RESUMEN

OBJECTIVES: We conducted a review and meta-analysis of published data to compare revascularization to deferral strategy for coronary lesions with grey zone fractional flow reserve (FFR). BACKGROUND: Optimal treatment for coronary stenoses with FFR values between 0.75 and 0.80, the so-called grey zone, remains a matter of debate. METHODS: We included all studies evaluating revascularization versus deferral for lesions with grey zone FFR. The primary outcome was study-defined major adverse cardiac events (MACE). Secondary outcomes were the composite of death or MI and target vessel revascularization (TVR). A total of 2362 patients were included, of whom 1181 underwent revascularization (revascularization group) and 1181 received medical treatment only (deferral group). RESULTS: After a mean follow-up period of 2.4 years, no difference was found for the primary outcome of the study-defined MACE between the two groups [RR = 1.33 (0.73-2.44), p = 0.35]. In addition, there was no difference for the secondary outcomes of death or MI and TVR between the two groups [RR = 1.39 (0.56-3.47), p = 0.48 and RR = 1.49 (0.89-2.51), p = 0.13, respectively]. CONCLUSIONS: In this meta-analysis revascularization of coronary stenoses with grey zone FFR showed no advantage over a deferral strategy in terms of study-defined MACE. Case by case judgment should be implemented to guide treatment in this special subset of patients.

Asunto(s)

Enfermedad de la Arteria Coronaria , Estenosis Coronaria , Reserva del Flujo Fraccional Miocárdico , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/terapia , Estenosis Coronaria/complicaciones , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/terapia , Humanos , Revascularización Miocárdica/efectos adversos , Resultado del Tratamiento

RESUMEN

Popularity of microcatheters (MCs) is growing among interventional cardiologists, especially when complex coronary anatomy is involved. However, MCs are still considered by many as a niche tool and their value in common clinical practice and in the setting of acute coronary interventions has not been fully appreciated. This case report highlights the decisive role of MC use in the successful completion of a primary percutaneous coronary intervention. Characteristics and indications of the most commonly used MC are briefly discussed.

Asunto(s)

Catéteres Cardíacos , Vasos Coronarios/diagnóstico por imagen , Intervención Coronaria Percutánea/instrumentación , Infarto del Miocardio con Elevación del ST/cirugía , Angiografía Coronaria , Vasos Coronarios/cirugía , Electrocardiografía , Diseño de Equipo , Humanos , Masculino , Persona de Mediana Edad , Miniaturización , Infarto del Miocardio con Elevación del ST/diagnóstico

RESUMEN

Bivalirudin is a direct thrombin inhibitor used during percutaneous coronary intervention (PCI). Treatment with bivalirudin compared to heparin plus glycoprotein IIb/IIIa inhibitors (GPI) reduced bleeding complications, but resulted in higher rates of ischemic events, including acute stent thrombosis in ST segment elevation myocardial infarction (STEMI) patients. Thus, it may be considered a reasonable alternative antithrombotic agent in patients at high risk of bleeding undergoing PCI. However its superiority over heparin alone is questioned particularly in the era of novel antiplatelet agents and transradial PCI.

RESUMEN

OBJECTIVES: The aim of this study is to identify possible predictors for same day discharge (SDD) after percutaneous coronary interventions (PCI). BACKGROUND: Same day discharge after PCI is becoming more and more appealing and patient's selection criteria are being formulated. METHODS: A retrospective analysis was performed in all PCI procedures from January 2013 until December 2015. Patients were discharged the same day (SDD group) or had at least one overnight stay (non-SDD group). The decision of SDD or not was on treating physician discretion. We evaluated predictors of SDD decision by a logistic regression analysis. RESULTS: One thousand one hundred sixty eight procedures were performed from our department during the study period: 308 patients (26.4%) were discharged the same day (SDD group) and the rest 860 procedures (73.6%) had at least one overnight stay (non-SDD group). Multivariate analysis revealed that forearm approach (OR=5.498, CI: 2.067-14.629; p=<0.001), patient's residency proximal to the hospital (OR=4.543, CI: 2.406-8.580; p<0.001), completion of the procedure before 13,00p.m. (OR=3.437, CI: 1.789-0.6.601; p<0.001) and the success of the performed procedure (OR=1.125, CI 1.043-2.135; p=0.044) were positive predictors of SDD, while presentation with non-ST elevation myocardial infarction or unstable angina (OR=0.542, CI: 0.268-0.872; p<0.010) and amount of contrast used (OR=0.910, CI: 0.852-0.969; p<0.030) were negative predictors of SDD. CONCLUSION: In retrospect, both procedural and demographic details play a crucial role in patient selection for same day discharge post coronary percutaneous intervention.

