Cardiovascular surgery and cardiology, current status of two sister specialties in Spain: the CARDIOXCARDIO study.

In recent years, there has been a notable shift in cardiovascular clinical practice within cardiology and surgery. The CARDIOXCARDIO study aimed to identify professionals' opinions on working practices and relations between specialties. A survey was simultaneously sent to the 4442 members of the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) and the Spanish Society of Cardiology (SEC), yielding 385 valid responses. More than half (59%) of respondents were men, mostly specialists (7.3% residents), and 74.8% worked in the field of cardiology, predominantly in public centers (88.3%). Using a Likert scale ranging from 1 to 5 (worst to best), respondents rated relations between surgery and cardiology with an average of 3.57±0.9 points. Cardiologists rated surgeons with a mean score of 3.83±0.8, while surgeons gave cardiologists a mean score of 3,92±0.72. In addition, respondents provided numerous suggestions for improvement, which are discussed in detail, highlighting certain discrepancies in criteria between specialties. Implementing strategies based on the suggestions of professionals, together with a proactive approach to continuous improvement, could substantially enhance the quality of cardiovascular care in Spain.

Characteristics and in-hospital mortality of elderly patients with heart failure in Spanish hospitals.

BACKGROUND: The prevalence of heart failure (HF) increases with age, and it is one of the leading causes of hospitalization and death in older patients. However, there are little data on in-hospital mortality in patients with HF ≥ 75 years in Spain. METHODS: A retrospective analysis of the Spanish Minimum Basic Data Set was performed, including all HF episodes discharged from public hospitals in Spain between 2016 and 2019. Coding was performed using the International Classification of Diseases, 10th Revision. Patients ≥ 75 years with HF as the principal diagnosis were selected. We calculated: (1) the crude in-hospital mortality rate and its distribution according to age and sex; (2) the risk-standardized in-hospital mortality ratio; and (3) the association between in-hospital mortality and the availability of an intensive cardiac care unit (ICCU) in the hospital. RESULTS: We included 354,792 HF episodes of patients over 75 years. The mean age was 85.2 ± 5.5 years, and 59.2% of patients were women. The most frequent comorbidities were renal failure (46.1%), diabetes mellitus (35.5%), valvular disease (33.9%), cardiorespiratory failure (29.8%), and hypertension (26.9%). In-hospital mortality was 12.7%, and increased with age [odds ratio (OR) = 1.07, 95% CI: 1.07-1.07, P < 0.001] and was lower in women (OR = 0.96, 95% CI: 0.92-0.97, P < 0.001). The main predictors of mortality were the presence of cardiogenic shock (OR = 19.5, 95% CI: 16.8-22.7, P < 0.001), stroke (OR = 3.5, 95% CI: 3.0-4.0, P < 0.001) and advanced cancer (OR = 2.6, 95% CI: 2.5-2.8, P < 0.001). In hospitals with ICCU, the in-hospital risk-adjusted mortality tended to be lower (OR = 0.85, 95% CI: 0.72-1.00, P = 0.053). CONCLUSIONS: In-hospital mortality in patients with HF ≥ 75 years between 2016 and 2019 was 12.7%, higher in males and elderly patients. The main predictors of mortality were cardiogenic shock, stroke, and advanced cancer. There was a trend toward lower mortality in centers with an ICCU.

Effects of intravenous lysine acetylsalicylate versus oral aspirin on platelet responsiveness in patients with ST-segment elevation myocardial infarction: the ECCLIPSE-STEMI trial.

