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Introduction Severe symptomatic aortic stenosis is associated with high mortality without intervention. However, true waiting times for aortic valvular intervention (AVI) and the risks associated with it are not known. Objectives To measure the waiting time between referral and AVI. To determine the impact of the waiting time for AVI by assessing the occurrence of adverse events during this period. To assess predictors of adverse outcomes during this period in view to identify patients (pts) who may require earlier AVI. Methods Retrospective single-center study of consecutive outpatients referred for AVI (either surgically or transcatheter (TAVI)) since 2014 to 2018. The primary endpoint was hospitalization due to heart failure or death from any cause, occurring in the waiting time for AVI. Cox regression analysis was performed. Results Were included 120 pts (54% male, mean age 75±9 years). 113 (94%) pts had high-gradient aortic stenosis. They were mainly in NHYA class II (56%). Fatigue was the main symptom (83%). The median NT-proBNP value was 819 (IQR 319–1780) ng/L. The mean peak velocity was 4.5±0.5 m/s, median gradient of 45 (IQR 42–54) mmHg, mean VTIs ratio of 0,21±0.04, with a mean estimated valvular area of 0.7±0.2 cm2 (0.4±0.1 cm2/m2). During a mean follow-up of 24±14 months since referral, 108 (90%) pts were submitted to AVI (75 pts underwent surgery; 33 pts underwent TAVI). The median waiting time for AVI was 4 (IQR 2–6) months (0–35 months). The median waiting time for surgery was 3 (IQR 2–6) months and for TAVI was 4 (IQR 3–8) months (p=0.25). The primary endpoint occurred in 19 (16%) pts: 13 (11%) pts were hospitalized due to heart failure and 7 (6%) pts died. The median time between referral and the occurrence of the primary endpoint was 3 (IQR 1–9) months. In univariate analysis, age >80 years, NHYA class ≥3, prior stroke and NT-proBNP were positively associated with the occurrence of the primary endpoint (p After multivariate analysis, prior stroke (HR 5; 95% CI 1.2–24; p=0.03) and NT-proBNP (HR 1/unit; 95% CI 1–1.001; p=0.01) were independently associated with events occurrence. NT-proBNP was an independent predictor of events with a good discriminative value (area under the ROC curve 0.73; 95% CI 0.61–0.83; p=0.004). NT-proBNP cut-off value of >1207ng/L identified pts with an event while waiting AVI with a sensitivity and specificity value of 69 and 73%, respectively. Left ventricle ejection fraction, severity parameters of aortic stenosis, systolic pulmonary artery pressure, concomitant coronary artery disease and the time between diagnosis and referral were not associated with the primary endpoint. Conclusion Mortality and worsening of heart failure while waiting for aortic valvular intervention occurred frequently. Factors such NT-pro-BNP and personal history of stroke can help to identify pts who may benefit from earlier intervention. Funding Acknowledgement Type of funding source: None

Introduction Thermodilution (TD) and indirect Fick (IF) methods are widely used to measure cardiac output (CO). They are often used interchangeably to make critical clinical decisions, yet few studies have compared these approaches concerning agreement and comparative prognostic value as applied in medical practice. Purpose To assess agreement between TD and IF methods and to compare how well these methods predict mortality. Methods Retrospective cohort study including all consecutive right heart catheterizations performed in a referral pulmonary hypertension (PH) centre from 2010 to 2018. Cardiac index (CI) was calculated by indexed CO to body surface area. PH was classified according to the new definition of the 6st World Symposium on Pulmonary Hypertension 2018 [mean pulmonary arterial pressure (mPAP) >20 mmHg]. Patients with cardiac or extra-cardiac shunts or significant (moderate to severe or severe) tricuspid regurgitation were excluded. All-cause mortality over 1 year after right heart catheterization was recorded. Logistic regression was used to identify predictors of the adverse event. Results From a total of 569 procedures, 424 fulfilled the inclusion criteria: mean age 56.7±15.4 years, 67.3% female. Haemodynamic parameters were diagnosed of PH in 86.2% of cases: mPAP 35.3±15.3 mmHg, 83.6% pre-capillary subtype, 42.9% belonging to group 4 (chronic thromboembolic pulmonary hypertension) and 26.6% to group 1 (pulmonary arterial hypertension). Mean values of CO and CI were, respectively, 4.5±2.8 L/min and 2.5±0.8 L/min/m2 measured by TD and 4.6±2.4 L/min and 2.6±1.3 L/min/m2 measured by IF method. There was a median difference (IF minus TD) of - 0.03 / min to CO and - 0.05 L/min/m2 to CI but both meausres correlated only modestly (r=0.6 to TD and r=0.5 to IF). One-year all-cause mortality rate was 5.4% (median time to death was 50.5 days). Lower values of CO and CI assessed by TD were significantly associated with all-cause mortality occurrence (CO TD: 4.5±1.3 L/min versus 3.6±1.0 L/min, p Conclusions There is only modest agreement between TD and IF CO and CI estimates. Despite being more time-consuming, TD measurements were predictors of all-cause mortality and present a highest prognostic value. These findings favored their used over IF in clinical practice. Funding Acknowledgement Type of funding source: None

