Detección de barreras e implementación de procedimientos para reducir la demora en el tratamiento del síndrome coronario agudo con elevación del segmento ST mediante angioplastia primaria / Barriers and Procedures to Reduce Treatment Delay in ST-Segment Elevation Acute Coronary Syndrome with Primary Percutaneous Coronary Intervention

RESUMEN Introducción: La demora a la reperfusión del síndrome coronario agudo con elevación del segmento ST es un factor determinante en el pronóstico. Su reducción podría disminuir la morbimortalidad. Objetivo: Identificar y modificar las barreras detectadas en 20 años de tratamiento del síndrome coronario agudo con elevación del segmento ST en un centro de tercer nivel de una ciudad de alta densidad demográfica para evaluar su efecto en el resultado del procedimiento. Material y métodos: Incluimos prospectiva y consecutivamente del 01/01/2000 al 31/12/2019, 3007 pacientes con síndrome coronario agudo con elevación del segmento ST dentro de las 12 h de iniciados los síntomas para realizar angioplastia primaria. Se dividió el tiempo desde el comienzo de los síntomas hasta la insuflación del balón en intervalos. Luego de identificar las barreras (2000-2009) se incorporaron cambios al procedimiento. Se organizó a la población en 2 grupos (G) G1: preimplementación de cambios (2000-2009) y G2: posimplementación (2010- 2019). Resultados: Se incluyeron en G1 1409 pacientes y en G2 1598. Sin diferencias demográficas, excepto por el tipo de angioplastia. Se identificaron demoras al realizar el diagnóstico, de comunicación entre médicos, del traslado y del ingreso del paciente a hemodinamia. Con los cambios, disminuimos el intervalo consulta-contacto con el hemodinamista [G1: 90 min (36-168) vs. G2: 77 min (36-144) p -0,01] y el intervalo contacto hemodinamista-ingreso a Hemodinamia [G1: 75 min (55-100) vs. G2: 51 min (34-70) p -0,01]. Se redujo la mortalidad intrahospitalaria (G1: 9,2% vs. G2:6,7% p -0,01) y al 6to mes (G1: 13,1% vs. G2: 7,5% p -0,01). Conclusiones: El retraso al diagnóstico, la dificultad en la comunicación y la forma de traslado fueron las principales causas de demora. La implementación de un protocolo de procedimientos permitió reducir las demoras. La evaluación continua de resultados y la educación permanente, constituyen los pilares fundamentales para la optimización de programas de atención en red.

ABSTRACT Background: The delay to reperfusion of ST-segment elevation acute coronary syndrome (STEACS) is a key factor in its prognosis, and its reduction could reduce morbidity and mortality. Objective: The aim of this study was to identify and modify the barriers detected in 20 years of STEACS treatment in a tertiary care center of a densely populated city to evaluate their effect on the outcome of the procedure. Methods: A total of 3007 patients with STEACS within 12 hours of symptoms onset were prospectively and consecutively included to undergo primary percutaneous coronary intervention (PCI) from January 1, 2000 to December 31, 2019. Time from symptoms onset to balloon inflation was divided into intervals. After barriers were identified (2000-2009), the procedure was changed. The population was divided into two groups (G) G1: pre-implementation (2000-2009) and G2: post-implementation (2010-2019) of changes. Results: G1 included 1409 and G2 1598 patients with no demographic differences except for the type of PCI. Delays were identified in diagnosis, communication between physicians, transfer and admission of the patient to the hemodynamics lab. Procedural changes decreased first medical contact-hemodynamic team contact interval [G1: 90 min (36-168) vs. G2: 77 min (36-144) p -0.01] and hemodynamic team contact-hemodynamics lab admission interval [G1: 75 min (55-100) vs. G2: 51 min (34-70) p -0.01] and reduced in-hospital (G1: 9,2% vs. G2: 6,7% p -0,01) and 6-month (G1: 13.1% vs. G2: 7.5% p -0. 01) mortality. Conclusions: Delay in diagnosis, difficulty in communication and type of transfer were the most important causes of delay. Implementing a procedural protocol reduced delays. Continuous evaluation of results and permanent education constitute the fundamental cornerstones for optimizing network care programs.

Is Dual-Axis Rotational Coronary Angiography Radiation Dose Reduction Achievable in a Population with 100% Suspected Coronary Artery Disease? A Randomized Trial.

BACKGROUND: Previous studies have shown a reduction in radiation dose and contrast volume using dual-axis rotational coronary angiography (DARCA), but this has not been replicated in a population with 100% coronary artery disease (CAD). OBJECTIVE: To find if DARCA dose reduction is achievable in this population, we sought to compare the radiation dose, contrast volume, and procedure time between DARCA and conventional coronary angiography (CCA) techniques in a setting characterized by a prevalence of 100% suspected coronary artery disease. METHODS: An all-comer, prospective, randomized, open-label trial was conducted. Cine acquisition dose-area product (DAP), cumulative air kerma (AK), effective dose (E), fluoroscopic time, contrast volume, AK, cine acquisition DAP (CADAP), fluoroscopic DAP (F-DAP), and total DAP were compared between DARCA and CCA groups. RESULTS: We included 503 consecutive patients with suspected CAD. 252 were assigned to DARCA and 251 to CCA. Stable coronary artery disease was reported in 465 cases and non-ST elevation acute coronary syndrome in 38. Mean age: 61.88 ± 11.2 years, male gender 70.2%. DARCA arm patients showed lower total E dose (6.85 [4.55-10.83] vs. 7.91 [5.58-11.94] Sv; P = .0023), and cine E (3.00 [2.00-4.00] vs. 4.00 [3.00-5.00] Sv; P < .0001). Total DAP was also lower (40.3 [26.8-63.7] vs. 46.5 [32.8-70.2] Gycm2; P = .0023), as a consequence of a lower CADAP (16.3 [10.5-22.9] vs. 23.4 [17.4-32.0] Gycm2; P < .0001), with lower AK (367 [248-1497] vs. 497 [381-1827] mGy; P < .0001), with less contrast medium used (90 [60.0-106.0] vs. 100 [75.0-120.0] mL; P = .014). CONCLUSION: In a population with 100% suspected coronary artery disease, DARCA provides accurate information required in CAD, is safe, and results in a significant decrease in contrast material volume and radiation dose compared with CCA. The required extra projections did not neutralize the DARCA radiation dose and contrast volume reduction achievements.

Mitral valve calcium assessment: An independent predictor of balloon valvuloplasty results.

