Lucio Padilla

Intravascular graft stent treatment of a ruptured fusiform dissecting aneurysm of the intracranial vertebral artery: technical case report.

OBJECTIVE AND IMPORTANCE An innovative stenting technique to treat a difficult case of a fusiform aneurysm of the intracranial vertebral artery (VA), with restoration of the vessel lumen, is described. CLINICAL PRESENTATION A 58-year-old patient experienced sudden pain in the upper cervical spine, followed by a severe headache. He underwent computed tomographic evaluation, which demonstrated subarachnoid hemorrhage in the prepontine cistern. A fusiform aneurysm of the distal right VA and critical stenosis of the left VA were detected in digital subtraction angiograms. The patient experienced a new subarachnoid hemorrhaging episode, and urgent endovascular treatment was planned. INTERVENTION The patient underwent angioplastic and stenting procedures in the left VA, with good results. Forty-eight hours later, an endovascular procedure was performed to treat the right VA aneurysm. We decided to use a graft stent (Jostent graft stent; Jomed, Conroe, TX) instead of a balloon to preserve the arterial lumen. The complete procedure was well tolerated by the patient, and he was discharged, without symptoms, 48 hours later. CONCLUSION The patient was discharged, without neurological deficits, 48 hours after completion of the endovascular procedure, with clopidogrel (75 mg/d) and aspirin (325 mg/d) therapy. This treatment was discontinued after 4 weeks. According to our search of the medical literature, this is the first clinical case in which an intracranial fusiform aneurysm was permanently sealed with a graft stent.

General utilities of multislice tomography in the cardiac field.

Objects: To show all cardiac evaluations multislice computed tomography (MSCT) can perform. Methods: MSCTs were performed on an MSCT scanner (Mx8000; Philips Medical Systems) with enhanced contrast acquisition. The reconstructed images were sent to a workstation for multiplanar reconstruction, volume rendering, and 3-D reconstruction. A total of 140 patients were studied with MSCT and conventional angiography (CA) to assess coronary artery stenosis. 30 of these patients were also evaluated by intravascular ultrasound (IVUS) for plaque characterization. A group of 20 patients were studied with MSCT, gated single-photon emission computed tomography (SPECT), and echocardiography for myocardial perfusion test and volumetric analysis. Results: The results of MSCT versus CA showed a sensitivity of 79.2% and a specificity of 93.7%, whereas for MSCT versus IVUS the sensitivity was 84.4% and the specificity 91.6%. A total of 156 plaques were detected by both methods. 105 (67%) were soft, 14 (24%) were fibrous and 37 (9%) were calcified. In the evaluation of myocardial perfusion, the cardiac software showed a sensitivity of 55% and a specificity of 80%. However, general evaluation disclosed a sensitivity of 88.5% and a specificity of 96.4%. The volumetric analysis showed a good correlation between MSCT and echocardiography for end-systolic volume (ESV), rS = 0.874, and end-diastolic volume (EDV), rS = 0.828. There was also a good correlation for the evaluation of the left ventricular anatomy: septal wall rS = 0.96, posterior wall rS = 0.81, and diameter of left ventricle rS = 0.69. Conclusion: Nowadays, MSCT allows different cardiologic evaluations with the same acquisition as that for the coronary arteries. These data show a general view of the patient providing information that is obtained by the hand of multiple cardiologic methods such as DA, IVUS, gated SPECT, and echocardiography.Methoden: Die MSCT wurde mit einem Mx8000 (Philips Medical Systems) nach Kontrastmittelgabe durchgeführt. Die rekonstruierten Bilder wurden an eine Workstation zur multiplanaren Rekonstruktion, Volumenrendering und 3-D-Rekonstruktion weitergeleitet. Insgesamt untersuchten wir 140 Patienten mittels MSCT und konventioneller Angiographie (Angio), um die Abschätzung von Koronarstenosen zu evaluieren. 30 dieser Patienten wurden zusätzlich mittels intravaskulärem Ultraschall (IVUS) zur Plaque-Charakterisierung untersucht. 20 Patienten hatten zusätzlich auch eine EKG-gesteuerte Single-Photon-Emissions-Computertomographie (SPECT) sowie eine Echokardiographie zur Beurteilung der Myokardperfusion und zur volumetrischen Analyse. Ergebnisse: Die Ergebnisse für den Vergleich von Angio mit MSCT ergaben eine Sensitivität von 79,2 % und eine Spezifität von 93,7 %. Im Vergleich zum IVUS fand sich für das MSCT eine Sensitiviät von 84,4 % bei einer Spezifität von 91,6%. 156 Plaques wurden von beiden Methoden erkannt, hiervon waren 105 (67%) weich, 14 (24%) fibrös und 37 (9%) kalzifiziert. Bei der Beurteilung der Myokardperfusion ergab sich für das MSCT eine Sensitivität von 55% bei einer Spezifität von 80%. Bei weiterer Analyse zeigte sich eine Senstivität von 88,5% und eine Spezifität von 96,4%. Die volumetrische Analyse zeigte eine gute Korrelation zwischen MSCT und Echokardiographie hinsichtlich der end-systolischen Volumina (ESV), r = 0,874 und enddiastolischen Volumina (EDV), r = 0,828. Hinsichtlich der Beurteilung der linksventrikulären Anatomie ergab sich ebenfalls eine gute Korrelation: Septum r = 0,96, posteriore Wand r = 0,81, LV-Durchmesser r = 0,69. Schlussfolgerung: das MSCT erlaubt heute eine differenzierte kardiologische Abklärung einschließlich der Koronaranatomie. Das MSCT liefert Informationen, die sonst nur mit mehreren Methoden wie IVUS, EKG-gesteuertes SPECT und Echokardiographie erhalten werden können.

