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Hidradenitis suppurativa is a chronic inflammatory skin disease that usually presents in young adults with painful abscesses in intertriginous areas. We present a case of severe hidradenitis suppurativa (Hidradenitis Suppurativa Investigator Global Assessment (HS-IGA) = 5; Hurley stage III) investigated by cardiology and respirology specialists for dyspnea. The patient's symptoms required right-sided cardiac catheterization via the right femoral vein in the inguinal area. The patient was able to undergo this invasive cardiac procedure without infectious complications using multidisciplinary management (dermatology, cardiology, respirology, internal medicine, and infectious diseases specialists), intravenous ertapenem 1 g/day for 6 weeks perioperatively, biologic therapy, and treatment of diabetes with semaglutide. The administration of ertapenem preoperatively and postoperatively of an invasive procedure can be beneficial, particularly when the upcoming intervention requires access to skin areas severely affected by hidradenitis suppurativa. Comorbidities such as obesity and diabetes should be addressed as their treatment might contribute to improve hidradenitis suppurativa.
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OBJECTIVES: To determine the role of warfarin (WF) prophylaxis in the prevention of left ventricular thrombus (LVT) formation and subsequent embolic complications following an anterior ST elevation myocardial infarction (STEMI) complicated by reduced left ventricular ejection fraction (LVEF) and wall motion abnormalities. BACKGROUND: The role of oral anticoagulation prophylaxis, in addition to dual antiplatelet therapy (DAPT), in the current era of percutaneous coronary intervention has not been well studied, despite being a class IIb recommendation in the AHA/ACC STEMI guidelines. METHODS: The Cochrane search strategy was used to search PubMed, Embase and the Cochrane library for relevant results. Four studies, two retrospective, one prospective registry, and a randomized feasibility control trial met criteria for inclusion. Data was pooled using a random effects model and reported as odds ratios (OR) with their 95% confidence intervals (CI). Primary outcomes of interest were rate of stroke, major bleeding and mortality. RESULTS: Pooled analysis included 526 patients in the No WF group and 347 patients in the WF group. No statistical difference in rate of stroke (OR: 2.72 [95% CI: 0.47-15.88; p=0.21]) or mortality (OR: 1.50 [95% CI 0.29-7.71; p=0.63]) was observed. Major bleeding was significantly higher in the WF group (OR: 2.56 [95% CI: 1.34-4.89; p=0.004]). CONCLUSIONS: The routine use of DAPT and WF for prophylaxis against LVT formation following an anterior STEMI with associated decrease in LVEF and wall motion abnormalities, appears to result in no mortality benefit or reduction in stroke rates, but may increase the frequency of major bleeding.
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Infarto de la Pared Anterior del Miocardio/terapia , Anticoagulantes/administración & dosificación , Embolia/prevención & control , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST/terapia , Trombosis/prevención & control , Warfarina/administración & dosificación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Infarto de la Pared Anterior del Miocardio/complicaciones , Infarto de la Pared Anterior del Miocardio/mortalidad , Infarto de la Pared Anterior del Miocardio/fisiopatología , Anticoagulantes/efectos adversos , Distribución de Chi-Cuadrado , Embolia/diagnóstico , Embolia/etiología , Embolia/mortalidad , Femenino , Hemorragia/inducido químicamente , Humanos , Masculino , Persona de Mediana Edad , Contracción Miocárdica , Oportunidad Relativa , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Inhibidores de Agregación Plaquetaria/administración & dosificación , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/complicaciones , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/fisiopatología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Volumen Sistólico , Trombosis/diagnóstico , Trombosis/etiología , Trombosis/mortalidad , Resultado del Tratamiento , Función Ventricular Izquierda , Warfarina/efectos adversos , Adulto JovenRESUMEN
Interatrial block (IAB) represents delay or block of conduction between the atria. IAB has been shown to predict the development or recurrence of atrial fibrillation (AF) in various clinical scenarios. Few studies have examined the correlation between coronary artery disease and the prevalence of IAB and its impact on AF. The aim of this study was to determine if specific coronary artery lesions (location and number) are associated with the presence of IAB and development of new-onset AF. Retrospective analysis of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) to our institution. Data were recorded for clinical, echocardiographic, angiographic, electrocardiographic, and outcome variables. Semiautomatic calipers and scanned electrocardiograms at 300 DPI maximized × 8 were used to measure P-wave duration, with a follow-up for a minimum of 1 year. The chi-square and independent-sample t tests were done using IBM SPSS. A total of 322 patients were included in the analysis. Men 72.3%, mean age 65.4 ± 11.9 years, mean ejection fraction of 55.2 ± 12.7% and mean left atrial diameter of 38.7 ± 6 mm. The prevalence of partial IAB was 31.9%, and advanced IAB was 6.5%. Patients with IAB were significantly older (<0.001) and had a greater prevalence of hypertension (0.014). The presence of diffuse coronary artery disease defined as >1 significant coronary artery lesion was associated with IAB (0.026). No specific coronary artery lesion location was found to be associated with IAB nor increased P-wave duration. Patients who developed AF during the follow-up had a significantly higher prevalence of IAB (p = 0.021) and also higher prevalence of diffuse coronary artery disease (p = 0.001). IAB is significantly associated with diffuse coronary artery disease in patients with NSTEMI. IAB is significantly associated with the development of new-onset AF within 12 months after NSTEMI.
