Left ventricular endocardial pacing in the real world: Five years of experience at a single center.

BACKGROUND: A left ventricular (LV) endocardial lead implant to achieve cardiac resynchronization therapy (CRT) is feasible when a conventional implant failed due to anatomical or technical issues or when the venous implant was performed but the patient did not respond to the therapy. METHODS: Data about the implantation procedure (age, sex, clinical characteristics, anticoagulant use, and previous devices), patient characteristics (indication, technique used, lead model, complications), and follow-up (clinical and echocardiographic outcome, LV lead electrical measurements) were analyzed for all CRT systems implanted using LV endocardial lead, due to failed conventional implant or nonresponse, between April 2011 and November 2016. RESULTS: Thirty-five patients were implanted with an active fixation LV endocardial lead during the study period, without significant complications. There were no dislodgements or severe complications related to the implant procedure in the follow-up period (36 ± 20 months) and a high percentage of patients responded to therapy, as assessed by several indicators. CONCLUSIONS: An LV endocardial lead implant was feasible when the conventional technique had previously failed or was not effective. A high rate of response was achieved without any significant complications.

Transfemoral access when superior venous approach is not feasible equals overall success of permanent pacemaker implantation. Ten-year series.

BACKGROUND: When permanent pacemaker implantation is not possible or advisable via superior venous access (i.e., axillary or subclavian veins), safe and feasible surgical alternatives are required. The femoral approach is relatively unknown and seldom studied. This single-center study analyzed 10-year outcomes of a femoral implantation approach. METHODS: Data about the implantation procedure (indication, approach, lead and pacemaker models, complications), patient characteristics (age, sex, medications, comorbidities), and follow-up were analyzed for all permanent pacemaker implantations using the femoral approach between June 2001 and June 2011. RESULTS: A permanent pacemaker was implanted with the femoral approach in 50 patients (mean age, 76 years [range: 45-96], 31 [61%] men). The most frequent indication was atrioventricular block, associated with sinus rhythm in 30 patients and with atrial fibrillation in eight patients. Overall, 20 patients (40%) were treated with oral anticoagulants postimplantation. Mean implantation time was 64 minutes (range: 20-210) and mean fluoroscopy time was 6.7 minutes (range: 0.2-50). Minimum follow-up window was 1 year (June 2012), with a mean of 50 months [range: 1-113]). No deaths, septic episodes, or severe complications were associated with the procedure, acute or long-term. Follow-up data were available for 46 patients, of who 21 (46%) died during follow-up (mean age, 87 years [range: 73-101]). No cause of death was associated with the femoral technique. CONCLUSION: Permanent pacemaker implantation through femoral access is not difficult for an experienced implant surgeon. Outcomes were comparable to systems implanted by superior venous approach, and no severe complications were observed at 10-year follow-up.

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.

[Ankle-brachial index in patients with chest pain and suspected acute coronary syndrome]. / Determinación del índice tobillo-brazo en pacientes con dolor torácico agudo de posible origen coronario.

BACKGROUND AND OBJECTIVE: Acute chest pain (ACP) is a non-specific symptom that may be the expression of coronary artery disease (CAD). Atherosclerosis is usually present in more than one vascular territory. Ankle-brachial index (ABI) is a useful tool for the diagnosis of peripheral arterial disease (PAD). Our aim was to evaluate the value of ABI in patients with ACP when CAD is suspected. PATIENTS AND METHODS: We performed a cross-sectional study of 94 patients, mean age: 57.4 (12.2), admitted consecutively due to ACP with suspicion of CAD. ABI and presence of CAD were determined. RESULTS: CAD was present in 22 patients (23.4%) and absent in 72 (76.6%). Asymptomatic PAD (ABI < or = 0.9) was present in 6 patients (27.2%) of CAD group and in 7 patients (9.7%) of the non-CAD group. Significant difference was found in ABI based on the presence or not of CAD [0.95 (0.23) vs 1.17 (0.15), p<0.001]. The diagnostic value of ABI for CAD detection was evaluated: area under the ROC curve was 0.8 (IC 95%: 0.70-0.87) and optimal cut-off point was 0.8 (sensitivity=22.7% and specificity=98.6%). In the multivariate analysis, ABI was the best independent predictor of CAD (p<0.001). CONCLUSION: ABI is a simple, cheap and efficient method, which complements other conventional diagnostic methods in the recognition of patients with ACP due to CAD.

