Chronic thromboembolic pulmonary hypertension: A comprehensive review of pathogenesis, diagnosis, and treatment strategies.

Chronic thromboembolic pulmonary hypertension (CTEPH) is part of group 4 of the pulmonary hypertension (PH) classification and generally affects more than a third of patients referred to PH centers. It is a three-compartment disease involving proximal (lobar-to-segmental) and distal (subsegmental) pulmonary arteries that are obstructed by persistent fibrothrombotic material, and precapillary pulmonary arteries that can be affected as in pulmonary arterial hypertension. It is a rare complication of pulmonary embolism (PE), with an incidence of around 3% in PE survivors. The observed incidence of CTEPH in the general population is around six cases per million but could be three times higher than this, as estimated from PE incidence. However, a previous venous thromboembolic episode is not always documented. With advances in multimodality imaging and therapeutic management, survival for CTEPH has improved for both operable and inoperable patients. Advanced imaging with pulmonary angiography helps distinguish proximal from distal obstructive disease. However, right heart catheterization is of utmost importance to establish the diagnosis and hemodynamic severity of PH. The therapeutic strategy relies on a stepwise approach, starting with an operability assessment. Pulmonary endarterectomy (PEA), also known as pulmonary thromboendarterectomy, is the first-line treatment for operable patients. Growing experience and advances in surgical technique have enabled expansion of the distal limits of PEA and significant improvements in perioperative and mid- to long-term mortality. In patients who are inoperable or who have persistent/recurrent PH after PEA, medical therapy and/or balloon pulmonary angioplasty (BPA) are effective treatment options with favorable outcomes that are increasingly used. All treatment decisions should be made with a multidisciplinary team that includes a PEA surgeon, a BPA expert, and a chest radiologist.

Preliminary outcomes of endovascular treatment of moyamoya disease.

PURPOSE: This study aimed to investigate the effectiveness and safety of endovascular revascularisation of intracranial artery occlusion and stenosis in moyamoya disease using stent angioplasty. MATERIALS AND METHODS: We recruited 12 patients (8 women and 4 men) with occlusion and stenosis of intracranial arteries in the context of moyamoya disease who underwent endovascular stent angioplasty. Clinical data, baseline conditions, lesion location, treatment outcomes, periprocedural complications, and follow-up outcomes were analysed. RESULTS: The occlusion was located at the M1 segment of the middle cerebral artery in 8 patients, at both the M1 and A2 segments in one patient, and at the C7 segment of the internal carotid artery in 3. Thirteen stents were deployed at the occlusion site, including the low-profile visualized intraluminal support (LVIS) device in 8 patients, an LVIS device and a Solitaire AB stent in one, and a Leo stent in 3, with a success rate of 100% and no intraprocedural complications. Plain CT imaging after stenting revealed leakage of contrast agent, which disappeared on the second day, resulting in no clinical symptoms or neurological sequelae. Follow-up angiography studies were performed in all patients for 6-12 months (mean, 8.8). Slight asymptomatic in-stent stenosis was observed in 2 patients (16.7%), and no neurological deficits were observed in the other patients. All preoperative ischaemic symptoms completely disappeared at follow-up. CONCLUSION: Stent angioplasty is a safe and effective treatment for occlusion and stenosis of intracranial arteries in moyamoya disease.

Chronic thromboembolic pulmonary hypertension treatment and sex: Systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of pulmonary embolism and a major cause of chronic pulmonary hypertension leading to right heart failure and death. While pulmonary endarterectomy is the treatment of choice, some patients might benefit from medical therapy or balloon pulmonary angioplasty. Sex differences in outcomes of these therapies are not well characterized. MATERIAL AND METHODS: We conducted a systematic review and meta-analysis to investigate sex differences in outcomes of various therapies for CTEPH. We searched MEDLINE, PubMed, Embase, CINAHL and the Cochrane Library databases between January 1, 2010 and April 30, 2021, published in English. We pooled incidence estimates using random-effects meta-analyses. We evaluated heterogeneity using the I2 statistic. We assessed publication bias using Begg's and Egger's tests. This study is registered in PROSPERO, CRD42021268504. RESULTS: A total of 19 studies met the eligibility criteria, but only 3 trials provided separate outcomes for women and men. Two studies evaluated the efficacy of BPA, and one study evaluated the efficacy of riociguat (129 patients). Overall, 57.3% of patients were women and 62.6% were in functional class III. Mean time of follow-up was 55.5 (SD 26.1) weeks. Women showed a significantly better response in cardiac index (mean difference [MD], 0.10L/min/m2; 95% confidence interval [CI], 0.04-0.16; I2=0%; P=0.001). Alternatively, the reduction of pulmonary vascular resistances was significantly higher for men than for women (MD, 161.17dynscm-5; 95% CI, 67.99-254.35; I2=0%; P=0.0007). CONCLUSIONS: Women and men might show different hemodynamic responses to riociguat or BPA for CTEPH.