Asunto(s)

Enfermedad de la Arteria Coronaria/terapia , Longevidad , Alta del Paciente , Intervención Coronaria Percutánea , Anciano , Distribución de Chi-Cuadrado , Toma de Decisiones Clínicas , Enfermedad de la Arteria Coronaria/diagnóstico , Técnicas de Apoyo para la Decisión , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Selección de Paciente , Intervención Coronaria Percutánea/efectos adversos , Valor Predictivo de las Pruebas , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

Coronary stent delivery can be extremely challenging in tortuous and calcified lesions especially when radial approach is chosen. Guide extension catheter is a useful tool for overcoming the inherent difficulties arising by the use of radial access in complex percutaneous interventions. We describe a technique for guide extension catheter system advancement by presenting two cases. This was performed stepwise by repeated distal balloon anchoring in the coronary artery of interest.

Asunto(s)

Angioplastia Coronaria con Balón/instrumentación , Catéteres Cardíacos , Estenosis Coronaria/terapia , Calcificación Vascular/terapia , Anciano de 80 o más Años , Angioplastia Coronaria con Balón/métodos , Angiografía Coronaria , Estenosis Coronaria/diagnóstico por imagen , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Stents , Resultado del Tratamiento , Calcificación Vascular/diagnóstico por imagen

RESUMEN

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) and transfemoral transcatheter aortic valve replacement (TAVR) are widely spreading minimally invasive procedures performed mainly through the femoral artery. Prostar XL and ProGlide vascular closure devices are used in clinical practice for the hemostasis in these procedures and they have been shown to be safe and effective. PURPOSE: The aim of our systematic review is to compare the safety of these two devices for percutaneous closure of large arteriotomies in patients undergoing TAVR and EVAR. METHODS: We searched PubMed, EMBASE, Google Scholar and the Cochrane Central Register of Controlled Trials for all randomized and observational published studies that compared Prostar XL vs. ProGlide. Relative risk was calculated by random-effects model. Review Manager 5.1 was used for statistical analysis. RESULTS: A total number of 2909 patients were included in our analysis. The rate of overall vascular complications did not differ between Prostar XL and ProGlide {RR 1.35 (0.80-2.29), p=0.27}. In contrary, the risk ratio of all bleeding complications with Prostar XL compared to ProGlide was 1.82 (1.47-2.24, p<0.001) and for major and life-threatening bleeding complications was 2.48 (1.65-3.73, p<0001, suggesting a lower bleeding risk with ProGlide). No statistical difference was found between groups for end-stage acute kidney injury (AKI), with a risk ratio of 2.14 (0.81-5.66), p=0.05. Finally, there were no differences in in-hospital and 30-days mortality rate between the two groups (1.41, 0.56-3.54, p=0.46 and 1.43, 0.55-3.73, p=0.47, respectively). CONCLUSIONS: Prostar XL is associated with greater risk of any bleeding as well as life threatening bleeding compared to the ProGlide device. However, no significant differences were observed in the rate of overall vascular complications, end stage AKI and in-hospital and 30-days mortality.

Asunto(s)

Estenosis de la Válvula Aórtica/cirugía , Procedimientos Endovasculares , Arteria Femoral/cirugía , Reemplazo de la Válvula Aórtica Transcatéter , Dispositivos de Cierre Vascular , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Resultado del Tratamiento

RESUMEN

AIMS: To evaluate the safety and efficacy of a novel technique with simultaneous compression of the ulnar artery in order to reduce the incidence of radial artery occlusion (RAO) after transradial cardiac catheterizations. METHODS AND RESULTS: Ipsilateral ulnar artery transient compression for 1 hour facilitating radial artery patent hemostasis (ULTRA) was performed in all patients treated transradially in October 2015 and was compared with patients treated with conventional patent hemostasis in September 2015. The primary endpoint of the study was to evaluate the incidence of RAO within 1 hour after removing the closure device, confirmed by the absence of palpation and the consecutive absence of flow signal with Doppler examination. A total of 119 patients were treated with the ULTRA method and 121 patients with conventional patent hemostasis. None of the patients treated with ULTRA had RAO compared with 6 patients (5%) of those treated with conventional patent hemostasis (P=.01). No hematomas EASY class ≥3, nerve injury, or ischemic pain complications were recorded in either group. CONCLUSION: The ULTRA technique may reduce the incidence of RAO in patients treated with the radial approach compared with conventional patent hemostasis.

