CIBELE LARROSA GARZILLO
Projetos de Pesquisa
Unidades Organizacionais
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina
14 resultados
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conferenceObject Comparison between off-pump and on-pump coronary artery bypass grafting in patients with severe lesions at the circumflex artery territory: 5-year follow-up of the MASS III trial(2013) MELO, R. M. V.; HUEB, W.; REZENDE, P. C.; GARZILLO, C. L.; LIMA, E. G.; OIKAWA, F. T. C.; COSTA, L. M. A.; HUEB, T. O.; RAMIRES, J. A. F.; KALIL FILHO, R.- Ten-year outcomes of patients randomized to surgery, angioplasty, or medical treatment for stable multivessel coronary disease: Effect of age in the Medicine, Angioplasty, or Surgery Study II trial(2013) REZENDE, Paulo Cury; HUEB, Whady; GARZILLO, Cibele Larrosa; LIMA, Eduardo Gomes; HUEB, Alexandre Ciappina; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoObjective: With progressive aging, coronary artery disease has been diagnosed at more advanced ages. Although patients aged 65 years or more have been referred to surgical or percutaneous coronary interventions, the best option for coronary artery disease treatment remains uncertain. The current study compared the 3 treatment options for coronary artery disease in patients aged 65 years or more and analyzed the impact of age in treatment options. Methods: Patients were separated according to age: 65 years or more (n = 200) and less than 65 years (n = 411). All patients were followed for 10 years. The rates of overall mortality, acute myocardial infarction, and new revascularizations were analyzed. Results: Of 200 patients aged 65 years or more, 68 were randomized to medical therapy, 68 were randomized to percutaneous coronary intervention, and 64 were randomized to coronary artery bypass grafting. At 10 years, overall survival was 63% (medical therapy), 69% (percutaneous coronary intervention), and 66% (coronary artery bypass grafting) (P = .93). The survival free of combined events was 43% (medical therapy), 38% (percutaneous coronary intervention), and 66% (coronary artery bypass grafting) (P = .007). The survival free of myocardial infarction was 82% (medical therapy), 77% (percutaneous coronary intervention), and 90%(coronary artery bypass grafting) (P = .17), and survival free of new revascularizations was 59% (medical therapy), 58% (percutaneous coronary intervention), and 91% (coronary artery bypass grafting) (P = .0003). When the 2 age groups were compared, survival free of myocardial infarction for patients treated by percutaneous coronary intervention was 77% (older patients) and 92% (younger patients) (P = .004). Conclusions: In this analysis, treatment options for patients aged 65 years or more who have coronary artery disease yield similar overall survival. However, coronary artery bypass grafting was associated with fewer coronary events, and percutaneous coronary intervention was associated with a higher incidence of myocardial infarction.
- Long-term analysis of left ventricular ejection fraction in patients with stable multivessel coronary disease undergoing medicine, angioplasty or surgery: 10-year follow-up of the MASS II trial(2013) GARZILLO, Cibele Larrosa; HUEB, Whady; GERSH, Bernard J.; LIMA, Eduardo Gomes; REZENDE, Paulo Cury; HUEB, Alexandre Ciappina; VIEIRA, Ricardo D'Oliveira; FAVARATO, Desiderio; PEREIRA, Alexandre Costa; SOARES, Paulo Rogerio; SERRANO JR., Carlos Vicente; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoBackground Assuming that coronary interventions, both coronary bypass surgery (CABG) and percutaneous coronary intervention (PCI), are directed to preserve left ventricular function, it is not known whether medical therapy alone (MT) can achieve this protection. Thus, we evaluated the evolution of LV ejection fraction (LVEF) in patients with stable coronary artery disease (CAD) treated by CABG, PCI, or MT as a post hoc analysis of a randomized controlled trial with a follow-up of 10 years. Methods Left ventricle ejection fraction was assessed with transthoracic echocardiography in patients with multivessel CAD, participants of the MASS II trial before randomization to CABG, PCI, or MT, and re-evaluated after 10 years of follow-up. Results Of the 611 patients, 422 were alive after 10.32 1.43 years. Three hundred and fifty had LVEF reassessed: 108 patients from MT, 111 from CABG, and 131 from PCI. There was no difference in LVEF at the beginning (0.61 0.07, 0.61 0.08, 0.61 0.09, respectively, for PCI, CABG, and MT, P 0.675) or at the end of follow-up (0.56 0.11, 0.55 0.11, 0.55 0.12, P 0.675), or in the decline of LVEF (reduction delta of 7.2 17.13, 9.08 18.77, and 7.54 22.74). Acute myocardial infarction (AMI) during the follow-up was associated with greater reduction in LVEF. The presence of previous AMI (OR: 2.50, 95 CI: 1.404.45; P 0.0007) and during the follow-up (OR: 2.73, 95 CI: 1.255.92; P 0.005) was associated with development of LVEF 45. Conclusion Regardless of the therapeutic option applied, LVEF remains preserved in the absence of a major adverse cardiac event after 10 years of follow-up.
