RESUMEN

OBJECTIVE: To assess the role of oral rapamycin in the prevention of coronary restenosis in patients undergoing coronary stenting. METHODS: From December 2001 through February 2003, 76 patients with 103 de novo lesions treated percutaneously with bare stents received a loading dose of oral rapamycin 6 mg followed by a daily dose of 2 mg during 28 days in phase I (49 arteries in 34 patients) and 2 mg/day plus 180 mg/day of diltiazem in phase II (54 arteries in 42 patients). Rapamycin blood concentrations were measured in all patients. A six month follow up angiogram was performed in 82.5% (85 of 103 arteries). Follow up angiographic binary restenosis (> 50%), target vessel revascularisation, late loss, treatment compliance, and major adverse cardiovascular events were analysed and correlated with rapamycin concentrations. RESULTS: Rapamycin was well tolerated and only three patients discontinued the treatment for mild side effects. Angiographic restenosis was found in 15% of the arteries with angiographic restudy (13 of 85). The target vessel had been revascularised at follow up in 13.6% of the 103 vessels initially treated (14 of 103) and in 18.4% of the 76 patients (14 of 76). In-stent restenosis in phase I was 19% compared with 6.2% in phase II (p = 0.06). Angiographic in-stent restenosis in lesions of patients with rapamycin blood concentrations > or = 8 ng/ml was 6.2% and with rapamycin concentrations < 8 ng/ml was 22% (p = 0.041). Late loss was also significantly lower when rapamycin concentrations were > or = 8 ng/ml (0.6 mm v 1.1 mm, p = 0.031). A Pearson test showed a linear correlation between follow up late loss and rapamycin blood concentration (r = -0.826, p = 0.008). CONCLUSION: Oral rapamycin administered for one month after percutaneous coronary intervention was safe and with few minor side effects. High rapamycin blood concentrations were associated with significantly lower late loss and angiographic in-stent restenosis.

Asunto(s)

Reestenosis Coronaria/prevención & control , Inmunosupresores/administración & dosificación , Sirolimus/administración & dosificación , Stents , Administración Oral , Angiografía Coronaria , Reestenosis Coronaria/sangre , Femenino , Humanos , Inmunosupresores/efectos adversos , Inmunosupresores/sangre , Masculino , Sirolimus/efectos adversos , Sirolimus/sangre

RESUMEN

OBJECTIVES: We sought to compare the maternal and fetal outcomes of patients with severe mitral stenosis submitted to percutaneous balloon dilation versus open mitral valve commissurotomy (MVC) during pregnancy. BACKGROUND: Heart failure in patients with mitral stenosis complicating pregnancy is a common problem in developing countries. Since 1984, percutaneous dilation of the mitral valve using a balloon catheter has become a therapeutic alternative to open heart surgery. Although the efficacy of percutaneous mitral valve balloon dilation is well established, its results have never before been compared with the results of commissurotomy during pregnancy. METHODS: We compared the clinical and obstetric complications in 45 women who were treated with percutaneous mitral valve balloon dilation (group I, n = 21; from 1990 to 1995) or open MVC (group II, n = 24; from 1985 to 1990) for severe heart failure due to mitral stenosis during pregnancy. RESULTS: In our study, percutaneous balloon dilation of the mitral valve had a success rate of 95% (Gorlin formula) and 90.5% (echocardiographic "pressure half-time" method), as demonstrated by the final mitral valve area achieved. This improvement was followed by a marked decrease in the mitral valve gradient, left atrial pressure and mean pulmonary artery pressure. Patients in both groups had similar improvements in symptoms. Patients who underwent percutaneous balloon dilation had significantly fewer fetal complications, with a reduction in fetal and neonatal mortality (1 death in group I vs. 8 in group II, p = 0.025). CONCLUSIONS: Percutaneous balloon mitral valvuloplasty is safe and effective and appears to be preferable for the fetus, compared with open MVC during pregnancy.

Asunto(s)

Cateterismo , Estenosis de la Válvula Mitral/terapia , Válvula Mitral/cirugía , Complicaciones Cardiovasculares del Embarazo/terapia , Adulto , Femenino , Humanos , Embarazo , Estudios Retrospectivos , Resultado del Tratamiento

RESUMEN

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 (> or = 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, < or = 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 degrees left anterior oblique, 30 degrees 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 degrees +/- 13 degrees, a control group was 70 degrees +/- 15 degrees ). 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 degrees to 50 degrees ). 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.