Infective endocarditis after transcatheter aortic valve implantation: Contributions of a single-centre experience on incidence and associated factors. / Endocarditis infecciosa después de TAVI: aportaciones de la experiencia en un único centro sobre la incidencia y los factores asociados.

INTRODUCTION: Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is an emerging complication. There are incomplete and disparate data on its incidence. We present the experience of a single-centre of incidence, mortality and associated factors of IE after TAVI. METHODS: A retrospective observational study of IE cases in people who received a TAVI, between 06/01/2009 and 11/01/2017, in a university hospital, during a median follow-up period of 15.3months (interquartile range [IQR] 9.1-36.2). Incidence, clinical, microbiological and prognostic data, and factors associated with IE after TAVI were analysed. RESULTS: Eleven patients with IE of 200 TAVI were detected. Global incidence: 5.5% (2.77 cases per 100 patient-year). The median of days from TAVI to IE was 112 (IQR 36-578), the in-hospital mortality rate was 36.4%, and the one-year mortality rate was 54.5%. All the organisms identified were gram-positive (4 Enterococcus faecalis, 3 coagulase-negative Staphylococcus). The patients with IE after TAVI were significantly younger (median 78years, IQR 73-80, versus 82 years, IQR 79-84, P=.002), they had a higher EuroSCORE (5.1±2.4 versus 3.2±1.2, P<.001), and they more frequently had a history of neoplasia (18.2% versus 4.2%, P<.03) CONCLUSIONS: In our area, IE after TAVI has an incidence greater than that described in multicentre series, this is in line with the trend published in the literature. It leads to high mortality and is associated with a worse baseline clinical situation.

Recurrent STEMI caused by multivessel spontaneous coronary dissection.

We present a case of a 52 year old female who suffered from a sudden syncope. A coronariography was performed and spontaneous coronary dissection was diagnosed in the posterior descending artery after an optical coherence tomography (OCT) was performed. A conservative management was decided. During hospitalization the patient presented with an episode of chest pain with an anterior ST elevation on ECG. Coronariography showed total occlusion of the left descending artery and again a dissection was diagnosed by OCT. This time, 2 stents were implanted in the affected artery. The hypothesis that the coronary adventitial volume of vasa vasorum is higher in patients with spontaneous coronary artery dissection has been demonstrated in a recent small study and it was observed in this patient. Conservative management is preferred in most cases, proceeding to revascularization for patients with ongoing chest pain, hemodynamic instability and ST elevation, mostly if it affects major arteries.

Kidney tumour mimicking cardiac mass.

The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis between a primary cardiac tumour (with myxoma being the most frequent), invasion of an extracardiac tumour, vegetations on the tricuspid valve, and an atrial thrombus. We describe the case of a patient who was admitted to our service with a diagnosis of suspected myxoma based on the chance transthoracic echocardiographic discovery of a right atrial mass. A transesophageal echocardiogram showed the process to be extracardiac, and magnetic resonance imaging showed it to originate at the renal level extending via the inferior vena cava to the right atrium. Tumour extension with thrombosis of the vena cava is a relatively frequent complication of renal carcinoma, but only exceptionally does it reach the right atrium. It is also exceptional that this was a chance finding in an asymptomatic patient.

Unusual cause of central aortic prosthetic regurgitation during transcatheter replacement.

