Introdução: A tomografia das artérias coronárias (ANGIO-TC) tem o potencial de medir as dimensões dos vasos e pode ser opção, aos métodos invasivos, para análises quantitativas em intervenções coronárias com suportes vasculares bioabsorvíveis (SVB) poliméricos radiolucentes. Objetivos: Medidas quantitativas pela ANGIO-TC do lúmen de segmentos coronários de pacientes submetidos a implante de um SVB com eluição de novolimus (DESolve®) foram comparadas às do ultrassom intracoronário (USIC). Os objetivos primários foram a comparação da área mínima e do volume do lúmen do SVB. Outros objetivos incluíram medidas nas margens do dispositivo, de referências do vaso e dos percentuais de estenose do SVB. A precisão de identificação do local de menor dimensão foi estimada pela distância entre este e a borda proximal do SVB. Método: Vinte e um pacientes submetidos a implante de um SVB DESolve e que foram reestudados após 6 meses com cinecoronariografia e USIC realizaram, também, ANGIO-TC. Sem conhecimento dos valores um do outro, um operador, em cada método, efetuou as medidas de volume, área e diâmetro mínimos do lúmen do SVB, de áreas e diâmetros mínimos do lúmen nas margens proximal e distal do SVB, de diâmetros e áreas de referência luminais e dos percentuais de estenose de diâmetros e áreas do SVB. Diferenças entre as médias foram significativas quando testes resultaram o valor de p< 0,05. Coeficientes de correlação foram calculados e a concordância foi analisada pelo método de Bland-Altman. Resultados: Os métodos não se mostraram correlacionados ao medirem área mínima do lúmen do SVB e a ANGIO-TC subestimou significativamente os valores em relação ao USIC (diferença de médias= -1,27 mm2; p= 0,004). As medidas do volume do lúmen do SVB mostraram correlação (r= 0,58; p= 0,006) e foram equivalentes (diferença de mediana= 5,4 mm3; p= 0,14). Em ambas, houve ampla variabilidade entre as medidas (variação percentual do erro de 128% para a área e de 119% para o volume). Os métodos mostraram correlações significativas para todas as demais variáveis. As médias das medidas de diâmetros, pela ANGIO-TC, não mostraram diferenças significativas em relação ao USIC. A ANGIO-TC subestimou significativamente as medidas da área mínima do lúmen no segmento distal ao SVB (diferença= -1,09 mm2; p = 0,017) e da área de referência dos vasos (diferença = -1,34 mm2; p = 0,008). Apesar do viés mínimo, os métodos mostraram ampla variação ao identificar o ponto de menor dimensão do SVB (erro percentual = 186%). A ANGIO-TC, assim como o USIC, não identificou casos de reestenose. Os métodos mostraram melhor nível de concordância ao medirem diâmetros e maiores discrepâncias ao estimarem percentuais de estenose. Conclusões: Em segmentos coronários com SVB polimérico, a ANGIOTC não obteve correlação e subestimou a área mínima do lúmen em relação ao USIC. Quantificações do volume do lúmen foram equivalentes e correlacionadas. Independentemente do nível de correlação, o padrão de concordância das medidas evidenciou um nível de acurácia insatisfatório para a ANGIO-TC substituir o USIC para quantificações de lumens em estudos com SVB radiolucentes, embora permaneça útil para análises visuais na prática clínica. / Computed tomography coronary angiography (CTA) is able to quantify vessel dimensions and might potentially be an alternative to substitute invasive methods for quantitative analysis in percutaneous coronary interventions with bioresorbable vascular scaffolds (BVS). This study compared quantitative measurements derived from CTA images to intravascular ultrasound (IVUS) in coronary segments implanted with radiolucent DESolve(TM) novolimuseluting BVS. Primary objectives were comparisons of BVS minimal luminal area and luminal volume in BVS. Secondary objectives included comparisons of minimal luminal areas and diameters in proximal and distal segments to the BVS, luminal vessel reference areas and diameters and BVS percent area and diameter stenosis. Precision of identifying BVS luminal minimal area were assessed by measuring distance from this point to proximal BVS border. Twenty-one patients underwent both CTA and IVUS, six months after BVS deployment. Each method was performed by an experienced operator, blinded to other\'s quantifications. Correlation coefficients were calculated and mean differences with 95% limits of agreement were assessed by Bland-Altman analysis. A p-value less than 0.05 were considered statistically significant. CTA did not show correlation to IVUS and significantly underestimated minimal luminal area in BVS (mean differences = -1.27 mm2; p = 0.004). Quantitative measurements of luminal volume in BVS were equivalent (median difference = 5.4 mm3; p = 0.14) and showed modest correlation (r= 0.58; p= 0.006). Both variables showed wide limits of agreement (percent error = 128% in minimal luminal area and 119% in luminal volume). Correlations were significant in all other variables. Both methods did not show significant differences quantifying all-segment diameters, and percent area and diameter stenosis. CTA significantly underestimated measurements of minimal luminal area in distal segment after BVS (mean difference = -1,09 mm2; p = 0,017) and luminal reference area (mean difference = -1,34 mm2; p = 0,008). CTA and IVUS showed nonsignificant bias to identify BVS luminal minimal area, but very wide limits of agreement (percent error= 186%). Both methods agreed in showing no cases of binary restenosis. Regardless of correlations or mean differences, all measures showed high variability, caracterized by wide limits of agreement. The least variations resulted from diameter quantifications, whereas estimated percent stenosis presented more disparities. These discrepancies between both methods showed that CTA analysis is still not fully developed to replace IVUS in the assessment of quantitative measurements in vessels treated with BVS. It remains, however, clinically useful for visual qualitative analysis.

