Digital health and cardiovascular healthcare professionals in Portugal: Current status, expectations and barriers to implementation.

INTRODUCTION AND OBJECTIVES: Digital health (DH) is a broad concept, bringing together technology and healthcare, that is playing an increasingly important role in the daily routine of healthcare professionals (HCPs) and promises to contribute to the prevention and treatment of cardiovascular disease. There are no solid data on the position of Portuguese HCPs toward the implementation of DH in cardiovascular medicine. This national cross-sectional study aims to provide a snapshot of DH implementation in Portuguese cardiovascular HCP routines and to identify both expectations and barriers to its adoption. METHODS: An 18-question survey was created specifically for this study and distributed to 1174 individuals on the Portuguese Society of Cardiology mailing list. RESULTS: We collected 117 valid responses (response rate 10%). Almost all participants had smartphones and laptops, and two-thirds had tablets. Electronic medical information systems were the most used DH tool (84% of respondents) and were considered the most important for improving cardiovascular care. Implantable technologies (sensors and devices), telemedicine and social media were used by more than two out of three respondents and considered «very important¼ or «extremely important¼ by most of them. Most participants showed positive expectations regarding the impact of DH in cardiovascular medicine: 78% agreed that DH could improve health outcomes, 64% that it promotes health literacy and 63% that it could decrease healthcare costs. The top-rated barriers were patients' inability to use smartphones, limited access to electronic devices, and lack of legal regulation of DH. CONCLUSION: Most Portuguese cardiovascular HCPs had at least three electronic devices (mainly smartphones, laptops and tablets) and showed positive expectations regarding DH's current and future impact on cardiovascular medicine. Patient DH literacy, technology adoption, and DH regulation were identified as the most important barriers to increasing the adoption of DH tools in cardiovascular medicine.

Prognostic value of flow-status in severe aortic stenosis patients undergoing percutaneous intervention.

PURPOSE: Low-flow status is a mortality predictor in severe aortic stenosis (SAS) patients, including after transcatheter aortic valve implantation (TAVI) treatment. However, the best parameter to assess flow is unknown. Recent studies suggest that transaortic flow rate (FR) is superior to currently used stroke volume index (SVi) in defining low-flow states. Therefore, we aimed to evaluate the prognostic value of FR and SVi in patients undergoing TAVI. METHODS: A single-centre retrospective analysis of all consecutive patients treated with TAVI for SAS between 2011 and 2019 was conducted. Low-FR was defined as < 200 mL/s and low-SVi as < 35 mL/m2. Primary endpoint was all-cause five-year mortality, analyzed using Kaplan-Meier curves and Cox regression models. Secondary endpoint was variation of NYHA functional class six months after procedure. Patients were further stratified according to ejection fraction (EF < 50%). RESULTS: Of 489 cases, 59.5% were low-FR, and 43.1% low-SVi. Low-flow patients had superior surgical risk, worse renal function, and had a higher prevalence of coronary artery disease. Low-FR was associated with mortality (hazard ratio 1.36, p = 0.041), but not after adjustment to EuroSCORE II. Normal-SVi was not associated with survival, despite a significative p-trend for its continuous value. No associations were found for flow-status and NYHA recovery. When stratifying according to preserved and reduced EF, both FR and SVi did not predict all-cause mortality. CONCLUSION: In patients with SAS undergoing TAVI, a low-FR state was associated with higher mortality, as well as SVi, but not at a 35 mL/m2 cut off.

Segmentation of X-ray coronary angiography with an artificial intelligence deep learning model: Impact in operator visual assessment of coronary stenosis severity.

