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INTERVENTIONAL CARDIOLOGY DISCUSSION FORUM
FORO DE DISCUSIÓN DE CARDIOLOGÍA INTERVENCIONISTA

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Web # 4  (#41-55)

(#28-40)

41
From: Dr. Rafael Diaz, Rosario, Argentina
To: coronary-pcvc@pcvc.sminter.com.ar
Date: Sábado, 06 de Noviembre de 1999
Subject: IAM: Conducta/AMI: Management

Estimado Dr. Heñin:
Con respecto al paciente que hace mencion en su e-mail, es uno de los tipicos casos que habitualmente se presentan para debatir diferentes estrategias ante un infarto en etapa hiperaguda.
La primera opcion que usted propone es tratamiento medico, supongo que se refiere a tratarlo sin utilizar recursos de reperfusion. Creo que ya casi no debatimos este punto. Queda a mi entender claro que este caso en particular se beneficiara con cualquier estrategia de reperfusion y no lo dejaria sin un oportuno y adecuado tratamiento. Con respecto a cual estrategia utilizaria, sea esta farmacologica o mecanica, creo que usted mejor que yo o cualquiera puede decidir al respecto. Usted esta frente a un paciente dentro de la primera hora, lo cual presupone que cualquiera sea la estrategia utilizada salvara musculo (y mucho). Si el team intervencionista con el cual usted cuenta puede organizarse rapidamente y no se demorara por problemas logisticos, puede de inmediato enviar su paciente al laboratorio de hemodinamia. Si piensa en cambio que la puesta en marcha de este demorara, no perderia tiempo y lo trataria farmacologicamente.
Si bien su paciente tiene riesgo intermedio o bajo durante su etapa hospitalaria, creo que no a largo plazo y comenzaria ya a delinear una adecuada estrategia de estratificacion de riesgo post-IAM asi como a modular en lo posible sus marcados factores de riesgo, que en este caso en particular son abundantes y seguramente determinaran el futuro pronostico.
En resumen no dudaria, intentaria reperfundir lo antes posible su paciente, con las medidas que mas se adecuen a su practica y centro.
Dr. Rafael Diaz
Rosario - Argentina

Dear Dr. Henin:
About the patient that you mention in your e-mail message, he is one of the typical cases that usually show up to debate different strategies faced with an infarction in the hyperacute stage.
The first option that you propose is medical treatment, I suppose that you mean to treat him without using reperfusion resources. I think that this topic is almost no longer debated. As I see it, it is clear that this particular case will benefit with any reperfusion strategy, and I would not
leave him without a timely and appropriate treatment. About which strategy I would use, whether it is pharmacological or mechanical, I think that you are more appropriate than I or anyone else to decide about it. You are faced with a patient within the first hour, what implies that whatever the strategy used, it will save muscle (and a lot). If the interventional team
that you have can organize quickly, and does not get delayed due to logistic problems, you
can send your patient immediately to the hemodynamic lab. If instead, you think that the team might be delayed, I would not waste time, and treat him pharmacologically.
Although your patient is in intermediate or low risk during his hospital stage, I think that it is not so in the long term, and I would begin now to outline a proper risk stratification strategy post-AMI, as well as modulating, as much as possible, his marked risk factors, that in this
particular case are numerous, and surely will determine the future prognosis.
Summarizing, I would not hesitate, and I would try to reperfuse your patient as soon as possible, with the measures that best fit your practice and center.
Dr. Rafael Diaz
Rosario - Argentina

Index
 

42
Date: Sat, 6 Nov 1999 09:28:13 -0800 (PST)
From: Ignacio Perez Galvez <irpg@yahoo.com>
Subject: Re:Infarto agudo de miocardio. Conducta.
To: interven-pcvc@pcvc.sminter.com.ar

Estimado colega:
        En su caso existen antecedentes que nos hacen pensar en que el caso posee una enfermedad multivaso y que podria tener algo de angina silente previa. Lo ideal seria hacer la ACTP primaria si el pte. llega en estado para ello, la opcion de la STK es muy buena, siempre que hagamos despues un estudio angiografico del pte. debido a la posibilidad de enfermedad multivaso, IMA inf., y evaluar si requiere ACTP o cirugia revascularizadora. La conducta la
tomara segun vea como esta el pte. y sus posibilidades.
         Espero mi opinion le ayude.
          Dr.Ignacio R. Perez
 

