Effect of upper lip compression on pain reduction during local anesthesia. A split-mouth randomized clinical trial

Objectives: To evaluate the effect of pressure on the skin of upper lip in decreasing pain perception during a local maxillary anesthetic injection. Material and Methods: A split-mouth crossover randomized clinical trial was designed. Seventy-one volunteer students (23.6±1.9 years old, 53.5% women) were selected. A group chosen at random had their left or right side of upper lip compressed by a wooden clothes peg as the compression instrument and 0.6 ml of lidocaine 2% with epinephrine 1:100,000 was administered at the buccal apex level of the lateral incisors tooth. Two weeks later anesthesia was administered on the opposite side of the lip according to the randomization recorded. The intensity of perceived pain level between the two injections using a 100 mm visual analog scale (VAS) and co-variable effect were compared (Wilcoxon test p < 0.05, RStudio). Results: The average of the perceived pain with and without upper lip compression was 27.6±14.5 mm (range 0-80 mm) and 36.33±17.9 mm (range 10-90 mm) respectively (p= 0.002). No significant differences were recorded according the covariance analysis with the sex (p = 0.55) and age (p = 0.89). Conclusion: The upper lip compression significantly reduces the perception of pain during a local maxillary anesthetic technique.

Intermittent inotropic support with levosimendan in advanced heart failure as destination therapy: The LEVO-D registry.

AIM: Patients with advanced heart failure (AHF) who are not candidates to advanced therapies have poor prognosis. Some trials have shown that intermittent levosimendan can reduce HF hospitalizations in AHF in the short term. In this real-life registry, we describe the patterns of use, safety and factors related to the response to intermittent levosimendan infusions in AHF patients not candidates to advanced therapies. METHODS AND RESULTS: Multicentre retrospective study of patients diagnosed with advanced heart failure, not HT or LVAD candidates. Patients needed to be on the optimal medical therapy according to their treating physician. Patients with de novo heart failure or who underwent any procedure that could improve prognosis were not included in the registry. Four hundred three patients were included; 77.9% needed at least one admission the year before levosimendan was first administered because of heart failure. Death rate at 1 year was 26.8% and median survival was 24.7 [95% CI: 20.4-26.9] months, and 43.7% of patients fulfilled the criteria for being considered a responder lo levosimendan (no death, heart failure admission or unplanned HF visit at 1 year after first levosimendan administration). Compared with the year before there was a significant reduction in HF admissions (38.7% vs. 77.9%; P < 0.0001), unplanned HF visits (22.7% vs. 43.7%; P < 0.0001) or the combined event including deaths (56.3% vs. 81.4%; P < 0.0001) during the year after. We created a score that helps predicting the responder status at 1 year after levosimendan, resulting in a score summatory of five variables: TEER (+2), treatment with beta-blockers (+1.5), Haemoglobin >12 g/dL (+1.5), amiodarone use (-1.5) HF visit 1 year before levosimendan (-1.5) and heart rate >70 b.p.m. (-2). Patients with a score less than -1 had a very low probability of response (21.5% free of death or HF event at 1 year) meanwhile those with a score over 1.5 had the better chance of response (68.4% free of death or HF event at 1 year). LEVO-D score performed well in the ROC analysis. CONCLUSION: In this large real-life series of AHF patients treated with levosimendan as destination therapy, we show a significant decrease of heart failure events during the year after the first administration. The simple LEVO-D Score could be of help when deciding about futile therapy in this population.

Exercise Intolerance in Post-Acute Sequelae of COVID-19 and the Value of Cardiopulmonary Exercise Testing- a Mini-Review.

Coronavirus disease (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), with systemic organ damage in the most severe forms. Long-term complications of SARS-CoV-2 appear to be restricted to severe presentations of COVID-19, but many patients with persistent symptoms have never been hospitalized. Post-acute sequelae of COVID-19 (PASC) represents a heterogeneous group of symptoms characterized by cardiovascular, general, respiratory, and neuropsychiatric sequelae. The pace of evidence acquisition with PASC has been rapid, but the mechanisms behind it are complex and not yet fully understood. In particular, exercise intolerance shares some features with other classic respiratory and cardiac disorders. However, cardiopulmonary exercise testing (CPET) provides a comprehensive assessment and can unmask the pathophysiological mechanism behind exercise intolerance in gray-zone PASC. This mini-review explores the utility of CPET and aims to provide a comprehensive assessment of PASC by summarizing the current evidence.

