Publications by authors named "Claudia Maria Rodrigues Alves"

19 Publications

  • Page 1 of 1

Accuracy of Post-thrombolysis ST-segment Reduction as an Adequate Reperfusion Predictor in the Pharmaco-Invasive Approach.

Arq Bras Cardiol 2021 07;117(1):15-25

Universidade Federal de Sao Paulo, São Paulo, SP - Brasil.

Background: Primary percutaneous coronary intervention is considered the "gold standard" for coronary reperfusion. However, when not available, the drug-invasive strategy is an alternative method and the electrocardiogram (ECG) has been used to identify reperfusion success.

Objectives: Our study aimed to assess ST-Segment changes in post-thrombolysis and their power to predict recanalization and using the angiographic scores TIMI-flow and Myocardial Blush Grade (MBG) as an ideal reperfusion criterion.

Methods: 2,215 patients with ST-Segment Elevation Myocardial Infarction (STEMI) undergoing fibrinolysis [(Tenecteplase)-TNK] and referred to coronary angiography within 24 h post-fibrinolysis or immediately referred to rescue therapy were studied. The ECG was performed pre- and 60 min-post-TNK. The patients were categorized into 2 groups: those with ideal reperfusion (TIMI-3 and MBG-3) and those with inadequate reperfusion (TIMI and MBG <3). The ECG reperfusion criterion was defined by the reduction of the ST-Segment >50%. A p-value <0.05 was considered for the analyses, with bicaudal tests.

Results: The ECG reperfusion criterion showed a positive predictive value of 56%; negative predictive value of 66%; sensitivity of 79%; and specificity of 40%. There was a weak positive correlation between ST-Segment reduction and ideal reperfusion angiographic data (r = 0.21; p <0.001) and low diagnostic accuracy, with an AUC of 0.60 (95%CI: 0.57-0.62).

Conclusion: The ST-Segment reduction was not able to accurately identify patients with adequate angiographic reperfusion. Therefore, even patients with apparently successful reperfusion should be referred to angiography soon, to ensure adequate macro and microvascular coronary flow.
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http://dx.doi.org/10.36660/abc.20200241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8294746PMC
July 2021

The Impact of Advanced Age on Major Cardiovascular Events and Mortality in Patients with ST-Elevation Myocardial Infarction Undergoing a Pharmaco-Invasive Strategy.

Clin Interv Aging 2020 21;15:715-722. Epub 2020 May 21.

Department of Medicine, Discipline of Cardiology, Escola Paulista de Medicina, Universidade Federal São Paulo, São Paulo, Brazil.

Background: There is little research in the efficacy and safety of a pharmaco-invasive strategy (PIS) in patients ≥75 years versus <75 years of age. We aimed to evaluate and compare the influence of advanced age on the risk of death and major adverse cardiac events (MACE) in patients undergoing PIS.

Methods: Between January 2010 and November 2016, 14 municipal emergency rooms in São Paulo, Brazil, used full-dose tenecteplase to treat patients with STEMI as part of a pharmaco-invasive strategy for a local network implementation.

Results: A total of 1852 patients undergoing PIS were evaluated, of which 160 (9%) were ≥75 years of age. Compared to patients <75 years, those ≥75 years were more often female, had lower body mass index, higher rates of hypertension; higher incidence of hypothyroidism, chronic renal failure, prior stroke, and diabetes. Compared to patients <75 years of age, in-hospital MACE and mortality were higher in patients with ≥75 years (6.5% versus 19.4%; p<0.001; and 4.0% versus 18.2%; p<0.001, respectively). Patients ≥75 years had higher rates of in-hospital major bleeding (2.7% versus 5.6%; p=0.04) and higher incidence of cardiogenic shock (7.0% versus 19.6%; p<0.001). By multivariable analysis, age ≥75 years was independent predictor of MACE (OR 3.57, 95% CI 1.72 to 7.42, p=0.001) and death (OR 2.07, 95% CI 1.12-3.82, p=0.020).