conferenceObject ON-PUMP VERSUS OFF-PUMP CORONARY ARTERY BYPASS SURGERY IN PATIENTS WITH ADVANCED AGE: FIVE-YEAR FOLLOW-UP OF MASS III TRIAL(2013) MELO, Rodrigo M. V.; HUEB, Whady; OIKAWA, Fernando T. C.; COSTA, Leandro; SERRANO, Carlos; GARZILLO, Cibele; REZENDE, Paulo; LIMA, Eduardo; FAVARATO, Desiderio; HUEB, Alexandre; RAMIRES, Jose; KALIL-FILHO, RobertoBackground: Advanced age is associated with increased mortality and morbidity in patients undergoing coronary artery bypass grafting (CABG), which may be a consequence of cardiopulmonary bypass. We aim to evaluate cardiac events and long-term clinical outcome in patients with advanced age and stable coronary artery disease (CAD) undergoing off-pump (OPCAB) and on-pump (ONCAB) CABG. Methods: The MASS III was a single-center randomized trial that evaluate 308 patients with stable CAD and preserved ventricular function assigned for: 155 to off-pump and 153 to on-pump CABG. Of this, 176 (58.3%) patients had 60 years or older at the time of randomization (90 of-pump and 86 on-pump). Primary composite end points were death, myocardial infarction, further revascularization, or stroke. Results: The two randomized groups were well-matched for baseline demographic, clinical, and angiographic characteristics. The mean age was 67.2 (±5.0) years. In hospital analysis ONCAB patients had a higher incidence of postoperative stroke or myocardial infarction: 13 (15.1%) vs 5 (5.6%); p=0.036. After 5-year follow-up, there were no significant differences between both strategies of CABG in the composite end points 29.1% vs 27.8%; (Hazard Ratio 1.07; CI 0.62 – 1.87; p=0.8) for ONCAB and OPCAB respectively. Conclusion: In this advanced age population, off-pump surgery did not add benefit in clinical outcome at 5-year follow-up.conferenceObject Expression of Ischemic Preconditioning in Patients With Stable Multivessel Coronary Artery Disease With and Without Diabetes Mellitus(2013) REZENDE, Paulo C.; GARCIA, Rosa M.; UCHIDA, Augusto H.; LIMA, Eduardo G.; GARZILLO, Cibele L.; SEGRE, Carlos A.; CESAR, Luiz A.; HUEB, Whady; RAMIRES, Jose A.; KALIL FILHO, Roberto- Impact of diabetes on 10-year outcomes of patients with multivessel coronary artery disease in the Medicine, Angioplasty, or Surgery Study II (MASS II) trial(2013) LIMA, Eduardo Gomes; HUEB, Whady; GARCIA, Rosa Maria Rahmi; PEREIRA, Alexandre Costa; SOARES, Paulo Rogerio; FAVARATO, Desiderio; GARZILLO, Cibele Larrosa; VIEIRA, Ricardo D'Oliveira; REZENDE, Paulo Cury; TAKIUTI, Myrthes; GIRARDI, Priscyla; HUEB, Alexandre Ciappina; RAMIRES, Jose A. F.; KALIL FILHO, RobertoIntroduction Diabetes mellitus is a major cause of coronary artery disease (CAD). Despite improvement in the management of patients with stable CAD, diabetes remains a major cause of increased morbidity and mortality. There is no conclusive evidence that either modality is better than medical therapy alone for the treatment of stable multivessel CAD in patients with diabetes in a very long-term follow-up. Our aim was to compare 3 therapeutic strategies for stable multivessel CAD in a diabetic population and non-diabetic population. Methods It was compared medical therapy (MT), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in 232 diabetic patients and 379 nondiabetic patients with multivessel CAD. Endpoints evaluated were overall and cardiac mortality. Results Patients (n = 611) were randomized to CABG (n = 203), PCI (n = 205), or MT (n = 203). In a 10-year follow-up, more deaths occurred among patients with diabetes than among patients without diabetes (P = .001) for overall mortality. In this follow-up, 10-year mortality rates were 32.3% and 23.2% for diabetics and non-diabetics respectively (P = .024). Regarding cardiac mortality, 10-year cardiac mortality rates were 19.4% and 12.7% respectively (P = .031). Considering only diabetic patients and stratifying this population by treatment option, we found mortality rates of 31.3% for PCI, 27.5% for CABG and 37.5% for MT (P = .015 for CABG vs MT) and cardiac mortality rates of 18.8%, 12.5% and 26.1% respectively (P = .005 for CABG vs MT). Conclusions/interpretation Among patients with stable multivessel CAD and preserved left ventricular ejection fraction, the 3 therapeutic regimens had high rates of overall and cardiac-related deaths among diabetic compared with nondiabetic patients. Moreover, better outcomes were observed in diabetic patients undergoing CABG compared to MT in relation to overall and cardiac mortality in a 10-year follow-up.
