RESUMEN

Coronary atherosclerotic disease is highly prevalent in chronic kidney disease (CKD). Although revascularization improves outcomes, procedural risks are increased in CKD, and unbiased data comparing coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) in CKD are sparse. To compare outcomes of CABG and PCI in stage 3 to 5 CKD, we identified randomized trials comparing these procedures. Investigators were contacted to obtain individual, patient-level data. Ten of 27 trials meeting inclusion criteria provided data. These trials enrolled 3993 patients encompassing 526 patients with stage 3 to 5 CKD of whom 137 were stage 3b-5 CKD. Among individuals with stage 3 to 5 CKD, mortality through 5 years was not different after CABG compared with PCI (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.67-1.46) or stage 3b-5 CKD (HR 1.29, CI 0.68-2.46). However, CKD modified the impact on survival free of myocardial infarction: it was not different between CABG and PCI for individuals with preserved kidney function (HR 0.97, CI 0.80-1.17), but was significantly lower after CABG in stage 3-5 CKD (HR 0.49, CI 0.29-0.82) and stage 3b-5 CKD (HR 0.23, CI 0.09-0.58). Repeat revascularization was reduced after CABG compared with PCI regardless, of baseline kidney function. Results were limited by unavailability of data from several trials and paucity of enrolled patients with stage 4-5 CKD. Thus, our patient-level meta-analysis of individuals with CKD randomized to CABG versus PCI suggests that CABG significantly reduces the risk of subsequent myocardial infarction and revascularization without affecting survival in these patients.

Asunto(s)

Puente de Arteria Coronaria/estadística & datos numéricos , Enfermedad de la Arteria Coronaria/mortalidad , Infarto del Miocardio/mortalidad , Intervención Coronaria Percutánea/estadística & datos numéricos , Insuficiencia Renal Crónica/complicaciones , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Incidencia , Infarto del Miocardio/prevención & control , Modelos de Riesgos Proporcionales , Ensayos Clínicos Controlados Aleatorios como Asunto , Análisis de Supervivencia

RESUMEN

OBJECTIVES: Assessment of aortic regurgitation (AR) immediately after transcatheter aortic valve replacement (TAVR) is essential to guide further intervention in cases of relevant AR. It was the aim of this study to identify a simple and reproducible hemodynamic parameter for the assessment of AR. BACKGROUND: Relevant AR after TAVR is present in up to 21% of cases and might be associated with adverse long-term outcomes. METHODS: Three hundred sixty-two consecutive patients who were treated with TAVR for symptomatic aortic valve stenosis were analyzed. AR was assessed by aortic root angiography according to the Sellers classification. For hemodynamic evaluation, the diastolic pressure-time (DPT) index was calculated after TAVR: the area between the aortic and left ventricular pressure-time curves was measured during diastole and divided by the duration of diastole to calculate the DPT index. The DPT index was finally adjusted for the respective systolic blood pressure: DPT indexadj = (DPT index/systolic blood pressure) × 100. RESULTS: Patients with angiographically nonrelevant AR (grade <2) had higher DPT indexadj (30.7 ± 6.8) compared with those with relevant AR (grade ≥2) (26.2 ± 5.8) (p < 0.05). Patients with DPT indexadj ≤27.9 had significantly higher 1-year mortality risk in comparison with those with DPT indexadj >27.9: 41.4% versus 13.5% (hazard ratio: 3.8; 95% confidence interval: 2.4 to 5.9; p [log rank-test] < 0.001). In multivariate regression analysis, DPT indexadj ≤27.9 was the strongest independent predictor of 1-year mortality (hazard ratio: 2.5; 95% confidence interval: 1.8 to 3.7; p < 0.001). CONCLUSIONS: DPT indexadj is a simple, investigator-independent parameter that should be considered to differentiate between relevant and nonrelevant AR after TAVR.