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Fibrilación Atrial/epidemiología , Enfermedad de la Arteria Coronaria/epidemiología , Bloqueo Cardíaco/epidemiología , Índice de Severidad de la Enfermedad , Factores de Edad , Anciano , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Electrocardiografía , Femenino , Humanos , Hipertensión/epidemiología , Masculino , Persona de Mediana Edad , Infarto del Miocardio sin Elevación del ST/epidemiología , Ontario/epidemiología , Estudios RetrospectivosRESUMEN
OBJECTIVE: To compare radiation exposure during transradial diagnostic coronary angiography (DCA) using standard single- or multi-catheters with different shapes. BACKGROUND: Transradial DCA can be performed using single- or multi-catheters to canulate left and right coronary ostia. To date, it remains unknown whether there are differences in radiation exposure between the two strategies. METHODS: From November 2012 to June 2014, 3,410 consecutive patients who underwent transradial DCA were recruited. Groups were based on the initial diagnostic catheter used and were dichotomized between single- and multi-catheters approach. All crossovers were excluded. The multi-catheters approach (Multi) group consisted of Judkins left and right catheters, whereas the single-catheter (Single) group included Amplatz, Barbeau, or Multipurpose catheters. Fluoroscopy time (FT) as a surrogate end-point for total radiation exposure and kerma-area product (KAP; patient radiation exposure) were collected as radiation exposure parameters. RESULTS: A single-catheter strategy was used in 439 patients, while 2,971 patients had a multi-catheters approach. There was no significant difference in FT between groups (2.86 ± 1.48 min for Multi vs. 2.87 ± 1.72 min for Single, P = 0.13). The multi-catheters approach was associated with a significant 15% reduction in KAP (3,599 ± 2,214 cGy · cm2 vs. 3,073 ± 1,785 cGy · cm2 , P < 0.0001) compared to the single-catheter approach. When pooling all patients, mean FT was 2.86 ± 1.51 min. Mean KAP was 3,141 ± 1,854 cGy · cm2 . Reference levels in our institution in both groups were below international diagnostic reference levels. Overall both FT and KAP decreased by 15% and 19%, respectively, over the 2-year study period. CONCLUSIONS: Compared to a single-catheter approach, a multi-catheters approach with standard Judkins catheters for DCA significantly reduced patient radiation exposure. Whether single catheter designed for DCA by radial approach can further reduce radiation exposure compared to Judkins catheters remains to be compared in randomized studies. © 2016 Wiley Periodicals, Inc.
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Cateterismo Cardíaco/instrumentación , Catéteres Cardíacos , Vasos Coronarios/diagnóstico por imagen , Arteria Radial/diagnóstico por imagen , Dosis de Radiación , Exposición a la Radiación , Anciano , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/métodos , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Punciones , Quebec , Exposición a la Radiación/efectos adversos , Exposición a la Radiación/prevención & control , Estudios Retrospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: Current decisions to refer for angiographic coronary assessment are based on pain character, risk scores, stress testing, and occasionally calcium scoring. Carotid plaque has emerged as an effective vascular biomarker, but the cost and time of a full carotid ultrasound examination are disadvantageous. Focused vascular ultrasound (FOVUS) is a rapid limited assessment of carotid plaque that can be conducted by non-vascular-trained operators. The objective of the study was to determine the test characteristics of FOVUS for the assessment of significant coronary atherosclerosis in symptomatic patients referred for cardiac assessment. METHODS: In this prospective study, FOVUS was performed in 208 outpatients at low to intermediate risk undergoing same-day angiography. Carotid artery maximal plaque height was measured in each participant. A previously established receiver operating characteristic curve determined that a value of ≥1.5 mm was the threshold for significant angiographic coronary artery disease. FOVUS scan results, alone or combined with stress testing, were analyzed for the prediction of significant coronary artery disease. RESULTS: The negative predictive value and sensitivity of plaque height alone by FOVUS were found to be 77% and 93%, respectively. Adding the FOVUS scan result to stress testing significantly increased the negative predictive value and sensitivity of these traditional risk stratification tools. CONCLUSIONS: Rapid carotid plaque height measurement by FOVUS enhanced atherosclerosis risk prediction in patients referred for cardiac assessment. Rapid plaque quantification had good negative predictive value and high sensitivity alone or in combination with stress testing. FOVUS may serve as a potential point-of-care ultrasound tool in the integrated assessment of cardiac pain.
