RESUMEN
Background After a loading dose of ticagrelor, the rate of high on-treatment platelet reactivity remains elevated, which increases periprocedural myocardial infarction and injury. This indicates that faster platelet inhibition with crushed ticagrelor (CTIC) or eptifibatide is needed to reduce high on-treatment platelet reactivity. The efficacy of CTIC versus eptifibatide bolus plus clopidogrel is unknown. Methods and Results A total of 100 P2Y12 naïve, troponin-negative patients with acute coronary syndrome were randomized to CTIC (180 mg) versus eptifibatide bolus (180 µg/kg×2 intravenous boluses) plus clopidogrel (600 mg) at the time of percutaneous coronary intervention. High on-treatment platelet reactivity was markedly higher with CTIC versus eptifibatide bolus plus clopidogrel (42% versus 0%; P<0.001) at 30 minutes and persisted up to 2 hours (12% versus 0%; P=0.01, respectively). Platelet aggregation by adenosine diphosphate dropped faster from baseline with eptifibatide bolus plus clopidogrel versus CTIC (0.5 versus 2 hours, respectively) and was higher with CTIC versus eptifibatide bolus plus clopidogrel at 0.5, 2, and 4 hours after loading dose (53±12% versus 1.3±2%; 35±11% versus 0.34±1.0%; and 23±9% versus 3.5±2%, respectively; P<0.001). Eptifibatide bolus plus clopidogrel, but not CTIC, significantly inhibited platelet aggregation induced by thrombin-receptor activating peptide. Periprocedural myocardial infarction and injury was higher with CTIC versus eptifibatide bolus plus clopidogrel (48% versus 28%, respectively; P=0.035). Post-percutaneous coronary intervention hemoglobin levels were not different between groups. Conclusions Eptifibatide bolus plus clopidogrel led to faster and more potent platelet inhibition than CTIC and reduced periprocedural myocardial infarction and injury in troponin-negative acute coronary syndrome patients undergoing percutaneous coronary intervention, with no significant hemoglobin drop after percutaneous coronary intervention. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02925923.
Asunto(s)
Síndrome Coronario Agudo/tratamiento farmacológico , Clopidogrel/administración & dosificación , Eptifibatida/administración & dosificación , Inhibidores de Agregación Plaquetaria/administración & dosificación , Ticagrelor/administración & dosificación , Síndrome Coronario Agudo/sangre , Síndrome Coronario Agudo/cirugía , Anciano , Combinación de Medicamentos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea , Estudios Prospectivos , Método Simple Ciego , Troponina/sangreRESUMEN
BACKGROUND: In patients with non-ST-segment elevation acute coronary syndromes, inhibition of platelet aggregation (IPA) with a potent P2Y12 inhibitor, ticagrelor, was inferior to tirofiban infusion at 2 hours, indicating that glycoprotein IIb/IIIa inhibitors are still needed. Ticagrelor and eptifibatide bolus only may maximally inhibit platelet aggregation and decrease bleeding, but IPA with ticagrelor and eptifibatide bolus versus 2-hour infusion is unknown. METHODS AND RESULTS: A total of 70 P2Y12-naïve patients, with high-risk non-ST-segment elevation acute coronary syndromes, were randomized to ticagrelor and eptifibatide bolus (group 1) versus ticagrelor and eptifibatide bolus with 2-hour infusion (group 2). Levels of IPA with ADP, thrombin receptor-activating peptide, collagen, and high on-treatment platelet reactivity were measured by light transmission aggregometry at baseline and at 2, 6, and 24 hours after percutaneous coronary intervention in both groups. The primary end point, IPA with ADP 20 µmol/L at 2 hours, was 99.59±0.43% in group 1 versus 99.88±1.0% in group 2 (P<0.001 for noninferiority). High on-treatment platelet reactivity with ADP was zero at 2, 6, and 24 hours in both groups. IPA levels with ADP, thrombin receptor-activating peptide, and collagen were significantly higher at 2 and 6 hours than at 24 hours in both groups. Periprocedural myocardial infarction was not significantly different between the groups. Hemoglobin level was significantly less at 24 hours versus baseline in group 2 (13.35±1.8 versus 12.38±1.8 g/dL, respectively; P<0.01). CONCLUSIONS: Ticagrelor and eptifibatide bolus maximally inhibited platelet aggregation at 2 hours, which was associated with no significant hemoglobin drop after percutaneous coronary intervention. This obviates the need for eptifibatide 2-hour infusion and might decrease bleeding complications. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01919723.
