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Introduction and Objective: Transcatheter aortic valve implantation (TAVI) is an alternative therapeutic approach to patients not considered suitable for surgical aortic valve replacement (SAVR) due to their high operative risk. We sought to assess the impact of TAVI on the profile and operative results of patients with severe aortic stenosis undergoing SAVR. Methods: A total of 214 patients were included, of whom 103 consecutive patients underwent isolated SAVR in 2005 and 111 in 2009. Patients’ demographic and operative data were collected retrospectively. Operative and one-year mortality and morbidity were analyzed. Results: Patients’ mean age was 70 years, and 56% were female. Following the introduction of a TAVI program, patients undergoing conventional surgery were older, with more comorbidities. Overall 30-day and one-year mortality were 2.8% and 7.0%, respectively. After the introduction of TAVI, the observed mortality rate for SAVR decreased, but not significantly (operative mortality: 3.9% before TAVI vs. 1.8% after TAVI, p=NS; one-year mortality: 10% vs. 4.5%, p=NS). Striking differences were observed in morbidity (operative morbidity: 23.3% before TAVI vs. 13.5% after TAVI, p=0.047, and one-year morbidity: 20.4% vs. 9.9%, p=0.032). Conclusions: Since the introduction of a TAVI program at our center, the number of patients undergoing SAVR has increased, with a slight rise in surgical risk, but without worsening the final operative results. The implementation of a TAVI program has thus had a positive impact on the volume of procedures, patient selection and outcomes in SAVR. Resumo: Introdução e objetivo: A implantação percutânea de próteses valvulares aórticas (TAVI) é uma alternativa terapêutica na abordagem dos doentes com estenose aórtica severa (EA) inoperáveis. Pretendeu-se avaliar o impacto do programa de TAVI no perfil dos doentes com EA submetidos a cirurgia de substituição valvular aórtica (AVR) isolada e nos resultados obtidos a curto e médio prazo. Métodos: Incluídos 214 doentes consecutivamente operados, dos quais 103 foram operados em 2005 e 111 em 2009, respetivamente, dois anos antes e dois anos após o início da TAVI no nosso centro. Os dados clínicos foram retrospetivamente extraídos. Analisados eventos de morbi-mortalidade no período pós-operatório e ao primeiro ano de seguimento. Resultados: A idade média dos doentes foi de 70 anos e a maioria do sexo feminino (56%). Na era pós-TAVI, foram operados doentes tendencialmente mais velhos e com mais comorbilidades. As mortalidades operatórias ao primeiro ano observadas foram de 2,8 e 7%. Após a introdução da TAVI, a mortalidade diminuiu, sem atingir significância estatística (mortalidade operatória: 3,9% pré-TAVI versus 1,8% pós-TAVI, p = ns e mortalidade no primeiro ano: 10 versus 4,5%, p = ns) e os indicadores de morbilidade melhoraram significativamente (morbilidade operatória: 23,3% pré-TAVI versus 13,5% pós-TAVI, p = 0,047 e morbilidade ao primeiro ano: 20,4 versus 9,9%, p = 0,032). Conclusões: Desde o início do programa de TAVI no nosso centro, o volume de AVR aumentou e foram operados doentes com pior perfil de risco, sem prejuízo dos indicadores de morbi-mortalidade. Teve assim um impacto positivo no volume de cirurgias realizadas, na seleção dos doentes operados e nos resultados obtidos. Keywords: Aortic stenosis, Surgical aortic valve replacement, Transcatheter aortic valve implantation, Palavras-chave: Estenose aórtica severa, Cirurgia de substituição valvular aórtica, Implantação percutânea de próteses valvulares aórticas