Introdução: Os stents farmacológicos (SF) de primeira geração surgiram com o intuito de reduzir as taxas de reestenose intra-stent e de revascularização da lesão-alvo, sendo mais eficazes quando comparados aos stents não-farmacológicos (SNF), porém com aumento de risco de trombose do stent (TS) muito tardia. A cobertura tecidual incompleta e a má aposição tardia das hastes dos stents podem estar vinculadas à TS. O SF de segunda geração BioMatrix®, que utiliza um polímero bioabsorvível, surgiu na expectativa de redução da TS. Devido à alta acurácia e reprodutibilidade e à análise precisa da cobertura tecidual e da aposição das hastes dos stents, a tomografia de coerência óptica (TCO) vem se tornando um método útil na análise desses aspectos. O objetivo desse estudo foi avaliar a cobertura tecidual e a aposição das hastes do SF BioMatrix® após longo período do implante. Métodos: Vinte pacientes submetidos ao implante do SF BioMatrix® (n = 15) ou do SNF S-Stent® (n = 5) foram acompanhados por um período mínimo de cinco anos e avaliados por meio da angiografia coronária quantitativa (ACQ), da ultrassonografia intracoronária (USIC) e da TCO. Para a análise estatística, foram utilizados os programas SPSS® versão 16.0 e SAS versão 9.2. O valor de p < 0,05 era considerado estatisticamente significante. As variáveis categóricas foram expressas em números absolutos e porcentuais e comparadas pelo teste exato de Fisher. As variáveis contínuas foram expressas em média e desvio padrão e/ou mediana e intervalo interquartílico e foram comparadas pelo teste não paramétrico de Mann-Whitney. Resultados: A ACQ demonstrou diferença, porém não significativa na perda tardia da luz entre o SF BioMatrix® e o S-Stent® [0,40 (0,21; 0,77) mm vs 0,68 (0,66; 0,82) mm, p = 0,205]. Os pacientes tratados com o SF BioMatrix® apresentaram porcentual de obstrução do stent significativamente menor quando comparados àqueles que receberam o S-Stent® [5,6 (4,4; 9,7)% vs 28,6 (24,7; 29,0)%, p =0,001]. A análise da TCO demonstrou 126 (8,7%) hastes não cobertas nos stents BioMatrix® e 23 (4,0%) nos S-Stents® (p = 0,297), estando a maioria delas bem apostas (117/126 e 21/23, respectivamente, p = 0,292). Apenas nove (0,6%) hastes nos SF e duas (0,4%) hastes nos SNF estavam simultaneamente sem cobertura tecidual e mal apostas (p = 0,924). No grupo BioMatrix®, apenas 1 (11,1%) paciente teve todas as hastes cobertas. Já no grupo S-Stent, 66,7% dos pacientes (2/3) apresentaram cobertura completa das hastes (p = 0,127). Conclusões: A avaliação tardia do SF BioMatrix® pela TCO mostrou cobertura tecidual e aposição em quase a totalidade de suas hastes, de maneira similar àquela encontrada nos SNF S-Stents®. / Introduction: First generation drug-eluting stents (DES) have emerged as a strategy to prevent in-stent restenosis and the need of target-vessel revascularization when compared to bare metal stents (BMS); but at the expense of a higher risk of very late stent thrombosis (ST). Uncovered and malapposed struts may be associated with both late and very late ST. It has been postulated that the second generation DES, the biolimus-eluting stent BioMatrixTM with biodegradable polymer, may reduce the incidence of ST. Given its high accuracy and reproducibility with precise analysis of the complete strut apposition and strut coverage, the optic coherence tomography (OCT) has been extensively used for stent analysis. The aim of this study was to assess the struts coverage and apposition of DES BioMatrixTM in a long-term follow up. Methods: Twenty patients undergoing a BioMatrixTM (n = 15) or BMS S-StentTM (n = 5) implantation were followed up for a period of at least five years and evaluated by means of OCT, quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS). All statistical analyses were performed using SPSSTM (v.16.0) and SAS (v.9.2) software. Statistical significance was considered at p values < 0.05. Categorical variables were expressed as counts and percentages, and continuous variables as mean SD and/or median and interquartile range. For per-patient level comparison, the difference between two stent types was evaluated by nonparametric Mann-Whitney U test while categorical variables were evaluated by the Fisher exact test. Results: QCA analysis showed no differences in the occurrence of intrastent late loss between the groups [0.40 (0.21; 0.77) mm vs 0.68 (0.66; 0.82) mm, p = 0.205 for BioMatrixTM and S-StentsTM, respectively]. The vessel, stent and lumen volumes assessed by IVUS after the procedure and 5 years later were similar between the two groups. Patients treated with BioMatrixTM had significantly less stent obstruction percentage when compared to those treated with S-StentTM [5.6 (4.4; 9.7)% vs 28.6 (24.7; 29.0)%, p = 0.001]. OCT analysis demonstrated 126 (8.7%) uncovered struts in the BioMatrixTM group compared to 23 (4.0%) in the S-StentsTM group (p = 0.297), being the majority of them well apposed (117/126 and 21/23, respectively, p = 0.292). Only 9 (0.6%) struts in the DES and 2 (0.4%) struts in the BMS groups were imultaneously uncovered and malapposed (p = 0.924). Among the BioMatrixTM patients, 55.6% (5/9) had more than 95% of covered struts and in only 1 (11.1%) patient all struts were covered. On the other hand, among the S-StentTM patients, 66.7% (2/3) had complete covered struts (p = 0.127). Conclusion: Long term assessment of DES BioMatrixTM by OCT showed tissue coverage and apposition in almost all struts, similary to those found in the BMS S-StentsTM.

