Sensitization during short-term mechanical circulatory support. Determinants, therapeutic management, and outcomes after heart transplant.

INTRODUCTION AND OBJECTIVES: The development of human-leukocyte antigen antibodies is a well-known adverse effect of the use of long-term ventricular assist devices (VADs). The aim of this study was to determine the incidence of sensitization during short-term mechanical circulatory support with VAD (CentriMag), its determinants, and its impact on posttransplant outcomes. METHODS: We performed a retrospective review of patients who were bridged to transplant with short-term VAD from 2009 to 2019. Sensitization was defined as a calculated panel-reactive antibody> 10%. The endpoints included overall survival and rejection-free survival. RESULTS: A total of 89 patients (median age 56.0 [interquartile range, 50.0-59.9] years, 16.8% female) received a short-term VAD as a bridge to transplant. The median duration of support was 23.6 [interquartile range, 16.6-35.0] days. Eleven patients (12.4%) became sensitized during support. The only factor significantly associated with sensitization was female sex (OR, 8.67; 95%CI, 1.93-38.8; P=.005). Of the 89 patients, 21 patients died during support; 68 patients underwent heart transplant. After a mean follow-up of 49.6 ±31.2 months, 8 patients (11.8%) died and 20 (29.4%) had at least 1 rejection episode. On multivariate analysis, sensitization was an independent predictor of acute rejection (HR, 3.64; 95%CI, 1.42-9.33; P=.007), with a nonstatistically significant trend to higher mortality (HR, 4.07; 95%CI, 0.96-17.3; P=.057). CONCLUSIONS: Sensitization with short-term VADs can occur and is significantly associated with female sex and with rejection. Sensitization also showed a nonstatistically significant trend to higher mortality.

Tendencias en el tratamiento del shock cardiogénico e impacto pronóstico del tipo de centros tratantes / Trends in cardiogenic shock management and prognostic impact of type of treating center

INTRODUCCIÓN Y OBJETIVOS: Las guías recomiendan centralizar la atención del shock cardiogénico (SC) en centros altamente especializados. El objetivo de este estudio fue evaluar la asociación entre las características de los centros tratantes y la mortalidad en el SC secundario a infarto de miocardio con elevación del segmento ST (IAMCEST). MÉTODOS: Se seleccionaron los episodios de alta con diagnóstico de SC-IAMCEST entre 2003-2015 del Conjunto Mínimo Básico de Datos del Sistema Nacional de Salud español. Los centros se clasificaron según disponibilidad de servicio de cardiología, laboratorio de hemodinámica, cirugía cardiaca y disponibilidad de Unidad de Cuidados Intensivos Cardiológicos (UCIC). La variable objetivo principal fue la mortalidad hospitalaria. RESULTADOS: Se identificaron 19.963 episodios. La edad media fue de 73,4±11,8 años. La proporción de pacientes tratados en hospitales con laboratorio de hemodinámica y cirugía cardiaca aumentó del 38,4% en 2005 al 52,9% en 2015; p <0,005). Las tasas de mortalidad bruta y ajustada por riesgo se redujeron progresivamente (del 82 al 67,1%, y del 82,7 al 66,8%, respectivamente, ambas p <0,001). La revascularización coronaria, tanto quirúgica como percutánea, se asoció de forma independiente con una menor mortalidad (OR = 0,29 y 0,25, p <0,001); La disponibilidad UCIC se asoció con menores tasas de mortalidad ajustadas (el 65,3±7,9% frente al 72±11,7%; p <0,001). CONCLUSIONES: La proporción de pacientes con SC-IAMCEST tratados en centros altamente especializados aumentó, mientras que la mortalidad disminuyó a lo largo del periodo de estudio. La revascularización y el ingreso en UCIC se asociaron con mejores resultados

