Atorvastatin Effect on Aortic Dilatation and Valvular Calcification Progression in Bicuspid Aortic Valve (BICATOR): A Randomized Clinical Trial.

BACKGROUND: Ascending aorta dilation and aortic valve degeneration are common complications in patients with bicuspid aortic valve. Several retrospective studies have suggested the benefit of statins in reducing these complications. This study aimed to determine whether atorvastatin treatment is effective in reducing the growth of aortic diameters in bicuspid aortic valve and if it slows the progression of valve calcification. METHODS: In a randomized clinical trial, 220 patients with bicuspid aortic valve (43 women; 46±13 years of age) were included and treated with either 20 mg of atorvastatin per day or placebo for 3 years. Inclusion criteria were ≥18 years of age, nonsevere valvular dysfunction, nonsevere valve calcification, and ascending aorta diameter ≤50 mm. Computed tomography and echocardiography studies were performed at baseline and after 3 years of treatment. RESULTS: During follow-up, 28 patients (12.7%) discontinued medical treatment (15 on atorvastatin and 13 taking placebo). Thus, 192 patients completed the 36 months of treatment. Low-density lipoprotein cholesterol levels decreased significantly in the atorvastatin group (median [interquartile range], -30 mg/dL [-51.65 to -1.75 mg/dL] versus 6 mg/dL [-4, 22.5 mg/dL]; P<0.001). The maximum ascending aorta diameter increased with no differences between groups: 0.65 mm (95% CI, 0.45-0.85) in the atorvastatin group and 0.74 mm (95% CI, 0.45-1.04) in the placebo group (P=0.613). Similarly, no significant differences were found for the progression of the aortic valve calcium score (P=0.167) or valvular dysfunction. CONCLUSIONS: Among patients with bicuspid aortic valve without severe valvular dysfunction, atorvastatin treatment was not effective in reducing the progression of ascending aorta dilation and aortic valve calcification during 3 years of treatment despite a significant reduction in low-density lipoprotein cholesterol levels. REGISTRATION: URL: https://www.clinicaltrialsregister.eu; Unique identifier: 2015-001808-57. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02679261.

Personalized pulmonary vein isolation with very high-power short-duration lesions guided by left atrial wall thickness: the QDOT-by-LAWT randomized trial.

AIMS: Pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) using very high-power short-duration (vHPSD) radiofrequency (RF) ablation proved to be safe and effective. However, vHPSD applications result in shallower lesions that might not be always transmural. Multidetector computed tomography-derived left atrial wall thickness (LAWT) maps could enable a thickness-guided switching from vHPSD to the standard-power ablation mode. The aim of this randomized trial was to compare the safety, the efficacy, and the efficiency of a LAWT-guided vHPSD PVI approach with those of the CLOSE protocol for PAF ablation (NCT04298177). METHODS AND RESULTS: Consecutive patients referred for first-time PAF ablation were randomized on a 1:1 basis. In the QDOT-by-LAWT arm, for LAWT ≤2.5 mm, vHPSD ablation was performed; for points with LAWT > 2.5 mm, standard-power RF ablation titrating ablation index (AI) according to the local LAWT was performed. In the CLOSE arm, LAWT information was not available to the operator; ablation was performed according to the CLOSE study settings: AI ≥400 at the posterior wall and ≥550 at the anterior wall. A total of 162 patients were included. In the QDOT-by-LAWT group, a significant reduction in procedure time (40 vs. 70 min; P < 0.001) and RF time (6.6 vs. 25.7 min; P < 0.001) was observed. No difference was observed between the groups regarding complication rate (P = 0.99) and first-pass isolation (P = 0.99). At 12-month follow-up, no significant differences occurred in atrial arrhythmia-free survival between groups (P = 0.88). CONCLUSION: LAWT-guided PVI combining vHPSD and standard-power ablation is not inferior to the CLOSE protocol in terms of 1-year atrial arrhythmia-free survival and demonstrated a reduction in procedural and RF times.

Iatrogenic Shapiro syndrome: a case report.

OBJECTIVES: Shapiro's syndrome (SS) is a rare condition characterized by spontaneous periodic hypothermia. The underlying pathophysiological mechanisms and etiology of this syndrome remain controversial, and fewer than 100 cases have been reported to date. The objective of this case report is to present a unique iatrogenic case of SS and contribute additional insights into the underlying etiology of this rare disorder. METHODS: We conducted an analysis of existing medical literature and described a clinical case of SS secondary to a neurosurgical procedure. RESULTS: To our knowledge, we present the first iatrogenic case of SS in a 53-year-old woman who underwent a partial right parieto-occipital lobectomy in 2003 as a treatment for refractory epilepsy. Several years after the surgical procedure, she began experiencing recurrent episodes of hypothermia. Brain magnetic resonance imaging (MRI) revealed the absence of the splenium of the corpus callosum (CC) and pituitary hyperplasia. After ruling out other potential causes of hypothermia, a diagnosis of SS was made. DISCUSSION: The most plausible mechanism to explain the recurrent hypothermia associated with SS in our patient is a probable disruption of the pathways involved in thermoregulation through the CC as a consequence of the surgical procedure. This case report provides further insights into the etiology of this rare disorder.

