Coronary artery disease has become a world wide medical problem. There is an overwhelming association between coronary atherosclerosis, angina pectoris, acute myocardial infarction and sudden death. The narrowing of coronary arteries is thought to damage the heart by limiting appropriate changes in coronary blood flow and by causing myocardial ischemia. This thesis attempts to examine the coronary circulation in patients who present with chest pain with and without coronary artery disease. One of the aims of this thesis is to validate the use of a short-lived radionuclide to study changes in regional myocardial perfusion. This technique has been applied in clinical medicine in an attempt to describe the disturbances of regional myocardial perfusion that occur in patients with coronary artery disease. These disturbances of perfusion have been related to the patients' symptoms, the electrocardiogram and the stenosed arteries seen in the arteriogram. Krypton-81m in solution is an inert freely diffusible gas (half-life 13 seconds) which emits a single 190 kev gamma ray. This tracer, a special catheter and a gamma camera have been developed in experiments to measure changes in regional myocardial perfusion. The systematic and rand-Om errors of the method have been defined in experiments. The results show that the mixing and delivered arterial concentration of krypton-81m are stable within a useful physiological range of changes in heart rate, blood pressure and coronary blood flow. Correlations with a reference technique have shown that the method can measure changes in regional myocardial perfusion between O and 3 ml/ml/min. The invasive method, the planar imaging and the need for calibration with washout at high levels of perfusion are investigated and described as limitations that must be considered. Eighty patients presenting with chest pain have been investigated by routine clinical methods, precordial mapping of the electrocardiogram during exercise and coronary arteriography. Changes in regional myocardial perfusion at rest and during atrial pacing has been measured using krypton-81m. The results have shown that stable mixing and delivered arterial concentration of krypton-81m can be achieved in the patients. Fifteen patients with negative exercise tests all demonstrated uniform increases in regional myocardial perfusion with pacing. The remaining 65 patients with positive exercise tests and significant coronary artery disease all showed both regional increases and decreases in myocardial perfusion during atrial pacing. In 16 of the 65 patients the jeopardized segment of ventricular myocardium showed significant increases in perfusion during the first 4 to 7 minutes of pacing. Th e increase stopped and regional perfusion in the affected segment then decreased progressively until the pacing was stopped. In 23 of the 65 patients the affected segment showed no changes in perfusion for 5 to 7 minutes of atrial pacing and then showed progressive decreases in regional myocardial perfusion until the pacing was stopped. Finally, in 26 of the 65 patients the affected segment showed immediate and progressive decreases of regional myocardial perfusion starting with the commencement of atrial pacing. In all the patients with disturbed perfusion ST segment depression in the electrocardiogram appeared after (140 ± 14 sec) the regional decrease of myocardial perfusion in the affected segment. Chest pain always appeared later at 220 ± 19 sec after the appearance of disturbed myocardial perfusion. Regional myocardial perfusion returned to normal in all the patients after the atrial pacing was stopped. There was a spatial relationship between the region of the ventricles affected by disturbed perfusion and the region of the precordium showing abnormal electrocardiographic signs during the exercise test. In conclusion, this clinical study has shown that patients with chest pain who have coronary artery disease suffer decreases of regional myocardial perfusion in affected segments of the ventricles during episodes of angina pectoris induced by atrial pacing. Regional perfusion may increase, remain stable or decrease in the affected segment following the onset of a stress test such as atrial pacing. This probably represents the amount of reserve function and adaptation left in the diseased coronary circulation and may be a useful physiological indicator of the severity of coronary disease and of patients at high risk. ST segment depression and pain have a close temporal relationship to the decreases of regional myocardial perfusion that occur in these patients. These studies suggest that there is a close relationship between myocardial perfusion and metabolism in health and disease. Both myocardial perfusion and metabolism will have to be affected by any rational therapy for angina pectoris and ischemic heart disease.