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Estenosis Carotídea/diagnóstico por imagen , Ecocardiografía/métodos , Interpretación de Imagen Asistida por Computador/métodos , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Proyectos Piloto , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
OBJECTIVES: To determine predictors of failure of transradial approach (TRA) in patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and develop a novel score specific for this population. METHODS: Consecutive patients with STEMI undergoing primary PCI in a tertiary care high-volume radial centre were included. TRA-PCI failure was categorised as primary (primary transfemoral approach (TFA)) or crossover (from TRA to TFA). Multivariate analysis was performed to determine independent predictors of TRA-PCI failure, and an integer risk score was developed. Clinical outcomes up to 1â year were assessed. RESULTS: From January 2006 to January 2011, 2020 patients were studied. Primary TRA-PCI failure occurred in 111 (5%) patients and crossover to TFA in 44 (2.2%) patients. Independent predictors of TRA-PCI failure were: weight ≤65â kg (OR: 3.0; 95% CI 1.9 to 4.8, p<0.0001), physician with ≤5% TFA conversion (OR: 0.45; 95% CI 0.2 to 0.9, p=0.033), and physician with ≥10% conversion to TFA (OR: 2.2; 95% CI 1.2 to 3.7, p=0.005), intra-aortic balloon pump (OR: 2.0; 95% CI 0.9 to 4.3, p=0.066), cardiogenic shock (OR: 2.8; 95% CI 1.4 to 5.6, p=0.0035), endotracheal intubation (OR: 107; 95% CI 42 to 339, p<0.0001), creatinine >133â µmol/L (OR: 3.6; 95% CI 1.9 to 6.8, p<0.0001), age ≥75 (OR: 1.7; 95% CI 1.0 to 2.9, p=0.031), prior PCI (OR: 2.6; 95% CI 1.5 to 4.5, p=0.0009), hypertension (OR: 1.8; 95% CI 1.2 to 2.9, p=0.009). An integer risk score ranging from -1 to 12 was developed, and predicted TRA-PCI failure from 0% to 100% (c-statistic of 0.868; 95% CI 0.866 to 0.869). Mortality at 1â year remained significantly higher after TRA-PCI failure (adjusted OR 2.2; 95% CI 1.2 to 3.9, p=0.011). CONCLUSIONS: In a high-volume radial centre, the incidence of TRA-PCI failure is low and can be accurately predicted using a 9-variables risk score. Since outcomes after TRA-PCI failure remained inferior, further effort to maximise the use of radial approach for primary PCI should be investigated.
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Cateterismo Cardíaco/efectos adversos , Intervención Coronaria Percutánea/efectos adversos , Arteria Radial , Infarto del Miocardio con Elevación del ST/terapia , Anciano , Cateterismo Cardíaco/métodos , Cateterismo Cardíaco/mortalidad , Técnicas de Apoyo para la Decisión , Femenino , Hospitales de Alto Volumen , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/mortalidad , Valor Predictivo de las Pruebas , Punciones , Quebec , Arteria Radial/diagnóstico por imagen , Medición de Riesgo , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/mortalidad , Centros de Atención Terciaria , Factores de Tiempo , Insuficiencia del TratamientoRESUMEN
OBJECTIVES: To evaluate the feasibility and potential benefits of performing sheathless 5Fr transradial percutaneous coronary interventions (PCI) using 4Fr diagnostic catheters as dilators. BACKGROUND: There is a direct association between artery-catheter mismatch and risk of radial artery occlusion. METHODS: We recruited 130 patients who underwent 4Fr sheathless diagnostic angiography with super torque (Cordis Corporation, USA) catheters followed by ad hoc PCI. To facilitate skin and vessel penetration, the Judkins right catheter (110 cm) was inserted inside the 5Fr guiding catheter (100 cm) as dilator. RESULTS: The mean age of patients was 63±12 years with 74% of males. Unfractionated heparin monotherapy was used in 84%, bivalirudin in 12%, and platelet glycoprotein 2b/3a inhibitors in 13%. Right radial artery was used in 99%. In three cases, no PCI was performed (FFR) and in two (1.5%) cases, a sheath was required after guiding catheter insertion due to local bleeding. In six cases (4.6%), upscale to 6Fr sheathed approach was required. No spasm occurred. Overall procedural success was achieved in 114/119 (96%) cases, including left main PCI, bifurcation PCI in 10 (8%) cases, CTO in 5 (4%) and IVUS use in 6 (5%) cases. Immediately after hemostasis completion, duplex ultrasound showed normal flow in 76%, occlusive thrombus in 13%, pseudo-aneurysmal dilatation in 11% and local hematoma surrounding puncture site in 20%. Hemoglobin dropped from 138±19 g/l to 131±16 g/l 4-6 hours after PCI. CONCLUSION: Using 4Fr diagnostic catheters as dilators, simple and complex PCI can be performed with standard 5Fr guiding catheters as sheathless techniques. However, suboptimal transition between diagnostic and guiding catheters likely creates radial artery trauma leading to frequent occlusive thrombus and hematoma surrounding the radial artery.
