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Acute coronary syndromes are common situations in medical practice, with high morbidity and mortality. Consequent to its relevance, its clinical management has always been subject of discussion and controversy. Since the past decade, the dual antiplatelet regimen has been the main therapeutic option used in its passivation, whereas percutaneous interventions have become the most common therapeutic option. Clopidogrel, the drug initially used in combination with aspirin, is effective and safe; however, it has disadvantages that led to the development of a new generation of more efficient antiplatelet drugs, such as prasugrel and ticagrelor. In large comparative clinical trials, these two drugs proved superior to clopidogrel in reducing major combined cardiac events. Hence the main guidelines currently support the two new agents, which are considered first-line drugs. Due to the clear differences between the protocols of clinical trials corroborating their inclusion in clinical practice, it is not possible to make direct comparison without the risk of generating hasty impressions. More recently, a large prospective, randomized clinical trial provided an appropriate head-to-head comparison between prasugrel and ticagrelor in cases of acute coronary disease, in a population submitted to invasive treatment. The study demonstrated a significant advantage of prasugrel. In this review, we discuss the primary details of these more contemporary drugs and the most relevant clinical trials related to them, identifying the advantages and disadvantages of each agent. At the end, we state our view on their current prescription.

The ideal antithrombotic management in patients with atrial fibrillation undergoing elective percutaneous coronary intervention or in acute coronary syndrome has not been definitively established yet. Dual antiplatelet therapy (aspirin and P2Y12 receptor inhibitors) reduces stent thrombosis and subsequent ischemic events. In turn, the presence of atrial fibrillation requires oral anticoagulation to prevent stroke and other thromboembolic complications. However, the combination of these two treatments, known as triple therapy, increases the risk of severe bleeding, with a negative prognostic impact. The use of direct anticoagulants, which reduce bleeding rates compared to warfarin, together with the maintenance of only one antiplatelet agent (P2Y12 inhibitors), known as dual therapy, may be a safer alternative in these patients. In this article, we reviewed several randomized studies comparing triple versus dual therapy, as well as meta-analyses with such studies, and the approaches suggested by the most recent guidelines, discussing the advantages and disadvantages of these treatments, in terms of safety and efficacy in this important and growing subgroup of patients.

Introduction The global coronavirus disease 2019 (COVID-19) pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus began in Wuhan, China, in December 2019, and it has affected over 4.4 million people worldwide, with 302,169 deaths as of May 16, 2020. 1 Though respiratory symptoms are the most common presentation of COVID-19, cardiac involvement is a prominent feature of this disease, occurring in 20% to 30% of hospitalized patients and contributing to 40% of deaths. 2-4 COVID-19-related [...]

Background The angiographic characteristics associated with saphenous vein graft degeneration and the high-risk profile of these patients increase the probability of adverse outcomes during and after percutaneous coronary intervention. This study set out to analyze the clinical and angiographic profile of patients, procedural characteristics, and hospital outcomes of percutaneous coronary intervention performed in saphenous vein grafts, and to investigate predictors of in-hospital mortality in this group. Methods A retrospective, observational study based on records kept by Central Nacional de [...]

Background The MGuard TM stent, which has a microscopic polymer mesh coating, is intended to reduce the distal embolization of fragments during percutaneous coronary intervention (PCI) in saphenous vein grafts (SVG). This study evaluated the early and late clinical outcomes of patients undergoing PCI in SVG with MGuard TM stents vs. drug-eluting stents (DES). Methods Observational, retrospective study conducted at two tertiary centers, involving a cohort of patients with SVG lesions submitted to elective or emergency treatment with MGuard TM stents or DES. Results A total of 271 patients were included, of whom 220 were treated with DES. The MGuard TM group had a higher proportion of women (25.5% vs. 10.5%; p = 0.01), with a mean age of 65.0 ± 13.9 years vs. 69.0 ± 9.6 years ( p = 0.06). The DES group more frequently used distal protection filter (5.8% vs. 10.0%; p = 0.001). Angiographic success was attained in most cases (96.2% vs. 98.0%; p = 0.22). The MGuard TM group had lower rates of early major adverse cardiovascular events (MACE) than the DES group (1.9% vs. 13.6%; p = 0.01), due solely to the lower incidence of periprocedural infarction. However, the MACE rate at 1 year was higher in the MGuard TM group (14.3% vs. 4.4%; p = 0.01) at the expense of a higher rate of target lesion revascularization (7.1% vs. 1.3%; p = 0.048). Conclusions The use of the MGuard TM stent resulted in a reduction of events during hospitalization; however, in the long term the DES were superior in reducing major outcomes, mainly the need for target lesion revascularization.

RESUMO Introducao O stent MGuard™, revestido por malha polimerica microscopica, tem a finalidade de reduzir a embolizacao distal de fragmentos durante a intervencao coronaria percutânea (ICP) em enxertos de veia safena (EVS). Avaliamos os desfechos clinicos precoces e tardios de pacientes submetidos a ICP de EVS com stents MGuard™ vs. stents farmacologicos (SF). Metodos Estudo observacional, retrospectivo, realizado em dois centros terciarios, envolvendo uma coorte de pacientes com lesoes em EVS, tratados de forma eletiva ou de emergencia com stents MGuard™ ou SF. Resultados Foram incluidos 271 pacientes, sendo 220 tratados com SF. O Grupo MGuard™ apresentou maior proporcao de mulheres (25,5% vs. 10,5%; p=0,01), com media de idades de 65,0 ± 13,9 anos vs. 69,0 ± 9,6 anos (p = 0,06). O Grupo SF utilizou com maior frequencia filtro de protecao distal (5,8% vs. 10,0%; p = 0,001). Sucesso angiografico foi obtido na maioria dos casos (96,2% vs. 98,0%; p = 0,22). O Grupo MGuard™ teve menores taxas de eventos cardiovasculares adversos maiores (ECAM) na fase hospitalar que o Grupo SF (1,9% vs. 13,6%; p = 0,01) devido exclusivamente a menor incidencia de infarto periprocedimento. Entretanto, a taxa de ECAM em 1 ano foi maior no grupo MGuard™ (14,3% vs. 4,4%; p = 0,01) a custa de maior taxa de revascularizacao da lesao alvo (7,1% vs. 1,3%; p = 0,048). Conclusoes A utilizacao de stent MGuard™ resultou em reducao de eventos na fase hospitalar, porem, no longo prazo, os SF foram superiores em reduzir desfechos maiores, sobretudo a necessidade de revascularizacao da lesao alvo.

