Self-expanding TAVI using the cusp overlap technique versus the traditional technique: electrocardiogram changes and 1-year cardiovascular outcomes.

INTRODUCTION AND OBJECTIVES: Transcatheter aortic valve implantation (TAVI) using the cusp overlap technique (COT) has shown a lower pacemaker implantation rate at 30 days. The objective of this study was to compare electrocardiogram changes and clinical outcomes between COT and the traditional technique (TT) at 1 year of follow-up. METHODS: Observational, retrospective, nonrandomized study of consecutive patients undergoing TAVI between January 2015 and January 2021. Patients were matched using a propensity score and the TT was compared with COT. The primary endpoints were electrocardiogram changes and a combined endpoint including pacemaker implantation, hospitalization, or cardiovascular death at 1 year. RESULTS: We included 254 patients. After propensity score matching, 184 patients (92 per group) remained. There were no statistically significant differences in baseline characteristics. At 1 year, COT patients showed a significant reduction in new onset left bundle branch block (49% vs 27%, P=.002) and less P wave (13.1±21.0 msec vs 5.47±12.5 msec; P=.003) and QRS prolongation (29.77±27.0 msec vs 16.38±25.4 msec, P <.001). COT was associated with a significant reduction in the occurrence of the primary endpoint (SHR, 0.39 [IC95%, 0.21-0.76]; P=.005). CONCLUSIONS: At 1 year of follow-up, COT reduced the incidence of new onset left bundle branch block and diminished QRS and P wave widening compared with the TT. COT was also associated with a statistically significant reduction in the occurrence of the combined primary cardiovascular endpoint.

Management and risk factors for mortality in very elderly patients with acute myocardial infarction.

AIM: Elderly patients often remain underrepresented in clinical trials. The aim of our study was to analyze the treatment, clinical outcome and risk factors for mortality in patients aged ≥85 years with ST-segment elevation myocardial infarction (STEMI). METHODS: From 2005-2011, 102 patients aged ≥85 years with STEMI admitted to a coronary care unit were retrospectively reviewed. Clinical data, treatment and outcome were recorded. Reperfusion strategy and its influence in hospital morbidity and mortality were evaluated. Morbidity was defined as the presence of heart failure (Killip-Kimball >1), arrhythmias, mechanical complications, stroke or major bleeding. Risk factors for mortality were assessed by multivariate analysis. RESULTS: The mean age was 87.5±2.5 years (range 85-96). Therapeutic strategy on admission was: primary-angioplasty (PCI) for 33 patients (32.3%) fibrinolysis for 30 patients (29.4%) and conservative treatment for 35 patients (34.3%). In the four remaining patients, rescue angioplasty was required. A total of 29 patients (28.4%) died, and morbidity was seen in 63 patients (61.7%). The morbidity and mortality rates in the conservative treatment group (77.1% and 48.5%) were higher than that found in the reperfusion strategy group (primary-PCI and fibrinolysis; 53.7% and 17.9%; P=0.02 and P=0.002, respectively). Regarding mortality, the univariate analysis showed that heart failure on admission (P=0.0001) and previous coronary artery disease (P=0.01) were prognostic variables. Only heart failure was an independent risk factor for mortality (odds ratio=3.64, 95% CI 0.78-21.87, P<0.0001). CONCLUSIONS: Mortality and morbidity in very elderly patients with STEMI are very high, especially in those not receiving reperfusion therapies. Heart failure on admission was an independent risk factor for hospital mortality.

[Isolated left ventricular non-compaction associated with Ebstein's anomaly. Multimodality non-invasive imaging for the assessment of congenital heart disease]. / Miocardiopatía no compactada asociada a anomalía de Ebstein. Importancia de la imagen cardiaca multimodal en las cardiopatías congénitas.

To establish the etiology of heart failure in patients with congenital heart disease can be challenging. Multiple concomitant anomalies that can be missed after an initial diagnosis could be seen in these patients. In patients with congenital heart disease, a more accurate evaluation of cardiac morphology and left ventricular systolic function could be evaluated by recent non-invasive cardiac imaging techniques. We present a rare case where multimodal cardiac imaging was useful to establish the final diagnosis of left ventricular non-compaction associated with Ebstein's anomaly.

Usefulness of Q-wave area for threshold-based stratification of global left ventricular myocardial infarct size.

