Juan Ruiz-García

Percutaneous Balloon Pericardiotomy as the Initial and Definitive Treatment for Malignant Pericardial Effusion

INTRODUCTION AND OBJECTIVES Malignant pericardial effusion has a high recurrence rate after pericardiocentesis. We sought to confirm the efficacy of percutaneous balloon pericardiotomy as the initial treatment of choice for these effusions. METHODS Retrospective analysis of the clinical, echocardiographic, and follow-up characteristics of a consecutive series of percutaneous balloon pericardiotomies carried out in a single center in patients with advanced cancer. RESULTS Seventeen percutaneous balloon pericardiotomies were performed in 16 patients with a mean age of 66.2 (15.2) years. Fourteen patients had pathologically confirmed metastatic neoplastic disease, 3 had previously required pericardiocentesis, and in the remaining patients percutaneous balloon pericardiotomy was the first treatment for the effusion. All patients had a severe circumferential effusion, and most presented evidence of hemodynamic compromise on echocardiography. In all cases, the procedure was successful, there were no acute complications, and it was well tolerated at the first attempt. There were no infectious complications during follow-up (median, 44 [interquartile range, 36-225] days). One patient developed a large pleural effusion that did not require treatment. Three patients needed a new pericardial procedure: 2 had elective pericardial window surgeries and 1 had a second percutaneous balloon pericardiotomy. CONCLUSIONS Percutaneous balloon pericardiotomy is a simple, safe technique that can be effective in the prevention of recurrence in many patients with severe malignant pericardial effusion. The characteristics of this procedure make it particularly useful in this group of patients to avoid more aggressive, poorly tolerated approaches.

Update in Pharmacological Management of Coronary No-Reflow Phenomenon

The no-reflow phenomenon (NRP) is defined as the lack of adequate myocardial tissue perfusion despite a patent epicardial coronary artery. The incidence of NRP varies between 2-5% of elective percutaneous coronary interventions (PCI) and 30% in primary PCI. Clinically, it is an independent predictor of myocardial infarction, in-hospital mortality, and long-term mortality. It may be categorized in interventional (after PCI, especially in saphenous venous grafts) or reperfusion NRP (after re-opening of a totally occluded coronary artery, usually during primary PCI or thrombolysis). There are many physiopathological factors implicated: distal microembolization, interstitial and intracellular edema, coronary spasm and capillary plugging. Although reperfusion and no reflow is a field of intense research, no single mechanical or pharmacological therapy has demonstrated a clear efficacy against NRP, probably due to its multifactorial nature. Once established, the treatment of NRP is based on vasodilators like adenosine, verapamil, nitroprusside or nicorandil. However, the efficacy of these measures is poor, so every effort should be made to prevent the apparition of NRP. The objective of this report is to provide an update of the pharmacological armamentarium available for the prevention and treatment of NRP, and suggest a systematic approach of the management of NRP according to the different possible clinical scenarios.

Percutaneous closure of left atrial appendage: device-indicated antiplatelet therapy may also lead to fatal bleeding. A call for evidence-based antiplatelet regimen

