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Resumen Introduccion y objetivos La calcificacion grave esta presente en mas del 50% de las oclusiones coronarias cronicas totales (OCT) tratadas mediante intervencion percutanea. Nuestro objetivo fue describir el uso contemporaneo de los dispositivos de modificacion de placa (DMP) en este contexto. Metodos Los pacientes se incluyeron en el Registro Iberico de OCT de forma prospectiva y consecutiva (32 centros de Espana y Portugal), de 2015 a 2020. Se compararon en funcion del uso o no de DMP. Resultados Se incluyo a 2.235 pacientes, en 1.900 de los cuales se logro cruzar con exito la lesion con guia. Se utilizo al menos un DMP en un 7% (134 pacientes) y mas de uno en 24 pacientes (1%). Los DMP seleccionados fueron: aterectomia rotacional (35,1%), litotricia (5,2%), laser (11,2%), balones de corte (27,6%), balones OPN (2,9%) o combinaciones de mas de uno (18%). Se utilizaron DMP en pacientes mas ancianos, con mayor riesgo cardiovascular y puntuaciones Syntax y J-CTO mas elevados. Esta mayor complejidad se asocio con procedimientos mas prolongados, pero similar longitud total de stent (52 frente a 57 mm; p = 0,105). Cuando la guia cruzo con exito la oclusion, la tasa de exito final del procedimiento fue del 87,2%, pero se incremento al 96,3% cuando se utilizaron DMP (p = 0,001). Por el contrario, los DMP no se asociaron con mayor tasa de complicaciones en el procedimiento (3,7 frente a 3,2%; p = 0,615). Pese al peor perfil de riesgo basal, a los 2 anos de seguimiento no hubo diferencias en la tasa de supervivencia (94,3% DPM frente a no-DMP: 94,3% no-DPM, respectivamente, p = 0,967). Conclusiones Cuando la guia cruzo con exito una OCT, la tasa de uso de los DMP fue del 7% y se asocio a una tasa de exito final del procedimiento significativamente mayor. Los resultados a medio plazo fueron comparables cuando se precisaron DMP pese a su mayor riesgo basal, lo que sugiere que un mayor uso adecuado de estas tecnicas en este contexto podria conllevar tanto beneficios tecnicos como pronosticos.

INTRODUCTION AND OBJECTIVES: Severe calcification is present in>50% of coronary chronic total occlusions (CTOs) undergoing percutaneous intervention. We aimed to describe the contemporary use and outcomes of plaque modification devices (PMDs) in this context. METHODS: Patients were included in the prospective, consecutive Iberian CTO registry (32 centers in Spain and Portugal), from 2015 to 2020. Comparison was performed according to the use of PMDs. RESULTS: Among 2235 patients, wire crossing was achieved in 1900 patients and PMDs were used in 134 patients (7%), requiring more than 1 PMD in 24 patients (1%). The selected PMDs were rotational atherectomy (35.1%), lithotripsy (5.2%), laser (11.2%), cutting/scoring balloons (27.6%), OPN balloons (2.9%), or a combination of PMDs (18%). PMDs were used in older patients, with greater cardiovascular burden, and higher Syntax and J-CTO scores. This greater complexity was associated with longer procedural time but similar total stent length (52 vs 57mm; P=.105). If the wire crossed, the procedural success rate was 87.2% but increased to 96.3% when PMDs were used (P=.001). Conversely, PMDs were not associated with a higher rate of procedural complications (3.7 vs 3.2%; P=.615). Despite the worse baseline profile, at 2 years of follow-up there were no differences in the survival rate (PMDs: 94.3% vs no-PMDs: 94.3%, respectively; P=.967). CONCLUSIONS: Following successful wire crossing in CTOs, PMDs were used in 7% of the lesions with an increased success rate. Mid-term outcomes were comparable despite their worse baseline profile, suggesting that broader use of PMDs in this setting might have potential technical and prognostic benefits.

