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Objective: Chronic inflammation's role in the pathogenesis, development, and rupture of vascular malformations is undebated. Advanced magnetic resonance imaging techniques with vessel wall studies, specifically Black Blood (bbMRI), may offer insights into vascular wall instability and predict rupture. This case series aims to assess bbMRI as a predictive diagnostic tool for brain arteriovenous malformations (bAVMs) rupture, suggesting early treatment., Material and Methods: A prospective study included demographic, clinical, and neuroimaging data from a consecutive series of patients with ruptured or unruptured bAVMs, regardless of age or gender, between October 2018 and March 2024. All patients underwent MRI brain resonance with Black Blood study. Those with impaired renal function were excluded. Statistical analyses tested sample homogeneity. Univariate and multivariate logistical regressions assessed bbMRI as a rupture predictor for bAVMs, with a p-value set at < 0.05., Results: Ninety patients were retrieved: 64 with unruptured and 26 with ruptured bAVMs. The mean age was 31.9 years, and 55 were female. Admission symptoms were headache, neurological deficits, and seizure in 49, 21, and 19 cases, respectively. bbMRI showed wall enhancement in 56 cases, with 19 in the ruptured and 37 unruptured groups. Univariate and multivariate analyses revealed a significant correlation between bbMRI wall enhancement and bAVM rupture (p:0.033; p:0.047)., Conclusion: bbMRI may be a useful and feasible diagnostic implement to determine vessel inflammation and the bAVMs prone to rupture. Additional studies are needed to confirm the positive bbMRI as a predictive factor for bAVMs rupture., Competing Interests: Declarations Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Federal University of São Paulo (No. 2936701). Consent to participate Informed consente was obtained from all individual participants included in the study. Consent to publish The authors affirm that human research participants provided informed consente for publication of the images in Figs. 1 and 2, 3 A, 3B, 3 C, 4 A, 4B and 4 C. Competing interests The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Pulmonary hypertension (PH) often complicates mitral stenosis (MS). The prognostic impact of pulmonary vascular resistance (PVR) in MS patients remains unclear. Previous study has demonstrated the prognostic impact of right atrial pressure (RAP) in patients with primary PH. We aim to determine the prognostic impact of PVR and RAP in patients with rheumatic MS undergoing percutaneous mitral balloon valvuloplasty (PMBV)., Methods: A total of 58 patients with symptomatic severe rheumatic MS who underwent PMBV between 2016 and 2020 were included. Patients were divided into two groups: PVR ≤ 2WU (N = 26) and PVR > 2WU (N = 32). The composite endpoint included death, reintervention or persistent NYHA functional class III-IV during follow-up., Results: The median age was 50 (42-60) years, with 82.8% being female. Median pulmonary artery systolic pressure (PASP) was 42 (35-50.5) mmHg. Patients with PVR ≤ 2WU had lower PASP on both echocardiogram and catheterization. The PMBV success rate was 75.9%. Multivariate analysis, adjusted for PVR, showed RAP as the only independent predictor of the composite endpoint (HR:1.507, 95% CI:1.015-2.237, p = 0.042). The optimal RAP cutoff was 9.5 mmHg (HR:3.481, 95% CI:1.041-11.641; p = 0.043)., Conclusions: RAP was an independent predictor of adverse outcomes in patients with rheumatic MS undergoing PMBV, while PVR did not show prognostic significance. These findings suggest that the prognostic value of PVR may be lower than expected.

Chronic total occlusion (CTO) percutaneous coronary intervention is a complex procedure and is associated with considerable risk of complications. Several success and complication scores have been developed; however, data regarding their external validation in other populations such as Latin America are scarce. This study aimed to evaluate the accuracy of the main predictors of success and complications in a broad cohort of procedures in the Latin American (LATAM) CTO registry. From April 2008 to December 2023, 3,706 consecutive procedures listed in the LATAM CTO registry were screened. Of these, 2,835 procedures had sufficient information to analyze the Multicenter CTO Registry in Japan (J-CTO); Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS); Ostial location, Rentrop grade, and Age (ORA); Clinical and Lesion-related Score (CL-score); and EuroCTO Score (CASTLE) success scores. The complication scores were PROGRESS (MACE, mortality, and pericardiocentesis) and Outcomes, Patient health status, and Efficiency iN Chronic Total Occlusion hybrid procedures (OPEN-CTO),OPEN-CLEAN. The J-CTO and CASTLE scores demonstrated the highest areas under the curve (AUC) of 0.718 and 0.703, respectively. The AUC value for the CL-score was 0.685, whereas the PROGRESS score had an AUC of 0.598 and the ORA AUC was 0.545. The level of agreement between scores was low; only 4% of the procedures were classified as difficult or very difficult by all scores and <1% were classified as easy by all 5 scores. Of the complication scores, PROGRESS mortality (AUC 0.651) and PROGRESS MACE (AUC 0.588) showed the best performance, identifying groups with >10% event rate. These results may improve the selection of revascularization techniques, especially for patient demographics that are historically underrepresented in CTO research., Competing Interests: Declaration of competing interest Dr. Quadros receives financial support from Boston Scientific Corp., APT Medical, and Asahi Intecc Co. Ltd. Dr. Quadros receives speaking and lecture fees from APT Medical. The remaining authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This study evaluated the anesthetic and sedative effects of the essential oil of Zingiber officinale (EOZO) on juvenile pacu (Piaractus mesopotamicus). Experiment 1 evaluated concentrations of 0, 50, 100, 200 and 400 mg L -1 EOZO for times of induction and recovery from anesthesia. Furthermore, hematological responses and residual components of EOZO in plasma were determined immediately after anesthesia. Experiment 2 evaluated the effect of 0, 10, 20 and 30 mg L -1 EOZO on water quality, blood variables and residual components of EOZO in plasma and tissues (muscle and liver) immediately after 2 h of transport. Survival was 100%. The three main compounds of EOZO [zingiberene (32.27%), β-sesquiphellandrene (18.42%) and β-bisabolene (13.93%)] were observed in animal plasma and tissues (muscle and liver) after anesthesia and transport, demonstrating a direct linear effect among the evaluated concentrations. The concentration of 200 mg L -1 EOZO promoted surgical anesthesia of pacu and prevented an increase in monocyte and neutrophil levels, yet did not alter other hematological parameters. The use of 30 mg L -1 EOZO has a sedative effect on juvenile pacu, thereby reducing oxygen consumption during transport. Furthermore, the use of 30 mg L -1 EOZO in transport water prevented an increase in hemoglobin and hematocrit, with minimal influences on other blood variables., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Quantitative flow ratio (QFR) and myocardial perfusion scintigraphy (MPS) are utilized for assessing coronary artery disease (CAD) significance. We aimed to analyze their concordance and prognostic impact., Aims: We aimed to analyze the concordance between QFR and MPS and their risk stratification., Methods: Patients with invasive coronary angiography and MPS were categorized as concordant if QFR ≤ 0.80 and summed difference score (SDS) ≥ 4 or if QFR > 0.80 and SDS < 4; otherwise, they were discordant. Concordance was classified by coronary territory involvement: total (three territories), partial (two territories), poor (one territory), and total discordance (zero territories). Leaman score assessed coronary atherosclerotic burden., Results: 2010 coronary territories (670 patients) underwent joint QFR and MPS analysis. MPS area under the curve for QFR ≤ 0.80 was 0.637. Concordance rates were total (52.5%), partial (29.1%), poor (15.8%), and total discordance (2.6%). Most concordance occurred in patients without significant CAD or with single-vessel disease (89.5%), particularly without MPS perfusion defects (91.5%). Leaman score (odds ratio [OR]: 0.839, 95% confidence interval [CI]: 0.805-0.875, p < 0.001) and MPS perfusion defect (summed stress score [SSS] ≥ 4) (OR: 0.355, 95% CI: 0.211-0.596, p < 0.001) were independent predictors for discordance. After 1400 days, no significant difference in death/myocardial infarction was observed based on MPS assessment, but Leaman score, functional Leaman score, and average QFR identified higher risk patients., Conclusions: MPS showed good overall accuracy in assessing QFR significance but substantial discordance existed. Predictors for discordance included higher atherosclerotic burden and MPS perfusion defects (SSS ≥ 4). Leaman score, QFR-based functional Leaman score, and average QFR provided better risk stratification for all-cause death and myocardial infarction than MPS., (© 2024 Wiley Periodicals LLC.)

