Ángel Cequier-Fillat

CRUSADE bleeding risk score validation for ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention

INTRODUCTION The CRUSADE bleeding risk score (CBRS) accurately predicts major bleeding in non-ST segment elevation myocardial infarction NSTEMI patients. However, little information exists about its application in ST segment elevation myocardial infarction STEMI. We aimed to assess the ability of CBRS to predict in-hospital major bleeding in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). MATERIALS AND METHODS We prospectively analyzed consecutive STEMI patients undergoing PPCI. Baseline characteristics, in-hospital complications and mid term mortality were recorded. Major bleeding was defined by the CRUSADE definition. Predictive ability of the CBRS was assessed by logistic regression method and the area under the ROC curve (AUC). RESULTS We included 1064 patients (mean age 63years). Mean CBRS value was 24. Most of patients (740/1064 (69.6%)) were in the two lowest risk quintiles of CBRS. Incidence of in-hospital major bleeding was 33/1064 (3.1%). The rates of in-hospital bleeding across the quintiles of risk groups were 0.4% (very low risk), 2.6% (low), 4.6% (moderate), 7.2% (high), and 13.4% (very high) (p 0.001). AUC was 0.80 (95% CI 0.73-0.87 p 0.001). In patients with radial access angiography (n=621) AUC was 0.81 (95% CI: 0.65-0.97). Mean follow up was 344days. Patients with bleeding events had higher mortality during follow up (HR 6.91; 95% CI 3.72-12.82; p 0.001). CONCLUSIONS Our patients had a significantly lower bleeding risk as compared to CRUSADE NSTEMI population. CBRS accurately predicted major in-hospital bleeding in this different clinical scenario, including patients with radial artery approach.

Implante percutáneo de válvula aórtica seguridad y eficacia del tratamiento del homoinjerto aórtico disfuncionante

INTRODUCTION AND OBJECTIVES Percutaneous aortic valve implantation for patients with severe symptomatic aortic stenosis and a high surgical risk is currently well established. We report our experience in terms of safety and effectiveness of transcatheter aortic valve implantation in other clinical context like the degenerated aortic homografts. METHODS We report our initial experience in four hospitals and five patients with degenerated aortic homograft and severe aortic regurgitation, refused for surgery for a heart team, that underwent percutaneous implantation of CoreValve(®) aortic prosthesis. RESULTS We included three males and two females. The mean age was 70 (3.5) years. All patients were symptomatic in New York Heart Association class III or IV. Procedures were performed through one of the femoral arteries in all patients and under sedation in three patients. The implant was successfully carried out in all cases. There were no major complications during the procedure or admission and the valvular defect was solved in all cases. In-hospital and 30-days mortality was 0. All patients had clinical improvement during follow-up with a reduction in at less two grades in the New York Heart Association functional scale. CONCLUSIONS In our experience the treatment of degenerated aortic homografts and aortic insufficiency with transcatheter aortic valve implantation showed to be safe and effective. The current challenge is to convey the good results of transcatheter aortic valve implantation in symptomatic aortic stenosis and high surgical risk to others disorders of the aortic valve. In the future, it is possible that transcatheter aortic valve implantation will expand its indications to majority of aortic valve disorders and patients with less surgical risk.

Invasive mechanical ventilation in acute coronary syndromes in the era of percutaneous coronary intervention

Background: Percutaneous coronary intervention (PCI) improves prognosis in patients with acute coronary syndromes (ACS) reducing ischaemic complications and the development of heart failure, thus potentially changing invasive mechanical ventilation (IMV) requirements. Little information exists about patients with ACS requiring IMV in the current era. We aimed to analyze IMV requirements and characteristics of ACS patients treated under current recommendations (including a high rate of PCI). Methods: Baseline characteristics, indications for IMV, management and in-hospital and mid-term clinical course were analyzed prospectively in a consecutive series of patients with ACS admitted to a tertiary care hospital. Results: We included 1821 patients, of which 106 (5.8%) required IMV. Mean follow-up was 347 days. PCI was performed in 84% of cases. Patients with IMV had more comorbidities, worse left ventricular function and more unstable hemodynamic parameters on admission. In-hospital mortality in patients requiring IMV was 29%. These patients also had higher mid-term mortality (hazard ratio (HR) 6.58; 95% confidence interval (CI) 4.49−9.64; p 0.001). The most common indication for IMV was cardiopulmonary arrest (CA) (65; 61%), followed by pulmonary oedema (27; 26%) and shock (14; 13.2%). Patients with CA were younger, with better hemodynamic parameters at admission, more favourable coronary anatomy and higher rates of PCI. There were no significant differences in overall mortality between the three groups. The main cause of death in CA patients was persistent vegetative state. Conclusions: Mortality in patients with ACS requiring IMV remained high despite a high rate of PCI. Baseline characteristics, management and clinical course were different according to the reason for IMV. The most common cause for IMV requirement was CA.

