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New-generation drug-eluting stents (DES) strongly reduce restenosis and repeat revascu- larization compared with bare-metal stents (BMS) for percutaneous coronary interven- tion. There is residual uncertainty as to whether other prognostically relevant outcomes are affected by DES versus BMS concerning initial presentation (chronic coronary syn- drome [CCS] vs acute coronary syndrome [ACS]). We performed an individual patient data meta-analysis of randomized trials comparing new-generation DES versus BMS (CRD42017060520). The primary outcome was the composite of cardiac death or myocar- dial infarction (MI). Outcomes were examined at maximum follow-up and with a 1-year landmark. Risk estimates are expressed as hazard ratio (HR) with 95% confidence inter- val (CI). A total of 22,319 patients were included across 14 trials; 7,691 patients (34.5%) with CCS and 14,628 patients (65.5%) with ACS. We found evidence that new-generation DES versus BMS consistently reduced the risk of cardiac death or MI in both patients with CCS (HR 0.83, 95% CI 0.70 to 0.98, p

The comparative effectiveness of transradial (TRA) compared with transfemoral (TFA) access in acute coronary syndrome (ACS) patients undergoing complex percutaneous coronary intervention (PCI) remains unclear.Among 8404 ACS patients in the Minimising Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX (MATRIX)-Access trial, 5233 underwent noncomplex (TRA: n = 2590; TFA: n = 2643) and 1491 complex (TRA: n = 777; TFA: n = 714) PCI. Co-primary outcomes were major adverse cardiovascular events (MACE, the composite of all-cause mortality, myocardial infarction, or stroke) and the composite of MACE and Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding (net adverse cardiovascular events [NACE]) at 30 days.Rates of 30-day MACE (HR 0.94, 95% CI 0.72-1.22) or NACE (HR 0.89, 95% CI 0.69-1.14) did not significantly differ between groups in the complex PCI group, whereas both primary end points were lower (HR 0.84, 95% CI 0.70-1.00; HR 0.83, 95% CI 0.70-0.98; respectively) with TRA among noncomplex PCI patients, with negative interaction testing (PAmong ACS patients, PCI complexity did not affect the comparative efficacy and safety of TRA vs TFA, whereas the absolute risk reduction of access-site major bleeding was greater with TRA compared with TFA in complex as opposed to noncomplex PCI.

Resumen Introduccion y objetivos El acceso transaxilar (ATx) se ha convertido en el acceso alternativo al transfemoral (ATF), mas utilizado en pacientes sometidos a implante percutaneo de valvula aortica (TAVI). El objetivo principal de este estudio es comparar la mortalidad total hospitalaria y a los 30 dias de los pacientes incluidos en el registro espanol de TAVI a los que se trato por acceso ATx frente a ATF. Metodos Se analizo a todos los pacientes incluidos en el registro espanol de TAVI tratados por ATx o ATF. Los eventos hospitalarios y a los 30 dias de seguimiento se definieron segun las recomendaciones de la Valve Academic Research Consortium. Se evaluo el impacto de la via de acceso mediante emparejamiento por puntuacion de propension segun las caracteristicas clinicas y ecograficas. Resultados Se incluyo a 6.603 pacientes, 191 (2,9%) tratados por ATx y 6.412 con ATF. Despues del ajuste (grupo de ATx, n = 113; grupo de ATF, n = 3.035), el exito del dispositivo fue similar entre ambos grupos (el 94% en el grupo de ATx frente al 95% en el de ATF; p = 0,95); sin embargo, se observo un incremento en la tasa de infarto agudo de miocardio (OR = 5,3; IC95%, 2,0-13,8; p = 0,001), complicaciones renales (OR = 2,3; IC95%, 1,3-4,1; p = 0,003) e implante de marcapasos (OR = 1,6; IC95%, 1,01-2,6; p = 0,03) en el grupo de ATx comparado con el de ATF. De mismo modo, la mortalidad hospitalaria y a los 30 dias fueron superiores en el grupo de ATx (respectivamente, OR = 2,2; IC95%, 1,04-4,6; p = 0,039; y OR = 2,3; IC95%, 1,2-4,5; p = 0,01). Conclusiones El ATx se asocia con un aumento en la mortalidad total tanto hospitalaria como a los 30 dias frente al ATF. Ante estos resultados, el ATx debe considerarse solo en caso de que el ATF no sea posible.

The RECALCAR project (Resources and Quality in Cardiology), an initiative of the Spanish Society of Cardiology, aims to standardize information to generate evidence on cardiovascular health outcomes. The objective of this study was to analyze trends in the resources and activity of cardiology units and/or services and to identify the results of cardiovascular care during the last decade in Spain.The study was based on the 2 annual data sources of the RECALCAR project: a survey on resources and activity of cardiology units and/or services (2011-2020) and the minimum data set of the National Health System (2011-2019), referring to heart failure (HF), STEMI, and non-STEMI.The survey included 70% of cardiology units and/or services in Spain. The number of hospital beds and length of stay decreased, while there was a notable increase in the number of cardiac imaging studies and percutaneous therapeutic procedures performed. Age- and sex-adjusted admissions for HF tended to decrease, despite an increase in mortality and the percentage of readmissions. In contrast, the trend in mortality and readmissions was highly favorable in STEMI; in non-STEMI, although positive, the trend was less marked.The information provided by the RECALCAR project shows a favorable trend in the last decade in resources, activity and results of certain cardiovascular processes and constitutes an essential source for future improvements and decision-making in health policy.

