Cusp-overlap technique during TAVI using the self-expanding Portico FlexNav system.

INTRODUCTION AND OBJECTIVES: The cusp overlap technique (COT) has been proposed to reduce conduction disturbances (CD) after transcatheter aortic valve implantation (TAVI) with self-expanding supra-annular devices, but there are scarce data on COT with intra-annular valves. The aim of this study was to determine whether the use of the COT during Portico implantation results in higher valve implantation and lower rates of CD. METHODS: We included 85 patients undergoing TAVI with the Portico FlexNav system: 43 retrospective patients using the standard 3-cusp view and 42 prospective patients with the COT. Primary endpoints were implantation depth and new-onset CD (composite outcome of new-onset left bundle branch block and new permanent pacemaker implantation). RESULTS: COT resulted in a higher implantation depth (noncoronary cusp: 4.9±3.9 vs 7.4±3.0; P=.005) and lower new-onset CD (31.0% vs 58.1%; P=.012), with a tendency toward a lower need for permanent pacemaker implantation (14.3% vs 30.2%, P=.078; 7.7% vs 31.0%; P=.011 in patients without pre-existing right bundle branch block). Transvalvular aortic gradients were slightly lower with COT (8.7±3.7 vs 11.0±6.1; P=.044). There were no differences in technical success or major procedure-related complications. On multivariate analysis, COT use was associated with a lower risk of new-onset CD. CONCLUSIONS: Use of the COT during Portico implantation is feasible and facilitates a higher valve implant, which in turn may help to reduce rates of new-onset CD.

Spontaneous Coronary Artery Dissection: Rediscovering an Old Cause of Myocardial Infarction.

Spontaneous coronary artery dissection is an uncommon, but not insignificant cause of acute coronary syndrome that overwhelmingly affects middle-aged women. The pathophysiology of coronary dissection appears to be an outside-in mechanism, where the initiating event is not an intimal tear but rather the formation of an intramural hematoma, which compromises blood flow by reducing the arterial lumen. Considering this mechanism, it is clear to see how intracoronary imaging techniques, such as optical coherence tomography and intravascular ultrasound, are most accurate in the diagnosis. However, they carry a high rate of complications and are therefore generally avoided when the clinical scenario and angiographic appearance both support the diagnosis of spontaneous coronary artery dissection. The natural history of the disease is toward healing of the vessel wall and restoration of blood flow. Therefore, conservative medical management is the preferred approach unless there are high-risk factors such as hemodynamic instability, signs of ischemia and severe proximal or multivessel lesions, in which percutaneous or surgical revascularization should be considered. Perioperative evaluation of these patients must take into account several aspects of this disease. Most of these patients will be receiving single or dual antiplatelet therapy, so one must consider the timing of the event and the surgical hemorrhagic risk when deciding to stop these therapies. Extracoronary vascular disease also must be assessed because it can have an effect on patient monitoring and risk of postoperative complications.

Características clínicas de las pericarditis y miopericarditis diagnosticadas en urgencias y factores asociados con la necesidad de hospitalización / Clinical features of pericarditis with and without myocardial involvement diagnosed in the emergency department and factors associated with need for hospitalization