Resumo: Introdução e objetivo: A implantação percutânea de próteses valvulares aórticas (TAVI) é uma alternativa terapêutica na abordagem dos doentes com estenose aórtica severa (EA) inoperáveis. Pretendeu-se avaliar o impacto do programa de TAVI no perfil dos doentes com EA submetidos a cirurgia de substituição valvular aórtica (AVR) isolada e nos resultados obtidos a curto e médio prazo. Métodos: Incluídos 214 doentes consecutivamente operados, dos quais 103 foram operados em 2005 e 111 em 2009, respetivamente, dois anos antes e dois anos após o início da TAVI no nosso centro. Os dados clínicos foram retrospetivamente extraídos. Analisados eventos de morbi-mortalidade no período pós-operatório e ao primeiro ano de seguimento. Resultados: A idade média dos doentes foi de 70 anos e a maioria do sexo feminino (56%). Na era pós-TAVI, foram operados doentes tendencialmente mais velhos e com mais comorbilidades. As mortalidades operatórias ao primeiro ano observadas foram de 2,8 e 7%. Após a introdução da TAVI, a mortalidade diminuiu, sem atingir significância estatística (mortalidade operatória: 3,9% pré-TAVI versus 1,8% pós-TAVI, p = ns e mortalidade no primeiro ano: 10 versus 4,5%, p = ns) e os indicadores de morbilidade melhoraram significativamente (morbilidade operatória: 23,3% pré-TAVI versus 13,5% pós-TAVI, p = 0,047 e morbilidade ao primeiro ano: 20,4 versus 9,9%, p = 0,032). Conclusões: Desde o início do programa de TAVI no nosso centro, o volume de AVR aumentou e foram operados doentes com pior perfil de risco, sem prejuízo dos indicadores de morbi-mortalidade. Teve assim um impacto positivo no volume de cirurgias realizadas, na seleção dos doentes operados e nos resultados obtidos. Abstract: Introduction and objective: Transcatheter aortic valve implantation (TAVI) is an alternative therapeutic approach to patients not considered suitable for surgical aortic valve replacement (SAVR) due to their high operative risk. We sought to assess the impact of TAVI on the profile and operative results of patients with severe aortic stenosis undergoing SAVR. Methods: A total of 214 patients were included, of whom 103 consecutive patients underwent isolated SAVR in 2005 and 111 in 2009. Patients’ demographic and operative data were collected retrospectively. Operative and one-year mortality and morbidity were analyzed. Results: Patients’ mean age was 70 years, and 56% were female. Following the introduction of a TAVI program, patients undergoing conventional surgery were older, with more comorbidities. Overall 30-day and one-year mortality were 2.8% and 7.0%, respectively. After the introduction of TAVI, the observed mortality rate for SAVR decreased, but not significantly (operative mortality: 3.9% before TAVI vs. 1.8% after TAVI, p=NS; one-year mortality: 10% vs. 4.5%, p=NS). Striking differences were observed in morbidity (operative morbidity: 23.3% before TAVI vs. 13.5% after TAVI, p=0.047, and one-year morbidity: 20.4% vs. 9.9%, p=0.032). Conclusions: Since the introduction of a TAVI program at our center, the number of patients undergoing SAVR has increased, with a slight rise in surgical risk, but without worsening the final operative results. The implementation of a TAVI program has thus had a positive impact on the volume of procedures, patient selection and outcomes in SAVR. Palavras-chave: Estenose aórtica severa, Cirurgia de substituição valvular aórtica, Implantação percutânea de próteses valvulares aórticas, Keywords: Aortic stenosis, Heart valve prosthesis implantation, Transcatheter aortic valve implantation

Background A permanent pacemaker (PPM) implantation is common after transcatheter aortic valve implantation (TAVI). We sought to evaluate requirements of pacing and incidence of pacemaker dependency during the first year after TAVI. Methods From August 2007 until May 2011, 65 patients underwent TAVI with self-expandable prosthesis. Five patients paced at baseline and two procedure-related deaths were excluded. Evaluation of ventricular pacing percentage (VP%) and look for spontaneous rhythm were performed at 3, 6, and 12 months. Results PPM implantation was required in 19/58 patients (33%). Mean VP% decreased between assessments (59% at 3 months, 48% at 6 months, 50% at 12 months), but overall VP% at 1 year was high (57% ± 43%) and most patients were paced ≥10% of time. A favorable annulus-to-aorta angle was associated with lower pacing requirements (60% of patients paced ≤10% of time vs 10% of patients paced >10% of time presented an angle ≤30⁰, P = 0.039). Pacemaker dependency was established in 27% of patients and could be predicted by the presence of porcelain aorta (odds ratio = 30, confidence interval 95% 1–638, P = 0.029). New postprocedural left bundle branch block (LBBB) had a negative impact on 1-year survival (58% vs 82% in non-LBBB group, P = 0.111). PPM implantation had no impact on 1-year survival. Conclusions One third of patients required PPM after TAVI and full recovery of advanced conduction abnormalities seems unlikely. Unfavorable aortic root orientation may hinder the deployment of the valve and contribute to the continued impairment of the conduction system. Porcelain aorta was a strong predictor of pacemaker dependency.