Di(2-ethylhexyl) phthalate (DEHP) is a chemical commonly used as a plasticizer to render polyvinyl chloride products more durable and flexible. Although exposure to DEHP has raised many health concerns due to the identification of DEHP as an endocrine disruptor, it is still used in consumer products, including polyvinyl chloride plastics, medical tubing, car interiors, and children’s toys. To investigate the impact of early life exposure to DEHP on the ovary and testes, newborn piglets were orally dosed with DEHP (20 or 200 mg/kg/day) or vehicle control (tocopherol-stripped corn oil) for 21 days. Following treatment, ovaries, testes, and sera were harvested for histological assessment and measurement of steroid hormone levels. In male piglets, progesterone and pregnenolone levels were significantly lower in both treatment groups compared to control, whereas in female piglets, progesterone was significantly higher in the 20 mg group compared to control, indicating sex-specific effects in a non-monotonic manner. Follicle numbers and gene expression of steroidogenic enzymes and apoptotic factors were not altered in treated ovaries compared to controls. In DEHP-treated testes, germ cell migration was impaired and germ cell death was significantly increased compared to controls. Overall, the results of this study suggest that neonatal exposure to DEHP in pigs leads to sex-specific disruption of the reproductive system.

Resumen Introduccion y objetivos Si bien la utilizacion de anticoagulantes orales directos (ACOD) en pacientes con fibrilacion auricular (FA) y protesis valvular biologica como alternativa a los antagonistas de la vitamina K (AVK) esta recogida en las guias, en la practica real son escasos los estudios que recogen estos pacientes, mas aun en nuestro pais, dadas las restricciones que existen a su prescripcion. Metodos Se analizo a los pacientes intervenidos de forma consecutiva en nuestro hospital de sustitucion valvular aortica por protesis biologica con indicacion de anticoagulantes orales por FA durante los anos 2013-2018. Comparamos caracteristicas clinicas basales, asi como tasas de eventos cerebrovasculares, hemorragias mayores y menores, y mortalidad de los tratados con ACOD frente a los tratados con AVK. Resultados Incluimos 132 pacientes tratados con AVK (62,6%) y 79 con ACOD (37,4%; apixaban 20%, edoxaban 10%, rivaroxaban 6% y dabigatran 3%). No hubo diferencias significativas en sus caracteristicas clinicas basales en cuanto a edad, sexo, funcion renal o escalas de riesgo embolico. El seguimiento medio fue de 32,85 ± 15 meses. La tasa de incidencia de ictus isquemico/accidente isquemico transitorio (AIT) fue de 1,5/100 pacientes/ano en el grupo ACOD frente a 1,32 en AVK. La tasa de incidencia de sangrado mayor fue de 2,02/100 pacientes/ano en el grupo ACOD frente a 3,7 en AVK. Los pacientes con AVK presentaron 6 ictus hemorragicos frente a ninguno en el grupo de pacientes con ACOD. Conclusiones La utilizacion de ACOD en pacientes con protesis cardiaca biologica e indicacion de ACO permanente por FA parece una alternativa eficaz y segura al uso de AVK.

Background In developed countries, health care delivery in dermatology is hampered by the low availability of dermatologists. Objective To analyze the feasibility of a teledermatology-based action plan to provide initial dermatologic care in areas with low availability of dermatologists. Methods A cross-sectional study describing the feasibility and cost of a 12-month action plan based on a store-and-forward teledermatology (TD) connecting primary care centers and a TD center. Teleconsultations from patients complaining of any cutaneous condition were included. The primary outcome measure was the percentage of patients not referred to the local dermatologist. Results Among the total of 15,523 teleconsultations attended in the TD-based action plan, 3360 (21.65%) required a face-to-face visit with a local dermatologist. In 32.32% (n = 5017) of the cases, a therapeutic and follow-up plan report was issued. The most common conditions managed were melanocytic nevi (15.63%, n = 2426), followed by seborrheic keratosis (14.89%, n = 2312), and actinic keratosis (8.65%, n = 1342). The average response time was 14.52 days (95% CI 14.35-15.23). The additional total investment in this action plan was $142,681.01, with a unit cost of 9.20$/patient. Limitations Noncontrolled study. Conclusions Experienced dermatologists working with store-and-forward TD can deliver a fast and effective response in health care areas with access limitations.

Introduction and objectives The pocket sized KardiaMobile (KM) is a monitoring device for ECG recording through a smartphone-based application. This system is generally aimed as screening tool to detect alterations in cardiac rhythm but its diagnostic potential for detection of ST changes remains largely unknown. This study sought to assess the diagnostic sensitivity of the KM system for detection of ST changes in patients with ST elevated myocardial infarction (STEMI). Methods Patients admitted with diagnosis of STEMI were consecutively included. Recordings with KM were obtained in leads I, II and anterior precordial. KM recordings were obtained as well from healthy individuals. All recordings were submitted for blinded assessment. Results A total of 112 patients with STEMI and 25 healthy individuals were included. Among those showing ST changes, these consisted mostly in depression (75%). Sensitivity was modest for individual leads (57-58%). The combination of 2-leads, when including the precordial, and the combination of 3-leads markedly increased sensitivity (88-98% and 100% respectively) for both inferior and anterior STEMI. Specificity was very high (96-100%) and the Youden's J statistic was excellent for the 2-leads combinations that included the precordial lead (0.84-0.94) and for the 3-leads combination (0.96). Conclusions The Kardia Mobile system with the combination of 2-leads (I + precordial or II + precordial) or 3-leads shows a very high sensitivity for both anterior and inferior STEMI.

