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Nunes RAB, Alves da Costa LM, Scudeler TL, de Carvalho Cantarelli MJ, Castello H, de Figueiredo Oliveira GB, Avezum Junior Á. Percutaneous coronary intervention or medical therapy in patients with severe aortic stenosis and coronary artery disease undergoing transcatheter aortic valve implantation: a real-world analysis using data from an international network. Coron Artery Dis 2023; 34:134-137. [PMID: 36720022 DOI: 10.1097/mca.0000000000001215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Patients undergoing transcatheter aortic valve implantation (TAVI) due to severe aortic stenosis have a high prevalence of coronary artery disease (CAD). As many of them have high surgical risk, CAD treatment in this group has typically been carried out with optimal medical treatment or paired with percutaneous coronary intervention (PCI). However, the best approach in this scenario is not well established. We aimed to evaluate 5-year cardiovascular outcomes in patients with aortic stenosis and chronic CAD treated with medical treatment alone compared to PCI coupled with medical therapy before or during TAVI. We used data from a large multinational electronic health record network (TriNetX). Patients aged 18 years or older with severe aortic stenosis and CAD who underwent TAVI in the last 10 years before the analysis were considered eligible. Five-year Kaplan-Meier curves and hazard ratios were calculated. We identified 19 058 patients undergoing isolated TAVI and 2277 patients undergoing TAVI and PCI. Using propensity matching scores, 2277 patients in each group were compared. The 5-year cumulative incidence of MACE was 22.92% in the isolated TAVI group, vs. 25.91% in the PCI-TAVI group. The probability of the composite primary outcome was not significantly different between the isolated TAVI group vs. the PCI-TAVI group [53.1 vs. 47.6%, adjusted hazard ratio (HR) 0.92, 95% confidence interval (CI), 0.80-1.05]. In a real-world study of patients with CAD and severe aortic stenosis, the 5-year probability of death, acute coronary syndrome and ischemic stroke did not differ between patients undergoing isolated TAVI compared to patients undergoing PCI before or during TAVI.
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Kassis JJ, Mangione FM, Cristóvão SA, Zuliani Mauro MF, Acosta Melo C, Dutra GA, Menezes Alves da Costa L, Alves da Costa F, Mangione JA. Pure Aortic Regurgitation Complicated by Membranous Interventricular Septum Aneurysm Treated With Transcatheter Aortic Valve Replacement. JACC: Case Reports 2023; 10:101762. [PMID: 36974043 PMCID: PMC10039378 DOI: 10.1016/j.jaccas.2023.101762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 12/12/2022] [Accepted: 01/11/2023] [Indexed: 03/17/2023]
Abstract
An 89-year-old woman with severe aortic regurgitation and an aneurysmal interventricular membranous septum extending into the aortic annulus underwent successful transcatheter aortic valve replacement. A challenging case because of the risk of valve mispositioning complications attributed to the co-occurrence of pure aortic regurgitation (very low calcium burden) with an aneurysmal interventricular membranous septum. (Level of Difficulty: Intermediate.).
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Affiliation(s)
| | | | | | | | | | | | - Leandro Menezes Alves da Costa
- Beneficência Portuguesa de São Paulo Hospital, São Paulo, Brazil
- Clínica Paulista de Doença Cardiovascular, São Paulo, Brazil
| | - Fernando Alves da Costa
- Beneficência Portuguesa de São Paulo Hospital, São Paulo, Brazil
- Clínica Paulista de Doença Cardiovascular, São Paulo, Brazil
| | - José Armando Mangione
- Beneficência Portuguesa de São Paulo Hospital, São Paulo, Brazil
- Address for correspondence: Dr Fernanda Mangione, Beneficência Portuguesa de São Paulo Hospital, Rua Maestro Cardim, 637 Bela Vista, São Paulo, São Paulo 01323-001, Brazil.