Ce travail de thèse s'articule autour de deux axes principaux : l'aide à la détection et l'aide à la caractérisation de la plaque d'athérosclérose. Il s'inscrit dans un programme de recherche qui vise à développer de nouveaux moyens de diagnostic des plaques d'athérome coronariennes et de prédiction du risque de rupture. La première partie de ce manuscrit présente l'athérosclérose, ses conséquences sur la santé des patients et les enjeux de modélisation auxquels nous sommes confrontés, notamment d'un point de vue Mécanique et Mathématique. Ce travail s'inscrit dans la lignée des problèmes inverses en mécanique des milieux continus et plus précisément en élasticité. La deuxième partie présente une méthode de détection de plaque basée sur le principe de palpographie. Cette nouvelle approche permet la prise en compte de toutes les composantes du tenseur des déformations mesurées à l'aide d'une technique intravasculaire ultrasonore (IVUS). La troisième partie est consacrée à l'élaboration d'outils de caractérisation de la plaque d'athérome et la reconstruction des propriétés mécaniques de ses différents constituants. Une nouvelle approche (I-FEM) basée sur la méthode des éléments finis est élaborée pour la résolution des problèmes inverses en élasticité linéaire. On présente le développement de ce nouveau code de calculs éléments finis qui a permis de reconstruire avec succès les cartographies d'élasticité des plaques d'athérome. De façon intéressante, I-FEM est basée sur la discrétisation des propriétés mécaniques (i.e. module d'Young et coefficient de Poisson) aux nœuds de l'élément fini. De plus, une deuxième méthode moins sensible au bruit (appelée "Fast-Modulography") est aussi proposée dans cette recherche doctorale. Elle s'inspire de la technique revisitée de palpographie développée au sein de notre laboratoire et a aussi pour but de fournir la cartographie de module d'Young (i.e. le modulogramme) de la lésion athéromateuse explorée par IVUS. Les méthodes proposées ont toutes été validées sur des données simulées, basées sur des géométries de plaques réelles acquises in-vivo à l'hôpital Cardiologique de Lyon. Une analyse de la sensibilité au bruit issu du signal ultrasonore, ainsi qu'une étude sur la stabilité et la convergence de la solution pour chacune de ces méthodes a été effectuée. L'ensemble des outils proposés semblent prometteurs. Leur utilisation pourrait aider à la compréhension des mécanismes biologiques liés au développement de la plaque d'athérome. En effet, ils pourraient permettre d'analyser les variations des propriétés mécaniques des constituants de la plaque lors de son évolution. De plus, ces mêmes outils cliniques nous permettrons de mieux diagnostiquer le degré de vulnérabilité à la rupture de la plaque explorée in vivo. / This thesis is structured around two main axes: 1) Atherosclerotic plaque detection, and 2) Atherosclerotic plaque characterization. It is a part of a research program which aims to develop new clinical tools to detect coronary atherosclerotic lesions and to predict the risk of rupture. The first part of this manuscript presents the atherosclerosis, its impact on patients' health and introduces modeling challenges we are facing, in particular in applied mechanics and mathematics. This work deals with the resolution of inverse problem in elasticity knowing the strain distributions (i.e. the elastograms). The second part of my manuscript presents a new detection method based on palpography technique. This original technique allows us, by considering all strain components, to quantify accurately the circumferential arterial wall compliance based on intravascular ultrasound (IVUS) sequence. The third part is devoted to the development of an elasticity reconstruction tool for atherosclerotic plaques. An original approach (named I-FEM), based on finite element method, is proposed for the resolution of inverse problem in linear elasticity. We detail the mathematical development of this new code, which was successfully used to reconstruct the Young's modulus maps (i.e. modulograms) of atherosclerotic plaques. Interestingly, I-FEM is based on the discretization of mechanical properties (Young Modulus and Poisson's ratio) at the finite element's nodes. Finally, in the last chapter of this part, I proposed a more robust (with regard to noise) reconstruction elasticity algorithm (called Fast-Modulography). This method was directly inspired by our previous study developed on palpography technique. It also aims to give a Young's modulus map of the atherosclerotic plaque explored by IVUS.All the proposed methods have been validated on simulated data, based on real geometries recorded in-vivo at the Cardiological hospital of Lyon. Analyzes of the noise sensitivity for IVUS data, and a study of the stability and the convergence of the solution have been conducted for all approaches.All these novel techniques appear to be promising. Using them could help for a better understood of the biological mechanisms involved in the atherosclerotic plaque development. Indeed, they could provide information about changes of mechanical properties during the plaque evolution. Furthermore, such clinical tools may be used to diagnose the risk of rupture of a vulnerable atherosclerotic plaque.