Mechanism involved in the paradoxical effects of active smoking following primary angioplasty: a subanalysis of the protection of distal embolization in high-risk patients with acute myocardial infarction trial.

Objective Cigarette smokers have an unexplained low mortality following ST-segment elevation acute myocardial infarction (STEMI). Our aim was to determine whether the presence of active smoking has a beneficial effect on myocardial reperfusion following primary percutaneous intervention (PCI). Methods A total of 140 STEMI patients treated with primary PCI were included in the analysis. All patients have 24-h ST-segment monitoring, each analyzed by an independent, blinded core laboratory. We divided the population according to the smoking status: active (n = 56) and nonactive smokers (n = 84). Results Both groups had similar baseline characteristics, except that active smokers were younger than nonsmokers. Postprocedural thrombolysis in myocardial infarction (TIMI) flow grade and TIMI frame were better in smokers whereas myocardial blush grade was similar between groups. Percentage of complete (≥70%) ST-segment resolution (STR) at 60 min was higher in active smokers than in nonactive smokers (76.4 versus 50%, P = 0.002). Multivariate logistic regression analysis identified active smoking as an independent predictor of complete STR at 60 min (OR 3.47; 95% CI 1.48–8.14; P = 0.004). At 30 days, no significant differences were found either in mortality (P = 0.62) or in major adverse cardiac events rates (death, reinfarction and congestive heart failure; P = 0.82) between the two groups. Conclusion In STEMI patients undergoing primary PCI, active smoking is associated with better myocardial reperfusion than nonsmoking. This finding may be the mechanism behind the smokers paradox and its beneficial effect in the short-term clinical outcome. These results await further confirmation in larger primary PCI databases.

Relationship between collateral circulation and successful myocardial reperfusion in acute myocardial infarction: a subanalysis of the PREMIAR trial.

