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Introduction and objective: Several scoring systems have been developed for risk stratification in patients with acute pulmonary embolism (PE). The Pulmonary Embolism Severity Index (PESI) and its simplified version (sPESI) are among the most used, however the high number of variables hinder its application. Our aim was to derive an easy-to-perform score based on simple parameters obtained at admission to predict 30-day mortality in acute PE patients. Methods: Retrospective study in 1115 patients with acute PE from two institutions (derivation cohort n=835, validation cohort n=280). The primary endpoint was all-cause mortality at 30 days. Statistically and clinically relevant variables were selected for multivariable Cox regression analysis. We derived and validated a multivariable risk score model and compared to other established scores. Results: The primary endpoint occurred in 207 patients (18.6%). Our model included five variables weighted as follows: modified shock index ≥1.1 (hazard ratio [HR] 2.57, 1.68–3.92, p1,1 (HR 2,57, 1,68-3,92, p

Ablation of atypical left atrial flutters (LAF) is very challenging due to the complexity of the underlying atrial substrate and diverse arrhythmia mechanisms. The interpretation of the arrhythmia mechanism is usually difficult, even using advanced three-dimensional (3D) mapping systems. SparkleMap is a novel mapping algorithm that displays each electrogram as a green dot that lights up at the point corresponding to the local activation time, superimposed either on the substrate or the local activation time 3D-maps. It is not affected by the setting of the “window of interest” and there is no need for user post-processing.We present the case of patient with a persistent atypical LAF in whom we tested the concept of complex arrhythmia interpretation exclusively based on the analysis of the substrate and evaluation of SparkleMap-derived wavefront propagation. We describe the workflow for map collection and the systematic approach for arrhythmia interpretation that resulted in the identification of a dual loop perimitral mechanism with a common slow conducting isthmus inside a scar at the septum/anterior atrial wall. This new method of analysis enabled the use of a specifically targeted and precise approach for ablation, with restoration of sinus rhythm within five seconds of radiofrequency application. After 18 months of follow-up, the patient remains free from recurrences, without anti-arrhythmic medication. This case report exemplifies how helpful new mapping algorithms can be in the interpretation of the arrhythmia mechanism in patients with complex LAF. It also suggests an innovative workflow to integrate the SparkleMap into the mapping approach. Resumo: A ablação dos flutters atípicos da aurícula esquerda constitui frequentemente um desafio devido à complexidade do substrato auricular subjacente e à diversidade dos mecanismos arrítmicos implicados. A interpretação do mecanismo da arritmia é usualmente difícil, mesmo utilizando sistemas avançados de mapeamento eletroanatómico tridimensional. O SparkleMap é um novo algoritmo de mapeamento que representa cada eletrograma como um ponto verde que acende no momento correspondente ao momento da ativação local. Pode ser sobreposto ao mapa tridimensional de substrato ou de ativação, não é influenciado pela escolha da janela de interesse do mapa e não requer pós-processamento manual.Apresentamos o caso de um doente com flutter atípico persistente em quem testámos a interpretação do mecanismo de arritmias complexas com base exclusivamente na análise do substrato e na avaliação da propagação das ondas eléctricas por SparkleMap. Descrevemos o protocolo para a colheita do mapa e para a análise sistemática do mecanismo da arritmia, que resultou na identificação de um mecanismo de dupla-reentrada, com um dos circuitos em rotação perimitral e localizando-se o istmo comum de condução lenta na parede anterior/septo, num canal de miocárdio viável intracicatricial. Este método de análise inovador resultou numa estratégia de ablação dirigida e precisa, que conduziu à reposição de ritmo sinusal após apenas 5 segundos de ablação. Com um seguimento de 18 meses, o doente mantém-se livre de recorrências, sem terapêutica antiarrítmica.Este caso clínico exemplifica como os novos algoritmos de mapeamento podem ser úteis na interpretação dos mecanismos arrítmicos em doentes com arritmias auriculares complexas e propõe um protocolo inovador para a incorporação do SparkleMap na estratégia de mapeamento.

Background: Cognitive impairment, anxiety and depression are common in heart failure (HF) patients and its evolution is not fully understood. Objectives: To assess the cognitive status of HF patients over time, its relation to anxiety and depression, and its prognostic impact. Methods: Prospective, longitudinal, single center study including patients enrolled in a structured program for follow-up after hospital admission for HF decompensation. Cognitive function, anxiety/depression state, HF-related quality of life (QoL) were assessed before discharge and during follow-up (between 6th and 12th month) using Montreal Cognitive Assessment (MoCA), Hospital Anxiety and Depression Scale (HADS) and Kansas City Cardiomyopathy Questionnaire, respectively. HF related outcomes were all cause readmissions, HF readmissions and the composite endpoint of all-cause readmissions or death. Results: 43 patients included (67±11.3 years, 69% male); followed-up for 8.2±2.1 months. 25.6% had an abnormal MoCA score that remained stable during follow-up (22.6±4.2 vs. 22.2±5.5; p=NS). MoCA score