As doenças periodontais (DP) são precedidas em importância apenas pela cárie dentária como problema de saúde bucal coletiva no Brasil. Ambas são doenças infecciosas ainda muito prevalentes, entretanto é dada às DP uma importância questionavelmente secundária, pois não são sistematicamente investigadas e prevenidas em saúde pública. Pelo fato de sua prevalência ser atualmente desconhecida no Brasil, a alta freqüência das formas leves e moderadas das doenças periodontais na população como um todo e de suas formas mais graves em grupos ou indivíduos de risco, dentre estes os portadores de cardiopatias isquêmicas, motivou este estudo no Ambulatório de Cardiopatia Isquêmica do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, cotejando os resultados com outros obtidos em grupo de pessoas não-cardiopatas atendidas na mesma instituição. Foi investigada a prevalência e gravidade das doenças periodontais, bem como a prevalência de seus fatores de risco, história médica da presença de doenças de interesse à periodontia (diabetes, hipertensão, acidente vascular cerebral) e comportamento relativo à higiene bucal. Dentre as 634 pessoas examinadas na fase de recrutamento dos participantes, 480 foram do grupo de pacientes cardiopatas isquêmicos e 154 de grupo de não-cardiopatas. Foram selecionados respectivamente de cada grupo, 58 e 62 participantes, na faixa etária de 30 a 79 anos, para a investigação periodontal. A média da idade foi de 53 anos em ambos os sexos para os pacientes cardiopatas e de 40 anos nos homens e 37 anos nas mulheres nos pacientes não-cardiopatas. Foram utilizados o Índice Periodontal Comunitário (IPC) e o índice de Perda de Inserção periodontal (PI), ambos recomendados pela OMS (1999). Os resultados mostraram um predomínio de sextantes nos escores indicativos das formas graves da DP entre os pacientes cardiopatas (74,1% contra 20,2%; p < 0,00001). Dentre os pacientes cardiopatas apenas 1,1% dos sextantes exibiram saúde periodontal, contra 32,0% nos pacientes não-cardiopatas (p < 0,00001). No tocante a história pregressa da DP, mensuradas através da perda de inserção, 6,0% dos sextantes não a exibiram entre os pacientes cardiopatas, contra 68,0% dos não-cardiopatas (p < 0,00001). Eram portadores de fatores de retenção de biofilme dental 100,0% dos pacientes cardiopatas e 82,3% dos pacientes não-cardiopatas (p < 0,001). Exigiam tratamento periodontal mais complexo, normalmente praticados por especialistas em periodontia, 94,8% dos pacientes cardiopatas contra 33,9% dos pacientes não-cardiopatas (p < 0,0001). Necessitavam de tratamento de bolsas > 6mm 79,3% dos pacientes cardiopatas contra 9,7% dos pacientes não-cardiopatas (p < 0,0001). Alguns fatores de risco comprovado e/ou provável às DP, foram investigados nos pacientes cardiopatas e pacientes não-cardiopatas: observou-se tabagismo em 10,4% e 33,9% (p < 0,01), respectivamente; alcoolismo em 44,8% e 24,2% (p < 0,02), respectivamente; diabetes em 29,3% e 1,6% (p < 0,0001), respectivamente; hipertensão arterial em 34,5% e 8,1% (p < 0,001), respectivamente. Conclusões: As DP mostraram-se muito prevalentes nos dois grupos estudados, sendo de maior gravidade nos pacientes com cardiopatia isquêmica. A elevada prevalência de fatores de risco às DP aponta para a necessidade de adoção de estratégias de intervenção para minimizá-los. / Periodontal diseases are preceded in importance only by dental caries as oral public health problem in Brazil. Both are infectious diseases and with high prevalences, however, a secondary importance is given to periodontal diseases because they are not routinely investigated and prevented at public health level. Presently its prevalence is not known in the Brazilian population. The high prevalence of mild and moderate forms of periodontal diseases in the general population, and its severe forms in specific groups or in high risk patients, as those with ischaemic coronary diseases, motivated this survey. It was carried out among patients from the Outpatient Clinic of Ischaemic Coronary Disease – Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo – and using for comparisons patients from other clinics of the same hospital. The prevalence and severity of periodontal diseases were investigated, as well as the prevalence of their risk factors, medical history of diseases with periodontic interest (diabetes, hypertension, stroke), and