OBJECTIVE: Percutaneous mitral valvuloplasty (PMV) is an effective treatment for patients with mitral valve stenosis. Echocardiographic score (ES) is a useful predictor of outcomes. However, mitral valve calcification (MVC) has been shown to predict immediate results even in patients with otherwise low ES. We sought to evaluate the usefulness of MVC assessment as a predictor of immediate and long-term outcomes after PMV. METHODS: PMV was performed in 168 consecutive patients. Clinical and echocardiographic variables were analyzed. Patients were classified into 2 groups: group 1: minimal MVC and group 2: moderate to severe MVC. Primary success was defined as post-PMV mitral valve area (MVA) ≥ 1.5 cm2 in the absence of major complications. Restenosis (RE) was defined as a decrease in MVA >50% of initial gain or a final MVA <1.5 cm2. RESULTS: Mean age was 46.5 ± 11 years, and 86.9% (146) were women. Forty-two patients (25%) had mild MVC (group 1), and 75% of the patients had moderate to severe MVC (group 2). Procedural success was achieved in 95.2% and 76.2% for groups 1 and 2, respectively, p = 0.01. MVA after PMV was 1.82 cm2 (IQR 25-75 = 1.60-2.00) in group 1 and 1.67 cm2 (IQR 25-75 = 1.44-1.97) in group 2, p = 0.02. After 48 months, 28.2% of patients presented RE. Multivariate analysis identified the presence of MVC as an independent predictor of poor immediate results (HR = 0.12, 95% IC 0.03-0.91) and RE (HR = 1.94, 95% CI = 1.02-5.21). CONCLUSION: Our study shows that the presence of MVC may predict immediate and long-term outcomes after PMV.

Vitamin D is Related to Markers of Vulnerable Plaque in Acute Myocardial Infarction.

BACKGROUND: Vitamin D is a fat soluble vitamin involved in calcium and bone metabolism; recently its deficiency has been related to cardiovascular disease. In cardiac tissue, vitamin D suppresses metalloproteinases (MMPs) expression, enzymes directly associated with vulnerable plaque. OBJECTIVE: To investigate whether the association between vitamin D and leptin is related to markers of vulnerable plaque, such as MMPs in patients with acute myocardial infarction. METHODS: We studied 66 male patients with acute myocardial infarction, undergoing primary angioplasty. Blood samples were obtained at admission and 24hs after the surgery. Leptin and vitamin D concentrations in serum and MMP-2 and -9 activities in plasma were determined. RESULTS: MMP-2 activity was increased in Vitamin D deficient/insufficient patients at admission (p=0.04) and 24 hs later (p=0.05). In a linear regression model, vitamin D explained 24% of the variance of MMP-2 activity (F=2.839 p=0.04). At admission, vitamin D correlated with serum leptin (r=-0.302 p=0.033), and explained 39.5% of its variation (F=4.432 p=0.003). CONCLUSION: In the studied population, vitamin D was inversely related to MMP-2 and leptin which are involved in coronary artery disease and acute myocardial infarction. The decrease in this hormone levels would be associated with a worse metabolic profile in acute coronary syndrome patients.

[Simple mechanical reperfusion in acute myocardial infarction: determinants, prognostic implications and relation with thrombus histology]. / Reperfusión mecánica simple en el infarto agudo de miocardio. Determinantes, implicaciones en el pronóstico y relación con la histología del trombo.

Simple mechanical reperfusion (SMR) is defined as reperfusion achieved after wire insertion at the occluded infarct-related artery in primary angioplasty. The determinants and prognostic implications of SMR and its relationship with the histopathology of the rescued thrombus were evaluated in 601 patients with acute myocardial infarction showing ST elevation and pre-procedural total occlusion of the infarct-related artery (TIMI flow 0). Two groups were considered according to the presence of SMR, defined as the visualization of contrast material after crossing the occlusion with the guide wire. SMR was achieved in 303 patients (50.4%) and was found to be associated with less time to treatment (248 vs. 286 minutes; p = 0.001), less deteriorated initial left ventricular function and shock at admission (9.2 vs. 16.4%; p = 0.008), higher successful rate (94.7% vs. 78.5%; p < 0,0001) and of higher rate of thrombus rescue: 70/81 vs. 27/79 patients (p < 0.0001). The right coronary artery was the most frequent infarct-related artery. Histopathology of the retrieved thrombi was available for 160 patients treated with thrombus aspiration. SMR was associated with smaller thrombus, lower contents of leukocytes and erythrocytes, and higher thrombus content of inflammatory cells, cholesterol and collagen crystals from the atheromatous plaque. SMR is an independent predictor of procedure success and its relationship with the anatomy of the thrombus could redefine the indication of thrombus aspiration.

Reperfusión mecánica simple en el infarto agudo de miocardio: Determinantes, implicaciones en el pronóstico y relación con la histología del trombo / Simple mechanical reperfusion in acute myocardial infarction: determinants, prognostic implications and relation with thrombus histology

La reperfusión mecánica simple (RMS) es la lograda en la angioplastia primaria al atravesar la oclusión en la arteria responsable de infarto con la guía intracoronaria. Para evaluar los determinantes de la RMS, su implicación en el pronóstico y su relación con la histopatología del trombo rescatado, fueron analizados los casos de 601 pacientes con infarto agudo de miocardio con elevación del segmento ST y oclusión total de la arteria responsable de infarto (flujo TIMI 0). Se consideraron dos grupos según la presencia de RMS, definida por la visualización de contraste distal a la lesión luego de atravesarla con la guía intracoronaria. Se realizó el análisis histopatológico de los trombos en un subgrupo de 160 pacientes tratados con tromboaspiración. En 303 (50.4%) pacientes se obtuvo RMS. La RMS se asoció a menor ventana al tratamiento (248 vs. 286 minutos, p = 0.001), menor deterioro de la función sistólica ventricular izquierda inicial y shock al ingreso (9.2 vs.16.4%, p = 0.008), mayor tasa de éxito (94.7 vs. 78.5%, p < 0.0001) y de rescate de trombos (70/81 vs. 27/79 pacientes, p < 0.0001). La arteria responsable de infarto más frecuente fue la coronaria derecha. La RMS se asoció con menor tamaño del trombo, menor concentración de leucocitos y eritrocitos y mayor contenido de células inflamatorias, cristales de colesterol y colágeno provenientes de la placa. La RMS es un predictor independiente de éxito y su relación con la anatomía del trombo podría redefinir la indicación de la tromboaspiración.

