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Introduction and Objectives: Little attention has been given to the effect of vascular access site on mortality, while an increasing body of evidence is showing that radial access has much more benefit than femoral access for ST-segment elevation myocardial infarction patients. We aimed to assess the influence of vascular access site on mortality at 30 days and at 1 year in ST-segment elevation myocardial infarction patients., Methods: We included all patients with ST-segment elevation myocardial infarction who had undergone primary angioplasty at 2 Galician hospitals between 2008 and 2010. We performed 2 multivariate regression models for each endpoint (30-day and 1-year mortality). The only difference between these models was the inclusion or not of the vascular access site (femoral vs radial). For each of the 4 models we calculated the Hosmer-Lemeshow test and the C-index. We also tested the interaction between hemodynamic instability and vascular access., Results: We included 1461 patients with a mean age of 64. Of these patients, 86% had radial access and 7.4% had hemodynamic instability. All-cause mortality was 6.8% (100/1461) at 30 days and 9.3% (136/1461) at 1 year. Vascular access site follows hemodynamic instability and age in terms of effect on mortality risk, with an odds ratio of 5.20 (95% confidence interval, 2.80-9.66) for 30-day mortality. A similar effect occurs for 1-year mortality. The C-index slightly improves (without achieving statistical significance) with the inclusion of the vascular access site., Conclusions: Vascular access site should be taken into account when predicting mortality after a primary percutaneous coronary intervention., (Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Introduction and Objectives: There is little information on the use of transcatheter aortic valve implantation in patients with severe aortic stenosis and porcelain aorta. The primary aim of this study was to analyze death from any cause after CoreValve(®) implantation in patients with severe aortic stenosis, with and without porcelain aorta., Methods: In this multicenter, observational prospective study, carried out in 3 hospitals, percutaneous aortic valves were implanted in 449 patients with severely calcified aortic stenosis. Of these, 36 (8%) met the criteria for porcelain aorta. The primary end-point was death from any cause at 2 years., Results: Patients with porcelain aorta more frequently had extracardiac vascular disease (11 [30.6%] vs 49 [11.9%]; P=.002), prior coronary revascularization (15 [41.7%] vs 98 [23.7%]; P=.017), and dyslipidemia (26 [72.2%] vs 186 [45%]; P=.02). In these patients, there was greater use of general anesthesia (15 [41.7%] vs 111 [16.9%]; P=.058) and axillary access (9 [25%] vs 34 [8.2%]; P=.004). The success rate of the procedure (94.4 vs 97.3%; P=.28) and the incidence of complications (7 [19.4%] vs 48 [11.6%]; P=.20) were similar in both groups. There were no statistically significant differences in the primary end point at 24 months of follow-up (8 [22.2%] vs 66 [16%]; P=.33). The only predictive variable for the primary end point was the presence of complications during implantation (hazard ratio=2.6; 95% confidence interval, 1.5-4.5; P=.001)., Conclusions: In patients with aortic stenosis and porcelain aorta unsuitable for surgery, percutaneous implantation of the CoreValve(®) self-expanding valve prosthesis is safe and feasible., (Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Background: To determine the prognostic value of pro B-type natriuretic peptide (pro-BNP) to predict mortality after transcatheter aortic valve implantation (TAVI). Logistic EuroSCORE (LES) overestimates observed mortality after TAVI. A new risk score specific to TAVI is needed to accurately assess mortality and outcome., Methods: Eighty-five patients were included. Indications for TAVI were nonoperable or surgically high-risk patients (LES>20%). Pro-BNP was measured 24h before the procedure. Cox proportional hazards model was used to evaluate clinical factors. The predictive accuracy of these Cox models was determined by using time-dependent receiver operating characteristic (ROC) curves., Results: Pro-BNP levels (log-transformed) were significantly higher in non-survivors than in survivors at 30 days (3.36 ± 0.43 vs. 3.81 ± 0.43, p<0.004) and at the end of follow-up (3.34 ± 0.42 vs. 3.63 ± 0.48, p<0.011). Multivariate analysis revealed that only increased log pro-BNP levels were associated with higher mortality rate at short [hazard ratio (HR) (95% confidence intervals (CI)]=5.35 (1.74-16.5), p=0.003] and long-term follow-ups [HR=11 (CI: 1.51-81.3), p=0.018]. LES was not associated with increased mortality at either time point [HR=1.03 (CI: 0.95-1.10), p=0.483 and HR=1.03 (CI: 0.98-1.07), p=0.230, respectively]. At 30, 90, 180, and 365 days, the c-index was 0.72 for log pro-BNP and 0.63 for LES (p=0.044)., Conclusion: Pre-procedure log transform of plasma pro-BNP levels are an independent and strong predictor of short- and long-term outcomes after TAVI and are more discriminatory than LES., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