BACKGROUND: Visual assessment of the percentage diameter stenosis (%DSVE ) of lesions is essential in coronary angiography (CAG) interpretation. We have previously developed an artificial intelligence (AI) model capable of accurate CAG segmentation. We aim to compare operators' %DSVE in angiography versus AI-segmented images. METHODS: Quantitative coronary analysis (QCA) %DS (%DSQCA ) was previously performed in our published validation dataset. Operators were asked to estimate %DSVE of lesions in angiography versus AI-segmented images in separate sessions and differences were assessed using angiography %DSQCA as reference. RESULTS: A total of 123 lesions were included. %DSVE was significantly higher in both the angiography (77% ± 20% vs. 56% ± 13%, p < 0.001) and segmentation groups (59% ± 20% vs. 56% ± 13%, p < 0.001), with a much smaller absolute %DS difference in the latter. For lesions with %DSQCA of 50%-70% (60% ± 5%), an even higher discrepancy was found (angiography: 83% ± 13% vs. 60% ± 5%, p < 0.001; segmentation: 63% ± 15% vs. 60% ± 5%, p < 0.001). Similar, less pronounced, findings were observed for %DSQCA < 50% lesions, but not %DSQCA > 70% lesions. Agreement between %DSQCA /%DSVE across %DSQCA strata (<50%, 50%-70%, >70%) was approximately twice in the segmentation group (60.4% vs. 30.1%; p < 0.001). %DSVE inter-operator differences were smaller with segmentation. CONCLUSION: %DSVE was much less discrepant with segmentation versus angiography. Overestimation of %DSQCA < 70% lesions with angiography was especially common. Segmentation may reduce %DSVE overestimation and thus unwarranted revascularization.

Coronary X-ray angiography segmentation using Artificial Intelligence: a multicentric validation study of a deep learning model.

INTRODUCTION: We previously developed an artificial intelligence (AI) model for automatic coronary angiography (CAG) segmentation, using deep learning. To validate this approach, the model was applied to a new dataset and results are reported. METHODS: Retrospective selection of patients undergoing CAG and percutaneous coronary intervention or invasive physiology assessment over a one month period from four centers. A single frame was selected from images containing a lesion with a 50-99% stenosis (visual estimation). Automatic Quantitative Coronary Analysis (QCA) was performed with a validated software. Images were then segmented by the AI model. Lesion diameters, area overlap [based on true positive (TP) and true negative (TN) pixels] and a global segmentation score (GSS - 0 -100 points) - previously developed and published - were measured. RESULTS: 123 regions of interest from 117 images across 90 patients were included. There were no significant differences between lesion diameter, percentage diameter stenosis and distal border diameter between the original/segmented images. There was a statistically significant albeit minor difference [0,19 mm (0,09-0,28)] regarding proximal border diameter. Overlap accuracy ((TP + TN)/(TP + TN + FP + FN)), sensitivity (TP / (TP + FN)) and Dice Score (2TP / (2TP + FN + FP)) between original/segmented images was 99,9%, 95,1% and 94,8%, respectively. The GSS was 92 (87-96), similar to the previously obtained value in the training dataset. CONCLUSION: the AI model was capable of accurate CAG segmentation across multiple performance metrics, when applied to a multicentric validation dataset. This paves the way for future research on its clinical uses.

Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement: Feasibility in clinical practice.

INTRODUCTION AND OBJECTIVE: Coronary artery disease is highly prevalent among patients with severe aortic stenosis who undergo transcatheter aortic valve replacement (TAVR). As indications for TAVR are now expanding to younger and lower-risk patients, the need for coronary angiography (CA) and percutaneous coronary intervention (PCI) during their lifetime is expected to increase. The objective of our study was to assess the need for CA and the feasibility of re-engaging the coronary ostia after TAVR. METHODS: We performed a retrospective analysis of 853 consecutive patients undergoing TAVR between August 2007 and December 2020. Patients who needed CA after TAVR were selected. The primary endpoint was the rate of successful coronary ostia cannulation after TAVR. RESULTS: Of a total of 31 CAs in 28 patients (3.5% of 810 patients analyzed: 57% male, age 77.8±7.0 years) performed after TAVR, 28 (90%) met the primary endpoint and in three cannulation was semi-selective. All failed selective coronary ostia cannulations occurred in patients with a self-expanding valve. Sixteen (52%) also had indication for PCI, which was successfully performed in all. The main indication for CA was non-ST-elevation acute coronary syndrome (35%, n=11). Two cases of primary PCI occurred without delay. There were no complications reported during or after the procedure. CONCLUSION: Although CA was rarely needed in patients after TAVR, selective diagnostic CA was possible in the overwhelming majority of patients. PCI was performed successfully in all cases, without complications.