Percutaneous closure of left atrial appendage (PCLAA) is an emerging procedure that may be considered in patients with atrial fibrillation, high thromboembolic risk and contraindications for long-term oral anticoagulation. Amplatzer Cardiac Plug (ACP) (St. Jude Medical, Inc., Minnesota, USA), one of the two available devices specifically developed for PCLAA, requires dual antiplatelet therapy (DAPT) for a not well-defined period. However, this antiplatelet regimen also increases the risk of major bleedings [1], which may be especially high in patients undergoing PCLAA. We report a case of fatal intracranial hemorrhage in a patient taking DAPT after a PCLAA. A 66-year-old man with hypertension, insulin-dependent diabetes, chronic renal failure on dialysis and carotid artery disease was referred to our center for PCLAA because of frequent episodes of paroxysmal AF and two previous severe lower gastrointestinal bleedings requiring hospital admission and blood transfusion (CHA2DS2-VASc score 4; HAS-BLED score 4). At that moment, he was under single antiplatelet treatment (clopidogrel 75 mg o.d.). PCLAA was then successfully and uneventfully performed with a 22 mm ACP (Fig. 1a–d), and the patient was discharged under acetyl-salicylic acid 100 mg and clopidogrel 75 mg daily. One month after the procedure, transesophageal echocardiography showed no evidence of thrombus on the surface of the atrial disc and no residual shunt through the device (Fig. 1e,f). Nevertheless, in the absence of recommendations for stopping DAPT at this time, and given the negative bleeding history during previous month, medical treatment remained unchanged. Two weeks later he was readmitted with sudden and severe deterioration in his level of consciousness. At that time non-contrast CT scan showed a large spontaneous intraparenchymal hematoma located in the posterior cranial fossa with secondary intraventricular hemorrhage (Fig. 1g,h) that caused the death of the patient in 48 h. In patients with AF there are some recognized factors that simultaneously increase both thromboembolic and bleeding risk. As a consequence many patients with high risk of thromboembolism do not receive anticoagulation. Because of that, PCLAA has emerged as a very attractive strategy for these patients. The main reason for antiplatelet treatment following implantation of an intracardiac device is to prevent thrombus formation in its surfaces whilst the discs become completely endothelialized. To the best of our knowledge, that period has not been studied in humans and so there are no consensus recommendations concerning the appropriate antithrombotic regimen following an ACP implantation. First reports on PCLAA prescribed DAPT for 6 months and aspirin indefinitely [2]. The largest series with ACP suggested however the use of DAPT for 1–3 months followed by aspirin exclusively for C5 months in all patients, but only based on the experience of the participating centers [3]. Moreover, as a proof of the empirical and variable approach, three recent series have reported three new different protocols [4–6]. We agree with some authors that argue that antiplatelet regimen cannot be based on the low thrombogenicity found with other Amplatzer devices used for septal defects as those procedures are usually performed in younger patients who are in sinus rhythm [3, 6]. In fact, we already have available data regarding thrombus formation on ACP J. Ruiz-Garcı́a (&) R. Moreno Interventional Cardiology Unit, Cardiology Department, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain e-mail: j.ruizgarcia@hotmail.com

Neoatherosclerosis as the Cause of Very Late Bare-metal Stent Restenosis: Optical Coherence Tomography Evaluation

A man aged 49 years, ex-smoker with a family history of premature ischemic heart disease, attended the emergency department after 1 month with clinical symptoms of progressive angina following even minimal exertion. In 2001, he had presented non-Q wave acute myocardial infarction and undergone conventional bare-metal stent (BMS) implantation in the mid left anterior descending artery. In 2007, a coronary angiogram for exertional angina showed no stent restenosis. Following a change in treatment, he remained asymptomatic and recorded negative exercise test results until this admission in 2012. In view of symptoms of unstable angina, a fresh coronary angiography was requested and this showed substantial, focal intrastent restenosis (Fig. 1). An angioplasty guidewire was advanced through the stenosis without complications and a decision was made to use optical coherence tomography for the assessment. The optical coherence tomography showed correct expansion of the stent, absence of uncovered struts, and presence of intrastent neoatherosclerosis (Fig. 2) with lipid-laden intima, a cavity resulting from the rupture of the fibrous cap of a fine-cap fibroatheroma, and an apparently more fibrous proximal portion with images compatible with cholesterol crystal deposits. The intrastent restenosis was predilated with a delivery balloon and a drug-eluting stent implanted. Bare-metal stent restenosis has traditionally been considered stable and benign, presenting neointimal growth in the first 6 to 12 months followed by a later quiescent period. However, the angiographic clinical course of our patient and optical coherence tomography images support the recent theory that neoatherosclerosis is an active causal mechanism in many cases of restenosis and late stent thrombosis. Moreover, symptoms of progressive angina and the discovery of ruptured plaque intrastent confirm that presentation is not consistently in the form of silent ischemia or stable angina and it has been estimated that 9.5% of BMS restenoses could present as acute coronary syndrome. Histopathologic studies have shown that, while neoatherosclerosis is a common process in BMS and drug-eluting stent, its occurrence is neither homogeneous nor simultaneous. In drugeluting stent, incidence is more frequent and it appears early; in BMS, it is quite exceptional at<2 years. Nonetheless, at-risk lesions (fine-cap fibroatheroma and ruptured plaque) are more frequently detected in BMS restenosis, even though—as in our patient (Figs. 2A-C)—they mostly appear at>5 years postimplantation. Very little data exist on optical coherence tomography evaluation of late restenosis in BMS. Takano et al. studied initial behavior (<6 months) and course (>5 years) of coronary segments with BMS revascularization and found homogeneous neointimal coating in the first phase, but only in the second phase established the presence of calcium deposits, lipid nuclei, or cholesterol crystals accompanied by significant reduction of lumen. Habara et al. compared findings on early (<1 year) and late (>5 years) BMS restenosis and described significant differences in neointimal structure, which was more heterogeneous in appearance and much like typical atherosclerotic plaque. Finally, Yonetsu et al. also reported greater attenuation and lipid content in late (>48 months) BMS restenosis neointima by comparison with early BMS restenoses. Given known morbidity and mortality associated with restenosis and stent thrombosis, it is essential we study the pathologic mechanism in greater depth. The rupture and exposure to the circulating blood of prothrombotic lipid material contained in the neointima may be the cause of many thromboses. The present case shows how optical coherence tomography can contribute to our understanding of these mechanisms. Rev Esp Cardiol. 2013;66(5):403–415