[EN] Trial Design: An interventional, phase 4, single group assignment, without masking (open label), preventive clinical trial was carried out in health workers with biological risk in their tasks, who have been filed as non-responders to conventional vaccination against Hepatitis B. Methods: 67 health workers with biological risk in their tasks, who have been filed as non-responders to conventional vaccination against Hepatitis B, were enrolled in the Clinical Trial. All participants were from 18 years up to 64 years old. Inclusion Criteria: NHS workers -including university students doing their internships in health centres dependent on the National Health System (inclusion of students is regulated and limited by specific instructions on labour prevention in each autonomous community)- classified as non-responders. The criteria defining them as non-responders to the conventional hepatitis B vaccine is anti HBsAb titers < 10 mUI/ml following the application of six doses of conventional vaccine at 20 lg doses (two complete guidelines). The objective of this study was to provide Health workersstaff with an additional protection tool against hepatitis B infection, and to evaluate the efficacy of the adjuvanted vaccine in healthy non-responders to conventional hepatitis B vaccine. The primary outcome was the measurement of antibody antiHBs before the first Fendrix dose and a month after the administration of each dose. Other outcome was collection of adverse effects during administration and all those that could be related to the vaccine and that occur within 30 days after each dose. In this study, only one group was assigned. There was no randomization or masking. Results: The participants were recruited between April 13, 2018 and October 31, 2019. 67 participants were enrolled in the Clinical Trial and included the analyses. The primary immunisation consists of 4 separate 0.5 ml doses of Fendrix , administered at the following schedule: 1 month, 2 months and 6 months from the date of the first dose. Once the positivity was reached in any of the doses, the participant finished the study and was not given the following doses. 68.66% (46 out 67) had a positive response to first dose of Fendrix. 57.14% (12 out 21) had a positive response to second dose of Fendrix . 22.22% (2 out 9) had a positive response to third dose of Fendrix and 42.96% (3 out 7) had a positive response to last dose of Fendrix. Overall, 94.02% (64 out 67) of participants had a positive response to Fendrix . No serious adverse event occurred. Conclusions: The use of Fendrix , is a viable vaccine alternative for NHS workers classified as ‘‘nonresponders”. Revaccination of healthy non-responders with Fendrix, resulted in very high proportions of responders without adverse events. Trial registration: The trial was registered in the Spanish National Trial Register (REEC), ClinicalTrials.gov and inclusion has been stopped (identifier NCT03410953; EudraCT-number 2016-004991-23). Funding: GRS 1360/A/16: Call for aid for the financing of research projects in biomedicine, health management and socio-health care to be developed in the centres of the Regional Health Management of Autonomous Community of Castile-Leon. In addition, this work has been supported by the Spanish Platform for Clinical Research and Clinical Trials, SCReN (Spanish Clinical Research Network), funded by the Subdirectorate General for Research Evaluation and Promotion of the Carlos III Health Institute (ISCIII), through the project PT13/0002/0039 and project PT17/0017/0023 integrated in the State Plan for R&D&I 2013–2016 and co-financed by and the European Regional Development Fund (ERDF).

Objectives This study sought to evaluate the incidence and causes of percutaneous coronary intervention (PCI) at different time periods following transcatheter aortic valve replacement (TAVR). Background Coronary artery disease (CAD) and aortic stenosis frequently coexist, but the optimal management of CAD following TAVR remains incompletely elucidated. Methods Patients undergoing unplanned PCI after TAVR were retrospectively included in an international multicenter registry. Results Between July 2008 and March 2019, a total of 133 patients (0.9%; from a total cohort of 15,325) underwent unplanned PCI after TAVR (36.1% after balloon-expandable bioprosthesis, 63.9% after self-expandable bioprosthesis). The median time to PCI was 191 days (interquartile range: 59 to 480 days). The daily incidence of PCI was highest during the first week after TAVR and then declined over time. Overall, the majority of patients underwent PCI due to an acute coronary syndrome, and specifically 32.3% had non–ST-segment elevation myocardial infarction, 15.4% had unstable angina, 9.8% had ST-segment elevation myocardial infarction, and 2.2% had cardiac arrest. However, chronic coronary syndromes are the main indication beyond 2 years. PCI success was reported in almost all cases (96.6%), with no significant differences between patients treated with balloon-expandable and self-expandable bioprostheses (100% vs. 94.9%; p = 0.150). Conclusions Unplanned PCI after TAVR is rare, with an incidence declining over time after TAVR. The main indication to PCI is acute coronary syndrome in the first 2 years after TAVR, and thereafter chronic coronary syndromes become prevalent. Unplanned PCIs are frequently successfully performed after TAVR, with no apparent differences between balloon-expandable and self-expandable bioprostheses. (Revascularization After Transcatheter Aortic Valve Implantation [REVIVAL]; NCT03283501 )