Prasugrel and ticagrelor, new P2Y12-ADP receptor antagonists, are associated with greater pharmacodynamic inhibition and reduction of cardiovascular events in patients with an acute coronary syndrome. However, evidence is lacked about the effects of achieving faster and stronger cyclooxygenase inhibition with intravenous lysine acetylsalicylate (LA) compared to oral aspirin. Recently, we demonstrated in healthy volunteers that the administration of intravenous LA resulted in a significantly reduction of platelet reactivity compared to oral aspirin. Loading dose of LA achieves platelet inhibition faster, and with less variability than aspirin. However, there are no data of this issue in patients with an ST-segment elevation myocardial infarction (STEMI). This is a prospective, randomized, multicenter, open platelet function study conducted in STEMI patients. Subjects were randomly assigned to receive a loading dose (LD) of intravenous LA 450 mg plus oral ticagrelor 180 mg, or LD of aspirin 300 mg plus ticagrelor 180 mg orally. Platelet function was evaluated at baseline, 30 min, 1 h, 4 h and 24 h using multiple electrode aggregometry and vasodilator-stimulated phosphoprotein phosphorylation (VASP). The primary endpoint of the study is the inhibition of platelet aggregation (IPA) after arachidonic acid (AA) 0.5 mM at 30 min. Secondary endpoints were the IPA at 1, 4, and 24 h after AA, and non-AA pathways through the sequence (ADP and TRAP). A total of 32 STEMI patients were randomized (16 LA, 16 aspirin). The inhibition of platelet aggregation after AA 0.5 mM at 30 min was greater in subjects treated with LA compared with aspirin: 166 vs. 412 respectively (p = 0.001). This differential effect was observed at 1 h (p = 0.01), but not at 4 and 24 h. Subjects treated with LA presented less variability and faster inhibition of platelet aggregation wit AA compared with aspirin. The administration of intravenous LA resulted in a significantly reduction of platelet reactivity compared to oral aspirin on ticagrelor inhibited platelets in patients with STEMI. Loading dose of LA achieves an earlier platelet inhibition, and with less variability than aspirin.Trial Registration: Unique identifier: NCT02929888; URL: http://www.clinicaltrials.gov.

Diagnosis-to-ablation time in atrial fibrillation: A modifiable factor relevant to clinical outcome.

INTRODUCTION: Recurrences after atrial fibrillation (AF) ablation are still common. Among the reported clinical and imaging predictors of recurrences, diagnosis-to-ablation time (DAT) has been defined as a predictor of ablation outcome in single-center studies. We aimed to validate DAT in a multicenter real-life cohort. METHODS: This was a multicenter study including consecutive patients undergoing first paroxysmal and persistent AF ablation with radiofrequency or cryoballoon catheters during 2013. Cox proportional hazard regression models were performed to identify predictors of recurrence. RESULTS: In total, 309 patients were included across nine centers (71% men, 57 ± 10 years old, 46% with hypertension, and 66% with CHA2 DS2 -VASc ≤ 1). Most patients had paroxysmal AF (67%) and underwent radiofrequency ablation (68%) with a median DAT of 51 (43) months. Patients with DAT ≤ 1 year (16.6%) were less likely to have repeat procedures (4% vs 18%; P = .017). The adjusted proportional hazards Cox model identified hypertension (P = .005), heart failure (P = .011), nonparoxysmal AF (P = .038), DAT > 1 year (P = .007), and LA diameter (P = .026) as independent predictors for AF recurrence. DAT > 1 year was the only modifiable factor independently associated with recurrence (HR 4.2 [95% CI, 1.5-11.9]) CONCLUSION: Diagnosis-to-ablation time is a modifiable factor independently associated with recurrent arrhythmia and repeat ablation after first AF ablation. An early intervention strategy during the first year from AF diagnosis might improve outcomes.

Lesion Index Titration Using Contact-Force Technology Enables Safe and Effective Radiofrequency Lesion Creation at the Root of the Aorta and Pulmonary Artery.