Transporting live fish is a common practice in fish farming, and is certainly one of the main problems that affect fish homeostasis. In this scenario, the use of natural additives has shown promise in improving fish resistance to adverse situations. This study aimed to assess the impact of Ocimum gratissimum L. essential oil (OGEO) on water quality, hematological parameters, and residue levels in the plasma, fillet, and liver of juvenile piraputanga (Brycon hilarii) during a two-hour transportation period. The fish were divided into plastic bags (4 L) and exposed to three different OGEO concentrations (10, 20, and 30 mg L-1), while a control group received no OGEO (three repetitions each). After the two-hour transportation, blood samples were collected, as well as portions of the fillet and liver for quantifying essential oil compounds, which were also measured in the plasma. Oxygen levels remained high throughout the transportation period, in all groups, while the pH decreased. Hemoglobin, MCHC, and MCH increased in fish exposed to OGEO concentrations of 20 and 30 mg L-1, compared to the control group. However, lymphocyte counts and the concentrations of essential oil compounds in plasma, fillet, and liver increased with higher OGEO concentrations. The use of 10 mg L-1 OGEO in the two-hour transport water is promising to ensure the survival and well-being of Brycon hilarii juveniles (weighing 16 g), showing to be safe and effective. The residual concentration of eugenol the major compound of OGEO in the fillet remains below the maximum limit of the recommended daily intake.

Background: Oncological patients with coronary artery disease face an elevated risk of hemorrhagic and ischemic events following percutaneous coronary intervention. Despite medical guidelines recommending minimal dual antiplatelet therapy (DAPT) duration for patients with cancer, dedicated data on abbreviated DAPT in this population is lacking. This study aims to evaluate the occurrence of ischemic and hemorrhagic events in patients with cancer compared with other high-bleeding risk individuals., Methods: Patient-level data from 4 high-bleeding risk coronary drug-eluting stent studies (ONYX One, LEADERS FREE, LEADERS FREE II, and SENIOR trials) treated with short DAPT were analyzed. The comparison focused on patients with high-bleeding risk with and without cancer, assessing 1-year rates of net adverse clinical events (all-cause death, myocardial infarction, stroke, revascularization, and Bleeding Academic Research Consortium [BARC] types 3 to 5 bleeding) and major adverse clinical events (all-cause death, myocardial infarction, stroke)., Results: A total of 5232 patients were included, of whom 574 individuals had cancer, and 4658 were at high-bleeding risk without previous cancer. Despite being younger with fewer risk factors, patients with cancer had higher net adverse clinical event (HR, 1.25; P =0.01) and major adverse clinical event (HR, 1.26; P =0.02), primarily driven by all-cause mortality and major bleeding (BARC 3-5), but not myocardial infarction, stroke, stent thrombosis, or repeat revascularization. Cancer was an independent predictor of net adverse clinical event ( P =0.005), major adverse clinical event ( P =0.01), and major bleeding ( P =0.03)., Conclusions: The present work is the first report on abbreviated DAPT dedicated to patients with cancer. Cancer is a major marker of adverse outcomes and these events had high lethality. Despite short DAPT, patients with cancer experienced higher rates of major bleeding compared with patients without cancer with high-bleeding risk, which occurred mainly after DAPT discontinuation. These findings reinforce the need for a more detailed and individualized stratification of those patients., Registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT03344653, NCT01623180, NCT02843633, NCT0284., Competing Interests: Disclosures Dr Urban is senior advisor at European Cardiovascular Research Center (CERC), a contract research organization based in Massy, France; Consultant to MedAlliance, Nyon, Switzerland and Consultant to Biosensors, Morges Switzerland. Dr Varenne received research grants from Abbott Vascular and Boston Scientific, lecture fees from Boston Scientific, Servier and Abbott Vascular; and congress support from Astra Zeneca. Dr Mehran reports institutional research payments from Abbott, Abiomed, Alleviant Medical, AM-Pharma, Amgen, Applied Therapeutics, Arena, AstraZeneca, AtriCure, Bayer, Biosensors, Biotronik, Boston Scientific, Bristol-Myers Squibb, CardiaWave, CeloNova, Chiesi, Concept Medical, CSL Behring, Cytosorbents, Daiichi Sankyo, Element Science, Faraday, Humacyte, Idorsia, Janssen, Magenta, Medtronic, Novartis, OrbusNeich, PhaseBio, Philips, Pi-Cardia, RenalPro, RM Global, Shockwave, Vivasure, Zoll; personal fees from Cine-Med Research, WebMD; Equity <1% in Applied Therapeutics, Elixir Medical, Stel, ControlRad (spouse); Scientific Advisory Board for American Medical Association, American College of Cardiology (BOT Member), Society for Cardiovascular Angiography and Interventions (Women in Innovations Committee Member), JAMA Associate Editor; Faculty Cardiovascular Research Foundation (no fee). Dr Stone has received speaker honoraria from Medtronic, Pulnovo, Infraredx; has served as a consultant to Valfix, TherOx, Robocath, HeartFlow, Ablative Solutions, Vectorious, Miracor, Neovasc, Abiomed, Ancora, Elucid Bio, Occlutech, CorFlow, Apollo Therapeutics, Impulse Dynamics, Cardiomech, Gore, Amgen, Adona Medical, Millennia Biopharma; and has equity/options from Ancora, Cagent, Applied Therapeutics, Biostar family of funds, SpectraWave, Orchestra Biomed, Aria, Cardiac Success, Valfix, Xenter. Dr Stone’s daughter is an employee at IQVIA. Institutional disclosure: Dr Stone’s employer, Mount Sinai Hospital, receives research support from Abbott, Abiomed, Bioventrix, Cardiovascular Systems Inc, Phillips, Biosense-Webster, Shockwave, Vascular Dynamics, Pulnovo and V-wave. Dr Campos has received honoraria from Abbott Vascular, Teleflex, and Terumo. Dr Oldroyd is chief medical officer of Biosensors International. Dr Capodanno received spaker’s fee and honoraria from Daiichi Sankyo, AstraZeneca, Sanofi, Terumo. The other authors report no conflicts.

Advanced oxidation processes (AOP), using semiconductor (SC) and hydroxyapatite (HA) composites, are promising due to the synergy of photocatalytic and adsorption properties. Still, dye removal efficiency of composites based on HA-SC remains low, because most of the research reported consider single SC materials. In this work, nanocrystalline xerogels of titanium oxide (TiO 2 ) with copper oxide (CuO) and HA were synthesized by the sol-gel process. HA was obtained by the precipitation method without heat treatment and calcined in the range of 200-1000 °C. TiO 2 and copper precursors were added to a sol containing HA in a 12:1 mol ratio, obtaining HA-TiO 2 and HA-CuO-TiO 2 nanomaterials. The xerogels were characterized by X-ray diffraction, scanning electron microscopy, emission field scanning electron microscopy and photoresponse. Their performance in the photocatalytic discoloration of an aqueous solution acid yellow dye 36 (AY36) was evaluated, using visible and UV light. The best discoloration was achieved with HA-CuO-TiO 2 xerogels with HA calcined at 600 °C, showing a degradation kinetic constant of 0.24 min -1 . In contrast, HA-TiO 2 materials showed little or no photocatalytic activity, but strong dye adsorption/desorption. The thermal treatment of HA determines the filament-like morphology and degree of compaction of the nanomaterials, which are relevant in the crystallite size and sensitization of the SC matrix. Further studies must address the surface chemistry and rectifying properties of the best SC composite to have a more complete understanding of the mechanisms involved., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Ltd.)