RESUMOIntroduçãoA revascularização miocárdica anatômica completa está associada a um melhor controle dos sintomas anginosos e a menores índices de eventos cardíacos maiores tardios. No entanto, em substancial número de pacientes tratados por meio de intervenção coronária percutânea (ICP), não logramos sua obtenção. Assim, nosso objetivo foi avaliar os fatores associados à revascularização miocárdica incompleta (RMI) em casos de ICP multiarterial.MétodosEstudo de coorte envolvendo 1.049 pacientes revascularizados de forma prospectiva e consecutiva por meio de ICP com tratamento de dois ou mais vasos, entre 2012 e 2014, divididos em dois grupos: RMI (n=324; 30,9%) e revascularização miocárdica completa (n=725; 69,1%).ResultadosA RMI foi significativamente associada a faixa etária maior (66,5 anos vs. 64,1 anos; p=0,003), hipertensão arterial (92,2% vs. 86,0%; p=0,006), insuficiência renal crônica (36.4% vs. 26.0%; p < 0,001), síndrome coronariana aguda (26,3% vs. 21,0%; p=0,05), revascularização cirúrgica prévia (16,1% vs. 7,1%; p=0,001), lesões em enxertos venosos (3,4% vs. 1,0%; p < 0,001) e oclusões crônicas (3,3% vs. 1,4%; p=0,005), bem como a menor acesso a stents farmacológicos (57,8% vs. 64,8%; p=0,002). Os resultados clínicos hospitalares não diferiram entre os grupos.ConclusõesA RMI ocorreu em cerca de um terço dos casos tratados, tendo sido observada associação significativa, com um perfil clínico de maior risco e com intervenções em lesões alvo comumente associadas com menor sucesso do procedimento. O grau de revascularização não gerou impacto nos resultados clínicos da fase hospitalar.ABSTRACTBackgroundComplete anatomical myocardial revascularization is associated with better angina control and lower rates of cardiac events. However, in a significant number of patients treated by percutaneous coronary intervention (PCI), complete revascularization is not achieved. Thus, the aim of this study was to evaluate factors associated with incomplete myocardial revascularization (IMR) in multivessel PCI patients.MethodsThis was a cohort study involving 1,049 prospectively and consecutively revascularized patients through PCI with treatment of two or more vessels, between 2012 and 2014, divided into two groups: IMR (n=324; 30.9%) and complete myocardial revascularization (n=725; 69.1%).ResultsIMR was significantly associated with older age (66.5 years vs. 64.1 years; p=0.003), arterial hypertension (92.2% vs. 86.0%; p=0.006), chronic renal failure (36.4% vs. 26.0%; p < 0.001), acute coronary syndrome (26.3% vs. 21.0%; p=0.05), previous surgical revascularization (16.1% vs. 7.1%; p=0.001), saphenous venous graft lesions (3.4% vs. 1.0%, p < 0.001), and chronic occlusions (3.3% vs. 1.4%, p=0.005), as well as lower access to drug‐eluting stents (57.8% vs. 64.8%; p=0.002). In‐hospital clinical outcomes did not differ between the groups.ConclusionsIMR occurred in approximately one‐third of treated cases, and a significant association was observed with a higher‐risk clinical profile and with target lesion interventions commonly associated with lower procedure success. The degree of revascularization had no impact on in‐hospital clinical outcomes.

BackgroundComplete anatomical myocardial revascularization is associated with better angina control and lower rates of cardiac events. However, in a significant number of patients treated by percutaneous coronary intervention (PCI), complete revascularization is not achieved. Thus, the aim of this study was to evaluate factors associated with incomplete myocardial revascularization (IMR) in multivessel PCI patients.MethodsThis was a cohort study involving 1,049 prospectively and consecutively revascularized patients through PCI with treatment of two or more vessels, between 2012 and 2014, divided into two groups: IMR (n = 324; 30.9%) and complete myocardial revascularization (n = 725; 69.1%).ResultsIMR was significantly associated with older age (66.5 years vs. 64.1 years; p = 0.003), arterial hypertension (92.2% vs. 86.0%; p = 0.006), chronic renal failure (36.4% vs. 26.0%; p < 0.001), acute coronary syndrome (26.3% vs. 21.0%; p = 0.05), previous surgical revascularization (16.1% vs. 7.1%; p = 0.001), saphenous venous graft lesions (3.4% vs. 1.0%, p < 0.001), and chronic occlusions (3.3% vs. 1.4%, p = 0.005), as well as lower access to drug-eluting stents (57.8% vs. 64.8%; p = 0.002). In-hospital clinical outcomes did not differ between the groups.ConclusionsIMR occurred in approximately one-third of treated cases, and a significant association was observed with a higher-risk clinical profile and with target lesion interventions commonly associated with lower procedure success. The degree of revascularization had no impact on in-hospital clinical outcomes.

Background In BIOACTIVE study, we evaluated vascular responses after the implant of biolimus A9-eluting stent (BES; BioMatrix TM ) and the everolimus-eluting stent (EES; XIENCE V TM ). In this study, we present the optical coherence tomography analysis (OCT) 6 months post-intervention. Methods Patients 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. Results OCT 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). Conclusions The 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.

Introdução: O volume de hiperplasia intimal correlaciona-se com a injúria arterial após implante de stents não farmacológicos. No entanto, pouco se sabe a respeito do impacto da injúria arterial na resposta inflamatória/proliferativa com os stents farmacológicos. Investigamos o impacto da injúria arterial, avaliada pela relação balão/artéria, no volume de obstrução neontimal, avaliado pelo ultrassom intracoronário 12 meses após o implante de stents farmacológicos com eluição de zotarolimus. Métodos: A relação balão/artéria foi definida como a razão do diâmetro máximo do balão, obtido no implante ou na pós-dilatação, e o diâmetro de referência do vaso pré-procedimento. Os pacientes foram categorizados em dois grupos: relação balão/artéria alta (≥ 1,15) e relação balão/artéria baixa (< 1,15). Resultados: Foram incluídos 86 pacientes, nos grupos relação balão/artéria baixa (n = 47/48 lesões) ou relação balão/artéria alta (n = 39/48 lesões). As características clínicas, angiográficas e do procedimento não diferiram entre os grupos, à exceção do diâmetro de referência dos vasos (2,73 ± 0,45 mm vs. 2,97 ± 0,40 mm; p = 0,01). Aos 12 meses, observou-se semelhante perda tardia intra-stent (0,59 ± 0,32 mm vs. 0,62 ± 0,42 mm; p = 0,92), bem como reestenose binária (4,2% em ambas as coortes; p > 0,99). O volume de obstrução neointimal intra-stent (15,2 ± 14,3% vs. 12,5 ± 10,1%; p = 0,62) não mostrou diferença entre os grupos. Não observamos correlação entre a relação balão/artéria e o volume de obstrução neointimal aos 12 meses (R2 = 0,0025; p = 0,88). Conclusões: A injúria arterial não se correlacionou com a quantidade de hiperplasia intimal após implante de stents farmacológicos com eluição de zotarolimus.

First generation drug-eluting stents (DES) are associated with reduced in-stent restenosis but significant increased risk of very late stent thrombosis (VLST). The absence of polymer in DES systems may reduce the occurrence of VLST. Optic coherence tomography (OCT) has been used for stent analysis as a surrogate safety endpoint. This study aimed to assess the long-term follow up of strut apposition and tissue coverage of BioMatrix DES by OCT. 20 patients undergoing BioMatrix DES (n = 15) or S-Stent BMS (n = 5) implantation were followed for at least 5 years and evaluated by quantitative coronary angiography, intravascular ultrasound, and OCT. The difference between the stent types was evaluated by nonparametric Mann-Whitney U test while categorical variables were evaluated by Fisher exact test. Rates of in-stent late loss were similar between groups [0.40 (0.21;0.77) vs. 0.68 (0.66; 0.82) mm, p = 0.205, for BioMatrix and S-Stent, respectively]. The vessel, stent and lumen volumes did not differ between groups. Patients treated with BioMatrix had significantly less stent obstruction [5.6 (4.4;9.7) vs. 28.6 (24.7;29.0) %, p = 0.001]. OCT analysis of 12 stents (Biomatrix = 9 and S-Stent = 3) demonstrated 126 (8.7 %) uncovered struts in the BioMatrix group compared to 23 (4.0 %) in the S-Stent group (p = 0.297), being the majority of them well apposed (117/126 and 21/23, respectively, p = 0.292). Only 9 (0.6 %) struts in the DES and 2 (0.4 %) struts in the BMS groups were simultaneously uncovered and malapposed (p = 0.924). BioMatrix DES was associated with lower rates of in-stent obstruction, and similar percentage of neointimal coverage on struts and of complete strut apposition.

