Background: Time is brain! This paradigm is forcing the development of strategies with potential to shorten the time from symptom onset to recanalization. One of these strategies is to transport select patients with acute ischaemic stroke directly to an angio-suite equipped with flat-detector computed tomography (FD-CT) to exclude intracranial haemorrhage, followed directly by invasive angiography and mechanical thrombectomy if large-vessel occlusion (LVO) is confirmed. Aim: To present existing published data about the direct transfer (DT) of stroke patients to angio-suites and to describe our initial experience with this stroke pathway. Methods: We performed a systematic PubMed search of trials that described DT of stroke patients to angio-suites and summarized the results of these trials. In January 2020, we implemented a new algorithm for acute ischaemic stroke care in our stroke centre. Select patients suitable for DT (National Institute of Health Stroke Scale score ≥10, time from symptom onset to door <4.5 h) were referred by neurologists directly to an angio-suite equipped with FD-CT. Patients treated using this algorithm were analysed and compared with patients treated using the standard protocol including CT and CT angiography in our centre. Results: We identified seven trials comparing the DT protocol with the standard protocol in stroke patients. Among the 628 patients treated using the DT protocol, 104 (16.5%) did not have LVO and did not undergo endovascular treatment (EVT). All the trials demonstrated a significant reduction in door-to-groin time with DT, compared with the standard protocol. This reduction ranged from 22 min (DT protocol: 33 min; standard protocol: 55 min) to 59 min (DT protocol: 22 min; standard protocol: 81 min). In three of five trials comparing the 90-day modified Rankin scale scores between the DT and standard imaging groups, this reduction in ischaemic time translated into better clinical outcomes, whereas the two other trials reported no such difference in scores. Between January 2020 and October 2021, 116 patients underwent EVT for acute ischaemic stroke in our centre. Among these patients, 65 (56%) met the criteria for DT (National Institutes of Health Stroke Scale score >10, symptom onset-to-door time <4.5 h), but only 7 (10.8%) were transported directly to the angio-suite. The reasons that many patients who met the criteria were not transported directly to the angio-suite were lack of personnel trained in FD-CT acquisition outside of working hours, ongoing procedures in the angio-suite, contraindication to the DT protocol due to atypical clinical presentation, and neurologist's decision for obtain complete neurological imaging. All seven patients who were transported directly to the angio-suite had LVOs. The median time from door-to-groin-puncture was significantly lower with the DT protocol compared with the standard protocol {29 min [interquartile range (IQR): 25-31 min] vs. 71 min [IQR: 55-94 min]; P < 0.001}. None of the patients had symptomatic intracranial haemorrhage in the DT protocol group, compared with 7 (6.4%) patients in the standard protocol group. Direct transfer of acute ischaemic stroke patients to the angio-suite equipped with FD-CT seems to reduce the time from patient arrival in the hospital to groin puncture. This reduction in the ischaemic time translates into better clinical outcomes. However, more data are needed to confirm these results.
- Publikační typ
- časopisecké články MeSH
OBJECTIVES: This study analyzed the learning curve effect when a new stroke thrombectomy program was initiated in a cardiac cath lab in close cooperation with neurologists and radiologists. BACKGROUND: Mechanical thrombectomy has proven to be the best treatment option for ischemic stroke patients, but this method is not widely available. METHODS: An endovascular treatment program for acute ischemic strokes was established in the cardiac cath lab of a tertiary university hospital in 2012. The decision to perform catheter-based thrombectomy was made by a neurologist and was based on acute stroke clinical symptoms and computed tomography angiographic findings. Patients with a large vessel occlusion of either anterior or posterior circulation were enrolled. The primary endpoint was the functional neurological outcome (Modified Rankin Scale [mRS] score) of the patient at 3 months. A total of 333 patients were enrolled between October 2012 and December 2019. RESULTS: The clinical (mRS) outcomes did not vary significantly across years 2012 to 2019 (mRS 0 to 2 was achieved in 47.9% of patients). Symptomatic intracerebral hemorrhage occurred in 19 patients (5.7%). Embolization in a new vascular territory occurred in 6 patients (1.8%). CONCLUSIONS: When a catheter-based thrombectomy program was initiated in an experienced cardiac cath lab in close cooperation between cardiologists, neurologists, and radiologists, outcomes were comparable to those of neuroradiology centers. The desired clinical results were achieved from the onset of the program, without any signs of a learning curve effect. These findings support the potential role of interventional cardiac cath labs in the treatment of acute stroke in regions where this therapy is not readily available due to the lack of neurointerventionalists.