Asunto(s)
Síndrome Coronario Agudo/tratamiento farmacológico , Adenosina/análogos & derivados , Péptidos/administración & dosificación , Intervención Coronaria Percutánea , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/cirugía , Adenosina/administración & dosificación , Cateterismo Cardíaco , Angiografía Coronaria , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Electrocardiografía , Eptifibatida , Femenino , Estudios de Seguimiento , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Agregación Plaquetaria/efectos de los fármacos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria , Estudios Prospectivos , Antagonistas del Receptor Purinérgico P2Y/administración & dosificación , Método Simple Ciego , Ticagrelor , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIMS: The use of contrast media with multidetector computed tomography (MDCT) may induce acute kidney injury in patients with renal failure undergoing transcatheter aortic valve replacement (TAVR). We investigated the role of large-field intravascular ultrasound (IVUS) vs. MDCT and two-dimensional transoesophageal echocardiography (2D-TEE) for annular sizing and predicting paravalvular regurgitation (PVR) during TAVR. METHODS AND RESULTS: The aortic annulus was measured by large-field IVUS and 2D-TEE, and compared with MDCT in 50 patients undergoing TAVR. The IVUS and MDCT annular areas and diameters were not significantly different (446 ± 87 mm2 and 23.8 ± 84 mm vs. 466 ± 84 mm2 and 24 ± 2.1 mm, respectively; P > 0.05). IVUS and MDCT mean annular diameters were significantly greater than TEE diameter (23.8 ± 2.4 and 24 ± 2.1 vs. 22 ± 0.65 mm, respectively; P < 0.01). PVR ≥ Mild occurred in 13 patients (26%); 5 patients required post-dilation and 2 patients a second valve. Receiver operating characteristic analyses showed that transcatheter heart valve (THV) area - IVUS or MDCT areas equally predicted of ≥ mild PVR (areas under the curve [AUC] 0.79 and 0.81, respectively; P < 0.001), and were greater than THV diameter-TEE diameter (AUC 0.79 and 0.81 vs. 0.56, respectively; P < 0.05). CONCLUSIONS: The aortic annular measurements and predicting PVR by large field IVUS were not significantly different from those of MDCT, but were greater than those of TEE. Large filed IVUS can be reliably used in lieu of MDCT for annular sizing in patients with aortic stenosis and renal failure or suboptimal MDCT images.
Asunto(s)
Estenosis de la Válvula Aórtica/diagnóstico por imagen , Ecocardiografía Transesofágica/métodos , Complicaciones Intraoperatorias/diagnóstico por imagen , Tomografía Computarizada Multidetector/métodos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Ultrasonografía Intervencional/métodos , Análisis de Varianza , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Área Bajo la Curva , Distribución de Chi-Cuadrado , Estudios de Cohortes , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Curva ROC , Medición de Riesgo , Índice de Severidad de la Enfermedad , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND AND PROPOSE: In coronary bifurcation lesions (CBL), hydrophilic guidewires used for side-branch (SB) protection can be withdrawn from underneath the stent easier than other wires. However, the safety of which has not been investigated. METHODS/MATERIALS: We performed scanning electron microscopic (SEM) examination of hydrophilic wires - the Whisper and Runthrough wires - used for SB protection during stenting and proximal optimization technique (POT) in 30 patients with CBL. The distal 15cm of the wire was examined every 1mm by SEM and 4500 segments were analyzed to investigate for wire fracture, polymer shearing (PS), and its correlations with post-stenting creatine kinase (CK)-MB release. RESULTS: SEM examination showed no evidence for wire fracture. The total area of PS and the largest defect on the wire were significantly larger with the Whisper wire versus the Runthrough wire (0.15±0.04mm2 vs. 0.026±0.01mm2 and 0.04±0.05mm2 vs. 0.01±0.01mm2; P<0.05, respectively). The total length of PS and the longest defect on the wire were significantly longer with the Whisper wire vs. the Runthrough wire (12.1±14.5mm vs. 2.7±3.0mm and 2.9±4.2mm vs. 1.0±1.2mm; P<0.05, respectively), but there were weak correlations between the extents of PS with CK-MB release. CONCLUSIONS: Hydrophilic guidewires may be safely used for SB protection during stenting and POT in CBLs. The extent of PS was significantly greater with the Whisper wire than with the Runthrough wire, but its correlation with post-stenting CK-MB release was weak.
