Pablo Díez-Villanueva

Direct injury to right coronary artery in patients undergoing tricuspid annuloplasty.

BACKGROUND Direct injury to the right coronary artery as a result of reparative operation on the tricuspid valve is a rare, probably underdiagnosed, but serious complication, which often involves dramatic clinical consequences. So far, only five cases have been described in the literature. METHODS We describe our single-center experience of this complication, and review and analyze relevant clinical and anatomic considerations related to this entity. Cases previously reported in the literature were also reviewed. RESULTS We describe four cases of direct injury to the right coronary artery in patients undergoing tricuspid annuloplasty (DeVega annuloplasty, 3; ring annuloplasty, 1) in our institution since 2005. All patients had right ventricular dilatation and severely dilated tricuspid annulus. Right coronary artery occlusion always occurred between the right marginal artery and the crux of the heart. Patients presented with hemodynamic or electrical instability. Coronary flow could be restored in 2 patients (percutaneously 1; surgically 1), both of whom finally survived, while it was not technically possible in the other 2 (1 died). CONCLUSIONS Occlusion of the right coronary artery in patients undergoing tricuspid annuloplasty is a rare complication that may occur if great annulus dilatation is present, thus altering both normal annular geometry and the relationship between the right coronary artery and the tricuspid annulus, particularly when DeVega annuloplasty is performed. Such an entity should be considered in the immediate postoperative period in an unstable patient, especially when complementary tests support this diagnosis. Prompt recognition and treatment can positively affect the patients outcome, most often by means of an emergency revascularization strategy.

Comorbidity and intervention in octogenarians with severe symptomatic aortic stenosis

BACKGROUND The benefit from intervention in elderly patients with symptomatic severe aortic stenosis (AS) and high comorbidity is unknown. Our aims were to establish the correlation between the Charlson comorbidity index and the prognosis of octogenarians with symptomatic sever AS and to identify patients who might not benefit from intervention. METHODS We used the data from PEGASO (Pronóstico de la Estenosis Grave Aórtica Sintomática del Octogenario--Prognosis of symptomatic severe aortic stenosis in octogenarians), a prospective registry that included consecutively 928 patients aged ≥ 80 years with severe symptomatic AS. RESULTS The mean Charlson comorbidity index was 3.0 ± 1.7, a total of 151 patients (16.3%) presented high comorbidity (index ≥ 5). Median survival was lower for patients with high comorbidity than for those without (16.7 ± 1.2 vs. 26.5 ± 0.6 months, p < 0.001). In patients without high comorbidity planned interventional management was clearly associated with prognosis (log rank p < 0.001), which was not the case in patients with high comorbidity (log rank p > 0.10). In multivariate analysis, the only variables that were independently associated with prognosis were planned medical management and Charlson index. Patients with high comorbidity presented non-cardiac death more frequently than those who had not (28.6% vs. 19.5%, p = 0.008). CONCLUSIONS One sixth of octogenarians with symptomatic severe AS have very high comorbidity (Charlson index ≥ 5). These patients have a poor prognosis in the short term and do not seem to benefit from interventional treatment.

Management of Nonagenarian Patients With Severe Aortic Stenosis: The Role of Comorbidity

BACKGROUND The number of nonagenarian patients with aortic stenosis will likely increase due to the ageing population. We assessed the clinical characteristics, management, and outcomes of nonagenarian patients with severe aortic stenosis. METHODS A total of 177 (117 females and 60 males) consecutive nonagenarian patients from two large contemporary registries were included in this study. Clinical characteristics, comorbidity as assessed by the Charlson Index, clinical management, and outcomes were recorded. The main outcome measure was 1-year mortality. RESULTS The mean patient age was 91.1 years, and 56 patients (31.6%) had a Charlson Index <3. A strong association between comorbidity and 1-year overall mortality was observed, with higher 1-year mortality in patients with Charlson Index ≥3 (66.4% vs. 32.1%, p<0.001). A total of 150 patients (84.7%) were managed conservatively, and 27 (15.3%) underwent transcatheter aortic valve implantation (TAVI). Predictors of a conservative management were treatment out of TAVI centres, lower mean aortic gradient and better functional class. Clinical management was not significantly different with different degrees of comorbidity. A trend toward higher mortality in patients undergoing conservative management was observed (58% vs. 40.7%, p=0.097). Independent predictors of mortality were higher Charlson Index, lower creatinine clearance, lower mean aortic gradient, poorer left ventricular ejection fraction, significant mitral regurgitation and conservative management. CONCLUSIONS About one third of nonagenarians with severe aortic stenosis have few comorbidities. The clinical management was similar irrespective of the Charlson Index. Both higher Charlson Index values and a conservative management were independently associated with a higher mortality.