Introduction Right ventricular (RV) adaptation to the increased pulmonary load is a key determinant of outcomes in pulmonary hypertension (PH). Pulmonary vascular resistance (PVR) is widely recognized as haemodynamic measure of RV overload. Cardiac filling pressure (CFP), RV stroke work (RVSW), pulmonary artery (PA) compliance and PA pulsatility index (PAPi) are emerging as new haemodynamic parameters to assess RV function. Aims To assess the predictive value of CFP, RVSW, PA compliance and PAPi in PH and to compare it with standard haemodynamic parameters. Methods Retrospective study including all consecutive right heart catheterizations performed from April/2009 to October/2019 in a PH referral centre. Procedures presenting PH were selected [mean pulmonary arterial pressure (mPAP) >20 mmHg, according to the new definition of the 6st World Symposium on PH]. CFP was calculated as [right atrial pressure (RAP) − pulmonary capillary wedge pressure], value >0.63 associated with RV failure; RVSW as CO / [(heart rate × (mPAP-RAP) × 0.0136], value Results From a total of 569 procedures, 470 fulfilled PH criteria: mean age 57.9±16.0 years, 67.7% female, 35.5% performed under pulmonary vasodilator therapy. Pre-capillary PH was diagnosed in 71.9% of cases. Chronic thromboembolic PH was the most common subtype (34.4%). Concerning standard haemodynamic parameters: mPAP was 39.0±12.0 mmHg, mean RAP 8.0±5.0 mmHg, mean RVP 7.5±5.0 uWood and CI 2.5±0.8 L/min/m2. Median value of CFP was 0.6 (IQR 0.4–0.8), RVSW 15.2 (IQR 9.7–25.0), PA compliance 2.1 (IQR 0.9–2.9) and PAPi 5.3 (IQR 3.2–8.5). All-cause mortality rate was 22.8%. Patients experiencing adverse events had lower values of cardiac index (2.3±0.6 vs 2.6±0.8 L/min/m2, p Conclusions In this study, new haemodynamic parameters to assess RV overload in PH were not independent predictors of adverse events as opposite to standard haemodynamic parameters. Further studies are needed to clarify their predictive value, as it has major implications for understanding the arterial load in diseases of the pulmonary circulation. Funding Acknowledgement Type of funding source: None