Simple mechanical reperfusion (SMR) is defined as reperfusion achieved after wire insertion at the occluded infarct-related artery in primary angioplasty. The determinants and prognostic implications of SMR and its relationship with the histopathology of the rescued thrombus were evaluated in 601 patients with acute myocardial infarction showing ST elevation and pre-procedural total occlusion of the infarct-related artery (TIMI flow 0). Two groups were considered according to the presence of SMR, defined as the visualization of contrast material after crossing the occlusion with the guide wire. SMR was achieved in 303 patients (50.4%) and was found to be associated with less time to treatment (248 vs. 286 minutes; p = 0.001), less deteriorated initial left ventricular function and shock at admission (9.2 vs. 16.4%; p = 0.008), higher successful rate (94.7% vs. 78.5%; p < 0,0001) and of higher rate of thrombus rescue: 70/81 vs. 27/79 patients (p < 0.0001). The right coronary artery was the most frequent infarct-related artery. Histopathology of the retrieved thrombi was available for 160 patients treated with thrombus aspiration. SMR was associated with smaller thrombus, lower contents of leukocytes and erythrocytes, and higher thrombus content of inflammatory cells, cholesterol and collagen crystals from the atheromatous plaque. SMR is an independent predictor of procedure success and its relationship with the anatomy of the thrombus could redefine the indication of thrombus aspiration.

Initial Results and Long-Term Follow-up of Percutaneous Mitral Valvuloplasty in Patients with Pulmonary Hypertension.

BACKGROUND: Percutaneous balloon mitral valvuloplasty (PMV) is an attractive therapeutic approach in patients with mitral stenosis. The aim of this study was to assess the immediate and long-term clinical, echocardiographic and haemodynamic outcomes of PMV in patients with severe pulmonary hypertension (PAH). METHODS: Percutaneous balloon mitral valvuloplasty was performed in 157 consecutive patients; 60 patients (38.2%) had significant PAH defined as baseline pulmonary artery mean pressure (PAMP) ≥ 30mm Hg (Group 1) and 97 patients (61.8%) had PAMP ≤ 30mmHg (Group 2). Pulmonary artery systolic pressure (PASP), mortality, need for mitral valve replacement or new PMV, and valve restenosis were evaluated during follow-up. RESULTS: Mean age was 44.2 years and 88.5% (139 patients) were women. Primary success was achieved in 79.6% of the patients (125 patients) without differences between the groups. Mitral valve area increased from 0.90cm2 to 1.76cm2, PASP fell from 57mmHg to 35mmHg in Group 1 and from 38mmHg to 30mmHg in Group 2. Median PASP in Group 1 was 35, 32, 36, 38 and 34mmHg at 12, 24, 36, 48 and 60 months. There were no significant differences in mitral valve area, PASP and clinical status between the groups. CONCLUSION: Percutaneous balloon mitral valvuloplasty is a safe and effective technique for the treatment of patients with mitral stenosis and PAH. A significant decrease in pulmonary pressure was observed after valvuloplasty. Although there was a gradual decrease of MVA at long-term follow-up, most patients remained asymptomatic and PASP was stable.

Matrix metalloproteinases and psychosocial factors in acute coronary syndrome patients.

UNLABELLED: Psychosocial factors have been linked to cardiovascular diseases independently of traditional risk factors. The impact of psychosocial factors on plaque destabilizing factors, such as matrix metalloproteinases (MMPs) has been proposed although scarcely studied. OBJECTIVE: To evaluate the relationships between hostility, perceived stress and social support with MMPs activity in patients after an Acute Myocardial Infarction (AMI). METHODS: Blood samples were obtained from 76 patients on admission, post-angioplasty, 24h, 7 days and 3 months after AMI. Hostility, perceived stress and social support were evaluated by validated questionnaires. RESULTS: Social support was positively correlated with patients ejection fraction (r=0.453, p=0.009). Patients with higher infarct size presented increased MMP-2 activity at admission (p=0.04). Patients with one diseased vessel had more social support than those with three diseased vessels (p=0.05). The highest values of MMP-2 and MMP-9 activity were observed at the acute event, decreasing, with the lowest activity at 3 months post-AMI (p<0.001). Only in patients with low social support, hostility correlated with MMP-2 activity, from AMI onset (r=0.645, p=0.013), to 7 days post AMI (r=0.557, p=0.038). Hostility explained up to 28% of the variance in MMP-2 activity (R(2)=0.28, p=0.005). Finally, in patients with high hostility, MMP-9 was positively correlated with IL-1ß (r=0.468, p=0.02). CONCLUSIONS: This study adds weight to the idea that two psychosocial factors, namely hostility and social support, acting jointly, may affect MMP-2 activity. Moreover, in hostile patients, there is a link between IL-1ß and MMP-9. These findings support the role of psychosocial factors in plaque destabilization and in the inflammatory process in AMI.

Predictores clínicos de no-reflujo en la angioplastia coronaria por infarto agudo de miocardio / Clinical Predictors of No-Reflow in Percutaneous Coronary Intervention for Acute Myocardial Infarction

Introducción El fenómeno de no-reflujo en el contexto de la angioplastia por infarto agudo de miocardio (IAM) es un hecho relativamente frecuente y asociado con peor pronóstico. La detección de variables clínicas vinculadas a este fenómeno antes del inicio del procedimiento podría ayudar a la adopción de medidas preventivas y por consiguiente a mejorar los resultados. Objetivo Determinar predictores clínicos de no-reflujo en el contexto de la angioplastia por IAM con elevación del segmento ST antes del inicio del procedimiento. Material y métodos Se analizaron 742 pacientes con IAM de < 12 horas de evolución tratados con angioplastia primaria. Se excluyeron los pacientes con flujo epicárdico TIMI 0 posintervención y se consideró no-reflujo a la presencia de flujo TIMI 1-2 posangioplastia inmediato en ausencia de lesión residual. Se analizaron variables demográficas, factores de riesgo coronario, antecedentes y demora al tratamiento. Se realizó un análisis multivariado por regresión logística múltiple para determinar el valor pronóstico independiente de las variables relacionadas con el no-reflujo. Resultados Se incluyeron 675 pacientes. Presentaron fenómeno de no-reflujo 119 pacientes (17,6%). Los pacientes con no-reflujo tenían mayor edad (60,8 ± 12 vs. 57,0 ± 11 años; p = 0,0001) y menor frecuencia de tabaquismo activo (58,8% vs. 67,8%; p = 0,03) y de antecedentes familiares (22,7% vs. 37,8%; p = 0,0007), sin diferencias significativas en el resto de los factores de riesgo coronario y antecedentes cardiovasculares. Se observó también con mayor frecuencia localización anterior del IAM (58,8% vs. 43,7%; p = 0,002), signos clínicos de insuficiencia cardíaca al ingreso (17,6% vs. 10,1%; p = 0,01), así como mayor demora al tratamiento [240 (151-360) vs. 195 (120-302) minutos; p = 0,02]. El análisis multivariado determinó que los predictores independientes de no-reflujo fueron: edad > 60 años, localización anterior y demora al tratamiento > 3 horas. Conclusión La edad avanzada, la localización anterior y la demora al tratamiento resultaron predictores clínicos independientes de no-reflujo. La confirmación de estos hallazgos en estudios prospectivos permitiría implementar estrategias para prevenir su aparición y, eventualmente, mejorar los resultados clínicos a largo plazo.

