Interventional cardiology in cancer patients: A position paper from the Portuguese Cardiovascular Intervention Association and the Portuguese Cardio-Oncology Study Group of the Portuguese Society of Cardiology.

The field of Cardio-Oncology has grown significantly, especially during the last decade. While awareness of cardiotoxicity due to cancer disease and/or therapies has greatly increased, much of the attention has focused on myocardial systolic disfunction and heart failure. However, coronary and structural heart disease are also a common issue in cancer patients and encompass the full spectrum of cardiotoxicity. While invasive percutaneous or surgical intervention, either is often needed or considered in cancer patients, limited evidence or guidelines are available for dealing with coronary or structural heart disease. The Society for Cardiovascular Angiography and Interventions consensus document published in 2016 is the most comprehensive document regarding this particular issue, but relevant evidence has emerged since, which render some of its considerations outdated. In addition to that, the recent 2022 ESC Guidelines on Cardio-Oncology only briefly discuss this topic. As a result, the Portuguese Association of Cardiovascular Intervention and the Cardio-Oncology Study Group of the Portuguese Society of Cardiology have partnered to produce a position paper to address the issue of cardiac intervention in cancer patients, focusing on percutaneous techniques. A brief review of available evidence is provided, followed by practical considerations. These are based both on the literature as well as accumulated experience with these types of patients, as the authors are either interventional cardiologists, cardiologists with experience in the field of Cardio-Oncology, or both.

A report on a survey among Portuguese Association of Interventional Cardiology associates regarding ionizing radiation protection practices in national interventional cath-labs.

INTRODUCTION AND OBJECTIVES: Concerns surrounding the consequences of ionizing radiation (IR) have increased in interventional cardiology (IC). Despite this, the ever-growing complexity of diseases as well as procedures can lead to greater exposure to radiation. The aim of this survey, led by Portuguese Association of Interventional Cardiology (APIC), was to evaluate the level of awareness and current practices on IR protection among its members. METHODS: An online survey was emailed to all APIC members, between August and November 2021. The questionnaire consisted of 50 questions focusing on knowledge and measures of IR protection in the catheterization laboratory. Results were analyzed using descriptive statistics. RESULTS: From a response rate of 46.9%, the study obtained a total sample of 159 responses (156 selected for analysis). Most survey respondents (66.0%) were unaware of the radiation exposure category, and only 60.4% reported systematically using a dosimeter. A large majority (90.4%) employed techniques to minimize exposure to radiation. All participants used personal protective equipment, despite eyewear protection only being used frequently by 49.2% of main operators. Ceiling suspended shields and table protectors were often used. Only two-thirds were familiar with the legally established limit on radiation doses for workers or the dose that should trigger patient follow-up. Most of the survey respondents had a non-certified training in IR procedures and only 32.0% had attended their yearly occupational health consultation. CONCLUSIONS: Safety methods and protective equipment are largely adopted among interventional cardiologists, who have shown some IR awareness. Despite this, there is room for improvement, especially concerning the use of eyewear protection, monitoring, and certification.

Aortic annulus rupture with fistula to the right ventricle following aortic valve replacement with a sutureless valve: A surgical complication with a percutaneous solution.

With the development of interventional procedures, iatrogenic aorto-right ventricular fistulae are increasingly reported. They may follow surgical aortic valve replacement or percutaneous aortic valve implantation, leading to high morbidity. Traditionally, treatment of fistulae was based on surgical repair, but with advances in endovascular technologies, more emphasis is now placed on percutaneous closure. We report the case of a 78-year-old patient with severe symptomatic aortic stenosis who underwent surgical aortic valve replacement with a Perceval sutureless valve. One month later, he presented with symptoms and signs of heart failure. Transthoracic and transesophageal echocardiography confirmed the presence of a aorto-right ventricular fistula. The fistula was successfully closed percutaneously with an Amplatzer Vascular Plug II, in an intracardiac echocardiography-guided procedure. Aorto-right ventricular fistula is a rare finding after surgical aortic valve replacement and to our knowledge it has never been associated with sutureless aortic valve replacement. A percutaneous procedure with an appropriately selected device may be encouraged because of the high morbidity and mortality of redo open-heart surgery. To minimize the risk of a second general anesthesia, the use of intracardiac echocardiography to guide the percutaneous procedure is feasible and safe.

