Implante alto de las válvulas autoexpandibles con la técnica de "Cusp-Overlap", una estrategia para disminuir la necesidad de marcapasos en el implante percutáneo de válvula aórtica. Evolución a 30 días / High Self-expandable Valve Implantation with the Cusp-Overlap Technique, a Strategy to Reduce the Need for Pacemaker in Transcatheter Aortic Valve Implantation. 30-day Outcome

RESUMEN Objetivo: Analizar si el implante más alto en el implante percutáneo de válvula aórtica (TAVI) con válvulas auto-expandibles utilizando la superposición de las cúspides derecha e izquierda disminuye la necesidad de marcapasos definitivo. Material y Métodos: Se analizaron 164 pacientes consecutivos que recibieron TAVI con válvulas auto- expandibles; en 101(61,6%) de ellos se implantaron utilizando la vista coplanar de las tres cúspides, a la cual llamamos técnica convencional (CON) y en 63 (38,4%) utilizamos la técnica COVL, con superposición de las cúspides derecha e izquierda . El punto final primario (PFP) fue la necesidad de marcapasos definitivo (MCPD) a 30 días. Resultado: No hubo diferencias entre los grupos en la edad media, prevalencia de sexo masculino, hipertensión, cirugía de revascularización previa, antecedente de accidente cerebrovascular (ACV), función renal, o hemodiálisis. Los pacientes en el grupo COVL tuvieron más diabetes, angioplastia coronaria (ATC) e infarto previos. La ATC pre-TAVI fue similar, con mayor score STS (6,3 ± 2,1 vs. 5,8 ± 2,4; p = 0,05). La presencia de fibrilación auricular fue mayor en el grupo COVL sin diferencia en bloqueo auriculoventricular, de rama derecha o izquierda. No hubo diferencia en el área valvular aórtica, gradiente medio y fracción de eyección ventricular izquierda. A 30 días se observó una reducción significativa del PFP en la estrategia COVL, (6,3% vs 17,8%, p = 0,03). No hubo diferencia en mortalidad, ACV, sangrado mayor, infarto agudo de miocardio o regurgitación aórtica. Hubo tendencia a menor presencia de nuevo bloqueo competo de rama izquierda en el grupo COVL (4,8% vs. 12,9%, p = 0,08). Conclusiones: El uso de la técnica de COVL, que permite un implante más alto en el TAVI con válvulas autoexpandibles, demostró en esta serie ser factible y seguro, con disminución de la necesidad de MCPD sin aumento de las complicaciones.

ABSTRACT Objective: The aim of this study was to analyze whether higher transcatheter aortic valve implantation with self-expandable valves using the right and left cusp overlap strategy decreases the need for permanent pacemaker. Methods: A total of 164 consecutive patients undergoing TAVI with self-expandable valves were analyzed: 101 (61.6%) implanted with the conventional technique (CON) using the three-cusp coplanar view, and 63 (38.4%) using the right and left cusp overlap (COVL) technique. The primary endpoint (PEP) was the need for permanent pacemaker (PPM) at 30 days. Results: Mean age, prevalence of male gender, hypertension, prior coronary artery bypass graft surgery (CABG), and history of stroke, kidney function or hemodialysis was not different between groups. Patients in the COVL group had more diabetes, coronary percutaneous transluminal coronary angioplasty (PTCA) and prior infarct, and pre-TAVI PTCA was similar, with higher STS score (6.3±2.2 vs. 5.8±2.4; p=0.05). The presence of atrial fibrillation was greater in the COVL group, without differences in right or left bundle branch or atrioventricular block. There was no difference in aortic valve area, mean gradient and left ventricular ejection fraction. At 30 days, the need of PPM was significantly reduced with the COVL technique (6.3%% vs. 17.8%; p=0.03). No difference was observed in mortality, stroke, major bleeding, acute myocardial infarction or aortic regurgitation, and the presence of new-onset complete left bundle branch block was lower in the COVL group (4.8% vs. 12.9%; p=0.08). Conclusions: Use of the COVL technique, which allows higher self-expandable valve implantation during TAVI, was feasible and safe, decreasing the need for PPM without increasing complications.

Endocarditis infecciosa luego del implante de válvula aórtica por cateterismo / Infective Endocarditis after Transcatheter Aortic Valve Implantation

RESUMEN Introducción: La endocarditis infecciosa (EI) post implante percutáneo de válvula aórtica (TAVI) es poco frecuente, con una alta tasa de morbimortalidad. Métodos: Se analizaron 630 pacientes consecutivos con TAVI, de los cuales 6 (0,95%) presentaron EI. Resultados: Cuatro eran hombres, edad 81,3 ± 2,2 años, y todos sintomáticos. La fracción de eyección ventricular izquierda (FEVI) fue 56,8 ± 5,3%. Todos recibieron un implante exitoso y uno presentó regurgitación moderada. Dos requirieron marcapaso definitivo, a uno de ellos se le debió recolocar el cable a las 24 hs. La EI se presentó a los 63,5 ± 73,3 días (mediana de 35 días). El germen aislado fue un coco (+) en cuatro casos. En uno se observó una vegetación en el ecocardiograma transesofágico. Un paciente falleció dentro de los 30 días. El seguimiento fue a 23 ± 22 meses, ningún paciente presentó nuevos eventos o internaciones. En el eco Doppler la FEVI fue de 55,9 ± 4,6%, el gradiente medio 8,2 ± 1,8 mmHg y la velocidad pico de 1,8 ± 0,2 m/seg. Un paciente terminó una regurgitación moderada. Conclusiones: En esta serie de pacientes, la EI post TAVI fue poco frecuente y presentó una evolución favorable con el tratamiento antibiótico.

