Gustavo Caires Novaes

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.

Uso do Sistema Manométrico Miniaturizado Pressure-Wire em Cardiopatias Estruturais Congênitas e Adquiridas

Background: Historically, intravascular pressure recording has contributed to the development of interventional cardiology. Although new imaging resources have gained much attention, accurate intravascular pressure measurement remains essential for the diagnosis and evaluation of interventional therapy methods. We describe the use of the miniature manometric system (pressure-wire) to obtain pressure curves in congenital and acquired structural heart diseases. Methods: The Radi Analyzer® Xpress (St. Jude Medical Inc., St. Paul, MN, USA) and PressureWire®Certus systems were used in procedures with 5 F catheters under eneral anesthesia and ventilatory support in children. Manometric tracings were obtained simultaneously from pressure-wire and the 5 F catheter in patients whose therapy strategies were dependent on the analysis of intravascular pressures, and in whom was not possible to obtain them accurately by conventional methods. Results: Pressure-wire was used to obtain pulmonary intravascular pressures in patients with systemic-pulmonary collaterals with or without angiographically detected stenosis, and with different structural heart diseases, in the evaluation of pulmonary branch stenosis, in the localization of surgical conduit stenosis (e.g. after Rastelli surgery), surgical shunts (such as Blalock-Taussig) and in the preoperative evaluation of cavo-pulmonary shunts. The procedure was performed safely, and manometric tracings were obtained with an adequate quality. Conclusions: The miniature manometric system is well accepted as a complementary diagnostic modality for the functional assessment of coronary lesions in interventional cardiology. It is also a complementary diagnostic method in different structural, congenital and acquired heart diseases.

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.

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.

Relato Preliminar sobre a Concentração Sanguínea de Níquel Após Oclusão Percutânea de Comunicação Interatrial com a Prótese Cocoon

Background: The possibility of nickel release to the bloodstream after implantation of latest generation atrial septal defect occlusion devices (Cocoon Septal OccluderTM), whose main component is nitinol (55% nickel and 45% titanium), remains controversial, especially in certain groups of patients such as children and women of childbearing age. Thus, the aim of this study was to evaluate the correlation between the device implantation and serum levels of nickel. Methods: This was a prospective longitudinal observational study conducted at a public hospital. Patients undergoing percutaneous atrial septal defect occlusion were clinically evaluated using transthoracic echocardiography and peripheral vein blood sampling for serum nickel before and after (1 day, 1 and 3 months) implantation. Results: The procedure and subsequent examinations were successfully performed in ten patients, with mean age of 34.4 years (range 5 to 60 years). Serial echocardiography confirmed the maintenance of adequate results of the procedure. Patients did not show manifestations that might suggest a reaction to metal, such as skin rash, dyspnea, thoracic discomfort, palpitations or migraine. Serum nickel levels did not show any significant changes and remained within the normal range for the population, according to the dosing methods within 3 months of the procedure. Conclusions: Preliminary results of this investigation with the Cocoon device have shown that during the initial period of endothelization after the procedure there was no significant nickel release into the bloodstream.

Use of the Miniature Pressure-Wire Manometric System in Congenital and Acquired Structural Heart Diseases

Background: Historically, intravascular pressure recording has contributed to the development of interventiona l cardiology. Although new imaging resources have gained much attention, accurate intravascular pressure measurement remains essential for the diagnosis and evaluation of interventiona l therapy methods. We describe the use of the miniature manometric system (pressure-wire) to obtain pressure curves in congenital and acquired structural heart diseases. Methods: The Radi Analyzer

Middle-term assessment of cardiovascular risk factor control in a prospective cohort of high-risk patients treated by percutaneous coronary intervention

ABSTRACT Background Secondary prevention after percutaneous coronary intervention (PCI) is essential to increase event-free survival and consists mainly in risk factor control. We analyzed the secondary prevention of high-risk patients included prospectively in the Sequence Variation in Platelet Aggregation in Response to Clopidogrel and aspirin trial (SPARC). Methods From December 2009 to February 2011 we enrolled 187 consecutive patients who were submitted to PCI with stent implantation and were evaluated in outpatient visits at 1, 3, 6, and 12 months of follow-up for the control of hypertension, dysglycemia, hyperlipidemia and smoking and their respective therapeutic measures. Results There was a significant increase in the number of patients with controlled hypertension (29%; P = 0.02), who stopped smoking (18%; P = 0.003), and received statins (19%; P Conclusions An important effect was observed on the index PCI admission with increased prescription of risk factor control drugs and achievement of therapeutic goals. This study identifies a relevant opportunity window for risk factor control at the index admission, when substantial gains are observed and maintained. However, it also shows further efforts are required to expand the benefit of secondary prevention in the middle-term follow-up of patients treated by PCI.