Introduction The no-reflow phenomenon in the setting of primary coronary intervention for acute myocardial infarction (AMI) is relatively common and is associated with adverse outcomes. The detection of clinical variables associated with this phenomenon before the procedure might help to adopt preventive measures and thus improve the results. Objective The aim of this study was to identify clinical predictors of the no-reflow phenomenon in the setting of percutaneous coronary intervention for ST-segment elevation acute myocardial infarction, prior to the procedure. Methods A total of 742 patients with AMI < 12 hours since onset of symptoms treated with primary percutaneous coronary intervention were analyzed. Patients with epicardial TIMI grade 0 flow after the procedure were excluded. No-reflow was considered as the presence of TIMI grade 1-2 flow immediately after the procedure in the absence of residual stenosis. Demographic variables, coronary risk factors, family history and delay to reperfusion were analyzed. Multivariate logistic regression was used to determine the independent prognostic value of the variables associated with no-reflow. Results A total of 675 patients were included. The no-reflow phenomenon was present in 119 patients (17.6%). Patients with no-reflow were older (60.8 ± 12 vs. 57.0 ± 11 years; p = 0.0001) and had less prevalence of current smoking (58.8% vs. 67.8%, p = 0.03) and of previous history (22.7% vs. 37.8%, p = 0.0007), with no significant differences in the rest of coronary risk factors and history of cardiovascular disease. Anterior AMI (58.8% vs. 43.7%, p = 0.002), heart failure at admission (17.6% vs. 10.1%, p = 0.01) and delay to reperfusion (240 [151-360] vs. 195 [120-302] minutes, p=0.02) were more frequent in the no-reflow group. Multivariate analysis identified age > 60 years, anterior infarction and delay to reperfusion > 3 hours as independent predictors of no-reflow. Conclusion Advanced age, anterior infarction and delay to reperfusion were independent clinical predictors of no-reflow. The confirmation of these findings in prospective studies might allow the implementation of strategies to prevent this phenomenon and eventually improve the long-term clinical outcomes.

Predictores clínicos de no-reflujo en la angioplastia coronaria por infarto agudo de miocardio / Clinical Predictors of No-Reflow in Percutaneous Coronary Intervention for Acute Myocardial Infarction

Introducción El fenómeno de no-reflujo en el contexto de la angioplastia por infarto agudo de miocardio (IAM) es un hecho relativamente frecuente y asociado con peor pronóstico. La detección de variables clínicas vinculadas a este fenómeno antes del inicio del procedimiento podría ayudar a la adopción de medidas preventivas y por consiguiente a mejorar los resultados. Objetivo Determinar predictores clínicos de no-reflujo en el contexto de la angioplastia por IAM con elevación del segmento ST antes del inicio del procedimiento. Material y métodos Se analizaron 742 pacientes con IAM de < 12 horas de evolución tratados con angioplastia primaria. Se excluyeron los pacientes con flujo epicárdico TIMI 0 posintervención y se consideró no-reflujo a la presencia de flujo TIMI 1-2 posangioplastia inmediato en ausencia de lesión residual. Se analizaron variables demográficas, factores de riesgo coronario, antecedentes y demora al tratamiento. Se realizó un análisis multivariado por regresión logística múltiple para determinar el valor pronóstico independiente de las variables relacionadas con el no-reflujo. Resultados Se incluyeron 675 pacientes. Presentaron fenómeno de no-reflujo 119 pacientes (17,6%). Los pacientes con no-reflujo tenían mayor edad (60,8 ± 12 vs. 57,0 ± 11 años; p = 0,0001) y menor frecuencia de tabaquismo activo (58,8% vs. 67,8%; p = 0,03) y de antecedentes familiares (22,7% vs. 37,8%; p = 0,0007), sin diferencias significativas en el resto de los factores de riesgo coronario y antecedentes cardiovasculares. Se observó también con mayor frecuencia localización anterior del IAM (58,8% vs. 43,7%; p = 0,002), signos clínicos de insuficiencia cardíaca al ingreso (17,6% vs. 10,1%; p = 0,01), así como mayor demora al tratamiento [240 (151-360) vs. 195 (120-302) minutos; p = 0,02]. El análisis multivariado determinó que los predictores independientes de no-reflujo fueron: edad > 60 años, localización anterior y demora al tratamiento > 3 horas. Conclusión La edad avanzada, la localización anterior y la demora al tratamiento resultaron predictores clínicos independientes de no-reflujo. La confirmación de estos hallazgos en estudios prospectivos permitiría implementar estrategias para prevenir su aparición y, eventualmente, mejorar los resultados clínicos a largo plazo.(AU)

Introduction The no-reflow phenomenon in the setting of primary coronary intervention for acute myocardial infarction (AMI) is relatively common and is associated with adverse outcomes. The detection of clinical variables associated with this phenomenon before the procedure might help to adopt preventive measures and thus improve the results. Objective The aim of this study was to identify clinical predictors of the no-reflow phenomenon in the setting of percutaneous coronary intervention for ST-segment elevation acute myocardial infarction, prior to the procedure. Methods A total of 742 patients with AMI < 12 hours since onset of symptoms treated with primary percutaneous coronary intervention were analyzed. Patients with epicardial TIMI grade 0 flow after the procedure were excluded. No-reflow was considered as the presence of TIMI grade 1-2 flow immediately after the procedure in the absence of residual stenosis. Demographic variables, coronary risk factors, family history and delay to reperfusion were analyzed. Multivariate logistic regression was used to determine the independent prognostic value of the variables associated with no-reflow. Results A total of 675 patients were included. The no-reflow phenomenon was present in 119 patients (17.6%). Patients with no-reflow were older (60.8 ± 12 vs. 57.0 ± 11 years; p = 0.0001) and had less prevalence of current smoking (58.8% vs. 67.8%, p = 0.03) and of previous history (22.7% vs. 37.8%, p = 0.0007), with no significant differences in the rest of coronary risk factors and history of cardiovascular disease. Anterior AMI (58.8% vs. 43.7%, p = 0.002), heart failure at admission (17.6% vs. 10.1%, p = 0.01) and delay to reperfusion (240 [151-360] vs. 195 [120-302] minutes, p=0.02) were more frequent in the no-reflow group. Multivariate analysis identified age > 60 years, anterior infarction and delay to reperfusion > 3 hours as independent predictors of no-reflow. Conclusion Advanced age, anterior infarction and delay to reperfusion were independent clinical predictors of no-reflow. The confirmation of these findings in prospective studies might allow the implementation of strategies to prevent this phenomenon and eventually improve the long-term clinical outcomes.(AU)

Resultados inmediatos y seguimiento a largo plazo de la valvuloplastia mitral percutánea / Immediate Outcomes and Long-Term Follow-Up of Percutaneous Mitral Valvuloplasty

