Miguel Rati

Favorable effects of immunosuppressive therapy in children with dilated cardiomyopathy and active myocarditis

Among 68 children with severe dilated cardiomyopathy, 43 (aged 10 months to 15 years) presented with active myocarditis, diagnosed by endomyocardial biopsy. They were divided into four treatment groups: I, controls: 9 patients submitted to conventional treatment (digitalis, diuretics, and vasodilators) for 8.1±0.7 (SD) months; II, prednisone: 12 patients received conventional therapy plus prednisone; III, azathioprine: 16 patients submitted to conventional therapy plus prednisone and azathioprine; IV, cyclosporine: 13 patients treated with conventional therapy plus prednisone and cyclosporine. Immunosuppressive therapy was maintained for a mean of 8.4±1.2 months. They were submitted to noninvasive (electrocardiogram, chest radiograph, Doppler echocardiogram, and radioisotopic scintigraphy) and invasive (hemodynamic) studies. In the control group only 2 of 9 patients showed clinical and hemodynamic improvement and 1 of 4, histologic regression of the myocarditis. Among patients submitted to conventional therapy plus prednisone, 3 of 12 presented clinical and hemodynamic improvement; 2 of 5 also showed histologic regression of inflammatory process. By contrast, patients treated with azathioprine or cyclosporine associated with prednisone had significantly better results: 13 of 16 and 10 of 13 patients, respectively, had clinical and hemodynamic improvement; all 6 patients in the azathioprine group and all 4 patients in the cyclosporine group had histologic regression of the myocarditis. Two patients in the prednisone group, one in the azathioprine group, and one in the cyclosporine group died during treatment, in cardiogenic shock. In our experience immunosuppressive therapy with azathioprine or cyclosporine associated with prednisone improves the prognosis of children with active myocarditis and severe ventricular dysfunction.

A Technique of Anastomosis of the Right Internal Mammary Artery to the Circumflex Artery and Its Branches

A new technique for direct revascularization of the left circumflex artery and its ventricular branches through anastomosis with the right internal mammary artery (RIMA) was applied in 56 patients. Postoperative angiographic studies in 17 patients showed that positioned behind the aorta, the RIMA can reach the circumflex artery with no tension, allowing adequate distal filling.

Comparison between Percutaneous Balloon Valvuloplasty and Open Commissurotomy for Mitral Stenosis

Eighty patients with tight and pliable mitral stenosis were randomized in a prospective trial comparing percutaneous balloon valvuloplasty and open commissurotomy. Mitral valve area increased significantly in both groups immediately after the procedures. However, a decrease in mitral valve area occurred in both groups at 6, 12 and 24 months during the follow-up. There was no death in either group. Two patients had significant mitral regurgitation after percutaneous balloon valvuloplasty. After 24 months, all patients in the commissurotomy group and 97.4% of the patients in the balloon valvuloplasty group were in New York Heart Association functional class I or II.

High versus low-pressure balloon inflation during Multilink™ stent implantation: Acute and long-term angiographic results

We compared the impact of low and high‐pressure balloon inflation on acute and late angiographic results of Multilink™ stent. Low‐pressure balloon inflation (9.5 ± 1.9 atm) was used in 43 stents and high pressure (17.1 ± 1.5 atm) in 44. A larger immediate luminal gain was achieved in stents with high‐pressure balloon inflation (1.80 ± 0.26 vs. 1.47 ± 0.62; P = 0.002), resulting in a larger mean diameter in this group (2.71 ± 0.37 vs. 2.48 ± 0.47; P = 0.017). At follow‐up, a larger luminal diameter was achieved in the high pressure group (1.93 ± 0.72 vs. 1.45 ± 0.66; P = 0.002) and a trend to a lower rate of angiographic restenosis (15% vs. 38%, P = 0.08). Cathet. Cardiovasc. Intervent. 50:398–401, 2000.