The aim of this study was to determine whether the presence of collateral circulation had a beneficial effect following primary angioplasty. In all, 114 patients who underwent primary angioplasty were included. Patients with collateral circulation had lower basal ST-segment deviation (P = .004), white cell count ( P = .001), peak creatine kinase (P = .001), and regional wall motion score values (P = .03) than patients without collateral circulation. After the procedure, the group with collaterals was associated with higher rates of normal myocardial blush, complete ST resolution, and shorter time to stable ST-recovery. Multivariable logistic analysis identified the presence of collateral circulation as independent predictor of normal myocardial blush (adjusted odds ratio = 3.98, 95% confidence interval, 1.12-14.09; P = .033) and rapid reperfusion (time to stable ST-segment recovery <7 minutes, adjusted odds ratio = 4.0, 95% confidence interval, 1.57-10.20; P = .004). The presence of collateral circulation has a protective effect on infarct size, resulting in faster reperfusion.

Use of drug-eluting stents for the treatment of in-stent restenosis in routine clinical practice

BackgroundAlthough target lesion revascularization (TLR) has been dramatically decreased by using drug-eluting stents (DESs) in de-novo lesions, their efficacy for in-stent restenosis (ISR) has not yet been well established. MethodsWe retrospectively analysed patients treated for ISR with DESs from three referral hospitals. ResultsEighty-seven consecutive patients, from June 2002 to April 2004, were included, with a mean age of 64±11 years; 83% were men, 32% had diabetes, 47% had had a previous myocardial infarction and 16% had low left ventricular ejection fraction. Angiographic characteristics were as follows: mean vessel diameter, 3.05±0.4 mm; lesion length, 17.8±7.7 mm; diameter stenosis, 84.0±10.7%; and complex lesion, 81%. The restenosis was focal in 45%, diffuse/proliferative in 51.3% and total occlusion in 3.7% of the cases. Sirolimus- and paclitaxel-eluting stents were used in 42 and 58% of the patients, respectively. Stent diameter was 3.1±0.3 mm and the length was 26.1±5.8 mm. Angiographic success was achieved in all patients, with one patient experiencing a post-procedural non-Q-wave myocardial infarction. At 6-month clinical follow-up, two patients had died from non-cardiac deaths, five had experienced a new TLR (5.7%, four percutaneous and one coronary artery bypass graft) and eight (9.2%) had had major adverse cardiac events. A stress test was performed in 60% of the population; target vessel ischemia was observed in one patient (3.3%). ConclusionIn this non-select cohort of patients, the use of DESs is a safe and effective strategy for ISR lesions.

Time to Stable ST-Segment Recovery Following Primary Angioplasty is Predictive of Regional Wall Motion Score and Clinical Outcome

We report the time to stable ST-segment reperfusion (TSTR) after primary angioplasty and its relationship with the clinical results; 137 patients who underwent primary angioplasty were included as part of the analysis. All patients had 24 hours ST-segment monitoring. Time to stable STR was defined as the beginning of ST-segment reperfusion (STR) lasting >4 hours without ST-segment reelevation. Six-month mortality was associated with slower TSTR (median 166.5 vs 6 minute, P = .001). Time to stable STR cutoff value of 136.5 minutes was identified as the best mortality predictor (area under the curve: 0.86, P = .001). Multivariate analysis identified Killip class ≥2 (P = .042), TSTR cutoff value (P = .002), and final thrombolysis myocardial infarction (TIMI) flow grade III (P = .067) as predictors of 6-month mortality. Time to stable STR may be a novel continuous electrocardiogram (ECG) parameter following primary angioplasty, which can identify high-risk patients that need to be considered for additional treatments.

Do men and women respond differently to percutaneous renal artery interventions

Background: Women have higher risk of contrast-induced nephropathy than men. The purpose of this study was to determine the relative impact of gender on long-term renal function after percutaneous renal interventions (PRI). Methods and Results: We included all patients undergoing PRI. Men (n = 72) and women (n = 28) had similar age, men had more diabetes, coronary and peripheral artery disease, higher serum creatinine and similar glomerular filtration rate (GFR), and prevalence of chronic kidney disease (CKD) stage ≥3 when compared with females. At follow-up, men had a significant improvement in GFR and systolic blood pressure, while females did not. The presence of severe CKD and male gender were the only predictors of long-term GFR improvement. Conclusion: Male patients and patients with poor baseline renal function showed an important benefit with PRI, suggesting that it is not too late for renal revascularization if properly indicated.

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.