Evolución del perfil clínico y pronóstico de pacientes con alta hospitalaria por insuficiencia cardíaca en las dos primeras décadas del sigloxxi. El Registro INCA-Ex / Clinical and prognostic profile evolution of patients discharged from hospital due to heart failure in the first two decades of the 21st century. The INCA-Ex Registry

Objetivo: Estudiar la evolución del perfil clínico de una población dada de alta con diagnóstico principal de insuficiencia cardíaca (IC) en las dos primeras décadas del siglo y las variables predictoras de mortalidad y reingreso en el primer año de alta. Diseño: Estudio observacional, retrospectivo, longitudinal. Emplazamiento: Área de salud Don Benito-Villanueva de la Serena, Badajoz, España. Participantes: Todos los pacientes dados de alta con diagnóstico principal de IC entre 2000 y 2019 en un complejo hospitalario general.Mediciones principalesSe recogieron variables sociodemográficas y clínicas, y se realizó un seguimiento de un año; la variable resultado fue un compuesto de mortalidad y/o reingreso. Resultados: Se incluyeron 4.107 altas, edad media 77,1 (DE 10,5) años, 53,1% de mujeres. El número de ingresos, la edad, los antecedentes de neoplasias, los ictus, la insuficiencia renal y la anemia fueron en aumento, así como los reingresos (p de tendencias <0,001), mientras permaneció constante la mortalidad. Fueron variables predictoras de reingreso y/o muerte HR (IC95%): edad (por año) 1,04 (1,03-1,04), diabetes: 1,11 (1,01-1,24), IC previa 1,41 (1,28-1,57), variable compuesta infarto, ictus y/o arteriopatía periférica 1,24 (1,11-1,38), enfermedad pulmonar obstructiva crónica (EPOC) 1,29 (1,15-1,44), neoplasia 1,33 (1,16-1,53), anemia 1,63 (1,41-1,86), insuficiencia renal 1,42 (1,26-1,60). Conclusiones: En los últimos 20años se han incrementado los ingresos de pacientes por IC, su edad y la comorbilidad. Fueron variables predictoras de mortalidad y/o reingreso la edad, la diabetes, la enfermedad cardiovascular previa, las neoplasias, la EPOC, la insuficiencia renal y la anemia; sin embargo, la mortalidad al año se mantuvo constante.(AU)

Aim: To study the evolution of the clinical profile of a population discharged with a main diagnosis of heart failure (HF) in the first two decades of the century and the predictive variables of mortality and readmission in the first year of discharge. Design: Observational, retrospective, longitudinal study. Site: Don Benito Villanueva de la Serena Badajoz health area. Participants: All patients discharged with a main diagnosis of HF between 2000 and 2019 in a general hospital complex were included. Main measurements: Sociodemographic and clinical variables were collected, and a one-year follow-up; the result variable was a composite of mortality and/or readmission. Results: A total of 4107 discharges were included, mean age 77.1 (SD±10.5) years, 53.1% women. The number of admissions, age, history of neoplasms, stroke, kidney failure, and anemia increased, as did readmissions (P for trends <.001), while mortality remained constant. Predictive variables for readmission and/or death were HR (95%CI): age (per year) 1.04 (1.03-1.04), diabetes: 1.11 (1.01-1.24), previous HF 1.41 (1.28-1.57), composite variable myocardial infarction, stroke and/or peripheral artery disease 1.24 (1.11-1.38), chronic obstructive pulmonary disease (COPD) 1.29 (1.15-1.44), neoplasia 1.33 (1.16-1.53), anemia 1.63 (1.41-1.86), chronic kidney failure 1.42 (1.26-1.60). Conclusions: In the last 20 years, admissions for heart failure, patient age, and comorbidity have increased. Predictive variables for mortality and/or readmission were age, diabetes, previous cardiovascular disease, neoplasms, COPD, kidney failure, and anemia; however, mortality at one year remained constant.(AU)

[Clinical and prognostic profile evolution of patients discharged from hospital due to heart failure in the first two decades of the 21st century. The INCA-Ex Registry]. / Evolución del perfil clínico y pronóstico de pacientes con alta hospitalaria por insuficiencia cardíaca en las dos primeras décadas del sigloxxi. El Registro INCA-Ex.

