Manuel F. Jiménez-Navarro

Percutaneous Implantation of the CoreValve ® Self-expanding Valve Prosthesis in Patients With Severe Aortic Stenosis and Porcelain Aorta: Medium-term Follow-up

INTRODUCTION AND OBJECTIVESnThere is little information on the use of transcatheter aortic valve implantation in patients with severe aortic stenosis and porcelain aorta. The primary aim of this study was to analyze death from any cause after CoreValve(®) implantation in patients with severe aortic stenosis, with and without porcelain aorta.nnnMETHODSnIn this multicenter, observational prospective study, carried out in 3 hospitals, percutaneous aortic valves were implanted in 449 patients with severely calcified aortic stenosis. Of these, 36 (8%) met the criteria for porcelain aorta. The primary end-point was death from any cause at 2 years.nnnRESULTSnPatients with porcelain aorta more frequently had extracardiac vascular disease (11 [30.6%] vs 49 [11.9%]; P=.002), prior coronary revascularization (15 [41.7%] vs 98 [23.7%]; P=.017), and dyslipidemia (26 [72.2%] vs 186 [45%]; P=.02). In these patients, there was greater use of general anesthesia (15 [41.7%] vs 111 [16.9%]; P=.058) and axillary access (9 [25%] vs 34 [8.2%]; P=.004). The success rate of the procedure (94.4 vs 97.3%; P=.28) and the incidence of complications (7 [19.4%] vs 48 [11.6%]; P=.20) were similar in both groups. There were no statistically significant differences in the primary end point at 24 months of follow-up (8 [22.2%] vs 66 [16%]; P=.33). The only predictive variable for the primary end point was the presence of complications during implantation (hazard ratio=2.6; 95% confidence interval, 1.5-4.5; P=.001).nnnCONCLUSIONSnIn patients with aortic stenosis and porcelain aorta unsuitable for surgery, percutaneous implantation of the CoreValve(®) self-expanding valve prosthesis is safe and feasible.

Rendimiento de la glucohemoglobina y un modelo de riesgo para la deteccion de diabetes desconocida en pacientes coronarios

INTRODUCTION AND OBJECTIVESnTraditionally, the oral glucose tolerance test has been useful to diagnose unknown diabetes. Recently, the American Diabetes Association committee has accepted glycated hemoglobin ≥ 6.5% as a criterion for unknown diabetes. The aim was to determine the benefit of glycated hemoglobin for diagnosing unknown diabetes and also create a predictive model that adjusts the indication for oral glucose tolerance test in coronary patients.nnnMETHODSnWe examined the glycemic profile of 338 coronary patients without previous diagnosis of diabetes, applying 2010 American Diabetes Association criteria. A unknown diabetes risk predictive model was developed using logistic regression analysis, and then validated in another cohort.nnnRESULTSnUsing the glycated hemoglobin criteria and/or fasting plasma glucose, unknown diabetes was diagnosed in 26 patients. The remaining patients were classified according to oral glucose tolerance test as follows: unknown diabetes 53 (17%), prediabetes 144 (46.2%), and normoglycemic 115 (36.8%). The diagnostic method for unknown diabetes was fasting plasma glucose in 25.3%, glycated hemoglobin in 7.6%, and oral glucose tolerance test in 67.1%. A risk model including fasting plasma glucose, glycated hemoglobin, left ventricular ejection fraction, age, and noncoronary vascular disease was shown to effectively predict unknown diabetes after oral glucose tolerance test: area under the ROC curve 0.8 (95% confidence interval: 0.74-0.87). When the oral glucose tolerance test is restricted to patients with a risk score >6 (31% of our sample) we properly identify 83% of unknown diabetes cases (sensitivity: 75%, specificity: 73%, positive predictive value: 40%, negative predictive value: 93%). The model was adequately validated in another cohort of 115 patients (area under the ROC curve 0.84 [95% confidence interval: 0.74-0.95]).nnnCONCLUSIONSnIn coronary patients, glycated hemoglobin alone failed to detect many cases of unknown diabetes. However, its inclusion in a risk prediction model leads to optimizing the usefulness of oral glucose tolerance test.

Uso de antagonistas de los receptores de aldosterona tras el infarto de miocardio. Datos del registro REICIAM

