Eduardo de Teresa-Galván

Factors Predicting and Having an Impact on the Need for a Permanent Pacemaker After CoreValve Prosthesis Implantation Using the New Accutrak Delivery Catheter System

OBJECTIVES The purpose of this study was to evaluate the need for a permanent pacemaker after transcatheter aortic valve implantation with the CoreValve prosthesis (Medtronic, Inc., Minneapolis, Minnesota) using the new Accutrak delivery system (Medtronic, Inc.). BACKGROUND The need for a permanent pacemaker is a recognized complication after transcatheter aortic valve implantation with the CoreValve prosthesis. METHODS Between April 23, 2008 and May 31, 2011, 195 consecutive patients with symptomatic aortic valve stenosis underwent transcatheter aortic valve implantation using the self-expanding CoreValve prosthesis. In 124 patients, the traditional delivery system was used, and in 71 patients, the Accutrak delivery system was used. RESULTS There were no significant differences in baseline electrocardiographic characteristics between the traditional system and the Accutrak patients: PR interval: 153 ± 46 mm versus 165 ± 30 mm, p = 0.12; left bundle branch block: 22 (20.2%) versus 8 (12.7%), p = 0.21; right bundle branch block: 21 (19.3%) versus 8 (12.7%), p = 0.26. The depth of the prosthesis in the left ventricular outflow tract was greater with the traditional system than with the Accutrak system (9.6 ± 3.2 mm vs. 6.4 ± 3 mm, p < 0.001) and the need for a permanent pacemaker was higher with traditional system than with Accutrak (35.1% vs. 14.3%, p = 0.003). The predictors of the need for a pacemaker were the depth of the prosthesis in the left ventricular outflow tract (hazard ratio [HR]: 1.2, 95% confidence interval [CI]: 1.08 to 1.34, p < 0.001), pre-existing right bundle branch block (HR: 3.5, 95% CI: 1.68 to 7.29, p = 0.001), and use of the traditional system (HR: 27, 95% CI: 2.81 to 257, p = 0.004). CONCLUSIONS The new Accutrak delivery system was associated with less deep prosthesis implantation in the left ventricular outflow tract, which could be related to the lower rate of permanent pacemaker requirement.

The genotype interactions of methylenetetrahydrofolate reductase and renin-angiotensin system genes are associated with myocardial infarction

We analyzed the evolution with age of the frequencies of the I/D polymorphism of the angiotensin I-converting enzyme (ACE), a1166c of the angiotensin II AT1 receptor (AT1R), M235T of the angiotensinogen (AGT) and A225V of their methylenetetrahydrofolate reductase (MTHFR) gene in a healthy (H) population and the subsequent comparison to age- and sex-matched groups of myocardial infarction (MI) subjects. A total of 472 H subjects were divided into three groups < 30, 30-55 and > 55 years old and 277 individuals with MI into two groups 30-55 and > 55 years old. The evolution with age showed that the AGT M allele (P < 0.001) and the MTHFR V allele (P < 0.05) frequency decreased with age in H men. The comparison between healthy and MI groups showed that the MM genotype frequency increased in MI men > 55 years (OR =4.16; 95% CI; 1.72-10.1) The cc genotype showed a similar behaviour (OR = 3.96; 95% CI; 1.21-12.9). In men, all the combinations with MM genotype presented a high risk, with OR values between 1.10 and 7.22. In women, the cc genotype increased in the MI > 55 group (OR = 6.66; 95% CI; 2.02-21.9). All the combinations with the cc genotype showed OR values between 1.71 and 13.3. The MM genotype in men and cc genotype in men and women, are independent risk factors for MI. We propose that the study of the allele frequency evolution in an H population at different ages is essential to determine risk factors for MI in case-control studies, since data from isolated age-matched groups can be misinterpreted.

Hereditary patterns of bicuspid aortic valve in a hundred families.

