Anaemia of chronic diseases: Pathophysiology, diagnosis and treatment. / Anemia de las enfermedades crónicas: fisiopatología, diagnóstico y tratamiento.

Anaemia of chronic disease (ACD) is generated by the activation of the immune system by autoantigens, microbial molecules or tumour antigens resulting in the release of cytokines that cause an elevation of serum hepcidin, hypoferraemia, suppression of erythropoiesis, decrease in erythropoietin (EPO) and shortening of the half-life of red blood cells. Anaemia is usually normocytic and normochromic, which is the most prevalent after iron deficiency anaemia, and it is the most frequent in the elderly and in hospitalized patients. If the anaemia is severe, the patient's quality of life deteriorates, and it can have a negative impact on survival. Treatment is aimed at controlling the underlying disease and correcting anaemia. Sometimes intravenous iron and EPO have been used, but the therapeutic future is directed against hepcidin, which is the final target of anaemia.

Current status of iron metabolism: Clinical and therapeutic implications. / Estado actual del metabolismo del hierro: implicaciones clínicas y terapéuticas.

Hepcidin is the main regulator of iron metabolism and a pathogenic factor in iron disorders. Hepcidin deficiency causes iron overload, whereas hepcidin excess causes or contributes to the development of iron-restricted anaemia in chronic inflammatory diseases. We know the mechanisms involved in the synthesis of hepcidin and, under physiological conditions, there is a balance between activating signals and inhibitory signals that regulate its synthesis. The former include those related to plasmatic iron level and also those related to chronic inflammatory diseases. The most important inhibitory signals are related to active erythropoiesis and to matriptase-2. Knowing how hepcidin is synthesised has helped design new pharmacological treatments whose main target is the hepcidin. In the near future, there will be effective treatments aimed at correcting the defect of many of these iron metabolism disorders.

Transcatheter mitral "valve-in-ring" implantation: a word of caution.

Transcatheter mitral valve-in-valve and valve-in-ring procedures have emerged as a potential alternative for patients with failed mitral bioprosthesis or mitral valve repair who are at very high or prohibitive surgical risk. However, transcatheter mitral valve-in-ring implantation (TMViRI) remains a challenging procedure, partially because of the oval shape of mitral rings, which may lead to prosthesis dysfunction when the ring is not able to adopt the circular shape of the transcatheter valve. We present a case of failed TMViRI in a dysfunctional mitral homograft. The potential factors leading to procedural failure are discussed.

Myocardial Injury After Transaortic Versus Transapical Transcatheter Aortic Valve Replacement.

BACKGROUND: The release of cardiac biomarkers of myocardial injury after transcatheter aortic valve replacement (TAVR) is common, but no data exist on patients undergoing TAVR through a transaortic approach. We aimed to evaluate the incidence and prognostic significance of the increase in cardiac biomarkers in nontransfemoral TAVR candidates, comparing transaortic and transapical approaches. METHODS: After excluding patients deemed suitable for transfemoral TAVR, 251 consecutive patients (transaortic, 45; transapical, 206) were prospectively evaluated. Creatine kinase-myocardial band and cardiac troponin T levels were measured at baseline and at 6, 12, 24, 48, and 72 hours after TAVR. Baseline and 6- to 12-month echocardiographic and clinical follow-up were performed. RESULTS: After TAVR, cardiac troponin T increased above the upper normal values in all patients (peak value 0.64 µg/L [IQR, 0.39 to 1.03 µg/L]), whereas creatine kinase-myocardial band levels increased in 88% of patients (transaortic 51%, transapical 96%, p < 0.001; peak value 20.1 µg/L [interquartile range, 14.3 to 31.6 µg/L]). Compared with the transaortic approach, the transapical approach was associated with a greater rise in both cardiac biomarkers (p < 0.001 for both), and a lesser improvement in left ventricular ejection fraction (p = 0.058) and global longitudinal strain (p = 0.039) at 6- to 12-month follow-up. Greater increases of cardiac troponin T levels were independently associated with 30-day and 1-year overall and cardiovascular mortality (p < 0.001 for all). A 15-fold rise in cardiac troponin T levels was the optimal threshold for determining poorer outcomes (p < 0.001). CONCLUSIONS: Periprocedural TAVR-related myocardial injury in nontransfemoral candidates was demonstrated in all patients, but the transapical approach was associated with significantly greater myocardial injury compared with the transaortic approach. A higher degree of myocardial injury translated into reduced left ventricular function improvement and lower early and midterm survival rates.

Effectiveness of low rate fluoroscopy at reducing operator and patient radiation dose during transradial coronary angiography and interventions.

