OBJETIVOS: Avaliar a segurança e a eficácia da fragmentação percutânea do trombo (FPT) no tromboembolismo pulmonar (TEP) maciço em pacientes com contra-indicação à administração de trombolíticos. MÉTODOS: Entre julho de 1999 e agosto de 2005, 10 pacientes (7 homens, 3 mulheres, idade média de 57±18 anos) com TEP maciço e contra-indicação à administração de trombolíticos foram submetidos a FPT. A saturação arterial de oxigênio (Sat.O2), índice de Walsh (IW), pressão arterial pulmonar média (PAP), pressão arterial sistêmica média (PAS) e função ventricular direita (FVD) ao ecocardiograma Doppler transtorácico foram avaliados pré e pós-procedimento. Foi realizada análise estatística por meio do teste de Wilcoxon pareado, sendo p significativo quando < 0,05. RESULTADOS: Após o tratamento por FPT houve melhora da Sat. O2 [87,4±1,3% vs 92,3±3,1% (p<0,001)], do IW [6,4±1,07 vs 4,4±1,42 (p=0,003), PAP [31,8±4,6 mmHg vs 25,5±3,4 mmHg (p<0,001)] e PAS [73,9±8,7 vs 85±8,3 (p=0,001). A FVD pré-procedimento percutâneo era grave nos 10 pacientes, porém até o 10º dia após a FPT passou a ser normal ou discreta em 8 e moderada em 1. Não houve complicações técnicas ou do sítio vascular de acesso relacionadas a FPT. Houve 1 óbito hospitalar (10%). O paciente em questão foi o único em quem não se obteve sucesso com o procedimento. CONCLUSÃO: A FPT mostrou-se segura pela ausência de complicações relacionadas ao procedimento. A melhora na Sat.O2, no IW, na PAP, na PAS e na FVD em 90% dos casos, revelaram a eficácia do procedimento, sugerindo ser esse uma alternativa no tratamento do TEP maciço em pacientes com contra-indicação à trombolíticos sistêmicos.

OBJECTIVES: To evaluate the safety and efficacy of percutaneous thrombus fragmentation (PTF) for massive pulmonary embolism (PE) in patients with contraindications to the administration of thrombolytics. METHODS: Between July 1999 and August 2005, 10 patients (7 males, 3 females, age 57±18 years) with massive PE and contraindications to the administration of thrombolytics underwent PTF. A transthoracic doppler echocardiogram was used to evaluate arterial oxygen saturation (Sat O2), the Walsh index (WI), mean pulmonary artery pressure (PAP), mean systemic blood pressure (SBP) and right ventricular function (RVF) before and after the procedure. Statistical analysis was conducted using the paired Wilcoxon test, of which p was significant when < 0.05. RESULTS: After the PTF treatment there was an improvement in Sat. O2 [87.4 ± 1.3% vs 92.3 ± 3.1% (p < 0.001)], WI [6.4 ± 1.07 vs 4.4 ± 1.42 (p = 0.003)], PAP [31.8 ± 4.6 mmHg vs 25.5 ± 3.4 mmHg (p < 0.001)] and SBP [73.9 ± 8.7 vs 85 ± 8.3 (p = 0.001). The ten patients had severe RVF before the percutaneous treatment; however, within 10 days after PTF, 8 presented normal or discrete function and 1 presented mitigated function. There were no technical or vascular access site complications related to PTF. One patient died in the hospital (10%). The procedure was successful for the other nine patients. CONCLUSION: The lack of adverse complications related to the procedure, proves that PTF is safe. The improvement in Sat O2, WI, PAP, SBP and RVF in 90% of the cases demonstrates the efficacy of the procedure, indicating that it is an alternative treatment for massive PE in patients with contraindications for the administration of systemic thrombolytics.