Major Bleeding Predictors in Patients with Left Atrial Appendage Closure: The Iberian Registry II.

INTRODUCTION AND OBJECTIVE: Major bleeding events in patients undergoing left atrial appendage closure (LAAC) range from 2.2 to 10.3 per 100 patient-years in different series. This study aimed to clarify the bleeding predictive factors that could influence these differences. METHODS: LAAC was performed in 598 patients from the Iberian Registry II (1093 patient-years; median, 75.4 years). We conducted a multivariate analysis to identify predictive risk factors for major bleeding events. The occurrence of thromboembolic and bleeding events was compared to rates expected from CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes, stroke history, vascular disease, sex) and HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile INR, elderly, drugs or alcohol) scores. RESULTS: Cox regression analysis revealed that age ≥75 years (HR: 2.5; 95% CI: 1.3 to 4.8; p = 0.004) and a history of gastrointestinal bleeding (GIB) (HR: 2.1; 95% CI: 1.1 to 3.9; p = 0.020) were two factors independently associated with major bleeding during follow-up. Patients aged <75 or ≥75 years had median CHA2DS2-VASc scores of 4 (IQR: 2) and 5 (IQR: 2), respectively (p < 0.001) and HAS-BLED scores were 3 (IQR: 1) and 3 (IQR: 1) for each group (p = 0.007). Events presented as follow-up adjusted rates according to age groups were stroke (1.2% vs. 2.9%; HR: 2.4, p = 0.12) and major bleeding (3.7 vs. 9.0 per 100 patient-years; HR: 2.4, p = 0.002). Expected major bleedings according to HAS-BLED scores were 6.2% vs. 6.6%, respectively. In patients with GIB history, major bleeding events were 6.1% patient-years (HAS-BLED score was 3.8 ± 1.1) compared to 2.7% patients-year in patients with no previous GIB history (HAS-BLED score was 3.4 ± 1.2; p = 0.029). CONCLUSIONS: In this high-risk population, GIB history and age ≥75 years are the main predictors of major bleeding events after LAAC, especially during the first year. Age seems to have a greater influence on major bleeding events than on thromboembolic risk in these patients.

Reducción de eventos a largo plazo tras el cierre de la orejuela izquierda. Resultados del Registro Ibérico II / Long-term event reduction after left atrial appendage closure. Results of the Iberian Registry II

Introducción y objetivos: Muchos pacientes con fibrilación auricular no valvular tienen contraindicados los anticoagulantes orales. El objetivo es estimar la incidencia de eventos tromboembólicos y hemorrágicos en pacientes con fibrilación auricular no valvular y cierre de la orejuela izquierda con seguimiento a largo plazo, y determinar los factores asociados con mayor mortalidad a largo plazo. Métodos: Cohorte prospectiva de pacientes reclutados desde 2009 a 2015. Se compararon los eventos tromboembólicos y hemorrágicos con los esperados según las escalas CHA2DS2-VASc y HAS-BLED. Se realizó un análisis multivariable para determinar las variables asociadas con la mortalidad. Resultados: Se reclutó a 598 pacientes (1.093 pacientes-año) con contraindicación de anticoagulantes (mediana de edad, 75,4 años). La tasa de éxito del cierre de la orejuela izquierda fue del 95,8%; 30 pacientes (5%) presentaron complicaciones. Las tasas de eventos (cada 100 pacientes-año) durante el seguimiento (media, 22,9 meses; mediana, 16,1 meses) fueron: muerte, 7,0%; ictus isquémico, 1,6% (frente al 8,5% esperado según CHA2DS2-VASc; p < 0,001); hemorragia intracraneal, 0,8%; hemorragia gastrointestinal, 3,2%, y hemorragia grave, 3,9% (frente al 6,3% esperado por HAS-BLED; p = 0,002). Estos resultados incluso mejoraron en el subgrupo de 176 pacientes con seguimiento > 24 meses (media, 46,6 meses; 683 pacientes-año) para las hemorragias graves, el 2,6% (frente al 6,3% esperado por HAS-BLED; p < 0,033). La edad (HR = 1,1), las hemorragias intracraneales (HR = 6,8) y el ictus (HR = 2,7) se asociaron con mayor mortalidad. Conclusiones: El cierre de la orejuela izquierda redujo significativamente las incidencias de ictus y de eventos hemorrágicos graves y el beneficio se mantuvo. La edad, las hemorragias intracraneales y el ictus se asociaron con mayor mortalidad