BackgroundPercutaneous revascularization in diabetic is frequent and the use of drug-eluting stents (DES) is desirable, since they reduce restenosis and the need for repeat revascularization. The objective of this study was to compare the long-term outcomes of diabetic patients treated with and without DES.MethodsA consecutive cohort of diabetic patients undergoing percutaneous coronary intervention (PCI) between January 2009 and December 2012 in a public tertiary hospital was prospectively followed-up.ResultsNine hundred and thirty-nine diabetic patients (38.3%) treated with DES and 580 (61.7%) treated with bare metal stents (BMS) were evaluated. The rate of major adverse cardiac events (MACE) in 12.6±3.4months was greater in the BMS group (9.5% vs. 14.8%; RR, 1.56; 95% CI, 1.07-2.27; P=0.02), as well as death (2.8% vs. 6.7%; RR, 2.41; 95% CI, 1.22-4.77; P

Background: Bioresorbable vascular scaffolds (BVS) were developed to improve the long-term results of percutaneous coronary intervention, restoring vasomotion. Objectives: To report very late follow-up of everolimus-eluting Absorb BVS (Abbott Vascular, Santa Clara, USA) in our center. Methods: Observational retrospective study, in a single Brazilian center, from August 2011 to October 2013, including 49 patients submitted to Absorb BVS implantation. Safety and efficacy outcomes were analyzed in the in-hospital and very late follow-up phases (> 2 years). Results: All 49 patients underwent a minimum follow-up of 2.5 years and a maximum of 4.6 years. Mean age was 56.8 ± 7.6 years, 71.4% of the patients were men, and 26.5% were diabetic. Regarding clinical presentation, the majority (94%) had stable angina or silent ischemia. Device success was achieved in 100% of cases with 96% overall procedure success rate. Major adverse cardiovascular events rate was 4% at 30 days, 8.2% at 1 year, and 12.2% at 2 years, and there were no more events until 4.6 years. There were 2 cases of thrombosis (1 subacute and 1 late). Conclusions: In this preliminary analysis, Absorb BVS showed to be a safe and effective device in the very late follow-up. Establishing the efficacy and safety profiles of these devices in more complex scenarios is necessary. Resumo Fundamento: Os suportes vasculares bioabsorvíveis (SVB) foram desenvolvidos com o intuito de melhorar os resultados da intervenção coronária percutânea a longo prazo, restabelecendo-se a vasomotricidade. Objetivos: Reportar o seguimento muito tardio do implante do SVB eluidor de everolimus Absorb® (Abbot Vascular, Santa Clara, EUA) em nosso centro. Métodos: Estudo observacional, retrospectivo, em um único centro brasileiro, que incluiu 49 pacientes submetidos ao implante do SVB Absorb® entre agosto/2011 e outubro/2013. Foram analisados os desfechos de segurança e eficácia na fase hospitalar e bastante tardia (> 2 anos). Resultados: Todos os 49 pacientes completaram um seguimento mínimo de 2,5 anos, sendo o máximo de 4,6 anos. A média de idade foi 56,8 ± 7,6 anos, sendo 71,4% da população estudada do sexo masculino e 26,5% composta por diabéticos. Considerando a apresentação clínica, a grande maioria (94%) tinha angina estável ou isquemia silenciosa. Obteve-se sucesso do dispositivo em 100% dos casos e do procedimento, em 96%. A taxa de eventos cardiovasculares maiores foi de 4% aos 30 dias, de 8,2% em 1 ano, e de 12,2% em 2 anos, sem mais eventos até 4,6 anos. Houve 2 casos de trombose (1 subaguda e 1 tardia) até o último seguimento. Conclusões: Nesta análise preliminar, o uso do SVB Absorb® mostrou-se seguro e eficaz no seguimento bastante tardio. Faz-se necessário estabelecer o perfil de eficácia e segurança destes dispositivos em cenários de maior complexidade.

INTRODUÇÃO: O escore SYNTAX foi desenvolvido como ferramenta para graduar a complexidade angiográfica da doença arterial coronária em pacientes com acometimento de três vasos e/ou com lesão de tronco. Avaliamos seu papel em predizer desfechos clínicos após intervenção coronária percutânea (ICP) em pacientes não-selecionados, tratados na prática diária de um hospital de referência. MÉTODOS: Análise de pacientes submetidos a ICP entre março e setembro de 2009 e acompanhados por até 12 meses. Os pacientes foram divididos em tercis de acordo com o escore SYNTAX. O desfecho primário foi composto de eventos cardíacos adversos maiores (ECAM) - óbito, infarto agudo do miocárdio não-fatal e revascularização do vaso-alvo. O desempenho do escore SYNTAX em predizer ECAM foi avaliado pela curva ROC (Receiver Operator Characteristic). RESULTADOS: Foram incluídos 234 pacientes com escore SYNTAX médio de 11,6 ± 6,2 pontos. O tercil I apresentou escore SYNTAX < 9 (média de 5,9); o tercil II, > 9 e < 13 (média de 10,8); e o tercil III, > 13 (média de 18,3). No seguimento clínico de 7,2 ± 4,9 meses, a incidência de ECAM foi maior no tercil III em comparação com os tercis I e II (2,5% vs. 6,4% vs. 14,1%; P = 0,0075). A curva ROC mostrou área sob a curva de 0,667 (P = 0,012), indicando moderada capacidade de prever a ocorrência de ECAM nessa população. CONCLUSÕES: O escore SYNTAX mostrou ser útil em prever a ocorrência de ECAM em pacientes pós-ICP tratados na prática clínica diária. BACKGROUND: The SYNTAX score was developed as an angiographic tool to grade the complexity of coronary artery disease in patients with three-vessel and/or left main disease. We evaluated its role in predicting clinical outcomes after percutaneous coronary intervention (PCI) in non-selected patients, treated in the daily clinical practice of a reference center. METHODS: Analysis of patients undergoing PCI from March to September 2009 and followed-up for up to 12 months. Patients were divided in tertiles according to the SYNTAX score. The primary endpoint included major adverse cardiac events (MACE) - death, non-fatal acute myocardial infarction and target-vessel revascularization. The ability of the SYNTAX score in predicting MACE was assessed by the ROC (Receiver Operator Characteristic) curve. RESULTS: Two hundred and thirty-four patients with a mean SYNTAX score of 11.6 ± 6.2 points were included. Tertile I had a SYNTAX score < 9 (average 5.9); tertile II, > 9 and < 13 (average 10.8); and tertile III, > 13 (average 18.3). In the clinical follow-up of 7.2 ± 4.9 months, the incidence of MACE was greater in tertile III when compared to tertiles I and II (2.5% vs. 6.4% vs. 14.1%; P = 0.0075). The ROC curve showed an area under the curve of 0.667 (P = 0.012) indicating a moderate ability to anticipate the occurrence of MACE in this population. CONCLUSIONS: The SYNTAX score proved to be seful in predicting the occurrence of MACE after PCI in real world patients.

