Maria Sanchez-Ledesma

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.

Hyperglycemia on admission predicts larger infarct size in patients undergoing percutaneous coronary intervention for acute ST-segment elevation myocardial infarction

AIMS To determine if hyperglycemia on admission correlates to infarct size measured by single-photon emission computed tomography (SPECT) in patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). METHODS We evaluated 347 STEMI patients who underwent primary PCI. Infarct size was determined by SPECT on Day 5. The population was divided into: hyperglycemia (glycemia on admission >11mmol/L) or non-hyperglycemia (<or=11mmol/L) regardless of diabetic status. RESULTS 61 (17.6%) patients presented with hyperglycemia on admission. There were no significant differences in baseline characteristics or in PCI characteristics between the two groups. Final TIMI 3 flow was achieved in 81.7% of patients with hyperglycemia vs 85.7% of patients with non-hyperglycemia (p=0.43). The infarct size was larger in the hyperglycemia group (6 [2-14]% vs 8.5 [3-18.25]%; p=0.016). A multivariate linear regression analysis showed that hyperglycemia on admission was an independent predictor of infarct size at Day 5 post-MI (p=0.004). CONCLUSION In patients with STEMI treated with primary PCI, hyperglycemia on admission is associated with larger infarct size determined by SPECT.

Association between -T786C NOS3 polymorphism and resistant hypertension: a prospective cohort study

BackgroundIt is estimated that 5% of the hypertensive patients are resistant to conventional antihypertensive therapy. Polymorphisms in the endothelial nitric oxide synthase (NOS3) gene have been associated with high blood pressure levels, but not with resistant hypertension. The aim of the present study was to investigate if the -786T>C and G894T (Glu298Asp) polymorphisms of the NOS3 gene were associated with resistant hypertension.MethodsA prospective case-control observational study was performed. From a series of 950 consecutive patients followed up during 42 months, 48 patients with resistant hypertension were detected. 232 patients with controlled high blood pressure were also included.ResultsNo differences were observed in the distribution of G894T (Glu298Asp) NOS3 genotypes between the resistant hypertension group and the controlled hypertension patients. However, genotype -786CC was more frequent in the group of patients with resistant hypertension (33.3%) than in the group of patients with controlled high blood pressure (17.7%) (p 0.03). Furthermore carriers of allele T (-786TC and -786TT) were more frequent in patients with controlled hypertension (82.3%) than those with resistant hypertension (66.7%) (Multivariate analysis; RR 2.09; 95% CI 1.03–4.24; p 0.004).ConclusionOur results indicate that genotype -786CC of the NOS3 gene increase the susceptibility to suffer resistant hypertension, which suggest that resistance to conventional therapy could be determined at the endothelial level.

Trombocitopenia inducida por heparina

La complicacion mas comun y reconocida del tratamiento con heparina es la hemorragia, pero una complicacion potencialmente mas peligrosa es el desarrollo de la trombocitopenia inducida por heparina (TIH). Todos los pacientes expuestos a heparina de cualquier tipo y a cualquier dosis estan en riesgo de TIH. Se debe a la formacion de anticuerpos contra el complejo heparina-factor plaquetario 4, que secundariamente activa las plaquetas y la coagulacion y finalmente produce un aumento en la formacion de trombina. El sintoma principal es una trombocitopenia brusca, con una caida del 50% en el recuento plaquetario con respecto a los valores basales, y/o complicaciones tromboticas que aparecen 5 a 14 dias tras el comienzo del tratamiento con heparina. La monitorizacion del recuento plaquetario en pacientes que reciben heparina permite el diagnostico precoz de la TIH. La demostracion de la activacion plaquetaria dependiente de heparina con metodos antigenicos o funcionales confirma el diagnostico. Una vez que se confirma serologicamente el diagnostico de TIH o la sospecha es alta, se debe suspender el tratamiento con heparina y valorar el tratamiento con anticoagulantes alternativos. En esta revision se discute los aspectos diagnosticos y el manejo de este sindrome.

Left atrial appendage exclusion using an Amplatzer device

Patients with atrial fibrillation are at an increased risk of having a cardioembolic stroke. Most of the thrombi responsible for these ischemic events originate in the left atrial appendage (LAA). Several surgical and percutaneous endovascular techniques have been explored to occlude the LAA. As an alternative of the surgical closure, percutaneous exclusion of the LAA is a new approach used to prevent strokes in high-risk patients with AF and contraindication to long-term oral anticoagulant therapy. Currently, two devices have been developed specifically for percutaneous occlusion of the LAA the PLAATO system and the WATCHMAN filter system. Although the Amplatzer septal occluder device was not originally intended to occlude the LAA it has been used with success in our centre for this purpose. We present an illustrative case of a patient with AF no longer suitable for chronic OCA referred for percutaneous exclusion of the LAA. She was treated successfully with an Amplatzer septal occluder. Although our experience with this device holds promise, future trials will be necessary to explore this strategy.