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Catéteres Cardíacos , Enfermedad de la Arteria Coronaria/cirugía , Intervención Coronaria Percutánea/instrumentación , Arteria Radial , Grado de Desobstrucción Vascular , Angiografía , Diseño de Equipo , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Arteria Radial/diagnóstico por imagen , Arteria Radial/fisiología , Resultado del Tratamiento , Ultrasonografía Doppler DúplexRESUMEN
BACKGROUND: Functional mitral regurgitation (MR) can occur secondary to severe aortic regurgitation (AR). However, data on the overall impact of mitral surgical intervention after aortic valve replacement (AVR) are scarce. We sought to study the left ventricular (LV) remodeling process and determine predictors of clinical outcomes of patients with pure severe AR in presence or absence of significant functional MR. METHODS: Patients were categorized into AR-MR group (≤ mild MR; n = 51, 76%) and AR + MR group (≥ moderate MR; n = 16, 24%). All patients in the AR + MR group underwent AVR and MR correction. Serial echocardiographic measurements and clinical follow-up up to 5 years were obtained in all patients. RESULTS: Significant reverse LV remodeling occurred in both groups compared with baseline. No 30-day deaths occurred. Mortality and heart failure-related hospitalization rates, at follow-up, were significantly higher in the AR + MR group (19% vs. 2%, P = 0.04 and 38% vs. 12% P = 0.03, respectively), but a similar proportion of patients from both groups was in New York Heart Association class I or II (87% vs. 92%, P = 0.62). Preoperative indexed stroke volume (SV) <50 mL/m2 was the only independent predictor of death and/or rehospitalization after surgery (odds ratio: 61.1, [95% CI, 12.6425.2]; P < 0.0001). CONCLUSION: Despite being a higher risk population, patients with moderate-to-severe functional MR secondary to severe AR experience similar postoperative mortality at the expense of a moderately higher 5-year overall mortality, rate of hospitalization for congestive heart failure, and medication use. Preoperative indexed SV < 50 mL/m2 may be helpful in predicting long-term outcomes.
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Insuficiencia de la Válvula Aórtica/mortalidad , Insuficiencia de la Válvula Aórtica/cirugía , Insuficiencia Cardíaca/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria , Insuficiencia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Comorbilidad , Femenino , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/prevención & control , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Quebec/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Resultado del Tratamiento , Ultrasonografía , Remodelación VentricularRESUMEN
OBJECTIVES: This study sought to determine the efficacy of low rate fluoroscopy at 7.5 frames/s (FPS) versus conventional 15 FPS for reduction of operator and patient radiation dose during diagnostic coronary angiography (DCA) and percutaneous coronary intervention (PCI) via the transradial approach (TRA). BACKGROUND: TRA for cardiac catheterization is potentially associated with increased radiation exposure. Low rate fluoroscopy has the potential to reduce radiation exposure. METHODS: Patients undergoing TRA diagnostic angiography ± ad-hoc PCI were randomized to fluoroscopy at 7.5 FPS versus 15 FPS prior to the procedure. Both 7.5 and 15 FPS fluoroscopy protocols were configured with a fixed dose per pulse of 40 nGy. Primary endpoints were operator radiation dose (measured with dosimeter attached to the left side of the thyroid shield in µSievert [µSv]), patient radiation dose (expressed as dose-area product in Gy·cm(2)), and fluoroscopy time. RESULTS: From October 1, 2012 to August 30, 2013, from a total of 363 patients, 184 underwent DCA and 179 underwent PCI. Overall, fluoroscopy at 7.5 FPS compared with 15 FPS was associated with a significant reduction in operator dose (30% relative reduction [RR], p < 0.0001); and in patient's dose-area product (19% RR; p = 0.022). When stratified by procedure type, 7.5 FPS compared with 15 FPS was associated with significant reduction in operator dose during both DCA (40% RR; p < 0.0001) and PCI (28% RR; p = 0.0011). Fluoroscopy at 7.5 FPS, compared with 15 FPS, was also associated with substantial reduction in patients' dose-area product during DCA (26% RR; p = 0.0018) and during PCI (19% RR; p = 0.13). Fluoroscopy time was similar in 7.5 FPS and 15 FPS groups for DCA (3.4 ± 2.0 min vs. 4.0 ± 4.7 min; p = 0.42) and PCI (11.9 ± 8.4 min vs. 13.3 ± 9.7 min; p = 0.57), respectively. CONCLUSIONS: Fluoroscopy at 7.5 FPS, compared with 15 FPS, is a simple and effective method in reducing operator and patient radiation dose during TRA DCA and PCI.