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Nunes RAB, Neves PDMDM, da Costa LMA, Bachour P, Cantarelli MJDC, Oliveira GBDF, Avezum Jr. Á. Five-year cardiovascular outcomes in patients with chronic myeloid leukemia treated with imatinib, dasatinib, or nilotinib: A cohort study using data from a large multinational collaborative network. Front Cardiovasc Med 2023; 10:888366. [PMID: 36824461 PMCID: PMC9941183 DOI: 10.3389/fcvm.2023.888366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 01/09/2023] [Indexed: 02/10/2023] Open
Abstract
Background Breakpoint cluster region-Abelson gene (BCR-ABL) tyrosine kinase inhibitors (TKIs) have revolutionized the treatment of patients with chronic myeloid leukemia (CML). However, concern has arisen about the cardiac safety profile of these drugs. Objectives This study aims to compare long-term risks of adverse cardiovascular and cerebrovascular events (ACE), heart failure or left ventricular ejection fraction (LVEF) < 50%, and venous thromboembolic events (VTE) in patients with CML treated with BCR-ABL TKIs, using data from a large multinational network. Methods Patients aged ≥ 18 years with CML treated with imatinib, dasatinib, or nilotinib without prior cardiovascular or cerebrovascular disease were included. We used propensity score matching to balance the cohorts. The 5-year cumulative incidences and hazard ratios were calculated. Results We identified 3,722 patients with CML under treatment with imatinib (n = 1,906), dasatinib (n = 1,269), and nilotinib (n = 547). Patients with imatinib compared to dasatinib showed a higher hazard ratio (HR) for ACE (HR 2,13, 95% CI 1.15-3.94, p = 0.016). Patients with imatinib presented a lower HR than nilotinib for ACE (HR 0.50, 95% CI 0.30-0.83, p = 0.0074). In relation to heart failure or LVEF < 50%, patients with imatinib had a higher HR than dasatinib (HR 9.41, 95% CI 1.22-72.17, p = 0.03), but no significant difference was observed between imatinib and nilotinib (HR 0.48, 95% CI 0.215-1.01, p = 0.064). Conclusion In this retrospective study with a large number of patients with CML, those treated with nilotinib had a higher 5-year ratio of ACE, while patients with dasatinib showed a lower ratio than patients with imatinib. The ratio of heart failure was higher in patients with imatinib than in patients with dasatinib, but not when compared to nilotinib.
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Affiliation(s)
- Rafael Amorim Belo Nunes
- Department of Cardiology, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil,*Correspondence: Rafael Amorim Belo Nunes,
| | | | | | - Philip Bachour
- Department of Hematology and Bone Marrow Transplant, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | | | - Álvaro Avezum Jr.
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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Nunes RAB, Abdo ANR, da Costa LMA, Skromov de Albuquerque A. Acute myocarditis in a patient with acute promyelocytic leukemia treated with all-trans retinoic acid and idarubicin: a possible relationship with the differentiation syndrome or early anthracycline cardiotoxicity? Hematol Transfus Cell Ther 2023; 45:127-130. [PMID: 34548260 PMCID: PMC9938446 DOI: 10.1016/j.htct.2021.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/16/2021] [Accepted: 06/24/2021] [Indexed: 02/06/2023] Open
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Lanz-Luces JR, Costa FA, Guzman LFE, Gagliardi ARDT, Lanz-Luces JA, Lanz-Souquett JD, Costa LMAD. DD Genotype and Atherosclerosis in Overweight Menopausal Women. International Journal of Cardiovascular Sciences 2021. [DOI: 10.36660/ijcs.20200400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Costa LMAD, Nunes RAB, Scudeler TL. Cardiopulmonary Resuscitation in Prone Position. International Journal of Cardiovascular Sciences 2021. [DOI: 10.36660/ijcs.20200091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Oikawa FTC, Hueb W, Nomura CH, Hueb AC, Villa AV, da Costa LMA, de Melo RMV, Rezende PC, Segre CAW, Garzillo CL, Lima EG, Ramires JAF, Filho RK. Abnormal elevation of myocardial necrosis biomarkers after coronary artery bypass grafting without established myocardial infarction assessed by cardiac magnetic resonance. J Cardiothorac Surg 2017; 12:122. [PMID: 29284532 PMCID: PMC5747262 DOI: 10.1186/s13019-017-0684-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The diagnosis of peri-procedural myocardial infarction is complex, especially after the emergence of high-sensitivity markers of myocardial necrosis. METHODS In this study, patients with normal baseline cardiac biomarkers and formal indication for elective on-pump coronary bypass surgery were evaluated. Electrocardiograms, cardiac biomarkers, and cardiac magnetic resonance imaging with late gadolinium enhancement were performed before and after procedures. Myocardial infarction was defined as more than ten times the upper reference limit of the 99th percentile for troponin I and for creatine kinase isoform (CK-MB) and by the findings of new late gadolinium enhancement on cardiac magnetic resonance. We assessed the release of cardiac biomarkers in patients with no evidence of myocardial infarction on cardiac magnetic resonance. RESULTS Of 75 patients referred for on-pump coronary bypass surgery, 54 (100%) did not have evidence of myocardial infarction on cardiac magnetic resonance. However, all had a peak troponin I above the 99th percentile; 52 (96%) had an elevation 10 times higher than the 99th percentile. Regarding CK-MB, 54 (100%) patients had a peak CK-MB above the 99th percentile limit, and only 13 (24%) had an elevation greater than 10 times the 99th percentile. The median value of troponin I peak was 3.15 (1.2 to 3.9) ng/mL, which represented 78.7 times the 99th percentile. CONCLUSION In this study, different from CK-MB findings, troponin was significantly increased in the absence of myocardial infarction on cardiac magnetic resonance. Thus, CK-MB was more accurate than troponin I for excluding procedure-related myocardial infarction. These data suggest a higher troponin cutoff for the diagnosis of coronary bypass surgery related myocardial infarction. CLINICAL TRIAL REGISTRATION http://www.isrctn.com/ISRCTN09454308 . Registered 08 May 2012.