INTRODUCTION: A relationship between carotid stenosis and coronary arterial disease (CAD) is widely accepted; however, data on the exact prevalence of coronary disease in patients with severe carotid stenosis are lacking. Information on the prevalence and predictors of CAD among these patients could impact diagnostic and treatment approaches. AIM: The primary aim of this study was to determine the prevalence of significant CAD among patients referred for carotid artery revascularization. The secondary objectives included characterizing the association between the level of advancement of carotid stenosis and the presence of CAD, and between atherosclerotic risk factors and the presence of CAD in patients with carotid stenosis, and also to determine whether there was a difference in the prevalence of CAD between patients with symptomatic versus asymptomatic carotid stenosis. PATIENTS AND METHODS: We included 200 patients with severe carotid stenosis, of whom 77 (38.5%) had symptomatic stenosis. All patients underwent coronary angiography no more than 6 months before the scheduled carotid revascularization. Of the 200 total of patients, 192 underwent carotid stenting, six underwent carotid endarterectomy, and two were treated conservatively. CAD was defined as stenosis of at least 50% on recent coronary angiography or a history of previous percutaneous coronary intervention and/or coronary aortic bypass graft; the prevalence was 77.5% among our patients. There was no statistically significant difference in the prevalence of CAD between patients with unilateral versus bilateral carotid stenosis or contralateral carotid occlusion. The difference in the severity of coronary disease, which was given by the SYNTAX score, was not significant between these groups. Factors associated with the presence of CAD were male sex, a history of smoking, and global or regional wall motion disorder on echocardiography. We did not find any significant difference in the prevalence of CAD between patients with symptomatic versus asymptomatic carotid stenosis. CONCLUSION: We observed a very high prevalence of concomitant CAD in patients with severe carotid stenosis. The results of our study suggest that routine preprocedural screening for CAD in patients with carotid artery stenosis could identify a large proportion of patients with silent CAD; whether treatment for CAD before carotid revascularization can prevent periprocedural myocardial infarction should be addressed in a randomized-controlled trial.
- MeSH
- endovaskulární výkony přístrojové vybavení MeSH
- hodnocení rizik MeSH
- koronární angiografie MeSH
- lidé středního věku MeSH
- lidé MeSH
- nemoci koronárních tepen diagnostické zobrazování epidemiologie MeSH
- prevalence MeSH
- prospektivní studie MeSH
- retrospektivní studie MeSH
- rizikové faktory MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- stenóza arteria carotis diagnostické zobrazování epidemiologie terapie MeSH
- stenty * MeSH
- stupeň závažnosti nemoci MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- srovnávací studie MeSH
- Geografické názvy
- Polsko MeSH
