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Background Patients with aortic stenosis may continue to have an increased risk of heart failure, arrhythmias, and death after successful transcatheter aortic valve implantation. Renin‐angiotensin system inhibitors may be beneficial in this setting. We aimed to explore whether ramipril improves the outcomes of patients with aortic stenosis after transcatheter aortic valve implantation. Methods and Results PROBE (Prospective Randomized Open, Blinded Endpoint) was a multicenter trial comparing ramipril with standard care (control) following successful transcatheter aortic valve implantation in patients with left ventricular ejection fraction >40%. The primary end point was the composite of cardiac mortality, heart failure readmission, and stroke at 1‐year follow‐up. Secondary end points included left ventricular remodeling and fibrosis. A total of 186 patients with median age 83 years (range 79–86), 58.1% women, and EuroSCORE‐II 3.75% (range 3.08–4.97) were randomized to receive either ramipril (n=94) or standard treatment (n=92). There were no significant baseline, procedural, or in‐hospital differences. The primary end point occurred in 10.6% in the ramipril group versus 12% in the control group (P=0.776), with no differences in cardiac mortality (ramipril 1.1% versus control group 2.2%, P=0.619) but lower rate of heart failure readmissions in the ramipril group (3.2% versus 10.9%, P=0.040). Cardiac magnetic resonance analysis demonstrated better remodeling in the ramipril compared with the control group, with greater reduction in end‐systolic and end‐diastolic left ventricular volumes, but nonsignificant differences were found in the percentage of myocardial fibrosis. Conclusions Ramipril administration after transcatheter aortic valve implantation in patients with preserved left ventricular function did not meet the primary end point but was associated with a reduction in heart failure re‐admissions at 1‐year follow‐up. Registration URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03201185.

Coronary obstruction (CO) is a rare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). The present article aims to summarize the evidence on CO risk factors and provide an overview of preventive strategies. We performed a comprehensive literature review focused on these items. The analysis included studies addressing patient-specific characteristics, procedural aspects, and the effectiveness of various prevention techniques in mitigating CO risk. Specific risk factors for CO, which can be assessed by evaluating patient characteristics using computed tomography, are described. Procedural factors associated with an increased risk of CO are discussed. Preventive techniques, including the chimney stent and bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA), are also described, highlighting the advantages and disadvantages of each method. The present review also provides an overview of emerging dedicated devices designed to address this complication. In conclusion, identifying patients at risk for CO is crucial for optimizing TAVI outcomes. Comprehensive imaging assessment and appropriate preventive strategies, such as the BASILICA technique, can mitigate the risk of CO and improve patient outcomes. Further research is needed to validate emerging dedicated devices.

La obstrucción de las arterias coronarias (OC) es una complicación rara, pero potencialmente fatal, del implante percutáneo de válvula aórtica (TAVI). El objetivo de esta revisión es resumir la evidencia sobre los factores de riesgo de OC y las estrategias preventivas. Se realizó una revisión integral de la literatura centrada en estos aspectos. El análisis consideró estudios que abordaran las características del paciente, los factores procedimentales y la efectividad de diferentes técnicas preventivas para reducir el riesgo de OC. Se describen los factores relacionados con el paciente y del procedimiento que condicionan un mayor riesgo de OC. A lo largo del texto se detallan las técnicas para disminuir el riesgo de OC, incluidos el stent en chimenea y la técnica BASILICA. Además, se aporta una descripción general de los dispositivos diseñados para abordar esta complicación. En conclusión, la identificación de los factores de riesgo de OC es crucial para optimizar los resultados del TAVI. La evaluación exhaustiva mediante imagen multimodal, junto a estrategias preventivas apropiadas, como la técnica BASILICA, pueden mitigar el riesgo de OC y mejorar los resultados. Aún se requiere más investigación para validar los dispositivos emergentes.

RESUMEN Introducción y objetivos: El abordaje sistemático en pacientes con angina con arterias coronarias no obstruidas (ANOCA) o con isquemia con arterias coronarias no obstruidas (INOCA) no está bien protocolizado. Métodos: Todos los pacientes con diagnóstico de INOCA o ANOCA se trasladaron a una clínica ambulatoria específica para evaluar su elegibilidad para el programa NOCA. Si eran elegibles, se sometían a una angiografía coronaria programada con pruebas de función coronaria y provocación intracoronaria con acetilcolina. La terapia médica se optimizó en consecuencia. Todos los pacientes tuvieron un seguimiento a 1, 3, 6 y 12 meses. Al inicio y a los 3 meses se aplicaron los cuestionarios SAQ y EuroQol-5D. Resultados: De 77 pacientes se excluyeron 23 (29,9%) y se incluyeron 54 (70,1%) (29 [53,7%] con INOCA y 25 [46,3%] con ANOCA). Se diagnosticó angina microvascular a 19 (35,2 %) pacientes, angina vasoespástica a 12 (22,2 %), angina microvascular y angina vasoespástica a 18 (33,3 %), y dolor torácico no coronario a 5 (9,3 %). Hubo un aumento significativo en el uso de bloqueadores beta, bloqueadores del calcio y nitratos. Se presentaron complicaciones en 3 (5,5%) pacientes. No hubo diferencias en la puntuación media del EQ-5D a los 3 meses y se observó una...