Asunto(s)

Aorta/fisiopatología , Insuficiencia de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Presión Arterial , Determinación de la Presión Sanguínea , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Anciano , Anciano de 80 o más Años , Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/mortalidad , Insuficiencia de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Área Bajo la Curva , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Análisis Multivariante , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Curva ROC , Reproducibilidad de los Resultados , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del Tratamiento , Función Ventricular Izquierda , Presión Ventricular

RESUMEN

OBJECTIVES: The purpose of this study was to evaluate the efficacy and long-term outcomes of a novel polymer/carrier-free drug-coated stent (DCS) in patients with de novo coronary lesions. BACKGROUND: The BioFreedom (BFD) DCS incorporates a low-profile, stainless-steel platform, with a surface that has been modified to create a selectively microstructured abluminal surface that allows adhesion and further release of Biolimus A9 (Biosensors Europe SA, Morges, Switzerland). METHODS: A total of 182 patients (183 lesions) were randomized into a 1:1:1 ratio for treatment with BFD "standard dose" (BFD) or BFD "low dose" (BFD-LD) versus first-generation paclitaxel-eluting stents (PES) at 4 sites in Germany. RESULTS: Baseline and procedural characteristics were well matched. At 4-month angiographic follow-up (Cohort 1, n = 75), in-stent late lumen loss (LLL) was significantly lower with BFD and BFD-LD versus PES (0.08 and 0.12 mm vs. 0.37 mm, respectively; p < 0.0001 for BFD vs. PES, and p = 0.002 for BFD-LD vs. PES). At 12 months (Cohort 2, n = 107), in-stent LLL (primary endpoint) was 0.17 mm in BFD versus 0.35 mm in PES (p = 0.001 for noninferiority; p = 0.11 for superiority); however, the BFD-LD (0.22 mm) did not reach noninferiority (p = 0.21). At 5 years (175 of 182), there were no significant differences in major adverse cardiac events (23.8%, 26.4%, and 20.3%) and clinically indicated target lesion revascularization (10.8%, 13.4%, and 10.2%) for BFD, BFD-LD, and PES, respectively; also, there was no definite/probable stent thrombosis reported. CONCLUSIONS: The BFD, but not the BFD-LD, demonstrated noninferiority versus PES in terms of in-stent LLL, a surrogate of neointimal hyperplasia, at 12-month follow-up. At 5 years, clinical event rates were similar, without occurrence of stent thrombosis in all groups. (BioFreedom FIM Clinical Trial; NCT01172119).

Asunto(s)

Fármacos Cardiovasculares/administración & dosificación , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Vasos Coronarios/efectos de los fármacos , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea/instrumentación , Sirolimus/análogos & derivados , Anciano , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/mortalidad , Vasos Coronarios/diagnóstico por imagen , Femenino , Alemania , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Neointima , Paclitaxel/administración & dosificación , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Diseño de Prótesis , Factores de Riesgo , Método Simple Ciego , Sirolimus/administración & dosificación , Acero Inoxidable , Propiedades de Superficie , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

BACKGROUND: Drug-eluting balloons (DEB) are an alternative treatment of in-stent restenosis (ISR), but data regarding outcomes of DEB in de novo lesions are lacking. METHODS AND RESULTS: We investigated the effect of DEB on target lesion revascularization (TLR), procedural complications (coronary dissection/rupture, pericardial effusion, stent thrombosis, peri-interventional NSTEMI, stroke), major adverse cardiac and cerebrovascular events (all-cause mortality, myocardial infarction, TLR, stroke) in patients with ISR and de novo lesions in an all-comers setting. Between April 2009 and October 2013, 484 consecutive patients (mean age 68.4 years; 77.9% male) were enrolled in a prospective registry. TLR rate was 4.9% at 12 months and 8.7% at long-term follow-up of 2.3 years. Subgroup analysis confirmed a TLR rate of 8.9% after DEB treatment of ISR in bare-metal stents (21/235 lesions), 13.0% in drug-eluting stents (21/161 lesions) and 0% for de novo lesions (0/76 lesions). At long-term follow-up, all-cause mortality/cardiac mortality was 8.7% (42/484)/3.3% (16/484) and MACCE rate was 18.4% (89/484 patients), with no differences between DEB for ISR compared with de novo lesions. CONCLUSIONS: DEB for ISR resulted in a low rate of TLR. Our data support DEB in ISR as an effective treatment option. DEB in small coronary vessels in our limited cohort appeared to be safe. Larger, randomized trials in small coronary vessels should be undertaken to verify the long-term results of the current trial.