Objectives This study sought to assess the efficacy of the drug-coated balloon (DCB) ESSENTIAL for the treatment of in-stent restenosis (ISR). Background DCBs have proven a valid therapeutic option for the management of ISR in several clinical trials, yet no class effect can be claimed. Accordingly, every new DCB model has to be individually evaluated through clinical studies. Methods This is a prospective, multicenter study including consecutive patients undergoing percutaneous coronary intervention for ISR with the ESSENTIAL DCB. A 6-month quantitative coronary angiography (QCA)/optical coherence tomography (OCT) follow-up was scheduled. The primary endpoint was OCT-derived in-segment maximal area stenosis. Secondary endpoints included QCA-derived in-segment late lumen loss (LLL) and target lesion failure (TLF) rates at 6, 12, and 24 months. TLF was defined as the composite of cardiac death, target vessel myocardial infarction, and target lesion revascularization . Results A total of 31 patients were successfully treated with DCB, with 67% of ISR corresponding to drug-eluting stents (DES). At 6 months, 26 patients underwent the scheduled angiographic follow-up. The mean value for in-segment maximal area stenosis was 51.4 ± 13% and the median value was 53% (IQR 46.4–59.5). In the DES-ISR subgroup, these parameters were 52.6 ± 10% and 55.2% (IQR 49.3–58.5), respectively. In-segment LLL was 0.25 ± 0.43 mm with only 2 (7.7%) patients showing binary restenosis (>50%). The incidence of TLF was 10% at 6 months, 13.3% at 12 months, and 13.3% at 24 months. Conclusions In this study, the ESSENTIAL DCB showed sustained efficacy in the prevention of recurrent restenosis after treatment of ISR. Summary We sought to assess the efficacy of the drug-coated balloon ESSENTIAL for the treatment of in-stent restenosis through a prospective, multicenter study including QCA and OCT assessment at 6-month follow-up. The primary endpoint was in-segment maximal area stenosis. Among the 31 patients successfully treated with the ESSENTIAL DCB, an angiographic follow-up was conducted in 26. Mean in-segment maximal area stenosis was 51.4 ± 13% and the median value was 53% (IQR 46.4–59.5). In the DES-ISR subgroup, corresponding values were 52.6 ± 10% and 55.2% (IQR 49.3–58.5), respectively. The observed in-segment LLL was 0.25 ± 0.43 mm and binary restenosis rate was 7.7%. TLF was 10% at 6 months and 13.3% at 12 and 24 months.

Resumen Este articulo presenta una revision de las publicaciones y los estudios de mayor relevancia en el ambito de la cardiologia intervencionista en el ano 2019. Dentro del intervencionismo coronario, el tratamiento del paciente con enfermedad multivaso, tanto en el contexto del sindrome coronario agudo como cronico, ha sido objeto de estudios de gran relevancia y con resultados solidos que potencialmente cambiaran nuestra practica clinica. Por otro lado, la comparacion entre diferentes estrategias de antiagregacion en pacientes con sindrome coronario agudo ha puesto de manifiesto la importancia de la individualizacion. Algunos sustratos anatomicos particulares, como el tratamiento de la oclusion cronica y las lesiones calcificadas siguen generando un buen numero de publicaciones. Los avances en el campo del intervencionismo en cardiopatia estructural han seguido aumentando exponencialmente en este ultimo ano. Destaca la aparicion de nuevas evidencias en el implante percutaneo de valvula aortica en pacientes de bajo riesgo, asi como los resultados en reparacion valvular percutanea mitral y tricuspide.

This study sought to determine, in patients with new-onset persistent left bundle branch block (NOP-LBBB) after transcatheter aortic valve implantation (TAVI), the incidence and factors associated with (i) LBBB recovery and (ii) permanent pacemaker implantation (PPI) at 1-year follow-up. This was a multicenter study including 153 patients (mean age: 81 ± 5 years, 56% of women) with NOP-LBBB post-TAVI (balloon-expandable valve in 112 patients). Delta PR (ΔPR) and delta QRS (ΔQRS) were defined as the difference in PR and QRS length between baseline and hospital discharge ECG, and the relative ΔPR and ΔQRS as absolute ΔPR and ΔQRS divided by baseline PR and QRS length, respectively. The patients had a clinical visit and 12-lead ECG at 1-year follow-up. LBBB recovery was observed in 50 patients (33%), and 14 patients (9%) had advanced conduction disturbances requiring PPI during the follow-up period. No clinical or ECG variables were associated with LBBB recovery, including prosthesis type (self- or balloon-expandable valve, p = 0.563), QRS width at baseline/discharge or absolute/relative ΔQRS (p >0.10 for all). The presence of atrial fibrillation at baseline (0.026), a longer PR interval at discharge (0.009), and a longer absolute and relative ΔPR (p = 0.002 and p = 0.004, respectively) were associated with an increased risk of PPI at 1-year follow-up. In conclusion, NOP-LBBB post-TAVI resolved in one-third of patients at 1-year follow-up, but no clinical or ECG variables were associated with LBBB recovery. Conversely, a nonsinus rhythm at baseline and a longer ΔPR were associated with an increased risk of PPI within the year after TAVI.