ABSTRACT Introduction and objectives: A systematic approach to patients with angina with no obstructed coronary arteries (ANOCA) or ischemia with no obstructed coronary arteries (INOCA) patients is not routinely implemented. Methods: All consecutive patients diagnosed with ANOCA/INOCA were referred to a designated outpatient clinic for a screening visit to assess their eligibility for a NOCA program. If eligible, patients underwent scheduled coronary angiograms with coronary function testing and intracoronary acetylcholine provocation testing. Medical therapy was optimized accordingly. All patients were then followed up at 1, 3, 6, and 12 months. Baseline and 3-month follow-up assessments included the Seattle Angina Questionnaire (SAQ) and EuroQol-5D questionnaire. Results: Of 77 patients screened, 23 (29.9%) were excluded and 54 (70.1%) were included (29 [53.7%] with INOCA and 25 [46.3%] with ANOCA). Microvascular angina was diagnosed in 19 (35.2%) patients, vasospastic angina in 12 (22.2%), both microvascular angina and vasospastic angina in 18 (33.3%), and noncoronary chest pain in 5 (9.3%). There was a notable increase in the use of beta-blockers, calcium channel blockers and nitrates. Complications occurred in 3 (5.5%) patients. Compared with baseline, there was no difference in the mean EQ-5D score at the 3-month follow-up, but there was a significant improvement in the SAQ score...

Background. Chronic total occlusion (CTO) plaque modification (CTO-PM) is often used for unsuccessful CTO interventions. Methods. A multicenter, prospective study included consecutive patients with failed CTO recanalization. At the end of the failed procedure, patients received either a conventional (CB) or drug-coated balloon (DCB) for CTO-PM at the operator’s discretion and underwent a new attempt of CTO recanalization ∼3 months later. Results. A total of 55 patients were enrolled (DCB: 22; CB: 33), with a median age of 66 years. The median J-score was 3, and CCS angina classes III–IV were present in 45% of the patients. After the first CTO-PCI attempt, no in-hospital cardiac deaths were registered. The overall rate of in-hospital myocardial infarction was 3.6%, without significant differences between the DCB and CB groups (4.5% after DCB vs 3.0% after CB, p=0.999). The success rate of the second CTO-PCI attempt was 86.8%, with a periprocedural complication rate of 5.7% and with an overall rate of in-hospital complications of 24.5%, without significant differences between the 2 groups (13.6% in the DCB group vs 32.2% in the CB group, p=0.195). Compared with CB, in the DCB group, the second CTO-PCI required a shorter median fluoroscopy time (33 vs 60 min, p

Background: Current European guidelines support transcatheter aortic valve implantation (TAVI) in intermediate-to-low-risk patients ≥75 years-old, but its prognostic relevance is unknown. Methods: Intermediate-to-low-risk (The Society of Thoracic Surgeons score p = 0.925). At Cox regression analysis, age did not predict the occurrence of all-cause death, neither as a continuous variable (HR 1.01, 95% CI 0.99–1.04, p = 0.294) nor dichotomizing according to the prespecified cutoff of 75 years (HR 0.97, 95% CI 0.63–1.51, p = 0.924). Time-to-event ROC curves showed low accuracy of age to predict all-cause mortality (area under the curve of 0.54 for both 1-year and 2-year outcomes). Conclusions: TAVI has comparable benefits across age strata for intermediate-to-low-risk patients. The age cutoff suggested by the current guidelines is not predictive of the risk of adverse events during hospital stays or of all-cause mortality through a mid-term follow-up.