Asunto(s)

Angiografía Coronaria/métodos , Enfermedad Coronaria/diagnóstico por imagen , Enfermedad Coronaria/etiología , Vasos Coronarios/fisiopatología , Arteria Pulmonar/diagnóstico por imagen , Adolescente , Adulto , Niño , Preescolar , Enfermedad Coronaria/epidemiología , Enfermedad Coronaria/fisiopatología , Femenino , Hemodinámica/fisiología , Humanos , Incidencia , Lactante , Masculino , Persona de Mediana Edad , Valores de Referencia , Medición de Riesgo , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad

RESUMEN

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).

Asunto(s)

Angioplastia Coronaria con Balón/instrumentación , Angiografía Coronaria , Enfermedad Coronaria/terapia , Stents , Enfermedad Aguda , Anciano , Enfermedad Coronaria/diagnóstico por imagen , Diseño de Equipo , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Presión , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

One hundred four patients presenting with acute myocardial infarction < 24 hours after onset were randomized to 2 groups: group I (n = 52) was treated with balloon angioplasty followed electively with Gianturco Roubin II stents, and group II was treated with conventional balloon angioplasty alone (n = 52). All lesions were suitable for stenting. Baseline clinical, demographic, and angiographic characteristics were similar in the 2 groups. Procedural success was defined as no laboratory death or emergent coronary bypass, Thrombolysis In Myocardial Infarction (TIMI) trial 2 or 3 flow after the procedure in a culprit vessel, and a residual stenosis < or = 30% for coronary angioplasty and < 20% for stent. Procedural success was 98% in group I versus 94.2% in group II, p = NS. Thirteen patients in group II (25%) had bailout stenting during the initial procedure. Adverse in-hospital events including either death, nonelective coronary bypass, recurrent ischemia, and reinfarction occurred in 3.8% in group I versus 19.2% in group II, p = 0.03. Repeat angiography performed routinely before hospital discharge revealed TIMI 3 flow in the infarct-related artery in 98% in group I versus 83% in group II, p < 0.03. At late follow-up, event-free survival was significantly better in the stent (83%) than in the coronary angioplasty (65%) group (p = 0.002). The procedural in-hospital and late outcomes of this randomized study demonstrate that balloon angioplasty followed electively by coronary stents can be used as the primary modality for patients undergoing coronary interventions for acute myocardial infarction, increasing TIMI 3 flow, reducing in-hospital adverse events, and improving late outcome compared with balloon angioplasty alone.

Asunto(s)

Angioplastia Coronaria con Balón/instrumentación , Puente de Arteria Coronaria , Mortalidad Hospitalaria , Infarto del Miocardio/terapia , Stents , Adulto , Anciano , Circulación Coronaria/fisiología , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/mortalidad , Radiografía , Recurrencia , Retratamiento , Resultado del Tratamiento

RESUMEN

To assess the time course and mechanism of early minimal luminal diameter (MLD) loss, serial angiographic observations were performed. Seventy-four patients (with 74 severe narrowings [ > or = 70%]) with acute ischemic syndromes who had an early loss in MLD of > 0.3 mm at 24 hours after percutaneous transluminal coronary angioplasty (PTCA) also underwent 1 hour post-PTCA angiography. In 12 consecutive patients with early loss 1 hour after PTCA, angioscopy was also performed to assess the mechanism of early loss. The percent diameter stenosis for the 74 lesions was 16.8 +/- 8.4% immediately after PTCA, 35.1 +/- 14.2% 1 hour after PTCA (p < 0.002 vs immediately after), and 41.4 +/- 13.2% at 24 hours (p < 0.10 vs 1 hour after). The MLD also showed similar differences: 2.6 +/- 0.3 mm immediately after to 2.0 +/- 0.4 mm 1 hour after(p < 0.002) to 1.8 +/- 0.4 mm 24 hours after PTCA (p < 0.10 vs 1 hour). In 60 patients (81%), the > 0.3 mm loss was detected 1 hour after PTCA. These 60 patients had no further decreases in MLD at 24 hours (1.9 +/- 0.4 vs 1.8 +/- 0.4 mm at 1 and 24 hours, respectively, p = NS). Adequate angioscopic images available in 11 patients showed that red thrombus was present in 1, minor or multiple dissection in 5, and neither thrombus nor dissection in 5 other patients (consistent with early wall recoil). Thus, in narrowings demonstrating early loss in MLD at 24 hours, 81% showed that the early loss occurred within 1 hour after PTCA. Early loss is not related to thrombus but usually to dissection or recoil.