AIM: To study the evolution of the clinical profile of a population discharged with a main diagnosis of heart failure (HF) in the first two decades of the century and the predictive variables of mortality and readmission in the first year of discharge. DESIGN: Observational, retrospective, longitudinal study. SITE: Don Benito Villanueva de la Serena Badajoz health area. PARTICIPANTS: All patients discharged with a main diagnosis of HF between 2000 and 2019 in a general hospital complex were included. MAIN MEASUREMENTS: Sociodemographic and clinical variables were collected, and a one-year follow-up; the result variable was a composite of mortality and/or readmission. RESULTS: A total of 4107 discharges were included, mean age 77.1 (SD±10.5) years, 53.1% women. The number of admissions, age, history of neoplasms, stroke, kidney failure, and anemia increased, as did readmissions (P for trends <.001), while mortality remained constant. Predictive variables for readmission and/or death were HR (95%CI): age (per year) 1.04 (1.03-1.04), diabetes: 1.11 (1.01-1.24), previous HF 1.41 (1.28-1.57), composite variable myocardial infarction, stroke and/or peripheral artery disease 1.24 (1.11-1.38), chronic obstructive pulmonary disease (COPD) 1.29 (1.15-1.44), neoplasia 1.33 (1.16-1.53), anemia 1.63 (1.41-1.86), chronic kidney failure 1.42 (1.26-1.60). CONCLUSIONS: In the last 20 years, admissions for heart failure, patient age, and comorbidity have increased. Predictive variables for mortality and/or readmission were age, diabetes, previous cardiovascular disease, neoplasms, COPD, kidney failure, and anemia; however, mortality at one year remained constant.

Applications designed to successfully implant in challenging left atrial appendage occlusion cases: a new tool for the interventional cardiologist.

An 85-year-old patient with permanent atrial fibrillation with a DDD pacemaker, and with indication for left atrial appendage occlusion (LAAO). Sent for LAAO due to recurrent gastrointestinal bleedings even on apixaban and with a CHA 2 DS 2 VASc and HAS-BLED scores of 4 and 3 respectively.

Benefit of primary percutaneous coronary interventions in the elderly with ST segment elevation myocardial infarction.

OBJECTIVE: Primary percutaneous coronary intervention (P-PCI) has demonstrated its efficacy in patients with ST segment elevation myocardial infarction (STEMI). However, patients with STEMI ≥75 years receive less P-PCI than younger patients despite their higher in-hospital morbimortality. The objective of this analysis was to determine the effectiveness of P-PCI in patients with STEMI ≥75 years. METHODS: We included 979 patients with STEMI ≥75 years, from the ATención HOspitalaria del Síndrome coronario study, a registry of 8142 consecutive patients with acute coronary syndrome admitted at 31 Spanish hospitals in 2014-2016. We calculated a propensity score (PS) for the indication of P-PCI. Patients that received or not P-PCI were matched by PS. Using logistic regression, we compared the effectiveness of performing P-PCI versus non-performance for the composite primary event, which included death, reinfarction, acute pulmonary oedema or cardiogenic shock during hospitalisation. RESULTS: Of the included patients, 81.5 % received P-PCI. The matching provided two groups of 169 patients with and without P-PCI. Compared with its non-performance, P-PCI presented a composite event OR adjusted by PS of 0.55 (95% CI 0.34 to 0.89). CONCLUSIONS: Receiving a P-PCI was significantly associated with a reduced risk of major intrahospital complications in patients with STEMI aged 75 years or older.