Asunto(s)

Arteriopatías Oclusivas , Cateterismo Cardíaco , Cateterismo Periférico , Endotaponamiento/métodos , Hemostasis Quirúrgica/métodos , Hemorragia Posoperatoria , Arteria Radial/cirugía , Arteria Cubital , Anciano , Arteriopatías Oclusivas/etiología , Arteriopatías Oclusivas/prevención & control , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/métodos , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/métodos , Femenino , Grecia , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Hemorragia Posoperatoria/etiología , Hemorragia Posoperatoria/prevención & control , Estudios Retrospectivos

RESUMEN

AIMS: To assess the efficacy and safety of transradial approach regardless of the Allen's test results for coronary angiography and angioplasty. METHODS AND RESULTS: Prospective data collection of 1035 consecutive patients who underwent coronary angiography with or without ad hoc angioplasty through the radial approach was conducted. Baseline demographic and procedural data were recorded. Allen's test was evaluated in all subjects before the procedure and catheterization was performed from the radial approach irrespective of the results. Radial artery patency was evaluated at discharge clinically, or by Doppler examination if pulse was not palpable. A total of 256 patients (24.7%) were found to have a negative Allen's test and 779 patients (75.3%) had a positive test. The baseline and procedural characteristics were similar in both groups. No significant differences in complications were reported. Radial artery thrombosis was observed in 6.2% of the negative Allen's test group and 4.8% of the positive Allen's test group (P=.85), but this was clinically silent even in the negative Allen's test group. CONCLUSION: Transradial approach for coronary angiography and ad hoc angioplasty can be performed with similar efficacy and safety regardless of the Allen's test results before the procedure.

Asunto(s)

Angioplastia Coronaria con Balón , Cateterismo Periférico , Angiografía Coronaria , Enfermedad de la Arteria Coronaria , Mano/irrigación sanguínea , Isquemia , Arteria Radial , Anciano , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/métodos , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/métodos , Angiografía Coronaria/efectos adversos , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/cirugía , Técnicas de Diagnóstico Cardiovascular , Femenino , Grecia , Humanos , Isquemia/etiología , Isquemia/fisiopatología , Isquemia/prevención & control , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Arteria Radial/fisiopatología , Arteria Radial/cirugía , Reproducibilidad de los Resultados , Resultado del Tratamiento , Grado de Desobstrucción Vascular

RESUMEN

BACKGROUND: Prognostic value of NT-proBNP is well established in patients with congenital heart disease. Growing evidence suggests that plasma NGAL is elevated in heart failure but data is limited in congenital heart disease. This study investigates the combined prognostic value of plasma NGAL with plasma NT-proBNP in adult patients with congenital heart disease. METHODS: Plasma levels of NT-proBNP and NGAL were measured in 76 consecutive adult patients (33 men, mean age 31.7 ± 14 yrs) with congenital heart disease and normal values of serum creatinine. Patients were divided in three groups: A: simple cardiac lesions, B: complex cardiac lesions and C: cyanotic lesions. Patients were also monitored for long-term major cardiovascular events: death, hospitalization, NYHA class worsening, new onset of arrhythmias, surgical or percutaneous intervention. RESULTS: NGAL value was significantly different between groups: In group A median NGAL value was 64.5 ± 36.7 ng/ml, in group B median NGAL value was 88.77 ± 36.17 ng/ml and in group C median NGAL value was 121 ± 40 ng/ml (group A vs. group B: p = 0.048, group B vs. group C: p = 0.037, group A vs. group C: p = 0.003). Plasma NT-proBNP predicted all events (HR = 1.001, CI = 1.001-1.002, p = 0.0006) as well as cardiovascular death alone (HR = 1.001, CI = 1.001-1.002, p = 0.0004); plasma NGAL was the only predictor of cardiovascular death (HR = 1.017, CI = 1.001-1.033, p = 0.037). CONCLUSION: Plasma NGAL levels were lower in patients with simple congenital disease compared to patients with complex congenital heart disease and cyanotic congenital heart disease. Plasma NGAL levels correlated with NT-proBNP and could predict cardiovascular death in this small cohort of patients.

Asunto(s)

Cardiopatías Congénitas/sangre , Cardiopatías Congénitas/diagnóstico , Lipocalinas/sangre , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangre , Proteínas Proto-Oncogénicas/sangre , Proteínas de Fase Aguda , Adolescente , Adulto , Anciano , Biomarcadores/sangre , Estudios de Cohortes , Femenino , Cardiopatías Congénitas/mortalidad , Humanos , Lipocalina 2 , Masculino , Persona de Mediana Edad , Pronóstico , Tasa de Supervivencia/tendencias , Adulto Joven

