Search

Aims: To determine the impact of permanent cardiac pacing after transcatheter aortic valve implantation (TAVI) with the CoreValveTM prosthesis in terms of all-cause mortality and morbidity [rehospitalizations for heart failure (HF) or stroke] at the long-term follow-up.Methods and results: The prospective analysis comprised 259 patients (138 women, 53.3%, age 78 ± 6 years) treated by a CoreValveTM prosthesis from April 2008 to December 2015. Forty-two patients were excluded for analysis: 9 with pre-existing permanent pacemaker (PPM) implantation, 19 who required a PPM during the follow-up and 14 patients because of hospital mortality during or after the CoreValveTM prosthesis implantation procedure. The remaining 217 patients were divided in two groups: Group-1 included those patients who required a PPM immediately after TAVI, and Group-2 included those patients who did not require permanent cardiac pacing at the long-term follow-up. Patients received follow-up at 1-month, 6-months, 12-months, and yearly thereafter. A total of 39 patients required a PPM immediately after TAVI (15.0%), but 178 patients (68.7%) did not. The mean follow-up was 37 ± 27 months (range 3-99 months) in both groups. There was no difference between the two groups in terms of all-cause mortality (52.6% vs. 56.8%, P = 0.125; HR 1.22 [0.87-1.77, 95% CI]), or stroke (13.3% vs. 15.1% P = 0.842; HR 1.12 [0.37-3.32, 95% CI]). However, patients who underwent PPM implantation developed an increase in readmissions for HF (21.1% vs. 31.9%, P = 0.015; HR 1.82 [1.23-3.92, 95% CI]).Conclusion: Patients requiring a PPM after TAVI did not have an increase in mortality, or an increase in the likelihood of developing a stroke at a long-term follow-up. However, this subgroup of patients showed an increase in rehospitalization due to HF at medium- and long-term follow-up. [ABSTRACT FROM AUTHOR]

Introduction and Objectives: Infective endocarditis (IE) caused by oral streptococci is considered to be a 'more benign' IE than those caused by other microorganisms. Our aim is to analyse the changes in its incidence and its differential characteristics in our setting., Methods: Observational, single-centre, prospective cohort study including all cases of IE diagnosed in our centre between 1987 and 2023. IE caused by oral streptococci were identified and their characteristicsand mortality were compared with those of other IE., Results: Of 569 cases of IE, 104 (18.5%) were oral streptococcal IE, decreasing from 29.5% in 1987-1999 to 12.2% in 2000-2023 (p<0.001). The incidence of serious complications was lower in oral IE (65.3 vs. 78.9%; p=0.003), as was in-hospital mortality (14.4 vs. 29.9%; p=0.001)., Conclusions: Oral streptococcal IEs account for almost 20% of all IEs in our setting. They have a better prognostic clinical profile, with a lower incidence of serious complications, and their mortality is significantly lower than that of other IE. Their incidence seems to be decreasing in recent years., (Copyright © 2024 Elsevier España, S.L.U. All rights reserved.)

Introduction: Left bundle branch area pacing (LBBAP) seems to be an alternative to coronary sinus pacing in patients with non-ischaemic dilated cardiomyopathy (NI-DCM) with left bundle branch block (LBBB) and in pacing-induced cardiomyopathy (PICM). The aim of the study was to compare the response of LBBAP in severe forms of both entities., Material and Methods: Prospective study of patients with severe forms of PICM and NI-DCM in NYHA II-IV who underwent LBBAP. Clinical, electrocardiographic, echocardiographic and electrical parameters were analysed and the medium-term prognostic impact was assessed., Results: Eighty patients were included, 25 with PICM and 55 with NI-DCM. PICM patients were older (PICM 75 [IQR 71-83.5] y.o vs NI-DCM 72 [IQR 60-78.5] y.o;p=0.01) and with longer baseline QRS duration (PICM 180 [IQR 167-194] ms vs NI-DCM 168 [IQR 153-178] ms;p<0.01), with no differences in left ventricular ejection fraction (LVEF) or medical treatment. QRS reduction occurred in both groups, being greater in PICM (PICM CI 95% 54±20 ms, p<0.01; NI-DCM CI 95% 40±15 ms;p<0.01). A NT-ProBNP levels reduction and LVEF improvement were observed without differences between groups. At follow-up, there were no differences in admissions for HF (PICM 4.2% vs NI-DCM 11%;p=0.413), cardiac mortality (PICM 14.9% vs NI-DCM 2.9%;p=0.13) and all-cause mortality (PICM 21.7% vs NI-DCM 10.9%;p=0.08)., Conclusion: LBBAP is an effective technique with a NT-ProBNP levels reduction and LVEF improvement in both groups without differences. At follow-up, both groups had a low rate of HF readmissions and there was a non-significant trend toward higher total mortality in PICM., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Although malnutrition is frequently observed in patients with heart failure (HF), this diagnosis should be performed carefully since HF itself is associated with increased inflammatory activity, which affects body weight, functionality, and some nutritional parameters; thus, its isolated interpretation can erroneously identify surrogate markers of severity as markers of malnutrition. In this context, we aimed to evaluate the prevalence of malnutrition using different classification systems and perform a comprehensive nutritional evaluation to determine the reliability of different diagnostic techniques., Patients and Methods: Eighty-three patients with a recent hospital admission due to HF were evaluated. GLIM diagnosis criteria and subjective global assessment (SGA) were performed; a comprehensive anthropometric, functional, and biochemical nutritional evaluation was performed, in which bioelectrical impedance analysis (BIA), nutritional ultrasound, and dual-energy X-ray absorptiometry (DXA) were performed. Additionally, mortality and additional admissions due to HF were determined after a mean follow up of 18 months., Results: Malnutrition according to the GLIM criteria (54%) accurately distinguished patients with impaired functionality, lower lean mass, skeletal mass index, and appendicular muscle mass (BIA), as well as lower trunk fat mass, trunk lean mass, fat-free mass (DXA), and decreased albumin and increased C-reactive protein serum levels. According to SGA, there were significant changes in body composition parameters determined by BIA, muscle ultrasound, and functional tests between well-nourished patients and patients with risk of malnutrition (53.7%) or who had malnutrition (7.1%), but not when the last two groups were compared. BIA and DXA showed strong correlations when evaluating muscle and fat mass in HF patients, but correlations with nutritional ultrasound were limited, as well as functional tests. A multivariate analysis showed that no significant association was observed between body composition and mortality, but preperitoneal fat was associated with an increased risk of new hospital admissions (OR: 0.73)., Conclusions: GLIM criteria identified a lower percentage of patients with HF and malnutrition compared with SGA; thus, SGA could have a role in preventing malnutrition in HF patients. Nutritional evaluation with BIA and DXA in patients with HF showed reliable results of body composition parameters in HF, and both help with the diagnosis of malnutrition according to the GLIM or SGA criteria and could provide complementary information in some specific cases.

