Atrial secondary tricuspid regurgitation: pathophysiology, definition, diagnosis, and treatment.

Atrial secondary tricuspid regurgitation (A-STR) is a distinct phenotype of secondary tricuspid regurgitation with predominant dilation of the right atrium and normal right and left ventricular function. Atrial secondary tricuspid regurgitation occurs most commonly in elderly women with atrial fibrillation and in heart failure with preserved ejection fraction in sinus rhythm. In A-STR, the main mechanism of leaflet malcoaptation is related to the presence of a significant dilation of the tricuspid annulus secondary to right atrial enlargement. In addition, there is an insufficient adaptive growth of tricuspid valve leaflets that become unable to cover the enlarged annular area. As opposed to the ventricular phenotype, in A-STR, the tricuspid valve leaflet tethering is typically trivial. The A-STR phenotype accounts for 10%-15% of clinically relevant tricuspid regurgitation and has better outcomes compared with the more prevalent ventricular phenotype. Recent data suggest that patients with A-STR may benefit from more aggressive rhythm control and timely valve interventions. However, little is mentioned in current guidelines on how to identify, evaluate, and manage these patients due to the lack of consistent evidence and variable definitions of this entity in recent investigations. This interdisciplinary expert opinion document focusing on A-STR is intended to help physicians understand this complex and rapidly evolving topic by reviewing its distinct pathophysiology, diagnosis, and multi-modality imaging characteristics. It first defines A-STR by proposing specific quantitative criteria for defining the atrial phenotype and for discriminating it from the ventricular phenotype, in order to facilitate standardization and consistency in research.

Characterization of the impact of catheter-tissue contact force in lesion formation during cavo-tricuspid isthmus ablation in an experimental swine model.

AIMS: Catheter-tissue contact is critical for effective lesion creation. The objective of this study was to determine in an experimental swine model the pathological effects of cavo-tricuspid isthmus ablation using two systems that provide reliable measures of the pressure at the catheter tip during radiofrequency ablation procedures. METHODS AND RESULTS: We performed the procedure in eight pigs in our experimental electrophysiology laboratory after right femoral vein dissection and insertion of a 12 Fr. introducer during general anaesthesia and endotracheal intubation. The target contact force during the applications was <10 grs. (axial or lateral), 10-20, 20-30, and >30 grs. in two pigs each. The power was set at 40 W and maximum target temperature at 45°C. We performed a radiofrequency line dragging from the tricuspid valve to the inferior vena cava in the eight pigs. Euthanasia of the animals was carried out a week after the procedure and a pathological examination of the lesions was performed. In the endocardial macroscopic analysis the extent of lesions, presence of thrombus, transmurality, and endothelial rupture was assessed. External surface was examined searching for transmural lesions. The mean contact force applied was 18.7 ± 8.4 grs. and the mean depth of the lesions was 3.6 ± 2 mm. Lesions were never transmural with average forces <10 grs., and the mean depth was very low (0.75 mm). To achieve transmural lesions contact forces of at least 20 grs. were required. We found a positive correlation (r = 0.85, P < 0.05) between the average force during the applications and depth of the lesions. CONCLUSION: When ablating the cavo-tricuspid isthmus in a swine model, contact forces of at least 20 grs. are required to achieve transmural lesions. Catheter-tissue contact is critical for effective lesion creation. This information is important for improving ablation efficacy.

Flow mapping inside a left ventricular aneurism: a potential tool to demonstrate thrombogenicity.

We describe the use of vector flow mapping (VFM), a novel echocardiographic technique allowing intracardiac flow visualization, to quantify flow intensity inside a left ventricular aneurysm in a 68-year-old man. VFM successfully identified areas of stagnant flow corresponding to the wall region where a thrombus had been formed.

Percutaneous closure of incomplete surgical left atrial appendage ligation: success begins with the decision to try.

The authors present a case of percutaneous closure of an incomplete surgical left atrial appendage (LAA) ligation with a new device LAmbre (Lifetech ScientificCo Ltd).

Dataset for the study of the effect of anticoagulation in the incidence of stroke and other outcomes in patients with left ventricular thrombus.