INTRODUÇÃO: A expansão radial e a sustentação da parede do vaso pelos stents melhoraram os resultados da angioplastia coronária por balão. Entre as características dos stents mais contemporâneos destacam-se a redução da espessura de suas hastes e plataformas com novos desenhos, mas não está claro se essas modificações podem resultar em próteses de menor força radial e suscetíveis a recolhimento elástico, especialmente em evoluções muito tardias. Este estudo teve como objetivo investigar se ocorre recolhimento elástico tardio em duas gerações de stents farmacológicos (SFs) em avaliação por ultrassom intracoronário (USIC) seriado a longo prazo. MÉTODOS: O estudo avaliou 25 pacientes com lesões coronárias únicas, de novo, tratados com SFs (12 CypherTM e 13 BioMatrixTM) e submetidos a USIC pós-procedimento e 4-6 meses e 4-5 anos após o implante. Foram comparados os volumes dos stents no período compreendido entre o procedimento índice e os reestudos de médio e longo prazos. O recolhimento elástico do stent foi definido como diminuição > 10% do volume índice do stent. RESULTADOS: A maioria dos pacientes era do sexo masculino (52%), com média de idade de 58,8 ± 7,6 anos, e 28% eram diabéticos. O volume do stent índice, objetivo primário deste estudo, foi de 7,7 ± 1,5 mm³/mm no pós-procedimento, de 7,7 ± 2,1 mm³/mm aos 4-6 meses, e de 7,8 ± 1,6 mm³/mm aos 4-5 anos, com variação tardia de -0,02 ± 1,6 mm³/mm (P = 0,97). A variação a longo prazo do volume do stent índice foi de 0,13 ± 1,8 mm³/mm (1,7%) para o stent CypherTM e de -0,05 ± 1,3 mm³/mm (-0,6%) para o stent BioMatrixTM (P = 0,78). CONCLUSÕES: A avaliação invasiva seriada por meio do USIC mostrou que SFs de aço inoxidável, de diferentes gerações, não demonstraram evidência de recolhimento elástico a longo prazo. BACKGROUND: Radial expansion and vessel wall scaffolding properties of stainless steel stents have improved the outcomes of coronary balloon angioplasty. Thinner struts and new platform designs are characteristic of more contemporaneous stents, but it is not clear whether these changes may result in devices with less radial strength, susceptible to elastic recoil, especially in the very late follow-up. This study was aimed at assessing late stent recoil in two generations of drug-eluting stents (DES) using serial intravascular ultrasound (IVUS) analysis. METHODS: Twenty-five patients with single de novo coronary lesions, treated with DES (12 CypherTM and 13 BioMatrixTM), were included and serial IVUS analysis was performed after stent implantation and at 4-6-months and 4-5 years of follow-up. Stent volume index was compared between the procedure and the mid and long-term follow-ups. Stent recoil was defined as a decrease > 10% of the stent volume index. RESULTS: Most of the patients were male (52%), with mean age of 58.8 ± 7.6 years, and 28% were diabetic. Stent volume index, the primary objective of this study, was 7.7 ± 1.5 mm³/mm post-procedure, 7.7 ± 2.1 mm³/mm at 4-6 months and 7.8 ± 1.6 mm³/mm at 4-5 years, with a delta of -0.02 ± 1.6 mm³/mm (P = 0.97). The long-term delta stent volume index was 0.13 ± 1.8 mm³/mm (1.7%) for the CypherTM stent and -0.05 ± 1.3 mm³/mm (-0.6%) for the BioMatrixTM stent (P = 0.78). CONCLUSIONS: Serial IVUS analysis showed that stainless steel DES of different generations did not show evidence of long-term elastic recoil.

Relato do caso de paciente do sexo masculino, 35 anos de idade, com atresia congenita do tronco da arteria coronaria esquerda, afeccao extremamente rara e com poucos casos descritos na literatura. Nessa afeccao, o ostio da coronaria esquerda esta ausente, o tronco da coronaria esquerda termina em fundo cego e o fluxo sanguineo se da da coronaria direita para a esquerda por pequenas arterias colaterais e retrogradamente. O diagnostico diferencial envolve outras malformacoes congenitas (arteria coronaria direita unica e origem anomala da arteria coronaria esquerda do tronco da arteria pulmonar) e doenca aterosclerotica adquirida do tronco da coronaria esquerda.

INTRODUÇÃO: Vários fatores têm sido relacionados à necessidade de revascularização da lesão-alvo, sejam eles clínicos, angiográficos ou ultrassonográficos. Quanto aos últimos, a área mínima do stent pós-procedimento (AMS) tem sido correlacionada com áreas luminais mínimas intrastent tardias (ALM), em pacientes tratados com stents farmacológicos e não-farmacológicos. OBJETIVO: Avaliar a AMS de pacientes tratados com stents liberadores de zotarolimus EndeavorTM capazes de predizer ALM < 4 mm², aos seis meses de evolução. MÉTODO: Estudo retrospectivo com 47 pacientes e 50 lesões tratados com stents liberadores de zotarolimus, submetidos a ultrassonografia intravascular (USIC) no procedimento índex e no seguimento de seis meses. Correlacionou-se a AMS com a ALM. Por meio da análise de curva ROC, avaliou-se a AMS preditora de ALM < 4 mm² no seguimento de seis meses. RESULTADOS: Observou-se correlação significativa (r² = 0,64; P = 0,001) entre AMS (6 ± 2,1 mm²) e ALM (4,6 ± 2,4 mm²). Houve diferença significativa quanto à AMS dos grupos com ALM < 4 mm² vs. > 4 mm² (4,8 mm² vs. 6,8 mm², respectivamente; P = 0,001). Pela análise da curva ROC, encontrou-se AMS pós-implante > 5,7 mm² como preditora de ALM > 4 mm² aos seis meses [área sob a curva: 0,815; intervalo de confiança (IC) 95%: 0,68-0,95; P < 0,001], com sensibilidade e especificidade de 80%. CONCLUSÃO: Em pacientes tratados com stents EndeavorTM, a AMS > 5,7 mm² esteve associada a ALM > 4 mm² no médio prazo. Tais achados podem auxiliar o implante ótimo desses stents.

INTRODUÇÃO: Os stents eluidores de sirolimus (SES) reduzem significativamente a incidência de reestenose e de eventos cardíacos maiores em comparação a stents convencionais. O biolimus A9 (BA9), um análogo do sirolimus, demonstrou eficácia e segurança similares no estudo randomizado e controlado STEALTH I. O objetivo deste estudo é comparar a eficácia do stent eluidor de BA9 com os SES, assim como seu desempenho em relação aos respectivos grupos controle, utilizando a análise volumétrica pelo ultra-som intracoronário (3D-USIC). MÉTODO: No total, 45 pacientes foram randomizados 2:1 para o grupo submetido a implante de stents eluidores de BA9 (n = 30) ou para o grupo controle (n = 15). Os resultados de angiografia coronária quantitativa e 3D-USIC foram comparados a uma série histórica de pacientes submetidos a implante de SES (n = 30) ou controles (n = 15). As características clínicas e angiográficas foram semelhantes entre os grupos, exceto pela maior quantidade de lesões tipo C e mulheres no grupo dos stents eluidores de BA9. RESULTADOS: Aos seis meses de seguimento, a perda tardia intrastent foi significativamente inferior nos grupos de BA9 e SES em comparação aos respectivos controles, mas foi semelhante quando estes foram comparados entre si (0,24 ± 0,39 mm vs. 0,15± 0,38 mm, respectivamente; p = NS). A obstrução volumétrica intra-stent foi significativamente reduzida nos grupos de BA9 e SES em comparação aos controles, mas semelhante quando comparados entre si (2,23% vs. 3,30%, respectivamente; p = NS). CONCLUSÃO: Os stents eluidores de BA9 reduziram significativamente a proliferação neo-intimal se comparados ao grupo controle, com eficácia similar à observada para os SES.

INTRODUCAO: Pacientes submetidos a intervencao percutânea em hospitais publicos brasileiros nao tem acesso aos stents farmacologicos. No inicio de 2006, participamos de um registro multicentrico internacional que disponibilizava o uso rotineiro dessas proteses, no cenario do mundo real. Neste artigo, procuramos identificar os perfis clinico, angiografico e do procedimento de pacientes consecutivamente tratados em periodos subsequentes de dois meses, de acordo com a disponibilidade desses modelos, visando a identificacao de eventuais alteracoes nesses perfis. METODO: Estudo observacional de uma serie de 471 pacientes, divididos em dois grupos: A, 229 casos dilatados na vigencia da disponibilidade de stents farmacologicos; e B, 242 pacientes subsequentes tratados da forma usual. Nao houve criterios de inclusao/exclusao. RESULTADOS: Stents farmacologicos foram mais implantados no grupo A (44% vs. 2%; p < 0,0001). No que se refere as caracteristicas de base, observou-se predominio significante de diabeticos dependentes de insulina em A (8% vs. 3%; p = 0,02), o mesmo ocorrendo com lesoes-alvo tipos B2 ou C (73% vs. 57%; p < 0,0001), lesoes situadas em bifurcacoes (15% vs. 9%; p = 0,02) e intervencoes multiarteriais (15% vs. 6%; p = 0,003). A angiografia quantitativa identificou os casos de A como portadores de estenoses situadas em vasos de menor calibre (2,4 mm vs. 2,6 mm; p = 0,0004), tambem exibindo lesoes mais longas (14,9 mm vs. 12,7 mm; p = 0,0008). CONCLUSOES: A disponibilidade dos stents farmacologicos gerou alteracoes no perfil dos casos tratados, que passou a abordar situacoes mais predispostas a reestenose, como os diabeticos dependentes de insulina, os multiarteriais com lesoes de alta complexidade e os portadores de lesoes mais longas em vasos de fino calibre.