Introduction and objectives: Many patients with nonvalvular atrial fibrillation are still left without protection due to a contraindication for anticoagulants. This study aimed to establish the occurrence of stroke and major bleeding events in patients with nonvalvular atrial fibrillation and left atrial appendage closure with long-term follow-up and to explore the factors associated with higher long-term mortality. Methods: Analysis of a multicenter single cohort prospectively recruited from 2009 to 2015. Thromboembolic and bleeding events were compared with those expected from CHA2DS2-VASc and HAS-BLED scores. Multivariate analysis examined variables associated with mortality during follow-up. Results: A total of 598 patients (1093 patient-years) with a contraindication for anticoagulants were recruited (median 75.4 years). The success rate of left atrial appendage closure device implantation was 95.8%. Thirty patients (5%) experienced periprocedural complications. The rate of events (per 100 patient-years) during follow-up (mean 22.9 months; median 16.1 months) was as follows: death 7.0%; ischemic stroke 1.6% (vs 8.5% expected according to CHA2DS2-VASc; P < .001); intracranial hemorrhage 0.8%; gastrointestinal bleeding 3.2%; severe bleeding 3.9% (vs 6.3% expected by HAS-BLED, P = .002). These results were improved in the subgroup of 176 patients with follow-up > 24 months (mean follow-up 46.6 months, 683 patient-years) for severe bleeding 2.6% (vs 6.3% expected by HAS-BLED, P < .033). The factors significantly associated with higher mortality were age (HR, 1.1), intracranial hemorrhage (HR, 6.8), and stroke during follow-up (HR, 2.7). Conclusions: Left atrial appendage closure significantly reduced the incidence of stroke and bleeding events and the benefit was maintained. Intracranial hemorrhage, age and stroke were associated with higher mortality

Fifteen years of coronary intravascular ultrasound in percutaneous coronary intervention in Portugal. / Quinze anos de ecografia intravascular coronária em intervenção coronária percutânea em Portugal.

INTRODUCTION: Coronary intravascular ultrasound (IVUS) is increasingly important in catheterization laboratories due to its positive prognostic impact. This study aims to characterize the use of IVUS in percutaneous coronary intervention (PCI) in Portugal. METHODS: A retrospective observational study was performed based on the Portuguese Registry on Interventional Cardiology of the Portuguese Society of Cardiology. The clinical and angiographic profiles of patients who underwent PCI between 2002 and 2016, the percentage of IVUS use, and the coronary arteries assessed were characterized. RESULTS: A total of 118 706 PCIs were included, in which IVUS was used in 2266 (1.9%). Over time, use of IVUS changed from none in 2002 to generally increasing use from 2003 (0.1%) to 2016 (2.4%). The age of patients in whom coronary IVUS was used was similar to that of patients in whom IVUS was not used, but in the former group there were fewer male patients, and a higher prevalence of cardiovascular risk factors (hypertension, hypercholesterolemia and diabetes), previous myocardial infarction, previous PCI, multivessel coronary disease, C-type or bifurcated coronary lesions, and in-stent restenosis. IVUS was used in 54.8% of elective PCIs and in 19.15% of PCIs of the left main coronary artery. CONCLUSION: Coronary IVUS has been increasingly used in Portugal since 2003. It is used preferentially in elective PCIs, and in patients with higher cardiovascular risk, with more complex coronary lesions and lesions of the left main coronary artery.

Long-term Event Reduction After Left Atrial Appendage Closure. Results of the Iberian Registry II.

