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Resumen Introduccion Existe un elevado numero de patologias extracardiacas que afectan al pericardio, manifestandose como pericarditis, derrame pericardico o, mas raramente, pericarditis constrictiva. Etiologia La pericarditis tuberculosa es la afectacion pericardica mas comun en el mundo, especialmente en paises subdesarrollados. Entre otras enfermedades extracardiacas que producen dano miocardico destacan: las infecciones bacterianas, la enfermedad renal avanzada o el tratamiento con dialisis, las enfermedades sistemicas autoinmunes y las neoplasias. Manifestaciones clinicas Las manifestaciones clinicas de las pericarditis asociadas a enfermedades extracardiacas suelen ser menos floridas que las de etiologia virica, con aparicion de sintomas constitucionales, ademas de signos y sintomas caracteristicos de las enfermedades subyacentes. Una complicacion no infrecuente es el desarrollo de derrame pericardico significativo con taponamiento cardiaco. Diagnostico La sospecha clinica, en primer lugar, es determinante para orientar la realizacion de un estudio etiologico protocolizado que permita realizar un diagnostico correcto. Pronostico El pronostico depende en gran medida del pronostico de la enfermedad extracardiaca subyacente. Tratamiento En la mayoria de los casos, el tratamiento fundamental es el de la enfermedad subyacente.

Resumen Introduccion El diagnostico de afectacion pericardica secundario a una enfermedad neoplasica requiere, inicialmente, de alta sospecha diagnostica y, posteriormente, de la aplicacion sistematica de un protocolo de estudio etiologico. Diagnostico Si se identifican factores predictores especificos de enfermedad neoplasica, se recomienda el drenaje del liquido pericardico mediante pericardiocentesis percutanea o con cirugia cardiaca. El estudio citologico del liquido pericardico puede determinar la existencia de infiltracion neoplasica pericardica. Sin embargo, en ocasiones se requiere el estudio anatomopatologico del pericardio obtenido con biopsia. Tratamiento Si existe compromiso hemodinamico, el tratamiento consistira en el drenaje con pericardiocentesis urgente. Ocasionalmente, se recomienda de forma escalonada el tratamiento antineoplasico, pericardiocentesis e instilacion intrapericardica de agentes citotoxicos o esclerosantes. La pericardiotomia percutanea con balon es un tratamiento seguro y eficaz en caso de taponamiento recurrente. En fases avanzadas de la enfermedad neoplasica subyacente, el tratamiento de eleccion es el paliativo para alivio exclusivo de los sintomas que sufre el enfermo.

Resumen Epidemiologia Tiene una baja incidencia en nuestro medio, con mayor prevalencia en varones. Algunas causas de inflamacion pericardica, entre ellas la tuberculosis, las pericarditis purulentas y las secundarias a enfermedades autoinmunes sistemicas o neoplasias pueden tener mayor riesgo de desarrollar constriccion pericardica. Etiologia/etiopatogenia La causa etiologica mas comun en nuestro medio es la idiopatica o virica. Manifestaciones clinicas Cursa con signos y sintomas de insuficiencia cardiaca derecha, a menudo acompanados de disnea o astenia, que pueden evolucionar hasta la insuficiencia hepatica, cirrosis y caquexia. Diagnostico Es imprescindible un correcto diagnostico diferencial con la miocardiopatia restrictiva. La ecocardiografia permite confirmar habitualmente el patron fisiopatologico de constriccion. La resonancia magnetica cardiaca y la tomografia computadorizada pueden aportar datos complementarios. Si existen dudas, puede ser necesario un cateterismo cardiaco con medicion invasiva de presiones. Pronostico Aunque es una causa potencialmente reversible de insuficiencia cardiaca, la tasa de mortalidad es elevada. La cirugia mejora significativamente el pronostico y la clase funcional cuando se realiza en estadios precoces de la enfermedad. Tratamiento El tratamiento medico suele ser insuficiente y el tratamiento definitivo requiere cirugia con realizacion de pericardiectomia en centros con experiencia.

Resumen Tipos La pericarditis infecciosa engloba tres etiologias diferentes: virica, purulenta y tuberculosa. Diagnostico El diagnostico de cada una de estas tres entidades requiere de un estudio especifico que debe protocolizarse. La pericarditis virica precisa del estudio analitico integral del liquido o tejido pericardico que englobe analisis histologico, citologico, inmunohistologico y molecular. En el caso de la pericarditis purulenta, su diagnostico se basa en el hallazgo de un liquido pericardico de aspecto purulento con predominio de leucocitos y en el analisis microbiologico del mismo. Por ultimo, la pericarditis tuberculosa requiere la demostracion del bacilo tuberculoso en liquido o tejido pericardicos. Tratamiento El tratamiento sera especifico dependiendo de su etiologia.

