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Introduction and objectives: Patients with left main coronary artery (LMCA) stenosis have been excluded from the trials that support the non-inferiority of the instantaneous wave-free ratio (iFR) compared to the fractional flow reserve (FFR) in the decision-making process of coronary revascularization. This study proposes to prospectively assess the concordance between the two indices in LMCA lesions and to validate the iFR cut-off value of 0.89 for clinical use. Methods: National, prospective, and observational multicenter registry of 300 consecutive patients with intermediate lesions in the LMCA (angiographic stenosis, 25% to 60%. A pressure gudiewire study and determination of the RFF and the iFR will be performed: in the event of a negative concordant result (FFR > 0.80/iFR > 0.89), no treatment will be performed; in case of a positive concordant result (FFR ≤ 0.80/iFR ≤ 0.89), revascularization will be performed; In the event of a discordant result (FFR> 0.80/iFR ≤ 0.89 or FFR ≤ 0.80/iFR> 0.89), an intravascular echocardiography will be performed and revascularization will be delayed if the minimum lumen area is > 6 mm2. The primary clinical endpoint will be a composite of cardiovascular death, LMCA lesion-related non-fatal infarction or need for revascularization of the LMCA lesion at 12 months. Conclusions: Confirm that an iFR-guided decision-making process in patients with intermediate LMCA stenosis is clinically safe and would have a significant clinical impact. Also, justify its systematic use when prescribing treatment in these potentially high-risk patients. Registered at ClinicalTrials.gov ( Identifier: NCT03767621).

Acute mitral regurgitation (MR) may develop in the setting of an acute myocardial infarction (AMI) because of papillary muscle dysfunction or rupture. Severe acute MR in this scenario is a life-threatening complication associated with hemodynamic instability and pulmonary edema, and has been linked to a worse prognosis even after reperfusion. Patients treated solely with medical therapy have the highest mortality rates. Surgery has been the only treatment strategy until recently, but the results of the technique are hindered by high rates of morbidity and mortality. Therefore, the development of less invasive interventions for correcting MR would be ideal. We aimed to review the current role of transcatheter interventions in this clinical setting.

BackgroundAortic valve replacement is the gold standard treatment for severe symptomatic aortic stenosis, but thrombosis of bioprosthetic valves (PVT) remains a concern.ObjectiveTo analyze the factors involved in the contact pathway during aortic valve replacement and to assess their impact on the development of thromboembolic complications.MethodsThe study was conducted in 232 consecutive patients who underwent: transcatheter aortic valve replacement (TAVR, N = 155), and surgical valve replacement (SAVR, N = 77) (MUVITAVI project). Demographic and clinical data, outcomes including a combined end point (CEP) of thrombotic events, and imaging controls were recruited. Samples were collected 24 h before and 48 h after valve replacement. FXII, FXI and (pre)kallikrein were evaluated by Western Blot and specific ELISA with nanobodies.ResultsThe CEP of thrombotic events was reached by 19 patients: 13 patients presented systemic embolic events and 6 patients subclinical PVT. Valve replacement did not cause FXII activation or generation of kallikrein. There was a significant reduction of FXI levels associated with the procedure, which was statistically more pronounced in SAVR than in TAVR. Cases with reductions of FXI below 80% of basal values had a lower incidence of embolic events during the procedure than patients in whom FXI increased above 150%: 2.7 vs. 16.7%; p: 0.04.ConclusionTAVR or SAVR did not significantly activate the contact pathway. A significant reduction of FXI, was observed, particularly in SAVR, associated with lower incidence of thrombotic events. These results encourage evaluating the usefulness and safety of FXI-directed antithrombotic treatments in these patients.