INTRODUCTION AND OBJECTIVES: Many patients with nonvalvular atrial fibrillation are still left without protection due to a contraindication for anticoagulants. This study aimed to establish the occurrence of stroke and major bleeding events in patients with nonvalvular atrial fibrillation and left atrial appendage closure with long-term follow-up and to explore the factors associated with higher long-term mortality. METHODS: Analysis of a multicenter single cohort prospectively recruited from 2009 to 2015. Thromboembolic and bleeding events were compared with those expected from CHA2DS2-VASc and HAS-BLED scores. Multivariate analysis examined variables associated with mortality during follow-up. RESULTS: A total of 598 patients (1093 patient-years) with a contraindication for anticoagulants were recruited (median 75.4 years). The success rate of left atrial appendage closure device implantation was 95.8%. Thirty patients (5%) experienced periprocedural complications. The rate of events (per 100 patient-years) during follow-up (mean 22.9 months; median 16.1 months) was as follows: death 7.0%; ischemic stroke 1.6% (vs 8.5% expected according to CHA2DS2-VASc; P < .001); intracranial hemorrhage 0.8%; gastrointestinal bleeding 3.2%; severe bleeding 3.9% (vs 6.3% expected by HAS-BLED, P = .002). These results were improved in the subgroup of 176 patients with follow-up > 24 months (mean follow-up 46.6 months, 683 patient-years) for severe bleeding 2.6% (vs 6.3% expected by HAS-BLED, P < .033). The factors significantly associated with higher mortality were age (HR, 1.1), intracranial hemorrhage (HR, 6.8), and stroke during follow-up (HR, 2.7). CONCLUSIONS: Left atrial appendage closure significantly reduced the incidence of stroke and bleeding events and the benefit was maintained. Intracranial hemorrhage, age and stroke were associated with higher mortality.

Comparative analysis of fractional flow reserve and instantaneous wave-free ratio: Results of a five-year registry. / Análise comparativa do fractional flow reserve (FFR) e do instantaneous wave­free ratio (iFR): resultados de um registo de 5 anos.

INTRODUCTION AND OBJECTIVE: Assessment of coronary lesions by the instantaneous wave free ratio (iFR) has generated significant debate. We aimed to assess the diagnostic performance of iFR and its impact on the decision to use fractional flow reserve (FFR) and on procedural characteristics. METHODS: In this single-center registry of patients undergoing functional assessment of coronary lesions, FFR was used as a reference for assessing the diagnostic performance of iFR. An iFR value <0.86 was considered positive and a value >0.93 was considered negative. RESULTS: Functional testing was undertaken of 402 lesions, of which 154 were assessed with both techniques, 222 with FFR only, and 26 with iFR only. Using a cut-off of ≤0.80 for iFR, the area under the curve was 0.73 (95% CI 0.65-0.81), with an optimal value of ≤0.91. FFR was undertaken in 93 out of 94 lesions with an inconclusive iFR and was performed in 69.1% of the remaining iFR-tested lesions. Concordance between iFR and FFR was 87% (chi-square=22.43; p<0.001). Notwithstanding, there were four out of 13 cases (30.7%) of positive iFR with negative FFR and three out of 42 (7.1%) cases of negative iFR and positive FFR. This difference was significant (p=0.026). iFR had no impact on procedure time, fluoroscopy time or radiation dose. CONCLUSION: iFR had a reasonable diagnostic performance. Operators often chose to perform FFR despite conclusive iFR results. iFR and FFR were highly concordant, but a non-negligible proportion of lesions classified as ischemic by iFR were classified as non-ischemic by FFR. iFR had no impact on procedural characteristics.

Combined MitraClip implantation and left atrial appendage occlusion using the Watchman device: A case series from a referral center.

INTRODUCTION: Patients referred for percutaneous transcatheter mitral valve repair using the MitraClip® system frequently have atrial fibrillation, which imposes additional challenges due to the need for oral anticoagulation. Left atrial appendage occlusion is currently regarded as a non-inferior alternative to anticoagulation in patients with non-valvular atrial fibrillation and both high thromboembolic and bleeding risk. Considering that both MitraClip implantation and left atrial appendage occlusion are percutaneous techniques that require transseptal puncture, it is technically attractive to consider their concomitant use. OBJECTIVES: We aim to evaluate the feasibility of a combined approach with MitraClip implantation and left atrial appendage occlusion in a single procedure. METHODS: We report the first case series regarding this issue, discussing the specific advantages, pitfalls and technical aspects of combining these two procedures. RESULTS: Five patients underwent left atrial appendage occlusion with the Watchman® device followed by MitraClip implantation in the same procedure. All patients experienced significant reduction in mitral valve regurgitation of at least two grades, optimal occluder position, no associated complications and significant clinical improvement assessed by NYHA functional class (reduction of at least one functional class, with four patients in class I at one-month follow-up). CONCLUSION: In selected patients rejected for surgical mitral valve repair, with atrial fibrillation and increased risk of bleeding and embolic events, a combined approach with MitraClip implantation and left atrial appendage occlusion in a single procedure is feasible, safe and effective.