ABSTRACT Background: Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is a rare complication with high morbidity and mortality. Methods: Of 630 consecutive patients undergoing TAVI, 6 (0.95%) presented IE. Results: Four patients were men, mean age was 81.3 ± 2.2 years and all the patients were symptomatic. Left ventricular ejection fraction (LVEF) was 56.8 ± 5.3%. The procedure was successful in all the patients and one presented moderate regurgitation. Two patients required definitive pacemaker and the lead had to be reimplanted 24 hours later in 1 patient. Time to IE was 63.5 ± 73.3 days (median 35 days). A Gram-positive coccus was isolated in four cases. One patient presented a vegetation on transesophagic echocardiography. One patient died within 30 days. During follow-up of 23 ± 22 months none of the patients presented new events or hospitalizations. On Doppler echocardiography, LVEF was 55.9 ± 4.6%, mean trans-aortic gradient was 8.2 ± 1.8 mm Hg and peak systolic velocity was 1.8 ± 0.2 m/s. One patient had moderate regurgitation. Conclusions: In this series of patients, IE after TAVI was uncommon and had a favorable course with antibiotic treatment.

Impact of Cusp-Overlap View for TAVR with Self-Expandable Valves on 30-Day Conduction Disturbances.

METHODS AND RESULTS: We retrospectively compared 257 consecutive patients undergoing TAVR with self-expandable valves using either CON (n = 101) or COVL (n = 156) in four intermediate/low volume centers. There were no significant differences in baseline characteristics between the groups. The 30-day incidence of new-onset LBBB (12.9% vs. 5.8%; p=0.05) and PPMI rate (17.8% vs. 6.4%; p=0.004) was significantly lower when using the COVL implantation view. There was no difference between the CON and COVL groups in 30-day incidence of death (4.9% vs. 2.6%), any stroke (0% vs. 0.6%), and the need for surgical aortic valve replacement (0% for both groups). CONCLUSION: Using the COVL view for implantation, we achieved a significant reduction of the LBBB and PPMI rate after TAVR in comparison with the traditional CON view, without compromising the TAVR outcomes when using self-expandable prostheses.

Tratamiento endovascular de aneurismas de aorta con estrategia minimalista / Endovascular Treatment of Aortic Aneurysms with Minimalistic Approach

RESUMEN Introducción: Los aneurismas de aorta siguen siendo una patología frecuente, en especial aquellos localizados en la aorta abdominal. Desde 1990, gracias al avance en los dispositivos y las técnicas endovasculares, la cirugía convencional ha dejado de ser la única opción de tratamiento. Presentamos nuestros resultados en el manejo del aneurisma de aorta con técnica endovascular mínimamente invasiva. Objetivos: Analizar los resultados a 30 días del implante de endoprótesis en la aorta torácica y abdominal con una estrategia mínimamente invasiva. Material y métodos: Entre marzo de 2012 y abril de 2019 se realizaron 395 implantes consecutivos de endoprótesis de aorta; en 264 (67%) de los cuales se utilizó una técnica mínimamente invasiva (MIN-A). De este grupo 240 procedimientos (90,9%) fueron llevados a cabo para reparar la aorta abdominal (EVAR) y 24 (9,1%) la aorta torácica (TEVAR). Resultados: De 264 pacientes se logró éxito técnico (ET) del implante en el 99,6% y éxito clínico (EC) en el 97,7%. La mortalidad a 30 días fue del 1,1% dado por neumonía, insuficiencia cardíaca y EPOC. Ningún paciente presentó IAM, ACV o necesitó de conversión a reparación quirúrgica de urgencia. El tiempo promedio del procedimiento fue de 62 minutos (SD ± 17). Algunos pacientes requirieron conversión a cierre quirúrgico del acceso [20 (7%) durante los primeros 100 casos, y 7 (3%) en los últimos 164 pacientes p = 0,05)]. El sangrado mayor que requirió transfusión fue del 1,1%. El tiempo promedio para la deambulación fue de 18 horas (SD ± 10), que luego de los primeros 100 pacientes disminuyó en forma significativa a 13 horas (SD ± 2,9 p = 0,05). La estadía hospitalaria en promedio fue de 1,4 días (SD ± 1,14) con 5 casos externados el mismo día del procedimiento. Conclusiones: Los procedimientos de reparación endovascular de aneurismas de la aorta con una estrategia miniinvasiva fueron factibles y seguros, ya que permitieron convertir estos procedimientos en abordajes percutáneos, con bajas tasas de complicaciones asociadas al acceso, menor tiempo quirúrgico, rápida deambulación y menor estadía hospitalaria, sin modificar la seguridad global del procedimiento. La curva de aprendizaje permitió bajar la tasa de conversiones a cirugía, así como los tiempos de deambulación.

