Transcatheter-Based Interventions for Tetralogy of Fallot Across All Age Groups.

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease. Palliative procedures, either surgical or transcatheter, aim to improve oxygen saturation, affording definitive procedures at a later stage. Transcatheter interventions have been used before and after surgical palliative or definitive repair in children and adults. This review aims to provide an overview of the different catheter-based interventions for TOF across all age groups, with an emphasis on palliative interventions, such as patent arterial duct stenting, right ventricular outflow tract stenting, or balloon pulmonary valvuloplasty in infants and children and transcatheter pulmonary valve replacement in adults with repaired TOF, including the available options for a large, dilated native right ventricular outflow tract.

A systematic review of contrast-enhanced computed tomography calcium scoring methodologies and impact of aortic valve calcium burden on TAVI clinical outcomes.

Different methodologies have been used to assess the role of AV calcification (AVC) on TAVI outcomes. This systematic review aims to describe the burden of AVC, synthesize the different methods of calcium score quantification, and evaluate the impact of AVC on outcomes after TAVI. We included studies of TAVI patients who had reported AV calcium scoring by contrast-enhanced multidetector CT and the Agatston method. The impact of calcification on TAVI outcomes without restrictions on follow-up time or outcome type was evaluated. Results were reported descriptively, and a meta-analysis was conducted when feasible. Sixty-eight articles were included, with sample sizes ranging from 23 to 1425 patients. Contrast-enhanced calcium scoring was reported in 30 studies, calcium volume score in 28 studies, and unique scoring methods in two. All studies with calcium volume scores had variable protocols, but most utilized a modified Agatston method with variable attenuation threshold values of 300-850 HU. Eight studies used the Agatston method, with the overall mean AV calcium score in studies published from 2010 to 2012 of 3342.9 AU [95%CI: 3150.4; 3535.4, I2 â€‹= â€‹0%]. The overall mean score was lower and heterogenous in studies published from 2014 to 2020 (2658.9 AU [95% CI: 2517.3; 2800.5, I2 â€‹= â€‹79%]. Most studies reported a positive association between calcium burden and increased risk of adverse outcomes, including implantation of permanent pacemaker (7/8 studies), paravalvular leak (13/13 studies), and risk of aortic rupture (2/2 studies). AVC quantification methodology with contrast-enhanced CT is still variable. AVC negatively impacts TAVI outcomes independently of the quantification method.

Paravalvular Leakages after Surgical Aortic-Valve Replacement and after Transcatheter Aortic-Valve Implantation: Strategies to Increase the Success Rate of Percutaneous Closure.

Moderate to severe paravalvular-leak (PVL) regurgitation after surgical aortic-valve replacement or after transcatheter valve implantation represents a well-known complication associated with symptoms related to heart failure, hemolysis, or both in patients with multiple comorbidities and with poor prognostic outcomes. The transcatheter closure of aortic paravalvular leaks (APVLs) is currently considered a valid alternative to cardiac surgery. Nevertheless, careful patient selection, optimal cardiac imaging for intraprocedural guidance, and expert operators are key for success. Although technically demanding, particularly in APVLs after transcatheter valve implantation, catheter-based closure is an effective, less invasive, and often the only option for high-risk patients with symptomatic PVL regurgitation.

Procedural and clinical outcomes after repeat edge-to-edge transcatheter mitral valve repair.

BACKGROUND AND OBJECTIVES: Evidence regarding redo percutaneous interventions for recurrent mitral regurgitation is scarce. We ought to evaluate procedural and clinical outcomes of repeated edge-to-edge transcatheter mitral valve repair (TMVR) interventions. METHODS: This multicenter study collected individual data from eight high-volume TMVR Centers in Spain. Between 2012 and 2020, all patients undergoing a second edge-to-edge TMVR intervention (Redo) were included in the study. RESULTS: Among a total of 1028 procedures, 31 patients (3%) with residual MR ≥ 3 at follow-up underwent a second procedure (Redo). Redo intervention was mainly conducted between the first and second year after the first procedure. The most common cause of MR progression was partial detachment (46.7%) followed by LV remodeling (35.5%). Procedural success was achieved in 87% of cases. After a mean follow-up of 1.75 ± 1.54 years, all-cause and cardiovascular mortality were 48.1% and 25%, respectively. Nearly half of the patients (48.1%) required at least one hospital admission for CHF within the follow-up period. However, most of the patients presented symptomatic improvement as depicted by an NYHA class ≤2. Elective mitral surgery was conducted in only one patient at follow-up due to insufficient MR reduction. CONCLUSIONS: According to our findings, redo edge-to-edge TMVR interventions were feasible and safe with a high procedural success rate. Clinical and echocardiographic follow-up showed however modest long-term results in this specific setting.