Documento de posición para la mejora en la reperfusión del infarto agudo de miocardio con elevación del ST en Latinoamérica / Position statement for improvement in reperfusion of ST-elevation myocardial infarction in Latin America

Resumen El tratamiento del infarto agudo de miocardio con elevación del segmento ST tiene barreras dependiendo de la región geográfica. La angioplastia coronaria primaria es el tratamiento de elección, siempre y cuando sea realizada dentro de tiempo y por operadores experimentados. Sin embargo, cuando no está disponible, la administración de fibrinólisis y el envío para angioplastia de rescate, en caso de reperfusión negativa, es la mejor estrategia. De la misma manera, la angioplastia coronaria, como parte de una estrategia farmacoinvasiva, es la mejor alternativa cuando hay reperfusión positiva. El desarrollo de redes de tratamiento del infarto aumenta el número de pacientes reperfundidos dentro de los tiempos recomendados y mejora los desenlaces. En América Latina, los programas nacionales para el tratamiento del infarto deben centrarse en mejorar los resultados y el éxito a largo plazo depende de trabajar hacia objetivos definidos y obtener métricas de rendimiento, por lo tanto, estos deben desarrollar métricas para cuantificar su desempeño. El siguiente documento discute todas estas alternativas y sugiere oportunidades de mejora.

Abstract The treatment of ST-segment elevation myocardial infarction has barriers depending on the geographic region. Primary coronary angioplasty is the treatment of choice, if it is performed on time and by experienced operators. However, when it is not available, the administration of fibrinolysis and referral for rescue angioplasty, in case of negative reperfusion, is the best strategy. In the same way, coronary angioplasty, as part of a pharmacoinvasive strategy, is the best alternative when there is positive reperfusion. The development of infarct treatment networks increases the number of patients reperfused within the recommended times and improves outcomes. In Latin America, national myocardial infarction treatment programs should focus on improving outcomes, and long-term success depends on working toward defined goals and enhancing functionality, therefore programs should develop capacity to measure their performance. The following document discusses all of these alternatives and suggests opportunities for improvement.

Impact of previous percutaneous coronary intervention on angiographic and clinical outcomes in patients with ST-segment elevation myocardial infarction.

BACKGROUND: The prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and previous percutaneous coronary intervention (PCI) is uncertain. OBJECTIVE: To evaluate if previous PCI in patients with STEMI increases the risk of major cardiovascular events, and if final epicardial blood flow differs according to the reperfusion strategy. MATERIAL AND METHODS: Observational, longitudinal, comparative sub-study of the PHASE-MX trial that included patients with STEMI and reperfusion within 12 hours of symptom onset, who were classified according to their history of PCI. The occurrence of the composite primary endpoint (cardiovascular death, re-infarction, congestive heart failure and cardiogenic shock) within 30 days was evaluated using Kaplan-Meier estimates, log-rank test and Cox proportional hazards model. Epicardial blood flow was assessed using the TIMI grading system after reperfusion. RESULTS: A total of 935 patients were included; 85.6% were males and 6.9% had a history of PCI; 53% underwent pharmacoinvasive therapy, and 47%, primary PCI. The incidence of the composite primary endpoint at 30 days in patients with a history of PCI was 9.8% vs 13.3% in those with no previous PCI (p = 0.06). Among the patients with previous PCI, 87.1% reached a final TIMI grade 3 flow after primary PCI vs. 75% in the group with pharmacoinvasive strategy (p = 0.235). CONCLUSIONS: A history of PCI does not increase the risk of major cardiovascular events at 30 days; however, it impacted negatively on the final angiographic blood flow of patients that received pharmacoinvasive therapy (compared to primary PCI).

ANTECEDENTES: El pronóstico de los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) y antecedente de intervención coronaria percutánea (ICP) es incierto. Objetivos: Evaluar si la ICP previa en pacientes con IAMCEST incrementa el riesgo de eventos cardiovasculares mayores y si el flujo final epicárdico varía según la estrategia de reperfusión. MATERIAL Y MÉTODOS: Subestudio de PHASE-MX, observacional, longitudinal y comparativo, de pacientes con IAMCEST reperfundidos en menos de 12 horas de iniciados los síntomas, divididos conforme el antecedente de ICP. El acaecimiento del criterio de valoración principal (muerte cardiovascular, reinfarto, insuficiencia cardíaca y choque cardiogénico) dentro de los 30 días se comparó con estimaciones de Kaplan-Meier, prueba de rangos logarítmicos y modelo de riesgos proporcionales de Cox. El flujo epicárdico final se evaluó con el sistema de clasificación del flujo TIMI después de la reperfusión. RESULTADOS: Se incluyeron 935 pacientes, 85.6 % del sexo masculino, 6.9 % de los cuales tenía antecedente de ICP; 53 % recibió terapia farmacoinvasiva y 47 %, ICP primaria. La incidencia del criterio de valoración principal en pacientes con ICP previa fue de 9.8 % versus 13.3 % en aquellos sin ese antecedente (p = 0.06); 87.1 % de los pacientes con ICP previa obtuvo flujo final de grado TIMI 3 versus 75 % del grupo con estrategia farmacoinvasiva (p = 0.235). CONCLUSIONES: El antecedente de ICP no incrementa el riesgo de eventos cardiovasculares mayores a los 30 días en pacientes con IAMCEST; sin embargo, impacta negativamente en el flujo sanguíneo angiográfico final de los pacientes que recibieron terapia farmacoinvasiva (en comparación con ICP primaria).

Experience from a regional percutaneous coronary intervention center: Aiming to assess and improve quality of care.