Introduction: A significant percentage of patients eventually diagnosed with cardiac transthyretin amyloidosis (TTRA) was previously diagnosed with hypertensive heart disease (HHD), since both conditions usually present with heart failure (HF) with preserved ejection fraction (HFpEF) and ventricular hypertrophy. Our objectives were to evaluate the clinical, electrocardiographic and echocardiographic differences, and to analyse whether there exists a differential prognosis between these two nosological entities., Materials and Methods: We retrospectively included all patients with HHD for whom a cardiac scintigraphy with 99m Tc-diphosphonate (GDPD) and a free light chains test in blood and urine were ordered for ATTR screening in our centre, in the period between 2016 and 2021. Those diagnosed with other types of amyloidosis were excluded from the analysis., Results: A total of 72 patients were analyzed: 33 were finally diagnosed with TTRA and 39 with CHTA. Patients with TTRA had higher levels of ultrasensitive troponin I (TnI-US) and N-terminal brain natriuretic propeptide (NT-ProBNP); in electrocardiography (ECG) they presented a pseudo-infarction pattern more frequently as well as conduction disturbances; in echocardiography (TTE) they presented a higher degree of ventricular hypertrophy, left ventricular dysfunction and worse diastolic function parameters, with elevated filling pressures. In the 4-year follow-up, the ATTR group showed greater need for pacemaker (PCM), with no evidence regarding mortality, development of atrial fibrillation (AF), or more admissions for heart failure (HF)., Conclusions: In our series, patients with TTRA showed clinical, electrocardiographic and echocardiographic differences compared to patients with HHD, with increased risk of need for PCM., (Copyright © 2023. Published by Elsevier España, S.L.U.)

Introduction and Objectives: Survivors of childhood cancer might be at increased risk of diastolic dysfunction at follow-up due to exposure to cardiotoxic treatment. Although assessment of diastolic function is challenging in this relatively young population, left atrial strain might provide a novel insight in this evaluation. Our aim was to examine diastolic function in a cohort of long-term survivors of childhood acute lymphoblastic leukemia by using left atrial strain and conventional echocardiographic parameters., Methods: Long-term survivors who were diagnosed at a single center between 1985 and 2015 and a control group of healthy siblings were recruited. Conventional diastolic function parameters and atrial strain were compared, and the latter was measured during the 3 atrial phases: reservoir (PALS), conduit (LACS) and contraction (PACS). Inverse probability of treatment weighting was used to account for differences between the groups., Results: We analyzed 90 survivors (age, 24.6±9.7 years, time since diagnosis 18 [11-26] years) and 58 controls. PALS and LACS were significantly reduced compared with the control group: 46.4±11.2 vs 52.1±11.7; P=.003 and 32.5±8.8 vs 38.2±9.3; P=.003, respectively. Conventional diastolic parameters and PACS were similar between the groups. The reductions in PALS and LACS were associated with exposure to cardiotoxic treatment in age- and sex-adjusted analysis (≥ moderate risk, low risk, controls): 45.4±10.5, 49.5±12.9, 52.1±11.7; P adj =.003, and 31.7±9.0, 35.2±7.5, 38.2±9.3; P adj =.001, respectively., Conclusions: Long-term childhood leukemia survivors showed a subtle impairment of diastolic function that was detected with atrial strain but not with conventional measurements. This impairment was more pronounced in those with higher exposure to cardiotoxic treatment., (Copyright © 2023 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Malnutrition and sarcopenia frequently affect patients with heart failure (HF), in which clinical outcomes and survival is decreased. Thus, appropriate nutritional screening and early nutrition support are highly recommended. Currently, nutritional support is not a standard of care in patients with HF, and the use of commercially available oral supplements (OSs) could provide an additional benefit to medical treatment in these patients., Aim: To compare the effect of the Mediterranean diet in combination with hypercaloric, hyperproteic OS in patients with HF., Patients and Methods: An open label, controlled clinical study in which patients were randomly assigned to receive a Mediterranean diet (control group) vs. hypercaloric, hyperproteic OS (intervention group) for twenty-four weeks. Thirty-eight patients were included; epidemiological, clinical, anthropometric, ultrasound (muscle echography of the rectus femoris muscle of the quadriceps and abdominal adipose tissue), and biochemical evaluations were performed. All patients received additional supplementation with vitamin D., Results: Baseline malnutrition according to the GLIM criteria was observed in 30% of patients, while 65.8% presented with sarcopenia. Body cell mass, lean mass, and body mass increased in the intervention group (absolute increase of 0.5, p = 0.03, 1.2 kg, p = 0.03, and 0.1 kg, p = 0.03 respectively). In contrast, fat mass increased in the control group (4.5 kg, p = 0.05). According to the RF ultrasound, adipose tissue, muscle area, and circumference tended to decrease in the intervention group; it is probable that 24 weeks was too short a period of time for evaluating changes in muscle area or circumference, as previously observed in another group of patients. In contrast, functionality, determined by the up-and-go test, significantly improved in all patients (difference 12.6 s, p < 0.001), including the control (10 s improvement, p < 0.001) and the intervention group (improvement of 8.9 s, p < 0.001). Self-reported QoL significantly increased in all groups, from 68.7 ± 22.2 at baseline to 77.7 ± 18.7 ( p = 0.01). When heart functionality was evaluated, LVEF increased in the whole cohort (38.7 ± 16.6 vs. 42.2 ± 8.9, p < 0.01); this increase was higher in the intervention group (34.2 ± 16.1 at baseline vs. 45.0% ± 17.0 after 24 weeks, p < 0.05). Serum values of NT-proBNP also significantly decreased in the whole cohort ( p < 0.01), especially in the intervention group ( p = 0.02). After adjusting by age and sex, nutritional support, baseline LVEF, NT-proBNP, and body composition parameters of functionality tests were not associated with mortality or new hospital admissions in this cohort., Conclusion: Nutritional support with hypercaloric, hyperproteic OS, Mediterranean diet, and vitamin D supplementation were associated with decreased NT-proBNP and improvements in LVEF, functionality, and quality of life in patients with HF, despite a significant decrease in hospital admissions.