Asunto(s)

Angioplastia Coronaria con Balón , Oclusión de Injerto Vascular/mortalidad , Oclusión de Injerto Vascular/cirugía , Paclitaxel/administración & dosificación , Sistema de Registros , Anciano , Anciano de 80 o más Años , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Femenino , Estudios de Seguimiento , Alemania , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Infarto del Miocardio/cirugía , Estudios Prospectivos

RESUMEN

OBJECTIVES: The purpose of this study was to evaluate the efficacy and long-term outcomes of a novel polymer/carrier-free drug-coated stent (DCS) in patients with de novo coronary lesions.BACKGROUND: The BioFreedom (BFD) DCS incorporates a low-profile, stainless-steel platform, with a surface that has been modified to create a selectively microstructured abluminal surface that allows adhesion and further release of Biolimus A9 (Biosensors Europe SA, Morges, Switzerland). METHODS: A total of 182 patients (183 lesions) were randomized into a 1:1:1 ratio for treatment with BFD "standard dose" (BFD) or BFD "low dose" (BFD-LD) versus first-generation paclitaxel-eluting stents (PES) at 4 sites in Germany.RESULTS: Baseline and procedural characteristics were well matched. At 4-month angiographic follow-up (Cohort 1, n = 75), in-stent late lumen loss (LLL) was significantly lower with BFD and BFD-LD versus PES (0.08 and 0.12 mm vs. 0.37 mm, respectively; p < 0.0001 for BFD vs. PES, and p = 0.002 for BFD-LD vs. PES). At 12 months (Cohort 2, n = 107), in-stent LLL (primary endpoint) was 0.17 mm in BFD versus 0.35 mm in PES (p = 0.001 for noninferiority; p = 0.11 for superiority)...

Asunto(s)

Enfermedad Coronaria , Intervención Coronaria Percutánea , Stents , Stents Liberadores de Fármacos

RESUMEN

OBJECTIVES: Constrictive pericarditis (CP) is an uncommon disease with multiple causes and unclear clinical outcomes. To date, few publications have clearly defined risk factors of poor outcomes after surgery for CP. We performed a retrospective analysis of almost 100 patients undergoing surgical treatment for CP at a single institution in order to identify risk factors for perioperative and long-term mortality. METHODS: A total of 97 consecutive patients (67.0% male) undergoing surgery for CP at our institution from 1995 to 2012 were included in the study. CP was diagnosed either preoperatively by cardiac catheterization and appropriate imaging or during surgery. Preoperative and intraoperative risk factors for 30-day and late mortality were analysed using stepwise multivariate logistic and Cox regression analyses. Median follow-up was 1.23 ± 3.96 years (mean 3.08 ± 3.96 years). RESULTS: The mean patient age was 60.0 ± 12.5 years and the underlying aetiology was idiopathic (50.5%), prior cardiac surgery (15.5%), prior mediastinal radiation (9.3%), and miscellaneous (24.7%). All patients underwent either radical (55.2%) or partial (44.8%) pericardiectomy. Concomitant procedures were performed in 54 (55.7%) patients. The total procedure time was 197.0 ± 105.0 min. Cardiopulmonary bypass (CPB) was used in 62 patients with a corresponding CPB time of 124.8 ± 68.4 min. In those patients who underwent CPB, cardioplegic arrest was performed in 53.2% of patients with a mean cross-clamp time of 74.9 ± 41.9 min. Overall 30-day, 1-year and 5-year survival rates were 81.4, 66.5 and 51.6%, respectively, without significant differences according to the underlying aetiology. Multivariate analysis revealed patients with reduced left ventricular ejection fraction (LVEF) [P = 0.01, odds ratio (OR) 3.6] and preoperative right ventricular dilatation (P = 0.04, OR 3.5) to be at significant risk of early mortality. Long-term mortality was independently predicted by the presence of coronary artery disease (CAD) [P < 0.001, hazard ratio (HR) 6.44], chronic obstructive pulmonary disease (P = 0.001, HR 4.21) and preoperative renal insufficiency (P = 0.012, HR 1.8). Concomitant tricuspid valve repair (TVR) appeared to provide protective effect on the long-term survival (P = 0.07). CONCLUSIONS: Surgery for CP is associated with a significant risk based on the poor preoperative patient status. Whenever justified, partial over radical pericardiectomy should be preferred and TVR should be indicated liberally. Reduced LVEF and right ventricular dilatation were independent predictors for early mortality, whereas CAD, chronic obstructive pulmonary disease and renal insufficiency were risk factors for late mortality. Thus, an optimal timing for surgery on CP remains crucial to avoid secondary morbidity with an even worse natural prognosis.

