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Aims Peri-procedural transcatheter valve embolization and migration (TVEM) is a rare but potentially devastating complication of transcatheter aortic valve implantation (TAVI). We sought to assess the incidence, causes, and outcome of TVEM in a large multicentre cohort. Methods and results We recorded cases of peri-procedural TVEM in patients undergoing TAVI between January 2010 and December 2017 from 26 international sites. Peri-procedural TVEM occurred in 273/29 636 (0.92%) TAVI cases (age 80.8 ± 7.3 years; 53.8% female), of which 217 were to the ascending aorta and 56 to the left ventricle. The use of self-expanding or first-generation prostheses and presence of a bicuspid aortic valve were independent predictors of TVEM. Bail-out measures included repositioning attempts using snares or miscellaneous tools (41.0%), multiple valve implantations (83.2%), and conversion to surgery (19.0%). Using 1:4-propensity matching, we identified a cohort of 235 patients with TVEM (TVEMPS) and 932 patients without TVEM (non-TVEMPS). In the matched cohort, all-cause mortality was higher in TVEMPS than in non-TVEMPS at 30 days (18.6% vs. 4.9%; P Conclusion Transcatheter valve embolization and migration occurred in approximately 1% and was associated with increased morbidity and mortality.

Sin financiación 4.642 JCR (2019) Q1, 30/138 Cardiac & Cardiovascular Systems 0.473 SJR (2019) Q3,196/362 Cardiology and Cardiovascular Medicine No data IDR 2019 UEC

Long-term left ventricular assist devices (LVADs) may be indicated as a bridge to heart transplantation, as a bridge to candidacy or as a destination therapy, and their use in our environment is continuously growing. The

Some important studies have shown that patient-prosthesis mismatch is a frequent occurrence after surgical aortic valve replacement that impairs survival. The Trifecta valve (St. Jude Medical Inc, St. Paul, MN) has special architecture designed to achieve the best hemodynamic profile. The aim of this study was to determine the prevalence of mismatch when using this prosthesis.This study included 1,302 patients at 3 months postoperatively, 339 patients with a Trifecta prosthesis and 963 patients (the control group) with a Mitroflow aortic valve (Sorin Group Inc, Mitroflow Division, Vancouver, Canada). Multinomial multivariate logistic regression was calculated to estimate the association between the Trifecta prosthesis and moderate or severe patient-prosthesis mismatch.Any degree of mismatch was present in 5.9% of the Trifecta group and in 42.4% in the Mitroflow group. Moderate patient-prosthesis mismatch was present in 3.8% of the patients with a Trifecta valve and in 32.6% in the Mitroflow group. Severe mismatch was present in 2.1% of the patients with a Trifecta prosthesis and in 9.8% of the patients with a Mitroflow valve. All differences were statistically significant (p0.001). The odds ratio of the Trifecta prosthesis as protector against mismatch was 16.9 (95% confidence interval, 9.5 to 30.4) and 11.9 (95% confidence interval, 5.3 to 26.7) for moderate or severe mismatch, respectively.The prevalence of patient-prosthesis mismatch using the Trifecta aortic prosthesis is extraordinary low. This finding may have great clinical repercussions in patients undergoing surgical aortic valve replacement.

This report describes a clinical case of a degenerated CoreValve (Medtronic, Minneapolis, MN) aortic prosthesis in a 59-year-old patient. Videos of a previously described surgical technique for late surgical explantation of a CoreValve are provided. This operation is feasible and easy to perform, partly because of the absence of adhesions at the coronary ostia. This report also comments on the controversy between mechanical and biologic prostheses in patients undergoing renal dialysis.