Clinical Cardiology, Geriatric Cardiology, Heart Failure, and Transplantation 2015: A Selection of Topical Issues.

Manuel Martinez-Selles,* Jose Luis Lambert Rodriguez, Vivencio Barrios, Pablo Diez-Villanueva, Jose Manuel Garcia Pinilla, Juan Cosin, Albert Ariza Sole, Sonia Mirabet Perez, Carlos Escobar, Oscar Diaz-Castro, Javier Segovia Cubero, and Jose Angel Rodriguez a Servicio de Cardiologia, Hospital Universitario Gregorio Maranon, Universidad Europea y Universidad Complutense, Madrid, Spain b Servicio de Cardiologia, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain c Servicio de Cardiologia, Hospital Universitario Ramon y Cajal, Madrid, Spain d Servicio de Cardiologia, Hospital Universitario de la Princesa, Madrid, Spain e Servicio de Cardiologia, Hospital Universitario Virgen de la Victoria, Malaga, Spain f Servicio de Cardiologia, Hospital Arnau de Vilanova, Valencia, Spain g Servicio de Cardiologia, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain h Servicio de Cardiologia, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, Spain i Servicio de Cardiologia, Hospital Universitario La Paz, Madrid, Spain j Servicio de Cardiologia, Hospital de Pontevedra, Pontevedra, Spain k Servicio de Cardiologia, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain l Servicio de Cardiologia, Hospital Universitario Juan Canalejo, A Coruna, Spain

Infective endocarditis: Absence of microbiological diagnosis is an independent predictor of inhospital mortality☆

Abstract Background Infective endocarditis (IE) is associated with high inhospital mortality. New microbiological diagnostic techniques have reduced the proportion of patients without etiological diagnosis, but in a significant number of patients the cause is still unknown. Our aim was to study the association of the absence of microbiological diagnosis with in-hospital prognosis. Methods Prospective cohort of 2000 consecutive patients with IE. Data were collected in 26 Spanish hospitals. Modified Duke criteria were used to diagnose patients with suspected IE. Results A total of 290 patients (14.8%) had negative blood cultures. Etiological diagnosis was achieved with other methods (polymerase chain reaction, serology and other cultures) in 121 (6.1%). Finally, there were 175 patients (8.8%) without microbiological diagnosis (Group A) and 1825 with diagnosis (Group B). In-hospital mortality occurred in 58 patients in Group A (33.1%) vs. 487 (26.7%) in Group B, p=0.07. Patients in Group A had a lower risk profile than those in Group B, with less comorbidity (Charlson index 1.9±2.0 vs. 2.3±2.1, p=0.03) and lower surgical risk (EuroSCORE 23.6±21.8 vs. 29.6±25.2, p=0.02). However they presented heart failure more frequently (53% vs. 40%, p=0.005). Multivariate analysis showed that the absence of microbiological diagnosis was an independent predictor of inhospital mortality (odds ratio 1.8, 95% Confidence Interval 1.1–2.9, p=0.016). Conclusion Approximately 9% of patients with IE had no microbiological diagnosis. Absence of microbiological diagnosis was an independent predictor of inhospital mortality.

Global Geriatric Assessment and In-Hospital Bleeding Risk in Elderly Patients with Acute Coronary Syndromes: Insights from the LONGEVO-SCA Registry

BACKGROUND Bleeding risk scores have shown a limited predictive ability in elderly patients with acute coronary syndromes (ACS). No study explored the role of a comprehensive geriatric assessment to predict in-hospital bleeding in this clinical setting. METHODS The prospective multicentre LONGEVO-SCA registry included 532 unselected patients with non-ST segment elevation ACS (NSTEACS) aged 80 years or older. Comorbidity (Charlson index), frailty (FRAIL scale), disability (Barthel index and Lawton-Brody index), cognitive status (Pfeiffer test) and nutritional risk (mini nutritional assessment-short form test) were assessed during hospitalization. CRUSADE score was prospectively calculated for each patient. In-hospital major bleeding was defined by the CRUSADE classification. The association between geriatric syndromes and in-hospital major bleeding was assessed by logistic regression method and the area under the receiver operating characteristic curves (AUC). RESULTS Mean age was 84.3 years (SD 4.1), 61.7% male. Most patients had increased troponin levels (84%). Mean CRUSADE bleeding score was 41 (SD 13). A total of 416 patients (78%) underwent an invasive strategy, and major bleeding was observed in 37 cases (7%). The ability of the CRUSADE score for predicting major bleeding was modest (AUC 0.64). From all aging-related variables, only comorbidity (Charlson index) was independently associated with major bleeding (per point, odds ratio: 1.23, p = 0.021). The addition of comorbidity to CRUSADE score slightly improved the ability for predicting major bleeding (AUC: 0.68). CONCLUSION Comorbidity was associated with major bleeding in very elderly patients with NSTEACS. The contribution of frailty, disability or nutritional risk for predicting in-hospital major bleeding was marginal.

