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BackgroundImpact of commissural alignment (CA) strategies with self-expandable supra-annular transcatheter aortic valves (TAVR) has not been investigated yet.MethodsMulticentric ambispective study including patients who underwent self-expandable TAVR in 7 centers with the Evolut Pro/Pro+ (EP)(Medtronic, USA) and Acurate neo2 (AN2)(Boston Scientific, USA). Comparison of those with CA attempt vs. those with no CA attempt was performed. The degree of commissural misalignment (CMA) was assessed by computed tomography/angiography and 1-year transvalvular gradients/regurgitation evaluated by echocardiography. A matched comparison according to annular dimensions/eccentricity, prosthesis size/type, and baseline left ventricular function and gradients was performed.ResultsA total of 557 patients, mean age 80.7±6.6 years, 61.4% men, and STS score of 4.3±3.1% were analyzed. A CA technique was attempted in 215 patients (38.6%), including 113 patients with AN2 and 102 patients with EP. None/mild CMA was found in 158 (73.5% vs. 43.6% if no CA attempted, pConclusionsThe use of CA strategies significantly reduced the rate of CMA for the self-expandable TAVR devices ACN2 and EP which was associated to lower transvalvular gradients and intra-prosthetic regurgitation progression at 1-year although no criteria of structural deterioration were met at this follow up.Clinicaltrials.org:NCT05097183CONDENSED ABSTRACTCommissural alignment (CA) strategies with Evolut Pro and Acurate neo2 TAVR devices were similarly successful in ¾ of the patients, representing a significant increase compared to traditional implantation. Patients with moderate/severe commissural misalignment (CMA) had a significantly greater progression of both peak and mean gradients and higher rate of new central aortic regurgitation at 1-year, but not a greater proportion of patients with mean gradient above 10mmHg. Hence, even at only 1-year of follow up and despite the lack of formal structural deterioration criteria, some hints suggest a more rapid deterioration if moderate/severe CMA is present after supra-annular TAVR.

Evidence regarding redo percutaneous interventions for recurrent mitral regurgitation is scarce. We ought to evaluate procedural and clinical outcomes of repeated edge-to-edge transcatheter mitral valve repair (TMVR) interventions.This multicenter study collected individual data from eight high-volume TMVR Centers in Spain. Between 2012 and 2020, all patients undergoing a second edge-to-edge TMVR intervention (Redo) were included in the study.Among a total of 1028 procedures, 31 patients (3%) with residual MR ≥ 3 at follow-up underwent a second procedure (Redo). Redo intervention was mainly conducted between the first and second year after the first procedure. The most common cause of MR progression was partial detachment (46.7%) followed by LV remodeling (35.5%). Procedural success was achieved in 87% of cases. After a mean follow-up of 1.75 ± 1.54 years, all-cause and cardiovascular mortality were 48.1% and 25%, respectively. Nearly half of the patients (48.1%) required at least one hospital admission for CHF within the follow-up period. However, most of the patients presented symptomatic improvement as depicted by an NYHA class ≤2. Elective mitral surgery was conducted in only one patient at follow-up due to insufficient MR reduction.According to our findings, redo edge-to-edge TMVR interventions were feasible and safe with a high procedural success rate. Clinical and echocardiographic follow-up showed however modest long-term results in this specific setting.

Resumen Introduccion y objetivos La reparacion de la valvula mitral transcateter (RVMT) con el sistema MitraClip es un tratamiento para los pacientes con insuficiencia mitral (IM) grave de alto riesgo quirurgico. El objetivo principal fue analizar los resultados del RVMT en pacientes con IM grave, segun la etiologia. Metodos Estudio observacional, prospectivo y multicentrico con inclusion de pacientes consecutivos. El objetivo primario fue el combinado de mortalidad por todas las causas y reingresos hospitalarios por insuficiencia cardiaca al ano. Se compararon las caracteristicas clinicas y del procedimiento y los eventos para cada grupo de IM. Se realizo un analisis multivariable para determinar las variables asociadas con el objetivo primario. Resultados Se incluyo a 558 pacientes; 364 (65,2%) tenian etiologia funcional; 111 (19,9%), degenerativa, y 83 (14,9%), mixta. La media de edad fue 72,8 ± 11,1 anos y eran varones el 70,3%. Respecto al objetivo primario, hubo 95 (17%) eventos en toda la serie. No hubo diferencias significativas entre los 3 grupos en el numero de eventos del objetivo primario: 11 (11,3%) en la IM degenerativa, 71 (21,3%) en la funcional y 13 (18,1%) en la mixta (p = 0,101). Los predictores independientes fueron la clase funcional (p = 0,029), la revascularizacion quirurgica previa (p = 0,031), el EuroSCORE II (p = 0,003), la diabetes mellitus (p = 0,037) y la fraccion de eyeccion del ventriculo izquierdo (p = 0,015). Conclusiones Este trabajo confirma con datos de la practica clinica la seguridad y la eficacia de la RVMT independientemente de la etiologia de la IM y se documentan los principales factores asociados con el pronostico durante el primer ano de seguimiento.

Background Several studies have demonstrated the benefits of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis, but the presence of persistent fibrosis and myocardial hypertrophy has been related to worse prognosis. Objectives The aim of this study was to explore the potential benefits of renin-angiotensin system (RAS) inhibitors on left ventricular remodeling and major clinical outcomes following successful transcatheter aortic valve replacement (TAVR). Methods Patients from 10 institutions with severe aortic stenosis who underwent TAVR between August 2007 and August 2017 were included. All baseline data were prospectively recorded, and pre-specified follow-up was performed. Doses and types of RAS inhibitors at discharge were recorded, and matched comparison according to their prescription at discharge was performed. Results A total of 2,785 patients were included. Patients treated with RAS inhibitors (n = 1,622) presented similar surgical risk scores but a higher rate of all cardiovascular risk factors, coronary disease, and myocardial infarction. After adjustment for these baseline differences, reduction of left ventricular volumes and hypertrophy was greater and cardiovascular mortality at 3-year follow-up was lower (odds ratio: 0.59; 95% confidence interval: 0.41 to 0.87; p = 0.007) in patients treated with RAS inhibitors. Moreover, RAS inhibitors demonstrated a global cardiovascular protective effect with significantly lower rates of new-onset atrial fibrillation, cerebrovascular events, and readmissions. Conclusions Post-TAVR RAS inhibitors are associated with lower cardiac mortality at 3-year follow-up and offer a global cardiovascular protective effect that might be partially explained by a positive left ventricular remodeling. An ongoing randomized trial will help confirm these hypothesis-generating findings. (Renin-Angiotensin System Blockade Benefits in Clinical Evolution and Ventricular Remodeling After Transcatheter Aortic Valve Implantation [RASTAVI]; NCT03201185)

Resumen Introduccion y objetivos Los resultados del estudio FREEDOM, fundamento de las guias de practica clinica, concluyen que la cirugia de revascularizacion coronaria es superior a la intervencion coronaria percutanea en pacientes diabeticos multivaso. El objetivo de este trabajo fue evaluar que porcentaje de pacientes de la vida real serian incluibles en dicho estudio y sus implicaciones pronosticas. Metodos Se siguio a 617 diabeticos multivaso, a los que se les habia realizado una coronariografia entre 2012 y 2014. Se clasificaron segun el cumplimiento de criterios para participar en dicho estudio y se analizo su impacto en la mortalidad y en los eventos cardiovasculares mayores. Resultados El 51,2% de los pacientes no cumplia los criterios de inclusion, tenian mas edad (69,3 frente a 66,1 anos; p Conclusiones Mas de la mitad de los diabeticos multivaso de la vida real no serian incluibles en un gran ensayo clinico, presentando 4 veces mas riesgo de muerte en el seguimiento.