Asunto(s)

Angioplastia Coronaria con Balón , Angiografía Coronaria , Adulto , Anciano , Angioscopía , Vasos Coronarios/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/patología , Isquemia Miocárdica/terapia , Factores de Tiempo

RESUMEN

Valvular function, assessed by Doppler technique, has not been extensively investigated during normal pregnancy. To prospectively study this feature, 18 normal pregnant women were followed during their pregnancies and puerperium, with serial clinical and pulsed-continuous Doppler echocardiographic examinations. In four gestational periods and the puerperium, we analysed: (a) ventricular and atrial dimensions, as well as valve annular diameters; (b) prevalence and characteristics of trivial valvular regurgitations. During pregnancy, slight but significant increases of the four cardiac chamber dimensions and valve annular diameters were observed, except for the aortic ring. The prevalence of physiologic valvular regurgitation in early pregnancy (mitral, 0%; tricuspid, 38.9%; pulmonary, 22.2%; aortic, 0%), was similar to a control group of 18 healthy non-pregnant women. As pregnancy evolved, there was a progressive and significant increase of multivalvular regurgitation, maximal at full-term (mitral, 27.8%; tricuspid, 94.4%; pulmonary, 94.4%, P < 0.05 vs. early pregnancy). Aortic regurgitation was not detected in any stage of pregnancy. In the puerperium, mitral regurgitation resolved, but tricuspid and pulmonary regurgitation were still significantly prevalent (83.3% and 66.7%, respectively, P < 0.05 vs. early pregnancy). It is concluded that physiologic multivalvular regurgitation is frequent in pregnancy, mainly involving right-sided valves in late gestational periods, occasionally persisting in the early puerperium. Chamber enlargement, valve annular dilatation, and increased prevalence of trivial valve regurgitation are time-related events during normal pregnancy, resulting from a reversible cardiac remodeling process induced by physiologic volume overload. These aspects should be considered for a correct interpretation of Doppler echocardiographic findings in pregnant women with suspected heart disease.

Asunto(s)

Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Complicaciones Cardiovasculares del Embarazo/diagnóstico por imagen , Adolescente , Adulto , Velocidad del Flujo Sanguíneo/fisiología , Volumen Cardíaco/fisiología , Ecocardiografía Doppler , Femenino , Edad Gestacional , Enfermedades de las Válvulas Cardíacas/fisiopatología , Válvulas Cardíacas/diagnóstico por imagen , Válvulas Cardíacas/fisiopatología , Hemodinámica/fisiología , Humanos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Embarazo , Complicaciones Cardiovasculares del Embarazo/fisiopatología , Estudios Prospectivos , Insuficiencia de la Válvula Pulmonar/diagnóstico por imagen , Insuficiencia de la Válvula Pulmonar/fisiopatología , Valores de Referencia , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/fisiopatología

RESUMEN

Maternal and fetal complications in a consecutive series of 60 pregnancies in 49 patients with prosthetic heart valves were prospectively evaluated. Group 1 consisted of 40 pregnancies in 31 patients who were taking oral anticoagulants. No oral anticoagulation was used in 20 pregnancies in 19 patients (group 2). In group 1 there were three instances of acute valvular thrombosis during the 35 pregnancies in patients with mechanical prostheses, with two maternal deaths. There were two episodes of cerebral embolism, one in group 1 and one in group 2. Patients with isolated aortic valve replacement had fewer maternal complications (2 of 13) than patients with isolated mitral valve replacement (15 of 42) without statistical significance. Severe bioprosthesis dysfunction occurred in 4 of 25 pregnancies (one rupture and three stenosis) with two maternal deaths, one in the puerperium and the other in the postoperative period of cardiac surgery during pregnancy. When analyzing obstetric events we observed seven spontaneous abortions and one hydatidiform mole. All spontaneous abortions occurred in group 1. The incidences of prematurity and low birth weight were significantly higher in group 1 than in group 2 (46.6% vs 10.5%, p less than 0.05, and 50% vs 10.5%, p less than 0.05, respectively). Moreover, there was a significant association between prematurity and the mother's New York Heart Association functional class (61.5% in classes III and IV vs 22.2% in classes I and II, p less than 0.05). There were five neonatal deaths, all in group 1 (p = NS vs group 2). Three infants had warfarin-related congenital defects.(ABSTRACT TRUNCATED AT 250 WORDS)

Asunto(s)

