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Abstract The best therapeutic strategy for chronic coronary syndrome (CCS) is still controversial. The lack of contemporaneity of medical treatment in many randomized clinical trials prior to the large-scale use of statins, antiplatelet agents, anti-diabetic drugs with cardiovascular protection, and changes in life habits with well-established goals limits the applicability of such studies in current clinical practice. Medical treatment is the only therapeutic option capable of reducing atherosclerotic damage and, therefore, of acting effectively in preventing the progression of this disease. The purpose of this brief review is to critically analyze the main contemporary studies that confront medical treatment with myocardial revascularization in CCS.

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O implante transcateter de MitraClip é uma opção promissora de tratamento da insuficiência mitral (IM) em pacientes com risco cirúrgico elevado. Neste relato, descreve-se o caso de paciente nonagenária com IM aguda por ruptura de cordoalha que, devido a risco cirúrgico proibitivo, foi submetida a implante transcateter de MitraClip com sucesso...

MitraClip transcatheter implant is a promising option for treating mitral regurgitation (MR) in patients with high surgical risk. This report describes the case of a nonagenarian patient with acute MR for chordae rupture that, due to prohibitive surgical risk, underwent a successful MitraClip transcatheter implant...

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Relata-se o caso de paciente octogenária, com infarto agudo do miocárdio (IAM) em evolução, que desenvolveu quadro inflamatório pulmonar agudo, compatível com diagnóstico de pneumonia em organização secundária ao uso de abciximab intracoronariano, em angioplastia percutânea coronariana (APC). Esse diagnóstico foi firmado por meio de alterações clínicas, radiográficas e tomográficas típicas e pela regressão dessas alterações após terapia com corticosteroide.

This report presents the case of an octogenarian female patient with acute myocardial infarction who developed an acute inflammatory pulmonary condition compatible with a diagnosis of secondary organizing pneumonia after intracoronary abciximab during percutaneous coronary angioplasty. This diagnosis was grounded on typical clinical, radiographic and tomographic alterations and the regression of these alterations after corticoid treatment.

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OBJECTIVE: To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients >70 years-old in comparison to patients <70 years-old. METHODS: Patients undergoing isolated CABG were selected for the study. The patients were grouped in G1 (age > 70 years-old) and G2 (age <70 years-old). The endpoints were in-hospital mortality, acute myocardial infarction (AMI), stroke, reexploration for bleeding, intra-aortic balloon for circulatory shock, respiratory complications, acute renal failure, mediastinitis, sepsis, atrial fibrillation, and complete atrioventricular block (CAVB). RESULTS: 1,033 patients were included, 257 (24.8%) in G1 and 776 (75.2%) in G2. Patients in G1 were more likely to have in-hospital mortality than G2 (8.9% vs. 3.6%, respectively; P=0.001), while the incidence of AMI was similar (5.8% vs. 5.5%; P=0.87) than G2. More patients in G1 had re-exploration for bleeding (12.1% vs. 6.1%; P=0.003). G1 had more incidence of respiratory complications (21.4% vs. 9.1%; P<0.001), mediastinitis (5.1% vs. 1.9%; P=0.013), stroke (3.9% vs. 1.3%; P=0.016), acute renal failure (7.8% vs. 1.3%; P<0.001), sepsis (3.9% vs. 1.9%;P=0.003), atrial fibrillation (15.6% vs. 9.8%; P=0.016), and CAVB (3.5% vs. 1.2%; P=0.023) than G2. There was no significant difference in the use of intra-aortic balloon. In the forward stepwise multivariate logistic regression analysis age > 70-year-old was an independent predictive factor for higher in-hospital mortality (P=0.004), reexploration for bleeding (P=0.002), sepsis (P=0.002), respiratory complications (P<0.001), mediastinitis (P=0.016), stroke (P=0.029), acute renal failure (P<0.001), atrial fibrillation (P=0.021) and CAVB (P=0.031). CONCLUSION: This study suggests that patients > 70 years-old were at increased risk of death and other complications in the CABG's postoperative period in comparison to younger patients.