O objetivo deste estudo foi descrever as características demográficas, clínicas, radiológicas e o prognóstico da doença oclusiva da artéria basilar (DOAB), em uma população multiétnica. Foram estudados 40 indivíduos com infartos no território da artéria basilar (AB) confirmados por ressonância magnética, que sobreviveram após 30 dias à fase aguda do acidente vascular cerebral isquêmico (AVCI). Todos os doentes apresentavam estenose ³ 50% ou oclusão da AB, documentada por angiografia por ressonância ou angiografia digital. Foram registrados: idade, sexo, grupo étnico, fatores de risco para doença vascular, quadro clínico na instalação do AVCI, local do infarto, segmento arterial acometido, grau de estenose e presença de circulação colateral. A escala modificada de Rankin (EMR) em 30 dias e após seis meses do evento isquêmico foi avaliada, assim como a taxa de recorrência de eventos vasculares isquêmicos. Associações entre dados demográficos, aspectos clínicos, radiológicos e prognóstico foram analisadas pelo teste da razão de verossimilhança ou pelo teste exato de Fisher. A comparação entre a pontuação na EMR em 30 dias e seis meses foi realizada pelo teste de Wilcoxon. Sessenta por cento dos pacientes eram homens e 33%, afro-brasileiros. A média (± desvio-padrão) de idade foi 55,8 ± 12,9 anos. A maioria (90%) dos pacientes apresentou múltiplos fatores de risco para doença vascular. Ataques isquêmicos transitórios (AIT) precederam os AVCIs em 48% dos casos. Antecedente de hipertensão arterial sistêmica (HAS) esteve presente em 80% dos doentes. O sintoma mais comum foi vertigem/desequilíbrio. A maioria dos infartos localizou-se na ponte (85%) e o terço médio da AB foi o mais freqüentemente afetado (33%). Oclusão arterial esteve presente em 58% dos casos. Lesões mais graves foram observadas em caso de acometimento do terço médio da AB (p=0,001). Aterosclerose de grandes artérias foi a etiologia mais comum do AVCI (88%), sendo mais freqüente nos pacientes acima de 45 anos (p<0,001). Somente um paciente foi tratado com trombólise intra-arterial e a maioria foi tratada com anticoagulação na fase aguda. A pontuação na EMR melhorou significativamente após seis meses (p<0,001). Podemos concluir que obtivemos alguns resultados diferentes de outras séries de países desenvolvidos, como maior proporção de afrodescendentes e oclusão da AB em pouco mais da metade dos casos. Taxas de AIT precedendo o AVCI, freqüência alta de aterosclerose como etiologia e bom prognóstico funcional foram semelhantes a descrições da literatura. Estes resultados representam um avanço no conhecimento da DOAB em nosso meio / The aim of this study was to describe demographical, clinical, radiological findings and outcome in stroke survivors with basilar artery occlusive disease (BAOC). We studied 40 patients with infarcts in the basilar artery (BA) territory confirmed by magnetic resonance imaging (MRI), who survived for at least 30 days after acute stroke. All patients had ³ 50% BA stenosis or occlusion, documented by magnetic resonance or digital subtraction angiography. The following characteristics were registered: age, sex, ethnical group, vascular risk factors, symptoms and signs, infarct location, site and degree of BA stenosis, and presence of collateral circulation. Modified Rankin Scale (MRS) scores at 30 days and six months after the ischemic event were evaluated, as well as transient ischemic attack (TIA) and stroke recurrence rates. Associations between demographical, clinical, radiological features and outcome were analyzed with Likelihoodratio and Fisher´s exact tests. The comparison between MRS scores at 30 days and six months was made with the Wilcoxon test. Sixty percent of the patients were male and 33% were Afro-Brazilian. Mean age was 55.8 ± 12.9 years. Most of the subjects (90%) had multiple vascular risk factors. TIAs preceded strokes in 48% of the patients. Eighty per cent had history of arterial hypertension. The most common neurological symptom was vertigo/dizziness. Most of the infarcts were located in the pons (85%) and the BA middle third was the most frequently affected segment (33%). BA occlusion occurred in 58% of the patients. More severe lesions were present in patients with occlusive disease in the middle third of the BA (p=0.001). Large-artery atherosclerosis was the most common stroke etiology (88%) and was more frequent in patients older than 45 years (p<0.001). Only one patient was treated with intra-arterial thrombolysis and most of the others received anticoagulation. MRS scores improved significantly at six months (p<0.001). In conclusion, we observed different results compared with other series, such as: greater proportion of afrodescendents, higher frequency of atherosclerosis and BA occlusion. Rates of preceding TIAs and good outcome at six months were similar to previously published data. These results represent a step forward towards understanding BAOC in a large Brazilian urban center

O enxerto de artéria torácica interna tem demonstrado capacidade de remodelamento devido a interação com o leito arterial coronariano. O objetivo deste estudo foi analisar a influência dos fatores clínicos e angiográficos no remodelamento dos enxertos, definido como variação no calibre vascular. Casuística e métodos: No período entre 1983 e 1999, 356 pacientes realizaram cirurgia de revascularização do miocárdio utilizando a artéria torácica interna esquerda para o ramo interventricular anterior e a artéria torácica interna direita para um ramo da circunflexa. Trinta e dois pacientes foram submetidos a cineangiocoronariografia pós-operatória, a qual foi posteriormente analisada com o aplicativo CASS II®. Este estudo observacional apresentou acompanhamento médio de 42 meses(6-204 meses). As variáveis angiográficas analisadas foram os diâmetros proximal e distal dos enxertos arteriais (variável dependente), área coronariana, pontuação de fluxo TIMI, diâmetro de estenose proximal, fluxo dominante distal e ramos patentes. Fatores de risco cardiovascular também foram incluídos. Resultados: O modelo de regressão linear múltiplo demonstrou um R2ajustado=0,69 (p=0,0001) para o modelo a direita e R2ajustado=0,46 (p=0,002) para a esquerda. Os enxertos apresentaram diâmetros proximal e distal de 2,67mm ±0,085 e 2,232mm ±0,085 à esquerda; 2,458mm ±0,088 e 2,010mm ± 0,091 (média±EP) à direita, respectivamente (p>0,05). Nenhuma variável clínica obteve correlação significante estatisticamente. A área coronariana apresentou coeficiente de beta=0,42 (0,14-0,6/IC-95%) e diâmetro de estenose proximal de 0,55 (0,40-0,65/IC-95%) para o remodelamento do lado direito. A área coronariana demonstrou coeficiente de beta=0,54 (0,3- 0,68/IC-95%) para o remodelamento do lado esquerdo. Conclusões: A artéria torácica interna não demonstrou diferença de calibre em relação a lateralidade (esquerda vs direita). O diâmetro de estenose proximal da artéria coronária revascularizada