Resumen Introduccion y objetivos La amiloidosis cardiaca (AC) es una enfermedad infiltrativa que ha cobrado especial relevancia en los ultimos anos. El objetivo del estudio fue definir el perfil del paciente diagnosticado de AC. Metodos Estudio retrospectivo realizado entre enero de 2013 y febrero de 2020 que recoge las caracteristicas clinicas, electrocardiograficas y de pruebas de imagen de los pacientes con diagnostico de AC. Resultados Se incluyeron 44 pacientes con diagnostico confirmado de AC (17 con AC primaria y 27 con AC por transtirretina), con una edad media de 73 ± 12 anos, el 71% fueron varones. El sintoma principal de inicio fue la insuficiencia cardiaca (IC): 59%. El septo interventricular medio fue de 16 ± 3 mm y la fraccion de eyeccion del ventriculo izquierdo se encontraba preservada en el 50% de los pacientes (22 pacientes). La rentabilidad de la biopsia endomiocardica fue del 100% (n = 14). La gammagrafia con 99mTc-acido 3,3-difosfono-1,2-propanodicarboxilico resulto positiva en el 41% de los pacientes con AC primaria y en el 96% con AC por transtirretina. A los 83,8 ± 14,1 meses de seguimiento, 19 pacientes fallecieron (15,6 por 100 pacientes/ano) y 21 tuvieron al menos un reingreso por IC (24,6 por 100 pacientes/ano). El subtipo de AC primaria y el inicio por insuficiencia cardiaca se asociaron a una mayor mortalidad y mayor tasa de reingresos hospitalarios. El grosor del septo interventricular tambien tuvo asociacion con la mortalidad. Conclusiones En nuestro estudio, la AC es mas prevalente en los varones en la septima decada de la vida, siendo la forma de presentacion mas habitual como IC, con alta prevalencia de fraccion de eyeccion del ventriculo izquierdo reducida en el momento del diagnostico. El pronostico de esta enfermedad es infausto, con una mayor mortalidad en aquellos pacientes con AC primaria.

Coronary artery perforation is one of the most common and feared complications of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We evaluated the utility of the recently presented OPEN-CLEAN (Coronary artery bypass graft, Length of occlusion, Ejection fraction, Age, calcificatioN) perforation score in an independent multicenter CTO PCI dataset. Of the 2,270 patients who underwent CTO PCI at 7 centers, 150 (6.6%) suffered coronary artery perforation. Patients with perforations were older (69 ± 10 vs 65 ± 10, p

Heart failure (HF) admission in chronic coronary syndrome (CCS) patients has a prognostic impact. Stratification schemes have been described for predicting this end-point but none of them has been externally validated.Our aim was to develop point-scores for predicting incident HF admission with data from previous studies, to perform an external validation in an independent prospective cohort, and to compare their discriminative ability for this event.Independent predictive variables of HF admission in CCS patients without baseline HF were selected from four previous prospective studies (CARE, PEACE, CORONOR and CLARIFY), generating scores based on the relative magnitude of the coefficients of Cox of each variable. Finally, the scores were validated and compared in a monocentric prospective cohort.The validation cohort included 1212 patients followed for up to 17 years, with 171 patients suffering at least one HF admission in follow-up. Discriminative ability for predicting HF admission was statistically significant for all, and paired comparison among them were all non-significant except for CORONOR score were superior to CLARIFY score (C-statistic 0.73, 95%CI 0.69-0.76 vs 0.69, 95%CI 0.65-0.73; p=0.03).All tested scores showed significant discriminative ability for predicting incident HF admission in this independent validation study. Their discriminative ability was similar, with significant differences only between the two scores with higher and lower performance.

BACKGROUND The aim of this study was to analyze the feasibility of a physiological coronary evaluation with the instantaneous wave-free ratio (iFR) of nonculprit lesions in patients with acute coronary syndrome (ACS) successfully revascularized. METHODS A multicenter registry including patients of four high-volume PCI centers with ACS and underwent successful revascularization of the culprit vessel and had other nonculprit lesions that were physiologically evaluated with the iFR between January 2017 and December 2019. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction, probable or definitive stent thrombosis and new revascularization (MACEs). RESULTS A total of 356 patients with 472 nonculprit lesions were included. The mean age was 66 ± 11 years. The clinical presentation was ACS without persistent ST-segment elevation (NSTE-ACS) in 235 patients (66%) and ST-segment elevation myocardial infarction (STEMI) in 121 patients (34%). After a median follow-up period of 21 (14-30) months, the primary endpoint occurred in 32 patients (9%). There were no differences in outcomes regarding clinical presentation (NSTEMI vs. NSTE-ACS, 9.1 vs. 8.9%, padj = 0.570) or iFR induced treatment strategy (patients with all lesions revascularized vs. patients with at least one lesion with an iFR > 0.89 deferred for revascularization, 10.5 vs. 8.4%, padj = 0.476). CONCLUSIONS The use of the iFR to guide percutaneous coronary intervention decision making in nonculprit lesions seems to be feasible, with an acceptable percentage of MACEs at the mid-term follow-up. Patients with deferred revascularization of lesions without physiological significance and patients undergoing complete revascularization had a similar risk of MACEs.