OBJETIVO: Identificar os perfis clínico/angiográfico e relacionados ao procedimento de pacientes com angina instável atendidos em um hospital terciário e tratados por meio de intervenções coronarianas percutâneas. MÉTODOS: Estudo de uma casuística consecutiva de 1.413 pacientes, selecionados a partir de um banco de dados informatizado e revascularizados percutaneamente no triênio 2002-2004. Não houve critérios de inclusão/exclusão. RESULTADOS: Hipertensão arterial sistêmica (74%) e hipercolesterolemia (65%) foram os fatores de risco clássicos para doença coronariana mais observados. Antecedentes de infarto do miocárdio e cirurgia de revascularização miocárdica foram respectivamente observados em 28% e 24% dos casos. Os subgrupos mais comumente tratados foram o IIB (48%) e IIIB (28%). O clopidogrel foi prescrito a 51% dos pacientes, enquanto os inibidores IIb IIIa foram utilizados em 7%. Doença coronariana multiarterial na cinecoronariografia diagnóstica ocorreu em 42% dos casos. Lesões-alvo tipo B2 ou C foram tratadas em 64%, das quais 94% situavam-se em vasos naturais. Lesões reestenóticas foram dilatadas em 5% dos pacientes. Todas as intervenções foram realizadas utilizando os stents coronarianos, a maioria dos quais (67%) do tipo convencional. CONCLUSÕES: 1) os subgrupos IIB e IIIB foram os mais comumente tratados (76%); 2) o clopidogrel foi o antitrombótico mais prescrito (51%); 3) a coronariopatia multiarterial foi observada em 42% dos casos, com predomínio de lesões-alvo complexas e situadas em vasos naturais; 4) a técnica de dilatação predominante foi o implante dos stents coronarianos.

OBJECTIVE: To identify clinical and angiographic profiles of patients with unstable angina seen at a tertiary hospital and treated with percutaneous coronary intervention (PCI). METHODS: Study of a consecutive series of 1413 patients, selected from a computerized database, who underwent percutaneous revascularization in the three-year period of 2002-2004. There were no inclusion/exclusion criteria. RESULTS: Systemic arterial hypertension (74%) and hypercholesterolemia (65%) were the classical risk factors for coronary disease most frequently observed. Coronary artery bypass grafting and history of myocardial infarction were found in 24% and 28% of the cases, respectively. The subgroups most commonly treated were the IIB (48%) and IIIB (28%). Clopidogrel was prescribed for 51% of the patients and glycoprotein IIb/IIIa inhibitors, for 7%. Multivessel disease evidenced by coronary angiography was detected in 42% of the cases. Type B2 or C lesions were treated in 64%, 94% of which in native vessels. Restenotic lesions were dilated in 5% of the patients. All interventions were performed using coronary stents, the majority of which (67%) were standard bare-metal stents. CONCLUSIONS: 1) Subgroups IIB and IIIB were the most frequently treated (76%); 2) Clopidogrel was the most prescribed antithrombotic agent (51%); 3) Multivessel coronary artery disease was found in 42% of the cases, most of which were complex target lesions located in native vessels; 4) Coronary stent implantation was the chief dilation technique used.

Os autores descrevem um caso de fratura de stent Cypher®. Inicialmente, a fratura foi acompanhada clinicamente (paciente era assintomático, sem evidência clara de isquemia à investigação não-invasiva). Entretanto, durante seguimento tardio, o paciente passou a apresentar sintomas de angina estável, necessitando de nova intervenção percutânea e, posteriormente, implante de novo stent farmacológico.

The authors describe a case of stent fracture following the use of Cypher®. Initially, the fracture was clinically approached (patient was asymptomatic with no clear evidence of ischemia in non-invasive assessment). However, during the long-term follow-up this patient started manifesting stable angina symptoms requiring new percutaneous intervention with additional drug-eluting stent implantation.

