Instantaneous wave-free ratio for guiding treatment of nonculprit lesions in patients with acute coronary syndrome: A retrospective study.

BACKGROUND: The aim of this study was to analyze the feasibility of a physiological coronary evaluation with the instantaneous wave-free ratio (iFR) of nonculprit lesions in patients with acute coronary syndrome (ACS) successfully revascularized. METHODS: A multicenter registry including patients of four high-volume PCI centers with ACS and underwent successful revascularization of the culprit vessel and had other nonculprit lesions that were physiologically evaluated with the iFR between January 2017 and December 2019. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction, probable or definitive stent thrombosis and new revascularization (MACEs). RESULTS: A total of 356 patients with 472 nonculprit lesions were included. The mean age was 66 ± 11 years. The clinical presentation was ACS without persistent ST-segment elevation (NSTE-ACS) in 235 patients (66%) and ST-segment elevation myocardial infarction (STEMI) in 121 patients (34%). After a median follow-up period of 21 (14-30) months, the primary endpoint occurred in 32 patients (9%). There were no differences in outcomes regarding clinical presentation (NSTEMI vs. NSTE-ACS, 9.1 vs. 8.9%, padj  = 0.570) or iFR induced treatment strategy (patients with all lesions revascularized vs. patients with at least one lesion with an iFR > 0.89 deferred for revascularization, 10.5 vs. 8.4%, padj  = 0.476). CONCLUSIONS: The use of the iFR to guide percutaneous coronary intervention decision making in nonculprit lesions seems to be feasible, with an acceptable percentage of MACEs at the mid-term follow-up. Patients with deferred revascularization of lesions without physiological significance and patients undergoing complete revascularization had a similar risk of MACEs.

Prosthesis-patient mismatch after transcatheter aortic valve replacement: prevalence and medium term prognostic impact.

Prosthesis-patient mismatch (PPM) occurs when the effective orifice area of the prosthesis is too small in relation to the patient's body surface area. There are few data available on the frequency and prognostic impact of PPM after transcatheter aortic valve implantation (TAVI). Our aim was to determine the prevalence of PPM and to investigate its association with medium-term clinical course of patients undergoing TAVI. We included 185 patients undergoing TAVI (79 ± 5 years, 49% male, 98% CoreValve) between April-2008 and December-2014. The effective orifice area (EOA) was determined by transthoracic echocardiography prior and after the procedure. We defined PPM as indexed EOA ≤ 0.85 cm2/m2 (severe PPM if ≤ 0.65 cm2/m2). All cause death, stroke and hospitalization for heart failure were considered as major clinical events. 45 patients (24%) showed PPM (severe 11 patients, 6%). PPM was associated with a higher EuroSCORE (OR 1.06, IC 95% 1.01-1.12, p = 0.03), body surface area ≥ 1.72 m2 (OR 3.58, IC 95% 1.30-9.87, p = 0.01) and small aortic annulus (OR 0.73, IC 95% 0.55-0.92, p = 0.03); and severe PPM with small prostheses size (OR 17.79, IC 95% 1.87-169.78, p = 0.012). The mean event-free survival was 34 ± 26 months. Patients with severe PPM showed lower rates of event free survival than the rest of the series (52% vs. 84%, p = 0.04) at 34 months follow up. In our series, PPM was present in a quarter of the patients after TAVI. Higher EuroSCORE, smaller prosthesis size, larger body surface area and smaller aortic annulus diameter were associated with PPM. Severe PPM was an independent factor associated with major events at medium-term follow up.

Cierre percutáneo de seudoaneurisma tras cirugía de Rastelli / Percutaneous closure of pseudoaneurysm after Rastelli surgery

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Reserva coronaria y función ventricular izquierda tras la terapia regenerativa en pacientes con infarto anterior agudo revascularizado / Coronary flow reserve and ventricular function following regenerative treatment in patients with revascularized acute anterior myocardial infarction