Background: Percutaneous left atrial appendage closure (LAAC) has been proposed as an alternative to anticoagulation therapy in patients with nonvalvular atrial fibrillation (NVAF) to decrease the thromboembolic risk, while avoiding the risks of chronic anticoagulation. This option may be attractive in patients with NVAF and chronic kidney disease (CKD), since they exhibit both high thromboembolic and bleeding risks. Objective: To evaluate the prognostic impact of the presence of CKD in patients with atrial fibrillation undergoing LAAC peri-procedure and during the follow-up as compared with patients with preserved renal function. Methods: Retrospective, observational study that included 124 consecutive patients with atrial fibrillation undergoing LAAC in a university hospital, and the results were evaluated according to the baseline renal function of the patients. Results: The median age was 75,5 years (IQR 67,6–80) and 62,1% were men, the median of CHA2DS2-Vasc and HASBLED scores was 4 (IQR 3−4) for both scores. Up to 57,3% of the total sample had CKD. Baseline characteristics were similar between groups, but CKD patients were older and had a higher HASBLED score. During the procedure, no thromboembolic, bleeding events, or deaths were observed. Combining the time of hospitalization and follow-up, no significant differences were observed between groups in the annual rate of thromboembolic events (0.97/100 patient-years [100PY] vs 4.06/100PY, P =,09), but there was a higher rate of bleeding events (5.67/100PY vs. 13.3/100PY, P =,033) and mortality among CKD patients (6.50/100PY vs. 17.2/100PY, P =,009), with an odds ratio of 2.711 (95% CI 1,96–6,95). In the multivariate analysis a preserved eGFR was independently associated with a lower mortality risk. Conclusions: LAAC is a valid alternative to oral anticoagulation in patients with CKD and atrial fibrillation, with a low rate of peri- and post-procedure complications, although CKD patients exhibited a higher risk of bleeding and mortality during the follow-up. However, these higher rates may not be necessarily related to the procedure. Resumen: Antecedentes: El cierre percutáneo de la orejuela izquierda (CPOI) se ha propuesto como una alternativa al tratamiento anticoagulante en pacientes con fibrilación auricular no valvular (FANV) para disminuir el riesgo tromboembólico, evitando los riesgos de la anticoagulación. Esta opción puede ser atractiva en pacientes con FANV y enfermedad renal crónica (ERC), ya que presentan un alto riesgo tanto tromboembólico como hemorrágico. Objetivo: Determinar el papel pronóstico de la presencia de ERC en pacientes con fibrilación auricular sometidos a un CPOI peri-procedimiento y durante el seguimiento comparado con los pacientes con función renal preservada. Métodos: Estudio retrospectivo, observacional de muestreo consecutivo que incluyó 124 pacientes sometidos a CPOI por fibrilación auricular en un hospital universitario y se compararon los resultados según la función renal basal. Resultados: La mediana de edad fue 75,5 años (RIQ 67,6–80), el 62,1% eran hombres, la mediana de CHA2DS2-Vasc y HASBLED era de 4 (RIQ 3−4) para ambas escalas. El 57,3% de la muestra tenía ERC. Las características basales eran similares entre ambos grupos, salvo una media de edad y un score de HASBLED superiores en los pacientes con ERC. Durante el procedimiento, no se observó ningún evento tromboembólico, de sangrado o muerte. Durante el tiempo de hospitalización y de seguimiento combinados, no hubo diferencias significativas entre grupos en la tasa anual de episodios tromboembólicos (0,97/100 pacientes-año [100PA] vs 4,06/100PA, P =,092), pero si se observó una mayor tasa de sangrados (5,67/100PA vs 13,3/100PA, P =,033), y de mortalidad (6,50/100PA vs 17,2/100PA, P =,009) en el grupo de ERC, con una odds ratio para mortalidad de 2,711 (IC95% 1,96–6,95). En el análisis multivariante, el FGe preservado se asoció independientemente con una menor mortalidad. Conclusiones: El CPOI es una alternativa válida a la anticoagulación oral en pacientes con ERC y fibrilación auricular, con una baja tasa de eventos peri y post-procedimiento. No obstante, los pacientes con ERC presentan mayor riesgo de sangrado y de mortalidad durante el seguimiento. Aunque estas mayores tasas no están necesariamente relacionadas con el procedimiento.