OBJETIVO: Avaliar a segurança e eficácia da estratégia de tratamento cirúrgico ou conservador em pacientes com de lesões duvidosas de tronco da coronária esquerda (TCE), baseada nos achados do ultra-som intracoronariano (USIC). MÉTODOS: Incluídos 66 pacientes consecutivos com lesões angiograficamente duvidosas no TCE submetidos a avaliação ao USIC. Foram divididos em dois grupos de acordo com os achados do USIC. Grupo I, mantidos em tratamento clínico [área mínima da luz (AML) > 6,0 mm² e/ou diâmetro mínimo da luz (DML) > 2,5 mm] e Grupo II, encaminhados a revascularização (AML < 6,0 mm² e/ou DML < 2,5 mm). Avaliou-se a ocorrência de eventos cardíacos maiores (óbito, infarto agudo do miocárdio e/ou revascularização da lesão alvo) durante a evolução. RESULTADOS: Quarenta e um (62%) pacientes foram alocados no Grupo I e 25 (38%) no Grupo II. A média de seguimento foi de 42,1 meses. A angiografia coronariana não conseguiu diferenciar os dois grupos pela gravidade da lesão (DML 1,98 mm Grupo I versus 1,72 mm Grupo II, p = 0,75) ao contrário do USIC (DML 3,41 mm Grupo I versus 2,01 mm Grupo II, p < 0,001). Não houve óbito ou infarto do miocárdio no Grupo I. A sobrevida livre de eventos cardíacos maiores foi de 95% no grupo I versus 87,5% no Grupo II (p=ns). CONCLUSÃO: A estratégia de decisão de tratamento de pacientes com lesões angiograficamente duvidosas no TCE, guiada pelos achado do USIC, mostrou-se segura e eficaz.

OBJECTIVE: To evaluate the safety and efficacy of surgical treatment approach vs. conservative approach in patients with ambiguous lesions in the left main coronary artery (LMCA), based on intracoronary ultrasound (ICUS) findings. METHODS: Sixty-six consecutive patients with angiographically ambiguous lesions were included and submitted to ICUS assessment. They were divided in two groups, according to the ICUS findings. Group I was maintained under clinical treatment [minimal lumen area (MLA) > 6.0 mm² and/or minimal lumen diameter (MLD) > 2.5 mm] and Group II was submitted to revascularization (MLA < 6.0 mm² and/or MLD < 2.5 mm). The occurrence of major cardiac events (death, acute myocardial infarction and/or revascularization of the target lesion) was assessed during follow-up. RESULTS: Forty-one (62%) patients were allocated in Group I and 25 (38%) in Group II. Mean follow-up was 42.1 months. The coronary angiography did not differentiate the two groups regarding lesion severity (MLD 1.98 mm in Group I vs. 1.72 mm in Group II; p = 0.75) in opposition to ICUS (MLD 3.41 mm in Group I vs. 2.01 mm in Group II; p < 0.001). There was no death or myocardial infarction in Group I. The survival rate free of major cardiac events was 95% in Group I vs. 87.5% in Group II (p=ns). CONCLUSION: Treatment decision-making of patients with ambiguous lesions in the LMCA guided by ICUS findings showed to be safe and effective.

OBJETIVO: Estabelecer a correlação da cintilografia de perfusão do miocárdio (CPM) com Tecnécio 99m-MIBI (MIBI) e injeção de adenosina, empregando a angiografia coronária quantitativa (ACQ) e o ultra-som intracoronário (UIC) como comparação. MÉTODOS: Estudo de 70 pacientes com doença arterial coronária (DAC), encaminhados à CPM com MIBI e adenosina. As manifestações clínicas, do eletrocardiograma (ECG) e os resultados das imagens foram correlacionadas às variáveis da análise visual e quantitativa da angiografia, bem como ao UIC. RESULTADOS: A média de idades foi de 60,6 anos, com 39 pacientes do sexo masculino. A angiografia coronária evidenciou estenose do diâmetro da luz (E%) de 49,94% em 105 artérias, com reavaliação à ACQ em 83 artérias (79%) e média de 44,20%, p<0,05. Infradesnível de ST durante adenosina associou-se a maiores graus de E% (55,0% vs 47,8%), p<0,05). A isquemia cintilográfica correlacionou-se a maior área porcentual de obstrução da luz pelo UIC (AO%). Os achados clínicos, do ECG e das imagens foram considerados em conjunto e expressos como respostas globais isquêmicas versus não-isquêmicas . A isquemia associou-se a menores valores do diâmetro mínimo da luz (DML) e da área mínima da luz (AML), obtidos à ACQ e ao UIC. CONCLUSÃO: A cintilografia do miocárdio com 99mTc-MIBI e adenosina correlaciona-se à AO% ao UIC, considerando-se as imagens de perfusão. Na avaliação dos resultados globais da prova observa-se associação com os diâmetros e as áreas da luz nos locais de obstrução, obtidos à ACQ e ao UIC.