BACKGROUND Optimal deployment of coronary stents in a bifurcation lesion remains a matter of debate. AIMS We sought to capture the daily practice of bifurcation stenting by means of a worldwide registry and to investigate how the post-implantation deployment techniques influence the clinical outcomes. METHODS Data from the e-ULTIMASTER registry were used to perform an analysis of 4395 patients undergoing percutaneous coronary intervention for bifurcation lesions. Inverse probability of treatment weights (IPTW) propensity score methodology was used to adjust for any baseline differences. The primary outcome of interest was target lesion failure (TLF) at 1-year (follow-up rate 96.2%). RESULTS Global one-year TLF rate was low: 5.1%. Proximal optimization technique was used in 33.9 % of cases and was associated with a reduction in adjusted TLF rate [4.0 (95% confidence interval:3.0-5.1)% versus 6.0(5.1-6.9)%, p

The use of a pressure wire as a jailed wire to evaluate side branch results during provisional stenting seems feasible. However, safety concerns exist due to the mechanical damage of the wire and the lack of prospective data evaluating the prognosis of patients treated using this technique. This study sought to evaluate the structural damage of the pressure wire in patients treated using the jailed pressure wire technique and to assess mid-term clinical outcomes.We enrolled 99 patients with single bifurcation lesions and provisional stenting as the strategy of choice. A jailed pressure wire was used to guide side branch intervention according to the instantaneous wave-free ratio (iFR). A total of 114 patients and the respective nonpolymer-coated jailed wires were used as historical controls. Guidewire damage was evaluated by stereomicroscopy. The primary endpoint was significant microscopic damage. Major adverse cardiac events were evaluated at 2-year follow-up.Significant microscopic damage was more frequent in pressure wires than in nonpolymer-coated wires (53.5% vs 22.8%, P.001). There were no fractures in either group. There were fewer side branch interventions in the pressure wire group (postdilation/kissing balloon, 32.3% vs 56.1%, P=.001; stenting, 0.0% vs 2.6%, P=.104). The 2-year rate of major adverse cardiac events was similar between the 2 groups (HRPressure wires were less resistant to jailing than conventional nonpolymer-coated wires. Patients treated with iFR-guided provisional stenting required fewer side branch interventions but had similar 2-year clinical outcomes than patients treated with the angiography-guided technique.

espanolIntroduccion y objetivos: Los pacientes con lesiones coronarias largas, secuenciales o difusas tratadas percutaneamente continuan presentando un riesgo alto de eventos cardiovasculares a pesar de la mejoria de la seguridad y de la eficacia de los nuevos stents liberadores de farmacos. El objetivo de este estudio es analizar la utilidad del software SyncVision /iFR (SyncVision version 4.1.0.5, Philips Volcano, Belgica) para guiar la revascularizacion en este tipo de lesiones. Metodos: Estudio aleatorizado, multicentrico, controlado y abierto para comparar la revascularizacion guiada por SyncVision /iFR respecto a la revascularizacion guiada por angiografia en pacientes con lesiones coronarias largas, secuenciales o difusas (identificador de ClinicalTrials.gov: NCT04283734). Se incluira a 100 pacientes (aleatorizacion 1:1 no estratificada). El objetivo primario es la longitud total del stent implantado. Como objetivo secundario se ha establecido un combinado de muerte cardiaca, infarto de miocardio, trombosis definitiva o probable del stent, nueva revascularizacion de la lesion tratada en el procedimiento basal o nueva revascularizacion de la lesion analizada en el procedimiento basal, y la presencia de isquemia residual evaluada por tomografia computarizada por emision de foton simple a los 6 meses de seguimiento. El tiempo de seguimiento sera de 12 meses tras el procedimiento indice. Resultados: El estudio se encuentra actualmente en fase de reclutamiento, con los primeros 7 pacientes ya incluidos. Esperamos completar el reclutamiento en febrero de 2021 y el seguimiento en febrero de 2022. Conclusiones: El estudio iLARDI es el primer estudio aleatorizado para la evaluacion de la potencial utilidad de la revascularizacion guiada por Syncvision en lesiones coronarias largas, secuenciales y difusas. EnglishIntroduction and objectives: patients with long, sequential and diffuse coronary lesions who undergo a percutaneous coronary intervention remain at a high risk of suffering cardiovascular events despite the improved safety and efficacy of the new drug-eluting stents. The objective of this study was to analyze the utility of SyncVision/iFR-guided revascularization (SyncVision version 4.1.0.5, Philips Volcano, Belgium) in this type of lesions. Methods: Randomized, multicenter, controlled, and open-label trial designed to compare SyncVision/iFR-guided and angiography-guided revascularizations in patients with long, sequential or diffuse significant angiographic coronary stenosis (ClinicalTrials.gov identifier: NCT04283734). A total of 100 patients will be randomized (1:1, no stratification). The primary endpoint is the average length of the stent implanted. The secondary endpoint is a composite of cardiac death, myocardial infarction, definitive or probable stent thrombosis, new target lesion revascularization or new target lesion failure; and the presence of residual ischemia as seen on single-photon emission computed tomography at the 6-month follow-up. Patients will be followed for 12 months after the procedure. Results: The trial is currently in the recruitment phase, and it has already recruited the first 7 patients. We expect to complete the recruitment phase by February 2021 and the follow-up by February 2022. Conclusions:The iLARDI study is the first randomized trial to assess the potential utility of SyncVision-guided revascularization in long, sequential and diffuse coronary lesions.