Impact of Chronic Kidney Disease in Chronic Total Occlusion Management and Clinical Outcomes.

BACKGROUND: Data on the impact of chronic kidney disease (CKD) on clinical outcomes in chronic total occlusion (CTO) patients is scarce, and the optimal treatment strategy for this population is not well established. This study aims to compare differences in CTO management and long-term clinical outcomes, including all-cause and cardiac mortalities, according to baseline glomerular filtration rate (GFR). METHODS: All patients with at least one CTO diagnosed in our center between 2010 and 2014 were included. Demographic and clinical data were registered. All-cause and cardiac mortalities were assessed during a median follow-up of 4.03 years (IQR 2.6-4.8). Clinical outcomes were compared between patients with CKD (GFR < 60 mL/min/1.73 m2) and without CKD (GFR ≥ 60 mL/min/1.73 m2). RESULTS: A total of 1248 patients (67.3 ± 10.9 years; 32% CKD) were identified. CKD patients were older and had a higher prevalence of hypertension, type 2 diabetes, peripheral arterial disease, and severe left ventricular dysfunction compared to patients with normal renal function (p < 0.05). Subjects with renal dysfunction were more often treated with MT alone, compared to patients without CKD (63% vs 45%; p < 0.001), who were more likely to undergo PCI or surgery. During follow-up, 386 patients [31%] died. CKD patients had a higher rate of all-cause and cardiac mortalities compared to patients without CKD (p < 0.001). The independent predictors for all-cause mortality were age, GFR < 60 mL/min/1.73 m2, Syntax Score I, and successful revascularization of the CTO (CABG or PCI-CTO). Among patients with CKD, advanced age, eGFR <30 mL/min/1.73 m2, and CTO successful revascularization were predictors of all-cause mortality. CONCLUSIONS: Patients with CKD were more often treated with MT alone. At long-term follow-up, revascularization of the CTO is associated with lower all-cause and cardiac mortalities in this population.

Design and Rationale for a Real-World Prospective, Multicenter Registry of Myocardial Revascularization Failure and Secondary Revascularization: The REVASEC Study.

AIM: To investigate key aspects of the problem of myocardial revascularization failure (MRF) and repeat or secondary myocardial revascularization (SR) in contemporary practice. METHODS: The registry of secondary revascularization (REVASEC) is an investigator-initiated, multicenter, prospective registry enhanced with data monitoring and independent event adjudication (ClinicalTrials.govNCT03349385). It includes patients with prior revascularization referred to coronary angiography for suspected MRF with broad inclusion criteria. The main objectives are to describe the characteristics of patients with prior revascularization referred for repeat angiography, to describe and the rate and mechanisms of MRF (stent or graft failure, coronary artery disease progression or residual coronary artery disease); to evaluate the management including medical treatment and SR of these patients; and to assess the prognosis according to the outlined causative mechanisms. The registry has one year follow up for the primary endpoint (Patient-oriented composite endpoint including all-cause death, any myocardial infarction or any new unplanned revascularization according to subsets of MRF), but extended follow-up will be carried out up to 5 years. CONCLUSION: The REVASEC Registry will provide updated data on the characteristics, patterns of treatment, and 1-year outcomes of patients with MRF and SR in contemporary clinical practice.

Clinical Impact of Medical Therapy Versus Revascularization in Patients With Chronic Coronary Total Occlusions.