RESUMEN Introducción y objetivos: Los pacientes con estenosis en el tronco coronario izquierdo (TCI) han sido excluidos de los ensayos que apoyan la no inferioridad del cociente de presiones en el índice diastólico instantáneo sin ondas (iFR) respecto a la reserva fraccional de flujo (RFF) en la toma de decisiones sobre revascularización coronaria. El presente estudio propone valorar de manera prospectiva la concordancia entre los dos índices en lesiones del TCI y validar el valor de corte del iFR de 0,89 para su uso clínico. Métodos: Registro multicéntrico nacional, prospectivo, observacional, con la inclusión de 300 pacientes consecutivos con lesiones intermedias (estenosis angiográfica 25-60%) en el TCI. Se realizará un estudio con guía de presión y determinación de RFF e iFR. En caso de resultado concordante negativo (RFF > 0,80 / iFR > 0,89), no se realizará tratamiento; en caso de resultado concordante positivo (RFF ≤ 0,80 / iFR ≤ 0,89), se realizará revascularización; en caso de resultado discordante (RFF > 0,80 / iFR ≤ 0,89 o RFF ≤ 0,80 / iFR > 0,89), se realizará estudio con ecocardiografía intravascular y se considerará diferir la revascularización si el área luminal mínima es > 6 mm2. El criterio de valoración clínico primario será la incidencia del combinado de muerte cardiovascular, infarto no mortal relacionado con la lesión del TCI o necesidad de revascularización de la lesión del TCI a los 12 meses. Conclusiones: La demostración de la seguridad clínica en la toma de decisiones del iFR en pacientes con lesiones intermedias en el TCI tendría un impacto clínico importante y justificaría su uso sistemático para la decisión del tratamiento en estos pacientes de potencial alto riesgo. Registrado en ClinicalTrials.gov (identificador: NCT03767621).

Introduction and objectives There is little evidence on rates of stent thrombosis (ST) in patients receiving dual antiplatelet therapy (DAPT) with ticagrelor or prasugrel . The aim of this study was to analyze the incidence and predictors of ST after an acute coronary syndrome among patients receiving DAPT with ticagrelor vs prasugrel. Methods We used data from the RENAMI registry (REgistry of New Antiplatelet therapy in patients with acute Myocardial Infarction), analyzing a total of 4123 acute coronary syndrome patients discharged with DAPT with ticagrelor or prasugrel in 11 centers in 6 European countries. The endpoint was definite ST within the first year. A competitive risk analysis was carried out using a Fine and Gray regression model, with death being the competitive event. Results A total of 2604 patients received DAPT with ticagrelor and 1519 with prasugrel; ST occurred in 41 patients (1.10%), with a similar cumulative incidence between ticagrelor (1.21%) and prasugrel (0.90%). The independent predictors of ST were age (sHR, 1.03; 95% C I, 1.01-1.06), ST segment elevation (sHR, 2.24; 95%CI, 1.22-4.14), previous myocardial infarction (sHR, 2.56; 95%CI, 1.19-5.49), and serum creatinine (sHR, 1.29; 95%CI, 1.08-1.54). Conclusions Stent thrombosis is infrequent in patients receiving DAPT with ticagrelor or prasugrel. The variables associated with an increased risk of ST were advanced age, ST segment elevation, previous myocardial infarction, and serum creatinine.

Resumen Introduccion y objetivos Hay muy poca evidencia sobre las tasas de trombosis del stent (TS) en pacientes que reciben tratamiento antiagregante plaquetario doble (TAPD) con ticagrelor o prasugrel. El objetivo de este estudio es analizar la incidencia y predictores de la TS tras un sindrome coronario agudo en pacientes que reciben TAPD con ticagrelor frente a prasugrel. Metodos Se utilizaron datos del registro RENAMI (REgistry of New Antiplatelet therapy in patients with acute Myocardial Infarction), y se analizo en total a 4.123 pacientes con sindrome coronario agudo dados de alta con TAPD con ticagrelor o prasugrel en 11 centros de 6 paises europeos. Se considero como evento la TS confirmada en el primer ano. Se realizo un analisis de riesgos competitivos mediante un modelo de regresion de Fine y Gray, siendo la muerte el evento competitivo. Resultados Recibieron TAPD con ticagrelor 2.604 pacientes y con prasugrel, 1.519; 41 pacientes (1,10%) presentaron TS, con incidencias acumuladas similares entre ticagrelor (1,21%) y prasugrel (0,90%). Los predictores independientes de la TS fueron: la edad (sHR = 1,03; IC95%, 1,01-1,06), la elevacion del segmento ST (sHR = 2,24; IC95%, 1,22-4,14), el antecedente de infarto de miocardio (sHR = 2,56; IC95%, 1,19-5,49) y la creatinina serica (sHR = 1,29; IC95%, 1,08-1,54). Conclusiones La TS es infrecuente en pacientes que reciben TAPD con ticagrelor y prasugrel. La edad avanzada, la elevacion del segmento ST, el antecedente de infarto y la creatinina serica son las variables que se asocian con mayor riesgo de TS.

