Denervação simpática renal em pacientes com cardiodesfibrilador implantável e tempestade elétrica

ResumoIntroduçãoCardiodesfibriladores implantáveis (CDIs) são geralmente indicados para pacientes com arritmias malignas considerados de alto risco. A hiperatividade simpática desempenha um papel crítico no desenvolvimento, na manutenção e no agravamento de arritmias ventriculares. Novas opções de tratamento nessa população representam uma necessidade clínica. Nosso objetivo foi relatar os resultados de pacientes com CDIs e tempestade elétrica submetidos à denervação simpática renal para controle da arritmia.MétodosOito pacientes com CDIs internados por tempestade elétrica refratária ao tratamento médico otimizado foram submetidos à denervação simpática renal. Condições subjacentes foram: doença de Chagas (n = 6), cardiomiopatia dilatada não isquêmica (n = 1) e cardiomiopatia isquêmica (n = 1). As informações sobre o número de taquicardias ventriculares/fibrilações ventriculares e episódios de terapias antitaquicardia na última semana pré‐procedimento e nos 30 dias pós‐tratamento foram obtidas por meio de interrogação dos CDIs.ResultadosAs medianas dos episódios de taquicardias ventriculares/fibrilações ventriculares, sobre‐estimulação e choques na semana que antecedeu a denervação simpática renal foram de 29 (9 a 106), 23 (2 a 94) e 7,5 (1 a 88), sendo significativamente reduzidas para 0 (0 a 12), 0 (0 a 30) e 0 (0 a 1), respectivamente, 1 mês após o procedimento (p = 0,002; p = 0,01; p = 0,003). Nenhum paciente morreu durante o acompanhamento. Não ocorreram complicações maiores relacionadas ao procedimento.ConclusõesEm pacientes com CDIs e tempestade elétrica refratária ao tratamento médico otimizado, a denervação simpática renal reduziu significativamente a carga de arritmia e, consequentemente, as sobre‐estimulações e os choques. Ensaios clínicos randomizados, no contexto de denervação simpática renal para controle de arritmias cardíacas refratárias, são necessários para trazer maior robustez aos nossos achados.AbstractBackgroundImplantable cardioverter‐defibrillators (ICDs) are usually indicated for patients with malignant arrhythmias considered as high risk. Sympathetic hyperactivity plays a critical role in the development, maintenance, and worsening of ventricular arrhythmias. New treatment options in this population represent a clinical necessity. This study's objective was to report the outcomes of patients with ICDs and electrical storm submitted to renal sympathetic denervation for arrhythmia control.MethodsEight patients with ICDs admitted for electrical storm refractory to optimal medical therapy underwent renal sympathetic denervation. Underlying diseases included Chagas disease (n = 6), non‐ischemic dilated cardiomyopathy (n = 1), and ischemic cardiomyopathy (n = 1). Information on the number of episodes of ventricular tachycardia/ventricular fibrillation and antitachycardia therapies in the week before the procedure and 30 days after treatment were obtained through interrogation of the ICDs.ResultsThe median numbers of episodes of ventricular tachycardia/ventricular fibrillation, antitachycardia pacing, and shocks in the week before renal sympathetic denervation were 29 (9 to 106), 23 (2 to 94), and 7.5 (1 to 88), and significantly reduced to 0 (0 to 12), 0 (0 to 30), and 0 (0 to 1), respectively, 1 month after the procedure (p = 0.002; p = 0.01; p = 0.003, respectively). No patients died during follow‐up. There were no major complications related to the procedure.ConclusionsIn patients with ICDs and electrical storm refractory to optimal medical treatment, renal sympathetic denervation significantly reduced arrhythmia load and, consequently, antitachycardia pacing and shocks. Randomized clinical trials in the context of renal sympathetic denervation to control refractory cardiac arrhythmias are needed to further support these findings

Impact of Routine Use of Drug-eluting Stents in Contemporary Interventional Cardiology at a Tertiary Center: One-decade Experience of the DESIRE Registry

ABSTRACTBackgroundDrug-eluting stents (DES) have changed contemporary interventional cardiology practice, enabling the approach of increasingly more complex clinical and angiographic scenarios. The objective of this study was to demonstrate the changes observed in the last 10 years in the indication and practice of percutaneous coronary intervention (PCI) at a tertiary private hospital in the State of São Paulo.MethodsDESIRE is a single-center prospective registry aiming at following the acute and late outcomes of consecutive patients treated by DES.ResultsFrom 2002 to 2011, 4,299 patients were included, with mean age of 64.3±11.2years, 23% were female and 30.5 were diabetic. The total number of lesions treated was 6,518 of which 61.5% were type B2/C. During the course of the study, DES were progressively more used, reaching a penetration of 88.4% in 2011. The complexity of PCIs has increased and in the past year 1.76 lesions per patient were treated with an average of 1.89 DES. The SYNTAX score increased from 12.3±4.4 (2002-2006) to 15.7±4.7 (2007-2011). Clinical follow-up was obtained in 98.2% of the patients, with a median of 5.2years, and during this period target-lesion revascularization rate was 5%, myocardial infarction was 6.7% and cardiovascular death was 4.1%. Stent thrombosis was observed in 2.4% of the cases.ConclusionsOur results showed a marked increment in the complexity profile of patients treated in the last 10 years and at the same time confirm the long-term effectiveness of DES, despite the clinical and angiographic profile of patients