INTRODUCTION AND OBJECTIVES: Current guidelines recommend centralizing the care of patients with cardiogenic shock in high-volume centers. The aim of this study was to assess the association between hospital characteristics, including the availability of an intensive cardiac care unit, and outcomes in patients with ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS). METHODS: Discharge episodes with a diagnosis of STEMI-related CS between 2003 and 2015 were selected from the Minimum Data Set of the Spanish National Health System. Centers were classified according to the availability of a cardiology department, catheterization laboratory, cardiac surgery department, and intensive cardiac care unit. The main outcome measured was in-hospital mortality. RESULTS: A total of 19 963 episodes were identified. The mean age was 73.4±11.8 years. The proportion of patients with CS treated at hospitals with a catheterization laboratory and cardiac surgery department increased from 38.4% in 2005 to 52.9% in 2015 (P <.005). Crude- and risk-adjusted mortality rates decreased over time, from 82% to 67.1%, and from 82.7% to 66.8%, respectively (both P <.001). Coronary revascularization, either percutaneous or coronary artery bypass grafting, was independently associated with a lower mortality risk (OR, 0.29 and 0.25; both P <.001, respectively). Intensive cardiac care unit availability was associated with lower adjusted mortality rates (65.3%±7.9 vs 72±11.7; P <.001). CONCLUSIONS: The proportion of patients with STEMI-related CS treated at highly specialized centers increased while mortality decreased during the study period. Better outcomes were associated with the increased performance of revascularization procedures and access to intensive cardiac care units over time

Trends in cardiogenic shock management and prognostic impact of type of treating center.

INTRODUCTION AND OBJECTIVES: Current guidelines recommend centralizing the care of patients with cardiogenic shock in high-volume centers. The aim of this study was to assess the association between hospital characteristics, including the availability of an intensive cardiac care unit, and outcomes in patients with ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS). METHODS: Discharge episodes with a diagnosis of STEMI-related CS between 2003 and 2015 were selected from the Minimum Data Set of the Spanish National Health System. Centers were classified according to the availability of a cardiology department, catheterization laboratory, cardiac surgery department, and intensive cardiac care unit. The main outcome measured was in-hospital mortality. RESULTS: A total of 19 963 episodes were identified. The mean age was 73.4±11.8 years. The proportion of patients with CS treated at hospitals with a catheterization laboratory and cardiac surgery department increased from 38.4% in 2005 to 52.9% in 2015 (P <.005). Crude- and risk-adjusted mortality rates decreased over time, from 82% to 67.1%, and from 82.7% to 66.8%, respectively (both P <.001). Coronary revascularization, either percutaneous or coronary artery bypass grafting, was independently associated with a lower mortality risk (OR, 0.29 and 0.25; both P <.001, respectively). Intensive cardiac care unit availability was associated with lower adjusted mortality rates (65.3%±7.9 vs 72±11.7; P <.001). CONCLUSIONS: The proportion of patients with STEMI-related CS treated at highly specialized centers increased while mortality decreased during the study period. Better outcomes were associated with the increased performance of revascularization procedures and access to intensive cardiac care units over time.

Background, incidence, and predictors of antiplatelet therapy discontinuation during the first year after drug-eluting stent implantation.

BACKGROUND: Predictors of antiplatelet therapy discontinuation (ATD) during the first year after drug-eluting stent implantation are poorly known. METHODS AND RESULTS: This was a prospective study with 3-, 6-, 9-, and 12-month follow-up of patients receiving at least 1 drug-eluting stent between January and April 2008 in 29 hospitals. Individual- and hospital-level predictors of ATD were assessed by hierarchical-multinomial regression analysis. ATD could be assessed in 1622 candidates for follow-up (82.5%). A total of 234 patients (14.4%) interrupted at least 1 antiplatelet therapy drug, predominantly clopidogrel (n=182, 11.8%). Bleeding events or invasive procedures led to ATD in 109 patients. This was predicted by renal impairment (odds ratio [OR] 2.81, 95% confidence interval [CI] 1.48 to 5.34), prior major hemorrhage (OR 3.77, 95% CI 1.41 to 10.03), and peripheral arterial disease (OR 1.78, 95% CI 1.01 to 3.15). Medical decisions led to ATD in 70 patients; this was predicted by long-term use of anticoagulant therapy (OR 3.88, 95% CI 1.26 to 11.98), undergoing the procedure in a private hospital (OR 13.3, 95% CI 1.69 to 105), and not receiving instructions about medication (OR 2.8, 95% CI 1.23 to 6.36). Thirty-nine patients interrupted ATD on their own initiative, mainly immigrants (OR 3.78, 95% CI 1.2 to 11.98) and consumers of psychotropic drugs (OR 2.58, 95% CI 1.3 to 5.12). CONCLUSIONS: ATD during the first year after drug-eluting stent implantation is based mainly on patient decision or a medical decision not associated with major bleeding events or major surgical procedures. Individual- and hospital-level variables are important to predict ATD.