Time-dependent variability of electrocardiogram (ECG) in patients with Brugada syndrome could affect the interpretation of provocative testing.The aim of this study was to characterize ECG changes during and after flecainide infusion.We studied 59 consecutive patients. The ECG was continuously analyzed during the first 30 minutes of provocative testing, and a single ECG was recorded 60 minutes later. We analyzed CYP2D6 and CYP3A5 variants affecting flecainide metabolism and performed blinded measurements at lead II.At baseline, ECG patterns were classified as follows: type II in 31 patients (53%), type III in 15 (25%), and normal ECG in 13 (22%). Because of induction of type I ECG, the percentage of responders progressively increased with longer recording time periods (6.8% in 10 minutes vs 11.9% in 20-30 minutes vs 18.6% in 90 minutes; P.01). Four patients displayed a late response, which was evidenced 90 minutes after the initiation of provocative testing. QRS width differentially increased between responders and nonresponders (P.01), with a maximum QRS width of 110 ms during the first 30 minutes being effective for identifying possible late responders (sensitivity 100%; specificity 85.6%; positive predictive value 88%; negative predictive value 100%). The incidence of CYP2D6 variants was lower in late responders than in early or delayed responders (0% vs 75% vs 100%; P = .04), while a homogeneous distribution of CYP3A5*3/*3 was observed in our population.Response to flecainide exhibits time-dependent variability of ECG patterns and intervals. Longer periods of ECG recording increase the recognition probability of type I ECG.

Resumen En este articulo se resume la evidencia disponible para el empleo del implante valvular aortico transcateter como tratamiento de eleccion para los pacientes con estenosis aortica grave sintomatica considerados inoperables y con esperanza de vida superior a 1 ano. Tambien se resume la evidencia disponible acerca de la no inferioridad del implante valvular aortico transcateter en comparacion con el recambio valvular aortico en pacientes de elevado riesgo quirurgico, por lo que se lo considera una alternativa valida a la cirugia. Finalmente se expone la experiencia reportada respecto a la aplicabilidad de este tratamiento en otros escenarios clinicos en los que se puede convertir, en un futuro cercano, en una alternativa terapeutica solida al recambio valvular aortico quirurgico.

Post-infarction ventricular septal defect (VSD) is a rare but potentially lethal complication of acute myocardial infarction. Medical management is usually futile, so definitive surgery remains the treatment of choice but the risk surgery is very high and the optimal timing for surgery is still under debate. A 55-year-old man with no previous medical history attended the emergency-room for 12 h evolution of oppressive chest pain and strong anginal pain 7 days ago. On physical examination, blood pressure was 96/70 mmHg, pansystolic murmur over left sternal border without pulmonary crackles. An electrocardiogram revealed sinus rhythm 110 bpm, elevation ST and Q in inferior-posterior leads. Transthoracic echocardiogram showed inferoposterior akinesia, posterior-basal septal rupture (2 cm × 2 cm) with left-right shunt. Suspecting VSD in inferior-posterior acute myocardial infarction evolved, we performed emergency coronarography with 3-vessels disease and complete subacute occlusion of the mid segment of the right coronary artery. Left ventriculography demonstrated shunting of contrast from the left ventricule to the right ventricule. He was rejected for heart transplantation because of his age. Considering the high surgical risk to early surgery and his hemodynamic and clinical stability, delayed surgical treatment is decided, and 4 days after admission the patient suffered hemodynamic instability so venoarterial extracorporeal membrane oxygenation system (ECMO) is implanted as a bridge to reparative surgery. The 9th day after admission double bypass, interventricular defect repair with pericardial two-patch exclusion technique, and ECMO decannulation were performed. The patient's postoperative course was free of complications and was discharged 10 days post VSD repair surgery. Follow-up 3-month later revealed the patient to be in good functional status and good image outcome with intact interventricular septal patch without shunt. ECMO as a bridge to reparative surgery in postinfarction VSD is an adequate option to stabilize patients until surgery.

