Hipólito Gutiérrez

Late Cardiac Death in Patients Undergoing Transcatheter Aortic Valve Replacement Incidence and Predictors of Advanced Heart Failure and Sudden Cardiac Death

BACKGROUND Little evidence exists of the burden and predictors of cardiac death after transcatheter aortic valve replacement (TAVR). OBJECTIVES The purpose of this study was to assess the incidence and predictors of cardiac death from advanced heart failure (HF) and sudden cardiac death (SCD) in a large patient cohort undergoing TAVR. METHODS The study included a total of 3,726 patients who underwent TAVR using balloon (57%) or self-expandable (43%) valves. Causes of death were defined according to the Valve Academic Research Consortium-2. RESULTS At a mean follow-up of 22 ± 18 months, 155 patients had died due to advanced HF (15.2% of total deaths, 46.1% of deaths from cardiac causes) and 57 had died due to SCD (5.6% of deaths, 16.9% of cardiac deaths). Baseline comorbidities (chronic obstructive pulmonary disease, atrial fibrillation, left ventricular ejection fraction ≤40%, lower mean transaortic gradient, pulmonary artery systolic pressure >60 mm Hg; p < 0.05 for all) and 2 procedural factors (transapical approach, hazard ratio [HR]: 2.38, 95% confidence interval [CI]: 1.60 to 3.54; p < 0.001; presence of moderate or severe aortic regurgitation after TAVR, HR: 2.79, 95% CI: 1.82 to 4.27; p < 0.001) independently predicted death from advanced HF. Left ventricular ejection fraction ≤40% (HR: 1.93, 95% CI: 1.05 to 3.55; p = 0.033) and new-onset persistent left bundle-branch block following TAVR (HR: 2.26, 95% CI: 1.23 to 4.14; p = 0.009) were independently associated with an increased risk of SCD. Patients with new-onset persistent left bundle-branch block and a QRS duration >160 ms had a greater SCD risk (HR: 4.78, 95% CI: 1.56 to 14.63; p = 0.006). CONCLUSIONS Advanced HF and SCD accounted for two-thirds of cardiac deaths in patients after TAVR. Potentially modifiable or treatable factors leading to increased risk of mortality for HF and SCD were identified. Future studies should determine whether targeting these factors decreases the risk of cardiac death.

Tomografía de coherencia óptica. Experiencia inicial en pacientes sometidos a intervencionismo coronario percutáneo

La tomografia de coherencia optica es una nueva tecnica de diagnostico intracoronario, con una alta resolucion, superior a la de otras tecnicas como la ecografia intravascular. Se estudio mediante tomografia de coherencia optica el resultado tras implantar stent en 6 pacientes sometidos a intervencionismo coronario, con una imagen angiografica normal tras la revascularizacion. Se observo protrusion de material al stent en todos los pacientes, microdisecciones en los bordes del stent en 4 pacientes y mala posicion del stent en 4 pacientes. En 2 pacientes, se observo formacion de pequenos trombos alrededor del cateter de tomografia. La tomografia de coherencia optica permite detectar zonas de resultado suboptimo tras el intervencionismo coronario, a pesar de una adecuada imagen angiografica.

Absence of accelerated atherosclerotic disease progression after intracoronary infusion of bone marrow derived mononuclear cells in patients with acute myocardial infarction--angiographic and intravascular ultrasound--results from the TErapia Celular Aplicada al Miocardio Pilot study.

BACKGROUND We tried to evaluate a putative negative effect on coronary atherosclerosis in patients receiving intracoronary infusion of unfractionated bone marrow mononuclear cells (BMMC) following an acute ST-elevation myocardial infarction. Peripheral blood mononuclear cells or enriched CD133(+) BMMC have been associated with accelerated atherosclerosis of the distal segment of the infarct related artery (IRA). METHODS Thirty-seven patients with ST-elevation myocardial infarction from the TECAM pilot study underwent intracoronary infusion of autologous BMMC 9 +/- 3.1 days after onset of symptoms. We compared angiographic changes from baseline to 9 months of follow-up in the distal non-stented segment of the IRA, as well as in the contralateral coronary artery, with a matched control group. A subgroup of 15 treated patients underwent additional IVUS within the distal segment of the IRA. RESULTS No difference between stem cell and control group were found regarding changes in minimum lumen diameter (0.006 +/- 0.42 vs 0.06 +/- 0.41 mm, P = ns) and the percentage of stenosis (-2.68 +/- 12.33% vs -1.78 +/- 8.75%, P = ns) at follow-up. Likewise, no differences were seen regarding changes in the contralateral artery (minimum lumen diameter -0.004 +/- 0.54 mm vs -0.06 +/- 0.35 mm, P = ns). In the intravascular ultrasound substudy, no changes were demonstrated comparing baseline versus follow-up in maximum area stenosis and plaque volume. CONCLUSIONS In this pilot study, analysis of a subgroup of patients found that intracoronary injection of unfractionated BMMC in patients with acute ST-elevation myocardial infarction was not associated with accelerated atherosclerosis progression at mid term. Prospective, randomised studies in large cohorts with long-term angiographic and intravascular ultrasound follow-up are necessary to determine the safety of this therapy.