The goal of this study was to determine the association between the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) and follow-up heart failure (HF) according to left ventricular ejection fraction (LVEF) in patients with acute myocardial infarction (AMI). This cohort study used a retrospective registry of 8169 consecutive patients discharged with a diagnosis of AMI from two university hospitals in Spain between 2010 and 2016. We used a multivariable competing risk analysis, survival-time inverse probability weighting (IPW) propensity score adjusting, and propensity score matching (PSM) to investigate the association between ACEI/ARB treatment and follow-up HF. During the follow-up (3.3 ± 2.2 years), 1296 patients were admitted for HF (5.2 per 100 person-years). ACEI/ARB use was not associated with fewer follow-up HF admissions in patients with LVEF > 40% (univariate analysis: sub-hazard ratio [sHR] 1.10; 95% confidence interval [CI] 0.95–1.27; p = 0.197; IPW adjusting analysis: sHR 1.11; 95% CI 0.95–1.29; p = 0.192; PSM analysis: sHR 1.12; 95% CI 0.92–1.36; p = 0.248). However, ACEI/ARB use was associated with a significant reduction in HF admission rates in patients with LVEF ≤ 40% (univariate analysis: HR 0.70; 95% CI 0.56–0.88; p = 0.003; IPW adjusting analysis: HR 0.64; 95% CI 0.50–0.83; p = 0.001; PSM analysis: HR 0.65; 95% CI 0.46–0.92; p = 0.014). Among hospitalized survivors of AMI, the use of ACEIs/ARBs was associated with a lower risk of follow-up HF in patients with LVEF ≤ 40% but not in those with LVEF > 40%. Further prospective studies are needed to confirm our results.

Resumen Introduccion y objetivos La puntuacion PARIS permite una estratificacion combinada de los riesgos isquemico y hemorragico de los pacientes con cardiopatia isquemica tratados con stent coronario y tratamiento antiagregante plaquetario doble (TAPD). Se desconoce su utilidad en pacientes con sindrome coronario agudo (SCA) tratados con ticagrelor o prasugrel. Se investiga este aspecto en un registro internacional. Metodos Estudio retrospectivo multicentrico con participacion voluntaria de 11 centros de 6 paises europeos. Se estudio a 4.310 pacientes con SCA dados de alta en TAPD con ticagrelor o prasugrel. Se definio evento isquemico como trombosis de stent o infarto de miocardio espontaneo, y evento hemorragico segun BARC (Bleeding Academic Research Consortium) tipo 3 o 5. Se calculo la discriminacion y la calibracion para ambas vertientes de la puntuacion PARIS (PARISisquemico y PARIShemorragico). El beneficio neto isquemico-hemorragico se obtuvo mediante la diferencia entre las probabilidades predichas de eventos isquemicos y hemorragicos. Resultados Durante 17,2 ± 8,3 meses, hubo 80 eventos isquemicos (el 1,9% anual) y 66 eventos hemorragicos (el 1,6% anual). PARISisquemico y PARIShemorragico se asociaron con el riesgo de eventos isquemicos (sHR = 1,27; IC95%, 1,16-1,39) y hemorragicos (sHR = 1,14; IC95%, 1,01-1,30) respectivamente. La discriminacion de eventos isquemicos fue discreta (indice C = 0,64) y la de eventos hemorragicos, pobre (indice C = 0,56), con buena calibracion para ambos. El beneficio neto isquemico-hemorragico resulto negativo (mas eventos hemorragicos) en pacientes con alto riesgo hemorragico y positivo (mas eventos isquemicos) en pacientes con alto riesgo isquemico. Conclusiones En pacientes con SCA tratados con TAPD con ticagrelor o prasugrel, la escala PARIS ayuda a establecer un equilibrio apropiado del riesgo isquemico-hemorragico.