BACKGROUND To study the following characteristics of bicuspid aortic valves (BAVs): 1) the recurrence rate in our population, 2) patterns of hereditary transmission in different BAV morphologies and 3) the aortic dimensions of BAVs in first-degree relatives (FDRs). METHODS A cross-sectional, prospective study of 100 consecutive families of BAV patients attending a university hospital. The following aortic valve morphologies were analysed and categorised: fusion of the right and left coronary cusps (BAV type A), right and noncoronary cusps (type B) and of the left and noncoronary cusps (type C). RESULTS There were 553 subjects studied, 100 cases with a BAV (46.8±15 years, 66% male, type 67% A, 32% B and 1% C; 42% with aortic dilatation), 348 FDRs (44.8% male), and 105 healthy control subjects (50% male). We detected 16 BAVs among 348 FDRs. The recurrence rates were 15% for families, 4.6% for FDRs, 7.05% in men and 2.60% in women. The morphologic concordance in family members was 68.8%. The aortic dimensions in 270 adult FDRs with a tricuspid aortic valve were significantly smaller compared with BAV patients (sinus index diameter 1.60±0.19 cm/m(2) vs. 1.82±0.29 cm/m(2), p<0.001; tubular index diameter 1.51±0.23 cm/m(2) vs. 2.00±0.45 cm/m(2), p<0.001) and similar to 103 control subjects(sinus index diameter 1.60±0.19 cm/m(2) vs. 1.59±0.17 cm/m(2), p=0.600 and tubular index diameter 1.51±0.23 cm/m(2) vs. 1.53±0.18 cm/m(2), p=0.519). CONCLUSIONS In our population, the BAV recurrence rate in FDRs was low (4.6%). The hereditary transmission of morphologic BAV types seems by chance, and the aortic dimensions in tricuspid FDRs are normal.

La producción científica cardiovascular en España y en el contexto europeo y mundial (2003-2007)

Introduccion y objetivos La publicacion de articulos de investigacion ha aumentado de manera considerable en los ultimos anos en todas las areas biomedicas. El objetivo de este trabajo es determinar el lugar que ocupa la investigacion cardiologica espanola de calidad en el contexto europeo y mundial y su evolucion durante el quinquenio 2003-2007. Metodos Utilizando como fuente de datos la base de datos Science Citation Index Expanded de Thomson Reuters, se comparo la produccion cientifica cardiovascular espanola con la de los paises de la Union Europea y los mas destacados del mundo, asi como la productividad relativa respecto al numero de habitantes y producto interior bruto y el numero de citas recibidas en las revistas del area «Cardiac & Cardiovascular Systems» del Journal Citation Reports (CCS-JCR). Resultados Espana ocupa el sexto puesto en el ranking europeo y el noveno en el mundial de la produccion cientifica, pasando al decimo mundial si se consideran unicamente las revistas del primer cuartil del area CCS-JCR. En numero de citas recibidas, Espana ocupa el septimo lugar europeo y undecimo mundial. En la productividad relativa respecto al numero de habitantes y el producto interior bruto, la posicion espanola es menos favorable, ocupando la decimoquinta y la decimoctava posicion, respectivamente. Conclusiones En investigacion cardiovascular, Espana ocupa posiciones similares a otras areas biomedicas, si bien su situacion es menos ventajosa respecto a algunos indicadores demograficos y economicos. Para que se mantengan los niveles adecuados de investigacion, es necesario que los gobiernos y las sociedades cientificas europeas consideren el fomento de la investigacion cardiologica de alta calidad como un objetivo primordial.

Closure of perivalvular leaks using an Amplatzer occluder.

Reoperation of patients with perivalvular leaks due to heart failure or hemolysis is associated with increased morbidity and mortality. Percutaneous closure using an Amplatzer device offers a promising alternative. We describe our initial experience between 2004 and 2006, during which we used an Amplatzer device in eight patients for the percutaneous closure of perivalvular leaks (four aortic and four mitral). The patients were all symptomatic and had a high surgical risk. Device placement was successful in all patients with mitral leaks and in three with aortic leaks. There were no periprocedural complications. With four of the seven (57%) device placements, there was a significant reduction in the degree of regurgitation and, at 12-month follow-up, only these four patients showed clinical improvements. Of the other three, one required reoperation and two died of non-cardiovascular causes. Percutaneous closure of perivalvular leaks was feasible and safe and can be regarded as a treatment option in patients with a high surgical risk.