Background: Multimodal training may induce positive effects in different physical domains. Compared to unimodal training, multimodal training allows similar effect sizes at lower overall training volumes. Studies are needed to investigate the potential value of multimodal training with systematic training, especially compared to other exercise-based interventions. This study aimed to compare the effects of a multimodal training with an outdoor walking program, on postural control, muscle strength, and flexibility in community-dwelling older adults. Methods: This study is a pragmatic controlled clinical trial. We compared two real community exercise groups: a multimodal group ( n  = 53) and an outdoor, overground walking group ( n  = 45). Both groups participated in 32 sessions of training, twice a week, over 16 weeks. Participants were evaluated using the Mini-Balance Evaluation Systems Test (Mini-BESTest), Handgrip, 5-Times Sit-to-Stand Test, 3-meter Gait Speed Test, and Sit and Reach Test. Results: There was an interaction effect between evaluation and group in the Mini- BESTest with difference between pre and post-intervention only in multimodal group. Regarding gait speed, there was an interaction effect between evaluation and group with difference between pre and post-intervention only in the walking group. In the Sit and Reach Test: there was interaction effect between evaluation and group with difference between pre and post-intervention only in the walking group. Conclusion: The multimodal training improved postural control, while an outdoor walking program improved gait speed and flexibility. Both interventions improved muscle strength without between-group differences.

Background: Guide catheter extensions (GCEs) increase support and facilitate equipment delivery, but aggressive instrumentation may be associated with a higher risk of complications., Aim: Our aim was to assess the impact of GCEs on procedural success and complications in patients submitted to chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We analyzed data from the multicenter LATAM CTO Registry. Procedural success was defined as <30% residual stenosis and TIMI 3 distal flow. Major adverse cardiac and cerebrovascular events (MACCE) was defined as the composite of all-cause death, myocardial infarction, target vessel revascularization, and stroke. Propensity score matching (PSM) was used to compare outcomes with and without GCE use., Results: From August 2010 to August 2021, 3049 patients were included. GCEs were used in 438 patients (14.5%). In unadjusted analysis, patients in the GCE group were older and had more comorbidities. The median J-CTO score and its components were higher in the GCE group. After PSM, procedural success was higher with GCE use (87.7% vs. 80.5%, p = 0.007). The incidence of coronary perforation (odds ratio [OR]: 1.46, 95% confidence interval [CI]: 0.78-2.71, p = 0.230), bleeding (OR: 1.99, 95% CI: 0.41-2.41, p = 0.986), in-hospital death (OR: 1.39, 95% CI: 0.54-3.62, p = 0.495) and MACCE (OR: 1.07, 95% CI: 0.52-2.19, p = 0.850) were similar in both groups., Conclusion: In a contemporary, multicenter cohort of patients undergoing CTO PCI, GCEs were used in older patients, with more comorbidities and complex anatomy. After PSM, GCE use was associated with higher procedural success, and similar incidence of adverse outcomes., (© 2024 Wiley Periodicals LLC.)

Biometric evaluations are essential to determine the growth characteristics related to the weight and length of fish. This study aimed to determine the growth patterns of juvenile piraputangas (Brycon hilarii) produced in hapas within an excavated pond. The piraputangas were anesthetized and micro-chipped and their biometric characteristics were measured. Subsequently, the fish were distributed in six hapas of eight m3 at the density of 20 fish/hapa, totaling 120 animals. During the experimental period six months, the fish were fed twice (5% of the biomass) a day. Every 30 days, all fish were sampled to measure the biometric characteristics of body weight (g); standard length; total length; head height; head length; body height and body width (cm). The calculations of the weight ratio with the biometric characteristics were determined using allometric equation and estimated by linear regression according to the equation log Y = log a + b log X. All tested relationships were significant by the Student t-test (p < 0.05). Allometric growth was positive for: weight x total length; standard weight x length; weight x head height; weight x head length and weight x body height. The relative condition factor of piraputangas observed in this study was 1.00. The study provided information on the allometric parameters of juvenile Brycon hilarii produced in hapas, and the relative condition factor indicated good growth conditions for piraputangas with positive allometric growth.

The objective of this study was to evaluate reproductive traits in adults of Astyanax lacustris subjected to different spawning inducers. The study involved 240 females (12.54 g ± 2.33 and 7.66 cm ± 0.63 cm) and 240 males (5.83 g ± 0.39 g and 6.14 cm ± 0.64 cm), all at reproductive age. Three different inducers were evaluated: (i) 0.4 pellets of Ovopel®/kg of body weight; (ii) 0.5 ml of buserelin acetate/kg of body weight; and (iii) carp pituitary extract (CPE) (5.5 mg CPE/kg body weight for females and 2.5 mg CPE/kg body weight for males), as well as saline solution (without hormone). The degree-hours for spawning were greater (P<0.05) for the Ovopel® treatment (with 204.93) than in the treatment with CPE (183.2). Ovary weight and gonadosomatic index were higher (P<0.05) in CPE and Ovopel® treatments when compared to buserelin acetate. The number of oocytes per female, absolute and relative fecundity were greater (P<0.05) for Ovopel® and CPE treatments. Fertilization rate was higher (P<0.05) in treatment with buserelin acetate (82.3%) in relation to Ovopel® (72.33%) and CPE (62.40%) treatments, and the highest (P<0.05) hatching rates were achieved with buserelin acetate and Ovopel®. The number of larvae per female body weight was greater (P<0.05) when Ovopel® was used. In conclusion, Ovopel® proves to be a more effective reproductive inducer for induced reproduction of A. lacustris when compared to CPE and buserelin acetate.

B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-pro BNP) are cardiac biomarkers that are released in response to increased ventricular and atrial wall stress. Aortic stenosis (AS) leads to hemodynamic changes and left ventricular hypertrophy and may be associated with natriuretic peptide levels. Several studies have shown that increased natriuretic peptide levels are correlated with AS severity and can predict the need for intervention. It can be useful in risk stratification, monitoring follow-up, and predicting cardiovascular outcomes of patients with severe AS. This paper aims to summarize the evidence of the role of BNP and NT-pro BNP in AS, before and after intervention., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Cavalcante, Kanhouche, Rosa, Campos, Lopes, Lopes, Sampaio, Brito Júnior, Tarasoutchi and Abizaid.)

Background: Ultra-thin strut drug-eluting stent (UTS-DES) may improve outcomes after percutaneous coronary intervention (PCI) but have received limited study in chronic total occlusion (CTO) PCI., Aims: To compare of 1-year incidence of major adverse cardiac events (MACE) between patients who underwent CTO PCI with ultrathin (≤ 75 μm) versus thin (>75 μm) strut DES in the LATAM CTO registry., Methods: Patients were considered for inclusion only if successful CTO PCI was performed and when only one type of stent strut thickness (ultrathin or thin) was used. A propensity score matching (PSM) was computed to produce similar groups in relation to clinical and procedural characteristics., Results: Between January 2015 and January 2020, 2092 patients underwent CTO PCI, of whom 1466 were included in the present analysis (475 in the ultra-thin and 991 in the thin strut DES). In unadjusted analysis the UTS-DES group had lower rate of MACE (HR: 0.63 95 % CI 0.42 to 0.94, p = 0.04) and repeat revascularizations (HR: 0.50 95 % CI 0.31 to 0.81, p = 0.02) at 1-year follow-up. After adjustment for confounding factors in a Cox regression model there was no difference in 1-year incidence of MACE between groups (HR: 1.15 95 % CI 0.41 to 2.97, p = 0.85). On PSM of 686 patients (343 in each group) the 1-year incidence of MACE (HR 0.68 95 % CI 0.37-1.23; P = 0.22) and individual components of MACE did not differ between groups., Conclusions: One-year clinical outcomes after CTO PCI were similar with ultrathin and thin strut DES., Competing Interests: Declaration of competing interest Carlos M. Campos received consultant honoraria and lectures from Abbott, Terumo and Teleflex. Emmanouil S Brilakis reports consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor, Circulation), Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, InfraRedx, and Medtronic; research support from Regeneron and Siemens; shareholder in MHI Ventures; Board of Trustees for the Society of Cardiovascular Angiography and Interventions. Alexandre Quadros received honoraria from Boston Scientific. And research funds from Boston Scientific and Terumo. The remaining authors report no conflicts of interest regarding the content herein., (Copyright © 2023. Published by Elsevier Inc.)