Dear colleague:
In your case there are antecedents that makes us think that the patient has multivessel
disease, and that could also have some previous silent angina. The ideal would be to perform
primary PTCA if the patient arrives in a state proper for it, the option of STK is very good,
providing that later we proceed with an angiography study of the patient, due to the
possibility of a multivessel disease, AMI, and to evaluate if he requires PTCA or
revascularization surgery. The management will be decided according to your view of the patient
and his possibilities.
I hope my opinion helps you.
          Dr.Ignacio R. Perez

Index
 

43
From: "Daniel Berrocal" <dberrocal@intramed.net.ar>
To: <interven-pcvc@pcvc.sminter.com.ar>
Subject: RE: Infarto agudo de miocardio. Conducta/Acute myocardial infarction. Management.
Date: Mon, 8 Nov 1999

Creo que el ejemplo clinico del Dr. Mario Henin es por demas acertado pues nos pone ante una verdadera disyuntiva sobre que hacer. En principio convengamos que en ausencia de otros predictores de riesgo el infarto inferior estricto es de tan buen pronostico que ni la fibrinolisis parece justificada y mucho menos resistir un analisis costo/beneficio.
Asumiendo que el paciente no tiene predictores de riesgo aumentado (infarto previo, compromiso de VD, diabetes, etc.) mi eleccion aunque opinable la basaria en lo precoz del evento y probablemente me inclinaria a realizar una coronariografia.
Si se tratase de una arteria CD no muy grande o de una rama de la misma sin otras lesiones coronarias, esto confirmaria el bajo riesgo y no dudaria en no tocarla aun con TIMI 0.
Si por el contrario, como ocurre frecuentemente, el tamanio del vaso y su miocardio tributario fuesen mayores que el esperable por el compromiso electrocardiografico, la intervencion estaria por demas justificada.
Dr. Daniel Berrocal
Buenos Aires - Argentina

Dear colleagues:
I think that Dr. Mario Henin's clinic example is extremely appropriate because it faces us with
a real dilemma about what to do. To begin with, let us agree in that in absence of other risk
predictors, strict inferior infarction is of such good prognosis that not even fibrinolysis
seems justified, let alone resisting a cost/benefit analysis.
Assuming that the patient does not have increased risk predictors (previous infarction,
involvement of LV, diabetes, etc.) my choice, though arguable, would be based in how early the
event is, and probably I would tend to perform a coronary angiography.
If it was a right coronary artery, not very large, or a ramus of it without other coronary
lesions, this would confirm the low risk, and I would not hesitate in touching it, even with
TIMI 0.
If, on the contrary, and as it frequently happens, the size of the vessel and its tributary
myocardium were large than what is to be expected due to electrocardiographic involvement, the
intervention would be extremely justified.
Dr. Daniel Berrocal
Buenos Aires - Argentina

Index
 

44


BOLETÍN Nº 2 - 6 de Noviembre de 1999


Estimados colegas, el Foro de Cardiología Intervencionista lleva un mes de funcionamiento, y ya se han publicado mas de 40 mensajes.

Para ingresar a las paginas web del PCVC deben completar siempre:
"username": fac         y       "password": pcvc

Podran ver los mails anteriores en el Archivo, ubicado en:

http://pcvc.sminter.com.ar/cvirtual/listas/interven/index.htm
Luego de la discusion amplia de un tema en el Foro, el Coordinador o algun miembro del Comite de Expertos hara un resumen del estado actual del tema.

Una NUEVA SECCION del Foro seran los ATENEOS. El primero de ellos acaba de
ser publicado, y esta alojado junto a las conferencias, en:

http://pcvc.sminter.com.ar/cvirtual/llave/activ.htm#interv
No dejen de verlos, ya que ademas de ser casos muy interesantes, vamos a contar con la opinion de expertos internacionales de cada tema sobre su interpretacion y la forma de resolverlos. En esta seccion vamos a poder ver imagenes!.
Se trata de un... Mirenlo y despues nos dicen que les parecio! Esperamos comentarios de todos!