BACKGROUND: Chronic total occlusions (CTOs) are prevalent angiographic findings in patients with suspected coronary artery disease. Conflicting results of randomized controlled trials and registries have not clarified the therapeutic approach for patients with CTO in clinical practice. Therefore, we sought to analyze variables influencing the decision-making process and their relationship with clinical outcomes according to the type of selected therapy. METHODS: A total of 1248 consecutive patients with at least 1 CTO were identified between 2010 and 2014 at our institution. Clinical and angiographic variables were collected to allow the calculation of several predictive scores. Primary outcome was all-cause death at the longest follow-up available. Other endpoints of interest included cardiac mortality and myocardial infarction. Medical therapy (MT) alone was indicated in 719 patients (58%), whereas percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) were used in 240 (19%) and 298 (24%), respectively. Age, acute myocardial infarction, previous CABG, and age, creatinine, ejection fraction (ACEF) score were independently associated with the decision for MT alone. Conversely, the presence of multivessel disease, left main coronary artery involvement, and high SYNTAX score favored the decision for CABG. At a median follow-up of 4.3 years, revascularization strategies were independently associated with all-cause mortality and cardiac mortality (hazard ratio [HR], 0.42; 95% confidence interval [CI] 0.27-0.65; P<.001 and HR, 0.32; 95% CI, 0.17-0.60; P<.001, respectively) for PCI and (HR, 0.39; 95% CI, 0.26-0.58 and HR, 0.51; 95% CI, 0.32-0.81; P<.01, respectively) for CABG. CONCLUSION: Several clinical and angiographic parameters influence the decision-making process of patients with CTO. CTO revascularization with either PCI or CABG appeared to be associated with improved clinical outcomes at long-term follow-up as compared with MT alone.

New holosystolic murmur after acute myocardial infarction.

In the era of primary percutaneous coronary intervention, mechanical complications after acute myocardial infarction are extremely rare, with an incidence of less than 0.5%. Rupture of the ventricular septum is the least frequent occurrence. Nevertheless, current mortality remains high and a prompt diagnosis and treatment are imperative to increase survival. Despite early surgical repair, mortality still remains high.

Multivessel spontaneous coronary artery dissection involving the left main coronary artery: a case report.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an infrequent and often misdiagnosis of a non-atherosclerotic cause of acute coronary syndrome (ACS). It is an important cause of ACS in young women, responsible for up to 25% of all cases in women <50 years of age without cardiovascular risk factors. Clinical presentation ranges from ST-segment-elevation myocardial infarction (MI) to ventricular fibrillation and sudden death. The treatment of patients with SCAD is a challenge and the ideal management strategy has yet to be determined. CASE SUMMARY: A 42-year-old woman without family history of cardiac disease and neither traditional atherosclerotic risk factors presented to our centre with an anterior acute ST-segment-elevation MI secondary to multiple spontaneous dissections of the left main, anterior descending, and ramus intermedius coronary arteries. Stenting was performed in the left anterior descending coronary artery and left main coronary artery to resolve its occlusion. Fibromuscular dysplasia was confirmed via computed tomography angiography. DISCUSSION: More cases are now being identified of SCAD due to increased clinical index of suspicion, earlier use of invasive angiography, and intracoronary imaging in patients presenting with acute chest pain. Despite this, the absence of previous cardiovascular risk factors and the ignorance of this pathology delay the start of an adequate medical treatment and the performance of a cardiac catheterization. Prognostic data are limited, partly because of its underdiagnosis and lack of prospective studies, so its knowledge is necessary to improve the prognosis of these patients.

Impact of revascularization versus medical therapy alone for chronic total occlusion management in older patients.

BACKGROUND: Chronic total occlusions (CTOs) are present in more than one third of older patients with myocardial ischemia, but controversy remains about the best therapeutic approach. AIMS: To compare long-term survival after CTO revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG]) versus medical treatment (MT) alone in patients aged 75 and older. METHODS AND RESULTS: A total of 1,252 consecutive patients with at least one CTO were identified from 2010 to 2014 in our center. Patients were stratified by age (<75 years vs. ≥75 years) in the present analysis. All-cause and cardiac mortality were assessed at a median follow-up of 3.5 years. In the older subgroup (26%), patients were more likely to be treated with MT alone (71% vs. 43% of younger patients; p < 0.001). Patients undergoing revascularization were younger and had higher left ventricular ejection fraction (LVEF) and lower age, creatinine, ejection fraction (ACEF) score (age/LVEF +1 if creatinine >2.0 mg/dL), compared to the MT group (p < 0.05). As compared to MT, revascularization predicted lower rates of cardiac mortality and all-cause mortality in older patients, both in the subgroups treated with CABG (hazard ratio [HR] 0.35, 95% confidence interval [CI] 0.17-0.71; HR 0.39, 95%CI 0.18-0.81) and PCI (HR 0.57, 95%CI 0.33-0.98; HR 0.59, 95%CI 0.28-1.2). No differences in mortality were observed according to type of revascularization procedure. CONCLUSIONS: Among patients aged at least 75 years with a CTO, revascularization (PCI or CABG) rather than MT alone may portend a better outcome in terms of all-cause and cardiac mortality.