Background: Worsening heart failure (WFH) includes heart failure (HF) hospitalisation, representing a strong predictor of mortality in patients with heart failure with reduced ejection fraction (HFrEF). However, there is little evidence analysing the impact of the number of previous HF admissions. Our main objective was to analyse the clinical profile according to the number of previous admissions for HF and its prognostic impact in the medium and long term., Methods: A retrospective study of a cohort of patients with HFrEF, classified according to previous admissions: cohort-1 (0-1 previous admission) and cohort-2 (≥2 previous admissions). Clinical, echocardiographic and therapeutic variables were analysed, and the medium- and long-term impacts in terms of hospital readmissions and cardiovascular mortality were assessed. A total of 406 patients were analysed., Results: The mean age was 67.3 ± 12.6 years, with male predominance (73.9%). Some 88.9% (361 patients) were included in cohort-1, and 45 patients (11.1%) were included in cohort-2. Cohort-2 had a higher proportion of atrial fibrillation (49.9% vs. 73.3%; p = 0.003), chronic kidney disease (36.3% vs. 82.2%; p < 0.001), and anaemia (28.8% vs. 53.3%; p = 0.001). Despite having similar baseline ventricular structural parameters, cohort-1 showed better reverse remodelling. With a median follow-up of 60 months, cohort-1 had longer survival free of hospital readmissions for HF (37.5% vs. 92%; p < 0.001) and cardiovascular mortality (26.2% vs. 71.9%; p < 0.001), with differences from the first month., Conclusions: Patients with HFrEF and ≥2 previous admissions for HF have a higher proportion of comorbidities. These patients are associated with worse reverse remodelling and worse medium- and long-term prognoses from the early stages, wherein early identification is essential for close follow-up and optimal intensive treatment.

Background: A percentage of patients with heart failure with reduced ejection fraction (HFrEF) improve left ventricular ejection fraction (LVEF) in the evolution. This entity, defined for the first time in an international consensus as heart failure with improved ejection fraction (HFimpEF), could have a different clinical profile and prognosis than HFrEF. Our main aim was to analyze the differential clinical profile between the two entities, as well as the mid-term prognosis., Material-Methods: Prospective study of a cohort of patients with HFrEF who had echocardiographic data at baseline and follow-up. A comparative analysis of patients who improved LVEF with those who did not was made. Clinical, echocardiographic and therapeutic variables were analyzed, and the mid-term impact in terms of mortality and hospital readmissions for HF was assessed., Results: Ninety patients were analyzed. Mean age was 66.5(10.4) years, with a male predominance (72.2%). Forty five patients (50%) improved LVEF (Group-1,HFimpEF) and forty five patients (50%) sustained reduced LVEF (Group-2,HFsrEF). The mean time to LVEF improvement in Group-1 was 12.6(5.7) months. Group-1 had a more favorable clinical profile: lower prevalence of cardiovascular risk factors, higher prevalence of de novo HF (75.6% vs. 42.2%; p<0.05), lower prevalence of ischemic etiology (22.2% vs. 42.2%; p<0.05), with less basal dilatation of the left ventricle. At the end of follow-up (mean 19(1) months) Group-1 had a lower hospital readmission rate (3.1% vs. 26.7%; p<0.01), as well as lower mortality (0% vs. 24.4%; p<0.01)., Conclusion: Patients with HFimpEF seem to have a better mid-term prognosis in terms of reduced mortality and hospital admissions. This improvement could be conditioned by the clinical profile of patients HFimpEF., (Copyright © 2023 Elsevier España, S.L.U. All rights reserved.)