ABSTRACT Background: Aortic aneurysms, particularly of the abdominal aorta, are still common. Since 1990, conventional surgery is no longer the only treatment option due to advances in endovascular devices and techniques. We present our results in the management of aortic aneurysms with a minimally invasive endovascular technique. Objectives: The aim of this study was to analyze the 30-day outcomes of endograft implantation in the thoracic aorta and abdominal aorta using a minimally invasive approach. Methods: Between March 2012 and April 2019, 395 consecutive endografts were implanted in the aorta, and 264 (67%) were performed using a minimally invasive approach (MIN-A). Among this group, 240 (90.9%) corresponded to abdominal endo-vascular aortic repair (EVAR) and 24 (9.1%) to thoracic endovascular aortic repair (TEVAR). Results: Technical success (TS) of the implant was achieved in 99.6% of the 264 patients and clinical success (CS) in 97.7%. Thirty-day mortality was 1.1% due to pneumonia, heart failure and chronic obstructive pulmonary disease. There were no cases of myocardial infarction, stroke or need for conversion to urgent surgical repair. Mean duration of the procedure was 62 minutes (SD ± 17). Some patients required conversion to surgical closure of the access site [20 (7%) during the first 100 cases and 7 (3%) in the final 164 patients, p = 0.05]. Three (1.1%) patients presented major bleeding requiring transfusion. Mean time to ambulation was 18 hours (SD ± 10) that significantly decreased to 13 hours after the first 100 patients (SD ± 2.9; p= 0.05). Mean length of hospital stay was 1.4 days (SD ± 1.14) with 5 patients discharged on the same day of the procedure. Conclusions: Endovascular aortic aneurysm repair using a minimally invasive strategy was feasible and safe, turning this procedure into a percutaneous approach, with low access site-related complications, shorter operative time, rapid ambulation and shorter length of hospital stay, without modifying overall safety of the procedure. The learning curve resulted in reduced rate of conversion to surgery and earlier ambulation.

Implante percutáneo de la válvula aórtica con estrategia minimalista / Minimalist Approach for Percutaneous Aortic Valve Implantation

RESUMEN Introducción: El reemplazo de válvula aórtica transcatéter (TAVR) se está convirtiendo en un procedimiento estándar para pacientes con alto riesgo quirúrgico que necesitan el reemplazo de la válvula aórtica. Esta técnica ha evolucionado rápidamente y la llamada estrategia minimalista está ganando adeptos en todo el mundo, mientras la evidencia en su favor todavía se está acumulando. Objetivo: Analizar los resultados a 30 días de la estrategia minimalista (MIN-A) en comparación con la técnica convencional (CON-A) en la experiencia de un solo centro. Material y métodos: Entre septiembre de 2009 y febrero de 2018, se realizaron 303 procedimientos consecutivos de TAVR por acceso femoral, 229 (75,6%) de ellos con MIN-A y 74 (24,4%) con CON-A. Resultados: La edad promedio de los pacientes fue de 79,5 años y ambos grupos tenían características similares. No hubo diferencias entre estos en lo referido a hipertensión, diabetes, tabaquismo, ICP o CRM previa, IAM, EPOC, fibrilación auricular y diálisis. La ATC por etapas antes del TAVR (procedimiento combinado) y la insuficiencia renal (eGFR < 60 ml / min / 1,73 m2) fueron más frecuentes en los sometidos a CON-A. El score del STS fue similar en ambos grupos. El tiempo del procedimiento fue menor en el grupo MIN-A (125 ± 26 vs. 211 ± 48 minutos; p < 0,001), al igual que el tiempo de hospitalización (4,1 vs. 6,3 días; p = 0,01). A los 30 días, no hubo diferencias en la mortalidad (3,9% frente a 1,4%; p = 0,29), IAM, accidente cerebrovascular, hemorragia, transfusión y complicaciones vasculares. Cuatro pacientes tuvieron falla del dispositivo de cierre (1 requirió reparación quirúrgica, 3 requirieron stent cubierto). Las fugas paravalvulares (PVL) moderadas fueron más frecuentes en el grupo CON-A (11,8% vs. 23%; p = 0,01), pero las PVL graves tuvieron similar incidencia (1,3% vs. 2,7%). Conclusión: La estrategia minimalista en el implante percutáneo de la válvula aórtica demostró ser factible y segura; dicha estrategia disminuyó el tiempo del procedimiento y la estadía en el hospital, con similares resultados clínicos que la estrategia convencional a 30 días, pero con mejor confort para el paciente.

ABSTRACT Background: Transcatheter aortic valve implantation (TAVI) is becoming the standard procedure for high-risk patients requiring aortic valve replacement. This technique has evolved rapidly and the so-called minimalist strategy is gaining worldwide attention, while supporting evidence is still being assembled. Objective: The aim of this study was to compare 30-day outcomes of the minimalist approach (MA) versus the standard approach (SA) for TAVI performed in a single center. Methods: Between September 2009 and February 2018, 303 consecutive TAVI procedures were performed, 229 (75.6%) using the MA and 74 (24.4%) with the SA. Results: Mean age was 79.5 years and both groups had similar characteristics. There were no differences in hypertension, diabetes, smoking habits, previous percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery, acute myocardial infarction (AMI), chronic obstructive pulmonary disease, atrial fibrillation and dialysis. PCI before TAVI (combined procedure) and kidney failure (eGFR <60 ml / min / 1.73 m2) were more common in the SA group. The STS score was similar in both groups. The total duration of the procedure and in-hospital stay were lower in the MA group (125±26 vs. 211±48 minutes; p <0.001, and 4.1 vs. 6.3 days; p=0.01, respectively). There were no differences in mortality (3.9% vs. 1.4%; p=ns), incidence of AMI, stroke, major bleeding requiring transfusion or vascular complications at 30 days. The closure device failed in four patients (one underwent surgical repair and three required a covered stent). Moderate paravalvular leaks (PVL) were more frequent in the SA group (11.8% vs. 23%; p=0.01) but the incidence of severe PVL was similar (1.3% vs. 2.7%). Conclusion: The MA for TAVI proved to be feasible and safe, reducing the procedure duration and in-hospital stay, with 30-day outcomes similar to those of the SA but providing better comfort for the patient.

