Resuming ultrasound activity after the acute phase of the COVID-19 pandemic.

Recently, Dr. Crespo et al. published in your Journal a paper recommending the use of ultrasonography during the current phase of the COVID-19 pandemic whilst wearing only a facial mask for protection, which we deem inadequate. Prevention is key when performing an ultrasound test, since this virus is highly contagious. During the pandemic, every patient should be considered as potentially infected and the procedure requires a close proximity. Therefore, extreme hygiene and a sonographer equipped with the appropriate personal protection (mask, cap, gown, gloves, shoe covers and goggles, with a facial screen and high-efficacy mask for confirmed or highly suspect cases) are of the utmost importance to prevent viral transmission.

Anomalous Origin of Left Coronary Artery with Intramural Aortic Course Causing Symptoms in a Teenaged Athlete.

Anomalous origin of the left coronary artery from the opposite sinus of Valsalva with an intramural aortic course is a rare congenital anomaly with a poor prognosis. We report the case of a 14-year-old soccer player who briefly lost consciousness while sprinting. He had exertional chest pain, syncope, ischemic changes on his electrocardiogram, and elevated cardiac troponin levels. Computed tomographic angiograms showed an anomalous origin of the left coronary artery from the right sinus of Valsalva and a course through the aortic wall toward the left coronary sinus. A surgically created neo-ostium in the left coronary sinus relieved the patient's ischemia, and he resumed playing soccer after cardiac rehabilitation.

TBC: A simple algorithm to rule out abnormalities in electrocardiograms of patients with pacemakers.

BACKGROUND: The aim of the study was to create a straightforward method to rule out abnormalities in electrocardiograms (ECGs) performed in patients with pacemakers. METHODS: The TBC method screens the ECG for any of the following findings: Tachycardia with pacing spikes, Bradycardia without spikes and Chaos with spikes unrelated to QRS-T complexes. T was considered to advise for patient assessment and B and C to require referral for urgent pacemaker evaluation. The diagnostic accuracy of the algorithm was validated using a cohort of 151 ECGs with normal and dysfunctional pacemakers. The effect of the algorithm was then evaluated for diagnostic skills and management of patients with pacemakers by non-cardiologists, comparing their diagnostic accuracy before and after teaching the algorithm. RESULTS: The TBC algorithm had a sensitivity of 86% and a specificity of 94% in diagnosing a malfunctioning pacemaker. The diagnostic skills and patient referral were significantly improved (74.8% vs. 89.5%, p < 0.001; and 57.4% vs. 83%, p < 0.001). CONCLUSIONS: TBC is an easy to remember and apply method to rule out severe abnormalities in ECGs of patients with pacemakers. TBC algorithm has a very good diagnostic capability and is easily applied by non-expert physicians with good results.

Incidence, Causes, and Impact of In-Hospital Infections After Transcatheter Aortic Valve Implantation.

In-hospital infections (IHI) are one of the most common and serious problems after invasive procedures. Transcatheter aortic valve implantation (TAVI) is an increasingly used alternative to surgery in patients with severe symptomatic aortic stenosis. The aim of this study was to determine the incidence, origin, risk factors, and clinical outcomes of IHI after TAVI. A total of 303 consecutive patients with severe aortic stenosis who underwent transfemoral TAVI were included and followed during a median time of 21 months. We examined the occurrence, types, origin, and timing of infections during hospital stay as well as short- and long-term clinical outcomes according to the occurrence of IHI. A total of 51 patients (17%; 62 infectious episodes) experienced IHI after TAVI. Respiratory and urinary tract infections were the most frequent type of infections (44% and 34%, respectively), followed by surgical site infection (8%) and bloodstream infection (5%). Positive cultures were obtained in 74% of the samples, of which 65% were gram-negative bacilli. Modifiable factors such as bleeding (p = 0.005) and length of coronary care unit stay (p <0.001) were independently associated with an increased infection risk. Patients with IHI had a longer hospital stay (14 vs 6 days, p <0.001), an increased mortality (hazard ratio 2.48, 95% CI 1.45 to 4.23) and readmission rate (hazard ratio 2.0, 95% CI 1.27 to 3.14) during the follow-up. In conclusion, IHI is a frequent complication after TAVI with a significant impact on short- and long-term clinical outcomes. The most important risk factors associated with the development of this complication were modifiable periprocedural aspects. These results underline the importance to implement specific preventive strategies to reduce in-hospital-acquired infections after TAVI.

N-Terminal Pro-Brain Natriuretic Peptide Is Associated with a Future Diagnosis of Cancer in Patients with Coronary Artery Disease.

OBJECTIVE: Several papers have reported elevated plasma levels of natriuretic peptides in patients with a previous diagnosis of cancer. We have explored whether N-terminal pro-brain natriuretic peptide (NT-proBNP) plasma levels predict a future diagnosis of cancer in patients with coronary artery disease (CAD). METHODS: We studied 699 patients with CAD free of cancer. At baseline, NT-proBNP, galectin-3, monocyte chemoattractant protein-1, soluble tumor necrosis factor-like weak inducer of apoptosis, high-sensitivity C-reactive protein, and high-sensitivity cardiac troponin I plasma levels were assessed. The primary outcome was new cancer diagnosis. The secondary outcome was cancer diagnosis, heart failure requiring hospitalization, or death. RESULTS: After 2.15±0.98 years of follow-up, 24 patients developed cancer. They were older (68.5 [61.5, 75.8] vs 60.0 [52.0, 72.0] years; p=0.011), had higher NT-proBNP (302.0 [134.8, 919.8] vs 165.5 [87.4, 407.5] pg/ml; p=0.040) and high-sensitivity C-reactive protein (3.27 [1.33, 5.94] vs 1.92 [0.83, 4.00] mg/L; p=0.030), and lower triglyceride (92.5 [70.5, 132.8] vs 112.0 [82.0, 157.0] mg/dl; p=0.044) plasma levels than those without cancer. NT-proBNP (Hazard Ratio [HR]=1.030; 95% Confidence Interval [CI]=1.008-1.053; p=0.007) and triglyceride levels (HR=0.987; 95%CI=0.975-0.998; p=0.024) were independent predictors of a new cancer diagnosis (multivariate Cox regression analysis). When patients in whom the suspicion of cancer appeared in the first one-hundred days after blood extraction were excluded, NT-proBNP was the only predictor of cancer (HR=1.061; 95%CI=1.034-1.088; p<0.001). NT-proBNP was an independent predictor of cancer, heart failure, or death (HR=1.038; 95%CI=1.023-1.052; p<0.001) along with age, and use of insulin and acenocumarol. CONCLUSIONS: NT-proBNP is an independent predictor of malignancies in patients with CAD. New studies in large populations are needed to confirm these findings.