Utilización de los dispositivos Amplatzer para el cierre de fugas perivalvulares

La reintervencion de los pacientes con fugas perivalvulares por insuficiencia cardiaca o hemolisis esta asociada a una elevada morbimortalidad. La utilizacion percutanea de los dispositivos Amplatzer supone una alternativa atractiva. Presentamos nuestra experiencia inicial: entre 2004 y 2006 realizamos cierre percutaneo con dispositivo Amplatzer a 8 pacientes con fugas perivalvulares (4 aorticas y 4 mitrales), sintomaticos y con alto riesgo quirurgico. La implantacion del dispositivo fue posible en todas las mitrales y en 3 aorticas. No hubo complicaciones durante el procedimiento. En 4 (57%) de los 7 implantes se logro una reduccion significativa del grado de regurgitacion y, tras 12 meses de seguimiento, solamente estos pacientes mejoraron clinicamente. De los 3 restantes, 1 paciente preciso reintervencion y 2 fallecieron por causa no cardiovascular. El tratamiento percutaneo de las fugas perivalvulares es factible y seguro y puede considerarse como una opcion terapeutica en subgrupos de alto riesgo quirurgico.

Influence of Sex on Perioperative Outcomes in Patients Undergoing Valve Replacement for Severe Aortic Stenosis

INTRODUCTION AND OBJECTIVES The influence of sex on the prognosis of patients undergoing aortic valve replacement for severe stenosis is unclear. Nevertheless, a number of studies have regarded sex as an independent risk factor. The aim of this study was to evaluate the influence of sex on perioperative outcomes in patients undergoing valve replacement for severe aortic stenosis. METHODS This retrospective study involved 577 consecutive patients who underwent aortic valve replacement surgery for severe aortic stenosis between 1996 and April 2007. RESULTS Women (44% of patients) were older than men (70.3+/-7.9 years vs. 66.8+/-9.8 years; P< .001), had a smaller body surface area (1.68+/-0.15 m(2) vs. 1.83+/-0.16 m(2); P< .001), more often had arterial hypertension (73% vs. 49%; P< .001), diabetes mellitus (33.5% vs. 24.5%; P=.001) and ventricular hypertrophy (89.1% vs. 83.1%; P< .001), and less often had coronary artery disease (19.1% vs. 31.8%; P< .001) and severe ventricular dysfunction (7.9% vs. 17.4%; P< .001). Nevertheless, women more often suffered acute myocardial infarction perioperatively (3.9% vs. 0.9%; P=.016), had a low cardiac output in the postoperative period (30.3% vs. 22.3%; P=.016) and experienced greater perioperative mortality (13% vs. 7.4%; P=.019) than men. However, after adjustment for various confounding factors, female sex was not a significant independent risk factor for mortality (odds ratio = 2.40; 95% confidence interval, 0.79-7.26; P=.119). CONCLUSIONS Perioperative mortality in women with severe aortic stenosis who underwent valve replacement was high. However, after adjustment for potential confounding factors, particularly body surface area, female sex was not an independent risk factor for mortality.

Survival and predictive factors of mortality after 30 days in patients treated with percutaneous implantation of the CoreValve aortic prosthesis

BACKGROUND Few data exist on the clinical impact of transcatheter aortic valve implantation (TAVI) in patients with symptomatic aortic stenosis and a high surgical risk. The aim of this study was to determine the survival and the factors predicting mortality after 30 days post-TAVI with the CoreValve prosthesis (Medtronic, Minneapolis, MN). METHODS From April 2008 to October 2010, the CoreValve prosthesis (Medtronic) was implanted in 133 consecutive high-risk surgical patients with symptomatic severe aortic stenosis. RESULTS The mean age was 79.5 ± 6.7 years. The logistic European System for Cardiac Operative Risk Evaluation was 21.5% ± 14%. The implantation success rate was 97.7%. In-hospital mortality was 4.5%, and the combined end point of death, vascular complications, myocardial infarction, or stroke had a rate of 9%. Survival at 12 and 24 months was 84.5% and 79%, respectively, after a mean follow-up of 11.3 ± 8 months. The New York Heart Association functional class improved from 3.3 ± 0.5 to 1.18 ± 0.4 and remained stable at 1 year. A high Charlson index (hazard ratio [HR] 1.44, 95% CI 1.09-1.89, P < .01) and a worse Karnofsky score before the procedure (HR 0.95, 95% CI 0.92-0.99, P = .021) were predictors of mortality after 30 days. CONCLUSIONS Transcatheter aortic valve implantation with the CoreValve prosthesis for patients with aortic stenosis and a high surgical risk is a safe, efficient option resulting in a medium-term clinical improvement. Survival during follow-up depends on the associated comorbidities. Early mortality beyond 30 days is predicted by preoperative comorbidity scores and the functional status of the patient.