Resumen: Antecedentes: El cierre percutáneo de la orejuela izquierda (CPOI) se ha propuesto como una alternativa al tratamiento anticoagulante en pacientes con fibrilación auricular no valvular para disminuir el riesgo tromboembólico, evitando los riesgos de la anticoagulación. Esta opción puede ser atractiva en pacientes con fibrilación auricular no valvular y enfermedad renal crónica (ERC), ya que presentan un alto riesgo tanto tromboembólico como hemorrágico. Objetivo: Determinar el papel pronóstico de la presencia de ERC en pacientes con fibrilación auricular sometidos a un CPOI periprocedimiento y durante el seguimiento comparado con los pacientes con función renal preservada. Métodos: Estudio retrospectivo, observacional de muestreo consecutivo que incluyó 124 pacientes sometidos a CPOI por fibrilación auricular en un hospital universitario y se compararon los resultados según la función renal basal. Resultados: La mediana de edad fue 75,5 años (RIQ 67,6-80), el 62,1% eran hombres, la mediana de CHA2DS2-Vasc y HASBLED era de 4 (RIQ 3-4) para ambas escalas. El 57,3% de la muestra tenía ERC. Las características basales eran similares entre ambos grupos, salvo una media de edad y un score de HASBLED superiores en los pacientes con ERC. Durante el procedimiento, no se observó ningún evento tromboembólico, de sangrado o muerte. Durante el tiempo de hospitalización y de seguimiento combinados, no hubo diferencias significativas entre grupos en la tasa anual de episodios tromboembólicos (0,97/100 pacientes-año [100PA] vs. 4,06/100PA, p = 0,092), pero si se observó una mayor tasa de sangrados (5,67/100PA vs. 13,3/100PA, p = 0,033), y de mortalidad (6,50/100PA vs. 17,2/100PA, p = 0,009) en el grupo de ERC, con una odds ratio para mortalidad de 2,711 (IC95% 1,96-6,95). En el análisis multivariante, el FGe preservado se asoció independientemente con una menor mortalidad. Conclusiones: El CPOI es una alternativa válida a la anticoagulación oral en pacientes con ERC y fibrilación auricular, con una baja tasa de eventos peri- y posprocedimiento. No obstante, los pacientes con ERC presentan mayor riesgo de sangrado y de mortalidad durante el seguimiento. Aunque estas mayores tasas no están necesariamente relacionadas con el procedimiento. Abstract: Background: Percutaneous left atrial appendage closure (LAAC) has been proposed as an alternative to anticoagulation therapy in patients with nonvalvular atrial fibrillation to decrease the thromboembolic risk, while avoiding the risks of chronic anticoagulation. This option may be attractive in patients with nonvalvular atrial fibrillation and chronic kidney disease (CKD), since they exhibit both high-thromboembolic and bleeding risks. Objective: To evaluate the prognostic impact of the presence of CKD in patients with atrial fibrillation undergoing LAAC peri-procedure and during the follow-up as compared with patients with preserved renal function. Methods: Retrospective, observational study that included 124 consecutive patients with atrial fibrillation undergoing LAAC in a university hospital, and the results were evaluated according to the baseline renal function of the patients. Results: The median age was 75.5 years (IQR 67.6–80) and 62.1% were men, the median of CHA2DS2-Vasc and HASBLED scores was 4 (IQR 3–4) for both scores. Up to 57.3% of the total sample had CKD. Baseline characteristics were similar between groups, but CKD patients were older and had a higher HASBLED score. During the procedure, no thromboembolic, bleeding events, or deaths were observed. Combining the time of hospitalization and follow-up, no significant differences were observed between groups in the annual rate of thromboembolic events (0.97/100 patient-years [100PY] vs. 4.06/100PY, p = .09), but there was a higher rate of bleeding events (5.67/100PY vs. 13.3/100PY, p = .033) and mortality among CKD patients (6.50/100PY vs. 17.2/100PY, p = .009), with an odds ratio of 2.711 (95% CI 1.96–6.95). In the multivariate analysis, a preserved eGFR was independently associated with a lower mortality risk. Conclusions: LAAC is a valid alternative to oral anticoagulation in patients with CKD and atrial fibrillation, with a low-rate of peri- and post-procedure complications, although CKD patients exhibited a higher risk of bleeding and mortality during the follow-up. However, these higher rates may not be necessarily related to the procedure.

Introducción y objetivos: Los nonagenarios son un grupo de edad en rápido crecimiento entre los pacientes cardiovasculares, en especial con estenosis aórtica, pero los datos sobre su pronóstico después de la implantación transcatéter de válvula aórtica (TAVI) son escasos. El objetivo de este estudio es analizar las características basales de los nonagenarios tratados con TAVI y determinar si la edad "65; 90 años está relacionada con un peor pronóstico en comparación con los pacientes no nonagenarios. Métodos: Se incluyó a todos los pacientes "65; 75 años inscritos en el registro prospectivo multicéntrico español de TAVI entre 2009 y 2018. Se excluyó a aquellos < 75 años. Resultados: Se inscribieron en el registro español de TAVI 8.073 pacientes "65; 75 años de 46 centros de España; 7.686 de > 75 a 90 años (95,2%) y 387 nonagenarios (4,79%). Se observó un aumento progresivo de los nonagenarios. El acceso transfemoral se utilizó en el 91,6% de los casos, predominantemente en los nonagenarios (91,4 frente a 95,1%; p = 0,01). Los nonagenarios tenían más probabilidades de morir durante la hospitalización (4,3 frente a 7,0%; p = 0,01). Sin embargo, no hubo diferencia en la tasa de mortalidad por cualquier causa al año de seguimiento (8,8 frente a 11,3%; p = 0,07). En el análisis multivariable, la edad "65; 90 años no se asoció de forma independiente con un aumento de la mortalidad por cualquier causa ajustada (HR = 1,37; IC95%, 0,91-1,97; p = 0,14). La creatinina basal y las complicaciones hemorrágicas intrahospitalarias se asociaron a un peor pronóstico a largo plazo en pacientes nonagenarios tratados con TAVI. Conclusiones: Los nonagenarios son una población creciente y de muy alto riesgo, con estenosis aórtica grave, para quienes la TAVI podría representar una estrategia segura y efectiva. Una cuidadosa selección de los pacientes por un equipo multidisciplinario la máxima eficiencia en esta población, en la que la función renal basal y las complicaciones hemorrágicas pueden determinar el pronóstico a largo plazo tras la TAVI.