During cardiology training, the cardiology fellow has to be trained in all things related to the indication, interpretation, and performing of nuclear cardiology studies using single photon emission computed tomography (SPECT). The aim of the present study was to analyse the relationship between the adequacy of indications of myocardial perfusion gated-SPECT and the years of experience since the completion of cardiology training.A descriptive, retrospective analysis was performed on a single-centre register, in which the indications (adequate or inadequate use) were recorded according to myocardial perfusion gated-SPECT guidelines, prescribed by cardiologists of a university hospital.A total of 950 gated-SPECT tests were analysed according to the appropriate or inadequate indication. The sample of study was distributed in quartiles (years) since the cardiologist finished the residency. Cardiologists with less than 10 years of clinical experience reported a higher proportion of gated-SPECT tests compared to the more experienced cardiologists (87.6 vs. 9.3%, P.001). After adjusting for age, gender, and cardiovascular risk factors, the multivariate analysis showed that, for each year of experience after completion of cardiology training, the probability of adequately indicating the test (OR: 1.33, 95% CI: 1.29-1.38, P.001) was statistically significant.The professional experience of the clinical cardiologist is the most important factor to perform an appropriate indication of gated-SPECT myocardial perfusion.

Aims Sensitivity to flecainide testing results in suboptimal findings in patients with Brugada syndrome (BrS), leading to safety concerns. Because cardiac syncope effectively predicts outcomes in BrS, we aimed to explore its predictive value in a large cohort of negative and positive responders (NR and PR) to standard flecainide testing. Methods and results We analysed the data of 251 consecutive patients, 177 NR vs. 74 PR, to flecainide testing, performed according to standard recommendations. Cardiac syncope was defined as syncope presenting without prodromal symptoms and in the absence of any specific situation. Comparing PR with NR, there were no differences regarding age (39 ± 15 vs. 44 ± 13 years; P = 0.052), male gender (70.1% vs. 66.2%; P = 0.553), and family history of sudden cardiac death in relatives younger than 45 years (27% vs. 27%; P = 1). Cardiac syncope was more frequent in PR (12.2% vs. 4%; P = 0.022), and previous sudden cardiac arrest (SCA) was documented only in PR (5.4% vs. 0%; P = 0.007). During the follow-up period (6.2 ± 3.3 years), one NR, who had previously experienced cardiac syncope, developed SCA 3 months after flecainide testing. Following resuscitation, a type I electrocardiogram was spontaneously recorded. The follow-up event rate was higher in patients with cardiac syncope, both in PR and in NR (P

Article 43 of the Spanish Constitution of 1978 establishes the right to health protection and healthcare for all citizens (1). The political organization of the Spanish state is made up of the central state and 17 highly decentralized regions (termed autonomous communities) with their respective governments and parliaments. In terms of health care, political devolution to regional governments has been incrementally implemented over the last 35 years. The taking-up of responsibilities in the field of health by the autonomous communities brings the management of healthcare closer to citizens and guarantees (2): Equity: access to benefits and right to health protection under conditions of effective equality throughout the country and free movement of all citizens. Quality: in the evaluation of the benefit delivered by clinical actions, incorporating only those which contribute added value to the improvement of health, implicating the healthcare system. Participation: public of citizens both in respect for the autonomy of their individual decisions as well as in the consideration of their expectations as users of the healthcare system. Spanish health system Over the last years, the establishment of health systems providing universal coverage in the most advanced European countries has contributed to a permanent improvement in many health indicators like population health status parameters, health care amenable outcomes, coverage, access and financial equity parameters, health care quality, users’ satisfaction and system legitimated by the population. According to the last OECD (Organisation for Economic Co-operation and Development) health statistics report, Spanish life expectancy is the highest in Europe (2.7 years above average) (3), clinical results are at the level of the most advanced countries (same cancer survival rates as in Sweden, France or Germany) (4) and its cost is on the average of the 35 OECD economies, in terms of total spending on gross domestic product (GDP), 9%, and below the average if we compare it in terms of per capita spending (5,6). In addition, it is an international benchmark for its universality and level of access compared to many other developed countries. This improvement in all these parameters has been associated to a continued increase in health spending. In all EU countries (including Spain), during most of the second half of the 20th century, health expenditure has been growing faster than national income. The same is happening in all member countries of the OECD, so this situation calls into question whether the economic sustainability of healthcare systems, most of which were created and developed in times of greater prosperity, will be guaranteed in the future (7). In the context of a worldwide economic crisis, the impact of financial difficulties of healthcare systems has become particularly evident in Spain, where unemployment rate is one of the highest in the European Union.