Reparación valvular mitral por cateterismo: experiencia inicial con MitraClip® / Percutaneous Mitral Valve Repair: Initial Experience with MitraClip™

RESUMEN Objetivos: Reportar y analizar los resultados iniciales de una serie de pacientes con insuficiencia mitral (IM) grave sintomática y alto riesgo para cirugía que recibieron reparación percutánea de la válvula mitral (RPVM) con MitraClip®. Material y métodos: Entre marzo de 2016 y octubre de 2018 recibieron RPVM con MitraClip® en forma consecutiva 12 sujetos con IM grave sintomática, con alto riesgo o contraindicación para cirugía. Se consideró "éxito del implante" (EI) el correcto agarre de las valvas con el clip que dejó una IM residual leve o moderada al finalizar el procedimiento, y "éxito del procedimiento (EP) a 30 días" el EI en ausencia de eventos adversos mayores (MACE), los que incluyeron muerte, infarto agudo de miocardio (IAM), accidente cerebrovascular (ACV), necesidad de cirugía valvular, derrame pericárdico, taponamiento o sangrado mayor. Datos basales y antecedentes de los pacientes: la media de edad fue de 74,1 ± 8,9 años; 7 eran hombres; 3, diabéticos; 10 eran hipertensos y dislipidémicos; 4 eran tabaquistas, 5 tenían fibrilación auricular, 2 portaban marcapasos definitivo, 3 documentaban IAM previo, 2 habían sido sometidos antes a ATC y 4 a cirugía cardíaca. La tasa de filtración glomerular estimada (eGFR) fue de 73,8 ± 34,8 ml/m2, 2 tenían < 60 ml/m2 y uno se encontraba en diálisis. Todos los pacientes estaban en clase funcional (CF) III-IV, con antecedentes de internaciones por insuficiencia cardíaca (IC). Características ecográficas: diámetro diastólico del ventrículo izquierdo (DDVI): 61,8 ± 6,4 mm; diámetro sistólico (DSVI): 46,3±2,1 mm; fracción de eyección del ventrículo izquierdo (FEVI): 47,5±13,4% (rango: 25-60%). La causa de la IM era degenerativa en 7 pacientes y funcional en 5. La evaluación del riesgo mostró un EuroSCORElog de 9,6±6,8; el STS score de mortalidad fue 16,1 ±1 3,5 y el de morbimortalidad 22,8 ± 17,7. Resultados: Se obtuvo EI en todos los pacientes; en 7 enfermos se implantó 1 solo clip y en los otros 5 se colocaron 2 clips; el gradiente residual medio posimplante fue 3,6 ± 0,2 mmHg. La IM posprocedimiento fue leve en 11 y mínima en 1. La estadía hospitalaria media fue de 1,9 ± 0,8 días (rango: 1-3 días). A los 30 días, todos los sujetos se encontraban en CF I-II; ningún paciente presentó eventos mayores o reinternación por IC. El seguimiento abarcó a todos los pacientes y se extendió por un tiempo medio de 8,8 ± 6,7 meses (rango: 1-30 meses). Dos pacientes fallecieron: 1 de neumonía a los 14 meses y otro a los 30 meses por IC refractaria luego de un reemplazo valvular aórtico por cateterismo (TAVI), manteniendo IM leve. No hubo otras complicaciones. Todos se encontraban en CF I-II, 1 requirió reinternación por IC (a los 7 meses). El eco-Doppler cardíaco de seguimiento demostró IM leve en 11 pacientes y moderada a grave en 1. Hubo una mejoría en la calidad de vida en todos los casos. Conclusiones: En esta serie inicial de un solo centro y que incluye la curva de aprendizaje, la RPVM con MitraClip® en pacientes con IM grave sintomática y alto riesgo quirúrgico fue segura y efectiva, con una mejoría clínica significativa y también en la calidad de vida en el seguimiento.

ABSTRACT Objective: To analyze and report our initial outcomes of Percutaneous Mitral Valve Repair (PMVR) with MitraClip® for patients with severe symptomatic Mitral Regurgitation (MR) and high surgical risk. Methods: Between March 2016 and October 2018 twelve consecutive PMVR with MitraClip® were performed in patients with severe symptomatic MR and contraindication or high surgical risk. Implantation Success (IS) was defined as adequate leaflets grasping, leaving < moderate residual MR at the end of the procedure and 30-day Procedural Success when IS was achieved without any Major Adverse Cardiovascular Event (MACE: death, AMI, Stroke, need of valvular surgery, pericardial effusion, tamponade or major bleeding). Results: Mean age was 74.1±8.9 years, all of them had hypertension and Dyslipemia 7 were men, 3 diabetics, 4 smokers, 5 had previous atrial fibrillation, 2 permanent pacemakers, 3 previous AMI, 2 of them had received PCI and 4 cardiac surgery. The eGFR was 73.8±34.8 ml/m2, 2 had <60 ml/m2 and one on dialysis. All Ptes were in FC III-IV and history of previous hospitalizations because heart failure. Echocardiographic findings: Left Ventricle End Diastolic Diameter (LVEDD) 61.8±6.4, End Systolic Diameter (LVESD) 46.3±2.1; left ventricular ejection fraction (LVEF) 47.5±13.4 (25-60). MI were degenerative in 7 Ptes and functional in 5. Risk Scores: EuroSCORE log was 9.6±6.8, STS for mortality 16.1±13.5 and the STS for morbimortality of 22.8±17.7 EI was achieved in all Ptes; 1 Single Clip was implanted in 7 Pts and 2 Clips in 5; Mean residual post-implantation gradient was 3.6±0.2 mmHg. IS was achieved in all; post-procedural MR was mild in 11 and trivial in one. Mean length of hospital stay was 1.9±0.8 (1-3) days. At 30 days all were in FC 0-II, no one presented MACE or rehospitalization because heart failure. Follow-Up was performed in all Ptes with an average time of 8.8±6.7 (1-30) months. Two patients died (1 from pneumonia at 14 months and another at 30 months due to refractory cardiac failure after TAVI, maintaining mild MR.) There were no other complications, all were in FC I-II, one required rehospitalization due to heart failure (at 7 month). Echo Doppler at follow-Up showed that 11 Ptes had <2 MR and 1 had >2 MR. The QOL improved during the follow-up Conclusion: In this initial series, from a single center that includes the learning curve of the team, PMVR with MitraClip® in Ptes with severe mitral regurgitation and high surgical risk was safe and effective, with a significant clinical improvement at follow-up