INTRODUCTION AND OBJECTIVES: Ischemic heart disease is the single most common cause of death in Europe. Mortality in patients presenting with ST-elevation myocardial infarction (STEMI) is associated with many factors, one of which is the time delay to treatment. The purpose of this work is to analyze the coronary pathway in our region in terms of timing, taking into consideration the place of first medical contact (FMC). METHODS: Consecutive patients admitted to our center with STEMI to undergo percutaneous coronary intervention (PCI) between 2013 and 2022 were analyzed. Age, gender, and time delays were collected. Analysis was performed with IBM SPSS version 28 for a significance level of 0.05. RESULTS: We found that non-PCI centers had a significantly greater FMC to diagnosis delay and diagnosis to wire delay compared to other places of origin. Only 2.2% of patients met the 10-min FMC to diagnosis target; 44.8% met the target of 90 min from diagnosis to wire in transferred patients, while 40.6% met the 60-min target for patients admitted to a PCI center. Median patient, electrocardiogram (ECG) and logistic delays are 92.0±146.0 min, 19.0±146.0 min and 15.5±46.3 min, respectively. CONCLUSION: A significant difference between state-of-the-art targets and reality was found, depending on the place of FMC, with the worst delays in non-PCI centers. Patient delay, ECG delay, FMC to diagnosis and logistic delay are identified as key areas in which to intervene.

Implicancias de la inteligencia artificial en los métodos de imagen endovascular / Implications of Artificial Intelligence in Intravascular Imaging Methods

RESUMEN La angioplastia transluminal coronaria (ATC) es una de las principales estrategias de revascularización en pacientes con enfermedad coronaria aterosclerótica (ECA). Numerosos estudios respaldan la optimización de la ATC mediante métodos de imagen endovascular; sin embargo, estos métodos son subutilizados en la práctica clínica contemporánea y enfrentan desafíos en la interpretación de los datos obtenidos, por lo que la integración de la inteligencia artificial (IA) se vislumbra como una solución atractiva para promover y simplificar su uso. La IA se define como un programa computarizado que imita la capacidad del cerebro humano para recopilar y procesar datos. El aprendizaje de máquinas es una subdisciplina de la IA que implica la creación de algoritmos capaces de analizar grandes conjuntos de datos sin suposiciones previas, mientras que el aprendizaje profundo se centra en la construcción y entrenamiento de redes neuronales artificiales profundas y complejas. Así, se ha demostrado que la incorporación de sistemas de IA a los métodos de imagen endovascular incrementa la precisión de la ATC, disminuye el tiempo del procedimiento y la variabilidad interobservador en la interpretación de los datos obtenidos, promueve así una mayor adopción y facilita su utilización. El propósito de la presente revisión es destacar cómo los sistemas actuales basados en IA pueden desempeñar un papel fundamental en la interpretación de los datos generados por los métodos de imagen endovascular, lo que conduce a una mejora en la optimización de la ATC en pacientes con ECA.

ABSTRACT Percutaneous coronary intervention (PCI) is one of the primary revascularization strategies in patients with coronary artery disease (CAD). Several studies support the use of intravascular imaging methods to optimize PCI. However, these methods are underutilized in contemporary clinical practice and face challenges in data interpretation. Therefore, the incorporation of artificial intelligence (AI) is seen as an attractive solution to promote and simplify their use. AI can be defined as a computer program that mimics the human brain in its ability to collect and process data. Machine learning is a sub-discipline of AI that involves the creation of algorithms capable of analyzing large datasets without making prior assumptions, while deep learning focuses on the construction and training of deep and complex artificial neural networks. The incorporation of AI systems to intravascular imaging methods improves the accuracy of PCI, reduces procedure duration, and minimizes interobserver variability in data interpretation. This promotes their wider adoption and facilitates their use. The aim of this review is to highlight how current AI-based systems can play a key role in the interpretation of data generated by intravascular imaging methods and optimize PCI in patients with CAD.

Influencia del antecedente de intervención coronaria percutánea sobre los desenlaces angiográficos y clínicos en pacientes con infarto agudo de miocardio con elevación del segmento ST / Impact of previous percutaneous coronary intervention on angiographic and clinical outcomes in patients with ST-segment elevation myocardial infarction

Resumen Antecedentes: El pronóstico de los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) y antecedente de intervención coronaria percutánea (ICP) es incierto. Objetivos: Evaluar si la ICP previa en pacientes con IAMCEST incrementa el riesgo de eventos cardiovasculares mayores y si el flujo final epicárdico varía según la estrategia de reperfusión. Material y métodos: Subestudio de PHASE-MX, observacional, longitudinal y comparativo, de pacientes con IAMCEST reperfundidos en menos de 12 horas de iniciados los síntomas, divididos conforme el antecedente de ICP. El acaecimiento del criterio de valoración principal (muerte cardiovascular, reinfarto, insuficiencia cardíaca y choque cardiogénico) dentro de los 30 días se comparó con estimaciones de Kaplan-Meier, prueba de rangos logarítmicos y modelo de riesgos proporcionales de Cox. El flujo epicárdico final se evaluó con el sistema de clasificación del flujo TIMI después de la reperfusión. Resultados: Se incluyeron 935 pacientes, 85.6 % del sexo masculino, 6.9 % de los cuales tenía antecedente de ICP; 53 % recibió terapia farmacoinvasiva y 47 %, ICP primaria. La incidencia del criterio de valoración principal en pacientes con ICP previa fue de 9.8 % versus 13.3 % en aquellos sin ese antecedente (p = 0.06); 87.1 % de los pacientes con ICP previa obtuvo flujo final de grado TIMI 3 versus 75 % del grupo con estrategia farmacoinvasiva (p = 0.235). Conclusiones: El antecedente de ICP no incrementa el riesgo de eventos cardiovasculares mayores a los 30 días en pacientes con IAMCEST; sin embargo, impacta negativamente en el flujo sanguíneo angiográfico final de los pacientes que recibieron terapia farmacoinvasiva (en comparación con ICP primaria).