Impact of drug eluting stents on the clinical practice of revascularisation of coronary artery disease.

AIMS: Drug-eluting stents (DES) have shown to reduce restenosis rates in all lesional subsets. This has expanded the application of percutaneous intervention (PCI). In this study we address the impact of the high DES penetration on the management of patients referred for coronary angiography. METHODS AND RESULTS: We have studied the cohorts of patients referred for coronary angiography in 2000-2001 prior to DES availability, and in 2005-2006 with a 73% DES implementation. In 2000-1 of 2,458 coronary angiographic studies, 84% had significant lesions (>50%), 56% had PCI, 8.8% had CABG and in 443 (18%) with significant lesions no revascularisation was attempted. In 2005-6 out of 2,600 angiographies, 84% had significant lesions, 64% had PCI, 6% had CABG and in 312 (12%) with significant lesions no revascularisation was done. The increase in PCI, the reduction in CABG and the decrease in non-revascularised diseased cases were all significant (p<0,001). The PCI and CABG groups in 2005-6 compared to 2000-1 had a more complex lesion profile with, however, less in-stent restenotic lesions treated (10% vs 4.2%; p<0.001). CONCLUSIONS: The wide clinical introduction of DES was associated with a significant increase in patients undergoing any kind of revascularisation, increasing the PCI volume to the detriment of CABG activity. Patients with PCI in 2006 had more complex lesions treated, whereas restenosis was less frequent.

[Prospective use of an intravascular ultrasound-derived minimum lumen area cut-off value in the assessment of intermediate left main coronary artery lesions]. / Aplicación prospectiva de un valor de corte de área luminal mínima por ecografía intravascular en la evaluación de lesiones intermedias del tronco.

BACKGROUND AND OBJECTIVES: Angiographic assessment of the severity of intermediate lesions in the left main coronary artery (LMCA) is subject to significant limitations. Intravascular ultrasound (IVUS) can provide accurate measurement, but there is no agreement on the minimum lumen cross-sectional area (MLA) that indicates significant disease. The aim of this study was to determine the long-term safety of applying a cut-off value of 6 mm2 for the MLA in the LMCA. METHODS: The study included patients with intermediate lesions (i.e., 25-50%) in unprotected LMCAs, with no previous evidence of associated ischemia. An IVUS examination was carried out and revascularization was indicated when the MLA was < or =6 mm2. RESULTS: In total, 79 patients were recruited between 2000-2005. In 31 (39%), the MLA was < or =6 mm2, and they underwent LMCA revascularization; in the remaining 48 (61%), the MLA was >6 mm2, and patients either underwent angioplasty for other lesions (n=37) or continued medical treatment (n=11). In a follow-up period of 40 [17] months, four patients (8.3%) died from heart disease, all of whom had an MLA between 9-10 mm2 in the baseline study. Revascularization of the LMCA was necessary in only two patients (4.2%), both of whom had elective surgery more than 2 years after the initial study. CONCLUSIONS: Intravascular ultrasound assessment of intermediate LMCA lesions using an MLA cut-off value of 6 mm2 appears safe over the long term provided the clinical and angiographic criteria applied to patient selection are similar to those used in this study.