Transcatheter aortic valve replacement (TAVR) is an increasingly common procedure for the treatment of aortic stenosis in elderly patients with comorbidities that prevent the use of standard surgery. It has been shown that implantation without aortic regurgitation is related to lower mortality. Mild paravalvular regurgitation is inevitable in some cases due to calcification of the aortic annulus and its usually somewhat elliptical shape. Central regurgitation is less common, but has been associated with valve overdilatation in cases in which reduction of paravalvular regurgitation was attempted after the initial inflation. However, there are no reported cases of central prosthetic aortic regurgitation due to acute LV dysfunction. We report a case in which central aortic regurgitation occurred due to transient ventricular dysfunction secondary to occlusion of the right coronary artery by an embolus. The regurgitation disappeared after thrombus aspiration and normal ventricular function was immediately recovered.

[Silent left ventricular pseudoaneurysm and rupture to a second pseudoaneurysm]. / Seudoaneurisma ventricular izquierdo silente con rotura a segunda bolsa seudoaneurismática.

Left ventricular pseudoaneurysm is usually associated with myocardial infarction and ventricular wall rupture, although it can also be associated with other pathological conditions. Rupture causes shock, and death if not repaired urgently. We report the very rare case of a man with coronary lesions that resulted in a silent myocardial infarction with rupture of the myocardial wall and the subsequent development of a large, posterolateral, left ventricular pseudoaneurysm. This was followed by rupture of the primary pseudoaneurysm and the consequent creation of a second pseudoaneurysm, which finally resulted in shock and death.

[Tako-tsubo syndrome: analysis of a series of 60 cases]. / Síndrome de Tako-tsubo: análisis de una serie de 60 casos.

BACKGROUND AND OBJECTIVE: The Tako-tsubo syndrome (TS) is a reversible acute cardiomyopathy simulating an infarction. We analyzed 60 patients admitted with TS in our center. PATIENTS AND METHOD: A percentage of 73.3 were women (mean age: 70.6 ± 11.8 years); 83.3% had some cardiovascular risk factor, 25% had an anxiety-depressive disorder and in 58.3% a precipitating factor was identified, emotional stress being the most frequent. A percentage of 15.3 showed complete left bundle branch block (LBBB). In 23.3% of patients, contractile abnormalities respected the apex (mid ventricular or diaphragmatic types). RESULTS: The anterior descending artery showed no significant lesions in 35% of patients and in 68.3% it had a diaphragmatic segment. Forty percent of patients developed heart failure (HF) and 18.3% cardiogenic shock (CS). The overall in-hospital mortality was 3.3%, while it was 8.3% among those patients who developed HF. The incidence of CS was higher among patients with LBBB (44.4 vs. 13.7%, P=.05) and males (43.8 vs. 9.1%, P=.005). CONCLUSIONS: Although in-hospital mortality in patients admitted due to TS is low, a significant percentage of these patients develop HF with a high mortality in this subgroup. Males and patients with LBBB had higher in-hospital morbidity.

A prospective randomised study of the paclitaxel-coated balloon catheter in bifurcated coronary lesions (BABILON trial): 24-month clinical and angiographic results.

AIMS: Paclitaxel drug-eluting balloons (pDEB) could be an attractive option to minimise side branch (SB) restenosis in bifurcated coronary lesions. We compared angiographic and clinical outcomes with pDEB plus bare metal stent (BMS) versus drug-eluting stents (DES) in de novo bifurcated lesions. METHODS AND RESULTS: This multicentre randomised trial included 108 patients. Sequential main branch (MB)/SB dilatation with pDEB, with provisional T-stenting with BMS in the MB was performed in the pDEB group, and with everolimus DES in the DES group. The primary endpoint was late lumen loss (LLL) at nine months. The secondary endpoint was the incidence of major adverse cardiac events (MACE: death, myocardial infarction, or target lesion revascularisation). In-segment MB LLL was 0.31±0.48 mm in the pDEB group, and 0.16±0.38 mm in the DES group (p=0.15); mean difference was 0.15 mm (upper limit one-sided 95% CI: 0.27 mm; p=0.001; non-inferiority test). LLL in SB was -0.04±0.76 mm in the pDEB group and -0.03±0.51 mm in the DES group (p=0.983). MACE and TLR were higher in the pDEB group (17.3% vs. 7.1%; p=0.105, and 15.4% vs. 3.6%; p=0.045), due to higher MB restenosis (13.5% vs. 1.8%; p=0.027). CONCLUSIONS: pDEB bifurcation pretreatment with BMS implantation in MB showed greater LLL (ns) and increased incidence of MACE compared to everolimus DES. Both strategies showed similar results in the SB.