Persistence of hypoplastic and recoarcted fifth aortic arch associated with type A aortic arch interruption: Surgical and balloon angioplasty results in an infant

SummaryA rare aortic malformation, the persistence of the fifth aortic arch (PFAA) associated with coarctation of the aorta, is reported in a 3-month-old male infant who underwent an emergency surgical intervention at 10 days of life, to relieve a severe aortic coarctation by pericardial patch technique.A successful balloon angioplasty was performed 2 months later eliminating a recoarctation. The gradient fell from 77 mmHg to 0, but a definitive surgical intervention for recoarctation was necessary 14 months after angioplasty.

Intracoronary brachytherapy in the treatment of in-stent restenosis. Initial experience in Brazil

Intracoronary brachytherapy using beta or gamma radiation is currently the most efficient type of therapy for preventing the recurrence of coronary in-stent restenosis. Its implementation depends on the interaction among interventionists, radiotherapists, and physicists to assure the safety and quality of the method. The authors report the pioneering experience in Brazil of the treatment of 2 patients with coronary in-stent restenosis, in whom beta radiation was used as part of the international multicenter randomized PREVENT study (Proliferation REduction with Vascular ENergy Trial). The procedures were performed rapidly and did not require significant modifications in the traditional techniques used for conventional angioplasty. Alteration in the radiological protection devices of the hemodynamic laboratory were also not required, showing that intracoronary brachytherapy using beta radiation can be incorporated into the interventional tools of cardiology in our environment.

Avaliação comparativa entre valvoplastia percutânea e comissurotomia a céu aberto na estenose mitral

PURPOSE: To compare immediate and late (12 months) follow up of clinical and Doppler echocardiographic results between percutaneous mitral balloon valvuloplasty and open commissurotomy in a prospective and randomized trial. METHODS: Eighty eight symptomatic patients with severe mitral stenosis and favorable anatomy were randomized in a prospective trial comparing the two procedures. All patients were submitted to clinical and Doppler echocardiographic evaluation before the procedures and immediate and twelve months thereafter. RESULTS: Mean mitral gradient (mmHg) decreased from 12.2±5.8 to 5.80±2.7 (p<0.001) in commissurotomy group (CG) and from 11.7±6.1 to 5.0±2.4 (p<0.001) in the balloon valvuloplasty group (VG). Mitral valve area (cm2) increased from 0.98±0.21 to 2.52±0.46 in CG and from 1.05±0.25 to 2.18±0.40 in VG (p<0.001). In both groups there was a slight decrease in mitral valve area at 12 month follow-up. There was no death in either group. One patient in the VG had moderate mitral regurgitation and underwent surgery. At the 12 month follow-up, all patients in CG and 97.7% of patients in VG were in New York Heart Association functional class I or II. CONCLUSION: Both procedures were safe and showed similar immediate improvement in mitral gradient and functional class. Mitral valve area had a greater increase immediately after commissurotomy, however there was a significantly greater reduction in the CG after 12 months of follow-up, when compared to balloon valvuloplasty. In both groups, mitral gradient remained reduced and most patients did not change functional class during the follow-up.

Intracoronary Haematoma as a Manifestation of Spontaneous Coronary Artery Dissection

The etiology of spontaneous coronary artery dissection has not been well clarified. Different studies associate it to pregnancy, physical stress, collagen diseases and vasculitis. In general, patients do not have the classic risk factors for coronary artery disease, which makes mandatory the suspicion of this condition, especially in young adults with acute coronary syndromes. We report the case of a 38-year-old female with non-ST segment elevation acute coronary syndrome and intracoronary hematoma with no apparent dissection, diagnosed by intravascular ultrasound, in the right coronary artery. There is no consensus so far on the best way to treat these cases.

Hematoma Intracoronário como Manifestação de Dissecção Espontânea de Artéria Coronária

The etiology of spontaneous coronary artery dissection has not been well clarified. Different studies associate it to pregnancy, physical stress, collagen diseases and vasculitis. In general, patients do not have the classic risk factors for coronary artery disease, which makes mandatory the suspicion of this condition, especially in young adults with acute coronary syndromes. We report the case of a 38-year-old female with non-ST segment elevation acute coronary syndrome and intracoronary hematoma with no apparent dissection, diagnosed by intravascular ultrasound, in the right coronary artery. There is no consensus so far on the best way to treat these cases.