Background During COVID-19 pandemic, elective invasive cardiac procedures (ICP) have been frequently cancelled or postponed. Consequences may be more evident in patients with diabetes. Objectives The objective was to identify the peculiarities of patients with DM among those in whom ICP were cancelled or postponed due to the COVID-19 pandemic, as well as to identify subgroups in which the influence of DM has higher impact on the clinical outcome. Methods We included 2,158 patients in whom an elective ICP was cancelled or postponed during COVID-19 pandemic in 37 hospitals in Spain. Among them, 700 (32.4%) were diabetics. Patients with and without diabetes were compared. Results Patients with diabetes were older and had a higher prevalence of other cardiovascular risk factors, previous cardiovascular history and co-morbidities. Diabetics had a higher mortality (3.0% vs. 1.0%; p = 0.001) and cardiovascular mortality (1.9% vs. 0.4%; p = 0.001). Differences were especially important in patients with valvular heart disease (mortality 6.9% vs 1.7% [p Conclusion Among patients in whom an elective invasive cardiac procedure is cancelled or postponed during COVID-19 pandemic, mortality and cardiovascular mortality is higher in patients with diabetes, irrespectively on other clinical conditions. These procedures should not be cancelled in patients with diabetes.

Background and aim: Recent randomized data comparing percutaneous mitral valve repair (PMVR) versus optimal medical treatment in patients with functional MR (FMR) seemed to highlight the importance of the learning curve not only for procedural outcomes but also for patient selection. The aim of the study was to compare a contemporary series of patients undergoing PMVR using a second-generation Mitraclip device (Mitraclip NT) with previous cohorts treated with a first-generation system. Methods: This multicenter study collected individual data from 18 centers between 2012 and 2017. The cohort was divided into three groups according to the use of the first-generation Mitraclip during the first (control-1) or second half (control-2) or the Mitraclip NT system. Results: A total of 545 consecutive patients were included in the study. Among all, 182 (33.3%), 183 (33.3%), and 180 (33.3%) patients underwent mitral repair in the control-1, control-2, and NT cohorts, respectively. Procedural success was achieved in 93.3% of patients without differences between groups. Major adverse events did not statistically differ among groups, but there was a higher rate of pericardial effusion in the control-1 group (4.3%, 0.6%, and 2.6%, respectively, p = 0.025). The composite endpoint of death, surgery, and admission for congestive heart failure (CHF) at 12 months was lower in the NT group (23.5% in control-1, 22.5% in control-2, and 8.3% in the NT group, p = 0.032). Conclusions: The present paper shows that contemporary clinical outcomes of patients undergoing PMVR with the Mitraclip system have improved over time.

BACKGROUND: During COVID-19 pandemic in Spain, elective procedures were canceled or postponed, mainly due to health care systems overwhelming. OBJECTIVE: The objective of this study was to evaluate the consequences of interrupting invasive procedures in patients with chronic cardiac diseases due to the COVID-19 outbreak in Spain. METHODS: The study population is comprised of 2,158 patients that were pending on elective cardiac invasive procedures in 37 hospitals in Spain on the 14th of March 2020, when a state of alarm and subsequent lockdown was declared in Spain due to the COVID-19 pandemic. These patients were followed-up until April 31th. RESULTS: Out of the 2,158 patients, 36 (1.7%) died. Mortality was significantly higher in patients pending on structural procedures (4.5% vs. 0.8%, respectively; p < .001), in those >80 year-old (5.1% vs. 0.7%, p < .001), and in presence of diabetes (2.7% vs. 0.9%, p = .001), hypertension (2.0% vs. 0.6%, p = .014), hypercholesterolemia (2.0% vs. 0.9%, p = .026) [Correction added on December 23, 2020, after first online publication: as per Dr. Moreno's request changes in p-values were made after original publication in Abstract.], chronic renal failure (6.0% vs. 1.2%, p < .001), NYHA > II (3.8% vs. 1.2%, p = .001), and CCS > II (4.2% vs. 1.4%, p = .013), whereas was it was significantly lower in smokers (0.5% vs. 1.9%, p = .013). Multivariable analysis identified age > 80, diabetes, renal failure and CCS > II as independent predictors for mortality. CONCLUSION: Mortality at 45 days during COVID-19 outbreak in patients with chronic cardiovascular diseases included in a waiting list due to cancellation of invasive elective procedures was 1.7%. Some clinical characteristics may be of help in patient selection for being promptly treated when similar situations happen in the future.

BACKGROUND In catheter-based procedures, acute kidney injury (AKI) is a frequent, serious complication ranging from 10% to 30%. In MitraClip (Abbott Vascular, Santa Clara, California), a usually contrast-free procedure, there is scarce data about its real incidence and impact. OBJECTIVES This study aimed to evaluate incidence, predictive factors, and midterm outcomes of AKI in patients with significant mitral regurgitation (MR) undergoing transcatheter valve repair with MitraClip. METHODS A total of 721 patients undergoing MitraClip were included. AKI was defined as an absolute or a relative increase in serum creatinine of >0.3 mg/dl or >= 50%, respectively, or the need for hemodialysis during index hospitalization. RESULTS The mean age of the patients was 72 +/- 11 years (28.3% women). Median estimated glomerular filtration rate (eGFR) was 43.7 ml/min/1.73 m(2) (interquartile range: 30.9 to 60.1 ml/min/1.73 m(2)), and was

