Ignacio Cruz-Gonzalez

Left atrial appendage occlusion for stroke prevention in atrial fibrillation: multicentre experience with the AMPLATZER Cardiac Plug.

AIMS To investigate the safety, feasibility, and efficacy of left atrial appendage occlusion (LAAO) with the AMPLATZER Cardiac Plug (ACP) for stroke prevention in patients with atrial fibrillation (AF). METHODS AND RESULTS Data from consecutive patients treated in 22 centres were collected. A total of 1,047 patients were included in the study. Procedural success was 97.3%. There were 52 (4.97%) periprocedural major adverse events. Follow-up was complete in 1,001/1,019 (98.2%) of successfully implanted patients (average 13 months, total 1,349 patient-years). One-year all-cause mortality was 4.2%. No death at follow-up was reported as device-related. There were nine strokes (0.9%) and nine transient ischaemic attacks (0.9%) during follow-up. The annual rate of systemic thromboembolism was 2.3% (31/1,349 patient-years), which is a 59% risk reduction. There were 15 major bleedings (1.5%) during follow-up. The annual rate of major bleeding was 2.1% (28/1,349 patient-years), which is a 61% risk reduction. Patients with single LAAO on aspirin monotherapy or no therapy and longer follow-up had fewer cerebral and fewer bleeding events. CONCLUSIONS In this multicentre study, LAAO with the ACP showed high procedural success and a favourable outcome for the prevention of AF-related thromboembolism. Modification in antithrombotic therapy after LAAO may result in reduction of bleeding events.

Intravascular Detection of the Vulnerable Plaque

Coronary heart disease (CHD) remains the leading cause of death in the United States, and an estimated 1.4 million Americans have a heart attack each year. Over the past 2 decades, the concept of the “vulnerable plaque” (VP) being responsible for the majority of acute coronary syndromes (ACS) has become widely accepted. Coincidentally, there has been rapid expansion of coronary imaging modalities, both invasive and noninvasive, seeking the ability to detect high-risk plaques before their disruption and formation of occlusive thrombus. Histological characteristics of the plaques that are vulnerable to rupture are thin fibrous cap (<65 μm), large lipid pool, and activated macrophages near the fibrous cap, all of which can be detected with high-resolution coronary imaging.1 Cellular mechanisms associated with plaque instability include inflammation, reduced collagen synthesis, local overexpression of collagenase, and smooth muscle cell apoptosis. These pathological processes can alter the plaque surface and its mechanical properties, which also have been targets of recent research. Noninvasive tests, such as CT and MRI are limited by low resolution and are unable to visualize most of the features of VP. At present, only intravascular modalities can potentially distinguish VP from benign types of plaques. In this review, we focus on the recent data from the various types of intravascular modalities currently available or in development and compare their advantages and limitations. Coronary plaque develops eccentrically, and increasing plaque volume induces positive remodeling of the vessel, resulting in external elastic membrane expansion and preservation of luminal area. Coronary angiography only visualizes the coronary lumen and does not provide any information about the characteristics of the arterial wall and its contents. For this reason, coronary angiography has failed as a diagnostic modality for detection of VP, which often causes only modest luminal narrowing. Various histological plaque components have been targeted as …

Left atrial appendage exclusion: State‐of‐the‐art

It is postulated that the source of thromboembolism in 90% of patients with non‐valvular atrial fibrillation (AF) arises from the left atrial appendage (LAA). Anticoagulation with warfarin is the standard medical therapy for stroke prevention in patients with AF. However, chronic warfarin therapy is contraindicated in 14 to 44% of patients with AF who are at risk for stroke. Mechanical exclusion of the LAA may prevent thrombus formation in the appendage and hence reduce the risk of stroke. Recently, several studies of percutaneous transcatheter delivery of dedicated LAA exclusion devices such as the PLAATO device, Watchman device and the Amplatzer cardiac plug, have shown encouraging results as an alternative to warfarin therapy for selected patients. This article aims to review the current evidence for LAA exclusion in patients with AF.

Thrombus formation after left atrial appendage exclusion using an amplatzer cardiac plug device

The feasibility and safety of left atrial appendage closure with the Amplatzer cardiac plug (AGA Medical Corp., Minneapolis, MN) have been recently published; no thrombus formation on the device surface has been reported previously. We describe a case of a 66‐year‐old man with permanent atrial fibrillation, previous stroke, and contraindication for long‐term oral anticoagulant therapy. A 22‐mm ACP device was deployed successfully without complications. The patient was discharged on acetyl salicylic acid 100 mg and clopidogrel 75 mg daily. After 4 weeks, the patient was admitted for a lower gastrointestinal bleeding and clopidogrel was stopped. A 3‐month follow‐up echocardiogram confirmed the exclusion of the LAA but it demonstrated the presence of a thrombus on the atrial surface of the device. It was decided to keep the patient on acetyl salicylic acid 100 mg with the addition of enoxaparin 60 mg bid. Transesophageal echocardiogram demonstrated total resolution of the thrombus after 2 months.