demonstrou correlação positiva com o remodelamento dos enxertos do lado direito. A área da artéria coronária revascularizada foi a única variável de influência para o remodelamento bilateral dos enxertos / Internal thoracic artery grafts has demonstrated capacity for remodeling due to interaction with the coronary artery bed. The goal was to analysis the influence of clinical and angiographic factors in this remodeling as defined as grafts caliber variation. Methods: In a period from 1983 to 1999, 356 patients underwent to coronary artery bypass surgery using the left internal thoracic artery anastomosed to interventricular anterior branch and the right internal thoracic artery to circumflex branches. Thirty two patients were submitted to postoperative coronary angiography which was further analysed by CASS II® software. The mean follow-up of this observational study was 42 months(6- 204 months). Angiographic variables analyzed was proximal and distal diameters of arterial grafts(dependent variable), coronary area, TIMI flow grade, proximal stenosis diameter, dominant distal flow and patent branches. Cardiovascular risk factors were included indeed. Results: The multiple regression model demonstrated R2adjusted=0.69 (p=0.0001) for right side and R2adjusted=0.46 (p=0.002) for left side. The grafts presented proximal and distal diameters of 2.67mm ±0.085 and 2.232mm ±0.085 from left side; 2.458mm ±0.088 and 2.010mm ±0.091 (mean±SE) from right side respectively (p > 0,05). None of the clinical variables had statistical significant correlation. The coronary area presented as a beta coefficient=0.42 (0.14-0.6/CI-95%) and proximal stenosis diameter of 0.55 (0.40-0.65/CI-95%) for right side remodeling. The coronary area shown a beta coefficient=0.54 (0.3- 0.68/CI-95%) for left side remodeling. Conclusions: The internal thoracic artery did not demonstrate difference in caliber about its laterality (left vs right). The proximal stenosis degree of the bypassed coronary artery demonstrated positive correlation with remodeling for the right side grafts. Bilateral grafts remodeling was only explained by positive correlation with the bypassed coronary area

A artéria radial (AR) constitui valiosa opção de enxerto na revascularização do miocárdio (RM), desde a retomada de seu uso, nos anos 1990. O objetivo deste estudo foi avaliar perviedade e remodelamento dos enxertos de AR e sua relação com lesão obstrutiva pré-operatória e parede miocárdica revascularizada, observando-se também os enxertos de artéria torácica interna (ATI). CASUÍSTICA E MÉTODO: Entre 1994 e 2007, 3.964 pacientes foram operados com uso da AR, no InCor/HCFMUSP. Foram selecionados os reestudos angiográficos (12 meses) de 100 pacientes, sendo 11 deles reestudados em duas épocas diferentes. Em 92 pacientes foi utilizada a ATI. Foram determinados os diâmetros médios de AR e ATI, através do software CASS-II®. RESULTADOS: O tempo médio de reestudo foi de 70,53 ±33,18 meses. Em 82 casos (82,0%), a AR revascularizou uma única coronária, mais freqüentemente (50,83%) os ramos marginal esquerdo (ME) ou ventricular posterior (VP/CX). As obstruções pré-operatórias entre 90 e 99% foram as mais prevalentes (39,0%). A perviedade observada foi de 80 casos para AR (80,0%) e 80 para ATIE (86,96%). Houve correlação entre as maiores obstruções pré-operatórias e maior perviedade da AR (p=0,024). Os diâmetros médios dos enxertos foram de 2,302mm ±0,479 (AR) e 2,262mm ±0,409 (ATI). Observaram-se AR maiores do que a média (>2,30mm) nas obstruções pré-operatórias de 100%, em comparação com as demais (p=0,017). As AR que revascularizaram a parede lateral apresentaram os maiores diâmetros, em comparação às demais (p=0,04). Nos 11 pacientes com 2 reestudos, os diâmetros médios das AR foram de: 2,482mm ±0,424 (primeiro reestudo) e 2,599mm ±0,532 (segundo reestudo)(p=n/s). Para as ATIE, observaram-se: 2,308mm ±0,459 (primeiro reestudo) e 2,326mm ±0,531 (segundo reestudo) (p=n/s). No segundo reestudo, observou-se maior número de AR com diâmetros maiores, relacionados às obstruções entre 90-100% (p=0,013). A parede miocárdica revascularizada não interferiu nos diâmetros dos enxertos. CONCLUSÕES: A obstrução pré-operatória interfere na perviedade e nos diâmetros dos enxertos de AR, especialmente nas obstruções de 90% ou mais. A parede miocárdica revascularizada não interfere na perviedade da AR, porém interfere nos diâmetros dos enxertos. Foi observado remodelamento dos enxertos de AR, estando as obstruções mais graves relacionadas aos maiores aumentos de diâmetros dos enxertos comportamento semelhante às ATI. / The radial artery (RA) is an invaluable option for coronary artery bypass grafting (CABG), since its re-introduction in the late 1990 s.The objective of this study was to assess patency and remodeling of RA grafts regarding the interference of pre-operative coronary obstruction and grafted myocardial wall, also observing the internal thoracic artery grafts (ITA). METHODS: Between 1994 and 2007, 3,964 patients were operated with RA grafts, at Heart Institute, University of São Paulo, Brazil. Post-operative coronary angiographies (12 months)of 100 patients were obtained, including 11 patients with two post-op exams, at different periods. In 92 patients the ITA was also used.The grafts medium diameters were obtained using the CASS-II® software. RESULTS: Mean time of post-op angiography was 70,53 ±33,18 months. In 82 cases (82,0%) the RA grafted a single coronary, more frequently (50,83%) the left marginal (LM) or posterior ventricular (PV) branches. Pre-op obstructions between 90 and 99% were more prevalent (39,0%). Patency was of 80 cases for the RA (80,0%) and 80 cases for the ATI grafts (86,96%). There was a correlation between more severe pre-op obstructions and greater patency of the RA grafts (p=0,024). The mean diameters were 2,302mm ±0,479 (RA) and 2,262mm ±0,409 (ITA). RA diameters were above the mean value (>2,30mm) in pre-op obstructions of 100%, compared to the rest (p=0,017). The RA grafting the lateral wall showed the larger diameters, compared to the rest (p=0,04). For the 11 patients with 2 post-op angiographies, mean diameters of RA grafts were: 2,482mm ±0,424 (first) and 2,599mm ±0,532 (second)(p=n/s). For ITA grafts, mean diameters were: 2,308mm ±0,459 (first) and 2,326mm ±0,531 (second)(p=n/s). For the second angiographies, RA grafts exhibited larger diameters, related to pre-op obstructions between 90 and 100% (p=0,013). The grafted myocardial wall showed no interference with graft diameter. CONCLUSIONS: Pre-op coronary obstruction interferes in patency and diameters of RA grafts, more evidently for obstructions of 90% or greater. The grafted myocardial wall does not interfere with RA patency, although it does interfere with graft diameter. Remodeling was observed in RA grafts, correlating greater pre-op coronary obstructions and more evident increase in graft diameter similarly to the ITA grafts.