Rationale and design of the rigorous atrial analysis in advanced interatrial block (ARABIA) prospective study.

BACKGROUND: Advanced interatrial block (IAB) is present in 10% of subjects ≥75 years and is associated with the risk of clinical events. METHODS AND RESULTS: Prospective multicenter study that will include subjects ≥75 years without exclusion criteria (indication for anticoagulation, cardiac devices, severe valve disease, systolic dysfunction, moderate or severe cognitive impairment, poor echocardiographic window, non-sinus rhythm or partial IAB, stroke, and life expectancy <2 years). A total of 356 subjects, 178 patients with advanced IAB (exposed) and 178 matched individuals with normal P-wave (non-exposed) will be included. Electrocardiogram and advanced transthoracic echocardiography will be performed. Two substudies will include magnetic resonance imaging: cardiac (86 subjects, 43 exposed, and 43 non-exposed) and brain (86 subjects, 43 exposed, and 43 non-exposed). The follow-up will be 2 years. Our main objective is to determine the association of advanced IAB, P-wave duration, and atrial imaging parameters (I] atrial global longitudinal strain, II] maximal left atrial volume index, III] left atrial ejection fraction, IV] left atrial fibrosis - % total left atrial area V] inter- and intra-atrial asynchrony/dyssynchrony) with clinical events (atrial fibrillation, stroke, cognitive impairment, and mortality). The secondary objective is to assess the association of the P-wave duration with atrial imaging parameters and of both with cerebral microemboli in magnetic resonance imaging. CONCLUSION: Our study will provide data regarding the association of advanced IAB, P-wave duration, and atrial imaging parameters with clinical events. We will also assess the association P-wave duration-atrial imaging parameters-cerebral microemboli.

Low-density lipoprotein cholesterol levels are associated with poor clinical outcomes in COVID-19.

BACKGROUND AND AIMS: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the sole causative agent of coronavirus infectious disease-19 (COVID-19). METHODS AND RESULTS: We performed a retrospective single-center study of consecutively admitted patients between March 1st and May 15th, 2020, with a definitive diagnosis of SARS-CoV-2 infection. The primary end-point was to evaluate the association of lipid markers with 30-days all-cause mortality in COVID-19. A total of 654 patients were enrolled, with an estimated 30-day mortality of 22.8% (149 patients). Non-survivors had lower total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-c) levels during the entire course of the disease. Both showed a significant inverse correlation with inflammatory markers and a positive correlation with lymphocyte count. In a multivariate analysis, LDL-c ≤ 69 mg/dl (hazard ratio [HR] 1.94; 95% confidence interval [CI] 1.14-3.31), C-reactive protein >88 mg/dl (HR 2.44; 95% CI, 1.41-4.23) and lymphopenia <1000 (HR 2.68; 95% CI, 1.91-3.78) at admission were independently associated with 30-day mortality. This association was maintained 7 days after admission. Survivors presented with complete normalization of their lipid profiles on short-term follow-up. CONCLUSION: Hypolipidemia in SARS-CoV-2 infection may be secondary to an immune-inflammatory response, with complete recovery in survivors. Low LDL-c serum levels are independently associated with higher 30-day mortality in COVID-19 patients.