The aim of our study is to assess the impact of anemia, chronic kidney disease, and diabetes mellitus on platelet reactivity (PR) in patients with severe aortic stenosis, both at baseline and after transcatheter aortic valve implantation (TAVI). This study is a prespecified subanalysis of the REAC-TAVI prospective, multicenter trial that included patients pretreated with aspirin + clopidogrel before TAVI. PR was measured at baseline and at 5 different time points after TAVI with the VerifyNow assay (Accriva Diagnostics, San Diego, CA), over a 3-month follow-up period. Patients with high PR (HPR) at baseline, before TAVI (n = 48) were randomized to aspirin + clopidogrel or aspirin + ticagrelor for 3 months, whereas those with normal PR (NPR) (n = 20) were continued on aspirin + clopidogrel. A "raiser response" in PR was defined as an increase in PR units >20% of baseline after TAVI. Patients with HPR before TAVI presented concomitant anemia and chronic kidney disease more frequently than their counterparts with NPR. Anemia and higher body mass index were independently associated with HPR to clopidogrel at baseline. Moreover, anemic patients with baseline HPR who were continued on clopidogrel presented higher PR after TAVI than patients with HPR switched to ticagrelor. All patients with baseline NPR presented a "raiser response" after TAVI, which was nonexistent among patients with HPR managed with ticagrelor. In summary, anemia seems as a relevant factor associated with baseline HPR and higher PR after TAVI in patients with baseline HPR randomized to clopidogrel, whereas ticagrelor proved more effective than clopidogrel at attaining sustained reductions in PR during follow-up, regardless of baseline comorbidities.

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.

Aims This study sought to investigate the prognostic effect of a protocol with optimisation targets for intravascular ultrasound (IVUS)-guided left main (LM) revascularisation. Methods and results A protocol was prospectively applied for IVUS-guided LM revascularisation (IVUS-PRO group) including predefined optimisation targets. Using propensity score matching, we selected as control groups patients with angiography-guided PCI (ANGIO group) and IVUS-guided PCI (IVUS group) from a large multicentre registry. The primary endpoint was a composite of cardiac death, LM-related infarction and LM revascularisation at 12 months. In each group, 124 patients with comparable characteristics were included. The incidence of the primary outcome was significantly higher in the ANGIO group compared to the IVUS-PRO group (12.9% vs 4.8%, HR 0.35, 95% CI: 0.15 to 0.82, p=0.02), but not with respect to the IVUS group (12.9% vs 8%, HR 0.51, 95% CI: 0.20 to 1.22, p=0.1), driven by a lower rate of LM revascularisation (8% in the ANGIO group, 6.4% in the IVUS group and 3.2% in the IVUS-PRO group). IVUS-PRO resulted in being an independent risk predictor (HR 0.45, 95% CI: 0.15 to 0.98; p=0.041). Conclusions IVUS guidance of LM stenting provides prognostic benefit with respect to the use of angiography alone, particularly when following a protocol with these predefined optimisation criteria.

Background Coronary Aneurysms are a focal dilatation of an artery segment >1.5-fold the normal size of adjacent segments. Although some series have suggested a prevalence of 0.3–12%, data are lacking. In addition, they are not mentioned in practice guidelines. Our aim was investigate its prevalence, management and long-term outcomes. Methods and results The coronary artery aneurysm registry (CAAR) involved 32 hospitals across 9 countries in America and Europe. We reviewed 436,467 consecutive angiograms performed over the period 2004–2016. Finally, 1565 patients were recruited. Aneurysm global prevalence was 0.35%. Most patients were male (78.5%) with a mean age of 65 years and frequent cardiovascular risk factors. The main indication for angiogram was an acute coronary syndrome, 966 cases. The number of aneurisms was ≤2 per patient in 95.8% of the cases, mostly saccular, most frequently found in the left anterior descending and with numbers proportional with coronary stenosis. Aortopathies were related with more aneurysms too. Most patients received any revascularization procedure (69%), commonly percutaneous (53%). After a median follow-up of 37.2 months, 485 suffered a combined event (MACE) and 240 died. Without major differences comparing CABG vs PCI, MACE and death were more frequent in patients who received bare metal stents. Conclusions Coronary artery aneurysms are not uncommon. Usually, they are associated with coronary stenosis and high cardiovascular risk. Antiplatelet therapy seems reasonable and a percutaneous approach is safe and effective.