Abstract Background: The prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and previous percutaneous coronary intervention (PCI) is uncertain. Objectives: To evaluate if previous PCI in patients with STEMI increases the risk of major cardiovascular events, and if final epicardial blood flow differs according to the reperfusion strategy. Material and methods: Observational, longitudinal, comparative sub-study of the PHASE-MX trial that included patients with STEMI and reperfusion within 12 hours of symptom onset, who were divided according to their history of PCI. The occurrence of the composite primary endpoint (cardiovascular death, re-infarction, congestive heart failure and cardiogenic shock) within 30 days was evaluated using Kaplan-Meier estimates, log-rank test and Cox proportional hazards model. Final epicardial blood flow was assessed using the TIMI grading system after reperfusion. Results: A total of 935 patients were included; 85.6% were males, and 6.9% had a history of PCI; 53% underwent pharmacoinvasive therapy, and 47%, primary PCI. The incidence of the composite primary endpoint at 30 days in patients with a history of PCI was 9.8% vs. 13.3% in those with no previous PCI (p = 0.06). Among the patients with previous PCI, 87.1% reached a final TIMI grade 3 flow after primary PCI vs. 75% in the group with pharmacoinvasive strategy (p = 0.235). Conclusions: A history of PCI does not increase the risk of major cardiovascular events at 30 days; however, it impacted negatively on the final angiographic blood flow of patients that received pharmacoinvasive therapy (compared to primary PCI).

[Update in the management of chronic thrombo-embolic pulmonary hypertension]. / Actualización del abordaje de la hipertensión pulmonar tromboembólica crónica.

Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.

Desfechos de curto prazo da cirurgia de carótida: experiência no "mundo real" em um centro único de formação profissional / Short term outcomes of carotid surgery: the real-world experience of a single teaching center

Resumo Contexto A abordagem cirúrgica para estenose carotídea sintomática está consolidada na literatura para a prevenção de eventos neurológicos, devendo seguir padrões ótimos de qualidade. Entretanto, há uma crescente preocupação relacionada à possibilidade ou não de replicar os dados dos trabalhos controlados no mundo real. Objetivos Avaliar a população com estenose carotídea sintomática submetida a cirurgia e seus desfechos de curto prazo em um contexto de mundo real em um centro de formação profissional. Métodos Tratou-se de um estudo observacional realizado por meio de coleta de dados em prontuário de janeiro de 2012 a janeiro de 2023. Foram excluídos pacientes operados por outras etiologias e com cirurgia cardíaca concomitante. Resultados Foram incluídos 70 pacientes submetidos a angioplastia ou endarterectomia carotídea. Os subgrupos populacionais submetidos a angioplastia ou endarterectomia foram semelhantes. Houve diferença estatisticamente relevante quanto à modalidade anestésica e ao tempo cirúrgico maior para o subgrupo de endarterectomia carotídea. Houve quatro casos de acidente vascular encefálico isquêmico, e três deles estavam relacionados à lesão, sendo dois menores e um maior. Dessa forma, a taxa de acidente vascular encefálico maior relacionado à lesão foi de 1,43% e de qualquer acidente vascular encefálico relacionado à lesão, de 4,29%. A taxa total de eventos adversos cardiovasculares maiores foi de 5,71%. Houve um caso de infarto agudo do miocárdio no grupo angioplastia e nenhum óbito. Não houve diferença estatística entre os grupos de endarterectomia e angioplastia quanto aos desfechos principais. Conclusões Os desfechos acidente vascular encefálico isquêmico, infarto agudo do miocárdio, óbito e eventos adversos cardiovasculares maiores neste centro são semelhantes aos encontrados em estudos clínicos randomizados, demonstrando viabilidade da manutenção deste tratamento em centros com programas de ensino.

Abstract Background Surgical treatment of symptomatic extracranial carotid stenosis is well established for preventing neurological events and should adhere to optimal quality standards. However, there is growing concern as to whether results of controlled trials are replicable in real-world settings. Objectives To assess a symptomatic carotid stenosis population that underwent surgery and its short-term outcomes in a real-world context at a professional training center. Methods Observational study using data collected from medical records from January 2012 to January 2023. Patients undergoing operations for other carotid diseases and with concomitant heart surgery were excluded. Results A total of 70 patients undergoing angioplasty or carotid endarterectomy were included. Population subsets undergoing angioplasty or endarterectomy were similar. Differences in anesthetic modality and a longer operative time in the carotid endarterectomy subgroup were statistically significant. There were 4 cases of stroke, only 3 of which (2 minor and 1 major) were related to the index lesion. Thus, the rate of major operation-related stroke was 1.43% and the rate of any lesion-related stroke was 4.29%. There was 1 case of AMI in the angioplasty group and there were no deaths in the sample. The overall rate of major adverse cardiovascular events was 5.71%. There were no statistical differences between the endarterectomy and angioplasty groups regarding the main outcomes. Conclusions The rates of outcomes of ischemic stroke, acute myocardial infarction, death, and major adverse cardiovascular events at this center are in line with the rates reported by randomized controlled trials, demonstrating the feasibility of carotid surgery in centers with teaching programs.