Portugal: coronary and structural heart interventions from 2010 to 2015.

The aim of the present paper is to report trends in Portuguese interventional cardiology from 2010 to 2015. We studied data from the prospective multicentre Portuguese National Registry of Interventional Cardiology (RNCI) to analyse percutaneous coronary intervention (PCI) procedures and structural heart interventions from 2010 to 2015. A total of 73,977 PCIs and 780 transcatheter aortic valve implants were performed during the study period. Since 2010 there has been a 60% increase in PCI procedures and a twofold increase in primary angioplasty rates reaching 316 per million population. Significant PCI trends were observed, notably the increase of radial access, a reduction in restenosis indications, as well as an increase in stent use, including DES, in imaging and in functional techniques. Importantly, there was a fourfold increase in the TAVI rates reaching 29 per million population.

Balloon aortic valvuloplasty in the transcatheter aortic valve implantation era: A single-center registry.

INTRODUCTION: Percutaneous balloon aortic valvuloplasty (BAV) has been limited by the risk of complications and restenosis. However, growing use of transcatheter aortic valve implantation (TAVI) has revived interest in this technique. We analyzed the current indications for BAV and outcomes in a single center. METHODS: Acute results and long-term outcomes were analyzed in a retrospective single-center registry of patients undergoing BAV between January 2013 and January 2016. RESULTS: Twenty-three patients underwent BAV, 56.5% male, mean age 78±7 years. Indications were severe aortic stenosis and decompensated heart failure (n=5), urgent non-cardiac surgery (n=8), or bridge to definitive treatment (n=10). Peak invasive gradient decreased from a median of 54.0±19.0 mmHg to 28.5±13.8 mmHg (p=0.002). Complications included one ischemic stroke, one lower limb ischemia and one femoral pseudoaneurysm requiring surgery. During a mean follow-up of 11±10 months, eight patients underwent TAVI and two underwent surgical aortic valve replacement. Thirteen patients died, nine of non-cardiovascular causes. On Kaplan-Meier analysis mortality was significantly lower among patients undergoing definitive treatment (20.0% vs. 84.6% at two-year follow-up; p=0.005). CONCLUSION: BAV should be considered for selected patients with temporary contraindications to definitive therapy or as palliative therapy.

Impact of Routine Fractional Flow Reserve Evaluation During Coronary Angiography on Management Strategy and Clinical Outcome: One-Year Results of the POST-IT.

BACKGROUND: Penetration of fractional flow reserve (FFR) in clinical practice varies extensively, and the applicability of results from randomized trials is understudied. We describe the extent to which the information gained from routine FFR affects patient management strategy and clinical outcome. METHODS AND RESULTS: Nonselected patients undergoing coronary angiography, in which at least 1 lesion was interrogated by FFR, were prospectively enrolled in a multicenter registry. FFR-driven change in management strategy (medical therapy, revascularization, or additional stress imaging) was assessed per-lesion and per-patient, and the agreement between final and initial strategies was recorded. Cardiovascular death, myocardial infarction, or unplanned revascularization (MACE) at 1 year was recorded. A total of 1293 lesions were evaluated in 918 patients (mean FFR, 0.81±0.1). Management plan changed in 406 patients (44.2%) and 584 lesions (45.2%). One-year MACE was 6.9%; patients in whom all lesions were deferred had a lower MACE rate (5.3%) than those with at least 1 lesion revascularized (7.3%) or left untreated despite FFR≤0.80 (13.6%; log-rank P=0.014). At the lesion level, deferral of those with an FFR≤0.80 was associated with a 3.1-fold increase in the hazard of cardiovascular death/myocardial infarction/target lesion revascularization (P=0.012). Independent predictors of target lesion revascularization in the deferred lesions were proximal location of the lesion, B2/C type and FFR. CONCLUSIONS: Routine FFR assessment of coronary lesions safely changes management strategy in almost half of the cases. Also, it accurately identifies patients and lesions with a low likelihood of events, in which revascularization can be safely deferred, as opposed to those at high risk when ischemic lesions are left untreated, thus confirming results from randomized trials. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01835808.