Background Lately drug-eluting stents (DES) have dramatically reduced restenosis rates and need for repeat revascularization in a wide subset of lesion and patients. However, their benefit for the treatment of large vessels (>3.0 mm) has yet to be established. Objective We investigated whether DES are superior to bare metal stents (BMS) in terms of clinical outcomes for the treatment of large coronary vessels. Methods This study assessed the long-term outcomes (cardiac death, acute myocardial infarction, and need for repeat intervention in the treated vessel) of patients treated with either a DES (Cypher and Taxus) or a BMS of ≥3.5 mm in diameter. A total of 250 consecutive patients who underwent DES implantation were clinically followed for 1 year and compared to 250 patients who were treated with BMS. Interventions in the setting of acute ST elevation myocardial infarction and treatment of bypass grafts were excluded. Results Cypher was the DES deployed in 70.8% of cases. Most of the enrolled patients were men (78%) with single vessel disease (65.6%). The left anterior descending artery was the culprit vessel in 34.2% of cases. Bare metal stent and DES cohorts had equivalent interpolated reference vessel diameter (3.19 ± 0.3 mm for BMS vs 3.18 ± 0.2 for DES; P = .1). Lesion was significantly longer in the group treated with DES (13.4 ± 5.1 mm for BMS group vs 14.3 ± 3.5 for DES; P = .0018). After 1 year of clinical follow-up, 95.2% of patients treated with DES and 91.2% of the patients who received BMS were free of major events ( P = .2). A trend toward higher target-lesion revascularization was noticed in the group treated with BMS (4.8% vs 1.6%; P = .07). Conclusion Percutaneous treatment of large coronary vessels carries a low risk of clinical events irrespective of the type of stent used.

The ZoMaxx Coronary Stent System elutes the antiproliferative agent zotarolimus via a biocompatible phosphorylcholine polymer loaded onto a novel, thin, stainless steel stent platform containing an 0.0007-inch inner layer of tantalum that enhances fluoroscopic radiopacity. The objective of this single-arm prospective clinical trial was to assess the safety and performance of the ZoMaxx stent for the treatment of coronary artery stenosis. Forty consecutive patients with ischemic coronary occlusive disease due to single de novo obstructive lesions of native coronary arteries were treated with 3 x 18 mm ZoMaxx stents at the Dante Pazzanese de Cardiologie in Saõ Paulo, Brazil, between April and July 2005. Independent core laboratories analyzed quantitative coronary angiography and intravascular ultrasound results immediately after stent implantation, and after 4 months. The lesion, procedure, and device-deployment success rates were all 100% (40 of 40). There were no major adverse cardiac events during the study. Follow-up quantitative coronary angiography at 4 months revealed in-stent and in-segment late lumen losses of 0.20 +/- 0.35 and 0.17 +/- 0.35 mm, respectively. Follow-up intravascular ultrasound at 4 months revealed 6.5 +/- 6.2% neointimal volume obstruction. There were no instances of late acquired stent incomplete apposition or stent thrombosis. In conclusion, the ZoMaxx Coronary Stent can be safely implanted for the treatment of de novo coronary artery stenosis. The inhibition of neointima formation as measured by follow-up angiography and IVUS after 4 months suggests therapeutic potential for the reduction of restenosis.

INTRODUCTION: To treat long complex coronary obstructions, total lesion coverage is recommended. When more than one stent is deployed an overlap segment is mandatory to avoid uncovered gaps between stents. There is no data comparing Sirolimus- (SES) versus Paclitaxel-eluting stents (PES) at overlapping segments in regards to neointimal inhibition or toxic effects on the vessel wall. OBJECTIVE: To evaluate, by means of serial intravascular ultrasound (IVUS), the efficacy in reducing neointimal proliferation and the vessel changes in the overlapping segment comparing these two drug-eluting stents. METHOD: Fifty-two patients with 72 de novo coronary lesions were randomized for SES or PES. Fourteen patients in the SES Group and twelve in the PES Group had overlapping segments. Quantitative coronary angiography and IVUS were performed at the time of the procedure and at 8 months follow-up. RESULTS: No significant baseline differences were identified between the 2 groups. The mean stent/lesion ratios were similar (1.74 ± 0.89 for SES vs. 2.01 ± 0.92 for PES; p= 0.47). SES and PES were comparable in reducing neointima hyperplasia in the overlapping zone (neointima volume 2.24 ± 0.9 mm3 after SES vs. 2.53 ± 1.5 mm3 after PES; p=0.1 and % neointima obstruction of 18.15 ± 8.5% after SES vs. 26.7 ± 16.8% after PES; p=0.1). There was no positive remodeling in the overlapping segment for both groups (expansion ratio 0.74 ± 0.18 vs. 0.76 ± 0.14, respectively; p=0.74). Other IVUS volumetric measurements were also equivalent between the two cohorts. CONCLUSION: In our preliminary experience, overlapping of DESs proved to be efficient in reducing neointimal formation and also safe, since no sign of local toxicity was observed.

INTRODUCAO: O estudo STEALTH I demonstrou a eficacia e seguranca dos stents eluidores de Biolimus A9 (BA9) em reduzir a perda-tardia angiografica e apresentar uma baixa incidencia de eventos cardiacos maiores, entretanto os achados de ultra-som intracoronario (USIC) ainda nao foram descritos. O objetivo deste estudo e descrever os achados de analise volumetrica por USIC nos pacientes recrutados em nossa instituicao. METODOS E RESULTADOS: Quarenta e cinco pacientes apresentando lesao coronaria de novo, unica, foram randomizados 2:1 para receber stents eluidores de BA9 (n=30) ou stents controle (n=15). A media de idade foi de 58 anos, com 16% diabeticos e 62% do sexo masculino. As caracteristicas clinicas e angiograficas foram similares entre os grupos. Aos 6 meses de seguimento nao houve diferenca significativa entre os grupos quanto a desfechos clinicos. O indice de hiperplasia intimal intra-stent foi inferior no grupo dos stents eluidores de BA9 em comparacao ao grupo controle (0.19+/-0.08 vs. 2.71+/-0.50, P

SUMMARYUse of Multiple Drug-Eluting Stents for the Treatmentof Multivessel Disease in a Diabetic Patient The incidence of diabetes mellitus has continuously risenover recent years. Patients with this chronic conditionhave a higher risk of developing coronary artery disease.Unfortunately, due to the frequent diffuse involvement ofmultiple vessels, the long term outcomes after percutaneousintervention, whether by balloon catheter or bare-metalstent, has always been poor and frequently inferior tocardiac surgery for this subset of patients. Recently, theintroduction of drug-eluting stents (DES) has brought newhope to treat patients with more complex diseases percu-taneously. In this paper we report a successful percutaneousapproach of a 63-year-old insulin dependent diabetic patienttreated with nine DES (Taxus TM , Boston Scientific). DESCRIPTORS: Coronary disease. Diabetes mellitus. Stents. RESUMO A incidencia de diabetes mellitus tem aumentado continua-mente nos ultimos anos. Os pacientes acometidos por estaenfermidade cronica tem maior risco de desenvolver doen-ca aterosclerotica coronaria. Infelizmente, devido ao frequenteenvolvimento difuso de multiplos vasos, a intervencao percu-tânea, quer seja com cateter-balao ou com stent nao farmaco-logico, tem sido associada a pior prognostico quando compa-rada a cirurgia de revascularizacao miocardica neste grupode pacientes. Recentemente, a introducao dos stents farma-cologicos renovou o entusiasmo para o tratamento percutâneode pacientes com lesoes mais complexas. Neste artigo,reportamos um caso de uma paciente de 63 anos, porta-dora de diabetes em uso de insulina, tratada percutaneamentecom nove stents farmacologicos (Taxus