A randomized study to compare bioactive titanium stents and everolimus-eluting stents in diabetic patients (TITANIC XV): 1-year results.

INTRODUCTION AND OBJECTIVES: Up to 25% of patients who undergo a percutaneous coronary intervention show some limitation in the use of drug-eluting stents. The aim of this study was to evaluate if titanium-nitride-oxide-coated stents could be a good alternative to everolimus-eluting stents in diabetic patients. METHODS: A total of 173 diabetic patients with lesions at moderate risk of restenosis (exclusion criteria: diameter < 2.5 mm or length > 28 mm in vessels < 3mm, chronic occlusion) were randomized to a titanium group (83 patients) or an everolimus group (90 patients). RESULTS: Baseline characteristics were well balanced; 28.3% of patients were insulin dependent. At 1 year, the incidence of major adverse cardiac events (death, nonfatal myocardial infarction, stroke, or repeat target vessel revascularization) was significantly higher in the titanium group than in the everolimus group (total, 14.5% vs 4.4%; P = .02; noninsulin-dependent subgroup, 9.7% vs 3.2%; P = .14; insulin-dependent subgroup, 28.6% vs 7.1%; P = .04). The incidence of death, nonfatal myocardial infarction, stroke, or any revascularization was 16.9% in the titanium group and 7.8% in the everolimus group (P = .06). Target lesion and vessel revascularizations occurred in 8.4% compared with 3.3% (P = .15) and in 13.3% compared with 3.3% (P = .01) in the titanium and everolimus groups, respectively. Angiographic follow-up at 9 months showed significantly less late lumen loss in the everolimus group (in-segment, 0.52 [standard deviation, 0.58) mm vs -0.05 [0.32] mm; in-stent, 0.76 [0.54] mm vs 0.13 [0.31] mm; P < .0001). CONCLUSIONS: The everolimus-eluting stent is superior to the titanium stent for clinical and angiographic end points in diabetic patients with lesions at moderate risk of restenosis.

Endocarditis infecciosa después de TAVI: aportaciones de la experiencia en un único centro sobre la incidencia y los factores asociados / Infective endocarditis after transcatheter aortic valve implantation: Contributions of a single-centre experience on incidence and associated factors

INTRODUCCIÓN: La endocarditis infecciosa (EI) sobre transcatheter aortic valve implantation (TAVI) es una complicación emergente. Existen datos incompletos y dispares sobre su incidencia. Se aporta la experiencia en nuestro centro sobre incidencia, mortalidad y factores asociados de la EI post-TAVI y se compara con datos de la literatura. MÉTODOS: Estudio retrospectivo observacional de los casos de EI diagnosticados en pacientes que habían recibido TAVI, entre el 1 de junio de 2009 y el 1 de noviembre de 2017, en un centro universitario tras una mediana de seguimiento de 15,3 meses (rango intercuartil [RIC] 9,1-36,2). Se analizaron la incidencia, los datos clínicos, microbiológicos y pronósticos, y los factores asociados a EI post-TAVI. RESULTADOS: Se detectaron 11 pacientes con EI de 200 TAVI. Incidencia global: 5,5% (2,77 casos por 100 años-paciente). La mediana de tiempo hasta la EI post-TAVI fue de 112 días (RIC 36-578), la tasa de mortalidad intrahospitalaria fue del 36,4% y la mortalidad al año, del 54,5%. Todos los microorganismos identificados fueron grampositivos (4 Enterococcus faecalis, 3 Staphylococcus coagulasa negativo). Los pacientes con EI post-TAVI eran significativamente más jóvenes (mediana 78, RIC 73-80, frente a 82, RIC 79-84, p = 0,002), tenían un EuroSCORE mayor (5,1 ± 2,4 frente a 3,2 ± 1,2, p < 0,001) y más frecuentemente antecedentes de neoplasia (18,2% frente al 4,2%, p < 0,03). CONCLUSIONES: En nuestro medio, la incidencia de EI post-TAVI es mayor que la descrita en series multicéntricas, lo que concuerda con la tendencia publicada en la literatura. Conlleva una elevada mortalidad y se asocia con una peor situación clínica basal

