Moysés de Oliveira Lima Filho

Compressão extrínseca da artéria coronária esquerda por dilatação aneurismática do tronco pulmonar em adolescente: involução após oclusão cirúrgica de comunicação interatrial seio venoso e plastia redutora do tronco pulmonar

We report the case of an adolescent referred with initial diagnosis of pulmonary hypertension. Non-invasive investigation disclosed a sinus venous atrial septal defect with pulmonary hypertension. The hemodynamic study confirmed diagnosis, and also showed extrinsic compression of left main coronary artery by pulmonary trunk. Surgical closure of the defect in addition to pulmonary trunk plasty were undertaken. Two years after the surgery the patient is well, with clinical signs of mild pulmonary hypertension, and showing no evidence--also on echocardiogram--of left coronary artery trunk obstruction.

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.

Valvoplastia mitral pela técnica de inoue: registro do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo

INTRODUCAO: Apesar da alta prevalencia de estenose mitral no Brasil, nota-se impressionante subnotificacao dos procedimentos de tratamento percutâneo dessa afeccao na literatura nacional. Este artigo tem como objetivo relatar os resultados e a evolucao dos pacientes com estenose mitral reumatica, tratados pela tecnica de Inoue. METODOS: Foram analisados parâmetros clinicos, ecocardiograficos e relacionados ao procedimento de pacientes tratados no periodo de 1997 a 2009 e acompanhados por pelo menos um mes. RESULTADOS: Foram avaliados 102 pacientes, a maioria do sexo feminino (89,2%), com media de idade de 38,1 ± 11,1 anos, dos quais 80,4% estavam em classe funcional II-III. A area valvar media pela ecocardiografia (ECO) era de 1,01 ± 0,19 cm2 e pelo cateterismo (CAT), de 0,87 ± 0,2 cm2. O escore de Wilkins & Block estava entre 5 e 8 em cerca de 90% dos pacientes e 88,2% estavam em ritmo sinusal. O procedimento alcancou sucesso em 76,5% dos casos, com aumento da area valvar mitral media de 1,9 ± 0,5 cm2 pelo ECO (P < 0,001) e de 2 ± 0,5 cm2 pelo CAT (P < 0,001). O gradiente medio atrio esquerdo-ventriculo esquerdo reduziu-se de 16,6 mmHg para 4,2 mmHg (P < 0,001). O debito cardiaco aumentou de 3,75 l/min para 4,67 l/min (P < 0,001), sendo um preditor de sucesso para o procedimento. Em 79,4% dos pacientes obteve-se a evolucao de um ano, em que 87,6% dos pacientes estavam em classe funcional I e apenas 2 pacientes necessitaram tratamento cirurgico. Durante o seguimento de cinco anos nao foi observado nenhum caso de acidente vascular cerebral ou obito de causa cardiaca. CONCLUSOES: A valvoplastia mitral por tecnica de Inoue para o tratamento da estenose mitral reumatica e tecnica eficaz a medio prazo, e com baixa taxa de complicacoes.

Rationale and design of a prospective study to assess the effect of microcirculatory antiplatelet and vasodilation therapy in patients with chronic chagas heart disease and coronary microvascular disease

Background: Studies on Trypanosoma cruzi infections and histopathologic studies in individuals with Chagas disease suggest that ischaemia plays a role in the pathogenesis of myocardial lesions in the chronic phase of the disease. These ischaemic disorders are caused by microcirculatory deregulation. Atypical angina is a common symptom in patients in the chronic phase of Chagas disease. In a large number of patients, despite the absence of significant angiographic coronary obstructions, the occurrence of perfusion abnormalities is documented by myocardial scintigraphy during stress, which is reversible after rest. Methods: This will be a single-centre, prospective, single cohort study with a therapeutic intervention followed by a late quantitative re-evaluation of myocardial perfusion defects initially detected in patients with Chagas disease and angiographically normal coronary arte ries. Myocardial perfusion single-photon emission computed tomography (SPECT) will be performed before and 90 days after therapeutic intervention using Technetium ( 99m Tc) sestamibi as a radiotracer and physical stress or vasodilation stimulation with dipyridamole. Therapeutic intervention will consist of acetylsalicylic acid (single daily dose of 100 mg) with verapamil (80 mg b.i.d.; a total daily dose of 160 mg). The primary endpoint of the study is a > 50% reduction of the area of ischaemic myocardium calculated by the polar scintigraphic map. Conclusions: This will be the first study of a therapeutic approach to attenuate or reverse ischaemic