Resumen Introduccion y objetivos Los pacientes mayores de 75 anos con infarto agudo de miocardio con elevacion del segmento ST sometidos a angioplastia primaria en situacion de shock cardiogenico sufren una gran mortalidad. La identificacion previa al procedimento de variables predictoras de la posterior mortalidad seria muy util para guiar la toma de decisiones. Metodos Analisis del registro multicentrico de angioplastia primaria en pacientes mayores de 75 anos (ESTROFA MI + 75), que incluye a 3.576 pacientes. Se analizaron las caracteristicas y la evolucion clinica del subgrupo con shock cardiogenico para identificar predictores de supervivencia a 1 ano tras la angioplastia y elaborar un indice pronostico. Se valido el indice en una cohorte independiente. Resultados Se incluyo a 332 pacientes. Los predictores basales independientes fueron: la localizacion anterior (HR = 2,8; IC95%, 1,4-6,0; p = 0,005), una fraccion de eyeccion 6 h (HR = 3,2; IC95%, 1,6-7,5; p = 0,001). Se diseno un indice basado en estas variables (indice «6-ANT-40»). La supervivencia a 1 ano fue del 54,5% de aquellos con indice 0, el 32,3% con indice 1, el 27,4% con indice 2 y el 17% con indice 3 (p = 0,004, estadistico C = 0,70). En una cohorte independiente de 124 pacientes, las supervivencias a 1 ano fueron del 64,5, el 40,0, el 28,9 y el 22,2% respectivamente (p = 0,008; estadistico C = 0,68). Conclusiones Un indice basado en simples variables clinicas previas al procedimiento (localizacion anterior, fraccion de eyeccion 6 h) permite estimar la supervivencia tras una angioplastia primaria de los pacientes mayores con shock cardiogenico, y asi ayudar en la toma de decisiones.

Background The consequences of homophobia can affect the integrity, mental and physical health of homosexual individuals in society. There are few studies in Peru that have evaluated homophobia in the medical student population. Objective To establish the social, educational and cultural factors associated with homophobia among Peruvian medical students. Methods A cross-sectional analytical study was conducted in 12 medicine schools in Peru. Homophobia was defined according to a validated test, which was associated with other variables. Statistical associations were identified. Results The lowest percentages of homophobic students (15–20%) were found in the four universities in Lima, while universities in the interior of the country had the highest percentages (22–62%). Performing a multivariate analysis, we found that the frequency of homophobia was lower for the following variables: the female gender (PRa = 0.74; 95% CI, 0.61–0.92; p = 0.005), studying at a university in Lima (PRa = 0.57; 95% CI, 0.43–0.75; p Conclusions Homophobia was less common in women, in those who study in the capital, those who profess Catholicism and those who know/have treated a homosexual. In contrast, male chauvinists were more homophobic.

Background Triple antithrombotic therapy (TT) is recommended for patients with nonvalvular atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). However, there is a lack of comparative data in a real-world clinical setting between non-vitamin K antagonist oral anticoagulants (NOAC) and vitamin K antagonists (VKA). The aim of this study was to compare the safety and efficacy of TT with NOAC or VKA after PCI in patients with AF at 1-year of follow-up. Materials and Methods This was an observational retrospective study in 2 tertiary care hospitals during 2013-2016. Patients with indication for anticoagulation due to AF from an initial registry of 5,269 patients undergoing PCI were identified. Safety primary endpoint was the occurrence of major bleeding events as defined by Bleeding Academic Consortium (BARC ≥ 3). The primary efficacy endpoint was defined as major adverse cardiovascular events (MACE). Results A total of 187 consecutive patients on TT were identified: 45.4% of were discharged on NOAC and 54.6% on VKA. Patients who received VKA presented more comorbidities and had a higher bleeding risk than those who received NOACs. Major bleeding events occurred in 17 patients (9%), with a higher rate in the VKA group (3.5% vs. 13% confidence interval, 0.19-0.86, P = 0.02). There were no differences in the rates of major adverse cardiovascular events, stroke or net clinical benefit. Conclusions In this real-world study, patients with AF undergoing PCI treated on NOAC-based TT showed lower bleeding rates than those on VKA, with a lower rate of major bleeding events, while efficacy was similar between groups.

OBJECTIVES We investigated the safety and efficacy of the bioabsorbable polymer-coated, everolimus-eluting coronary stent (SYNERGY) stent in a real-world study population with acute coronary syndromes (ACS). BACKGROUND A number of clinical trials support the overall efficacy and safety of the SYNERGY stent. However, a recent trial (TIDES-ACS) in the context of ACS reported worrying figures of infarction and definite/probable stent thrombosis in the SYNERGY control arm. METHODS This is a multicenter registry (10 centers) including consecutive patients with ACS (unstable angina, non-ST elevated myocardial infarction, ST elevated myocardial infarction) who underwent percutaneous revascularization with the implantation of SYNERGY stent. The primary endpoint was the composite of cardiac death, myocardial infarction and target lesion revascularization at 12 months. RESULTS A total of 1008 patients were included with age 65.4 ± 14.8 years, 23.8% females and a 24.5% diabetics. Regarding presentation, a 15.2% with unstable angina, 43% with non-ST elevated myocardial infarction and 41.8% with ST elevated myocardial infarction. Primary outcome was met in 3% (7% in SYNERGY TIDES-ACS arm, P superiority