Exercise Ventilatory Inefficiency in Post-COVID-19 Syndrome: Insights from a Prospective Evaluation.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is a systemic disease characterized by a disproportionate inflammatory response in the acute phase. This study sought to identify clinical sequelae and their potential mechanism. METHODS: We conducted a prospective single-center study (NCT04689490) of previously hospitalized COVID-19 patients with and without dyspnea during mid-term follow-up. An outpatient group was also evaluated. They underwent serial testing with a cardiopulmonary exercise test (CPET), transthoracic echocardiogram, pulmonary lung test, six-minute walking test, serum biomarker analysis, and quality of life questionaries. RESULTS: Patients with dyspnea (n = 41, 58.6%), compared with asymptomatic patients (n = 29, 41.4%), had a higher proportion of females (73.2 vs. 51.7%; p = 0.065) with comparable age and prevalence of cardiovascular risk factors. There were no significant differences in the transthoracic echocardiogram and pulmonary function test. Patients who complained of persistent dyspnea had a significant decline in predicted peak VO2 consumption (77.8 (64-92.5) vs. 99 (88-105); p < 0.00; p < 0.001), total distance in the six-minute walking test (535 (467-600) vs. 611 (550-650) meters; p = 0.001), and quality of life (KCCQ-23 60.1 ± 18.6 vs. 82.8 ± 11.3; p < 0.001). Additionally, abnormalities in CPET were suggestive of an impaired ventilatory efficiency (VE/VCO2 slope 32 (28.1-37.4) vs. 29.4 (26.9-31.4); p = 0.022) and high PETCO2 (34.5 (32-39) vs. 38 (36-40); p = 0.025). INTERPRETATION: In this study, >50% of COVID-19 survivors present a symptomatic functional impairment irrespective of age or prior hospitalization. Our findings suggest a potential ventilation/perfusion mismatch or hyperventilation syndrome.

El cateterismo cardiaco derecho de esfuerzo predice eventos en los pacientes con estenosis aórtica degenerativa asintomática / Exercise right heart catheterization predicts outcome in asymptomatic degenerative aortic stenosis

INTRODUCCIÓN Y OBJETIVOS: La estenosis aórtica degenerativa es la valvulopatía más frecuente. Aún no está claro cómo identificar a los pacientes asintomáticos con fracción de eyección del ventrículo izquierdo normal y alta probabilidad de eventos que por ello pudieran beneficiarse de una intervención valvular precoz. En este estudio se describe un protocolo de hemodinámica de esfuerzo para los pacientes asintomáticos con estenosis aórtica moderada o grave para evaluar su valor pronóstico para esta población. MÉTODOS: Estudio prospectivo unicéntrico de una población de pacientes con estenosis aórtica moderada o grave asintomáticos. Los pacientes realizaron una ergoespirometría para confirmar la ausencia de síntomas en esfuerzo. Después los pacientes se sometieron a un cateterismo cardiaco derecho basal y de esfuerzo. Se definió evento como muerte o necesidad de reemplazo de válvula aórtica quirúrgico o percutáneo basado en las guías clínicas. RESULTADOS: Se sometió a 33 pacientes a cateterismo cardiaco derecho basal y de esfuerzo. El área valvular aórtica media fue de 1,08 cm2 y el gradiente aórtico medio, 39 mmHg. La presión arterial pulmonar media fue de 21 mmHg, con una presión de oclusión en la arteria pulmonar de 14 mmHg y un gasto cardiaco de 5,6 l/min. La presión pulmonar media en ejercicio máximo fue de 34 mmHg. Tras un seguimiento medio de 27 meses, 8 pacientes sufrieron un evento (24%). No hubo diferencias en las variables basales, el área valvular aórtica o los parámetros de ergoespirometría. Los pacientes con evento no tuvieron mayores presiones pulmonares o presiones de llenado en ejercicio máximo, pero el grupo con eventos mostró menor saturación de oxígeno en la arteria pulmonar en esfuerzo (mediana, el 48 frente al 57%; p = 0,03). CONCLUSIONES: El cateterismo cardiaco de esfuerzo es seguro y factible en esta población. La saturación de oxígeno en la arteria pulmonar en esfuerzo podría identificar a un grupo de pacientes con un aumento del riesgo de eventos adversos graves

INTRODUCTION AND OBJECTIVES: Degenerative aortic stenosis (DAS) is the most frequent valvular heart disease. It remains unclear how to identify asymptomatic DAS patients with normal left ventricular ejection fraction who have a high probability of event occurrence and would thus benefit from early intervention. Here, we describe a protocol for exercise hemodynamics in true asymptomatic patients with moderate or severe DAS and assess the prognostic value of the data obtained in this population. METHODS: This study involved a prospective single-centre registry of consecutive asymptomatic patients with moderate or severe DAS. Patients underwent cardiopulmonary exercise testing to confirm symptom absence during exercise and then right heart catheterization (RHC) at rest and during exercise. Events were defined as death, surgical aortic valve replacement, or transcatheter aortic valve implantation according to clinical guidelines. RESULTS: Thirty-three patients underwent baseline and exercise RHC. The mean aortic valve area was 1.08 cm2 and the aortic gradient was 39mmHg. The mean pulmonary artery pressure was 21mmHg with a pulmonary artery occlusion pressure of 14mmHg and cardiac output of 5.6 L/min. The mean pulmonary artery pressure at peak exercise was 34mmHg. After a mean follow-up of 27 months, 8 patients experienced an event (24%). There were no differences in baseline variables, aortic valve area, or cardiopulmonary exercise testing parameters between the event and event-free groups. Patients with an event did not have higher pulmonary or filling pressures after peak exercise but had lower pulmonary artery oxygen saturation on effort (median, 48% vs 57%, P=.03). Exercise RHC is feasible and safe in this population. Peak pulmonary artery oxygen saturation might identify patients with increased risk of serious adverse events

