Left atrial wall thickness of the pulmonary vein reconnection sites during atrial fibrillation redo procedures.

BACKGROUND: Left atrial wall thickness (LAWT) has been related to pulmonary vein (PV) reconnections after atrial fibrillation (AF) ablation. The aim was to integrate 3D-LAWT maps in the navigation system and analyze the relationship with local reconnection sites during AF-redo procedures. METHODS: Consecutive patients referred for AF-redo ablation were included. Procedure was performed using a single catheter technique. LAWT maps obtained from multidetector computerized tomography (MDCT) were imported into the navigation system. LAWT of the circumferential PV line, the reconnected segment and the reconnected point, were analyzed. RESULTS: Sixty patients [44 (73%) male, age 61 ± 10 years] were included. All reconnected veins were isolated using a single catheter technique with 55 min (IQR 47-67) procedure time and 75 s (IQR 50-120) fluoroscopy time. Mean LAWT of the circumferential PV line was 1.46 ± 0.22 mm. The reconnected segment was thicker than the rest of segments of the circumferential PV line (2.05 + 0.86 vs. 1.47 + 0.76, p < .001 for the LPVs; 1.55 + 0.57 vs. 1.27 + 0.57, p < .001 for the RPVs). Mean reconnection point wall thickness (WT) was at the 82nd percentile of the circumferential line in the LPVs and at the 82nd percentile in the RPVs. CONCLUSION: A single catheter technique is feasible and efficient for AF-redo procedures. Integrating the 3D-LAWT map into the navigation system allows a direct periprocedural estimation of the WT at any point of the LA. Reconnection points were more frequently present in thicker segments of the PV line. The use of 3D-LAWT maps can facilitate reconnection point identification during AF-redo ablation.

Survival benefit of revascularization versus optimal medical therapy alone for chronic total occlusion management in patients with diabetes.

BACKGROUND: Chronic total occlusion (CTO) is common in patients with diabetes mellitus. Data on the long-term outcomes after treatment of CTOs in this high-risk population are scarce. AIM: To compare the long-term clinical outcomes of CTO revascularization either by coronary artery bypass graft (CABG) or successful percutaneous coronary intervention (PCI) versus optimal medical treatment (MT) alone in patients with diabetes. METHODS AND RESULTS: A total of 538 consecutive patients with diabetes and at least one CTO were identified from 2010 to 2014 in our center. In the present analysis, patients were stratified according to the CTO treatment strategy that was selected. MT was selected in 61% of patients whereas revascularization in the remaining 39%. Patients undergoing revascularization were younger, had higher left ventricular ejection fraction (LVEF), lower ACEF score, and more positive myocardial ischemia detection results compared to the MT group (p < .001).Patients referred for CABG had higher rates of left main disease compared to the PCI and MT groups (32% vs. 3% and 11%, respectively; p < .001). Complete revascularization was more often achieved in the CABG group, compared to the PCI group (62% vs. 32% p < .001). Multivariable analysis showed that revascularization with CABG was associated with lower rates of all-cause and cardiac mortality rates compared to MT, [hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.25-0.70, p < .001 and HR 0.40, 95% CI 0.20-81, p = .011, respectively]. Successful CTO-PCI showed a trend towards benefit in all-cause mortality (HR 0.58, 95% CI 0.33-1.04, p = .06). CONCLUSION: In our registry, CTO revascularization in diabetic patients, especially with CABG, was associated with lower long-term mortality rates as compared to MT alone.

Tocilizumab plus glucocorticoids in severe and critically COVID-19 patients. A single center experience / Tocilizumab más glucocorticoides para tratar pacientes graves y en situación crítica infectados por COVID-19. Experiencia de un centro

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Renin-Angiotensin System Inhibition Following Transcatheter Aortic Valve Replacement.