Introduction: Beta-blocker doses that have been shown to be effective in randomized clinical trials are not commonly used in daily clinical practice. The aim of this study was to analyze whether there is a prognostic benefit of high rather than low doses of beta-blockers after an acute coronary syndrome (ACS). Methods: In this retrospective cohort study, 2092 ACS patients discharged from hospital between June 2013 and January 2016 were classified according to the beta-blocker dose prescribed: high dose (≥50% of the target dose tested in clinical trials) and low dose (

Background The role of frailty as a prognostic factor in non-selected patients with symptomatic severe aortic stenosis (SAS) is still uncertain. This study aims to examine the association between the frailty syndrome and mortality among very old patients with symptomatic SAS, and to assess whether the association varies with the type of SAS treatment. Methods and results Prospective study of 606 patients aged ≥75years with symptomatic SAS, recruited from February 2010 to January 2015, who were followed up through June 2015. At baseline, frailty was defined as having at least three of the following five criteria: muscle weakness, slow gait speed, low physical activity, exhaustion, and unintentional weight loss. Statistical analyses were performed with multivariate Cox regression. At baseline, 49.3% patients were frail. During a mean follow-up of 98weeks, 35.3% of patients died. The hazard ratio (95% confidence interval) of mortality among frail versus non-frail patients was 1.83 (1.33–2.51). The corresponding results were 1.58 (1.09–2.28) among patients under medical treatment, 3.06 (1.25–7.50) in those with transcatheter aortic valve replacement, and 1.97 (0.83–4.67) in those with surgical aortic valve replacement, p for interaction=0.21. When the frailty criteria were considered separately, mortality was also higher among patients with slow gait speed [1.52 (1.05–2.19)] or low physical activity [1.35 (1.00–1.85)]. Conclusions Frailty is associated with increased mortality among patients with symptomatic SAS, and this association does not vary with the type of SAS treatment. Future studies evaluating the benefits of different treatments in SAS patients should account for baseline frailty.

Introduction and objectives The PARIS score allows combined stratification of ischemic and hemorrhagic risk in patients with ischemic heart disease treated with coronary stenting and dual antiplatelet therapy (DAPT). Its usefulness in patients with acute coronary syndrome (ACS) treated with ticagrelor or prasugrel is unknown. We investigated this issue in an international registry. Methods Retrospective multicenter study with voluntary participation of 11 centers in 6 European countries. We studied 4310 patients with ACS discharged with DAPT with ticagrelor or prasugrel. Ischemic events were defined as stent thrombosis or spontaneous myocardial infarction, and hemorrhagic events as BARC (Bleeding Academic Research Consortium) type 3 or 5 bleeding. Discrimination and calibration were calculated for both PARIS scores (PARIS ischemic and PARIShemorrhagic). The ischemic-hemorrhagic net benefit was obtained by the difference between the predicted probabilities of ischemic and bleeding events. Results During a period of 17.2 ± 8.3 months, there were 80 ischemic events (1.9% per year) and 66 bleeding events (1.6% per year). PARISischemic and PARIShemorrhagic scores were associated with a risk of ischemic events (sHR, 1.27; 95%CI, 1.16-1.39) and bleeding events (sHR, 1.14; 95%CI, 1.01-1.30), respectively. The discrimination for ischemic events was modest (C index = 0.64) and was suboptimal for hemorrhagic events (C index = 0.56), whereas calibration was acceptable for both. The ischemic-hemorrhagic net benefit was negative (more hemorrhagic events) in patients at high hemorrhagic risk, and was positive (more ischemic events) in patients at high ischemic risk. Conclusions In patients with ACS treated with DAPT with ticagrelor or prasugrel, the PARIS model helps to properly evaluate the ischemic-hemorrhagic risk.

A 73-year-old man was admitted for non-ST segment elevation acute myocardial infarction. Coronary angiography suggested intrastent thrombosis as the etiology, but optical coherence tomography revealed a non-expanded stent, which was successfuly crushed and covered with a new stent.

Rationale, aims and objectives Transcatheter aortic valve implantation constitutes an example of a technology introduced into the Galician Health Care System basket and subjected to a post-introduction observational study after coverage. This paper aims to describe the process and results of this experience, illustrating the main challenges and opportunities in using these studies for supporting decision making. Methods The study protocol was developed by a multidisciplinary team consisting of experts from the Galician HTA Agency (avalia-t), interventional cardiologists and cardiac surgeons. Together they agreed on the information that was relevant and feasible for collection, and planned the study design, data collection and analysis of results. Results During the 1-year recruitment period, 94 patients underwent percutaneous aortic valve replacement in the three authorized centres. Implantation rate and prosthesis models differed substantially across the centres. Overall, procedural success rate was 96.8% and hospital mortality was 7.4%. Complications during post-surgical admission were recorded in 40.4% of patients. Moderate residual aortic regurgitation was observed in 10% of patients, and the procedure was associated with a stroke rate of 3.3% at 30 days and 5.3% at 1 year. Conclusions Post-introduction observation has made it feasible to determine the use of this procedure within the SERGAS context and has enabled the assessment of performance in real-life conditions. The proposed strategic actions and interventions have been drawn up based upon the collective judgement of a group of experienced professionals, and have served to establish recommendations on further research that would be required to optimize health benefits.