Evaluación en la vida real de los anticoagulantes orales de acción directa y el cierre de la orejuela en situaciones clínicas complejas / Real-world assessment of direct oral anticoagulants and left atrial appendage closure in complex clinical situations

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Endocarditis infecciosa después de TAVI: aportaciones de la experiencia en un único centro sobre la incidencia y los factores asociados / Infective endocarditis after transcatheter aortic valve implantation: Contributions of a single-centre experience on incidence and associated factors

INTRODUCCIÓN: La endocarditis infecciosa (EI) sobre transcatheter aortic valve implantation (TAVI) es una complicación emergente. Existen datos incompletos y dispares sobre su incidencia. Se aporta la experiencia en nuestro centro sobre incidencia, mortalidad y factores asociados de la EI post-TAVI y se compara con datos de la literatura. MÉTODOS: Estudio retrospectivo observacional de los casos de EI diagnosticados en pacientes que habían recibido TAVI, entre el 1 de junio de 2009 y el 1 de noviembre de 2017, en un centro universitario tras una mediana de seguimiento de 15,3 meses (rango intercuartil [RIC] 9,1-36,2). Se analizaron la incidencia, los datos clínicos, microbiológicos y pronósticos, y los factores asociados a EI post-TAVI. RESULTADOS: Se detectaron 11 pacientes con EI de 200 TAVI. Incidencia global: 5,5% (2,77 casos por 100 años-paciente). La mediana de tiempo hasta la EI post-TAVI fue de 112 días (RIC 36-578), la tasa de mortalidad intrahospitalaria fue del 36,4% y la mortalidad al año, del 54,5%. Todos los microorganismos identificados fueron grampositivos (4 Enterococcus faecalis, 3 Staphylococcus coagulasa negativo). Los pacientes con EI post-TAVI eran significativamente más jóvenes (mediana 78, RIC 73-80, frente a 82, RIC 79-84, p = 0,002), tenían un EuroSCORE mayor (5,1 ± 2,4 frente a 3,2 ± 1,2, p < 0,001) y más frecuentemente antecedentes de neoplasia (18,2% frente al 4,2%, p < 0,03). CONCLUSIONES: En nuestro medio, la incidencia de EI post-TAVI es mayor que la descrita en series multicéntricas, lo que concuerda con la tendencia publicada en la literatura. Conlleva una elevada mortalidad y se asocia con una peor situación clínica basal

INTRODUCTION: Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is an emerging complication. There are incomplete and disparate data on its incidence. We present the experience of a single-centre of incidence, mortality and associated factors of IE after TAVI. METHODS: A retrospective observational study of IE cases in people who received a TAVI, between 06/01/2009 and 11/01/2017, in a university hospital, during a median follow-up period of 15.3months (interquartile range [IQR] 9.1-36.2). Incidence, clinical, microbiological and prognostic data, and factors associated with IE after TAVI were analysed. RESULTS: Eleven patients with IE of 200 TAVI were detected. Global incidence: 5.5% (2.77 cases per 100 patient-year). The median of days from TAVI to IE was 112 (IQR 36-578), the in-hospital mortality rate was 36.4%, and the one-year mortality rate was 54.5%. All the organisms identified were gram-positive (4 Enterococcus faecalis, 3 coagulase-negative Staphylococcus). The patients with IE after TAVI were significantly younger (median 78 years, IQR 73-80, versus 82 years, IQR 79-84, P=.002), they had a higher EuroSCORE (5.1±2.4 versus 3.2 ± 1.2, P < .001), and they more frequently had a history of neoplasia (18.2% versus 4.2%, P < .03). CONCLUSIONS: In our area, IE after TAVI has an incidence greater than that described in multicentre series, this is in line with the trend published in the literature. It leads to high mortality and is associated with a worse baseline clinical situation

Infective endocarditis after transcatheter aortic valve implantation: Contributions of a single-centre experience on incidence and associated factors. / Endocarditis infecciosa después de TAVI: aportaciones de la experiencia en un único centro sobre la incidencia y los factores asociados.