Background The efficacy and safety of pharmacoinvasive strategy following fibrinolysis for ST-elevation myocardial infarction (STEMI) in relation to renal function have not been established. Methods Using patient-level data from 4 randomized controlled trials, we examined the efficacy and safety of pharmacoinvasive versus standard treatment after fibrinolysis for STEMI. Patients were stratified based on the estimated glomerular filtration rate (eGFR) on presentation ( 2 vs ≥60 mL/min/1.73 m 2 ). The primary outcome was the composite of death or reinfarction at 30 days. Results Of 2,029 patients, 457 (23%) had an eGFR 2 . Patients with eGFR 2 were older and had higher Thrombolysis in Myocardial Infarction risk scores. Compared with patients with eGFR ≥ 60 mL/min/1.73 m 2 , patients with renal dysfunction had higher rates of the primary outcome (5.3% vs 11.8%, respectively; P P heterogeneity = .73) or the rate of death or reinfarction at 1 year ( P heterogeneity = .64) in relation to eGFR. Patients with renal dysfunction had higher rates of in-hospital major bleeding compared with patients with eGFR ≥60 mL/min/1.73 m 2 (7.7% vs 4.3%, respectively; P = .004); however, there was no difference in bleeding events between treatment arms in the overall cohort or in relation to eGFR ( P heterogeneity = .67). Conclusions Renal impairment is associated with increased rates of adverse events in STEMI patients treated with fibrinolysis. However, the safety and efficacy of pharmacoinvasive strategy are preserved in patients with renal impairment on presentation.

espanolResumen Se define como derrame pericardico a la existencia no fisiologica de liquido en el saco pericardico. Cuando el aumento de la presion intrapericardica impide el llenado efectivo de las cavidades cardiacas se alcanza la grave situacion hemodinamica de taponamiento cardiaco. En nuestro medio, la principal causa de derrame pericardico es la idiopatica. El taponamiento cardiaco puede desarrollarse ante un derrame pericardico de cualquier origen. Los sintomas asociados al derrame pericardico son secundarios a la compresion mecanica de las estructuras vecinas. Los principales signos clinicos que puede presentar un paciente con taponamiento cardiaco son: taquicardia, hipotension arterial, aumento de la presion venosa yugular, ruidos cardiacos disminuidos y pulso paradojico. La ecocardiografia transtoracica es la prueba diagnostica de primera eleccion en ambas entidades. El tratamiento del derrame pericardico depende de la etiologia del mismo. Se recomienda el drenaje del liquido pericardico urgente mediante pericardiocentesis percutanea o drenaje quirurgico para tratar el taponamiento cardiaco. EnglishAbstract Pericardial effusion is defined as the non-physiological presence of fluid in the pericardial sac. When increased intrapericardial pressure restricts the effective filling of the heart cavities this causes the serious haemodynamic situation of cardiac tamponade. In our environment, the principal cause of pericardial effusion is idiopathic. Cardiac taponade can develop in the event of a pericardial effusion of any origin. The symptoms associated with pericardial effusion are secondary to mechanical compression of the neighbouring structures. The main clinical signs that a patient with cardiac taponade can present are tachycardia, arterial hypotension, increased jugular vein pressure, diminished heart sounds and pulsus paradoxus. Transthoracic echocardiogram is the diagnostic test of choice for both conditions. Treatment of pericardial effusion depends on its aetiology. Emergency drainage of the pericardial fluid is recommended by means of percutaneous pericardiocentesis or surgical drainage to treat the cardiac taponade.

Aims Radiofrequency ablation (RFA) of septal accessory pathways (APs) is associated with a significant rate of first procedure failures and complications. Cryoablation is an alternative energy source but there are no studies comparing both ablation techniques. We aimed to systematically review the literature and compare the efficacy and safety of cryoablation vs. RFA of septal APs. Methods and results We conducted two separate meta-analysis of cryoablation and RFA of septal APs and calculated the global estimates of the efficacy and safety. Sixty-four articles were included: 38 articles reporting RFA and 27 articles reporting cryoablation procedures. Additionally, we included the previously non-published cryoablation registry of septal APs performed at our institution. Overall, 4244 septal APs constitute our study population, 3495 in the RFA cohort and 749 in the cryoablation cohort. Acute procedural success rate of cryoablation was 86.0% (95% CI 81.6-89.4%) and RFA 89.0% (95% CI 86.8-91.0%). Recurrence rate of cryoablation was 18.1% (95% CI 14.8-21.8%) and RFA 9.9% (95% CI 8.2-12.0%). Long-term success rate after multiple ablation procedures of cryoablation was 75.9% (95% CI 68.2-82.3%) and RFA 88.4% (95% CI 84.7-91.3%). There were no reported cases of persistent atrioventricular block (AVB) with cryoablation and 2.7% (95% CI 2.2-3.4%) with RFA. Conclusion Studies of RFA for treatment of septal APs report higher efficacy rates than do studies using cryoablation, but a significantly higher rate of AVB.