Souvislost mezi postižením koronárních a karotických tepen je všeobecně uznávána. Studie sledující přítomnost ischemické choroby srdeční u pacientů s postižením karotických tepen popisují prevalenci až 77 % v závislosti na studované populaci. Zvýšené kardiovaskulární (KV) riziko je popisováno jak u pacientů s asymptomatickou, tak i symptomatickou stenózou karotidy. Pacienti s asymptomatickou stenózou karotické tepny mají zhruba třikrát vyšší riziko úmrtí z kardiovaskulárních příčin nebo infarktu myokardu v porovnání s referenční populací bez postižení karotických tepen, a toto riziko může být u pacientů se symptomatickou stenózou karotické tepny dokonce ještě vyšší. U těchto pacientů je proto indikována protidestičková a hypolipidemická terapie nejen z důvodu prevence cévní mozkové příhody, ale zejména ke snížení celkového kardiovaskulárního rizika. Revaskularizační výkony na karotických tepnách jsou zavedenou metodou léčby pacientů se symptomatickou stenózou karotické tepny, u kterých vedou k významnému absolutnímu snížení rizika recidivy cévní mozkové příhody. U pacientů s významnou, ale asymptomatickou stenózou karotické tepny zůstává indikace k revaskularizaci sporná. V tomto případě se zdá revaskularizace nejvíc přínosná u těch pacientů, kteří mají přítomny specifické klinické nebo zobrazovací charakteristiky, jež značí zvýšené riziko rozvoje cévní mozkové příhody. Screening a léčba asymptomatické ischemické choroby srdeční může být prospěšná pro pacienty s nedávno symptomatickou stenózou karotické tepny, zejména v případě, že je v plánu provedení revaskularizačního výkonu na karotických tepnách. Z důvodu nedostatku důkazů o přínosnosti rutinní profylaktické karotické revaskularizace u pacientů s karotickou stenózou podstupujících aortokoronární bypass – CABG (ve smyslu snížení výskytu perioperační cévní mozkové příhody), se jeví jako přínosné omezení profylaktické karotické revaskularizace před CABG pouze na pacienty v nejvyšším riziku perioperační cévní mozkové příhody, tedy ty s významnými bilaterálními stenózami obou karotických tepen nebo s anamnézou předchozí CMP/TIA.
It is commonly accepted that a relationship exists between coronary and carotid arterial disease, given that the prevalence of coronary artery disease (CAD) in patients with carotid stenosis is as high as 77%, depending on the population studied. Elevated cardiovascular (CV) risks are apparent in patients with either asymptomatic or symptomatic carotid stenosis. Patients with asymptomatic carotid stenosis are at about a three-fold higher risk of CV death/myocardial infarction compared with a matched population without carotid stenosis, and this risk may be even higher among patients with symptomatic carotid stenosis. Thus, antiplatelet and lipid-lowering therapies are indicated not only to prevent stroke, but also especially to lower elevated CV risks. Carotid revascularization has become well established in patients with symptomatic carotid stenosis, which is associated with significant absolute risk reductions in terms of recurrent stroke, but remains controversial for patients with significant but asymptomatic carotid stenosis. Carotid revascularization in those with asymptomatic carotid stenosis seems to principally benefit patients with specific clinical/imaging features indicating a high risk of stroke. Screening and treatment of asymptomatic CAD can be beneficial for patients with recently symptomatic carotid stenosis and especially for those for whom surgical or endovascular carotid revascularization is planned. Because evidence of the benefits afforded by prophylactic revascularization of asymptomatic carotid artery stenosis in all CABG candidates (in terms of reducing perioperative stroke) is lacking, it may be reasonable to restrict prophylactic carotid revascularization to patients at the highest risk of postoperative stroke, thus those with severe bilateral lesions or a history of prior stroke/transient ischemic event.