Background To date, the first-line treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA), although a significant number of patients will have inoperable disease or residual pulmonary hypertension (PH). Balloon pulmonary angioplasty (BPA) has provided a new therapeutic option for these patients. In addition, medical therapy (MT) also plays an important role. Purpose Characterization of a population of patients with CTEPH or chronic thromboembolic disease (CTED) and comparison of the different treatment strategies according to the updated treatment algorithm. Methods Retrospective analysis of patients with CTEPH/CTED followed in a referral centre for the treatment of PH submitted to different treatment strategies: PEA plus MT and BPA in patients with residual PH (group 1), MT plus BPA (group 2), and MT only (group 3). Cox regression was used to identify predictors of all-cause mortality. Results 58 patients were included (median age 63.5 years, 74% female); 17% had CTED, and the remaining had CTEPH 50% (n=29) were submitted to PEA (group 1), of which 58% had residual PH (21% underwent BPA, n=3). Among the remaining patients, 31% (n=9) underwent MT plus BPA (group 2), and 69% (n=20) were treated with MT only (group 3). Overall, 55% were under pulmonary vasodilator therapy, including 38% with riociguat. Most of the patients (67%) were in functional class III or IV, the distance in the 6MWT was 328±147 meters, the median NT-proBNP was 538pg/ml, 40% had RV systolic dysfunction, the mean mPAP was 42±13 mmHg, and the mean PVR was 11±6 WU. Comparing the different treatment strategies, during follow-up (median 945 days) the following differences were found (comparison between group 1 vs group 2 vs group 3): improvement in functional class (class III-IV: 0% vs 0% vs 58%); distance in 6MWT (438±83 vs 390±79 vs 281±105 meters); evolution of NT-proBNP (−984±1736 vs −198±205 vs +1177±2342); normalization of RV dimensions (89% vs 50% vs 20%); resolution of pericardial effusion (100% vs 100% vs 0%); normalization of mPAP (73% vs 71% vs 0%); PVR (median 3.4 vs 2.7 vs 10.6 WU); all-cause mortality (7% vs 0% vs 35%) (p In the overall population, the most relevant predictors of all-cause mortality were the absence of functional class improvement, baseline and follow-up NT-proBNP, baseline and follow-up SPAP by echocardiogram, and maintenance of treatment with prostanoids (p Conclusion Our results confirm that, in patients with CTEPH/CTED, PEA is associated with functional, and hemodynamic improvement and increased survival, although BPA is an alternative in patients with inoperable disease or residual PH, with similar results on short-term follow-up. Patients who are not submitted to surgical or percutaneous intervention have a poor prognosis, both in terms of morbidity and mortality.

Introduction Unlike stable coronary disease, there is no consensus about the best revascularization strategy for unprotected left main coronary artery (ULMCA) disease associated with acute myocardial infarction (MI). Recent studies have shown that percutaneous coronary intervention (PCI) is technically feasible with acceptable outcomes, making it a reasonable alternative to surgical revascularization (CABG). Aims To describe the practice of ULMCA revascularization in MI patients (pts) and its evolution over an 9-year period. To analyze the prognosis of this population and determine the effect of revascularization on outcome. Methods Retrospective, multicenter national observational study that included 19 430 MI pts from October 2010 to December 2018. Pts who presented ULMCA as culprit lesion were selected and then compared the subgroup that underwent revascularization by PCI alone versus (vs.) CABG alone. Primary endpoint (PE) was a composite of all-cause death, nonfatal re-MI and nonfatal stroke during hospital stay. Secondary endpoint (SE) was all-cause death rate at 1-year after hospital discharge. Results 204 pts with ULMCA as culprit lesion were selected (1.1% of all pts): 77.9% male, mean age 69±12 years, 97 (47.5%) underwent CABG alone, 92 (45.1%) PCI alone, 10 (4.9%) no revascularization and 5 (2.5%) both strategies. At admission, pts undergoing PCI alone presented more frequently with ST-segment elevation, persistent chest pain, cardiogenic shock and higher values of GRACE risk score. During hospital stay, severe left ventricular (LV) systolic dysfunction ( Conclusions MI with ULMCA as culprit lesion is infrequent and associated with a high rate of adverse events during hospital stay. PCI was preferred in higher risk pts but, even after adjustment, it was associated with a less favorable short-term outcome compared to surgical strategy. Nevertheless, long-term prognosis was excellent in hospital survivors with no difference between both techniques. Randomized trials are needed to determine the ideal revascularization strategy for these pts.