Introduction and objectives: Current therapeutic options for severe aortic stenosis (AS) include transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Our aim was to describe the prognosis of patients with severe AS after the decision to perform an intervention, to study the variables influencing their prognosis, and to describe the determinants of waiting time > 2 months. Methods: Subanalysis of the IDEAS (Influence of the Severe Aortic Stenosis Diagnosis) registry in patients indicated for TAVI or SAVR. Results: Of 726 patients with severe AS diagnosed in January 2014, the decision to perform an intervention was made in 300, who were included in the present study. The mean age was 74.0 +/- 9.7 years. A total of 258 (86.0%) underwent an intervention: 59 TAVI and 199 SAVR. At the end of the year, 42 patients (14.0%) with an indication for an intervention did not receive it, either because they remained on the waiting list (34 patients) or died while waiting for the procedure (8 patients). Of the patients who died while on the waiting list, half did so in the first 100 days. The mean waiting time was 2.9 +/- 1.6 for TAVI and 3.5 +/- 0.2 months for SAVR (P = .03). The independent predictors of mortality were male sex (HR, 2.6; 95% CI, 1.1-6.0), moderate-severe mitral regurgitation (HR, 2.6; 95% CI, 1.5-4.5), reduced mobility (HR, 4.6; 95% CI, 1.7-12.6), and nonintervention (HR, 2.3; 95% CI, 1.02-5.03). Conclusions: Patients with severe aortic stenosis awaiting therapeutic procedures have a high mortality risk. Some clinical indicators predict a worse prognosis and suggest the need for early intervention. (C) 2018 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

A 64-year-old man presented with previous non-ST elevation myocardial infarction and cardiogenic shock. Due to hemodynamic instability, percutaneous coronary intervention (PCI) was performed with implantation of two everolimus-eluting stents by V-stenting technique to LM-LAD and LM-LCX. After 9 months without symptoms, he developed progressive angina. Non-selective LM coronary angiography was performed due to stents protrusion in the aortic root. A 128-slice dual-source coronary CT angiography showed severe LM-LAD stent underexpansion with critical in-stent restenosis at the proximal third. Two days later, selective angiography and optical coherence tomography depicted stent underexpansion and confirmed the in-stent restenosis. This case is illustrative of the potential role of the complementary use of invasive and non-invasive imaging techniques. The coronary CT angiography was very useful to identify the severity and mechanism of restenosis, and thus guiding the PCI procedure in a case of especially difficult catheterization.

Interventricular septal hematoma is a rare but potentially dangerous complication of retrograde chronic total occlusion (CTO) percutaneous coronary interventions (PCI) [(1,2)][1]. A 58-year-old man was referred for right coronary artery CTO-PCI performed by a retrograde approach via the collateral