Asunto(s)
Cateterismo Cardíaco/instrumentación , Catéteres Cardíacos , Enfermedad de la Arteria Coronaria/terapia , Intervención Coronaria Percutánea/instrumentación , Polímeros/química , Stents , Anciano , Biomarcadores/sangre , Cateterismo Cardíaco/efectos adversos , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Forma MB de la Creatina-Quinasa/sangre , Diseño de Equipo , Falla de Equipo , Femenino , Humanos , Interacciones Hidrofóbicas e Hidrofílicas , Masculino , Microscopía Electrónica de Rastreo , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Propiedades de Superficie , Resultado del TratamientoRESUMEN
BACKGROUND: Transcatheter aortic valve replacement (TAVR) was FDA approved for the Sapien valve (Edwards Lifesciences) in the United States in November 2011. We sought to examine the impact of TAVR post-FDA approval on aortic valve surgery at our institution. STUDY DESIGN: Prospective data were collected on 573 consecutive patients that underwent surgical aortic valve replacement (SAVR) or TAVR with either the Sapien or Sapien XT from January 1, 2009 through December 31, 2014. RESULTS: Patients were divided into the following groups: SAVR before TAVR (n = 215), SAVR post TAVR (n = 163), and TAVR (n = 195). The 30-day mortality was not different among the 3 groups, but the mortality for the SAVR post TAVR group was better than the SAVR before TAVR group (p = 0.03). Postoperative hospital length of stay, ventilation hours, and atrial fibrillation were all decreased in the TAVR group. The number of isolated SAVRs increased after TAVR from 60 per year in group 1 to 67 per year in group 2. The total number of all isolated aortic valve procedures (SAVR + TAVR) increased from 60 per year to 177 per year. The TAVR group was divided into the following subgroups to examine the procedural learning curve: patients 1 to 50, patients 51 to 100, and patients 101 to 195. Mortality was higher in group 1 (8%) vs group 2 (0%) and group 3 (1%). CONCLUSIONS: Since initiation of the TAVR program at our institution, the total number of aortic valve procedures has increased. Transcatheter aortic valve replacement patients had more preoperative comorbidities, but no difference in postoperative morbidity or mortality and shorter length of stay. Transcatheter aortic valve replacement mortality has continued to improve since the inception of the program.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Centros de Atención Terciaria , Reemplazo de la Válvula Aórtica Transcatéter/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/etiología , Estenosis de la Válvula Aórtica/mortalidad , Estudios de Cohortes , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Transcatheter aortic valve replacement has recently become a suitable alternative for senile aortic stenosis in patients not suitable for surgery. With growing operative experience, appropriate patient selection, advances in imaging evaluation, and technical refinements, the outcomes have improved. Despite its less invasive nature, a unique set of complications and events are encountered during the transcatheter aortic valve replacement procedure and in the postoperative period. Knowledge of these complications, their prompt detection, and quick adequate treatment are critical in reducing the mortality and morbidity.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Diagnóstico por Imagen , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Complicaciones Posoperatorias/diagnóstico , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Ecocardiografía Transesofágica , Humanos , Imagen por Resonancia Magnética , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: Transcatheter aortic valve replacement (TAVR) has recently become a suitable alternative for treatment of symptomatic aortic stenosis in patients who are at very high risk for morbidity and mortality with conventional corrective surgery. In the fall of 2011, the Food and Drug Administration approved the use of TAVR, allowing for reimbursement at institutions outside of investigative trials. We report the initiation of a TAVR-based program at an academic tertiary care facility that did not participate in the Placement of Aortic Transcatheter Valves (PARTNER) 1 or PARTNER II trials. METHODS: A total of 160 patients were evaluated for TAVR from May 2012 through June 2013. Transcatheter aortic valve replacement was found to be appropriate for 50 (31%). RESULTS: In this experience, morbidity and mortality were similar to those reported for the PARTNER trial (30-day hospital mortality was 8%). A single case of presumed cerebrovascular accident was observed. These results demonstrate that the real-world application can be done with comparable results. Implementation of lessons learned in the trials allowed a very short learning curve and excellent results after only a limited number of patients. Use of computed tomography reconstructed images for operative planning, including fluoroscopic angle, facilitated minimal use of contrast in each case. CONCLUSIONS: Transcatheter aortic valve replacement is a viable option for patients at very high risk for surgical intervention in the post-Food and Drug Administration approval era. Real-world results comparable with published outcomes from experienced centers involved in the PARTNER trial can be achieved.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Centros Médicos Académicos , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Complicaciones Posoperatorias , Resultado del Tratamiento , Estados Unidos , United States Food and Drug AdministrationRESUMEN
We discuss a patient with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) who underwent percutaneous coronary intervention and hemodynamic support with a new short-term percutaneously inserted device, the Impella CP (Abiomed). We also review the evidence for mechanical circulatory support and management strategies in patients with AMI-CS.
