI from 1992 to 2005 METHOD: Data from 9,938 patients undergoing PCI in two centers were divided into three groups: pre-stent period, from 1992 to 1996 (n = 2,500), intermediate period, from 2002 to 2003 (n = 3,711) and more recent period, from 2004 to 2005 (n = 3,727) RESULTS: Since the advent of stents, an older population (58.2 ± 10.7 years vs. 62.7 ± 11.7 years vs. 67.8 + 11.6 years; P = 0.01), with more complex type B2/C lesions (52.2% vs. 72.7% vs 79%; P < 0.01) is being treated, with a lower rate of acute vessel occlusion (7.8% vs. 1.7% vs. 1.1%; P < 0.01), emergency coronary artery bypass grafting (1.2% vs. 1,1% vs. 0.7%; P < 0.01) and mortality (3.3% vs. 2.2% vs. 2%; P < 0.01). Predictors of the need of emergency bypass surgery were multivessel disease [odds ratio (OR) 3.42, 95% confidence interval (95% CI) 1.75-6.7), acute myocardial infarction (OR 3.65, 95% CI 2.3-5.8) and lesion complexity [type B2/C, American Heart Association/American College of Cardiology - AHA/ACC (OR 3.27, 95% CI 1.6-6.75)]. The use of stents, however, conferred a protective effect against the need of emergency bypass surgery (OR 0.58, 95% CI 0.4-0.85) CONCLUSION: Advances in technology, devices and adjunctive pharmacotherapy have improved PCI, reducing the need of emergency coronary artery bypass grafting.

Síndrome coronária aguda sem supradesnível de ST de alto risco: a mortalidade intra-hospitalar é proporcional ao retardo para a intervenção

FUNDAMENTOS: Estudos recentes mostram que uma abordagem invasiva rotineira para pacientes com sindrome coronaria aguda sem supradesnivelamento do segmento ST diminui eventos em relacao a uma abordagem conservadora, mas o tempo ideal para esta abordagem ainda e motivo de debate. METODO: No periodo de maio/2003 a novembro/ 2005, 466 pacientes com infarto agudo do miocardio, sem supradesnivel do segmento ST, foram submetidos a intervencao coronaria percutânea, em nossa instituicao. Excluimos aqueles pacientes com instabilidade hemodinâmica a admissao. Os pacientes foram divididos em dois grupos, de acordo com o tempo entre a admissao e a realizacao da angioplastia: 1) Grupo Precoce (intervencao 6 horas) com 314 pacientes. Foram analisados os dados do procedimento e a mortalidade intra-hospitalar. RESULTADOS: Os dois grupos foram semelhantes quanto as suas caracteristicas clinicas, exceto pela maior frequencia de cirurgia coronaria previa no Grupo Tardio. Pacientes no Grupo Precoce foram tratados com uma mediana de 3 horas (intervalo interquartil 2-4 horas) e, no Grupo Tardio, apos 23 horas (intervalo interquartil 14-48 horas). Pacientes tratados precocemente apresentaram mortalidade intrahospitalar significativamente menor que os pacientes do Grupo Tardio (0,7 vs. 4,8%; p=0,02). A analise multivariada, idade, insuficiencia cardiaca e tempo de tratamento foram identificados como preditores independentes de obito hospitalar. CONCLUSAO: A realizacao de angioplastia precoce parece reduzir o risco obito intra-hospitalar em pacientes com infarto agudo do miocardio sem supradesnivel do segmento ST tratados no dia-a-dia. O impacto clinico da implementacao de protocolos de tratamento acelerado para estes pacientes deve ser avaliado no ambiente de estudos randomizados.