Introduction Current clinical practice guidelines recommend risk stratification in patients with acute coronary syndrome (ACS) upon admission to the hospital. The Global Registry of Acute Coronary Events (GRACE) risk score was developed in a large multinational registry to predict both mortality and the combined events of death or reinfarction during the hospital stay and 6 months after discharge. Given the substantial regional variation and temporal changes in patient characteristics and management patterns, specially in non-ST segment elevation myocardial infarction (NSTEMI) patients, we sought to validate this risk score in a contemporary Portuguese population. Purpose To assess the discriminatory power of the GRACE risk score in a Portuguese contemporary cohort of patients with NSTEMI submitted to invasive strategy, regarding in-hospital mortality and the combined end-point of reinfarction and/or in-hospital mortality. Methods We included patients with NSTEMI submitted to coronary angiogram from the Portuguese Registry on Acute Coronary Syndrome (ProACS). For each patient, we calculated the GRACE risk score and classified them in low, intermediate or high risk, according to the cut-offs recommended in the guidelines. The discriminatory capacity of the GRACE risk score was evaluated by the area under the receiver operating characteristic [ROC] curve. The primary endpoint was defined as the occurrence of reinfarction and in-hospital mortality, and the secondary endpoint was in-hospital mortality. A model with an AUC-ROC between 0.8 and 0.9 was considered to have a good capacity for discrimination. Results Among the 19.430 patients included in the ProACS between October 2010 and January 2019, we identified 7304 patients with NSTEMI that performed coronary angiogram and had the GRACE score calculated (37.6%). Patients were divided in three groups according to the GRACE score (group 1: 1–108; group 2: 109–140; group 3: 141–372), with 24.9% included in group 1, 33.0% in group 2, and 42.1% in group 3. Most patients were male (73.4%), with a mean age of 66±12 years, and 48.0% were admitted to non-percutaneous coronary intervention centers. In-hospital mortality was 1.0% and the primary endpoint occurred in 2.2% of the patients. The discriminatory capacity of the GRACE score in our population was good regarding in-hospital mortality: the area under the ROC curve was 0.83 (95% confidence interval [CI], 0.783–0.878), with the best cut-off of 148. The discriminatory capacity for the primary end-point was reasonable; the area under the ROC curve was 0.700 (95% CI 0.654–0.745), and the best cut-off was 164. Conclusions In our population of patients with NSTEMI submitted to an invasive strategy, the GRACE risk score presented a moderate discriminatory capacity for the occurrence of reinfarction and in-hospital, and a a good discriminatory power for in-hospital mortality.

Background The population of elderly patients with acute myocardial infarction (MI) is clearly underrepresented in contemporary clinical trials. This population presents a higher risk of both cardiovascular and bleeding events, making the decision of the antithrombotic strategy particularly challenging. Purpose To characterize the antithrombotic therapy used in patients with MI and age ≥75 years, and to identify predictors of major bleeding and cardiovascular events in this population. Methods Retrospective analysis of patients with a diagnosis of MI and age ≥75 years included in the Portuguese Registry of Acute Coronary Syndromes between October 2010 and January 2018. Logistic regression analysis was used to identify predictors of major bleeding and of the combined endpoint of in-hospital mortality and reinfarction. Results The analysis included 17.868 patients of which 30.1% with age ≥75 years. This population had a mean age of 82±5 years, 57% were male and 36% had a diagnosis of STEMI. On admission 10% presented with Killip-Kimball (KK) class III or IV, 14% were on atrial fibrillation (AF), and the mean Hb and creatinine levels were 13±2 g/dl and 1.6±1.2 mg/dl, respectively. In comparison with younger patients, this population had higher Grace and Crusade scores (178 vs 139, and 41 vs 24, respectively). Most elderly patients (74%) underwent coronary angiography (71% by radial artery access) and 75% were submitted to percutaneous revascularization, 9% to surgery, and 1% to an hybrid strategy. Aspirin was used in 96% of patients, clopidogrel in 82%, ticagrelor in 13% (vs 25% of younger patients; p In multivariate logistic regression analysis, the predictors of major bleeding were diastolic blood pressure (BP) on admission I, AF, left bundle branch block, and left ventricle systolic dysfunction. Conclusions This study reflects the contemporary national reality of the management of elderly patients with MI. Overall, this population has a high risk of major bleeding, but several characteristics are associated with an even higher risk, such as the hemodynamic profile, renal function, and the use of GPI.