Asunto(s)

Pericardiectomía/mortalidad , Pericarditis Constrictiva/cirugía , Puente Cardiopulmonar/mortalidad , Femenino , Humanos , Periodo Intraoperatorio , Modelos Logísticos , Masculino , Persona de Mediana Edad , Pericarditis Constrictiva/complicaciones , Pericarditis Constrictiva/mortalidad , Periodo Preoperatorio , Modelos de Riesgos Proporcionales , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Insuficiencia Renal/complicaciones , Insuficiencia Renal/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Disfunción Ventricular Izquierda/mortalidad

RESUMEN

BACKGROUND: MicroRNAs (miRNAs) are small non-coding molecules regulating gene expression. Recently circulating miRNAs could be detected in the plasma, serving as novel biomarkers. Different forms of exercise mobilize progenitor cells from the bone marrow, helping in tissue repair. Data of different forms of exercise on endothelial cell damage are lacking. The aim of the study was to evaluate the impact of different exercise modalities on the plasma concentration of miRNA-126, as a marker for endothelial damage. METHODS: The plasma concentration of miRNA-126 and miRNA-133 (marker for muscle damage) was assessed by qRT-PCR analysis in plasma samples from healthy individuals performing one of the following exercise tests: (1) maximal symptom-limited exercise test, (2) bicycling for 4 h, (3) running a marathon, and (4) resistance exercise. RESULTS: A maximal symptom-limited exercise test resulted in a significant increase of circulating miRNA-126 at maximum power (2.1-fold versus begin), whereas the concentration of miRNA-133 remained unchanged. In line, four hours of cycling increased plasma concentration of miRNA-126 with a maximum 30 minutes after begin (4.6-fold versus begin) without an impact on miRNA-133 concentration. Finishing a marathon race resulted in an increase of miRNA-126 and miRNA-133. In contrast, eccentric resistance training led to an isolated increase of miRNA-133 level (2.1-fold versus begin) with unchanged miRNA-126. CONCLUSION: Different endurance exercise protocols lead to damage of the endothelial cell layer as evident by an increase in miRNA-126. On the other hand, resistance exercise has no impact on the endothelial cells, but leads to a destruction of muscular cells.

Asunto(s)

Células Endoteliales/metabolismo , MicroARNs/sangre , Resistencia Física/genética , Adulto , Ciclismo , Células Endoteliales/patología , Femenino , Marcadores Genéticos , Humanos , Masculino , Entrenamiento de Fuerza , Carrera , Factores de Tiempo , Regulación hacia Arriba

Asunto(s)

Divertículo/complicaciones , Cardiopatías/complicaciones , Defectos del Tabique Interventricular/complicaciones , Procedimientos Quirúrgicos Cardíacos , Divertículo/diagnóstico , Divertículo/fisiopatología , Divertículo/cirugía , Ecocardiografía Doppler en Color , Ecocardiografía Transesofágica , Cardiopatías/diagnóstico , Cardiopatías/fisiopatología , Cardiopatías/cirugía , Soplos Cardíacos/etiología , Defectos del Tabique Interventricular/diagnóstico , Defectos del Tabique Interventricular/fisiopatología , Defectos del Tabique Interventricular/cirugía , Hemodinámica , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Rotura Septal Ventricular/etiología

