Abstract: INTRODUCTION: Human immunodeficiency virus (HIV) has been linked in recent years with a higher rate of cardiovascular events. The aim of our study was to analyze the main risk factors associated with the onset of an acute coronary syndrome (ACS) and in-hospital prognosis in patients with HIV, undergoing percutaneous coronary intervention (PCI). PATIENTS AND METHODS: We studied the baseline clinical characteristics, angiographic findings, results of PCI and in-hospital outcome in 23 patients with HIV hospitalized for an ACS between September 2006 and March 2009. The results were compared with 60 HIV-negative patients admitted with an ACS. RESULTS: HIV patients showed a lower average age and a higher rate of smoking. From a clinical point of view there were no statistically significant differences in clinical presentation, with a similar incidence of ACS with or without ST segment elevation ACS. HIV patients presented a non significant higher incidence of cardiogenic shock on admission (13% HIV vs 8% HIV negative, p 0,301). HIV-negative patients angiography showed the most calcified multivessel involvement with the highest number of diseased vessels (2.35 vs. 1.45, p<0.001). PCI results: HIV patients presented a lower rate of success (TIMI 3 final); 75% versus 85% in HIV-negative patients (p=0.105). There was no significant difference in hospital mortality (8.7 vs 1.7%, p=0.129). CONCLUSIONS: HIV patients hospitalized for an ACS, despite being younger and presenting lower prevalence of traditional cardiovascular risk factors, did not present differences in terms of cardiovascular mortality compared with HIV negative patients.
Abstract: Controversy exists about the safety and efficacy of drug-eluting stents (DES) in saphenous vein bypass grafts (SVGs). The aim of this study was to perform a meta-analysis of all published studies comparing DES and bare-metal stents (BMS) in patients with SVGs disease.
Abstract: Chronic total coronary occlusions constitute a sub-group of lesions at very high risk of restenosis after successful percutaneous coronary intervention. The sirolimus-eluting coronary stent is the only drugeluting stent that has demonstrated to reduce angiographic restenosis and the need for new revascularisation procedures in comparison with bare-metal stents in randomised clinical trials focusing on these lesions. Everolimus-eluting stents have shown to offer optimal angiographic and clinical outcomes in comparison with bare-metal stents and paclitaxel-eluting stents, but no randomised trials have tested the device in chronic total occlusions. The CIBELES (non-acute Coronary occlusIon treated By EveroLimus- Eluting Stent) will randomise 208 patients with chronic total coronary occlusions in 13 centres from Portugal and Spain to receive everolimus- or sirolimus-eluting coronary stents. The primary endpoint will be angiographic in-stent late loss.
Abstract: Very late thrombosis in an implanted bare-metal stent is a very uncommon event outside the context of brachytherapy and few data about its pathophysiology are available. We performed an intravascular ultrasound study during primary angioplasty in five patients with very late bare-metal stent thrombosis and carried out a histological analysis of the material removed by manual thrombectomy. The mean time from the index procedure was 7±4 years. Intravascular ultrasound findings were: calcified atherosclerosis with in-stent plaque rupture, complex plaque in the distal segment of the stent, in-stent neointimal proliferation associated with underexpansion, and severe in-stent proliferation. Histological findings were consistent with the intravascular ultrasound images: recent thrombus with areas of old thrombosis in all cases and remnant atheromatous plaque and endothelium. Consequently, in-stent or distal stent atherosclerosis progression and progressive neointimal proliferation were the likely pathophysiological mechanisms.
Abstract: Patent foramen ovale (PFO) is a relatively common congenital condition which has been implicated in cryptogenic stroke as a result of paradoxical thromboembolism by right-to-left shunting. Many studies have demonstrated that transcatheter PFO closure significantly reduced the incidence of recurrent strokes in a small group of high-risk patients with PFO and atrial septal aneurysm compared with antithrombotic drugs. Two-dimensional transoesophageal echocardiography (2D TEE) has become the election technique for guiding patent foramen ovale closure. Real-time Three-dimensional transoesophageal echocardiography (3D TEE) may be potentially superior to 2D TEE in the accurate assessment of the morphology and efficacy of transcatheter closure devices because of a better spacial orientation.