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Affiliation(s)
- Fernando Teiichi Costa Oikawa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Whady Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Cesar Higa Nomura
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Ciappina Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Volney Villa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Leandro Menezes Alves da Costa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rodrigo Morel Vieira de Melo
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Paulo Cury Rezende
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Carlos Alexandre Wainrober Segre
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Cibele Larrosa Garzillo
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Eduardo Gomes Lima
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Jose Antonio Franchini Ramires
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Vieira de Melo RM, Hueb W, Nomura CH, Ribeiro da Silva EE, Villa AV, Oikawa FTC, da Costa LMA, Rezende PC, Garzillo CL, Lima EG, Franchini Ramires JA, Kalil Filho R. Biomarker release after percutaneous coronary intervention in patients without established myocardial infarction as assessed by cardiac magnetic resonance with late gadolinium enhancement. Catheter Cardiovasc Interv 2017; 90:87-93. [DOI: 10.1002/ccd.27125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 04/05/2017] [Accepted: 04/23/2017] [Indexed: 12/24/2022]
Affiliation(s)
| | - Whady Hueb
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | - Cesar Higa Nomura
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | | | - Alexandre Volney Villa
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | | | | | - Paulo Cury Rezende
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | - Cibele Larrosa Garzillo
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | - Eduardo Gomes Lima
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | | | - Roberto Kalil Filho
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
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da Costa LMA, Hueb W, Nomura CH, Hueb AC, Villa AV, Oikawa FTC, Vieira de Melo RM, Rezende PC, Segre CAW, Garzillo CL, Lima EG, Ramires JAF, Kalil Filho R. Significant elevation of biomarkers of myocardial necrosis after coronary artery bypass grafting without myocardial infarction established assessed by cardiac magnetic resonance. Medicine (Baltimore) 2017; 96:e6053. [PMID: 28178154 PMCID: PMC5313011 DOI: 10.1097/md.0000000000006053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The release of myocardial necrosis biomarkers after off-pump coronary artery bypass grafting (OPCAB) frequently occurs. However, the correlation between biomarker release and the diagnosis of procedure-related myocardial infarction (MI) (type 5) has been controversial. This study aimed to evaluate the amount and pattern of cardiac biomarker release after elective OPCAB in patients without evidence of a new MI on cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE).Patients with normal baseline cardiac biomarkers referred for elective OPCAB were prospectively included. CMR with LGE was performed in all patients before and after interventions. Measurements of troponin I (cTnI) and creatine kinase MB fraction (CK-MB) were systematically performed before and after the procedure. Patients with new LGE on the postprocedure CMR were excluded.All of the 53 patients without CMR evidence of a procedure-related MI after OPCAB exhibited a cTnI elevation peak above the 99th percentile. In 48 (91%), the peak value was >10 times this threshold. However, 41 (77%) had a CK-MB peak above the limit of the 99th percentile, and this peak was >10 times the 99th percentile in only 7 patients (13%). The median peak release of cTnI was 0.290 (0.8-3.7) ng/mL, which is 50-fold higher than the 99th percentile.In contrast with CK-MB, considerable cTnI release often occurs after an elective OPCAB procedure, despite the absence of new LGE on CMR.