ABSTRACT Introduction and objectives: Nonagenarians are a fast-growing age group among cardiovascular patients, especially with aortic stenosis, but data about their prognosis after transcatheter aortic valve implantation (TAVI) is scarce. The objective of our study is to analyze the baseline characteristics of nonagenarians treated with TAVI and determine whether age ≥ 90 years is associated with a worse prognosis compared to non-nonagenarian patients. Methods: We included all patients ≥75 years enrolled in the multicenter prospective Spanish TAVI registry between 2009 and 2018. Patients < 75 years were excluded. Results: A total of 8073 elderly patients (≥ 75 years) from 46 Spanish centers were enrolled in the Spanish TAVI registry; 7686 were between ≥ 75 and < 90 years old (95.2%), and 387 were nonagenarian patients (4.79%). A gradual increase of nonagenarians was observed. The transfemoral access was used in 91.6% of the cases, predominantly among the nonagenarian patients (91.4% vs 95.1%, P = .01). Nonagenarians were more likely to die during their hospital stay (4.3% vs 7.0% among nonagenarians, P = .01). However, no difference was seen in the all-cause mortality rates reported at the 1-year follow-up (8.8% vs 11.3%, P =.07). In the multivariate analysis, age ≥ 90 years was not independently associated with a higher adjusted all-cause mortality rate (HR, 1.37, 95%CI, 0.91–1.97, P = .14). The baseline creatinine levels, and the in-hospital bleeding complications were all associated with a worse long-term prognosis in nonagenarians treated with TAVI. Conclusions: Nonagenarians are a very high-risk and growing population with severe AS in whom TAVI may be a safe and effective strategy. Careful patient selection by the TAVI heart team is mandatory to achieve maximum efficiency in this population where the baseline kidney function and bleeding complications may determine the long-term prognosis after TAVI.

Background Malnutrition is associated with poor prognosis in several cardiovascular diseases. However, its prognostic impact in patients undergoing transcatheter edge‐to‐edge mitral valve repair (TEER) is not well known. This study sought to assess the prevalence, clinical associations, and prognostic consequences of malnutrition in patients undergoing TEER. Methods and Results A total of 892 patients undergoing TEER from the international MIVNUT (Mitral Valve Repair and Nutritional Status) registry were studied. Malnutrition status was assessed with the Controlling Nutritional Status score. The association of nutritional status with mortality was analyzed with multivariable Cox regression models, whereas the association with heart failure admission was assessed by Fine‐Gray models, with death as a competing risk. According to the Controlling Nutritional Status score, 74.4% of patients with TEER had any degree of malnutrition at the time of TEER (75.1% in patients with body mass index

Objective: This study sought to investigate the effect of body mass index on outcomes in patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation. Methods: A total of 12,381 patients undergoing transfemoral transcatheter aortic valve implantation were divided into body mass index categories: underweight (30 kg/m2). Primary endpoints were differences in 30-day and 1-year all-cause mortality. Secondary endpoints included all other clinical endpoints such as stroke. Univariate and multivariate odds ratios were calculated using logistic and cox regression analyses. Results: Two percent (n = 205) of patients were underweight, 29% (n = 3564) were normal weight, 44% (n = 5460) were overweight, and 25% (n = 3152) were obese. Thirty-day mortality was lower in overweight (5.3%, odds ratio, 0.73; 95% confidence interval, 0.61-0.88; P = .001) and obese patients (5.2%, odds ratio, 0.74; 95% confidence interval, 0.60-0.92; P = .006), but higher in underweight (9.8%, odds ratio, 1.51; 95% confidence interval, 0.92-2.47; P = .010) as compared to normal weight patients (6.9%). After multivariate adjustment, 30-day mortality was not significantly different across body mass index categories. However, 1-year mortality was higher in underweight patients (hazard ratio, 1.52; 95% confidence interval, 1.10-2.09; P = .011). Stroke rates were comparable between body mass index groups. Conclusions: For overweight and obese patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation, there was no 30-day difference in mortality compared with patients with normal weight. However, underweight patients showed higher rates of 1-year mortality after transcatheter aortic valve implantation.