Calidad de atención en el manejo de enfermedad cerebrovascular isquémica aguda posterior a la iniciativa angels / Acute ischemic cerebrovascular disease management quality of care following the adoption of the angels initiative

Introducción: el ataque cerebrovascular (ACV) es común a nivel mundial, una de cada cuatro personas puede presentarlo a lo largo de la vida. Constituye la segunda causa de muerte y la tercera principal de discapacidad. Es importante la atención integral para lograr un impacto en la calidad de vida. Objetivo: determinar la calidad de atención en el manejo del ACV isquémico agudo de los pacientes que consultaron al servicio de neurología en los Hospitales de San José e Infantil Universitario de San José, Bogotá DC, entre enero 1/2019 y enero 1/2020. Metodología: estudio descriptivo de corte transversal. El criterio de inclusión fue pacientes mayores de 18 años con diagnóstico de ACV isquémico. La información se recolectó de las historias clínicas, se empleó estadística descriptiva para analizar los datos. Resultados: se incluyeron 411 pacientes, 88,8% sin alteración del estado de conciencia, 26,4% ingresaron antes de las 4,5 horas de ventana para trombólisis, se realizaron procedimientos de recanalización endovenosa a 11,4%. El tiempo puerta aguja tuvo una mediana de 37,2 minutos comparado con la mediana nacional de tiempo que fue 56,5 min según lo registrado en la plataforma ResQ. El 72% recibió terapia antiagregante y estatina 88.8%. Discusión y conclusiones: al identificar los síntomas es importante ser estrictos en el tiempo de atención y la implementación de plataformas para óptimos planes de atención. Se requieren campañas masivas de educación, así como que planes de mejora institucionales.

Introduction: cerebrovascular attack (CVA) is common worldwide. One in four people may have a stroke during their lifetime. It is the second leading cause of death and the third leading cause of disability. Thus, it is important to provide integrated care to achieve an impact on quality of life. Objective: to determine ischemic CVA management quality of care among patients seen at the neurology service of the San José and Infantil Universitario de San José hospitals in Bogotá DC, between January 1/2019 and January 1/2020. Methodology: a descriptive, cross-sectional study. The inclusion criteria included patients over 18 years of age diagnosed with ischemic CVA. Information was collected from clinical records. Data was analyzed using descriptive statistics. Results: 411 patients were included; 88.8% had an altered state of consciousness, 26.4% were admitted within the 4.5-hour window for thrombolysis; 11.4% underwent intravenous reperfusion procedures. Door-to-needle time: median was 37.2 minutes versus the national media of 56.5 min according to the ResQ records platform; 72% received anti-platelet therapy and 88.8% received statins. Discussion and conclusions: the establishment of a strict time to care and the implementation of platforms to improve care plans, is essential. Massive education campaigns are required, as well as, institutional improvement plans.

Sirolimus-coated balloon in acute and chronic coronary syndromes: subanalysis of the EASTBOURNE registry.

INTRODUCTION AND OBJECTIVES: The PEACE study (Performance of a sirolimus-eluting balloon strategy in acute and chronic coronary syndromes) investigated for the first time whether a sirolimus-coated balloon (SCB) (Magic Touch, Concept Medical, India) is associated with different outcomes depending on whether it is used in acute coronary syndromes (ACS) or chronic coronary syndromes (CCS). METHODS: This was a post-hoc analysis from the all-comers EASTBOURNE Registry (NCT03085823). Out of 2083 patients enrolled, an SCB was used to treat 968 (46.5%) ACS and 1115 (53.5%) CCS patients. The primary endpoint was target lesion revascularization at 12 months, while secondary endpoints were angiographic success and major adverse cardiovascular events. RESULTS: Baseline demographics, mean reference vessel diameter and mean lesion length were comparable between ACS and CCS. Predilatation was more commonly performed in ACS (P=.007). SCB was inflated at a standard pressure in both groups with a slight trend toward longer inflation time in ACS. Angiographic success was high in both groups (ACS 97.4% vs CCS 97.7%, P=.820) with limited bailout stenting. Similarly, at 12 months the cumulative incidence of target lesion revascularization (ACS 6.6% vs CCS 5.2%, P=.258) was comparable between ACS and CCS. Conversely, a higher rate of major adverse cardiovascular events in acute presenters was mainly driven by myocardial infarction recurrencies (ACS 10.4% vs CCS 8.3%, P=.009). In-stent restenosis showed a higher proportion of target lesion revascularization and major adverse cardiovascular events than de novo lesions, independently of the type of presentation at the index procedure. CONCLUSIONS: This SCB shows good performance in terms of acute and 1-year outcomes independently of the clinical presentation.

Alta temprana en infarto agudo de miocardio con elevación del segmento ST tratado con angioplastia primaria: estudio de intervención no controlado en Argentina / Early Discharge in Acute ST-segment Elevation Myocardial Infarction Treated with Primary Angioplasty: Uncontrolled Intervention Study in Argentina

RESUMEN Introducción y objetivos: El alta hospitalaria temprana (dentro de las primeras 48 horas) en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) tratados con angioplastia coronaria primaria con stent (ATCp) ha sido adoptada en países desarrollados. Sin embargo, su implementación en Sudamérica ha sido dispar. Material y métodos: Estudio piloto de intervención no controlado, argentino, de pacientes con IAMCEST de bajo riesgo tratados con ATCp, para evaluar tasa de alta temprana y comparar la incidencia de eventos cardiovasculares adversos mayores (MACE) con la que ocurre en pacientes externados en forma no temprana. Resultados: Desde 2013 hasta 2021 se trataron con ATCp 320 pacientes con IAMCEST, de los que 158 fueron de bajo riesgo. Alta temprana en 63,9% (IC 95% 55,9-71,4%). La diabetes (OR 0,31; IC 95% 0,12-0,83) y el IAMCEST anterior (OR 0,34; IC 95% 0,16-0,69) se asociaron en forma independiente con menor probabilidad de alta temprana. Durante una mediana de seguimiento de 27,2 meses, la razón de tasas de incidencia de MACE entre los grupos de alta temprana y no temprana fue de 0,77 (IC 95 % 0,25-2,58; p = 0,61). Las variables asociadas de forma independiente con MACE fueron la revascularización completa (HR 0,18; IC 95% 0,03-0,95) y el tiempo de fluoroscopía (HR 1,02; IC 95% 1,01-1,05). No hubo diferencias significativas en las complicaciones del acceso vascular, las tasas de reingreso a 30 días y sobrevida global entre los grupos. Conclusiones: El alta temprana en pacientes con IAMCEST de bajo riesgo tratados con ATCp puede ser factible incluso en países en desarrollo, sin aumento significativo de la morbimortalidad.