Extracorporeal membrane oxygenation systems have undergone rapid technological improvements and are now feasible options for medium-term support of severe cardiac or pulmonary failure. We report five cases of electrical storm that was rescued by the insertion of peripheral veno-arterial extracorporeal membrane oxygenation systems. This device could help to restore systemic circulation as well as permitting organ perfusion in patients with cardiogenic shock in relation to electrical storm thus achieving greater electrical stability. Also, in some cases extracorporeal membrane oxygenation support could facilitate electrophysiology study.

Introduction Antitachycardia pacing (ATP) terminates the majority (but not all) of slow VTs (S-VT) with a cycle length (CL) >320 ms. Purpose To analyze the efficacy, safety and predictors of ATP, comparing the first (ATP-1) to the second (ATP-2) and third (ATP-3) attempts. Methods We studied 556 S-VT (CL=354±18 ms; range: 321–415 ms; 1.6% syncopes) occurring in 67 patients. ATP programming was standardized, including three consecutive bursts of 15 pulses at 91% of VT CL. Results ATP effectiveness declined significantly from ATP-1 (436/556: 78%) compared to ATP-2 (24/103: 23%) and ATP-3 (10/79: 13%), p Several predictors of ATP efficacy were found by logistic regression: a) ATP-1: P-RR (OR=7.3; p Patients with a dQRS≥120 ms had a lower adjusted effectiveness of ATP and a higher proportion of S-VT causing syncope. Table. Table 1 Patients with QRS Conclusions The efficacy of ATP in terminating S-VT is mainly due to the ATP-1. The regularization of RR intervals after ineffective ATP-1 underlies the lower efficacy of ATP-2 and ATP-3. Since the dQRS correlated significantly with the PPI-CLd, patients with a dQRS≥120 ms had a lower ATP-1, ATP-2 and ATP-3 effectiveness, leading to a higher incidence of syncope.

Current guidelines recommend sacubitril/valsartan (S/V) for patients (p.) with heart failure and reduced left ventricular ejection fraction (LVEF) but there is lack of evidence of its efficacy and safety in p. with cancer and heart failure. Our aim was to analyze the potential benefit of S/V in specific cardio-oncology clinics. Methods We performed a retrospective multicenter registry (HF-COH) in six Spanish hospitals with cardio-oncology clinics including all p. treated with S/V. Clinical and echocardiographic data, NYHA functional class, type of neoplasms and anti-tumoral treatment were described. Median follow-up was 7.2 [7.9] months. Results Sixty-one p. were included (median age was 64 [21] years old; 64%women, 43% hypertensive, 54% dyslipidemics and 28% diabetics). Most of p. (97%) had cancer therapy related cardiac dysfunction (CTRD) with a median time from anti-cancer therapy to CTRD of 40 [132] months. Breast (46%) and hematological (38%) cancers were the most frequent neoplasms, 31% of p. had metastatic disease and 71% had been treated with anthracyclines. In 5% S/V was initiated at CTRCD diagnosis while in 95% S/V was started to improve clinical status in p. already treated with ACE inhibitors or ARBs. 87% were on beta-blocker therapy and 74% on mineralocorticoid receptor antagonists.Maximal S/V titration dose was achieved in 8.2% of p. (24/26mg: 43%; 49/51mg: 33%) S/V was discontinued in 4 p. (reasons: 2 hypotension; 1: renal failure; 1: pruritus) Baseline NT-proBNP levels, functional class, and LVEF improved at the end of follow-up in p. who continued with S/V (all p values ≤0.01). No statistical differences were found in creatinine clearance or potassium serum levels. Table Patient parameters before and after S/V Before S/V After S/V P value LVEF (%) 33 [7] 39.5 [15] Conclusions Our experience suggests that S/V is well tolerated and improves functional class and left ventricular function parameters in patients with CTRCD.

Background Among ICD patients, the burden of non-sustained ventricular tachycardias (NSVT) occurring during the first 6 months after implant is associated independently with an increase in cardiac death. It is unknown whether there are differences between the incidence of Electrical Storm (ES) and the cause of cardiac mortality (CM) according to the burden of NSVT. Purpose To determine the relationship between the burden of NSVT occurring early after ICD implant and the risk of ES in the long-term among ICD patients with left ventricular dysfunction. Methods In this prospective study, 416 patients (age: 65±11; LVEF: 30±8; ischemic etiology: 62%, primary prevention: 63%) with LVEF 5 beats at ≥150 bpm terminating spontaneously before therapy that occurred within the first six months after ICD implant. Results A total of 31 patients (7.5%) presenting with ES during the follow-up. After classifying the subjects into three groups according to the burden of NSVT (tertiles): no NSVT (N=166, group 1); 1–5 NSVT (n=130, group 2) and >5 NSVT (n=120, group 3), the cumulative incidence of ES was higher in group 3: 2.4% vs. 3.1% vs. 19.2%, with an average of time from implant to ES significantly shorter (mean [95% CI, months]): 97 (94–100) vs. 103 (99–106) vs. 86 (79–93); p5 NSVT (p5 TVNS (HR=4.66; p=0.001) were identified as independent predictors of ES. Cardiac mortality (CM) was independently higher in subjects with >5 NSVT (HR=1.7; p=0.03). The most frequent cause of CM was cardiac failure irrespective of NSVT burden (93% in patients with ≤5 NSVT and 79% in >5 NSVT); however CM due to ES was exclusive of individuals with >5 NSVT: 15% vs. 0% (p Figure 1 Conclusions 1. The burden of NSVT occurring during the first 6 months after an ICD implant is associated independently with a higher risk of ES in the long-term. 2. The adjusted risk of ES is 4-fold higher in individuals with >5 NSVT. 3. The most frequent etiology of CM is heart failure; CM due to ES is exclusive of patients with >5 NSVT causing the 15% of deaths in such population.