Introduction and objectives: Transcatheter mitral valve repair (TMVR) with MitraClip is a therapeutic option for high surgical risk patients with severe mitral regurgitation (MR). The main objective of this study was to analyze differences in outcomes in patients with severe MR according to the cause of MR. Methods: Observational, multicenter, and prospective study with consecutive patient inclusion. The primary endpoint was the combination of all-cause mortality and new readmissions due to heart failure after 1 year. We compared clinical and procedural characteristics and the event rate for each MR group. We performed a multivariate analysis to identify predictive variables for the primary endpoint. Results: A total of 558 patients were included: 364 (65.2%) with functional etiology, 111 (19.9%) degenerative and 83 (14.9%) mixed. The mean age was 72.8 +/- 11.1 years and 70.3% of the sample were men. There were 95 (17%) events in the overall sample. No significant differences were found in the 3 groups in the number of primary outcome events: 11 (11.3%) in degenerative MR, 71 (21.3%) in functional MR, and 13 (18.1%) in mixed MR (P=.101). Independent predictors were functional class (P=.029), previous surgical revascularization (P=.031), EuroSCORE II (P=.003), diabetes mellitus (P=.037), and left ventricular ejection fraction (P=.015). Conclusions: This study confirms the safety and efficacy of TMVR with MitraClip irrespective of MR etiology in real-life data and shows the main factors related to prognosis during the first year of follow up. (C) 2019 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Objectives The authors aimed to determine the procedural learning curve and minimum annual institutional volumes associated with optimum clinical outcomes for transcatheter aortic valve replacement (TAVR). Background Transcatheter aortic valve replacement (TAVR) is a complex procedure requiring significant training and experience for successful outcome. Despite increasing use of TAVR across institutions, limited information is available for its learning curve characteristics and minimum annual volumes required to optimize clinical outcomes. Methods The study collected data for patients at 16 centers participating in the international TAVR registry since initiation of the respective TAVR program. All cases were chronologically ordered into initial (1 to 75), early (76 to 150), intermediate (151 to 225), high (226 to 300), and very high (>300) experience operators for TAVR learning curve characterization. In addition, participating institutions were stratified by annual TAVR case volume into low-volume ( 100) groups for comparative analysis. Procedural and 30-day clinical outcomes were collected and multivariate regression analysis performed for 30-day mortality and the early safety endpoint. Results A total of 3,403 patients comprised the study population. On multivariate analysis, all-cause mortality was significantly higher for initial (odds ratio [OR]: 3.83; 95% confidence interval [CI]: 1.93 to 7.60), early (OR: 2.41; 95% CI: 1.51 to 5.03), and intermediate (OR: 2.53; 95% CI: 1.19 to 5.40) experience groups compared with the very high experience operators. In addition, the early safety endpoint was significantly worse for all experience groups compared with the very high experience operators. Low annual volume ( Conclusions TAVR procedures display important learning curve characteristics with both greater procedural safety and a lower mortality when performed by experienced operators. In addition, TAVR performed at low annual volume (

Resumen Introduccion La regurgitacion mitral es la segunda valvulopatia en frecuencia, y pese a su mal pronostico casi la mitad de los pacientes no son considerados candidatos a cirugia. Para este perfil de pacientes se ha empleado MitraClip® con resultados prometedores en regurgitacion mitral funcional y degenerativa. Material y metodos Analisis retrospectivo de las caracteristicas y resultados de 72 pacientes tratados con MitraClip® entre noviembre de 2011 y octubre de 2016. Resultados La etiologia de la regurgitacion fue funcional en el 61,1%, degenerativa o mixta en el 38,9%. La etiologia funcional se asocio a menor edad (67,9 ± 8,74 vs 74,6 ± 13,06 anos, p = 0,21) y fraccion de eyeccion (34 ± 8,5% vs 57 ± 15%; p Conclusion El tratamiento con MitraClip® es seguro y efectivo en etiologia funcional y degenerativa, aunque esta ultima podria asociarse a menor mortalidad tardia.

Objectives The aim of this study was to determine the prognosis and specific complications of patients with prosthetic mitral valves (PMVs) undergoing transcatheter aortic valve replacement (TAVR). Background TAVR is performed relatively often in patients with PMVs, but specific risks are not well described. Methods A multicenter analysis was conducted, including patients with severe symptomatic aortic stenosis who underwent TAVR at 10 centers. Patients’ clinical characteristics and outcomes were evaluated according to the presence of a PMV. Results The mean age of the study population (n = 2,414) was 81 ± 8 years, and 48.8% were men. A total of 91 patients (3.77%) had PMVs. They were more commonly women, younger, and had higher surgical risk. PMVs were implanted a median of 14 years before TAVR, and most patients had mechanical prostheses (73.6%). Eighty-six patients (94.5%) were on long-term vitamin K inhibitor therapy, and bridging antithrombotic therapy was administered in 59 (64.8%). TAVR device embolization occurred in 6.7% (vs. 3.3% in the non-PMV group; p = 0.127), in all instances when distance between the PMV and the aortic annulus was Conclusions TAVR presents similar mortality irrespective of the presence of a PMV. However, patients with PMVs had higher bleeding risk that was independently associated with higher mortality. Risk for valve embolization was relatively high, but it occurred only in patients with PMV–to–aortic annulus distances

Despite rapidly increasing use of TAVR across institutions, limited data is available for the effect of procedural experience on TAVR outcomes. We investigate the relationship between institutional experience and TAVR outcomes.1953 patients undergoing TAVR at 8 international sites were grouped into chronological quantiles (Q) to assess temporal changes on procedural and clinical outcomes and multivariate logistic regression performed to determine predictors of device success, early safety and all-cause mortality.The mean age of patients was 81±7years and 991 (51%) were female. The quantiles comprised of first 62 cases for Q1, 63-133 for Q2, 134 to 242 for Q3 and 243 to 476 for Q4. Device success increased from Q1 to Q4 (78% vs 89%, p0.001) with significant improvement in the early safety endpoint (19% vs 10%, p0.001). All cause mortality reduced by half in Q4 compared to Q1 (8% vs 4%, p=0.01) and rates of major vascular complications, major bleeding and valve embolization decreased with increasing experience. The multivariate analysis identified TAVR in Q3 and Q4 to be independently associated with higher device success and lower risk of complications. TAVR in Q4 was independently associated with lower mortality (OR 0.36 95% CI 0.19-0.70, p=0.002).Greater institutional experience with TAVR procedures improves device success and clinical outcomes. An experience of242 cases is independently associated with lower mortality. These findings have important implications for defining minimum volume criteria for institutions and training standards for TAVR procedure.

Resumen Introduccion y objetivos El implante percutaneo de valvula aortica (TAVI) es una alternativa eficaz y segura al tratamiento quirurgico de pacientes con estenosis aortica (EA) grave inoperables o con alto riesgo quirurgico. El objetivo primario de este estudio es evaluar la supervivencia a muy largo plazo de pacientes con EA grave tratados mediante TAVI. Metodos Estudio observacional, multicentrico y prospectivo con seguimiento de todos los pacientes consecutivos con EA grave sintomatica a los que se trato mediante TAVI en 3 hospitales espanoles de alto volumen. Resultados Se incluyo a 108 pacientes a los que se implanto una protesis autoexpandible CoreValve. La media de edad en el momento del implante era 78,6 ± 6,7 anos, 49 pacientes (45,4%) eran varones y la media de EuroSCORE logistico, 16% ± 13,9%. La mediana de seguimiento fue de 6,1 anos (2.232 dias). Las supervivencias al final de los anos 1 a 6 fueron del 84,3% (el 92,6% tras el periodo de hospitalizacion), el 77,8, el 72,2, el 66,7, el 58,3 y el 52,8%. Al final del seguimiento habian fallecido 71 pacientes (65,7%), 18 (25,3%) por causa cardiaca. De los supervivientes, el 82,5% se encontraba en clases I - II de la New York Heart Association . Seis pacientes (5,5%) presentaron disfuncion protesica. Conclusiones La supervivencia a largo plazo de los pacientes con EA tras una TAVI es aceptable. Las principales causas de mortalidad son la cardiovascular durante el primer ano y no cardiacas los anos posteriores. La funcionalidad de la valvula se mantiene a lo largo del tiempo.