Ventricular Support With Extracorporeal Membrane Oxygenation: A New Rescue Alternative for Refractory Cardiogenic Shock

en una evolucion favorable. Como conclusion, creemos que en la miocarditis aguda lo mas importante es el tratamiento de soporte en la fase inicial. Algunos pacientes precisan asistencia ventricular, sin que ello implique un mal pronostico a largo plazo. En cuanto al diagnostico, la resonancia magnetica es una exploracion de gran utilidad. El reto principal es obtener una exploracion de buena calidad en los pacientes de menor edad (neonatos y lactantes). La biopsia endomiocardica podria reservarse para los pacientes con peor evolucion. En cuanto al pronostico, la afeccion del ventriculo derecho podria ser mas frecuente en los neonatos, pues estos tienen una reactividad vascular pulmonar muy marcada. En estos pacientes, la disfuncion derecha podria ser secundaria a la hipertension pulmonar y no implicar necesariamente mal pronostico.

Early Prognostic Evaluation After Mild Therapeutic Hypothermia in Sudden Cardiac Arrest Survivors

1. Finsterer J. Genetic, pathogenetic, and phenotypic implications of the mitochondrial A3243G tRNALeu(UUR) mutation. Acta Neurol Scand. 2007;116:1–14. 2. Cobo-Marcos M, Cuenca S, Gámez Martı́nez JM, Bornstein B, Ripoll Vera T, GarciaPavia P. Utilidad del análisis genético de la miocardiopatı́a hipertrófica en la práctica real. Rev Esp Cardiol. 2013;66:746–7. 3. Taylor RW, Turnbull DM. Mitochondrial DNA mutations in human disease. Nat Rev Genet. 2005;6:389–402. 4. Ley 14/2006 sobre técnicas de Reproducción Asistida. BOE 126 de 27 de Mayo 2006 [accessed 24 Jul 2014]. Available at: http://www.boe.es/boe/dias/2006/05/ 27/pdfs/A19947-19956.pdf 5. Third scientific review of the safety and efficacy of methods to avoid mitochondrial disease through assisted conception: 2014 update [accessed 24 Jul 2014]. Available at: http://www.hfea.gov.uk/docs/Third_Mitochondrial_replacement_scientific_ review.pdf

Cardiogenic shock and coronary endothelial dysfunction predict cardiac allograft vasculopathy after heart transplantation.

Cardiac allograft vasculopathy remains one of the major causes of death post‐heart transplantation. Its etiology is multifactorial and prevention is challenging. The aim of this study was to prospectively determine factors related to cardiac allograft vasculopathy after heart transplantation. This research was planned on 179 patients submitted to heart transplant. Performance of an early coronary angiography with endothelial function evaluation was scheduled at three‐month post‐transplant. Patients underwent a second coronary angiography after five‐yr follow‐up. At the 5‐ ± 2‐yr follow‐up, 43% of the patients had developed cardiac allograft vasculopathy (severe in 26% of them). Three independent predictors of cardiac allograft vasculopathy were identified: cardiogenic shock at the time of the transplant operation (OR: 6.49; 95% CI: 1.86–22.7, p = 0.003); early coronary endothelial dysfunction (OR: 3.9; 95% CI: 1.49–10.2, p = 0.006), and older donor age (OR: 1.05; 95% CI: 1.00–1.10, p = 0.044). Besides early endothelial coronary dysfunction and older donor age, a new predictor for development of cardiac allograft vasculopathy was identified: cardiogenic shock at the time of transplantation. In these high‐risk patient subgroups, preventive measures (treatment of cardiovascular risk factors, use of novel immunosuppressive agents such as mTOR inhibitors) should be earlier and much more aggressive.