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Cateterismo Cardíaco , Angiografía Coronaria , Exposición Profesional/prevención & control , Intervención Coronaria Percutánea , Arteria Radial/diagnóstico por imagen , Dosis de Radiación , Radiografía Intervencional , Anciano , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/métodos , Cineangiografía , Angiografía Coronaria/efectos adversos , Angiografía Coronaria/métodos , Relación Dosis-Respuesta en la Radiación , Fluoroscopía , Humanos , Masculino , Persona de Mediana Edad , Exposición Profesional/efectos adversos , Traumatismos Ocupacionales/prevención & control , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Quebec , Traumatismos por Radiación/prevención & control , Monitoreo de Radiación , Protección Radiológica , Radiografía Intervencional/efectos adversos , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: Studies assessing ischemic mitral regurgitation (IMR) comprised of heterogeneous population and evaluated IMR in the subacute setting. The incidence of early IMR in the setting of primary PCI, its progression and clinical impact over time is still undetermined. We sought to determine the predictors and prognosis of early IMR after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). METHODS: Using our primary PCI database, we screened for patients who underwent ≥2 transthoracic echocardiograms early (1-3 days) and late (1 year) following primary PCI. The primary outcomes were: (1) major adverse events (MACE) including death, ischemic events, repeat hospitalization, re-vascularization and mitral repair or replacement (2) changes in quantitative echocardiographic assessments. RESULTS: From January 2006 to July 2012, we included 174 patients. Post-primary PCI IMR was absent in 95 patients (55%), mild in 60 (34%), and moderate to severe in 19 (11%). Early after primary PCI, IMR was independently predicted by an ischemic time > 540 min (OR: 2.92 [95% CI, 1.28 - 7.05]; p = 0.01), and female gender (OR: 3.06 [95% CI, 1.42 - 6.89]; p = 0.004). At a median follow-up of 366 days [34-582 days], IMR was documented in 44% of the entire cohort, with moderate to severe IMR accounting for 15%. During follow-up, MR regression (change ≥ 1 grade) was seen in 18% of patients. Moderate to severe IMR remained an independent predictor of MACE (HR: 2.58 [95% CI, 1.08 - 5.53]; p = 0.04). CONCLUSIONS: After primary PCI, IMR is a frequent finding. Regression of early IMR during long-term follow-up is uncommon. Since moderate to severe IMR post-primary PCI appears to be correlated with worse outcomes, close follow-up is required.
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Enfermedad de la Arteria Coronaria/terapia , Ecocardiografía/métodos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/mortalidad , Infarto del Miocardio/terapia , Intervención Coronaria Percutánea , Anciano , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Bases de Datos Factuales , Diagnóstico Precoz , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/cirugía , Infarto del Miocardio/mortalidad , Infarto del Miocardio/cirugía , Valor Predictivo de las Pruebas , Pronóstico , Resultado del TratamientoAsunto(s)
Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Insuficiencia de la Válvula Mitral/mortalidad , Prolapso de la Válvula Mitral/mortalidad , Estudios Observacionales como Asunto/mortalidad , Complicaciones Posoperatorias/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/tendencias , Humanos , Insuficiencia de la Válvula Mitral/cirugía , Prolapso de la Válvula Mitral/cirugía , Estudios Observacionales como Asunto/tendencias , Complicaciones Posoperatorias/diagnóstico , Factores de TiempoRESUMEN
OBJECTIVES: To study the causes of and to develop a risk score for failure of transradial approach (TRA) for percutaneous coronary intervention (PCI). BACKGROUND: TRA-PCI failure has been reported in 5% to 10% of cases. METHODS: TRA-PCI failure was categorized as primary (clinical reasons) or crossover failure. Multivariate analysis was performed to determine independent predictors of TRA-PCI failure, and an integer risk score was developed. RESULTS: From January to June 2010, TRA-PCI was attempted in 1,609 (97.3%) consecutive patients, whereas 45 (2.7%) had primary TRA-PCI failure. Crossover TRA-PCI failure occurred in 30 (1.8%) patients. Causes of primary TRA-PCI failure included chronic radial artery occlusion (11%), previous coronary artery bypass graft (27%), and cardiogenic shock (20%). Causes for crossover TRA-PCI failure included: inadequate puncture in 17 patients (57%); radial artery spasm in 5 (17%); radial loop in 4 (13%); subclavian tortuosity in 2 (7%); and inadequate guide catheter support in 2 (7%) patients. Female sex (odds ratio [OR]: 3.2; 95% confidence interval [CI]: 1.95 to 5.26, p < 0.0001), previous coronary artery bypass graft (OR: 6.1; 95% CI: 3.63 to 10.05, p < 0.0001), and cardiogenic shock (OR: 11.2; 95% CI: 2.78 to 41.2, p = 0.0011) were independent predictors of TRA-PCI failure. Risk score values from 0 to 7 predicted a TRA-PCI failure rate from 2% to 80%. CONCLUSIONS: In a high-volume radial center, 2.7% of patients undergoing PCI are excluded from initial TRA on clinical grounds, whereas crossover to femoral approach is required in only 1.8% of the cases. A new simple clinical risk score is developed to predict TRA-PCI failure.