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OBJETIVO: Analisar os resultados da cirurgia de revascularização miocárdica (CRVM) isolada com circulação extracorpórea em pacientes com idade > 70 anos em comparação àqueles com < 70 anos. MÉTODOS: Pacientes submetidos consecutivamente à CRVM isolada. Os pacientes foram agrupados em G1 (idade e" 70 anos) e G2 (idade < 70 anos). Os desfechos analisados foram letalidade hospitalar, infarto agudo miocárdio (IAM), acidente vascular encefálico (AVE), reoperação para revisão de hemostasia (RRH), necessidade de balão intra-aórtico (BIA), complicações respiratórias, insuficiência renal aguda (IRA), mediastinite, sepse, fibrilação atrial (FA) e bloqueio atrioventricular total (BAVT). RESULTADOS: Foram estudados 1033 pacientes, 257 (24,8%) do G1 e 776 (75,2%) do G2. A letalidade hospitalar foi significantemente maior no G1 quando comparado ao G2 (8,9% vs. 3,6%, P=0,001), enquanto a incidência de IAM foi semelhante (5,8% vs. 5,5%; P=0,87). Maior número de pacientes do G1 necessitou de RRH (12,1% vs. 6,1%; P=0,003). Da mesma forma, no G1 houve maior incidência de complicações respiratórias (21,4% vs. 9,1%; P<0,001), mediastinite (5,1% vs. 1,9%; P=0,013), AVE (3,9% vs. 1,3%; P=0,016), IRA (7,8% vs. 1,3%, P<0,001), sepse (3,9% vs. 1,9%; P=0,003), fibrilação atrial (15,6% vs. 9,8%; P=0,016) e BAVT (3,5% vs. 1,2%; P=0,023) do que o G2. Não houve diferença significante na necessidade de BIA. Na análise regressão logística multivariada "forward stepwise", a idade >70 anos foi fator preditivo independente para maior letalidade operatória (P=0,004) e para RRH (P=0,002), sepse (P=0,002), complicações respiratórias (P<0,001), mediastinite (P=0,016), AVE (P=0,029), IRA (P<0,001), FA (P=0,021) e BAVT (P=0,031) no pós-operatório. CONCLUSÃO: Este estudo sugere que pacientes com idade > 70 anos estão sob maior risco de morte e outras complicações no pós-operatório de CRVM em comparação aos pacientes mais jovens.

OBJECTIVE: To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients >70 years-old in comparison to patients <70 years-old. METHODS: Patients undergoing isolated CABG were selected for the study. The patients were grouped in G1 (age > 70 years-old) and G2 (age <70 years-old). The endpoints were in-hospital mortality, acute myocardial infarction (AMI), stroke, reexploration for bleeding, intra-aortic balloon for circulatory shock, respiratory complications, acute renal failure, mediastinitis, sepsis, atrial fibrillation, and complete atrioventricular block (CAVB). RESULTS: 1,033 patients were included, 257 (24.8%) in G1 and 776 (75.2%) in G2. Patients in G1 were more likely to have in-hospital mortality than G2 (8.9% vs. 3.6%, respectively; P=0.001), while the incidence of AMI was similar (5.8% vs. 5.5%; P=0.87) than G2. More patients in G1 had re-exploration for bleeding (12.1% vs. 6.1%; P=0.003). G1 had more incidence of respiratory complications (21.4% vs. 9.1%; P<0.001), mediastinitis (5.1% vs. 1.9%; P=0.013), stroke (3.9% vs. 1.3%; P=0.016), acute renal failure (7.8% vs. 1.3%; P<0.001), sepsis (3.9% vs. 1.9%;P=0.003), atrial fibrillation (15.6% vs. 9.8%; P=0.016), and CAVB (3.5% vs. 1.2%; P=0.023) than G2. There was no significant difference in the use of intra-aortic balloon. In the forward stepwise multivariate logistic regression analysis age > 70-year-old was an independent predictive factor for higher in-hospital mortality (P=0.004), reexploration for bleeding (P=0.002), sepsis (P=0.002), respiratory complications (P<0.001), mediastinitis (P=0.016), stroke (P=0.029), acute renal failure (P<0.001), atrial fibrillation (P=0.021) and CAVB (P=0.031). CONCLUSION: This study suggests that patients > 70 years-old were at increased risk of death and other complications in the CABG's postoperative period in comparison to younger patients.