Introduction: Worsening heart failure (HF) is associated with a high risk of death and rehospitalization. Despite that, real world evidence about the impact of worsening HF on clinical practice is scarce., Areas Covered: A narrative review about registries addressing recent worsening HF events in Spain, with special emphasis on patients recently hospitalized for HF was performed., Expert Opinion: Worsening HF can be defined as situations where the patient's HF deteriorates to the extent that it necessitates initiation or intensification of diuretic treatment (mainly intravenous). The events can occur at the outpatient level, generally in the day hospital, in the emergency department or even hospitalization. Early identification of worsening HF events is essential to establish appropriate treatment as soon as possible. In this context, robust clinical benefits have been reported for renin-angiotensin system inhibitors, sacubitril-valsartan, beta-blockers, mineralocorticoid receptor antagonists, SGLT2 inhibitors, and vericiguat. In Spain, several registries of patients with HF have been developed, some of them including patients recently hospitalized for HF, but not with recent worsening HF events. Therefore, registries addressing recent worsening events would be desirable. Using a practical approach, this review analyzes the importance of worsening HF events, with special emphasis on Spanish data.

Background: Heart failure (HF) admission in chronic coronary syndrome (CCS) patients has a prognostic impact. Stratification schemes have been described for predicting this endpoint, but none of them has been externally validated., Objectives: Our aim was to develop point scores for predicting incident HF admission with data from previous studies, to perform an external validation in an independent prospective cohort and to compare their discriminative ability for this event., Methods: Independent predictive variables of HF admission in CCS patients without baseline HF were selected from four previous prospective studies (CARE, PEACE, CORONOR and CLARIFY), generating scores based on the relative magnitude of the coefficients of Cox of each variable. Finally, the scores were validated and compared in a monocentric prospective cohort., Results: The validation cohort included 1212 patients followed for up to 17 years, with 171 patients suffering at least one HF admission in the follow-up. Discriminative ability for predicting HF admission was statistically significant for all, and paired comparisons among them were all nonsignificant except for CORONOR score was superior to CLARIFY score (C-statistic 0.73, 95%CI 0.69-0.76 vs. 0.69, 95% CI 0.65-0.73; p = 0.03)., Conclusion: All tested scores showed significant discriminative ability for predicting incident HF admission in this independent validation study. Their discriminative ability was similar, with significant differences only between the two scores with higher and lower performance., (© 2022 Stichting European Society for Clinical Investigation Journal Foundation. Published by John Wiley & Sons Ltd.)

Background: Women and men with chronic coronary syndrome (CCS) have different clinical features and management, and studies on mid-term prognosis have reported conflicting results. Our objective was to investigate the impact of the female sex in the prognosis of the disease in the very long term. Methods and Results: We investigated differential features and very long-term prognosis in 1268 consecutive outpatients with CCS (337 [27%] women and 931 [73%] men). Women were older than men, more likely to have hypertension, diabetes, angina, and atrial fibrillation, and less likely to be exsmoker/active smoker and to have been treated with coronary revascularization ( p  < 0.05 for all). The prescription of statins, antiplatelets, and betablockers was similar in both groups. After up to 17 years of follow-up (median = 11 years, interquartile range = 4-15 years), cumulative incidences of acute myocardial infarction (10.2% vs. 11.8%) or stroke (11% vs. 10%) at median follow-up were similar, but the risks of major cardiovascular events (acute myocardial infarction, stroke, or cardiovascular death, 41.2% vs. 33.6%), hospital admission for heart failure (20.9% vs. 11.9%), or cardiovascular death (32.3% vs. 22.1%) were significantly higher for women ( p  < 0.0005), with a nonsignificant trend to higher overall mortality (45.2% vs. 39.1%, p  = 0.07). However, after multivariate adjustment, all these differences disappeared. Conclusion: Although women and men with CCS presented a different clinical profile, and crude rates of major cardiovascular events, heart failure and cardiovascular death were higher in women, female sex was not an independent prognostic factor in this study with up to 17 years of follow-up.

Our aim was to investigate the role of left atrial longitudinal strain (LALS) in the non-invasive diagnosis of acute cellular rejection (ACR) episodes in heart transplant (HTx) recipients. Methods: We performed successive echocardiographic exams in 18 consecutive adult HTx recipients in their first year after HTx within 3 h of the routine surveillance endomyocardial biopsies (EMB) in a single center. LALS parameters were analyzed with two different software. We investigated LALS association with ACR presence, as well as inter-vendor variability in comparable LALS values. Results: A total of 147 pairs of EMB and echo exams were carried out. Lower values of LALS were significantly associated with any grade of ACR presence. Peak atrial longitudinal strain (PALS) offered the best diagnostic value for any grade of ACR, with a C statistic of 0.77 using one software (95% CI 0.68−0.84, p < 0.0005) and 0.64 with the other (95% CI 0.54−0.73, p = 0.013) (p = 0.02 for comparison between both curves). Reproducibility between comparable LALS parameters was poor (intraclass correlation coefficients were 0.60 for PALS, 95% CI 0.42−0.73, p < 0.0005; and 0.42 for PALS rate, 95% CI −0.13−0.68, p < 0.0005). Conclusions: LALS variables might be a sensitive marker of ACR in HTx recipients, principally discriminating between those studies without rejection and those with any grade of ACR. Inter-vendor variability was significant.