BACKGROUND: Ablation of some myocardial substrates requires catheter-based radiofrequency delivery at the root of a great artery. We studied the safety and efficacy parameters associated with catheter-based radiofrequency delivery at the root of the aorta and pulmonary artery. METHODS: Thirty-six pigs underwent in-vivo catheter-based ablation under continuous contact-force and lesion index (power, contact-force, and time) monitoring during 60-s radiofrequency delivery with an open-irrigated tip catheter. Twenty-eight animals were allocated to groups receiving 40 W (n=9), 50 W (n=10), or 60 W (n=9) radiofrequency energy, and acute (n=22) and chronic (n=6) arterial wall damage was quantified by multiphoton microscopy in ex vivo samples. Adjacent myocardial lesions were quantified in parallel samples. The remaining 8 pigs were used to validate safety and efficacy parameters. RESULTS: Acute collagen and elastin alterations were significantly associated with radiofrequency power, although chronic assessment revealed vascular wall recovery in lesions without steam pop. The main parameters associated with steam pops were median peak temperature >42°C and impedance falls >23 ohms. Unlike other parameters, lesion index values of 9.1 units (interquartile range, 8.7-9.8) were associated with the presence of adjacent myocardial lesions in both univariate ( P=0.03) and multivariate analyses ( P=0.049; odds ratio, 1.99; 95% CI, 1.02-3.98). In the validation group, lesion index values using 40 W over a range of contact-forces correlated with the size of radiofrequency lesions (R2=0.57; P=0.03), with no angiographic or histopathologic signs of coronary artery damage. CONCLUSIONS: Lesion index values obtained during 40 W radiofrequency applications reliably monitor safe and effective lesion creation at the root of the great arteries.

Early prognostic value of an Algorithm based on spectral Variables of Ventricular fibrillAtion from the EKG of patients with suddEn cardiac death: A multicentre observational study (AWAKE) / Valor pronóstico precoz de un algoritmo basado en variables espectrales de la fibrilación ventricular del ECG de pacientes con muerte súbita cardiaca: estudio observacional multicéntrico (AWAKE)

Abstract Objective: Ventricular fibrillation (VF)-related sudden cardiac death (SCD) is a leading cause of mortality and morbidity. Current biological and imaging parameters show significant limitations on predicting cerebral performance at hospital admission. The AWAKE study (NCT03248557) is a multicentre observational study to validate a model based on spectral ECG analysis to early predict cerebral performance and survival in resuscitated comatose survivors. Methods: Data from VF ECG tracings of patients resuscitated from SCD will be collected using an electronic Case Report Form. Patients can be either comatose (Glasgow Coma Scale GCS --- ≤8) survivors undergoing temperature control after return of spontaneous circulation (RoSC), or those who regain consciousness (GCS = 15) after RoSC; all admitted to Intensive Cardiac Care Units in 4 major university hospitals. VF tracings prior to the first direct current shock will be digitized and analyzed to derive spectral data and feed a predictive model to estimate favorable neurological performance (FNP). The results of the model will be compared to the actual prognosis. Results: The primary clinical outcome is FNP during hospitalization. Patients will be categorized into 4 subsets of neurological prognosis according to the risk score obtained from the predictive model. The secondary clinical outcomes are survival to hospital discharge, and FNP and survival after 6 months of follow-up. The model-derived categorisation will be also compared with clinical variables to assess model sensitivity, specificity, and accuracy. Conclusions: A model based on spectral analysis of VF tracings is a promising tool to obtain early prognostic data after SCD.

Resumen Objetivo: La muerte súbita (MS) por fibrilación ventricular (FV) es una importante causa de morbilidad y mortalidad. Los métodos biológicos y de imagen actuales muestran limitaciones para predecir el pronóstico cerebral al ingreso hospitalario. AWAKE es un estudio observacional, multicéntrico, con el objetivo de validar un modelo basado en el análisis espectral del elec- trocardiograma (ECG), que predice precozmente el pronóstico cerebral y la supervivencia en pacientes resucitados y en estado de coma. Métodos: Se recogerán datos de los ECG con FV de pacientes reanimados de MS. Los pacientes pueden ser tanto supervivientes en estado de coma (Glasgow Coma Scale GCS ≤ 8) sometidos a control de temperatura tras la recuperación de circulación espontánea (RCE), como aquellos que recuperan la consciencia (GCS = 15) tras RCE; todos ellos ingresados en unidades de terapia intensiva cardiológica de 4 hospitales de referencia. Los registros de FV previos al primer choque se digitalizarán y analizarán para obtener datos espectrales que se incluirán en un modelo predictivo que estime el pronóstico neurológico favorable (PNF). El resultado del modelo se comparará con el pronóstico real. Resultados: El objetivo principal es el PNF durante la hospitalización. Los pacientes se categorizarán en 4 subgrupos de pronóstico neurológico según la estimación de riesgo obtenida en el modelo predictivo. Los objetivos secundarios son supervivencia al alta hospitalaria, y PNF y supervivencia a los 6 meses. El resultado de este modelo también se comparará con el pronóstico según variables clínicas. Conclusiones: Un modelo basado en el análisis espectral de registros de FV es una herramienta prometedora para obtener datos pronósticos precoces tras MS por FV.