En breve comenzaran a publicarse los Temas Libres de Cardiología Intervencionista



SUGERENCIAS:
1- Para los que no asistan al Congreso de la AHA, a partir del lunes 8 se podran ver cuatro sesiones plenarias en: www.aha99plenarysessions.com

2- Tambien para el lunes 8 de noviembre esta programada una cibersesion en vivo: "Optimizing outcomes in the MI patient: A multidisciplinary approach". Para participar de este Simposio, hay que inscribirse por anticipado en: www.mi-outcomes.com

Saludos a todos.

Dr. Raul Bretal                            Dr. Hugo Londero
Moderador interven-pcvc            Coordinador interven-pcvc

_________________________________________

BULLETIN No 2 - November 6th, 1999
_________________________________________

Dear colleague:
The Forum on Interventional Cardiology has been operating for a month, and more than 40
messages has already been published.

To access the web pages of the FVCC you must always enter:
"username": fac and "password": pcvc
You can see the previous messages in the File, at:

http://pcvc.sminter.com.ar/cvirtual/listas/interven/index.htm
After a comprehensive discussion of a subject in the Forum, the Coordinator or a member of the
Experts Committee will make a summary of the current state of the subject.

A NEW SECTION of the Forum will be the ATHENAEUMS (clinical rounds). The first of them has just been published, and can be found with the conferences, at:

http://pcvc.sminter.com.ar/cvirtual/llave/activ.htm#interv
Do not fail to see them, since besides dealing with very interesting cases, we will have the
opinion from international experts in each topic, about their interpretation and the way to
solve them. In this section we will be able to see images!
It is about a... Look at it, and later tell us what you think about it! We expect everybody's
commentaries!

Soon, the Brief Communications on Interventional Cardiology will begin to be published.
____________________________________________
SUGGESTIONS:
1- For those who do not attend the AHA Congress, from Monday, 08 of November, four plenary
sessions will be available at: www.aha99plenarysessions.com

2- An on line cyber-session is also programmed for Monday, 08 of November: "Optimizing outcomes in the MI patient: A multidisciplinary approach".
To take part in this Symposium, you have to subscribe in advance at:

www.mi-outcomes.com

Greetings,

Dr. Raul Bretal                            Dr. Hugo Londero
Moderador interven-pcvc            Coordinador interven-pcvc

Index
 

45
From: Alfredo C. Piombo: apiombo@intramed.net.ar
Date: Tue, 9 Nov 1999
To: coronary-pcvc e interven-pcvc
Subject: IAM: Conducta/AMI: Management

He notado en la mayoria de los colegas que sus respuestas se basan en su propia experiencia y no en la evidencia cientifica. De lo contrario, ¿como puede postularse el estudio angiografico de un paciente que cursa uno de los infartos de mas bajo riesgo?  ¿Que estudio clínico randomizado avala esta conducta?  ¿Que sociedad cientifica nacional o internacional recomienda una conducta de este tipo?
¿De donde surge que todos los infartos deben ser estudiados angiograficamente? Estados Unidos realiza angiografías coronarias en el IAM en una cifra enormemente superior a la de otros paises como el Canada. No obstante, tiene la misma mortalidad. Lo mismo ocurre con la angina inestable.
Al hablar de angioplastia primaria, ¿quienes tienen los mismos resultados del pequenio estudio PAMI ?
¿No sera mas representativo el estudio GUSTO II-b que a los 6 meses no encuentra ninguna diferencia entre tromboliticos y angioplastia ni siquiera en el triple end-point de muerte, reinfarto y stroke?
Si el mayor metaanalisis realizado sobre trombolisis en el IAM (el FTT) no encuentra diferencias en los pacientes con IAM inferior ( 8.4% vs. 7.5%, 2p=0.08 ) ¿no sera porque todos los infartos inferiores no son iguales, siendo que algunos se benefician y otros no ?  Mucho menos se ha demostrado que la angioplastia reduzca la mortalidad en el infarto inferior.
Por lo tanto, mas alla de lo anecdotico del caso, creo que como medicos es nuestra tarea y nuestra obligacion, la de discriminar en nuestros pacientes niveles de riesgo y poder así administrar racionalmente los recursos de salud, que son siempre limitados (en cualquier pais del mundo).
Ningun tratamiento en medicina es para todos, y es bueno que asi sea, de lo contrario nuestra profesion se volveria intolerablemente aburrida.
Dr. Alfredo C. Piombo.
 