Desensitization to acetylsalicylic acid in patients undergoing percutaneous coronary intervention. Experience in a tertiary center.

1. Garcı́a E, Martı́n-Hernández P, Unzué L, Hernández-Antolı́n R, Almerı́a C, Cuadrado A. Utilidad de colocar una guı́a desde la femoral contralateral para facilitar el tratamiento percutáneo de complicaciones vasculares en los TAVI. Rev Esp Cardiol. 2014;67:410–2. 2. Bogunovic N, Scholtz W, Prinz C, Faber L, Horstkotte D, van Buuren F. Percutaneous closure of left atrial appendage after transcatheter aortic valve implantation – An interventional approach to avoid anticoagulation therapy in elderly patients: TAVI and closure of LAA to avoid warfarin therapy. EuroIntervention. 2012;7:1361–3. 3. Puls M, Seipelt R, Schillinger W. Complete interventional heart repair of multiple concomitant cardiac pathologies in a staged approach. Catheter Cardiovasc Interv. 2013;81:896–900.

Atrioventricular Conduction Disorder as a First Manifestation of Arrhythmogenic Right Ventricular Dysplasia.

Arrhythmogenic right ventricular dysplasia (ARVD) has a prevalence in the general population of 1:2500 to 1:5000. Sudden death is the first manifestation of the disease in 11% to 22% of patients. We present the case of a 58-year-old man, with no personal or family history of heart disease, who was admitted to our hospital with a 1-month history of dyspnea. The electrocardiogram showed sinus rhythm with second-degree atrioventricular block Mobitz I, narrow QRS with RR’ pattern and epsilon wave in V1, inverted T waves from V1 to V4, and isolated ventricular ectopic beats with complete left bundle branch block (Figure 1A). Magnetic resonance imaging showed 31% ejection fraction of the right ventricle (RV), with ventricular volume in the upper limit of normal (end-diastolic volume indexed to body surface area, 92 mL/m), which was greater than the left ventricular volume (end-diastolic volume indexed to body surface area, 72 mL/m), with interventricular septum shift to the left due to volume overload in the right chambers (Figure 1B). We also observed dyskinesia, fibrosis and aneurysmal dilatation on the RV outflow tract and inferior wall. This combination of findings enabled us to confirm a diagnosis of ARVD. In view of the patient’s symptomatic atrioventricular block, a permanent pacemaker was indicated. We finally decided to insert an implantable cardioverter-defibrillator (ICD), due to intermediate risk of sudden death. During admission, telemetry showed no arrhythmia episodes. The patient was asymptomatic on discharge and genetic testing found no mutations associated with ARVD. One month later, the patient returned to our clinic to report an ICD discharge. The electrograms showed regular occurrence of atrial tachyarrhythmia, not previously observed, electrically-stimulated ventricular rhythm most of the time and several episodes of sustained ventricular tachycardia (SVT), all interrupted with antitachycardia pacing except 1, which received an ICD shock (Figure 2). Immediately before each SVT episode, we observed that the atrial arrhythmia did not reach the ventricle (appropriate mode switch), followed by detection of a ventricular beat, and then the SVT preceded by a paced ventricular beat. The patient was prescribed amiodarone, beta-blockers and anticoagulation therapy. Electroanatomic mapping in the electrophysiological study showed extensive areas of endocardial scarring on the RV inflow tract, basal portion of the inferior wall, and outflow tract. After receiving substrate ablation, the patient was discharged. He remains asymptomatic after 12 months of follow-up.

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.

Recommendations of the Geriatric Cardiology Section of the Spanish Society of Cardiology for the Assessment of Frailty in Elderly Patients With Heart Disease

Frailty is an age-associated clinical syndrome characterized by a decrease in physiological reserve in situations of stress, constituting a state of vulnerability that involves a higher risk of adverse events. Its prevalence in Spain is high, especially in elderly individuals with comorbidity and chronic diseases. In cardiovascular disease, frailty is associated worse clinical outcomes and higher morbidity and mortality in all scenarios, in both acute and chronic settings, and could consequently influence diagnosis and treatment. However, frailty is often not addressed or included when planning the management of elderly patients with heart disease. In this article, we review the available scientific evidence and highlight the most appropriate scales for the measurement and assessment of frailty, some of which are more useful and have better predictive capacity than others, depending on the clinical context. We also underline the importance of properly identifying and assessing frailty in order to include it in the treatment and care plan that best suits each patient.