Objectives This study sought to investigate the clinical impact of the use of intravascular ultrasound (IVUS) during revascularization of patients with left main coronary artery (LM) disease with drug-eluting stents (DES). Background Whether the use of IVUS during the procedure adds a clinical benefit remains unclear. There is only 1 previous observational study, with relevant limitations, supporting the value of this strategy. Methods We performed a patient-level pooled analysis of 4 registries of patients with LM disease treated with DES in Spain. A propensity score-matching method was used to obtain matched pairs of patients with and without IVUS guidance. Results A total of 1,670 patients were included, and 505 patients (30.2%) underwent DES implantation under IVUS guidance (IVUS group). By means of the matching method, 505 patients without the use of IVUS during revascularization were selected (no-IVUS group). Survival free of cardiac death, myocardial infarction, and target lesion revascularization at 3 years was 88.7% in the IVUS group and 83.6% in the no-IVUS group (p = 0.04) for the overall population, and 90% and 80.7%, respectively (p = 0.03), for the subgroups with distal LM lesions. The incidence of definite and probable thrombosis was significantly lower in the IVUS group (0.6% vs. 2.2%; p = 0.04). Finally, IVUS-guided revascularization was identified as an independent predictor for major adverse events in the overall population (hazard ratio: 0.70, 95% confidence interval: 0.52 to 0.99; p = 0.04) and in the subgroup with distal lesions (hazard ratio: 0.54, 95% confidence interval: 0.34 to 0.90; p = 0.02). Conclusions The results of this pooled analysis show an association of IVUS guidance during percutaneous coronary intervention with better outcomes in patients with LM disease undergoing revascularization with DES.

Pulmonary vein stenosis (PVS) is rare condition characterized by a challenging diagnosis and unfavorable prognosis at advance stages. At present, injury from radiofrequency ablation for atrial fibrillation has become the main cause of the disease. PVS is characterized by a progressive lumen size reduction of one or more pulmonary veins that, when hemodynamically significant, may raise lobar capillary pressure leading to signs and symptoms such as shortness of breath, cough, and hemoptysis. Image techniques (transesophageal echocardiography, computed tomography, magnetic resonance and perfusion imaging) are essential to reach a final diagnosis and decide an appropriate therapy. In this regard, series from referral centers have shown that surgical and transcatheter interventions may improve prognosis. The purpose of this article is to review the etiology, assessment and management of PVS.

Resumen Introduccion y objetivos En el sindrome coronario agudo sin elevacion del segmento ST de riesgo intermedio o alto, las guias de actuacion clinica recomiendan la realizacion de coronariografia con intencion de revascularizar. Sin embargo, para los pacientes muy ancianos la evidencia que avala esta recomendacion es muy escasa. Metodos Analizamos retrospectivamente a todos los pacientes con sindrome coronario agudo sin elevacion del segmento ST y edad ≥ 85 anos ingresados en un unico centro entre 2004 y 2009. Mediante propensity score, emparejamos 1:1 a los pacientes con abordaje intervencionista con aquellos en que se decidio manejo conservador. Se comparo la supervivencia y la supervivencia libre de eventos isquemicos. Resultados Se incluyo a 228 pacientes consecutivos (media de edad 88 [intervalo, 85-101] anos). Se decidio abordaje intervencionista en 100 pacientes (128 con manejo conservador). Los enviados a abordaje intervencionista eran mas jovenes y mas frecuentemente varones y tenian menos comorbilidad, menos demencia y menos frecuentemente elevacion de troponina. Se emparejo a 63 pacientes del grupo de abordaje intervencionista con 63 del grupo de manejo conservador mediante propensity score. En el seguimiento a 3 anos de los pacientes emparejados, el grupo de abordaje intervencionista presento mayor supervivencia (log rank test = 4,24; p = 0,039) y mayor supervivencia libre de eventos isquemicos (log rank test = 8,63; p = 0,003). En la poblacion total, ajustando por quintiles de propensity score, el abordaje intervencionista se relaciono con mayor supervivencia (hazard ratio = 0,52; intervalo de confianza del 95%, 0,32-0,85) y mayor supervivencia libre de eventos isquemicos (hazard ratio = 0,48; intervalo de confianza del 95%, 0,32-0,74). Conclusiones Casi todos los pacientes muy ancianos ingresados por sindrome coronario agudo sin elevacion del segmento ST estan en riesgo intermedio-alto. En estos pacientes, el abordaje intervencionista se relaciona con mayor supervivencia y mayor supervivencia libre de eventos isquemicos.