IntroductionCardiac adipose tissue is a source of progenitor cells with regenerative capacity. Studies in rodents demonstrated that the intramyocardial delivery of cells derived from this tissue improves cardiac function after myocardial infarction (MI). We developed a new reparative approach for damaged myocardium that integrates the regenerative properties of cardiac adipose tissue with tissue engineering. In the adipose graft transposition procedure (AGTP), we dissect a vascularised flap of autologous pericardial adipose tissue and position it over the myocardial scarred area. Following encouraging results in acute and chronic MI porcine models, we performed the clinical trial (NCT01473433, AdiFLAP trial) to evaluate safety in patients with chronic MI undergoing coronary artery bypass graft. The good safety profile and trends in efficacy warranted a larger trial.Study designThe AGTP II trial (NCT02798276) is an investigator initiated, prospective, randomised, controlled, multicentre study to assess the efficacy of the AGTP in 108 patients with non-revascularisable MI. Patients will be assigned to standard clinical practice or the AGTP. The primary endpoint is change in necrotic mass ratio by gadolinium enhancement at 91 and 365 days. Secondary endpoints include improvement in regional contractibility by MRI at 91 and 365 days; changes in functional MRI parameters (left ventricular ejection fraction, left and right ventricular geometric remodelling) at 91 and 365 days; levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) at 7, 91 and 365 days; appearance of arrhythmias from 24 hour Holter monitoring at 24 hours, and at 91 and 365 days; all cause death or re-hospitalisation at 365 days; and cardiovascular death or re-hospitalisation at 365 days.Ethics and disseminationThe institutional review board approved the trial which will comply with the Declaration of Helsinki. All patients will provide informed consent. It may offer a novel, effective and technically simple technique for patients with no other therapeutic options. The results will be submitted to indexed medical journals and national and international meetings.Trial registration numberClinicalTrials.gov:NCT02798276, pre-results.

Sin financiación 1.755 JCR (2017) Q4, 28/33 Critical Care Medicine UEC

Growth differentiation factor-15 (GDF-15) is a stress-responsive cytokine that increased in patients with established type 2 diabetes mellitus (DM). Diabetic cardiomyopathy (DC), defined as left ventricular diastolic dysfunction (LVDD) in patients with type 2 DM in the absence of arterial hypertension, heart disease, or other heart disease, was assessed by GDF-15 levels in type 2 DM patients with and without DC. A total of 213 DM outpatients had blood samples drawn and on the same day (basal) underwent echocardiography and treadmill exercise testing. Plasma GDF-15 concentrations were measured by an enzyme-linked immunosorbent assay (ELISA) at baseline. DC was diagnosed in the presence of LVDD, defined when early mitral valve flow velocity (E) and early diastolic lengthening velocity (E') ratio was E/E' ≥ 15. The prevalence of DC was 21.13%. GDF-15 levels were higher in patients with DC compared with those without DC (5,273 [8,708.4] vs 2,812.66 [7,662.1] pg/ml, respectively, p0.001). We assessed predictors of DC using multivariate regression analysis. GDF-15 (odds ratio 9.9; 95% confidence interval [3.9 to 24.5], p0.001) was the unique independent predictor of DC. The results of receiver operating characteristic curve show that the cut-off point of 3,812 pg/ml of GDF-15 was indicative for DC (AUC = 0.83, sensitivity = 82.2% and specificity = 70.2%, p0.0001). In conclusion, GDF-15 represents a useful and novel tool to screen DC in patients with type 2 DM.

Background: there is increasing interest for computing corrected QT intervals in patients with prolonged depolarization. We aimed to analyze the effect of prolonged QRS in the QT and in the diagnostic accuracy of frequency-correction. Methods and Results: in 28 patients admitted for self-expanding aortic valve implantation, sequential pacing was performed in the AAI mode in two different phases: before and immediately after the release of the prosthesis. We evaluated the accuracy of the Bazett, Fridericia, Framingham and Hodges formulas with the reference of the QT at 60 bpm (QTc/deviation). The widening of the QRS was the main contributor to the QT prolongation (Pearson 0.79, CI95%: 0.75&ndash, 0.84). Prolongation in other intervals (ST segment and T-wave) significantly contribute in the higher frequency range (p &lt, 0.05). The Bazett&rsquo, s formula displayed the highest QTc/deviation, while Framingham and Hodges retrieved the lowest QTc/deviation and the best fit (p &lt, 0.001). In addition, the Bazett&rsquo, s formula displayed the highest correlation between variations in the QTc/deviation and the widening of the QRS (Pearson coefficient &minus, 0.54, p &lt, 0.001) in comparison with the Fridericia, Framingham and Hodges formulas (&minus, 0.51, &minus, 0.37 and &minus, 0.38 respectively, 0.001). There was also a linear effect of the heart rate in the QTc/deviation obtained with the Bazett&rsquo, s formula (p = 0.015), not observed for other formulas. Conclusions: The prolonged depolarization of the ventricles introduces direct and linear prolongation in the QT interval, but also a non-linear distortion in cardiac repolarization that contributes for QT prolongation at the higher frequency range. The Bazett&rsquo, s formula displays significantly higher sensitivity to prolongation of ECG intervals.