Exercise right heart catheterization predicts outcome in asymptomatic degenerative aortic stenosis.

INTRODUCTION AND OBJECTIVES: Degenerative aortic stenosis (DAS) is the most frequent valvular heart disease. It remains unclear how to identify asymptomatic DAS patients with normal left ventricular ejection fraction who have a high probability of event occurrence and would thus benefit from early intervention. Here, we describe a protocol for exercise hemodynamics in true asymptomatic patients with moderate or severe DAS and assess the prognostic value of the data obtained in this population. METHODS: This study involved a prospective single-centre registry of consecutive asymptomatic patients with moderate or severe DAS. Patients underwent cardiopulmonary exercise testing to confirm symptom absence during exercise and then right heart catheterization (RHC) at rest and during exercise. Events were defined as death, surgical aortic valve replacement, or transcatheter aortic valve implantation according to clinical guidelines. RESULTS: Thirty-three patients underwent baseline and exercise RHC. The mean aortic valve area was 1.08 cm2 and the aortic gradient was 39mmHg. The mean pulmonary artery pressure was 21mmHg with a pulmonary artery occlusion pressure of 14mmHg and cardiac output of 5.6 L/min. The mean pulmonary artery pressure at peak exercise was 34mmHg. After a mean follow-up of 27 months, 8 patients experienced an event (24%). There were no differences in baseline variables, aortic valve area, or cardiopulmonary exercise testing parameters between the event and event-free groups. Patients with an event did not have higher pulmonary or filling pressures after peak exercise but had lower pulmonary artery oxygen saturation on effort (median, 48% vs 57%, P=.03). CONCLUSIONS: Exercise RHC is feasible and safe in this population. Peak pulmonary artery oxygen saturation might identify patients with increased risk of serious adverse events.

La insuficiencia tricúspide, y no la insuficiencia mitral, determina la mortalidad en pacientes que presentan insuficiencia mitral no grave previa a TAVI / Tricuspid but not mitral regurgitation determines mortality after TAVI in patients with nonsevere mitral regurgitation

Introducción y objetivos: Muchos pacientes sometidos a implante percutáneo de válvula aórtica (TAVI) presentan insuficiencia mitral (IM) de grado moderado o menor. El impacto de la insuficiencia tricuspídea (IT) sigue sin resolverse. Se analiza el impacto de la IM moderada frente a leve-ausente y su evolución, y de la IT concomitante y su interacción con la IM. Métodos: Estudio retrospectivo multicéntrico de 813 pacientes tratados con TAVI entre 2007 y 2015 con IM ≤ 2 y abordaje transfemoral. Resultados: La edad media fue 81 ± 7 años y el Society of Thoracic Surgeons-score fue de 6,9 ± 5,1%. El 37,3% presentó IM moderada, con resultados comparables intrahospitalarios y de mortalidad a 6 meses frente a IM < 2 (11,9 frente a 9,4%; p = 0,257). Sin embargo, experimentaron más rehospitalizaciones y peor clase de la New York Heart Association (p = 0,008 y 0,001, respectivamente). Solo un 3,8% demostró un aumento en el grado de IM > 2 tras el TAVI. La presencia de IT moderada/grave se asoció con una mortalidad intrahospitalaria y de seguimiento del 13 y el 34,1%, independientemente del grado de IM. La IT moderada-grave fue predictor independiente de mortalidad (HR = 18,4; IC95%, 10,2-33,3; p < 0,001). Conclusiones: La presencia de IM moderada no supuso mayor mortalidad a corto-medio plazo tras el TAVI, pero asoció más rehospitalizaciones. La presencia de IT moderada/grave implicó mayor mortalidad. Esto sugiere que una evaluación minuciosa de los mecanismos subyacentes entre ambas insuficiencias valvulares debe realizarse para determinar la mejor estrategia para evitar la futilidad relacionada con TAVI