OBJECTIVE: To correlate myocardial perfusion scintigraphy (MPS) with Tc-99m-MIBI and adenosine infusion using quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS). METHODS: Seventy patients with coronary artery disease (CAD) referred for myocardial perfusion scintigraphy (MPS) with MIBI and adenosine were studied. Clinical, electrocardiographic (ECG), and scintigraphic findings were correlated with variables of visual and quantitative angiographic analysis, as well as to those of IVUS. RESULTS: The mean age of patients was 60.6 years, and 39 were male. Coronary angiography showed percentage of diameter stenosis (% DS) of 49.94% in 105 arteries, 83 of which were re-evaluated by QCA (79%), mean of 44.20%, p<0.05. ST-segment depression during adenosine infusion was associated with higher degrees of % DS (55.0% vs. 47.8%), p<0.05). Scintigraphic ischemia was correlated with greater cross-sectional area of lumen obstruction by IVUS (% CSA). Clinical, ECG, and IVUS findings were considered together and expressed as global ischemic versus non-ischemic responses. Ischemia was associated with lower values of minimal lumen diameter (MLD) and minimal lumen area (MLA) determined by QCA and IVUS. CONCLUSION: Tc-99m-MIBI and adenosine myocardial SPECT is correlated with % CSA on IVUS, perfusion images considered. Global results assessment showed association between lumen diameter and area at obstructed sites as determined by QCA and IVUS.

OBJETIVO: Investigar se a hiper-homocisteinemia é fator de risco independente para doença aterosclerótica coronariana em idosos. MÉTODOS: Estudo caso-controle com 172 idosos, 88 pertencentes ao grupo controle e 84 ao grupo caso, que apresentavam cineangiocoronariografia solicitada por indicações clínicas. Angiografia coronariana quantitativa foi realizada em 91% dos pacientes. Homocisteinemia foi avaliada sob forma contínua e categorizada, por análise univariada e multivariada. RESULTADOS: Quando analisada sob forma contínua, verificou-se que, na análise univariada, os idosos do grupo caso apresentaram média de níveis de homocisteinemia significativamente mais elevada que a dos idosos do grupo controle (14,33±4,59 µmol/l versus 11,99± 4,59 µmol/l , p=0,015). Na análise multivariada, a homocisteinemia sob forma contínua associou-se a razão de risco para doença arterial coronariana de 1,07 a cada aumento de 1 µmol/l de nível de homocisteína. Aumento de 5 µmol/l correspondeu a razão de risco de 1,40. Quando analisada sob forma categorizada, definiu-se como hiper-homocisteinemia os valores encontrados acima do percentil 75 do grupo controle (14 µmol/l ). Hiper-homocisteinemia foi encontrada em 34% dos idosos, sendo 37,3% no grupo controle e 62,7% no grupo caso (p=0,009). Na análise multivariada, a hiperhomocisteinemia constituiu fator de risco independente para doença aterosclerótica coronariana em idosos, com razão de risco para doença arterial coronariana de 2,03, intervalo de confiança 95%, 1,02-4,03. CONCLUSÃO: Hiper-homocisteinemia foi fator de risco independente para doença arterial coronariana em idosos.