INTRODUCTION: Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is an emerging complication. There are incomplete and disparate data on its incidence. We present the experience of a single-centre of incidence, mortality and associated factors of IE after TAVI. METHODS: A retrospective observational study of IE cases in people who received a TAVI, between 06/01/2009 and 11/01/2017, in a university hospital, during a median follow-up period of 15.3months (interquartile range [IQR] 9.1-36.2). Incidence, clinical, microbiological and prognostic data, and factors associated with IE after TAVI were analysed. RESULTS: Eleven patients with IE of 200 TAVI were detected. Global incidence: 5.5% (2.77 cases per 100 patient-year). The median of days from TAVI to IE was 112 (IQR 36-578), the in-hospital mortality rate was 36.4%, and the one-year mortality rate was 54.5%. All the organisms identified were gram-positive (4 Enterococcus faecalis, 3 coagulase-negative Staphylococcus). The patients with IE after TAVI were significantly younger (median 78 years, IQR 73-80, versus 82 years, IQR 79-84, P=.002), they had a higher EuroSCORE (5.1±2.4 versus 3.2 ± 1.2, P < .001), and they more frequently had a history of neoplasia (18.2% versus 4.2%, P < .03). CONCLUSIONS: In our area, IE after TAVI has an incidence greater than that described in multicentre series, this is in line with the trend published in the literature. It leads to high mortality and is associated with a worse baseline clinical situation

Immediate and one-year results in 35 consecutive patients after closure of left atrial appendage with the Amplatzer cardiac plug.

INTRODUCTION AND OBJECTIVES: Left atrial appendage closure can be an attractive option for patients with nonvalvular atrial fibrillation and a contraindication to oral anticoagulants, provided that satisfactory results can be achieved during implantation and follow-up. METHODS: Thirty-five consecutive patients, not eligible for randomized trials with oral anticoagulants, had an Amplatzer occlusion device implanted under general anesthesia. After the first 5 patients, 3-dimensional imaging was incorporated. The results of the implantation and the follow-up were analyzed over a 1-year period. RESULTS: The mean age was 74.65 (7.61) years, with a CHADS2 score of 2.41 (1.53) and a CHA2DS2-VASc score of 3.17 (1.60). Implantation failed in 1 patient and 5 needed a change in the selected plug size. There were no cardiac complications during the implantation or hospital stay. There was 1 vascular complication (arteriovenous fistula). Transesophageal echocardiography monitoring was performed at 24h, 1, 3, 6, and 12 months and we found 5 thrombi which were resolved with heparin. In the follow-up period of 21.14 (10.09) months, 3 patients aged>80 years died, none of them due to heart problems, and one transient ischemic stroke without further consequences. CONCLUSIONS: Left atrial appendage closure by an experienced operator can be a treatment option with few complications and with efficient results at>1 year in reducing thromboembolic and hemorrhagic complications, even in very high-risk groups.