Background In recent years, the use of surgically implanted biological aortic valves has been favored over mechanical prosthesis in patients between 50 and 70 years of age. However, outcomes on long-term survival are contradictory. The objective of this study was to determine if patients with mechanical valves have worse long-term survival than patients with biological prostheses. Methods We systematically searched published studies that: (1) were propensity score-matched or randomized controlled trials; (2) provided survival data with a minimum follow-up of 5 years; and (3) included patients older than 50 and younger than 70 years of age. Review articles, case reports, and editorials were excluded. We conducted a meta-analysis on the basis of 2 types of analysis. A reconstruction of the database of each study to simulate a patient-level meta-analysis was performed. Log rank test of Kaplan–Meier curves was recalculated. Hazard ratio (HR) was calculated using a univariate Cox regression. In addition, we calculated a pooled HR using the fixed-effect inverse variance method. Results Four propensity score-matched studies and 1 randomized controlled trial met the inclusion criteria. Data of 4686 patients were analyzed. Survival rates for mechanical versus biological valves at 10 and 15 years of follow-up were: 76.78% (95% confidence interval [CI], 74.72%-78.69%) versus 74.09% (95% CI, 71.96%-76.08%), and 61.58% (95% CI, 58.29%-64.69%) versus 58.04% (95% CI, 54.57%-61.35%). Log rank test was statistically significant (P = .012) and the pooled HR was 0.86 (95% CI, 0.76-0.97; P = .01). Conclusions Compared with biological aortic valves, mechanical valves are associated with a long-term survival benefit for patients between 50 and 70 years.

Sin financiación 4.638 JCR (2015) Q1, 20/124 Cardiac & Cardiovascular Systems UEC

Background Transcatheter aortic valve implantation (TAVI) is the recommended therapy for patients with severe aortic stenosis who are not suitable candidates for surgery. The aim of this study was to describe early experience and long-term follow-up with the CoreValve self-expanding aortic prosthesis at 42 Ibero-American hospitals. Methods Multiple centre observational study including 1220 consecutive patients with symptomatic severe aortic stenosis who are not suitable candidates for surgery and underwent transcatheter aortic valve implantation with the self-expanding Medtronic CoreValve System between December 2007 and May 2012. Results The registry included 1220 consecutive patients with a mean age of 80.8±6.3years and a mean logistic euroSCORE of 17.8%±13%. The procedural success rate was 96.1%. Hospital mortality was 7.3% and combined end-point was 21.3%. Aortic regurgitation after TAVI was present in 24.5% (Sellers grade≥2). The estimated 1-year and 2-year survival rates were 82.1% and 73.4% respectively. The following issues were significant independent risk factors for hospital mortality: acute kidney failure (odds ratio 3.55); stroke (odds ratio 5.72); major bleeding (odds ratio 2.64) and euroSCORE (odds ratio 1.02). Long-term predictors of mortality were diabetes mellitus (hazard ratio 1.59, 95% confidence interval 1.09–2.31), severe chronic obstructive pulmonary disease (hazard ratio 1.85, 95% confidence interval 1.85–2.88), and functional classes NYHA III–IV (hazard ratio 1.31, 95% confidence interval 1.01–1.70). Conclusions Transcatheter aortic valve implantation constitutes a safe and viable therapeutic option for high operative risk patients with severe aortic stenosis. Long-term prognosis is conditioned by associate comorbidities.

W Aortic stenosis A B S T R A C T 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 W 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 W self-expanding valve prosthesis is safe and feasible.