Introducción El tratamiento de la estenosis mitral ha cambiado en las últimas décadas. Se ha demostrado que, frente al tratamiento quirúrgico, la valvuloplastia mitral percutánea (VMP) presenta resultados hemodinámicos comparables y una evolución similar. Objetivo Evaluar la eficacia y la evolución clínica y ecocardiográfica inmediata y a largo plazo de la VMP. Material y métodos Se incluyeron 132 pacientes que habían sido sometidos a VMP, con una mediana de seguimiento de 48 meses. Se consideró éxito primario cuando se obtuvo un área pos-VMP ≥ 1,5 cm². En el seguimiento se evaluaron: muerte, necesidad de reemplazo valvular mitral o de nueva VMP y reestenosis valvular. Resultados La media de edad fue de 44,6 años; el 88,5% de los pacientes (n = 115) eran de sexo femenino. La mediana del área valvular mitral pre-VMP era de 0,90 cm² (IIC 25-75: 0,81-1,00), la presión sistólica de la arteria pulmonar era de 44 mm Hg (IIC 25-75: 35-52) y el puntaje ecocardiográfico, de 7 (IIC 25-75: 6-9). Se obtuvo éxito primario en 104 pacientes (78,8%). En el seguimiento a 4 años, el 86,5% de los pacientes (n = 109) se encontraban asintomáticos. Se registraron tres muertes intrahospitalarias (2,2%) y tres en el seguimiento (2,2%). Se realizó una nueva VMP en 10 pacientes y reemplazo valvular mitral en cuatro. Las variables asociadas con reestenosis en el seguimiento fueron el puntaje ecocardiográfico > 8 (p = 0,04) y el área valvular mitral pos-VMP < 1,8 cm² (p = 0,02). Luego del análisis multivariado, el área valvular mitral pos-VMP < 1,8 cm² fue el único predictor de reestenosis (OR: 2,6; IC 95%: 1,08-6,25). Conclusiones La VMP es segura y eficaz, eficacia que se mantiene a largo plazo. Los mejores resultados inmediatos se obtienen en pacientes con puntaje ecocardiográfico bajo y en ritmo sinusal, mientras que aquellos con un área valvular mitral mayor pos-VMP son los que presentan menor reestenosis en el seguimiento.

Background The treatment of mitral valve stenosis has changed over the last decades. The hemodynamic results and the outcome of percutaneous mitral valvuloplasty (PMV) have proved to be comparable to those of surgical treatment. Objective To evaluate the efficacy and the immediate and long-term clinical and echocardiographic outcome of PMV. Methods A total of 132 patients undergoing PMV were included, with a median follow-up of 48 months. The primary success was defined as a mitral valve area of ≥ 1.5 cm² following PMV. Mortality, need for mitral valve replacement or new PMV and mitral valve restenosis were evaluated during follow-up. Results Mean age was 44.6 years; 88.5% of patients (n=115) were women. Median mitral valve area before PMV was 0.90 cm² (IQR 25-75: 0.81-1.00), systolic pulmonary artery pressure was 44 mm Hg (IQR 25-75: 35-52) and the echocardiographic score was 7 (IQR 25-75: 6-9). Primary success was achieved in 104 patients (78.8%). After four years of follow-up, 86.5% of patients (n=109) were free of symptoms. Three patients (2.2%) died during hospitalization and three (2.2%) during follow-up. A new PMV was performed in 10 patients and four patients underwent mitral valve replacement. During follow-up, an echocardiographic score of >8 (p=0.04) and a mitral valve area following PMV of 2 (p=0.02) were the variables associated with restenosis. After performing multivariate analysis, the only predictor associated with restenosis following PMV was a mitral valve area 2 (OR: 2.6; 95% CI: 1.08-6.25). Conclusions Percutaneous mitral valvuloplasty is a safe and efficient method with long-term efficacy. The best outcomes are achieved in patients with low echocardiographic score and who are in sinus rhythm, and those with greater mitral valve area following PMV have lower restenosis during follow-up.

Resultados inmediatos y seguimiento a largo plazo de la valvuloplastia mitral percutánea / Immediate Outcomes and Long-Term Follow-Up of Percutaneous Mitral Valvuloplasty

Introducción El tratamiento de la estenosis mitral ha cambiado en las últimas décadas. Se ha demostrado que, frente al tratamiento quirúrgico, la valvuloplastia mitral percutánea (VMP) presenta resultados hemodinámicos comparables y una evolución similar. Objetivo Evaluar la eficacia y la evolución clínica y ecocardiográfica inmediata y a largo plazo de la VMP. Material y métodos Se incluyeron 132 pacientes que habían sido sometidos a VMP, con una mediana de seguimiento de 48 meses. Se consideró éxito primario cuando se obtuvo un área pos-VMP ≥ 1,5 cm². En el seguimiento se evaluaron: muerte, necesidad de reemplazo valvular mitral o de nueva VMP y reestenosis valvular. Resultados La media de edad fue de 44,6 años; el 88,5% de los pacientes (n = 115) eran de sexo femenino. La mediana del área valvular mitral pre-VMP era de 0,90 cm² (IIC 25-75: 0,81-1,00), la presión sistólica de la arteria pulmonar era de 44 mm Hg (IIC 25-75: 35-52) y el puntaje ecocardiográfico, de 7 (IIC 25-75: 6-9). Se obtuvo éxito primario en 104 pacientes (78,8%). En el seguimiento a 4 años, el 86,5% de los pacientes (n = 109) se encontraban asintomáticos. Se registraron tres muertes intrahospitalarias (2,2%) y tres en el seguimiento (2,2%). Se realizó una nueva VMP en 10 pacientes y reemplazo valvular mitral en cuatro. Las variables asociadas con reestenosis en el seguimiento fueron el puntaje ecocardiográfico > 8 (p = 0,04) y el área valvular mitral pos-VMP < 1,8 cm² (p = 0,02). Luego del análisis multivariado, el área valvular mitral pos-VMP < 1,8 cm² fue el único predictor de reestenosis (OR: 2,6; IC 95%: 1,08-6,25). Conclusiones La VMP es segura y eficaz, eficacia que se mantiene a largo plazo. Los mejores resultados inmediatos se obtienen en pacientes con puntaje ecocardiográfico bajo y en ritmo sinusal, mientras que aquellos con un área valvular mitral mayor pos-VMP son los que presentan menor reestenosis en el seguimiento.(AU)