The optimal duration of anticoagulation in patients with left ventricular thrombus (LVT) is unknown. The data package herein presented contains the information used to assess the effect of duration of anticoagulation in the incidence of stroke in patients with left ventricular thrombus (LVT) in a tertiary hospital. In order to collect the required data, all transthoracic echocardiography studies at our institution from January 1st 2014 to December 31st 2021 with LVT were retrieved using dedicated software (Phillips Intellispace Cardiovascular; Koninklijke Phillips N.V., 2004-2020). Second, a dataset was designed ad hoc for this study in which the recruited data for the predefined objectives were obtained from electronic medical records. These data included clinical and demographic information including treatment choices (vitamin K antagonists [VKA] versus direct oral anticoagulants [DOAC]), duration of treatment, reason for interruption of treatment, occurrence of stroke, acute myocardial infarction, bleeding events, thrombus resolution, recurrence, and death. Retrieved data were stored in an excel sheet for analysis using the statistical package STATA (StataCorp v. 15.0, College station, TX). This methodology allows the reuse of these data for further analysis, in the context of the present study and also for future recruitment of additional patients from other institutions to increase statistical power.

Checkpoint Immunotherapy-Induced Myocarditis and Encephalitis Complicated With Complete AV Block: Not All Hope Is Lost.

Immune checkpoint inhibitors are associated with a myriad of autoimmune adverse events. We present a 70-year-old patient with renal-cell carcinoma treated with nivolumab/ipilimumab complicated with myocarditis and encephalitis in which gradual impairment of the His-Purkinje system progressed to complete atrioventricular block. Full recovery was achieved after treatment with corticosteroids and immunoglobulins. (Level of Difficulty: Intermediate.).

Effect of Duration of Anticoagulation in the Incidence of Stroke in Patients With Left-Ventricular Thrombus.

The optimal duration of anticoagulation in patients with left-ventricular thrombus (LVT) is unclear. In the present study, we aimed to analyze the effect of treatment duration (≤12 months [short-term anticoagulation, (STA)] versus >12 months [long-term anticoagulation, (LTA)]) in the incidence of stroke and other secondary outcomes (acute myocardial infarction, bleeding, and mortality). Multivariate Cox regression was used to determine the association between treatment duration and stroke, adjusted for baseline embolic risk. A total of 98 cases of LVT (age 64.3 ± 12.8 years, female 18 [18%]) were identified. Sixty-one patients (62%) received LTA. Patients receiving LTA were older than those receiving STA (66.5 ± 11.6 vs 60.7 ± 13.9 years, p = 0.029), more often had atrial fibrillation (31% vs 0%, p <0.001), and had a higher CHA2DS2-VASc score (4.3 ± 1.6 vs 3.6 ± 1.6, p = 0.046). Stroke occurred in 2 and 10 patients (3% vs 27%, p <0.001), acute myocardial infarction in 2 and 3 patients (3% vs 8%, p = 0.292), bleeding in 4 and 3 patients (7% vs 8%, p = 0.773), and mortality in 12 and 7 patients (20% vs 19%, p = 0.927) in the LTA and STA groups, respectively. In multivariate analysis, after adjusting for embolic risk, LTA was associated with decreased risk of stroke at 5 years (adjusted hazard ratio 0.16; 95% confidence interval 0.03 to 0.72, p = 0.017). In conclusion, our data suggest that prolonged anticoagulation in patients with LVT may be associated with significantly lower risk of stroke.

Carotid intima-media thickness as a screening tool in cardiovascular primary prevention.

BACKGROUND AND OBJECTIVE: Increased carotid intima-media thickness (CIMT) is associated with cardiovascular events. The purpose of this study was to identify advanced subclinical atherosclerosis in patients who are at low or intermediate risk. METHODS: Thousand hundred and eighteen Spanish subjects were prospectively enrolled in an ambulatory screening of cardiovascular risk (CVR). Three hundred and twenty patients aged over 30 years with low-intermediate CVR according to European SCORE function underwent carotid ultrasonography. Carotid IMT and plaque assessment were performed using high-resolution B-mode ultrasonography. Participants with abnormal CIMT were reclassified to high CVR. RESULTS: According to SCORE function, 104 patients (32·5%) were of low CVR and 216 (67·5%) of intermediate CVR. Mean carotid IMT was 0·62 ± 0·13 mm, and carotid plaque was found in 35 (10·9%) patients. Carotid ultrasonography changed the risk stratum in 59 (18·4%) patients, who were reclassified to high CVR. Reclassification was more frequent in the intermediate CVR group than in the low CVR group (22·7% vs. 9·6%, P = 0·005) and was associated to age (P = 0·002), history of arterial hypertension (P < 0·001) and increased systolic blood pressure (P = 0·05). CONCLUSIONS: CIMT calculated by high-resolution B-mode ultrasonography could become an important tool in preventive medicine. Measuring CIMT may be useful in identifying asymptomatic individuals with subclinical atherosclerosis not detected by the actual CVR functions.