Social media use by cardiovascular healthcare professionals in Portugal.

INTRODUCTION AND OBJECTIVES: Social media (SoMe) has a flourishing role in cardiovascular (CV) medicine as a facilitator of academic communication not only during conferences and congresses, but also by scientific societies and journals. However, there is no solid data illustrating the use of SoMe by CV healthcare professionals (CVHP) in Portugal. Hence, the main goal of this national cross-sectional survey was to accurately characterize SoMe use by Portuguese CVHPs. METHODS: A 35-item questionnaire was specifically developed for this study, approved by the Digital Health Study Group of the Portuguese Society of Cardiology (SPC), and sent, by e-mail, to the mailing list of the SPC (including 1293 potential recipients). RESULTS AND CONCLUSION: There were 206 valid answers. Fifty-two percent of respondents were female and 58% were younger than 44 years of age with almost two out of three participants being physicians. Ninety-two percent of the survey participants reported that they are currently using SoMe; LinkedIn was the most common platform used for professional purposes. Sixty-four percent believed SoMe had had a positive impact on their clinical practice; 77% and 49% had used SoMe for acquiring and sharing information related to COVID-19, respectively. In conclusion, the majority of Portuguese CVHPs that participated in this survey are actively using SoMe, with a greater participation of those <45 years of age; its clinical impact is positive, with a leading role in the dissemination of evidence during the COVID pandemic.

Anti-SARS-CoV-2 vaccine-induced myocarditis - real but, in general, rare and mild: A consensus statement from the Studies Committee of the Portuguese Society of Cardiology.

Acute myocarditis (especially) and pericarditis have been consistently associated with the administration of vaccines against SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), generating anxiety in the general population, uncertainty in the scientific community and obstacles to ambitious mass vaccination programs, especially in foreign countries. Like some of its European counterparts, the Portuguese Society of Cardiology (SPC), through its Studies Committee, decided to take a position on some of the most pressing questions related to this issue: (i) How certain are we of this epidemiological association? (ii) What is the probability of its occurrence? (iii) What are the pathophysiological bases of these inflammatory syndromes? (iv) Should their diagnosis, treatment and prognosis follow the same steps as for typical idiopathic or post-viral acute myopericarditis cases? (v) Is the risk of post-vaccine myocarditis great enough to overshadow the occurrence of serious COVID-19 disease in unvaccinated individuals? In addition, the SPC will issue clinical recommendations and offer its outlook on the various paths this emerging disease may take in the future.

Rescue percutaneous repair of ischemic acute severe mitral regurgitation.

Acute severe mitral regurgitation (MR) because of secondary left ventricular impaired regional contractility can present with severe acute heart failure, associated with a high risk for rapid decompensation, pulmonary edema and cardiogenic shock. Frequently, in these highly unstable patients, surgical risk can be prohibitive. Evidence for percutaneous repair of acute MR is scarce, but a few case series show that this approach could be safe and effective for bailing out hemodynamically unstable patients. We report a case of an 84-year-old man with acute ischemic severe MR post-acute myocardial infarction (MI), who remained hemodynamically unstable despite coronary revascularization, positive pressure non-invasive ventilation, vasodilator therapy and intra-aortic balloon pump (IABP) support. In heart team discussions, he was considered a high risk surgical candidate. We decided on rescue off-label percutaneous mitral valve repair with a MitraClip device (Abbott Vascular, Santa Clara, California), with good clinical result, allowing weaning from the supports and discharge seven days after the procedure. At one-year follow-up, the patient maintained a MV repair results and had a good functional status. In unstable patients with acute ischemic MR, percutaneous MV repair could be a rescue therapeutic option to consider, allowing hemodynamic compensation with potential persistent MR improvement up to one-year follow-up.

Left atrial volume index and outcome after transcatheter edge-to-edge valve repair for secondary mitral regurgitation.