[Aims] Current guidelines recommend sacubitril/valsartan for patients with heart failure and reduced left ventricular ejection fraction (LVEF), but there is lack of evidence of its efficacy and safety in cancer therapy‐related cardiac dysfunction (CTRCD). Our aim was to analyse the potential benefit of sacubitril/valsartan in patients with CTRCD., [Methods and results] We performed a retrospective multicentre registry (HF‐COH) in six Spanish hospitals with cardio‐oncology clinics including all patients treated with sacubitril/valsartan. Demographic and clinical characteristics and laboratory and echocardiographic data were collected. Median follow‐up was 4.6 [1; 11] months. Sixty‐seven patients were included (median age was 63 ± 14 years; 64% were female, 87% had at least one cardiovascular risk factor). Median time from anti‐cancer therapy to CTRD was 41 [10; 141] months. Breast cancer (45%) and lymphoma (39%) were the most frequent neoplasm, 31% had metastatic disease, and all patients were treated with combination antitumor therapy (70% with anthracyclines). Thirty‐nine per cent of patients had received thoracic radiotherapy. Baseline median LVEF was 33 [27; 37], and 21% had atrial fibrillation. Eighty‐five per cent were on beta‐blocker therapy and 76% on mineralocorticoid receptor antagonists; 90% of the patients were symptomatic NYHA functional class ≥II. Maximal sacubitril/valsartan titration dose was achieved in 8% of patients (50 mg b.i.d.: 60%; 100 mg b.i.d.: 32%). Sacubitril/valsartan was discontinued in four patients (6%). Baseline N‐terminal pro‐B‐type natriuretic peptide levels (1552 pg/mL [692; 3624] vs. 776 [339; 1458]), functional class (2.2 ± 0.6 vs. 1.6 ± 0.6), and LVEF (33% [27; 37] vs. 42 [35; 50]) improved at the end of follow‐up (all P values ≤0.01). No significant statistical differences were found in creatinine (0.9 mg/dL [0.7; 1.1] vs. 0.9 [0.7; 1.1]; P = 0.055) or potassium serum levels (4.5 mg/dL [4.1; 4.8] vs. 4.5 [4.2; 4.8]; P = 0.5). Clinical, echocardiographic, and biochemical improvements were found regardless of the achieved sacubitril–valsartan dose (low or medium/high doses)., [Conclusions] Our experience suggests that sacubitril/valsartan is well tolerated and improves echocardiographic functional and structural parameters, N‐terminal pro‐B‐type natriuretic peptide levels, and symptomatic status in patients with CTRCD., This study was funded by the Instituto de Salud Carlos III, Ministerio de Ciencia, Innovación y Universidades, Spain, and the EU—European Regional Development Fund, by means of a competitive call for excellence in research projects (PIE14/00066) as well as by the Spanish Cardiovascular Network (CIBERCV).

Iodinated contrast media (CM) are the leading cause of acute renal failure of toxic origin. Between 21% and 50% of patients that receive them develop contrast-induced nephropathy (CIN). All prophylactic measures used so far have failed to provide effective prevention. Since oxidative stress is involved in the damage, a possible preventive strategy could be the administration of antioxidant substances, such as quercetin. This compound has shown renoprotective effects in experimental studies. The aim of this study was to evaluate whether quercetin may be helpful in preventing CIN in patients undergoing coronary catheterization. A clinical phase II study was conducted. Patients were distributed in two groups, namely, CM (patients who only received contrast media) and CM+Q (patients who were pretreated with quercetin orally for 3&ndash, 5 days). Results showed less incidence of CIN in the CM+Q group, possibly due to glomerular protection, evidenced by a lower increase in serum creatinine and albuminuria, and a lower decrease in the glomerular filtration rate (GFR). Furthermore, in this group, the relative risk of developing CIN observed in patients that received a high dose of contrast media was inferior. In conclusion, this is the first study that demonstrates that quercetin is a promising safe candidate in preventing CIN.

