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INTRODUCTION AND OBJECTIVES: Transfemoral access is the most frequently used vascular approach in chronic total occlusion percutaneous coronary interventions (CTO-PCI). The aim of this study was to evaluate the safety and feasibility of a transradial access CTO-PCI program and its impact on angiographic and clinical results and length of hospital stay. METHODS: Retrospective multicenter cohort study including 2550 consecutive CTO-PCI procedures included in a multicenter registry with accurate information on vascular access. A total of 896 procedures were performed as radial-only access while 1654 were performed through at least 1 femoral puncture. Clinical and angiographic data were collected. RESULTS: The mean age was 66.3± 11.4 years. The mean Japan-chronic total occlusion score (2.7±0.3) was similar in the 2 groups. Successful revascularization was achieved in 2009 (79.6%) cases, 78.2% and 82.1% in the femoral and radial access cohorts, respectively (P=.002). Periprocedural in-hospital complications were observed in 5.1% and 2.3% (P=.02), with fewer access site-dependant vascular complications in the transradial cohort (2.3% vs 0.2%; P=.009). The mean length of hospital stay was significantly shorter in the transradial access group (0.89±1.4 vs 2.2±3.2 days, P<.001). CONCLUSIONS: A transradial program for CTO-PCI is safe and effective in most CTO lesions. The transradial strategy has fewer vascular complications and shorter length of hospital stay without compromising the success rate.
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Enfermedades Cardiovasculares , Oclusión Coronaria , Intervención Coronaria Percutánea , Humanos , Persona de Mediana Edad , Anciano , Intervención Coronaria Percutánea/métodos , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/cirugía , Estudios de Factibilidad , Estudios de Cohortes , Arteria Radial/cirugía , Arteria Femoral/cirugía , Resultado del Tratamiento , Angiografía Coronaria , Sistema de Registros , Enfermedad CrónicaRESUMEN
BACKGROUND: We aimed to compare the performance of the recent CASTLE score to J-CTO, CL and PROGRESS CTO scores in a comprehensive database of percutaneous coronary intervention of chronic total occlusion procedures. METHODS: Scores were calculated using raw data from 1,342 chronic total occlusion procedures included in REBECO Registry that includes learning and expert operators. Calibration, discrimination and reclassification were evaluated and compared. RESULTS: Mean score values were: CASTLE 1.60±1.10, J-CTO 2.15±1.24, PROGRESS 1.68±0.94 and CL 2.52±1.52 points. The overall percutaneous coronary intervention success rate was 77.8%. Calibration was good for CASTLE and CL, but not for J-CTO or PROGRESS scores. Discrimination: the area under the curve (AUC) of CASTLE (0.633) was significantly higher than PROGRESS (0.557) and similar to J-CTO (0.628) and CL (0.652). Reclassification: CASTLE, as assessed by integrated discrimination improvement, was superior to PROGRESS (integrated discrimination improvement +0.036, p<0.001), similar to J-CTO and slightly inferior to CL score (- 0.011, p = 0.004). Regarding net reclassification improvement, CASTLE reclassified better than PROGRESS (overall continuous net reclassification improvement 0.379, p<0.001) in roughly 20% of cases. CONCLUSION: Procedural percutaneous coronary intervention difficulty is not consistently depicted by available chronic total occlusion scores and is influenced by the characteristics of each chronic total occlusion cohort. In our study population, including expert and learning operators, the CASTLE score had slightly better overall performance along with CL score. However, we found only intermediate performance in the c-statistic predicting chronic total occlusion success among all scores.