AIMS: To investigate the role of left atrial volume index (LAVi) in patients with secondary mitral regurgitation (SMR) undergoing transcatheter edge-to-edge mitral valve repair (TEER). METHODS AND RESULTS: Outcomes were evaluated in SMR patients of a European multicentre registry according to baseline LAVi. Main analysis was performed for all-cause mortality; residual mitral regurgitation (MR) and New York Heart Association (NYHA) class improvement were analysed for patients available. A total of 1074 patients were included with a median LAVi (interquartile range) of 58 ml/m2 (46-73). Postprocedural reduction of MR grade to ≤2+ was similar across LAVi quintiles, ranging 91%-96% (p = 0.26). Symptomatic benefit (≥1 NYHA class improvement) also did not differ by LAVi quintiles (61%-68% of patients) (p = 0.66). The risk of mortality increased by 23%-42% in the four upper quintiles compared to the bottom quintile (LAVi <42 ml/m2 ). The hazard ratio (HR) of mortality was 1.35 (95% confidence interval [CI] 1.02-1.78, p = 0.035) associated with a LAVi >42 ml/m2 , which was attenuated after multivariable adjustment (HR 1.18, 95% CI 0.83-1.67, p = 0.36). A significant interaction was found for MR severity and pulmonary hypertension, with an increased risk of death associated with enlarged LAVi in patients with inframedian effective regurgitant orifice area (HR 1.99, 95% CI 1.06-3.74, p = 0.032) and in patients with systolic pulmonary pressure ≤50 mmHg (HR 1.67, 95% CI 1.02-2.75, p = 0.042) in multivariable analysis. CONCLUSION: Procedural success and symptomatic benefit were high throughout the whole range of LAVi. The prognostic impact of left atrial enlargement was relevant in patients with less severe SMR and without pulmonary hypertension, reinforcing the need to identify patients in the early course of backward congestion to achieve good long-term outcome after TEER.

Fighting the pandemic with collaboration at heart: Report from cardiologists in a COVID-19-dedicated Portuguese intensive care unit.

INTRODUCTION AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) spread quickly around the world. Although mainly a respiratory illness, there is growing interest in non-respiratory manifestations, particularly cardiovascular ones. At our center, mobilization of cardiologists with intensive care training was needed. Our aim is to describe patients with severe COVID-19 admitted to a Portuguese intensive care unit (ICU), the cardiovascular impact of the disease and the experience of cardiologists working in a COVID-19 ICU. METHODS: Data from adult patients with COVID-19 admitted to the ICU of Centro Hospitalar de Vila Nova de Gaia/Espinho between 16 March 2020 and 21 April 2020 were analyzed retrospectively. RESULTS: Thirty-five patients were admitted. Mean age was 62.6±6.0 years and 23 (65.7%) were male. Dyslipidemia was the most common cardiovascular risk factor (65.7%, n=23), followed by hypertension (57.1%, n=20). Mean ICU stay time was 15.9±10.0 days. Patients had high rates of mechanical ventilation (88.6%, n=31) and vasopressor support (88.6%, n=31). Low rates of new onset left systolic dysfunction were detected (8.5%, n=2). One patient required venoarterial extra-corporeal membrane oxygenation. Mortality was 25% (n=9). Acute myocardial injury and N-terminal pro-B-type natriuretic peptide (NT-proBNP) elevation was detected in 62.9% (n=22). Patients that died had higher NT-proBNP compared to those discharged alive (p<0.05). Care by cardiologists frequently changed decision making. CONCLUSIONS: The cardiovascular impact of COVID-19 seems relevant but is still widely unknown. Studies are needed to clarify the role of cardiac markers in COVID-19 prognosis. Multidisciplinary care most likely results in improved patient care.

Fighting the pandemic with collaboration at heart: Report from cardiologists in a COVID-19-dedicated Portuguese intensive care unit.