I have noticed in most colleagues that their answers are based in their own experience, and not
in scientific evidence. Otherwise, how can it be posed the angiography study in a patient that
is in evolution of one of the infarctions of lowest risk? What randomized clinical study
supports this management? What scientific society, national or international recommends this
kind of management?
From where it emerges that all infarctions must be studied by angiography? USA is carrying out
coronary angiographies in AMI in an amount enormously above other countries like Canada.
However, they have the same mortality. The same happens with unstable angina.
When talking about primary angioplasty, who has the same results as the small PAMI study?
The study GUSTO II-b would not be more representative, that after 6 months does not find any
difference between thrombolysis and angioplasty, not even in the triple end-point of death,
reinfarction, and stroke?
If the largest meta-analysis carried out on thrombolysis in AMI (the FTT) does not find
differences in patients with inferior AMI (8.4% vs. 7.5%, 2p=0.08), the reason may be that not
all inferior infarctions are equal, since some benefit and others do not? Least of all has been
demonstrated that angioplasty reduces mortality in inferior infarction.
Therefore, beyond the anecdote, I think that as physicians it is our duty and our commitment to
distinguish the levels of risk in our patients, so that we can manage rationally the health
resources, that are always limited (in any country of the world).
No treatment in medicine is for everyone, and it is good that it is so, otherwise our
profession would be unbearably boring.
Dr. Alfredo C. Piombo.

Index
 

46
From: Dr. Raúl Bretal   rbretal@netverk.com.ar
Date: Thu, 11 Nov 1999
To: interven-pcvc@pcvc.sminter.com.ar
Subject: IAM: Conducta/AMI: Management

Entre los argumentos que se esgrimen ocasionalmente para cuestionar la realizacion de ATC primaria se encuentra el que los resultados obtenidos con esta terapeutica en estudios como el PAMI, realizado en un centro de gran experiencia en dicho tratamiento, no son trasladables a otros centros.
Existe hoy alguna evidencia cientifica en contra de esto:
En el plenario "Optimizing outcomes in the MI patient: A multidisciplinary approach", realizado el 8 de Noviembre, durante el Congreso de la AHA99, el Dr Thomas P. Wharton, Jr., de Oklahoma, presento su conferencia: "Community Hospital Approach to the Treatment of the AMI Patient", en la que mostro los resultados de un estudio muticentrico realizado en Hospitales Comunitarios de USA, que no tienen cirugia cardiaca (de baja complejidad), llamado "NO S.O.S.".
A todos los pacientes que ingresaron con criterios de gravedad de acuerdo al estudio PAMI (>70 anios, FC>100, IAM ant) se les realizo ATC primaria, excluyendo shock cardiogenico. Los resultados mostraron mortalidad de 5.5%.
Al Comparar sus resultados con los pacientes de estas mismas caracteristicas del estudio PAMI, no existieron diferencias significativas.
No se trata de un estudio randomizado, pero el estudio sugiere que los resultados del PAMI para este grupo de pacientes serian transferibles a Hospitales de mucha menor complejidad y que manejan menor volumen de pacientes.
Dr. Raul Bretal
La Plata - Argentina
 

Between the arguments used from time to time to question primary PTCA, we find one that claims that the results obtained with these therapeutic in studies such as PAMI, carried out in a center of great experience in this treatment, cannot be translated to other centers.
Today, there is some scientific evidence against this:
In the plenary "Optimizing outcomes in the MI patient: A multidisciplinary approach", carried out on November 8th, during the Congress by the AHA99, Dr. Thomas P. Wharton Jr. from Oklahoma, presented his lecture: "Community Hospital Approach to the Treatment of the AMI Patient", where he showed results from a multicentric study carried out in Community Hospitals in USA, that do not have cardiac surgery (of low complexity), called "NO S.O.S.".
All patients that were admitted with criteria of severity according to the PAMI study (>70 years, HR>100, previous AMI) underwent primary PTCA, excluding cardiogenic shock. Results showed a 5.5% mortality. When comparing results with the patients with the same characteristics of the PAMI study, there were no significant differences.
This is not a randomized study, but it suggests that results from PAMI for this group of patients would be transferable to Hospitals of much less complexity, and that handle a smaller amount of patients.
Dr. Raul Bretal
La Plata - Argentina