behaviour related to oral hygiene. During the recruitment phase, among 634 patients examined, 480 were from the group with cardiopathy and 154 from the group without cardiopathy. From each group were selected, respectively, 58 and 62 participants, aged 30 to 79 years for the periodontal investigation. Mean age was 53 years for both sexes in the group with cardiopathy and 40 years for men and 37 years for women in the group without cardiopathy. The Community Periodontal Index and the Attachment Periodontal Index, both recommended by the World Health Organization (1999), were used. Results showed a predominance of sextants in the scores indicating severe forms of periodontal diseases among patients with cardiopathy (74.1 vs. 20.2%; p< 0.00001). Among patients with cardiopathy, only 1.1% of the sextants showed periodontal health against 32.0% in the other group (p< 0.00001). Previous history of periodontal diseases, measured through lost of insertion, was present in 6.0% of the sextants in patients with cardiopathy and 68.0% in those without cardiopathy (p< 0.0001). All patients with cardiopathy and 82.3% of those without cardiopathy were carriers of retention factors of dental biofilm (p< 0.001). It was found that 94.8% of the patients with cardiopathy against 33.9% of the other group (p< 0.0001) required more complex periodontal treatment, usually performed by periodontal specialists. Treatment of sites &#8805; 6mmm was required by 79.3% of the patients with cardiopathy and by 9.7% from the other group (p< 0.0001). The frequency of confirmed or possible risk factors for periodontal diseases in the groups with and without cardiopathy were, respectively: smoking – 10.4 and 33.9% (p< 0.001); alcoholism – 44.8 and 24.2% (p< 0.02); diabetes – 29.3 and 1.6% (p< 0.0001); hypertension – 34.5 and 8.1% (p< 0.001). Conclusions: Periodontal diseases were highly prevalent in the two groups studied, but with higher severity among patients with cardiopathy. The high frequency of risk factors for periodontal diseases in both groups appointed to the need of intervention strategies towards these risk factors.

Introdução: O melhor tratamento para a doença arterial coronariana (DAC) em pacientes com doença multiarterial é ainda objeto de debate. A revascularização coronária híbrida (RMH) é um procedimento que combina as vantagens da cirurgia de revascularização miocárdica convencional (CRM) com a anastomose da artéria interventricular anterior esquerda (IVA) usando o enxerto da artéria torácica interna esquerda (ATIE), sem o uso de circulação extracorpórea (CEC), com benefícios do tratamento percutâneo, minimamente invasivo, das artérias coronárias acometidas restantes. Objetivo: Avaliar, em um estudo piloto, a viabilidade e a segurança da RMH em pacientes com doença multiarterial e comparar os resultados iniciais (30 dias) e em um ano após, com a CRM. Métodos: estudo clínico prospectivo com 50 pacientes, randomizados em relação 2: 1 para tratamento híbrido (grupo RMH, n = 34) ou CRM convencional (grupo CRM, n = 16). Todos os pacientes eram portadores doença coronária triarterial, com SYNTAX escore intermediário ou alto ( > 22). Neste estudo foi analisada a viabilidade da RMH na ausência de eventos adversos maiores (um composto de mortalidade geral, infarto agudo do miocárdio (IAM), acidente vascular encefálico (AVE) e revascularização não planejada). Resultados: Entre agosto de 2014 e novembro de 2017, 50 pacientes foram incluídos no estudo (RMH = 34 e CRM = 16). O desfecho primário foi observado em 3 pacientes (6%), todos pertencentes ao grupo RMH (8,8%), porém sem significância estatística (p = 0,54). Não houve diferença estatística entre os grupos (RMH vs CRM) em termos de mortalidade (5,9% vs 0%), IAM (5,9% vs 0%) ou qualquer dos desfechos secundários avaliados. Os pacientes que apresentaram alguma das complicações (4 pacientes 8,0%) tiveram uma tendência de ser mais velhos (62 vs 59 anos; p = NS), maior incidência de angina instável (5,9% vs 0%) e apresentar pontuações de risco cirúrgico mais elevadas (EuroSCORE 1,40 vs 0,70; p = 0,19) do que os pacientes sem complicações. Conclusões: O RMH é uma técnica viável e segura quando comparada à cirurgia convencional, com taxas de complicações semelhantes. No entanto, devido ao baixo número de pacientes incluídos faz-se necessária a realização de um estudo multicêntrico