BackgroundDespite the spread of ST-elevation myocardial infarction (STEMI) emergency intervention networks, inequalities in healthcare access still have a negative impact on cardiovascular prognosis. The Family Income Ratio of Barcelona (FIRB) is a socioeconomic status (SES) indicator that is annually calculated. Our aim was to evaluate whether SES had an effect on mortality and complications in patients managed by the “Codi IAM” network in Barcelona.MethodsThis is a cohort study with 3,322 consecutive patients with STEMI treated in Barcelona from 2010 to 2016. Collected data include treatment delays, clinical and risk factor characteristics, and SES. The patients were assigned to three SES groups according to FIRB score. A logistic regression analysis was conducted to estimate the adjusted effect of SES on 30-day mortality, 30-day composite cardiovascular end point, and 1-year mortality.ResultsThe mean age of the patients was 65 ± 13% years, 25% were women, and 21% had diabetes mellitus. Patients with low SES were younger, more often hypertensive, diabetic, dyslipidemic (p < 0.003), had longer reperfusion delays (p < 0.03) compared to participants with higher SES. Low SES was not independently associated with 30-day mortality (OR: 0.95;9 5% CI: 0.7–1.3), 30-day cardiovascular composite end point (OR: 1.03; 95% CI: 0.84–1.26), or 1-year all-cause mortality (HR: 1.09; 95% CI: 0.76–1.56).ConclusionAlthough the low-SES patients with STEMI in Barcelona city were younger, had worse clinical profiles, and had longer revascularization delays, their 30-day and 1-year outcomes were comparable to those of the higher-SES patients.

RESUMEN Introducción y objetivos: El objetivo primario de este estudio fue presentar la mortalidad total intrahospitalaria del registro español de implante percutáneo de válvula aórtica (TAVI) desde su inicio hasta el año 2018, y como objetivos secundarios otros eventos clínicos intrahospitalarios, la mortalidad total a los 30 días y la evaluación de cuál ha sido la evolución temporal de este registro. Métodos: Fueron analizados todos los pacientes consecutivos incluidos en el registro español de TAVI. En este análisis temporal se dividió la población en pacientes tratados antes de 2014 (cohorte A: 2009-2013) y pacientes tratados entre los años 2014 y 2018 (cohorte B). Resultados: Desde agosto de 2007 hasta junio de 2018 se incluyeron 7.180 pacientes. La edad media fue de 81,2 ± 6,5 años y el 53% eran mujeres. El EuroSCORE logístico fue del 12% (8-20). Se utilizó un acceso transfemoral en el 89%. La mortalidad total intrahospitalaria fue del 4,7% y a los 30 días fue del 5,7%. En el análisis temporal durante la fase hospitalaria, las tasas de infarto, accidente cerebrovascular, necesidad de marcapasos, taponamiento, obstrucción coronaria y complicaciones vasculares fueron similares en ambos grupos. Sin embargo, en la cohorte B se observó una reducción de la necesidad de conversión a cirugía y de mala posición de la válvula, y además la tasa de éxito del implante fue mayor (93 frente a 96%; p < 0,001). La mortalidad por cualquier causa ajustada tanto intrahospitalaria como a los 30 días, fue significativamente menor en la cohorte B (odds ratio [OR] = 0,65; intervalo de confianza del 95% [IC95%], 0,48-0,86; p = 0,003; y OR = 0,71; IC95%, 0,54-0,92; p = 0,002, respectivamente). Conclusiones: En el análisis temporal del registro español de TAVI se observan un cambio en el perfil clínico de los pacientes y una mejora en la evolución clínica tanto intrahospitalaria como a los 30 días en los pacientes tratados en los últimos años.

ABSTRACT 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.