OBJECTIVES: This study sought to determine the efficacy of low rate fluoroscopy at 7.5 frames/s (FPS) versus conventional 15 FPS for reduction of operator and patient radiation dose during diagnostic coronary angiography (DCA) and percutaneous coronary intervention (PCI) via the transradial approach (TRA). BACKGROUND: TRA for cardiac catheterization is potentially associated with increased radiation exposure. Low rate fluoroscopy has the potential to reduce radiation exposure. METHODS: Patients undergoing TRA diagnostic angiography ± ad-hoc PCI were randomized to fluoroscopy at 7.5 FPS versus 15 FPS prior to the procedure. Both 7.5 and 15 FPS fluoroscopy protocols were configured with a fixed dose per pulse of 40 nGy. Primary endpoints were operator radiation dose (measured with dosimeter attached to the left side of the thyroid shield in µSievert [µSv]), patient radiation dose (expressed as dose-area product in Gy·cm(2)), and fluoroscopy time. RESULTS: From October 1, 2012 to August 30, 2013, from a total of 363 patients, 184 underwent DCA and 179 underwent PCI. Overall, fluoroscopy at 7.5 FPS compared with 15 FPS was associated with a significant reduction in operator dose (30% relative reduction [RR], p < 0.0001); and in patient's dose-area product (19% RR; p = 0.022). When stratified by procedure type, 7.5 FPS compared with 15 FPS was associated with significant reduction in operator dose during both DCA (40% RR; p < 0.0001) and PCI (28% RR; p = 0.0011). Fluoroscopy at 7.5 FPS, compared with 15 FPS, was also associated with substantial reduction in patients' dose-area product during DCA (26% RR; p = 0.0018) and during PCI (19% RR; p = 0.13). Fluoroscopy time was similar in 7.5 FPS and 15 FPS groups for DCA (3.4 ± 2.0 min vs. 4.0 ± 4.7 min; p = 0.42) and PCI (11.9 ± 8.4 min vs. 13.3 ± 9.7 min; p = 0.57), respectively. CONCLUSIONS: Fluoroscopy at 7.5 FPS, compared with 15 FPS, is a simple and effective method in reducing operator and patient radiation dose during TRA DCA and PCI.

Five-year follow-up of the plaque sealing with paclitaxel-eluting stents vs medical therapy for the treatment of intermediate nonobstructive saphenous vein graft lesions (VELETI) trial.

BACKGROUND: Very few data exist on the long-term follow-up of patients with intermediate nonobstructive saphenous vein graft (SVG) lesions. The purpose of this study was to evaluate the 5-year clinical outcomes of the patients enrolled in the Moderate Vein Graft Lesion Stenting With the Taxus Stent and Intravascular Ultrasound (VELETI) and the factors associated with SVG disease progression and outcomes. METHODS: Patients with ≥ 1 intermediate SVG lesion (30%-60% diameter stenosis) were randomized to either stenting the SVG lesion with a paclitaxel-eluting stent (PES group, n = 30) or to medical treatment alone (MT group, n = 27). All patients were followed yearly up to 5 years. RESULTS: Major adverse cardiac events (MACEs) (cardiac death, myocardial infarction [MI], revascularization) related to the target SVG lesion tended to be lower in the PES group (17% vs 33%; P = 0.146) due to a lower lesion revascularization rate (13% vs 33%; P = 0.072), with no difference in cardiac death or MI between groups. MACEs related to the target SVG and global MACEs were similar between groups (P > 0.20 for both). A higher cholesterol level at baseline was the only independent predictive factor of MACEs related to the target SVG (P = 0.016). CONCLUSIONS: Over a 5-year period, one third of intermediate lesions in old SVGs progressed, leading to a cardiac event. Stenting these lesions with PESs tended to improve clinical outcomes by reducing lesion progression but not SVG failure. Higher cholesterol levels were associated with SVG disease progression and clinical events. This pilot study provides the basis for a larger trial to determine the efficacy of intermediate SVG lesion plaque sealing.

Obstrução coronária após implante de válvula aórtica por cateter para o tratamento de bioprótese valvular cirúrgica com disfunção: revisão sistemática da literatura / Coronary obstruction following transcatheter aortic valve implantation for degenerative bioprosthetic surgical valves: A systematic literature review