Left ventricular (LV) infarct size affects prognosis after acute myocardial infarction (AMI). Delayed enhancement cardiac magnetic resonance (DE-CMR) provides accurate infarct quantification but is unavailable or contraindicated in many patients. This study tested whether simple electrocardiography (ECG) parameters can stratify LV infarct size. One hundred fifty-two patients with AMI underwent DE-CMR and serial 12-lead ECG. Electrocardiograms were quantitatively analyzed for multiple aspects of Q-wave morphology, including duration, amplitude, and geometric area (QWAr) summed across all leads except aVR. Patients with pathologic Q waves had larger infarcts measured by DE-CMR or enzymes (both p <0.001), even after controlling for infarct distribution by CMR or x-ray angiography. Comparison between early (4 ± 0.4 days after AMI) and follow-up (29 ± 6 days) ECG demonstrated temporal reductions in Q-wave amplitude (1.8 ± 1.4 vs 1.6 ± 1.6 mV; p = 0.03) but not QWAr (41 ± 38 vs 39 ± 43 mV•ms; p = 0.29). At both times, QWAr augmented stepwise with DE-CMR quantified infarct size (p <0.001). QWAr increased markedly at 10% LV infarct threshold, with differences more than threefold on early ECG (59 ± 39 vs 18 ± 20 mV•ms; p <0.001) and nearly fivefold (59 ± 46 vs 13 ± 16 mV•ms; p <0.001) on follow-up. Diagnostic performance compared with a 10% infarction cutoff was good on early (area under the curve = 0.84) and follow-up (area under the curve = 0.87) ECG. Optimization of sensitivity (95% to 98%) enabled QWAr to exclude affected patients with 90% to 94% negative predictive value at each time point. In conclusion, LV infarct size is accompanied by stepwise increments in Q-wave morphology, with QWAr increased three- to fivefold at a threshold of 10% LV infarction. Stratification based on QWAr provides excellent negative predictive value for exclusion of large (≥10%) LV infarct burden.

Primary cardiac tumors: 32 years of experience from a Spanish tertiary surgical center.

INTRODUCTION: Primary cardiac tumors are rare entities with an autopsy frequency ranging between 0.001% and 0.3%. Our objective was to review 32 years of experience from a Spanish tertiary surgical center. METHOD: We collected data on 73 patients with a histopathological diagnosis of a primary cardiac tumor in a retrospective analysis from 1979 to 2012. Tissue samples were obtained either at surgery or from necropsy and subsequently divided into benign and malignant groups. RESULTS: Benign neoplasms accounted for 84.9% of cases. The average age at diagnosis was 61 years, and tumors were twice as frequent among women. It was an incidental finding in one quarter of patients. In symptomatic patients, the typical presentation was of cardioembolic stroke or of congestive symptoms. Myxoma (93.5%) was the most common diagnosis, typically affecting the left atrium (74.2%). Surgical resection was curative for 95% of these patients. Malignant tumors represented 15.1% of cases with an average age at diagnosis of 50 years. Over 90% of these patients were symptomatic at presentation with the cardinal symptom being heart failure. Undifferentiated sarcoma was the most frequent malignant tumor (36.4%). Less than 20% of patients were alive 1 year after diagnosis despite the treatment. CONCLUSIONS: In our study, primary cardiac tumors were insidious. The most common was left atrial myxoma in which surgical resection was considered curative. Undifferentiated sarcoma was the most frequent malignant tumor. Malignant neoplasms carried a worse prognosis with unsuccessful total excision and the presence of metastatic disease being markers of an adverse outcome.

Atrioventricular conduction disturbance characterization in transcatheter aortic valve implantation with the CoreValve prosthesis.

BACKGROUND: Atrioventricular (AV) block is one of the most frequent complications of CoreValve transcatheter aortic valve implantation (TAVI). The aim of this study was to analyze the effects of CoreValve implantation on AV conduction. METHODS AND RESULTS: Electrophysiological study was performed immediately before and after CoreValve implantation in 18 consecutive, permanent pacemaker-free patients. An electrode was placed on the His bundle during valve implantation, and data were continuously recorded during the procedure. With surface ECG, a median (first, third quartile) QRS width of 96 (84, 116) to 150 (121, 164) ms (P=0.001) and PR interval of 180 (159, 216) to 210 (190, 240) ms (P=0.008) were significantly prolonged, and QRS axis was left deviated 30° (-32°, 46°) to -20° (-60°, 2°) (P=0.005). With intracardiac electrograms, the AH (97 [70, 123] to 115 [96, 135] ms, P=0.021) and HV (52 [42, 55] to 60 [50, 70] ms, P=0.002) intervals were increased. At the end of the procedure, we observed significant ECG- or electrophysiological study-persistent conduction disturbances in 14 (78%) patients. Five patients experienced transient changes (2 AV blocks and 3 left bundle branch blocks). CONCLUSIONS: CoreValve implantation worsens AV conduction in most patients, either transiently or permanently. This worsening is the result of direct damage either on the His bundle or on the AV node.