Introduction and objectives: The objective of this study was to describe our experience with coronary physiology assessment using the instantaneous wave-free ratio (iFR) and/or a Syncvision-guided iFR-pullback study [Syncvision version 4.1.0.5, Philips Volcano, Belgium] in all-comer patients. Methods: Consecutive patients undergoing coronary physiology assessment with the iFR (and/or a Syncvision-guided iFR-pullback study) at our center between January 2017 and December 2019 were included. The iFR cut-off value was 0.89. The primary endpoint was a composite of cardiac death, myocardial infarction, probable or definitive stent thrombosis, and target lesion revascularization. Results: A total of 277 patients with 433 lesions evaluated were included. The mean age was 65 ± 10 years and 74% were men. Personal history of diabetes mellitus was present in 41% of patients. Clinical presentation was stable angina in 160 patients (58%), and acute coronary syndrome in 117 patients (42%). iFRs > 0.89 were obtained in 266 lesions (61.4%) on which the PCI was postponed. The remaining lesions were revascularized. The Syncvision software was used to guide the iFR-pullback study in 155 lesions (36%) and the decision-making process, mainly in long, diffuse or sequential lesions (91 lesions, 58.7%), and intermediate lesions (52 lesions, 33.5%). After a median follow-up of 18 months, the primary endpoint occurred in 17 patients (6.1%) without differences regarding the baseline iFR (≤ 0.89 or > 0.89) (4.2% vs 3.8%; P = .9) or the clinical presentation (stable angina or acute coronary syndrome) (4.4% vs 8.5%; P = .1) Conclusions: The use of coronary physiology assessment with the iFR and the Syncvision-guided iFR-pullback study in the routine daily practice and in all-comer patients seems safe with a low percentage of major adverse cardiovascular events at the mid-term follow-up.

Introduction and objectives: patients with long, sequential and diffuse coronary lesions who undergo a percutaneous coronary intervention remain at a high risk of suffering cardiovascular events despite the improved safety and efficacy of the new drug-eluting stents. The objective of this study was to analyze the utility of SyncVision/iFR-guided revascularization (SyncVision version 4.1.0.5, Philips Volcano, Belgium) in this type of lesions. Methods: Randomized, multicenter, controlled, and open-label trial designed to compare SyncVision/iFR-guided and angiography-guided revascularizations in patients with long, sequential or diffuse significant angiographic coronary stenosis (ClinicalTrials.gov identifier: NCT04283734). A total of 100 patients will be randomized (1:1, no stratification). The primary endpoint is the average length of the stent implanted. The secondary endpoint is a composite of cardiac death, myocardial infarction, definitive or probable stent thrombosis, new target lesion revascularization or new target lesion failure; and the presence of residual ischemia as seen on single-photon emission computed tomography at the 6-month follow-up. Patients will be followed for 12 months after the procedure. Results: The trial is currently in the recruitment phase, and it has already recruited the first 7 patients. We expect to complete the recruitment phase by February 2021 and the follow-up by February 2022. Conclusions: The iLARDI study is the first randomized trial to assess the potential utility of SyncVision-guided revascularization in long, sequential and diffuse coronary lesions.

Introduction and objectives The NitOcclud Le VSD Coil was specifically designed for transcatheter occlusion of ventricular septal defects (VSD) and became available for this purpose in August 2010. Our objective was to describe the Spanish experience of this technique and analyze its reliability and short- to mid-term efficacy. Methods National multicenter observational study, which retrospectively recruited all patients (of any age) with VSD (of any location or type) who underwent percutaneous NitOcclud occlusion, using an intention-to-treat analysis, until January 2019. Results A total of 117 attempts were made to implant at least 1 NitOcclud in 116 patients in 13 institutions. The median [range] age and weight was 8.6 [0.4-69] years and 27 [5.8-97] kg, respectively. In 99 patients (85%), the VSD was an isolated congenital defect. The location was perimembranous in 95 (81%), and 74 (63%) of them were aneurysmatic. The mean fluoroscopy time was 34 [11.4-124] minutes. Of the 117 attempts, 104 were successful (89%) with a follow-up of 31.4 [0.6-59] months. At the last review, final complete occlusion of the defect without residual shunt or with only a minimal shunt was achieved in 92.3% (no shunt, n = 73; trivial shunt, n = 23). Four patients required a second procedure for residual shunt occlusion. Two devices had to be surgically explanted due to severe hemolysis. There were no deaths or other major complications. Conclusions The NitOcclud device can be used successfully for a wide anatomical spectrum of VSD. The main issue is residual shunt, but its incidence decreases over time. The incidence of hemolysis was very low and no permanent changes were detected in atrioventricular conduction.