Background The treatment of mitral valve stenosis has changed over the last decades. The hemodynamic results and the outcome of percutaneous mitral valvuloplasty (PMV) have proved to be comparable to those of surgical treatment. Objective To evaluate the efficacy and the immediate and long-term clinical and echocardiographic outcome of PMV. Methods A total of 132 patients undergoing PMV were included, with a median follow-up of 48 months. The primary success was defined as a mitral valve area of ≥ 1.5 cm² following PMV. Mortality, need for mitral valve replacement or new PMV and mitral valve restenosis were evaluated during follow-up. Results Mean age was 44.6 years; 88.5% of patients (n=115) were women. Median mitral valve area before PMV was 0.90 cm² (IQR 25-75: 0.81-1.00), systolic pulmonary artery pressure was 44 mm Hg (IQR 25-75: 35-52) and the echocardiographic score was 7 (IQR 25-75: 6-9). Primary success was achieved in 104 patients (78.8%). After four years of follow-up, 86.5% of patients (n=109) were free of symptoms. Three patients (2.2%) died during hospitalization and three (2.2%) during follow-up. A new PMV was performed in 10 patients and four patients underwent mitral valve replacement. During follow-up, an echocardiographic score of >8 (p=0.04) and a mitral valve area following PMV of 2 (p=0.02) were the variables associated with restenosis. After performing multivariate analysis, the only predictor associated with restenosis following PMV was a mitral valve area 2 (OR: 2.6; 95% CI: 1.08-6.25). Conclusions Percutaneous mitral valvuloplasty is a safe and efficient method with long-term efficacy. The best outcomes are achieved in patients with low echocardiographic score and who are in sinus rhythm, and those with greater mitral valve area following PMV have lower restenosis during follow-up.(AU)

[Instability in multiple atherosclerotic plaques in patients who died of acute myocardial infarction]. / Inestabilidad en múltiples placas ateroescleróticas en pacientes fallecidos por infarto agudo de miocardio.

In acute coronary syndromes inflammatory process plays an important role in atherosclerotic plaque instability. Our aim was to evaluate the presence and distribution of vulnerable plaques and inflammatory infiltrates in patients who died of acute myocardial infarction in comparison to patients who died of non-coronary heart disease. We analyzed pathologic studies of the heart of 68 patients who died of acute myocardial infarction and 15 patients who died of non-coronary heart disease. The presence of thrombus, intraplaque hemorrhage, endothelial rupture and inflammatory infiltrates were registered. In patients who died of myocardial infarction, we found thrombus in 73.5% of the involved arteries and in 28.7% of the non involved (p < 0.0001). Intraplaque hemorrhage was found in 70.5% of involved arteries and in 39.7% of the non involved (p < 0.0001); endothelial rupture in 29.4% of involved arteries and in 3.7% of non involved arteries (p < 0.0001). There was no difference in the presence of inflammatory infiltrates (76.5% versus 68.4%). Comparing with patients who have died of non-coronary heart disease, the presence of thrombus was significantly higher (73.5% vs. 13.3%; p < 0.0001), as well as the presence of intraplaque hemorrhage (70.5% vs. 0%; p < 0.0001) and of inflammatory infiltrates in atherosclerotic plaques (76.5% vs. 46.6%; p = 0.021). In patients who died of acute myocardial infarction we observed plaque instability and inflammatory activity, not only in the infarct related artery but also in the non involved arteries.

Inestabilidad en múltiples placas ateroescleróticas en pacientes fallecidos por infarto agudo de miocardio / Instability in multiple atherosclerotic plaques in patients who died of acute myocardial infarction

Los procesos inflamatorios en los síndromes coronarios agudos juegan un rol importante en la inestabilidad de la placa ateroesclerótica. Nuestro objetivo fue evaluar la presencia y distribución de placas vulnerables e infiltrados inflamatorios en pacientes fallecidos por infarto agudo de miocardio y su comparación con los hallazgos en pacientes fallecidos por cuadros no coronarios. Se analizaron los estudios anatomopatológicos de corazón de 68 pacientes fallecidos por infarto agudo de miocardio y 15 fallecidos por causa no coronaria. Se registró la presencia de trombo, hemorragia intraplaca, ruptura endotelial e infiltrado inflamatorio. Al evaluar los pacientes fallecidos por IAM, encontramos trombo en 73.5% de las arterias responsables del IAM y en 28.7% de las no responsables (p < 0.0001). La hemorragia intraplaca se halló en el 70.5% de las arterias responsables y en 39.7% de las no responsables, p < 0.0001; ruptura endotelial en el 29.4% de las arterias responsables y en 3.7% de las no responsables, p < 0.0001. No encontramos diferencias en la presencia de infiltrado inflamatorio (76.5% versus 68.4%). Comparando con los fallecidos por causas no coronarias, la presencia de trombo fue significativamente superior (73.5% vs. 13.3%; p < 0.0001), así como la de hemorragia intraplaca (70.5% vs. 0%; p < 0.0001) y de infiltrado inflamatorio en las placas ateroescleroticas (76.5% vs. 46.6%; p = 0.021). En los pacientes fallecidos por infarto agudo de miocardio se observa inestabilidad de placa y actividad inflamatoria, no sólo en la arteria responsable del infarto sino también en las arterias no responsables del infarto.

In acute coronary syndromes inflammatory process plays an important role in atherosclerotic plaque instability. Our aim was to evaluate the presence and distribution of vulnerable plaques and inflammatory infiltrates in patients who died of acute myocardial infarction in comparison to patients who died of non-coronary heart disease. We analyzed pathologic studies of the heart of 68 patients who died of acute myocardial infarction and 15 patients who died of non-coronary heart disease. The presence of thrombus, intraplaque hemorrhage, endothelial rupture and inflammatory infiltrates were registered. In patients who died of myocardial infarction, we found thrombus in 73.5% of the involved arteries and in 28.7% of the non involved (p < 0.0001). Intraplaque hemorrhage was found in 70.5% of involved arteries and in 39.7% of the non involved (p < 0.0001); endothelial rupture in 29.4% of involved arteries and in 3.7% of non involved arteries (p < 0.0001). There was no difference in the presence of inflammatory infiltrates (76.5% versus 68.4%). Comparing with patients whoo have died of non-coronary heart disease, the presence of thrombus was significantly higher (73.5% vs. 13.3%; p < 0.0001), as well as the presence of intraplaque hemorrhage (70.5% vs. 0%; p < 0.0001) and of inflammatory infiltrates in atherosclerotic plaques (76.5% vs. 46.6%; p = 0.021). In patients who died of acute myocardial infarction we observed plaque instability and inflammatory activity, not only in the infarct related artery but also in the non involved arteries.