Conclusion: In patients with ST-segment elevation myocardial infarction undergoing PIS, age ≥75 years was an independent factor that entailed a 3.5-fold higher MACE and 2-fold higher mortality rate compared to patients <75 years of age.
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http://dx.doi.org/10.2147/CIA.S218827DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247595PMC
November 2020

Randomized clinical study on radial artery compression time after elective coronary angiography.

Rev Lat Am Enfermagem 2018 Nov 29;26:e3084. Epub 2018 Nov 29.

Universidade Federal de São Paulo, Escola Paulista de Enfermagem, São Paulo, SP, Brasil.

Objective: to compare two compression times of the radial artery after coronary angiography with customized compressive dressing regarding the occurrence of hemostasis and vascular complications.

Method: a randomized clinical study was carried out in patients undergoing elective transradial coronary angiography in two study groups: (G30), whose compressive dressing was maintained for 30 minutes, and (G60), whose compressive dressing was maintained for 60 minutes, both until the first evaluation of hemostasis. Variables related to patients, procedure, occurrence of hemostasis, and vascular complications were analyzed. Patency of the radial artery was assessed with Doppler vascular ultrasonography, immediately after removing the compressive dressing and 30 days after the procedure.

Results: the sample consisted of 152 patients in G30 and 151 in G60. Hemostasis was evidenced in the first evaluation in 76.3% of G30 patients and 84.2% of G60 patients (p = 0.063). There were 91 immediate complications, being 53 hematomas and 38 occlusions of the radial artery. We identified 18 late occlusions, 7 (5.5%) in G30 and 11 (8.2%) in G60.

Conclusion: the different compression times of the radial artery after coronary angiography did not significantly influence the occurrence of hemostasis and vascular complications. Brazilian Registry of Clinical Trials (Rebec): RBR-7VJYMJ.
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http://dx.doi.org/10.1590/1518-8345.2584.3084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280184PMC
November 2018

Initial experience with the use of fractional flow reserve in the hemodynamic evaluation of transplant renal artery stenosis.

Catheter Cardiovasc Interv 2018 03 7;91(4):820-826. Epub 2018 Feb 7.

Cardiology Division, Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM, São Paulo, SP, Brazil.

Objective: To describe and standardize an original protocol for fractional flow reserve (FFR) pre and postangioplasty in an initial series of patients with clinically manifested transplant renal artery stenosis (TRAS).

Background: There is no data in the literature about the use of FFR in TRAS.

Methods: Patients with TRAS detected in a noninvasive study were referred to diagnostic angiography and stenosis considered visually severe (≥ 60%) were included. After selective cannulation, a PressureWire 0.014" (Certus™-St. Jude Medical) was advanced to the distal portion of the vessel. Resting Pd/Pa ratio (ratio of mean distal to lesion and mean proximal pressures) and translesional systolic pressure gradient were obtained and FFR and hyperemic translesional systolic and mean pressure gradients (HSG and HMG) were registered after papaverine induced maximum hyperemia-pre and poststent implantation. Creatinine levels and office blood pressure measurements were registered at the baseline, 6 and 12 months after intervention.

Results: Ten consecutive patients had successful stent implantation and were included. After treatment, significant increase in FFR (0.76 ± 0.09 vs. 0.96 ± 0.04, P < 0.001) and reduction in systolic hyperemic gradients (-41.40 ± 19.18, P < 0.001) and mean (-24.00 ± 11.65, P < 0.001) were observed. A strong negative correlation was observed between FFR and percent stenosis diameter-%SD (r = -0.89, P < 0.001) and HSG (r = -0.9, P < 0.001) as well as a strong positive correlation between FFR and baseline Pd/Pa ratio (r = 0.9, P < 0.001).