Index
 

47
From: "Daniel Berrocal" <dberrocal@intramed.net.ar>
To: <interven-pcvc@pcvc.sminter.com.ar>
Subject: RE: IAM: Conducta/AMI: Management
Date: Thu, 11 Nov 1999

Creo que el aporte del Dr. Piombo es valioso y que el caso es sin duda polemico, sin embargo me gustaria agregar un par de reflexiones:
1) Creo que el bajo riesgo del infarto inferior ha estado presente en la mayoria de las respuestas. Sin embargo aun en el Consenso de cardiopatia Isquemica se coincidio en que la precocidad del evento era un importante elemento a considerar a la hora de decidir que hacer. El caso planteado por Mario llevaba 2 hs. de evolución.
2) Si no hay evidencia para realizar ATC en el IAM inferior estricto tampoco la hay para el uso de estreptokinasa en este subgrupo.
3) Ya hemos coincidido en que probablemente solo el 30-40% aproximadamente de nuestras decisiones asistenciales cotidianas, cuenten con estudios randomizados con suficiente poder para abalar las mismas.
4) Respecto a costos, los analisis del PAMI y el de nuestro estudio FAP mostraron que el mayor costo inicial de la ATC se compenza al anio y esto sin considerar una tasa de TIMI3 altamente superior con angioplastia.
Dr. Daniel Berrocal
Buenos Aires, Argentina.
 

I think that Dr. Piombo's contribution is valuable, and that the case is undoubtedly controversial, however, I would like to add a couple of observations:
1) I think that the low risk of inferior infarction has been present in most of the answers. However, even in the "Consenso de cardiopatia isquemica" (Consensus for ischemic heart disease) it was agreed that precocity of the event was an important element to consider at the time of deciding what to do. The case posed by Mario had 2hs. of evolution.
2) If there is no evidence to perform PTCA in strict inferior AMI, there is none for use of streptokynase in this subgroup either.
3) We have already agreed that probably only a 30-40% approximately of our daily attention decisions, have randomized studies with enough power to back them.
4) Regarding costs, the analysis from PAMI, and from our study FAP showed that the greater initial cost of PTCA is compensated after a year, and this without considering a rate of TIMI3 highly superior with angioplasty.
Dr. Daniel Berrocal
Buenos Aires, Argentina.

Index
 

48
From: "Ricardo Clavijo" <rclavijo@interredes.com.ar>
To: <interven-pcvc@pcvc.sminter.com.ar>
Subject: RE: IAM: Conducta/AMI: Management
Date: Thu, 11 Nov 1999

Sin duda como dice el Dr. Piombo no todos los pacientes con infarto son iguales, no es lo mismo un infarto inferior en un paciente con infarto anterior previo que otro que debuta con un infarto inferior.
Con una conducta de reperfusion (trombolisis o angioplastia) en el infarto buscamos no solo salvar vidas sino tambien salvar miocardio.
Con respecto a este punto  quisiera citar un articulo (J Am Coll Cardiol 1998;31:338-43) "Tissue-Type Plasminogen Activator Therapy Versus Primary Coronary Angioplasty: Impact on Myocardial Tissue Perfusion and Regional Function 1 Month After Uncomplicated Myocardial Infarction". Donde se compararon los pacientes con trombolisis exitosa versus los tratados con angioplastia directa.En este estudio la angioplastia directa muestra mayor efectividad en la mejoria de la microcirculacion y una disminucion del deterioro miocardico al mes del infarto.
Dr. Ricardo Clavijo - San Juan, Argentina.
 