Aim: Amyloidosis is a disease in which amyloid fibrils can be deposited in different cardiac structures, and several electrocardiographic abnormalities can be produced by this phenomenon. The objective of this study was to describe the most common basal electrocardiographic alterations in patients diagnosed with cardiac amyloidosis (CA) and to determine if these abnormalities have an impact on the need of pacemaker., Methods: This retrospective study included patients who had an established diagnosis of CA [light-chain cardiac amyloidosis (LA-CA) or transthyretin cardiac amyloidosis (TTR-CA)] between January 2013 and March 2021. The baseline heart rate, the percentage of patients with a pseudo-infarct pattern, low-voltage pattern or cardiac conductions disturbances, and the impact of these factors on the need of pacemaker were analysed., Results: Fifty-eight patients with CA (20 with LA-CA and 38 with TTR-CA) were included, and the majority were male (69.0%). Twenty-one patients had atrial fibrillation (AF) at diagnosis. Thirty-five patients had a pseudo-infarct pattern, 35% had a low-voltage pattern, and 22% had criteria for ventricular hypertrophy. Two hirds had a conduction disorder: 18 patients with first degree atrioventricular block, 12 right bundle branch block, 3 left bundle branch block and 25 with a branch hemiblock. There were no differences between LA-CA and TTR-CA. Patients with TTR-CA had a greater need for pacemakers in the folow-up (39±40 meses). Bundle branch block was a predictor of the need for a permanent pacemaker (HR: 23.43; CI 95%: 4.09.134.09; P=.01)., Conclusions: Electrocardiographic abnormalities in patients diagnosed wich CA are heterogeneus. Most frecuent is the presence of conduction disorders, the pseudoinfarction pattern, followed by the low voltage pattern. Patients with any bundle branch block at the baseline electrocardiogram need more frecuent to require a pacemaker during follow-up, especially in TTR-CA., (Copyright © 2021 Elsevier España, S.L.U. All rights reserved.)

Background: Heart failure (HF) is one of the mayor contributors to cardiovascular morbidity and mortality in patients with diabetes. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have demonstrated to reduce the risk of hospitalization for HF in patients with type 2 diabetes mellitus (T2D). We aimed to assess the risk for re-hospitalization in a cohort of patients hospitalized for HF according to whether or not they received canagliflozin at discharge, as well as changes in N-terminal pro-B-type natriuretic peptide (NT-ProBNP) concentration during follow-up., Methods: We conducted a retrospective longitudinal study at a tertiary centre including 102 consecutive T2D patients discharged for acute HF without contraindication for SGLT2 inhibitors. We compared adverse clinical events (HF rehospitalization and cardiovascular death) and NT-ProBNP changes according to canagliflozin prescription at discharge., Results: Among the 102 patients included, 45 patients (44.1%) were prescribed canagliflozin and the remaining 57 (55.9%) were not prescribed any SGLT2 inhibitors (control group). After a median follow-up of 22 months, 45 patients (44.1%) were hospitalized for HF. Most of the rehospitalizations occurred during the first year (37.3%). HF readmission at first year occurred in 10 patients (22.2%) in the canagliflozin group and 29 patients (49.1%) in the control group (hazard ratio (HR): 0.45; 95% confidence interval (CI): 0.21-0.96; p < 0.039). A composite outcome of hospitalization for HF or death from cardiovascular causes was lower in the canagliflozin group (37.8%) than in the control group (70.2%) (HR: 0.51; 95% CI: 0.27-0.95; p < 0.035). Analysis of NT-ProBNP concentration showed an interaction between canagliflozin therapy and follow-up time ( p = 0.002)., Conclusions: Canagliflozin therapy at discharge was associated with a lower risk of readmission for HF and a reduction in NT-ProBNP concentration in patients with diabetes after hospitalization for HF.

To investigate the value of tissue Doppler velocities for ruling out treatment-requiring acute cellular rejection (TR-ACR), in the context of myocardial deformation analysis performed by means of speckle tracking echocardiography. We performed serial echocardiograms in 37 heart transplant recipients in their first year post-transplantation within 3 h of the routine surveillance endomyocardial biopsies (EMB). The association of the sum of lateral mitral annulus systolic (s') and early diastolic (e') velocities, in absolute values, measured by tissue Doppler echocardiography (s'+ e'), with TR-ACR (ACR grade ≥ 2R) was investigated by multivariate analysis, including classic echocardiographic parameters and myocardial deformation variables. A total of 251 pairs of EMB and echo exams were performed, 35 (14%) with rejection grade ≥ 2R (TR-ACR). s' + e' was independently associated to TR-ACR (OR 0.80, 95%CI 0.72-0.89, p < 0.0005), with a C statistic of 0.79 (95%CI 0.71-0.87, p < 0.0005) by ROC curve analysis. An  s'+ e' value ≥ 23 cm/s, present in 43% of studies, had a negative predictive value of 98% for ruling out TR-ACR. Moreover, in the same patients, s'+ e' significantly decreased when TR-ACR occurred after a study without this condition (- 3.7 ± 3.3 cm/s, p = 0.003), but it was similar when rejection status was the same in the present versus the previous study. A drop in s'+ e' value < 2.7 cm/s from the previous echocardiogram, had a 99% negative predictive value for ruling out TR-ACR. Tissue Doppler velocities, a widely available echo parameter, were found to be a valuable marker for ruling out TR-ACR in this multivariate study which included myocardial deformation variables.