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Hueb W, Gersh BJ, Alves da Costa LM, Costa Oikawa FT, Vieira de Melo RM, Rezende PC, Garzillo CL, Lima EG, Nomura CH, Villa AV, Hueb AC, Cassaro Strunz CM, Favarato D, Takiuti ME, de Albuquerque CP, Ribeiro da Silva EE, Franchini Ramires JA, Kalil Filho R. Accuracy of Myocardial Biomarkers in the Diagnosis of Myocardial Infarction After Revascularization as Assessed by Cardiac Resonance: The Medicine, Angioplasty, Surgery Study V (MASS-V) Trial. Ann Thorac Surg 2016; 101:2202-8. [PMID: 26912303 DOI: 10.1016/j.athoracsur.2015.11.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/14/2015] [Accepted: 11/13/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The lack of a correlation between myocardial necrosis biomarkers and electrocardiographic abnormalities after revascularization procedures has resulted in a change in the myocardial infarction (MI) definition. METHODS Patients with stable multivessel disease who underwent percutaneous or surgical revascularization were included. Electrocardiograms and concentrations of high-sensitive cardiac troponin I (cTnI) and creatine kinase (CK)-MB were assessed before and after procedures. Cardiac magnetic resonance and late gadolinium enhancement were performed before and after procedures. MI was defined as more than five times the 99th percentile upper reference limit for cTnI and 10 times for CK-MB in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), respectively, and new late gadolinium enhancement for cardiac magnetic resonance. RESULTS Of the 202 patients studied, 69 (34.1%) underwent on-pump CABG, 67 (33.2%) off-pump CABG, and 66 (32.7%) PCI. The receiver operating characteristic curve showed the accuracy of cTnI for on-pump CABG, off-pump CABG, and PCI patients was 21.7%, 28.3%, and 52.4% and for CK-MB was 72.5%, 81.2%, and 90.5%, respectively. The specificity of cTnI was 3.6%, 9.4%, and 42.1% and of CK-MB was 73.2%, 86.8%, and 96.4%, respectively. Sensitivity of cTnI was 100%, 100%, and 100% and of CK-MB was 69.2%, 64.3%, and 44.4%, respectively. The best cutoff of cTnI for on-pump CABG, off-pump CABG, and PCI was 6.5 ng/mL, 4.5 ng/mL, and 4.5 ng/mL (162.5, 112.5, and 112.5 times the 99th percentile upper reference limit) and of CK-MB was 37.5 ng/mL, 22.5 ng/mL, and 11.5 ng/mL (8.5, 5.1, and 2.6 times the 99th percentile upper reference limit), respectively. CONCLUSIONS Compared with cardiac magnetic resonance, CK-MB was more accurate than cTnI for diagnosing MI. These data suggest a higher troponin cutoff for the diagnosis of procedure-related MI.
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Affiliation(s)
- Whady Hueb
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil.
| | | | | | | | | | - Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Cibele Larrosa Garzillo
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Eduardo Gomes Lima
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Cesar Higa Nomura
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Alexandre Volney Villa
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Alexandre Ciappina Hueb
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Celia Maria Cassaro Strunz
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Desiderio Favarato
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Myrthes Emy Takiuti
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Cicero Piva de Albuquerque
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | | | | | - Roberto Kalil Filho
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
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Rezende PC, Rahmi RM, Uchida AH, da Costa LMA, Scudeler TL, Garzillo CL, Lima EG, Segre CAW, Girardi P, Takiuti M, Silva MF, Hueb W, Ramires JAF, Kalil Filho R. Type 2 diabetes mellitus and myocardial ischemic preconditioning in symptomatic coronary artery disease patients. Cardiovasc Diabetol 2015; 14:66. [PMID: 26025451 PMCID: PMC4451743 DOI: 10.1186/s12933-015-0228-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 05/21/2015] [Indexed: 01/10/2023] Open
Abstract
Background The influence of diabetes mellitus on myocardial ischemic preconditioning is not clearly defined. Experimental studies are conflicting and human studies are scarce and inconclusive. Objectives Identify whether diabetes mellitus intervenes on ischemic preconditioning in symptomatic coronary artery disease patients. Methods Symptomatic multivessel coronary artery disease patients with preserved systolic ventricular function and a positive exercise test underwent two sequential exercise tests to demonstrate ischemic preconditioning. Ischemic parameters were compared among patients with and without type 2 diabetes mellitus. Ischemic preconditioning was considered present when the time to 1.0 mm ST deviation and rate pressure-product were greater in the second of 2 exercise tests. Sequential exercise tests were analyzed by 2 independent cardiologists. Results Of the 2,140 consecutive coronary artery disease patients screened, 361 met inclusion criteria, and 174 patients (64.2 ± 7.6 years) completed the study protocol. Of these, 86 had the diagnosis of type 2 diabetes. Among diabetic patients, 62 (72 %) manifested an improvement in ischemic parameters consistent with ischemic preconditioning, whereas among nondiabetic patients, 60 (68 %) manifested ischemic preconditioning (p = 0.62). The analysis of patients who demonstrated ischemic preconditioning showed similar improvement in the time to 1.0 mm ST deviation between diabetic and nondiabetic groups (79.4 ± 47.6 vs 65.5 ± 36.4 s, respectively, p = 0.12). Regarding rate pressure-product, the improvement was greater in diabetic compared to nondiabetic patients (3011 ± 2430 vs 2081 ± 2139 bpm x mmHg, respectively, p = 0.01). Conclusions In this study, diabetes mellitus was not associated with impairment in ischemic preconditioning in symptomatic coronary artery disease patients. Furthermore, diabetic patients experienced an improvement in this significant mechanism of myocardial protection.