Tomografía de coherencia óptica en la disección coronaria espontánea y en las complicaciones derivadas de su tratamiento percutáneo

A 53-year-old man who had recently abandoned triple antihypertensive therapy was referred by his healthcare center following a first episode of angina at rest, which coincided with a significant increase in blood pressure (180/100 mmHg) and was accompanied by diffuse transitory ST-segment depression. Coronary angiography showed tapering of the proximal-middle segment of the median branch, which intracoronary nitroglycerin failed to modify (Fig. 1A). As spontaneous coronary dissection (SCD) was suspected, optical coherence tomography (OCT) was used to study the vessel after unfractionated heparin (85 U/kg) was administered. The OCT confirmed focal intimal rupture (Fig. 1Aa) and revealed a double lumen proximally (Fig. 1Ab) and a subocclusive intramural hematoma more distally (Fig. 1Ac). Given that the patient had experienced several episodes similar to that for which he was admitted while receiving optimal medical treatment (acetylsalicylic acid, clopidogrel, fondaparinux, beta blockers and nitroglycerin), as well as the elevated troponin T observed (11 ng/mL), and his good median branch caliber, the treatment of choice was percutaneous revascularization with a direct drug-eluting stent (3 38 mm at 14 atm), which would completely cover the hematoma and intimal rupture (Fig. 1B). Using OCT, we confirmed the adequate seal and stent placement (Fig. 1Ba), although OCT also disclosed distal progression of the dissection, causing substantial obstruction of the vessel (Fig. 1Bb) and the distal deployment of our guidewire in the false lumen (Fig. 1Bc). After relocating the guidewire in the true lumen (Fig. 1Bd), a second drug-eluting stent was overlapped distally. Subsequent angiography revealed proximal progression of the hematoma causing severe lumen reduction in the median branch ostium and circumflex artery (Figs. 2A and Aa), which required 2 drug-eluting stent implants (Figs. 2Ab and Ac). We finally confirmed satisfactory angiographic results for the intervention (Fig. 2B) when OCT visualized adequate stent placement at the ostial level–which did not protrude into the left main coronary artery–and showed that the dissection had not progressed this far (Fig. 2Ba) or to the left anterior descending coronary artery (Fig. 2Bb). The patient was discharged with no new complications. From our point of view, the patient and his clinical course raise several interesting issues. Firstly, although SCD has typically been described in young women with no cardiovascular risk factors we should not forget that it also affects middle-aged men (<20%-30% of patients). The (unclear) pathophysiology of SCD has been attributed to intramural hematoma formation originating in inflammatory atherosclerotic processes, rupture of vasa vasorum,

Expectations of Survival Following Cardiopulmonary Resuscitation. Predictions and Wishes of Patients With Heart Disease.