Introduction: Classical low-flow, low-gradient aortic stenosis (LFLG-AS) is an advanced stage of aortic stenosis, which has a poor prognosis with medical treatment and a high operative mortality after surgical aortic valve replacement (SAVR). There is currently a paucity of information regarding the current prognosis of classical LFLG-AS patients undergoing SAVR and the lack of a reliable risk assessment tool for this particular subset of AS patients. The present study aims to assess mortality predictors in a population of classical LFLG-AS patients undergoing SAVR., Methods: This is a prospective study including 41 consecutive classical LFLG-AS patients (aortic valve area ≤1.0 cm 2 , mean transaortic gradient <40 mmHg, left ventricular ejection fraction <50%). All patients underwent dobutamine stress echocardiography (DSE), 3D echocardiography, and T1 mapping cardiac magnetic resonance (CMR). Patients with pseudo-severe aortic stenosis were excluded. Patients were divided into groups according to the median value of the mean transaortic gradient (≤25 and >25 mmHg). All-cause, intraprocedural, 30-day, and 1-year mortality rates were evaluated., Results: All of the patients had degenerative aortic stenosis, with a median age of 66 (60-73) years; most of the patients were men (83%). The median EuroSCORE II was 2.19% (1.5%-4.78%), and the median STS was 2.19% (1.6%-3.99%). On DSE, 73.2% had flow reserve (FR), i.e., an increase in stroke volume ≥20% during DSE, with no significant differences between groups. On CMR, late gadolinium enhancement mass was lower in the group with mean transaortic gradient >25 mmHg [2.0 (0.0-8.9) g vs. 8.5 (2.3-15.0) g; p  = 0.034), and myocardium extracellular volume (ECV) and indexed ECV were similar between groups. The 30-day and 1-year mortality rates were 14.6% and 43.8%, respectively. The median follow-up was 4.1 (0.3-5.1) years. By multivariate analysis adjusted for FR, only the mean transaortic gradient was an independent predictor of mortality (hazard ratio: 0.923, 95% confidence interval: 0.864-0.986, p  = 0.019). A mean transaortic gradient ≤25 mmHg was associated with higher all-cause mortality rates (log-rank p  = 0.038), while there was no difference in mortality regarding FR status (log-rank p  = 0.114)., Conclusions: In patients with classical LFLG-AS undergoing SAVR, the mean transaortic gradient was the only independent mortality predictor in patients with LFLG-AS, especially if ≤25 mmHg. The absence of left ventricular FR had no prognostic impact on long-term outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Tessari, Lopes, Campos, Rosa, Sampaio, Soares, Lopes, Nazzetta, Sândoli de Brito Júnior, Ribeiro, Vieira, Mathias, Fernandes, Lopes, Rochitte, Pomerantzeff, Abizaid and Tarasoutchi.)

Vasculitis is a complication of several infectious diseases affecting the central nervous system, which may result in ischemic and/or hemorrhagic stroke, transient ischemic attack, and aneurysm formation. The infectious agent may directly infect the endothelium, causing vasculitis, or indirectly affect the vessel wall through an immunological mechanism. The clinical manifestations of these complications usually overlap with those of non-infectious vascular diseases, making diagnosis challenging. Intracranial vessel wall magnetic resonance imaging (VWI) enables the evaluation of the vessel wall and the diseases that affect it, providing diagnostic data beyond luminal changes and enabling the identification of inflammatory changes in cerebral vasculitis. This technique demonstrates concentric vessel wall thickening and gadolinium enhancement, associated or not with adjacent brain parenchymal enhancement, in patients with vasculitis of any origin. It permits the detection of early alterations, even before a stenosis occurs. In this article, we review the intracranial vessel wall imaging features of infectious vasculitis of bacterial, viral, and fungal etiologies., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Major advances have been seen in techniques and devices for performing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs), but there are limited real-world practice data from developing countries., Objectives: To report clinical and angiographic characteristics, procedural aspects, and clinical outcomes of CTO PCI performed at dedicated centers in Brazil., Methods: Included patients underwent CTO PCI at centers participating in the LATAM CTO Registry, a Latin American multicenter registry dedicated to prospective collection of these data. Inclusion criteria were procedures performed in Brazil, age 18 years or over, and presence of CTO with PCI attempt. CTO was defined as a 100% lesion in an epicardial coronary artery, known or estimated to have lasted at least 3 months., Results: Data on 1196 CTO PCIs were included. Procedures were performed primarily for angina control (85%) and/or treatment of moderate/severe ischemia (24%). Technical success rate was 84%, being achieved with antegrade wire approaches in 81% of procedures, antegrade dissection and re-entry in 9%, and retrograde approaches in 10%. In-hospital adverse cardiovascular events occurred in 2.3% of cases, with a mortality rate of 0.75%., Conclusions: CTOs can be treated effectively in Brazil by using PCI, with low complication rates. The scientific and technological development observed in this area in the past decade is reflected in the clinical practice of dedicated Brazilian centers.

Objectives: The aim of the present study is to assess multimodality imaging findings according to systemic biomarkers, high-sensitivity troponin I (hsTnI) and B-type natriuretic peptide (BNP) levels, in low-flow, low-gradient aortic stenosis (LFLG-AS)., Background: Elevated levels of BNP and hsTnI have been related with poor prognosis in patients with LFLG-AS., Methods: Prospective study with LFLG-AS patients that underwent hsTnI, BNP, coronary angiography, cardiac magnetic resonance (CMR) with T1 mapping, echocardiogram and dobutamine stress echocardiogram. Patients were divided into 3 groups according to BNP and hsTnI levels: Group 1 ( n  = 17) when BNP and hsTnI levels were below median [BNP < 1.98 fold upper reference limit (URL) and hsTnI < 1.8 fold URL]; Group 2 ( n  = 14) when BNP or hsTnI were higher than median; and Group 3 ( n  = 18) when both hsTnI and BNP were higher than median., Results: 49 patients included in 3 groups. Clinical characteristics (including risk scores) were similar among groups. Group 3 patients had lower valvuloarterial impedance ( P  = 0.03) and lower left ventricular ejection fraction ( P  = 0.02) by echocardiogram. CMR identified a progressive increase of right and left ventricular chamber from Group 1 to Group 3, and worsening of left ventricular ejection fraction (EF) (40 [31-47] vs. 32 [29-41] vs. 26 [19-33]%; p  < 0.01) and right ventricular EF (62 [53-69] vs. 51 [35-63] vs. 30 [24-46]%; p  < 0.01). Besides, there was a marked increase in myocardial fibrosis assessed by extracellular volume fraction (ECV) (28.4 [24.8-30.7] vs. 28.2 [26.9-34.5] vs. 31.8 [28.9-35.5]%; p  = 0.03) and indexed ECV (iECV) (28.7 [21.2-39.1] vs. 28.8 [25.4-39.9] vs. 44.2 [36.4-51.2] ml/m 2 , respectively; p  < 0.01) from Group 1 to Group 3., Conclusions: Higher levels of BNP and hsTnI in LFLG-AS patients are associated with worse multi-modality evidence of cardiac remodeling and fibrosis., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Lopes, Campos, Rosa, Sampaio, Morais, de Brito Júnior, Vieira, Mathias, Fernandes, de Santis, Santos, Rochitte, Capodanno, Tamburino, Abizaid and Tarasoutchi.)

Background and Objectives: Hospitalization by Covid-19 can cause persistent functional consequences after hospital discharge due to direct and indirect effects of SARS-COV-2 in several organs and systems of the body added to post-intensive care syndrome and prolonged bed rest. These impacts can lead to dependency in activities of daily living, mainly in older people due to aging process and functional decline. This study aimed to compare the effects of hospitalization by Covid-19 on functional capacity of adults and older people and to identify its associated factors., Methods: Cross-sectional observational study of 159 survivors of hospitalization by Covid-19 after 1 month from discharge at Hospital das Clínicas of the University of São Paulo, divided into groups: adults (aged < 60 years) and older people (aged ≥ 60 years). Those who did not accept to participate, without availability or without ability to understand the questionnaires were excluded. Functional capacity was assessed by the Barthel Index and patients were classified according to their scores. Data analysis was performed in JASP Statistics program and the sample was compared between the age groups. Wilcoxon test was applied to compare before and after periods, Mann-Whitney test was used for between groups comparison. We adopted alpha = 0.05., Results: The total Barthel Index median score was lower 1 month after hospital discharge than in the pre-Covid-19 period. Older people had worse functional status than adults before and also showed greater impairment after hospital discharge. Both groups showed lower Barthel Index classification than before, and older people presented more functional dependence than adults in both periods. Age, sarcopenia and frailty were associated factors., Discussion: Hospitalization by Covid-19 impacts functional capacity after 1 month from discharge, especially in older people. Age, sarcopenia and frailty are associated factors. These results suggest need for care and rehabilitation of Covid-19 survivors., (© 2022 John Wiley & Sons Ltd.)