Introducción y objetivos: Las células madre de médula ósea pueden regenerar el miocardio infartado por distintos mecanismos. La relación entre la recuperación de la función muscular y microvascular después del tratamiento regenerativo ha sido poco estudiada. El objetivo es analizar la relación entre los cambios en función ventricular y función microvascular en pacientes con infarto agudo que reciben la terapia. Métodos: Se analizó a 88 pacientes con infarto anterior revascularizado incluidos en 2 ensayos clínicos y 1 estudio piloto que evaluaban la eficacia de la terapia celular. El estudio de la reserva coronaria y la función ventricular se analizaron con la misma metodología en todos ellos. Se administraron células mononucleares derivadas de médula ósea autóloga (n = 40), factor estimulante de colonias granulocíticas (n = 14) o la combinación de ambos (n = 10). Hubo un grupo control (n = 24) que solo recibió revascularización convencional. Resultados: La media de fracción de eyección se incrementó del 37 ± 8% al 46 ± 12% (p < 0,05). La media de incremento de la reserva de flujo coronario fue de 1,6 ± 0,5 a 2,3 ± 0,9 (p < 0,05). No hubo correlación entre los parámetros de función muscular y los parámetros de función microvascular al seguimiento. Conclusiones: Hay cambios favorables en el miocardio tras el tratamiento con terapia regenerativa después de un infarto, aunque no se ha encontrado correlación entre los cambios de función muscular y microvascular

Introduction and objectives: Bone marrow stem cells may reconstruct infarcted myocardium through distinct mechanisms. However, little is known on the relationship between recovery of muscular and microvascular function after regenerative treatments. Our objective was to analyze the relationship between changes in left ventricular and microvascular function in patients with anterior acute myocardial infarction receiving regenerative treatment. Methods: We performed a pooled analysis of 2 clinical trials and a pilot study evaluating stem cell therapy in 88 patients with revascularized acute anterior myocardial infarction. Coronary flow reserve and left ventricular function were analyzed with identical methods in all patients. Patients treated with regenerative treatment received intracoronary bone¿marrow-derived mononuclear cell transplant (n = 40), subcutaneous administration of granulocyte colony-stimulating factor (n = 14), or a combination of both (n = 10). A control group of 24 patients was treated with conventional revascularization. Results: Mean ejection fraction increased from 37% 8% to 46% ± 12%, (P < .05). Mean coronary flow reserve increased from 1.6 0.5 to 2.3 0.9 (P < .05). However, there was no correlation between parameters of left ventricular function and microvascular parameters at follow-up. Conclusions: Left ventricular function shows favorable changes after regenerative treatment of infarction. However, no correlation was found between changes in microvascular and myocardial function after regenerative therapy

One Versus 2-stent Strategy for the Treatment of Bifurcation Lesions in the Context of a Coronary Chronic Total Occlusion. A Multicenter Registry.

INTRODUCTION AND OBJECTIVES: There is little evidence on the optimal strategy for bifurcation lesions in the context of a coronary chronic total occlusion (CTO). This study compared the procedural and mid-term outcomes of patients with bifurcation lesions in CTO treated with provisional stenting vs 2-stent techniques in a multicenter registry. METHODS: Between January 2012 and June 2016, 922 CTO were recanalized at the 4 participating centers. Of these, 238 (25.8%) with a bifurcation lesion (side branch ≥ 2mm located proximally, distally, or within the occluded segment) were treated by a simple approach (n=201) or complex strategy (n=37). Propensity score matching was performed to account for selection bias between the 2 groups. Major adverse cardiac events (MACE) consisted of a composite of cardiac death, myocardial infarction, and clinically-driven target lesion revascularization. RESULTS: Angiographic and procedural success were similar in the simple and complex groups (94.5% vs 97.3%; P=.48 and 85.6% vs 81.1%; P=.49). However, contrast volume, radiation dose, and fluoroscopy time were lower with the simple approach. At follow-up (25 months), the MACE rate was 8% in the simple and 10.8% in the complex group (P=.58). There was a trend toward a lower MACE-free survival in the complex group (80.1% vs 69.8%; P=.08). After propensity analysis, there were no differences between the groups regarding immediate and follow-up results. CONCLUSIONS: Bifurcation lesions in CTO can be approached similarly to regular bifurcation lesions, for which provisional stenting is considered the technique of choice. After propensity score matching, there were no differences in procedural or mid-term clinical outcomes between the simple and complex strategies.

Effect of New-Onset Left Bundle Branch Block After Transcatheter Aortic Valve Implantation (CoreValve) on Mortality, Frequency of Re-Hospitalization, and Need for Pacemaker.