[Carotid intima-media thickness and its current usefulness]. / El grosor íntimo-medial carotídeo y su utilidad actual.

Cardiovascular risk stratification is currently part of routine clinical practice to establish cardiovascular prevention strategies. A complementary approach to the assessment scales of cardiovascular risk stratification is the non-invasive evaluation of the atherosclerotic lesion to identify patients at high risk for cardiovascular complications. Carotid intima-media thickness is a non-invasive method based on ultrasound suitable for the detection of subclinical atherosclerosis. It allows us to stratify cardiovascular risk beyond conventional cardiovascular risk factors and would complement the cardiovascular risk functions. The inclusion of the carotid intima-media thickness in cardiovascular risk stratification may help identify asymptomatic individuals with a high cardiovascular risk not detected by current scales of cardiovascular risk stratification.

Impact of device-host interaction on paravalvular aortic regurgitation with different transcatheter heart valves.

AIMS: We sought to evaluate the interaction of different aortic root phenotypes with self-expanding (SEV), balloon-expandable (BEV) and mechanically expanded (MEV) and the impact on significant aortic regurgitation. METHODS AND RESULTS: We included 392 patients with a SEV (N = 205), BEV (N = 107) or MEV (N = 80). Aortic annulus eccentricity index and calcification were measured by multi-slice CT scan. Paravalvular aortic regurgitation was assessed by contrast aortography (primary analysis) and transthoracic echocardiography (secondary analysis). In mildly calcified roots paravalvular regurgitation incidence was similar for all transcatheter heart valves (SEV 8.4%; BEV 9.1%; MEV 2.0% p = 0.27). Conversely, in heavily calcified roots paravalvular regurgitation incidence was significantly higher with SEV (SEV 45.9%; BEV 0.0%; MEV 0.0% p < 0.001). When paravalvular regurgitation was assessed by TTE, the overall findings were similar although elliptic aortic roots were associated with more paravalvular regurgitation with SEV (20.5% vs. BEV 4.5% vs. MEV 3.2%; p = 0.009). CONCLUSIONS: In heavily calcified aortic roots, significant paravalvular aortic regurgitation is more frequent with SEV than with BEV or MEV, but similar in mildly calcified ones. These findings may support patient-tailored transcatheter heart valve selection. CLASSIFICATIONS: Aortic stenosis; multislice computed tomography; transcatheter aortic valve replacement; paravalvular aortic regurgitation. CONDENSED ABSTRACT: We sought to evaluate the interaction of different aortic root phenotypes with self-expanding (SEV), balloon-expandable (BEV) and mechanically expanded (MEV) and the impact on significant aortic regurgitation. We included 392 patients with a SEV (N = 205), BEV (N = 107) or MEV (N = 80). Aortic annulus eccentricity index and calcification were measured by multi-slice CT scan. Paravalvular aortic regurgitation was assessed by contrast aortography and transthoracic echocardiography. We found that in heavily calcified aortic roots, significant paravalvular aortic regurgitation is more frequent with SEV than with BEV or MEV, but similar in mildly calcified ones.

Contemporary differences between men and women with acute coronary syndromes: CIAM multicenter registry.