After an in-hospital cardiorespiratory arrest, fewer than 25% of patients survive until hospital discharge, and substantial neurological sequelae are present in around 30% of survivors. Patients’ preferences regarding cardiopulmonary resuscitation (CPR) are tied to their perception of the chances of a successful outcome. An excessive optimism in our patients with regard to maneuvers such as CPR in the context of cardiovascular disease may have an impact on their expectations, thereby influencing whether they opt for do not resuscitate orders or advance directives. Our main objective was to determine the prognosis of cardiology patients after cardiorespiratory arrest and to assess whether this may have an impact on their desire for resuscitation. To this end, we conducted a descriptive study based on a voluntary and anonymous survey (Figure), administered during a private face-to-face interview with a single cardiologist (J. Ruiz-Garcı́a) in a consecutive series of patients after their visit to the cardiologist in a general hospital. In total, 130 consecutive cardiology patients were included in the study (Table). No patient refused to participate and only 2 preferred not to answer a question about do not resuscitate orders. The predicted mean survival at hospital discharge (question 1A) according to the responses of our group of patients was 75.6% 23.0% (median 80%, interquartile range 60%-94%). The predicted mean survival free of substantial neurological deterioration (question 1B) was 64.5% 26.2% (median 70%, interquartile range 50%-86%). With these expectations, 116 patients (89%) wished to be resuscitated in their current state, 1 would refuse CPR, and 12 (9%) had never considered this question. In the event of a change in their clinical condition and diagnosis with a chronic disease with a life expectancy less than 12 months, this number was significantly reduced (71 patients, 55%; P < .01) while the number of patients who would refuse CPR or who had never considered this question increased to 22 (17%; P < .01) and 34 (26%; P < .01), respectively. Twenty-eight patients (22%) reported never having seen or been present at a CPR; of those who had, most (86%) had seen it in a film or television series. Only 1 patient had deposited an advanced directives document or living will. However, 89 (69%) wanted to be the ones who took en España. [cited 09 Feb 2016]. Available at: http://www.aulacardioproteccion. net/uploads/2/9/9/7/2997300/_ministerior_de_sanidad.pdf 2. Bossaert LL. Perspectiva sobre las guı́as de reanimación de 2010 del European Resuscitation Council: la necesidad de hacerlo mejor. Rev Esp Cardiol. 2011;64:445–50. 3. Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, et al. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S414–35. 4. Castro Cuervo C, Cuartas Álvarez T, Castro Delgado R, Arcos González P. Study of knowledge in cardiopulmonary resuscitation and automated external defibrillation in sports instructors of public sport centers in Asturias (Spain). Enferm Clin. 2015;25:344–7.

Comparison between diabetic and non-diabetic patients after successful percutaneous coronary intervention for chronic total occlusions in the drug-eluting stent era

OBJECTIVE Diabetes mellitus and chronic total occlusions are associated with unfavorable outcome after percutaneous coronary intervention. We sought to assess the clinical and angiographic outcomes of diabetic and non-diabetic patients who underwent successful percutaneous revascularization of chronic total occlusions with drug-eluting stents. METHODS Baseline clinical and angiographic characteristics, procedural details, nine-month angiographic follow-up and clinical events at 12 months were compared between 75 diabetic and 132 non-diabetic patients included in a clinical trial that randomized successful recanalization of chronic total occlusions to receive sirolimus- or everolimus-eluting stents. RESULTS In both diabetic and non-diabetic groups there was a favorable non-significantly different angiographic result at nine months, with low in-stent late loss (0.14±0.60 mm vs. 0.25±0.68 mm, p=0.305) and rates of binary restenosis (4.0% vs. 10.6%, p=0.180) and reocclusion (0.0% vs. 2.3%, p=0.334). During follow-up similar survival from death (97.3±1.9% vs. 99.2±0.8%, log-rank p=0.273), acute myocardial infarction (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192), target vessel revascularization (88.7±3.8% vs. 88.2±2.9%, log-rank p=0.899) and stent thrombosis (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192) was observed. Furthermore, the presence of more diffuse peripheral and coronary artery disease and higher frequency of calcified lesions in diabetic patients did not lead to significant differences in the approach (20.0% vs. 25.0% radial approach, p=0.413), strategy (6.7% vs. 3.8% retrograde strategy, p=0.353), total stent length (48.1±24.6 mm vs. 49.2±23.9 mm, p=0758) or contrast volume (261.3±116.4 ml vs. 297.4±135.9 ml, p=0.109) required for revascularization. CONCLUSIONS In the drug-eluting stent era, diabetic and non-diabetic patients have comparable favorable clinical and angiographic outcomes after successful percutaneous revascularization of chronic total occlusions.Objective Diabetes mellitus and chronic total occlusions are associated with unfavorable outcome after percutaneous coronary intervention. We sought to assess the clinical and angiographic outcomes of diabetic and non-diabetic patients who underwent successful percutaneous revascularization of chronic total occlusions with drug-eluting stents.