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Intervención Coronaria Percutánea/métodos , Arteria Radial , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria/efectos adversos , Femenino , Arteria Femoral , Hospitales de Alto Volumen , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Intervención Coronaria Percutánea/efectos adversos , Quebec , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Choque Cardiogénico/complicaciones , Centros de Atención Terciaria , Insuficiencia del TratamientoRESUMEN
We sought to determine whether preoperative baseline echocardiographic analysis and the type of surgical procedure are predictive of the magnitude and timing of postoperative left ventricular (LV) remodeling in patients undergoing valve surgery for pure severe mitral regurgitation (MR) secondary to leaflet prolapse. Seventy-two consecutive patients without coronary artery disease undergoing valve repair (MVr; n = 42) or replacement (MVR; n = 30) underwent preoperative, early (1 to 2 days) and late postoperative (4.5 ± 2.5 and 18 ± 8.0 months) echocardiography. Patients were categorized according to their baseline LV ejection fraction (EF) (Group 1: EF ≥60%, Group 2: EF = 50% to 59%, Group 3: EF <50%). Preservation of the subvalvular apparatus was achieved in most patients undergoing MV replacement (87%). Over a median follow-up period of 450 days, LVEF changed as follows: Group 1: 63% ± 2% to 60% ± 3% (p <0.0001); Group 2: 55% ± 3% to 52% ± 6% (p <0.0001); Group 3: 43% ± 4% to 42% ± 5% (p <0.01). Two-thirds of the observed changes in LV diameters and volumes occurred in the first 6 months. Preoperative LVEF was the best predictor of postoperative LVEF ≥60% (odds ratio 1.50, 95% confidence interval, 1.25 to 1.97; p <0.0001). No significant difference was found in LV remodeling parameters between patients undergoing MVr and MVR. In conclusion, patients with pure severe MR due to valve prolapse LVEF remained normal after surgery only in patients with baseline LVEF ≥60%. MVR with subvalvular preservation was associated with similar postoperative remodeling as MVr.
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Insuficiencia de la Válvula Mitral/cirugía , Prolapso de la Válvula Mitral/cirugía , Remodelación Ventricular , Distribución de Chi-Cuadrado , Ecocardiografía , Femenino , Prótesis Valvulares Cardíacas , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Prolapso de la Válvula Mitral/complicaciones , Prolapso de la Válvula Mitral/diagnóstico por imagen , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Estadísticas no Paramétricas , Resultado del TratamientoRESUMEN
OBJECTIVES: PTOLEMY-2 was a prospective multicenter phase I single-arm feasibility trial to evaluate the second-generation permanent percutaneous transvenous mitral annuloplasty (PTMA) device in reducing functional mitral regurgitation (MR). BACKGROUND: Percutaneous MR reduction has been performed through a direct method of clipping and securing the mitral leaflets together or an indirect approach of reducing mitral annular dimension via the coronary sinus. The PTMA device is the only coronary sinus mitral repair device without a static fixation element. METHODS: Patients with at least moderate functional MR, New York Heart Association functional class II to IV, and left ventricular ejection fraction of 20% to 50% were enrolled at 14 centers in 5 countries. Device effects on patients were assessed by serial echocardiography, quality of life (QOL), and exercise capacity metrics. RESULTS: A total of 43 patients were recruited, and 30 patients (70%) were implanted with a permanent PTMA device with a mean follow-up of 5.8 ± 3.8 months. The primary safety end point (freedom from death, myocardial infarction, stroke, or emergency surgery) at 30 days was met in 28 patients, whereas 2 patients died of device-related complications. The primary efficacy end point (MR reduction of at least 1.0 grade or reduction of regurgitant orifice area by 0.1 cm(2) or regurgitant volume by 15 mL or regurgitant fraction by 10% compared with baseline) was obtained in 13 patients. No significant changes were noted in MR parameters, ventricular volumes, or QOL. Distance walked on 6 minutes testing at 6-month follow-up increased from 331 ± 167 m to 417 ± 132 m (P = .65). Compared with nonresponders, responders had a higher baseline regurgitant orifice area >0.2 cm(2) (P = .001) and less prior history of myocardial infarction (P = .02), coronary artery bypass surgery (P = .03), and ischemic MR (P = .04). CONCLUSIONS: Overall, PTMA had mild impact on MR reduction, left ventricular remodeling, QOL, and exercise capacity. During follow-up, the risk/benefit ratio remained suboptimal.
Asunto(s)
Cateterismo Cardíaco , Insuficiencia Cardíaca/complicaciones , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Anuloplastia de la Válvula Mitral/instrumentación , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Remodelación Ventricular , Anciano , Anciano de 80 o más Años , Ecocardiografía , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia de la Válvula Mitral/fisiopatología , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Chronic total occlusion (CTO) in a non-infarct-related artery and chronic kidney failure (CKD) are associated with worse outcomes after primary percutaneous coronary intervention (PCI). The aim of this study was to investigate the interaction of CTO and CKD in patients who underwent primary PCI for acute ST-segment elevation myocardial infarction (STEMI). Patients with STEMIs with or without CKD, defined as an estimated glomerular filtration rate <60 ml/min/1.73 m(2), were categorized into those with single-vessel disease and those with multivessel disease with or without CTO. The primary outcomes were the incidence of 30-day and 1-year mortality. Among 1,873 consecutive patients with STEMIs included between 2006 and 2011, 336 (18%) had CKD. The prevalence of CTO in a non-infarct-related artery was 13% in patients with CKD compared with 7% in those without CKD (p = 0.0003). There was a significant interaction between CKD and CTO on 30-day mortality (p = 0.018) and 1-year mortality (p = 0.013). Independent predictors of late mortality in patients with CKD were previous myocardial infarction (hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.01 to 2.79), age >75 years (HR 1.86, 95% CI 1.19 to 2.95), a left ventricular ejection fraction after primary PCI <40% (HR 2.20, 95% CI 1.36 to 3.63), left main culprit artery (HR 4.46, 95% CI 1.64 to 10.25), and shock (HR 7.44, 95% CI 4.56 to 12.31), but multivessel disease with CTO was not a predictor. In contrast, multivessel disease with CTO was an independent predictor of mortality in patients without CKD (HR 3.30, 95% CI 1.70 to 6.17). In conclusion, in patients with STEMIs who underwent primary PCI, with preexisting CKD, the prevalence of CTO in a non-infarct-related artery was twice as great. In these patients, the clinical impact of CTO seems to be overshadowed by the presence of CKD.