Current measures of anthracycline-induced cardiotoxicity, defined by decreases in left ventricular ejection fraction (LVEF), may become apparent only at a late stage when the myocardium has been significantly damaged, exceeding its ability to compensate ([1][1]). Our group has recently shown in a

There is currently no other hot topic like the ability of current technology to develop capabilities similar to those of human beings, even in medicine. This ability to simulate the processes of human intelligence with computer systems is known as artificial intelligence (AI). This article aims to clarify the various terms that still sound foreign to us, such as AI, machine learning (ML), deep learning (DL), and big data. It also provides an in-depth description of the concept of AI and its types; the learning techniques and technology used by ML; cardiac imaging analysis with DL; and the contribution of this technological revolution to classical statistics, as well as its current limitations, legal aspects, and initial applications in cardiology. To do this, we conducted a detailed PubMed search on the evolution of original contributions on AI to the various areas of application in cardiology in the last 5 years and identified 673 research articles. We provide 19 detailed examples from distinct areas of cardiology that, by using AI, have shown diagnostic and therapeutic improvements, and which will aid understanding of ML and DL methodology.

BACKGROUND: Anthracycline-induced cardiotoxicity is a major clinical problem, and early cardiotoxicity markers are needed. OBJECTIVES: The purpose of this study was to identify early doxorubicin-induced cardiotoxicity by serial multiparametric cardiac magnetic resonance (CMR) and its pathological correlates in a large animal model. METHODS: Twenty pigs were included. Of these, 5 received 5 biweekly intracoronary doxorubicin doses (0.45 mg/kg/injection) and were followed until sacrifice at 16 weeks. Another 5 pigs received 3 biweekly doxorubicin doses and were followed to 16 weeks. A third group was sacrificed after the third dose. All groups underwent weekly CMR examinations including anatomical and T2 and T1 mapping (including extracellular volume [ECV] quantification). A control group was sacrificed after the initial CMR. RESULTS: The earliest doxorubicin-cardiotoxicity CMR parameter was T2 relaxation-time prolongation at week 6 (2 weeks after the third dose). T1 mapping, ECV, and left ventricular (LV) motion were unaffected. At this early time point, isolated T2 prolongation correlated with intracardiomyocyte edema secondary to vacuolization without extracellular space expansion. Subsequent development of T1 mapping and ECV abnormalities coincided with LV motion defects: LV ejection fraction declined from week 10 (2 weeks after the fifth and final doxorubicin dose). Stopping doxorubicin therapy upon detection of T2 prolongation halted progression to LV motion deterioration and resolved intracardiomyocyte vacuolization, demonstrating that early T2 prolongation occurs at a reversible disease stage. CONCLUSIONS: T2 mapping during treatment identifies intracardiomyocyte edema generation as the earliest marker of anthracycline-induced cardiotoxicity, in the absence of T1 mapping, ECV, or LV motion defects. The occurrence of these changes at a reversible disease stage shows the clinical potential of this CMR marker for tailored anthracycline therapy. This study was partially supported by grants from the Ministerio de Ciencia, Innovacion y Universidades through the Carlos III Institute of Health-Fondo de Investigacion Sanitaria (P116/02110), the European Regional Development Fund (SAF2013-49663-EXP), and the Spanish Society of Cardiology (FEC basic science in cardiology grant). This research program is part of an institutional agreement between the CNIC and FIIS-Fundacion Jimenez Diaz. This study forms part of a Master Research Agreement between the CNIC and Philips Healthcare, and is part of a bilateral research program between Hospital de Salamanca Cardiology Department and the CNIC. The CNIC is supported by the Ministerio de Ciencia, Innovacion y Universidades, and the Pro-CNIC Foundation, and is a Severo Ochoa Center of Excellence (MEIC award SEV-2015-0505). Drs. Galan-Arriola and Villena-Gutierrez are P-FIS fellows (Instituto de Salud Carlos III). Dr. Fernandez-Jimenez has received funding through the European Union Horizon 2020 Research and Innovation program under grant MSCA-IF-GF-707642. Dr. Sanchez -Gonzalez is an employee of Philips Healthcare. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Sí

