WITHDRAWN: Use of Repositionable Transcatheter Aortic Valve Systems in Past Mechanical Prosthetic Mitral Valve Recipients.

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Acute Coronary Syndromes, Gastrointestinal Protection, and Recommendations Regarding Concomitant Administration of Proton-Pump Inhibitors (Omeprazol/Esomeprazole) and Clopidogrel.

The Food and Drug Administration and the European Medicines Agency sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. The purpose is to know the gastroprotective approach in patients with acute coronary syndrome (ACS) and the level of follow-up of the alert. In 17 hospitals with catheterization laboratory in Spain, 1 per region, we studied 25 consecutive patients per hospital whose diagnosis of discharge since October 1, 2013, had been any type of ACS. We analyzed their baseline clinical profile, the gatroprotective agents at admission and discharge and the antiplatelet therapy at discharge. The number of patients included was 425: age 67.2 ± 12.5 years, women 29.8%, diabetes 36.5%. The patients presented unstable angina in 21.6%, non-ST-elevation myocardial infarction in 35.3% and ST-elevation myocardial infarction in 43.1%. Conservative approach was chosen in 17.9%, bare-metal stents 32.2%, ≥ 1 drug-eluting stent 48.5%, and surgery 1.4%. Aspirin was indicated in 1.9%, aspirin + clopidogrel 73.6%, aspirin + prasugrel 17.6%, and aspririn + ticagrelor 6.8%. Gastroprotective agents were present in 40.2% patients at admission and this percentage increased to 93.7% at discharge. Of the 313 (73.6%) on clopidogrel in 96 (30.6%) was combined with omeprazole and 3 (0.95%) with esomeprazole, whereas the most commonly used was pantoprazole with 190 patients (44.7%). In conclusion, almost the totality of the patients with an ACS receive gastroprotective agents at the moment of discharge, most of them with proton-pump inhibitors. In one every 3 cases of the patients who are on clopidogrel, the recommendation of the Food and Drug Administration and the European Medicines Agency is not followed.

Immediate and Long-Term Results of Drug-Eluting Stents in Mammary Artery Grafts.

UNLABELLED: Percutaneous intervention of a coronary graft is the treatment of choice when the graft fails. The objective is to report the long-term results of drug-eluting stents (DES) in mammary artery grafts (MAG). Patients who had been treated with DES for MAG in 27 centers were selected. The baseline and procedural clinical data were included prospectively, and the follow-up was performed with the patients, families, and medical records. Two hundred and sixty-eight patients were included: age 65.5 ± 10.1 years, diabetes 47.8%, ejection fraction 55.5 ± 14.9%. INDICATION: stable angina 28.4%, unstable angina 38.1%, non-ST-elevation myocardial infarction 21.6%, ST-elevation myocardial infarction 5.3%, and heart failure 6.7%; 1.19 ± 0.59 stents/patient were implanted measuring 18.8 ± 8.8 mm in length and 2.68 ± 0.35 mm in diameter. Rapamycin was used in 78 cases (29.1%), paclitaxel in 77 (28.7%), everolimus in 70 (26.1%), zotarolimus in 34 (12.7%), and biolimus in 9 (3.4%). All cases were successful except for 1 in which the patient died 30 minutes after the procedure. There were no other inhospital events. After a follow-up of 41 months (Q25: 23.7 to Q75: 57.8), 24 patients (9%) died of heart-related causes and 20 (7.5%) of noncardiac causes. Repeat revascularization was necessary in 31 cases, and in 1 additional patient, there was total occlusion, which was not treated. These 32 patients represented 11.9% of the total. In conclusion, the implantation of DES in MAG shows very high procedural success and also low long-term event rates.

Postdilatation for treatment of perivalvular aortic regurgitation after transcatheter aortic valve implantation.