para obtermos uma melhor evidência clínica / Background: The best treatment for coronary artery disease in patients with multivessel disease is still subject of debate. The hybrid coronary revascularization (HCR) is a procedure that combines both the advantages of conventional coronary artery bypass surgery (CABG) with the revascularization of the left anterior descending artery using the left internal mammary artery graft, without the use of cardiopulmonary bypass, with minimally invasive benefits of percutaneous treatment of remaining affect arteries. Objective: To assess, in a pilot study, feasibility and safety of hybrid coronary revascularization on patients with multivessel coronary artery disease and to compare early results (within 30 days) and one year of this approach to conventional surgery. Methods: Prospective clinical study, which included 50 patients, randomized in a 2:1 ratio for hybrid treatment (HCR group, n=34) or conventional CABG (CABG group, n=16). All patients had three-vessel disease, with an intermediate or high Syntax Score ( > 22). The primary endpoint of the study was the feasibility of HCR in the absence of major adverse events (a compound of overall mortality, acute myocardial infarction, stroke or unplanned revascularization). Results: Between August 2014 and November 2017, 50 patients were included in the study (HCR=34 and CABG =16). The primary endpoint was observed in 3 patients (6.0%), all belonging to HCR group (8.8%), however, without statistical significance (p=0.54). There was no statistical difference between the groups (HCR vs. CABG, respectively) in terms of mortality (5.9% vs 0%), myocardial infarction (5.9% vs 0%), or any of the secondary outcomes evaluated. Patients who presented any of the complications (4 patients 8.0%) had a tendency to be older (62 vs 59 years; p=NS), have more unstable angina (5.9% vs 0%) and to presented higher risk scores (EuroSCORE 1.40 vs 0.70; p=0.19) than patients without complications. Conclusions: HCR is a feasible and safe technique when compared to conventional surgery, with similar complications rates. However, the study is underpowered due to the low number of patients included and there is a need for a multicenter clinical trial

As doenças periodontais (DP) são precedidas em importância apenas pela cárie dentária como problema de saúde bucal coletiva no Brasil. Ambas são doenças infecciosas ainda muito prevalentes, entretanto é dada às DP uma importância questionavelmente secundária, pois não são sistematicamente investigadas e prevenidas em saúde pública. Pelo fato de sua prevalência ser atualmente desconhecida no Brasil, a alta freqüência das formas leves e moderadas das doenças periodontais na população como um todo e de suas formas mais graves em grupos ou indivíduos de risco, dentre estes os portadores de cardiopatias isquêmicas, motivou este estudo no Ambulatório de Cardiopatia Isquêmica do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, cotejando os resultados com outros obtidos em grupo de pessoas não-cardiopatas atendidas na mesma instituição. Foi investigada a prevalência e gravidade das doenças periodontais, bem como a prevalência de seus fatores de risco, história médica da presença de doenças de interesse à periodontia (diabetes, hipertensão, acidente vascular cerebral) e comportamento relativo à higiene bucal. Dentre as 634 pessoas examinadas na fase de recrutamento dos participantes, 480 foram do grupo de pacientes cardiopatas isquêmicos e 154 de grupo de não-cardiopatas. Foram selecionados respectivamente de cada grupo, 58 e 62 participantes, na faixa etária de 30 a 79 anos, para a investigação periodontal. A média da idade foi de 53 anos em ambos os sexos para os pacientes cardiopatas e de 40 anos nos homens e 37 anos nas mulheres nos pacientes não-cardiopatas. Foram utilizados o Índice Periodontal Comunitário (IPC) e o índice de Perda de Inserção periodontal (PI), ambos recomendados pela OMS (1999). Os resultados mostraram um predomínio de sextantes nos escores indicativos das formas graves da DP entre os pacientes cardiopatas (74,1% contra 20,2%; p < 0,00001). Dentre os pacientes cardiopatas apenas 1,1% dos sextantes exibiram saúde periodontal, contra 32,0% nos pacientes não-cardiopatas (p < 0,00001). No tocante a história pregressa da DP, mensuradas através da perda de inserção, 6,0% dos sextantes