BACKGROUND: Several studies have demonstrated the benefits of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis, but the presence of persistent fibrosis and myocardial hypertrophy has been related to worse prognosis. OBJECTIVES: The aim of this study was to explore the potential benefits of renin-angiotensin system (RAS) inhibitors on left ventricular remodeling and major clinical outcomes following successful transcatheter aortic valve replacement (TAVR). METHODS: Patients from 10 institutions with severe aortic stenosis who underwent TAVR between August 2007 and August 2017 were included. All baseline data were prospectively recorded, and pre-specified follow-up was performed. Doses and types of RAS inhibitors at discharge were recorded, and matched comparison according to their prescription at discharge was performed. RESULTS: A total of 2,785 patients were included. Patients treated with RAS inhibitors (n = 1,622) presented similar surgical risk scores but a higher rate of all cardiovascular risk factors, coronary disease, and myocardial infarction. After adjustment for these baseline differences, reduction of left ventricular volumes and hypertrophy was greater and cardiovascular mortality at 3-year follow-up was lower (odds ratio: 0.59; 95% confidence interval: 0.41 to 0.87; p = 0.007) in patients treated with RAS inhibitors. Moreover, RAS inhibitors demonstrated a global cardiovascular protective effect with significantly lower rates of new-onset atrial fibrillation, cerebrovascular events, and readmissions. CONCLUSIONS: Post-TAVR RAS inhibitors are associated with lower cardiac mortality at 3-year follow-up and offer a global cardiovascular protective effect that might be partially explained by a positive left ventricular remodeling. An ongoing randomized trial will help confirm these hypothesis-generating findings. (Renin-Angiotensin System Blockade Benefits in Clinical Evolution and Ventricular Remodeling After Transcatheter Aortic Valve Implantation [RASTAVI]; NCT03201185).

Ecocardiografía transesófagica mínimamente invasiva con microsonda de última generación para el cierre percutáneo de la orejuela izquierda. Experiencia inicia / Minimally-invasive transesophageal echocardiography for left atrial appendage occlusion with a latest-generation microprobe. Initial experience

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Eventos trombóticos y hemorrágicos después de una intervención coronaria percutánea tras parada cardiaca extrahospitalaria con y sin hipotermia terapéutica / Thrombotic and bleeding events after percutaneous coronary intervention in out-of-hospital cardiac arrest with and without therapeutic hypothermia

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Impact of revascularization versus medical therapy alone for chronic total occlusion management in older patients.

BACKGROUND: Chronic total occlusions (CTOs) are present in more than one third of older patients with myocardial ischemia, but controversy remains about the best therapeutic approach. AIMS: To compare long-term survival after CTO revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG]) versus medical treatment (MT) alone in patients aged 75 and older. METHODS AND RESULTS: A total of 1,252 consecutive patients with at least one CTO were identified from 2010 to 2014 in our center. Patients were stratified by age (<75 years vs. ≥75 years) in the present analysis. All-cause and cardiac mortality were assessed at a median follow-up of 3.5 years. In the older subgroup (26%), patients were more likely to be treated with MT alone (71% vs. 43% of younger patients; p < 0.001). Patients undergoing revascularization were younger and had higher left ventricular ejection fraction (LVEF) and lower age, creatinine, ejection fraction (ACEF) score (age/LVEF +1 if creatinine >2.0 mg/dL), compared to the MT group (p < 0.05). As compared to MT, revascularization predicted lower rates of cardiac mortality and all-cause mortality in older patients, both in the subgroups treated with CABG (hazard ratio [HR] 0.35, 95% confidence interval [CI] 0.17-0.71; HR 0.39, 95%CI 0.18-0.81) and PCI (HR 0.57, 95%CI 0.33-0.98; HR 0.59, 95%CI 0.28-1.2). No differences in mortality were observed according to type of revascularization procedure. CONCLUSIONS: Among patients aged at least 75 years with a CTO, revascularization (PCI or CABG) rather than MT alone may portend a better outcome in terms of all-cause and cardiac mortality.

Análisis morfológico y funcional de la arteria descendente anterior de pacientes con síndrome de tako-tsubo / Functional and morphological assessment of left anterior descending artery in patients with tako-tsubo syndrome

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Percutaneous coronary intervention due to chronic total occlusion in the left main coronary artery after bypass grafting: A feasible option in selected cases.