Objectives: To compare the incidence of permanent pacemaker implantation (PPI) with the CoreValve and Evolut R prostheses, to evaluate the implantation depth with both types of prostheses, and to study factors predicting the need for PPI., Background: The Evolut R CoreValve can be recaptured and repositioned during deployment, allowing a more precise implantation., Methods: A total of 208 patients treated with CoreValve and 137 patients treated with Evolut R were analyzed. The depth of the prosthesis in the LVOT was measured by angiography in the annular perpendicular view projection after deploymen in all patients., Results: Baseline conduction abnormalities were comparable between the groups (85/208, 40.9% vs. 53/137, 38.7%; p = 0.69). The mean prosthesis depth was 10.3 ± 8.6 mm in the CoreValve group and 5.5 ± 2.7 mm in the Evolut R group; p < 0.0001. Conduction disturbances after valve implantation were more frequent with the CoreValve (new-onset left bundle branch block: 93, 44.7% vs. 16, 11.7%; p < 0.05, first-degree atrioventricular block: 23, 11.1% vs. 5, 3.6%; p < 0.05). In addition, the incidence of PPI was significantly lower with Evolut R (45, 21.6% vs. 15, 10.9%; p = 0.01). The predictors of the need for PPI were the mean depth of the prosthesis (OR: 1.13, 95% CI: 1.06-1.21; p < 0.0001) and prior right bundle branch block (OR 10.22, 95% CI: 4.62-22.63; p < 0.0001)., Conclusions: The recapturable capability of the Evolut R system allowed for higher and precise valve implantation. This fact had an impact on the reduction in the need for PPI., (© 2019 Wiley Periodicals, Inc.)

Purpose: Our objective was to investigate the impact of inter-vendor variability in the ability of myocardial strain analysis to detect acute cellular rejection (ACR) in heart transplant recipients., Methods: We performed serial echocardiographic examinations in 18 consecutive adult heart transplanted patients, in their first year post-transplantation, within 3 hours of the routine surveillance endomyocardial biopsies (EMB) in a single center. Myocardial strain was analyzed using two software in two different institutions, and inter-vendor variability of strain values and its association with ACR (any grade or grade ≥2R) was investigated. The parameter of comparison was the peak value of the average curve of strain during the entire cardiac cycle., Results: A total of 147 pairs of EMB-echocardiogram were performed, 65 with no ACR, 63 with ACR grade 1R, and 19 with ACR grade ≥2R. Intra-class correlation coefficients for left ventricle longitudinal, radial, and circumferential strain were 0.38, 0.39, and 0.77, respectively, and 0.32 for right ventricular longitudinal strain. Neither software found significant association of left ventricular longitudinal strain with rejection. Grade ≥2R ACR was associated with left ventricular circumferential strain measured with the first software and with left ventricular radial strain with the other; and ACR of any grade was only significantly associated with right ventricle longitudinal strain measured with the first software., Conclusions: Inter-vendor reproducibility of strain values was low in this study. Some strain parameters were associated to ACR, although these results were inconsistent between two commercially available software. Specific validation of each software is warranted for this clinical indication., (© 2019 Wiley Periodicals, Inc.)

Introduction and Objectives: Data are lacking on the long-term prognosis of stable ischemic heart disease (SIHD). Our aim was to analyze long-term survival in patients with SIHD and to identify predictors of mortality., Methods: A total of 1268 outpatients with SIHD were recruited in this single-center prospective cohort study from January 2000 to February 2004. Cardiovascular and all-cause death during follow-up were registered. All-cause and cardiovascular mortality rates were compared with those in the Spanish population adjusted by age, sex, and year. Predictors of these events were investigated., Results: The mean age was 68±10 years and 73% of the patients were male. After a follow-up lasting up to 17 years (median 11 years), 629 (50%) patients died. Independent predictors of all-cause mortality were age (HR, 1.08; 95%CI, 1.07-1.11; P <.001), diabetes (HR, 1.36; 95%CI, 1.14-1.63; P <.001), resting heart rate (HR, 1.01; 95%CI, 1.00-1.02; P <.001), atrial fibrillation (HR, 1.61; 95%CI, 1.22-2.14; P=.001), electrocardiographic changes (HR, 1.23; 95%CI, 1.02-1.49; P=.02) and active smoking (HR, 1.85; 95%CI, 1.31-2.80; P=.001). All-cause mortality and cardiovascular mortality rates were significantly higher in the sample than in the general Spanish population (47.81/1000 patients/y vs 36.29/1000 patients/y (standardized mortality rate, 1.31; 95%CI, 1.21-1.41) and 15.25/1000 patients/y vs 6.94/1000 patients/y (standardized mortality rate, 2.19; 95%CI, 1.88-2.50, respectively)., Conclusions: The mortality rate was higher in this sample of patients with SIHD than in the general population. Several clinical variables can identify patients at higher risk of death during follow-up., (Copyright © 2018 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Cellular therapies have been increasingly applied to diverse human diseases. Intracoronary infusion of bone marrow-derived mononuclear cells (BMMNC) has demonstrated to improve ventricular function after acute myocardial infarction. However, less information is available about the role of BMMNC therapy for the treatment of dilated myocardiopathies (DCs) of non-ischemic origin. This article presents the methodological description of a study aimed at investigating the efficacy of intracoronary injection of autologous BMMNCs in the improvement of the ventricular function of patients with DC., Methods: This randomised, placebo-controlled, double-blinded phase IIb clinical trial compares the improvement on ventricular function (measured by the changes on the ejection fraction) of patients receiving the conventional treatment for DC in combination with a single dose of an intracoronary infusion of BMMNCs, with the functional recovery of patients receiving placebo plus conventional treatment. Patients assigned to both treatment groups are monitored for 24 months. This clinical trial is powered enough to detect a change in Left Ventricular Ejection Fraction (LVEF) equal to or greater than 9%, although an interim analysis is planned to re-calculate sample size., Discussion: The study protocol was approved by the Andalusian Coordinating Ethics Committee for Biomedical Research (Comité Coordinador de Ética en Investigación Biomédica de Andalucia), the Spanish Medicines and Medical Devices Agency (Agencia Española de Medicamentos y Productos Sanitarios), and is registered at the EU Clinical Trials Register (EudraCT: 2013-002015-98). The publication of the trial results in scientific journals will be performed in accordance with the applicable regulations and guidelines to clinical trials., Trial Registration: ClinicalTrials.gov Identifier NCT02033278 (First Posted January 10, 2014): https://clinicaltrials.gov/ct2/show/NCT02033278 ; EudraCT number: 2013-002015-98, EU CT Register: https://www.clinicaltrialsregister.eu/ctr-search/search?query=2013-002015-98 . Trial results will also be published according to the CONSORT statement at conferences and reported peer-reviewed journals.