ABSTRACT Background and objectives: Early discharge (within the first 48 hours) in patients with ST-segment elevation myocardial infarction (STEMI) managed with primary percutaneous coronary intervention (PCI) with stenting is a strategy that has been adopted in developed countries. However, its implementation in South America has been uneven. Methods: We conducted an uncontrolled intervention pilot study on low-risk STEMI patients managed with primary PCI to evaluate the early discharge rate and compare the incidence of major adverse cardiovascular events (MACE) with those occurring in patients discharged later. Results: Of 320 STEMI patients managed with primary PCI from 2013 to 2021, 158 were low-risk patients and 63.9% (95% CI 55.9-71,4%) of them were discharged early. Diabetes (OR 0.31, 95% CI 0.12-0.83), and anterior wall STEMI (OR 0.34, 95% CI 0.16-0.69) were independently associated with lower probability of early discharge. During a median follow-up period of 27.2 months, the incidence rate ratio of MACE between the early discharge and non-early discharge groups was 0.77 (95% CI 0.25-2.58; p = 0.61). The variables independently associated with MACE were complete revascularization (HR 0.18, 95% CI 0.03-0.95) and fluoroscopy time (HR 1.02, 95% CI 1.01-1.05). There were no significant differences in vascular access complications, 30-day readmission rate and overall survival between groups. Conclusions: Early discharge in low-risk STEMI patients managed with primary PCI may be feasible even in developing countries, without significantly increasing morbidity and mortality.

Herramientas para la toma de decisiones en pacientes con enfermedad de múltiples vasos / Tools for Decision Making in Patients with Multivessel Disease

RESUMEN La decisión sobre la mejor estrategia de revascularización para los pacientes con enfermedad de múltiples vasos se ha tornado una tarea compleja a medida que la angioplastia coronaria ha mejorado sus resultados. En la siguiente revisión nos propusimos evaluar las variables que en nuestra experiencia definen el beneficio de una técnica sobre la otra, entendiendo que de esta manera la decisión del médico tratante se hace más sencilla y objetiva. Por otro lado, y festejando el saludable protagonismo que se le da al paciente, creemos que esta evaluación permite ofrecer argumentos sólidos para ayudarlo en la toma de la decisión.

ABSTRACT The decision on the best revascularization strategy for patients with multivessel disease has become a complex task as coronary angioplasty has improved its results. In the following review, we set out to evaluate the variables that, in our experience, define the benefit of one technique over the other, understanding that in this way the treating physician's decision will become simpler and more objective. On the other hand, and celebrating the healthy prominence given to patients, we believe that this evaluation allows solid arguments to help them in decision making.

Infarto de miocardio en Argentina. Tercer reporte del registro ARGEN-IAM-ST y comportamiento de la mortalidad en 8 años / Acute Myocardial Infarction in Argentina. Third ARGEN-IAM-ST Registry Report and 8-Year Mortality Behavior

RESUMEN Introducción. Se presenta el tercer reporte general del registro continuo de infarto ARGEN- IAM-ST. Objetivos. Evaluar los principales marcadores de atención y las complicaciones del infarto agudo de miocardio (IAM) con elevación del segmento ST en el registro continuo de infarto ARGEN-IAM-ST. Conocer la evolución de la terapia de reperfusión y la mortalidad en los últimos 8 años. Material y métodos. Estudio prospectivo multicéntrico, con alcance nacional. Se incluyeron pacientes con IAM con elevación del segmento ST de hasta 36 horas de evolución. Resultados. Se incluyeron 6765 pacientes, con una edad media de 61 ± 12 años, 65 % de género masculino. Se observó una importante carga de factores de riesgo cardiovascular: hipertensión arterial 58 %, diabetes 23 %, dislipidemia 42 %, tabaquismo activo 37 % y antecedentes familiares de enfermedad cardiovascular 17 %. El 13,5 % presentó antecedente de enfermedad coronaria; al ingreso un 49 % presentó IAM de cara anterior y el 23 % falla cardíaca. La mediana de tiempo de dolor a la consulta fue de 120 minutos (rango intercuartílico, RIC, 60-285), el tiempo puerta-aguja fue de 50 minutos (RIC 25-110) y el tiempo puerta balón fue de 100 minutos (RIC 58-190). La mortalidad general intrahospitalaria fue del 8,8 %. Se realizó un análisis exploratorio y descriptivo para observar la variación de la reperfusión y mortalidad durante 8 años donde no se muestran cambios acentuados en la mortalidad a pesar de las altas tasas de reperfusión. Conclusión. En los últimos 8 años la mortalidad registrada en el registro ARGEN IAM-ST se ha mantenido en valores elevados a pesar de las altas tasas de reporte de reperfusión.