Objetivo: Analizar los episodios de pericarditis aguda (PA) diagnosticados en urgencias en función de la edad y de la afectación miocárdica (miopericarditis, MioP), y determinar los factores asociados a hospitalización. Método: Estudio observacional, descriptivo, unicéntrico de casos consecutivos, con análisis retrospectivo de todos los casos diagnosticados de PA en urgencias durante 10 años (2008-2017), y revisión de las características clínicas, ECG, analíticas y ecográficas (en MioP). Se compararon características clínicas según la edad (< 50 y $ 50 años) y existencia de MioP. Los factores asociados a hospitalización (PA y MioP) se identificaron de forma cruda y ajustada por las diferencias clínicas entre grupos. Resultados: Se diagnosticaron 983 PA (34% mujeres, mediana de edad: 42 años). Los pacientes más jóvenes referían con mayor frecuencia dolor torácico (DT) punzante y modificable con la respiración o cambios posturales, y los más mayores tenían más comorbilidades cardiovasculares, refirieron más frecuentemente DT opresivo y generaron mayor sospecha de síndrome coronario agudo. Las alteraciones en el ECG (OR = 4,26; IC95% = 1,89-9,59) se asociaron a MioP (72 casos, 7%). Ingresaron 62 PA (6%), hecho asociado a antecedente de insuficiencia renal (OR = 4,83; IC95% = 1,66-14,05), DT que se modifica con movimientos respiratorios/posturales (OR = 0,54, IC95% = 0,29-0,99), taquicardia (OR = 2,29, IC95% = 1,15-4,55) y MioP (OR = 8,73, IC95% = 4,65-16,38). Ingresaron 24 MioP (33%), hecho asociado a alteraciones en la ecoscopia dirigida (protocolo FOCUS; OR = 13,72, IC95% = 1,80-104). Conclusiones: La edad puede condicionar la presentación clínica en los pacientes con PA. Las alteraciones en el segmento ST en el ECG son sugestivos de implicación miocárdica. La insuficiencia renal, la taquicardia y la MioP son factores que incrementan la decisión de hospitalización en las PA; mientras que en las MioP, las alteraciones ecográficas

Objectives: To analyze the clinical features of acute pericarditis diagnosed in the emergency department according to patient age and myocardial involvement (myopericarditis) and to determine factors associated with hospitalization. Methods: Retrospective, descriptive, observational, single-center study of consecutive patients. We analyzed all cases of pericarditis diagnosed in the emergency department over a period of 10 years (2008-2017), reviewing clinical, electrocardiographic, and laboratory findings as well as ultrasound imaging for myocardial involvement. Characteristics were analyzed by age (under 50 years or 50 or older) and presence or not of myocardial involvement. Factors associated with hospitalization for both pericarditis and myopericarditis were identified by crude and adjusted odds ratios (ORs). Results: A total of 983 patients were diagnosed with pericarditis (34% women, mean age, 42 years). The younger patients more often reported sharp chest pain modified by breathing or posture changes. Older patients had more concurrent cardiovascular disease and described chest pain as pressure (oppressive); acute coronary syndrome was suspected more often in the older patients. The only independent predictor of myopericarditis was a finding of electrocardiographic abnormalities, recorded in 72 cases (7%) (OR, 4.26; 95% CI, 1.89-9.59). Sixty-two patients (6%) were admitted for pericarditis. Associated factors were renal insufficiency (OR, 4.83; 95% CI, 1.66-14.05), pain modified by breathing or posture changes (OR, 0.54; 95% CI, 0.29-0.99), tachycardia (OR, 2.29; 95% CI, 1.15-4.55), and myopericarditis (OR, 8.73; 95% CI, 4.65-16.38). Admission of 24 patients (33%) for myocarditis was related to focused cardiac ultrasound findings (OR, 13.72; 95% CI, 1.80-104). Conclusions: Age may affect the presentation of pericarditis. ST segment abnormalities on an electrocardiogram suggest myocardial involvement. Renal insufficiency, tachycardia, and myocardial involvement are the factors associated with a decision to admit patients with pericarditis. Ultrasound findings are associated with admission for myopericarditis

Clinical features of pericarditis with and without myocardial involvement diagnosed in the emergency department and factors associated with need for hospitalization. / Características clínicas de las pericarditis y miopericarditis diagnosticadas en urgencias y factores asociados con la necesidad de hospitalización.