Background: Microvascular lung vessels obstructive thromboinflammatory syndrome has been proposed as a possible mechanism of respiratory failure in COVID-19 patients. However, it has only been observed in post-mortem studies and has never been documented in vivo , probably because of a lack of CT scan sensitivity in small pulmonary arteries. The aim of the present study was to assess the safety, tolerability, and diagnostic value of optical coherence tomography (OCT) for the assessment of patients with COVID-19 pneumonia for pulmonary microvascular thromboinflammatory syndrome., Methods: The COVID-OCT trial was a multicenter, open-label, prospective, interventional clinical study. Two cohorts of patients were included in the study and underwent pulmonary OCT evaluation. Cohort A consisted of patients with COVID-19 with a negative CT scan for pulmonary thrombosis and elevated thromboinflammatory markers (D-dimer > 10,000 ng/mL or 5,000 < D-dimer < 10,000 ng/mL and one of: C-reactive Protein > 100 mg/dL, IL-6 > 6 pg/mL, or ferritin > 900 ng/L). Cohort B consisted of patients with COVID-19 and a CT scan positive for pulmonary thrombosis. The primary endpoints of the study were: (i) to evaluate the overall safety of OCT investigation in patients with COVID-19 pneumonia, and (ii) to report on the potential value of OCT as a novel diagnostic tool for the diagnosis of microvascular pulmonary thrombosis in COVID-19 patients., Results: A total of 13 patients were enrolled. The mean number of OCT runs performed in each patient was 6.1 ± 2.0, both in ground glass and healthy lung areas, achieving a good evaluation of the distal pulmonary arteries. Overall, OCT runs identified microvascular thrombosis in 8 patients (61.5%): 5 cases of red thrombus, 1 case of white thrombus, and 2 cases of mixed thrombus. In Cohort A, the minimal lumen area was 3.5 ± 4.6 mm 2 , with stenosis of 60.9 ± 35.9% of the area, and the mean length of thrombus-containing lesions was 5.4 ± 3.0 mm. In Cohort B, the percentage area obstruction was 92.6 ± 2.6, and the mean thrombus-containing lesion length was 14.1 ± 13.9 mm. No peri-procedural complications occurred in any of the 13 patients., Conclusion: OCT appears to be a safe and accurate method of evaluating the distal pulmonary arteries in hospitalized COVID-19 patients. Here, it enabled the first in vivo documentation of distal pulmonary arterial thrombosis in patients with elevated thromboinflammatory markers, even when their CT angiogram was negative for pulmonary thrombosis., Clinical Trial Registration: ClinicalTrial.gov, identifier NCT04410549., Competing Interests: MM was a proctor for Abbott. MA received consultant fees from Abbott. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Hajjar, Ancona, Filho, Tresoldi, Caldas, Monti, Carnevale, De Cobelli, Moreira de Assis, Ciceri, Landoni, Dijkstra, Moroni, Abizaid, Willemann Ungaretti, Carvalho Carmona, De Backer, Pompilio, Britto, Campos, Zangrillo and Montorfano.)

Background: Low areal bone mineral density (BMD), increased fracture risk and altered bone remodeling have been described among stone formers (SFs), but the magnitude of these findings differs by age, sex, menopausal status and urinary calcium (uCa). This study aimed to investigate volumetric BMD (vBMD), bone microarchitecture and biomechanical properties by high-resolution peripheral quantitative computed tomography (HR-pQCT) and finite element analysis (FEA) in young SFs, irrespective of calciuria, further distinguishing trabecular from cortical compartments., Methods: HR-pQCT/FEA was performed at the distal tibia (DT) and distal radius (DR) in 106 SFs (57 males and 49 premenopausal females; median age 37 years) and compared with 106 non-SFs (NSFs) retrieved from an existing database, matched for age, sex and body mass index (BMI). Biochemical/hormonal serum and urinary parameters were obtained from SFs., Results: SFs exhibited significantly lower trabecular number (TbN) and higher trabecular separation (TbSp) than NSFs at both anatomical sites and lower cortical porosity in the DR. In a subgroup analysis separated by sex, female SFs presented significantly lower TbvBMD, relative bone volume fraction (BV/TV) and TbN and higher TbSp than NSFs at both sites, while male SFs showed significantly lower stiffness and failure load. Multivariate analysis showed TbN to be independently associated with sex and BMI at both sites and with uCa at the DR., Conclusions: The present findings suggest that bone disease represents an early event among SFs, associated at least in part with calcium excretion and mainly characterized by trabecular bone microarchitecture impairment, especially among women, but with reduced bone strength parameters in men., (© The Author(s) 2022. Published by Oxford University Press on behalf of the ERA.)

Introduction: Fractional flow reserve (FFR) has been established as the gold standard in the physiological assessment of coronary obstructions severity. However, the need to insert an intracoronary pressure guidewire is a factor that limits its use. Quantitative flow ratio (QFR) is a method that infers the value of FFR from 3-dimensional quantitative coronary angiography (3D-QCA), eliminating the use of a pressure wire and coronary hyperemia. The present study aims to evaluate the diagnostic accuracy of QFR and 3D-QCA in comparison with FFR for the identification of significant obstructive coronary lesions (FFR ≤.80) and the feasibility to assess QFR in a cohort of patients without dedicated angiographic acquisition., Methods: Consecutive patients with coronary angiography with moderate obstructive lesions that had previous FFR measurement were evaluated. Validation of QFR was assessed by the area under the curve (AUC) and other statistical tools, using FFR as the reference method., Results: Seventy-five arteries from 69 patients were evaluated. The accuracy of the QFR to detect FFR ≤.80 was 84.0% (95% confidence interval, 75.6-92.4). The correlation and agreement between FFR and QFR were r=0.54 (P<.01) and mean difference was -0.02 ± 0.09 (P=.09), respectively. The AUC of QFR and 3D-QCA identifying stenosis >50% was 0.854 and 0.755, respectively (P=.09)., Conclusion: QFR demonstrated good accuracy compared with FFR for the assessment of moderate obstructive coronary lesions in an unselected clinical practice population. However, many patients were excluded from the analysis and there was no statistical difference between the receiver operator characteristic curves of the QFR and percent diameter stenosis.

Background Coronary perforation is a life-threatening complication of acute percutaneous coronary intervention (PCI) for chronic total occlusions (CTO), but data on midterm outcomes are limited. Methods and Results Data from LATAM (Latin American)-CTO Registry (57 centers; 9 countries) were analyzed. We assessed the risk of 30-day, 1-year major adverse cardiac events of coronary perforation using time-to-event and weighted composite end point analysis having CTO PCI without perforation as comparators. Additionally, we studied the independent predictors of perforation in these patients. Of 2054 patients who underwent CTO PCI between 2015 and 2018, the median Multicenter CTO Registry in Japan and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention-Chronic total occlusions scores were 2.0 (1.0-3.0) and 1.0 (0.0-2.0), respectively. The perforation rate was 3.7%, of which 55% were Ellis class 1. After 1-year coronary perforation had higher major adverse cardiac events rates (24.9% versus 13.3%; P <0.01). Using weighted composite end point, perforation was associated with increased bleeding and ischemic events at 6 months ( P =0.04) and 1 year ( P <0.01). We found as independent predictors associated with coronary perforation during CTO PCI: maximum activated clotting time ( P <0.01), Multicenter CTO Registry in Japan score ≥2 ( P =0.05), antegrade knuckle wire ( P =0.04), and right coronary artery CTO PCI ( P =0.05). Conclusions Coronary perforation was infrequent and associated with anatomical and procedural complexity, resulting in higher risk of hemorrhagic and ischemic events. Landmark and weighted analysis showed a sustained burden of major events between 6 months and 1 year follow-up.