INTRODUCTION AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) spread quickly around the world. Although mainly a respiratory illness, there is growing interest in non-respiratory manifestations, particularly cardiovascular ones. At our center, mobilization of cardiologists with intensive care training was needed. Our aim is to describe patients with severe COVID-19 admitted to a Portuguese intensive care unit (ICU), the cardiovascular impact of the disease and the experience of cardiologists working in a COVID-19 ICU. METHODS: Data from adult patients with COVID-19 admitted to the ICU of Centro Hospitalar de Vila Nova de Gaia/Espinho between 16 March 2020 and 21 April 2020 were analyzed retrospectively. RESULTS: Thirty-five patients were admitted. Mean age was 62.6±6.0 years and 23 (65.7%) were male. Dyslipidemia was the most common cardiovascular risk factor (65.7%, n=23), followed by hypertension (57.1%, n=20). Mean ICU stay time was 15.9±10.0 days. Patients had high rates of mechanical ventilation (88.6%, n=31) and vasopressor support (88.6%, n=31). Low rates of new onset left systolic dysfunction were detected (8.5%, n=2). One patient required venoarterial extra-corporeal membrane oxygenation. Mortality was 25% (n=9). Acute myocardial injury and N-terminal pro-B-type natriuretic peptide (NT-proBNP) elevation was detected in 62.9% (n=22). Patients that died had higher NT-proBNP compared to those discharged alive (p<0.05). Care by cardiologists frequently changed decision making. CONCLUSIONS: The cardiovascular impact of COVID-19 seems relevant but is still widely unknown. Studies are needed to clarify the role of cardiac markers in COVID-19 prognosis. Multidisciplinary care most likely results in improved patient care.

INTRODUÇÃO E OBJETIVOS: A doença pelo novo coronavirus (COVID-19) espalhou-se rapidamente pelo globo. Embora tenha atingimento essencialmente respiratório, existe interesse nas manifestações extrarrespiratórias, nomeadamente nas cardiovasculares. No nosso centro, foi necessária a mobilização de cardiologistas com experiência em cuidados intensivos para enfrentar este desafio. O objetivo desta investigação é descrever a população internada com COVID-19 grave numa UCI portuguesa, o impacto cardiovascular desta doença e a nossa experiência enquanto cardiologistas numa UCI COVID-19. MÉTODOS: Dados de adultos com COVID-19 internados na UCI do Centro Hospitalar de Vila Nova de Gaia/Espinho entre 16/03/2020 e 21/04/2020 foram analisados retrospetivamente. RESULTADOS: Foram internados 35 doentes. A média de idade foi 62,6±6,0 anos e 23 (65,7%) doentes eram homens. A dislipidemia foi o fator de risco cardiovascular mais prevalente (65,7%, n=23), seguida pela hipertensão (57,1%, n=20). O tempo médio de internamento em UCI foi 15,9±10,0 dias. A necessidade de ventilação mecânica (88,6%, n=31) e suporte vasopressor (88,6%, n=31) foi alta, mas poucos doentes desenvolveram disfunção sistólica de novo (n=2,85%). A mortalidade foi de 25% (n=9). Foi detetada lesão miocárdica aguda e elevação do NT-proBNP em 62,9% (n=22) dos doentes, sendo os níveis de NT-proBNP mais elevados nos doentes que faleceram (p<0,05). A participação de cardiologistas na UCI alterou frequentemente a decisão clínica. CONCLUSÃO: O impacto cardiovascular da COVID-19 parece relevante mas é parcamente conhecido, sendo necessários mais estudos para clarificar o papel dos marcadores cardíacos no prognóstico da COVID-19. As equipas multidisciplinares provavelmente melhoram os cuidados de saúde prestados a estes doentes.

Long-term outcomes after radiofrequency catheter ablation of the atrioventricular node: The experience of a Portuguese tertiary center.

INTRODUCTION: In patients with supraventricular arrhythmias and high ventricular rate, unresponsive to rate and rhythm control therapy or catheter ablation, atrioventricular (AV) node ablation may be performed. OBJECTIVES: To assess long-term outcomes after AV node ablation and to analyze predictors of adverse events. METHODS: We performed a detailed retrospective analysis of all patients who underwent AV node ablation between February 1997 and February 2019, in a single Portuguese tertiary center. RESULTS: A total of 123 patients, mean age 69±9 years and 52% male, underwent AV node ablation. Most of them presented atrial fibrillation at baseline (65%). During a median follow-up of 8.5 years (interquartile range 3.8-11.8), patients improved heart failure (HF) functional class (NYHA class III-IV 46% versus 13%, p=0.001), and there were reductions in hospitalizations due to HF (0.98±1.3 versus 0.28±0.8, p=0.001) and emergency department (ED) visits (1.1±1 versus 0.17±0.7, p=0.0001). There were no device-related complications. Despite permanent pacemaker stimulation, left ventricular ejection fraction did not worsen (47±13% vs. 47%±12, p=0.63). Twenty-eight patients died (23%). The number of ED visits due to HF before AV node ablation was an independent predictor of the composite adverse outcome (OR 1.8, 95% CI 1.24-2.61, p=0.002). CONCLUSIONS: Despite pacemaker dependency, the clinical benefit of AV node ablation persisted at long-term follow-up. The number of ED visits due to HF before AV node ablation was an independent predictor of the composite adverse outcome. AV node ablation should probably be considered earlier in the treatment of patients with supraventricular arrhythmias and HF, especially in cases that are unsuitable for selective ablation of the specific arrhythmia.