Resumen Introduccion y objetivos El dispositivo NitOcclud Le VSD Coil, disenado especificamente para el cierre de la comunicacion interventricular ( C IV), se comercializo en agosto de 2010. Se propuso describir el empleo de esta tecnica en Espana, analizando su fiabilidad y su eficacia a corto-medio plazo. Metodos Estudio observacional retrospectivo multicentrico espanol sobre pacientes de todas las edades con CIV, de cualquier naturaleza y localizacion, sometidos a cateterismo para intento de cierre con NitOcclud Le VSD Coil hasta enero de 2019. Resultados Con la participacion de 13 instituciones, se registro un total de 117 procedimientos para implantar al menos 1 dispositivo NitOcclud en 116 pacientes. Las medianas (intervalo) de edad y peso fueron 8,6 (0,4-69) anos y 27 (5,8-97) kg. En 99 casos (85%), la CIV era un defecto congenito aislado. La localizacion era perimembranosa en 95 pacientes (81%), 74 (63%) con bolson aneurismatico subtricuspideo. El tiempo de fluoroscopia fue 34 (11,4-124) min. El implante resulto exitoso en el 89% (104/117), con un tiempo de seguimiento de 31,4 (0,6-59) meses. La tasa de cierre completo o casi completo del defecto en la ultima revision era del 92,3% (ausente, 73; shunt trivial, 23). Cuatro pacientes precisaron un nuevo cateterismo para cierre de cortocircuito residual. Hubo que retirar quirurgicamente 2 dispositivos por hemolisis grave. No hubo muertes ni otras complicaciones mayores. Conclusiones El dispositivo NitOcclud puede utilizarse con exito para cierre de un amplio espectro anatomico de CIV. La persistencia de shunt residual inicial es significativa, pero disminuye con el tiempo. La incidencia de hemolisis es muy baja, y no se detectan alteraciones permanentes de la conduccion auriculoventricular.

Objectives The authors sought to examine the outcomes of percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) chronic total occlusions (CTOs). Background The outcomes of PCI for ISR CTOs have received limited study. Methods The authors examined the clinical and angiographic characteristics and procedural outcomes of 11,961 CTO PCIs performed in 11,728 patients at 107 centers in Europe, North America, Latin America, and Asia between 2012 and 2020, pooling patient-level data from 4 multicenter registries. In-hospital major adverse cardiovascular events (MACE) included death, myocardial infarction, stroke, and tamponade. Long-term MACE were defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization. Results ISR represented 15% of the CTOs (n = 1,755). Patients with ISR CTOs had higher prevalence of diabetes (44% vs. 38%; p Conclusions ISR CTOs represent 15% of all CTO PCIs and can be recanalized with similar success and in-hospital MACE as de novo CTOs.

Background Patients with non-left-main coronary bifurcation lesions are usually best treated with a stepwise provisional approach. However, patients with true left main stem bifurcation lesions have been shown in one dedicated randomized study to benefit from systematic dual stent implantation. Methods and results Four hundred and sixty-seven patients with true left main stem bifurcation lesions requiring intervention were recruited to the EBC MAIN study in 11 European countries. Patients were aged 71 ± 10 years; 77% were male. Patients were randomly allocated to a stepwise layered provisional strategy (n = 230) or a systematic dual stent approach (n = 237). The primary endpoint (a composite of death, myocardial infarction, and target lesion revascularization at 12 months) occurred in 14.7% of the stepwise provisional group vs. 17.7% of the systematic dual stent group (hazard ratio 0.8, 95% confidence interval 0.5–1.3; P = 0.34). Secondary endpoints were death (3.0% vs. 4.2%, P = 0.48), myocardial infarction (10.0% vs. 10.1%, P = 0.91), target lesion revascularization (6.1% vs. 9.3%, P = 0.16), and stent thrombosis (1.7% vs. 1.3%, P = 0.90), respectively. Procedure time, X-ray dose and consumables favoured the stepwise provisional approach. Symptomatic improvement was excellent and equal in each group. Conclusions Among patients with true bifurcation left main stem stenosis requiring intervention, fewer major adverse cardiac events occurred with a stepwise layered provisional approach than with planned dual stenting, although the difference was not statistically significant. The stepwise provisional strategy should remain the default for distal left main stem bifurcation intervention. Study registration http://clinicaltrials.gov NCT02497014.