Acute Coronary Syndrome Coronary artery disease Coronary angiography Interventional cardiology The Elderly Geriatric medicine Prognosis Survival A B S T R A C T Introduction and objectives: In moderate or high risk non-ST segment elevation acute coronary syndrome, clinical practice guidelines recommend a coronary angiography with intent to revascularize. However, evidence to support this recommendation in very elderly patients is poor. Methods: All patients over 85 years old admitted to our hospital between 2004 and 2009 with a diagnosis of non-ST segment elevation acute coronary syndrome were retrospectively included. Using a propensity score, patients undergoing the interventional approach and those undergoing conservative management were matched and compared for survival and survival without ischemic events. Results: We included 228 consecutive patients with a mean age of 88 years (range: 85 to 101). Those in the interventional approach group (n = 100) were younger, with a higher proportion of males and less comorbidity, less cognitive impairment and lower troponin I levels compared with patients in the conservative management group (n = 128). We matched 63 patients from the interventional approach group and 63 from the conservative management group using propensity score. In the matched patients, the interventional approach group exhibited better survival (log rank 4.24; P = .039) and better survival free of ischemic events (log rank 8.63; P = .003) at the 3-year follow-up. In the whole population, adjusted for propensity score quintiles, the interventional approach group had lower mortality (hazard ratio 0.52; 95% confidence interval: 0.32-0.85) and a better survival free of ischemic events (hazard ratio 0.48; 95% confidence interval: 0.32-0.74). Conclusions: Nearly all the very elderly patients admitted with non-ST segment elevation acute coronary syndrome were of moderate or high risk. In these patients, the interventional approach was associated with overall better survival and better survival free of ischemic events.

Aims The aim of the study was to validate a novel formula for aortic area, based on the principle of continuity equation (CE), that substitutes Doppler-derived stroke volume (SV) by SV directly measured with real-time three-dimensional (RT3D) echo and semi-automated border detection. RT3D has proved outstanding accuracy for left ventricular volume calculation. So far, however, neither this potential has been applied to haemodynamic assessment, nor RT3D has succeeded in the evaluation of aortic valve disease. Methods and results Aortic area was measured in 41 patients with aortic stenosis using Gorlin's equation, Hakki's formula, Doppler CE, two-dimensional Simpson's volumetric method, and by the novel RT3D method. RT3D has the best linear association and absolute agreement with Gorlin of all non-invasive methods r = 0.902, intraclass correlation coefficient (ICC) = 0.846, better than CE ( r = 0.646, ICC = 0.626) and two-dimensional volumetric method ( r = 0.627, ICC = 0.378). Linear and Passing–Bablok regression show that RT3D fits better to Gorlin ( r 2 = 0.814) than CE ( r 2 = 0.417) and two-dimensional method ( r 2 = 0.393). Its accuracy is comparable to Hakki's formula, routinely employed in catheter laboratories. Inter- and intraobserver agreements (ICC) were, respectively, 0.732 and 0.985, better than CE (0.662, 0.857). RT3D also grades most efficiently the severity of aortic stenosis as mild, moderate, or severe (weighted kappa = 0.932). RT3D underestimates aortic area (95% CI 0.084–0.193). ROC curves, however, show that the optimal cutoff point to consider aortic stenosis severity remains close to 1 cm2 (1.06 cm2). Conclusions RT3D is more accurate than CE and than two-dimensional volumetric methods to calculate area and to grade the severity of aortic stenosis. Area obtained by three-dimensional echo is slightly underestimated, but its range is clinically negligible.