A perda precoce do diâmetro luminal após angioplastia coronária e sua influência no fenômeno da reestenose

OBJETIVO: Analisar a perda do diâmetro luminal minimo (DLM) nos primeiros 15min apos angioplastia coronaria por balao (AC), quantificando sua influencia na reestenose coronaria. METODOS: Foram estudadas, prospectivamente, 86 AC em 86 pacientes. Os pacientes foram divididos em dois subgrupos de acordo com a presenca ou ausencia de reestenose; o 1o grupo compreendendo as 31 lesoes com reestenose e o 2o, as 55 lesoes sem reestenose. RESULTADOS: A analise univariada mostrou que a relacao balao/arteria foi menor no grupo com reestenose (0,92±0,01 vs 1,00±0,11, P= .003). O grupo com reestenose apresentou maior recolhimento elastico absoluto e relativo no 1°min (0,79±0,54 vs 0,68±0,59mm; P= 0,007 e 32,04±14,27 vs 22,15±16,65%; P= 0,006.) e no controle angiografico do 15°min (1,25±0,59 vs 0,90±0,65mm, P= 0,017 e 46,75±15,69 vs 29,18±17,84%, P<0,00001) do que o grupo sem reestenose. O DLM no 1°min foi menor no grupo com reestenose (2,15±0,42 vs 2,43±0,58mm; P=0,022). O grupo com reestenose apresentou uma maior perda precoce no DLM (0,46±0,34 vs 0,22±0,35mm, P= 0,004). Este decrescimo na luz do vaso determinou que o DLM do 15°min fosse ainda menor no grupo com reestenose (1,69±0,48 vs 2,20±0,61; P= 0,0001). Da analise multivariada, entretanto, identificou-se apenas a relacao balao/arteria e o DLM do 15°min como os dois fatores independentes mais relacionados a reestenose. CONCLUSAO: O recolhimento elastico e a perda do DLM ao longo dos 15min sao fatores diretamente relacionados a reestenose. Entretanto, a analise multivariada mostrou que a relacao balao/arteria e o DLM de 15min sao os dois fatores independentes mais fortemente preditores de reestenose.Purpose To evaluate the early luminal diameter loss in the first 15min after percutaneous transluminal coronary angioplasty (PTCA) and its influence on coronary restenosis. Methods In a prospective study, we evaluated 86 patients. The patients were divided in two groups based on the presence or absence of coronary restenosis. Thirty one lesions developed restenosis and 55 lesions did not. Results Univariate analysis showed that balloon/ artery ratio was lower in the group of restenosis (0.92±0,01 vs 1.00±0,11, P= .003). Absolute and relative elastic recoil at 1 min was greater in the group that developed restenosis (0.79±0.54 vs 0.68±0.59mm; P= .007 and 32.04±14.27 vs 22.15±16.65%; P= .006). Similarly, absolute and relative elastic recoil at 15 min were greater in the group with restenosis (1.25±0.59 vs 0.90±0.65mm, P= .017 e 46.75±15.69 vs 29.18±17.84%, P< .00001). Minimal luminal diameter( MLD) at 1min was lower in the group with restenosis (2.15±0.42 vs 2.43±0.58mm; P= .022). The very early loss was greater in the group with restenosis (0.46±0.34 vs 0.22±0.35mm, P= .004). MLD at 15 min was lower in the group of restenosis than in the group without restenosis (1.69±0.48 vs 2.20±0.61; P= .0001). Multivariate analisys revealed balloon/artery ratio and MLD at 15 min as independent correlates of the late outcome. Conclusion The late outcome of PTCA is influenced by elastic recoil and the early MLD loss after PTCA. However, the strongest and most important predictors of late outcome by multivariate analysis were balloon/artery ratio and MLD at 15 min.