Aims: To determine the impact of permanent cardiac pacing after transcatheter aortic valve implantation (TAVI) with the CoreValveTM prosthesis in terms of all-cause mortality and morbidity [rehospitalizations for heart failure (HF) or stroke] at the long-term follow-up., Methods and Results: The prospective analysis comprised 259 patients (138 women, 53.3%, age 78 ± 6 years) treated by a CoreValveTM prosthesis from April 2008 to December 2015. Forty-two patients were excluded for analysis: 9 with pre-existing permanent pacemaker (PPM) implantation, 19 who required a PPM during the follow-up and 14 patients because of hospital mortality during or after the CoreValveTM prosthesis implantation procedure. The remaining 217 patients were divided in two groups: Group-1 included those patients who required a PPM immediately after TAVI, and Group-2 included those patients who did not require permanent cardiac pacing at the long-term follow-up. Patients received follow-up at 1-month, 6-months, 12-months, and yearly thereafter. A total of 39 patients required a PPM immediately after TAVI (15.0%), but 178 patients (68.7%) did not. The mean follow-up was 37 ± 27 months (range 3-99 months) in both groups. There was no difference between the two groups in terms of all-cause mortality (52.6% vs. 56.8%, P = 0.125; HR 1.22 [0.87-1.77, 95% CI]), or stroke (13.3% vs. 15.1% P = 0.842; HR 1.12 [0.37-3.32, 95% CI]). However, patients who underwent PPM implantation developed an increase in readmissions for HF (21.1% vs. 31.9%, P = 0.015; HR 1.82 [1.23-3.92, 95% CI])., Conclusion: Patients requiring a PPM after TAVI did not have an increase in mortality, or an increase in the likelihood of developing a stroke at a long-term follow-up. However, this subgroup of patients showed an increase in rehospitalization due to HF at medium- and long-term 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., (Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