não a exibiram entre os pacientes cardiopatas, contra 68,0% dos não-cardiopatas (p < 0,00001). Eram portadores de fatores de retenção de biofilme dental 100,0% dos pacientes cardiopatas e 82,3% dos pacientes não-cardiopatas (p < 0,001). Exigiam tratamento periodontal mais complexo, normalmente praticados por especialistas em periodontia, 94,8% dos pacientes cardiopatas contra 33,9% dos pacientes não-cardiopatas (p < 0,0001). Necessitavam de tratamento de bolsas > 6mm 79,3% dos pacientes cardiopatas contra 9,7% dos pacientes não-cardiopatas (p < 0,0001). Alguns fatores de risco comprovado e/ou provável às DP, foram investigados nos pacientes cardiopatas e pacientes não-cardiopatas: observou-se tabagismo em 10,4% e 33,9% (p < 0,01), respectivamente; alcoolismo em 44,8% e 24,2% (p < 0,02), respectivamente; diabetes em 29,3% e 1,6% (p < 0,0001), respectivamente; hipertensão arterial em 34,5% e 8,1% (p < 0,001), respectivamente. Conclusões: As DP mostraram-se muito prevalentes nos dois grupos estudados, sendo de maior gravidade nos pacientes com cardiopatia isquêmica. A elevada prevalência de fatores de risco às DP aponta para a necessidade de adoção de estratégias de intervenção para minimizá-los. / Periodontal diseases are preceded in importance only by dental caries as oral public health problem in Brazil. Both are infectious diseases and with high prevalences, however, a secondary importance is given to periodontal diseases because they are not routinely investigated and prevented at public health level. Presently its prevalence is not known in the Brazilian population. The high prevalence of mild and moderate forms of periodontal diseases in the general population, and its severe forms in specific groups or in high risk patients, as those with ischaemic coronary diseases, motivated this survey. It was carried out among patients from the Outpatient Clinic of Ischaemic Coronary Disease – Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo – and using for comparisons patients from other clinics of the same hospital. The prevalence and severity of periodontal diseases were investigated, as well as the prevalence of their risk factors, medical history of diseases with periodontic interest (diabetes, hypertension, stroke), and behaviour related to oral hygiene. During the recruitment phase, among 634 patients examined, 480 were from the group with cardiopathy and 154 from the group without cardiopathy. From each group were selected, respectively, 58 and 62 participants, aged 30 to 79 years for the periodontal investigation. Mean age was 53 years for both sexes in the group with cardiopathy and 40 years for men and 37 years for women in the group without cardiopathy. The Community Periodontal Index and the Attachment Periodontal Index, both recommended by the World Health Organization (1999), were used. Results showed a predominance of sextants in the scores indicating severe forms of periodontal diseases among patients with cardiopathy (74.1 vs. 20.2%; p< 0.00001). Among patients with cardiopathy, only 1.1% of the sextants showed periodontal health against 32.0% in the other group (p< 0.00001). Previous history of periodontal diseases, measured through lost of insertion, was present in 6.0% of the sextants in patients with cardiopathy and 68.0% in those without cardiopathy (p< 0.0001). All patients with cardiopathy and 82.3% of those without cardiopathy were carriers of retention factors of dental biofilm (p< 0.001). It was found that 94.8% of the patients with cardiopathy against 33.9% of the other group (p< 0.0001) required more complex periodontal treatment, usually performed by periodontal specialists. Treatment of sites &#8805; 6mmm was required by 79.3% of the patients with cardiopathy and by 9.7% from the other group (p< 0.0001). The frequency of confirmed or possible risk factors for periodontal diseases in the groups with and without cardiopathy were, respectively: smoking – 10.4 and 33.9% (p< 0.001); alcoholism – 44.8 and 24.2% (p< 0.02); diabetes – 29.3 and 1.6% (p< 0.0001); hypertension – 34.5 and 8.1% (p< 0.001). Conclusions: Periodontal diseases were highly prevalent in the two groups studied, but with higher severity among patients with cardiopathy. The high frequency of risk factors for periodontal diseases in both groups appointed to the need of intervention strategies towards these risk factors.