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Fundamentos : Admite-se que os riscos de complicações pós-operatórias sejam maiores na angina instável pós-infarto.Objetivo: Verificar se a angina instável (AI) pósinfarto (classe C de Braunwald) aumenta o risco de eventos cardiovasculares maiores (ECMA) nacirurgia de revascularização miocárdica (CRVM) em comparação às síndromes coronarianas estáveis. Métodos: Em pacientes submetidos consecutivamenteà CRVM isolada, durante um período de dois anos, comparou-se a incidência de ECMA [morte, infarto agudo do miocárdio com onda Q (IAM) e acidentevascular encefálico (AVE)] entre aqueles com síndromes coronarianas estáveis (G1) e aqueles com AI classe B (G2) e AI classe C (G3) de Braunwald.Resultados: De 333 pacientes operados no período, 238 (71,0%) compunham o G1, 56 (17,0%) o G2 e 39 (12,0%) o G3. Mais pacientes dos G2 e G3apresentavam DPOC (12,5% e 10,0% vs 2,9%, p=0,005) e necessidade de cirurgia de urgência/emergência (18,0% e 33% vs 0,4%; p=0,0001) do que o G1. Não houve diferença significativa na morte hospitalar (4,6%, 8,9% e 5,1%; p=0,45), IAMQ (2,9%,3,6% e 5,1%; p=0,69) e AVE (5,5%, 0%, e 5,1%; p=0,17) ou ECMA (10,9%, 12,5% e 12,8%; p=0,85) entre osG1, G2 e G3, respectivamente.Conclusão: Este estudo sugere que a angina instável pós-IAM não aumenta o risco de eventos cardiovasculares maiores na CRVM em comparaçãoàs síndromes coronarianas estáveis.

Background: It is assumed that post-infarction unstable angina increases the risk of post-operative complications.Objective: To ascertain whether post-infarction unstable angina (Braunwald class C) increases the risk of major cardiovascular events (MACE) for coronary artery bypass surgery (CABG) in comparison to stable coronary syndromes. Methods: In patients undergoing individual CABGconsecutively for a period of two years, the incidence of MACE (hospital mortality, non-fatal Q-wave myocardial infarction [AMI], and stroke) wascompared for patients with stable coronary syndromes (G1) and patients with class B unstable angina (G2),and patients with Braunwald class C unstable angina (G3). Results: Among 333 patients operated during thatperiod, 238 (71%) belonged to G1, 56 (17%) to G2, and 39 (12%) to G3. More G2 and G3 patients presentedCOPD (12.5% and 10.0% vs 2.9%, p=0.005), and the need for emergency / urgent surgery (18.0% and 33.0%vs 0.4%; p=0.0001) than in G1. No significant difference appeared in hospital mortality (4.6%, 8.9%, and 5.1%; p=0.45), non-fatal AMI (2.9%, 3.6%, and 5.1%; p=0.69), and stroke (5.5%, 0%, and 5.1%; p=0.17) or MACE(10.9%, 12.5%, and 12.8%; p=0.85) among G1, G2, and G3 respectively.Conclusion: This study suggests that post-infarction unstable angina did not increase the risk of MACE in CABG compared to stable coronary syndromes.

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Fundamentos: A cirurgia de revascularização miocárdica (CRVM) promove uma melhora da sobrevivência de pacientes com doença arterial coronariana (DAC) e disfunção ventricular esquerda (DFVE).Objetivo: Analisar se a CRVM é capaz de igualar a sobrevivência de pacientes portadores de doença arterialcoronariana com DFVE e sem DFVE. Métodos: Pacientes (n=259) que sobreviveram à CRVM realizada entre 1/10/2001 e 31/1/2004 foramacompanhados por três anos após a cirurgia. A DFVE foi caracterizada por uma fração de ejeção do ventrículoesquerdo (FE) ≤40%. Foram formados dois grupos de acordo com a presença (G1; n=45) ou não (G2; n=214) deDFVE. Resultados: O G1 apresentava mais síndromes coronarianas agudas antes da CRVM (64,4% vs 40,2%;p=0,005); insuficiência cardíaca congestiva (17,8% vs 1,9%; p<0,0001); história prévia de infarto agudo do miocárdio (80% vs 60,3%; p=0,016) e doença pulmonarobstrutiva crônica (11,1% vs 2,3%; p=0,016) do que o G2. A sobrevivência cumulativa em três anos de seguimentofoi significantemente menor no G1 do que no G2 (88,8±4,7% vs 95,7±1,3%, respectivamente; p=0,05). ADFVE, no entanto, não foi fator independente para a menor sobrevivência no seguimento (p=0,119).Conclusão: Este estudo sugere que a CRVM não é capaz de igualar a sobrevivência de pacientes portadores de DAC e DFVE com a de pacientes com DAC sem DFVE.