Undoubtedly, as Dr. Piombo says, not all patients with infarction are equal, an inferior infarction in a patient with previous anterior infarction is not the same as another who debuts with inferior infarction.
With a reperfusion management (thrombolysis or angioplasty) in infarction our goal is not only to save lives, but to save myocardium as well.
About this topic I would like to quote an article (J Am Coll Cardiol 1998;31:338-43) "Tissue-Type Plasminogen Activator Therapy Versus Primary Coronary Angioplasty: Impact on Myocardial Tissue Perfusion and Regional Function 1 Month After Uncomplicated
Myocardial Infarction", where the patients with successful thrombolysis were compared with those treated with direct angioplasty. In this study, direct angioplasty displays a greater effectiveness in improvement of microcirculation and a decrease in myocardial damage, a month after infarction.
Dr. Ricardo Clavijo - San Juan, Argentina.

Index

49
From: owner-pcvc@pcvc.sminter.com.ar
To: interven-pcvc@sminter.com.ar
Date: 16/11/99
Subject: Boletin Nº3/Bulletin #3

Estimados colegas:
Los que aun no vieron el primer caso presentado en Ateneo por el Dr. Oscar Mendiz, pueden hacerlo en: http://pcvc.sminter.com.ar/cvirtual/listas/interven/cases/case1/presesp.htm
Tambien estan publicados los comentarios del Dr. Zvonimir Krajcer en:
http://pcvc.sminter.com.ar/cvirtual/listas/interven/cases/case1/copin.htm
La proxima semana se publicaran las opiniones del Dr Juan C. Parodi.

Tampoco dejen de ver las conferencias de Cardiologia Intervencionista en:
http://pcvc.sminter.com.ar/cvirtual/llave/activ.htm#interv

Todos los comentarios sobre los temas presentados enviarlos a la direccion de la lista: interven-pcvc@pcvc.sminter.com.ar

Dr. Raul Bretal                            Dr. Hugo Londero
  Moderador                                   Coordinador

Dear colleagues:
Those of you who still did not see the first case presented in the Athenaeum by Dr. Oscar Mendiz, can do it at:
http://pcvc.sminter.com.ar/cvirtual/listas/interven/cases/case1/presesp.htm

Commentaries by Dr. Zvonimir Krajcer are also published at:
http://pcvc.sminter.com.ar/cvirtual/listas/interven/cases/case1/copin.htm

Next week, opinions by Dr. Juan C. Parodi will be published.

Be sure to see the lectures on Interventional Cardiology at:
http://pcvc.sminter.com.ar/cvirtual/llave/activ.htm#interv

You can submit all commentaries about the topics presented to the address of the list:
interven-pcvc@pcvc.sminter.com.ar

Dr. Raul Bretal                            Dr. Hugo Londero
  Moderador                                   Coordinador

Index

50
From: "Ortiz Baeza" <ortizbaeza@impsat1.com.ar>
To: <interven-pcvc@pcvc.sminter.com.ar>
Subject: AAA
Date: Tue, 9 Nov 1999

He visto el interesante caso presentado por el Dr. Mendiz y los comentarios del Dr. Zvonimir Krajcer  en cuanto a la resolucion este caso. La pregunta que me hago en relacion a este y a otros casos similares es la conducta a tener con respecto al tratamiento de las arterias hipogastricas. En el caso expuesto ambas hipogastricas aparecen ocluidas post procedimiento. Concretamente cual es la incidencia de complicaciones por la oclusion de las mismas o si es este un efecto deseado para evitar un eventual endo leak?.
Dr. Oscar Ortiz Baeza
ortizbaeza@impsat1.com.ar
 

I have seen the interesting case presented by Dr. Mendiz, and the commentaries by Dr. Zvonimir Krajcer regarding the solution of this case. The question I ask regarding this, and other similar cases is, what management should be carried out regarding treatment of hypogastrium arteries. In the case exposed, both hypogastrium arteries appear occluded after the procedure. Specifically, which is the incidence of complications for occlusion of them, or if there is a desired effect to avoid a possible endo-leak?
Dr. Oscar Ortiz Baeza
ortizbaeza@impsat1.com.ar

Index
 

51
De: Alejandro F. Luque Coqui (alucoq@attglobal.net)
Para: coronary-pcvc e interven-pcvc
Fecha: Miércoles 17/11/1999
Tema: IAM: Conducta/AMI: Management