ResumenObjetivosDurante los últimos años el número de pacientes de avanzada edad que presentan insuficiencia cardíaca congestiva se ha incrementado de manera dramática. En el contexto del estancamiento global del trasplante cardíaco nace la necesidad de una terapia definitiva alternativa para estos pacientes. Recientemente, los dispositivos de asistencia ventricular izquierda (DAVI) han experimentado un auge, sobrepasando incluso el número de pacientes trasplantados mundialmente. El desarrollo tecnológico de los nuevos dispositivos y el surgimiento de nuevas técnicas quirúrgicas derivados de la cirugía cardíaca mínimamente invasiva han formado parte de este desarrollo. El propósito del presente estudio fue revisar la primera serie de implantes de DAVI mínimamente invasivo en pacientes septuagenarios.MétodosEl diseño del ensayo clínico es monocéntrico prospectivo. Se incluyó a todos los pacientes mayores o iguales a 70 años que requirieron un implante de DAVI (HVAD, HeartWare Inc.) como terapia de destino durante los años 2013 y 2015 en la Medizinische Hochschule Hannover. El seguimiento concluyó luego de 2 años. Todos los pacientes fueron operados por una técnica mínimamente invasiva compuesta por una miniesternotomía en «J» y una toracotomía lateral izquierda.ResultadosUn total de 14 pacientes fueron incluidos (edad 71,8±1,5 años, 100% hombres, miocardiopatía isquémica 64,3%). El 50% de los casos correspondía a una reoperación, un 7,1% recibió soporte mecánico circulatorio previo. Todos los pacientes fueron operados utilizando circulación extracorpórea (CEC) (tiempo medio de CEC 51±8min). El tiempo promedio de permanencia en la Unidad de Cuidados Intensivos fue de 6,4±5,2 días. Eventos adversos en el transcurso postoperatorio temprano fueron: reintervención quirúrgica por sangrado 7,1%, falla ventricular derecha 14,3% y diálisis 14,3%. Los niveles de supervivencia fueron: 30 días: 85,7%, un año: 78,6%, y 2 años: 70,7%.ConclusionesNuestros resultados iniciales demuestran que el implante mínimamente invasivo de DAVI puede ser realizado de manera eficaz, segura y con buenos resultados en pacientes septuagenarios terapia de destino. Los bajos niveles de eventos adversos durante el seguimiento por 2 años demuestran que la terapia de destino puede ser realizada incluso en pacientes septuagenarios.AbstractObjectivesThe number of elderly patients suffering from congestive heart failure has increased dramatically in recent years. In the context of global stagnation of heart transplantation, comes the need for an alternative definitive therapy for these patients. Recently left ventricular assist devices (LVAD) have increased significantly, surpassing even the number of transplants worldwide. The technological development of new devices and the emergence of new surgical techniques arising from minimally invasive cardiac surgery have been part of this development. The purpose of this study was to review the first series of minimally invasive LVAD implants in septuagenarian patients.MethodsA prospective single-centre clinical trial was conducted on all patients greater than or equal to 70 years that required an LVAD implant (HVAD, HeartWare Inc.) as destination therapy for the years 2013 to 2015 in the Medizinische Hochschule Clinic in Hannover. The monitoring ended after two years. All patients were operated by a minimally invasive technique consisting of a “J” mini-sternotomy and a left lateral thoracotomy.ResultsA total of 14 patients were included (age 71.8 ± 1.5 years, all (100%) males, and 64.3% with ischaemic heart disease). It was a second operation for 50% of the cases, and 7.1% received a prior mechanical circulatory assist device (MCAD). All patients were operated on using extracorporeal circulation (ECC) for a mean time of 51 ± 8 min). The mean length of stay in ICU was 6.4 ± 5.2 days. Adverse events during the early post-operative period included, surgical re-intervention due to bleeding (7.1%), right ventricular failure (14.3%), and dialysis (14.3%). Survival rates were: 30 days: 85.7% 1 year: 78.6% 2 years: 70.7%.ConclusionsThe initial results show that minimally invasive implantation of LVAD can be performed effectively, safely, and with good results in septuagenarian patients as destination therapy. There were low levels of adverse events during a two year follow-up, showing that destination therapy can be performed even in patients in their seventies.

Background and objectives Leptin is a plasmatic peptide hormone that has been related to cardiovascular homeostasis and atherosclerosis but much is still unknown about its relationship with coronary artery disease. The aim of this study was to evaluate the value of serum leptin in patients with stable angina and its relationship with the severity of coronary disease. Patients and methods 204 patients, 152 with stable angina (coronary artery disease group) and 52 without coronary disease excluded by cardiac computerized tomography (control group) were included. The coronary artery disease group was divided into 2 subgroups according to severity of coronary disease (single or multivessel disease, 46 and 106 patients, respectively). Serum leptin levels were determined by Enzyme-Linked InmunoSorbent Assay. Results Leptin levels were significantly higher in patients with multivessel disease and were independently associated with a greater severity of coronary artery disease when compared with controls (OR 1.14; 95%CI: 1.03–1.27; p = 0.014) and with patients with single vessel disease (OR 1.12; 95%CI: 1.01–1.25; p = 0.036). Serum leptin was tested as a diagnostic marker of multivessel disease with an area under the curve obtained from Receiver Operating Characteristics of 0.6764 (95%CI 0.5765–0.7657). Conclusions Serum leptin levels were associated in patients with stable angina with the severity of coronary artery disease, suggesting its value in the development of coronary disease and as a future therapeutic target.

Paravalvular leak (PVL) is an uncommon yet serious complication associated with the implantation of mechanical or bioprosthetic surgical valves and more recently recognized with transcatheter aortic valves implantation (TAVI). A significant number of patients will present with symptoms of congestive heart failure or haemolytic anaemia due to PVL and need further surgical or percutaneous treatment. Until recently, surgery has been the only available therapy for the treatment of clinically significant PVLs despite the significant morbidity and mortality associated with re-operation. Percutaneous treatment of PVLs has emerged as a safe and less invasive alternative, with low complication rates and high technical and clinical success rates. However, it is a complex procedure, which needs to be performed by an experienced team of interventional cardiologists and echocardiographers. This review discusses the current understanding of PVLs, including the utility of imaging techniques in PVL diagnosis and treatment, and the principles, outcomes and complications of transcatheter therapy of PVLs.