New-onset conduction disturbances are common after transcatheter aortic valve implantation (TAVI). The most common complication is left bundle branch block (LBBB). The clinical impact of new-onset LBBB after TAVI remains controversial. The aim of this study was to analyze the clinical impact of new-onset LBBB in terms of mortality and morbidity (need for pacemakers and admissions for heart failure) at long-term follow-up. From April 2008 to December 2014, 220 patients who had severe aortic stenosis were treated with the implantation of a CoreValve prosthesis. Sixty-seven of these patients were excluded from the analysis, including 22 patients with pre-existing LBBB and 45 with a permanent pacemaker, implanted previously or within 72 hours of implantation. The remaining 153 patients were divided into 2 groups: group 1 (n = 80), those with persistent new-onset LBBB, and group 2 (n = 73), those without conduction disturbances after treatment. Both groups were followed up at 1 month, 6 months, 12 months, and yearly thereafter. Persistent new-onset LBBB occurred in 80 patients (36%) immediately after TAVI; 73 patients (33%) did not develop conduction disturbances. The mean follow-up time of both groups was 32 ± 22 months (range 3 to 82 months), and there were no differences in time between the groups. There were no differences in mortality between the groups (39% vs 48%, p = 0.58). No differences were observed between the groups in re-hospitalizations for heart failure (11% vs 16%, p = 0.55). Group 1 did not require pacemaker implantation more often at follow-up (10% vs 13%, p = 0.38) than group 2. In conclusion, new-onset LBBB was not associated with a higher incidence of late need for a permanent pacemaker after CoreValve implantation. In addition, it was not associated with a higher risk of late mortality or re-hospitalization.

Modificación de la conducción auriculoventricular tras el implante de prótesis aórtica Core Valve / Atrioventricular conduction changes after corevalve transcatheter aortic valve implantation

Introducción y objetivos: Con frecuencia se producen alteraciones en la conducción tras el implante de una prótesis CoreValve. Se pretende analizar qué cambios se producen en la conducción cardiaca de pacientes con estenosis aórtica tratados con este tipo de prótesis. Métodos: Desde abril de 2008 hasta diciembre de 2013, se seleccionó a 181 pacientes con estenosis aórtica grave tratados con esta prótesis y estudiados mediante electrocardiograma. Se estudió a un subgrupo de 137 pacientes consecutivos (75,7%) mediante electrocardiogramas intracavitarios antes y tras implante protésico. El objetivo principal del estudio es la necesidad de marcapasos definitivo en las primeras 72 h tras el implante protésico. Se analizaron numerosas variables para predecir esta eventualidad. Resultados: Tras el implante, los intervalos PR y QRS se incrementaron de 173 ± 47 a 190 ± 52 ms (p < 0,01) y de 98 ± 22 a 129 ± 24 ms (p < 0,01), mientras que los intervalos AH y HV se alargaron de 95 ± 39 a 108 ± 41 ms (p < 0,01) y de 54 ± 10 a 66 ± 23 ms (p < 0,01). En total, 89 pacientes (49%) presentaron bloqueo de rama izquierda de novo y 33 (25%) precisaron marcapasos en las primeras 72 h. Los predictores independientes de marcapasos fueron el bloqueo de rama derecha basal y la profundidad protésica. Los intervalos intracavitarios carecieron de valor predictivo. Además, 13 pacientes requirieron marcapasos después de las 72 h. Conclusiones: El implante de prótesis CoreValve produce alta incidencia de alteraciones de la conducción; la más frecuente es el bloqueo de rama izquierda; el 25% de los pacientes precisaron marcapasos definitivo. La necesidad de marcapasos se relacionó con el bloqueo de rama derecha basal y la profundidad protésica (AU)