RESUMEN

BACKGROUND: Exercise training (ET) in addition to optimal medical therapy (OMT) in patients with stable coronary artery disease (CAD) has been demonstrated to be superior to percutaneous coronary interventions (PCI) with respect to the composite endpoint of death, myocardial infarction, stroke, revascularization and hospitalization due to worsening of angina. One mechanism leading to this superiority discussed in the literature is the increase in coronary collateral blood flow due to ET. Until now, data demonstrating the positive effect of ET on the collateral blood flow and the functional capacity of the coronary collateral circulation are still lacking. METHODS/DESIGN: The EXCITE trial is a three-armed randomized, prospective, single-center, open-label, controlled study enrolling 60 patients with stable CAD and at least one significant coronary stenosis (fractional flow reserve ≤0.75). The study is designed to compare the influence and efficacy of two different 4-week ET programs [high-intensity interval trainings (IT) versus moderate-intensity exercise training (MT) in addition to OMT] versus OMT only on collateral blood flow (CBF). The primary efficacy endpoint is the change of the CBF of the target vessel after 4 weeks as assessed by coronary catheterization with a pressure wire during interruption of the antegrade flow of the target vessel by balloon occlusion. Secondary endpoints include the change in plaque composition as assessed by intravascular ultrasound (IVUS) after 4 weeks, myocardial perfusion as analyzed in MRI after 4 weeks and 12 months, peak oxygen uptake (V02 peak), change in endothelial function and biomarkers after 4 weeks, 3, 6 and 12 months. The safety endpoint addresses major adverse cardiovascular events (death from cardiovascular cause, myocardial infarction, stroke, TIA, target vessel revascularization or hospitalization) after 12 months. DISCUSSION: The trial investigates whether ET for 4 weeks increases the CBF in patients with significant CAD compared to a sedentary control group. It also examines the impact of two intensities of ET on the CBF as well as the histological plaque composition. The trial started recruitment in June 2009 and will complete recruitment until June 2012. First results are expected in December 2012 (4-week follow-up), final results (12-month long-term secondary endpoint) in December 2013. TRIAL REGISTRATION: Clinical trial registration information-URL: http://www.clinicaltrials.gov.Unique identifier: NCT01209637.

Asunto(s)

Circulación Colateral , Circulación Coronaria , Estenosis Coronaria/terapia , Vasos Coronarios/patología , Vasos Coronarios/fisiopatología , Terapia por Ejercicio/métodos , Placa Aterosclerótica , Proyectos de Investigación , Biomarcadores/sangre , Cateterismo Cardíaco , Angiografía Coronaria , Estenosis Coronaria/diagnóstico , Estenosis Coronaria/mortalidad , Estenosis Coronaria/patología , Estenosis Coronaria/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Endotelio Vascular/fisiopatología , Terapia por Ejercicio/efectos adversos , Terapia por Ejercicio/mortalidad , Reserva del Flujo Fraccional Miocárdico , Alemania , Humanos , Imagen por Resonancia Magnética , Imagen de Perfusión Miocárdica/métodos , Consumo de Oxígeno , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Intervencional

Asunto(s)

Angioplastia Coronaria con Balón , Estenosis de la Válvula Aórtica/terapia , Cateterismo Cardíaco , Enfermedad de la Arteria Coronaria/complicaciones , Estenosis Coronaria/terapia , Implantación de Prótesis de Válvulas Cardíacas/métodos , Femenino , Humanos , Masculino

RESUMEN

BACKGROUND: It is assumed that patients with non-ST-elevation myocardial infarctions (NSTEMI) showing an infero- or posterolateral occluded culprit artery (OCA) during diagnostic angiography frequently elude standard 12-lead electrocardiogram diagnosis. In addition, coronary collaterals may have beneficial effects in patients with OCA. METHODS: We examined 448 consecutive NSTEMI patients within 72 h of symptom onset. All patients underwent early invasive angiography plus optimal medical therapy. We compared clinical characteristics and 30-days/6-month major adverse cardiovascular events (MACE) between patients with OCA and non-OCA. The secondary objective was to investigate the effect of angiographically visible coronary collaterals on 6-month MACE in patients with OCA. RESULTS: The angiograms revealed OCA in 130 (29%) of 448 patients. Patients with OCA showed more often infero- or posterolateral lesions (75 vs. 53%, p < 0.001) and more collaterals (57 vs. 8%, p < 0.001) compared with those with non-OCA. Patients with OCA had larger infarcts (peak CK-MB 2.1 ± 2.3 vs. 1.2 ± 1.1 µmol/L/s, p < 0.001), lower left ventricular ejection fraction (42 ± 21 vs. 48 ± 20%, p = 0.01), were more often revascularized (89 vs. 78%, p = 0.005), and had higher risk-adjusted 6-month MACE largely driven by its association with non-fatal reinfarctions (HR 2.16, 95% CI 1.04-4.50, p = 0.04). Patients with OCA and angiographically absent collaterals had significantly higher risk-adjusted 6-month MACE than those with OCA and angiographically visible collaterals (HR 1.96, 95% CI 1.02-3.76, p = 0.04). CONCLUSIONS: Approximately one-fourth of patients with NSTEMI revealed OCA that was more frequently found in coronary arteries supplying the infero- or posterolateral myocardium. Patients with OCA had larger infarcts and more non-fatal reinfarctions than patients with non-OCA. Well-developed collaterals may limit the myocardial damage in these patients.