Vascular endothelial growth factor overexpression does not enhance adipose stromal cell-induced protection on muscle damage in critical limb ischemia.

OBJECTIVES: Critical limb ischemia complicates peripheral artery disease leading to tissue damage and amputation. We hypothesized that modifying adipose stromal cells (ASCs) to overexpress human vascular endothelial growth factor 165 (VEGF) would limit ischemic muscle damage to a larger extent than nonmodified ASCs. APPROACH AND RESULTS: Rabbits with critical hindlimb ischemia were injected with allogeneic abdominal fat-derived ASCs transfected with plasmid-VEGF165 (ASCs-VEGF; n=10). Additional rabbits received nontransfected ASCs (ASCs; n=10) or vehicle (placebo; n=10). One month later, ASCs-VEGF rabbits exhibited significantly higher density of angiographically visible collaterals and capillaries versus placebo (both P<0.05) but not versus ASCs (both P=NS). Arteriolar density, however, was increased in both ASCs and ASCs-VEGF groups (both P<0.05 versus placebo). ASCs-VEGF and ASCs showed comparable post-treatment improvements in Doppler-assessed peak systolic velocity, blood pressure ratio, and resistance index. Ischemic lesions were found in 40% of the muscle samples in the placebo group, 19% in the ASCs-VEGF group, and 17% in the ASCs groups (both P<0.05 versus placebo, Fisher test). CONCLUSIONS: In a rabbit model of critical limb ischemia, intramuscular injection of ASCs genetically modified to overexpress VEGF increase angiographically visible collaterals and capillary density. However, both modified and nonmodified ASCs increase arteriolar density to a similar extent and afford equal protection against ischemia-induced muscle lesions. These results indicate that modifying ASCs to overexpress VEGF does not enhance the protective effect of ASCs, and that arteriolar proliferation plays a pivotal role in limiting the irreversible tissue damage of critical limb ischemia.

Hybrid strategy for unstable patients with severe carotid and cardiac disease requiring surgery.

BACKGROUND: Concurrent severe carotid and cardiac disease is a challenging situation where staged surgery is probably the most common strategy. However, in patients with an unstable clinical presentation, the best approach is still a matter of debate. The aim of the study was to report in-hospital and midterm outcome in patients who received carotid artery stenting and synchronous cardiac surgery. METHODS: From June 1998 to July 2012, 54 consecutive patients who were treated at a high-volume university medical center with this hybrid approach were included in the study. All of the patients received carotid angioplasty while being administered aspirin and regular unfractionated heparin. Then, all of the patients were immediately transferred to the operating room for coronary and/or cardiac valve surgery. All of the patients were administered aspirin and clopidogrel once bleeding was ruled out, after surgery. RESULTS: There were 5 in-hospital surgical related deaths, and no patient suffered a stroke or required carotid urgent re-intervention. At follow-up (55 ± 28 months; range 1-144 months), there were no new neurological deficits, while one additional death occurred. CONCLUSIONS: In this series, synchronous carotid stenting and cardiac surgery were feasible with an acceptable complication rate in a high-surgical-risk population, which could not undergo staged procedures.

Complicaciones eléctricas posimplante de válvula aórtica percutáneo: evolución clínica y eléctrica / Clinical Outcomes of Electrical Disorders after Transcatheter Aortic Valve Implantation

Introducción El implante valvular aórtico percutáneo es una opción terapéutica cada vez más utilizada en pacientes en los que se descarta la cirugía. A pesar de que las alteraciones agudas de la conducción son una de las complicaciones más frecuentes, su significado clínico y electrocardiográfico no es del todo claro. Objetivos Determinar las implicaciones pronósticas del desarrollo de alteraciones agudas de la conducción luego del implante valvular aórtico percutáneo. Resultados Entre marzo de 2009 y febrero de 2012 se incluyeron para el análisis 47 pacientes; de ellos, 30 (63%) presentaron alteraciones agudas de la conducción: 19 pacientes solo bloqueo completo de rama izquierda (BCRI), 9 pacientes solo bloqueo auriculoventricular completo (BAVC) y 2 pacientes presentaron ambos trastornos, los que totalizaron 21 BCRI y 11 BAVC. A 12 (25%) se les implantó un marcapasos definitivo previo al alta: en 11 por BAVC y en 1 por BCRI agudo más fibrilación auricular. En solo un paciente el BAVC revirtió en hemodinamia. Los pacientes que persistieron con BAVC posintervención presentaron una media de estimulación ventricular en la intervalometría al mes del 90%, mientras que en el paciente con BAVC que revirtió en hemodinamia fue de solo el 3% y en el paciente con BCRI más fibrilación auricular fue < 10%. La incidencia de insuficiencia cardíaca en el posoperatorio fue mayor en los pacientes con alteraciones agudas de la conducción (p = 0,007), al igual que la estadía hospitalaria (p = 0,045). En el seguimiento no hubo diferencias en la tasa de reinternación ni en la mortalidad. Conclusiones En el presente estudio el desarrollo de alteraciones agudas de la conducción mostró un aumento en la incidencia de insuficiencia cardíaca y en los días de internación, sin incremento en la tasa de otros eventos mayores. La colocación de un marcapasos definitivo luego del BAVC podría realizarse en forma inmediata, ya que el trastorno generalmente es irreversible.