INTRODUÇÃO: Aposição incompleta (AI) é descrita após implante de stents farmacológicos (SF) e pode associar-se à trombose de stents. Em razão de diferentes plataformas, polímeros e fármacos utilizados, diferenças na eficácia e na segurança entre SF também são esperadas. OBJETIVO: Avaliar a incidência de AI persistente e tardia após implante de stents com sirolimus (SES) e com zotarolimus (ZES) e a evolução dos pacientes que apresentem essa alteração. MÉTODO: Análise de 242 pacientes tratados com SF (175 pacientes com SES - Cypher® - e 67 pacientes com ZES - EndeavorTM) e submetidos a ultra-sonografia intracoronária após o implante e aos seis meses. RESULTADOS: No grupo tratado com SES, 7 (4%) pacientes apresentaram AI tardia e 12 (6,8%), AI persistente. No grupo tratado com ZES, nenhum caso de AI tardia foi identificado e, em 4 pacientes, observou-se AI após o implante e que desapareceu aos seis meses. Nos pacientes com AI tardia, observou-se aumento evolutivo dos volumes do vaso (de 377,2 ± 148,9 mm³ para 431,9 ± 155,1 mm³; p = 0,51) e da placa (de 206,1 ± 51,5 mm³ para 236,9 ± 68,4 mm³; p = 0,36). O volume de hiperplasia intimal foi maior após ZES (16,6 ± 5,8 mm³ vs. 5,1 ± 5,5 mm³; p < 0,0001). Após nove meses, não ocorreram eventos cardíacos adversos nos pacientes com AI. CONCLUSÃO: A incidência de AI tardia foi de 2,9% e observada após SES. A presença de AI não esteve relacionada a eventos adversos a médio prazo. BACKGROUND: Incomplete stent apposition (ISA) has been documented after drug-eluting stents (DES) and could be related to stent thrombosis. Because DES differ in metal platform, polymer and pharmacological agent, differences in performance and safety are expected. OBJECTIVE: We sought to investigate the frequency and clinical consequences of ISA after implantation of sirolimus- (SES) and zotarolimuseluting stents (ZES). METHODS: 242 patients (pts) who underwent DES placement (175 pts with Cypher® and 67 pts with EndeavorTM stents) had serial intravascular ultrasound (IVUS) performed (at index procedure and after 6-months). RESULTS: 7 pts (4%) had late-acquired ISA after SES. Another 12 (6.8%) pts treated with SES had persistent ISA. Among pts treated with ZES, none had late ISA and 4 had ISA observed after stent implantation that completely resolved at 6-months. There was an increase in vessel (377.2 ± 148.9 to 431.9 ± 155.1 mm³, p = 0.51) and in plaque volume (206.1 ± 51.53 to 236.91 ± 68.4 mm³, p=0.36) in pts with late ISA. Amount of neointimal hyperplasia was significantly higher in ZES than SES (16.6 ± 5.8 mm³ vs 5.1 ± 5.5 mm³, p < 0.0001). After 9 months, no adverse clinical event was observed in pts with ISA. CONCLUSION: Overall incidence of IVUS-detected late incomplete DES apposition was 2.9%, all after SES. The presence of ISA was not related to clinical adverse events during mid term follow-up.

We report the outcomes of patients who had in-stent restenosis (IRS) that was treated with intravascular brachytherapy (IVBT) or sirolimus-eluting stent (SES) implantation. The benefit of IVBT for treating ISR is well documented. SES implantation decreases first-time ISR and, in preliminary reports, has been used to treat ISR. Fifty consecutive patients who had ISR were treated; the first 25 patients underwent SES implantation and the next 25 patients were treated with IVBT using a beta-Cath System (a 40-mm strontium-90/yttrium-90 source). Quantitative angiographic and intravascular ultrasound follow-up were performed at 5.2 +/- 1.1 and 12.1 +/- 1.2 months; clinical follow-up was performed at 15 months. SES deployment and IVBT were successful in all patients. At 12-month follow-up, 8 patients who underwent IVBT had angiographic recurrence (4 in the stent and 4 at the stent edge); only 1 patient who underwent SES implantation developed recurrent ISR. At 12 months, in-stent late luminal loss was similar between the SES and IVBT groups (0.35 +/- 0.45 vs 0.34 +/- 0.46 mm, p = 0.9); however, in-stent net luminal gain was higher in the SES group than in the IVBT group (1.32 +/- 0.13 vs 0.57 +/- 0.19 mm, p

We performed serial intravascular ultrasound analysis in patients who underwent balloon dilatation for in-stent restenosis. Early lumen loss was detected by intravascular ultrasound and was associated with minimal changes at the edges and at the external elastic membrane. These results on intravascular ultrasound suggest compression and decompression as the main mechanisms for early lumen loss after dilatation of in-stent restenotic lesions.

). The patients were followed up to determine the rate of major cardiac events (MCE) in 2 years, the need for revascularization of the target lesion, and to identify the clinical, angiographic, and ultrasound predictors of events. Results Seventy-five (43%) patients had MLA ≥ 4.0 mm 2 and were clinically treated; 98 (57%) patients had MLA < 4.0 mm 2 and ; P < 0.001)). The clinical impact of the decision was favorable, and no difference was observed in regard to the occurrence of major cardiac events: (group 1: 5 (7%) vs group 2: 14 (15%); P = 0.09). The need for revasculari- zation of the target lesion also did not differ (group 1: 3 (4%) vs group 2: 11 (12%); P = 0.07). The predictive variables for MCE were diabetes, functional class III (FC III) angina before hospitali- zation, and MLA assessed on ultrasound. Conclusion This strategy for deciding on appropriate treatment guarantees low rates of MCE in both groups in the 24-month follow-up, with reduced revascularization rates. The predictive variables of major cardiac events were as follows: diabetes mellitus, FC III angina, and MLA on intravascular ultrasound.

OBJECTIVE:To verify the influence of moderate- or high-pressure balloon inflation during primary coronary stent implantation for acute myocardial infarction. METHODS: After successful coronary stent implantation, 82 patients were divided into 2 groups according to the last balloon inflation pressure: group 1 (superscript three12 to superscript three16 to 20 atm), each with 41 cases. All patients underwent late coronary angiography. RESULTS: In group 1, the mean stent deployment pressure was 13.58±0.92 atm, and in the group 2 it was 18.15±1.66 atm. Stents implanted with moderate pressures (superscript three12 to superscript three16 atm) did not cause a measurable improvement in late outcome, either in the late loss, its index, and the net gain, or in clinical and angiographic restenosis rates.

he FREEDOM study, recently presented at American Heart Association (AHA) congress in November 2012 and simultaneously published in the presti­gious New England Journal of Medicine, demonstrated that myocardial revascularisation surgery provides better results than percutaneous coronary intervention (PCI) with drug­eluting stents (DES) for the treatment of diabetic patients with complex coronary artery disease. In this international multicenter study involving 140 hospitals, of which four are located in Brazil (Instituto Dante Pazzanese de Cardiologia – Sao Paulo, SP; Instituto do Coracao do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo – Sao Paulo, SP; Hospital Universitario da Pontificia Universidade Catolica de Porto Alegre – Porto Alegre, RS; and Hospital Cardiologico Costantini – Curitiba, PR), 1,900 diabetic patients with multivessel involvement and no lesions in the left main coronary artery were randomized to coronary artery bypass graft (CABG) surgery or PCI procedures.