Serum levels of Growth Arrest-Specific 6 protein and soluble AXL in patients with ST-segment elevation myocardial infarction.

BACKGROUND: Serum soluble AXL (sAXL) and its ligand, Growth Arrest-Specific 6 protein (GAS6), intervene in tissue repair processes. AXL is increased in end-stage heart failure, but the role of GAS6 and sAXL in ST-segment elevation myocardial infarction (STEMI) is unknown. OBJECTIVES: To study the association of sAXL and GAS6 acutely and six months following STEMI with heart failure and left ventricular remodelling. METHODS: GAS6 and sAXL were measured by enzyme-linked immunosorbent assay at one day, seven days and six months in 227 STEMI patients and 20 controls. Contrast-enhanced magnetic resonance was performed during admission and at six months to measure infarct size and left ventricular function. RESULTS: GAS6, but not sAXL, levels during admission were significantly lower in STEMI than in controls. AXL increased progressively over time (p<0.01), while GAS6 increased only from day 7. GAS6 or sAXL did not correlate with brain natriuretic peptide or infarct size. However, patients with heart failure (Killip >1) had higher values of sAXL at day 1 (48.9±11.9 vs. 44.0±10.7 ng/ml; p<0.05) and at six months (63.3±15.4 vs. 55.9±13.7 ng/ml; p<0.05). GAS6 levels were not different among subjects with heart failure or left ventricular remodelling. By multivariate analysis including infarct size, Killip class and sAXL at seven days, only the last two were independent predictors of left ventricular remodelling (odds ratio 2.24 (95% confidence interval: 1.08-4.63) and odds ratio 1.04 (95% confidence interval: 1.00-1.08) respectively). CONCLUSION: sAXL levels increased following STEMI. Patients with heart failure and left ventricular remodelling have higher sAXL levels acutely and at six month follow-up. These findings suggest a potential role of the GAS6-AXL system in the pathophysiology of left ventricular remodelling following STEMI.

Central extracorporeal membrane oxygenation as a bridge to decision in a patient with a ventricular septal rupture complicating a myocardial infarction / Análisis de las medidas de prevención secundaria introducidas en pacientes con historia de síndrome coronario agudo

Abstract In the era of primary percutaneous coronary intervention, mechanical complications after acute myocardial infarction are extremely rare, with an incidence of less than 0.5%. Rupture of the ventricular septum is the least frequent occurrence. Despite early surgical repair, mortality still remains high. Patients who are at high risk of perioperative death include those with cardiogenic shock and multiorgan dysfunction. In this group, a mechanical circulatory support such as an Extracorporeal Membrane Oxygenation circuit could be used as bridge to surgical repair is feasible or heart transplantation, as it provides hemodynamic stability and the potential to correct multiorgan dysfunction. We reported a case pf ECMO device implantation as a bridge to heart transplantation in a patient with post infarction ventricular septal rupture. Unfortunately, while on the waiting list for heart transplantation with maximum priority the patient had massive diffuse alveolar hemorrhage secondary to the anticoagulation required by the equipment and died.

Resumen En la era de la intervención coronaria percutánea primaria, las complicaciones mecánicas tras un infarto de miocardio agudo son extremadamente infrecuentes, con una incidencia de menos del 0,5%. La ruptura del septum ventricular es el caso menos frecuente. A pesar de la reparación quirúrgica, la mortalidad sigue siendo elevada. Los pacientes con alto riesgo de muerte perioperativa incluyen a aquellos con shock cardiógeno y síndrome de disfunción multiorgánica. En este grupo, podría utilizarse soporte circulatorio mecánico, tal como el circuito de oxigenación por membrana extracorpórea, como puente hacia la reparación quirúrgica o trasplante cardiaco, ya que aporta estabilidad dinámica y la posibilidad de corregir el síndrome de disfunción multiorgánica. Se reporta un caso de implantación de dispositivo de membrana extracorpórea, como puente al trasplante cardiaco, en un paciente con ruptura del septum ventricular tras infarto. Lamentablemente, a pesar de estar en lista de espera con prioridad máxima, sufrió una hemorragia alveolar difusa masiva, secundaria a la anticoagulación requerida por el equipo, y falleció.