Introduction The indication of transcatheter aortic valve implantation in patients considered not suitable candidates for surgery is increasing. Despite acute disorders of the conduction system are common complications, their clinical and electrocardiographic significance is not completely clear. Objectives To determine whether acute disorders of the conduction system after transcatheter aortic valve implantation has prognostic implications. Results Between March 2009 and February 2012, 47 patients were included in the analysis. Thirty patients (63%) had acute disorders of the conduction system: 19 patients presented isolated complete left bundle branch block (LBBB), 9 patients isolated complete atrioventricular block (CAVB), and 2 patients both conduction disorders, with a total of 21 LBBBs and 11 CAVBs. A definite pacemaker was implanted in 12 patients (25%) before discharge: in 11 due to CAVB and in 1 due to acute LBBB plus atrial fibrillation. Complete AVB reverted in the catheterization laboratory in only one patient. At one month, average ventricular pacing was 90% in patients with persistent CAVB after the intervention, only 3% in the only patient in whom CAVB reverted at the catheterization laboratory and < 10% in the patient with LBB plus atrial fibrillation. The incidence of postoperative heart failure and hospital stay was greater in patients with acute disorders of the conduction system (p = 0.007 and p = 0.045, respectively). There were no differences in new hospitalizations and mortality during follow-up. Conclusions In this study, the development of acute disorders of the conduction system was associated with increased incidence of heart failure and hospital stay but not with the incidence of major events. A definite pacemaker could be implanted immediately after CAVB develops as the conduction disorder is generally irreversible.

Trombolisis farmacológica y mecánica en tromboembolismo pulmonar submasivo / Pharmacological and mechanical thrombolysis in submassive pulmonary embolism

La enfermedad tromboembólica pulmonar, en sus formas aguda, subaguda o crónica, presenta dificultades para su tratamiento y tiene elevada morbimortalidad. La gravedad del evento agudo y su potencial compromiso sobre la función del ventrículo derecho necesitan estrategias terapéuticas, a veces combinadas, para cambiar el curso de la enfermedad a favor de la supervivencia del paciente. Las trombolisis farmacológica y mecánica son instrumentos útiles para tratar un evento embólico pulmonar agudo grave. Se presenta el caso de una joven que desarrolló una embolia pulmonar submasiva de instalación subaguda en quien la terapia combinada y secuencial trombolítica, farmacológica y mecánica, fue exitosa.

Thromboembolic pulmonary disease is challenging for physicians when diagnosed in acute, sub-acute and chronic clinical patients, not only due to its morbi-mortality, but also because of its complex therapeutic management. Severity of the acute condition and potential commitment of right ventricular systolic function require therapeutic strategies, sometimes combined, in order to change the disease´s course, optimizing patient survival. Pharmacological and mechanical thrombolysis are useful therapeutic tools for patients suffering from severe acute pulmonary embolism. This study refers to a young woman who developed a sub-massive pulmonary embolism, of sub-acute onset. She underwent the combined sequential therapeutic strategy of pharmacological and mechanical thrombolysis with successful outcome.

Transcatheter aortic valve implantation without balloon predilation: a single-center pilot experience.

AIM: To assess the results of transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve prosthesis (Medtronic, Minneapolis, MN), without balloon predilation, in high-risk patients with degenerated severe aortic stenosis. METHODS AND RESULTS: Fifty-one consecutive patients who underwent direct TAVI, 98% through a transfemoral approach. Patients were 79 ± 8 years of age, 74% in New York Heart Association classes III or IV and at high risk for surgical valve replacement (mean logistic EuroScore 20 ± 15). Mean aortic valve area was 0.7 ± 0.2 cm(2). Procedural success rate was 94.2%. In-hospital, there were 2 deaths, 1 minor stroke with minimal sequelae, and 14 (28%) pacemaker implantation. At 30 days, there was one additional stroke and no new deaths. The mean postprocedural transprosthetic gradient was 15 ± 5 mm Hg; periprosthetic severe regurgitation was absent and moderate in one case. After a median follow-up of 7 months, there were five additional deaths (two cardiac), while 84% of survivors were in New York Heart Association classes I or II. CONCLUSIONS: These results suggest that direct CoreValve implantation in patients with severe aortic stenosis is feasible and may lead to hemodynamic and clinical improvement in patients who are poor candidates for aortic valve surgery, pending confirmation in larger series with longer follow-up.

High-dose plasmid-mediated VEGF gene transfer is safe in patients with severe ischemic heart disease (Genesis-I). A phase I, open-label, two-year follow-up trial.

