Roman Arnold

Treatment of Aortocoronary Vein Graft Lesions With Membrane-Covered Stents: A Multicenter Surveillance Trial

BackgroundStent implantation in lesions of degenerated aortocoronary vein grafts is associated with a high risk of periprocedural thrombus embolization and in-stent restenosis. Methods and ResultsIn a multicenter study, we followed up 109 consecutive patients (mean age 66±8 years, 12% female) who received polytetrafluoroethylene (PTFE) membrane–covered stents for 125 de novo stenoses in vein grafts 11±5 years after bypass surgery. Stent deployment was successful in all but 1 patient; 1 patient suffered from subacute stent thrombosis. Six-month cardiac mortality was 7% (8 patients), 3 patients (3%) underwent repeat bypass surgery, and 9 patients (8%) required target-lesion PTCA. Repeat angiography revealed vessel occlusions in 9% and in-stent restenosis in 8% of patients by the end of follow-up. ConclusionsMembrane-covered stents appear to be a safe and efficient treatment strategy associated with a low incidence of restenosis and target-vessel revascularization. Compared with previous studies, the investigated device is not associated with an increase in mortality or late vessel occlusions.

Prognostic value of N-terminal pro-B-type natriuretic peptide for conservatively and surgically treated patients with aortic valve stenosis

Objective: To evaluate the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with aortic stenosis being treated conservatively or undergoing aortic valve replacement (AVR). Methods: 159 patients were followed up for a median of 902 days. 102 patients underwent AVR and 57 were treated conservatively. NT-proBNP at baseline was raised in association with the degree of severity and of functional status. Results: During follow up 21 patients (13%) died of cardiac causes or required rehospitalisation for decompensated heart failure. NT-proBNP at baseline was higher in patients with an adverse outcome than in event-free survivors (median 623 (interquartile range 204–1854) pg/ml v 1054 (687–2960) pg/ml, p  =  0.028). This difference was even more obvious in conservatively treated patients (331 (129–881) pg/ml v 1102 (796–2960) pg/ml, p  =  0.002). Baseline NT-proBNP independently predicted an adverse outcome in the entire study group and in particular in conservatively treated patients (area under the curve (AUC)  =  0.65, p  =  0.028 and AUC  =  0.82, p  =  0.002, respectively) but not in patients undergoing AVR (AUC  =  0.544). At a cut-off value of 640 pg/ml, baseline NT-proBNP was discriminative for an adverse outcome. Conclusion: NT-proBNP concentration is related to severity of aortic stenosis and provides independent prognostic information for an adverse outcome. However, this predictive value is limited to conservatively treated patients. Thus, the data suggest that assessing NT-proBNP may have incremental value for selecting the optimal timing of valve replacement.

Grosor íntima-media carotídeo en población española: valores de referencia y asociación con los factores de riesgo cardiovascular

INTRODUCTION AND OBJECTIVES Carotid intima-media thickness as measured with ultrasonography is an inexpensive and noninvasive predictor of cardiovascular events. The objectives of this study were to determine the population reference ranges of carotid intima-media thickness for individuals aged 35-84 years in Spain and to analyze the association of carotid intima-media thickness with cardiovascular risk factors (age, smoking, diabetes, pulse pressure, lipid profile, and body mass index). METHODS Population-based cross-sectional study conducted in Gerona (Spain). We described the mean and maximal values of carotid intima-media thickness of the carotid artery and of its 3 segments (common carotid, carotid bulb and internal carotid). We assessed cardiovascular risk factors and analyzed their association with carotid intima-media thickness using adjusted linear regression models. RESULTS A total of 3161 individuals (54% women) were included, with mean age 58 years. Men showed significantly higher mean common carotid intima-media thickness than did women (0.71 vs 0.67 mm). The strongest predictors of this measure were age (coefficients for 10-year increase: 0.65 and 0.58 for women and men, respectively), smoking in men (coefficient: 0.26), high-density lipoprotein cholesterol in women (coefficient for 10 mg/dL, increase: -0.08) and pulse pressure in both sexes (coefficients for 10 mmHg increase: 0.08 and 0.23 for women and men, respectively). The results were similar for the mean carotid intima-media thickness of all the segments. CONCLUSIONS This population-based study presents the reference ranges for carotid intima-media thickness in the Spanish population. The main determinants of carotid intima-media thickness were age and pulse pressure in both sexes.

