Predictors of pacemaker implantation after TAVI in a registry including self, balloon and mechanical expandable valves.

The need for permanent pacemaker implantation (PPMI) is a burdensome complication of transcatheter aortic valve implantation (TAVI). The aim of our study was to evaluate different anatomical, clinical, electrocardiographic, and procedural variables associated with the development of conduction abnormalities after TAVI across the entire device spectrum. Single-center prospective cohort of consecutive patients who underwent TAVI since March 2017. Final cohort was studied to detect areas of calcium within aortic valve characterized by leaflet sector and region. Membranous septum (MS) length was assessed throughout a modified coronal view. Device selection and positioning were performed according to the operator criteria. Device selection and positioning were performed according to the operator criteria. From the 273 patients included, 57 underwent PPMI (20.8%). Univariate analysis determined right bundle branch block (RBBB), QRS duration, MS length and calcium within LVOT of non-coronary cuspid as independent predictors. After multivariable logistic regression, both RBBB (OR 6.138; 95% CI 1.23-30.73, P = 0.027) and MS length (OR 0.259; 95% CI 0.164-0.399, P < 0.005) emerged as statistically significant. As a model, they could predict PPMI in 88.7%, independently of which valve used. Youden index analysis yielded 7.69 mm as the optimal cut-off with a negative and positive predictive value of 94.7 and 71.9%, respectively. In our experience, both RBBB pattern and short membranous septum (< 8 mm) were strongly and independently associated with new permanent pacemaker implantation, regardless of the device type. Our findings suggest that this simple evolved measure of MS length may guide device selection and implantation technique and facilitate early discharge.

Diagnostic accuracy of computed tomography angiography for the exclusion of coronary artery disease in candidates for transcatheter aortic valve implantation.

Coronary CT angiography (CTA) is currently considered a reliable method to exclude obstructive coronary artery disease (CAD) before valvular heart surgery in patients with low pretest probability. However, its role in excluding obstructive CAD before transcatheter aortic valve implantation (TAVI) is less well established. Single-center retrospective study where patients with severe symptomatic aortic stenosis underwent both CTA and invasive coronary angiography (ICA) as part of TAVI planning. CTA exams were conducted on a 64-slice dual source scanner, with a median interval of 45 days to ICA (IQR 25-75 [13-82]). In both tests, obstructive CAD was defined as a ≥50% stenosis in an epicardial vessel ≥2 mm diameter. Per-patient, per-vessel and per-proximal segment analyses were conducted, excluding and including non-evaluable segments. The study included 200 patients (120 women, mean age 83 ± 6 years). The prevalence of obstructive CAD on ICA was 35.5% (n = 71). On a per-patient analysis (assuming non-evaluable segments as stenotic), CTA showed sensitivity of 100% (95% CI, 95-100%), specificity of 42% (95% CI, 33-51%), and positive and negative predictive values of 48% (95% CI, 44-51%) and 100% (95% CI, 92-100%), respectively. CTA was able to exclude obstructive CAD in 54 patients (27%), in whom ICA could have been safely withheld. Despite the high rate of inconclusive tests, pre-procedural CTA is able to safely exclude obstructive CAD in a significant proportion of patients undergoing TAVI, possibly avoiding the need for ICA in roughly one quarter of the cases.

Comparison of multiparametric risk scores for predicting early mortality after transcatheter aortic valve implantation.

INTRODUCTION: Surgical risk scores are widely used to identify patients at high surgical risk who may benefit from transcatheter aortic valve implantation (TAVI). A multiparametric TAVI mortality risk score based on a French registry (FRANCE-2) has recently been developed. The aim of our study was to compare the 30-day mortality prediction performance of the FRANCE-2, EuroSCORE II and STS scores. METHODS: We retrospectively studied 240 patients from a single-center prospective registry who underwent TAVI between January 2008 and December 2015. All scores were assessed for calibration and discrimination using calibration-in-the-large and ROC curve analysis, respectively. RESULTS: The observed mortality was 5.8% (n=14). The median EuroSCORE II, STS and FRANCE-2 scores were 5.0 (IQR 3.2-8.3), 5.1 (IQR 3.6-7.1) and 2.0 (IQR 1.0-3.0), respectively. Discriminative power was greater for EuroSCORE II (C-statistic 0.67) and STS (C-statistic 0.67) than for FRANCE-2 (C-statistic 0.53), but this was not statistically significant (p=0.26). All scores showed adequate calibration. CONCLUSIONS: All scores showed modest performance in early mortality prediction after TAVI. Despite being derived from a TAVI population, FRANCE-2 was no better than surgical risk scores in our population.

Factors influencing patient delay before primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: The Stent for life initiative in Portugal.