Background: Takotsubo cardiomyopathy (TTC) is classified into 4 types depending on the anatomical area affected identified on gross visual assessment. We have sought to understand if it is feasible and advantageous to use left ventricular global longitudinal strain (LVGLS), LV segmental longitudinal strain and right ventricle free wall strain (RVFWS) to classify TTC., Methods: We conducted a retrospective observational study on twenty-five patients who meet the Modified Mayo Clinic Criteria for TTC [1]. Two independent reviewers performed strain analysis, they were both blinded to patient's diagnosed classification and outcomes., Results: Based on classification by traditional assessment the 92% (N.=23) were diagnosed with typical TTC, indicating apical involvement. The entire LV was affected, 67% (N.=16) had abnormal strain (STE>-18) in all three LV regions (base, mid-ventricle and apex). Seventy-one percent of patients (N.=17) had abnormal LVGLS (>-18). Abnormal strain across all three LV regions was associated with higher prevalence (70%, N.=8 Vs 30%, N.=4, respectively) of composite cardiovascular events and longer length of hospital stay. There was a statistically significant difference in average length of hospital stay in those patients who had abnormal strain in all three regions compared to those that did not have abnormal strain across all three regions (8 days compared to 3.44 days, P=0.02)., Conclusions: A new classification of TCC based on strain analysis should be developed. The traditional model is arbitrary; it fails to recognize that in most patients the entire LV is affect, it does not have prognostic significance and the most prevalent typical variant indicates apical involvement. Our study suggests that the entire LV is affected, and strain analysis has prognostic significance.

Objectives: To evaluate the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in patients with and without prior coronary artery bypass graft (CABG) surgery., Background: Data on the outcomes of CTO PCI in patients with versus without CABG remains limited and with scarce representation from developing regions like Latin America., Methods: We evaluated patients undergoing CTO PCI in 42 centers participating in the LATAM CTO registry between 2008 and 2020. Statistical analyses were stratified according to CABG status. The outcomes of interest were technical and procedural success and in-hospital major adverse cardiac and cerebrovascular events (MACCE)., Results: A total of 1662 patients were included (n = 1411 [84.9%] no-CABG and n = 251 [15.1%] prior-CABG). Compared with no-CABG, those with prior-CABG were older (67 ± 11 vs. 64 ± 11 years; p < 0.001), had more comorbidities and lower left ventricular ejection fraction (52.8 ± 12.8% vs. 54.4 ± 11.7%; p = 0.042). Anatomic complexity was higher in the prior-CABG group (J-CTO score 2.46 ± 1.19 vs. 2.10 ± 1.22; p < 0.001; PROGRESS CTO score 1.28 ± 0.89 vs. 0.91 ± 0.85; p < 0.001). Absence of CABG was associated with lower risk of technical and procedural failure (OR: 0.60, 95% CI: 0.43-0.85 and OR: 0.58, 95% CI: 0.40-0.83, respectively). No significant differences in the incidence of in-hospital MACCE (3.8% no-CABG vs. 4.4% prior-CABG; p = 0.766) were observed between groups., Conclusion: In a contemporary multicenter CTO-PCI registry from Latin America, prior-CABG patients had more comorbidities, higher anatomical complexity, lower success, and similar in-hospital adverse event rates compared with no-CABG patients., (© 2021 Wiley Periodicals LLC.)

Objectives: We aimed to explore angiographic patterns and in-hospital outcomes of patients with concomitant coronavirus disease-19 (COVID-19) and myocardial infarction (MI)., Background: Patients with COVID-19 may experience MI during the course of the viral infection. However, this association is currently poorly understood., Methods: This is a multicenter prospective study of consecutive patients with concomitant COVID-19 and MI who underwent coronary angiography. Quantitative and qualitative coronary angiography were analyzed by two observers in an independent core lab., Results: A total of 152 patients were included, of whom 142 (93.4%) had COVID-19 diagnosis confirmation. The median time between symptom onset and hospital admission was 5 (1-10) days. A total of 83 (54.6%) patients presented with ST-elevation MI. The median angiographic Syntax score was 16 (9.0-25.3) and 69.0% had multi-vessel disease. At least one complex lesion was found in 73.0% of patients, 51.3% had a thrombus containing lesion, and 57.9% had myocardial blush grades 0/1. The overall in-hospital mortality was 23.7%. ST-segment elevation MI presentation and baseline myocardial blush grades 0 or 1 were independently associated with a higher risk of death (HR 2.75, 95%CI 1.30-5.80 and HR 3.73, 95%CI 1.61-8.61, respectively)., Conclusions: Patients who have a MI in the context of ongoing COVID-19 mostly present complex coronary morphologies, implying a background of prior atherosclerotic disease superimposed on a thrombotic milieu. The in-hospital prognosis is poor with a markedly high mortality, prompting further investigation to better clarify this newly described condition., (© 2021 Wiley Periodicals LLC.)

The patient reported angina measurement with the Seattle Angina Questionnaire (SAQ) has shown to have prognostic implications and became an endpoint in clinical trials. Our objective was to study physician-reported and SAQ severity with the total coronary atherosclerotic burden as assessed by 4 angiographic scores. We prospectively analyzed data of consecutive patients scheduled for coronary angiography or percutaneous coronary intervention. The Canadian Cardiovascular Society (CCS) angina categories was used as physician-reported angina. SAQ domains were categorized as severe (0 to 24), moderate 25 to 75 and mild angina (>75). All angina assessments were done before coronary angiography. Gensini, Syntax, Friesinger, and Sullivan angiographic scores were used for total atherosclerotic burden quantification: 261 patients were included in the present analysis. The median age was 66.0 (59.0 to 71.8) years, 53.6% were male and 43.7% had diabetes. The median SYNTAX score was 6.0 (0 to 18.0). The worse the symptoms of CCS categories, the more severe was the atherosclerotic burden in all angiographic scores: SYNTAX (p = 0.01); Gensini (p <0.01); Friesinger (p = 0.02) and Sullivan (p = 0.03). Conversely, SAQ domains were not able to discriminate the severity of CAD in any of the scores. The only exception was the severe SAQ quality of life that had worse Gensini score than the mild SAQ quality of life (p = 0.04). In conclusion, CCS angina categories are related to the total atherosclerotic burden in coronary angiography, by all angiographic scores. SAQ domains should be used as a measure of patient functionality and quality of life but not as a measure of CAD severity., (Copyright © 2021. Published by Elsevier Inc.)

Cancer and cardiovascular disease are the leading causes of mortality in the world. The prevalence of cardiovascular risk factors and coronary artery disease in cancer patients is elevated, and it is associated with high mortality. Several mechanisms, such as the proinflammatory and procoagulant states present in cancer patients, may contribute to these scenarios. Oncological therapy can predispose patients to acute thrombosis, accelerated atherosclerosis and coronary spasm. Treatment decisions must be individualized and based on the cancer history and balancing bleeding and thrombosis risks., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Costa, Andrade, Carter, Seleme, Costa, Campos and Hajjar.)