INTRODUÇÃO: A prevalência da fibrilação atrial, os gastos com o sistema de saúde e a elevada morbidade e mortalidade associados a ela, têm justificado a procura por um melhor entendimento de suas bases fisiopatológicas e por novas abordagens terapêuticas. O objetivo deste manuscrito é avaliar a exeqüibilidade, a segurança e os resultados em três meses da cirurgia vídeo-assistida para a ablação da fibrilação atrial com radiofreqüência bipolar. MÉTODOS: Dez pacientes (90% homens) com fibrilação atrial sintomática e refratária à terapia medicamentosa foram submetidos ao procedimento cirúrgico proposto no Instituto Nacional de Cardiologia, Rio de Janeiro, no período de Maio 2007 a Maio de 2008. Foram analisadas variáveis de peri e pós-operatório. Além da avaliação clínica dos sintomas, todos os pacientes foram submetidos a um ecocardiograma e Holter de 24horas antes e três meses após a cirurgia. Realizou-se também uma angiotomografia de veias pulmonares no terceiro mês de seguimento pós-operatório. RESULTADOS: O procedimento foi realizado conforme planejado em todos os pacientes. Cem por cento das veias pulmonares direitas e 90% das esquerdas tiveram o isolamento elétrico confirmado. Não houve lesão iatrogênica de estruturas intra-torácicas ou óbitos. Dois pacientes apresentaram pneumonia pós-operatória e longo tempo de permanência hospitalar no início da experiência clínica. Nove dos dez pacientes saíram do centro cirúrgico em ritmo sinusal. Houve uma recorrência da fibrilação atrial em três meses (11,1%). No total, 80% dos pacientes estão livres de fibrilação atrial em três meses. Houve melhora significativa da função diastólica avaliada ecocardiograficamente pela relação E/E após a cirurgia (9,0 ± 2,23 para 7,7 ± 1,07; p=0,042) que se associa a uma melhora dos sintomas de insuficiência cardíaca classe funcional da New York Heart Association (2,4 ± 0,5 para 1,6 ± 0,7; p=0,011). Não houve evidência de estenose de veias pulmonares à angiotomografia nesta série. CONCLUSÃO: A cirurgia torácica vídeo-assistida para o tratamento da fibrilação atrial é exeqüível e segura mas a incorporação desta nova técnica à prática clínica requer uma curva de aprendizado da equipe envolvida. A melhora dos sintomas de insuficiência cardíaca está relacionada à melhora da função diastólica do ventrículo esquerdo / BACKGROUND: Atrial fibrillation prevalence, its health system cost and the high morbidity and mortality associated with it have justified the search for a better understanding of its pathophysiology and new therapeutic management. The objective of this study was to assess the feasibility, the safety and the three months results of the video-assisted thoracoscopic surgery for the ablation of atrial fibrillation using bipolar radiofrequency. METHODS: Ten patients (90% male) with symptomatic and refractory atrial fibrillation underwent the proposed surgical procedure at the National Institute of Cardiology, Rio de Janeiro, Brazil, from May 2007 to May 2008. Peri and post-operative data were collected for analysis. Besides clinical evaluation, all patients have been submitted to an echocardiogram and a 24h Holter monitoring before and three months after the procedure. A pulmonary veins angiotomography was also performed three months after surgery. RESULTS: The surgical procedure was done as planned in all patients and 100% of the right pulmonary veins were isolated. Ninety per cent of the left pulmonary veins were confirmed to be electrically isolated. There was no surgical injury to any intra thoracic organ or death in this series. Two patients had post-operative pneumonia that required prolonged in hospital stay early in the experience. Nine of ten patients were in sinus rhythm just after surgery. There was one recurrence of atrial fibrillation within the three months follow up (11,1%). In general, eighty per cent (80%) of the patients are free of atrial fibrillation three months after surgery. There was a significant improvement in diastolic function measured by the relation E/E on the echocardiogram before and after the procedure (9,0 ± 2,23 to 7,7 ± 1,07; p=0,042). This was associated to an improvement of heart failure symptoms of New York Heart Association (2,4 ± 0,5 to 1,6 ± 0,7; p=0,011). There was no pulmonary vein stenosis in this cohort. CONCLUSIONS: Video-assisted thoracoscopic surgery for the treatment of atrial fibrillation is feasible and safe although it requires a learning curve to incorporate this new technique to clinical practice. The improvement on heart failure symptoms is associated to an improvement on diastolic left ventricular function

Orientadores: Celso Darío Ramos, João Augusto Lima / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-25T22:27:02Z (GMT). No. of bitstreams: 1 Godoy_GustavoKhattarde_D.pdf: 2269934 bytes, checksum: b16ad3f63241f0e2537f807b8c45d497 (MD5) Previous issue date: 2014 / Resumo: Este trabalho consiste na comparação de diferentes métodos de imagem utilizados na prática clínica para a detecção da doença coronariana isquêmica, umas das maiores causas de mortalidade nos países desenvolvidos, utilizando como base o estudo multicêntrico Internacional, Core 64. Através de uma análise retrospectiva foram selecionados 63 pacientes de um total de 405 do estudo principal Core 64 que tinham realizado, além da Tomografia Computadorizada e da Cinecoronariografia, a Cintilografia de Perfusão Miocárdica com o objetivo principal de avaliar a correlação