Estudio aleatorizado para comparar el stentbioactivo de titanio con el stent de everolimus en pacientes diabéticos (TITANIC XV), resultados a 1 año / A Randomized Study to Compare Bioactive Titanium Stents and Everolimus-eluting Stents in Diabetic Patients (TITANIC XV): 1-year Results

Introducción y objetivos Hasta un 25% de los pacientes sometidos a intervencionismo coronario percutáneo presentan alguna limitación para la utilización de los stents farmacoactivos. Nuestro objetivo es evaluar si el stent bioactivo de titanio y óxido nítrico podía ser una buena alternativa al stent de everolimus para pacientes diabéticos.MétodosSe aleatorizó a 173 pacientes diabéticos con lesiones de riesgo de reestenosis intermedio (criterios de exclusión: diámetro < 2,5 mm o longitud > 28 mm en vasos < 3 mm, oclusión crónica): 83 pacientes en el grupo con titanio y 90 en el grupo con everolimus.ResultadosLas variables basales estaban bien equilibradas, el 28,3% eran insulinodependientes. Al año, las incidencias de eventos adversos cardiacos mayores (muerte, infarto de miocardio no fatal, ictus o nueva revascularización del vaso tratado) eran significativamente más frecuente en el grupo con titanio que en el grupo con everolimus (total, el 14,5 frente al 4,4%; p = 0,02; subgrupo no insulinodependiente, el 9,7 frente al 3,2%; p = 0,14; insulinodependiente, el 28,6 frente al 7,1%; p = 0,04) y de muerte, infarto de miocardio no fatal, ictus o cualquier revascularización, del 16,9% en el grupo con titanio y el 7,8% en el grupo con everolimus (p = 0,06). La revascularización de la lesión diana se produjo en el 8,4 frente al 3,3% (p = 0,15), y la del vaso tratado, el 13,3 frente al 3,3% (p = 0,01). El seguimiento angiográfico a 9 meses mostró una pérdida luminal tardía significativamente menor en el grupo con everolimus (en el segmento, 0,52 ± 0,58 frente a -0,05 ± 0,32 mm; en el stent, 0,76 ± 0,54 frente a 0,13 ± 0,31 mm; p < 0,0001). ConclusionesEl stent de everolimus fue superior al titanio en pacientes diabéticos incluso con lesiones de riesgo de eventos clínicos y angiográficos intermedio (AU)

Introduction and objectives Up to 25% of patients who undergo a percutaneous coronary intervention show some limitation in the use of drug-eluting stents. The aim of this study was to evaluate if titanium-nitride-oxide-coated stents could be a good alternative to everolimus-eluting stents in diabetic patients.MethodsA total of 173 diabetic patients with lesions at moderate risk of restenosis (exclusion criteria: diameter < 2.5 mm or length > 28 mm in vessels < 3 mm, chronic occlusion) were randomized to a titanium group (83 patients) or an everolimus group (90 patients).ResultsBaseline characteristics were well balanced; 28.3% of patients were insulin dependent. At 1 year, the incidence of major adverse cardiac events (death, nonfatal myocardial infarction, stroke, or repeat target vessel revascularization) was significantly higher in the titanium group than in the everolimus group (total, 14.5% vs 4.4%; P = .02; noninsulin-dependent subgroup, 9.7% vs 3.2%; P = .14; insulin-dependent subgroup, 28.6% vs 7.1%; P = .04). The incidence of death, nonfatal myocardial infarction, stroke, or any revascularization was 16.9% in the titanium group and 7.8% in the everolimus group (P = .06). Target lesion and vessel revascularizations occurred in 8.4% compared with 3.3% (P = .15) and in 13.3% compared with 3.3% (P = .01) in the titanium and everolimus groups, respectively. Angiographic follow-up at 9 months showed significantly less late lumen loss in the everolimus group (in-segment, 0.52 [standard deviation, 0.58) mm vs -0.05 [0.32] mm; in-stent, 0.76 [0.54] mm vs 0.13 [0.31] mm; P < .0001).ConclusionsThe everolimus-eluting stent is superior to the titanium stent for clinical and angiographic end points in diabetic patients with lesions at moderate risk of restenosis (AU)

Torsade-de-pointes in a patient under flecainide treatment, an unusual case of proarrhythmicity.