The 15th European Bifurcation Club (EBC) meeting was held in Barcelona in October 2019. It facilitated a renewed consensus on coronary bifurcation lesions (CBL) and unprotected left main (LM) percutaneous interventions. Bifurcation stenting techniques continue to be refined, developed and tested. It remains evident that a provisional approach with optional side branch treatment utilising T, T and small protrusion (TAP) or culotte continues to provide flexible options for the majority of CBL patients. Debate persists regarding the optimal treatment of side branches, including assessment of clinical significance and thresholds for bail-out treatment. In more complex CBL, especially those involving the LM, adoption of dedicated two-stent techniques should be considered. Operators using such techniques have to be fully familiar with their procedural steps and should acknowledge associated limitations and challenges. When using two-stent techniques, failure to perform a final kissing inflation is regarded as a technical failure, since it may jeopardise clinical outcome. The development of novel technical tools and drug regimens deserves attention. In particular, intracoronary imaging, bifurcation simulation, drug-eluting balloon technology and tailored antiplatelet therapy have been identified as promising tools to enhance clinical outcomes. In conclusion, the evolution of a broad spectrum of bifurcation PCI components has resulted from studies extending from bench testing to randomised controlled trials. However, further advances are still needed to achieve the ambitious goal of optimising the clinical outcomes for every patient undergoing PCI on a CBL.

Background: Two-dimensional speckle-tracking echocardiography (2DSTE) has been present for years. However, it is underutilized due to the expertise and time requirements for its analysis. Our aims were to provide strain values in a paediatric Spanish population and to assess the feasibility and reproducibility of a new strain software analysis in our environment. Methods: A cross-sectional study of 156 healthy children aged 6 to 17 years. Longitudinal strain (LS) analysis of the left ventricle, right ventricle, and left atrium was performed. Feasibility and reproducibility were assessed. The associations of clinical and echocardiographic variables with strain values were investigated by multivariate analysis. Results: Mean age was 11 ± 3 years (50% female). Feasibility of LS measurement ranged from 94.2% for left ventricle global LS (LVGLS) to 98.1% for other chamber strain parameters. Strain values were 26.7 ± 2.3% for LVGLS; 30.5 ± 4.4% and 26.9 ± 4% for right ventricle free wall LS (RVFWLS) and four chambers view LS (RV4CLS) respectively; and 57.8 ± 10.5%, 44.9 ± 9.5%, and 12.9 ± 5.5% for left atrium LS reservoir phase (LALSr), conduct phase (LALScd) and contraction phase (LALSct), also respectively. Body surface area (BSA) and age presented a negative correlation with strain values. Higher values were found in females than in males, except for LALScd. Excellent intra- and inter-observer reproducibility were found for right and left ventricular strain measurement, with intraclass correlation coefficients (ICC) ranging from 0.88 to 0.98, respectively. In conclusion, we described strain values in a healthy Spanish paediatric population. LS assessment by this new strain analysis software by semi-automatic manner was highly feasible and reproducible.

The Bifurcation Academic Research Consortium (Bif-ARC) project originated from the need to overcome the paucity of standardization and comparability between studies involving bifurcation coronary lesions. This document is the result of a collaborative effort between academic research organizations and the most renowned interventional cardiology societies focused on bifurcation lesions in Europe, the United States, and Asia. This consensus provides standardized definitions for bifurcation lesions; the criteria to judge the side branch relevance; the procedural, mechanistic, and clinical endpoints for every type of bifurcation study; and the follow-up methods. Considering the complexity of bifurcation lesions and their evaluation, detailed instructions and technical aspects for site and core laboratory analysis of bifurcation lesions are also reported. The recommendations included within this consensus will facilitate pooled analyses and the effective comparison of data in the future, improving the clinical relevance of trials in bifurcation lesions, and the quality of care in this subset of patients.

Percutaneous coronary intervention (PCI) for aorto-ostial chronic total coronary occlusion (CTO) can be a particularly challenging lesion subset. The aim of this study was to analyze the technical aspects and outcomes of aorto-ostial CTO PCI in a multicenter registry.Patients undergoing aorto-ostial CTO PCI at 4 centers between February 2013 and December 2018 were included. Success rates, as well as procedural aspects and outcomes, were analyzed.A total of 103 patients were included. Mean age was 64±10 years and the mean J-CTO score was 3.1±1.1. Thirty-one lesions (30.4%) were flush ostial CTOs. Technical and procedural success were achieved in 79 (76.7%) and 78 (75.7%) of the patients, respectively. The retrograde approach was the most frequent successful crossing technique (n=49; 62.0%), especially in flush vs nonflush aorto-ostial CTOs (82.6% vs 53.5%; P=.02). The only variable independently associated with technical failure was the absence of interventional collaterals (OR, 12.38; 95%CI, 4.02-38.15; P.001). Coronary perforation occurred in 4 patients (3.9%) requiring covered stent implantation (without subsequent cardiac tamponade) and 2 patients (1.9%) had a stroke (one of which was a transient ischemic attack). During a median follow-up of 31 months, 3 (2.9%) patients died from cardiovascular causes and 13 (12.6%) required repeat target vessel revascularization.Aorto-ostial occlusions represent a challenging subset for PCI. However, an acceptable success rate with favorable outcomes during follow-up can be achieved by experienced operators. The presence of interventional collaterals allowing the use of the retrograde approach is key for achieving procedural success.