Introdução: O melhor tratamento para a doença arterial coronariana (DAC) em pacientes com doença multiarterial é ainda objeto de debate. A revascularização coronária híbrida (RMH) é um procedimento que combina as vantagens da cirurgia de revascularização miocárdica convencional (CRM) com a anastomose da artéria interventricular anterior esquerda (IVA) usando o enxerto da artéria torácica interna esquerda (ATIE), sem o uso de circulação extracorpórea (CEC), com benefícios do tratamento percutâneo, minimamente invasivo, das artérias coronárias acometidas restantes. Objetivo: Avaliar, em um estudo piloto, a viabilidade e a segurança da RMH em pacientes com doença multiarterial e comparar os resultados iniciais (30 dias) e em um ano após, com a CRM. Métodos: estudo clínico prospectivo com 50 pacientes, randomizados em relação 2: 1 para tratamento híbrido (grupo RMH, n = 34) ou CRM convencional (grupo CRM, n = 16). Todos os pacientes eram portadores doença coronária triarterial, com SYNTAX escore intermediário ou alto ( > 22). Neste estudo foi analisada a viabilidade da RMH na ausência de eventos adversos maiores (um composto de mortalidade geral, infarto agudo do miocárdio (IAM), acidente vascular encefálico (AVE) e revascularização não planejada). Resultados: Entre agosto de 2014 e novembro de 2017, 50 pacientes foram incluídos no estudo (RMH = 34 e CRM = 16). O desfecho primário foi observado em 3 pacientes (6%), todos pertencentes ao grupo RMH (8,8%), porém sem significância estatística (p = 0,54). Não houve diferença estatística entre os grupos (RMH vs CRM) em termos de mortalidade (5,9% vs 0%), IAM (5,9% vs 0%) ou qualquer dos desfechos secundários avaliados. Os pacientes que apresentaram alguma das complicações (4 pacientes 8,0%) tiveram uma tendência de ser mais velhos (62 vs 59 anos; p = NS), maior incidência de angina instável (5,9% vs 0%) e apresentar pontuações de risco cirúrgico mais elevadas (EuroSCORE 1,40 vs 0,70; p = 0,19) do que os pacientes sem complicações. Conclusões: O RMH é uma técnica viável e segura quando comparada à cirurgia convencional, com taxas de complicações semelhantes. No entanto, devido ao baixo número de pacientes incluídos faz-se necessária a realização de um estudo multicêntrico para obtermos uma melhor evidência clínica / Background: The best treatment for coronary artery disease in patients with multivessel disease is still subject of debate. The hybrid coronary revascularization (HCR) is a procedure that combines both the advantages of conventional coronary artery bypass surgery (CABG) with the revascularization of the left anterior descending artery using the left internal mammary artery graft, without the use of cardiopulmonary bypass, with minimally invasive benefits of percutaneous treatment of remaining affect arteries. Objective: To assess, in a pilot study, feasibility and safety of hybrid coronary revascularization on patients with multivessel coronary artery disease and to compare early results (within 30 days) and one year of this approach to conventional surgery. Methods: Prospective clinical study, which included 50 patients, randomized in a 2:1 ratio for hybrid treatment (HCR group, n=34) or conventional CABG (CABG group, n=16). All patients had three-vessel disease, with an intermediate or high Syntax Score ( > 22). The primary endpoint of the study was the feasibility of HCR in the absence of major adverse events (a compound of overall mortality, acute myocardial infarction, stroke or unplanned revascularization). Results: Between August 2014 and November 2017, 50 patients were included in the study (HCR=34 and CABG =16). The primary endpoint was observed in 3 patients (6.0%), all belonging to HCR group (8.8%), however, without statistical significance (p=0.54). There was no statistical difference between the groups (HCR vs. CABG, respectively) in terms of mortality (5.9% vs 0%), myocardial infarction (5.9% vs 0%), or any of the secondary outcomes evaluated. Patients who presented any of the complications (4 patients 8.0%) had a tendency to be older (62 vs 59 years; p=NS), have more unstable angina (5.9% vs 0%) and to presented higher risk scores (EuroSCORE 1.40 vs 0.70; p=0.19) than patients without complications. Conclusions: HCR is a feasible and safe technique when compared to conventional surgery, with similar complications rates. However, the study is underpowered due to the low number of patients included and there is a need for a multicenter clinical trial