AIM: Differences exist in the diagnosis and treatment of acute coronary syndrome (ACS) between men and women. However, recent advancements in the management of ACSs might have attenuated this sex gap. We evaluated the status of ACS management in a multicenter registry in 10 tertiary Spanish hospitals. METHODS: We enrolled 1056 patients in our study, including only those with type 1 myocardial infarctions or unstable angina presumably not related to a secondary cause in an 'all-comers' design. RESULTS: The women enrolled (29%) were older than men (71.0 ±â€Š12.8 vs. 64.0 ±â€Š12.3, P = 0.001), with a higher prevalence of hypertension (71.0 vs. 56.5%, P < 0.001), insulin-treated diabetes (13.7 vs. 7.9%, P = 0.003), dyslipidemia (62.2 vs. 55.3%, P = 0.038), and chronic kidney disease (16.9 vs. 9.1%, P = 0.001). Women presented more frequently with back or arm pain radiation (57.3 vs. 49.7%, P = 0.025), palpitations (5.9 vs. 2.0%, P = 0.001), or dyspnea (33.0 vs. 19.4%, P = 0.001). ACS without significant coronary stenosis was more prevalent in women (16.8 vs. 8.1%, P = 0.001). There were no differences in percutaneous revascularization rates, but drug-eluting stents were less frequently employed in women (75.4 vs. 67.8%, P = 0.024); women were less often referred to a cardiac rehabilitation program (19.9 vs. 33.9%, P = 0.001). There were no significant differences in in-hospital complications such as thrombosis or bleeding. CONCLUSION: ACS presenting with atypical symptoms and without significant coronary artery stenosis is more frequent in women. Selection of either an invasive procedure or conservative management is not influenced by sex. Cardiac rehabilitation referral on discharge is underused, especially in women.

Identification of candidates for coronary artery bypass grafting admitted with STEMI and Multivessel Disease.

BACKGROUND: The optimal management of patients with multivessel coronary artery disease (MVD) admitted with STEMI is under debate. CABG is rarely performed, even on ideal candidates. A provisional PCI without stent implantation may allow complete surgical revascularization (CSR) in a subset of patient that we sought to identify in this study. METHODS: Patients with STEMI from April 2014 to October 2016 were evaluated and those with a TIMI flow <3 in the culprit vessel, and an additional stenosis of >70% in an epicardial vessel or sidebranch >2.5 mm were selected. Epidemiological variables, surgical risk scores and SYNTAX and SYNTAX II scores were analyzed. All the selected patients were discussed in a post hoc heart-team, and predictors of 12-month events were also analyzed. RESULTS: Seventy-two (19.0%) accomplished MVD criteria. Mean SYNTAX was 19 ±â€¯13 points and SYNTAX II score recommended CABG in 12 patients (16.7%) and heart-team discussion in 60 (83.3%). All patients were discussed in a post hoc heart-team, which concluded that 21 (29.2%) patients could have been good candidates for CSR. After one year follow-up, SYNTAX II PCI > 40 was found to be the sole independent predictor for 12-month events (OR 12.9 [2.7-62.1], p = 0.001). CONCLUSIONS: MVD and STEMI with a SYNTAX II PCI > 40 should be discussed in an ad-hoc heart team, after a provisional revascularization of the culprit vessel, and should be considered for CSR, especially when the RCA is the culprit artery and there is a complex disease in the left coronary artery.

Arritmias ventriculares en el síndrome de takotsubo: cuestión de sexo / Sex-related risk of arrhythmia in takotsubo syndrome

Resumen El síndrome de takotsubo, también conocido como miocardiopatía de estrés, representa un difícil reto diagnóstico, pues en muchos casos su presentación es superponible al infarto de miocardio por ruptura de placa; el diagnóstico definitivo se basa en la ausencia de lesiones culpables en la coronariografía. La fisiopatología de la enfermedad no está por completo establecida, y tiene un pronóstico generalmente benigno. Sin embargo, existe un porcentaje no despreciable de pacientes que sufren complicaciones graves, entre las que destacan las arritmias malignas tipo taquicardia ventricular polimórfica por prolongación del intervalo QT. A pesar de que el síndrome de takotsubo afecta principalmente a las mujeres, quienes por otra parte también suelen tener intervalos QT más prolongados en condiciones basales, la muerte súbita de origen arrítmico aparece con mayor frecuencia en los hombres que sufren esta enfermedad. Se presentan dos casos de ensanchamiento extremo del intervalo QT corregido en pacientes con takotsubo que tuvieron desenlaces diferentes. El propósito de este trabajo es destacar y revisar las diferencias electrocardiográficas y pronósticas relacionadas con el sexo de los sujetos que desarrollan esta controvertida enfermedad.