Coronary Artery Perforations in the Contemporary Interventional Era

BACKGROUND Coronary perforations represent a serious complication of percutaneous coronary intervention (PCI). METHODS We performed a retrospective analysis of documented coronary perforations at Massachusetts General Hospital from 2000 to 2008. Medical records review and detailed angiographic analysis were performed in all patients. RESULTS Sixty-eight cases of coronary perforation were identified from a total of 14,281 PCIs from March 2000 to March 2008 representing an overall incidence of 0.48%. The study cohort was predominantly male (61.8%), mean age 71+/-11 years with 78% representing acute cases (unstable angina: 36.8%, NSTEMI: 30.9%, STEMI: 10.3%). Coronary artery perforation occurred as a complication of wire manipulation in 45 patients (66.2%) with 88.9% of this group being hydrophilic wires, of coronary stenting in 11 (16.2%), of angioplasty alone in 6 (8.8%), and of rotational atherectomy in 8 (11.8%). The perforation was sealed with an angioplasty balloon alone in 16 patients (23.5%), and with stents in 14 patients (20.6%) (covered stents: 11.8% and noncovered stents: 8.8%). Emergency CABG was performed in 2 patients (2.9%). Five patients (7.4%) developed periprocedural MI. The in-hospital mortality rate was 5.9% in the study cohort. CONCLUSION Coronary artery perforation as a complication of PCI is still rare as demonstrated in our series with an incidence of 0.48%. The predominant cause of coronary perforations in the current era of PCI is wire injury.

Foramen oval permeable: situación actual

El foramen oval permeable es una lesion cardiaca congenital presente en el 25% de la poblacion adulta. Su diagnostico, evaluacion y tratamiento han despertado un creciente interes desde que se propuso que esta entidad tiene relacion con diversas patologias como el infarto cerebral criptogenico, el sindrome platipnea-ortodesoxia, el sindrome de descompresion o las migranas. Sin embargo, hay datos contradictorios sobre estas asociaciones. De la misma forma, el tratamiento de eleccion en los pacientes con foramen oval permeable es un tema que permanence en discusion. Este articulo aborda una revision sobre la anatomia, la embriologia, la epidemiologia, las asociaciones clinicas y las opciones terapeuticas de esta entidad.

Clinical outcomes of state-of-the-art percutaneous coronary revascularization in patients with de novo three vessel disease: 1-year results of the SYNTAX II study.

Abstract Aims To investigate if recent technical and procedural developments in percutaneous coronary intervention (PCI) significantly influence outcomes in appropriately selected patients with three-vessel (3VD) coronary artery disease. Methods and results The SYNTAX II study is a multicenter, all-comers, open-label, single arm study that investigated the impact of a contemporary PCI strategy on clinical outcomes in patients with 3VD in 22 centres from four European countries. The SYNTAX-II strategy includes: heart team decision-making utilizing the SYNTAX Score II (a clinical tool combining anatomical and clinical factors), coronary physiology guided revascularisation, implantation of thin strut bioresorbable-polymer drug-eluting stents, intravascular ultrasound (IVUS) guided stent implantation, contemporary chronic total occlusion revascularisation techniques and guideline-directed medical therapy. The rate of major adverse cardiac and cerebrovascular events (MACCE [composite of all-cause death, cerebrovascular event, any myocardial infarction and any revascularisation]) at one year was compared to a predefined PCI cohort from the original SYNTAX-I trial selected on the basis of equipoise 4-year mortality between CABG and PCI. As an exploratory endpoint, comparisons were made with the historical CABG cohort of the original SYNTAX-I trial. Overall 708 patients were screened and discussed within the heart team; 454 patients were deemed appropriate to undergo PCI. At one year, the SYNTAX-II strategy was superior to the equipoise-derived SYNTAX-I PCI cohort (MACCE SYNTAX-II 10.6% vs. SYNTAX-I 17.4%; HR 0.58, 95% CI 0.39–0.85, P = 0.006). This difference was driven by a significant reduction in the incidence of MI (HR 0.27, 95% CI 0.11–0.70, P = 0.007) and revascularisation (HR 0.57, 95% CI 0.37–0.9, P = 0.015). Rates of all-cause death (HR 0.69, 95% CI 0.27–1.73, P = 0.43) and stroke (HR 0.69, 95% CI 0.10–4.89, P = 0.71) were similar. The rate of definite stent thrombosis was significantly lower in SYNTAX-II (HR 0.26, 95% CI 0.07–0.97, P = 0.045). Conclusion At one year, clinical outcomes with the SYNTAX-II strategy were associated with improved clinical results compared to the PCI performed in comparable patients from the original SYNTAX-I trial. Longer term follow-up is awaited and a randomized clinical trial with contemporary CABG is warranted. ClinicalTrials.gov Identifier NCT02015832