We evaluated the incidence, clinical predictors, and outcomes of contrast-induced nephropathy (CIN) after coronary angiography in patients with myocardial infarction and normal kidney function. We studied 202 consecutive patients with glomerular filtration rate >60 mL/min/1.73 m(2). The CIN was defined according to 3 definitions: increases in serum creatinine (sCr) ≥25%, ≥0.3 mg/dL, and ≥0.5 mg/dL. The CIN occurred in 56 (27.7%), 42 (20.8%), and 13 (6.4%) patients, respectively. In multivariate analysis, the presence of a high Global Registry of Acute Coronary Events (GRACE) risk score (>140) was an independent predictor of CIN in its milder forms (≥25% and ≥0.3 mg/dL of rise in sCr). Increase in sCr ≥0.3 mg/dL was an independent predictor of bleeding. Increase in sCr ≥0.5 mg/dL was an independent predictor of in-hospital cardiac events (mortality, myocardial infraction [MI], and heart failure). As conclusion, the GRACE score is a useful tool to predict CIN in patients with MI and normal renal function.

Introduction and Objectives: Percutaneous aortic valve implantation for patients with severe symptomatic aortic stenosis and a high surgical risk is currently well established. We report our experience in terms of safety and effectiveness of transcatheter aortic valve implantation in other clinical context like the degenerated aortic homografts., Methods: We report our initial experience in four hospitals and five patients with degenerated aortic homograft and severe aortic regurgitation, refused for surgery for a heart team, that underwent percutaneous implantation of CoreValve(®) aortic prosthesis., Results: We included three males and two females. The mean age was 70 (3.5) years. All patients were symptomatic in New York Heart Association class III or IV. Procedures were performed through one of the femoral arteries in all patients and under sedation in three patients. The implant was successfully carried out in all cases. There were no major complications during the procedure or admission and the valvular defect was solved in all cases. In-hospital and 30-days mortality was 0. All patients had clinical improvement during follow-up with a reduction in at less two grades in the New York Heart Association functional scale., Conclusions: In our experience the treatment of degenerated aortic homografts and aortic insufficiency with transcatheter aortic valve implantation showed to be safe and effective. The current challenge is to convey the good results of transcatheter aortic valve implantation in symptomatic aortic stenosis and high surgical risk to others disorders of the aortic valve. In the future, it is possible that transcatheter aortic valve implantation will expand its indications to majority of aortic valve disorders and patients with less surgical risk., (Copyright © 2011 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Objective: Our aim in this study was to provide novel information on the molecular mechanisms playing a major role in the unwanted platelet activation associated with ST-elevation myocardial infarction (STEMI)., Methods and Results: We compared the platelet proteome of 11 STEMI patients to a matched control group of 15 stable chronic ischemic cardiopathy patients. In addition, we did a prospective study to follow the STEMI patients over time. Proteins were separated by high-resolution 2D gel electrophoresis, identified by mass spectrometry, and validated by Western blotting. Platelets from STEMI patients on admission displayed 56 protein spot differences (corresponding to 42 unique genes) compared with the control group. The number of differences decreased with time during the patients' follow-up. Interestingly, the adapter protein CrkL and the active form of Src (phosphorylated in Tyr418) were found to be upregulated in platelets from STEMI patients. Major signaling pathways related to the proteins identified include integrin, integrin-linked kinase, and glycoprotein VI (GPVI) signaling. Interestingly, a study on an independent cohort of patients showed a higher degree of activation of GPVI signaling in STEMI patients., Conclusions: CrkL, the active form of Src, and GPVI signaling are upregulated in platelets from STEMI patients.