Percutaneous coronary intervention due to chronic total occlusion in the left main coronary artery after bypass grafting: A feasible option in selected cases.

INTRODUCTION: Chronic total occlusion (CTO) of the left main coronary artery (LMCA) is an infrequent finding. Revascularization is recommended in the presence of demonstrated viability or ischemia. Coronary artery bypass grafting (CABG) has long been considered the preferred option. Patients with previous CABG due to LMCA disease with occlusion of one graft and progression of the LMCA to CTO constitute a special population, as just one ischemic artery remains. For these patients, there is no other option for revascularization other than cardiac surgery (requiring resternotomy) or percutaneous coronary intervention (PCI) of the LMCA. METHODS AND RESULTS: Out of 620 patients with CTO diagnosed in our center, we identified five with previous CABG due to LMCA disease for a retrospective case series. They had occlusion of one graft and progression of the LMCA to CTO. All five underwent PCI. Each patient received a functional classification for angina, myocardial ischemic tests, and a follow-up coronary angiogram during a median follow-up of 63 months. Coronary angiogram showed CTO of the semi-protected LMCA lesions with two CABGs previously performed in all patients, one occluded and the other patent. Three patients had occluded saphenous vein grafts to the circumflex coronary artery, and the rest had left internal mammary artery-left anterior descending artery CABG failure. Ischemia and viability were demonstrated. Surgery was ruled out due to high surgical risk. PCI due to CTO of the LMCA with drug-eluting stents was performed. In a five-year follow-up period, four patients remained asymptomatic and event free. One post-PCI death occurred from non-cardiovascular cause. CONCLUSIONS: PCI due to CTO of the LMCA following CABG can be successful and safe and can provide sustained clinical improvements in selected cases.

A rare cause of severe mitral stenosis and reversible pulmonary hypertension.

Myxoma is a rare cause of severe mitral stenosis. We describe a challenging case of severe mitral stenosis and reversible pulmonary hypertension produced by a giant left atrial myxoma. The greatest risk is a diagnostic delay due to focus on discarding a pulmonary etiology of dyspnea. Physical examination and early echocardiographic assessment are the keys to avoid overlooking this uncommon pathology.

Out-of-hospital cardiac arrest and stent thrombosis: Ticagrelor versus clopidogrel in patients with primary percutaneous coronary intervention under mild therapeutic hypothermia.

BACKGROUND: Out-of-Hospital Cardiac Arrest (OHCA) and mild therapeutic hypothermia (MTH) have been linked to increased risk of Stent Thrombosis (ST) in comatose survivors who undergo percutaneous coronary intervention (PCI). In this sense, there is no formal recommendation about which antiplatelet regimen should be used in patients with acute coronary syndromes (ACS) after OHCA. AIMS: To compare the incidence of probable/definite ST and bleeding events between ticagrelor and clopidogrel, in patients with ACS under MTH after an OHCA. METHODS AND RESULTS: From January 2010 to August 2016, 144 patients underwent MTH after an OHCA. Overall, 114 had an ACS (79%) and 98 (67,3%) were treated with primary PCI and stent implantation. Among them, 61 (62,2%) were treated with clopidogrel, and 32 (32,6%) with ticagrelor. During hospitalization, the incidence of probable or definite ST was significantly higher in patients receiving clopidogrel compared to ticagrelor (11,4% vs. 0%; p: 0.04), and no significant differences in any (28,6% vs. 25%; p: 0.645) or major bleeding (BARC 3 or 5) (11,4% vs. 12,5%; p: 0.685) were found. Hospital mortality did not differ between groups (26,2% vs. 25%; p: 0.862). CONCLUSIONS: In this study, as compared to clopidogrel, ticagrelor was associated with a lower rate of ST, without differences in haemorrhagic events in patients with OHCA for an ACS under MTH. Similarly to other settings, ticagrelor might be a valid alternative to clopidogrel in these patients.