INTRODUCTION AND OBJECTIVESnAlthough of proven effectiveness, there are no data available on the patterns of aldosterone antagonists use in the setting of acute myocardial infarction.nnnMETHODSnThe REICIAM registry is a prospective study designed to provide data regarding the incidence and management of heart failure after acute myocardial infarction. The aim of the present analysis was to determine the patterns of aldosterone antagonists use in this situation.nnnRESULTSnFrom a total of 2703 patients with acute myocardial infarction, 416 (15.4%) were considered optimal candidates to receive aldosterone antagonists, but only 228 (54.8%) received the treatment. The independent factors associated with their administration were male sex (odds ratio=2.06; 95% confidence interval, 1.23-3.49; P=.006), absence of prior kidney failure (odds ratio=3.31; 95% confidence interval, 1.26-9.06; P=.02), presentation with ST elevation (odds ratio=2.01; 95% confidence interval, 1.21-3.35; P=.007) and the development of malignant arrhythmias (odds ratio=2.75; 95% confidence interval, 1.3-6.05; P=.009). The lower the ejection fraction, the higher the likelihood of receiving aldosterone antagonists. The major independent predictor for receiving aldosterone antagonists was the prescription of diuretics during hospitalization (odds ratio=7.11; 95% confidence interval, 3.72-14.23; P <.00001), but also treatment with clopidogrel, beta-blockers, and statins. Although patients treated with aldosterone antagonists had a higher risk profile, they had a better 30-day survival rate than untreated patients (88.3% and 77.7% respectively; P <.0001).nnnCONCLUSIONSnThe use of aldosterone antagonists in post-acute myocardial infarction is only 54.8% of the optimal candidates. Their use is associated with male sex, a higher risk profile, and the use of diuretics and other drugs of proven efficacy in secondary prevention.

La extensión de la enfermedad coronaria determina la movilización de las células progenitoras endoteliales y las citocinas tras un primer infarto de miocardio con elevación del ST

INTRODUCTION AND OBJECTIVESnMultivessel coronary disease is still a postinfarction prognostic marker despite new forms of reperfusion, such as primary angioplasty. The aim of this study was to determine the time sequence of various sets of endothelial progenitor cells and angiogenic cytokines (vascular endothelial growth factor, hepatocyte growth factor) according to the degree of extension of the postinfarction coronary disease.nnnMETHODSnWe studied the release kinetics in 32 patients admitted for a first myocardial infarction with ST elevation, grouped according to whether they had single or multivessel disease, and 26 controls.nnnRESULTSnThe patients had a higher number of endothelial progenitor cells and angiogenic cytokines than the controls at all 3 measurements (admission, day 3, and day 7) of the following subsets: CD34, CD34+CD133+, CD34+KDR+, and CD34+CD133+KDR+CD45+(weak); this latter was higher on day 7. The levels of these cell subsets were all higher in the patients with single-vessel disease and at all 3 measurements. The vascular endothelial growth factor levels were raised during the first week and the hepatocyte growth factor showed an early peak on admission for infarction. No significant differences were seen in the cytokines according to coronary disease extension.nnnCONCLUSIONSnAlthough the release kinetics of different subsets of endothelial progenitor cells in patients with a first acute myocardial infarction with ST elevation was similar in those with single vessel disease to those with multivessel disease, the number of circulating endothelial progenitor cells was greater in the patients with single vessel disease. The vascular endothelial growth factor levels were raised during the first postinfarction week and the hepatocyte growth factor were higher on admission.

Impact of transcatheter aortic valve implantation with the CoreValve prosthesis in patients with severe aortic stenosis and left ventricular dysfunction

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Influence of preinfarction angina on the release kinetics of endothelial progenitor cells and cytokines during the week after infarction

Eur J Clin Invest 2011; 41 (11): 1220–1226

Expression of epicardial adipose tissue thermogenic genes in patients with reduced and preserved ejection fraction heart failure

Epicardial adipose tissue has been proposed to participate in the pathogenesis of heart failure. The aim of our study was to assess the expression of thermogenic genes (Uncoupling protein 1 (UCP1), peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α), and PR-domain-missing 16 (PRDM16) in epicardial adipose tissue in patients with heart failure, stablishing the difference according to left ventricular ejection fraction (reduced or preserved). Among the 75 patients in our study, 42.7% (n=32) had reduced left ventricular ejection fraction. UCP1, PGC1α and PRDM16 mRNA in EAT were significantly lower in patients with reduced left ventricular ejection fraction. Multiple regression analysis showed that age, male gender, body max index, presence of obesity, type-2-diabetes mellitus, hypertension and coronary artery disease and left ventricular ejection fraction were associated with the expression levels of UCP1, PGC1α and PRDM16 mRNA. Thermogenic genes expressions in epicardial adipose tissue (UCP1: OR 0.617, 95%CI 0.103-0.989, p=0.042; PGC1α: OR 0.416, 95%CI 0.171-0.912, p=0.031; PRDM16: OR 0.643, 95%CI 0.116-0.997, p=0.044) were showed as protective factors against the presence of heart failure with reduced left ventricular ejection fraction, and age (OR 1.643, 95%CI 1.001-3.143, p=0.026), presence of coronary artery disease (OR 6.743, 95%CI 1.932-15.301, p<0.001) and type-2-diabetes mellitus (OR 4.031, 95%CI 1.099-7.231, p<0.001) were associated as risk factors. The adequate expression of thermogenic genes has been shown as possible protective factors against heart failure with reduced ejection fraction, suggesting that a loss of functional epicardial adipose tissue brown-like features would participate in a deleterious manner on heart metabolism. Thermogenic genes could represent a future novel therapeutic target in heart failure.