Background: Takotsubo cardiomyopathy (TTC) is characterized by transient left ventricular (LV) dysfunction, electrocardiographic changes that can mimic acute myocardial infarction (MI), and release of myocardial enzymes in the absence of obstructive coronary artery disease (CAD). Conventionally, gross visual assessment of LV angiogram has been used to classify TTC. We aim to compare quantitative assessment of different regions of LV on angiogram and segmental strain on transthoracic echo to determine a better way to classify TTC rather than conventional qualitative visual assessment., Methods: We conducted a retrospective observational study of 20 patients diagnosed with TTC who had LV angiogram and transthoracic echocardiograms performed on presentation that were suitable for analysis. Twenty LV angiograms were analyzed using Rubo DICOM viewer software. Areas of different LV regions were measured in diastole and systole, and percentage changes in area of these regions were calculated. Percentage changes in area of less than 10% was considered "akinetic." On the other hand, using echocardiograms of these patients, LV regional longitudinal strain (LS) was derived from speckle-tracking analysis. These findings were compared to determine concordance between both modalities., Results: On quantitative analysis of 20 LV angiograms, the area of all the three LV regional (apex, mid ventricle, and base) shortening (>10%) was observed in 16 patients (80%) during systole as compared to diastole. However, only 4 out of 20 patients (20%) were noted to have apical region area change of <10% between diastole and systole. Analysis of LV regional LS patterns of 20 patients showed that 14 patients had abnormal values (> -18%) in all three LV regions: apex, mid ventricle, and base. The apical region was the most severely affected region (mean LS -13.9%), followed by the basal region (mean -14.7%) and the mid ventricular region (mean -15.1%). Comparing the results of both modalities showed that there was 35% (n = 7) concordance in the results noted for base and apical regions of the LV, whereas only 20% (n = 4) concordance was noted in mid ventricular region., Conclusion: Contractility (shortening) on LV angiogram is present in a majority of patients in the three LV regions, but contractility assessed by LS is impaired in most of them. The concordance in both quantitative assessment modalities was low. LV angiogram may not be an accurate imaging modality to assess contractility patterns in Takotsubo patients, and echocardiographic LS analysis should be taken as the preferred imaging modality., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Chronic kidney disease is commonly found in patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) and has marked impact in their prognosis. It has been shown however that TAVR may improve renal function by alleviating the hemodynamic barrier imposed by AS. Nevertheless, the predictors of and clinical consequences of renal function improvement are not well established. Our aim was to assess the predictors of improvement of renal function after TAVR., Methods: The present work is an analysis of the Brazilian Registry of TAVR, a national non-randomized prospective study with 22 Brazilian centers. Patients with baseline renal dysfunction (estimated glomerular filtration rate [eGFR] < 60mL/min/1.73m2) were stratified according to renal function after TAVR: increase >10% in eGFR were classified as TAVR induced renal function improvement (TIRFI); decrease > 10% in eGFR were classified as acute kidney injury (AKI) and stable renal function (neither criteria)., Results: A total of 819 consecutive patients with symptomatic severe AS were included. Of these, baseline renal dysfunction (estimated glomerular filtration rate [eGFR] < 60mL/min/1.73m2) was present in 577 (70%) patients. Considering variance in renal function between baseline and at discharge after TAVR procedure, TIRFI was seen in 197 (34.1%) patients, AKI in 203 (35.2%), and stable renal function in 177 (30.7%). The independent predictors of TIRFI were: absence of coronary artery disease (OR: 0.69; 95% CI 0.48-0.98; P = 0.039) and lower baseline eGFR (OR: 0.98; 95% CI 0.97-1.00; P = 0.039). There was no significant difference in 30-day and 1-year all-cause mortality between patients with stable renal function or TIRFI. Nonetheless, individuals that had AKI after TAVR presented higher mortality compared with TIRFI and stable renal function groups (29.3% vs. 15.4% vs. 9.5%, respectively; p < 0.001)., Conclusions: TIRFI was frequently found among baseline impaired renal function individuals but was not associated with improved 1-year outcomes., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Dr. de Brito Jr. and Dr. Mangione are proctors for Edwards Lifescience and Medtronic. Dr. Ribeiro is proctor and consultant for Edwards Lifescience, Medtronic and Boston Scientific. Dr. Caramori is proctor for Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Objective: To investigate the efficacy of sclerotherapy with monoethanolamine oleate (MEO) in a series of cases of benign oral vascular lesions (BOVL)., Material and Methods: Clinical records and images were retrieved (2015-2019), and data regarding age, gender, location, size, symptomatology, treatment and outcomes of patients were collected. All patients were diagnosed according to the classification of International Society for the Study of Vascular Anomalies and received the same treatment protocol (MEO 0.05 g/mL). The collected data were submitted to descriptive analysis and Pearson's chi-square test (p ≤ 0.05)., Results: Thirty-seven patients were treated. Most were female (70.3%) aged 9 to 88 years (median, 57.5 ± 17.4 years). Lower lip (54.1%) was the most affected site followed by buccal mucosa (16.2%). Thirty-two lesions were asymptomatic and 35.1% showed ≤ 0.5 cm in size. In 48.6% of the patients, only one application of MEO was performed. Complete regression occurred in 62.2% of cases, whereas 27% showed partial regression. One patient showed hypersensitivity during treatment. There was no significant difference between clinical outcome and age, anatomic site, size, and number of applications of MEO., Conclusions: Sclerotherapy with MEO is an acceptable and affordable treatment and can provide satisfactory results in BOVL, especially where other treatment options could compromise the esthetic aspects., Clinical Relevance: As it is a non-invasive therapy leading, in most cases, to adequate clinical results, safety, and tolerability, sclerotherapy with MEO can be considered an effective treatment for BOVL.

Background: The impact of simultaneous adverse climate conditions in the risk of myocardial infarction (MI) was not tested before. The aim of the present study was to investigate the impact of the combination of climate and air pollution features in the number of admissions and mortality due to acute myocardial infarction in 39 municipalities of São Paulo from 2012 to 2015., Methods: Data about MI admissions were obtained from the Brazilian public health system (DataSUS). Daily information on weather were accessed from the Meteorological Database for Teaching and Research. Additionally, daily information on air pollution were obtained from the Environmental Company of the State of São Paulo. A hierarchical cluster analysis was applied for temperature, rainfall patterns, relative air humidity, nitrogen dioxide, particulate matter 2.5 and particulate matter 10. MI admissions and in-hospital mortality were compared among the clusters., Results: Data analysis produced 3 clusters: High temperature variation-Low humidity-high pollution (n=218 days); Intermediate temperature variation/high humidity/intermediate pollution (n=751 days) and low temperature variation/intermediate humidity-low pollution (n=123 days). All environmental variables were significantly different among clusters. The combination of high temperature variation, dry weather and high pollution resulted in a significant 9% increase in hospital admissions for MI [30.5 (IQR 25.0-36.0)]; patients/day; P<0.01). The differences in weather and pollution did not have impact on in-hospital mortality (P=0.88)., Conclusion: The combination of atmospheric conditions with high temperature variation, lower temperature, dryer weather and increased inhalable particles was associated with a marked increase of hospital admissions due to MI., Competing Interests: Declaration of Competing Interests None of the authors have conflicts of interest to declare, (Copyright © 2020. Published by Elsevier Inc.)

Objectives: This article aimed to compare the outcomes after hybrid revascularization with conventional coronary artery bypass grafting (CABG) surgery., Background: The concept of hybrid coronary revascularization combines the advantages of CABG and percutaneous coronary intervention to improve the treatment of patients with complex multivessel disease., Methods: The Myocardial hybrid revascularization versus coronary artERy bypass GraftING for complex triple-vessel disease-MERGING study is a pilot randomized trial that allocated 60 patients with complex triple-vessel disease to treatment with hybrid revascularization or conventional CABG (2:1 ratio). The primary outcome was the composite of all-cause death, myocardial infarction, stroke, or unplanned repeat revascularization at 2 years., Results: Clinical and anatomical characteristics were similar between groups. After a mean follow-up of 802 ± 500 days, the primary endpoint rate was 19.3% in the hybrid arm and 5.9% in the CABG arm (p = NS). The incidence of unplanned revascularization increased over time in both groups, reaching 14.5 versus 5.9% in the hybrid and in the CABG groups, respectively (p = .4). Of note, in the hybrid group, there were no reinterventions driven by the occurrence of stent restenosis., Conclusions: Hybrid myocardial was feasible but associated with increasing rates of major adverse cardiovascular events during 2 years of clinical follow-up, while the control group treated with conventional surgery presented with low rates of complications during the same period. In conclusion, before more definitive data arise, hybrid revascularization should be applied with careful attention in practice, following a selective case-by-case indication., (© 2020 Wiley Periodicals, Inc.)