Conclusion: FFR was a well-tolerated, valid and reproducible tool during percutaneous intervention for TRAS. Good correlation was observed between FFR and others hemodynamic parameters of lesion severity.
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http://dx.doi.org/10.1002/ccd.27476DOI Listing
March 2018

P2Y receptor inhibition with prasugrel and ticagrelor in STEMI patients after fibrinolytic therapy: Analysis from the SAMPA randomized trial.

Int J Cardiol 2017 Mar 27;230:204-208. Epub 2016 Dec 27.

Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo, Brazil. Electronic address:

Background: A pharmacodynamic comparison between ticagrelor and prasugrel after fibrinolytic therapy has not yet been performed.

Methods: In the single-center SAMPA trial, 50 consecutive STEMI patients previously treated with clopidogrel and undergoing a pharmacoinvasive strategy were randomized to either a ticagrelor (n=25) 180mg loading dose followed by 90mg bid, or a prasugrel (n=25) 60mg loading dose followed by 10mg/day, initiated after fibrinolytic therapy but before angiography. Platelet reactivity was assessed with the VerifyNow P2Y assay at 0, 2, 6, and 24h after randomization.

Results: Mean times from fibrinolysis to prasugrel or ticagrelor administration were 11.1±6.9 and 13.3±6.3h, respectively (p=0.24). The values of PRU decreased significantly from baseline to 2h (all p<0.001) and from 2h to 6h (all p<0.001) in both groups. There was no difference in PRU values between 6h and 24h. The mean PRU values at 0, 2, 6, and 24h were 234.9, 127.8, 45.4, and 48.0 in the prasugrel group and 233.1, 135.1, 67.7, and 56.9 in the ticagrelor group, respectively. PRU values did not significantly differ between groups at any time period of the study.

Conclusions: In patients with STEMI treated with fibrinolytic therapy, platelet inhibition after clopidogrel is suboptimal and can be further increased with more potent agents. Ticagrelor and prasugrel demonstrated a similar extent of P2Y receptor inhibition within 24h, although maximal platelet inhibition after these potent agents was not achieved for 6h.
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http://dx.doi.org/10.1016/j.ijcard.2016.12.173DOI Listing
March 2017

Pregnancy-associated spontaneous coronary artery dissection: insights from a case series of 13 patients.

Eur Heart J Cardiovasc Imaging 2017 Jan 28;18(1):54-61. Epub 2016 Feb 28.

Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil

Aims: We sought to present a series of 13 pregnancy-associated spontaneous coronary artery dissection (P-SCAD), their angiographic and multimodal imaging findings, acute phase treatment, and outcomes.

Methods And Results: Between 2005 and 2015, 13 cases of P-SCAD were collected from a database of 11 tertiary hospitals. The mean age was 33.8 ± 3.7 years; most patients had no risk factors for coronary artery disease, and the majority were multiparous. P-SCAD occurred during the puerperium in 12 patients with a median time of 10 days. Only one patient presented with P-SCAD in the 37th week of pregnancy, and she was the only patient who died in this series. Six patients (46%) presented with ST-segment elevation acute myocardial infarction (STEMI), six (46%) presented with non-STEMI, and one presented with unstable angina; one-third of women had cardiogenic shock. In 12 patients, the dissection involved the left anterior descending or circumflex artery, and it extended to the left main coronary artery in 6 patients. Intravascular ultrasound or optical coherence tomography helped to confirm diagnosis and guide treatment in 46% of cases. Seven women were managed clinically; percutaneous coronary intervention was performed in five cases, and coronary artery bypass grafting was performed in one patient.

Conclusion: In these 13 cases of P-SCAD, clinical presentation commonly included acute myocardial infarction and cardiogenic shock. Multivessel dissections and involvement of the left coronary artery and left main coronary artery were highly prevalent. Clinicians must be aware of angiographic appearances of P-SCAD for prompt diagnosis and management in these high-risk patients.
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http://dx.doi.org/10.1093/ehjci/jew021DOI Listing
January 2017

Influence of gender on the risk of death and adverse events in patients with acute myocardial infarction undergoing pharmacoinvasive strategy.