Aims: The aim of the study was to assess the safety and efficacy of percutaneous closure of paravalvular prosthetic leak (PVL) and to identify the predictors of procedural success and early complications. Methods and results: A total of 514 first -attempt percutaneous PVT, closure in 469 patients were included at 19 centres. Technical and procedural success was achieved in 86.6% and 73.2% of the patients, respectively. In multivariate analysis, the independent predictors for procedural success in antral lesions were the type of device used (AMPLATZER AVP III vs. others, FIR 2.68 [1.29-5.54], p=0.008) and the number of procedures perfomied at the centre (top quartile vs. others, IIR 1.93 [1.051-3.53], p=0.03). For aortic leaks the only predictor of procedural success was the leak size (>= 10 nun vs.

IntroductionTranscatheter aortic valve implantation (TAVI) as a treatment in severe aortic stenosis (AS) is an excellent alternative to conventional surgical replacement. However, long-term outcomes are not benign. Renin-angiotensin system (RAS) blockade has shown benefit in terms of adverse remodelling in severe AS and after surgical replacement.Methods and analysisThe RAS blockade after TAVI (RASTAVI) trial aims to detect if there is a benefit in clinical outcomes and ventricular remodelling with this therapeutic strategy following the TAVI procedure. The study has been designed as a randomised 1:1 open-label study that will be undertaken in 8 centres including 336 TAVI recipients. All patients will receive the standard treatment. The active treatment group will receive ramipril as well. Randomisation will be done before discharge, after signing informed consent. All patients will be followed up for 3 years. A cardiac magnetic resonance will be performed initially and at 1 year to assess ventricular remodelling, defined as ventricular dimensions, ejection fraction, ventricular mass and fibrosis. Recorded events will include cardiac death, admission due to heart failure and stroke. The RASTAVI Study will improve the management of patients after TAVI and may help to increase their quality of life, reduce readmissions and improve long-term survival in this scenario.Ethics and disseminationAll authors and local ethics committees have approved the study design. All patients will provide informed consent. Results will be published irrespective of whether the findings are positive or negative.Trial registration numberNCT03201185.

Background: The impact of preexisting left bundle branch block (LBBB) in transcatheter aortic valve replacement (TAVR) recipients is unknown. The aim of this study was to determine the impact of preexisting LBBB on clinical outcomes after TAVR. Methods and Results: This multicenter study evaluated 3404 TAVR candidates according to the presence or absence of LBBB on baseline ECG. TAVR complications and causes of death were defined according to Valve Academic Research Consortium-2 definitions. Follow-up outpatient visits or telephone interviews were conducted at 30 days, 12 months, and yearly thereafter. Echocardiography examinations were performed at baseline, at hospital discharge, and at 1-year follow-up. Preexisting LBBB was present in 398 patients (11.7%) and was associated with an increased risk of permanent pacemaker implantation (PPI; 21.1% versus 14.8%; adjusted odds ratio, 1.51; 95% CI, 1.12–2.04) but not death (7.3% versus 5.5%; adjusted odds ratio, 1.33; 95% CI, 0.84–2.12) at 30 days. At a mean follow-up of 22±21 months, there were no differences between patients with and without preexisting LBBB in overall mortality (adjusted hazard ratio, 0.94; 95% CI, 0.75–1.18) and cardiovascular mortality (adjusted hazard ratio, 0.90; 95% CI, 0.68–1.21). In a subanalysis of 2421 patients without PPI at 30 days and with complete follow-up about the PPI, preexisting LBBB was not associated with an increased risk of PPI or sudden cardiac death. Patients with preexisting LBBB had a lower left ventricular ejection fraction (LVEF) at baseline and at 1-year follow-up ( P P =0.327). Conclusions: Preexisting LBBB significantly increased the risk of early (but not late) PPI after TAVR, without any significant effect on overall mortality or cardiovascular mortality. Preexisting LBBB was associated with lower LVEF pre-TAVR but did not prevent an increase in LVEF post-TAVR similar to patients without LBBB.

Background Little evidence exists of the burden and predictors of cardiac death after transcatheter aortic valve replacement (TAVR). Objectives The purpose of this study was to assess the incidence and predictors of cardiac death from advanced heart failure (HF) and sudden cardiac death (SCD) in a large patient cohort undergoing TAVR. Methods The study included a total of 3,726 patients who underwent TAVR using balloon (57%) or self-expandable (43%) valves. Causes of death were defined according to the Valve Academic Research Consortium–2. Results At a mean follow-up of 22 ± 18 months, 155 patients had died due to advanced HF (15.2% of total deaths, 46.1% of deaths from cardiac causes) and 57 had died due to SCD (5.6% of deaths, 16.9% of cardiac deaths). Baseline comorbidities (chronic obstructive pulmonary disease, atrial fibrillation, left ventricular ejection fraction ≤40%, lower mean transaortic gradient, pulmonary artery systolic pressure >60 mm Hg; p 160 ms had a greater SCD risk (HR: 4.78, 95% CI: 1.56 to 14.63; p = 0.006). Conclusions Advanced HF and SCD accounted for two-thirds of cardiac deaths in patients after TAVR. Potentially modifiable or treatable factors leading to increased risk of mortality for HF and SCD were identified. Future studies should determine whether targeting these factors decreases the risk of cardiac death.

Resumen El implante valvular aortico transcateter ha supuesto una revolucion en el campo del intervencionismo, con unos resultados excelentes, pero no esta exento de complicaciones. Las alteraciones de la conduccion auriculoventricular son las mas prevalentes, fundamentalmente el bloqueo de rama izquierda del haz de His, por la proximidad del nodulo auriculoventricular y el haz de His a la valvula aortica. El tipo de valvula percutanea influye en la incidencia de trastornos de conduccion y la posterior necesidad de marcapasos. Un implante de marcapasos supone un empeoramiento de la funcion ventricular en el seguimiento, pero parece que no afecta a la mortalidad. La posicion de la protesis es uno de los principales factores de la necesidad de marcapasos, y los nuevos disenos permitiran un implante mas controlado y un mejor posicionamiento, pero no llegaran a excluir el riesgo de bloqueo auriculoventricular completo. Conocer mejor esta complicacion permitira disminuir el grado de incertidumbre que puedan suponer los bloqueos auriculoventriculares paroxisticos y sus consecuencias clinicas.

Resumen Introduccion y objetivos La regurgitacion mitral sintomatica tiene un pronostico desfavorable sin tratamiento quirurgico. Sin embargo, segun el registro europeo de enfermedad cardiaca valvular, no se intervino al 49% de los pacientes en esa situacion. El tratamiento percutaneo de la regurgitacion mitral con MitraClip® se ha demostrado seguro y eficaz anadido al tratamiento medico en este perfil de pacientes. El objetivo de este trabajo es describir la experiencia inicial con MitraClip® en Espana. Metodos Estudio observacional retrospectivo que incluye a todos los pacientes tratados desde noviembre 2011 hasta julio 2013 por los cuatro hospitales espanoles con mayor numero de implantes. Resultados Se trato a 62 pacientes (el 77,4% varones), principalmente con regurgitacion mitral funcional restrictiva (85,4%), de gravedad grado III (37%) o IV (63%), fraccion de eyeccion media del 36 ± 14% y clase funcional de la New York Heart Association III (37%) o IV (63%). En el 98% de los pacientes, se implanto con exito el dispositivo. Al ano, el 81,2% tenia regurgitacion mitral ≤ 2 y el 90,9% en clase funcional de la New York Heart Association ≤ II . Hubo un solo caso de mortalidad periprocedimiento (sepsis 20 dias despues del implante) y otros 3 fallecimientos en el seguimiento (media, 9,1 meses). Fue necesario implantar un nuevo dispositivo por dehiscencia parcial del previo a 2 pacientes y se sometio a trasplante cardiaco a otros 2. Conclusiones El tratamiento con MitraClip® en Espana se ha dirigido principalmente a pacientes con insuficiencia mitral funcional, disfuncion ventricular sistolica significativa y elevado riesgo quirurgico, y se perfila como una opcion segura de tratamiento con capacidad de reducir la regurgitacion mitral y mejorar la capacidad funcional.