Resumen Introduccion y objetivos El impacto de la intervencion coronaria percutanea (ICP) sobre oclusiones coronarias cronicas totales (OCT) presenta controversias. Se analizan los resultados agudos y al seguimiento en nuestro entorno. Metodos Registro prospectivo de ICP sobre OCT en 24 centros durante 2 anos. Resultados Se realizaron 1.000 ICP sobre OCT en 952 pacientes. La mayoria tenia sintomas (81,5%) y cardiopatia isquemica previa (59,2%), y hubo intentos de desobstruccion previos en un 15%. El SYNTAX anatomico fue 19,5 ± 10,6 y tenia J-score > 2 el 17,3%. El procedimiento fue retrogrado en 92 pacientes (9,2%). La tasa de exito fue del 74,9%, mayor en aquellos sin ICP previa (el 82,2 frente al 75,2%; p = 0,001), con J-score ≤ 2 (el 80,5 frente al 69,5%; p = 0,002) y con el uso de ecografia intravascular (el 89,9 frente al 76,2%; p = 0,001), que fue predictor independiente del exito. Por el contrario, lesiones calcificadas, > 20 mm o con munon proximal romo lo fueron de fracaso. El 7,1% tuvo complicaciones, como perforacion (3%), infarto (1,3%) o muerte (0,5%). Al ano de seguimiento, el 88,2% mejoro clinicamente en caso de ICP exitosa (frente al 34,8%; p Conclusiones Los pacientes del Registro Iberico con OCT tratados con ICP presentan complejidad clinico-anatomica, tasas de exito y complicaciones similares a los de otros registros nacionales e importante impacto de la recanalizacion exitosa en la mejoria funcional, que a su vez se asocio con menor mortalidad.

The characterization of Martian surface winds as a function of time of day and season at one location can increase our knowledge of Mars surface conditions and assist in planning for future unmanned and manned missions. Martian surface winds vary greatly with location, and even at a particular landing site show a high degree of diurnal, seasonal, and interannual variability. Thus characterizing surface wind speeds and directions requires a long time series, which is rarely obtained on Mars. The Rover Environmental Monitoring Station (REMS) instrument on the Mars Science Laboratory (MSL) rover has been measuring Martian winds since 2012, thus has provided more than two Martian years of wind data at the first Martian landing site to have significant topography, in the trench of Gale Crater. Unfortunately, likely debris impacts during landing damaged the wind sensor, making it difficult to extract useful wind data. The first part of this paper presents a new retrieval that allows “good” wind measurements to be extracted from the raw dataset obtained under such conditions. In addition, a characterization of wind speeds and directions in Gale Crater is presented, after processing the full dataset of wind data in order to obtain the representative winds for different diurnal timeslots and seasons. Results suggest complex wind patterns and great variability depending on local time and season. Also, a significant influence by the synoptic scale circulation in the wind patterns is observed, although the local-scale circulation is suggested to be the major contributor to the observed surface winds in Gale Crater.

The characterization of Martian surface wind speed as a function of time of day and season at one location can increase our knowledge of Mars surface conditions and assist in planning for future unmanned and manned missions, since the probability of the wind speed exceeding a given value is often required for both engineering and geophysical applications. Wind speeds are also useful for assessing the aeolian impact of the circulation. The Rover Environmental Monitoring Station (REMS) instrument on the Mars Science Laboratory (MSL) rover has been measuring Martian winds since 2012, thus has provided more than two Mars years of wind data in the first Martian landing site with significant topography. Unfortunately, dust debris during the MSL landing stage damaged the sensor, making difficult to extract useful wind data. This paper complements the characterization performed in the companion paper, by producing a wind speed characterization based on probability distribution models. Significant diurnal and seasonal wind speed variability is found, due to complex interactions between the synoptic flow, the regional and local slope winds and microscale flow around MSL. The highest wind speed probabilities are found in general during the midday period, particularly around the equinoxes. In addition, the REMS data suggest strong flows during the summer nighttime, which could be related to the increased aeolian activity detected then by MSL.

Patients with pure native aortic valve regurgitation (NAVR) and increased surgical risk are often denied surgery. This retrospective study aimed to evaluate the "off-label" use of transcatheter heart valves (THV) for the treatment of NAVR. A total of 254 high surgical risk patients with NAVR (age 74 ± 12 years, Society of Thoracic Surgeons risk score 6.6 ± 6.2%) underwent transcatheter aortic valve implantation (TAVI) with early generation (43%) or newer generation (57%) devices at 46 different sites. Device success was significantly higher in patients treated with newer as compared with early generation THV (82% vs 47%, p

Objectives The authors sought to determine: 1) the global arrhythmic burden; 2) the rate of arrhythmias leading to a treatment change; and 3) the incidence of high-degree atrioventricular block (HAVB) at 12-month follow-up in patients with new-onset persistent left bundle branch block (LBBB) following transcatheter aortic valve replacement (TAVR). Background Controversial data exist on the occurrence of significant arrhythmias in patients with LBBB post-TAVR. Methods This was a multicenter prospective study including 103 consecutive patients with new-onset persistent LBBB post-TAVR with the balloon-expandable SAPIEN XT/3 valve (n = 53), or the self-expanding CoreValve/Evolut R system (n = 50). An implantable cardiac monitor (Reveal XT, Reveal Linq) was implanted at 4 (3 to 6) days post-TAVR, and patients had continuous electrocardiogram monitoring for 12 months. All arrhythmic events were adjudicated in a central electrocardiography core lab. Primary endpoints were the incidence of arrhythmias leading to a treatment change, and the incidence of HAVB at 12-month follow-up. Results A total of 1,553 new arrhythmic events were detected in 44 patients (1,443 episodes of tachyarrhythmia in 26 patients [atrial fibrillation/flutter/atrial tachycardia: 1,427, ventricular tachycardia 16]; 110 episodes of bradyarrhythmia in 21 patients [HAVB 54, severe bradycardia 56]). All arrhythmic events were silent in 34 patients (77%), the arrhythmic event led to a treatment change in 19 patients (18%), and 11 patients (11%) required pacemaker or implantable cardioverter-defibrillator implantation (due to HAVB, severe bradycardia, or ventricular tachycardia episodes in 9, 1, and 1 patient, respectively). A total of 12 patients died at 1-year follow-up, 1 from sudden death. Conclusions A high incidence of arrhythmic events was observed at 1-year follow-up in close to one-half of the patients with LBBB post-TAVR. Significant bradyarrhythmias occurred in one-fifth of the patients, and PPM was required in nearly one-half of them. These data support the use of a cardiac monitoring device for close follow-up and expediting the initiation of treatment in this challenging group of patients. (Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEft Bundle Branch Block After Transcatheter Aortic Valve Implantation [MARE study]: NCT02153307)