Comentarios al pronóstico a largo plazo de pacientes con infarto agudo de miocardio sin elevación del segmento ST y arterias coronarias sin estenosis significativa

Hemos leı́do con interés el artı́culo publicado por RedondoDiéguez et al. Tras su lectura nos gustarı́a aportar algunos comentarios. En el año 2010 publicamos resultados del registro GYSCA analizando la relevancia del tipo de hospital (terciario o comarcal) en el abordaje y el pronóstico del sı́ndrome coronario agudo sin elevación del ST (SCASEST). Datos de este registro han sido objeto de comunicaciones a congresos, incluyendo lo referente a los pacientes sin lesiones significativas (LS). El GYSCA fue un registro prospectivo de 1.133 pacientes consecutivos ingresados por SCASEST en 15 hospitales españoles. La prevalencia de coronariografı́as sin LS fue del 14,8%. Al alta, estos pacientes recibieron menos tratamientos en prevención secundaria. La incidencia de eventos cardiacos mayores al año fue menor (el 2,5 frente al 14%; p < 0,001) (figura 1A). Ningún paciente de este grupo falleció por causa cardiaca. En cuanto a los eventos evaluados en el estudio de Redondo-Diéguez et al (mortalidad o reingreso por sı́ndrome coronario agudo), la incidencia en el GYSCA fue del 4,1 frente al 11,2% (p = 0,042) (figura 1B). Este seguimiento (1 año) fue menor que en el estudio de RedondoDiéguez et al (4,8 años), si bien cabe destacar que el GYSCA fue un estudio prospectivo con mı́nimas pérdidas en el seguimiento. También analizamos las diferencias pronósticas según la extensión de la enfermedad coronaria. La mortalidad fue muy similar entre los pacientes sin LS y aquellos con enfermedad de un vaso (figura 2). Consideramos que el pronóstico de los pacientes sin LS deberı́a centrarse en los eventos coronarios y la mortalidad cardiaca, ya que la mortalidad total no refleja fielmente la contribución de la enfermedad coronaria al pronóstico. Nuestro estudio mostró mejor evolución en esta población, dato que coincide con Cortell et al, cuyos pacientes con infarto de miocardio sin elevación del ST sin LS tuvieron menor mortalidad o infarto a los 3 años (el 6 frente al 27%; p = 0,0001). Aunque otros estudios coinciden en un pronóstico favorable en ausencia de LS, no hay acuerdo sobre la benignidad de la entidad, ya que la mayorı́a reporta un pequeño porcentaje de eventos recurrentes, especialmente si existen irregularidades en la coronariografı́a. La frecuencia de SCASEST sin LS descrita es del 8,6-14%, diferencias que podrı́an depender de las caracterı́sticas de las poblaciones estudiadas (SCASEST con o sin elevación de biomarcadores) y de la definición de lesiones no significativas (coronarias normales o estenosis 50%). Además, el mecanismo fisiopatológico del evento isquémico no siempre supone la rotura de una placa de ateroma. La dificultad estriba en una orientación etiológica correcta que permita optimizar el tratamiento. Probablemente los pacientes con enfermedad arterioesclerótica con reperfusión espontánea muestren un pronóstico similar al de los individuos con lesiones «culpables». La ausencia de obstrucción se podrı́a confundir con ausencia de enfermedad e inducir a una menor aplicación de la prevención secundaria, lo cual expondrı́a al paciente a mayor riesgo de eventos. De hecho, en el estudio de Redondo-Diéguez et al y el GYSCA, los sujetos sin LS recibieron menos tratamientos con indicación de clase I en prevención secundaria. Por lo tanto, resulta fundamental establecer un diagnóstico etiológico correcto, para lo cual disponemos de técnicas como la Rev Esp Cardiol. 2015;68(9):820–822