INTRODUCTION: Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is an emerging complication. There are incomplete and disparate data on its incidence. We present the experience of a single-centre of incidence, mortality and associated factors of IE after TAVI. METHODS: A retrospective observational study of IE cases in people who received a TAVI, between 06/01/2009 and 11/01/2017, in a university hospital, during a median follow-up period of 15.3months (interquartile range [IQR] 9.1-36.2). Incidence, clinical, microbiological and prognostic data, and factors associated with IE after TAVI were analysed. RESULTS: Eleven patients with IE of 200 TAVI were detected. Global incidence: 5.5% (2.77 cases per 100 patient-year). The median of days from TAVI to IE was 112 (IQR 36-578), the in-hospital mortality rate was 36.4%, and the one-year mortality rate was 54.5%. All the organisms identified were gram-positive (4 Enterococcus faecalis, 3 coagulase-negative Staphylococcus). The patients with IE after TAVI were significantly younger (median 78years, IQR 73-80, versus 82 years, IQR 79-84, P=.002), they had a higher EuroSCORE (5.1±2.4 versus 3.2±1.2, P<.001), and they more frequently had a history of neoplasia (18.2% versus 4.2%, P<.03) CONCLUSIONS: In our area, IE after TAVI has an incidence greater than that described in multicentre series, this is in line with the trend published in the literature. It leads to high mortality and is associated with a worse baseline clinical situation.

Seguridad del MitraClip en pacientes con cable endocárdico de resincronización cardiaca en el ventrículo izquierdo a través del septo interventricular / Safety of MitraClip implantation in patients with a left ventricular endocardial lead for cardiac resynchronization therapy through the interventricular septum

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Trombosis tardía asociada a dispositivo de cierre percutáneo de orejuela. ¿Es poco frecuente o está infradiagnosticada? / Late thrombosis associated with left atrial appendage closure devices. Is it rare or is it underdiagnosed?

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Unusual cause of central aortic prosthetic regurgitation during transcatheter replacement.

Transcatheter aortic valve replacement (TAVR) is an increasingly common procedure for the treatment of aortic stenosis in elderly patients with comorbidities that prevent the use of standard surgery. It has been shown that implantation without aortic regurgitation is related to lower mortality. Mild paravalvular regurgitation is inevitable in some cases due to calcification of the aortic annulus and its usually somewhat elliptical shape. Central regurgitation is less common, but has been associated with valve overdilatation in cases in which reduction of paravalvular regurgitation was attempted after the initial inflation. However, there are no reported cases of central prosthetic aortic regurgitation due to acute LV dysfunction. We report a case in which central aortic regurgitation occurred due to transient ventricular dysfunction secondary to occlusion of the right coronary artery by an embolus. The regurgitation disappeared after thrombus aspiration and normal ventricular function was immediately recovered.

Comparison of imaging techniques to assess appendage anatomy and measurements for left atrial appendage closure device selection.

BACKGROUND: The adequate device size selection for left atrial appendage closure is crucial to ensuring adequate implantation and for avoiding the need for multiple attempts that increase the risk of complications. Our aim was to evaluate the information obtained using different imaging techniques to select the size of the closure device in a clinical environment. METHODS: Thirty-seven patients who consecutively underwent implantation of Amplatzer cardiac plug (ACP) devices were studied. All patients were examined using computed tomography (CT) prior to intervention. Measurements were compared to those obtained using intraoperative transesophageal echocardiography (IOTEE) and angiography. Size was determined by the longest axis of the appendage ostium. The influence of all techniques on the correct selection of final size was assessed. RESULTS: The measurements taken using the three techniques agreed in only 21.6% of the cases, leading to accurate selection of device size. Two techniques coincided as follows: IOTEE-CT in 45.9%, angiography-CT in 35.13%, and angiography-IOTEE in 24.3%. Measurements using CT were definitive for ACP selection in 75.7% of cases, angiography in 48.6%, and echocardiography in 51.4%. Device size was undermeasured with angiography in 35.1% of cases, and with IOTEE in 24.3%; CT overmeasured 21.6% of cases. The combination of angiography-CT was the most accurate for selection of device size. CONCLUSION: CT most often predicts the appropriate device size. If it fails, it usually overestimates the size. Agreement of measurements with all three techniques is the most accurate situation; when two agree, the most accurate combination is angiography and CT.

A prospective randomised study of the paclitaxel-coated balloon catheter in bifurcated coronary lesions (BABILON trial): 24-month clinical and angiographic results.