Background There is a paucity of outcome data on patients who are morbidly obese (MO) undergoing transcatheter aortic valve replacement. We aimed to determine their periprocedural and midterm outcomes and investigate the impact of obesity phenotype. Methods and Results Consecutive patients who are MO (body mass index, ≥40 kg/m2, or ≥35 kg/m2 with obesity‐related comorbidities; n=910) with severe aortic stenosis who underwent transcatheter aortic valve replacement in 18 tertiary hospitals were compared with a nonobese cohort (body mass index, 18.5–29.9 kg/m2, n=2264). Propensity‐score matching resulted in 770 pairs. Pre–transcatheter aortic valve replacement computed tomography scans were centrally analyzed to assess adipose tissue distribution; epicardial, abdominal visceral and subcutaneous fat. Major vascular complications were more common (6.6% versus 4.3%; P=0.043) and device success was less frequent (84.4% versus 88.1%; P=0.038) in the MO group. Freedom from all‐cause and cardiovascular mortality were similar at 2 years (79.4 versus 80.6%, P=0.731; and 88.7 versus 87.4%, P=0.699; MO and nonobese, respectively). Multivariable analysis identified baseline glomerular filtration rate and nontransfemoral access as independent predictors of 2‐year mortality in the MO group. An adverse MO phenotype with an abdominal visceral adipose tissue:subcutaneous adipose tissue ratio ≥1 (VAT:SAT) was associated with increased 2‐year all‐cause (hazard ratio [HR], 3.06; 95% CI, 1.20–7.77; P=0.019) and cardiovascular (hazard ratio, 4.11; 95% CI, 1.06–15.90; P=0.041) mortality, and readmissions (HR, 1.81; 95% CI, 1.07–3.07; P=0.027). After multivariable analysis, a (VAT:SAT) ratio ≥1 remained a strong predictor of 2‐year mortality (hazard ratio, 2.78; P=0.035). Conclusions Transcatheter aortic valve replacement in patients who are MO has similar short‐ and midterm outcomes to nonobese patients, despite higher major vascular complications and lower device success. An abdominal VAT:SAT ratio ≥1 identifies an obesity phenotype at higher risk of adverse clinical outcomes.

Background Hypothermia has been associated with therapeutic benefits including reduced mortality and better neurologic outcomes in survivors of cardiac arrest. However, undesirable side effects have been reported in patients undergoing coronary interventions. Using a large animal model of temperature management, we aimed to describe how temperature interferes with the coronary vasculature. Methods and Results Coronary hemodynamics and endothelial function were studied in 12 pigs at various core temperatures. Left circumflex coronary artery was challenged with intracoronary nitroglycerin, bradykinin, and adenosine at normothermia (38°C) and mild hypothermia (34°C), followed by either rewarming (38°C; n=6) or moderate hypothermia (MoHT; 32°C, n=6). Invasive coronary hemodynamics by Doppler wire revealed a slower coronary blood velocity at 32°C in the MoHT protocol (normothermia 20.2±11.2 cm/s versus mild hypothermia 18.7±4.3 cm/s versus MoHT 11.3±5.3 cm/s, P=0.007). MoHT time point was also associated with high values of hyperemic microvascular resistance (>3 mm Hg/cm per second) (normothermia 2.0±0.6 mm Hg/cm per second versus mild hypothermia 2.0±0.8 mm Hg/cm per second versus MoHT 3.4±1.6 mm Hg/cm per second, P=0.273). Assessment of coronary vasodilation by quantitative coronary analysis showed increased endothelium‐dependent (bradykinin) vasodilation at 32°C when compared with normothermia (normothermia 6.96% change versus mild hypothermia 9.01% change versus MoHT 25.42% change, P=0.044). Results from coronary reactivity in vitro were in agreement with angiography data and established that endothelium‐dependent relaxation in MoHT completely relies on NO production. Conclusions In this porcine model of temperature management, 34°C hypothermia and rewarming (38°C) did not affect coronary hemodynamics or endothelial function. However, 32°C hypothermia altered coronary vasculature physiology by slowing coronary blood flow, increasing microvascular resistance, and exacerbating endothelium‐dependent vasodilatory response.

The optimal antithrombotic strategy following left atrial appendage occlusion (LAAO) is not yet clearly established. Low-dose non-vitamin K antagonist oral anticoagulants (NOAC) might represent a valid alternative, but data regarding their usage is scarce. The aim of this study was to examine the efficacy and safety of low-dose NOAC compared to single (SAPT) or dual antiplatelet therapies (DAPT) after LAAO. We included consecutive patients with non-valvular atrial fibrillation who underwent LAAO and received low-dose apixaban, SAPT, or DAPT at discharge. The primary objective of this study included an efficacy endpoint (thromboembolic events and device related thrombosis (DRT)) and a safety endpoint (incidence of major bleeding) within the first three months after LAAO. A total of 139 patients were included. This group involved SAPT in 26 (18%), DAPT in 73 (53%), and apixaban in 40 (29%) patients. Follow-up at three-months showed no significant differences in the primary efficacy endpoint (2 (8%) SAPT, 3 (4%) DAPT and 0 (0%) apixaban; p value = 0.25). In contrast, the primary safety endpoint occurred more frequently in DAPT patients (7 (10%) DAPT, 0 (0%), SAPT and 0 with apixaban; p value = 0.03). Combining both efficacy and safety outcomes, low dose apixaban had a lower rate of events (2 (8%) with SAPT, 9 (12%) with DAPT and 0 (0%) with apixaban; p = 0.046). Low-dose apixaban after LAAO may be a valid alternative to DAPT and SAPT as depicted by the reduction in the occurrence of major bleedings and combined DRT/major bleedings respectively. Randomized data will be necessary to validate this strategy.