The Ibero-American transcatheter aortic valve implantation registry with the CoreValve prosthesis. Early and long-term results

BACKGROUND Transcatheter aortic valve implantation (TAVI) is the recommended therapy for patients with severe aortic stenosis who are not suitable candidates for surgery. The aim of this study was to describe early experience and long-term follow-up with the CoreValve self-expanding aortic prosthesis at 42 Ibero-American hospitals. METHODS Multiple centre observational study including 1220 consecutive patients with symptomatic severe aortic stenosis who are not suitable candidates for surgery and underwent transcatheter aortic valve implantation with the self-expanding Medtronic CoreValve System between December 2007 and May 2012. RESULTS The registry included 1220 consecutive patients with a mean age of 80.8 ± 6.3 years and a mean logistic euroSCORE of 17.8% ± 13%. The procedural success rate was 96.1%. Hospital mortality was 7.3% and combined end-point was 21.3%. Aortic regurgitation after TAVI was present in 24.5% (Sellers grade ≥ 2). The estimated 1-year and 2-year survival rates were 82.1% and 73.4% respectively. The following issues were significant independent risk factors for hospital mortality: acute kidney failure (odds ratio 3.55); stroke (odds ratio 5.72); major bleeding (odds ratio 2.64) and euroSCORE (odds ratio 1.02). Long-term predictors of mortality were diabetes mellitus (hazard ratio 1.59, 95% confidence interval 1.09-2.31), severe chronic obstructive pulmonary disease (hazard ratio 1.85, 95% confidence interval 1.85-2.88), and functional classes NYHA III-IV (hazard ratio 1.31, 95% confidence interval 1.01-1.70). CONCLUSIONS Transcatheter aortic valve implantation constitutes a safe and viable therapeutic option for high operative risk patients with severe aortic stenosis. Long-term prognosis is conditioned by associate comorbidities.

Identification of serum endoglin as a novel prognostic marker after acute myocardial infarction.

Endoglin is a proliferation‐associated and hypoxia‐inducible protein expressed in endothelial cells. The levels of soluble circulating endoglin and their prognostic significance in patients with acute myocardial infarction (AMI) are not known. In this observational prospective study serum endoglin levels were measured by ELISA in 183 AMI patients upon admission to hospital and 48 hrs later and in 72 healthy controls. Endoglin levels in AMI patients on admission were significantly lower than in healthy controls (4.25 ± 0.99 ng/ml versus 4.59 ± 0.87 ng/ml; P= 0.013), and decreased further in the first 48 hours (3.65 ± 0.76 ng/ml, P < 0.001). Upon follow‐up (median 319 days), patients who died had a significantly greater decrease in serum endoglin level over the first 48 hrs than those who survived (1.03 ± 0.91 versus 0.54 ± 0.55 ng/ml; P= 0.025). Endoglin decrease was an independent predictor of short‐term (30 days) (hazard ratio 2.33;95% CI = 1.27–4.23; P= 0.006) cardiovascular mortality, and also predicts overall cardiovascular mortality during the follow‐up (median 319 days) in AMI patients (hazard ratio 2.13;95% CI = 1.20–3.78; P= 0.01). In conclusion, early changes in serum endoglin may predict mortality after AMI.

Predicting Success and Long-Term Outcomes of Percutaneous Mitral Valvuloplasty: A Multifactorial Score

BACKGROUND Percutaneous mitral valvuloplasty (PMV) success depends on appropriate patient selection. A multifactorial score derived from clinical, anatomic/echocardiographic, and hemodynamic variables would predict procedural success and clinical outcome. METHODS Demographic data, echocardiographic parameters (including echocardiographic score), and procedure-related variables were recorded in 1085 consecutive PMVs. Long-term clinical follow-up (death, mitral valve replacement, redo PMV) was performed. Multivariate regression analysis of the first 800 procedures was performed to identify independent predictors of procedural success. Significant variables were formulated into a risk score and validated prospectively. RESULTS Six independent predictors of PMV success were identified: age less than 55 years, New York Heart Association classes I and II, pre-PMV mitral area of 1 cm(2) or greater, pre-PMV mitral regurgitation grade less than 2, echocardiographic score of 8 or greater, and male sex. A score was constructed from the arithmetic sum of variables present per patient. Procedural success rates increased incrementally with increasing score (0% for 0/6, 39.7% for 1/6, 54.4% for 2/6, 77.3% for 3/6, 85.7% for 4/6, 95% for 5/6, and 100% for 6/6; P < .001). In a validation cohort (n = 285 procedures), the multifactorial score remained a significant predictor of PMV success (P < .001). Comparison between the new score and the echocardiographic score confirmed that the new index was more sensitive and specific (P < .001). This new score also predicts long-term outcomes (P < .001). CONCLUSION Clinical, anatomic, and hemodynamic variables predict PMV success and clinical outcome and may be formulated in a scoring system that would help to identify the best candidates for PMV.