J Thromb Thrombolysis 2014 Nov;38(4):510-6

Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.

Pharmacoinvasive treatment is an acceptable alternative for patients with ST-segment elevation myocardial infarction (STEMI) in developing countries. The present study evaluated the influence of gender on the risks of death and major adverse cardiovascular events (MACE) in this population. Seven municipal emergency rooms and the Emergency Mobile Healthcare Service in São Paulo treated STEMI patients with tenecteplase. The patients were subsequently transferred to a tertiary teaching hospital for early (<24 h) coronary angiography. A total of 469 patients were evaluated [329 men (70.1%)]. Compared to men, women had more advanced age (60.2 ± 12.3 vs. 56.5 ± 11 years; p = 0.002); lower body mass index (BMI; 25.85 ± 5.07 vs. 27.04 ± 4.26 kg/m2; p = 0.009); higher rates of hypertension (70.7 vs. 59.3%, p = 0.02); higher incidence of hypothyroidism (20.0 vs. 5.5%; p < 0.001), chronic renal failure (10.0 vs. 8.8%; p = 0.68), peripheral vascular disease (PVD; 19.3 vs. 4.3%; p = 0.03), and previous history of stroke (6.4 vs. 1.3%; p = 0.13); and higher thrombolysis in myocardial infarction risk scores (40.0 vs. 23.7%; p < 0.001). The overall in-hospital mortality and MACE rates for women versus men were 9.3 versus 4.9% (p = 0.07) and 12.9 versus 7.9% (p = 0.09), respectively. By multivariate analysis, diabetes (OR 4.15; 95% CI 1.86-9.25; p = 0.001), previous stroke (OR 4.81; 95% CI 1.49-15.52; p = 0.009), and hypothyroidism (OR 3.75; 95% CI 1.44-9.81; p = 0.007), were independent predictors of mortality, whereas diabetes (OR 2.05; 95% CI 1.03-4.06; p = 0.04), PVD (OR 2.38; 95% CI 0.88-6.43; p = 0.08), were predictors of MACE. In STEMI patients undergoing pharmacoinvasive strategy, mortality and MACE rates were twice as high in women; however, this was due to a higher prevalence of risk factors and not gender itself.
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http://dx.doi.org/10.1007/s11239-014-1072-7DOI Listing
November 2014

Predictors of in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive treatment.

Clinics (Sao Paulo) 2013 Dec;68(12):1516-20

Department of Cardiology, Universidade Federal de São Paulo, São PauloSP, Brazil.

Objectives: To identify predictors of in-hospital mortality in patients with acute myocardial infarction undergoing pharmacoinvasive treatment.

Methods: This was an observational, prospective study that included 398 patients admitted to a tertiary center for percutaneous coronary intervention within 3 to 24 hours after thrombolysis with tenecteplase. ClinicalTrials.gov: NCT01791764 RESULTS: The overall in-hospital mortality rate was 5.8%. Compared with patients who survived, patients who died were more likely to be older, have higher rates of diabetes and chronic renal failure, have a lower left ventricular ejection fraction, and demonstrate more evidence of heart failure (Killip class III or IV). Patients who died had significantly lower rates of successful thrombolysis (39% vs. 68%; p = 0.005) and final myocardial blush grade 3 (13.0% vs. 61.9%; p<0.0001). Based on the multivariate analysis, the Global Registry of Acute Coronary Events score (odds ratio 1.05, 95% confidence interval (CI) 1.02-1.09; p = 0.001), left ventricular ejection fraction (odds ratio 0.9, 95% CI 0.89-0.97; p = 0.001), and final myocardial blush grade of 0-2 (odds ratio 8.85, 95% CI 1.34-58.57; p = 0.02) were independent predictors of mortality.