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Oclusión Coronaria/cirugía , Intervención Coronaria Percutánea , Anciano , Área Bajo la Curva , Oclusión Coronaria/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Medición de Riesgo , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
INTRODUCTION AND OBJECTIVE: Major bleeding events in patients undergoing left atrial appendage closure (LAAC) range from 2.2 to 10.3 per 100 patient-years in different series. This study aimed to clarify the bleeding predictive factors that could influence these differences. METHODS: LAAC was performed in 598 patients from the Iberian Registry II (1093 patient-years; median, 75.4 years). We conducted a multivariate analysis to identify predictive risk factors for major bleeding events. The occurrence of thromboembolic and bleeding events was compared to rates expected from CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes, stroke history, vascular disease, sex) and HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile INR, elderly, drugs or alcohol) scores. RESULTS: Cox regression analysis revealed that age ≥75 years (HR: 2.5; 95% CI: 1.3 to 4.8; p = 0.004) and a history of gastrointestinal bleeding (GIB) (HR: 2.1; 95% CI: 1.1 to 3.9; p = 0.020) were two factors independently associated with major bleeding during follow-up. Patients aged <75 or ≥75 years had median CHA2DS2-VASc scores of 4 (IQR: 2) and 5 (IQR: 2), respectively (p < 0.001) and HAS-BLED scores were 3 (IQR: 1) and 3 (IQR: 1) for each group (p = 0.007). Events presented as follow-up adjusted rates according to age groups were stroke (1.2% vs. 2.9%; HR: 2.4, p = 0.12) and major bleeding (3.7 vs. 9.0 per 100 patient-years; HR: 2.4, p = 0.002). Expected major bleedings according to HAS-BLED scores were 6.2% vs. 6.6%, respectively. In patients with GIB history, major bleeding events were 6.1% patient-years (HAS-BLED score was 3.8 ± 1.1) compared to 2.7% patients-year in patients with no previous GIB history (HAS-BLED score was 3.4 ± 1.2; p = 0.029). CONCLUSIONS: In this high-risk population, GIB history and age ≥75 years are the main predictors of major bleeding events after LAAC, especially during the first year. Age seems to have a greater influence on major bleeding events than on thromboembolic risk in these patients.
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INTRODUCTION AND OBJECTIVES: Many patients with nonvalvular atrial fibrillation are still left without protection due to a contraindication for anticoagulants. This study aimed to establish the occurrence of stroke and major bleeding events in patients with nonvalvular atrial fibrillation and left atrial appendage closure with long-term follow-up and to explore the factors associated with higher long-term mortality. METHODS: Analysis of a multicenter single cohort prospectively recruited from 2009 to 2015. Thromboembolic and bleeding events were compared with those expected from CHA2DS2-VASc and HAS-BLED scores. Multivariate analysis examined variables associated with mortality during follow-up. RESULTS: A total of 598 patients (1093 patient-years) with a contraindication for anticoagulants were recruited (median 75.4 years). The success rate of left atrial appendage closure device implantation was 95.8%. Thirty patients (5%) experienced periprocedural complications. The rate of events (per 100 patient-years) during follow-up (mean 22.9 months; median 16.1 months) was as follows: death 7.0%; ischemic stroke 1.6% (vs 8.5% expected according to CHA2DS2-VASc; P < .001); intracranial hemorrhage 0.8%; gastrointestinal bleeding 3.2%; severe bleeding 3.9% (vs 6.3% expected by HAS-BLED, P = .002). These results were improved in the subgroup of 176 patients with follow-up > 24 months (mean follow-up 46.6 months, 683 patient-years) for severe bleeding 2.6% (vs 6.3% expected by HAS-BLED, P < .033). The factors significantly associated with higher mortality were age (HR, 1.1), intracranial hemorrhage (HR, 6.8), and stroke during follow-up (HR, 2.7). CONCLUSIONS: Left atrial appendage closure significantly reduced the incidence of stroke and bleeding events and the benefit was maintained. Intracranial hemorrhage, age and stroke were associated with higher mortality.
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Apéndice Atrial/cirugía , Fibrilación Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/métodos , Sistema de Registros , Dispositivo Oclusor Septal , Accidente Cerebrovascular/prevención & control , Anciano , Anciano de 80 o más Años , Apéndice Atrial/diagnóstico por imagen , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Ecocardiografía Transesofágica , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Portugal/epidemiología , Estudios Prospectivos , España/epidemiología , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Several studies have demonstrated the benefits of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis, but the presence of persistent fibrosis and myocardial hypertrophy has been related to worse prognosis. OBJECTIVES: The aim of this study was to explore the potential benefits of renin-angiotensin system (RAS) inhibitors on left ventricular remodeling and major clinical outcomes following successful transcatheter aortic valve replacement (TAVR). METHODS: Patients from 10 institutions with severe aortic stenosis who underwent TAVR between August 2007 and August 2017 were included. All baseline data were prospectively recorded, and pre-specified follow-up was performed. Doses and types of RAS inhibitors at discharge were recorded, and matched comparison according to their prescription at discharge was performed. RESULTS: A total of 2,785 patients were included. Patients treated with RAS inhibitors (n = 1,622) presented similar surgical risk scores but a higher rate of all cardiovascular risk factors, coronary disease, and myocardial infarction. After adjustment for these baseline differences, reduction of left ventricular volumes and hypertrophy was greater and cardiovascular mortality at 3-year follow-up was lower (odds ratio: 0.59; 95% confidence interval: 0.41 to 0.87; p = 0.007) in patients treated with RAS inhibitors. Moreover, RAS inhibitors demonstrated a global cardiovascular protective effect with significantly lower rates of new-onset atrial fibrillation, cerebrovascular events, and readmissions. CONCLUSIONS: Post-TAVR RAS inhibitors are associated with lower cardiac mortality at 3-year follow-up and offer a global cardiovascular protective effect that might be partially explained by a positive left ventricular remodeling. An ongoing randomized trial will help confirm these hypothesis-generating findings. (Renin-Angiotensin System Blockade Benefits in Clinical Evolution and Ventricular Remodeling After Transcatheter Aortic Valve Implantation [RASTAVI]; NCT03201185).