QRS duration reflects underlying changes in conduction velocity during increased intraventricular pressure and heart failure.

Pressure overload and heart failure electrophysiological remodeling (HF-ER) in pigs are associated with decreased conduction velocity (CV) and dispersion of repolarization, which lead to higher risk of ventricular arrhythmia. This work aimed to establish the correlation between QRS complex duration and underlying changes in CV during increased intraventricular pressure (IVP) and/or HF-ER ex-vivo, and to determine whether QRS duration could be sensitive to an acute increase in left ventricular (LV) afterload in-vivo. HF-ER was induced in 7 pigs by high-rate ventricular pacing. Seven weight-matched animals were used as controls. Isolated Langendorff-perfused hearts underwent programmed ventricular stimulation to study QRS complex duration and CV under low/high IVP, using volume-conducted ECG and epicardial optical mapping, respectively. Four additional pigs underwent open-chest surgery to increase LV afterload by partially clamping the ascending aorta, while measuring QRS complex duration during sinus rhythm (SR). In 13 hearts included for analysis, both HF-ER and increased IVP showed significantly slower epicardial CV (-40% and -15%, p < 0.001 and p = 0.004, respectively), which correlated with similar widening of the QRS complex (+41% and +17%, p = 0.005 and p < 0.001, respectively). HF-ER hearts shower larger prolongation of the QRS complex than controls upon increasing the IVP (+21% vs. +12%, respectively. HF-ER*IVP interaction: p = 0.004). QRS complex widened after increasing LV afterload in-vivo (n=3), with correlation between QRS duration and aortic diastolic pressures (R = 0.58, p < 0.001). In conclusion, high IVP and/or HF-ER significantly decrease CV, which correlates with QRS widening on the ECG during ventricular pacing. Increased myocardial wall stress also widens the QRS complex during SR in-vivo.

The atrial fibrillation ablation pilot study: a European Survey on Methodology and results of catheter ablation for atrial fibrillation conducted by the European Heart Rhythm Association.

AIMS: The Atrial Fibrillation Ablation Pilot Study is a prospective registry designed to describe the clinical epidemiology of patients undergoing an atrial fibrillation (AFib) ablation, and the diagnostic/therapeutic processes applied across Europe. The aims of the 1-year follow-up were to analyse how centres assess in routine clinical practice the success of the procedure and to evaluate the success rate and long-term safety/complications. METHODS AND RESULTS: Seventy-two centres in 10 European countries were asked to enrol 20 consecutive patients undergoing a first AFib ablation procedure. A web-based case report form captured information on pre-procedural, procedural, and 1-year follow-up data. Between October 2010 and May 2011, 1410 patients were included and 1391 underwent an AFib ablation (98.7%). A total of 1300 patients (93.5%) completed a follow-up control 367 ± 42 days after the procedure. Arrhythmia documentation was done by an electrocardiogram in 76%, Holter-monitoring in 52%, transtelephonic monitoring in 8%, and/or implanted systems in 4.5%. Over 50% became asymptomatic. Twenty-one per cent were re-admitted due to post-ablation arrhythmias. Success without antiarrhythmic drugs was achieved in 40.7% of patients (43.7% in paroxysmal AF; 30.2% in persistent AF; 36.7% in long-lasting persistent AF). A second ablation was required in 18% of the cases and 43.4% were under antiarrhythmic treatment. Thirty-three patients (2.5%) suffered an adverse event, 272 (21%) experienced a left atrial tachycardia, and 4 patients died (1 haemorrhagic stroke, 1 ventricular fibrillation in a patient with ischaemic heart disease, 1 cancer, and 1 of unknown cause). CONCLUSION: The AFib Ablation Pilot Study provided crucial information on the epidemiology, management, and outcomes of catheter ablation of AFib in a real-world setting. The methods used to assess the success of the procedure appeared at least suboptimal. Even in this context, the 12-month success rate appears to be somewhat lower to the one reported clinical trials.