Conclusions: In this prospective study that evaluated patients with ST-segment elevation myocardial infarction treated by a pharmacoinvasive strategy, the in-hospital mortality rate was 5.8%. The Global Registry of Acute Coronary Events score, left ventricular ejection fraction, and myocardial blush were independent predictors of mortality in this high-risk group of acute coronary syndrome patients.
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http://dx.doi.org/10.6061/clinics/2013(12)07DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3840375PMC
December 2013

Ankle-brachial index as a predictor of coronary disease events in elderly patients submitted to coronary angiography.

Clinics (Sao Paulo) 2013 Dec;68(12):1481-7

Departamento de Cardiologia, Universidade Federal do Estado de São Paulo, São PauloSP, Brazil.

Objectives: To correlate the importance of the ankle-brachial index in terms of cardiovascular morbimortality and the extent of coronary arterial disease amongst elderly patients without clinical manifestations of lower limb peripheral arterial disease.

Methods: We analyzed prospective data from 100 patients over 65 years of age with coronary arterial disease, as confirmed by coronary angiography, and with over 70% stenosis of at least one sub-epicardial coronary artery. We measured the ankle-brachial index immediately after coronary angiography, and a value of <0.9 was used to diagnose peripheral arterial disease.

Results: The patients' average age was 77.4 years. The most prevalent risk factor was hypertension (96%), and the median late follow-up appointment was 28.9 months. The ankle-brachial index was <0.9 in 47% of the patients, and a low index was more prevalent in patients with multiarterial coronary disease compared to patients with uniarterial disease in the same group. Using a bivariate analysis, only an ankle-brachial index of <0.9 was a strong predictive factor for cardiovascular events, thereby increasing all-cause deaths and fatal and non-fatal acute myocardial infarctions two- to three-fold.

Conclusion: In elderly patients with documented coronary disease, a low ankle-brachial index (<0.9) was associated with the severity and extent of coronary arterial disease, and in late follow-up appointments, a low index was correlated with an increase in the occurrence of major cardiovascular events.
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http://dx.doi.org/10.6061/clinics/2013(12)02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3840368PMC
December 2013

Relation between the ankle-brachial index and the complexity of coronary artery disease in older patients.

Clin Interv Aging 2013 2;8:1611-6. Epub 2013 Dec 2.

Department of Interventional Cardiology, Federal University of São Paulo, São Paulo, Brazil.

Background: In the elderly, the ankle-brachial index (ABI) has greater than 90% sensitivity and specificity for peripheral artery disease identification. A well-known relation exists between peripheral artery disease and the number of diseased coronary vessels. Yet, other anatomical characteristics have important impacts on the type of treatment and prognosis.

Purpose: To determine the relation between ABI and the complexity of coronary artery disease, by different anatomical classifications.

Methods: This study was a prospective analysis of patients ≥65 years old who were undergoing elective coronary angiography for ischemic coronary disease. The ABI was calculated for each leg, as the ratio between the lowest ankle pressure and the highest brachial pressure. The analysis of coronary anatomy was performed by three interventional cardiologists; it included classification of each lesion with >50% diameter stenosis, according to the American Heart Association criteria, and calculation of the SYNTAX score.

Results: The study recruited 204 consecutive patients (median age: 72.5 years). Stable angina was present in 51% of patients. Although only 1% of patients reported peripheral artery disease, 45% exhibited an abnormal ABI. The number of lesions per patient, the number of patients with complex lesions, and the median SYNTAX scores were greater in the group with abnormal ABI. However, among 144 patients with obstructive coronary artery disease, despite abnormal ABI being able to identify a higher rate of patients with B2 or C type lesions (70.9% versus 53.8%; P=0.039), the mean SYNTAX scores (13 versus 9; P=0.14), and the proportion of patients with SYNTAX score >16 (34.2% versus 27.7%; P=0.47), were similar, irrespective of ABI.