Abstract Aims Non‐invasive telemonitoring (TM) in patients with heart failure (HF) and reduced left ventricular ejection fraction (HFrEF) may be useful in the early diagnosis of HF decompensation, allowing therapeutic optimization and avoiding re‐hospitalization. We describe a TM programme in this population and evaluate its effectiveness during a 12 month period. Methods and results We conducted a single‐centre study of patients discharged from hospital after decompensated HF, allocated into three groups: prospective TM programme, prospective HF protocol follow‐up programme (PFP) with no TM facilities, and retrospective propensity‐matched usual care (UC). TM effectiveness was assessed by all‐cause hospitalizations and mortality; HF‐related hospitalization (HFH), days lost to unplanned hospital admissions/death, functional capacity and quality of life (New York Heart Association, Kansas City Cardiomyopathy Questionnaire, 6 min walk test, and plasma N‐terminal pro‐brain natriuretic peptide) were also evaluated. A total of 125 patients were included [65.9 ± 11.9 years, 32% female, left ventricular ejection fraction 27% (21–32)]. TM was similar to PFP regarding effectiveness; TM reduced all‐cause hospitalization and mortality (HR 0.27; 95% CI 0.11–0.71; P

With the increasing number of cardiovascular implantable electronic device upgrade and vein obstruction caused by previous leads, it is important to have alternative techniques to upgrade the device with the maintenance of functioning leads.We report an 83-year old male with 13-year old one-lead dual-chamber pacemaker, ischemic cardiac disease and pre-dialytic chronic kidney disease submitted to an upgrade to cardiac resynchronization therapy. A sub-occlusion in the transition of left brachiocephalic vein and the superior vena cava was documented. Re-permeabilization was only achieved with a TightRail™ rotating dilator sheath over a guidewire with successful left ventricle lead implant.

Introduction: Heart failure is associated with high rates of readmission and mortality, and there is a need for measures to improve outcomes. This study aims to assess the impact of the implementation of a protocol-based follow-up program for heart failure patients on readmission and mortality rates and quality of life. Methods: A quasi-experimental study was performed, with a prospective registry of 50 consecutive patients discharged after hospitalization for acute heart failure. The study group was followed by a cardiologist at days 7-10 and the first, third, sixth and 12th month after discharge, with predefined procedures. The control group consisted of patients hospitalized for heart failure prior to implementation of the program and followed on a routine basis. Results: No significant differences were observed between the two groups regarding mean age (67.1±11.2 vs. 65.8±13.4 years, p=0.5), NYHA functional class (p=0.37), or median left ventricular ejection fraction (27% [19.8-35.3] vs. 29% [23.5-40]; p=0.23) at discharge. Mean follow-up after discharge was similar (11±5.3 vs. 10.9±5.5 months, p=0.81).The protocol-based follow-up program was associated with a significant reduction in all-cause readmission (26% vs. 60%, p=0.003), heart failure readmission (16% vs. 36%, p=0.032), and mortality (4% vs. 20%, p=0.044). In the study group there was a significant improvement in all quality of life measures (p

Objective: Animal studies suggested that angiotensin-converting enzyme inhibitors (ACEi) and angiotensin-receptor blockers (ARB) facilitate the inoculation of potentially leading to a higher risk of infection and/or disease severity. We aimed to systematically evaluate the risk of COVID-19 infection and the risk of severe COVID-19 disease associated with previous exposure to (ACEi) and/or ARB). Methods: MEDLINE, CENTRAL, PsycINFO, Web of Science Core Collection were searched in June 2020 for controlled studies. Eligible studies were included and random-effects meta-analyses were performed. The estimates were expressed as odds ratios (OR) and 95% confidence intervals (95%CI). Heterogeneity was assessed with I2 test. The confidence in the pooled evidence was appraised using the GRADE framework. Results: Twenty-seven studies were included in the review. ACEi/ARB exposure did not increase the risk of having a positive test for COVID-19 infection (OR 0.99, 95%CI 0.89–1.11; I2 = 36%; 5 studies, GRADE confidence moderate). The exposure to ACEi/ARB did not increase the risk of all-cause mortality among patients with COVID-19 (OR 0.91, 95%CI 0.74–1.11; I2 = 20%; 17 studies; GRADE confidence low) nor severe/critical COVID-19 disease (OR 0.90, 95%CI 0.74–1.11; I2 = 55%; 17 studies; GRADE confidence very low). Exploratory analyses in studies enrolling hypertensive patients showed a association of ACEi/ARB with a significant decrease of mortality risk. Conclusions: ACEi/ARB exposure does not seem to increase the risk of having the SARS-CoV-2 infection or developing severe stages of the disease including mortality. The potential benefits observed in mortality of hypertensive patients reassure safety, but robust studies are required to increase the confidence in the results.