Jorge Roberto Büchler

Transposition of the great arteries with posterior aorta and subaortic conus: anatomical and surgical correlation

Three hearts studied at autopsy with transposition of the great arteries and posterior aorta with isolated or predominantly subaortic conus are described. In all cases the aorta was posterior and to the right of the pulmonary trunk. In two cases it was significantly distant from the pulmonary trunk and in one it was very close. The caliber of the pulmonary trunk was larger than that of the aorta: greater than 2:1 in two cases and less than 2:1 in one case. A well developed subaortic conus was seen in all cases and a small subpulmonary conus in one case. In the other two cases, the pulmonary valve was in fibrous continuity with the mitral valve. In all cases the aortic valve was higher than the pulmonary valve, the relative heights above the ventricles being 25/20, 25/30 and 40/60 mm, respectively. The left coronary artery ran posteriorly and to the left of the pulmonary trunk in all the cases. The length of the main stem of the left coronary artery was 11, 11 and 30 mm, respectively. We discuss the significance of this type of transposition of the great arteries for techniques currently used for surgical correction.

Balloon valvoplasty in calcific aortic stenosis: a therapeutic alternative

Percutaneous balloon valvoplasty was used to treat calcific aortic stenosis in 3 women aged 73, 67 and 61 years, respectively. We approached through the left brachial artery in the first case and the right femoral artery in the other two. An 18 mm balloon was used in all cases, the systolic gradient being reduced from 50, 180 and 48 to 7, 50 and 35 mm Hg, respectively. A mild and transitory systemic embolization was observed in one case. Aortic regurgitation was not present in two patients either before or after valvoplasty. In the other case, a grade 1/6 murmur indicative of regurgitation prior to the procedure increased to a grade 2/6 afterwards. A small and localized aortic dissection was present in one case but disappeared in the control angiography performed 11 days later.

Lesão no segmento proximal da artéria coronária descendente anterior: resultados entre o tratamento cirúrgico (mamária) e o percutâneo (stent com fármaco)

Objectives: To correlate the permeability and clinical evolution of single and multilateral patients, bearers of obstructive atherosclerosis heart disease in the proximal third of the anterior descending coronary artery (DA), who were submitted to myocardial revascularization using the left internal mammary or underwent a drug eluting stent procedure. Method: This a case history cohort study in which two centers participated. Three hundred patients were retrospectively analyzed, whose lesions were treated at the proximal one third of the DA: in the G-1 group, 150 patients, underwent myocardial revascularization surgery and, the G-2 group, 150 patients, received drug eluting stents, 95 of them received paclitaxel and 55 received sirolimus. All major adverse cardiovascular events were registered during the period (MACE) during the period between the two procedures and the angiographic restudy. Deaths were not included in these MACE, since all patients were restudied through coronariography. There were clinical and angiographic demographic differences between the two groups: the G-1 patients showed a higher incidence of diabetes (29.3% versus 20.0%, p<0.05) and three artery atherosclerosis disease 50% versus 30.6%, p<0.05) with a lower incidence of one artery (13.3% versus 30.6%, p<0.001). Results: The permeability of the two procedures was quite high in both groups. Those patients free of MACE in G-1 RESUMO

Spasm of the left main coronary artery: an indication for surgery?

A patient with severe angina at rest was studied by coronary angiography. A severe spasm in the left main coronary artery was observed; after nifedipine and isosorbide dinitrate a moderate stenosis was still present and surgery was successfully performed.

Desempenho do Stent Recoberto por Titânio-Óxido Nítrico em Pacientes com Doença Coronária Multiarterial

Background: To date, there are no studies evaluating the use of the titanium-nitride-oxide coated stent in patients with multivessel coronary artery disease. We have compared the performance of the Titan-2® stent to that of the second generation drug-eluting stents in this scenario. Methods: From 2011 to 2012, 284 patients were treated with the Titan-2® stent, of which 100 (35.2%) had multivessel coronary artery disease. This group was compared to 100 patients, of a group of 304 (38.9%) patients with multivessel coronary artery disease treated with second generation drug-eluting stents with durable or biodegradable polymers. The primary endpoint was the occurrence of major adverse cardiovascular events at 1 year. Results: Clinical, angiographic and procedure-related characteristics of the patients did not show differences between groups. Most patients in the Titan-2® group were male (70%), mean age was 68.4 ± 12.9 years and 25% were diabetic. Stable symptomatic patients were prevalent (68%), 51% had three-vessel disease and ventricular function was preserved (55.6 ± 12.7%). The incidence of major adverse cardiovascular events at 1 year in the Titan-2® group was 21% (vs. 17%; p = 0.59), death was observed in 3% (vs. 2%; p > 0.99) of the patients, acute myocardial infarction in 5% (vs. 4%; p > 0.99) and a new revascularization procedure in 13% (vs. 11%; p = 0.83). Definitive stent thrombosis was not observed in either group. Conclusions: The Titan-2® stent showed similar results to those of the second-generation drug-eluting stents, which makes it attractive for use in the complex scenario of patients with multivessel coronary artery disease.