Conclusion: In patients ≥65 years old the presence of peripheral artery disease could discriminate a group of patients with greater occurrence of B2 and C type lesions, but similar median SYNTAX score.
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http://dx.doi.org/10.2147/CIA.S52778DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3854920PMC
March 2014

P2Y12 platelet receptors: importance in percutaneous coronary intervention.

Arq Bras Cardiol 2013 Sep 6;101(3):277-82. Epub 2013 Aug 6.

Apart from their role in hemostasis and thrombosis, platelets are involved in many other biological processes such as wound healing and angiogenesis. Percutaneous coronary intervention is a highly thrombogenic procedure inducing platelets and monocytes activation through endothelial trauma and contact activation by intravascular devices. Platelet P2Y12 receptor activation by adenosine diphosphate facilitates non-ADP agonist-mediated platelet aggregation, dense granule secretion, procoagulant activity, and the phosphorylation of several intraplatelet proteins, making it an ideal drug target. However, not all compounds that target the P2Y12 receptor have similar efficacy and safety profiles. Despite targeting the same receptor, the unique pharmacologic properties of each of these P2Y12 receptor-directed compounds can lead to very different clinical effects.
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http://dx.doi.org/10.5935/abc.20130162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032309PMC
September 2013

Endovascular treatment of type B aortic dissection: the challenge of late success.

Ann Thorac Surg 2009 May;87(5):1360-5

Department of Cardiothoracic Surgery, Federal University of São Paulo, Paulista School of Medicine, São Paulo, Brazil.

Background: Thoracic endovascular aortic repair of type B aortic dissection is a therapeutic option for selected patients. However, late outcomes of this intervention are virtually unknown, and the series already published are heterogenous regarding demographics, indications, and type of devices.

Methods: From 1997 to 2004, 106 patients exclusively with classic complicated or symptomatic type B aortic dissection were treated with thoracic endovascular aortic repair, using the same device. We present in-hospital outcomes and late follow-up for 73 patients.

Results: Technical success was achieved for 99% of patients, and the clinical success rate was 83% (exclusion of the false lumen, no early death or surgical conversion). In-hospital death occurred in 5 patients, 2 of them after surgical conversion. Three patients required urgent surgical conversion. Neurologic complications occurred in 5 patients (1 case of paraplegia). The average time of follow-up was 35.9 +/- 28.5 months. During follow-up, 37% of patients initially successfully treated reached a failure criterion (new endovascular or surgical intervention in the same aortic segment or death due to aortic or unknown cause). Kaplan-Meier curve showed late survival rates higher than 80% in 2 years.

Conclusions: Patients with both acute and chronic type B aortic dissection had excellent initial results with thoracic endovascular aortic repair. Although event-free survival rates decreased gradually with time owing to the frequent need for new interventions, survival curves were comparable to those for less complex patients undergoing clinical or surgical treatment. Randomized studies are required to establish the actual benefit of this new approach.
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http://dx.doi.org/10.1016/j.athoracsur.2009.02.050DOI Listing
May 2009

[Functional assessment of the left atrial appendage with transesophageal echocardiography before and after percutaneous valvotomy in the mitral stenosis].

Arq Bras Cardiol 2005 Jun 28;84(6):457-60. Epub 2005 Jun 28.

Universidade Federal de São Paulo--UNIFESP, São Paulo, Brazil.

Objective: To assess the effects of the relief of the mitral stenosis by percutaneous ballon valvotomy in the function of the left atrial appendage.

Methods: Twelve patients with symptomatic mitral stenosis, in sinus rhythm, were studied. They were submitted to the transesophageal echocardiogram before and after effective percutaneous ballon valvotomy. Concerning the left atrial appendage, the peak flow velocities and the respective integral of the anterograde and retrograde flow, in addition to the ejection fraction calculated through the planimetry of the area of that structure, were analyzed at the pulsatile Doppler.