New-onset conduction disturbances are common after transcatheter aortic valve implantation (TAVI). The most common complication is left bundle branch block (LBBB). The clinical impact of new-onset LBBB after TAVI remains controversial. The aim of this study was to analyze the clinical impact of new-onset LBBB in terms of mortality and morbidity (need for pacemakers and admissions for heart failure) at long-term follow-up. From April 2008 to December 2014, 220 patients who had severe aortic stenosis were treated with the implantation of a CoreValve prosthesis. Sixty-seven of these patients were excluded from the analysis, including 22 patients with pre-existing LBBB and 45 with a permanent pacemaker, implanted previously or within 72 hours of implantation. The remaining 153 patients were divided into 2 groups: group 1 (n = 80), those with persistent new-onset LBBB, and group 2 (n = 73), those without conduction disturbances after treatment. Both groups were followed up at 1 month, 6 months, 12 months, and yearly thereafter. Persistent new-onset LBBB occurred in 80 patients (36%) immediately after TAVI; 73 patients (33%) did not develop conduction disturbances. The mean follow-up time of both groups was 32 ± 22 months (range 3 to 82 months), and there were no differences in time between the groups. There were no differences in mortality between the groups (39% vs 48%, p = 0.58). No differences were observed between the groups in re-hospitalizations for heart failure (11% vs 16%, p = 0.55). Group 1 did not require pacemaker implantation more often at follow-up (10% vs 13%, p = 0.38) than group 2. In conclusion, new-onset LBBB was not associated with a higher incidence of late need for a permanent pacemaker after CoreValve implantation. In addition, it was not associated with a higher risk of late mortality or re-hospitalization., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction and Objectives: Conduction disturbances often occur after CoreValve transcatheter aortic valve implantation. The aim was to analyze which cardiac conduction changes occur in patients with aortic stenosis treated with this type of prosthesis., Methods: A total of 181 patients with severe aortic stenosis treated with this prosthesis and studied by electrocardiography between April 2008 and December 2013 were selected. A subgroup of 137 (75.7%) consecutive patients was studied by intracardiac electrocardiogram before and after prosthesis implantation. The primary endpoint of the study was the need for a permanent pacemaker within 72 hours after prosthesis implantation. Numerous variables to predict this possibility were analyzed., Results: Following implantation, PR and QRS intervals were increased from 173±47 ms to 190±52ms (P < .01) and from 98±22ms to 129±24 ms (P < .01), whereas the A-H and H-V intervals were prolonged from 95±39ms to 108±41ms (P < .01) and from 54±10ms to 66±23ms (P < .01). A total of 89 (49%) patients had new-onset left bundle-branch block, and 33 (25%) required a pacemaker within the first 72hours. The independent predictors for a pacemaker were baseline right bundle-branch block and prosthetic depth. Intracardiac intervals had no predictive value. In addition, 13 patients required a pacemaker after 72 hours., Conclusions: CoreValve prosthesis implantation has a high incidence of conduction disturbance, with left bundle-branch block being the most common. A total of 25% of patients required a permanent pacemaker. The need for a pacemaker was related to baseline right bundle-branch block and prosthetic depth., (Copyright © 2015 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: This study sought to determine whether several anatomic or evolving characteristics of the coarctation may create challenging conditions for treatment., Background: Stent repair of coarctation of aorta is an alternative to surgical correction., Methods: We analyzed our 21-year experience in the percutaneous treatment of complex coarctation of aorta. Adverse conditions for treatment were as follow: 1) complete interruption of the aortic arch (n = 11); 2) associated aneurysm (n = 18); 3) complex stenosis (n = 30); and 4) the need for re-expansion and/or restenting (n = 21). Twenty patients (33%) belonged to more than 1 group. Ten interruptions were type A and 1 was type B. The mean length of the interrupted aorta was 9 ± 11 mm. The associated aneurysms were native in 8 patients and after previous intervention in 10 patients. Aneurysm shapes were fusiform in 8 patients and saccular in 10. The following characteristics defined complex stenosis as long diffuse stenosis, very tortuous coarctation, or stenosis involving a main branch or an unusual location. Patients previously stented at an early age, required re-expansion and/or restenting after reaching 16 ± 5 years of age., Results: Two patients had died by 1-month follow-up. The remaining 58 patients did well and were followed-up for a mean period of 10 ± 6 years. Late adverse events occurred in 3 patients (5%). All remaining patients are symptom-free, with normal baseline blood pressure. Imaging techniques revealed good patency at follow-up without associated aneurysm or restenosis. The actuarial survival free probability of all complex patients at 15 years was 92%., Conclusions: Stent repair of complex coarctation of aorta is feasible and safe. Initial results are maintained at later follow-up., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Mitral regurgitation (MR) is a complication that may occur during transcatheter aortic valve implantation (TAVI) in a certain percentage of cases and may require different treatments depending on the mechanism. Our purpose was to describe the occurrence rate of this complication during TAVI with the CoreValve prosthesis, as well as to assess the usefulness of transesophageal echocardiogram (TEE) in the detection of the mechanism of MR., Methods and Results: We analyzed a total of 129 cases of severe aortic stenosis treated with CoreValve prosthesis from June 2008 to October 2011. We defined a significant MR after TAVI as grade III MR or higher, considering either the new appearance of MR or the worsening of a preexisting MR, as assessed by both TEE and angiography. In our series, there was a total of 11 cases of significant MR after TAVI (8.5%). Angiography detected 100% of the MR cases, but was unable to determine the mechanism of MR in any case. TEE, on the other hand, determined 100% of the MR cases, and determined that 1 case was caused by mechanical asynchrony due to a new left bundle branch block, 3 cases were due to an aortic prosthesis impingement on the anterior mitral leaflet, 2 cases were due to the appearance of a systolic anterior movement of the anterior mitral leaflet with dynamic obstruction of the left ventricular outflow tract, 1 case was caused by a commissural tearing of the valve, and 4 cases were explained by a "functional" mechanism, probably due to transient damage of the subvalvular mitral apparatus by the delivery system. All cases had an MR grade II or less as evidenced by transthoracic echocardiography at discharge. Surgery was not required in any case. Knowledge of the mechanism of MR made it possible to provide the best treatment option in each case., Conclusion: There is a certain percentage of patients treated with CoreValve prosthesis who develop significant MR during the procedure. TEE, unlike angiography, can define the very diverse mechanisms of MR in 100% of cases, and elucidates the best approach to this complication. Surgery was not required in any case.

Purpose: We aimed to analyze the feasibility of two-dimensional speckle-tracking echocardiography (2DSTE) in evaluating myocardial strain in consecutive, nonselected patients in daily clinical practice., Methods: Strain analysis using 2DSTE was attempted in 59 consecutive patients: 24 patients with severe aortic stenosis, 28 patients with dilated cardiomyopathy, and 7 healthy controls. The analysis was done by four expert echocardiographers and one cardiology resident., Results: It was possible to obtain reliable data for radial strain in 175 of 354 segments (49%), circumferential strain in 192 of 354 segments (54%), and longitudinal strain in 319 of 354 segments (90%). Experienced echocardiographers felt assessment of radial and circumferential strain was appropriate in more segments than did the cardiology resident (57% and 58% vs. 23% and 40%, respectively, P < 0.01)., Conclusion: Longitudinal strain analysis with 2DSTE is feasible in most segments, but the radial and circumferential strain evaluation was only feasible in approximately half of the patients., (© 2012, Wiley Periodicals, Inc.)