Introduction and objectives: Many patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or less. The impact of coexistent tricuspid regurgitation (TR) remains to be determined. We sought to analyze the impact of moderate vs none-to-mild MR and its trend after TAVI, as well as the impact of concomitant TR and its interaction with MR. Methods: Multicenter retrospective study of 813 TAVI patients treated through the transfemoral approach with MR ≤ 2 between 2007 and 2015. Results: The mean age was 81 ± 7 years and the mean Society of Thoracic Surgeons score was 6.9% ± 5.1%. Moderate MR was present in 37.3% of the patients, with similar in-hospital outcomes and 6-month follow-up mortality to those with MR < 2 (11.9% vs 9.4%; P = .257). However, they experienced more rehospitalizations and worse New York Heart Association class (P = .008 and .001, respectively). Few patients (3.8%) showed an increase in the MR grade to > 2 post-TAVI. The presence of concomitant moderate/severe TR was associated with in-hospital and follow-up mortality rates of 13% and 34.1%, respectively, regardless of MR grade. Moderate-severe TR was independently associated with mortality (HR, 18.4; 95%CI, 10.2-33.3; P < .001). Conclusions: The presence of moderate MR seemed not to impact short- and mid-term mortality post-TAVI, but was associated with more rehospitalizations. The presence of moderate or severe TR was associated with higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility

Transubclavian approach: A competitive access for transcatheter aortic valve implantation as compared to transfemoral.

AIMS: Empirically, transfemoral (TF) approach is the first choice for transcatheter aortic valve implantation (TAVI). We aimed to investigate whether transubclavian (TSc) and TF approaches present comparable major outcomes according to current evidence. METHODS: We systematically searched PubMed, EMBASE, and Cochrane database for studies with symptomatic aortic stenosis patients who underwent TAVI through TF or TSc/axillary access from January/2006 to January/2017. Searched terms were: ("aortic stenosis" OR "transcatheter aortic" OR "TAVI" OR "TAVR") and ("transfemoral" OR "transaxillary" OR "transubclavian"). Major outcomes according to Valve Academic Research Consortium-2 criteria were gathered. The odds ratio (OR) was used as a summary statistic. A random-effects model was used. A fully percutaneous TSc TAVI case from our institution illustrates minimalist approach. RESULTS: Final analysis was made with six studies including 4,504 patients (3,886 TF and 618 TSc). Baseline characteristics of compared groups in individual studies were similar, with the exception of a higher logistic EuroSCORE in the TSc group (23.7 ± 1.92 vs. 21.17 ± 3.51, P = 0.04) and higher prevalence of coronary and peripheral artery disease with OR = 0.67 [95% CI: 0.54-0.83] (P = 0.0003) and OR = 0.08 [95% CI: 0.05-0.12] (P < 0.00001), respectively. TSc group presented comparable 30-day mortality (OR = 1.37; [95%CI: 0.85-2.21]; P = 0.20). There were no differences for procedural success, 30-day stroke rate, need for new pacemaker implantation, major vascular complications, and acute kidney injury requiring dialysis. Also, no differences were found concerning 1-year mortality. CONCLUSIONS: Our study suggests that TSc approach may be, not only an alternative route to TF approach for TAVI, but even a competitive one in certain patients with increased risk of femoral injury.

Tricuspid but not Mitral Regurgitation Determines Mortality After TAVI in Patients With Nonsevere Mitral Regurgitation.