Results: There was a significant increase of the anterograde flow velocity of the left atrial appendage after percutaneous ballon valvotomy (pre: mean of 0.30 m/s; post: mean of 0.47 m/s; p<0.05) and their respective integrals. The same happened with the retrograde flow velocity (pre: mean of 0.35 m/s, post: mean of 0.53 m/s; p<0.05). There was a tendency of increase of the ejection fraction of the left atrial appendage after the procedure (pre: mean of 20%, post: mean of 31%; p=0.08).

Conclusion: The effective opening of the stenosed mitral orifice resulting from the percutaneous ballon valvotomy determined an improvement of the flow pattern of the left atrial appendage, which can potentially contribute for the reduction of the embolic risk.
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http://dx.doi.org/10.1590/s0066-782x2005000600005DOI Listing
June 2005

A change in the treatment of abdominal aortic aneurysms.

Arq Bras Cardiol 2003 Nov 1;81(5):518-25. Epub 2003 Dec 1.

São Paulo Federal University, São Paulo, SP, Brazil.

Objective: One of the most exciting potential applications of percutaneous therapy is the treatment of abdominal aneurysms.

Methods: Of 230 patients treated with a self-expanding polyester-lined stent-graft for different aortic pathologies at our institution, we selected 80 abdominal aneurysm cases undergoing treatment (from May 1997 to December 2002). The stent was introduced through the femoral artery, in the hemodynamic laboratory, with the patient under general anesthesia, with systemic heparinization, and induced hypotension.

Results: The procedure was successful in 70 (92.9%) cases; 10 patients with exclusion of abdominal aortic aneurysms were documented immediately within the hemodynamic room and 5 patients persisted with a residual leak. Two surgical conversions were necessary. Additional stent-grafts had to be inserted in 3 (3.7%) cases. In the follow-up, 91.4% of patients were alive at a mean follow-up of 15.8 months.

Conclusion: We believe that stent-grafts are an important tool in improving the treatment of abdominal aneurysms, and this new policy may change the conventional medical management of these patients.
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http://dx.doi.org/10.1590/s0066-782x2003001300008DOI Listing
November 2003

Revolutionary treatment of aneurysms and dissections of descending aorta: the endovascular approach.

Ann Thorac Surg 2002 Nov;74(5):S1815-7; discussion S1825-32

Federal University of São Paulo, Paulista School of Medicine and Affiliated Hospitals, SP, Brazil.

Background: Acute aortic dissection is a life-threatening medical condition. It is associated with high morbidity and mortality. Type B dissections are usually managed clinically during the acute phase. Conventional surgery carries high mortality rates due to the presence of serious complications. We herein present treatment of this condition with a less invasive endovascular approach. Other clinical situations such as penetrating ulcers, intramural hematomas, and true aneurysms of descending aorta were similarly treated.

Methods: From December 1996 to March 2002, 191 patients with type B dissections were treated with self-expandable, polyester-covered stents. There were 120 patients (62.8%) with type B dissections, 61 patients (31.9%) with true aneurysms, 6 patients (3.1%) with penetrating ulcers or intramural hematomas, and 4 patients (2.1%) with trauma. Patients with abdominal aneurysms (44) and stents introduced under direct vision through the aortic arch (70) were excluded. The stent graft was delivered in the catheterization laboratory under general anesthesia, with induced hypotension and heparinization. All stents used were made in Brazil (Braile Biomedics, Sao Jose do Rio Preto, SP).

Results: The procedure was performed in 191 consecutive cases. The success rate was 91.1% (174/191). Success was defined as occlusion of the thoracic intimal tear, or exclusion of the aneurysm without leaks. Hospital mortality was 10.4% (20/191 patients), due to preoperative comorbidities. Six patients required conversion to surgery. No case of paraplegia was observed. An actuarial survival curve showed 87.4% +/- 29% survival in the late follow-up period.