The COR trial: a randomized study with continuous rhythm monitoring to compare the efficacy of cryoenergy and radiofrequency for pulmonary vein isolation.

BACKGROUND: Results from randomized trials designed to compare cryoenergy with radiofrequency for pulmonary vein (PV) isolation are lacking. OBJECTIVE: To compare the efficacy of a simplified strategy for PV cryoablation (group C) vs PV isolation with open-irrigated radiofrequency catheters (group R). METHODS: Fifty patients with paroxysmal atrial fibrillation (AF) and 4 independent PVs received a Reveal XT implantable cardiac monitor and were randomized to group C or group R. In group C, PV ablation was done with a single Arctic Front balloon (23 or 28 mm) per patient and two 300-second applications per PV. No further applications were delivered to close residual conduction gaps. In group R, bidirectional PV conduction block was pursued with Lasso and Navistar ThermoCool catheters and the CARTO system. The primary end point was the proportion of patients remaining free from AF recurrences ≥2 minutes without taking antiarrhythmic drugs 12 months after ablation. RESULTS: The primary end point was met by 12 (48%) patients in group C and 25 (68%) patients in group R (odds ratio 0.43; P = .05). This difference disappeared after adjustment for acute procedural outcome. In patients for whom all 4 PVs were blocked at the end of the procedure, there was no difference between group C and group R in the primary end point (67% vs 68%; P = .94). CONCLUSIONS: The efficacy of the simplified strategy for PV cryoablation tested in this study is inferior to PV isolation using open-irrigated radiofrequency catheters with electrophysiological and electroanatomical guidance. Complete PV conduction block is critical to the success of AF ablation.

Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study).

BACKGROUND: Catheter ablation (CA) is a highly effective therapy for the treatment of paroxysmal atrial fibrillation (AF) when compared with antiarrhythmic drug therapy (ADT). No randomized studies have compared the two strategies in persistent AF. The present randomized trial aimed to compare the effectiveness of CA vs. ADT in treating persistent AF. METHODS AND RESULTS: Patients with persistent AF were randomly assigned to CA or ADT (excluding patients with long-standing persistent AF). Primary endpoint at 12-month follow-up was defined as any episode of AF or atrial flutter lasting >24 h that occurred after a 3-month blanking period. Secondary endpoints were any atrial tachyarrhythmia lasting >30 s, hospitalization, and electrical cardioversion. In total, 146 patients were included (aged 55 ± 9 years, 77% male). The ADT group received class Ic (43.8%) or class III drugs (56.3%). In an intention-to-treat analysis, 69 of 98 patients (70.4%) in the CA group and 21 of 48 patients (43.7%) in the ADT group were free of the primary endpoint (P = 0.002), implying an absolute risk difference of 26.6% (95% CI 10.0-43.3) in favour of CA. The proportion of patients free of any recurrence (>30 s) was higher in the CA group than in the ADT group (60.2 vs. 29.2%; P < 0.001) and cardioversion was less frequent (34.7 vs. 50%, respectively; P = 0.018). CONCLUSION: Catheter ablation is superior to medical therapy for the maintenance of sinus rhythm in patients with persistent AF at 12-month follow-up. CLINICAL TRIAL REGISTRATION INFORMATION: NCT00863213 (http://clinicaltrials.gov/ct2/show/NCT00863213).

Early recurrence is a predictor of late failure in surgical ablation of atrial fibrillation.