Resumen Introduccion y objetivos La intervencion coronaria percutanea (ICP) de oclusiones coronarias totales cronicas (OTC) aorto-ostiales constituye un reto como subgrupo. El objetivo de este estudio es analizar los aspectos tecnicos y resultados tras la ICP de OTC aorto-ostiales en un registro multicentrico. Metodos Se incluyo a los pacientes de 4 centros con una OTC aorto-ostial tratados con ICP entre febrero de 2013 y diciembre de 2018. Se analizaron las tasas de exito, los aspectos del procedimiento y los resultados. Resultados Se incluyo a 103 pacientes. La media de edad fue 64 ± 10 anos y la puntuacion J-OTC, 3,1 ± 1,1. Habia 31 OTC (30,4%) con ausencia total de munon. El exito tecnico y del procedimiento se obtuvo en 79 (76,7%) y 78 (75,7%) de los pacientes respectivamente. El abordaje retrogrado fue la tecnica de cruce exitosa mas frecuente (n = 49; 62,0%), especialmente en OTC sin munon (el 82,6 frente al 53,5%; p = 0,02). La ausencia de colaterales intervencionistas fue la unica variable asociada con fallo tecnico (OR = 12,38; IC95%, 4,02-38,15; p Conclusiones Las OTC aorto-ostiales representan un subgrupo tecnicamente complejo. Sin embargo, operadores expertos pueden obtener una tasa de exito aceptable con resultados favorables al seguimiento. La presencia de colaterales intervencionistas, que permiten el acceso retrogrado, parece ser clave para que el procedimiento sea exitoso.

Objectives To assess the efficacy and safety of excimer laser coronary atherectomy (ELCA), as well as, the long-term outcomes and the factors associated with ELCA failure in uncrossable lesions. Background Uncrossable lesions constitute a challenge for percutaneous coronary intervention. Methods This multicenter registry included 126 patients with 126 uncrossable lesions. Study endpoints were ELCA success, technical success and a composite of cardiac death, myocardial infarction (MI), and target-lesion revascularization (TLR) on follow-up. Predictors of ELCA failure were analyzed. Results Moderate or severe calcification was present in 79 (62.7%) of the lesions and 58 (46%) were a chronic total occlusion. ELCA success was obtained in 103 (81.8%) patients. Rotational atherectomy was attempted as bailout in 21 out of 23 ELCA failure (91.3%), being successful in 14 (66.7%) of them. Finally, technical and procedural success were achieved in 114 (90.5%) and 110 (87.3%) of the patients. Severe calcification was independently associated with ELCA failure (OR: 3.73, 95% CI: 1.35-10.32; p = .011). Two (1.6%) patients died (one after a stroke and another patient because of heart failure), 4 (3.2%) developed a non-Q MI without clinical consequences and 1 (0.8%) patient had a Q-MI. Other complications were ventricular tachycardia/fibrillation (n = 2; 1.6%) and flow-limiting dissection (n = 1, 0.8%). At follow-up (median 424 days), 3 (2.4%) patients died (1 (0.8%) from cardiovascular cause) and 15 (11.9%) required TLR. Conclusions In our multicenter experience, ELCA use demonstrated to be safe and reasonably effective with a rate of events on follow-up relatively low. Severe calcification was associated with ELCA failure.

Resumen Introduccion y objetivos La reparacion de la valvula mitral transcateter (RVMT) con el sistema MitraClip es un tratamiento para los pacientes con insuficiencia mitral (IM) grave de alto riesgo quirurgico. El objetivo principal fue analizar los resultados del RVMT en pacientes con IM grave, segun la etiologia. Metodos Estudio observacional, prospectivo y multicentrico con inclusion de pacientes consecutivos. El objetivo primario fue el combinado de mortalidad por todas las causas y reingresos hospitalarios por insuficiencia cardiaca al ano. Se compararon las caracteristicas clinicas y del procedimiento y los eventos para cada grupo de IM. Se realizo un analisis multivariable para determinar las variables asociadas con el objetivo primario. Resultados Se incluyo a 558 pacientes; 364 (65,2%) tenian etiologia funcional; 111 (19,9%), degenerativa, y 83 (14,9%), mixta. La media de edad fue 72,8 ± 11,1 anos y eran varones el 70,3%. Respecto al objetivo primario, hubo 95 (17%) eventos en toda la serie. No hubo diferencias significativas entre los 3 grupos en el numero de eventos del objetivo primario: 11 (11,3%) en la IM degenerativa, 71 (21,3%) en la funcional y 13 (18,1%) en la mixta (p = 0,101). Los predictores independientes fueron la clase funcional (p = 0,029), la revascularizacion quirurgica previa (p = 0,031), el EuroSCORE II (p = 0,003), la diabetes mellitus (p = 0,037) y la fraccion de eyeccion del ventriculo izquierdo (p = 0,015). Conclusiones Este trabajo confirma con datos de la practica clinica la seguridad y la eficacia de la RVMT independientemente de la etiologia de la IM y se documentan los principales factores asociados con el pronostico durante el primer ano de seguimiento.