INTRODUCTION AND AIMS: Shorter patient delays are associated with a better prognosis for patients diagnosed with ST-segment elevation myocardial infarction (STEMI). This study aimed to identify predictors of patient delay in the Portuguese population. METHODS: Data on 994 patients with suspected STEMI of less than 12 hours' duration and referred for primary percutaneous coronary intervention (pPCI) and admitted to 18 Portuguese interventional cardiology centers were collected for a one-month period every year from 2011 to 2015. Univariate and multivariate linear regression models were used to identify predictors of patient delay. RESULTS: No significant differences were observed in patient delay over the course of the survey. The multivariate analysis identified five predictors of patient delay: age ≥75 years (exp[beta] 1.28; 95% CI 1.10-1.50; p=0.001), symptom onset between 0:00 and 8:00 a.m. (exp[beta] 1.26; 95% CI 1.10-1.45; p=0.001), and attending a primary care unit before first medical contact (exp[beta] 1.75; 95% CI 1.41-2.16; p<0.001) predicted longer patient delay, while calling the national medical emergency number (112) (exp[beta] 0.84; 95% CI 0.71-1.00; p=0.045) and transport by the emergency medical services to the pPCI facility (exp[beta] 0.71; 95% CI 0.59-0.84; p<0.001) predicted shorter patient delay. CONCLUSIONS: We identified five factors predicting patient delay, which will help in planning interventions to reduce patient delays and to improve the outcome of patients with STEMI.

Renal denervation for resistant hypertension.

There is a marked contrast between the high prevalence of hypertension and the low rates of adequate control. A subset of patients with suboptimal blood pressure control have drug-resistant hypertension, in the pathophysiology of which chronic sympathetic hyperactivation is significantly involved. Sympathetic renal denervation has recently emerged as a device-based treatment for resistant hypertension. In this review, the pathophysiological mechanisms linking the sympathetic nervous system and cardiovascular disease are reviewed, focusing on resistant hypertension and the role of sympathetic renal denervation. An update on experimental and clinical results is provided, along with potential future indications for this device-based technique in other cardiovascular diseases.

[Acute myocardial infarction complicated by cardiogenic shock: what changed over a 10-year time span?]. / Choque cardiogénico no enfarte agudo do miocárdio: o que mudou nos últimos 10 anos?

BACKGROUND: Despite improvements in treatment, mortality associated with cardiogenic shock (CS) following acute myocardial infarction remains high. AIM: To compare two groups of patients admitted with CS over a 10-year time span. METHODS: We performed a retrospective analysis of two patient populations presenting with CS admitted in the periods May 1998-May 2001 (group A) and May 2008-May 2011 (group B). Clinical characteristics, diagnostic methods, treatment and outcomes were compared, and independent predictors of death at six months were analyzed. RESULTS: The incidence of CS was 3.7% in group A (n=25) and 4.8% in group B (n=42). There were no significant differences in clinical characteristics except for age (60.2±12.3 vs. 66.5±11.3 years; p=0.043) and the proportion of patients admitted within six hours of symptom onset (29.2% vs. 54.8%, p=0.045). There was a reduction in use of pulmonary artery catheterization (52.0% vs. 19.0%, p=0.005) but an increase in dialysis (4.0% vs. 28.6%, p=0.014). There was no difference in the proportion of patients reperfused within 12 hours or revascularized, but use of percutaneous coronary intervention (PCI) increased (75.0% vs. 92.9%, p=0.042). There were no differences in outcomes, including mortality at 30 days (32.0 vs. 35.7%; p=0.757) and six months (36.0 vs. 42.9%; p=0.683). Diabetes was the sole baseline characteristic identified as an independent predictor of death at six months (hazard ratio [HR] 3.02; 95% confidence interval [CI] 1.38-6.60; p=0.006) and mortality was lower among revascularized patients (HR 0.11; 95% CI 0.03-0.42; p=0.001). CONCLUSIONS: Over a 10-year time span, despite earlier hospital admission and increased use of support therapies and PCI, short- and medium-term mortality remained unchanged.

Revascularization and prognosis in female patients with non-ST-segment elevation acute coronary syndromes.

BACKGROUND: After an acute myocardial infarction, women have a higher risk of death or reinfarction. In unstable angina, female gender seems to be protective. On the other hand, studies suggest that women are less frequently given coronary angiography. OBJECTIVES: To evaluate, in our population of patients admitted for non-ST-elevation acute coronary syndrome (ACS), the influence of gender in prognosis and in the use of invasive procedures. POPULATION AND METHODS: We studied 387 consecutive patients, 20% female, admitted to our ICU for non-ST-segment elevation ACS. We compared demographic and clinical variables, the use of coronary angiography and myocardial revascularization procedures, according to gender. We analyzed the combined endpoint of death or (re)infarction at 30 days and for the total follow-up period of 420 +/- 322 days. RESULTS: The women were older (65 +/- 10 vs. 62 +/- 11 years, p = 0.05), and more frequently had a history of hypertension (p = 0.005), diabetes mellitus (p = 0.07), previous surgical myocardial revascularization (p = 0.048) and higher heart rate on admission (p = 0.048). Smoking was more frequent in men (p < 0.001). The most frequent diagnosis was unstable angina; 76% for women vs. 66% in men (p = 0.12). Coronary angiography was performed during hospitalization in 87%, in both genders. Myocardial revascularization was performed in 62% of the women and 69% of the men (p = 0.26). At 30 days, the frequency of death or (re)infarction was 11% for women and 10% for men (log-rank, p = 0.79). By multivariate analysis (Cox regression), the independent predictors of outcome at 30 days were previous myocardial revascularization and heart failure on admission. For the total follow-up, we did not find differences in the occurrence of the combined endpoint, and the independent predictors of outcome were previous surgical myocardial revascularization, heart failure on admission, ST segment depression on the admission ECG and surgical myocardial revascularization. CONCLUSIONS: In non-ST-elevation ACS, women present some differences in their demographic and clinical profile. We did not find differences in the use of invasive procedures or prognosis in the short and medium term.