Value of CT in patients undergoing self-expandable TAVR to assess outcomes of concomitant mitral regurgitation.

Current guidelines on valvular heart disease recommend double valve replacement when significant aortic stenosis and mitral regurgitation (MR) occur simultaneously [(1,2)][1]. Given the higher risk of combined mitro-aortic surgery, transcatheter aortic valve replacement (TAVR) has emerged as a good

Optical coherence tomography. Initial experience in patients undergoing percutaneous coronary intervention.

Optical coherence tomography is a new intracoronary diagnostic technique that has a higher resolution than other techniques, such as intravascular ultrasound. We used optical coherence tomography to study outcomes after stent implantation in six patients who had undergone percutaneous coronary intervention, and in whom angiography showed normal results after revascularization. Material was observed to protrude through the stent struts in all patients, small dissections were seen at the stent edges in four patients, and there was incomplete stent apposition in four patients. In two patients, small amounts of thrombus were observed to form around the tomography catheter. With optical coherence tomography, it was possible to detect areas in which the results of percutaneous coronary intervention were suboptimal, despite a satisfactory appearance on angiography.

Transubclavian approach: A competitive access for transcatheter aortic valve implantation as compared to transfemoral

Empirically, transfemoral (TF) approach is the first choice for transcatheter aortic valve implantation (TAVI). We aimed to investigate whether transubclavian (TSc) and TF approaches present comparable major outcomes according to current evidence.

Multivessel disease in patients over 75 years old with ST elevated myocardial infarction. Current management strategies and related clinical outcomes in the ESTROFA MI + 75 nation-wide registry

BACKGROUND In elderly patients with ST elevated myocardial infarction (STEMI) and multivessel disease (MVD the outcomes related with different revascularization strategies are not well known. METHODS Subgroup-analysis of a nation-wide registry of primary angioplasty in the elderly (ESTROFA MI+75) with 3576 patients over 75years old from 31 centers. Patients with MVD were analyzed to describe treatment approaches and 2years outcomes. RESULTS Of 1830 (51%) with MVD, 847 (46%) underwent multivessel revascularization either in acute (51%), staged (44%) or both procedures (5%). Patients with previous myocardial infarction and those receiving drug-eluting stents or IIb-IIIa inhibitors were more prone to be revascularized, whereas older patients, females and those with Killip III-IV, renal failure and higher ejection fraction were less likely. Survival free of cardiac death and infarction at 2years was better for those undergoing multivessel PCI (85.8% vs. 80.4%, p<0.0008), regardless of Killip class. Multivessel PCI was protective of cardiac death and infarction (HR 0.60, 95% CI 0.40-0.89; p=0.011). Complete revascularization made no difference in outcomes among those patients undergoing multivessel PCI. The best prognosis corresponded to those undergoing multivessel PCI in staged procedures (p<0.001). A propensity score matching analysis (514 patients in each group) yielded similar results. CONCLUSIONS In elderly patients with STEMI and MVD, multivessel PCI was related with better outcomes especially after staged procedures. Among those undergoing multivessel PCI, anatomically defined completeness of revascularization had not prognostic influence. SUMMARY We sought to investigate the revascularization strategies applied and their prognostic implications in patients aged over 75years with ST elevated myocardial infarction showing multivessel disease. Of 1830 patients, 847 (46%) underwent multivessel PCI either in acute (51%), staged (44%) or both procedures (5%). Multivessel PCI was independent predictor of cardiac death and infarction with the best prognosis corresponding to those undergoing staged procedures.