The aim of this study was to determine the prognosis and specific complications of patients with prosthetic mitral valves (PMVs) undergoing transcatheter aortic valve replacement (TAVR).TAVR is performed relatively often in patients with PMVs, but specific risks are not well described.A multicenter analysis was conducted, including patients with severe symptomatic aortic stenosis who underwent TAVR at 10 centers. Patients' clinical characteristics and outcomes were evaluated according to the presence of a PMV.The mean age of the study population (n = 2,414) was 81 ± 8 years, and 48.8% were men. A total of 91 patients (3.77%) had PMVs. They were more commonly women, younger, and had higher surgical risk. PMVs were implanted a median of 14 years before TAVR, and most patients had mechanical prostheses (73.6%). Eighty-six patients (94.5%) were on long-term vitamin K inhibitor therapy, and bridging antithrombotic therapy was administered in 59 (64.8%). TAVR device embolization occurred in 6.7% (vs. 3.3% in the non-PMV group; p = 0.127), in all instances when distance between the PMV and the aortic annulus was 7 mm. Mortality rates did not show a difference, but the rate of bleeding was higher in patients with PMV (24.2% vs. 16.1%; p = 0.041), even in those treated via the transfemoral approach (22.2% vs. 13.9%; p = 0.048). Indeed, bleeding complications, prior atrial fibrillation, chronic obstructive pulmonary disease, surgical risk, and New York Heart Association functional class were independent predictors of mortality.TAVR presents similar mortality irrespective of the presence of a PMV. However, patients with PMVs had higher bleeding risk that was independently associated with higher mortality. Risk for valve embolization was relatively high, but it occurred only in patients with PMV-to-aortic annulus distances 7 mm.

This study sought to assess the influence of baseline right bundle branch block (RBBB) on all-cause and cardiovascular mortality as well as sudden cardiac death (SCD) among patients undergoing transcatheter aortic valve replacement (TAVR).Few data exist regarding the late clinical impact of pre-existing RBBB in TAVR recipients.A total of 3,527 patients (mean age 82 ± 8 years, 50.1% men) were evaluated according to the presence of RBBB on baseline electrocardiography. Intraventricular conduction abnormalities were classified according to the American Heart Association, American College of Cardiology Foundation, and Heart Rhythm Society recommendations for standardization and interpretation of the electrocardiogram. TAVR complications and causes of death were defined according to Valve Academic Research Consortium 2 definitions.RBBB was present on baseline electrocardiography in 362 patients (10.3%) and associated with higher 30-day rates of permanent pacemaker implantation (PPI) (40.1% vs. 13.5%; p 0.001) and death (10.2% vs. 6.9%; p = 0.024). At a mean follow-up of 20 ± 18 months, pre-existing RBBB was independently associated with all-cause mortality (hazard ratio [HR]: 1.31; 95% confidence interval [CI]: 1.06 to 1.63; p = 0.014) and cardiovascular mortality (HR: 1.45; 95% CI: 1.11 to 1.89; p = 0.006) but not with SCD (HR: 0.71; 95% CI: 0.22 to 2.32; p = 0.57). Patients with pre-existing RBBB and without PPI at discharge from the index hospitalization had the highest 2-year risk for cardiovascular death (27.8%; 95% CI: 20.9% to 36.1%; log-rank p = 0.007). In a subanalysis of 1,245 patients without PPI at discharge from the index hospitalization and with complete follow-up regarding the need for PPI, pre-existing RBBB was independently associated with the composite of SCD and PPI (HR: 2.68; 95% CI: 1.16 to 6.17; p = 0.023).Pre-existing RBBB was found in 10% of TAVR recipients and was associated with poorer clinical outcomes. Patients with baseline RBBB without permanent pacemakers at hospital discharge may be at especially high risk for high-degree atrioventricular block and/or SCD during follow-up. Future studies should evaluate strategies aimed at the early detection of patients at risk for late development of high-degree atrioventricular block.

Resumen Introduccion Un tercio de los pacientes con estenosis aortica severa sometidos a recambio valvular quirurgico asocian enfermedad coronaria, incrementandose el riesgo de la cirugia. El implante valvular aortico transcateter (TAVI) ha emergido como tratamiento alternativo para los pacientes con estenosis aortica severa y alto riesgo quirurgico. Sin embargo, se conoce poco el efecto de la enfermedad coronaria en estos pacientes. El objetivo fue conocer la prevalencia y el impacto que presenta la enfermedad coronaria en los pacientes sometidos al implante valvular percutaneo. Metodos Entre abril de 2008 y diciembre de 2011 se trataron 230 pacientes con estenosis aortica severa y sintomatica, con alto riesgo quirurgico, con la protesis aortica CoreValve. A todos los pacientes se les realizo una coronariografia previa. Resultados El 36,1% presentaron enfermedad coronaria, predominando varones (60%) y con mayor disfuncion ventricular que los pacientes sin enfermedad coronaria (24% vs. 12%, p = 0,02). No hubo diferencias en la mortalidad hospitalaria (4,1% vs. 7,2%, p = 0,303) al comparar los pacientes con y sin enfermedad coronaria. La supervivencia a los 12 y 24 meses fue ligeramente inferior en los pacientes con enfermedad coronaria (80,9% vs. 91,4% y 72,6% vs. 86,5%, p = 0,048, respectivamente). Los pacientes con enfermedad coronaria revascularizados previamente presentaron una supervivencia ligeramente superior a los pacientes no revascularizados, 82,9% vs. 78,6% a los 12 meses y del 67,2% vs. 61,15% a los 24 meses, p = 0,63. Conclusiones El tratamiento de la enfermedad coronaria en los pacientes con estenosis aortica severa previo al implante de la protesis aortica percutanea CoreValve mejora el pronostico de los mismos a corto y a medio plazo.

Objectives The aim of this study was to determine the impact of the degree of residual aortic regurgitation (AR) and acuteness of presentation of AR after transcatheter aortic valve replacement (TAVR) on outcomes. Background The degree of residual AR after TAVR leading to excess mortality remains controversial, and little evidence exists on the impact of the acuteness of presentation of AR. Methods A total of 1,735 patients undergoing TAVR with balloon-expandable or self-expanding valves were included. The presence and degree of AR were evaluated by transthoracic echocardiography; acute AR was defined as an increase in AR severity of ≥1 degree compared with pre-procedural echocardiography. Results Residual AR was classified as mild in 761 patients (43.9%) and moderate to severe in 247 patients (14.2%). The presence of moderate to severe AR was an independent predictor of mortality at a mean follow-up of 21 ± 17 months compared with none to trace (adjusted hazard ratio [HR]: 1.81, 95% confidence interval [CI]: 1.32 to 2.48; p 0.50). Conclusions AR occurred very frequently after TAVR, but an increased risk of mortality at ∼2-year follow-up was observed only in patients with acute moderate to severe AR.