anatomofisiológica entre os diferentes métodos de imagem na avaliação da patologia coronariana de causa obstrutiva. Para isto, foram identificados através da avaliação anatômica quantitativa, tanto pela tomografia quanto pela cinecoronariografia, a presença de estenoses coronarianas causando obstruções entre 30 e 80% do lúmen arterial e correlacionados com a presença de defeitos perfusionais quantificados pela cintilografia de perfusão miocárdica equivalentes ao mesmo território coronariano. Após a análise estatística constatou-se que tanto a tomografia como a cinecoronariografia apresentam sensibilidade e especificidade apenas moderadas para prognosticar as alterações perfusionais detectadas pela cintilografia de perfusão miocárdica, no entanto, ambos os métodos são complementares e de fundamental importância na prática clínica para a manejamento diagnóstico e terapêutico dos pacientes portadores da doença coronariana isquêmica / Abstract: This work is related to a comparison between different modalities of imaging in the detection of obstructive coronary artery disease causing myocardial ischemia one of the biggest cause of death in developed countries using as base a multicenter trial Core 64. A retrospective analysis was performed using a subgroup of 63 patients of a total of 405 to evaluate the diagnostic accuracy of Multi-Detector Computed Tomography Angiography (MDCTA) and Conventional Coronary Angiography in detecting myocardial ischemia identified by Myocardial Perfusion Imaging (SPECT). Threshold of 30-80% of coronary artery stenosis identified by MDCTA and conventional coronary angiography were settled and correlated to the presence of myocardial ischemia of the same coronary artery territory. After statistical analyses a similar modest accuracy for quantitative coronary arterial stenosis assessment by both QCTA and QCA for identifying patients with myocardial perfusion were found, however either MDCTA, conventional coronary angiography and SPECT are complementary methods and play an import roll not only diagnosing but guiding clinical treatment in patients with coronary artery disease / Doutorado / Clinica Medica / Doutor em Clínica Médica

Les malformations artérioveineuses (MAV) cérébrales sont une pathologie rare et hétérogène dont l’imagerie est complexe du fait de leur caractère dynamique et la prise en charge controversée notamment du fait des risques liés aux traitements proposés.La première partie de cette thèse porte sur l’imagerie des MAVs, axée sur une nouvelle technique, l’angiographie en 4 dimensions. Initialement, nous avons étudié sa faisabilité et validé cette technique en la comparant à l’angiographie cérébrale conventionnelle. Puis nous l’avons comparé à une autre modalité dynamique, l’angiographie par résonance magnétique en 4 dimensions, dans l’analyse des caractéristiques angio-architecturales des MAVs. Enfin, nous avons utilisé cette technique comme aide au planning pré et peropératoire dans la chirurgie des micro-MAVs.La seconde partie de cette thèse porte sur la prise en charge des patients porteurs d’une MAV dans le cadre d’études cliniques. Face à l’absence de consensus et aux hétérogénéités des pratiques sur la prise en charge de cette pathologie, la réflexion de ce travail a été conduite en plusieurs temps : un état des lieux basé sur une revue systématique des critiques faites à un essai randomisé sur les MAVs non rompues ; puis la conception d’une nouvelle étude pragmatique en soins courant, randomisée et intégrant le jugement clinique du praticien et de l’équipe multidisciplinaire ; l’évaluation de l’applicabilité de cette conception aux différentes pratiques via l’interrogation des praticiens par questionnaires ; la mise en place de cette étude multicentrique internationale TOBAS (Treatment of Brain Arteriovenous Malformation) ; et enfin, l’analyse des résultats de la phase pilote montrant la faisabilité de l’étude. / Brain arteriovenous malformations (AVMs) are a rare and heterogeneous pathology. Imaging anAVM is complex because of their temporal dynamic feature. The management is controversial in particular due to the risks associated with the proposed treatments.The first part of this work is about imaging AVMs. We focused on a new technique, 4-Dimensional digital substraction angiography (4D DSA). Initially, we studied its feasibility and validated this technique in comparison with conventional cerebral angiography. Then we compared 4D DSA with another dynamic modality, 4-dimensional magnetic resonance angiography (4D MRA), in the analysis of angio-architectural characteristics of AVMs. Finally, we used this technique as a supplementary tool in the pre- and intraoperative planning of micro-AVM surgery.The second part deals with the management of AVMs patients in clinical studies. Given the lack of consensus, and the heterogeneity of practices in the management of this pathology, the conduct of this work was done in several stages: a systematic review and a critical analysis of a randomized trial recently published on unruptured brain AVMs; the design of a new pragmatic randomized trial incorporating the clinical judgment of the multidisciplinary team, the evaluation of the applicability of this design to the different practices using questionnaires; the implementation of this international multi-center study called TOBAS (Treatment of Brain Arteriovenous Malformation); and finally, the analysis of the pilot phase of the study.