COAPT-Like Profile Predicts Long-Term Outcomes in Patients With Secondary Mitral Regurgitation Undergoing MitraClip Implantation.

OBJECTIVES: The aim of this study was to evaluate whether fulfilling COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) criteria identifies patients with better outcomes after MitraClip treatment for secondary mitral regurgitation (SMR). BACKGROUND: To date, COAPT is the only trial showing a prognostic benefit of MitraClip implantation compared with conservative management. METHODS: Three hundred four patients with SMR undergoing MitraClip placement in addition to optimal medical therapy at 3 European centers were analyzed. A COAPT-like profile was defined as absence of all the following criteria: severe left ventricular impairment, moderate to severe right ventricular dysfunction, severe tricuspid regurgitation, severe pulmonary hypertension, and hemodynamic instability. Freedom from all-cause death and from a composite endpoint (cardiovascular death and heart failure hospitalization) were evaluated at 2- and 5-year follow-up. RESULTS: A COAPT-like profile was observed in 65% of the population. Compared with non-COAPT-like patients, those fulfilling COAPT criteria had greater survival free from all-cause death and from the composite endpoint at both 2 year (75% vs. 55% and 67% vs. 47%; p < 0.001 for both) and 5-year (49% vs. 25% and 40% vs. 19%; p < 0.001 for both) follow-up. Among the non-COAPT-like patients, similar outcomes were observed in those fulfilling 1 or ≥1 criterion. Left ventricular impairment had a late impact on outcomes, while right ventricular impairment, pulmonary hypertension, and hemodynamic instability had early effects. COAPT-like profile was an independent predictor of long-term outcomes, as well as administration of neurohormonal antagonists, European System for Cardiac Operative Risk Evaluation II score, and previous heart failure hospitalization. CONCLUSIONS: A COAPT-like profile, including specific echocardiographic and clinical criteria, identifies patients with SMR who have a better prognosis after MitraClip implantation.

Short and long-term clinical impact of transcatheter aortic valve implantation in Portugal according to different access routes: Data from the Portuguese National Registry of TAVI.

INTRODUCTION: The Portuguese National Registry of Transcatheter Aortic Valve Implantation records prospectively the characteristics and outcomes of transcatheter aortic valve implantation (TAVI) procedures in Portugal. OBJECTIVES: To assess the 30-day and one-year outcomes of TAVI procedures in Portugal. METHODS: We compared TAVI results according to the principal access used (transfemoral (TF) vs. non-transfemoral (non-TF)). Cumulative survival curves according to access route, other procedural and clinical variables were obtained. The Valve Academic Research Consortium-2 (VARC-2) composite endpoint of early (30-days) safety was assessed. VARC-2 predictors of 30-days and 1-year all-cause mortality were identified. RESULTS: Between January 2007 and December 2018, 2346 consecutive patients underwent TAVI (2242 native, 104 valve-in-valve; mean age 81±7 years, 53.2% female, EuroSCORE-II - EuroS-II, 4.3%). Device success was 90.1% and numerically lower for non-TF (87.0%). Thirty-day all-cause mortality was 4.8%, with the TF route rendering a lower mortality rate (4.3% vs. 10.1%, p=0.001) and higher safety endpoint (86.4% vs. 72.6%, p<0.001). The one-year all-cause mortality rate was 11.4%, and was significantly lower for TF patients (10.5% vs. 19.4%, p<0.002). After multivariate analysis, peripheral artery disease, previous percutaneous coronary intervention, left ventricular dysfunction and NYHA class III-IV were independent predictors of 30-day all-cause mortality. At one-year follow-up, NYHA class III-IV, non-TF route and occurrence of life-threatening bleeding predicted mortality. Kaplan-Meier survival analysis of the first year of follow-up shows decreased survival for patients with an EuroS-II>5% (p<0.001) and who underwent non-TF TAVI (p<0.001). CONCLUSION: Data from our national real-world registry showed that TAVI was safe and effective. The use of a non-transfemoral approach demonstrated safety in the short term. Long-term prognosis was, however, adversely associated with this route, with comorbidities and the baseline clinical status.

