Advantages and disadvantages of biodegradable platforms in drug eluting stents

Coronary angioplasty with drug-eluting stent (DES) implantation is currently the most common stent procedure worldwide. Since the introduction of DES, coronary restenosis as well as the incidence of target vessel and target lesion revascularization have been significantly reduced. However, the incidence of very late stent thrombosis beyond the first year after stent deployment has more commonly been linked to DES than to baremetal stent (BMS) implantation. Several factors have been associated with very late stent thrombosis after DES implantation, such as delayed healing, inflammation, stent mal-apposition and endothelial dysfunction. Some of these adverse events were associated with the presence of durable polymers, which were essential to allow the elution of the immunosuppressive drug in the first DES designs. The introduction of erodable polymers in DES technology has provided the potential to complete the degradation of the polymer simultaneously or immediately after the release of the immunosuppressive drug, after which a BMS remains in place. Several DES designs with biodegradable (BIO) polymers have been introduced in preclinical and clinical studies, including randomized trials. In this review, we analyze the clinical results from 6 observational and randomized studies with BIO polymers and discuss advantages and disadvantages of this new technology.Fil: Rodriguez Granillo, Gaston Alfredo. Rutgers University; Estados Unidos. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Investigaciones Cardiológicas. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Cardiológicas; ArgentinaFil: Rubilar, Bibiana. Sanatorio "Otamendi y Miroli S.A.". Servicio de Diagnóstico por Imágenes. Departamento de Imágenes en Cardiología. Centro de Investigaciones Cardiovasculares; ArgentinaFil: Rodriguez Granillo, Gaston Alfredo. Sanatorio "Otamendi y Miroli S.A.". Servicio de Diagnóstico por Imágenes. Departamento de Imágenes en Cardiología. Centro de Investigaciones Cardiovasculares; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Investigaciones Cardiológicas. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Cardiológicas; ArgentinaFil: Rodriguez, Alfredo E.. Sanatorio "Otamendi y Miroli S.A.". Servicio de Diagnóstico por Imágenes. Departamento de Imágenes en Cardiología. Centro de Investigaciones Cardiovasculares; Argentin

Amputación de miembro inferior en pacientes diabéticos del Hospital de Clínicas de Asunción – Paraguay. Una estimación de costos directos.

Una de las complicaciones crónicas más incapacitantes de la diabetes mellitus es lainsuficiencia vascular periférica que puede llevar a la amputación del miembro inferior. Objetivo:Estimar los costos directos totales de los procedimientos quirúrgicos de amputaciones de miembroinferior de causa diabética en pacientes que acudieron al Servicio de Urgencias del Hospital deClínicas de Asunción, Paraguay durante el año 2008.Material y Método: Estudio descriptivo, de corte transversal de estimación y cálculos de costosdirectos que realizaron los pacientes, el entorno familiar y el servicio de salud pública en los casosde amputaciones de miembro inferior.Resultados: Se registraron 65 amputaciones de miembro inferior de causa diabética distribuidasde la manera siguiente: amputación de dedo 29,2%, amputación transmetatarsiana 14%, transtibial30,7%, transfemoral 26,1%. El costo directo total respectivamente para cada tipo de amputaciónfue de, en dólares americanos: 11,641.61; 8,314.69; 18,477.09; 15,705.53. El costo total de lasamputaciones ascendió a 54,138.93 dólares americanos

Chronic myocardial infarction detection and characterization during coronary artery calcium scoring acquisitions

Background: Hypoenhanced regions on multidetector CT (MDCT) coronary angiography correlate with myocardial hyperperfusion. In addition to a limited capillary density, chronic myocardial infarction (MI) commonly contains a considerable amount of adipose tissue. Objective: We explored whether regional myocardial hypoenhancement on contrast-enhanced MDCT could be identified with standard coronary artery calcium (CAC) scoring acquisitions with noncontrast CT. Methods: Consecutive patients with a history of MI who were referred for contrast-enhanced MDCT from November 2006 until March 2009 were studied. Noncontrast CT for CAC scoring was also performed. The correlation between regional myocardial hypoenhancement on contrast-enhanced CT and regional myocardial hypoattenuated areas on noncontrast CT was defined. Results: Eighty-three patients (mean age, 61.5 ± 12.5 years; n = 67; 81% male) with previous MI were studied. A total of 1411 myocardial segments were evaluated. Two hundred thirty-nine segments (17%) showed myocardial hypoenhancement by MDCT and 140 segments (9.6%) by CAC. On a patient level, noncontrast CT showed a sensitivity, specificity, positive predictive value, (PPV) and negative predictive value (NPV) of 66% (95% CI, 0.53-0.77), 100% (95% CI, 0.76-1.00), 100% (95% CI, 0.90-1.00), and 41% (95% CI, 0.26-0.58), respectively, to detect myocardial hypoenhancement. On a per segment level, noncontrast CT showed a sensitivity, specificity, PPV, and NPV of 58% (95% CI, 0.51-0.64), 100% (95% CI, 0.99-1.00), 99% (95% CI, 0.94-1.00), and 92% (95% CI, 0.90-0.93), respectively, to detect myocardial hypoenhancement. Conclusions: Our findings suggest that chronic MI can be detected with standard CAC scoring acquisitions. © 2010 Society of Cardiovascular Computed Tomography.Fil: Rodriguez Granillo, Gaston Alfredo. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Rosales, Miguel A.. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Renes, Paola. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Diez, Eduardo. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Pereyra, Jorge. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Gomez, Estela. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: De Lillo, Gustavo. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Degrossi, Elina. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Rodriguez, Alfredo E.. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: McFadden, Eugene P.. Cork University Hospital; Irland