Edad y deseos de reanimación cardiopulmonar en pacientes cardiológicos

A pesar de que la supervivencia actual al alta tras una parada ardiorrespiratoria (PCR) intrahospitalaria es menor del 25%, y que erca del 30% de esos supervivientes presentan secuelas neuroógicas significativas1, hemos comprobado recientemente que la upervivencia media al alta (76%) y la supervivencia media libre e deterioro neurológico significativo (65%) predicha por una serie onsecutiva de pacientes cardiológicos ambulatorios españoles, se leja significativamente de esa realidad2. La edad es un factor independiente de menor supervivencia al lta tras una reanimación cardiopulmonar (RCP), observándose que partir de los 75 años esa supervivencia es menor del 20%3. La conordancia entre los deseos del paciente sobre su reanimación y la ercepción de su médico de los mismos también empeora signifiativamente con ella4. En función de estos antecedentes elaboramos el presente anáisis con el objetivo principal de valorar si existen diferencias en a percepción de los resultados de la RCP en función de la edad si estas influyen en los deseos de reanimación. Se utilizó para llo un estudio transversal y descriptivo, desarrollado a través de na encuesta voluntaria y anónima, realizada durante una entreista presencial y personal, a una serie consecutiva de pacientes al nalizar su consulta hospitalaria de cardiología general2. Se realizó n estudio comparativo posterior entre el grupo de pacientes < 75 ños (n = 95; edad media 58,5 ± 12,9 años; 42% mujeres) y ≥ 75 años n = 35; edad media 81,3 ± 3,9 años; 51% mujeres). Se encontraron diferencias significativas, entre ambos grupos, n la supervivencia total media predicha al alta (79 vs. 67%; < 0,01), y en la supervivencia al alta sin deterioro neurológico sigificativo (70 vs. 51%; p < 0,01). Sin embargo, a pesar del mayor ptimismo de los más jóvenes, no existían diferencias en los deseos e reanimación. Así, 84 pacientes (88%) del primer grupo y 32 (91%) el segundo deseaban ser reanimados en su estado actual (p = 0,75), echazando la RCP tan solo un paciente < 75 años. En caso de ufrir una enfermedad crónica con limitación de su esperanzada e vida, continuaban deseando la RCP 48 pacientes < 75 años (51%) 23 ≥ 75 años (66%) (p = 0,16), mientras que aumentaba a 17 (18%) y pacientes (14%) (p = 0,79), respectivamente el número que rechaaba la RCP. 1

Infranodal Atrioventricular Block as a Possible Cause of Exercise-induced Cardiac Arrest

currents at the end of phase 1 of the action potential that enables the unmasking of the B-ECG. The case of a delayed positive response to flecainide reported here might indicate that results considered to be negative at the time of the challenge test may be false negatives, since the electrocardiographic monitoring time is usually 30 minutes or less. Studies involving a larger number of patients should be carried out to examine whether the systematic prolongation of the monitoring period following a FT could contribute to reducing the number of false negatives. V1 V1

Utilidade prática das técnicas de diagnóstico intracoronário no tratamento percutâneo da reestenose intrastent

We report a case of very late bare-metal stent restenosis, in which assessment by two intracoronary imaging techniques (intravascular ultrasound and optical coherence tomography) revealed the underlying mechanism (neoatherosclerosis) and facilitated percutaneous treatment (direct bare-metal stent-in-stent). We also take the opportunity to briefly describe the advantages and limitations of both techniques in this pathology.