Introduction Rotational atherectomy (RA) is an adjunctive tool for the management of heavily calcified coronary lesions during percutaneous coronary intervention (PCI), but the clinical outcomes remain unclear. Access site choice is also poorly defined and there is growing evidence that transradial approach (TRA) is associated with lower complications and lower mortality. Objectives To assess the safety and long-term outcomes of RA for calcified coronary lesions and to investigate the influence of vascular access site in the efficacy and safety of the procedure. Methods Retrospective single-centre study that included consecutive PCI with RA performed from January 2006 to December 2017. Endpoint was a composite of major adverse cardiac events (MACE), defined as cardiovascular death, nonfatal myocardial infarction, nonfatal stroke and target vessel revascularization, at 1- and 5-year. Results 246 procedures were included in a total of 236 patients (pts): mean age 70.1±9.7 years, 73.6% male; 36.2% had previous PCI, 12.2% vascular peripheral disease (VPD), 24% reduced left ventricle ejection fraction (LVEF) and 6.9% were under hemodialysis. PCI with RA was mostly performed due to stable angina (48.9%) and via TRA (55.3%), with a total of 371 treated segments and a median number of 1 vessel treated per intervention. The left anterior descending artery was the most frequently treated artery (67.5%). Single burr was used in 76% of cases (mean number of burrs 1.23; mean burr size 1.5 mm). Procedural success rate was 94.7%. Complications were recorded in 9.3%, with no procedure related death. Clinical follow-up was complete in 98.8% of pts at 1-year and 81.3% at 5-year (mean time 62.3±41.8 months). Survival free of MACE at 1- and 5-year were 83.7% and 73.2%, respectively. Multivariate Cox regression identified 6 independent predictors (only 1 protector) for 1-year MACE (Fig. A) and 6 independent predictors (all of increased risk) for 5-year MACE (Fig. B). TRA was protector of 1-year MACE and Kaplan-Meier curves showed benefit for both 1- and 5-year MACE occurrence (Fig. C and D), without significant difference in procedural success (p=0.92) and complications (p=0.45) rate comparing to transfemoral approach. Conclusions RA followed by stenting was a safe procedure with a high immediate success rate but an increased number of long-term cardiovascular events. Some clinical conditions, such as previous PCI, VPD and reduced LVEF, seems to adversely influence the long-term outcome while TRA appears to be protective.

Aims: Radial access was associated with a significant reduction in major bleeding, compared to femoral access, in the treatment of ST segment Elevation Myocardial Infarction (STEMI). It is not yet clear its impact on in-hospital mortality. The aims of this study are to compare in-hospital mortality in patients undergoing primary PCI via radial access or femoral access, based on the Portuguese Interventional Cardiology Registry (PICR), and evaluate the interaction with the use of glycoprotein IIbIIIa (GP IIbIIIa) inhibitors. Methods and results: 6559 consecutive pts with STEMI undergoing primary PCI prospectively included in the PICR from Jan/2007 to Dec/2012. Radial access was used in 1384 pts (21%) and femoral access in 5175 (81.9%). We compared demographic and clinical variables between the 2 groups. Independent predictors of in-hospital mortality were identified by multivariate analysis. The interaction with the use of GP IIbIIIa inhibitors was also evaluated. In-hospital mortality occurred in 3.3% of pts undergoing primary PCI via femoral access and in 0.8% of pts undergoing primary PCI via radial access (p

Aim: Quantify the extent of residual coronary disease after coronary bypass surgery (CABG) in very old patients (> 80) with multivessel disease and evaluate its impact on 1 year prognosis. Methods: Retrospective analysis from a single centre of 122 consecutive patients with ≥80 years of age undergoing isolated CABG between January 2005 and December 2010 (mean age 83±2; 63% men and 30% diabetics). We have identified 45 patients (37%) with complete revascularization (group A) and 77 patients (63%) with incomplete revascularization (group B). The baseline syntax score (SS), the residual syntax score after surgery (rSS) and the difference between the two syntax scores (Δ SS) were calculated. Kaplan Meier curves were used to compare the overall survival free from death and major cardiovascular events (MACCE: death, myocardial infarction, stroke and revascularization) at one year of follow-up. The area under the ROC curve (AUC) was used as a measure of discriminatory power of Syntax scores for MACCE and the test used to adjust the model was Hosmer-Lemeshow. Results: At one year follow-up (obtained in 96% of pts) freedom from primary composite end point was 79% (12,6% death, 9,0% myocardial infarction, 3,4% stroke and 0,8% revascularization). There were no differences in baseline clinical characteristics between the groups, which had similar surgical risk (median EuroSCORE II 3,91±2,8 vs 4,27±4,3; p=0,504). Group B patients showed a trend to higher rate of MACCE at 1 year (27,0 vs. 11,4; p=0,062), without differences in mortality (14,9 vs. 9,1; p=0,409). The subgroup analysis in the Kaplan-Meyer method revealed that MACCE was significantly lower in group A compared to group B (7,5% vs. 24,2% at 1 year, Log-rank p=0,033) and there was no difference in mortality between the two groups (5,0% vs. 12,1% at 1 year, Log-rank p=0,219). The SS and the ΔSS were not predictors of MACCE at 1 year (AUC: 0,51; 0,41-0,61; p=0,888; Hosmer Lemeshow: p=0,384) and (AUC: 0,56; 0,46-0,65; p0,406; Hosmer Lemeshow: p=0,904), respectively; the rSS showed a limited discriminatory power (AUC: 0,65; 0,55-0,74; p=0,049; Hosmer Lemeshow: p=0,292). Conclusions: The incomplete surgical revascularization in very old patients can be associated with more major cardiovascular events following. Further studies are needed to properly assess the impact of this strategy in this patient population.