OBJECTIVE: To investigate whether hyperhomocysteinemia is an independent risk factor for atherosclerotic disease in elderly individuals METHODS: A case-control study with 172 elderly individuals, 88 belonging to control group and 84 to case group, who showed coronary angiography requested for clinical indications. Quantitative coronary angiography was performed in 91% of the patients. Homocysteinemia was assessed in a continuous and categorized way, through univariate and multivariate analysis. RESULTS: When analyzed continuously, in univariate analysis, it was verified that case group elderly individuals showed an average homocysteinemia levels significantly higher than the control group individuals' (14.33±4.59 µmol/l against 11.99±4.59 µmol/l, p=0.015). In multivariate analysis, continuous homocysteinemia was associated to the risk rate for coronary artery disease of 1.07 for each 1 µmol/l increase of homocysteine level. Na increase of 5 µmol/l corresponded to the risk rate of 1.40. When analyzed in categorized way, the values found over percentile 75 of control group (14 µmol/l) were defined as hyperhomocysteinemia. Hyperhomocysteinemia was found in 34% of elderly individuals, being 37.3% in control group and 62.7% in case group (p= 0.009). In multivariate analysis, hyperhomocysteinemia constituted an independent risk factor for coronary atherosclerotic disease for elderly individuals, with a risk rate for coronary artery disease of 2.03, confidence interval 95%, 1.02-4.03. CONCLUSION: Hyperhomocysteinemia was an independent risk factor for coronary artery disease in elderly individuals.

OBJECTIVE: Analyze the dromotropic disturbances (vector-electrocardiographic), and the possible anatomic causes, provoked by selective alcohol injection in the septal branch, for percutaneous treatment, of obstructive hypertrophic cardiomyopathy. METHODS: Ten patients with a mean age of 52.7 years underwent percutaneous septal ablation (PTSA) from october 1998; all in functional class III/IV). Twelve-lead electrocardiogram was performed prior to and during PTSA, and later electrocardiogram and vectorcardiogram according to Frank's method. The patients were followed up for 32 months. RESULTS: On electrocardiogram (ECG) prior to PTSA all patients had sinus rhythm and left atrial enlargement, 8 left ventricular hypertrophy of systolic pattern. On ECG immediately after PTSA, 8 had complete right bundle-branch block; 1 transient total atrioventricular block; 1 alternating transient bundle-branch block either right or hemiblock. On late ECG 8 had complete right bundle-branch block confirmed by vectorcardiogram, type 1 or Grishman. CONCLUSION: Septal fibrosis following alcohol injection caused a predominance of complete right bundle-branch block, different from surgery of myotomy/myectomy.

OBJECTIVE - To assess mortality and the psychological repercussions of the prolonged waiting time for candidates for heart surgery. METHODS - From July 1999 to May 2000, using a standardized questionnaire, we carried out standardized interviews and semi-structured psychological interviews with 484 patients with coronary heart disease, 121 patients with valvular heart diseases, and 100 patients with congenital heart diseases. RESULTS - The coefficients of mortality (deaths per 100 patients/year) were as follows: patients with coronary heart disease, 5.6; patients with valvular heart diseases, 12.8; and patients with congenital heart diseases, 3.1 (p<0.0001). The survival curve was lower in patients with valvular heart diseases than in patients with coronary heart disease and congenital heart diseases (p<0.001). The accumulated probability of not undergoing surgery was higher in patients with valvular heart diseases than in the other patients (p<0.001), and, among the patients with valvular heart diseases, this probability was higher in females than in males (p<0.01). Several patients experienced intense anxiety and attributed their adaptive problems in the scope of love, professional, and social lives, to not undergoing surgery. CONCLUSION - Mortality was high, and even higher among the patients with valvular heart diseases, with negative psychological and social repercussions.