Efficacy and safety of a double-coated paclitaxel-eluting coronary stent: The EUCATAX trial

Objectives: The aim of this study was the comparison of a new double-coated paclitaxel-eluting coronary stent with bare-metal stent (BMS) in patients undergoing percutaneous coronary intervention. Background: Stent coating with biodegradable polymers as a platform for elution of drugs has the potential for complete elution of drugs and for decreasing the risk of late complications. Methods: Multicenter randomized trial comparing a paclitaxel-eluting stent (PES) coated with a biodegradable polymer and glycocalyx with the equivalent BMS. We randomly assigned 422 patients with de novo coronary lesions to PES (211 patients) or to BMS (211 patients). Primary end point was target vessel failure (TVF) defined as cardiac death, myocardial infarction, and target vessel revascularization. Clinical secondary end points were target vessel revascularization, target lesion revascularization, stent thrombosis (ST), and major adverse cardiovascular events (MACE). Angiographic secondary end points were late loss and binary restenosis. Results: At 1 year of follow-up, TVF rate was 9.5% in the PES group and 17.1% in the BMS group (P = 0.02), and MACE rate was 10% in PES and 19% in BMS arm (P = 0.009). All other secondary end points were reached but ST. ST rate was low and similar in both study arms. Conclusions: The study shows that patients treated with PES with dual coating technology had significantly lower incidence of TVF and MACE than those treated with BMS design; however, longer follow-up should be necessary to assess true advantages of this technology compared with the previous one.Fil: Rodriguez, Alfredo E.. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Vigo, Cesar F.. Sanatorio del Salvador S. A.; ArgentinaFil: Delacasa, Alejandro. Sanatorio Belgrano; ArgentinaFil: Mieres, Juan. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Fernandez Pereira, Carlos. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Bernardi, Victor. Clinica del Sol;Fil: Bettinoti, Marcelo. Sanatorio Guemes Sociedad Anonima.; ArgentinaFil: Rodriguez Granillo, Gaston Alfredo. Sanatorio "Otamendi y Miroli S.A.". Servicio de Diagnóstico por Imágenes. Departamento de Imágenes en Cardiología. Centro de Investigaciones Cardiovasculares; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Curotto, Valeria. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Rubilar, Bibiana. Sanatorio "Otamendi y Miroli S. A."; ArgentinaFil: Tronge, Jorge. No especifíca;Fil: Palacios, Igor F.. Massachusetts General Hospital; Estados UnidosFil: Antoniucci, David. Careggi Hospital; Itali

Five-Year Follow-Up of the Argentine Randomized Trial of Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease (ERACI II)

ObjectivesThe purpose of the present study is to report the five-year follow-up results of the ERACI II trial.BackgroundImmediate and one-year follow-up results of the ERACI II study showed a prognosis advantage of percutaneous coronary intervention (PCI) with stents over coronary artery bypass grafting (CABG).MethodsA total of 450 patients were randomly assigned to undergo either PCI (n = 225); or CABG (n = 225). Only patients with multi-vessel disease were enrolled. Clinical follow-up during five years was obtained in 92% of the total population after hospital discharge. The primary end point of the study was to compare freedom from major adverse cardiovascular events (MACE) at 30 days, 1 year, 3 years, and 5 years of follow-up.ResultsAt five years of follow-up, patients initially treated with PCI had similar survival and freedom from non-fatal acute myocardial infarction than those initially treated with CABG (92.8% vs. 88.4% and 97.3% vs. 94% respectively, p = 0.16). Freedom from repeat revascularization procedures (PCI/CABG) was significantly lower with PCI compared with CABG (71.5% vs. 92.4%, p = 0.0002). Freedom from MACE was also significantly lower with PCI compared with CABG (65.3% vs. 76.4%; p = 0.013). At five years similar numbers of patients randomized to each revascularization procedure were asymptomatic or with class I angina.ConclusionsAt five years of follow-up, in the ERACI II study, there were no survival benefits from any revascularization procedure; however patients initially treated with CABG had better freedom from repeat revascularization procedures and from MACE

Reduced risk of myocardial infarct and revascularization following coronary artery bypass grafting compared with percutaneous coronary intervention in patients with chronic kidney disease