Asunto(s)
Corazón Auxiliar , Infarto del Miocardio , Intervención Coronaria Percutánea/métodos , Choque Cardiogénico , Anciano , Angiografía Coronaria/métodos , Ecoencefalografía/métodos , Electrocardiografía/métodos , Hemodinámica , Humanos , Masculino , Infarto del Miocardio/complicaciones , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/cirugía , Choque Cardiogénico/etiología , Choque Cardiogénico/fisiopatología , Choque Cardiogénico/terapia , Resultado del TratamientoRESUMEN
Arteries stimulated by angiotensin II (AII) to contract do not display the expected augmentation of O2 consumption seen with other cardiovascular contractile agonists. We tested the hypothesis that superoxide (O2-) or other reactive oxidant species generated by AII played a role in the paradoxical O2 consumption response in porcine carotid artery, with or without an intact endothelium. Endothelium-denuded arteries were incubated with either 1 microM diphenylene iodonium (DPI), an inhibitor of NAD(P)H oxidase, 300 u/ml superoxide dismutase (SOD), a scavenger of O2-, or 20 U/ml catalase, an enzyme which promotes conversion of O2- (scavenged in the form of H2O2) to O2. DPI treatment resulted in the expected increase in O2 consumption upon contractile activation with AII challenge (1.05+/- 0.23 micromol/g/min; n = 6, p < .01), as did treatment with SOD (0.67+/- 0.20 micromol/g/min; n = 4, p < .05). Catalase incubation resulted in a burst of O2 generation upon AII challenge (1.30 +/- 0.21 micromol/g/min; n = 10, p < .001). In endothelium-intact arteries, O2 consumption was again not augmented with AII challenge; instead, a burst of O2 production was observed (0.66 +/- 0.22 micromol/g/min; n = 9, p < .05), which was not affected further by addition of catalase. Thus, the absence of apparent augmentation of O2 consumption during contractile activation of endothelium-denuded arteries was attributed to simultaneous NAD(P)H oxidase-dependent production of O2-, and attendant H2O2 and O2 generation which either and masked the detection of O2 consumed or suppressed mitochondrial uptake of O2, or both. An intact endothelium was required to manifest the burst of O2 generation with AII stimulation under normal conditions.
Asunto(s)
Angiotensina II/farmacología , Arterias/efectos de los fármacos , Arterias/metabolismo , Endotelio/efectos de los fármacos , Endotelio/metabolismo , Consumo de Oxígeno/fisiología , Superóxidos/metabolismo , Animales , Arterias/citología , Catalasa/metabolismo , Compuestos Onio/farmacología , Superóxido Dismutasa/metabolismo , PorcinosRESUMEN
Angiotensin II (AII) is a neurohormone and contractile agonist of vascular smooth muscle that has been shown to be involved in the pathogenesis of vascular disease, which may be partially caused by its effect on oxidant stress. Energy metabolism was examined in pig carotid arteries treated with AII, because the activity of pathways of intermediary metabolism of glucose determines the status of cytosolic NADH/NAD and NADPH/NADP redox, factors which are involved in oxidant stress. Contractile responses to AII were characterized by an increase in isometric force followed by a gradual decline to near-basal levels. Despite contractile activation, no change in glycolysis, lactate production, glucose oxidation, fatty acid oxidation, O2 consumption, glycogen content or high-energy phosphates was detected when compared to resting unstimulated arteries. Paradoxically, total uptake of glucose was inhibited by AII. Treatment with diphenylene iodinium, an inhibitor of NAD(P)H oxidase and superoxide production, reversed the inhibition of glucose uptake and revealed the expected increase in glucose uptake and oxidation upon contractile activation of smooth muscle by AII. The intracellular [lactate]/[pyruvate] ratio was increased, reflecting an increase in cytosolic NADH/NAD redox, whereas NADPH/NADP redox was decreased by AII. No change in NADPH/NADP redox was observed when membrane depolarization with K+ was used as the contractile agent. It is concluded that the pattern of force generation, metabolism and energetics of AII-stimulated contraction are significantly different from that of other contractile agonists. Most notably AII inhibited glucose uptake. NAD(P)H oxidase and/or attendant superoxide may play a role in modulating glucose metabolism. AII induces opposite changes in NADH/NAD redox and NADPH/NADP redox, which may have important consequences for oxidant stress.