We sought to determine if early recurrence of atrial fibrillation (AF) after surgical ablation is a risk factor of late failure. Between February 2004 to May 2009, 106 patients underwent surgical ablation of concomitant permanent AF with radiofrequency. Operations primarily consisted of valve surgery in 85% of patients. Hospital mortality was 2.8% (n = 3). The median follow-up was 37 months (interquartile rank 12-77), and was complete in 99% of patients. Freedom from AF was 82%, 76% and 68% at one, two and three years, respectively. Patients with early recurrence of AF had less prevalence of sinus rhythm in late follow-up (P < 0.001). Multivariate Cox regression analysis showed that AF duration [hazard ratio (HR) 1.014, 95% CI 1.009-1.020, P < 0.001] and early recurrence of AF (HR 3.45, 95% CI 1.50-7.95, P = 0.004) were independent risk factors for failure. In conclusion, in our series, early recurrence of AF after surgical ablation is a strong predictor of late failure.

Novel mutation (H402R) in the S1 domain of KCNH2-encoded gene associated with long QT syndrome in a Spanish family.

Long-QT syndrome is a congenital cardiac disease resulting in ventricular arrhythmias and sudden death. Genetic mutations in two protein ion-channel genes, KCNQ1 and KCNH2. The mutations position in these genes provides additional information about the evaluation of the risk-stratification. In a Spanish family in whom previous repetitive syncope episodes, sudden death and pathological prolongation of the QT interval were documented, a novel heterozygous mutation in the KCNH2 gene (A1218>G) was identified. This mutation loading to amino acid substitution H420R in the S1 transmembrane domain of KCNH2. The new A1218>G mutation in the KCNH2 gene detected in this Spanish family causes arrhythmia manifestation in the carriers.

Predictores de éxito de la ablación desde el seno no coronario de la raíz aórtica de taquicardias auriculares con origen en la proximidad del nodo auriculoventricular / Predictores of success of the ablation from the not coronary bosom of the aortic root of taquicardias earphones with origin in the proximity of the node atrioventricular

Introducción. Las taquicardias auriculares (TA) con origen en la proximidad del nodo AV representan hasta el 10 por ciento de las TA. El tratamiento con readiofrecuencia(RF) implica riesgo de lesión del nodo AV. Pacientes. Se evaluaron 11 pacientes de una serie de 61 TA con activación auricular más precoz en la proximidad del nodo AV. Resultados. La aplicación de RF tuvo éxito en 10 localizaciones: 5 perihisiana derecha, 1 foramen oval derecho, 1 septum interauricular izquierdo y 3 seno no coronario de Valsalva. La morfología de la onda P y la longitud de ciclo de las TA no fueron diferentes entre las localizaciones. La activación auricular menor a 80ms y un electrograma unipolar con morfología QS fueron observados solo en pacientes con éxito desde la raíz aórtica. El mapa de isocronas con CARTO de la aurícula derecha no fue útil en predecir el lugar de éxito. La aplicación de RF en la raíz aórtica terminó la taquicardia en zonascon precocidades entre 20 y 35 ms.Conclusión. No se encontraron predictores del lugar de éxito de la aplicación de radiofrecuencia en pacientes con TA originada en la proximidad del nodo AV. El acceso aórtico retrógrado puede ser eficiente y seguro en el tratamiento de algunas TA.

Introduction. Focal atrial tachycardias (AT) originating from near the AV node represent 10 per cent of AT. Radiofrequency (RF) treatment implies risk of impairing AV conduction. Patients. The study population included 11 patients of a consecutive series of 61 with AT in whom mapping of the right atrium revealed earliest activation near the AV node. Results. Radiofrequency current was successful in 10 patients: 5 right perihisian, 1 right oval foramen, 1 left side of the interatrial septum and 3 in the noncoronary sinus of Valsalva; applications of RF and cryoablation,only transiently terminated the arrhythmia. The Pwave morphology and cycle length of AT did not differ between different locations. Atrial activation was shorter 80 ms and unipolar electrogram with QS morphology, were only present in patients with ablation procedure performed at the aortic root. CARTO© isochronal maps of right atrium not useful to identify successful ablationsite. Mapping the aortic root found precocities from 20 to 35 ms at noncoronary sinus, RF energy delivered from this site successfully terminated the tachycardia. Conclusion. There were no good predictors for the best ablation approach in patients with atrial tachycardia originating near AV node. Aortic approach may be safe and efficient on the treatment of AT.