Flecainide is an antiarrhythmic considered safe in patients who have no structural cardiopathy, and frequently used in the prevention of atrial fibrillation. However, in patients with a history of infarction and/or severe conduction disorders, its proarrhythmicity may be lethal. Torsade-de-pointes type tachycardia is not included as one of these proarrhythmic effects, since the drug's scant action on ventricular repolarization makes this adverse effect very unlikely. We present the case of a patient who, shortly after beginning treatment with flecainide, was admitted because of syncope related to bradyarrhythmias, long QT, and torsade-de-pointes. There have been very few published cases in which one finds such an association between flecainide and this infrequent arrhythmia.

Permanent transfemoral pacemaker: a single-center series performed with an easier and safer surgical technique.

INTRODUCTION: When venous access via the upper venous tree is not possible, the usual approach is to proceed to epicardial lead placement. MATERIAL AND METHODS: This report presents a consecutive series of 12 permanent pacemaker systems utilizing the right femoral vein for venous access implanted between May 2001 and October 2004. RESULTS: A modification of the previously reported surgical technique was used with a mean implant time of 52 minutes. Five were dual-chamber systems and seven were VVIR. All the leads implanted were active fixation. There was a 0% dislodgment rate and a mean follow-up of 18 months. During this time, three patients required revision or treatment of a pocket complication. All systems remained in the pacing mode as originally programmed with stable low sensing and pacing thresholds. There was no clinical evidence for acute or chronic venous thrombosis and no evidence of asymptomatic venous obstruction in eight patients who underwent echo-duplex studies. CONCLUSION: We believe that the permanent femoral implant utilizing the technical modifications described in this article, offers an alternative to epicardial lead placement when the usual upper venous tree access is not available.

Síndrome de Tako-tsubo: análisis de una serie de 60 casos / Tako-tsubo syndrome: Analysis of a series of 60 cases

Fundamentos y objetivo: El síndrome de Tako-tsubo (SmT) es una miocardiopatía aguda reversible que simula un infarto. Analizamos los 60 pacientes ingresados con SmT en nuestro centro. Pacientes y método: El 73,3% eran mujeres (edad media [DE] de 70,6 [8,11] años). El 83,3% tenía algún factor de riesgo cardiovascular, el 25% tenía trastorno ansiosodepresivo y en el 58,3% se identificó algún desencadenante, siendo el estrés emocional el más frecuente. El 15,3% mostró bloqueo completo de rama izquierda (BCRI). En el 23,3% las alteraciones de la contractilidad respetaban el ápex (formas medioventriculares o diafragmáticas). Resultados: La arteria descendente anterior mostró lesiones no significativas en el 35% de los pacientes, y en el 68,3% tenía trayecto diafragmático. El 40% desarrolló insuficiencia cardiaca (ICC) y el 18,3% shock cardiogénico (SC). La mortalidad hospitalaria global fue del 3,3%, siendo del 8,3% entre aquellos que desarrollaron ICC. La incidencia de SC fue mayor entre los pacientes con BCRI (44,4 frente a 13,7%; p=0,05) y los varones (43,8 frente a 9,1%; p=0,005). Conclusiones: Aunque la mortalidad hospitalaria del SmT es baja, un porcentaje importante de pacientes desarrollan ICC, siendo la mortalidad de este subgrupo elevada. Los pacientes varones y aquellos con BCRI presentaron mayor morbilidad hospitalaria

Background and objective: The Tako-tsubo syndrome (TS) is a reversible acute cardiomyopathy simulating an infarction. We analyzed 60 patients admitted with TS in our center. Patients and method: A percentage of 73.3 were women (mean age: 70.6±11.8 years); 83.3% had some cardiovascular risk factor, 25% had an anxiety-depressive disorder and in 58.3% a precipitating factor was identified, emotional stress being the most frequent. A percentage of 15.3 showed complete left bundle branch block (LBBB). In 23.3% of patients, contractile abnormalities respected the apex (mid ventricular or diaphragmatic types). Results: The anterior descending artery showed no significant lesions in 35% of patients and in 68.3% it had a diaphragmatic segment. Forty percent of patients developed heart failure (HF) and 18.3% cardiogenic shock (CS). The overall in-hospital mortality was 3.3%, while it was 8.3% among those patients who developed HF. The incidence of CS was higher among patients with LBBB (44.4 vs. 13.7%, P=.05) and males (43.8 vs. 9.1%, P=.005). Conclusions: Although in-hospital mortality in patients admitted due to TS is low, a significant percentage of these patients develop HF with a high mortality in this subgroup. Males and patients with LBBB had higher in-hospital morbidity