Performance of the Titanium-Nitride-Oxide Coated Stent in Patients with Multivessel Coronary Artery Disease

ABSTRACT Background To date, there are no studies evaluating the use of the titanium-nitride-oxide coated stent in patients with multivessel coronary artery disease. We have compared the performance of the Titan-2® stent to that of the second generation drug-eluting stents in this scenario. Methods From 2011 to 2012, 284 patients were treated with the Titan-2® stent, of which 100 (35.2%) had multivessel coronary artery disease. This group was compared to 100 patients, of a group of 304 (38.9%) patients with multivessel coronary artery disease treated with second generation drug-eluting stents with durable or biodegradable polymers. The primary endpoint was the occurrence of major adverse cardiovascular events at 1 year. Results Clinical, angiographic and procedure-related characteristics of the patients did not show differences between groups. Most patients in the Titan-2® group were male (70%), mean age was 68.4 ± 12.9 years and 25% were diabetic. Stable symptomatic patients were prevalent (68%), 51% had three-vessel disease and ventricular function was preserved (55.6 ± 12.7%). The incidence of major adverse cardiovascular events at 1 year in the Titan-2® group was 21% (vs. 17%; p = 0.59), death was observed in 3% (vs. 2%; p > 0.99) of the patients, acute myocardial infarction in 5% (vs. 4%; p > 0.99) and a new revascularization procedure in 13% (vs. 11%; p = 0.83). Definitive stent thrombosis was not observed in either group. Conclusions The Titan-2® stent showed similar results to those of the second-generation drug-eluting stents, which makes it attractive for use in the complex scenario of patients with multivessel coronary artery disease. RESUMO Desempenho do Stent Recoberto por Titânio-Oxido Nitrico em Pacientes com Doenca Coronaria Multiarterial Introdcao Ate o momento, nenhum estudo avaliou o stent recoberto por titânio-oxido nitrico em pacientes com doenca arterial coronariana multiarterial. Comparamos o desempenho do stent Titan-2® ao stents farmacologicos de segunda geragao nesse cenario. Metodos No periodo de 2011 a 2012, 284 pacientes foram tratados com o stent Titan-2®, dos quais 100 (35,2%) eram portadores de doenca arterial coronariana multiarterial. Esse grupo foi comparado a 100 pacientes, de um grupo de 304 (38,9%), com doenca arterial coronariana multiarterial, tratados com o stent farmacologico de segunda geracao com polimeros duraveis ou biodegradaveis. O desfecho primario foi a ocorrencia de eventos cardiacos adversos maiores em 1 ano. Resultados Caracteristicas clinicas, angiograficas e do procedimento nao apresentaram diferencas entre os grupos. A maioria dos pacientes do grupo Titan-2® era do sexo masculino (70%), com idade de 68,4 ± 12,9 anos e 25% eram diabeticos. Predominaram os quadros clinicos estaveis (68%), 51% tinham acometimento triarterial e a funcao ventricular estava preservada. A incidencia de eventos cardiovasculares adversos maiores em 1 ano no grupo Titan-2® foi de 21% (vs. 17%; p = 0,59), obito ocorreu em 3% (vs. 2%; p > 0,99) dos pacientes, infarto do miocardio em 5% (vs. 4%; p > 0,99) e nova revascularizacao miocardica em 13% (vs. 11%; p = 0,83). Nao foram constatadas tromboses de stent definitivas em nenhum grupo. Conclusoes O uso do Titan-2® apresentou resultados similares aos do stent farmacologico de segunda geracao, o que o torna atrativo para ser utilizado no complexo cenario de pacientes portadores de doenca arterial coronariana multiarterial.