Aplicación prospectiva de un valor de corte de área luminal mínima por ecografía intravascular en la evaluación de lesiones intermedias del tronco / Prospective use of an intravascular ultrasound-derived minimum lumen area cut-off value in the assessment of intermediate left main coronary artery lesions

Introducción y objetivos. La angiografía presenta limitaciones importantes para definir la severidad de las lesiones intermedias del tronco común. La ecografía endovascular (EEV) permite realizar una evaluación precisa, pero no hay consenso respecto a los valores de área luminal mínima (ALM) que indican significación. El objetivo de este estudio es evaluar la seguridad a largo plazo de la aplicación de un valor de corte de 6 mm2 para el ALM en el tronco. Métodos. Se ha incluido a pacientes con lesiones intermedias (25-50%) de tronco no protegido, sin datos previos indicativos de isquemia atribuible. Se realizó estudio con EEV y se indicó revascularización en los pacientes con ALM ≤ 6 mm2. Resultados. En el período 2000-2005 se ha incluido a 79 pacientes, en 31 (39%) el ALM fue ≤ 6 mm2 y recibieron revascularización del tronco, en los restantes 48 (61%) el ALM fue > 6 mm2 y sólo se actuó sobre otras lesiones (n = 37) o continuaron con tratamiento médico (n = 11). En un seguimiento de 40 ± 17 meses se han producido 4 muertes cardiacas (8,3%), que ocurrieron en casos con un ALM de 9-10 mm2 en el estudio basal. Sólo en 2 casos (4,2%) fue preciso efectuar procedimientos de revascularización del tronco que consistieron en cirugías electivas tras más de 2 años del estudio inicial. Conclusiones. La evaluación con EEV de las lesiones intermedias de tronco y la consideración de un valor de corte de 6 mm2 para el ALM resulta segura a largo plazo, siempre que se consideren unos criterios clinicoangiográficos de aplicabilidad como los considerados en este estudio (AU)

Background and objectives. Angiographic assessment of the severity of intermediate lesions in the left main coronary artery (LMCA) is subject to significant limitations. Intravascular ultrasound (IVUS) can provide accurate measurement, but there is no agreement on the minimum lumen cross-sectional area (MLA) that indicates significant disease. The aim of this study was to determine the long-term safety of applying a cut-off value of 6 mm2 for the MLA in the LMCA. Methods. The study included patients with intermediate lesions (i.e., 25­50%) in unprotected LMCAs, with no previous evidence of associated ischemia. An IVUS examination was carried out and revascularization was indicated when the MLA was ≤6 mm2. Results. In total, 79 patients were recruited between 2000­2005. In 31 (39%), the MLA was ≤6 mm2, and they underwent LMCA revascularization; in the remaining 48 (61%), the MLA was >6 mm2, and patients either underwent angioplasty for other lesions (n=37) or continued medical treatment (n=11). In a follow-up period of 40 [17] months, four patients (8.3%) died from heart disease, all of whom had an MLA between 9­10 mm2 in the baseline study. Revascularization of the LMCA was necessary in only two patients (4.2%), both of whom had elective surgery more than 2 years after the initial study. Conclusions. Intravascular ultrasound assessment of intermediate LMCA lesions using an MLA cut-off value of 6 mm2 appears safe over the long term provided the clinical and angiographic criteria applied to patient selection are similar to those used in this study (AU)

Perforación cardiaca tardía tras cierre percutáneo de un defecto septal interauricular con dispositivo Amplatzer / Late cardiac perforation after percutaneous closure of an atrial septal defect using an amplatzer device

No disponible

No disponible

[Two-year clinical follow-up in 200 patients receiving sirolimus-eluting stents in lesions at a high risk of restenosis]. / Seguimiento clínico a 2 años de 200 pacientes tratados con stent liberador de rapamicina en lesiones de alto riesgo de reestenosis.

INTRODUCTION AND OBJECTIVES: Sirolimus-eluting stents (SESs) have been shown to reduce the rate of restenosis significantly in all types of coronary lesion. However, reports of late cases of thrombosis and restenosis have raised questions about long-term outcome in patients treated with these stents. Our aim was to evaluate long-term outcome in patients undergoing SES placement in lesions at a high risk of restenosis. PATIENTS AND METHOD: Since SESs became available, we have used them to treat lesions at risk of restenosis. We studied clinical outcomes in consecutive patients treated with SESs who were followed up for more than 2 years. RESULTS: The study included 200 patients (age 60[11] years, 22% diabetics) who were treated between June 2002 and April 2003 for 309 lesions: 16% were total occlusions, 16.8% in-stent restenoses, 28% diffuse lesions, and 30% small-vessel lesions. The total stent length per patient was 29 (16) mm and the mean diameter was 2.78 (0.27) mm. In a mean clinical follow-up period of 29 (3.2) months (range 24-34 months), there were four deaths, two (1%) of which were cardiac, four (2%) non-fatal infarctions, four (2%) in-stent thromboses (all occurred late, at 3, 7, 26 and 31 months), four (2%) cases requiring target lesion revascularization (at 3, 5, 14 and 15 months), and six (3%) requiring revascularization of a new lesion. CONCLUSIONS: Long-term follow-up of patients undergoing SES placement in lesions at a high risk of restenosis revealed a very low restenosis rate. However, the incidence of late thrombosis appeared to be elevated and warrants further evaluation in larger studies.