INTRODUCTION: Chronic total occlusion (CTO) of the left main coronary artery (LMCA) is an infrequent finding. Revascularization is recommended in the presence of demonstrated viability or ischemia. Coronary artery bypass grafting (CABG) has long been considered the preferred option. Patients with previous CABG due to LMCA disease with occlusion of one graft and progression of the LMCA to CTO constitute a special population, as just one ischemic artery remains. For these patients, there is no other option for revascularization other than cardiac surgery (requiring resternotomy) or percutaneous coronary intervention (PCI) of the LMCA. METHODS AND RESULTS: Out of 620 patients with CTO diagnosed in our center, we identified five with previous CABG due to LMCA disease for a retrospective case series. They had occlusion of one graft and progression of the LMCA to CTO. All five underwent PCI. Each patient received a functional classification for angina, myocardial ischemic tests, and a follow-up coronary angiogram during a median follow-up of 63 months. Coronary angiogram showed CTO of the semi-protected LMCA lesions with two CABGs previously performed in all patients, one occluded and the other patent. Three patients had occluded saphenous vein grafts to the circumflex coronary artery, and the rest had left internal mammary artery-left anterior descending artery CABG failure. Ischemia and viability were demonstrated. Surgery was ruled out due to high surgical risk. PCI due to CTO of the LMCA with drug-eluting stents was performed. In a five-year follow-up period, four patients remained asymptomatic and event free. One post-PCI death occurred from non-cardiovascular cause. CONCLUSIONS: PCI due to CTO of the LMCA following CABG can be successful and safe and can provide sustained clinical improvements in selected cases.

Knowledge of the Guarani language in medical students at a university hospital in Paraguay. / Grado de conocimiento del idioma guaraní en estudiantes de medicina en un hospital universitario de Paraguay.

INTRODUCTION: Paraguay is a bilingual country and knowledge of the guarani language is an important communication tool for the doctor- patient relationship. OBJECTIVE: To determine the degree of and the factors that influence the knowledge of the Guaraní language in medical students at a University Hospital in Paraguay. METHODS: Observational, cross-sectional, analytical study in which an anonymous questionnaire was applied to the final year medical students of a University Hospital of Paraguay. The baseline characteristics of the medical students and their degree of knowledge of the Guarani language were described. The association between the characteristics of the students and the degree of knowledge of the Guarani language was evaluated with the Chi square association test and the logistic regression model. RESULTS: We included 264 students in the survey. Eighty two percent come from the capital, 72% made their pre-university studies in the capital; 92% studied Guaraní in primary and secondary education; 67.9% do not interpret Guarani correctly; 8.5% understand and express themselves totally in Guaraní. Of these, 86% refer to have the greater learning of the language in their home; 75.2% of respondents believe that primary and secondary education did not help in learning the language. The degree of knowledge of the language (speaks and understands the Guarani language correctly) varies according to: the origin of the student, the inland regions or the capital (31.25% vs. 2.5%, adjusted OR = 0.24, 95% confidence interval: 0.06 to 0.92, p = 0.003); the location of primary and secondary school: inland versus capital (25.6% vs. 1%, adjusted OR: 0.08, 95% confidence interval: 0.01 to 0.53, p = 0.009). CONCLUSIONS: The degree of knowledge of the Guaraní language of the students is lower compared to the general population; those who best understand and express themselves were born or studied in the interior of the country. The majority considers that primary and secondary education contribute little in the learning of Guaraní. Since language is an important communication tool in the patient-doctor relationship and knowing that Guarani is the most spoken language in the country, strategies for its learning should be implemented.

