Iván J. Núñez-Gil

Transapical mitral valve-in-valve implantation: a novel approach guided by three-dimensional transoesophageal echocardiography

Prosthesis deterioration rate, years after a previous surgical valve replacement, is rising. Usually, the standard management is reoperation, but for very high risk patients an alternative has arisen: the valve-in-valve approach. We present an 84-year-old Caucasian woman with a mitral bioprosthesis (Mosaic II, number 29) since 1994. Over the last few months the patient displayed worsening heart failure symptoms, until her current admission in NYHA III-IV functional class, because of a severely degenerated mitral prosthesis (severe regurgitation, severe pulmonary hypertension). The transapical access, conventionally used for transcatheter aortic valve implantation (Edwards SAPIEN THV 23) was chosen, guided by transoesophageal echocardiography (TOE) with a new three-dimensional (3D) probe. After the procedure, the mitral regurgitation completely disappeared, an appropriate valve opening was achieved (valve area >2 cm(2)) and the patient was discharged 6 days later, remaining well in the outpatient follow-up. Only a restricted number of patients have been submitted to mitral transcatheter valve-in-valve implantation and to the best of our knowledge this is the first accurate description of the 3D TOE part, focusing on the surgeon requirements.

Prognostic implications of bundle branch block in patients undergoing primary coronary angioplasty in the stent era.

The presence of bundle branch block (BBB) in patients with ST-segment elevation myocardial infarction has been associated with a poor outcome. However, the implications of BBB in patients undergoing primary angioplasty in the stent era are poorly established. Furthermore, the prognostic implications of BBB type (right vs left and previous vs transient or persistent) remain unknown. We analyzed the data from 913 consecutive patients with ST-segment elevation myocardial infarction treated with primary angioplasty. All clinical, electrocardiographic, and angiographic data were prospectively collected. The median follow-up period was 19 months. The primary end point was the combined outcome of death and reinfarction. BBB was documented in 140 patients (15%). Right BBB (RBBB) was present in 119 patients (13%) and was previous in 27 (23%), persistent in 45 (38%), and transient in 47 (39%). Left BBB (LBBB) was present in 21 patients (2%) and was previous in 8 (38%), persistent in 9 (43%), and transient in 4 (19%). Patients with BBB were older, and more frequently had diabetes, anterior infarctions, a greater Killip class, a lower left ventricular ejection fraction, and greater mortality (all p <0.005) than patients without BBB. The short- and long-term primary outcome occurred more frequently in patients with persistent RBBB/LBBB than in those with previous or transient RBBB/LBBB. On multivariate analysis, persistent RBBB/LBBB emerged as an independent predictor of death and reinfarction. In conclusion, in patients undergoing primary angioplasty in the stent era, BBB is associated with poor short- and long-term prognosis. This risk appears to be particularly high among patients with persistent BBB.

Effects of intensive glucose control on platelet reactivity in patients with acute coronary syndromes. Results of the CHIPS Study ("Control de Hiperglucemia y Actividad Plaquetaria en Pacientes con Sindrome Coronario Agudo").

Objectives Hyperglycaemia has been associated with increased platelet reactivity and impaired prognosis in patients with acute coronary syndrome (ACS). Whether platelet reactivity can be reduced by lowering glucose in this setting is unknown. The aim of this study was to assess the functional impact of intensive glucose control with insulin on platelet reactivity in patients admitted with ACS and hyperglycaemia. Methods This is a prospective, randomised trial evaluating the effects of either intensive glucose control (target glucose 80–120 mg/dl) or conventional control (target glucose 180 mg/dl or less) with insulin on platelet reactivity in patients with ACS and hyperglycaemia. The primary endpoint was platelet aggregation following stimuli with 20 μM ADP at 24 h and at hospital discharge. Aggregation following collagen, epinephrine and thrombin receptor-activated peptide, as well as P2Y12 reactivity index and surface expression of glycoprotein IIb/IIIa and P-selectin were also measured. Results Of the 115 patients who underwent random assignment, 59 were assigned to intensive and 56 to conventional glucose control. Baseline platelet functions and inhospital management were similar in both groups. Maximal aggregation after ADP stimulation at hospital discharge was lower in the intensive group (47.9±13.2% vs 59.1±17.3%; p=0.002), whereas no differences were found at 24 h. Similarly all other parameters of platelet reactivity measured at hospital discharge were significantly reduced in the intensive glucose control group. Conclusions In this randomised trial, early intensive glucose control with insulin in patients with ACS presenting with hyperglycaemia was found to decrease platelet reactivity. Clinical Trial Registration Number http://www.controlledtrials.com/ISRCTN35708451/ISRCTN35708451.

Vegetation size at diagnosis in infective endocarditis: influencing factors and prognostic implications.