Conclusions: Stent grafts are an important development in the treatment of descending aortic aneurysms or dissections. This novel approach may replace conventional surgical treatment of these conditions, with earlier intervention and less morbidity.
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http://dx.doi.org/10.1016/s0003-4975(02)04138-3DOI Listing
November 2002

Treatment of thoracoabdominal aneurysm with self-expandable aortic stent grafts.

Ann Thorac Surg 2002 Nov;74(5):1685-7

Department of Cardiovascular Surgery, Medical School, São Paulo Federal University, São Paulo, Brazil.

A 67-year-old man with a large thoracoabdominal aneurysm was treated utilizing the endovascular approach with multiple stent graft implantation. The proximal thoracic and distal abdominal necks of the aneurysm had favorable anatomy for insertion of multiple endovascular stents. The proximal end was located just distal to the left subclavian artery, and stents were placed to the region of the celiac axis. The infrarenal aneurysm was treated with a bifurcated stent graft to the iliac arteries. The patient has had a smooth post-stent insertion course and remains well after 3 months of follow-up.
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http://dx.doi.org/10.1016/s0003-4975(02)04028-6DOI Listing
November 2002

Endovascular treatment of thoracic disease: patient selection and a proposal of a risk score.

Ann Thorac Surg 2002 Apr;73(4):1143-8

Federal University of Sao Paulo, Paulista School of Medicine, São Paulo, Brazil.

Background: Although selection criteria and subgroup analysis are still in the early developmental stages, endovascular treatment of aortic disease has become an alternative to surgery for many patients.

Methods: From November 1996 to November 1999, 49 patients were treated with a self-expandable endoprosthesis at our institution. Most patients had acute aortic dissections. Thirteen of these patients did not follow the anatomic selection protocol. We retrospectively analyzed these patients to compare our numerical risk score (which includes clinical and anatomic criteria) between groups with or without success and between groups that followed the anatomic protocol (P) or did not follow the anatomic protocol (E [exception]).

Results: Success rates were similar in groups P and E, although mortality rates were higher in group E. Patients from group E had longer procedures and required multiple stents more frequently. The proposed risk score was able to differentiate between groups with or without success, as well as between groups P and E.

Conclusions: In order to reduce mortality and morbidity rates, careful selection criteria must be followed when treating patients endovascularly. Although it is time-consuming, using objective criteria can help select patients for endovascular treatment. We propose that patients with a risk score higher than 11 should only undergo percutaneous treatment when they have an unacceptably high surgical risk, and even so only after a detailed discussion of the risks.
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http://dx.doi.org/10.1016/s0003-4975(02)03386-6DOI Listing
April 2002

Self-expandable aortic stent-grafts for treatment of descending aortic dissections.

Ann Thorac Surg 2002 Apr;73(4):1138-41; discussion 1141-2

Cardiovascular Surgery, Medical School, São Paulo Federal University, São Paulo, Brazil.

Background: Acute aortic dissection is a life-threatening medical condition that is associated with high morbidity and mortality.

Methods: Of 198 patients treated with a self-expanding polyester-covered stent-graft for various pathologic aortic conditions in our institution, we selected 70 consecutive patients with type B aortic dissection who were undergoing treatment. The stent-graft was introduced through the femoral artery in the angiography suite, under general anesthesia with systemic heparinization and induced hypotension.

Results: The procedure was performed in 70 patients; of these, 58 had descending aortic dissection and 12 had atypical dissections. The procedure was successful in 65 patients (92.9%), as documented by exclusion of the false lumen of the thoracic aorta. Eleven patients (18.9%) had persistent blood flow in the false lumen of the abdominal aorta due to distal reentries. Five patients (7.1%) underwent conversion to surgery. Insertion of additional stent-grafts was required in 34 patients (48.6%). At 29 months of follow-up, 91.4% of the patients were alive.

Conclusions: Stent-grafts are an important means of treating aortic dissections, which may replace conventional medical treatment of this condition for the majority of patients.
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http://dx.doi.org/10.1016/s0003-4975(02)03397-0DOI Listing
April 2002
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