conferenceObject Prognosis in 10 years of follow-up of three therapeutic strategies for chronic multivessel coronary artery disease in women (study MASS)(2013) MANSUR, A. P.; HUEB, W. A.; TAKADA, J. Y.; AVAKIAN, S. D.; REZENDE, P. C.; SEGRE, A.; SOARES, P. R.; GARZILLO, C.; RAMIRES, J. A. F.; KALIL FILHO, R.conferenceObject BIOMARKERS AND CMR WITH LATE GADOLINIUM ENHANCEMENT FOR DIAGNOSIS OF PROCEDURE-RELATED MYOCARDIAL NECROSIS: A PROSPECTIVE TRIAL USING THE THIRD UNIVERSAL DEFINITION OF MYOCARDIAL INFARCTION(2013) HUEB, Whady; NOMURA, Cesar; VILLA, Alexandre V.; PARGA, Jose; COSTA, Leandro; MELO, Rodrigo M. V.; OIKAWA, Fernando T. C.; STRUNZ, Celia; REZENDE, Paulo; LIMA, Eduardo; GARZILLO, Cibele L.; RIBEIRO, Expedito E.; HUEB, Alexandre; SERRANO, Carlos; RAMIRES, Jose; KALIL-FILHO, RobertoBackground: The elevation of cardiac biomarkers after percutaneous or surgical myocardial revascularization procedures is common. However, the correlation between the release and the diagnosis of procedure-related myocardial infarction (Ml) remains unknown. In this study we aim to compare the release of cardiac biomarkers after mechanical interventions with the presence of late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR). Methods: In this prospective study, we evaluated 64 stable multivessel coronary artery disease patients with preserved ventricular function and formal indication to revascularization. The release of troponin and CKMB for diagnosis of procedure-related Ml was defined as the third universal definition of Ml. CMR with LGE was performed in all patients before and after interventions. Measurements of cardiac biomarkers were performed before and after the procedure, every 6 hours until 48h after PCI and 72h after CABG. Results: Of 64 patients, 44 (68.8%) underwent CABG and 20 (31.2%) underwent PCI; 46 (72%) were male, 45 (70%) had 3-vessel disease, 33 (52%) had diabetes and 23 (36%) had class Ill/IV of angina. For CABG patients, injury occurred in 95.5% (troponin) and 25% (CKMB); for PCI patients injury occurred in 70% (troponin) and 5% (CKMB). From the initial 64 patients, 14 (21.9%) had new LGE on post-procedure CMR, 13 after CABG and 1 after PCI. From these 14 patients, 7 (50%) presented elevation of CKMB above the cutoffs and troponin was elevated in all patients. From the 50 patients with no new LGE on CMR, 5 (10%) presented CKMB elevation and 42 (84%) presented troponin elevation above the 99th percentile. Based on current cutoffs, troponin had a sensitivity of 100% and specificity of 16% (positive predictive value of 25% and negative predictive value of 100%). CKMB had a sensitivity of 50% and specificity of 90% (positive predictive value of 58% and negative predictive value of 87%). Conclusion: In this study, cardiac biomarkers had a low accuracy for the diagnosis of procedure-related myocardial infarction based on LGE CMR.- Hypotheses, rationale, design, and methods for evaluation of ischemic preconditioning assessed by sequential exercise tests in diabetic and non-diabetic patients with stable coronary artery disease - a prospective study(2013) REZENDE, Paulo Cury; GARCIA, Rosa Maria Rahmi; UCHIDA, Augusto Hiroshi; COSTA, Leandro Menezes Alves; SCUDELER, Thiago Luis; MELO, Rodrigo Morel Vieira; OIKAWA, Fernando Teiichi Costa; GARZILLO, Cibele Larrosa; LIMA, Eduardo Gomes; SEGRE, Carlos Alexandre Wainrober; FAVARATO, Desiderio; GIRARDI, Priscyla; TAKIUTI, Myrthes; STRUNZ, Celia Cassaro; HUEB, Whady; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoBackground: Ischemic preconditioning is a powerful mechanism of myocardial protection and in humans it can be evaluated by sequential exercise tests. Coronary Artery Disease in the presence of diabetes mellitus may be associated with worse outcomes. In addition, some studies have shown that diabetes interferes negatively with the development of ischemic preconditioning. However, it is still unknown whether