Abstract Cardiac surgery with cardiopulmonary bypass (CPB) results in hemodilution, systemic inflammatory response, activation of coagulation and fibrinolysis, and microembolisation, which may all contribute to postoperative organ dysfunction. As an attempt to attenuate these side effects, the use of minimized cardiopulmonary bypass (MCPB) systems has increased. Compared to conventional CPB (CCPB), they are characterized with reduced artificial surface area and blood-air interface. The goal of these alterations has been to reduce systemic inflammation, preserve coagulation function and minimize the need for blood tranfusions. This study was aimed at determining whether or not MCPB attenuates the adverse effects of CPB. In study I, the safety, feasibility and effect on transfusion requirements of MCPB was investigated in unselected coronary artery bypass surgery (CABG) patients. In studies II and III, the incidence of retinal microembolism after CABG and aortic valve replacement (AVR) surgery with MCPB was compared to that of CCPB by means of fluorescein angiography. Furthermore, in studies II and III, the effect of MCPB on systemic inflammation, coagulation, endothelial activation and injury, as well as on platelet activity, was compared to those of CCPB. In study IV, the effect of MCPB on intestinal mucosal damage following CPB was compared to CCPB in a porcine model of prolonged CPB. MCPB appeared as safe and feasible as CCPB in unselected CABG patients (Study I). MCPB was associated with decreased retinal microembolism compared to CCPB in CABG patients (Study II). Conversely, the difference in retinal microembolism in AVR patients was not statistically significant (Study III). MCPB was associated with a decrease in neutrophil activation in CABG and AVR patients as compared to CCPB. However, there were no differences in coagulation, endothelial activation and injury, or in platelet activity (Studies II, III). There were no differences in markers of intestinal mucosal damage between MCPB and CCPB following prolonged CPB in the experimental model (Study IV). The results of this study suggest that MCPB may be used safely with CABG patients, with beneficial effects on hematocrit, and attenuated neutrophil activation. In CABG patients, MCPB is associated with reduced retinal microembolism, suggesting a decreased embolic load to the brain. The clinical feasibility of MCBP requires further technical evolution in the management of valve surgery. The results of the animal model support previous concerns regarding intestinal mucosal damage during CPB. / Tiivistelmä Sydänkeuhkokoneen käyttö aiheuttaa elimistössä hemodiluution, yleistyneen tulehdusvasteen ja hyytymisjärjestelmän aktivoitumisen sekä mikroembolisaatiota. Ilmiöt ovat yleensä lieviä ja ohimeneviä, mutta voivat johtaa elintoimintahäiriöihin ja pitkittyneeseen toipumiseen sydänleikkauksen jälkeen. Haittojen lievittämiseksi sydänkeuhkokonetta on pyritty kehittämään fysiologisemmaksi. Miniperfuusiolaitteistoissa kiertävän veren kontakti pintamateriaalien ja ilman kanssa jää pienemmäksi ja veren laimenemista tapahtuu vähemmän. Tutkimuksen tavoitteena oli selvittää voidaanko miniperfuusiolla lievittää sydänkeuhkokoneen haittoja. Ensimmäisessä osatyössä selvitettiin miniperfuusion käyttökelpoisuutta ja vaikutusta verensiirtotarpeeseen ohitusleikkauspotilailla valikoimattomassa aineistossa. Toisessa ja kolmannessa osatyössä selvitettiin silmänpohjan mikroembolioiden ilmaantuvuutta miniperfuusion ja perinteisen sydänkeuhkokoneen käytön jälkeen ohitusleikkauspotilailla ja aorttaläppäleikkauspotilailla. Toisessa ja kolmannessa osatyössä selvitettiin lisäksi miniperfuusion vaikutuksia yleistyneen tulehdusvasteen voimakkuuteen, hyytymisjärjestelmään sekä endoteelin aktivaatioon perinteiseen sydänkeuhkokoneeseen verrattuna. Neljännessä osatyössä verrattiin kokeellisessa mallissa miniperfuusion ja perinteisen sydänkeuhkokoneen vaikutuksia suoliston limakalvon eheyteen. Miniperfuusio ilmeni yhtä käyttökelpoiseksi kuin perinteinen sydänkeuhkokone ohitusleikkauspotilaiden hoidossa. Ohitusleikkauspotilailla ilmeni vähemmän silmänpohjan mikroembolioita miniperfuusion jälkeen, mutta aorttaläppäleikkauspotilailla ero ei ollut tilastollisesti merkitsevä. Miniperfuusion käyttöön liittyi vähemmän neutrofiilien aktivaatiota. Tekniikoiden välillä ei ilmennyt eroa hyytymisjärjestelmän eikä endoteelin aktivaatiota osoittavissa merkkiaineissa. Sydänkeuhkokoneen käyttö aiheutti saman tasoisen suoliston limakalvon vaurion miniperfuusiolla ja perinteisellä sydänkeuhkokoneella. Tutkimuksen perusteella miniperfuusiotekniikkaa voidaan käyttää turvallisesti ohitusleikkauspotilaiden hoidossa ja sen käyttö vähentää hemodiluutiota ja neutrofiilien aktivaatiota verrattuna perinteiseen sydänkeuhkokoneeseen. Miniperfuusiolla voidaan vähentää sydänkeuhkokoneen käytön aiheuttamaa silmänpohjan mikroembolisaatiota, joka saattaa viitata vähäisempään aivoverenkierron mikroembolisaatioon. Miniperfuusiotekniikoiden tulee edelleen kehittyä hyödyttämään enemmän myös aorttaläppäleikkauspotilaita. Löydökset koskien sydänkeuhkokoneen aiheuttamia suoliston limakalvovaurioita vahvistavat aiempaa olettamusta suoliston haavoittuvuudesta sydänleikkauksen jälkeen.