Fernando Worner*, Alberto San Roman, Pedro Luis Sanchez, Ana Viana Tejedor y Jose Ramon Gonzalez-Juanatey Hospital Universitari Arnau de Vilanova, IRB LLEIDA, Lleida, Espana Hospital Clinico Universitario, Valladolid, Espana Hospital Universitario de Salamanca-IBSAL, Salamanca, Espana d Instituto Cardiovascular, Hospital Clinico San Carlos, Madrid, Espana Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruna, Espana

espanolResumen Los sindromes pericardicos pueden requerir el tratamiento quirurgico con fines diagnosticos o terapeuticos. La pericardiocentesis esta indicada principalmente en el tratamiento del taponamiento cardiaco y los derrames pericardicos graves sintomaticos. Puede realizarse con fines diagnosticos en la pericarditis bacteriana y neoplasica no filiadas o ante sospecha de pericarditis purulenta. Las principales tecnicas quirurgicas son la pericardioscopia, que permite toma de biopsias dirigidas, la ventana pericardica y la pericardiectomia. El tratamiento definitivo de la pericarditis constrictiva y algunos casos seleccionados de pericarditis recurrente es la pericardiectomia quirurgica. Requiere una reseccion amplia mediante esternotomia. Debe realizarse en centros con experiencia, puesto que tiene unas tasas de morbilidad y mortalidad elevadas. EnglishAbstract Pericardial syndromes can require a surgical approach for diagnostic or therapeutic purposes. Pericardiocentesis is the main treatment indicated for cardiac taponade and serious symptomatic pericardial effusion. It can be performed for diagnostic purposes in non-related bacterial and neoplastic pericarditis or if purulent pericarditis is suspected. The main surgical techniques are pericardioscopy, which enables targeted biopsy, pericardial window and pericardiectomy. The definitive treatment of constrictive pericarditis and some select cases of recurrent pericarditis is surgical pericardiectomy. It requires a wide resection via sternotomy. It should be performed in centres with expertise, since it has high rates of morbidity and mortality.

A 76-year-old man with nonvalvular atrial fibrillation under oral anticoagulant treatment with direct inhibitor of factor Xa was admitted because of systemic embolism. Transesophageal echocardiogram showed a thrombus in a “chicken wing” left atrial appendage (LAA). The patient was discharged on

Objective Primary percutaneous coronary intervention (P-PCI) has demonstrated its efficacy in patients with ST segment elevation myocardial infarction (STEMI). However, patients with STEMI >= 75 years receive less P-PCI than younger patients despite their higher in-hospital morbimortality. The objective of this analysis was to determine the effectiveness of P-PCI in patients with STEMI >= 75 years. Methods We included 979 patients with STEMI >= 75 years, from the ATencion HOspitalaria del Sindrome coronario study, a registry of 8142 consecutive patients with acute coronary syndrome admitted at 31 Spanish hospitals in 2014-2016. We calculated a propensity score (PS) for the indication of P-PCI. Patients that received or not P-PCI were matched by PS. Using logistic regression, we compared the effectiveness of performing P-PCI versus non-performance for the composite primary event, which included death, reinfarction, acute pulmonary oedema or cardiogenic shock during hospitalisation. Results Of the included patients, 81.5 % received P-PCI. The matching provided two groups of 169 patients with and without P-PCI. Compared with its non-performance, P-PCI presented a composite event OR adjusted by PS of 0.55 (95% CI 0.34 to 0.89). Conclusions Receiving a P-PCI was significantly associated with a reduced risk of major intrahospital complications in patients with STEMI aged 75 years or older., Supported by: MARATO TV3 (081630), de AGAUR (2014SGR240); del Instituto de Salud Carlos III: Red de Investigacion Cardiovascular RD12/0042 (Programa HERACLES); Red RedIAPP RD06/0018; CP12/03287; CIBER Epidemiologia y Salud Publica; CIBERCV de enfermedades Cardiovasculares, Fondo Europeo de Desarrollo Regional (FEDER) (European Regional Development Funds - ERDF-); FIS CP12/03287, FIS 14/00449, FIS PI081327, FIS INTRASALUD PI1101801.

A new statistical analysis methodology, “Multivariate Gaussian Subspatial Regression” (MGSR), has been applied to randomized clinical trial data collected from percutaneous coronary intervention (PCI) patients, which combines the descriptive quality of Factorial Techniques and the predictive power of Gaussian Processes.This model has been built from 3 different quantitative coronary angiographic core-lab measures of the same lesion from 2 separate angiograms (at baseline before PCI, at baseline immediately after PCI and at 12 months follow-up). Measurements of the pre-PCI variables of a patient are mapped to the factorial plane and predictions are visualized as regions of interest in this plane.MGSR makes it possible to detect patients at risk of coronary stent restenosis or patients in whom ruling out the disease, in a graphical way; avoiding unnecessary, costly and possibly risky treatments for patients with no complications predicted; and advising to closely follow patients at risk. In addition, the model recovers missing values regardless of the variables, and once fitted, it corrects itself when more dependent variables are included.MGSR software is freely available online at https://github.com/victorvicpal/MGSR.