Introduction and Objectives: To validate the axillary approach as a safe and efficient option for the transcatheter aortic valve implantation in patients who have contraindication for femoral approach at three Spanish hospitals., Methods: We included patients with severe symptomatic aortic stenosis at very high or prohibitive surgical risk, selected by a multidisciplinary team, for transcatheter aortic valve implantation, and had contraindication to the femoral approach., Results: We included 19 of 186 (10.5%) patients, who were implanted a percutaneous aortic valve, between November 2008 and March 2010. The mean age was 78.3 (standard deviation [SD]±8.65) years and 73.7% were males. The mean logistic EuroSCORE was 28.7% (SD±16.3%). The procedural success rate was 100%. After the procedure the maximum transvalve gradient decreased from 81.7 mmHg (SD±21.5) to 15.8 mmHg (SD±5.5), and no patient presented residual aortic regurgitation >2. The all-cause mortality, with a mean follow-up time of 9.2 (SD±3.2) months was 10.5%, and the in-hospital and 30-day mortality rates were 0%. The global incidence of major complications due to the procedure was 15.7%. Definitive pacemaker implantation was carried out for atrioventricular block in 8 patients (44.4%)., Conclusions: The axillary approach for transcatheter aortic valve implantation using the CoreValve(®) and contraindication to the femoral approach is safe and efficient for selected patients, with excellent results in terms of success implantation and in hospital and 30-day mortality., (Copyright © 2010 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Background and Objectives: Chronic renal failure (CRF) is an emergent pathology in industrialized countries and is associated with high prevalence of coronary artery disease. Our aim is to determine the influence of CRF in the appearance of adverse cardiovascular events after sirolimus-eluting stent implantation in a non selected cohort., Patients and Methods: Observational retrospective study with a cohort of 461 patients who received one or more sirolimus-eluting stent between September 2002 and December 2005 at our institution. We evaluated the incidence of adverse cardiovascular events during the follow-up period and their relation with chronic kidney disease. We used the abbreviated Modification of Diet in Renal Disease (MDRD) equation to calculate the GFR., Results: The mean follow-up was 42 months (SD ± 13) and the mean age was 61 ± 11 years and 85 percent of the group were men. Chronic renal failure was present in 50 patients, 11 percent of the cohort. In a multivariate model, after adjustment for age, sex, left ventricle election fraction, anemia, diabetes, hypertension, Killip class and stent thrombosis, chronic renal failure was an independent predictive factor of death from any cause (hazard ratio, 3.82; 95 percent confidence interval, 1.41-10.33, p = 0.008), and an significant risk factor for restenosis (hazard ratio 3.47; 95 percent confidence interval, 1.01-11.97, p = 0.045). Significant differences were not found in thrombosis between patients with or without CRF (8% vs 3.4%, p = 0,109), although a trend was observed in the CRF group. There no were statistical association with need for a new target vessel revascularization (TVR) after coronary intervention either (18.8% versus 10.5%, p = 0.094)., Conclusions: The presence of chronic renal failure in patients with coronary disease is associated with higher risk of restenosis and is a potent predictor of mortality after sirolimus-eluting stent implantation., (Copyright © 2009 Elsevier España, S.L. All rights reserved.)

The incidence of chronic renal failure has increased in the last years in industrialized countries. In Spain the prevalence of this pathology is estimated at 10-12% of the population, and the stages III-V of the disease, corresponding to the estimated glomerular filtration rate less than 60 ml/min/m2, represent the 5%. From the cardiovascular point of view, both chronic and acute coronary syndrome is a very important subgroup of patients because of the increased association between chronic renal failure and coronary artery disease. In fact, ACS is the main cause of death in patients with advanced chronic renal failure. Frequently, this kind of patients are excluded from prospective randomized clinical trials, consequently scientific evidence is not available to guide the therapy of coronary revascularization.

Introduction and Objectives: The high level of metabolic activity present in visceral adipose tissue is associated with the development of atherothrombosis. Subcutaneous adipose tissue secretes larger quantities of the adipocytokines leptin and adiponectin than visceral adipose tissue. Epicardial adipose tissue secretes inflammatory mediators, and the resulting proinflammatory activity is greater than that associated with subcutaneous adipose tissue. The aim of this study was to compare adiponectin and leptin expression in human epicardial and subcutaneous adipose tissue., Methods: Samples of both epicardial and subcutaneous adipose tissue were taken from 46 patients who were undergoing heart surgery, coronary artery bypass surgery, or aortic or mitral valve replacement. Levels of protein and gene expression of leptin and adiponectin were assessed immunohistochemically and by RT-PCR, respectively. Levels of mRNA expression in the 2 adipose tissue types were compared by real-time quantitative PCR., Results: Significant differences were found between adiponectin and leptin mRNA expression in epicardial and subcutaneous adipose tissue, with epicardial adipose tissue exhibiting lower levels of adiponectin and leptin expression. Moreover, adiponectin and leptin mRNA expression in epicardial adipose tissue was higher in women than men., Conclusions: Adiponectin and leptin expression is lower in epicardial than in subcutaneous adipose tissue. Moreover, there are differences in adiponectin and leptin expression in epicardial adipose tissue between women and men.