Actividad inflamatoria en múltiples placas ateroscleróticas en pacientes fallecidos por infarto agudo de miocardio / Inflammatory Activity in Multiple Atherosclerotic Plaques of Patients Dying of Acute Myocardial Infarction

Introducción Estudios clínicos y anatomopatológicos sugieren que los procesos inflamatorios tienen un papel importante en la inestabilidad de la placa aterosclerótica, dado que en pacientes con síndromes coronarios agudos se observan infiltrados inflamatorios difusos en las arterias coronarias. Objetivos Evaluar y localizar la distribución de placas vulnerables e infiltrados inflamatorios en pacientes fallecidos por infarto agudo de miocardio. Material y métodos Mediante microscopia óptica se estudiaron las arterias coronarias de 58 pacientes fallecidos por infarto de miocardio. En las arterias coronarias relacionadas con el infarto y en las no relacionadas se registraron las siguientes variables: presencia de trombo, rotura de placa, hemorragia intraplaca y presencia de infiltrado inflamatorio. Resultados Al analizar las diferencias existentes entre las arterias responsables del infarto y en las no responsables se encontraron diferencias significativas con respecto a la presencia de trombo (69% versus 38%; p < 0,008) y de hemorragia intraplaca (69% versus 50%; p < 0,03). No se encontró una diferencia significativa entre la arteria responsable y la no responsable al evaluar la presencia de infiltrado inflamatorio en las placas ateroscleróticas (77% versus 71%; p = ns). Conclusión En el infarto agudo de miocardio se comprobó la presencia de actividad inflamatoria que afectaba a más de un vaso, con compromiso de otras arterias además de la responsable del infarto. Se detectó también accidente agudo de placa en más de una arteria coronaria.

Background Data from clinical and histopathologic studies suggest that inflammation plays a key role in instability of atherosclerotic plaque as patients with acute coronary syndromes present diffuse inflammatory infiltrates in the coronary arteries. Objectives To assess and locate the distribution of vulnerable plaques and inflammatory infiltrates in patients who died of acute myocardial infarction. Material and Methods We examined the coronary arteries from 58 patients who died of myocardial infarction using light microscopy. The following variables were evaluated in culprit and non-culprit coronary arteries: presence of thrombus, plaque rupture, intraplaque hemorrhage and inflammatory infiltrate. Results The presence of thrombus and intraplaque hemorrhage was significantly greater in culprit coronary arteries compared to non-culprit vessels (69% versus 38%; p<0.008, and 69% versus 50%; p<0.03, respectively). There were no significant differences in the presence of inflammatory infiltrates in atherosclerotic plaques from culprit and non-culprit coronary arteries (77% versus 71%; p=ns). Conclusion Inflammatory activity was demonstrated in acute myocardial infarction affecting not only the infarct-related artery but also other coronary vessels. Plaque accident was also present in more than one coronary artery.

Demoras en la realización de la angioplastia primaria en los pacientes trasladados con infarto agudo de miocardio: un problema médico-asistencial / Time Delays in Performing Primary Angioplasty in Patients Transferred with Acute Myocardial Infarction: a Health-Care Issue

Introducción En el infarto agudo de miocardio (IAM) está comprobado que cuanto más tempranamente se realice la reperfusión, mejores serán sus resultados a corto y a largo plazos, por lo que el tiempo entre el inicio de los síntomas y la reperfusión coronaria es un elemento de gran importancia en la estrategia de su tratamiento. Este lapso se encuentra conformado por dos períodos: "tiempo paciente" y "tiempo médico-asistencial". En la angioplastia primaria, el análisis de estos tiempos y sus intervalos es el paso obligado para lograr una reducción de la demora a la reperfusión. Objetivos Analizar los tiempos en cada etapa del proceso traslado-realización de una angioplastia, ya sea primaria o de rescate, en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMEST) que debieron ser trasladados desde un hospital derivador a un centro de referencia en el ámbito de la ciudad de Buenos Aires para someterse al procedimiento, como primer paso para un programa de optimización de los tiempos. Material y métodos Estudio prospectivo, observacional, de pacientes derivados al Hospital General de Agudos "Dr. Cosme Argerich" con diagnóstico de IAMEST e indicación de ATC. Se analizaron los tiempos parciales desde el inicio de los síntomas hasta la reperfusión coronaria, para lo cual se consideró "tiempo paciente" desde el inicio de los síntomas hasta la llegada al hospital derivador y "tiempo médico-asistencial" al comprendido entre la llegada al hospital derivador y la insuflación del balón. Resultados Se incluyeron 313 pacientes, 225 (72%) con angioplastia primaria (ATCP) y 88 (28%) con angioplastia de rescate (ATCR). Las medianas (cuartiles) de tiempo en ATCP fueron: tiempo paciente: 90' (40-240), llegada al hospital derivador-llamada al Equipo de Hemodinamia Cardiovascular de Urgencia (EHCU): 80' (35-150), llamada EHCU-ingreso hemodinamia: 75' (55-100), ingreso hemodinamia-balón: 35' (23-52), tiempo médico-asistencial: 200' (142-290), tiempo traslado ambulancia: 31' (26-40). Las medianas (cuartiles) de tiempo en ATCR fueron: tiempo paciente: 90' (30-120), llegada al hospital derivador-llamada EHCU: 180' (120-245), llamada EHCU-ingreso hemodinamia: 85' (60-115), ingreso hemodinamia-balón: 40' (26-61), tiempo médico-asistencial: 297' (230-395), tiempo traslado ambulancia: 34' (28-44). Conclusiones El "tiempo paciente" comprende aproximadamente un tercio del tiempo total empleado. El "tiempo médico-asistencial" constituye el principal responsable del retraso al procedimiento. La reducción de las demoras sólo será efectiva si se encara a través de un programa que contemple un enfoque multifactorial e interdisciplinario.

Background It has been exhaustively proved that in patients with acute myocardial infarction (AMI) time to reperfusion is closely related to short and long-term outcomes; therefore, time between onset of symptoms and coronary reperfusion is extremely important. This time interval comprises two periods: "patient time" and "health-care time". In terms of primary angioplasty, analysis of both time intervals is a necessary step to achieve a reduction in delay to reperfusion. Objective The aim of this study was to analyze the time intervals in each stage of the process hospital transfer-angioplasty (either primary or rescue angioplasty) in patients with ST-segment elevation acute myocardial infarction (STEMI) transferred from a hospital with no angioplasty facilities to a tertiary medical center in the city of Buenos Aires, as a first step for implementing a time optimized program. Material and Methods We conducted a prospective and observational study of patients transferred to the Hospital General de Agudos "Dr. Cosme Argerich" for percutaneous coronary intervention (PCI) due to STEMI. Time intervals from symptoms onset until coronary reperfusion were analyzed: "patient time", defined as the time interval from onset of symptoms until arrival at the referral center, and "health-care time", defined as the time interval from arrival at the referral center to balloon inflation. Results The study included 313 patients; 225 (72%) underwent primary percutaneous coronary intervention (PCI) and rescue angioplasty (RPCI) was performed in 88 patients (28%). Median (quartile) time intervals in PCI patients were as follows: patient time: 90' (40-240); arrival at referral center- call to the catheterization laboratory team on duty (CLTOD) time: 80' (35-150); call to CLTOD-arrival at the cath lab time: 75' (55-100); arrival at the cath lab-balloon time: 35' (23-52); health-care time: 220' (142-290); ambulance transport time: 31' (26-40). Median (quartile) time intervals in RPCI patients were as follows: patient time: 90' (30-120); arrival at referral center-call to CLTOD time: 180' (120-245); call to CLTOD-arrival at the cath lab time: 85' (60-115); arrival at the cath lab-balloon time: 40' (26- 61), health-care time: 297' (230-395); ambulance transport time: 34' (28-44). Conclusions "Patient time" interval accounts for approximately one third of the total time. "Health-care time" is the main cause related to time delay in starting the procedure. Reduction in time delays might only be achieved by implementing a program focused on multifactorial and interdisciplinary strategies.