Stent thrombosis (ST) is an infrequent event following 2nd generation drug-eluting stents (DES); however, its occurrence may be catastrophic. Our objective was to report the incidence of ST in a large population treated with Endeavor zotarolimus-eluting stents (E-ZES) and randomized to short- (3

Background Our aims were to compare coronary artery bypass grafting (CABG) and stenting for the treatment of diabetic patients with multivessel coronary disease enrolled in the Arterial Revascularization Therapy Study (ARTS) trial and to determine the costs of these 2 treatment strategies. Methods and Results Patients (n=1205) were randomly assigned to stent implantation (n=600; diabetic, 112) or CABG (n=605; diabetic, 96). Costs per patient were calculated as the product of each patient’s use of resources and the corresponding unit costs. Baseline characteristics were similar between the groups. At 1 year, diabetic patients treated with stenting had the lowest event-free survival rate (63.4%) because of a higher incidence of repeat revascularization compared with both diabetic patients treated with CABG (84.4%, P P =0.04). Conversely, diabetic and nondiabetic patients experienced similar 1-year event-free survival rates when treated with CABG (84.4% and 88.4%). The total 1-year costs for stenting and CABG in diabetic patients were $12 855 and $16 585 ( P Conclusions Multivessel diabetic patients treated with stenting had a worse 1-year outcome than patients assigned to CABG or nondiabetics treated with stenting. The strategy of stenting was less costly than CABG, however, regardless of diabetic status.

PURPOSE: The authors analyzed the 30-day and 6-month outcomes of 1,126 consecutive patients who underwent coronary stent implantation in 1996 and 1997. METHODS: The 30-day results and 6-month angiographic follow-up were analyzed in patients treated with coronary stents in 1996 and 1997. All patients underwent coronary stenting with high-pressure implantation (>12 atm) and antiplatelet drug regimen (aspirin plus ticlopidine). RESULTS: During the study period, 1,390 coronary stents were implanted in 1,200 vessels of 1,126 patients; 477 patients were treated in the year 1996 and 649 in 1997. The number of percutaneous procedures performed using stents increased significantly in 1997 compared to 1996 (64 % vs 48%, p=0.0001). The 30-day results were similar in both years; the success and stent thrombosis rates were equal (97% and 0.8%, respectively). The occurrence of new Q wave MI (1.3% vs 1.1%, 1996 vs 1997, p=NS), emergency coronary bypass surgery (1% vs 0.6%, 1996 vs 1997, p=NS) and 30-day death rates (0.2% vs 0.5%, 1996 vs 1997, p=NS) were similar. The 6-month restenosis rate was 25% in 1996 and 27% in 1997 (p= NS); the target vessel revascularization rate was 15% in 1996 and 16% in 1997 (p = NS). CONCLUSIONS: Intracoronary stenting showed a high success rate and a low incidence of 30-day occurrence of new major coronary events in both periods, despite the greater angiographic complexity of the patients treated with in 1997. These adverse variables did not have a negative influence at the 6-month clinical and angiographic follow-up, with similar rates of restenosis and ischemia-driven target lesion revascularization rates.

The use of drug-eluting stents aiming at by-pass the disadvantage of stainless steel stents have been associated to late thrombosis after withdrawal of anti-platelet agents. We report a case with another complication, the development of a coronary aneurysm in the stent area more than three years after index procedure. Late chronic local inflammatory responses may be responsible for the weakening, erosion and aneusrysm formation.

Objetivo - Avaliar a eficiencia, a seguranca e a praticidade da angiografia coronaria com cateteres 4 French (F), pela tecnica de Judkins. Metodos - De agosto/95 a janeiro/96, 70 pacientes com suspeita de insuficiencia coronaria submeteram-se a cinecoronariografia , utilizando introdutores e cateteres 4F. Apos o exame, realizava-se compressao local por 15min e, 60min apos, os pacientes eram orientados a caminhar, sob vigilância , sendo dada a alta hospitalar apos 4h, . Resultados - A idade variou de 31 a 83 (m = 57) anos, sendo 39 (56%) homens, com peso entre 43 a 101 (m = 69) kg. Obteve-se otima qualidade de imagem em 62 casos (88%), havendo a necessidade de substituicao por cateteres de maior calibre (6 a 8F) em 8 (12%) pacientes. Nao ocorreram complicacoes vasculares ou sangramentos maiores. Em apenas 2 (3%) casos, houve discreto sangramento, resolvido com nova compressao local. Sessenta pacientes (85%) deambularam aos 60±5min e tiveram alta hospitalar com 4h, em media. Conclusao - A utilizacao de cateteres 4F por via femoral, para realizacao de cinecoronariografia permite a deambulacao muito precoce (media = 60±5min) e sem complicacoes hemorragicas. Verificaram-se pequena utilizacao de contraste (media = 60ml) e reducao da permanencia hospitalar. Esta tecnica torna o exame cinecoronariografico mais simples, menos traumatico e menos invasivo.

INTRODUÇÃO: A revascularização percutânea de diabéticos é frequente e a utilização de stents farmacológicos (SF) é desejável, pois estes reduzem a reestenose e a necessidade de nova revascularização. O objetivo desse estudo foi comparar os resultados clínicos de longo prazo entre diabéticos tratados com e sem SF. MÉTODOS: Analisou-se uma coorte consecutiva de diabéticos submetidos à intervenção coronária percutânea (ICP) entre janeiro de 2009 e dezembro de 2012, em hospital terciário da rede pública. Esses pacientes foram acompanhados prospectivamente. RESULTADOS: Avaliamos 939 diabéticos, sendo 359 (38,3%) tratados com SF e 580 (61,7%) tratados com stents não farmacológicos (SNF). A taxa de eventos cardiovasculares adversos maiores (ECAM) em 12,6 ± 3,4 meses foi maior no grupo SNF (9,5% vs. 14,8%; risco relativo - RR = 1,56; intervalo de confiança de 95% - IC 95% 1,07-2,27; P = 0,02), assim como o óbito (2,8% vs. 6,7%; RR = 2,41; IC 95% 1,22-4,77; P < 0,01) e a revascularização do vaso alvo (3,9% vs. 7,2%; RR = 1,85; IC 95% 1,03-3,35; P = 0,04). Não foram observadas diferenças na incidência de infarto do miocárdio (1,7% vs. 0,5%; RR = 0,30; IC 95% 0,07-1,23; P = 0,08) ou acidente vascular encefálico (1,1% vs. 0,2%; RR = 0,15; IC 95% 0,01-1,37; P = 0,07). A análise multivariada revelou que a doença renal crônica (RR = 2,05; IC 95% 1,40-2,98; P < 0,01) e a síndrome coronária aguda (RR = 2,08; IC 95% 1,42-3,02; P < 0,01) foram os únicos preditores independentes de ECAM. CONCLUSÕES: Em pacientes diabéticos não selecionados, a evolução clínica tardia foi pior para os tratados com SNF. Após o ajuste das variáveis de confusão, o uso de SF não se mostrou preditor independente da redução de ECAM. BACKGROUND: Percutaneous revascularization in diabetic is frequent and the use of drug-eluting stents (DES) is desirable, reducing restenosis and the need for repeat revascularization. The objective of this study was to compare the long-term outcomes of diabetic patients treated with and without DES. METHODS: A consecutive cohort of diabetic patients undergoing percutaneous coronary intervention (PCI) between 01/2009 and 12/2012 in a public tertiary hospital was prospectively followed-up. RESULTS: Nine hundred and thirty-nine diabetic patients (38.3%) treated with DES and 580 (61.7%) treated with bare metal stents (BMS) were evaluated. The rate of major adverse cardiac events (MACE) in 12.6 ± 3.4 months was greater in the BMS group (9.5% vs. 14.8%; RR, 1.56; 95% CI, 1.07-2.27; P = 0.02), as well as death (2.8% vs. 6.7%; RR, 2.41; 95% CI, 1.22-4.77; P < 0.01), and target vessel revascularization (3.9% vs. 7.2%; RR, 1.85; 95% CI, 1.03-3.35; P = 0.04). There were no differences in the incidence of myocardial infarction (1.7% vs. 0.5%; RR, 0.30; 95% CI, 0.07-1.23; P = 0.08) or stroke (1.1% vs. 0.2%; RR, 0.15; 95% CI, 0.01-1.37; P = 0.07). Multivariate analysis indicated that chronic kidney disease (RR, 2.05; 95% CI, 1.40-2.98; P < 0.01) and acute coronary syndrome (RR, 2.08; 95% CI 1.42-3.02; P < 0.01) were the only independent predictors of MACE. CONCLUSIONS: In non-selected diabetic patients the long-term clinical outcome was worse for patients treated with BMS. After adjusting for confounding variables, the use of DES was not an independent predictor of reduced MACE.