[Impact of plasma pro-B-type natriuretic peptide amino-terminal and galectin-3 levels on the predictive capacity of the LIPID Clinical Risk Scale in stable coronary disease]. / Impacto de los niveles plasmáticos de pro-péptido natriurético tipo B aminoterminal, proteína quimiotáctica de monocitos-1 y galectina3 en la capacidad predictiva de eventos de la escala clínica LIPID en la enfermedad coronaria estable.

INTRODUCTION: At present, there is no tool validated by scientific societies for risk stratification of patients with stable coronary artery disease (SCAD). It has been shown that plasma levels of monocyte chemoattractant protein-1 (MCP-1), galectin-3 and pro-B-type natriuretic peptide amino-terminal (NT-proBNP) have prognostic value in this population. OBJECTIVE: To analyze the prognostic value of a clinical risk scale published in Long-term Intervention with Pravastatin in Ischemic Disease (LIPID) study and determining its predictive capacity when combined with plasma levels of MCP-1, galectin-3 and NT-proBNP in patients with SCAD. METHODS AND RESULTS: A total of 706 patients with SCAD and a history of acute coronary syndrome (ACS) were analyzed over a follow up period of 2.2 ± 0.99 years. The primary endpoint was the occurrence of an ischemic event (any SCA, stroke or transient ischemic attack), heart failure, or death. A clinical risk scale derived from the LIPID study significantly predicted the development of the primary endpoint, with an area under the ROC curve (Receiver Operating Characteristic) of 0.642 (0.579 to 0.705); P<0.001. A composite score was developed by adding the scores of the LIPID and scale decile levels of MCP -1, galectin -3 and NT-proBNP. The predictive value improved with an area under the curve of 0.744 (0.684 to 0.805); P<0.001 (P=0.022 for comparison). A score greater than 21.5 had a sensitivity of 74% and a specificity of 61% for the development of the primary endpoint (P<0.001, log -rank test). CONCLUSION: Plasma levels of MCP-1, galectin -3 and NT-proBNP improve the ability of the LIPID clinical scale to predict the prognosis of patients with SCAD.

Usefulness of a combination of monocyte chemoattractant protein-1, galectin-3, and N-terminal probrain natriuretic peptide to predict cardiovascular events in patients with coronary artery disease.

Patients with coronary artery disease may develop not only ischemic events but also heart failure and death due to previous myocardial damage. The purpose of this study was to test the prognostic value of a panel of plasma biomarkers related to vascular (monocyte chemoattractant protein-1 [MCP-1] and soluble tumor necrosis factor-like weak inducer of apoptosis) and myocardial damage (galectin-3, N-terminal fragment of brain natriuretic peptide [NT-proBNP], and neutrophil gelatinase-associated lipocalin) in 706 patients with chronic coronary artery disease followed for 2.2 ± 0.99 years. Secondary outcomes were the incidence of acute ischemic events (ST elevation myocardial infarction, non-ST elevation acute coronary syndrome, stroke, or transient ischemic attack) and death or heart failure. The primary outcome was the combination of the secondary outcomes. Cox proportional hazards model was used for analysis. Fifty-three patients developed acute ischemic events. Increasing MCP-1 plasma levels (p = 0.002), age, and body mass index predicted this outcome independently. Thirty-three patients developed death and/or heart failure. Galectin-3 (p = 0.007), NT-proBNP plasma levels (p = 0.004), hypertension, glomerular filtration rate, and the use of nitrates and anticoagulants were associated with this outcome independently. The development of the primary outcome was predicted independently by MCP-1 (p <0.001), NT-proBNP (p = 0.005), and galectin-3 (p = 0.019); hypertension; atrial fibrillation; and treatment with nitrates. Every biomarker with a value above the median increased the risk of developing this outcome by 1.832 (95% confidence interval 1.356 to 2.474, p <0.001). High-sensitivity C-reactive protein and lipid levels were not associated with any outcome. In conclusion, increasing MCP-1, galectin-3, and NT-proBNP plasma levels are associated with a greater incidence of cardiovascular events.

Successful removal of a floating thrombus in ascending aorta.

Free-floating thrombus in ascending aorta is a rare cause of peripheral embolism with potentially fatal consequences. We report the case of a young patient with syncope and sudden lumbar pain. Computed tomographic scan revealed a large pedunculated floating mass attached to the posterior wall of the ascending aorta, probably responsible of renal embolic infarction; transthoracic echocardiography confirmed the diagnosis. Surgery was urgently performed. The thrombus was excised, and was not related to atherosclerotic disease of the aortic wall. We conclude that once diagnosis is clear, urgent surgery must be considered to avoid any further embolic complications.