Comparison of medium-term outcomes obtained with drug-eluting stents and coronary artery bypass grafts in an unselected population of diabetic patients with multivessel coronary disease. Propensity score analysis.

INTRODUCTION AND OBJECTIVES Since the introduction of drug-eluting stents, the optimum revascularization strategy in diabetic patients with multivessel coronary disease has remained controversial. METHODS This study used multivariate logistic regression analysis and propensity score matching to compare results in 270 consecutive diabetic patients (2000-2004) with multivessel disease (> or =2 vessels with a >70% de novo stenosis involving the proximal left anterior descending coronary artery) who underwent either coronary artery bypass grafting (CABG; n=142) or implantation of a drug-eluting stent (DES; i.e. rapamycin or paclitaxel; n=128). The following clinical outcomes (i.e. major adverse cardiac or cerebrovascular events [MACCEs]) were assessed: death, nonfatal myocardial infarction (MI), stroke and repeat revascularization at 2 years. RESULTS Patients who received DESs were older (67.5+/-7 years vs. 65.3+/-8 years; P=.05) and more often had a previous MI (49.2% vs. 28.2%; P< .01), but no more often had a depressed left ventricular ejection fraction < or =45% (32.4% vs. 28.1%). Coronary anatomy was more complex in surgical patients (SYNTAX score, 25.9+/-7 vs. 18.5+/-6; P< .001) and the quality of revascularization was better (i.e. anatomically complete revascularization: 52.8% vs. 28.1%; P< .01). The incidence of MACCEs was 18.7% in the CABG group and 21.8% in the DES group (adjusted odds ratio [OR] = 0.93; 95% confidence interval [CI], 0.47-1.86). The composite endpoint of death, MI or stroke occurred in 15.8% undergoing CABG and 12.9% receiving a DES (adjusted OR = 1.19; 95% CI, 0.72-1.88). There was less need for revascularization in CABG patients (4.3% vs. 12.1%; adjusted OR = 0.42; 95% CI, 0.16-1.14; P=.09). CONCLUSIONS In an unselected population of diabetic patients with multivessel coronary disease, the principle advantage of CABG was the reduced need for revascularization. There was no difference in the rate of death, MI or stroke.

Deformación ventricular izquierda en ecocardiografía bidimensional: valores y tiempos en sujetos normales

El analisis de la deformacion o strain y la tasa de deformacion o strain rate podrian valorar cuantitativamente la contractilidad segmentaria. Esto es factible con Doppler tisular y, mas recientemente, tambien con ecografia bidimensional mediante el rastreo de senales miocardicas (speckle tracking). Este trabajo se diseno para conocer el valor de estos parametros en sujetos sanos y su reproducibilidad. Se estudio a 105 sujetos sanos —55 mujeres (52,45%); edad, 38,8 ± 9,5 (20-59) anos— mediante speckle tracking con la aplicacion Vector Velocity Imaging. Se obtuvieron los valores medios de strain y strain rate de cada segmento, asi como el tiempo hasta el pico maximo, normalizado con la longitud del ciclo (TpN). Los valores medios fueron: strain circunferencial, 22,2 ± 4,81% con TpN 0,39 ± 0,06; strain longitudinal, 19,84 ± 4,59% con TpN 0,42 ± 0,06; strain rate circunferencial, 1,64 ± 0,48 1/s con TpN 0,23 ± 0,06; strain rate longitudinal, 1,3 ± 0,49 1/s con TpN 0,21 ± 0,09. Las variabilidades del observador y entre observadores fueron moderadas.