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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Rosa Maria Rahmi
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Augusto Hiroshi Uchida
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Leandro Menezes Alves da Costa
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Thiago Luis Scudeler
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Cibele Larrosa Garzillo
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Eduardo Gomes Lima
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Carlos Alexandre Wainrober Segre
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Priscyla Girardi
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Myrthes Takiuti
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Marcela Francisca Silva
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Whady Hueb
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Jose Antonio Franchini Ramires
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Roberto Kalil Filho
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
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Rezende PC, da Costa LMA, Scudeler TL, Nakamura D, Giorgi MCP, Hueb W. Recurrent angina caused by coronary subclavian steal syndrome confirmed by positron emission tomography. Ann Thorac Surg 2015; 99:e111-4. [PMID: 25952243 DOI: 10.1016/j.athoracsur.2015.01.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 12/29/2014] [Accepted: 01/16/2015] [Indexed: 11/19/2022]
Abstract
Coronary subclavian steal syndrome is a rare cause of recurrent angina after coronary artery bypass grafting. Identification of the myocardial ischemic region is crucial because it guides revascularization interventions to improve symptoms and myocardial ischemia. Positron emission computed tomography (PET) with rubidium might be a helpful tool because it identifies ischemia, localizes more precisely the ischemic region, and evaluates coronary flow reserve. Here, we report a case of recurrence of angina after coronary artery bypass grafting caused by an obstruction in the left subclavian artery and consequently by coronary steal syndrome confirmed by PET.
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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | | | - Thiago Luis Scudeler
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Debora Nakamura
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | | | - Whady Hueb
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil.
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Rezende PC, Scudeler TL, da Costa LMA, Hueb W. Conservative strategy for treatment of stable coronary artery disease. World J Clin Cases 2015; 3:163-170. [PMID: 25685763 PMCID: PMC4317610 DOI: 10.12998/wjcc.v3.i2.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/25/2014] [Indexed: 02/05/2023] Open
Abstract
Patients with coronary artery disease vary widely in terms of prognosis, which is mainly dependent on ventricular function. In relation to the major outcomes of death and myocardial infarction, it is not clear in the literature if an invasive strategy of myocardial revascularization is superior to a conservative strategy of optimized medical therapy. Moreover, with the exception of patients with left main coronary disease, this similarity in prognosis also occurs in different subgroups of patients.
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Scudeler TL, Rezende PC, Oikawa FTC, da Costa LMA, Hueb AC, Hueb W. A case of mid-apical obstructive hypertrophic cardiomyopathy treated with a transapical myectomy approach: a case report. J Med Case Rep 2014; 8:364. [PMID: 25384531 PMCID: PMC4232228 DOI: 10.1186/1752-1947-8-364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 08/27/2014] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Hypertrophic cardiomyopathy is a genetic cardiac disease characterized by marked variability in morphological expression and natural history. The hypertrophic myocardium is often confined to the septum or lateral wall of the left ventricle, but it can also be encountered in the middle or apical segments of the myocardium. Treatment is based on medical therapy. Others therapies, such as embolization of the septal artery or ventriculomyectomy, are indicated in special situations. Surgery is the standard treatment, and it is classically done via a transaortic approach; however, in cases in which the hypertrophic myocardium is confined to mid-apical segments, a transapical approach is an option. Only a few cases of mid-apical obstructive hypertrophic cardiomyopathy treated with a myectomy using a transapical approach have been reported in the English-language literature. In this report, we present a case of a patient with mid-apical obstructive hypertrophic cardiomyopathy treated using this new approach. CASE PRESENTATION A 63-year-old Caucasian woman presented with a history of chest pain and shortness of breath causing significant limitations on her daily life activities. She had a history of coronary artery disease. Her physical examination was unremarkable. Transthoracic echocardiography revealed normal systolic function and significant concentric left ventricular hypertrophy that was greater in the mid-apical region. Nuclear magnetic resonance imaging confirmed significant hypertrophy of the median segments of the left ventricle. The patient had persistent symptoms despite receiving optimized medical treatment, and a surgical approach was indicated. As a myectomy using transaortic technique was thought to be difficult to perform in her case, a transapical approach was used. No complications occurred, and her symptoms resolved. CONCLUSION A transapical myectomy should be taken into consideration for patients with mid-apical obstructive hypertrophic cardiomyopathy that is refractory to medical treatment.