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Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Estenosis de la Válvula Aórtica/terapia , Válvula Aórtica/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Disfunción Ventricular Izquierda/prevención & control , Función Ventricular Izquierda/fisiología , Remodelación Ventricular , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/fisiopatología , Ecocardiografía , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/efectos de los fármacos , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Complicaciones Posoperatorias , Periodo Posoperatorio , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/etiologíaRESUMEN
BACKGROUND: Stroke recurrence despite optimal oral anticoagulation (OAC) might represent a novel indication for left atrial appendage occlusion (LAAO). The heterogeneity of these patients is generally high, as the presence of valvular atrial fibrillation (VAF) is common. The aim of this study was to explore the role of LAAO as an adjunctive therapy to OAC in patients with recurrent stroke despite optimal OAC. METHODS: The study screened consecutive patients who underwent percutaneous LAAO at nine centers between 2009 and 2017. Patients with recurrent stroke despite optimal OAC were selected and those with an absolute or relative contraindication to OAC were not included in the study. RESULTS: Among 837 patients who underwent LAAO between the study period, a total of 22 (2.6%) met the inclusion criteria. There was a high percentage of VAF (38%) and 59% presented more than one cardioembolic event before LAAO. All patients underwent successful implantation of the device and no procedural major adverse events were reported. In all but 3 patients, anticoagulation was continued after LAAO. With a median clinical follow-up of 1.8 years (range, 0.7-2.8 years), only 1 stroke and 1 transient ischemic attack were reported, translating into a significant reduction of cerebrovascular events before and after LAAO (2.0 ± 1.0 events vs 0.1 ± 0.3 events; P<.01). Imaging follow-up revealed only 1 case of device thrombosis. CONCLUSIONS: LAAO as an adjunctive therapy to OAC seems to be feasible and safe in patients with previous cardioembolic events despite optimal OAC. In our series, this strategy was associated with a low rate of cerebrovascular events after LAAO.
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Anticoagulantes/administración & dosificación , Apéndice Atrial/cirugía , Fibrilación Atrial/terapia , Dispositivo Oclusor Septal , Accidente Cerebrovascular/prevención & control , Administración Oral , Anciano , Fibrilación Atrial/complicaciones , Femenino , Estudios de Seguimiento , Humanos , Masculino , Estudios Retrospectivos , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION AND OBJECTIVES: There is current controversy regarding the benefits of percutaneous recanalization (PCI) of chronic total coronary occlusions (CTO). Our aim was to determine acute and follow-up outcomes in our setting. METHODS: Two-year prospective registry of consecutive patients undergoing PCI of CTO in 24 centers. RESULTS: A total of 1000 PCIs of CTO were performed in 952 patients. Most were symptomatic (81.5%), with chronic ischemic heart disease (59.2%). Previous recanalization attempts had been made in 15%. The mean SYNTAX score was 19.5 ± 10.6 and J-score was > 2 in 17.3%. A retrograde procedure was performed in 92 patients (9.2%). The success rate was 74.9% and was higher in patients without previous attempts (82.2% vs 75.2%; P = .001), those with a J-score ≤ 2 (80.5% vs 69.5%; P = .002), and in intravascular ultrasound-guided PCI (89.9% vs 76.2%, P = .001), which was an independent predictor of success. In contrast, severe calcification, length > 20mm, and blunt proximal cap were independent predictors of failed recanalization. The rate of procedural complications was 7.1%, including perforation (3%), myocardial infarction (1.3%), and death (0.5%). At 1-year of follow-up, 88.2% of successfully revascularized patients showed clinical improvement (vs 34.8%, P < .001), which was associated with lower mortality. At 1-year of follow-up, the mortality rate was 1.5%. CONCLUSIONS: Compared with other national registries, patients in the Iberian registry undergoing PCI of a CTO showed similar complexity, success rate, and complications. Successful recanalization was strongly associated with functional improvement, which was related to lower mortality.