Variabilidad inter e intraobservador en la valoración ecocardiográfica de la función del ventrículo derecho

Introduccion y objetivos La valoracion ecocardiografica de la funcion sistolica ventricular derecha es actualmente una cuestion pendiente de resolver, dadas las peculiaridades anatomicas del ventriculo derecho. Se han desarrollado diversos metodos para su calculo. El objetivo del presente estudio es determinar la fiabilidad y reproducibilidad de diferentes parametros ecocardiograficos estudiando su variabilidad inter e intraobservador. Metodos Se incluyeron 30 pacientes con valvulopatia mitral aislada candidatos a cirugia cardiaca. Se realizo un ecocardiograma a todos los pacientes por dos investigadores de forma independiente en un periodo de 24 h. El analisis intraobservador se obtuvo a partir del primer mes desde imagenes grabadas. Los parametros utilizados fueron la TAPSE (elevacion sistolica del plano del anillo tricuspideo), la velocidad pico sistolica del anillo tricuspideo por Doppler tisular, la fraccion de acortamiento del tracto de salida ventricular derecho, la fraccion de acortamiento de los diametros del ventriculo derecho y la fraccion de acortamiento de las areas del ventriculo derecho. La variabilidad fue analizada mediante el coeficiente de correlacion intraclase. Resultados La fuerza de concordancia de la TAPSE y la velocidad pico del anillo tricuspideo es buena en el analisis interobservador y excelente en el analisis intraobservador. Sin embargo, la fraccion de acortamiento del tracto de salida, de las areas y de los diametros muestran una pobre concordancia en el analisis inter e intraobservador Conclusiones Las medidas ecocardiograficas mas fiables y reproducibles en la valoracion de la funcion sistolica ventricular derecha en pacientes con valvulopatia mitral aislada son la TAPSE y la velocidad pico del anillo tricuspideo.

Inter- and Intra-Observer Variability in the Echocardiographic Evaluation of Right Ventricular Function

INTRODUCTION AND OBJECTIVES Echocardiographic evaluation of right ventricular systolic function remains subject to debate because of the anatomic peculiarities of the right ventricle. Several methods have been developed for quantifying right ventricular systolic function. The aim of this study was to determine the reliability and reproducibility of a number of echocardiographic parameters by evaluating their inter-observer and intra-observer variability. METHODS The study included 30 patients with isolated mitral valvulopathy scheduled for heart surgery. All underwent echocardiography, which was performed independently by two echocardiographers within 24 hours. The intra-observer analysis was carried out using the recorded images at least 1 month after they had been obtained. The parameters studied were the tricuspid annular plane systolic excursion (TAPSE), the tricuspid annular peak systolic velocity on tissue Doppler imaging, right ventricular outflow tract fractional shortening, fractional shortening of right ventricular diameters, and fractional shortening of right ventricular areas. Variability was analyzed using the intraclass correlation coefficient. RESULTS The degree of concordance on TAPSE and tricuspid annular peak systolic velocity measurement was good in the inter-observer analysis and excellent in the intra-observer analysis. However, concordance was poor on measurements of the fractional shortening of the right ventricular outflow tract, areas and diameters on both inter-observer and intra-observer analyses. CONCLUSIONS The most reliable and reproducible echocardiographic parameters for evaluating right ventricular systolic function in patients with isolated mitral valvulopathy were the TAPSE and the tricuspid annular peak systolic velocity.

Análisis cuantitativo de la función ventricular izquierda como herramienta para la investigación clínica. Fundamentos y metodología

La utilizacion de la fraccion de eyeccion del ventriculo izquierdo como objetivo subrogado en los ensayos clinicos esta avalada por numerosos estudios. Para que el rendimiento de este objetivo sea aceptable, es esencial ser muy rigurosos en la adquisicion de las imagenes y es conveniente utilizar unidades especificamente dedicadas a analizar cuantitativamente parametros de imagen con las diversas tecnicas disponibles. A continuacion se expone la evidencia disponible en relacion con la fraccion de eyeccion y los volumenes del ventriculo izquierdo, la importancia de las unidades de analisis de imagen y las distintas tecnicas disponibles. Finalmente, se comenta sobre las tecnicas de imagen de eleccion segun el contexto clinico.

Initial experience of percutaneous treatment of mitral regurgitation with MitraClip® therapy in Spain.

INTRODUCTION AND OBJECTIVES Symptomatic mitral regurgitation has an unfavorable prognosis unless treated by surgery. However, the European registry of valvular heart disease reports that 49% of patients with this condition do not undergo surgery. Percutaneous treatment of mitral regurgitation with MitraClip® has been proved a safe, efficient adjunct to medical treatment in patients with this profile. The objective of the present study is to describe initial experience of MitraClip® therapy in Spain. METHODS Retrospective observational study including all patients treated between November 2011 and July 2013 at the 4 Spanish hospitals recording the highest numbers of implantations. RESULTS A total of 62 patients (77.4% men) were treated, mainly for restrictive functional mitral regurgitation (85.4%) of grade III (37%) or grade IV (63%), mean (standard deviation) ejection fraction 36% (14%), and New York Heart Association functional class III (37%) or IV (63%). Device implantation was successful in 98% of the patients. At 1 year, 81.2% had mitral regurgitation ≤ 2 and 90.9% were in New York Heart Association functional class ≤ II. One periprocedural death occurred (sepsis at 20 days post-implantation) and another 3 patients died during follow-up (mean, 9.1 months). Two patients needed a second implantation due to partial dehiscence of the first device and 2 others underwent heart transplantation. CONCLUSIONS In Spain, MitraClip® therapy has principally been aimed at patients with functional mitral regurgitation, significant systolic ventricular dysfunction, and high surgical risk. It is considered a safe alternative treatment, which can reduce mitral regurgitation and improve functional capacity.

