Marcus Nogueira da Gama

Extrinsic compression of the left main coronary artery by a dilated pulmonary artery: Clinical, angiographic, and hemodynamic determinants

Extrinsic compression of the left main coronary artery (LMC) by the pulmonary artery (PA) is a very unusual and poorly understood entity, usually associated with the presence of adult congenital heart disease. We identified 12 patients (age range, 6 months to 55 years) with LMC stenosis (≥ 50%) presumably secondary to compression by a dilated main PA and related to various forms of heart disease (11 congenital, 1 pulmonary hypertension). In all cases, the main PA was dilated with the main PA/aortic root diameter increased (mean, 2.0; normal value, ≤ 1.0), and in all but two, PA pressures were increased (> 30 mm Hg systolic). Left coronary trunk stenosis was usually visualized in only one angiographic view (best seen in 45° left anterior oblique, 30° cranial projection). The LMC also appeared to be inferiorly displaced and in close contact with the left aortic sinus (mean angle between sinus and LMC was 23° ± 13°, a control group was 70° ± 15°). In one patient, surgical correction of the dilated PA was associated with a reduction in LMC stenosis from 85% to < 50% and less inferior left main displacement (from 25° to 50°). Patients with a dilated main PA may exhibit extrinsic LMC compression leading to significant eccentric narrowing and downward displacement of the LMC. In the presence of significant dilatation of the main PA from any etiology, functional and/or anatomic studies should be performed to exclude significant LM obstruction. Cathet Cardiovasc Intervent 2001;52:49–54.

Dissecção Espontânea de Artéria Coronária: Abordagem Terapêutica e Desfechos de Uma Série Consecutiva de Casos

Background: Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and diagnosis is made by necropsy in more than 70% of the cases. Optimal treatment is still uncertain, and the treatment options are percutaneous coronary intervention, coronary artery bypass surgery and medical therapy. The objective of this study was to evaluate the clinical characteristics, treatment modalities and outcome of a series of cases with spontaneous coronary artery dissection. Methods: Retrospective, single-center study, based on the analysis of the database at a high-complexity cardiology service. Results: We identified 25 patients with spontaneous coronary artery dissection, 56% were female, with a mean age of 48.8 ± 10 years. Only 24% had no risk factor for atherosclerosis and in 92% of the cases, the clinical presentation was of acute coronary syndrome. The left anterior descending artery was the most commonly affected vessel (48,1%) and there was only one case involving multiple vessels. The conservative approach was used in 56%, percutaneous coronary intervention in 40% and coronary artery bypass grafting in 4%. The in-hospital and late event-free survival was 92% and 84.2%, respectively. Conclusions: Spontaneous coronary artery dissection predominated in young women, with at least one risk factor for coronary artery disease. The choice of different therapeutic strategies confirms the still controversial nature of the optimal approach for spontaneous coronary artery dissection. We believe that individualized therapy is still the optimal modality.

Tratamento de lesão de tronco da artéria coronária esquerda após radioterapia do tórax

Prevention of late cardiovascular complications after radiation therapy (RT) for treatment of a malignant tumor is challenging. We report the case of a young male patient with Hodgkins lymphoma treated with RT, who developed ischemic heart disease during follow-up, although he had no cardiovascular risk factors. We conclude that patients undergoing RT who experience chest pain should be fully investigated for coronary artery disease.

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.

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.

Trends in the Use of the Transradial Approach in More Than a Decade: The InCor's Experience

ABSTRACT Background : The use of the radial approach for diagnostic cardiac catheterization and percutaneous coronary interventions varies among different interventional cardiology centers in the world. We describe the trends in the use of this approach over the past 14 years at a tertiary hospital. Methods : Consecutive coronary procedures performed from 1999 to 2013 at a single center, in patients aged ≥ 35 years were identified. Age, gender, resource provider (Public or Private Healthcare System) and the complexity of the procedure (diagnostic or therapeutic) were retrospectively analyzed. Results : 103,253 procedures were included. The Brazilian Public Healthcare Service (SUS – Sistema Unico de Saude ) was the resource provider in 77% of the cases. Mean age of patients was 62.2 ± 11.3 years and 58% were male. The radial approach was used in 6,402 (6.2%) procedures, showing a significant rise over time, which was more evident when analyzed comparatively for the six timepoints of service experience: 0.2%; 0.6%; 3.1%; 2.1%; 6.9%, and 24.4% respectively (p Conclusions : We demonstrated progressive changes in the profile of the use of access routes for diagnostic cardiac catheterization and percutaneous coronary interventions at a large center over time. These data are consistent with the global trend and are significantly robust, especially when the last sextile is analyzed. RESUMO Tendencias da Utilizacao da Via de Acesso Transradiai em Mais de Uma Decada: A Experiencia do InCor Introduco : A utilizacao da via radial para a realizacao de cateterismo cardiaco diagnostico e intervencao coronaria percutânea varia entre os diversos centros de hemodinâmica. Descrevemos as tendencias do uso dessa via de acesso ao longo dos ultimos 14 anos num servico terciario. Metodos : Foram identificados procedimentos coronarianos consecutivos realizados de 1999 a 2013, em um unico centro, em pacientes com idade ≥ 35 anos. Dados como idade, sexo, fonte provedora de recursos (Sistema de Saude Publico ou Saude Suplementar/Privado) e complexidade do procedimento (diagnostico ou terapeutico) foram retrospectivamente analisados. Resultados : Foram incluidos 103.253 procedimentos, dos quais o Sistema Unico de Saude (SUS) foi o provedor de recursos em 77% dos casos. A media de idades dos pacientes foi 62,2 ± 11,3 e 58,8% eram do sexo masculino. A via radial foi utilizada em 6.402 (6,2%) dos procedimentos, apresentando ascenSao significativa ao longo do tempo, mais evidente quando analisada comparativamente nos seis periodos de experiencia do servico: 0,2%, 0,6%, 3,1%, 2,1%, 6,9% e 24,4%, respectivamente (p Conclusoes : Demonstramos a progressiva modificacao do perfil de utilizacao das vias de acesso para a realizacao de cateterismo cardiaco diagnostico e intervencao coronaria percutânea de um centro de grande porte ao longo do tempo. Esses dados sao condizentes com a tendencia mundial e de significativa robustez, principalmente quando analisado o ultimo sextil.

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.

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.

Remoção Precoce do Introdutor Arterial Após Intervenção Coronária Percutânea por Via Femoral: Estudo de Segurança e Eficácia

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 < 0.01), mainly due to a reduced time to sheath removal (42.3 ± 21.1 minutes vs. 338.6 ± 61.5 minutes; p < 0.01), with no impact on the duration of femoral compression (16.0 ± 3.6 minutes vs. 16.4 ± 5.1 minutes; 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.