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Oclusión Coronaria/cirugía , Revascularización Miocárdica/métodos , Anciano , Enfermedad Crónica , Oclusión Coronaria/mortalidad , Femenino , Humanos , Masculino , Isquemia Miocárdica/etiología , Isquemia Miocárdica/mortalidad , Isquemia Miocárdica/cirugía , Revascularización Miocárdica/estadística & datos numéricos , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/estadística & datos numéricos , Portugal/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Estudios Prospectivos , Sistema de Registros , Reoperación/estadística & datos numéricos , España/epidemiología , Cirugía Asistida por Computador/métodos , Resultado del Tratamiento , Ultrasonografía Intervencional/métodosRESUMEN
The clinical impact of in-stent thrombosis is high because it is associated with high mortality and 20 % of the patients suffer a recurrent event within the two following years. The aim of this study was to characterise the morphologic and proteomic profile of in-stent thrombi (IST) in comparison to thrombi developed on native coronary arteries (CT) to identify a differential molecular signature. The study included 45 patients with ST-elevation-myocardial-infarction (STEMI) treated by primary-percutaneous-intervention and thrombus aspiration: 21 had IST and 24 had CT. Thrombi were characterised by morphologic immunohistochemical analysis and differential proteomic profiling (2-DE+MALDI-TOF/TOF). Bioinformatic analysis revealed differences in proteins related to oxidative-stress and cell death/survival. IST showed a higher content of structural proteins (gelsolin, actin-cytoplasmic-1, tropomyosin, and myosin) together with an imbalance in redox-homeostasis related proteins (increased superoxide-dismutase and decreased peroxiredoxin-2 thrombus content), and a coordinated increase of chaperones (HSP60 and HSC70) and cellular quality control-related proteins (26S-protease-regulatory-subunit-7). These changes were reflected into a significant decrease in HSC70 systemic levels and a significant increase in advanced-oxidation-protein-products (AOPP) indicative of increased oxidative stress-mediated protein damage in IST. Our results reveal an imbalance in redox-related proteins indicative of an exacerbated oxidative-stress that leads to an accumulation of AOPP serum levels in IST. Moreover, the coordinated increase in chaperones and regulatory proteins reflects the activation of intracellular protection mechanisms to maintain protein integrity in IST. The failure to counterbalance the stress situation could trigger cellular apoptosis leading to the destabilization of the thrombus and to a worse prognosis of IST-STEMI-patients.
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Trombosis Coronaria/metabolismo , Inmunidad Innata , Estrés Oxidativo , Intervención Coronaria Percutánea/instrumentación , Infarto del Miocardio con Elevación del ST/terapia , Stents , Biomarcadores/metabolismo , Biología Computacional , Trombosis Coronaria/diagnóstico por imagen , Trombosis Coronaria/etiología , Trombosis Coronaria/terapia , Femenino , Fibrinógeno/metabolismo , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Chaperonas Moleculares/metabolismo , Intervención Coronaria Percutánea/efectos adversos , Proteómica/métodos , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Espectrometría de Masa por Láser de Matriz Asistida de Ionización Desorción , Trombectomía , Resultado del TratamientoRESUMEN
INTRODUCTION AND OBJECTIVES: The beneficial effect of coronary collateral circulation (CC) in patients with ST-segment elevation myocardial infarction is controversial. The aim of this study was to evaluate the impact of CC before reperfusion with primary angioplasty (PA) on the long-term prognosis of these patients. METHODS: Retrospective observational study of a cohort of 947 patients treated with PA and TIMI grade ≤ 1 flow in a single center from 2005 to 2013. Propensity score matching was used to create 2 groups of 175 patients each, matched by the degree of CC (Rentrop 0-1 vs Rentrop 2-3). In the matched cohort, we determined the impact of CC on total mortality, cardiovascular mortality, and a combined adverse cardiovascular event endpoint for a median follow-up of 864 (interquartile range, 396-1271) days. RESULTS: Of a total of 947 patients included, 735 (78%) had Rentrop 0 to 1 and 212 (22%) had Rentrop 2 to 3. During follow-up, 105 patients died, 71 from cardiovascular causes. In the matched cohort, the total mortality rate was similar between the 2 groups (Rentrop 0-1 [8.8%] vs Rentrop 2-3 [6.3%]; HR = 1.22; 95%CI, 0.50-2.94; P = .654). There were no differences in cardiovascular mortality (Rentrop 0-1 [4.6%] vs Rentrop 2-3 [2.3%]; sHR = 0.49; 95%CI, 0.14-1.62; P = .244) or the composite endpoint including cardiovascular death, reinfarction, target vessel revascularization, and coronary artery bypass surgery (Rentrop 0-1 [18.8%] vs Rentrop 2-3 [13.1%]; sHR = 0.68; 95%CI, 0.40-1.15; P = .157). CONCLUSIONS: In this contemporary series, the presence of good CC before PA was not associated with better long-term clinical outcomes.