Introduction and Objectives: The Stents Coated With the Biodegradable Polymer on Their Abluminal Faces and Elution of Sirolimus Versus Biolimus Elution for the Treatment of de Novo Coronary Lesions - DESTINY Trial is a non-inferiority randomized study that compared the Inspiron™ sirolimus-eluting stent (SES) with the control Biomatrix™ Flex biolimus-eluting stent (BES). Previous reports in the first year showed similar outcomes for both stents, in clinical, angiographic, optical coherence tomography, and intravascular ultrasound assessments. The present analysis aims to compare the clinical performance of these two biodegradable polymer drug-eluting stents five years after the index procedure., Methods: A total of 170 patients (194 lesions) were randomized in a 2:1 ratio for treatment with SES or BES, respectively. The primary endpoint for the present study was the five-year rate of combined major adverse cardiac events, defined as cardiac death, myocardial infarction, or target lesion revascularization., Results: At five years, the primary endpoint occurred in 12.5% and 17.9% of the SES and BES groups, respectively (p=0.4). There was no definite or probable stent thrombosis among patients treated with the novel SES stent during the five years of follow-up, and no stent thrombosis after the first year in the BES group., Conclusions: The novel Inspiron™ stent had similar good clinical performance in long-term follow-up when compared head-to-head with the control latest-generation Biomatrix™ Flex biolimus-eluting stent., (Copyright © 2020 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Areas covered:In this review, we outline the underlying causes of acute coronary syndrome (ACS) as evaluated by optical coherence tomography (OCT). We report both the definitions of each mechanism and its frequency as reported in the literature to date. Finally, we present an algorithm based on the findings in the review that gives an outlined approach to perform intervention on ACS patients.Expert opinion:Although the most common and most accepted intervention in ACS cases is stent implantation, data suggest a stentless approach in cases of plaque erosion, which generally occurs in younger patients presenting with an acute coronary syndrome that have TIMI flow of 2/3 and either a small or large burden of thrombus and underlying stenosis of less than 50%.

Posterior fossa arteriovenous malformations (AVMs) can be a challenging disease, especially those large in size. AVMs can be treated with a combination of endovascular treatment and microsurgery. Here, the authors present the case of a 16-year-old female patient with progressive dizziness and episodic syncope. The workup of the patient showed a hemispheric cerebellar AVM, Spetzler-Martin grade IV. She underwent combined treatment (endovascular and microsurgery) with no complications and cure of the malformation. The video can be found here: https://youtu.be/rNw&#95;Kyd76Mg., Competing Interests: Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication., (© 2021 The Authors.)

Background: Acute kidney injury (AKI) has shown to adversely affect outcomes in patients undergoing transcutaneous aortic valve replacement (TAVR), and its correct risk estimation may interfere in procedural planning and strategies. The aim of the study was to test and compare 6 scores in predicting AKI after TAVR., Methods: We tested 6 scores (the contrast material limit score, volume-to-creatinine clearance ratio, ACEF, CR4EATME3AD3, Mehran model A, and Mehran model B) in a total of 559 consecutive patients included in the Brazilian TAVR registry., Results: All scores had a poor accuracy and calibration to predict the occurrence of AKI grade 1 or 2. All scores improved the accuracy of AKI risk prediction when stratified for AKI grade 2/3 and AKI grade 3 for all scores. The CR4EATME3AD3 was the best predictor of AKI stage 2/3 (AUC: 0.62; OR: 1.12; 95% CI 1.01-1.26; p = 0.04) and AKI stage 3 (AUC: 0.64; OR: 1.16; 95% CI 1.02-1.32; p = 0.02). Mehran models A and B were both good models for AKI stage 3 (AUC: 0.63; OR: 1.10; 95% CI 1.01-1.22; p = 0.05; and AUC: 0.62; OR: 1.10; 95% CI 1.00-1.21; p = 0.05, respectively)., Conclusions: None of the current models demonstrated validity in detecting AKI when its lower grades were evaluated. CR4EATME3AD3 was the best score in predicting moderate to severe AKI after TAVR. These findings suggest that contrast-induced AKI may not be the only factor related to kidney injury after TAVR., (© 2021 The Author(s) Published by S. Karger AG, Basel.)

Objectives: The aim of this study was to evaluate the hypothesis that prasugrel monotherapy following successful everolimus-eluting stent implantation is feasible and safe in patients with stable coronary artery disease (CAD)., Background: Recent studies have suggested that short dual-antiplatelet therapy strategies may provide an adequate balance between ischemic and bleeding risks. However, the complete omission of aspirin immediately after percutaneous coronary intervention (PCI) has not been tested so far., Methods: The study was a multicenter, single-arm, open-label trial with a stopping rule based on the occurrence of definite stent thrombosis (if >3, trial enrollment would be terminated). Patients undergoing successful everolimus-eluting stent implantation for stable CAD with SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores <23 were included. All participants were on standard dual-antiplatelet therapy at the time of index PCI. Aspirin was discontinued on the day of the index procedure but given prior to the procedure; prasugrel was administered in the catheterization laboratory immediately after the successful procedure, and aspirin-free prasugrel became the therapy regimen from that moment. Patients were treated solely with prasugrel for 3 months. The primary ischemic endpoint was the composite of cardiac death, spontaneous target vessel myocardial infarction, or definite stent thrombosis, and the primary bleeding endpoint was Bleeding Academic Research Consortium types 3 and 5 bleeding up to 3 months., Results: From February 22, 2018, to May 7, 2019, 201 patients were enrolled. All patients underwent PCI for stable CAD. Overall, 98.5% of patients were adherent to prasugrel at 3-month follow-up. The primary ischemic and bleeding endpoints occurred in 1 patient (0.5%). No stent thrombosis events occurred., Conclusions: Aspirin-free prasugrel monotherapy following successful everolimus-eluting stent implantation demonstrated feasibility and safety without any stent thrombosis in selected low-risk patients with stable CAD. These findings may help underpin larger randomized controlled studies to evaluate the aspirin-free strategy compared with traditional dual-antiplatelet therapy following PCI. (Acetyl Salicylic Elimination Trial: The ASET Pilot Study [ASET]; NCT03469856)., (Copyright © 2020. Published by Elsevier Inc.)

Objective: The present study evaluated the effect of endovascular administration of calcium chloride to the carotid artery of swines, to create a model of arterial calcification., Methods: Fifteen Large White pigs were used for the study. Via endovascular treatment, carotid arteries were exposed during 9 min to either calcium chloride (experimental artery) or saline (control artery) with the use of the TAPAS catheter. Intravascular ultrasound (IVUS) imaging was obtained at baseline, postprocedure and at 30 days. Optical coherence tomography (OCT) imaging was obtained in vitro after carotids were harvested. Longitudinally cut parallel arterial segments were placed in a system of delicate clamps and underwent uniaxial strain test. All arteries underwent histopathological examination., Results: Calcium chloride treated segments showed extensive circumferential parietal calcification evident on both IVUS and OCT. Reduction in minimal lumen area on IVUS was evident in experimental arteries both at 24 hr and 30 days postprocedure. Histopathologic assessment (Von Kossa stain) confirmed medial calcification with mild intimal thickening. Biomechanical testing showed treated segments to have smaller breaking strength and less elastic deformation than controls., Conclusion: We developed a nonexpensive, reproducible model of early carotid medial calcification in pigs. Our model has the potential to help the development of research to unravel mechanisms underlying arterial calcification, the use of current or new devices to treat calcified lesions as well as to serve as an option for training interventionalists on the use of such devices., (© 2020 Wiley Periodicals LLC.)

The association of immobility and camouflage is widespread as a defensive mechanism in prey from varied taxa. However, many experiments assessing the reaction of prey to predator cues are conducted under artificial laboratory conditions. In a previous experiment we observed the tadpoles of Ololygon machadoi (Hylidae) to respond to predator visual and/or chemical cues by choosing backgrounds that improve their disruptive properties, but detected no associated reduction of movement. Here we experimentally demonstrate this response in the species' natural habitat, on backgrounds where the tadpoles are likely to achieve their best camouflage. We also tested whether previous experiences could influence both background choice and immobility in O. machadoi tadpoles. These novel experimental results suggest that a defensive behavior-i.e., reduction of movement-in these tadpoles is more strongly expressed under the natural conditions where they evolved, compared to laboratory conditions where prey and predator were brought into closer contact. Besides, previous experiences are likely to play an important role in expressed defensive responses.