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Affiliation(s)
| | | | | | | | | | - Whady Hueb
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo, Avenida Doutor Enéas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, 05403-000 São Paulo, SP, Brazil.
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Vieira de Melo RM, Hueb W, Rezende PC, Alves da Costa LM, Oikawa FTC, Lima EG, Hueb AC, Scudeler TL, Kalil Filho R. Comparison between off-pump and on-pump coronary artery bypass grafting in patients with severe lesions at the circumflex artery territory: 5-year follow-up of the MASS III trial. Eur J Cardiothorac Surg 2014; 47:455-8. [DOI: 10.1093/ejcts/ezu216] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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16
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Hueb W, Gersh BJ, Rezende PC, Garzillo CL, Lima EG, Vieira RD, Garcia RMR, Favarato D, Segre CAW, Pereira AC, Soares PR, Ribeiro E, Lemos P, Perin MA, Strunz CC, Dallan LAO, Jatene FB, Stolf NAG, Hueb AC, Dias R, Gaiotto FA, da Costa LMA, Oikawa FTC, de Melo RMV, Serrano CV, de Ávila LFR, Villa AV, Filho JRP, Nomura C, Ramires JAF, Kalil Filho R. Hypotheses, rationale, design, and methods for prognostic evaluation of cardiac biomarker elevation after percutaneous and surgical revascularization in the absence of manifest myocardial infarction. A comparative analysis of biomarkers and cardiac magnetic resonance. The MASS-V Trial. BMC Cardiovasc Disord 2012; 12:65. [PMID: 22898311 PMCID: PMC3468382 DOI: 10.1186/1471-2261-12-65] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 08/01/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the release of cardiac biomarkers after percutaneous (PCI) or surgical revascularization (CABG) is common, its prognostic significance is not known. Questions remain about the mechanisms and degree of correlation between the release, the volume of myocardial tissue loss, and the long-term significance. Delayed-enhancement of cardiac magnetic resonance (CMR) consistently quantifies areas of irreversible myocardial injury. To investigate the quantitative relationship between irreversible injury and cardiac biomarkers, we will evaluate the extent of irreversible injury in patients undergoing PCI and CABG and relate it to postprocedural modifications in cardiac biomarkers and long-term prognosis. METHODS/DESIGN The study will include 150 patients with multivessel coronary artery disease (CAD) with left ventricle ejection fraction (LVEF) and a formal indication for CABG; 50 patients will undergo CABG with cardiopulmonary bypass (CPB); 50 patients with the same arterial and ventricular condition indicated for myocardial revascularization will undergo CABG without CPB; and another 50 patients with CAD and preserved ventricular function will undergo PCI using stents. All patients will undergo CMR before and after surgery or PCI. We will also evaluate the release of cardiac markers of necrosis immediately before and after each procedure. Primary outcome considered is overall death in a 5-year follow-up. Secondary outcomes are levels of CK-MB isoenzyme and I-Troponin in association with presence of myocardial fibrosis and systolic left ventricle dysfunction assessed by CMR. DISCUSSION The MASS-V Trial aims to establish reliable values for parameters of enzyme markers of myocardial necrosis in the absence of manifest myocardial infarction after mechanical interventions. The establishments of these indices have diagnostic value and clinical prognosis and therefore require relevant and different therapeutic measures. In daily practice, the inappropriate use of these necrosis markers has led to misdiagnosis and therefore wrong treatment. The appearance of a more sensitive tool such as CMR provides an unprecedented diagnostic accuracy of myocardial damage when correlated with necrosis enzyme markers. We aim to correlate laboratory data with imaging, thereby establishing more refined data on the presence or absence of irreversible myocardial injury after the procedure, either percutaneous or surgical, and this, with or without the use of cardiopulmonary bypass.
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Affiliation(s)
- Whady Hueb
- Heart Institute of the University of São Paulo, São Paulo, Brazil.
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