Perdon si vuelvo a opinar pero creo que existe una confusion aqui.
Esta confusion se da en el momento en que se piensa que las opiniones vertidas sobre el caso que presentado, son muy heterogenas. Para mi es bien claro que las opiniones se han dividido en una controversia que se esta dando en todo el mundo que es darle tratamiento trombolitico o ACPT primaria, o sea terapia de reperfusion farmacologica o mecanica pero en ambos casos se esta discutiendo la forma no el fondo. Sabemos los latinoamericanos que vivimos en el tercer mundo del subdesarrollo, etc, etc, sin embargo a pesar de esto, estamos haciendo angioplastia coronaria y cirugia de corazon, y este caso en lo particular si llega a un centro en donde puedo realizarle ACPT primaria con exito en el momento adecuado  seria incluso un desperdicio de recursos no hacerlo; es obvio que ningun tratamiento es para todos y aqui es el criterio del medico a cargo el que decide el mejor tratamiento de este paciente. Asi que con todo respeto para todas las opiniones vertidas aqui, yo en lo particular no veo en las diferentes opiniones, tal disparidad.
Alejandro F. Luque Coqui
Mexico

Sorry for expressing my opinion again, but there is a confusion here.
This confusion arises in the moment in which one thinks that the opinions expressed on the case you presented, are very heterogeneous. The way I see it, it is very clear that opinions have splitted in a controversy that is happening throughout the world, regarding administration of thrombolysis or performing primary PTCA, that is to say mechanical or pharmacological
reperfusion therapy, but in both cases what is being argued is the form, not the content. We know, Latin-Americans live in the Third World, in underdeveloped countries, etc., etc., but in spite of this, we are performing coronary angiography, and heart surgery, and if this case in
particular arrives at a center where I can perform primary PTCA successfully in the right moment, it would even be a waste of resources not to do it; it is obvious that no treatment is for everyone, and here it is the criteria of the doctor in charge which decides the best treatment for this patient. So, I in particular, with due respect to all opinions expressed here, do not see
in the different opinions such disparity.
Alejandro F. Luque Coqui
Mexico

Index

52
From: "Dr. Gustavo R. Bonzón" <bonzon@arnet.com.ar>
To: <interven-pcvc@pcvc.sminter.com.ar>
Subject: Reestenosis intrastent
Date: Fri, 19 Nov 1999

Partiendo de la experiencia inicial de Pichard y las ultimas novedades presentadas por el mismo autor junto a otros como Mehran, etc., quisiera conocer la estrategia utilizada por los colegas integrantes de la lista para resolver los patrones 2 y 3 de reestenosis intrastent, o sea las variedades difusa intrastent y difusa proliferativa.
El patron 2 es tratado por la mayoria con balon solo o rotablator mas balon, con o sin stent intrastent?.
El patron 3 implica definitivamente la ablacion de material por rotablator o laser o puede ser tratado con balon sin o con stent posterior, considerando que la proliferacion excede los extremos del stent? Suelen ver reestenosis intrastent tipo 3 en los seguimientos de los tratados con tecnica de balon y stent de identica longitud o con la tecnologia focus?
Dr. Gustavo R. Bonzón

Starting from the initial experience of Pichard, and the last news presented by the same author along with others as Mehran, etc., I would like to know the strategy used by the colleagues who are members of the list, to solve patterns 2 and 3 of intrastent restenosis, that is to say intrastent diffuse, and proliferation diffuse varieties.
Pattern 2 is treated by most people with only a balloon, or rotablator plus balloon: with or without intrastent stent?
Does pattern 3 imply definitely material ablation by rotablator or laser, or can it be treated with balloon with or without posterior stent, considering that proliferation exceeds the ends of the stent? Do you usually see intrastents restenosis type 3 in the follow ups of those treated with balloon technique, and stent of identical length, or with the focus technology?
Dr. Gustavo R. Bonzón

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53
From: Dr. Oscar Mendiz <almendiz@yahoo.com>
Subject: Re: AAA
To: interven-pcvc@pcvc.sminter.com.ar
Date: Fri, 19 Nov 1999