Resultados inmediatos y a más de un año en 35 pacientes consecutivos a los que se realiza cierre de orejuela izquierda con el dispositivo Amplatzer Cardiac Plug / Immediate and one-year results in 35 consecutive patients after closure of left atrial appendage with the amplatzer cardiac plug

Introducción y objetivos. El cierre del apéndice auricular izquierdo puede ser una opción terapéutica atractiva para pacientes con fibrilación auricular no valvular y contraindicación para tomar anticoagulantes orales, siempre que se obtengan buenos resultados durante la implantación y en el seguimiento. Métodos. Se analizó a 35 pacientes consecutivos y no elegibles para los estudios aleatorizados con anticoagulantes orales a los que se implantó el dispositivo oclusor Amplatzer. Tras los primeros 5 casos, se incorporó una técnica de imagen 3D. Se analizaron los resultados de la implantación y de seguimiento durante 1 año. Resultados. La media de edad era 74,65 ± 7,61 años, con un CHADS2 de 2,41 ± 1,53 y un CHA2DS2-VASc de 3,17 ± 1,60. No se pudo implantar el dispositivo en 1 caso y en 5 fue necesario cambiar la medida seleccionada. No hubo ninguna complicación cardiaca durante la implantación ni durante la estancia hospitalaria. Hubo una complicación vascular (fístula arteriovenosa). Se realizó seguimiento con ecocardiografía transesofágica a las 24 h y tras 1, 3, 6 y 12 meses; se documentaron 5 trombos, que se resolvieron con heparina. En el seguimiento de 21,14 ± 10,09 meses, hubo 3 muertes de pacientes mayores de 80 años, ninguna de ellas cardiológica, y un accidente isquémico transitorio sin secuelas. Conclusiones. El cierre del apéndice auricular izquierdo por un operador con cierta experiencia puede ser una opción terapéutica con pocas complicaciones y con resultados a más de 1 año eficaces en la reducción de complicaciones tromboembólicas y hemorrágicas, incluso en poblaciones de muy alto riesgo (AU)

Introduction and objectives. Left atrial appendage closure can be an attractive option for patients with nonvalvular atrial fibrillation and a contraindication to oral anticoagulants, provided that satisfactory results can be achieved during implantation and follow-up. Methods. Thirty-five consecutive patients, not eligible for randomized trials with oral anticoagulants, had an Amplatzer occlusion device implanted under general anesthesia. After the first 5 patients, 3-dimensional imaging was incorporated. The results of the implantation and the follow-up were analyzed over a 1-year period. Results. The mean age was 74.65 (7.61) years, with a CHADS2 score of 2.41 (1.53) and a CHA2DS2-VASc score of 3.17 (1.60). Implantation failed in 1 patient and 5 needed a change in the selected plug size. There were no cardiac complications during the implantation or hospital stay. There was 1 vascular complication (arteriovenous fistula). Transesophageal echocardiography monitoring was performed at 24h, 1, 3, 6, and 12 months and we found 5 thrombi which were resolved with heparin. In the follow-up period of 21.14 (10.09) months, 3 patients aged>80 years died, none of them due to heart problems, and one transient ischemic stroke without further consequences. Conclusions. Left atrial appendage closure by an experienced operator can be a treatment option with few complications and with efficient results at>1 year in reducing thromboembolic and hemorrhagic complications, even in very high-risk groups (AU)