What is the optimal anticoagulation level with argatroban during percutaneous coronary intervention

Argatroban is increasingly used in patients with heparin-induced thrombocytopenia. Although the recommended activated clotting time during percutaneous coronary intervention is 300–450 s, this recommendation is based on the limited data. This single-center, retrospective study evaluated the efficacy (composite of death, myocardial infarction, or urgent revascularization) and safety (evaluated by thrombolysis in myocardial infarction major bleeding) of argatroban during percutaneous coronary intervention according to activated clotting time levels. Patients were divided into three groups according to the activated clotting time achieved during the procedure (<300s, 300–450s, and >450 s). In this study, 120 consecutive patients with confirmed or suspected heparin-induced thrombocytopenia received argatroban (241 ± 104 μg/kg bolus, followed by a 18 ± 10 μg/kg per min infusion) during percutaneous coronary intervention. The indication for percutaneous coronary intervention was stable angina in 20% of patients, unstable angina or non-ST elevation myocardial infarction in 58%, and ST elevation myocardial infarction in 22%. An adjunctive glycoprotein IIb/IIIa inhibitor was used in 56 patients (46.7%). When divided into three groups on the basis of the activated clotting time (<300, 300–450, >450 s), no significant difference was observed between the groups in the efficacy endpoint, which occurred in 9.8% (6/61) of patients in the group with activated clotting time less than 300 s, 19.6% (9/46) of patients in the group with activated clotting time 300–450 s, and 7.7% (1/13) of patients in the group with activated clotting time more than 450 s (P = 0.58). The rate of major bleeding was higher in the group of patients with activated clotting time more than 450 s (1.6, 0, and 15.4% patients, respectively; P = 0.006). These results suggest that in patients undergoing percutaneous coronary intervention, argatroban provides adequate anticoagulation with a low bleeding rate, when activated clotting time is maintained below 450 s.

Impact of concomitant aortic regurgitation on percutaneous mitral valvuloplasty: Immediate results, short-term, and long-term outcome

BACKGROUND The aim of the study is to examine the effect of concomitant aortic regurgitation (AR) on percutaneous mitral valvuloplasty (PMV) procedural success, short-term, and long-term clinical outcome. No large-scale study has explored the impact of coexistent AR on PMV procedural success and outcome. METHODS Demographic, echocardiographic, and procedure-related variables were recorded in 644 consecutive patients undergoing 676 PMV at a single center. Mortality, aortic valve surgery (replacement or repair) (AVR), mitral valve surgery (MVR), and redo PMV were recorded during follow-up. RESULTS Of the 676 procedures performed, 361 (53.4%) had no AR, 287 (42.5%) mild AR, and 28 (4.1%) moderate AR. There were no differences between groups in the preprocedure characteristics, procedural success, or in the incidence of inhospital adverse events. At a median follow-up of 4.11 years, there was no difference in the overall survival rate (P = .22), MVR rate (P = .69), or redo PMV incidence (P = .33). The rate of AVR was higher in the moderate AR group (0.9% vs 1.9% vs 13%, P = .003). Mean time to AVR was 4.5 years and did not differ significantly between patients with no AR, mild AR, or moderate AR (2.9 +/- 2.1 vs 5.7 +/- 3.6 vs 4.1 +/- 2.5 years, P = .46). CONCLUSIONS Concomitant AR at the time of PMV does not influence procedural success and is not associated with inferior outcome. A minority of patients with MS and moderate AR who undergo PMV will require subsequent AVR on long-term follow-up. Thus, patients with rheumatic MS and mild to moderate AR remain good candidates for PMV.

Difference in outcome among women and men after percutaneous mitral valvuloplasty

Objective: To analyze the differences in anatomical, clinical and echocardiographic characteristics of women and men undergoing PMV and to evaluate the relationship between sex, PMV success, and immediate and long‐term clinical outcome. Background: Rheumatic mitral stenosis (MS) is predominantly a disease of middle‐aged women. Percutaneous mitral valvuloplasty (PMV) has become the standard of care for suitable patients. However little is known about the relationship between sex, PMV success, and procedural outcome. Methods and results: We evaluated measures of procedural success and clinical outcome in consecutive patients (839 women and 176 men) who underwent PMV. Despite a lower baseline echocardiographic score (7.47 ± 2.15 vs. 8.02 ± 2.18, P = 0.002), women were less likely to achieve PMV success (69% vs. 83%, adjusted OR 0.44, 95% CI 0.27–0.74, P = 0.002), and had a smaller post‐procedural MV area (1.86 ± 0.7 vs. 2.07 ± 0.7 cm2, P < 0.001). Overall procedural and in‐hospital complication rates did not differ significantly between women and men. However, women were significantly more likely to develop severe MR immediately post PMV (adjusted OR 2.41, 95% CI 1.0–5.83, P = 0.05) and to undergo MV surgery (adjusted HR 1.54, 95% CI 1.03–2.3, P = 0.037) after a median follow‐up of 3.1 years. Conclusions: Compared to men, women with rheumatic MS who undergo PMV are less likely to have a successful outcome and more likely to require MV surgery on long‐term follow‐up despite more favorable baseline MV anatomy.

Effect of Elevated Pulmonary Vascular Resistance on Outcomes After Percutaneous Mitral Valvuloplasty

Patients with mitral stenosis with severe pulmonary hypertension constitute a high-risk subset for surgical commissurotomy or valve replacement. The aim of the present study was to examine the effect of elevated pulmonary vascular resistance (PVR) on percutaneous mitral valvuloplasty (PMV) procedural success, short- and long-term clinical outcomes (i.e., mortality, mitral valve surgery, and redo PMV) in 926 patients. Of the 926 patients, 263 (28.4%) had PVR ≥4 Woods units (WU) and 663 (71.6%) had PVR <4 WU. Patients with PVR ≥4 WU were older and more symptomatic and had worse valve morphology for PMV. The patients with PVR ≥4 WU also had lower PMV procedural success than those with PVR <4 WU (78.2% vs 85.6%, p = 0.006). However, after multivariate adjustment, PVR was no longer an independent predictor of PMV success nor an independent predictor of the combined end point at a median follow-up of 3.2 years. In conclusion, elevated PVR at PMV is not an independent predictor of procedural success or long-term outcomes. Therefore, appropriately selected patients with rheumatic mitral stenosis might benefit from PMV, even in the presence of elevated preprocedural PVR.