A rotura do septo interventricular (RSI) reduz a perspectiva de sobrevida do paciente com infarto agudo do miocárdio (IAM). Entre 1968 e 1987, atendemos 48 pacientes (p) com este diagnóstico, sendo 16 (33%) mantidos clinicamente e 32 (67%) submetidos a cirurgia. Todos os p clínicos faleceram durante a internação. Dentre os p operados, o IAM se localizava na parede anterior em 18 (56%) e na inferior em 14 (44%), com mortalidades respectivas de 6 (33%) e 4 (29%). Disfunção ventricular esquerda severa (Killip III e IV) foi encontrada em 26 (81%). Em 18 (56%) p foi introduzido o cateter de Swan-Ganz. Dos 31 (97%) p que se submeteram a cinecoronariografia, 22 (71%) apresentavam lesão uniarterial e 9 (29%), doença multiarterial. Entre os p com lesões isoladas, a descendente anterior foi acometida em 15 (68%), a coronária direita em 6 (27%) e a circunflexa em 1 (5%). A cirurgia foi realizada nas 2 primeiras semanas de evolução em 8 (25%) e, após este período, em 24 (75%), com mortalidades de 6 (75%) e 4 (17%), respectivamente. O balão intra-aórtico foi usado em 7 (22%). Os procedimentos cirúrgicos associados ao fechamento da RSI foram revascularização miocárdica em 10 (31%), aneurismectomia de VE em 17 (53%) e infartectomia e 6 (19%). Na evolução tardia, dos 22 sobreviventes, 14 (64%) encontram-se assintomáticos, 1 (5%) sintomático, ocorreram 4 (18%) óbitos e perdeu-se a evolução de 3 (13%). Concluímos que, apesar do risco cirúrgico, a cirurgia precoce ainda é a melhor opção terapêutica desta complicação.

The ventricular septal rupture (VSR) following acute myocardial infarction (AMI) is a rare and catasthrophic complication with a high mortality rate. Surgery is the only effective procedure to try to control this complication. However the surgical mortality is elevated and is closely related to the post-infarct period thus making the indication for the precise time for surgery one the fundamental aspects for its success. In a population of 48 patients with diagnosis of VSD following AMI, according to the criteria of the Myocardial Infarction Research United, we treated 32 (67%) with surgery. The diagnosis was confirmed by hemodynamic in all patients. The AMI was anterior in 18 cases (56%) and inferior in 14 (44%); the mortality rate is 6 (33%) and 4 (29%) cases respectively. Severe heart failure (Killip III and IV) was present in 26 cases (81%) and life threatening arrhythmias in 13 (41%). A Swan-Ganz catheter was introduced at bedside in 18 (56%) patients to confirm the diagnosis and provide a better therapeutic management. Angiographic studies were performed in 31 (97%). Cineangiography showed a critical lesion (obstruction equal or greater than 70% of the lumen) in one vessel in 22 patients (71%): left anterior descending coronary artery in 15 (68%), right coronary artery in 6 (27%) and left circunflex in 1 (5%). Nine cases (29%) had critical lesions in two vessels. The pulmonary artery pressure was always elevated in those patients in whom the pressure was measured. Clinical treatment was used in 16 (33%) cases and all died during hospitalization. Eight patients (25%) underwent the surgery within the first two weeks and 24 (75%) after this period; mortality rate was 6 (75%) and 4 (17%) cases respectively. Nine patients were re-catheterized in the post operative period and only one presented signs of significant shunt in the ventricular level. This patient who was the oldest of the group was reoperated later. Of the 22 patients discharged from the hospital 15 are long-term survivors. In 3 the follow-up was lost and 4 died. The accumulated data allows us to conclude that: 1) the attempt to postpone surgery by keeping the patients under medical treatment waiting for a more favorable time for surgery did not produce satisfactory results; 2) surgery should be performed in the acute phase (first two weeks) in spite of a still elevated mortality in this group; 3) after the first two weeks the results are good with low mortality rate for this kind of surgery; 4) VSD reappearence was infrequent.