Bioresorbable Scaffold T-stenting Evaluated With Optical Coherence Tomography

A 69-year-old man without cardiovascular risk factors was admitted to our hospital with unstable angina. After 48 hours he underwent coronary angiography, showing severe disease of mid left anterior descending (LAD) coronary artery and proximal segment of the first diagonal (DX) (Figure 1A). Balloon predilation was performed in LAD and 2 bioresorbable everolimus-eluting (3 28 mm and 3.5 28 mm) overlapped scaffolds (Absorb, Abbott Vascular, Santa Clara, California, United States) were implanted in LAD, jailing the DX. The result at LAD was excellent but DX worsened to 90% stenosis with TIMI II flow (Figure 1B). Hence, ‘‘kissing-balloon’’ dilation was performed with a 3 15 mm balloon at LAD and 2.5 15 mm balloon at DX (Figure 1C). As the compromise of DX persisted, we implanted a bioresorbable everolimus-eluting scaffold (2.5 18 mm) through the proximal stent in a T-fashion stenting, inflating a 3 15 mm balloon in LAD to avoid scaffold protrusion, with excellent angiographic final result (Figure 1D). Several optical coherence tomography pullbacks from LAD and DX were performed, confirming correct strut apposition. There was a slight protrusion of the DX scaffold into LAD, perhaps because the balloon used to avoid scaffold protrusion was too small (Figure 2A: pullback from LAD and 2B: pullback from DX, *struts protruding from DX in LAD). Patient was discharged on dual antiplatelet therapy (acetylsalicylic acid, clopidogrel) for a year. Six months later remained asymptomatic. Although increasing, experience with bioresorbable scaffolds in some situations, such as bifurcations, is limited. This is, to the best of our knowledge, the first case in which a true T-stenting was performed using bioresorbable scaffolds. Figure 1. 10 20 LAD

Comparison of the Hemodynamic Performance of the Balloon-expandable SAPIEN 3 Versus Self-expandable Evolut R Transcatheter Valve: A Case-matched Study

INTRODUCTION AND OBJECTIVES The SAPIEN 3 (S3) valve and the Medtronic Evolut R (EVR) are second-generation transcatheter valves, designed to further reduce the rate of paravalvular aortic regurgitation (AoR). The aim of this study was to compare the 2 devices in terms of valve performance in a case-matched study with independent echocardiographic analysis. METHODS Of a population of 201 patients who underwent transcatheter aortic valve implantation, 144 patients (S3, n = 80; EVR, n = 64) were matched according to aortic annulus diameter and aortic valve calcium score, as assessed by computed tomography. All echocardiographic examinations collected at baseline and at 1- and 6-month follow-up were centrally analyzed. RESULTS The 2 groups were well balanced in baseline clinical and echocardiographic characteristics. The EVR valve showed a better hemodynamic profile as assessed by peak aortic gradient (EVR 13 ± 7 vs S3 20 ± 10mmHg; P<.001), mean aortic gradient (EVR 7 ± 3 vs S3 11 ± 6mmHg; P<.001), and Doppler velocity index (EVR 0.65±0.15 vs S3 0.51±0.16; P<.001). The rate of moderate-severe or any paravalvular (≥ mild) AoR was higher in the EVR group (11% and 50%) than in the S3 group (2.5% and 21%; P <.05, respectively), with a larger number of paravalvular jets (P <.001). CONCLUSIONS In a case-matched cohort of transcatheter aortic valve implantation patients, the S3 valve was associated with a lower rate of paravalvular AoR but also with a higher residual gradient than the EVR system.

Culotte Technique With a Bioresorbable Vascular Scaffold: 12 Months' Follow-up.

Se realizó una coronariografı́a a una mujer de 60 años de edad con sı́ndrome coronario agudo sin elevación del segmento ST, en la cual se observó una oclusión de la primera rama marginal (figura 1 A). Tras la predilatación se vieron dos ramas de similar diámetro, con importante estenosis de la rama inferior y estenosis leve en el ostium de la rama superior (figura 1 B). Se implantó un armazón vascular bioabsorbible Absorb (Abbott Vascular, California, USA) de 3 x 28 mm en la primera rama marginal hacia la rama inferior. Al observar una estenosis grave del ostium de la rama superior enjaulada, se implantó un segundo Absorb de 3 x 18 mm según la técnica de culotte, seguido de dilatación kissing balloon con dos balones NC (no compliantes) de 2,5 mm a 6 atmósferas (para evitar la sobreexpansión de la zona proximal) y a continuación posdilatación en la primera rama marginal-rama inferior (NC de 3 x 15 mm) (figura 1C). Rev Esp Cardiol. 2016;69(10):973–974