Aim The aim of this study was to determine the effects of advanced chronic kidney disease (CKD) on early and late outcomes after transcatheter aortic valve implantation (TAVI), and to evaluate the predictive factors of poorer outcomes in such patients. Methods and results This was a multicentre study including a total of 2075 consecutive patients who had undergone TAVI. Patients were grouped according the estimated glomerular filtration rate as follows: CKD stage 1-2 (≥60 mL/min/1.73 m2; n = 950), stage 3 (30–59 mL/min/1.73 m2; n = 924), stage 4 (15–29 mL/min/1.73 m2; n = 134) and stage 5 (

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

ResumenIntroducción y objetivosEl tratamiento de la estenosis aórtica grave sintomática se ha revolucionado con la técnica de reemplazo valvular aórtico transcatéter. El objeto del presente estudio es presentar la evolución y los predictores de mortalidad de los pacientes incluidos entre 2010 y 2011 en el Registro Nacional de Reemplazo Valvular Aórtico Transcatéter.MétodosSe han recogido 131 variables previas al procedimiento; 31 perioperatorias y 76 de seguimiento clínico. Se ha analizado el éxito inmediato del implante, la variable combinada de seguridad a los 30 días y la mortalidad por cualquier causa a 30 días y al seguimiento máximo (media, 244 días).ResultadosDesde enero de 2010 hasta diciembre de 2011, se ha incluido a 1.416 pacientes: 806 válvulas Edwards y 610 CoreValve. El éxito del implante y la mortalidad hospitalaria fueron del 94 y el 9% respectivamente, sin diferencias entre válvulas y accesos. La variable combinada de seguridad a 30 días y la mortalidad al seguimiento máximo fueron del 14 y el 16% del total respectivamente, también similares entre grupos de válvulas y accesos. La presencia de comorbilidades (insuficiencia renal, enfermedad vascular periférica, fracción de eyección y fibrilación auricular), la necesidad de conversión a cirugía y la insuficiencia aórtica al menos moderada tras el implante se identificaron como predictores independientes de mortalidad a medio plazo.ConclusionesLa selección del paciente teniendo en cuenta su comorbilidad y la optimización del resultado para minimizar el grado de insuficiencia aórtica residual pueden mejorar el pronóstico de estos pacientes.AbstractIntroduction and objectivesThe treatment of severe symptomatic aortic stenosis has been revolutionized by the technique of transcatheter valve replacement. The purpose of this study was to present the outcomes and predictors of mortality in patients enrolled between 2010 and 2011 in the Transcatheter Aortic Valve Replacement National Registry.MethodsWe collected 131 preprocedural, 31 periprocedural, and 76 follow-up variables, and analyzed the immediate implant success rate, the 30-day safety endpoint, and all-cause 30-day and mid-term (mean follow-up, 244 days) mortality.ResultsFrom January 2010 to December 2011, a total of 1416 patients were included: 806 with Edwards valves and 610 with CoreValves. The implant success and 30-day mortality rates were 94% and 8%, respectively, without differences between types of valves and approaches. The 30-day safety endpoint and mid-term mortality rates were 14% and 16%, respectively, which were also similar between groups. The presence of comorbidities (renal failure, peripheral vascular disease, ejection fraction, and atrial fibrillation), the need for conversion to surgery, and at least moderate aortic regurgitation after transcatheter aortic valve implantation were identified as independent predictors of in-hospital and mid-term mortality.ConclusionsThe prognosis of valve implant patients could be improved by including comorbidities in patient selection and by minimizing the degree of residual aortic regurgitation to optimize the results of the procedure.

W Aortic stenosis A B S T R A C T Introduction and objectives: There is little information on the use of transcatheter aortic valve implantation in patients with severe aortic stenosis and porcelain aorta. The primary aim of this study was to analyze death from any cause after CoreValve W implantation in patients with severe aortic stenosis, with and without porcelain aorta. Methods: In this multicenter, observational prospective study, carried out in 3 hospitals, percutaneous aortic valves were implanted in 449 patients with severely calcified aortic stenosis. Of these, 36 (8%) met the criteria for porcelain aorta. The primary end-point was death from any cause at 2 years. Results: Patients with porcelain aorta more frequently had extracardiac vascular disease (11 (30.6%) vs 49 (11.9%); P=.002), prior coronary revascularization (15 (41.7%) vs 98 (23.7%); P=.017), and dyslipidemia (26 (72.2%) vs 186 (45%); P=.02). In these patients, there was greater use of general anesthesia (15 (41.7%) vs 111 (16.9%); P=.058) and axillary access (9 (25%) vs 34 (8.2%); P=.004). The success rate of the procedure (94.4 vs 97.3%; P=.28) and the incidence of complications (7 (19.4%) vs 48 (11.6%); P=.20) were similar in both groups. There were no statistically significant differences in the primary end point at 24 months of follow-up (8 (22.2%) vs 66 (16%); P=.33). The only predictive variable for the primary end point was the presence of complications during implantation (hazard ratio=2.6; 95% confidence interval, 1.5- 4.5; P=.001). Conclusions: In patients with aortic stenosis and porcelain aorta unsuitable for surgery, percutaneous implantation of the CoreValve W self-expanding valve prosthesis is safe and feasible.

Objective Determine whether remote ischaemic postconditioning (RIP) protects against percutaneous coronary intervention-related myocardial infarction (PCI-MI). Design Single-centre, randomised, blinded to the researchers, clinical trial. ClinicalTrials.gov (NCT 01113008). Setting Tertiary hospital centre. Patients 232 patients underwent elective PCI for stable or unstable angina. Interventions Patients were randomised to RIP (induction of three 5-min cycles of ischaemia in the arm after the PCI) versus placebo. Main outcome measures The primary outcome measure was the peak 24-h troponin I level. PCI-MI was defined by an elevation of troponin values >3 or >5 of the 99th percentile according to the classical or the new definition. The secondary outcome measure was hospital admission, PCI for stable angina or acute coronary syndrome and mortality after 1 year of follow-up. The use of RIP in diabetic patients was specifically studied. Results The mean age was 64.6 years, and 42% were diabetic. The peak troponin in the RIP patients was 0.476 vs 0.478 ng/mL (p=0.99). PCI-MI occurred in 36% of the RIP patients versus 30.8% in the placebo group (p=0.378). Diabetic RIP patients had more PCI-MI (new definition): OR 2.7; 95% CI 1.10 to 6.92; p=0.027. The secondary outcome measure was seen in 11.7% of the RIP patients versus 10.8% in the placebo group (p=0.907). Conclusions RIP did not reduce the damage associated with elective PCI or cardiovascular events during the follow-up. The diabetic population who underwent RIP had more PCI-MI.