Seguimiento clínico a 2 años de 200 pacientes tratados con stent liberador de rapamicina en lesiones de alto riesgo de reestenosis / Two-year clinical follow-up in 200 patients receiving sirolimus-eluting stents in lesions at a high risk of restenosis

Introducción y objetivos. Los stents de rapamicina (SR) han demostrado reducir la tasa de reestenosis en múltiples estudios, pero se han descrito algunos casos de reestenosis y trombosis tardías que proyectan dudas sobre sus resultados a largo plazo (> 2 años). Nos planteamos estudiar retrospectivamente la evolución a largo plazo de pacientes tratados con SR en lesiones de alto riesgo de reestenosis. Pacientes y método. Desde su introducción, hemos utilizado SR en los casos con lesiones de mayor riesgo de reestenosis. Estudiamos la evolución clínica de los pacientes en los que se implantaron SR y que cuentan con un seguimiento clínico superior a 2 años. Resultados. Se estudió a 200 pacientes (edad 60 ± 11 años, un 22% diabéticos) tratados entre junio de 2002 y abril de 2003 en 309 lesiones: un 16%, oclusiones totales; un 16,8%, reestenosis intra-stent; un 28%, difusas, y un 30%, en vaso pequeño. La longitud total de stent por paciente fue de 29 ± 16 mm y el diámetro del stent, de 2,78 ± 0,27 mm. En el seguimiento clínico de 29 ± 3,2 meses se produjeron los siguientes eventos: 4 muertes, de las que 2 (1%) fueron cardiacas; 4 infartos (2%); 4 trombosis de stent documentadas (2%), todas tardías a los 3, 7, 26 y 31 meses; 4 casos (2%) de revascularización por reestenosis del segmento tratado a los 3, 5, 14 y 15 meses, y 6 casos (3%) de revascularización de otra lesión. Conclusiones. La evolución a largo plazo de los pacientes con SR en lesiones de alto riesgo reestenótico muestra una tasa de reestenosis clínica muy baja. La incidencia de trombosis tardía parece resultar algo elevada y debería ser evaluada en series más amplias

Introduction and objectives. Sirolimus-eluting stents (SESs) have been shown to reduce the rate of restenosis significantly in all types of coronary lesion. However, reports of late cases of thrombosis and restenosis have raised questions about long-term outcome in patients treated with these stents. Our aim was to evaluate long-term outcome in patients undergoing SES placement in lesions at a high risk of restenosis. Patients and method. Since SESs became available, we have used them to treat lesions at risk of restenosis. We studied clinical outcomes in consecutive patients treated with SESs who were followed up for more than 2 years. Results. The study included 200 patients (age 60[11] years, 22% diabetics) who were treated between June 2002 and April 2003 for 309 lesions: 16% were total occlusions, 16.8% in-stent restenoses, 28% diffuse lesions, and 30% small-vessel lesions. The total stent length per patient was 29 (16) mm and the mean diameter was 2.78 (0.27) mm. In a mean clinical follow-up period of 29 (3.2) months (range 24-34 months), there were four deaths, two (1%) of which were cardiac, four (2%) non-fatal infarctions, four (2%) in-stent thromboses (all occurred late, at 3, 7, 26 and 31 months), four (2%) cases requiring target lesion revascularization (at 3, 5, 14 and 15 months), and six (3%) requiring revascularization of a new lesion. Conclusions. Long-term follow-up of patients undergoing SES placement in lesions at a high risk of restenosis revealed a very low restenosis rate. However, the incidence of late thrombosis appeared to be elevated and warrants further evaluation in larger studies