Background Ticagrelor use during acute coronary syndromes demonstrated a decrease in all‐cause mortality in the PLATO (Platelet Inhibition and Patient Outcomes) trial. This effect has been attributed to a non–platelet‐derived improvement in endothelial function. The aim of this study was to determine differences in the number of endothelial progenitor cells and/or circulating endothelial cells found in peripheral blood in patients treated with either ticagrelor or clopidogrel during non–ST‐segment–elevation myocardial infarction. Methods and Results In this multicenter, randomized study ( NCT 02244710), patients were considered for inclusion after non–ST‐segment–elevation myocardial infarction whenever they were P2Y 12 ‐inhibitor naïve. Ticagrelor and clopidogrel were allocated at a 1:1 ratio. Blood samples for determining endothelial progenitor cells and circulating endothelial cells were extracted before the antiplatelet loading dose, 48 hours after presentation of index symptoms, and 1 month after the event. A multichannel cytometer was used for optimal cell characterization. A total of 96 patients fulfilled the inclusion criteria. Circulating endothelial cell levels corrected by white blood cells were as follows at baseline, 48 hours, and 1 month: 44 (28–64), 50 (33–63), and 38 (23–62) cells/mL, respectively, for clopidogrel and 38 (29–60), 45 (32–85), and 35 (24–71) cells/mL, respectively, for ticagrelor ( P =0.6). Endothelial progenitor cell levels were 29 (15–47), 27 (15–33), and 18 (10–25) cells/mL, respectively, for clopidogrel and 20 (11–33), 22 (12–32), and 18 (11–29) cells/mL, respectively, for ticagrelor ( P =0.9). No differences in intraindividual changes were found. Conclusions Patients treated with ticagrelor during non–ST‐segment–elevation myocardial infarction, in comparison to clopidogrel, showed similar levels of endothelial progenitor cells and circulating endothelial cells. These data suggest that the endothelial protective effect mediated by ticagrelor is not related to bone marrow physiology modulation. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT 02244710.

We are grateful to Stiermaier et al, Sacha and Feusette, and Bulluck and Hausenloy for their interest and comments on our article,1 in which we showed that myocardial edema in the week after ST-segment–elevation myocardial infarction in humans is a bimodal phenomenon. We concur with Stiermaier et al on the implications of our findings, and the need to put these data into perspective. Indeed, in the discussion of our paper, we speculated on the potential explanations for divergent findings in the literature. It is important to note that our clinical study was specifically designed to validate the hypothesis generated in previous experimental studies,2,3 and thus the timing for each cardiac magnetic resonance (CMR) was exquisitely chosen. Thus, we first analyzed the dynamics of the initial wave of edema (online-only Data Supplement Figure I from Fernandez-Jimenez et al)1 to define the optimal timing for the first CMR scan in patients and not miss the initial wave of edema. The fact that this initial wave of edema peaks very early, and is significantly attenuated …

Purpose: To obtain initial data on the effect of different levels of targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA). Methods: We designed a multicentre pilot trial with 1:1:1 randomization to either 32 °C (n = 52), 33 °C (n = 49) or 34 °C (n = 49), via endovascular cooling devices during a 24-h period in comatose survivors of witnessed OHCA and initial shockable rhythm. The primary endpoint was the percentage of subjects surviving with good neurologic outcome defined by a modified Rankin Scale (mRS) score of ≤ 3, blindly assessed at 90 days. Results: At baseline, different proportions of patients who had received defibrillation administered by a bystander were assigned to groups of 32 °C (13.5%), 33 °C (34.7%) and 34 °C (28.6%; p = 0.03). The percentage of patients with an mRS ≤ 3 at 90 days (primary endpoint) was 65.3, 65.9 and 65.9% in patients assigned to 32, 33 and 34 °C, respectively, non-significant (NS). The multivariate Cox proportional hazards model identified two variables significantly related to the primary outcome: male gender and defibrillation by a bystander. Among the 43 patients who died before 90 days, 28 died following withdrawal of life-sustaining therapy, as follows: 7/16 (43.8%), 10/13 (76.9%) and 11/14 (78.6%) of patients assigned to 32, 33 and 34 °C, respectively (trend test p = 0.04). All levels of cooling were well tolerated. Conclusions: There were no statistically significant differences in neurological outcomes among the different levels of TTM. However, future research should explore the efficacy of TTM at 32 °C. Clinical trial registration: ClinicalTrials.gov unique identifier: NCT02035839 (http://clinicaltrials.gov). © 2018, Springer-Verlag GmbH Germany, part of Springer Nature and ESICM. Sanofi España 18.967 JCR (2018) Q1, 2/33 Critical Care Medicine 3.654 SJR (2018) Q1, 2/91 Critical Care and Intensive Care Medicine No data IDR 2018 UEM