Evaluación del flujo retrógrado diastólico en la aorta descendente para cuantificar la insuficiencia aórtica / Descending Aorta Diastolic Retrograde Flow Assessment for Aortic Regurgitation Quantification

Introducción: El flujo diastólico retrógrado en la aorta descendente se ha relacionado con la gravedad de la insuficiencia aórtica; sin embargo, la mayoría de los parámetros vinculados con la velocidad del flujo no se encuentran validados con una técnica de imágenes de referencia. Objetivo: Evaluar la utilidad del flujo retrógrado diastólico en la aorta torácica descendente y la aorta abdominal en la cuan-tificación de la insuficiencia aórtica utilizando como referencia la resonancia magnética. Material y métodos: Se incluyeron 40 pacientes consecutivos en un estudio prospectivo de ecocardiografía y resonancia magnética. Por Doppler pulsado se analizaron los siguientes parámetros: a) la integral velocidad-tiempo del flujo retrógrado diastólico y b) la velocidad máxima telediastólica del flujo regurgitante, ambos en la aorta torácica, y c) el flujo holodiastólico inverso en la aorta abdominal. El protocolo de resonancia magnética incluyó secuencias de contraste de fase para calcular la fracción regurgitante. Valores > 30% se consideraron diagnósticos de insuficiencia aórtica grave. Resultados: Once pacientes (30%) tenían una fracción regurgitante > 30%. La integral velocidad-tiempo del flujo retrógrado diastólico demostró la mayor precisión en el diagnóstico de insuficiencia aórtica grave: ABC = 0,87; p < 0,001. Un punto de corte para la integral velocidad-tiempo del flujo retrógrado diastólico > 15 cm demostró una sensibilidad del 91% y una especificidad del 86% para detectar insuficiencia aórtica grave. El flujo pandiastólico inverso en la aorta abdominal mostró una excelente especificidad (100%) para el diagnóstico de insuficiencia aórtica grave, aunque con baja sensibilidad (50%). Conclusiones: La evaluación del flujo retrógrado diastólico en la aorta torácica descendente permite un diagnóstico adecuado de la insuficiencia aórtica grave. El flujo holodiastólico inverso, aunque es poco sensible, muestra una alta especificidad.

Utilidad de la resonancia magnética cardíaca en la valoración de los pacientes con dolor torácico, troponinas elevadas y ausencia de obstrucción arterial coronaria / Cardiac Magnetic Resonance Imaging in Patients with Chest Pain, High Troponin Levels and Absence of Coronary Artery Obstruction

El infarto de miocardio con coronarias angiográficamente normales tiene una prevalencia de aproximadamente el 7-10%. Muchas veces, el diagnóstico etiológico es dificultoso, y tiene importancia tanto en la clínica como en el pronóstico. El objetivo de nuestro estudio fue mostrar una serie consecutiva de pacientes con diagnóstico inicial de síndrome coronario agudo con elevación de troponina y ausencia de obstrucción arterial coronaria; en los cuales, la RM cardíaca (RMC) orientó al diagnóstico etiológico mediante la caracterización de la lesión miocárdica. Desde enero de 2005 hasta diciembre de 2009 ingresaron 720 pacientes consecutivos, con diagnóstico inicial de síndrome coronario agudo y troponinas positivas, de los cuales, 64 no presentaron lesiones coronarias angiográficamente significativas. A estos pacientes, luego del cateterismo (dentro de las 72 ± 24 hs) se les practicó RMC, realizándose secuencias de cine (b-SSFP) en eje corto, con 2, 3 y 4 cámaras para valorar la motilidad segmentaria, en secuencias potenciadas en T2 e imágenes de realce tardío del miocardio (RTM) con secuencia "inversión-recuperación". De estos pacientes, 39 fueron diagnosticados de miocarditis; 12 con infartos, 8 con síndrome de Takotsubo, 2 con miocardiopatía hipertrófica apical y solo 3 casos quedaron sin diagnóstico. Estos hallazgos ponen de manifiesto la gran utilidad de la RMC en el escenario clínico de síndromes de dolor precordial, ECG no definitivos y troponinas elevadas con arterias angiográficamente normales. La presencia de RTM y su patrón de distribución permiten definir el diagnóstico etiológico y orientar a la interpretación del proceso fisiopatológico.

The prevalence of myocardial infarction with angiographically normal coronary arteries is approximately 7-10%. The etiological diagnosis is sometimes difficult and is important in terms of clinical practice and prognosis. The goal of our study was to show a series of consecutive patients with an initial diagnosis of acute coronary syndrome with high troponin levels and absence of coronary artery obstruction in which cardiac magnetic resonance imaging (CMRI) gave a description of the myocardial lesion, orientating towards the etiological diagnosis. From January 2005 to December 2009, 720 consecutive patients with an initial diagnosis of acute coronary syndrome and elevated troponins were included; 64 of these patients did not present angiographically significant coronary artery stenosis. Within 72 ± 24 h after coronary angiography, these patients underwent CMRI using b-SSFP sequences for cine imaging in short-axis, 2-, 3- and 4- chamber views for the evaluation of segmental wall motion, with T2-weighted and delayed enhancement (DE) images of the myocardium with an "inversion-recovery" sequence. The following diagnoses were made: myocarditis (39 patients); myocardial infarction (12 patients); Tako-Tsubo syndrome (8 patients); apical hypertrophic cardiomyopathy (2 patients); 3 patients remained without diagnosis. These findings demonstrate the usefulness of CMRI in the clinical scenario of patients with chest pain, inconclusive ECG findings and high troponin levels with angiographically normal coronary arteries. The presence and distribution pattern of DE make it possible to define the etiological diagnosis and interpret the physiopathological process.