OBJECTIVES: We aimed to assess safety and, secondarily, the efficacy of intramyocardial high-dose plasmid-vascular endothelial growth factor (VEGF) 165 (pVEGF165) gene transfer in no-option patients with coronary artery disease (CAD). BACKGROUND: Controlled trials of pVEGF165 in CAD have shown little benefit. One possible reason is shortness of dosage. We have shown in large mammalian models of chronic myocardial ischemia and acute myocardial infarction that intramyocardial pVEGF165 at doses significantly higher than those used in recent phase II trials is safe and efficacious on myocardial perfusion, left ventricular function, and infarct size limitation. METHODS: Using an injection catheter, 10 patients with severe CAD not amenable for revascularization received 10 intramyocardial injections of 0.38 mg (total dose, 3.8 mg) pVEGF165 in zones exhibiting myocardial ischemia, as assessed by combined stress 99mTc-sestamibi single-photon emission computed tomography and stress echocardiography. RESULTS: No serious adverse events related to either VEGF or the injection procedure occurred over the 2-year follow-up. One patient suffered femoral artery thrombosis after a follow-up coronary angiography, successfully resolved with medical treatment. Six patients suffered uncomplicated coronary ischemic events during the second year follow-up. Angina functional class decreased from 2.6 ± 0.2 to 1.2 ± 0.3 (mean ± SEM, P < 0.05), quality of life increased from 56.9 ± 3.2 to 82.6 ± 2.4 (P < 0.05), the summed difference score of myocardial perfusion decreased from 13.4 ± 2 to 7.7 ± 1.8 (P < 0.04), and stress ejection fraction did not change (44.2 ± 3.6% to 47.8 ± 3.1%, P = NS). CONCLUSIONS: High-dose intramyocardial pVEGF165 is safe at 2 years follow-up in patients with severe CAD. The efficacy results observed must be taken cautiously given the uncontrolled, open-label study design.

Beneficios y complicaciones del implante directo de prótesis aórtica autoexpandible para el tratamiento de la estenosisvalvular aórtica grave / Outcomes of Direct Implantation of Self-Expandable Aortic Valve Prosthesis for Severe Aortic Stenosis / Outcomes of Direct Implantation of Self-Expandable Aortic Valve Prosthesis for Severe Aortic Stenosis

Objetivo Describir la experiencia inicial con el implante directo de la prótesis aórtica autoexpandible CoreValve® en un centro argentino de alta complejidad cardiovascular. Material y métodos Desde mayo a diciembre de 2010 se incluyeron en forma consecutiva pacientes con estenosis aórtica grave (EAG) de alto riesgo sometidos a implante directo de prótesis CoreValve® (n = 21). Los criterios de inclusión fueron: área de la válvula aórtica < 1 cm2 (< 0,6 cm2/m2), anillo valvular aórtico de entre 20 y 27 mm, diámetro de la aorta ascendente a nivel de la unión sinotubular ≤ 40 (prótesis pequeña) o ≤ 43 mm (prótesis grande) y diámetro de la arteria femoral > 6 mm. Resultados La edad fue de 79 ± 8 años, el área valvular aórtica fue de 0,7 ± 0,2 cm2 y el EuroSCORE logístico fue del 26% ± 15% (50% con EuroSCORE logístico ≥ 20%). Tras el implante, el gradiente transaórtico máximo por ecocardiograma descendió de 80 ± 22 mm Hg a 14 ± 5 mm Hg. Dos pacientes presentaron insuficiencia aórtica de grado grave, que mejoraron luego de la posdilatación. La tasa de éxito del procedimiento fue del 95%, ya que un paciente falleció luego del implante valvular. Se implantó un marcapasos definitivo por bloqueo auriculoventricular en 6 pacientes. La sobrevida acumulada (media de seguimiento 5 ± 2,8 meses) fue del 75%. Conclusión Nuestra experiencia inicial sugiere que el implante directo de la prótesis CoreValve® es una opción terapéutica segura y factible para los pacientes con EAG de alto riesgo quirúrgico.

Objective To describe the initial experience with aortic valve implantation via a direct approach using a self-expanding CoreValveTM aortic valve prosthesis in a tertiary care center from Argentina. Material and methods From May to December 2010, 21 consecutive patients with severe aortic stenosis (SAS) and high surgical risk undergoing percutaneous aortic valve replacement with CoreValveTM prosthesis were included. The inclusion criteria were the following: aortic valve area <1 cm2 (<0.6 cm2/m2); aortic annulus diameter of 20-27 mm; diameter of the ascending aorta at the level of the sinotubular junction ≤ 40 (small prosthesis) or ≤ 43 mm (large prosthesis), and femoral artery diameter >6 mm. Results Mean age was 79±8 years, mean aortic valve area was 0.7±0.2 cm2 and mean logistic EuroSCORE was 26±15% (50% with logistic EuroSCORE ³ 20%). After valve implantation, peak transaortic pressure gradient measured by echocardiography decreased from 80±22 to 14±5 mm Hg. Two patients developed severe aortic regurgitation which improved with post-dilation. The success rate of the procedure was of 95% as a patient died immediately after valve implant. A definite pacemaker was implanted to six patients due to atrioventricular block. Cumulative survival was 75% after a mean follow-up of 5±2.8 months. Conclusion Our initial experience suggests that direct implantation of CoreValveTM prosthesis is a safe and feasible therapeutic option for patients with SAS and high surgical risk.

Clinical outcome after saphenous vein stenting with Taxus Liberté stent: results from the OLYMPIA Registry (TAXUS Liberté Postapproval Global Program).