Asunto(s)
Oclusión Coronaria/complicaciones , Infarto del Miocardio/complicaciones , Infarto del Miocardio/cirugía , Intervención Coronaria Percutánea , Insuficiencia Renal Crónica/complicaciones , Anciano , Enfermedad Crónica , Oclusión Coronaria/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Prevalencia , Insuficiencia Renal Crónica/mortalidadRESUMEN
BACKGROUND: Transradial approach (TRA) for cardiac catheterizations and interventions improves clinical outcomes compared with transfemoral access, and its use is increasing worldwide. However, there are limited data on successive use of same artery for repeat procedures. METHODS: Between May 2010 and May 2011, all consecutive patients undergoing a repeat TRA procedure (≥2) were retrospectively identified. Success rates and reasons for failure to use ipsilateral radial artery for repeat access were identified. RESULTS: A total of 519 patients underwent 1,420 procedures. In 480 patients (92%), right radial artery was used as initial access, and left radial artery, in 39 patients. All patients underwent ≥2 procedures; 218 patients, ≥3; 87 patients, ≥4; 39 patients, ≥5; 19 patients, ≥6; 11 patients, ≥7; and 5 patients, ≥8 procedures. Two patients had, respectively, 9 and 10 procedures. The success rate for second attempt was 93%, 81% for third, and declining to 60% for ≥8. Linear regression analysis estimated a 5% failure rate for each repeat attempt (R(2) = 0.87, P = .007). The main reason for failure was related to clinical radial artery occlusion (RAO) including absent or faint pulse, poor oximetry, and failed puncture. All patients with clinical RAO were asymptomatic. By multivariate analysis, female gender (odds ratio [OR] 3.08, 95% CI 1.78-5.39, P < .0001), prior coronary artery bypass graft (OR 5.26, 95% CI 2.67-10.42, P < .0001), and repeat radial access (OR 2.14, 95% CI 1.70-2.76, P < .0001) were independent predictors of radial access failure. CONCLUSION: Successive TRA is both feasible and safe in most cases for up to 10 procedures. However, failure rate for TRA increases with successive procedures, primarily due to clinical RAO. Strategies to minimize the risks of chronic clinical RAO and allow repeat use of ipsilateral radial artery need to be further defined.
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Cateterismo Cardíaco/métodos , Arteria Radial/cirugía , Anciano , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/estadística & datos numéricos , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
BACKGROUND: Although radial approach is increasingly used in percutaneous coronary interventions (PCIs) including in acute myocardial infarction (MI), patients with cardiogenic shock have been excluded from comparisons with femoral approach. The aim of our study was to compare clinical outcomes in patients undergoing primary PCI with cardiogenic shock by radial and femoral approach. METHODS AND RESULTS: From 2,663 patients presenting with ST-elevation MI in 2 large volume radial centers, we identified 197 patients (7.4%) with signs of cardiogenic shock immediately before undergoing primary PCI. Radial approach was used in 55% of cases when at least 1 radial artery was weakly palpable, either spontaneously or after intravenous noradrenaline bolus. Patients in the radial group were older (69 ± 12 vs 64 ± 12 years, P = .010), had less diabetes (13% vs 26%, P = .028), and required less often intubation prior PCI (42% vs 66%, P = .0006) or intraaortic balloon pump (36% vs 55%, P = .0096). Mortality at 1 year was 44% in the radial group and 64% in the femoral group (P = .0044). Independent predictors of late mortality included radial approach (hazard ratio [HR] 0.65, 95% CI 0.42-0.98, P = .041), the use of glycoprotein IIb-IIIa receptor inhibitors (HR 0.63, 95% CI 0.40-0.96, P = .032), baseline creatinine ≥110 µmol/L (HR 3.34, 95% CI 2.20-5.12, P < .0001), initial glycemia >200 mg/dL (HR 2.02, 95% CI 1.34-3.11, P = .0008), and age >65 years (HR 1.80, 95% CI 1.18-2.79, P = .006). CONCLUSION: Radial approach was safe and feasible in more than half of the patients with ST-elevation MI and cardiogenic shock treated by primary PCI. After adjustment for baseline and procedural characteristics, radial approach remained associated with better survival. However, prognosis of patients undergoing primary PCI in cardiogenic shock remains poor.