Asunto(s)

Angioplastia Coronaria con Balón , Fármacos Cardiovasculares/uso terapéutico , Circulación Colateral , Puente de Arteria Coronaria , Circulación Coronaria , Oclusión Coronaria/terapia , Infarto del Miocardio/terapia , Anciano , Anciano de 80 o más Años , Angina Inestable/etiología , Angina Inestable/mortalidad , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/instrumentación , Angioplastia Coronaria con Balón/mortalidad , Biomarcadores/sangre , Fármacos Cardiovasculares/efectos adversos , Distribución de Chi-Cuadrado , Angiografía Coronaria , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/mortalidad , Oclusión Coronaria/fisiopatología , Forma MB de la Creatina-Quinasa/sangre , Femenino , Alemania , Humanos , Incidencia , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/mortalidad , Infarto del Miocardio/fisiopatología , Miocardio/enzimología , Miocardio/patología , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Recurrencia , Medición de Riesgo , Factores de Riesgo , Stents , Volumen Sistólico , Factores de Tiempo , Resultado del Tratamiento , Función Ventricular Izquierda

RESUMEN

BACKGROUND: Guidelines recommend door-to-balloon times (DBTs) below 60 min for patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). The purpose of this study was to determine if an optimised STEMI-protocol reduces DBT and increases the number of patients to receive PCI within 60 min of hospital presentation. We hypothesised that DBT of <30 min can be accomplished for the majority of patients. METHODS AND RESULTS: Between 2001 and 2008 data from 1,146 consecutive patients with acute STEMI admitted for primary PCI within 12 h after symptom-onset were analysed. Times to angioplasty from symptom-onset (pain-to-balloon time, PBT) and from hospital arrival (DBT) to PCI and clinical outcomes were analysed. In the end of 2003 numerous strategies were implemented to reduce revascularisation times. These strategies resulted in a stable reduction of median DBT to 29 min [interquartile range (IQR) 22-39]. Overall, 94% of patients had median DBT < 60 min and 56% <30 min. Consequently, PBT was significantly reduced from median 218 min (IQR 168-286) to 167 min (IQR 119-245) for non-transferred patients. Major cardiac adverse events (composite of congestive heart failure, reinfarction and cardiac death) were significantly associated with DBT > 30 min and age, systolic blood pressure, anterior infarction, PBT > 4 h, cardiogenic shock as well as multivessel disease. CONCLUSIONS: A dedicated STEMI-protocol including several hospital strategies is feasible during daily clinical practice to decrease revascularisation times, results in a greater proportion of patients achieving guideline recommendations, and is associated with an improved clinical outcome.

Asunto(s)

Angioplastia Coronaria con Balón , Servicio de Cardiología en Hospital/organización & administración , Infarto del Miocardio/terapia , Anciano , Protocolos Clínicos , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reperfusión Miocárdica , Revascularización Miocárdica , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

Purpose: Patients with atrial fibrillation are at an increased risk of having a cardio embolic stroke. Stroke is a leading cause of death and disability worldwide. Current guidelines recommend an antithrombotic regimen to prevent thromboembolism in medium and high risk patients with AF. However, a substantial number of patients are not eligible for this therapy. The exclusion of the left atrial appendage (LAA) from circulation seems to be an alternative strategy for stroke prevention in AF. This review focuses on the different strategies for LAA exclusion with special focus on the WATCHMAN Device. Two devices are currently in use for percutaneous transcatheter occlusion of the LAA: the WATCHMAN® - device and the AMPLATZER® -septal occluder. For both devices safety and feasibility data are available. Additionally about 200 patients received a PLAATO® -device- which is currently no more available due to economic reasons. Patients treated with the PLAATO device were at high risk for thromboembolic stroke and had contraindications for oral anticoagulation therapy. The Watchman® -device was implanted in 800 patients that were eligible for long-term anticoagulation therapy with a moderate risk for thromboembolic stroke due to non-valvular AF. Summary: For both devices, a reduction in the risk of stroke was documented and device implantation was shown to be safe and feasible. Provided the ongoing trials show noninferiority to oral anticoagulation, another therapeutic option will become available to prevent ischemic strokes.