Tomografía de coherencia óptica. Experiencia inicial en pacientes sometidos a intervencionismo coronario percutáneo

La tomografia de coherencia optica es una nueva tecnica de diagnostico intracoronario, con una alta resolucion, superior a la de otras tecnicas como la ecografia intravascular. Se estudio mediante tomografia de coherencia optica el resultado tras implantar stent en 6 pacientes sometidos a intervencionismo coronario, con una imagen angiografica normal tras la revascularizacion. Se observo protrusion de material al stent en todos los pacientes, microdisecciones en los bordes del stent en 4 pacientes y mala posicion del stent en 4 pacientes. En 2 pacientes, se observo formacion de pequenos trombos alrededor del cateter de tomografia. La tomografia de coherencia optica permite detectar zonas de resultado suboptimo tras el intervencionismo coronario, a pesar de una adecuada imagen angiografica.

Anatomical and clinical predictors of valve dysfunction and aortic dilation in bicuspid aortic valve disease

Objective Bicuspid aortic valve (BAV) is associated with early valvular dysfunction and proximal aorta dilation with high heterogeneity. This study aimed to assess the determinants of these complications. Methods Eight hundred and fifty-two consecutive adults diagnosed of BAV referred from cardiac outpatient clinics to eight echocardiographic laboratories of tertiary hospitals were prospectively recruited. Exclusion criteria were aortic coarctation, other congenital disorders or intervention. BAV morphotype, significant valve dysfunction and aorta dilation (≥2 Z-score) at sinuses and ascending aorta were established. Results Three BAV morphotypes were identified: right–left coronary cusp fusion (RL) in 72.9%, right–non-coronary (RN) in 24.1% and left–non-coronary (LN) in 3.0%. BAV without raphe was observed in 18.3%. Multivariate analysis showed aortic regurgitation (23%) to be related to male sex (OR: 2.80, p<0.0001) and valve prolapse (OR: 5.16, p<0.0001), and aortic stenosis (22%) to BAV-RN (OR: 2.09, p<0.001), the presence of raphe (OR: 2.75, p<0.001), age (OR: 1.03; p<0.001), dyslipidaemia (OR: 1.77, p<0.01) and smoking (OR: 1.63, p<0.05). Ascending aorta was dilated in 76% without differences among morphotypes and associated with significant valvular dysfunction. By contrast, aortic root was dilated in 34% and related to male sex and aortic regurgitation but was less frequent in aortic stenosis and BAV-RN. Conclusions Normofunctional valves are more prevalent in BAV without raphe. Aortic stenosis is more frequent in BAV-RN and associated with some cardiovascular risk factors, whereas aortic regurgitation (AR) is associated with male sex and sigmoid prolapse. Although ascending aorta is the most commonly dilated segment, aortic root dilation is present in one-third of patients and associated with AR. Remarkably, BAV-RL increases the risk for dilation of the proximal aorta, whereas BAV-RN spares this area.

Absence of accelerated atherosclerotic disease progression after intracoronary infusion of bone marrow derived mononuclear cells in patients with acute myocardial infarction--angiographic and intravascular ultrasound--results from the TErapia Celular Aplicada al Miocardio Pilot study.

BACKGROUND We tried to evaluate a putative negative effect on coronary atherosclerosis in patients receiving intracoronary infusion of unfractionated bone marrow mononuclear cells (BMMC) following an acute ST-elevation myocardial infarction. Peripheral blood mononuclear cells or enriched CD133(+) BMMC have been associated with accelerated atherosclerosis of the distal segment of the infarct related artery (IRA). METHODS Thirty-seven patients with ST-elevation myocardial infarction from the TECAM pilot study underwent intracoronary infusion of autologous BMMC 9 +/- 3.1 days after onset of symptoms. We compared angiographic changes from baseline to 9 months of follow-up in the distal non-stented segment of the IRA, as well as in the contralateral coronary artery, with a matched control group. A subgroup of 15 treated patients underwent additional IVUS within the distal segment of the IRA. RESULTS No difference between stem cell and control group were found regarding changes in minimum lumen diameter (0.006 +/- 0.42 vs 0.06 +/- 0.41 mm, P = ns) and the percentage of stenosis (-2.68 +/- 12.33% vs -1.78 +/- 8.75%, P = ns) at follow-up. Likewise, no differences were seen regarding changes in the contralateral artery (minimum lumen diameter -0.004 +/- 0.54 mm vs -0.06 +/- 0.35 mm, P = ns). In the intravascular ultrasound substudy, no changes were demonstrated comparing baseline versus follow-up in maximum area stenosis and plaque volume. CONCLUSIONS In this pilot study, analysis of a subgroup of patients found that intracoronary injection of unfractionated BMMC in patients with acute ST-elevation myocardial infarction was not associated with accelerated atherosclerosis progression at mid term. Prospective, randomised studies in large cohorts with long-term angiographic and intravascular ultrasound follow-up are necessary to determine the safety of this therapy.