INTRODUÇÃO: Há poucos dados na literatura que avaliam a obstrução coronária após implante transcateter de válvula aórtica (TAVI, do inglês transcatheter aortic valve implantation) para o tratamento de disfunção de bioprótese aórtica (valve-in-valve - ViV). O presente estudo avaliou, por meio de revisão sistemática da literatura, as características clínicas, o manejo e os desfechos clínicos de pacientes com obstrução coronária após TAVI-ViV. MÉTODOS: Estudos publicados entre 2002 e 2013 avaliando a obstrução coronária como complicação de TAVI-ViV foram identificados por meio de busca eletrônica sistemática. Foram avaliados dados basais sobre as características clínicas e do procedimento, manejo da complicação e desfechos clínicos. RESULTADOS: Foram identificadas, no total, quatro publicações descrevendo sete pacientes. A maioria dos pacientes era do sexo feminino (71%), sendo a média de idade de 82 ± 5 anos, com STS-PROM de 9,4 ± 2,6%. As médias da altura do tronco da artéria coronária esquerda (TCE) e o diâmetro médio da raiz aórtica foram de 8,8 ± 1,5 mm e 28,0 ± 5,0 mm, respectivamente. A maioria dos pacientes apresentava biopróteses com suporte e folhetos montados externamente, ou eram próteses sem suporte (stentless) e o TCE foi envolvido em todos os casos. A intervenção coronária percutânea (ICP) foi tentada em todos os pacientes, tendo sucesso em quatro deles (57%). A mortalidade intra-hospitalar foi 42,9% (três casos), todos após ICP sem sucesso. CONCLUSÕES: A obstrução coronária após TAVI-ViV ocorreu mais frequentemente em mulheres com bioprótese com suporte e folheto montado externamente ou com bioprótese sem suporte. O TCE foi envolvido em todos os casos e a ICP foi realizada com sucesso em 60% deles. Esforços contínuos poderão auxiliar na detecção dos fatores associados a essa complicação, no intuito de se implementarem medidas apropriadas para sua prevenção.

BACKGROUND: Very few data exist on coronary obstruction following transcatheter aortic valve implantation (TAVI) for degenerative bioprosthetic valves (valve-in-valve - ViV). The present study evaluated, through a systematic review of the literature, the clinical characteristics, management and clinical outcomes of patients with coronary obstruction after ViV-TAVI. METHODS: Studies published between 2002 and 2013 evaluating coronary obstruction as a complication of ViV-TAVI were identified using a systematic electronic search. Data on the clinical and procedural characteristics, management of the complication, and clinical outcomes were analyzed. RESULTS: A total of four publications describing seven patients were identified. Most patients (71%) were women, with mean age of 82 ± 5 years, and STS-PROM score of 9.4 ± 2.6%. Mean left coronary artery (LCA) ostium height and aortic root width were 8.8 ± 1.5 mm and 28.0 ± 5.0 mm, respectively. Most patients had stented bioprosthetic valves with externally mounted leaflets or stentless aortic bioprosthesis, and the LCA was involved in all patients. Percutaneous coronary intervention (PCI) was attempted in all patients and was successful in four (57%). In-hospital mortality was 42.9% (three cases), all of them after failed PCI. CONCLUSIONS: Coronary obstruction following ViV-TAVI occurred more frequently in women with stented bioprosthetic valves with externally mounted leaflets or with stentless bioprosthesis. The LCA was involved in all cases and PCI was successful in 60% of them. Continued efforts may help identify the factors associated with this complication so that appropriate prevention measures may be implemented.

Transapical implantation of the SAPIEN 3 valve.

We report two cases of high-risk aortic stenosis treated with the SAPIEN 3 valve. This is the first procedure performed with this type of valve through the transapical approach. This new balloon-expandable valve incorporates a lower profile cobalt-chromium stent and an additional outer skirt to enhance paravalvular sealing. The procedure was performed without complications and no paravalvular leak was detected in control echocardiogram at follow-up.

Utilidad de las derivaciones paraesternales altas en el diagnóstico del Síndrome de Brugada / Utility of high parasternal electrocardiographic leads in the diagnosis of Brugada Syndrome

The use of high right precordial (HPL) leads to "unmask" Brugada syndrome (BrS) has been described by some groups. We report a family with three cases of BrS. In two, HPL were obtained by placing V1 to V3 electrodes on the first, second, and third right parasternal spaces, and V4 to V6 on the first, second, and third left parasternal spaces. A control group of 45 subjects without BrS was also studied. Compared with standard V1 and V2 leads, the abnormal repolarization pattern of the BrS was accentuated only in the BrS cases using HPL. In none of the control subjects alterations of the J point or ST segment were observed in HPL. These observations exemplify the relevance of HPL for the diagnosis of the BrS.

Cavernosometría y cavernosografía dinámica en el estudio de la impotencia / Cavernosometry and dinamic cavernosography in the impotence diagnosis

El estudio del drenaje venoso del pene, actualmente tiene máxima importancia dado que en un 23% es causa predominante de impotencia orgánica. La cavernosometría en conjunto con la cavernosografía son los procedimientos de mayor relevancia y el único medio actual de diagnóstico en esta patología. Se explica la técnica con o, sin papaverina en 28 exámenes y se comunican los resultados, los que son semejantes a los obtenidos por autores extranjeros. El volumen minuto es de 100-120 ml para la erección y de 30-40 ml como volumen de mantención en la cavernosometría sin papaverina y sin fuga venosa. Cuando existe fuga venosa es de mas de 180 ml. para la erección y 110 ml para la mantención. Con papaverina: 30-35 ml/minuto volumen de erección y 3-6 ml como mantención sin fuga venosa. Con fuga venosa los volumenes son de 90 y 45 ml. respectivamente