Anomalías Inducidas por Medicamentos/epidemiología , Aborto Espontáneo/epidemiología , Anticoagulantes/efectos adversos , Prótesis Valvulares Cardíacas , Trabajo de Parto Prematuro/epidemiología , Complicaciones Cardiovasculares del Embarazo/tratamiento farmacológico , Aborto Espontáneo/inducido químicamente , Adulto , Anticoagulantes/uso terapéutico , Femenino , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Trabajo de Parto Prematuro/inducido químicamente , Embarazo , Complicaciones Cardiovasculares del Embarazo/epidemiología , Estudios Prospectivos , Factores de Riesgo

Asunto(s)

Cardiomiopatías/fisiopatología , Complicaciones Cardiovasculares del Embarazo , Adolescente , Adulto , Envejecimiento/fisiología , Población Negra , Cardiomiopatías/diagnóstico , Cardiomiopatías/mortalidad , Electrocardiografía , Femenino , Humanos , Paridad , Embarazo , Tercer Trimestre del Embarazo , Pronóstico , Estudios Prospectivos

Asunto(s)

Fibrosis Endomiocárdica/cirugía , Adulto , Cateterismo Cardíaco , Ecocardiografía , Electrocardiografía , Fibrosis Endomiocárdica/diagnóstico , Femenino , Humanos , Masculino

RESUMEN

Infusion of glucose-insulin-potassium during acute myocardial infarction has favorable clinical and hemodynamic effects, presumably as a result of decreased myocardial utilization of free fatty acids. In 14 patients with coronary artery disease, hypertonic glucose (a bolus of 10 g followed by infusion of a 30% glucose solution at a constant rate of 10 mg/kg/min) was infused and arterial and coronary sinus levels of glucose, lactate and free fatty acids were measured before and after 15 and 30 minutes of infusion. Arterial glucose and lactate levels increased significantly after glucose infusion, whereas free fatty acid levels decreased significantly. Modest but significant correlations also existed between glucose arterial levels and the arterial-coronary sinus glucose difference (r = 0.53, p less than 0.001); arterial lactate and the arterial-coronary sinus lactate difference (r = 0.35, p less than 0.01); arterial free fatty acids; and the arterial-coronary sinus free fatty acid difference (r = 0.62, p less than 0.001). These results with a hypertonic glucose infusion are similar to those reported after infusion of glucose-insulin-potassium without the potential for harmful adverse effects from infusions of insulin or potassium. Therefore, infusion of hypertonic glucose may be beneficial in patients with coronary artery disease. Further work is necessary to study its effects in different subgroups of patients with coronary artery disease.

Asunto(s)

Angina de Pecho/sangre , Glucemia/metabolismo , Solución Hipertónica de Glucosa/farmacología , Glucosa/farmacología , Infarto del Miocardio/sangre , Miocardio/metabolismo , Anciano , Angina de Pecho/fisiopatología , Ácidos Grasos no Esterificados/sangre , Femenino , Humanos , Lactatos/sangre , Masculino , Persona de Mediana Edad , Infarto del Miocardio/fisiopatología , Oxígeno/sangre

Asunto(s)

Gasto Cardíaco , Contracción Miocárdica , Volumen Sistólico , Taquicardia/fisiopatología , Anciano , Ecocardiografía , Electrocardiografía , Frecuencia Cardíaca , Ventrículos Cardíacos , Humanos , Masculino

RESUMEN

Os autores relatam os resultados de estudos realizados em paciente do sexo masculino, com 69 anos de idade, portador de disfuncao ventricular grave, secundaria a cardiopatia isquemica. Durante crises espontaneas de taquicardia ventricular registraram-se o eletrocardiograma, o ecograma (modo M) da valva mitral e da raiz da aorta, simultaneamente ao registro da curva de velocidade de fluxo atraves da raiz da aorta, por metodo baseado no efeito Doppler. Registraram-se as mesmas variaveis em ritmo sinusal, apos cardioversao eletrica. Dividiram-se os batimentos ventriculares em 3 grupos, de acordo com a relacao temporal entre a ocorrencia da onda P e do complexo QRS: grupo 1 - batimentos precedidos de sistoles atriais ineficazes; grupo 2 - batimentos precedidos de sistoles atriais eficazes; grupo 3 batimentos nao precedidos de sistoles atriais. Observam-se extremas diferencas entre os valores do volume sistolico para cada grupo de batimentos, com os maiores volumes sistolicos correspondendo ao grupo II. A crise de taquicardia ventricular foi bem tolerada pelo paciente, apesar da severa disfuncao ventricular, possivelmente em decorrencia de ter havido dissociacao atrioventricular

Asunto(s)

Humanos , Masculino , Anciano , Taquicardia , Atrios Cardíacos , Ventrículos Cardíacos

Asunto(s)

Lepra