Abstract Takotsubo syndrome, also known as stress cardiomyopathy, is a difficult diagnostic challenge as, in many cases, its presentation can overlap with that of myocardial infarction due to plaque rupture. The definitive diagnosis is based on the lack of culprit lesions on coronariography. The pathophysiology of the disease has not been completely ascertained, and it has a generally benign prognosis. However, a not inconsiderable percentage of patients experience serious complications, notably malignant arrhythmias like polymorphic ventricular tachycardia due to a prolonged QT interval. Despite takotsubo syndrome affecting mainly women who, furthermore, generally have longer basal QT intervals, sudden death due to arrhythmias is more common in men with this disease. Two cases are presented of extremely prolonged corrected QT intervals in patients with takotsubo, with different outcomes. The purpose of this paper is to highlight and review the electrocardiographic and prognostic differences related to the gender of the individuals who develop this controversial disease.

[Coronary disease risk and prevalence of heart disease in primary care patients with hypertension and renal disease]. / Riesgo coronario y prevalencia de cardiopatías en pacientes hipertensos con afectación renal en asistencia primaria.

INTRODUCTION AND OBJECTIVES: The presence of renal disease significantly alters the cardiovascular risk of patients with high blood pressure. However, few studies have examined renal parameters in primary care patients. The objectives of this study were to investigate cardiovascular risk and the factors influencing it in hypertensive patients with renal disease and to compare the findings with those in hypertensive patients without renal disease. METHODS: The CORONARIA study involved primary care patients with hypertension from all regions of Spain and included two groups with different degrees of renal disease. RESULTS: In total, 703 patients (9.8%) had renal disease. Hypertensive patients with renal disease had a worse cardiovascular risk profile than other hypertensives. The prevalence of diabetes was double in patients with renal disease. Moreover, the risk of a coronary event was significantly higher in those with renal disease. One-third of hypertensives with renal disease had another previously diagnosed cardiovascular disease. In addition, they more frequently had a history of angina, were twice as likely to have had a myocardial infarction, and were more than twice as likely to have undergone revascularization or to have peripheral vascular disease or cerebrovascular disease. Heart failure was four times more frequent in these patients with renal disease than in other hypertensives. CONCLUSIONS: Patients with hypertension and renal disease have a higher risk of cardiovascular disease, exhibit an increased prevalence of diabetes, and suffer from more extensive target organ damage.

[Cardiovascular risk in diabetes mellitus and hypertension in Spain. The CORONARIA study]. / Riesgo cardiovascular en diabetes mellitus e hipertensión arterial en España. Estudio CORONARIA.

BACKGROUND AND OBJECTIVE: Diabetes mellitus is a prevalent disease with high cardiovascular mortality. Treatment of risk factors can reduce the associated cardiovascular risk. The CORONARIA study included 7253 patients with high risk systemic hypertension from different regions of Spain. The aim of this study was to analyze the cardiovascular risk (CR) of diabetic patients at baseline and after one-year follow-up. PATIENTS AND METHOD: A total of 2105 (29%) patients with type 2 diabetes and systemic hypertension are included in the CORONARIA study. The CR profile is evaluated at baseline and after treatment of systemic hypertension with amlodipine (5-10 mg), while other cardiovascular risk factors were also treated. Data were compared with non diabetics. RESULTS: Patients with systemic hypertension in Spain show a very high prevalence of diabetes (29%); it is higher in women than men (p<0.05) and higher in secondary prevention than primary prevention (p<0.05). Prevalence diabetes was higher in Murcia, Andalucía, Extremadura and Comunidad Valenciana, and lower in Madrid and País Vasco than the Spanish mean. The CR in primary prevention was significantly higher in diabetics than in non-diabetics (female: 22.9% vs 12.3% in Framingham, and 10.1% vs 5.2% in REGICOR; male: 39.9% vs 27.8% in Framingham and 15.7% vs 10.3% in REGICOR). After one year treatment, cardiovascular risk decreased significantly in both groups of patients, but it did more in diabetics (Framingham: -11.6% vs -6.7%; REGICOR: -5.3% vs -2.8%). CONCLUSIONS: Most patients with diabetes and systemic hypertension did not have an adequate control of CR factors and presented a high cardiovascular risk. Treatment reduced the CR significantly in a greater proportion of diabetic than non diabetic-patients.