We evaluated the incidence of clinical events after implantation of the TAXUS Liberté paclitaxel-eluting stent in saphenous vein graft (SVG) lesions in an unselected patient population. The OLYMPIA (TAXUS Liberté Post-Approval Global Registry) program gathered data on 21 954 patients receiving at least 1 TAXUS Liberté stent, including 345 patients with SVG lesions. All cardiac events were monitored with independent adjudication of end points. Patients enrolled at procedure started with no mandated inclusion/exclusion criteria. In SVG-OLYMPIA (n = 345), baseline comorbidities/complex disease were more frequent than the rest of the OLYMPIA (n = 21 560). SVG-OLYMPIA had similar cardiac death, target vessel revascularization, and definitive stent thrombosis rates than the rest of OLYMPIA. Despite higher baseline risk, the SVG-OLYMPIA had similar 12-month clinical outcome than the rest of the OLYMPIA registry, confirming the safety and efficacy of the TAXUS Liberté stent in this high-risk group.

Tratamiento de la compresión del tronco de la arteria coronaria izquierda en pacientes con hipertensión pulmonar / Treatment of compression of the left main coronary artery in patients with pulmonary hypertension

La angina de pecho es un síntoma frecuente en pacientes con hipertensión pulmonar (HP) de cualquier etiología. Aunque su fisiopatología no está aclarada, las causas propuestas son: la isquemia subendocárdica por aumento del estrés parietal del ventrículo derecho, la dilatación de la arteria pulmonar por incrementos transitorios de la presión pulmonar y la compresión extrínseca del tronco de la arteria coronaria izquierda (TCI) por la arteria pulmonar (AP) dilatada. Se presentan tres casos que muestran la relación entre la angina de pecho y la compresión del TCI en pacientes con HP asociada a cardiopatías congénitas, tratados mediante implante de stent coronario.

Chest pain is a frequent symptom in patients with pulmonary hypertension of any etiology. Its pathophysiology has not been clearly established, the proposed causes are ischemia due to increased right ventricle wall stress, transient increased pulmonary hypertension resulting in acute pulmonary artery dilatation and external compression of the left main coronary artery (LMCA) by a dilated pulmonary artery. We report and discuss here three cases where the association between chest pain and compression of the LMCA by a dilated pulmonary artery could be shown, and they were treated with coronary stenting.

Initial experience with transradial access for carotid artery stenting.

We report our experience using transradial access (TRA) for carotid artery stenting (CAS). Eighty-eight patients underwent CAS using a nonfemoral approach, 79 of them by TRA. Carotid artery stenting was performed using standard techniques with a long hydrophilic sheath. Mean age was 69.5 years. A total of 46 patients were symptomatic and 34 were asymptomatic. Transradial access and procedural success were achieved in 98.8% and 96.6% of the cases, respectively. There were no deaths, myocardial infarction, or radial access site complications. In all, 2 patients sustained a stroke, 1 hemorrhage, and 1 ischemia. Carotid artery stenting using TRA was safe and technically feasible.

Lifesaving kissing stent for pulmonary trunk stenosis due to primary angiosarcoma.

A 62-year-old diabetic female was referred to our institution with a 6-month history of pulmonary hypertension and worsening right-sided heart failure. Computed tomography of the chest and pulmonary angiogram revealed a pulmonary artery mass. Due to patient's frail state, palliative kissing stenting to both pulmonary arteries was performed with optimal angiographic results and overt clinical improvement. At 5 month follow-up, both stents were patent and adequate lung perfusion was observed bilaterally.

Estratégia híbrida combinando angioplastia carotídea e cirurgia cardiovascular / Hybrid strategy combining carotid stenting and cardiovascular surgery

Fundamentos: Lesões carotídeas estão presentes em 8% a 14% dos candidatos a cirurgia cardiovascular e aumentam o risco de acidente vascular cerebral perioperatório. Esse problema é particularmente importante em pacientes com doença coronária e/ou valvar grave que não são candidatos a procedimentos de revascularização em momentos diferentes. Avaliamos os resultados de uma estratégia híbrida de tratamento, na qual angioplastia carotídea e cirurgia cardiovascular foram realizadas de forma sequencial, com intervalo de algumas horas. Método: Foram tratadas lesões carotídeas > 70% em pacientes sintomáticos e > 80% nos assintomáticos. Ácido acetilsalicílico foi administrado antes da angioplastia carotídea e heparina, no momento do procedimento. Finalizada a intervenção percutânea, os pacientes foram transferidos para a sala de cirurgia para realização do procedimento cardiovascular. Clopidogrel foi administrado habitualmente 8 horas após o término da cirurgia...

Background: Carotid lesions are observed in 8% to 14% of cardiovascular surgery candidates and increase the risk of perioperative stroke. This is particularly important in patients with coronary disease and/or severe valve disease who are not candidate to revascularization procedures at different time points. We assessed the results of a hybrid strategy, where carotid angioplasty and cardiovascular surgery were performed sequentially with an interval of a few hours. Method: Carotid lesions > 70% in symptomatic patients and > 80% in asymptomatic patients were treated. Acetylsalicylic acid was administered prior to carotid stenting and heparin was administered at the time of the procedure. Once the percutaneous intervention was over, patients were transferred to the surgery room to carry out the cardiovascular procedure. Clopidogrel was administered 8 hours after the end of the surgery...

Angioplastia infrapatelar en la isquemia de miembros inferiores / Bellow-the-Knee angioplasty for inferior limb claudication

Analizar la evolución hospitalaria y alejada de los pacientes (ptes.) que recibieron una angioplastia periférica infrapatelar (ATP-IFP) por claudicación de miembros inferiores...

To analyze in-hospital and long term evolution of patients who underwent bellow-the knee (BTK) Angioplaty for inferior limb claudication...