INTRODUCTION AND OBJECTIVES: Many patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or less. The impact of coexistent tricuspid regurgitation (TR) remains to be determined. We sought to analyze the impact of moderate vs none-to-mild MR and its trend after TAVI, as well as the impact of concomitant TR and its interaction with MR. METHODS: Multicenter retrospective study of 813 TAVI patients treated through the transfemoral approach with MR ≤ 2 between 2007 and 2015. RESULTS: The mean age was 81 ± 7 years and the mean Society of Thoracic Surgeons score was 6.9% ± 5.1%. Moderate MR was present in 37.3% of the patients, with similar in-hospital outcomes and 6-month follow-up mortality to those with MR < 2 (11.9% vs 9.4%; P = .257). However, they experienced more rehospitalizations and worse New York Heart Association class (P = .008 and .001, respectively). Few patients (3.8%) showed an increase in the MR grade to > 2 post-TAVI. The presence of concomitant moderate/severe TR was associated with in-hospital and follow-up mortality rates of 13% and 34.1%, respectively, regardless of MR grade. Moderate-severe TR was independently associated with mortality (HR, 18.4; 95%CI, 10.2-33.3; P < .001). CONCLUSIONS: The presence of moderate MR seemed not to impact short- and mid-term mortality post-TAVI, but was associated with more rehospitalizations. The presence of moderate or severe TR was associated with higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility.

Cambios microscópicos in vitro de cuerpos de prueba de amalgama de plata sometidos a altas temperaturas observados mediante microscopía electrónica de barrido / In vitro microscopic changes of dental amalgam test bodies subjected to high temperatures observed by scanning electron microscopy

Objetivo: describir los cambios microscópicos in vitro de 27 cuerpos de prueba elaborados en amalgama de plata de tres marcas comerciales (Contour® Kerr®, Admix® SDI® y Nu Alloy® Newstethic®) sometidos a altas temperaturas (200ºC, 400ºC y 600ºC) observados mediante microscopia electrónica de barrido. Materiales y métodos: estudio observacional descriptivo, de corte transversal y de naturaleza pseudo-experimental que analizó el comportamiento in vitro de 27 cuerpos de prueba elaborados en tres marcas comerciales de amalgama de plata (Contour® Kerr®, Admix® SDI® y Nu Alloy® Newstethic®) sometidos a altas temperaturas (200ºC, 400ºC, 600ºC). Resultados: las tres marcas comerciales de amalgama de plata empleadas en este estudio tuvieron un comportamiento similar, excepto en el comportamiento de los nódulos de plata. Estos aparecieron a los 200ºC en Admix® SDI® y a los 400ºC en Contour® Kerr® y Nu Alloy® Newstethic®. El análisis en microscopía electrónica de barrido y espectrofotometría de la superficie de los cuerpos de prueba evidenció el aumento estadísticamente significativo (p<0,05) del porcentaje de peso atómico de Hg, Cu y Sn. Conclusiones: los cuerpos de prueba de las tres marcas comerciales de amalgama de plata sufren cambios en su microestructura en la medida que aumenta la temperatura. La formación de los nódulos de Ag fue explicada como una consecuencia del comportamiento de la fase gamma 1 de Ag-Hg al aumentar la temperatura, la cual empieza a disociarse a los 200ºC en Admix® SDI® y a los 400ºC en Contour® Kerr® y Nu Alloy® Newstethic®.

Objective: describe the in vitro microscopic changes of dental amalgam test bodies subjected to high temperatures observed by scanning electron microscopy. Materials and methods: descriptive observational cross-sectional study of pseudo-experimental nature that analyzed by scanning electron microscopy (SEM) the in vitro behavior of 27 test bodies elaborated in three brands of dental amalgam (Contour® Kerr®, Admix® SDI® and Nu Alloy® Newstethic®) subjected to high temperatures (200ºC, 400ºC, 600ºC). Results: the three trademarks of dental amalgam used in this study had a similar behavior, except for the behavior of silver nodules. These appeared to 200ºC in the test bodies of Admix® SDI® and 400ºC in the test bodies of Contour® Kerr® and Nu Alloy® Newstethic®. The analysis of scanning electron microscopy and spectrophotometry at the surface of the test bodies showed the statistically significant increase (p<0.05) the percentage of atomic weight of mercury, copper and tin. Conclusions: the test bodies of the three trademarks of dental amalgam undergo changes in their microstructure so long as the temperature increases. The formation of silver nodules was explained as a consequence of the behavior of the gamma 1 phase silver-mercury with increasing temperature, which begins to dissociate at 200ºC in the test bodies of Admix® SDI® and 400ºC in the test bodies of Contour® Kerr® and Nu Alloy® Newstethic®.