Avaliação da acurácia diagnóstica da angiotomografia coronária de múltiplos detectores

INTRODUCTION: Coronary computed tomographic angiography (CCTA) has been widely accepted as a non-invasive diagnostic tool for coronary artery disease (CAD). The objective of this study was to evaluate the diagnostic performance of CCTA and its influence on modification of percutaneous revascularization strategies. METHOD: The study included two groups of patients: a main group (MG), including 100 patients screened with a suspect of severe CAD by CCTA and indication for coronary cineangiography (CINE), and a control group (CG) for comparison, including 100 patients selected during the same period, with indication for CINE according to clinical criteria or by positive functional tests. We evaluated the performance of CCTA for the diagnosis of lesions > 50% in coronary segments, arteries and patients and the revascularization strategies adopted. RESULTS: The sensitivity, specificity and positive and negative predictive values of CCTA were 86%, 95%, 71% and 100% for the coronary segments, 91%, 92%, 80% and 100% for the coronary arteries and 100%, 90%, 100% and 100% for patients, respectively. In the MG, percutaneous coronary intervention (PCI) was performed in 90% of the patients, whereas in the CG, percutaneous coronary intervention was performed in 43% of the patients (P = 0.01). CONCLUSION: CCTA had a high diagnostic performance in detecting CAD and allowed ad hoc PCI to be performed in 90% of the patients. This strategy, however, must await randomized studies to confirm these results.

Intervenção coronária percutânea em pacientes nonagenários

BACKGROUND: Elderly people represent a significant part of the Brazilian population and the population > 90 years has tripled in the past three decades. This retrospective study was aimed at analyzing the results of percutaneous coronary intervention in ninety-year-old patients. METHOD: Overall, 31 ninety-year-old patients (G1) undergoing percutaneous coronary treatment from January 1995 to January 2009 were retrospectively evaluated. These patients were compared to 6,222 patients 2 vessel disease (RR 1.82, IC 1.04-3.19; P = 0.011), left main coronary artery lesion (RR 2.98, IC 0.97-9.17; P = 0.001), presence of unstable angina (RR 2.48, IC 0.97-9.17; P = 0.0013) and diabetes (RR 2.35, IC 1.21-4.55; P = 0.0015) were MACE predicting variables. CONCLUSION: Ninety-year-old patients had a higher incidence of cardiovascular events than younger patients. However, when the technique is feasible and patients have good clinical condition, percutaneous coronary intervention may be effectively used with an acceptable safety margin.

Ostial Lesions in Main Coronary Arteries Treated with the Szabo Technique

Background: Percutaneous coronary intervention (PCI) in ostial lesions is one of the major challenges in contemporary interventional cardiology. Despite the technological advances, ostial lesions still present a higher rate of immediate and late adverse events compared with non-ostial lesions. The objective of this study was to evaluate coronary ostial lesions treated with the Szabo technique. Methods: Ten patients treated by PCI using the Szabo technique to treat ostial lesions in main coronary arteries between October and November, 2011, were included. Aorto-ostial lesions were excluded. Results: Of the ten treated patients, seven were males, with ages ranging from 42 to 75 years, and 60% had acute coronary syndromes without ST-segment elevation. The circumflex artery was treated in six patients, and a 7 F catheter was used in eight patients. In three patients, both guidewires twisted during the advancement of the stent to the lesion, which was solved by partially retrieving and repositioning the standard target-vessel wire. Procedural success was observed in 90% of the cases. There were no in-hospital deaths, (re) infarctions or emergency revascularisations. Conclusions: In this study, the Szabo technique successfully treated ostial lesions in main coronary arteries and provided adequate positioning of the stent in most cases.

Desempenho do stent farmacológico firebird em diabéticos portadores de doença coronária multiarterial

BACKGROUND: Preliminary data have shown the Firebird™ and the Cypher® stents have similar safety and efficacy profiles. However, to date, no study has evaluated the percutaneous coronary intervention (PCI) with the Firebird™ stent in diabetic patients. METHODS: The performance of the Firebird™ stent in diabetic patients with multivessel coronary artery disease (CAD) (n = 100) was compared to that of the Cypher® stent, using historical data from the ARTS-II study (n = 159). We compared the major adverse cardiovascular events (MACE) at one year. RESULTS: Most of the patients in the Firebird™ group were male (65%), with mean age of 63.3 ± 10.4 years and 5% were receiving insulin. Stable coronary syndromes were prevalent (60%), 45% had three-vessel CAD and ventricular function was preserved (56.6 ± 13.7%). In patients with three-vessel CAD, 135 lesions were treated with > 3 stents in 78% of the cases and 2 stents in the remaining ones. In patients with two-vessel CAD, 110 lesions were treated with > 2 stents in 80% of the cases and 1 stent in the remaining ones. The incidence of MACE at one year of the Firebird™ stent was 21%, death was observed in 3% of the patients, myocardial infarction in 2% and a new revascularization procedure in 18%, predominantly at the expense of a new PCI in 14% of the cases. Comparison with the Cypher® group did not show differences for any of the evaluated endpoints. CONCLUSIONS: In our study, the use of the Firebird™ stent showed similar results to those of patients in the ARTS-II study, which makes it attractive for use in the complex scenario of diabetic patients with multivessel CAD.