Resumen Introduccion y objetivos Muchos pacientes sometidos a implante percutaneo de valvula aortica (TAVI) presentan insuficiencia mitral (IM) de grado moderado o menor. El impacto de la insuficiencia tricuspidea (IT) sigue sin resolverse. Se analiza el impacto de la IM moderada frente a leve-ausente y su evolucion, y de la IT concomitante y su interaccion con la IM. Metodos Estudio retrospectivo multicentrico de 813 pacientes tratados con TAVI entre 2007 y 2015 con IM ≤ 2 y abordaje transfemoral. Resultados La edad media fue 81 ± 7 anos y el Society of Thoracic Surgeons-score fue de 6,9 ± 5,1%. El 37,3% presento IM moderada, con resultados comparables intrahospitalarios y de mortalidad a 6 meses frente a IM 2 tras el TAVI. La presencia de IT moderada/grave se asocio con una mortalidad intrahospitalaria y de seguimiento del 13 y el 34,1%, independientemente del grado de IM. La IT moderada-grave fue predictor independiente de mortalidad (HR = 18,4; IC95%, 10,2-33,3; p Conclusiones La presencia de IM moderada no supuso mayor mortalidad a corto-medio plazo tras el TAVI, pero asocio mas rehospitalizaciones. La presencia de IT moderada/grave implico mayor mortalidad. Esto sugiere que una evaluacion minuciosa de los mecanismos subyacentes entre ambas insuficiencias valvulares debe realizarse para determinar la mejor estrategia para evitar la futilidad relacionada con TAVI.

Introduction and objectives Bioresorbable vascular scaffolds (BVS) have the potential to restore vasomotion but the clinical implications are unknown. We sought to evaluate angina and ischemia in the long-term in patients treated with BVS and metallic drug-eluting stents (mDES). Methods Multicenter study including patients with 24 ± 6 months of uneventful follow-up, in which stress echocardiography was performed and functional status was assessed by the Seattle Angina Questionnaire (SAQ). The primary endpoint was a positive result in stress echocardiography. Results The study included 102 patients treated with BVS and 106 with mDES. There were no differences in the patients’ baseline characteristics. Recurrent angina was found in 18 patients (17.6%) in the BVS group vs 25 (23.5%) in the mDES group ( P = .37), but SAQ results were significantly better in the BVS group (angina frequency 96.0 ± 8.0 vs 89.2 ± 29.7; P = .02). Stress echocardiography was positive in 11/92 (11.9%) of BVS patients vs 9/96 (9.4%) of mDES patients in the ( P = .71) and angina was induced in 2/102 (1.9%) vs 7/106 (6.6%) ( P = .18), respectively, but exercise performance was better in the BVS group even in those with positive tests (exercise duration 9.0 ± 2.0 minutes vs 7.7 ± 1.8 minutes; P = .02). A propensity score matching analysis yielded similar results. Conclusions The primary endpoint was similar in both groups. In addition, recurrent angina was similar in patients with BVS and mDES. The better functional status, assessed by means of SAQ and exercise performance, detected in patients receiving BVS should be confirmed in further studies.

Introduction and objectives Many patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or less. The impact of coexistent tricuspid regurgitation (TR) remains to be determined. We sought to analyze the impact of moderate vs none-to-mild MR and its trend after TAVI , as well as the impact of concomitant TR and its interaction with MR. Methods Multicenter retrospective study of 813 TAVI patients treated through the transfemoral approach with MR ≤ 2 between 2007 and 2015. Results The mean age was 81 ± 7 years and the mean Society of Thoracic Surgeons score was 6.9% ± 5.1%. Moderate MR was present in 37.3% of the patients, with similar in-hospital outcomes and 6-month follow-up mortality to those with MR P = .257). However, they experienced more rehospitalizations and worse New York Heart Association class ( P = .008 and .001, respectively). Few patients (3.8%) showed an increase in the MR grade to > 2 post-TAVI. The presence of concomitant moderate/severe TR was associated with in-hospital and follow-up mortality rates of 13% and 34.1%, respectively, regardless of MR grade. Moderate-severe TR was independently associated with mortality (HR, 18.4; 95%CI, 10.2-33.3; P Conclusions The presence of moderate MR seemed not to impact short- and mid-term mortality post-TAVI, but was associated with more rehospitalizations. The presence of moderate or severe TR was associated with higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility.