Asunto(s)

Enfermedades Cardiovasculares/prevención & control , Ejercicio Físico/fisiología , Aptitud Física/fisiología , Aterosclerosis/prevención & control , Vasos Sanguíneos/fisiología , Enfermedades Cardiovasculares/epidemiología , Endotelio Vascular/fisiología , Humanos , Óxido Nítrico/metabolismo , Especies Reactivas de Oxígeno/metabolismo , Conducta de Reducción del Riesgo

RESUMEN

PURPOSE OF REVIEW: Stroke is a leading cause of death and disability worldwide. Many strokes occur in patients with atrial fibrillation. Current guidelines recommend an antithrombotic regimen with warfarin to prevent thromboembolism in atrial fibrillation; however, a substantial number of patients are not eligible for this therapy. The exclusion of the left atrial appendage from circulation seems to be an alternative strategy for stroke prevention in atrial fibrillation. The review focuses on the different devices for stroke prevention in patients with atrial fibrillation. RECENT FINDINGS: Recently, two devices developed for percutaneous transcatheter occlusion of the left atrial appendage have been studied: the PLAATO (Percutaneous Left Atrial Appendage Transcatheter Occlusion) device and the WATCHMAN device. Safety and feasibility data are available for both devices. About 200 patients have received a PLAATO device. These patients were at high risk for thrombembolic stroke and were not candidates for oral anticoagulation therapy. The WATCHMAN device was implanted in 75 patients that were eligible for long-term anticoagulation therapy with a moderate risk for thrombembolic stroke due to nonvalvular atrial fibrillation. SUMMARY: For both devices, a reduction in the risk of stroke was documented, and device implantation was shown to be safe and feasible. Provided the ongoing trials show noninferiority to oral anticoagulation, another therapeutic option will become available to prevent ischemic strokes.

Asunto(s)

Apéndice Atrial/cirugía , Cateterismo Cardíaco/métodos , Prótesis e Implantes , Accidente Cerebrovascular/prevención & control , Anticoagulantes/uso terapéutico , Apéndice Atrial/patología , Fibrilación Atrial/complicaciones , Humanos , Diseño de Prótesis , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/patología

Asunto(s)

Enfermedades de la Aorta/complicaciones , Enfermedades Bronquiales/complicaciones , Calcinosis/complicaciones , Disnea/complicaciones , Endocardio , Cardiopatías/complicaciones , Osificación Heterotópica/complicaciones , Enfermedades de la Tráquea/complicaciones , Anciano , Aorta Torácica , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Calcinosis/diagnóstico , Ecocardiografía , Electrocardiografía , Femenino , Atrios Cardíacos , Cardiopatías/diagnóstico , Humanos , Imagen por Resonancia Cinemagnética , Radiografía Torácica

RESUMEN

Cardiogenic shock (CS) remains the most common cause of death in patients with acute myocardial infarction (AMI). In addition to percutaneous coronary intervention, inotropes, and fluids, intraaortic balloon pumping (IABP) is most widely used for initial haemodynamic stabilization. However, the main limitation of IABP is the lack of active circulatory support and the requirement of a certain level of left ventricular (LV) function. In many patients with severe depression of LV function, haemodynamic support and LV unloading derived from IABP is insufficient to reverse CS. The use of percutaneous LV assist devices (LVAD) with active circulatory support might be beneficial in CS patients not responding to standard treatment including IABP support. This review reports the current experience of percutaneous LVAD in CS complicating AMI.

Asunto(s)

Puente Cardiopulmonar/métodos , Corazón Auxiliar , Infarto del Miocardio/terapia , Choque Cardiogénico/terapia , Humanos , Infarto del Miocardio/complicaciones , Choque Cardiogénico/complicaciones