Objectives We aimed to determine whether body mass index (BMI) is a prognostic indicator for long-term, all-cause mortality in patients undergoing transcatheter aortic valve implantation (TAVI). Background Obesity in patients with established cardiovascular disease has previously been identified as an indicator of good prognosis, a phenomenon known as the "obesity paradox". The prognostic significance of BMI in patients with severe aortic stenosis (AoS) undergoing TAVI is a matter of current debate, as published studies are scarce and their results conflicting. Methods This is an observational, retrospective study involving 770 patients who underwent TAVI for AoS. The cohort was divided into three groups based on their BMI: normal weight (≥18.5 to 2 ), overweight (≥25 to 2 ) and obese (≥30kg/m 2 ). The predictive effect of BMI on all-cause mortality 3years following TAVI intervention was analysed using a Cox regression. Results 155 patients died during follow-up. The overweight group ( n =302, 38.97%), experienced a lower mortality rate compared to the normal weight and obese groups (15.9% vs 25.7% and 21.0%, respectively [log-rank p -value=0.036]). After adjustment by logistic EuroSCORE, being overweight was found to be an independent protective factor against mortality (HR: 0.63 [95% CI: 0.42 to 0.94], p =0.024). This was not the case for obesity (HR: 0.92 [95% CI: 0.63 to 1.35], p =0.664). We therefore describe for the first time, a "J-shaped" regression curve describing the relationship between BMI and mortality. Conclusions BMI is a predictive factor of all-cause mortality in AoS patients undergoing TAVI. This relationship takes the form of a "J-shaped" curve in which overweight patients are associated with the lowest mortality rate at follow-up.

Introduction and objectives Transcatheter aortic valve implantation (TAVI) is a safe and effective alternative to surgical treatment in patients with severe aortic stenosis (AS) and those who are inoperable or at high surgical risk. The primary objective of this study was to evaluate the long-term survival of consecutive patients with severe AS treated with TAVI. Methods Observational, multicenter, prospective, follow-up study of consecutive patients with severe symptomatic AS treated by TAVI in 3 high-volume hospitals in Spain. Results We recruited 108 patients, treated with a self-expanding CoreValve prosthesis. The mean age at implantation was 78.6 ± 6.7 years, 49 (45.4%) were male and the mean logistic EuroSCORE was 16% ± 13.9%. The median follow-up was 6.1 years (2232 days). Survival rates at the end of years 1, 2, 3, 4, 5, and 6 were 84.3% (92.6% after hospitalization), 77.8%, 72.2%, 66.7%, 58.3%, and 52.8%. During follow-up, 71 patients (65.7%) died, 18 (25.3%) due to cardiac causes. Most (82.5%) survivors were in New York Heart Association class I or II . Six patients (5.5%) developed prosthetic valve dysfunction. Conclusions Long-term survival in AS patients after TAVI is acceptable. The main causes of death are cardiovascular in the first year and noncardiac causes in subsequent years. Valve function is maintained over time.

The purpose of this study was to evaluate the need for a permanent pacemaker after transcatheter aortic valve implantation with the CoreValve prosthesis (Medtronic, Inc., Minneapolis, Minnesota) using the new Accutrak delivery system (Medtronic, Inc.).The need for a permanent pacemaker is a recognized complication after transcatheter aortic valve implantation with the CoreValve prosthesis.Between April 23, 2008 and May 31, 2011, 195 consecutive patients with symptomatic aortic valve stenosis underwent transcatheter aortic valve implantation using the self-expanding CoreValve prosthesis. In 124 patients, the traditional delivery system was used, and in 71 patients, the Accutrak delivery system was used.There were no significant differences in baseline electrocardiographic characteristics between the traditional system and the Accutrak patients: PR interval: 153 ± 46 mm versus 165 ± 30 mm, p = 0.12; left bundle branch block: 22 (20.2%) versus 8 (12.7%), p = 0.21; right bundle branch block: 21 (19.3%) versus 8 (12.7%), p = 0.26. The depth of the prosthesis in the left ventricular outflow tract was greater with the traditional system than with the Accutrak system (9.6 ± 3.2 mm vs. 6.4 ± 3 mm, p0.001) and the need for a permanent pacemaker was higher with traditional system than with Accutrak (35.1% vs. 14.3%, p = 0.003). The predictors of the need for a pacemaker were the depth of the prosthesis in the left ventricular outflow tract (hazard ratio [HR]: 1.2, 95% confidence interval [CI]: 1.08 to 1.34, p0.001), pre-existing right bundle branch block (HR: 3.5, 95% CI: 1.68 to 7.29, p = 0.001), and use of the traditional system (HR: 27, 95% CI: 2.81 to 257, p = 0.004).The new Accutrak delivery system was associated with less deep prosthesis implantation in the left ventricular outflow tract, which could be related to the lower rate of permanent pacemaker requirement.

Resumen Introduccion y objetivos Se analiza la informacion contenida en la base de datos sobre Actividad de Hemodinamica y Cardiologia Intervencionista de la Sociedad Espanola de Cardiologia para el ano 2011, concretamente en lo referente a la comunidad de Andalucia. Se establecen comparaciones con el registro precedente del ano 2009 y con el publicado a nivel nacional en el ano 2011. Resultados Durante el ano 2011 se realizaron en Andalucia 2.537 coronariografias (CNG)/millon de habitantes, cifra ligeramente superior a la del ano 2009 (2.480 CNG/millon de habitantes) y sustancialmente inferior a la media nacional para el ano 2011 (3.008 CNG/millon de habitantes). Existe un crecimiento en las tecnicas de diagnostico intracoronario, particularmente en la guia de presion (295 casos en 2011 vs 124 en 2009). Con respecto al intervencionismo coronario percutaneo (ICP), se realizaron 1.369 ICP/millon de habitantes, que supone un minimo crecimiento con respecto al ano 2009 (1.350 ICP/millon de habitantes) siendo la media muy proxima al promedio nacional (1.374 ICP/millon de habitantes). Se mantuvo el numero de ICP sobre la enfermedad multivaso (26,8% en 2011 vs 26,4% en 2009) y cayo la frecuencia de procedimientos sobre el tronco comun izquierdo no protegido (440 casos en 2011 vs 608 en 2009). El uso del stent farmacoactivo (SFA) mantuvo porcentajes similares al ano 2009 (58,7%). Se aprecia un incremento importante de la via radial que supera por primera vez a la femoral (51,7%). En el seno del infarto agudo de miocardio con ascenso de ST destaca un incremento del ICP primario (164 procedimientos/millon de habitantes en 2011 vs 108 procedimientos/millon de habitantes en 2009) a pesar de lo cual este indicador sigue estando bastante por debajo de la media nacional (254 procedimientos/millon de habitantes). Continua creciendo el numero de implantes percutaneos de protesis aorticas (de 91 en 2009 a 270 en 2011) asi como el resto de procedimientos en cardiopatia estructural. Conclusiones En el ano 2011 se produce una disminucion de la velocidad con que crece el volumen de actividad de cardiologia intervencionista en Andalucia. En este escenario de ralentizacion se observa un incremento del ICP primario, todavia por debajo de la media nacional. Se mantiene la tendencia alcista de los procedimientos estructurales, sobre todo del implante percutaneo de protesis aortica.