Impact of Side Branch Predilation on Percutaneous Coronary Intervention in Complex Coronary Bifurcation Lesions

ABSTRACTBackgroundThe treatment of coronary bifurcation lesions with single stenting in the main vessel and provisional side branch stenting may be limited by the degree of anatomical/morphological complexity. Side branch predilation, a procedural step that is typically avoided, may be required to maintain side branch patency. The impact of side branch predilation on the immediate results of percutaneous coronary intervention in complex coronary bifurcation lesions was investigated.MethodsBetween May, 2008 and August, 2009, 59 patients with single coronary bifurcation lesions and significant involvement of the main and side branches were included in the study. The main exclusion criteria were the involvement of the left main coronary artery, ST-elevation acute myocardial infarction (< 72 hours) and in-stent restenosis.ResultsThe mean age of patients was 61.2±11 years, 25.4% were female, and 30.1% had diabetes mellitus. Lesions were most prevalent in the left anterior descending artery/diagonal branch (86.4%). During the procedure, 8.5% (5/59) of lesions had unsuccessful side branch predilation, and four of these bifurcations were treated with two stents. In the multivariate model, side branch stenosis at baseline was the only significant predictor of unsuccessful side branch predilation (odds ratio 1.15, 95%CI: 1.01–1.30; P=0.04), and side branch stenosis > 87.6% was identified as the most accurate cut-off value to predict failure in the receiver operating characteristic (ROC) curve.ConclusionsSide branch predilation was associated with immediate side branch failure in < 10% of cases, and the only significant predictor in the multivariate model was side branch stenosis severity (> 85%) at baseline

Vascular response after implantation of biolimus A9-eluting stent with bioabsorbable polymer and everolimus-eluting stents with durable polymer. Results of the optical coherence tomography analysis of the BIOACTIVE randomized trial

AbstractBackgroundIn BIOACTIVE study, we evaluated vascular responses after the implant of biolimus A9-eluting stent (BES; BioMatrixTM) and the everolimus-eluting stent (EES; XIENCE VTM). In this study, we present the optical coherence tomography analysis (OCT) 6 months post-intervention.MethodsPatients were randomized to treatment with BES (n = 22) or EES (n = 18). The primary outcome was the frequency of non-covered, poorly positioned struts by OCT.ResultsOCT was performed in 26 patients (BES: n = 15; EES: n = 11) and 749 tomographic images and 7,725 stent struts were analyzed. BES and EES showed similar luminal and stent areas. Neointimal hyperplasia area, neointimal thickness and the percentage of in-stent obstruction (8.44 ± 5.10% vs. 9.21 ± 6.36%; p = 0.74) were similar. The rates of not covered struts (BES: 2.10 ± 3.60% vs. ESS: 2.46 ± 2.15%, p = 0.77) and poorly positioned struts (BES: 0.48 ± 1.48% vs. EES 0.44 ± 1.05%, p = 0.94) were similarly low. The frequency of frames with signs consistent with peri-strut inflammatory infiltrate was low and similar between BES (15.53 ± 20.77%) and EES (11.70 ± 27.51%; p = 0.68).ConclusionsThe second-generation drug-eluting stents BES and EES were equally effective at suppressing the neointimal formation after 6 months, with favorable vascular responses. The frequency of frames with peri-strut infiltrate signals per patient was low, and lower than that observed historically with first-generation drug-eluting stents

Novel genes detected by transcriptional profiling from whole-blood cells in patients with early onset of acute coronary syndrome

AbstractBackgroundGenome-wide expression analysis using microarrays has been used as a research strategy to discovery new biomarkers and candidate genes for a number of diseases. We aim to find new biomarkers for the prediction of acute coronary syndrome (ACS) with a differentially expressed mRNA profiling approach using whole genomic expression analysis in a peripheral blood cell model from patients with early ACS.Methods and resultsThis study was carried out in two phases. On phase 1 a restricted clinical criteria (ACS-Ph1, n=9 and CG-Ph1, n=6) was used in order to select potential mRNA biomarkers candidates. A subsequent phase 2 study was performed using selected phase 1 markers analyzed by RT-qPCR using a larger and independent casuistic (ACS-Ph2, n=74 and CG-Ph2, n=41). A total of 549 genes were found to be differentially expressed in the first 48h after the ACS-Ph1. Technical and biological validation further confirmed that ALOX15, AREG, BCL2A1, BCL2L1, CA1, COX7B, ECHDC3, IL18R1, IRS2, KCNE1, MMP9, MYL4 and TREML4, are differentially expressed in both phases of this study.ConclusionsTranscriptomic analysis by microarray technology demonstrated differential expression during a 48h time course suggesting a potential use of some of these genes as biomarkers for very early stages of ACS, as well as for monitoring early cardiac ischemic recovery