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Arteria Femoral/cirugía , Infarto del Miocardio/cirugía , Intervención Coronaria Percutánea/métodos , Hemorragia Posoperatoria/epidemiología , Arteria Radial/cirugía , Choque Cardiogénico/cirugía , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/tratamiento farmacológico , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Choque Cardiogénico/tratamiento farmacológico , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
Door-to-balloon (DTB) time is an important metric in primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction to optimize clinical outcomes. The aim of this study was to compare the impact of immediate PCI on culprit lesions in patients with ST-segment elevation myocardial infarctions versus diagnostic angiography followed by PCI on DTB times and procedural data at a high-volume tertiary care radial center. All patients who underwent primary PCI <12 hours after symptom onset were studied. Procedural data and all-cause mortality were assessed in all patients. The primary outcome was DTB time. From January 2006 to June 2011, 1,900 patients were included and divided into 2 groups: 562 patients (30%) underwent primary PCI followed by contralateral diagnostic angiography, and 1,338 patients (70%) underwent diagnostic angiography before primary PCI. No significant differences were observed in baseline characteristics. Left anterior descending coronary artery-related ST-segment elevation myocardial infarctions were more often found in patients who underwent PCI first (54% vs 34%, p <0.0001). Overall, there was a reduction of 8 minutes in DTB time between patients who underwent PCI first and those who underwent angiography first (32 minutes [interquartile range 24 to 52] vs 40 minutes [interquartile range 30 to 69], respectively, p <0.0001). After adjustment, immediate PCI remained an independent predictor of DTB time ≤90 minutes (odds ratio 2.42, 95% confidence interval 1.70 to 3.52, p <0.0001). There were no differences in early and late clinical outcomes. In conclusion, a strategy of transradial direct PCI of the infarct-related artery in selected patients before complete coronary angiography was associated with a benefit of 8 minutes in DTB time. Further study is required to determine whether this strategy can favorably affect clinical outcomes.
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Angioplastia Coronaria con Balón , Angiografía Coronaria , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/terapia , Intervención Coronaria Percutánea/métodos , Angioplastia Coronaria con Balón/mortalidad , Electrocardiografía , Femenino , Fluoroscopía , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Intervención Coronaria Percutánea/mortalidad , Estudios Retrospectivos , Estadísticas no Paramétricas , Factores de Tiempo , Resultado del TratamientoRESUMEN
We present the case of a patient with dilated ischemic cardiomyopathy and severe mitral regurgitation. Due to several comorbidities, he underwent percutaneous transvenous mitral annuloplasty. Postoperatively, he complained of atypical chest pain. He was treated for pericarditis and died suddenly 10 days after the procedure. Autopsy showed distal perforation of the anterior interventricular vein with migration of the device on the diaphragm.
Asunto(s)
Cateterismo Cardíaco/efectos adversos , Seno Coronario/lesiones , Migración de Cuerpo Extraño/etiología , Anuloplastia de la Válvula Mitral/efectos adversos , Válvula Mitral/cirugía , Anciano de 80 o más Años , Cateterismo Cardíaco/instrumentación , Ecocardiografía Transesofágica , Resultado Fatal , Estudios de Seguimiento , Migración de Cuerpo Extraño/diagnóstico por imagen , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Anuloplastia de la Válvula Mitral/instrumentación , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Factores de TiempoRESUMEN
OBJECTIVES: To determine the prevalence of a concurrent CTO in men and women and to examine its impact on mortality. BACKGROUND: The impact of chronic total occlusion (CTO) in patients with ST-elevation myocardial infarction (STEMI) according to gender has not been assessed. METHODS: Patients referred with STEMI were categorized into single vessel disease (SVD), multivessel disease (MVD) without, with 1 or > 1 CTO. The primary end-point was the 1-year mortality. RESULTS: Among the 2020 STEMI patients included between 2006 and 2011, 24% were female. Women were older, had more hypertension and renal failure (P < 0.0001 for all). The prevalence of 1 or > 1 concurrent CTO was similar in both sexes, 7 and 1%, respectively. Early and late mortality was significantly higher in women compared with men (P < 0.0001). In women, the mortality was significantly worse in patients with > 1 CTO (100%) and with 1 CTO (36.4%) compared with those with MVD without CTO (18.4%) or with SVD (10.4%) (P < 0.0001). MVD with and without concurrent CTO were both independent predictors of 1-year mortality in women (HR 3.58; 95 % CI 1.69-7.18 and HR 2.76; 95 % CI 1.33-5.51) whereas only MVD with CTO was predictive in men (HR 2.19; 95% CI 1.20-3.97). CONCLUSIONS: Among unselected STEMI patients, the prevalence of CTO was equal in both sexes whereas early and late mortality remained significantly higher in women. Other factors than the presence of a concurrent CTO must be explored to explain differences in survival after STEMI between women and men.