Background: Coronary artery bypass graft (CABG) surgery prolongs the survival of patients with coronary artery disease (CAD) and left ventriculardysfunction (LVD). Objective: To verify whether CABG can match the survival times of CAD patients with and without LVD. Methods: 259 patients who survived CAGB performed between October 1, 2001 and January 31, 2004 were followed up for three years, with LVD characterized by a left ventricle ejection fraction of ≤40%. Two groups of patients were established, based on the presence (G1; n=45) or absence (G2; n=214) of LVD. Results: G1 patients presented more acute coronarysyndromes before CABG (64.4% vs 40.2%; p=0.005), congestive heart failure (17.8% vs 1.9%; p<0.0001),previous history of acute myocardial infarction (80% vs 60.3%; p=0.016), and chronic obstructive pulmonarydisease (11.1% vs 2.3%; p=0.016) than G2. The threeyear cumulative survival rate was significantly lowerin G1 than in G2 (88.8±4.7% vs 95.7±1.3%, respectively; p=0.05). However, LVD was not an independent factor for shorter survival times during the follow-up period (p=0.119).Conclusion: this study suggests that CABG is unable to match the survival of patients with CAD and LVD to the survival of patients with CAD without LVD.

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BACKGROUND: The extracorporeal membrane oxygenation (ECMO) has been used in the neonatal and childhood periods with excellent results. The adult experience has been modest with inferior immediate results. The intermediate survival, however, has been promising. We have been using the extracorporeal membrane oxygenation for temporary mechanical circulatory support of adults that present with acute refractory cardiogenic shock in our institution. There is no other published experience of the use of this system in this scenario in Brazil. OBJECTIVE: To describe our experience with the use of the extracorporeal membrane oxygenation for circulatory support in adults. METHODS: Retrospective analysis of the medical files of patients submitted to the implant of extracorporeal membrane oxygenation system for circulatory assistance in acute and refractory cardiogenic shock. RESULTS: Eleven patients (63,5 yo; 45,5% male) were considered for analysis from 2005 to 2007. Median support time was 77 hours (10-240 h) and 5 patients have survived 30 days (45,5%). Two patients were subsequently submitted to prolonged paracorporeal circulatory assistance. Mortality on ECMO (6 patients) was due to multiple organ failure (66,6%) and refractory bleeding (33,4%). CONCLUSION: ECMO system is an option to be used in acute refractory cardiogenic shock as a bridge to recovery or selecting patients that might benefit from prolonged paracorporeal assist devices (bridge to bridge).

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FUNDAMENTO: A oxigenação por membrana extracorpórea (ECMO) em recém-nascidos e crianças tem resultados excelentes. A experiência em adultos é mais modesta e os resultados imediatos são inferiores. Entretanto, a sobrevida em cinco anos de pacientes que sobrevivem a esse método é bastante promissora. Não há relato na literatura brasileira de experiências com esse sistema nesse contexto. OBJETIVO: Relatar a experiência com o uso da oxigenação por membrana extracorpórea no adulto que se apresenta em choque cardiogênico agudo e refratário. MÉTODOS: Análise retrospectiva de prontuários médicos de pacientes submetidos a implante do sistema de oxigenação por membrana extracorpórea para a assistência circulatória no choque cardiogênico agudo e refratário. RESULTADOS: Onze pacientes (63,5 anos; 45,5 por cento homens) foram considerados para análise no período de 2005 a 2007. O tempo médio de suporte circulatório foi de 77 horas (10-240h) e cinco pacientes estavam vivos em 30 dias (45,5 por cento). Dois pacientes foram subseqüentemente submetidos a implante de assistência circulatória prolongada após um período de ressuscitação em ECMO, um dos quais foi submetido ao transplante cardíaco. As causas de morte durante a assistência com ECMO (seis pacientes) incluíram falência multiorgânica (66,6 por cento) ou sangramento refratário (33,4 por cento). CONCLUSÃO: O sistema ECMO é uma opção de assistência circulatória temporária para pacientes adultos com falência cardíaca aguda refratária, podendo ser utilizado como ponte para a recuperação ou com o intuito de selecionar candidatos à assistência circulatória prolongada (ponte para a ponte).