Introduction and objectives: Conduction disturbances often occur after CoreValve transcatheter aortic valve implantation. The aim was to analyze which cardiac conduction changes occur in patients with aortic stenosis treated with this type of prosthesis. Methods: A total of 181 patients with severe aortic stenosis treated with this prosthesis and studied by electrocardiography between April 2008 and December 2013 were selected. A subgroup of 137 (75.7%) consecutive patients was studied by intracardiac electrocardiogram before and after prosthesis implantation. The primary endpoint of the study was the need for a permanent pacemaker within 72 hours after prosthesis implantation. Numerous variables to predict this possibility were analyzed. Results: Following implantation, PR and QRS intervals were increased from 173 ± 47 ms to 190 ± 52 ms (P < .01) and from 98 ± 22 ms to 129 ± 24 ms (P < .01), whereas the A-H and H-V intervals were prolonged from 95 ± 39 ms to 108 ± 41 ms (P < .01) and from 54 ± 10 ms to 66 ± 23 ms (P < .01). A total of 89 (49%) patients had new-onset left bundle-branch block, and 33 (25%) required a pacemaker within the first 72 hours. The independent predictors for a pacemaker were baseline right bundle-branch block and prosthetic depth. Intracardiac intervals had no predictive value. In addition, 13 patients required a pacemaker after 72 hours. Conclusions: CoreValve prosthesis implantation has a high incidence of conduction disturbance, with left bundle-branch block being the most common. A total of 25% of patients required a permanent pacemaker. The need for a pacemaker was related to baseline right bundle-branch block and prosthetic depth (AU)

Atrioventricular Conduction Changes After CoreValve Transcatheter Aortic Valve Implantation.

INTRODUCTION AND OBJECTIVES: Conduction disturbances often occur after CoreValve transcatheter aortic valve implantation. The aim was to analyze which cardiac conduction changes occur in patients with aortic stenosis treated with this type of prosthesis. METHODS: A total of 181 patients with severe aortic stenosis treated with this prosthesis and studied by electrocardiography between April 2008 and December 2013 were selected. A subgroup of 137 (75.7%) consecutive patients was studied by intracardiac electrocardiogram before and after prosthesis implantation. The primary endpoint of the study was the need for a permanent pacemaker within 72 hours after prosthesis implantation. Numerous variables to predict this possibility were analyzed. RESULTS: Following implantation, PR and QRS intervals were increased from 173±47 ms to 190±52ms (P < .01) and from 98±22ms to 129±24 ms (P < .01), whereas the A-H and H-V intervals were prolonged from 95±39ms to 108±41ms (P < .01) and from 54±10ms to 66±23ms (P < .01). A total of 89 (49%) patients had new-onset left bundle-branch block, and 33 (25%) required a pacemaker within the first 72hours. The independent predictors for a pacemaker were baseline right bundle-branch block and prosthetic depth. Intracardiac intervals had no predictive value. In addition, 13 patients required a pacemaker after 72 hours. CONCLUSIONS: CoreValve prosthesis implantation has a high incidence of conduction disturbance, with left bundle-branch block being the most common. A total of 25% of patients required a permanent pacemaker. The need for a pacemaker was related to baseline right bundle-branch block and prosthetic depth.

Optical coherence tomography evaluation of late strut coverage patterns between first-generation drug-eluting stents and everolimus-eluting stent.

OBJECTIVES: To compare strut coverage patterns between everolimus-eluting stent (EES) and first-generation drug-eluting stents (DES) at more than 12 months after successful implantation, using optical coherence tomography (OCT). BACKGROUND: No sufficient OCT data has been reported comparing late strut coverage patterns between EES and first-generation DES. The favorable late results after EES implantation could be related to lower rates of uncovered and malapposed struts. METHODS: A total of 66 DES (21 EES, 23 SES, and 22 PES) that were implanted at least 1 year in advance in 40 patients and met good late angiographic results were evaluated by OCT. The percentage of uncovered and malapposed struts, calculated as the ratio of uncovered or malapposed struts to total struts in all cross-sectional images per stent, was compared among the three groups. RESULTS: A total of 35,061 struts were analyzed: 11,967 from EES, 11,855 from SES, and 11m239 from PES. The average tissue coverage thickness of the struts per stent was greater in EES than in SES and PES (109 ± 40 µm vs. 72 ± 27 µm and 83 ± 26 µm, respectively; P = 0.001). The percentage of uncovered struts (1.9 ± 4.1% in EES vs. 11.6 ± 12.7% in SES, P = 0.01 and vs. 7.1 ± 5.2% in PES, P < 0.001) and malapposed struts (0.1 ± 0.3% in EES vs. 1.8 ± 3.5% in SES, P = 0.01 and vs. 3.5 ± 5.1% in PES, P = 0.02) was much lower in EES than in first-generation DES, with no significant differences between SES and PES. CONCLUSIONS: Late strut coverage patterns are not similar between EES and first-generation DES. EES showed a lower percentage of uncovered and malapposed struts.