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 bypass surgery (CABG) and percutaneous intervention (PCI) in CKD are sparse. To compare outcomes of CABG and PCI in stage 3-5 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 3-5 CKD of which 137 were stage 3b-5 CKD. Among individuals with stage 3-5 CKD survival through 5-years was not different following CABG compared with PCI (hazard ratio 0.99, 95% confidence interval: 0.67, 1.46) or stage 3b-5 CKD (1.29: 0.68, 2.46). However, CKD modified the impact on survival free from myocardial infarction: it was not different between CABG and PCI for individuals with preserved kidney function (0.97: 0.80, 1.17), but was significantly lower following CABG in stage 3-5 CKD (0.49: 0.29, 0.82) and stage 3b-5 CKD (0.23: 0.09, 0.58). Repeat revascularization was reduced following 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 impacting survival in these patients

Self-collected saliva for SARS-CoV-2 detection: A prospective study in the emergency room

Current diagnostic standards involve severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detection in nasopharyngeal swabs (NPS), but saliva is an attractive and noninvasive option for diagnosis. The objectives were to determine the performance of saliva in comparison with NPS for detecting SARS-CoV-2 and to compare the optimized home brew reverse-transcription polymerase chain reaction (RT-PCR) with a commercial RT-PCR. Paired NPS and saliva specimens were prospectively collected and tested by RT-PCR from patients presenting at an emergency room with signs and symptoms compatible with coronavirus disease-2019. A total of 348 samples from 174 patients were tested by RT-PCR assays. Among 174 patients with symptoms, 63 (36%) were SARS-CoV-2 positive in NPS using the optimized home-brew PCR. Of these 63 patients, 61 (98%) were also positive in saliva. An additional positive SARS-CoV-2 saliva was detected in a patient with pneumonia. Kappa Cohen´s coefficient agreement between NPS and saliva was 0.96 (95% confidence interval [CI], 0.90?0.99). Median Ct values in NPS versus saliva were 18.88 (interquartile range [IQR], 15.60?23.58; range, 11.97?38.10) versus 26.10 (IQR, 22.75?30.06; range, 13.78?39.22), respectively (p <.0001). The optimized home-brew RT-PCR demonstrated higher analytical and clinical sensitivity compared with the commercial RT-PCR assay. A high sensitivity (98%) and agreement (kappa 0.96) in saliva samples compared to NPS was demonstrated when using an optimized home-brew PCR even when the viral load in saliva was lower than in NPS. This noninvasive sample is easy to collect, requires less consumable and avoids discomfort to patients. Importantly, self-collection of saliva can diminish exposure to healthcare personnel.Fil: Echavarría, Marcela Silvia. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Reyes, Noelia Soledad. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; ArgentinaFil: Rodriguez, Pamela Elizabeth. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Ypas, Martin. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; ArgentinaFil: Ricarte, Joaquina Carmen. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Rodriguez, María P.. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; ArgentinaFil: Pérez, Matías Gastón. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Seoane, Alejandro. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; ArgentinaFil: Martinez, Alfredo. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; ArgentinaFil: Videla, Cristina Mónica. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Stryjewski, Martin E.. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; ArgentinaFil: Carballal, Guadalupe. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

The effect of age on outcomes of coronary artery bypass surgery compared with balloon angioplasty or bare-metal stent implantation among patients with multivessel coronary disease. A collaborative analysis of individual patient data from 10 randomized trials.

OBJECTIVES: This study sought to assess whether patient age modifies the comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). BACKGROUND: Increasingly, CABG and PCI are performed in older patients to treat multivessel disease, but their comparative effectiveness is uncertain. METHODS: Individual data from 7,812 patients randomized in 1 of 10 clinical trials of CABG or PCI were pooled. Age was analyzed as a continuous variable in the primary analysis and was divided into tertiles for descriptive purposes (≤56.2 years, 56.3 to 65.1 years, ≥65.2 years). The outcomes assessed were death, myocardial infarction and repeat revascularization over complete follow-up, and angina at 1 year. RESULTS: Older patients were more likely to have hypertension, diabetes, and 3-vessel disease compared with younger patients (p < 0.001 for trend). Over a median follow-up of 5.9 years, the effect of CABG versus PCI on mortality varied according to age (interaction p < 0.01), with adjusted CABG-to-PCI hazard ratios and 95% confidence intervals (CI) of 1.23 (95% CI: 0.95 to 1.59) in the youngest tertile; 0.89 (95% CI: 0.73 to 1.10) in the middle tertile; and 0.79 (95% CI: 0.67 to 0.94) in the oldest tertile. The CABG-to-PCI hazard ratio of less than 1 for patients 59 years of age and older. A similar interaction of age with treatment was present for the composite outcome of death or myocardial infarction. In contrast, patient age did not alter the comparative effectiveness of CABG and PCI on the outcomes of repeat revascularization or angina. CONCLUSIONS: Patient age modifies the comparative effectiveness of CABG and PCI on hard cardiac events, with CABG favored at older ages and PCI favored at younger ages