he FREEDOM study, recently presented at American Heart Association (AHA) congress in November 2012 and simultaneously published in the presti­gious New England Journal of Medicine, demonstrated that myocardial revascularisation surgery provides better results than percutaneous coronary intervention (PCI) with drug­eluting stents (DES) for the treatment of diabetic patients with complex coronary artery disease. In this international multicenter study involving 140 hospitals, of which four are located in Brazil (Instituto Dante Pazzanese de Cardiologia – Sao Paulo, SP; Instituto do Coracao do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo – Sao Paulo, SP; Hospital Universitario da Pontificia Universidade Catolica de Porto Alegre – Porto Alegre, RS; and Hospital Cardiologico Costantini – Curitiba, PR), 1,900 diabetic patients with multivessel involvement and no lesions in the left main coronary artery were randomized to coronary artery bypass graft (CABG) surgery or PCI procedures.

Background Previous studies have shown that coronary plaque composition plays a pivotal role in plaque instability, and imaging modalities and serum biomarkers have been investigated to identify vulnerable plaque. Virtual histology IVUS (VH-IVUS) characterizes plaque components as calcified, fibrotic, fibrofatty, or necrotic core. C-reactive protein (hsCRP) is an independent risk factor and a powerful predictor of future coronary events. However, a relationship between inflammatory response indicated by CRP and plaque characteristics in ACS patients remains not well established. Objective To determine, by using VH-IVUS, the relation between coronary plaque components and plasma high-sensitivity CRP levels in patients with acute coronary syndromes (ACS). Methods 52 patients with ACS were enrolled in this prospective study. Electrocardiographically-gated VH-IVUS were performed in the culprit lesion before PCI. Blood sample was drawn from all patients before the procedure and after 24 hours, and hs-CRP levels were determined. Results Mean age was 55.3±4.9 years, 76.9% were men and 30.9% had diabetes. Mean MLA was 3.9±1.3 mm², and plaque burden was 69±11.3%, as assessed by IVUS. VH-IVUS analysis at the minimum luminal site identified plaque components: fibrotic (59.6±15.8%), fibrofatty (7.6±8.2%), dense calcium (12.1±9.2%) and necrotic core (20.7±12.7%). Plasma hs-CRP (mean 16.02±18.07 mg/L) did not correlate with necrotic core (r=-0.089, p = 0.53) and other plaque components. Conclusions In this prospective study with patients with ACS, the predominant components of the culprit plaque were fibrotic and necrotic core. Serum hs C-reactive protein levels did not correlate with plaque composition.

Background: The newly developed balloon-expandable Mguard stent system, a combination of an ultra-thin polymer mesh sleeve attached to the external surface of a BMS, was conceived to provide embolic protection during PCI of SVG and thrombus-containig lesions. Although the acute results (

INTRODUÇÃO: Embora os stents farmacológicos tenham reduzido de forma inconteste o crescimento neointimal e sua consequência clínica direta, a reestenose, questionamentos acerca de sua segurança a longo prazo têm motivado o desenvolvimento de novas tecnologias. A aplicação sistêmica de fármacos antiproliferativos teria o potencial de solucionar o problema da reestenose e ao mesmo tempo amenizar a questão da segurança tardia inerente aos polímeros sintéticos. Recentemente, estudo investigando a administração intravenosa de uma solução de paclitaxel ligado à albumina (ABI-007) produziu efeito discreto na redução da formação de tecido neointimal. Este trabalho teve como objetivo avaliar, por meio da angiografia e do ultrassom intracoronário (USIC) seriados, a efetividade da aplicação intracoronária do ABI-007 na supressão da hiperplasia neointimal após implante de stents não-farmacológicos MÉTODO: Entre novembro de 2006 e maio de 2007, pacientes portadores de lesões coronárias de novo, com extensão < 18 mm, em vasos nativos de 2,5 mm a 3,5 mm de diâmetro, foram submetidos a intervenção coronária percutânea com implante de stents não-farmacológicos, seguida de injeção intracoronária de 70 mg/m² de ABI-007. Avaliação com angiografia e USIC foi programada para todos os pacientes imediatamente após o procedimento e aos seis meses de seguimento. Desfecho primário era a perda luminal tardia (QCA) e o porcentual de obstrução volumétrica gerado pela hiperplasia neointimal (USIC) aos seis meses RESULTADOS: Foram incluídos 11 pacientes, com média de idade de 58,4 ± 7,3 anos, 54% do sexo feminino e 18,2% de diabéticos. A artéria descendente anterior foi o vaso mais frequentemente tratado (45,5%) e a maioria das lesões era do tipo A/B1 (63,7%). A administração de ABI-007 foi bem tolerada por todos os pacientes. Aos seis meses, a perda luminal tardia foi de 0,84 ± 0,46 mm, tendo sido identificados três casos (27,3%) de reestenose binária. Ao USIC, o porcentual de obstrução volumétrica foi de 38,4 ± 16,2%. Não houve casos de remodelamento vascular significativo, nem de má-aposição tardia dos stents. Ao final de dois anos, não houve ocorrência de eventos cardíacos maiores CONCLUSÃO: Embora a administração intracoronária de ABI-007 tenha sido bem tolerada, sem efeitos tóxicos adversos reportados, essa modalidade terapêutica apresentou baixa capacidade de suprimir a formação de tecido neointimal após implante de stents nãofarmacológicos, com perda tardia e porcentual de obstrução volumétrica semelhantes aos observados após implante de stents não-farmacológicos isolados. BACKGROUND: Although drug-eluting stents have proven to be highly effective in decreasing neointimal hyperplasia and its direct clinical consequence, restenosis, concerns regarding their long-term safety have led to the development of new technologies. The systemic use of antiproliferative drugs may resolve restenosis while minimizing the longterm safety issues inherent to synthetic polymers. Recently, a study investigating the intravenous administration of albumin-bound paclitaxel (ABI-007) showed that it produced a mild effect on the reduction of neointimal tissue formation. The present study was aimed at investigating, by means of serial angiography and intravascular ultrasound (IVUS), the efficacy of intracoronary ABI-007 administration in the suppression of neointimal hyperplasia after bare-metal stent implantation METHOD: From November 2006 and May 2007, patients with de novo coronary lesions < 18 mm were submitted to percutaneous coronary intervention using bare-metal stents, followed by a 70 mg/m² intracoronary injection of ABI-007. Angiography and IVUS assessment was planned for all of the patients immediately after the procedure and at the six-month follow-up. The primary end-point was late lumen loss (LL) and percent neointimal volume obstruction caused by neointimal hyperplasia (IVUS) at 6 months RESULTS: 11 patients were included, with mean age of 58.4 ± 7.3 years, 54% were female and 18.2% diabetics. Left anterior descending artery was the most frequent vessel treated (45.5%) and most of the lesions were type A/B1 (63.7%). ABI-007 administration was well tolerated by all patients. At the 6-month follow-up, LL was 0.84 ± 0.46 mm and three cases (27.3%) of binary restenosis were identified. IVUS percent volumetric obstruction was 38.4 ± 16.2%. No cases of significant vascular remodeling or late acquired stent malapposition were observed. After two years, there were no cases of major adverse cardiac events CONCLUSION: Although the intracoronary ABI-007 administration was well tolerated, with no adverse toxic events reported, this treatment modality demonstrated a low capacity of suppressing neointimal tissue formation after bare-metal stent implantation, with late loss and percent of volumetric obstruction percentages similar to those observed after bare-metal stent implantation alone.