AIMS: Paclitaxel drug-eluting balloons (pDEB) could be an attractive option to minimise side branch (SB) restenosis in bifurcated coronary lesions. We compared angiographic and clinical outcomes with pDEB plus bare metal stent (BMS) versus drug-eluting stents (DES) in de novo bifurcated lesions. METHODS AND RESULTS: This multicentre randomised trial included 108 patients. Sequential main branch (MB)/SB dilatation with pDEB, with provisional T-stenting with BMS in the MB was performed in the pDEB group, and with everolimus DES in the DES group. The primary endpoint was late lumen loss (LLL) at nine months. The secondary endpoint was the incidence of major adverse cardiac events (MACE: death, myocardial infarction, or target lesion revascularisation). In-segment MB LLL was 0.31±0.48 mm in the pDEB group, and 0.16±0.38 mm in the DES group (p=0.15); mean difference was 0.15 mm (upper limit one-sided 95% CI: 0.27 mm; p=0.001; non-inferiority test). LLL in SB was -0.04±0.76 mm in the pDEB group and -0.03±0.51 mm in the DES group (p=0.983). MACE and TLR were higher in the pDEB group (17.3% vs. 7.1%; p=0.105, and 15.4% vs. 3.6%; p=0.045), due to higher MB restenosis (13.5% vs. 1.8%; p=0.027). CONCLUSIONS: pDEB bifurcation pretreatment with BMS implantation in MB showed greater LLL (ns) and increased incidence of MACE compared to everolimus DES. Both strategies showed similar results in the SB.

Anatomical classification of left atrial appendages in specimens applicable to CT imaging techniques for implantation of amplatzer cardiac plug.

BACKGROUND: Certain anatomical characteristics of the left atrial appendage (LAA) are associated with complexity in the implantation of occluder devices. OBJECTIVE: The aim was to define characteristics measurable by three-dimensional imaging that would predict complexities both in the implantation procedure and the selection of the appropriate device size. METHODS: An anatomical study was performed of 50 postmortem hearts, of which 15 had a history of atrial fibrillation, and of 30 consecutive patients undergoing LAA occlusion with the Amplatzer cardiac plug (ACP). The specimens were classified according to variables that can be visualized using computerized tomography (CT). The CT scans of 30 consecutive patients were classified according to the level of the LAA ostium, the left lateral ridge (LLR), the LAA limbus and distance from LAA to the mitral annulus before undergoing LAA occlusion, and the results were correlated. RESULTS: Three types of LAA orifice were defined: type I, with a usually higher, anterior LAA ostium, a short, flattened and wide LLR and almost nonexistent limbus; type II, presenting a long, pointed and narrow LLR, and a longer, more defined limbus; type III, with a lower LAA ostium, close to the left atrium floor and the mitral annulus, a marked separation from the left pulmonary vein orifices and a limbus of intermediate length. CONCLUSION: LAA with lower ostia are more difficult to occlude. Types II and III have very prominent LLRs with longer limbi, which may increase the difficulty of inserting the guide and making measurements for selection of the right ACP size.

MGuard® stent retrieval after failed implantation and withdrawal.

SUMMARY: We present two cases of right coronary artery occlusion in which MGuard® stent implantation failed for different causes, leading to a retrieval procedure adapted to the situation. Complete retrieval was possible in both cases. These cases illustrate the need for careful selection of the lesions that are going to be treated with this type of stent, for which pre-dilatation is recommended in severe lesions located just after an acute vessel angle, the evaluation of proximal angulation and calcification, as well as strategies for complete retrieval in case of implantation failure.

Resultados inmediatos y a más de un año en 35 pacientes consecutivos a los que se realiza cierre de orejuela izquierda con el dispositivo Amplatzer Cardiac Plug / Immediate and one-year results in 35 consecutive patients after closure of left atrial appendage with the amplatzer cardiac plug