OBJECTIVES: To analyze the clinical features of acute pericarditis diagnosed in the emergency department according to patient age and myocardial involvement (myopericarditis) and to determine factors associated with hospitalization. MATERIAL AND METHODS: Retrospective, descriptive, observational, single-center study of consecutive patients. We analyzed all cases of pericarditis diagnosed in the emergency department over a period of 10 years (2008-2017), reviewing clinical, electrocardiographic, and laboratory findings as well as ultrasound imaging for myocardial involvement. Characteristics were analyzed by age (under 50 years or 50 or older) and presence or not of myocardial involvement. Factors associated with hospitalization for both pericarditis and myopericarditis were identified by crude and adjusted odds ratios (ORs). RESULTS: A total of 983 patients were diagnosed with pericarditis (34% women, mean age, 42 years). The younger patients more often reported sharp chest pain modified by breathing or posture changes. Older patients had more concurrent cardiovascular disease and described chest pain as pressure (oppressive); acute coronary syndrome was suspected more often in the older patients. The only independent predictor of myopericarditis was a finding of electrocardiographic abnormalities, recorded in 72 cases (7%) (OR, 4.26; 95% CI, 1.89-9.59). Sixty-two patients (6%) were admitted for pericarditis. Associated factors were renal insufficiency (OR, 4.83; 95% CI, 1.66-14.05), pain modified by breathing or posture changes (OR, 0.54; 95% CI, 0.29-0.99), tachycardia (OR, 2.29; 95% CI, 1.15- 4.55), and myopericarditis (OR, 8.73; 95% CI, 4.65-16.38). Admission of 24 patients (33%) for myocarditis was related to focused cardiac ultrasound findings (OR, 13.72; 95% CI, 1.80-104). CONCLUSION: Age may affect the presentation of pericarditis. ST segment abnormalities on an electrocardiogram suggest myocardial involvement. Renal insufficiency, tachycardia, and myocardial involvement are the factors associated with a decision to admit patients with pericarditis. Ultrasound findings are associated with admission for myopericarditis.

OBJETIVO: Analizar los episodios de pericarditis aguda (PA) diagnosticados en urgencias en función de la edad y de la afectación miocárdica (miopericarditis, MioP), y determinar los factores asociados a hospitalización. METODO: Estudio observacional, descriptivo, unicéntrico de casos consecutivos, con análisis retrospectivo de todos los casos diagnosticados de PA en urgencias durante 10 años (2008-2017), y revisión de las características clínicas, ECG, analíticas y ecográficas (en MioP). Se compararon características clínicas según la edad (< 50 y $ 50 años) y existencia de MioP. Los factores asociados a hospitalización (PA y MioP) se identificaron de forma cruda y ajustada por las diferencias clínicas entre grupos. RESULTADOS: Se diagnosticaron 983 PA (34% mujeres, mediana de edad: 42 años). Los pacientes más jóvenes referían con mayor frecuencia dolor torácico (DT) punzante y modificable con la respiración o cambios posturales, y los más mayores tenían más comorbilidades cardiovasculares, refirieron más frecuentemente DT opresivo y generaron mayor sospecha de síndrome coronario agudo. Las alteraciones en el ECG (OR = 4,26; IC95% = 1,89-9,59) se asociaron a MioP (72 casos, 7%). Ingresaron 62 PA (6%), hecho asociado a antecedente de insuficiencia renal (OR = 4,83; IC95% = 1,66-14,05), DT que se modifica con movimientos respiratorios/posturales (OR = 0,54, IC95% = 0,29-0,99), taquicardia (OR = 2,29, IC95% = 1,15-4,55) y MioP (OR = 8,73, IC95% = 4,65-16,38). Ingresaron 24 MioP (33%), hecho asociado a alteraciones en la ecoscopia dirigida (protocolo FOCUS; OR = 13,72, IC95% = 1,80-104). CONCLUSIONES: La edad puede condicionar la presentación clínica en los pacientes con PA. Las alteraciones en el segmento ST en el ECG son sugestivos de implicación miocárdica. La insuficiencia renal, la taquicardia y la MioP son factores que incrementan la decisión de hospitalización en las PA; mientras que en las MioP, las alteraciones ecográficas.