INTRODUCCIÓN: Paraguay es un país bilingüe, y el conocimiento del idioma guaraní constituye una herramienta importante de comunicación en la relación médico-paciente. OBJETIVO: Dar cuenta del grado y los factores que determinan el conocimiento del idioma guaraní, en estudiantes de medicina de último año en un hospital universitario de Paraguay. MÉTODOS: Estudio observacional, transversal y analítico. En él se aplicó una encuesta anónima con cuestionario a los alumnos de último año de medicina de un hospital universitario de Paraguay. Se realizó un estudio descriptivo de las características basales de los estudiantes de medicina y de su grado de conocimiento del idioma guaraní. Se efectuó la prueba de Chi-cuadrado para comparar variables categóricas, y se aplicó un estudio de regresión logística para determinar factores que determinan el grado de conocimiento del idioma. RESULTADOS: Fueron encuestados 264 estudiantes. El 82% provenía de la capital, 72% realizó sus estudios preuniversitarios en Asunción. El 92% estudió guaraní en la educación primaria y secundaria; 67,9% no lo interpreta correctamente. El 8,5% entienden y se expresan totalmente en guaraní; de ellos el 86% refirió que su mayor aprendizaje del idioma fue en el hogar familiar. El 75,2% de los encuestados consideró que la educación primaria y secundaria no ayudó en el aprendizaje. El grado de conocimiento del idioma (habla y entiende el idioma guaraní correctamente), varía si el estudiante proviene del interior o de la capital (31,25% versus 2,5%; OR ajustado: 0,24, intervalo de confianza 95% de 0,06 a 0,92; p=0,003); y según la localidad de la escuela primaria y secundaria: interior versus capital (25,6 y 1% respectivamente; OR ajustado: 0,08; intervalo de confianza 95% de 0,01 a 0,53; p=0,009). CONCLUSIONES: El grado de conocimiento de los estudiantes del guaraní es menor, comparado con población general. Los que mejor se expresan y comprenden el idioma, nacieron o lo estudiaron en el interior del país. La mayoría considera de poco aporte la educación primaria y secundaria para el aprendizaje del guaraní. Siendo el idioma una herramienta importante de comunicación en la relación médico–paciente, y sabiendo que el guaraní es el idioma más hablado del país; se deberían implementar estrategias para su aprendizaje.

Impact of Timing on the Functional Recovery Achieved With Platelet Supplementation After Treatment With Ticagrelor.

BACKGROUND: American College of Cardiology/American Heart Association guidelines advise waiting 5 to 7 days before operating on P2Y12 inhibitor-treated acute coronary syndrome patients, to allow dissipation of its antiplatelet effects. Platelet transfusion is often used to restore hemostasis during operations, but its effectiveness and optimal timing are unclear. We investigated the degree of functional gains obtained from platelet supplementation after loading and maintenance of dual antiplatelet therapy with ticagrelor and the influence of timing on this strategy. METHODS AND RESULTS: After baseline platelet testing (Multiplate Analyzer and VerifyNow), cardiovascular disease patients (n=20; 56.9±7.9 years; 65% men; 75% diabetic) received dual antiplatelet therapy as a single loading dose (ticagrelor 180 mg plus aspirin 325 mg) and as daily/maintenance treatment for 5 to 7 days (maintenance therapy: ticagrelor 90 mg BID plus aspirin 81 mg QD). At 4, 6, 24, and 48 hours from (last) dosing, patients' blood samples were supplemented with concentrated platelets from healthy donors in vitro, raising platelet counts by 0% (unsupplemented control), 25%, 50%, and 75%, and the function retested. Reactivity in supplemented samples was compared with respective 0% sample and with the pretreatment baseline. Results under loading dose and maintenance therapy regimens were nearly identical. Platelet reactivity was higher (P<0.05) in nearly all supplemented samples versus respective controls. Aggregations with supplementation were 59% to 79% of baseline at 24 hours and equal to baseline at 48 hours. CONCLUSIONS: Platelet reactivity of ticagrelor-treated patients can be restored using concentrated platelets after a loading dose/maintenance therapy in a time-dependent manner under in vitro testing. Although statistically significant improvements are evident 6 hours after (last) dosing, ≥24 hours maybe needed for clinically meaningful restoration in platelet function. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier: NCT02201394.

Parada cardiaca debido a hemorragia subaracnoidea simulando un síndrome coronario agudo / Cardiac arrest due to a subarachnoid hemorrhage simulating an acute coronary síndrome

Sr. Editor: El síndrome coronario agudo es la principal causa de parada cardiaca extrahospitalaria en países occidentales1. Las guías europeas de reanimación cardiopulmonar recomiendan una coronariografía urgente con miras a realizar una intervención coronaria percutánea primaria en los supervivientes de una parada cardiaca extrahospitalaria2),(3. Las causas extracardiacas de parada cardiaca extrahospitalaria como la hemorragia subaracnoidea son menos comunes y de mal pronóstico. Se presentan dos casos de parada cardiaca extrahospitalaria por hemorragia subaracnoidea que simularon un síndrome coronario agudo, el cual requirió coronariografía urgente.

Síndrome coronario agudo en paciente con dextrocardia y situs inversus / Acute coronary syndrome in dextrocardia and situs inversus patient

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