Implante percutáneo de válvula aórtica en pacientes con prótesis mitral previa / Transcatheter aortic valve implantation in patients with previous mitral prostheses

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Acquired Aseptic Intracardiac Shunts Following Transcatheter Aortic Valve Replacement: A Systematic Review.

OBJECTIVES: The aim of this study was to describe the incidence, mechanisms, features, and management of aseptic intracardiac shunts (AICS). BACKGROUND: AICS following transcatheter aortic valve replacement (TAVR) are an uncommon and barely described complication. METHODS: A systematic review was performed of all published cases of AICS following TAVR, and the incidence, predictors, main features, management, and related outcomes were analyzed. RESULTS: A total of 31 post-TAVR AICS were gathered. After excluding transapical fistulas, the 28 remaining cases corresponded with an incidence of about 0.5%. Mean age and mean logistic European System for Cardiac Operative Risk Evaluation score were 80 ± 11 years and 19.2 ± 8.3%, respectively. Prior radiation therapy for cancer was present in 14.3%, and 42.8% had severe calcification of the aortic valve. TAVR was undertaken using balloon-expandable prostheses in the majority of cases (85.7%), via the transapical approach in one-third. Median time from TAVR to diagnosis was 21 days (interquartile range: 7 to 30 days), with intraprocedural suspicion in 12 cases (42.9%) and a mean Qp/Qs ratio of 1.8 ± 0.6. The most common location for AICS was the interventricular septum (60.7%). Heart failure was frequent (46.4%), but 14 patients (50%) remained asymptomatic. Medical treatment (71.4%) was associated with poor outcomes (30-day mortality rate 25%), especially in symptomatic patients (35% vs. 0%; p = 0.020) and in those with higher Qp/Qs ratios (1.9 ± 0.6 vs. 1.4 ± 0.1), while cardiac surgery (3.6%), and percutaneous closure (25%) led to good outcomes after a median follow-up period of 3 months (interquartile range: 1 to 9 months). CONCLUSIONS: Post-TAVR AICS are uncommon but have high 30-day mortality if left untreated, especially in symptomatic patients. Percutaneous closure was feasible and safe in symptomatic patients but remains controversial in asymptomatic subjects.

Therapeutic alternatives after aborted sternotomy at the time of surgical aortic valve replacement in the TAVI Era-Five centre experience and systematic review.

BACKGROUND: We aimed to analyze causes, management, and outcomes of the unexpected need to abort sternotomy in aortic stenosis (AS) patients accepted for surgical aortic valve replacement (SAVR) in the transcatheter aortic valve implantation (TAVI) era. METHODS: Cases of aborted sternotomy (AbS) were gathered from 5 centers between 2009 and 2014. A systematic review of all published cases in the same period was performed. RESULTS: A total of 31 patients (71% males, 74±8years, LogEuroSCORE 11.9±7.4%) suffered an AbS (0.19% of all sternotomies). Main reasons for Abs included previously unknown porcelain aorta (PAo) in 83.9%, mediastinal fibrosis due to radiotherapy in 12.9%, and chronic mediastinitis in 3.2%. Median time between AbS and next intervention was 2.3months (IQR: 0.7-5.8) with no mortality within this period. Only a case was managed with open surgery. In 30 patients (96.8%) TAVI was performed with a rate of success of 86.7%. Three patients (9.7%) presented in-hospital death and 17 (54.8%) had in-hospital complications including heart failure (9.6%), major bleeding (6.9%), and acute kidney injury (9.6%). Older patients (76±8 vs. 70±8years, p=0.045), previous cardiac surgery (60% vs. 15.4%, p=0.029), and shorter time from AbS to next intervention (5.1±5 vs. 1±0.7months, p=0.001) were related to higher six-month mortality (22.6%). CONCLUSIONS: The main reason for AbS was PAo. This entity was associated to a higher rate of complications and mortality, especially in older patients and with prior cardiac surgery. A preventive strategy in these subgroups might be based on imaging evaluation. TAVI was the most extended therapy.

Mitral Regurgitation After Transcatheter Aortic Valve Replacement: Prognosis, Imaging Predictors, and Potential Management.