- MeSH
- asymptomatické nemoci MeSH
- ischemická choroba srdeční diagnostické zobrazování komplikace MeSH
- kardiovaskulární nemoci * komplikace MeSH
- lidé MeSH
- nemoci koronárních tepen epidemiologie farmakoterapie klasifikace komplikace MeSH
- rizikové faktory MeSH
- stenóza arteria carotis * diagnóza farmakoterapie chirurgie klasifikace prevence a kontrola MeSH
- transplantace cév MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
BACKGROUND: Little is known about the valve degeneration process after transcutaneous aortic valve implantations (TAVI) that can have an important impact on patients' long-term prognosis. AIM: To evaluate degenerative changes of TAVI using computed tomography (CT) compared to findings in patients that underwent surgical aortic valve replacement (SAVR). Subsequently, to compare the level of immune and inflammatory markers in both groups and test their possible role in the valve degeneration process. METHODS AND RESULTS: 49 patients after TAVI and 29 patients in the control group after SAVR underwent 2 years of follow-up and 8 patients from the TAVI group and 7 patients after SAVR underwent five years of follow-up. CT was performed in all patients and calcifications on prosthesis cusps in both groups were measured using Agatson calcium score. TAVI patients were older compared to patients who underwent SAVR [82 (62;86) vs. 74 (64;84) years, p<0.001], and had more comorbidities - higher EuroScore I [21.0 (5.0;46.0) vs. 6.15 (2.54;11.17), p<0.001]. TAVI patients had more often concomitant coronary artery disease (69.4% vs. 13.8%, p<0.001) and previous history of cardiac surgery (32.7% vs. 0.0%, p<0.001). Slight calcifications (mean Agatson score 50.76) on prosthetic cusps were found in 2 patients 4-5 years after TAVI and in 1 patient 2 years after SAVR (p=NS). Even though significant differences were found in values of tumor necrosis factor-α and E-selectin before, 1 year, and 2 years after implantation, no significant changes in values of inflammatory markers were observed during follow-up period in both groups of patients. Detailed analysis revealed no significant difference between values of inflammatory markers of patients with and without calcifications present on CT. CONCLUSION: Minimal degenerative changes on TAVI prosthesis were observed in mid- and long-term follow-up. Systemic immune response did not differ between patients after TAVI and SAVR.
- MeSH
- aortální chlopeň diagnostické zobrazování chirurgie MeSH
- aortální stenóza chirurgie MeSH
- biologické markery krev MeSH
- C-reaktivní protein analýza MeSH
- chirurgická náhrada chlopně metody MeSH
- cytokiny krev MeSH
- E-selektin krev MeSH
- lidé středního věku MeSH
- lidé MeSH
- multidetektorová počítačová tomografie MeSH
- následné studie MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- studie případů a kontrol MeSH
- transkatetrální implantace aortální chlopně * MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- srovnávací studie MeSH
Transcatheter aortic valve implantation (TAVI) is a widely used intervention in patients who are at high risk or contraindicated for cardiac surgery. The procedure is technically feasible in most patients and has very good mid-term clinical outcomes. In this special report, we evaluated the long-term outcome after TAVI and durability of percutaneously implanted aortic valve prostheses by reviewing all available long-term follow-up data. We herein present the clinical and hemodynamic data derived from patients 2-5 years after TAVI and describe all published cases of prosthesis degeneration.
Few cases of infective endocarditis (IE) as a complication of percutaneous transcatheter aortic valve implantation (TAVI) have been reported. Here, we present a case of IE caused by Streptococcus viridans that occurred 6 months after TAVI with the corevalve revalving system. The patient was successfully treated with antibiotics and was asymptomatic during the 2 years after IE. We also present a review of the literature, including 15 published cases of IE after TAVI.
- MeSH
- antibakteriální látky terapeutické užití MeSH
- aortální stenóza diagnóza terapie MeSH
- bakteriální endokarditida diagnóza farmakoterapie mikrobiologie MeSH
- časové faktory MeSH
- chirurgická náhrada chlopně škodlivé účinky přístrojové vybavení MeSH
- echokardiografie transezofageální MeSH
- infekce spojené s protézou diagnóza farmakoterapie mikrobiologie MeSH
- lidé MeSH
- počítačová rentgenová tomografie MeSH
- protézy - design MeSH
- senioři nad 80 let MeSH
- srdeční chlopně umělé škodlivé účinky MeSH
- srdeční katetrizace škodlivé účinky přístrojové vybavení MeSH
- streptokokové infekce diagnóza farmakoterapie mikrobiologie MeSH
- viridující streptokoky izolace a purifikace MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
- přehledy MeSH