The role of vegetation as the key feature of infective endocarditis is universally recognized. Nowadays, the wide availability of transesophageal echocardiography has made of it the most employed technique to establish the diagnosis by visualizing vegetations. However, the factors which influence the size of vegetation when first detected are not clearly determined. Furthermore, there is considerable controversy regarding the prognostic implications of the size of vegetation. This is of paramount significance to early identify patients at high risk for complications, which might benefit from aggressive attitudes. We present a study based on TEE. Our results show that the size of vegetation at admission is mostly determined by anatomical and not microbiological factors, and the prognostic influence of vegetations on the risk of embolisms, need of surgery, persistent infection and septic shock.

Comparison of local versus general anesthesia in patients undergoing transcatheter aortic valve replacement: A meta-analysis

Transcatheter aortic valve replacement (TAVR) is typically performed under general anesthesia (GA). However, there is increasing data supporting the safety of performing TAVR under local anesthesia/conscious sedation (LA). We performed a meta‐analysis to gain better understanding of the safety and efficacy of LA versus GA in patients with severe aortic stenosis undergoing TAVR.

Optical Coherence Tomography Findings in Tako-Tsubo Cardiomyopathy

Tako-Tsubo (TT) cardiomyopathy is a rare clinical entity, initially described in Japan, characterized by a transient apical dyskinesia of unknown origin.1,2 Patients present with signs and symptoms typical of myocardial infarction, but the epicardial coronary arteries are normal and left ventricular wall motion abnormalities spontaneously resolve during follow-up.1–2 Although different etiologies have been proposed to explain the pathophysiology of TT, its cause remains unknown. Here we describe optical coherence tomography findings of a patient presenting with TT. A 63-year-old woman with a history of hypertension was admitted for prolonged chest pain. An ECG showed widespread 1- to 2-mm ST-segment elevation from V2 to V5. An echocardiogram revealed extensive anteroapical akinesia. Urgent coronary angiography using a left radial access revealed normal coronary …

Mild heart failure is a mortality marker after a non-ST-segment acute myocardial infarction

BACKGROUND The Killip classification categorizes heart failure (HF) in acute myocardial infarction, and has a prognostic value. Although non-ST-elevation myocardial infarction (NSTEMI) is increasing steadily, little information is available about the prognostic value of low Killip class in this scenario. Our aim was to assess the prognostic value of mild HF in NSTEMI. METHODS 835 patients with NSTEMI between 2005 and 2007 were prospectively recruited. Patients in Killip-1 (K1=684) or Killip-2 class (K2=113) were selected (38, with K>2, excluded). Clinical, angiographic, treatment strategies, and 30-day all-cause mortality, together with other cardiovascular outcomes were recorded. RESULTS K2 patients were mostly women (K1 27.9% vs K2 48.0%, p<0.001) and older (K1 66.6years vs K2 73.8years, p<0.001) with a higher frequency of diabetes mellitus (p<0.001) and hypertension (p<0.001). Smoking was less frequent in the K2-group (p=0.003). A previous infarction/revascularization history was similar in both groups. The infarction size, assessed by Troponin I/Creatin kinase, did not differ between groups (p=0.378 and p=0.855). Multivessel coronary disease and revascularization procedures were less common in group K2 (p=0.015 and p=0.005 vs group K1, respectively). Patients in K2 had a worse prognosis in terms of maximum Killip class, death and major adverse cardiovascular events (p<0.001). After multivariate analysis, mild HF at presentation was an independent risk factor for mortality (OR=6.50; IC 95%: 2.48-16.95; p<0.001). CONCLUSION Mild HF at presentation in NSTEMI is linked to a poor prognosis, with increased short-term mortality. Thus, a more aggressive approach including early cardiac catheterization and revascularization should be considered.

Functional mitral regurgitation after a first non-ST segment elevation acute coronary syndrome: very-long-term follow-up, prognosis and contribution to left ventricular enlargement and atrial fibrillation development

Objective To assess the relationship between functional mitral regurgitation (MR) after a non-ST segment elevation acute coronary syndrome (NSTSEACS) and long-term prognosis, ventricular remodelling and further development of atrial fibrillation (AF), since functional MR is common after myocardial infarction. Design and setting Prospective cohort study conducted in a tertiary referral centre. Patients We prospectively studied 237 patients consecutively discharged in New York Heart Association class I–II (74% men; mean age 66.1 years) after a first NSTSEACS. All underwent an ECG the first week after admission and were echocardiographically and clinically followed-up (median 6.95 years). Results MR was detected in 95 cases (40.1%) and became an independent risk factor for the development of heart failure (HF) and major adverse cardiovascular events (MACE) (per MR degree, HRHF 1.71, 95% CI 1.138 to 2.588, p=0.01; HRMACE 1.49, 95% CI 1.158 to 1.921, p=0.002). Left ventricular diastolic (grade I 12.7±40.7; grade II 26.8±12.4; grade III 46.3±50.9 mL, p=0.01) and systolic (grade I 10.4±37.3; grade II 10.12±12.7; grade III 36.8±46.0 mL, p=0.02) mean volumes were higher after follow-up in patients with MR, in proportion to the initial degree of MR. In the rhythm analysis (126 patients; previously excluding those with any history of AF) during follow-up, 11.4% of patients with degree I MR, 14.3% with degree II MR and 75% with degree III MR developed AF, while only 5.1% of those with degree 0 developed AF, p<0.001. Conclusions MR is common after an NSTSEACS. The presence and greater degree of MR confers a worse long-term prognosis after a first NSTSEACS. This can in part be explained by increased negative ventricular remodelling and increased occurrence of AF.