Purpose: The "Stent for Life" (SFL) project's main goal is to improve local ST-elevation myocardial infarction (STEMI) treatment in countries with lower rates of primary percutaneous coronary intervention (PPCI). It was in this setting that the Portuguese Association of Cardiovascular Intervention joined, in February 2011, the SFL Initiative, which helped to define actions to increase the quantity and quality of PPCI performed in Portugal. This study is intended to describe the progress seen after the first year of Portugal inclusion in the SFL Initiative. Methods: The Initial phase of SFL's project in Portugal was focused on public campaigns and to improve prehospital access through the National Institute for Medical Emergency (INEM). To evaluate the progress seen after this first year, a national survey was implemented for a one-month period in two consecutive periods: the first was applied in 2011 at the time of initial integration of SFL Initiative in Portugal ("Moment Zero") and the second in 2012 after one year of operation ("Moment One"). We compared the performance indicators of PPCI between the two consecutive years. Results: Seventeen national Portuguese centres of Interventional Cardiology where PPCI is carried out 24/7 participated in this study: 201 pts on "Moment Zero" and 196 in "Moment One" (mean age was 62±13 years, 20% female and 18% were diabetic). Only 33% of the patients used the single national number for medical emergencies (112) to call for support in "Moment Zero", but there was a slight increase of 5% in absolute value after one year of SFL's intervention. There was a significant reduction in patients which the first medical contact was a non-PPCI hospital (62% vs 47%, p=0.004) and an increased in direct transfer from INEM service to a PPCI centre (13% vs 37%, p

Aims: To study the prevalence of conversion from Radial (RA) to Femoral Access (FA) in cardiac catheterization and identify its clinical and demographic predictors. Methods and results: Prospective multicentre registry, including 7664 consecutive pts undergoing catheterization via RA between Jan/2009 and Out/2012 (66±11 years, 32% female). A total of 2982 procedures (38.9%) were PCIs and the most used route was the right RA (97.6%). We evaluated the incidence of conversion to FA and its predictors by logistic regression analysis. RA failure rate was 6.2%, with conversion to FA in most cases (93.9%). The need for conversion was more frequent in older pts (mean age 69±12 yrs vs 65±11 yrs, p

Purpose: Transradial approach (TRA) has become increasingly common for coronary angiography and intervention (CA/PCI) and a wealth of knowledge exists about its feasibility. Nevertheless radial injury and occlusion do occur and little is known about the success rate with its repeated use. Evidence of a long lasting use of the TRA might encourage a shift toward this access route. We aimed to evaluate the feasibility of a second TRA its predictors of failure. Methods: In a dual centre prospective registry, patients who underwent a first procedure by right TRA were identified. Whenever a second coronary angiography was necessary during follow-up, and the interventionalist's clinical assessment was favourable, the right TRA was again used. We compared the rates of crossover to another access and sought predictors of crossover. Results: From January 2009 to October 2012, 6392 patients (median age 66, interquartile range 16; 67% male; 37% due to ACS) who underwent a first procedure (36% PCI) by right TRA were identified; the crossover rate to another access was 5.8%. During the study period, a second TRA was performed in 686 of these patients in whom the interventionalist's clinical assessment was favourable; the crossover rate to another access was 6.9% and similar to the first TRA (Chi-square p=0.267). Three independent predictors of failure in the latter group were identified by binary logistic regression, with the following adjusted odds-ratio (95% confidence interval): female sex 3.67 (1.98-6.8), use of 10 cm (vs. 25 cm) introducer sheath 3.52 (1.73-7.16) and previous valvular surgery 3.02 (1.06-8.61). No differences with statistical significance were observed regarding advanced age, low body surface area, need for intervention or smaller sheath diameter. Conclusions: A second transradial approach is as feasible as the first. The use of shorter sheaths, female sex and previous valvular surgery patients reduce success in subsequent radial access.

Which are the possible causes for the cardiac dysfunction in this patient presenting for the first time with …