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Circulación Colateral/fisiología , Circulación Coronaria/fisiología , Infarto del Miocardio con Elevación del ST/cirugía , Cuidados Posteriores , Anticoagulantes/uso terapéutico , Angiografía Coronaria/mortalidad , Angiografía Coronaria/estadística & datos numéricos , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/cirugía , Quimioterapia Combinada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reperfusión Miocárdica/mortalidad , Reperfusión Miocárdica/estadística & datos numéricos , Variaciones Dependientes del Observador , Inhibidores de Agregación Plaquetaria/uso terapéutico , Pronóstico , Puntaje de Propensión , Recurrencia , Estudios Retrospectivos , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/fisiopatología , España/epidemiologíaAsunto(s)
Enfermedad de la Arteria Coronaria , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Implantes Absorbibles , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Everolimus , Humanos , Intervención Coronaria Percutánea/efectos adversos , Diseño de Prótesis , Andamios del Tejido , Resultado del TratamientoRESUMEN
Introducción y objetivos: Muchos pacientes con fibrilación auricular no valvular tienen contraindicados los anticoagulantes orales. El objetivo es estimar la incidencia de eventos tromboembólicos y hemorrágicos en pacientes con fibrilación auricular no valvular y cierre de la orejuela izquierda con seguimiento a largo plazo, y determinar los factores asociados con mayor mortalidad a largo plazo. Métodos: Cohorte prospectiva de pacientes reclutados desde 2009 a 2015. Se compararon los eventos tromboembólicos y hemorrágicos con los esperados según las escalas CHA2DS2-VASc y HAS-BLED. Se realizó un análisis multivariable para determinar las variables asociadas con la mortalidad. Resultados: Se reclutó a 598 pacientes (1.093 pacientes-año) con contraindicación de anticoagulantes (mediana de edad, 75,4 años). La tasa de éxito del cierre de la orejuela izquierda fue del 95,8%; 30 pacientes (5%) presentaron complicaciones. Las tasas de eventos (cada 100 pacientes-año) durante el seguimiento (media, 22,9 meses; mediana, 16,1 meses) fueron: muerte, 7,0%; ictus isquémico, 1,6% (frente al 8,5% esperado según CHA2DS2-VASc; p < 0,001); hemorragia intracraneal, 0,8%; hemorragia gastrointestinal, 3,2%, y hemorragia grave, 3,9% (frente al 6,3% esperado por HAS-BLED; p = 0,002). Estos resultados incluso mejoraron en el subgrupo de 176 pacientes con seguimiento > 24 meses (media, 46,6 meses; 683 pacientes-año) para las hemorragias graves, el 2,6% (frente al 6,3% esperado por HAS-BLED; p < 0,033). La edad (HR = 1,1), las hemorragias intracraneales (HR = 6,8) y el ictus (HR = 2,7) se asociaron con mayor mortalidad. Conclusiones: El cierre de la orejuela izquierda redujo significativamente las incidencias de ictus y de eventos hemorrágicos graves y el beneficio se mantuvo. La edad, las hemorragias intracraneales y el ictus se asociaron con mayor mortalidad
Introduction and objectives: Many patients with nonvalvular atrial fibrillation are still left without protection due to a contraindication for anticoagulants. This study aimed to establish the occurrence of stroke and major bleeding events in patients with nonvalvular atrial fibrillation and left atrial appendage closure with long-term follow-up and to explore the factors associated with higher long-term mortality. Methods: Analysis of a multicenter single cohort prospectively recruited from 2009 to 2015. Thromboembolic and bleeding events were compared with those expected from CHA2DS2-VASc and HAS-BLED scores. Multivariate analysis examined variables associated with mortality during follow-up. Results: A total of 598 patients (1093 patient-years) with a contraindication for anticoagulants were recruited (median 75.4 years). The success rate of left atrial appendage closure device implantation was 95.8%. Thirty patients (5%) experienced periprocedural complications. The rate of events (per 100 patient-years) during follow-up (mean 22.9 months; median 16.1 months) was as follows: death 7.0%; ischemic stroke 1.6% (vs 8.5% expected according to CHA2DS2-VASc; P < .001); intracranial hemorrhage 0.8%; gastrointestinal bleeding 3.2%; severe bleeding 3.9% (vs 6.3% expected by HAS-BLED, P = .002). These results were improved in the subgroup of 176 patients with follow-up > 24 months (mean follow-up 46.6 months, 683 patient-years) for severe bleeding 2.6% (vs 6.3% expected by HAS-BLED, P < .033). The factors significantly associated with higher mortality were age (HR, 1.1), intracranial hemorrhage (HR, 6.8), and stroke during follow-up (HR, 2.7). Conclusions: Left atrial appendage closure significantly reduced the incidence of stroke and bleeding events and the benefit was maintained. Intracranial hemorrhage, age and stroke were associated with higher mortality
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Humanos , Masculino , Femenino , Anciano , Apéndice Atrial/cirugía , Dispositivos de Cierre Vascular/estadística & datos numéricos , Defectos del Tabique Interatrial/cirugía , Fibrilación Atrial/complicaciones , Efectos Adversos a Largo Plazo/prevención & control , Registros de Enfermedades/estadística & datos numéricos , Fibrilación Atrial/tratamiento farmacológico , Anticoagulantes/efectos adversos , Estudios Prospectivos , Tromboembolia/epidemiología , Hemorragia/epidemiología , Accidente Cerebrovascular/prevención & control , Indicadores de Morbimortalidad , Contraindicaciones de los MedicamentosRESUMEN
Introducción y objetivos: El impacto de la intervención coronaria percutánea (ICP) sobre oclusiones coronarias crónicas totales (OCT) presenta controversias. Se analizan los resultados agudos y al seguimiento en nuestro entorno. Métodos: Registro prospectivo de ICP sobre OCT en 24 centros durante 2 años. Resultados: Se realizaron 1.000 ICP sobre OCT en 952 pacientes. La mayoría tenía síntomas (81,5%) y cardiopatía isquémica previa (59,2%), y hubo intentos de desobstrucción previos en un 15%. El SYNTAX anatómico fue 19,5 +/- 10,6 y tenía J-score > 2 el 17,3%. El procedimiento fue retrógrado en 92 pacientes (9,2%). La tasa de éxito fue del 74,9%, mayor en aquellos sin ICP previa (el 82,2 frente al 75,2%; p = 0,001), con J-score ≤ 2 (el 80,5 frente al 69,5%; p = 0,002) y con el uso de ecografía intravascular (el 89,9 frente al 76,2%; p = 0,001), que fue predictor independiente del éxito. Por el contrario, lesiones calcificadas, > 20 mm o con muñón proximal romo lo fueron de fracaso. El 7,1% tuvo complicaciones, como perforación (3%), infarto (1,3%) o muerte (0,5%). Al año de seguimiento, el 88,2% mejoró clínicamente en caso de ICP exitosa (frente al 34,8%; p < 0,001). Dicha mejoría se asoció con menor mortalidad. La tasa de mortalidad al año fue del 1,5%. Conclusiones: Los pacientes del Registro Ibérico con OCT tratados con ICP presentan complejidad clínico-anatómica, tasas de éxito y complicaciones similares a los de otros registros nacionales e importante impacto de la recanalización exitosa en la mejoría funcional, que a su vez se asoció con menor mortalidad
Introduction and objectives: There is current controversy regarding the benefits of percutaneous recanalization (PCI) of chronic total coronary occlusions (CTO). Our aim was to determine acute and follow-up outcomes in our setting. Methods: Two-year prospective registry of consecutive patients undergoing PCI of CTO in 24 centers. Results: A total of 1000 PCIs of CTO were performed in 952 patients. Most were symptomatic (81.5%), with chronic ischemic heart disease (59.2%). Previous recanalization attempts had been made in 15%. The mean SYNTAX score was 19.5 +/- 10.6 and J-score was > 2 in 17.3%. A retrograde procedure was performed in 92 patients (9.2%). The success rate was 74.9% and was higher in patients without previous attempts (82.2% vs 75.2%; P = .001), those with a J-score ≤ 2 (80.5% vs 69.5%; P = .002), and in intravascular ultrasound-guided PCI (89.9% vs 76.2%, P = .001), which was an independent predictor of success. In contrast, severe calcification, length > 20mm, and blunt proximal cap were independent predictors of failed recanalization. The rate of procedural complications was 7.1%, including perforation (3%), myocardial infarction (1.3%), and death (0.5%). At 1-year of follow-up, 88.2% of successfully revascularized patients showed clinical improvement (vs 34.8%, P < .001), which was associated with lower mortality. At 1-year of follow-up, the mortality rate was 1.5%. Conclusions: Compared with other national registries, patients in the Iberian registry undergoing PCI of a CTO showed similar complexity, success rate, and complications. Successful recanalization was strongly associated with functional improvement, which was related to lower mortality
Asunto(s)
Humanos , Intervención Coronaria Percutánea/métodos , Oclusión Coronaria/cirugía , Isquemia Miocárdica/cirugía , Angioplastia/estadística & datos numéricos , Registros de Enfermedades/estadística & datos numéricos , Estudios Prospectivos , Indicadores de Morbimortalidad , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiologíaRESUMEN
AIMS: Paclitaxel drug-eluting balloons (pDEB) could be an attractive option to minimise side branch (SB) restenosis in bifurcated coronary lesions. We compared angiographic and clinical outcomes with pDEB plus bare metal stent (BMS) versus drug-eluting stents (DES) in de novo bifurcated lesions. METHODS AND RESULTS: This multicentre randomised trial included 108 patients. Sequential main branch (MB)/SB dilatation with pDEB, with provisional T-stenting with BMS in the MB was performed in the pDEB group, and with everolimus DES in the DES group. The primary endpoint was late lumen loss (LLL) at nine months. The secondary endpoint was the incidence of major adverse cardiac events (MACE: death, myocardial infarction, or target lesion revascularisation). In-segment MB LLL was 0.31±0.48 mm in the pDEB group, and 0.16±0.38 mm in the DES group (p=0.15); mean difference was 0.15 mm (upper limit one-sided 95% CI: 0.27 mm; p=0.001; non-inferiority test). LLL in SB was -0.04±0.76 mm in the pDEB group and -0.03±0.51 mm in the DES group (p=0.983). MACE and TLR were higher in the pDEB group (17.3% vs. 7.1%; p=0.105, and 15.4% vs. 3.6%; p=0.045), due to higher MB restenosis (13.5% vs. 1.8%; p=0.027). CONCLUSIONS: pDEB bifurcation pretreatment with BMS implantation in MB showed greater LLL (ns) and increased incidence of MACE compared to everolimus DES. Both strategies showed similar results in the SB.
Asunto(s)
Angina de Pecho/terapia , Angioplastia Coronaria con Balón/métodos , Reestenosis Coronaria/prevención & control , Estenosis Coronaria/terapia , Paclitaxel/uso terapéutico , Moduladores de Tubulina/uso terapéutico , Anciano , Angina de Pecho/etiología , Aspirina/uso terapéutico , Clopidogrel , Angiografía Coronaria , Estenosis Coronaria/complicaciones , Stents Liberadores de Fármacos , Everolimus , Femenino , Humanos , Inmunosupresores/uso terapéutico , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/uso terapéutico , Sirolimus/análogos & derivados , Sirolimus/uso terapéutico , Stents , Ticlopidina/análogos & derivados , Ticlopidina/uso terapéutico , Resultado del TratamientoAsunto(s)
Apéndice Atrial/cirugía , Fibrilación Atrial/cirugía , Cateterismo Cardíaco/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Dispositivo Oclusor Septal , Accidente Cerebrovascular/prevención & control , Anciano , Fibrilación Atrial/complicaciones , Femenino , Humanos , Masculino , Accidente Cerebrovascular/etiologíaRESUMEN
No disponible
Asunto(s)
Humanos , Ataque Isquémico Transitorio/prevención & control , Apéndice Atrial/cirugía , Dispositivos de Cierre Vascular , Anticoagulantes , Fibrilación Atrial/cirugíaRESUMEN