Background: Defining the optimal conduction of percutaneous-coronary-intervention (PCI) to treat bifurcation lesions has been the subject of many clinical studies showing that the applied stenting technique may influence clinical outcome. Accordingly, bifurcation stenting classifications and technical sequences should be standardized to allow proper reporting and comparison. Methods: The European Bifurcation Club (EBC) is a multidisciplinary group dedicated to optimize the treatment of bifurcations and previously created a classification of bifurcation stenting techniques that is based on the first stent implantation site. Since some techniques have been abandoned, others have been refined and dedicated devices became available, EBC promoted an international task force aimed at updating the classification of bifurcation stenting techniques as well as at highlighting the best practices for most popular techniques. Original descriptive images obtained by drawings, bench tests and micro-computed-tomographic reconstructions have been created in order to serve as tutorials in both procedure reporting and clinical practice. Results: An updated Main-Across-Distal-Side (MADS)-2, classification of bifurcation stenting techniques has been realized and is reported in the present article allowing standardized procedure reporting in both clinical practice and scientific studies. The EBC-promoted task force deeply discussed, agreed on and described (using original drawings and bench tests) the optimal steps for the following major bifurcation stenting techniques: (a) 1-stent techniques (“provisional” and “inverted provisional”) and (b) 2-stent techniques (“T/TAP,” “culotte,” and “DK-crush”). Conclusions: The present EBC-promoted paper is intended to facilitate technique selection, reporting and performance for PCI on bifurcated lesions during daily clinical practice.

Introduction and objectives: This study primary endpoint was to present the in-hospital all-cause mortality of the Spanish TAVI registry from its inception until 2018. Secondary endpoints included other in-hospital clinical events, 30-day all-cause mortality, and an assessment of the time trend of this registry. Methods: All consecutive patients included in the Spanish TAVI registry were analyzed. In this time-based analysis, the population was been divided into patients treated before 2014 (cohort A: 2009-2013) and patients treated between 2014 and 2018 (cohort B). Results: From August 2007 to June 2018, 7180 patients were included. The mean age was 81.2 ± 6.5 years and 53% were women. The logistic EuroSCORE was 12% (8-20). Transfemoral access was used in 89%. In-hospital and 30-day all-cause mortality was 4.7% and 5.7%, respectively. On the time-based analyses during the hospital stay, the rate of myocardial infarction, stroke, need for pacemakers, tamponade, coronary obstruction, and vascular complications was similar between both groups. However, cohort B showed less need for conversion to surgery and malapposition of the valve. Also, the implant success rate increased from 93% to 96% (P< .001). In-hospital and 30-day all-cause mortality was significantly lower in cohort B, ([OR, 0.65; IC95%, 0.48-0.86; P= .003] and [OR, 0.71; IC95%, 0.54-0.92; P= .002], respectively). Conclusions: The time trend analysis of the Spanish TAVI registry showed a change in the patients’ clinical profile and an improvement in the in-hospital clinical outcomes and 30-day all-cause mortality in patients treated more recently.

To investigate the value of tissue Doppler velocities for ruling out treatment-requiring acute cellular rejection (TR-ACR), in the context of myocardial deformation analysis performed by means of speckle tracking echocardiography. We performed serial echocardiograms in 37 heart transplant recipients in their first year post-transplantation within 3 h of the routine surveillance endomyocardial biopsies (EMB). The association of the sum of lateral mitral annulus systolic (s′) and early diastolic (e′) velocities, in absolute values, measured by tissue Doppler echocardiography (s′+ e′), with TR-ACR (ACR grade ≥ 2R) was investigated by multivariate analysis, including classic echocardiographic parameters and myocardial deformation variables. A total of 251 pairs of EMB and echo exams were performed, 35 (14%) with rejection grade ≥ 2R (TR-ACR). s′ + e′ was independently associated to TR-ACR (OR 0.80, 95%CI 0.72–0.89, p

In this article, we analyse the changes occurred over the last 20 years in the percutaneous treatment of bifurcation lesions based on our own experience. We also analyse the more relevant papers recently published, as well as the strategies and guidelines recommended for the percutaneous management of bifurcation lesions. Technical aspects are relevant in this field and, for this reason, a significant section of this manuscript is dedicated to the technique used together with some tips and tricks also provided here. The technical advances made over the last years have significantly increased the success rate in the management of these complex lesions. At the same time, the technique of treatment has been standardized allowing the management of all type of bifurcations including distal left main disease.