Prognostic value of body mass index in transcatheter aortic valve implantation: A “J”-shaped curve

OBJECTIVESnWe aimed to determine whether body mass index (BMI) is a prognostic indicator for long-term, all-cause mortality in patients undergoing transcatheter aortic valve implantation (TAVI).nnnBACKGROUNDnObesity in patients with established cardiovascular disease has previously been identified as an indicator of good prognosis, a phenomenon known as the obesity paradox. The prognostic significance of BMI in patients with severe aortic stenosis (AoS) undergoing TAVI is a matter of current debate, as published studies are scarce and their results conflicting.nnnMETHODSnThis is an observational, retrospective study involving 770 patients who underwent TAVI for AoS. The cohort was divided into three groups based on their BMI: normal weight (≥18.5 to <25kg/m2), overweight (≥25 to <30kg/m2) and obese (≥30kg/m2). The predictive effect of BMI on all-cause mortality 3years following TAVI intervention was analysed using a Cox regression.nnnRESULTSn155 patients died during follow-up. The overweight group (n=302, 38.97%), experienced a lower mortality rate compared to the normal weight and obese groups (15.9% vs 25.7% and 21.0%, respectively [log-rank p-value=0.036]). After adjustment by logistic EuroSCORE, being overweight was found to be an independent protective factor against mortality (HR: 0.63 [95% CI: 0.42 to 0.94], p=0.024). This was not the case for obesity (HR: 0.92 [95% CI: 0.63 to 1.35], p=0.664). We therefore describe for the first time, a J-shaped regression curve describing the relationship between BMI and mortality.nnnCONCLUSIONSnBMI is a predictive factor of all-cause mortality in AoS patients undergoing TAVI. This relationship takes the form of a J-shaped curve in which overweight patients are associated with the lowest mortality rate at follow-up.

Long-term Follow-up of Patients With Severe Aortic Stenosis Treated With a Self-expanding Prosthesis

INTRODUCTION AND OBJECTIVESnTranscatheter aortic valve implantation (TAVI) is a safe and effective alternative to surgical treatment in patients with severe aortic stenosis (AS) and those who are inoperable or at high surgical risk. The primary objective of this study was to evaluate the long-term survival of consecutive patients with severe AS treated with TAVI.nnnMETHODSnObservational, multicenter, prospective, follow-up study of consecutive patients with severe symptomatic AS treated by TAVI in 3 high-volume hospitals in Spain.nnnRESULTSnWe recruited 108 patients, treated with a self-expanding CoreValve prosthesis. The mean age at implantation was 78.6 ± 6.7 years, 49 (45.4%) were male and the mean logistic EuroSCORE was 16% ± 13.9%. The median follow-up was 6.1 years (2232 days). Survival rates at the end of years 1, 2, 3, 4, 5, and 6 were 84.3% (92.6% after hospitalization), 77.8%, 72.2%, 66.7%, 58.3%, and 52.8%. During follow-up, 71 patients (65.7%) died, 18 (25.3%) due to cardiac causes. Most (82.5%) survivors were in New York Heart Association class I or II. Six patients (5.5%) developed prosthetic valve dysfunction.nnnCONCLUSIONSnLong-term survival in AS patients after TAVI is acceptable. The main causes of death are cardiovascular in the first year and noncardiac causes in subsequent years. Valve function is maintained over time.

Diferencias en el pronostico de la insuficiencia cardiaca con funcion sistolica conservada o deprimida en pacientes mayores de 70 anos que toman bloqueadores beta

INTRODUCTION AND OBJECTIVESnMost studies have shown that prognosis of heart failure with preserved systolic function is as poor as that of heart failure with depressed systolic function, although these results may be biased by the fact that these types of heart failure have different characteristics (age, comorbidity, treatment), which can influence prognosis. Our aim was to determine whether short-term morbidity and mortality differed in these 2 subgroups of heart failure patients when they were comparable in terms of age, associated comorbidity, and therapy.nnnMETHODSnWe analyzed 2 groups of patients aged >70 years who were candidates to receive beta blockers (preserved systolic function, 245; depressed systolic function, 374), consecutively discharged from 53 participating Spanish hospitals with a diagnosis of heart failure, and compared cardiovascular morbidity and mortality 3 months after discharge.nnnRESULTSnMean age was similar (77.5±4.8 vs 78.2±5.5 years). Left ventricular ejection fraction was 56.2%±8.1% vs 33%±6.9% (P<.001). The combined event rate (death, hospitalization for heart failure, acute coronary syndrome, or stroke) at 3 months after discharge was lower in patients with heart failure and preserved systolic function (13.4% vs 20.6%; P=.026). Depressed systolic function was an independent predictor of greater incidence of events (odds ratio=1.732; P=.048).nnnCONCLUSIONSnIn patients of similar age and receiving similar treatment, short-term prognosis is better in patients with heart failure and preserved systolic function than in those with depressed systolic function.