La demora en la realización de la angioplastia primaria: ¿una causa relacionada con el paciente o con el sistema médico-asistencial? / Delay in Performing Primary Angioplasty: Is it due to a Reason Related to the Patient or to the Healthcare System?

Introducción Uno de los inconvenientes en la utilización generalizada de la angioplastia primaria (ATCP) es el retraso en su aplicación. La mayoría de los datos actuales proceden de ensayos clínicos de otros países, en tanto que en nuestro medio existe poco conocimiento respecto de su aplicación en la práctica habitual. Objetivos Analizar los tiempos involucrados en cada etapa de la realización de una ATCP en un centro donde constituye el tratamiento de elección, como primer paso para un programa de optimización de los tiempos y determinar si la demora obedece a una situación vinculada al paciente o al sistema médico-asistencial. Material y métodos El presente es un estudio prospectivo observacional en pacientes con IAM de menos de 12 horas. Se consideró "tiempo paciente" desde el inicio de los síntomas hasta el arribo al hospital y "tiempo médico-asistencial" desde la llegada al hospital hasta la insuflación del balón. Resultados Se realizó ATCP en 224 pacientes ingresados con diagnóstico de IAM. Las medianas (percentiles 25-75) fueron "tiempo paciente": 60 minutos (40-150), "tiempo médico-asistencial": 93 minutos (72-128). Este último comprende: tiempo 1 (llegada al hospital-llamada al equipo de hemodinamia): 20 minutos (10-45), tiempo 2 (llamada al equipo de hemodinamia-ingreso en sala de hemodinamia): 38 minutos (23-52), tiempo 3 (ingreso en sala de hemodinamia-primer balón insuflado): 31 minutos (21-45). Conclusiones El "tiempo paciente" constituye menos de la mitad del tiempo total empleado. El "tiempo médico-asistencial" determina el mayor retraso al procedimiento; por lo tanto, inicialmente, el mayor énfasis debe dirigirse a corregir este último, dentro del cual el tiempo llamada-primer balón constituye un factor fundamental.

Introduction One of the inconveniences in the general utilization of primary angioplasty (PCTA) is the delay in its application. Most of present data come from clinical trials from other countries, whereas little is known about its application in the regular practice in our country. Objectives To analize the periods of time needed for each stage of a PCTA in a facility where the election treatment is used as a first step for a time-optimization program, and to determine if the delay is due to a situation related to the patient or to the healthcare system. Material and Methods This is a prospective observational study in patients with AMI of less than 12-hours since onset. The "patient time" was counted from the onset of the symptoms to the arrival in hospital, and the "medical care time" was determined from the arrival in hospital to the balloon inflation. Results PCTA was performed in 224 patients admitted with diagnosis of AMI. The median values (25th to 75th percentile) were "patient time": 60 minutes (40-150), "medical care time": 93 minutes (72-128). The "medical care time" includes: time 1 (arrival in hospital-call for the hemodynamics team): 20 minutes (10-45), time 2 (call for the hemodynamics team-admittance in hemodynamics room): 38 minutes (23-52), time 3 (admittance in hemodynamics roomirst inflated balloon): 31 minutes (21-45). Conclusions The "patient time" represents less than half the total time consumed. The "medical care time" determines the higher delay for the procedure; therefore, more emphasis should be placed in improving this time, within which the time for calling for the first balloon is a key factor.

Cinefluoroscopic assessment of mechanical disc prostheses: its value as a complementary method to echocardiography.

BACKGROUND AND AIM OF THE STUDY: Many types of mechanical prostheses are used for heart valve replacement, but it is difficult to distinguish between them using transthoracic echocardiography. Hence, cinefluoroscopy complements the echocardiographic evaluation of cardiac prostheses. The aims of the present study were to: (i) describe the contribution of cinefluoroscopy in identifying different prostheses; (ii) compare gradients obtained by Doppler echocardiography with the opening angle of the discs assessed by cinefluoroscopy; and (iii) assess the ability of cinefluoroscopy to distinguish normal from dysfunctional prostheses. METHODS: A total of 229 mechanical disc prostheses was prospectively evaluated with cinefluoroscopy. Eight prosthetic valves (six aortic, two mitral) were excluded due to the coexistence of severe left ventricular dysfunction. Thus, the final analysis comprised 221 prosthetic valves (146 aortic, 75 mitral). RESULTS: Based on the characteristics of the ring and the discs, cinefluoroscopy identified 87 single-leaflet and 134 bileaflet prostheses. Disc motion allowed distinction to be made between normal and dysfunctional prostheses (opening angle: 74 +/- 13 degrees versus 49 +/- 18 degrees). Fluoroscopy could not define disc profile or the ring in 6% of aortic valves and in 26% of mitral prostheses. The technique could be used to identify the TriTechnologies and HP-Biplus valves, but could not provide data on prosthetic function due to radiolucency of the discs. Among the 146 aortic prostheses, Doppler echocardiography helped to identify 109 normal valves and 37 dysfunctional valves. Among 75 mitral prostheses, 54 normal and 21 dysfunctional prosthetic valves were identified. When both methods were correlated, the sensitivity, specificity and positive and negative predictive values of fluoroscopy to distinguish normal from malfunctioning prostheses were 83%, 80%, 89%, and 71%, respectively. CONCLUSION: Each prosthesis type has radioscopic characteristics that allow its identification. Fluoroscopy permitted rapid and easy evaluation of mechanical prosthetic valve function, and in most cases allowed a distinction to be made between normal and dysfunctional prostheses. The presence of high gradients by Doppler echocardiography, with normal opening angles by fluoroscopy, and without pannus on transesophageal echocardiography, is indicative of patient-prosthesis mismatch. Fluoroscopy was superior to echocardiography in identifying disc motion, whilst Doppler study allowed the measurement of gradients and areas, and semiquantification of regurgitation. Thus, cinefluooscopy rapidly provides valuable information which is complementary to that obtained by echocardiography.