ABSTRACT Background. The continuous Argentine ST-segment Elevation Acute Myocardial Infarction (ARGEN-IAM-ST) registry presents its third general report. Objectives. The aim of this study was to evaluate the main ST-segment elevation myocardial infarction (STEMI) markers of care and its complications in the continuous ARGEN-IAM-ST registry, and assess the outcome of reperfusion therapy and mortality in the last 8 years. Methods. This was a national, prospective, multicenter study, including STEMI patients with up to 36-hour evolution. Results. A total of 6765 patients, mean age 61±12 years, 65 % male , were included in the study. A significant burden of cardiovascular risk factors was observed: 58 % of patients had hypertension, 23 % diabetes, 42 % dyslipidemia, 37 % were active smokers, and 17 % had a family history of cardiovascular disease. In 13.5 % of cases, patients had prior history of coronary heart disease. On admission, 49 % presented with anterior AMI and 23 % with heart failure. Median (interquartile range, IQR) pain-consultation time was 120 minutes (IQR 60-285), door-to-needle time 50 minutes (IQR 25-110) and door-to-balloon time 100 minutes (IQR 58-190) Overall in-hospital mortality was 8.8 %. An exploratory and descriptive analysis was performed to assess the variation in reperfusion and mortality over 8 years, showing no marked changes in mortality despite high reperfusion rates. Conclusion. In the last 8 years, the mortality recorded in the ARGEN-IAM-ST registry has remained at high values despite the high reperfusion rates reported.

Spanish cardiac catheterization and coronary intervention registry. 32nd official report of the Interventional Cardiology Association of the Spanish Society of Cardiology (1990-2022).

INTRODUCTION AND OBJECTIVES: This article presents the annual activity report of the Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) for the year 2022. METHODS: All Spanish centers with catheterization laboratories were invited to participate. Data were collected online and were analyzed by an external company in collaboration with the members of the board of the ACI-SEC. RESULTS: A total of 111 centers participated. The number of diagnostic studies increased by 4.8% compared with 2021, while that of percutaneous coronary interventions (PCI) remained stable. PCIs on the left main coronary artery increased by 22%. The radial approach continued to be preferred for PCI (94.9%). There was an upsurge in the use of drug-eluting balloons, as well as in intracoronary imaging techniques, which were used in 14.7% of PCIs. The use of pressure wires also increased (6.3% vs 2021) as did plaque modification techniques. Primary PCI continued to grow and was the most frequent treatment (97%) in ST-segment elevation myocardial infarction. Most noncoronary procedures maintained their upward trend, particularly percutaneous aortic valve implantation, atrial appendage closure, mitral/tricuspid edge-to-edge therapy, renal denervation, and percutaneous treatment of pulmonary arterial disease. CONCLUSIONS: The Spanish cardiac catheterization and coronary intervention registry for 2022 reveals a rise in the complexity of coronary disease, along with a notable growth in procedures for valvular and nonvalvular structural heart disease.

Utilización de la estrategia farmacoinvasiva en Argentina. Análisis del registro ARGEN-IAM ST / Use of the Pharmacoinvasive Strategy in Argentina. ARGEN-IAM ST Registry Analysis

RESUMEN Introducción : La angioplastia primaria (ATCp) es el tratamiento de elección para el infarto agudo de miocardio con elevación del segmento ST (IAMCEST). En nuestro país, de tanta extensión territorial y con tiempos a la reperfusión subóptimos, la estrategia farmacoinvasiva (Finv) podría considerarse. Material y métodos : El ARGEN-IAM-ST es un registro prospectivo, multicéntrico, nacional y observacional. Se incluyen pacien tes con IAMCEST dentro de las 36 horas de evolución. Se definió en el mismo la utilización de Finv y las variables asociadas. Resultados : Se analizaron 4788 pacientes de los cuales en el 88,56 % se realizó ATCp, en el 8,46 % trombolíticos con reperfusión positiva (TL+), y solo en un 2,98% Finv. La mediana y rango intercuartílico (RIC) del tiempo total de isquemia fueron menores en aquellos que recibieron TL+ (165 min, RIC 100-269) y los que fueron a Finv (191 min, RIC 100-330) que en aquellos que fueron a ATCp (280 min, RIC 179- 520), p <0,001. No existieron diferencias en mortalidad intrahospitalaria, en el grupo Finv 4,9%, 5,2% en el grupo TL + y en el grupo ATCp 7,8% (p = 0,081). No hubo diferencias en término de sangrados mayores. Se observó que un 57% de los pacientes con TL+ reunían características de alto riesgo, y no recibieron Finv acorde a lo recomendado Conclusiones : Solo 3 de cada 100 pacientes con IAMCEST que se reperfunden reciben Finv. Su implementación no está ligada en forma sistemática al alto riesgo de eventos. Pese a esta subutilización, por presentar un menor tiempo total de isquemia que la ATCp, sin aumento en los sangrados clínicamente relevantes persiste como una opción a considerar en nuestra realidad.