Fundamento y objetivo Tras un infarto de miocardio (IM), las celulas progenitoras endoteliales (CPE) procedentes de la medula osea son movilizadas hacia sangre periferica. El objetivo de nuestro trabajo fue estudiar los factores que influyen en dicha movilizacion celular espontanea. Pacientes y metodo En este estudio se han analizado en 47 pacientes con IM extenso (definido por una fraccion de eyeccion ventricular izquierda [FEVI]

Resumen Introduccion y objetivos En el intervencionismo percutaneo sobre el tronco comun izquierdo el caracter urgente del procedimiento y el shock cardiogenico constituyen los principales predictores de eventos. Para procedimientos electivos, el pronostico y la identificacion de predictores estan menos establecidos. El objetivo de este estudio es valorar el pronostico a corto y medio plazo del intervencionismo percutaneo sobre el tronco comun izquierdo no protegido cuando este se efectua de forma electiva. Metodos y resultados Serie multicentrica de 250 pacientes consecutivos incluidos entre enero del 2004 y marzo del 2008. El 49,6% de los pacientes presentaba EuroScore de alto riesgo. La mortalidad cardiaca intrahospitalaria fue del 0,4%, y tras un seguimiento medio de 19,6 meses, la incidencia de eventos cardiacos adversos mayores fue del 18,4% (infarto no fatal, 2,0%; revascularizacion del vaso diana, 6,8%; mortalidad cardiaca, 9,6%). Los predictores independientes de eventos cardiacos adversos mayores en el seguimiento fueron el EuroScore de alto riesgo (HR; 2,59, IC del 95%, 1,35-5,00; p = 0,004) y el uso de 2 stents para la lesion del tronco comun (HR 2,05; IC del 95%, 1,05-4,00; p = 0,035). Conclusiones En nuestro estudio el intervencionismo percutaneo electivo sobre el tronco comun no protegido de la coronaria izquierda se efectua principalmente en pacientes de alto riesgo quirurgico, resultando un procedimiento factible y con un porcentaje de eventos adversos en el seguimiento aceptable. Los predictores de eventos en el seguimiento son el EuroScore de alto riesgo y el uso de 2 stents para la lesion en el tronco comun.

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Resumen Introduccion y objetivos El implante de protesis percutanea aortica ha surgido como opcion terapeutica para pacientes con estenosis aortica severa sintomatica con contraindicacion para reemplazo valvular quirurgico por alto riesgo perioperatorio. Describimos las caracteristicas clinicas de una poblacion tratada con implante percutaneo de protesis aortica Corevalve. Metodos Desde abril de 2008 a enero de 2010, 102 pacientes fueron derivados a nuestro centro para valorar el reemplazo valvular aortico percutaneo, realizandose en 81. De los 21 pacientes no tratados, 5 fueron desestimados por anatomia vascular y/o medidas de valvula aortica, 7 murieron durante la evaluacion, 2 presentaban estenosis aorticas moderadas y estaban asintomaticos, en 2 se decidio tratamiento quirurgico, 2 se desestimaron por demencia y 3 retiraron el consentimiento. Se incluyeron pacientes de alto riesgo quirurgico (EuroSCORE logistico) y pacientes que rechazaron cirugia convencional. Resultados La edad media fue 79 ± 7,9 anos, siendo el 57% ≥ 80 anos y el 64% mujeres. El EuroSCORE logistico medio fue 21,4 ± 16%. El indice Charlson fue 3,6 ± 1,9, y el indice Barthel, 72 ± 21. El EuroSCORE logistico medio fue mayor en pacientes de alto riesgo quirurgico frente a los que rechazaron la cirugia (26,2 ± 17,2 vs 11,9 ± 4,6; p = 0,008). El indice de masa corporal fue de 28,9 ± 5,5. La fraccion de eyeccion media fue 61,8 ± 15,6%, con 14 (17,3%) pacientes con disfuncion severa. El 96,3% se encontraban en clase funcional III o IV NYHA. El gradiente transaortico maximo fue de 79 ± 21 mmHg, con area media de 0,64 ± 0,2 cm2. Presentaban enfermedad arterial coronaria 28 (34,6%). Se realizo valvuloplastia aortica en 7 pacientes. 31 pacientes presentaban enfermedad pulmonar cronica y 19 insuficiencia renal cronica. Conclusiones La poblacion con estenosis aortica severa sintomatica tratada con protesis aortica percutanea se caracterizo por presentar alto riesgo quirurgico y alta prevalencia de comorbilidades asociadas.

Recently, percutaneous aortic valve replacement has emerged as a therapeutic option for patients with severe symptomatic aortic stenosis and a high surgical risk. We report our initial experience in four patients with percutaneous implantation of a CoreValve aortic prosthesis to treat aortic bioprosthesis dysfunction involving aortic stenosis or regurgitation. In-hospital and medium-term outcomes were analyzed. The procedure was performed under local anesthesia and guided by angiography. The prosthesis was implanted successfully in all patients, although a second prosthesis was required in one case because the first was positioned too high. There were no major complications. After a mean follow-up of 7 months (SD, 4.7), all patients remained asymptomatic.

Resumen El implante valvular aortico percutaneo ha surgido recientemente como alternativa terapeutica para pacientes con estenosis aortica severa sintomatica y alto riesgo quirurgico. Se presenta la experiencia inicial en el tratamiento de la disfuncion de la bioprotesis aortica mediante el implante percutaneo de protesis aortica CoreValve en 4 pacientes, tanto con estenosis como con insuficiencia aortica, y se analiza los resultados hospitalarios y a medio plazo. El procedimiento se realizo con anestesia local y guiado por angiografia. Se implantaron con exito en todos los casos, si bien uno preciso una segunda protesis por posicionamiento alto de la primera. No hubo complicaciones mayores. Tras un seguimiento medio de 7 ± 4,7 meses, todos los pacientes se encuentran asintomaticos.

Introduction and objectives: To validate the axillary approach as a safe and efficient option for the transcatheter aortic valve implantation in patients who have contraindication for femoral approach at three Spanish hospitals. Methods: We included patients with severe symptomatic aortic stenosis at very high or prohibitive surgical risk, selected by a multidisciplinary team, for transcatheter aortic valve implantation, and had contraindication to the femoral approach. Results: We included 19 of 186 (10.5%) patients, who were implanted a percutaneous aortic valve, between November 2008 and March 2010. The mean age was 78.3 (standard deviation [SD] 8.65) years and 73.7% were males. The mean logistic EuroSCORE was 28.7% (SD 16.3%). The procedural success rate was 100%. After the procedure the maximum transvalve gradient decreased from 81.7 mmHg (SD 21.5) to 15.8 mmHg (SD 5.5), and no patient presented residual aortic regurgitation >2. The all-cause mortality, with a mean follow-up time of 9.2 (SD 3.2) months was 10.5%, and the in-hospital and 30-day mortality rates were 0%. The global incidence of major complications due to the procedure was 15.7%. Definitive pacemaker implantation was carried out for atrioventricular block in 8 patients (44.4%). Conclusions: The axillary approach for transcatheter aortic valve implantation using the CoreValve W and contraindication to the femoral approach is safe and efficient for selected patients, with excellent results in terms of success implantation and in hospital and 30-day mortality.