Introducción y objetivos: El efecto beneficioso de la circulación colateral (CC) coronaria en pacientes con infarto agudo de miocardio con elevación del segmento ST es controvertido. Se investigó su impacto antes de la reperfusión con angioplastia primaria (AP) en el pronóstico a largo plazo de estos pacientes. Métodos: Estudio observacional retrospectivo de una cohorte de 947 pacientes tratados con AP y flujo de grado TIMI ≤ 1 en un centro entre 2005 y 2013. Tras emparejar por puntuación de propensión, se obtuvieron 2 grupos de 175 pacientes emparejados por el grado de CC (Rentrop 0-1 frente a 2-3). En la cohorte emparejada se determinó el impacto de la CC en la mortalidad total, la mortalidad cardiovascular y un combinado de eventos cardiovasculares tras una mediana de seguimiento de 864 [intervalo intercuartílico, 396-1.271] días. Resultados: Del total de 947 pacientes incluidos, 735 (78%) tenían Rentrop 0-1 y 212 (22%), Rentrop 2-3. Durante el seguimiento, 105 fallecieron, 71 de causa cardiovascular. En la cohorte emparejada, la tasa de mortalidad total fue similar entre los grupos (Rentrop 0-1 [8,8%] frente a Rentrop 2-3 [6,3%]; HR = 1,22; IC95%, 0,50-2,94; p = 0,654). Tampoco hubo diferencias en la mortalidad cardiovascular (Rentrop 0-1, [4,6%] frente a Rentrop 2-3 [2,3%]; sub-HR = 0,49; IC95%, 0,14-1,62; p = 0,244) ni en el combinado de eventos muerte cardiovascular, reinfarto, revascularización del vaso diana y cirugía de revascularización coronaria (Rentrop 0-1 [18,8%] frente a Rentrop 2-3 [13,1%]; sub-HR = 0,68; IC95%, 0,40-1,15; p = 0,157). Conclusiones: En esta serie contemporánea, la presencia de buena CC antes de la AP no se asoció a mejor pronóstico de los pacientes en cuanto a eventos clínicos a largo plaz (AU)
Introduction and objectives: The beneficial effect of coronary collateral circulation (CC) in patients with ST-segment elevation myocardial infarction is controversial. The aim of this study was to evaluate the impact of CC before reperfusion with primary angioplasty (PA) on the long-term prognosis of these patients. Methods: Retrospective observational study of a cohort of 947 patients treated with PA and TIMI grade ≤ 1 flow in a single center from 2005 to 2013. Propensity score matching was used to create 2 groups of 175 patients each, matched by the degree of CC (Rentrop 0-1 vs Rentrop 2-3). In the matched cohort, we determined the impact of CC on total mortality, cardiovascular mortality, and a combined adverse cardiovascular event endpoint for a median follow-up of 864 (interquartile range, 396-1271) days. Results: Of a total of 947 patients included, 735 (78%) had Rentrop 0 to 1 and 212 (22%) had Rentrop 2 to 3. During follow-up, 105 patients died, 71 from cardiovascular causes. In the matched cohort, the total mortality rate was similar between the 2 groups (Rentrop 0-1 [8.8%] vs Rentrop 2-3 [6.3%]; HR = 1.22; 95%CI, 0.50-2.94; P = .654). There were no differences in cardiovascular mortality (Rentrop 0-1 [4.6%] vs Rentrop 2-3 [2.3%]; sHR = 0.49; 95%CI, 0.14-1.62; P = .244) or the composite endpoint including cardiovascular death, reinfarction, target vessel revascularization, and coronary artery bypass surgery (Rentrop 0-1 [18.8%] vs Rentrop 2-3 [13.1%]; sHR = 0.68; 95%CI, 0.40-1.15; P = .157). Conclusions: In this contemporary series, the presence of good CC before PA was not associated with better long-term clinical outcomes (AU)
Asunto(s)
Humanos , Angioplastia Coronaria con Balón , Reperfusión Miocárdica , Circulación Colateral/fisiología , Tiempo , Estudios Retrospectivos , Supervivencia , Resultado del Tratamiento , Estudios Controlados Antes y Después/estadística & datos numéricosAsunto(s)
Aneurisma Falso/etiología , Aneurisma Falso/terapia , Cateterismo Cardíaco/efectos adversos , Manejo de la Enfermedad , Complicaciones Posoperatorias , Arteria Radial , Anciano , Anciano de 80 o más Años , Aneurisma Falso/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
No disponible