Les maladies coronariennes constituent l'ensemble des troubles affectant les artères coronaires. Elles sont la première cause mondiale de mortalité. Par conséquent, la détection précoce de ces maladies en utilisant des techniques peu invasives fournit un meilleur résultat thérapeutique, et permet de réduire les coûts et les risques liés à une approche interventionniste. Des études récentes ont montré que la tomodensitométrie peut être utilisée comme une alternative non invasive et fiable pour localiser et quantifier ces lésions. Cependant, l'analyse de ces examens, basée sur l'inspection des sections du vaisseau, reste une tâche longue et fastidieuse. Une haute précision est nécessaire, et donc seulement les cliniciens hautement expérimentés sont en mesure d'analyser et d'interpréter de telles données pour établir un diagnostic. Les outils informatiques sont essentiels pour réduire les temps de traitement et assurer la qualité du diagnostic. L'objectif de cette thèse est de fournir des outils automatisés de traitement d'angiographie CT, pour la visualisation et l'analyse des artères coronaires d'une manière non invasive. Ces outils permettent aux pathologistes de diagnostiquer et évaluer efficacement les risques associés aux maladies cardio-vasculaires tout en améliorant la qualité de l'évaluation d'un niveau purement qualitatif à un niveau quantitatif. Le premier objectif de ce travail est de concevoir, analyser et valider un ensemble d'algorithmes automatisés utiles pour la détection et la quantification de sténoses des artères coronaires. Nous proposons un nombre de techniques couvrant les différentes étapes de la chaîne de traitement vers une analyse entièrement automatisée des artères coronaires. Premièrement, nous présentons un algorithme dédié à l'extraction du cœur. L'approche extrait le cœur comme un seul objet, qui peut être utilisé comme un masque d'entrée pour l'extraction automatisée des coronaires. Ce travail élimine l'étape longue et fastidieuse de la segmentation manuelle du cœur et offre rapidement une vue claire des coronaires. Cette approche utilise un modèle géométrique du cœur ajusté aux données de l'image. La validation de l'approche sur un ensemble de 133 examens montre l'efficacité et la précision de cette approche. Deuxièmement, nous nous sommes intéressés au problème de la segmentation des coronaires. Dans ce contexte, nous avons conçu une nouvelle approche pour l'extraction de ces vaisseaux, qui combine ouvertures par chemin robustes et filtrage sur l'arbre des composantes connexes. L'approche a montré des résultats prometteurs sur un ensemble de 11 examens CT. Pour une détection et quantification robuste de la sténose, une segmentation précise de la lumière du vaisseau est cruciale. Par conséquent, nous avons consacré une partie de notre travail à l'amélioration de l'étape de segmentation de la lumière, basée sur des statistiques propres au vaisseau. La validation avec l'outil d'évaluation en ligne du challenge de Rotterdam sur la segmentation des coronaires, a montré que cette approche présente les mêmes performances que les techniques de l'état de l'art. Enfin, le cœur de cette thèse est consacré à la problématique de la détection et la quantification des sténoses. Deux approches sont conçues et évaluées en utilisant l'outil d'évaluation en ligne de l'équipe de Rotterdam. La première approche se base sur l'utilisation de la segmentation de la lumière avec des caractéristiques géométriques et d'intensité pour extraire les sténoses coronaires. La seconde utilise une approche basée sur l'apprentissage. Durant cette thèse, un prototype pour l'analyse automatisée des artères coronaires et la détection et quantification des sténoses a été développé. L'évaluation qualitative et quantitative sur différents bases d'examens cardiaques montre qu'il atteint le niveau de performances requis pour une utilisation clinique / Coronary heart diseases are the group of disorders that affect the coronary artery vessels. They are the world's leading cause of mortality. Therefore, early detection of these diseases using less invasive techniques provides better therapeutic outcome, as well as reduces costs and risks, compared to an interventionist approach. Recent studies showed that X-ray computed tomography (CT) may be used as an alternative to accurately locate and grade heart lesions in a non invasive way. However, analysis of cardiac CT exam for coronaries lesions inspection remains a tedious and time consuming task, as it is based on the manual analysis of the vessel cross sections. High accuracy is required, and thus only highly experienced clinicians are able to analyze and interpret the data for diagnosis. Computerized tools are critical to reduce processing time and ensure quality of diagnostics. The goal of this thesis is to provide automated coronaries analysis tools to help in non-invasive CT angiography examination. Such tools allow pathologists to efficiently diagnose and evaluate risks associated with CVDs, and to raise the quality of the assessment from a purely qualitative level to a quantitative level. The first objective of our work is to design, analyze and validate a set of automated algorithms for coronary arteries analysis with the final purpose of automated stenoses detection and quantification. We propose different algorithms covering different processing steps towards a fully automated analysis of the coronary arteries. Our contribution covers the three major blocks of the whole processing chain and deals with different image processing fields. First, we present an algorithm dedicated to heart volume extraction. The approach extracts the heart as one single object that can be used as an input masque for automated coronary arteries segmentation. This work eliminates the tedious and time consuming step of manual removing obscuring structures around the heart (lungs, ribs, sternum, liver...) and quickly provides a clear and well defined view of the coronaries. This approach uses a geometric model of the heart that is fitted and adapted to the image data. Quantitative and qualitative analysis of results obtained on a 114 exam database shows the efficiency and the accuracy of this approach. Second, we were interested to the problem of coronary arteries enhancement and segmentation. In this context, we first designed a novel approach for coronaries enhancement that combines robust path openings and component tree filtering. The approach showed promising results on a set of 11 CT exam compared to a Hessian based approach. For a robust stenoses detection and quantification, a precise and accurate lumen segmentation is crucial. Therefore, we have dedicated a part of our work to the improvement of lumen segmentation step based on vessel statistics. Validation on the Rotterdam Coronary Challenge showed that this approach provides state of the art performances. Finally, the major core of this thesis is dedicated to the issue of stenosis detection and quantification. Two different approaches are designed and evaluated using the Rotterdam online evaluation framework. The first approach get uses of the lumen segmentation with some geometric and intensity features to extract the coronary stenosis. The second is using a learning based approach for stenosis detection and stenosis. The second approach outperforms some of the state of the art works with reference to some metrics. This thesis results in a prototype for automated coronary arteries analysis and stenosis detection and quantification that meets the level of required performances for a clinical use. The prototype was qualitatively and quantitatively validated on different sets of cardiac CT exams