OBJECTIVES: This study sought to analyze the clinical impact of the degree and improvement of mitral regurgitation in TAVR recipients, validate the main imaging determinants of this improvement, and assess the potential candidates for double valve repair with percutaneous techniques. BACKGROUND: Many patients with severe aortic stenosis present with concomitant mitral regurgitation (MR). Cardiac imaging plays a key role in identifying prognostic factors of MR persistence after transcatheter aortic valve replacement (TAVR) and for planning its treatment. METHODS: A total of 1,110 patients with severe aortic stenosis from 6 centers who underwent TAVR were included. In-hospital to 6-month follow-up clinical outcomes according to the degree of baseline MR were evaluated. Off-line analysis of echocardiographic and multidetector computed tomography images was performed to determine predictors of improvement, clinical outcomes, and potential percutaneous alternatives to treat persistent MR. RESULTS: Compared with patients without significant pre-TAVR MR, 177 patients (16%) presented with significant pre-TAVR MR, experiencing a 3-fold increase in 6-month mortality (35.0% vs. 10.2%; p < 0.001). After TAVR, the degree of MR improved in 60% of them. A mitral annular diameter of >35.5 mm (odds ratio: 9.0; 95% confidence interval: 3.2 to 25.3; p < 0.001) and calcification of the mitral apparatus by multidetector computed tomography (odds ratio: 11.2; 95% confidence interval: 4.03 to 31.3; p < 0.001) were independent predictors of persistent MR. At least 14 patients (1.3% of the entire cohort, 13.1% of patients with persistent MR) met criteria for percutaneous mitral repair with either MitraClip (9.3%) or a balloon-expandable valve (3.8%). CONCLUSIONS: Significant MR is not uncommon in TAVR recipients and associates with greater mortality. In more than one-half of patients, the degree of MR improves after TAVR, which can be predicted by characterizing the mitral apparatus with multidetector computed tomography. According to standardized imaging criteria, at least 1 in 10 patients whose MR persists after TAVR could benefit from percutaneous mitral procedures, and even more could be treated with MitraClip after dedicated pre-imaging evaluation.

Propensity score matched comparison of transcatheter aortic valve implantation versus conventional surgery in intermediate and low risk aortic stenosis patients: A hint of real-world.

BACKGROUND: Recently, the use of transcatheter aortic valve implantation (TAVI) in inter-mediate-low risk patients has been evaluated in the PARTNER II randomized trial. However, in the last years, this therapy has been employed in this scenario with underreported results, as compared to surgical aortic valve replacement (SAVR). METHODS: We enrolled 362 consecutive patients with severe symptomatic aortic stenosis and intermediate-low surgical risk (logEuroSCORE < 20%), treated in our center with TAVI (103 patients) or single SAVR (259 patients) between 2009 and 2014. Patients were matched according to age, gender, logEuroSCORE, and use of bioprosthesis. RESULTS: Mean age of the patients was 73 ± 10.4 years, and 40.3% were women. LogEuroSCORE and Society Thoracic Surgeons score were 7.0 ± 4.4% and 4.2 ± 2.5%, respectively, with mean left ventricular ejection fraction of 52 ± 9%. There were no differences regarding other comorbidities. The length-of-hospitalization was 11 ± 5 days after TAVI vs. 17 ± 9 days after SAVR (p = 0.003). After matched comparison, no differences in terms of in-hospital mortality (5.7% after TAVI vs. 2.9% after SAVR, p = 0.687) and 1-year mortality (11.4% vs. 7.1%, p = 0.381) were found. The combined endpoint of stroke and mortality at 1-year was also similar between both groups (15.7% in TAVI patients vs. 14.4% after SAVR, p = 0.136). Multivariate analysis determined that aortic regurgitation (AR) was an independent predictor of mortality (OR = 3.623, 95% CI: 1.267-10.358, p = 0.016). Although the rate of AR was higher after TAVI, none of the patients treated with the newest generation devices (10.7%) presented more than a mild degree of AR. CONCLUSIONS: TAVI is feasible and shows comparable results to surgery in terms of early, 1-year mortality, as well as cerebrovascular events in patients with severe aortic stenosis and intermediate-low operative risk. Better transvalvular gradients, yet higher rates of AR were found, however, newer devices presented comparable rate of AR.