RESUMEN

OBJECTIVE: This study surveyed the frequencies of single nucleotide polymorphisms (SNPs) M235T AGT and C825T GNB3, and their association with insulin resistance, other biochemical markers and qualitative variables in subjects with high normal blood pressure and/or prehypertension in the Greek population. DESIGN: 330 men and women of Greek origin were divided into 3 groups: a) hypertensive, b) prehypertensive and c) control group. These groups were genetically tested for these polymorphisms and insulin resistance with the HOMA index. RESULTS: No statistically significant differences were found among the polymorphisms of the compared groups. However, the ? allele carriers (CT/TT vs. CC) of the C825T polymorphism were associated with an increased BMI in all 3 groups (p=0.004). The HOMA index was higher in the hypertensive (p=0.006) and prehypertensive (p=0.016) versus the control group, and similar results were found for insulin (hypertensive vs. control p=0.012, prehypertensive vs. control p=0.001) without statistical significance between the first 2 groups (p=0.522). Additionally, there was a statistically significant difference between the control group and the hypertensive and prehypertensive groups regarding cholesterol (control vs. hypertensive p=0.001, control vs. prehypertension p=0.018) and triglycerides (control vs. hypertensive p=0.0001, control vs. prehypertension p=0.007). Differences were also noted between the control and the hypertensive group regarding the value of HDL (p=0.005) and LDL (p=0.013). CONCLUSION: This study failed to demonstrate a correlation between specific SNPs, blood pressure and insulin resistance in the 3 groups. However, T allele carriers of the polymorphism C825T were found to have an increased BMI. Similarly, increased insulin resistance and lipidemia were more common in the hypertensive and prehypertensive populations.

Asunto(s)

Angiotensinógeno/genética , Presión Sanguínea/genética , Proteínas de Unión al GTP Heterotriméricas/genética , Resistencia a la Insulina/genética , Prehipertensión/genética , Adulto , Anciano , Alelos , Índice de Masa Corporal , Estudios Transversales , Femenino , Frecuencia de los Genes , Predisposición Genética a la Enfermedad , Genotipo , Grecia , Humanos , Masculino , Persona de Mediana Edad , Polimorfismo de Nucleótido Simple

RESUMEN

Chronic skeletal muscle ischemia protects the ischemic heart by preserving coronary flow and inducing arterioangiogenesis. We sought to determine the effect and the underlying molecular mechanisms of preconditioning (PreC) and postconditioning (PostC), applied in a model of chronic skeletal muscle ischemia. Male rabbits were divided into 3 series. In each series, the animals were subjected either to severe hind limb (HL) ischemia, by excision of the femoral artery, or to sham operation (SHO). After 4 weeks, all the animals underwent 30 minutes of regional heart ischemia and 3 hours reperfusion. The animals of the first series received no further intervention (HL and SHO groups), those of the second series underwent PreC (HL + PreC and SHO + PreC), and of the third series PostC (HL + PostC and SHO + PostC). Infarct size (I) and risk zones (R) were determined, and their ratio was calculated in percentage. Three additional series of experiments were performed with respective interventions up to the 10th minute of reperfusion, where sample tissue was obtained for assessment of protein kinase B (Akt), endothelial nitric oxide synthase (eNOS), glycogen synthase kinase 3ß (GSK3ß), p44/42, signal transducer and activator of transcription (STAT) 3, and STAT5. All groups demonstrated significantly smaller percentage of I/R compared with the SHO group (HL: 14.4% ± 3.7%, HL + PreC: 13.1% ± 1.0%, SHO + PreC: 21.3% ± 1.6%, HL + PostC: 18.0% ± 1.1%, and SHO + PostC: 24.3% ± 1.7%, P < .05 vs 35.7% ± 4.4% in SHO). The PreC and PostC did not further reduce the infarct size in HL groups. The Akt, eNOS, GSK3ß, p44/42, and STAT3 were activated in all PreC or PostC groups regardless of the infarct size reduction. The STAT5 was activated only in the HL groups compared with the SHO groups. In conclusion, chronic skeletal muscle ischemia results in effective cardioprotection, which is not further enhanced with application of PreC or PostC. The Akt, eNOS, GSK3ß, p44/42, and STAT3 may only be considered as indicators of the intracellular changes taking place during protection. Activation of STAT5 is possibly the end effector, which is responsible for infarct size reduction provided by chronic skeletal muscle ischemia.

Asunto(s)

Líquido Intracelular/fisiología , Precondicionamiento Isquémico Miocárdico/métodos , Músculo Esquelético/irrigación sanguínea , Infarto del Miocardio/prevención & control , Transducción de Señal/fisiología , Animales , Isquemia , Masculino , Músculo Esquelético/metabolismo , Infarto del Miocardio/metabolismo , Infarto del Miocardio/patología , Conejos , Distribución Aleatoria