Base racional e plano de estudo prospectivo para avaliar o efeito de terapêutica antiplaquetária e vasodilatadora microcirculatória em pacientes com cardiopatia chagásica crônica e distúrbios microvasculares coronários

BACKGROUND: There is evidence based on experimental models studies in infections by Trypanosoma cruzi, as well as histopathologic studies in individuals with Chagas heart disease, suggesting that ischemia plays a role in the pathogenesis of myocardial lesions in the chronic phase of the disease. These ischemic disorders are caused by microcirculatory dysregulation. Atypical angina is a common symptom in patients in the chronic phase of Chagas heart disease. In a large number of patients, despite the absence of significant angiographic coronary obstructions, the occurrence of perfusion abnormalities is documented by myocardial scintigraphy during stress, which is reversible after rest. METHODS: This is a single center, prospective, single cohort study, with a therapeutic intervention, followed by a late quantitative reevaluation of the myocardial perfusion defects, initially detected in patients with Chagas heart disease and angiographically normal coronary arteries. Myocardial perfusion single-photon emission computed tomography (SPECT) will be performed before and 90 days after the therapeutic intervention, using sestamibi-Tc99m as a radiotracer and physical exercise or vasodilation stimulation with dipyridamole as stressors. Therapeutic intervention will consist of acetylsalicylic acid (single daily dose of 100 mg) associated to verapamil (80 mg bid and a total daily dose of 160 mg). The primary endpoint of the study is a reduction > 50% of the area of ischemic myocardium calculated by the polar scintigraphic map. CONCLUSIONS: This is the first study of a therapeutic approach to attenuate or revert ischemic myocardial perfusion abnormalities of microvascular origin in patients with chronic Chagas heart disease.

Persistência de distúrbios perfusionais miocárdicos após intervenção coronária percutânea com êxito: dependência de fatores microcirculatórios

INTRODUCTION: The transitory persistence of perfusion defects immediately after successful percutaneous coronary interventions to correct coronary stenosis is well known METHODS: To test the hypothesis that such perfusion abnormalities are associated with microcirculatory disorders caused by coronary microembolization we compared the intensity and extent of these perfusion defects detected using myocardial scintigraphy in groups of patients randomly assigned to coronary balloon angioplasty (BA) or to rotational atherectomy plus balloon angioplasty (RA + B). The clinical and angiography characteristics were comparable in both groups, as well as the success of the coronary angioplasty procedure. RESULTS: Before the percutaneous coronary intervention the myocardium defect index, related to the extent and severity of hypoperfusion, was comparable for the two groups, both under stress (AB = 7.72±1.91 vs. RA + B = 8.61±3.38) and at rest (AB = 3.11±1.22 vs. RA + B = 2.40±1.63). After the procedure, the perfusion defect index decreased for both groups during stress, but with statistical significance only in the AB Group = 3.96±1.40 vs. RA + B = 3.71±1.89. The difference between the two groups was greater at rest after the coronary intervention procedure: the defect index decreased with marginal significance for the AB Group to 1.46±0.66 and increased, though without statistical significance, for the RA + B Group to 3.47±1.92. CONCLUSION: These results are compatible with the notion that transitory persistence of perfusion defects after successful coronary angioplasty are dependent on microcirculatory disorders associated to microembolization during the procedure.

Use of computed tomography and automated software for quantitative analysis of the vasculature of patients with pulmonary hypertension

Objective To perform a quantitative analysis of the lung parenchyma and pulmonary vasculature of patients with pulmonary hypertension (PH) on computed tomography angiography (CTA) images, using automated software. Materials and Methods We retrospectively analyzed the CTA findings and clinical records of 45 patients with PH (17 males and 28 females), in comparison with a control group of 20 healthy individuals (7 males and 13 females); the mean age differed significantly between the two groups (53 ± 14.7 vs. 35 ± 9.6 years; p = 0.0001). Results The automated analysis showed that, in comparison with the controls, the patients with PH showed lower 10th percentile values for lung density, higher vascular volumes in the right upper lung lobe, and higher vascular volume ratios between the upper and lower lobes. In our quantitative analysis, we found no differences among the various PH subgroups. We inferred that a difference in the 10th percentile values indicates areas of hypovolemia in patients with PH and that a difference in pulmonary vascular volumes indicates redistribution of the pulmonary vasculature and an increase in pulmonary vasculature resistance. Conclusion Automated analysis of pulmonary vessels on CTA images revealed alterations and could represent an objective diagnostic tool for the evaluation of patients with PH.

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.

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.