BACKGROUND: The extracorporeal membrane oxygenation (ECMO) has been used in the neonatal and childhood periods with excellent results. The adult experience has been modest with inferior immediate results. The intermediate survival, however, has been promising. We have been using the extracorporeal membrane oxygenation for temporary mechanical circulatory support of adults that present with acute refractory cardiogenic shock in our institution. There is no other published experience of the use of this system in this scenario in Brazil. OBJECTIVE: To describe our experience with the use of the extracorporeal membrane oxygenation for circulatory support in adults. METHODS: Retrospective analysis of the medical files of patients submitted to the implant of extracorporeal membrane oxygenation system for circulatory assistance in acute and refractory cardiogenic shock. RESULTS: Eleven patients (63,5yo; 45,5 percentmale) were considered for analysis from 2005 to 2007. Median support time was 77 hours (10-240h) and 5 patients have survived 30 days (45,5 percent). Two patients were subsequently submitted to prolonged paracorporeal circulatory assistance. Mortality on ECMO (6 patients) was due to multiple organ failure (66,6 percent) and refractory bleeding (33,4 percent). CONCLUSION: ECMO system is an option to be used in acute refractory cardiogenic shock as a bridge to recovery or selecting patients that might benefit from prolonged paracorporeal assist devices (bridge to bridge).

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OBJETIVO: Determinar o valor prognóstico da cintilografia de perfusão miocárdica (CPM) de estresse quando aplicada aos pacientes com suspeita de síndrome coronariana aguda (SCA). MÉTODOS: Estudo retrospectivo, onde pacientes internados na unidade de dor torácica (UDT), de dezembro de 2002 a abril de 2004, com suspeita de SCA, depois de afastado infarto agudo do miocárdio (IAM) ou de angina instável de alto risco, realizaram CPM sob estresse. RESULTADOS: Selecionados 301 pacientes, idade média 65,3±12,5 anos e 164 (54,5 por cento) homens. O exame foi iniciado em média 13±12 horas após a internação. Encontrou-se isquemia miocárdica (ISQ) em 142 pacientes (47,2 por cento). O sexo masculino (n=94, p=<0,0001), história de diabete melito (n=31, p=0,033), IAM (n=52, p=<0,0001), de revascularização miocárdica cirúrgica (n=46, p=<0,0001) e de angioplastia coronariana transluminal percutânea (n=68, p=<0,0001) apresentaram correlação com a presença de ISQ (n=73, p<0,001). O seguimento foi de 697,7±326,6 dias. Nenhuma variável cintilográfica se correlacionou com a ocorrência de desfecho primário (óbito ou IAM). A presença de cintilografia alterada (n=76, p<0,0001), de ISQ (n=73, p<0,0001) e a fração de ejeção após estresse abaixo de 45 por cento (n=21, p=0,006) se correlacionaram com ocorrência de desfecho secundário (todos os eventos). A presença de ISQ foi a variável de maior peso pela análise multivariada para predizer desfecho secundário (Risco Relativo = 6,5; IC 95 por cento = 1,61 a 26,83; p=0,009). CONCLUSÃO: A presença de ISQ foi o fator independente de maior peso para predizer eventos adversos em pacientes internados na UDT.

OBJECTIVE: To evaluate the prognostic value of stress myocardial perfusion scintigraphy (MPS) applied to patients with suspected acute coronary syndrome (ACS). METHODS: Retrospective study. Patients with suspected acute coronary syndrome (ACS) admitted into the chest pain unit (CPU) from December 2002 to April 2004, after exclusion of acute myocardial infarction (AMI) and high risk unstable angina they underwent stress MPS. RESULTS: Selected 301 patients, 65.3 ± 12.5 years and 164 (54.5 percent) male gender. The test was performed 13 ± 12 hours after admission. Myocardial ischemia (ISQ) was found in 142 patients (47.2 percent). Male gender (n=94, p=<0.0001), history of diabetes mellitus (n=31, p=0.033), past of AMI (n=52, p=<0.0001), past of surgical myocardial revascularization (n=46, p=<0.0001) and past of percutaneous revascularization (n=68, p=<0.0001) presented correlation with ISQ. The follow-up was 697.7 ± 326.6 days. No MPS variable correlated with the occurrence of primary outcome. Abnormal scintigraphy (n=76, p < 0.0001), ISQ (n=73, p < 0.0001) and post-stress left ventricular ejection fraction below 45 percent (n=21, p=0.006) correlated with secondary outcome. The presence of ISQ was the major variable in the multivariate analysis for the prediction of secondary outcome (RR = 6.5; CI 95 percent = 0.009). CONCLUSION: Presence of ISQ was the major independent factor in prediction of adverse events for patients admitted into the CPU.

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