OBJECTIVES: The study is made to describe the efficacy and safety of balloon postdilatation (BPD) for the treatment of residual aortic regurgitation (RAoR) after transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS: A single-center observational study is made with 157 consecutive patients accepted to TAVI. The patients were divided into two groups (no BPD-period and BPD-period). Before BPD, RAoR ≥ 2 was seen in 25% of the patients in group 1 and in 29% of the patients in group 2 (P ≥ 0.593). BPD was carried out in 95% (n = 21) of the patients in group 2 with RAoR ≥ 2. Regurgitation improved one grade in 68% of the cases (n = 15), 2 grades in 14% (n = 3), and remained without change in 18% (n = 4). RAoR < 2 was achieved in 91% (n = 73) of the patients in group 2 versus 75% (n = 58) in group 1 (RR = 0.35, 95% CI 0.16-0.80, P = 0.013). We recorded no aortic ring ruptures, damage to the device or displacements. Slight central regurgitation not present before BPD was registered in one case. CONCLUSIONS: BPD offers a very good safety profile and reduces RAoR in a large percentage of cases. BPD should be considered for the treatment of moderate to severe RAoR following TAVI.

Coronary stent immobilization during angioplasty by transcoronary ventricular pacing via a guidewire.

INTRODUCTION AND OBJECTIVES: In some patients, cardiac contractions cause the coronary artery segment adjacent to a stent to move in such a way that accurate stent positioning is difficult. A number of techniques have been described for immobilizing the stent at the target site by inducing periods of either asystole or tachycardia. This study shows how pulsatile motion can be controlled by means of rapid ventricular pacing via an angioplasty guidewire. METHODS: The study involved 27 consecutive patients in whom excessive stent movement during angioplasty complicated accurate stent implantation. In these selected patients, myocardial tachycardia was induced by transcoronary ventricular pacing via an angioplasty guidewire with the aim of reducing the pulsatile motion of the stent. RESULTS: At baseline, the median displacement was 4.08 mm (interquartile range 2.75 mm). During pacing at 100 and 150 beats per minute, the median displacement was 1.39 mm and 0.54 mm, respectively (interquartile range 1.66 mm and 0.54 mm, respectively). Transcoronary myocardial pacing was effective in 96% of cases. No complications associated with pacing were reported. CONCLUSIONS: Transcoronary ventricular pacing via an angioplasty guidewire was an effective and safe method for achieving stent immobilization in cases where there was excessive pulsatile motion.

Drug-eluting stent implantation in bifurcated lesions with balloon-crushing technique and 6 fr guiding catheter: immediate and mid-term results.

UNLABELLED: Bifurcated lesions are associated with higher complexity and restenosis. Sometimes implantation of two stents is necessary, requiring larger guiding catheters. We describe the implantation of two drug-eluting stents (DES) utilizing the balloon-crushing technique and 6 Fr catheters. METHODS: This was a prospective and observational study of a cohort of 15 consecutive patients with 1 bifurcated lesion treated with 2 DES through a 6 Fr catheter and the balloon-crushing technique between April and November 2005. The baseline characteristics of the patients, lesions and procedures were registered. Clinical follow up was obtained by telephone contact. RESULTS: Patient age ranged from 71.6+/- 9.4 years; 6 patients (40%) had diabetes; ejection fraction was 56 +/- 12%; radial access was used in 4 patients (26.6%). In 9 patients (60%) the target lesion was the left main artery; in 3 patients (20%) the target lesion was the LAD/diagonal and in the remaining 3 patients (20%), the target lesion was the circumflex/obtuse marginal. The median follow-up period was 316 days. There were 2 sudden deaths: 1 patient whose target lesion was the left main artery died 10 days following the procedure, and the other patient whose lesion was in the in LAD/diagonal died at day-187, 10 days following stent thrombosis. Both of them presented with severe ventricular dysfunction prior to the intervention. One patient required new percutaneous intervention due to in-segment restenosis in the left main artery. The composite major adverse cardiac events at follow up was 5 (33.3%, 2 deaths, 2 non-Q-wave myocardial infarctions and 1 revascularization). CONCLUSIONS: This technique permits the treatment of bifurcated lesions with 2 stents using 6 Fr guiding catheters, which could be very useful in radial access procedures. However, though the angiographic results were very satisfactory, the events observed in the follow-up period require a word of caution about its mid-term safety.