Safety and Efficacy of Intense Antithrombotic Treatment and Percutaneous Coronary Intervention Deferral in Patients With Large Intracoronary Thrombus

The optimal management of a large intracoronary thrombus in patients with acute coronary syndromes without an urgent need of revascularization is unclear. We investigated whether deferring percutaneous coronary intervention (PCI) after a course of intensive antithrombotic therapy (ATT) (glycoprotein IIb/IIIa inhibitors, enoxaparin, aspirin, and clopidogrel) improves the outcomes compared with immediate PCI. We studied 133 stable patients with ACS and a large intracoronary thrombus and without an urgent need for revascularization at angiography. The angiographic and in-hospital outcomes of a prospective cohort of 89 patients who had undergone deferred angiography with or without PCI after ATT (d-PCI) were compared with a historical cohort of 44 patients who had undergone immediate PCI, matched for age, gender, and Thrombolysis In Myocardial Infarction thrombus grade. The absolute thrombus volume was measured before and after ATT using dual quantitative coronary angiography. All d-PCI patients remained stable during ATT (60.0 ± 30.8 hours). A significant reduction in the Thrombolysis In Myocardial Infarction thrombus grade (4, range 4 to 5, vs 3, range 2 to 4; p <0.001), thrombus volume (51.1, range 32.1 to 83, vs 38.1, range 21.7 to 50.7 mm(3); p <0.001), stenosis severity (73.8 ± 25.8% vs 60.3 ± 32.5%; p <0.001) and better Thrombolysis In Myocardial Infarction flow (2, range 0 to 3, vs 3, 1.5 to 3; p <0.001) were noted after ATT. PCI, stenting, and thrombus aspiration were performed less frequently in the d-PCI group (76.4% vs 100%, p <0.001; 70.8% vs 93.2%, p = 0.003; and 21% vs 100%, p <0.001, respectively). However, distal embolization and slow and/or no-reflow were more common during immediate PCI (31.8% vs 9%; p = 0.001). No life-threatening or severe hemorrhagic complications were observed, although the rate of mild and/or moderate bleeding was similar between the 2 groups (6.8% in immediate PCI vs 7.9% in d-PCI; p = 0.829). In conclusion, compared with immediate PCI, d-PCI after ATT in selected, stabilized patients with ACS and a large intracoronary thrombus and without an urgent need for revascularization is probably safe and associated with a reduction in thrombotic burden, angiographic complications, and the need of revascularization. These benefits were observed without an increase in hemorrhagic complications.

Impact of Intravenous Lysine Acetylsalicylate Versus Oral Aspirin on Prasugrel-Inhibited Platelets Results of a Prospective, Randomized, Crossover Study (the ECCLIPSE Trial)

Background—Prasugrel and ticagrelor, new P2Y12-adenosine diphosphate receptor antagonists, are associated with greater pharmacodynamic inhibition and reduction of cardiovascular events compared with clopidogrel in patients with an acute coronary syndrome. However, evidence is lacking about the effects of achieving faster and stronger cyclooxygenase inhibition with intravenous lysine acetylsalicylate (LA) compared with oral aspirin on prasugrel-inhibited platelets. Methods and Results—This was a prospective, randomized, single-center, open, 2-period crossover platelet function study conducted in 30 healthy volunteers. Subjects were randomly assigned to receive a loading dose of intravenous LA 450 mg plus oral prasugrel 60 mg or loading dose of aspirin 300 mg plus prasugrel 60 mg orally in a crossover fashion after a 2-week washout period between treatments. Platelet function was evaluated at baseline, 30 minutes, 1 h, 4 h, and 24 h using light transmission aggregometry and vasodilator-stimulated phosphoprotein phosphorylation. The primary end point of the study, inhibition of platelet aggregation after arachidonic acid 1.5 mmol/L at 30 minutes, was significantly higher in subjects treated with LA compared with aspirin: 85.3% versus 44.3%, respectively, P=0.003. This differential effect was observed at 1 hour (P=0.002) and 4 hours (P=0.048), but not at 24 hours. Subjects treated with LA presented less variability and faster and greater inhibition of platelet aggregation with arachidonic acid compared with aspirin. Conclusions—The administration of intravenous LA resulted in a significant reduction of platelet reactivity compared with oral aspirin on prasugrel-inhibited platelets. Loading dose of LA achieves an earlier platelet inhibition and with less variability than aspirin. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT02243137.