Abstract: BACKGROUND: The use of drug-eluting stents (DES) in unfavourable patients has been associated with higher rates of clinical complications and stent thrombosis, and because of that concerns about the use of DES in high-risk settings have been raised. OBJECTIVE: This study sought to demonstrate that the clinical benefit of DES increases as the risk profile of the patients increases. METHODS: A meta-regression analysis from 31 randomized trials that compared DES and bare-metal stents, including overall 12,035 patients, was performed. The relationship between the clinical benefit of using DES (number of patients to treat [NNT] to prevent one episode of target lesion revascularization [TLR]), and the risk profile of the population (rate of TLR in patients allocated to bare-metal stents) in each trial was evaluated. RESULTS: The clinical benefit of DES increased as the risk profile of each study population increased: NNT for TLR=31.1-1.2 (TLR for bare-metal stents); p<0.001. The use of DES was safe regardless of the risk profile of each study population, since the effect of DES in mortality, myocardial infarction, and stent thrombosis, was not adversely affected by the risk profile of each study population (95% confidence interval for beta value 0.09 to 0.11, -0.12 to 0.19, and -0.03 to-0.15 for mortality, myocardial infarction, and stent thrombosis, respectively). CONCLUSIONS: The clinical benefit of DES increases as the risk profile of the patients increases, without affecting safety.
Abstract: It has been estimated that up to 12% of patients with acute myocardial infarction do not present coronary atherosclerotic disease demonstrable with angiographic studies. We assessed the clinical characteristics and prognosis of acute coronary syndrome without ST-segment elevation with angiographically normal coronary arteries.
Abstract: The no-reflow phenomenon (NRP) is characterized by an inadequate myocardial tissue perfusion in the presence of a patent epicardial coronary artery. It generally occurs after temporary occlusion of the artery causing myocardial ischemia and necrosis that persist after relief of the vessel occlusion, without evidence of epicardial mechanical obstruction. Currently, the main scenario of NRP is the setting of percutaneous coronary interventions (PCI), especially in patients with acute myocardial infarction or saphenous vein graft disease, and its occurrence is associated with adverse clinical outcomes. Pathophysiology of NRP is not fully understood but it seems to be related with microvascular damage. Several mechanisms have been involved, such as distal microembolization, interstitial and intracellular edema, coronary spasm and capillary plugging. Diagnosis of NRP is generally based on clinical and angiographic data. Several methods have been proposed for the assessment of NRP, such as electrocardiography, myocardial contrast echocardiography, contrast-enhanced magnetic resonance imaging, nuclear imaging or positron emission tomography, that have demonstrated additional prognostic value over angiography. There are different pharmacological and mechanical approaches for the prevention of NRP but none of them have demonstrated a clear efficacy. The treatment of established NRP is mainly based on the administration of coronary vasodilators, like adenosine, verapamil or nitroprusside, but clinical results are frequently disappointing. The objective of this review is to describe the state of the art of the pathophysiology, diagnosis and pharmacological management of NRP.
Abstract: Pulmonary artery dissection is a rare clinical entity, which has been related to pulmonary arterial hypertension. It is frequently presented as cardiogenic shock or sudden death, so diagnosis is often made at autopsy. The management with best results is surgery. We report a case of pulmonary artery dissection associated with previous aortic valve replacement with a favourable outcome, using conservative medical therapy.
Abstract: We describe a nonagenarian patient in whom a paclitaxel-eluting stent was lost during an attempt of direct stent implantation at the distal right coronary artery after removal of the guide-wire. The potential usefulness of intravascular ultrasound in the management of this complication is illustrated. The dislodged stent could not be located by fluoroscopy. However, intravascular ultrasound allowed to find the undeployed stent at the proximal segment of the right coronary artery. It showed that the guide-wire was placed outside the lost stent lumen and this undeployed stent was crushed against a previously implanted stent by another stent with optimal intravascular ultrasound-guided implantation.