Late gadolinium enhancement location assessed by magnetic resonance and arrhythmogenic risk in hypertrophic cardiomyopathy.

INTRODUCTION AND OBJECTIVES: Late gadolinium enhancement (LGE) extent has emerged as a predictor of sudden cardiac death (SCD) in patients with hypertrophic cardiomyopathy (HCM), however little is known about the arrhythmogenic relevance of its specific location in the left ventricle. Our aim was to analyze the influence of LGE location on the occurrence of ventricular arrhythmias (VA) and SCD in patients with HCM. METHODS: We performed a retrospective analysis of clinical and Holter records of HCM patients who underwent cardiac magnetic resonance at our center. LGE extent and distribution were assessed using the American Heart Association 17-segment model. VA was defined as non-sustained or sustained ventricular tachycardia, ventricular fibrillation or SCD. RESULTS: Sixty-one patients (age 57.0±16.7 years) were included and VA occurred in 24.6% (n=15). Patients with VA showed greater LGE extent than those without (7.40±5.3 vs. 3.52±3.0 segments, p=0.007). Analyzing the distribution of LGE, a set of arrhythmogenic segments (apex/basal inferior/basal anterolateral/mid inferoseptal) was found. The extent of LGE involvement in these segments was also greater in patients with VA (2.07±1.03 vs. 0.65±0.71 segments, p<0.001; area under the curve 0.861 for VA) and this difference remained significant after adjustment for potentially confounding variables. CONCLUSIONS: The extent of LGE involvement of a set of segments with an apparent relation to cardiac areas of increased mechanical stress was significantly and independently associated with the occurrence of VA, suggesting that not only the extent but also the location of LGE is important for the assessment of SCD risk in HCM patients.

Present and future economic impact of transcatheter aortic valve replacement on the Portuguese national healthcare system.

INTRODUCTION: Transcatheter aortic valve replacement (TAVR) has changed the treatment paradigm of severe aortic stenosis (AS). Nevertheless, in Portugal the penetration rate of TAVR is still very low and there is a paucity of data regarding its economic impact on the Portuguese healthcare system. AIMS: To perform an economic analysis of the present and future impact of TAVR in Portugal and to propose health policy recommendations for a new reimbursement model. METHODS: Hospital data from a high-volume center were used as a sample to calculate the costs of TAVR in Portugal. Information regarding the national penetration rate was derived from the EAPCI Valve for Life initiative. To estimate the future demand for TAVR, three scenarios (S) were constructed: S1, TAVR penetration according to current guidelines; S2, including intermediate-risk patients; and S3, including low-risk patients aged over 75 years. RESULTS: The total cost of each TAVR procedure in Portugal was 22 134.50 euros for the self-expanding valve (SEV) and 23 321.50 euros for the balloon-expanding valves (BEV). Most of the cost was driven by the price of the valve (SEV 74.5% vs. BEV 81.5%). The current national economic impact is estimated at 12 500 000 euros per year. In S1, the expected penetration rate would be 189 procedures per million population; in S2 we estimated an increase of 28% to 241 procedures per million population and in S3 an increase of 107% to 391 procedures per million population. The total economic impact would increase to 43 770 586 euros in S1 and to 90 754 310 euros in S3. CONCLUSIONS: TAVR is associated with a significant present and future economic impact on the Portuguese healthcare system. A new model of reimbursement in Portugal should be discussed and implemented.