RESUMEN

Despite being as common as an acute myocardial infarction in the emergency department, the diagnostic criteria and the therapeutic guidelines for heart failure treatment are much less well defined. Thanks to the recently published guidelines of the European Society of Cardiology (ESC) the diagnosis of acute heart failure syndromes (AHFS) is now better standardized. The ESC distinguishes between six AHFS: (I) acute decompensated chronic heart failure, (II) acute heart failure with hypertension/hypertensive crisis, (III) acute heart failure with pulmonary edema, (IV) cardiogenic shock, (V) high-output failure, and (VI) right-sided acute heart failure. To distinguish between these entities in a clinical setting, a well-structured clinical examination is of paramount importance. Signs of peripheral hypoperfusion and congestion/fluid overload need to be recognized rapidly. These two clinical parameters permit the assessment of the patient based on the Clinical Severity Classification. Further diagnostic work-up should include chest X-ray, echocardiography, clinical chemistry, and blood gas analysis. The invasive coronary angiography is only beneficial in the context of an acute ST elevation myocardial infarction or NSTEMIs with persistent symptoms of angina. In all other cases cardiac catheterization should be deferred until the patient is recompensated. Diagnostic algorithms help to maintain a high standard in clinical diagnosis and improve the safety and efficacy of subsequent therapeutic interventions.

Asunto(s)

Gasto Cardíaco Bajo/clasificación , Gasto Cardíaco Bajo/diagnóstico , Sistemas de Apoyo a Decisiones Clínicas , Servicios Médicos de Urgencia/métodos , Guías de Práctica Clínica como Asunto , Enfermedad Aguda , Diagnóstico Diferencial , Servicios Médicos de Urgencia/normas , Medicina de Emergencia/métodos , Medicina de Emergencia/normas , Alemania , Humanos , Pautas de la Práctica en Medicina/normas

RESUMEN

PURPOSE: To evaluate the feasibility of cerebral protection during carotid artery stenting (CAS) using the Mo.Ma device, which prevents cerebral embolization by proximal endovascular blockage of blood flow in the internal and external carotid arteries. METHODS: In 14 European centers, 157 patients (121 men; mean age 68.0+/-8.3 years) were enrolled in a prospective registry between March 2002 and March 2003. Eligible patients had a symptomatic (>50%) or asymptomatic (>70%) stenosis of the internal carotid artery suitable for carotid stenting. Protected carotid stenting was performed with the Mo.Ma system, which occludes both the common and external carotid arteries via 2 independently inflatable compliant low-pressure balloons before any device is advanced across the lesion. Blood is aspirated through the catheter intermittently or at the end of the procedure. RESULTS: The device was successfully positioned and stents were implanted in all cases. Diameter stenosis was reduced from 84.1%+/-7.8% to 6.7%+/-5.1%. The mean duration of flow blockage was 7.6+/-5.9 minutes. In 12 (7.6%) patients, transient intolerance to flow blockade was observed, but the procedures were completed successfully. In 124 (79.6%) cases, there was macroscopic evidence of debris after filtering the aspirated blood. In-hospital complications included 4 (2.5%) minor strokes, 8 (5.1%) transient ischemic attacks, no deaths, and no major strokes, resulting in a 2.5% death/stroke rate at discharge. At 30-day follow-up, there was 1 cardiac death, 1 major stroke, and 3 minor strokes, for an overall 5.7% 30-day death/stroke rate and a 30-day major stroke and death rate of 1.3%. CONCLUSIONS: Cerebral protection with proximal endovascular blood flow blockage during CAS is feasible, with a high procedural success rate.

Asunto(s)

Angioplastia/instrumentación , Estenosis Carotídea/cirugía , Embolia Intracraneal/prevención & control , Stents , Anciano , Anciano de 80 o más Años , Angioplastia/efectos adversos , Diseño de Equipo , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Humanos , Embolia Intracraneal/etiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sistema de Registros , Resultado del Tratamiento

RESUMEN

Catheter-based coronary bypass has evolved since its origin in 1995. We present a status update of one version of catheter-based bypass, percutaneous in situ coronary venous arterialization (PICVA), its successes and failures, and the many questions and challenges that remain. Initial clinical experience with PICVA demonstrated promising mitigation of angina in no-option patients, but was complicated by a relatively low procedural completion rate and a high incidence of MACE. A great deal was learned in these initial cases. The system of devices is currently undergoing significant modification, and further clinical study is underway.

Asunto(s)

Cateterismo Cardíaco/métodos , Puente de Arteria Coronaria/métodos , Cateterismo Cardíaco/instrumentación , Angiografía Coronaria , Puente de Arteria Coronaria/instrumentación , Vasos Coronarios/diagnóstico por imagen , Diseño de Equipo , Humanos , Stents , Ultrasonografía Intervencional