Objectives Recent studies have found increased long-term cardiovascular morbidity after off-pump coronary artery bypass surgery (OPCAB). We evaluated the efficacy and safety of dual antiplatelet therapy (DAT) in the prevention of cardiovascular events at two years after OPCAB surgery. Methods Retrospective study that included all patients that underwent OPCAB surgery in our institution between 2009 and 2010. Single or dual antiplatelet therapy was initiated at hospital discharge, and its effect in patients' prognosis was analyzed. Follow-up was conducted by telephone and using the hospital databases. The primary end-point was the composite of acute coronary syndrome (ACS), revascularization, stroke, or cardiovascular death. Results The study included 237 patients divided into: (A) 128 patients who received single antiplatelet therapy and (B) 109 patients who received dual antiplatelet therapy. The mean follow-up was 23.85 months (standard deviation 0.5 months). 13.9% of patients had a primary end-point event. Patients in group A had a higher event rate compared with group B (18.8% vs. 8.3%, p = 0.02), with a significant reduction in hospital readmissions for ACS (10.9% vs. 3.7%, p = 0.035). In the multivariate analysis, dual antiplatelet therapy was an independent protective factor in the occurrence of events (hazard ratio = 0.395, 95% CI, 0.176 to 0.885, p = 0.024). There were no significant differences between the two groups with respect to bleeding events. Conclusion Dual antiplatelet therapy after OPCAB surgery is associated with a decrease in the appearance of new cardiovascular events, due to a reduction in the number of hospital readmissions for ACS. doi: 10.1111/jocs.12144 (J Card Surg 2013;28:366–372)

Introduction and objectives High-sensitivity troponin assays have improved the diagnosis of acute coronary syndrome in patients presenting with chest pain and normal troponin levels as measured by conventional assays. Our aim was to investigate whether N-terminal pro-brain natriuretic peptide provides additional information to troponin determination in these patients. Methods A total of 398 patients, included in the PITAGORAS study, presenting to the emergency department with chest pain and normal troponin levels as measured by conventional assay in 2 serial samples (on arrival and 6 h to 8 h later) were studied. The samples were also analyzed in a central laboratory for high-sensitivity troponin T (both samples) and for N-terminal pro-brain natriuretic peptide (second sample). The endpoints were diagnosis of acute coronary syndrome and the composite endpoint of in-hospital revascularization or a 30-day cardiac event. Results Acute coronary syndrome was adjudicated to 79 patients (20%) and the composite endpoint to 59 (15%). When the N-terminal pro-brain natriuretic peptide quartile increased, the diagnosis of acute coronary syndrome also increased (12%, 16%, 23% and 29%; P =.01), as did the risk of the composite endpoint (6%, 13%, 16% and 24%; P =.004). N-terminal pro-brain natriuretic peptide elevation (>125 ng/L) was associated with both endpoints (relative risk= 2.0; 95% confidence interval, 1.2-3.3; P =.02; relative risk=2.4; 95% confidence interval, 1.4-4.2; P =.004). However, in the multivariable models adjusted by clinical and electrocardiographic data, a predictive value was found for high-sensitivity T troponin but not for N-terminal pro-brain natriuretic peptide. Conclusions In low-risk patients with chest pain of uncertain etiology evaluated using high-sensitivity T troponin, N-terminal pro-brain natriuretic peptide does not contribute additional predictive value to diagnosis or the prediction of short-term outcomes.

The mechanism of coronary thrombus formation is a complex phenomenon that involves different cellular components. ARTERIA is a prospective, multicenter study that will include patients presenting with a diagnosis of ST-elevation acute coronary syndrome undergoing thrombus aspiration during an emergency primary percutaneous coronary revascularization. The purpose of the ARTERIA study is to try to clarify whether there is an association between inflammatory markers measured in blood and in intracoronary thrombi and, if any, what set of molecules provides better prognostic information in these patients. Our study will help to elucidate the complex relationship between thrombus and circulating blood. 2.522 JCR (2013) Q2, 60/165 Biotechnology & applied microbiology, 38/87 Toxicology UEC