Introducción y objetivos. El cierre del apéndice auricular izquierdo puede ser una opción terapéutica atractiva para pacientes con fibrilación auricular no valvular y contraindicación para tomar anticoagulantes orales, siempre que se obtengan buenos resultados durante la implantación y en el seguimiento. Métodos. Se analizó a 35 pacientes consecutivos y no elegibles para los estudios aleatorizados con anticoagulantes orales a los que se implantó el dispositivo oclusor Amplatzer. Tras los primeros 5 casos, se incorporó una técnica de imagen 3D. Se analizaron los resultados de la implantación y de seguimiento durante 1 año. Resultados. La media de edad era 74,65 ± 7,61 años, con un CHADS2 de 2,41 ± 1,53 y un CHA2DS2-VASc de 3,17 ± 1,60. No se pudo implantar el dispositivo en 1 caso y en 5 fue necesario cambiar la medida seleccionada. No hubo ninguna complicación cardiaca durante la implantación ni durante la estancia hospitalaria. Hubo una complicación vascular (fístula arteriovenosa). Se realizó seguimiento con ecocardiografía transesofágica a las 24 h y tras 1, 3, 6 y 12 meses; se documentaron 5 trombos, que se resolvieron con heparina. En el seguimiento de 21,14 ± 10,09 meses, hubo 3 muertes de pacientes mayores de 80 años, ninguna de ellas cardiológica, y un accidente isquémico transitorio sin secuelas. Conclusiones. El cierre del apéndice auricular izquierdo por un operador con cierta experiencia puede ser una opción terapéutica con pocas complicaciones y con resultados a más de 1 año eficaces en la reducción de complicaciones tromboembólicas y hemorrágicas, incluso en poblaciones de muy alto riesgo (AU)

Introduction and objectives. Left atrial appendage closure can be an attractive option for patients with nonvalvular atrial fibrillation and a contraindication to oral anticoagulants, provided that satisfactory results can be achieved during implantation and follow-up. Methods. Thirty-five consecutive patients, not eligible for randomized trials with oral anticoagulants, had an Amplatzer occlusion device implanted under general anesthesia. After the first 5 patients, 3-dimensional imaging was incorporated. The results of the implantation and the follow-up were analyzed over a 1-year period. Results. The mean age was 74.65 (7.61) years, with a CHADS2 score of 2.41 (1.53) and a CHA2DS2-VASc score of 3.17 (1.60). Implantation failed in 1 patient and 5 needed a change in the selected plug size. There were no cardiac complications during the implantation or hospital stay. There was 1 vascular complication (arteriovenous fistula). Transesophageal echocardiography monitoring was performed at 24h, 1, 3, 6, and 12 months and we found 5 thrombi which were resolved with heparin. In the follow-up period of 21.14 (10.09) months, 3 patients aged>80 years died, none of them due to heart problems, and one transient ischemic stroke without further consequences. Conclusions. Left atrial appendage closure by an experienced operator can be a treatment option with few complications and with efficient results at>1 year in reducing thromboembolic and hemorrhagic complications, even in very high-risk groups (AU)

Immediate and one-year results in 35 consecutive patients after closure of left atrial appendage with the Amplatzer cardiac plug.

INTRODUCTION AND OBJECTIVES: Left atrial appendage closure can be an attractive option for patients with nonvalvular atrial fibrillation and a contraindication to oral anticoagulants, provided that satisfactory results can be achieved during implantation and follow-up. METHODS: Thirty-five consecutive patients, not eligible for randomized trials with oral anticoagulants, had an Amplatzer occlusion device implanted under general anesthesia. After the first 5 patients, 3-dimensional imaging was incorporated. The results of the implantation and the follow-up were analyzed over a 1-year period. RESULTS: The mean age was 74.65 (7.61) years, with a CHADS2 score of 2.41 (1.53) and a CHA2DS2-VASc score of 3.17 (1.60). Implantation failed in 1 patient and 5 needed a change in the selected plug size. There were no cardiac complications during the implantation or hospital stay. There was 1 vascular complication (arteriovenous fistula). Transesophageal echocardiography monitoring was performed at 24h, 1, 3, 6, and 12 months and we found 5 thrombi which were resolved with heparin. In the follow-up period of 21.14 (10.09) months, 3 patients aged>80 years died, none of them due to heart problems, and one transient ischemic stroke without further consequences. CONCLUSIONS: Left atrial appendage closure by an experienced operator can be a treatment option with few complications and with efficient results at>1 year in reducing thromboembolic and hemorrhagic complications, even in very high-risk groups.