diabetes may influence the expression of ischemic preconditioning in patients with stable multivessel coronary artery disease. Methods/Design: This study will include 140 diabetic and non-diabetic patients with chronic, stable coronary artery disease and preserved left ventricular systolic function. The patients will be submitted to two sequential exercise tests with 30-minutes interval between them. Ischemic parameters will be compared between diabetic and non-diabetic patients. Ischemic preconditioning will be considered present when time to 1.0 mm ST-segment deviation is greater in the second of two sequential exercise tests. Exercise tests will be analyzed by two independent cardiologists. Discussion: Ischemic preconditioning was first demonstrated by Murry et al. in dog's hearts. Its work was reproduced by other authors, clearly demonstrating that brief periods of myocardial ischemia followed by reperfusion triggers cardioprotective mechanisms against subsequent and severe ischemia. On the other hand, the demonstration of ischemic preconditioning in humans requires the presence of clinical symptoms or physiological changes difficult to be measured. One methodology largely accepted are the sequential exercise tests, in which, the improvement in the time to 1.0 mm ST depression in the second of two sequential tests is considered manifestation of ischemic preconditioning. Diabetes is an important and independent determinant of clinical prognosis. It's a major risk factor for coronary artery disease. Furthermore, the association of diabetes with stable coronary artery disease imposes worse prognosis, irrespective of treatment strategy. It's still not clearly known the mechanisms responsible by these worse outcomes. Impairment in the mechanisms of ischemic preconditioning may be one major cause of this worse prognosis, but, in the clinical setting, this is not known. The present study aims to evaluate how diabetes mellitus interferes with ischemic preconditioning in patients with stable, multivessel coronary artery disease and preserved systolic ventricular function.
- Effect of Hypoglycemic Agents on Ischemic Preconditioning in Patients With Type 2 Diabetes and Symptomatic Coronary Artery Disease(2013) RAHMI, Rosa Maria; UCHIDA, Augusto Hiroshi; REZENDE, Paulo Cury; LIMA, Eduardo Gomes; GARZILLO, Cibele Larrosa; FAVARATO, Desiderio; STRUNZ, Celia M. C.; TAKIUTI, Myrthes; GIRARDI, Priscyla; HUEB, Whady; KALIL FILHO, Roberto; RAMIRES, Jose A. F.OBJECTIVE-To assess the effect of two hypoglycemic drugs on ischemic preconditioning (IPC) patients with type 2 diabetes and coronary artery disease (CAD). RESEARCH DESIGN AND METHODS-We performed a prospective study of 96 consecutive patients allocated into two groups: 42 to group repaglinide (R) and 54 to group vildagliptin (V). All patients underwent two consecutive exercise tests (ET1 and ET2) in phase 1 without drugs. In phase 2, 1 day after ET1 and -2, 2 mg repaglinide three times daily or 50 mg vildagliptin twice daily was given orally to patients in the respective group for 6 days. On the seventh day, 60 min after 6 mg repaglinide or 100 mg vildagliptin, all patients underwent two consecutive exercise tests (ET3 and ET4). RESULTS-In phase 1, IPC was demonstrated by improvement in the time to 1.0 mm ST-segment depression and rate pressure product (RPP). All patients developed ischemia in ET3; however, 83.3% of patients in group R experienced ischemia earlier in ET4, without significant improvement in RPP, indicating the cessation of IPC (P < 0.0001). In group V. only 28% of patients demonstrated IPC cessation, with 72% still having the protective effect (P < 0.0069). CONCLUSIONS-Repaglinide eliminated myocardial IPC, probably by its effect on the K-ATP channel. Vildagliptin did not damage this protective mechanism in a relevant way in patients with type 2 diabetes and CAD, suggesting a good alternative treatment in this population.