ABSTRACT Background : Primary percutaneous coronary intervention (PPCI) is the treatment of choice for acute ST-elevation myocardial infarction (STEMI). In Argentina, a country with a large area and suboptimal reperfusion times, the pharmacoinvasive (PI) strategy might be considered. Methods : ARGEN-IAM-ST is a national prospective, multicenter, and observational registry that includes STEMI patients with less than 36 hours of progression. The PI strategy usage and its associated variables were defined. Results : In this registry, 4788 patients were analyzed, of which 88.56% underwent PPCI, 8.46% received thrombolytics with positive reperfusion (TL+), and only 2.98% received PI strategy. Median and interquartile range (IQR) of total ischemia time were lower in patients receiving TL+ (165 min, IQR 100-269) and PI (191 min, IQR 100-330) than in patients undergoing PPCI (280 min, IQR 179-520), p <0.001. No differences in intra-hospital mortality were observed: 4.9% in the PI strategy group, 5.2% in the TL+ group and 7.8% in the PPCI group (p = 0.081). No differences in major bleeding events were observed. It was observed that 57% of the TL+ patients met the criteria for high cardiovascular risk, but they did not receive PI strategy, as recommended. Conclusions : Only 3 out of 100 reperfused STEMI patients received PI strategy. Its administration is not systematically associated to high cardiovascular risk. Despite the under-usage, it remains an option to be considered due to its total ischemia time lower than in the PPCI, with no increase in clinically significant bleedings.

Optimización del tiempo puerta-balón mediante la implementación de un programa de mejora de procesos. Resultados a 5 años de funcionamiento / Optimization of Door-to-Balloon Time Implementing a Process Improvement Program. Results after 5 Years

RESUMEN Introducción : de estar disponible, la angioplastia primaria (ATCp), en tiempos adecuados y en centros con experiencia, es la mejor estrategia de reperfusión para el infarto agudo de miocardio con supradesnivel del segmento ST (IAMCEST). El tiempo puerta-balón (TPB) es una expresión de eficiencia operativa de la institución que realiza la ATCp, con impacto en la evolución del paciente. El objetivo de este trabajo fue analizar los resultados a largo plazo de un programa de mejora continua del proceso TPB. Material y métodos : se incluyeron en forma prospectiva y consecutiva pacientes con diagnóstico de IAMCEST sometidos a ATCp desde enero de 2015 a mayo de 2022. La población se dividió en dos períodos: período de implementación inmediata y período de seguimiento a largo plazo. Resultados : se ingresaron 671 pacientes en forma prospectiva y consecutiva. En el primer período, de implementación, (P1), se incluyeron 91 pacientes, y en el segundo período, de seguimiento del programa, (P2), 580 pacientes. La mediana (rango intercuartilo, RIC) de TPB fue de 46 min (29-59) en P1 vs 42 min(25-52) en el P2, p = 0,055. En el segundo período se evi denció una reducción de las preactivaciones (P1 54,1% vs P2 30%,p = 0,02) y los procedimientos on hours (42% en p1 vs 30% en P2, p = 0,029). Conclusión : el registro mostró el mantenimiento de los buenos resultados a largo plazo a pesar de una reducción de las preactivaciones y los procedimientos on hours.

ABSTRACT Background : If available, primary transluminal coronary angioplasty (PTCA), performed timely and in experienced sites, is the best reperfusion strategy for ST elevation myocardial infarction (STEMI). The door-to-balloon (DTB) time expresses operational efficiency of the site in charge of the PTCA, with an impact on patient's progress. The aim of this study was to analyze the long-term results of a continuous improvement program for the DTB time process. Methods : Patients diagnosed with STEMI who had undergone PTCA from January 2015 to May 2022 were prospectively and consecutively enrolled. The population was divided in two periods: an immediate implementation period and a long-term follow-up period. Results : 671 patients were prospectively and consecutively enrolled. During the implementation period (P1) 91 patients were enrolled, and 580 during the program follow-up (P2). The median (interquartile range, IQR) DTB time was 46 min (29-59) for P1 vs 42 min(25-52) for P2, p=0.055). The second period showed a reduction in pre-activations (P1 54,1% vs P2 30% p=0.02) and on-hour procedures (42% for P1 versus 30% for P2, p=0.029). Conclusion : The registry showed long-term maintenance of good results, despite reduced reactivations and on-hour procedures.

Outcome of moderate-severe tricuspid regurgitation after pulmonary endarterectomy or balloon pulmonary angioplasty.

INTRODUCTION AND OBJECTIVES: The management of persistent moderate-severe tricuspid regurgitation (TR) in patients with chronic thromboembolic pulmonary hypertension after treatment with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) is not well defined. This study aimed to analyze the progression and predictors of significant persistent postintervention TR and its prognostic impact. METHODS: This single-center observational study included 72 patients undergoing PEA and 20 who completed a BPA program with a previous diagnosis of chronic thromboembolic pulmonary hypertension and moderate-to-severe TR. RESULTS: The postintervention prevalence of moderate-to-severe TR was 29%, with no difference between the PEA- or BPA-treated groups (30.6% vs 25% P=.78). Compared with patients with absent-mild postprocedure TR, those with persistent TR had higher mean pulmonary arterial pressure (40.2±1.9 vs 28.5±1.3mmHg P <.001), pulmonary vascular resistance (472 [347-710] vs 282 [196-408] dyn.s/cm5; P <.001), and right atrial area (23.0 [21-31] vs 16.0 [14.0-20.0] P <.001). The variables independently associated with persistent TR were pulmonary vascular resistance> 400 dyn.s/cm5 and postprocedure right atrial area> 22cm2. No preintervention predictors were identified. The variables associated with increased 3-year mortality were residual TR and mean pulmonary arterial pressure> 30mmHg. CONCLUSIONS: Residual moderate-to-severe TR following PEA-PBA was associated with persistently high afterload and unfavorable postintervention right chamber remodeling. Moderate-to-severe TR and residual pulmonary hypertension were associated with a worse 3-year prognosis.