Resumen Introduccion y objetivos Los armazones vasculares bioabsorbibles (AVB) tienen el potencial de restaurar la vasomotilidad, pero se desconocen las implicaciones clinicas. En este estudio se evaluan la angina y la isquemia a largo plazo tras el implante de AVB y stents farmacoactivos metalicos (SFAm). Metodos Estudio multicentrico, que incluyo a pacientes tras 24 ± 6 meses de evolucion sin eventos a los que se realizo ecografia de estres y se aplico el Seattle Angina Questionnaire (SAQ). El objetivo primario fue el resultado positivo en la ecografia de estres. Resultados Se incluyo a 102 pacientes tratados con AVB y 106 con SFAm, sin diferencias basales significativas. Se produjo recurrencia de la angina en 18 pacientes (17,6%) con AVB frente a 25 (23,5%) con SFAm (p = 0,37), pero los resultados del SAQ fueron significativamente mejores en el grupo AVB (frecuencia de angina, 96.0 ± 8.0 frente a 89,2 ± 29,7; p = 0,02). La ecografia de estres fue positiva en 11/92 (11,9%) con AVB frente a 9/96 (9,4%) con SFAm (p = 0,71) y se indujo angina en 2/102 (1,9%) frente a 7/106 (6,6%) (p = 0,18), pero el desempeno en el ejercicio fue mejor con AVB incluso en aquellos con tests positivos (duracion del ejercicio, 9,0 ± 2,0 frente a 7,7 ± 1,8 min; p = 0,02). Un analisis por puntuacion de propension de tratamiento ofrecio resultados similares. Conclusiones El objetivo primario fue comparable en ambos grupos. La recurrencia de la angina fue similar entre los tratados con AVB y con SFAm. El mejor estado funcional, medido por SAQ y nivel de ejercicio, detectado en pacientes con AVB tendria que confirmarse en futuros estudios.

In this paper, kink scattering in the dimensional reduction of the bosonic sector of a one-parameter family of generalized Wess-Zumino models with three vacuum points is discussed. The value of the model parameter determines the specific location of the vacua. The influence of the vacuum arrangements (evolving from three collinear vacua to three vacua placed at the vertices of an equilateral triangle) on the kink scattering is investigated. Two different regimes can be distinguished: in the first one, two symmetric BPS kinks/antikinks arise whereas in the second one a new different BPS kink/antikink emerges, with the exception of a three-fold rotational symmetry case, where the three topological defects are identical. The scattering between the two symmetric kinks is thoroughly analyzed. Two different scattering channels have been found: kink-kink reflection and kink-kink hybridization. In the last case, the collision between the two symmetric kinks gives rise to the third different kink. Resonance phenomena also appear allowing a vibrating kink to split into two symmetric kinks moving away., Comment: 23 pages, 15 figures

Resumen El mayor reto que afronta el ser humano es la preservacion de la salud. La unica via para generar mejores soluciones a los problemas de salud es la innovacion, la verdadera innovacion. La unica fuente de autentica innovacion es la investigacion, la investigacion de calidad. El trayecto desde un estudio de investigacion basica a un ensayo clinico aleatorizado es largo y no esta libre de «baches» e incluso «minas». Estos son los obstaculos y las barreras que limitan la disponibilidad de recursos, dificultan el proceso administrativo-regulatorio y constrinen las iniciativas de los investigadores. Asistimos a una creciente demanda de evidencia que guie la practica clinica, pero paradojicamente acometer investigacion biomedica se hace cada vez mas complejo, caro y dificil de integrar a la practica clinica, por el aumento de las barreras a la realizacion de los aspectos practicos de la investigacion. Nos enfrentamos al reto de aumentar el volumen de la investigacion biomedica y al mismo tiempo mejorar su eficiencia y sus resultados. Este articulo revisa las diferentes etapas y modalidades de la investigacion biomedica, desde los estudios no clinicos en modelos animales o computacionales a los ensayos aleatorizados y registros clinicos, centrandose en las limitaciones y los retos a los que se enfrentan, pero tambien aportando soluciones y alternativas que pueden ayudar a superarlos. Afortunadamente, los retos son siempre oportunidades disfrazadas.

Objectives The aim of this study was to determine the prognosis and specific complications of patients with prosthetic mitral valves (PMVs) undergoing transcatheter aortic valve replacement (TAVR). Background TAVR is performed relatively often in patients with PMVs, but specific risks are not well described. Methods A multicenter analysis was conducted, including patients with severe symptomatic aortic stenosis who underwent TAVR at 10 centers. Patients’ clinical characteristics and outcomes were evaluated according to the presence of a PMV. Results The mean age of the study population (n = 2,414) was 81 ± 8 years, and 48.8% were men. A total of 91 patients (3.77%) had PMVs. They were more commonly women, younger, and had higher surgical risk. PMVs were implanted a median of 14 years before TAVR, and most patients had mechanical prostheses (73.6%). Eighty-six patients (94.5%) were on long-term vitamin K inhibitor therapy, and bridging antithrombotic therapy was administered in 59 (64.8%). TAVR device embolization occurred in 6.7% (vs. 3.3% in the non-PMV group; p = 0.127), in all instances when distance between the PMV and the aortic annulus was Conclusions TAVR presents similar mortality irrespective of the presence of a PMV. However, patients with PMVs had higher bleeding risk that was independently associated with higher mortality. Risk for valve embolization was relatively high, but it occurred only in patients with PMV–to–aortic annulus distances