INTRODUCTION:The aim of this study was to determine prognostic factors for the risk of new vascular events during the first 6 months after acute myocardial infarction (AMI) or atherothrombotic stroke (AS). We were interested in the prognostic role of endothelial progenitor cells (EPC) and circulating endothelial cells (CEC). METHODS:Between February 2009 and July 2012, 100 AMI and 50 AS patients were consecutively studied in three Spanish centres. Patients with previously documented coronary artery disease or ischemic strokes were excluded. Samples were collected within 24h of onset of symptoms. EPC and CEC were studied using flow cytometry and categorized by quartiles. Patients were followed for up to 6 months. NVE was defined as new acute coronary syndrome, transient ischemic attack (TIA), stroke, or any hospitalization or death from cardiovascular causes. The variables included in the analysis included: vascular risk factors, carotid intima-media thickness (IMT), atherosclerotic burden and basal EPC and CEC count. Multivariate survival analysis was performed using Cox regression analysis. RESULTS:During follow-up, 19 patients (12.66%) had a new vascular event (5 strokes; 3 TIAs; 4 AMI; 6 hospitalizations; 1 death). Vascular events were associated with age (P = 0.039), carotid IMT≥0.9 (P = 0.044), and EPC count (P = 0.041) in the univariate analysis. Multivariate Cox regression analysis showed an independent association with EPC in the lowest quartile (HR: 10.33, 95%CI (1.22-87.34), P = 0.032] and IMT≥0.9 [HR: 4.12, 95%CI (1.21-13.95), P = 0.023]. CONCLUSIONS:Basal EPC and IMT≥0.9 can predict future vascular events in patients with AMI and AS, but CEC count does not affect cardiovascular risk.

INTRODUCTION: Chagas disease remains a major cause of mortality in several countries of Latin America and has become a potential public health problem in non-endemic countries as a result of migration flows. Cardiac involvement represents the main cause of mortality, but its diagnosis is still based on nonspecific criteria with poor sensitivity. Early identification of patients with cardiac involvement is desirable, since early treatment may improve prognosis. This study aimed to assess the role of diastolic dysfunction, abnormal myocardial strain and elevated brain natriuretic peptide (BNP) in the early identification of cardiac involvement in Chagas disease. METHODOLOGY/PRINCIPAL FINDINGS: Fifty-four patients divided into 3 groups--group 1 (undetermined form: positive serology without ECG or 2D-echocardiographic abnormalities; N = 32), group 2 (typical ECG abnormalities of Chagas disease but normal 2D-echocardiography; N = 14), and group 3 (regional wall motion abnormalities, left ventricular [LV] end-diastolic diameter >55 mm or LV ejection fraction 37 pg/ml) were noted in 0%, 13%, 29% and 63% in controls and groups 1 to 3, respectively. Half of patients in the undetermined form had impaired relaxation patterns, whereas half of patients with ECG abnormalities suggestive of Chagas cardiomyopathy had normal diastolic function. In group 1, BNP levels were statistically higher in patients with diastolic dysfunction as compared to those with normal diastolic function (27 ± 26 vs. 11 ± 8 pg/ml, p = 0.03). CONCLUSION/SIGNIFICANCE: In conclusion, the combination of diastolic function and BNP measurement adds important information that could help to better stratify patients with Chagas disease.

Gastrointestinal bleeding of obscure origin or with an intractable cause is particularly common in patients with atrial fibrillation subject to oral anticoagulant therapy. This condition is highly recurrent and therefore gives rise to high morbidity and mortality rates, thus entailing a vicious cycle that is difficult to solve. Percutaneous left atrial appendage closure has become a therapeutic alternative for patients with atrial fibrillation and a contraindication for oral anticoagulation. This technique would allow the discontinuation of oral anticoagulants, thus helping to reduce the risk for gastrointestinal bleeding, and would also be protective against embolic events in this group of patients, thereby eventually breaking this vicious cycle. We report our experience with percutaneous left atrial appendage closure in the management of patients with atrial fibrillation who are subject to oral anticoagulation therapy and suffer from obscure or intractable gastrointestinal bleeding.