Queria responder al Dr Ortiz Baeza que el paciente presentado para la discusion no se le ocluyeron ambas hipogastricas.
Quiza la apreciacion correcta que el realiza, surja de cierta degradacion en el paso de las imagenes o que no focalizamos en el sector de la hipogastrica izquierda que quedo permeable y que nace de la cara anterior de la iliaca por lo que no se aprecia bien en la angiografia enviada.
Como comentario general quiero agregar que siempre respetamos al menos una higogastrica permeable para disminuir la posibilidad de colitis isquemica que suele ser una complicacion catastrofica.
La necesidad de mantener una iliaca permeable es una limitante importante para muchos pacientes, motivo por el cual se trabaja arduamente en el desarrollo de los dispositivos. Asi es que, ya existen algunos que permiten tratar iliacas primitivas de hasta 18 mm de diametro, y ya hay algunos modelos en prueba que permitirian dejar la hipogastrica permeable (bifurcados iliacos).
Oscar A. Mendiz

I would like to answer to Dr. Ortiz Baeza, that the patient presented for discussion had not both hypogastrium arteries occluded.
Maybe the correct appraisal you carried out, arises from a certain degradation in the passing of images, or from not focusing on the sector of the left hypogastrium artery that remained patent, and that springs from the anterior side of the iliac artery, and due to this the submitted angiography cannot be seen properly.
As a general commentary, I would like to add that we always respected al least one patent hypogastrium artery to diminish the possibility of ischemic colitis, that is usually a catastrophic complication.
The need to keep a patent iliac artery is an important limitation for many patients, because of this we work very hard in developing devices. Thus, there are already some that allow treatment of primitive iliac arteries of up to 18mm of diameter, and there are already some models being tested, that would allow to leave the patent hypogastrium artery (iliac bifurcates).
Oscar A. Mendiz

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54
From: "Eric  Vidal" <evidal@caracas.c-com.net>
To: <interven-pcvc@pcvc.sminter.com.ar>
Subject: Medicacion pre angioplastia
Date: Mon, 22 Nov 1999

Estimados colegas del Foro:
Quisiera conocer por parte de los hemodinamistas cuales precauciones  y medicaciones previo al procedimiento de angioplastia primaria o no, hay algunos trabajos donde indican vitamina E, otros Probucol; hay nuevos medicamentos que han ayudado a disminuir la reestenosis, por ejemplo el uso de ticlopidina.
Cuales serian las precauciones previas al procedimiento?.
Dr.Eric Vidal
evidal@caracas.c-com.net

Dear colleagues of the Forum:
I would like to learn from specialists in hemodynamics, which precautions and medications previous to the primary angioplasty procedure, or not, should be performed. There are some works that indicate vitamin E, others Probucol; there are new medications that have helped to diminish restenosis, for example, use of ticlopidine.
Which would be the precautions previous to the procedure?
Dr.Eric Vidal
evidal@caracas.c-com.net

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55
From: "Dr. Aitor Alberdi" <aisca@arnet.com.ar>
To: <interven-pcvc@pcvc.sminter.com.ar>
Subject: Re: AAA
Date: Sun, 7 Nov 1999

Estimados colegas:
1-¿Los doctores invitados a comentar, reciben un material adicional al que nosotros visualizamos?
2-¿El uso del Fogarty, fue realizado por cirujanos o hemodinamistas?¿Hay un video de esa accion terapeutica?¿Se puede ver?
3-La protesis Vanguard II, en que etapa de desarrollo de investigacion se encuentra?¿En la experiencia internacional, hubo otra disrupcion de la malla del stent?¿Si hay mallas metalicas que son expandidas a altas presiones con balon, puede un fogarty provocar una disrrupccion del stent?¿Este inconveniente no podria estar relacionado a una debilidad estructural del
stent (fabricacion) y no exclusivamente a la accion del fogarty?
Dr. Aitor Alberdi

Dear colleagues:
1. Doctors who are invited to comment, receive additional material besides what we see?
2. Use of Fogarty, was carried out by surgeons or hemodynamics specialists? Is there a video of this therapeutic action? Can we see it?
3. The Vanguard II prosthesis: in which stage of development of research is now? According to international experience: was there another disruption in the mesh of the stent? If there are metallic meshes that are expanded to high pressures with balloon, can a fogarty cause a disruption of the stent? Is it possible that this inconvenience may be related to a structural weakness of the stent (manufacturing), and not exclusively to the action of the fogarty?
Dr. Aitor Alberdi

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