Resumo: A não compactação isolada do ventrículo esquerdo (NCIVE) é uma cardiomiopatia rara, caracterizada pela presença de trabeculações miocárdicas proeminentes e recessos intertrabeculares profundos que comunicam com a cavidade ventricular. A existência de diferentes critérios de diagnóstico, bem como a ausência de recomendações consensuais relativas à sua terapêutica, têm contribuído para que sejam descritas séries de doentes com características clínicas e prognósticos distintos, o que dificulta o reconhecimento da verdadeira história natural desta patologia. Este trabalho tem por objetivo contribuir para a caracterização da NCIVE, através da descrição de uma população afetada, no que se refere à sua apresentação clínica, diagnóstico, estratificação de risco, terapêutica instituída e seguimento. A propósito da revisão dos casos, é feita uma discussão da literatura atual mais relevante acerca do tema. Abstract: Isolated left ventricular noncompaction (LVNC) is a rare cardiomyopathy characterized by excessive and prominent trabeculations associated with deep recesses that communicate with the ventricular cavity. Determining the natural history of this condition has been hampered by differences in clinical features and prognosis in published series, which are partly the result of differing diagnostic criteria and the lack of management guidelines. This work aims to contribute to the characterization of isolated LVNC by analyzing an affected population in terms of clinical presentation, diagnosis, risk stratification, treatment and follow-up. We also discuss the most relevant data from the literature concerning this cardiomyopathy. Palavras-chave: Não compactação isolada do ventrículo esquerdo, Cardiomiopatia, Diagnóstico, Terapêutica, Prognóstico, Keywords: Isolated left ventricular noncompaction, Cardiomyopathy, Diagnosis, Therapy, Prognosis

Background Preliminary studies have shown the potential of myocardial computed tomography perfusion (CTP) analysis for ischemia detection in both animals and humans. Objective To provide validation data on stress-rest CTP protocols as additive tools to improve the accuracy of multidetector computed tomography (MDCT) for coronary artery disease (CAD) in symptomatic patients. Methods Ninety symptomatic patients with suspected CAD (62 ± 8 years, 66% males) underwent both MDCT and invasive coronary angiography (XA). The MDCT protocol included a prospective calcium score acquisition, a helical acquisition with retrospective gating during infusion of adenosine (140 μg/kg/min) and a prospective scan for computed tomography angiography (CTA) at rest (total effective radiation dose: 5.1 ± 0.8 mSv). Significant and higher-grade CADs were defined by the presence of ≥50% or ≥70% stenosis in at least one coronary artery, as evaluated by quantitative coronary angiography (QCA) using XA images. Results On a patient-based model, CTA sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) to detect ≥50% or ≥70% stenosis were 98%, 71%, 80%, and 97% (global accuracy 86%) and 100%, 60%, 64%, and 100% (accuracy 77%), respectively. An integrative approach of CTA and CTP results had the best performance for detection of CAD with sensitivity of 83%, specificity of 98%, PPV of 98%, and NPV of 84% (accuracy 84%) for detection of 50% stenosis and 97%, 90%, 88%, and 98% (accuracy 93%), respectively, for the 70% threshold. The integration of results had the best overall performance in all scenarios but was particularly advantageous in the prediction of higher-grade CAD, with an area under the curve of 0.93, compared with 0.80 for isolated CTA and 0.82 for CTP and in patients with severe calcifications (sensitivity 92%, specificity 87%, overall accuracy of 90%). Conclusions The integration of functional and morphological data using CTA and CTP improved MDCT accuracy for detection of clinically relevant CAD at both thresholds of 50% and 70% in this intermediate to high pretest probability population.

Background: Previous reports have suggested the occurrence of cardiac conduction disorders and permanent pacemaker (PPM) requirement after transcatheter aortic valve implantation (TAVI). Based on a single-center experience, we aim to assess the incidence of postprocedural conduction disorders, need for PPM, and its determinants after TAVI with a self-expanding bioprosthesis. Methods: From August 2007 to October 2009, 32 consecutive patients underwent TAVI with the Medtronic CoreValve (MCV) System (Medtronic Inc., Minneapolis, MN, USA). Three patients paced at baseline and two cases of procedure-related mortality were excluded. We analyzed the 12-lead electrocardiogram at baseline, immediately after procedure and at discharge. Requirements for PPM were documented and potential clinical, electrophysiological, echocardiographic, and procedural predictors of PPM requirement were studied. Results: After TAVI, eight patients (29.6%) required PPM implantation due to high-grade atrioventricular (AV) block. The prevalence of left bundle branch block increased from 13.8% to 57.7% directly after implantation (P = 0.001). Need for PPM was correlated to the depth of prosthesis implantation (r = 0.590; P = 0.001). At a cutoff point of 10.1 mm, the likelihood of pacemaker could be predicted with 87.5% sensitivity and 74% specificity and a receiver operator characteristic curve area of 0.86 ± 0.07 (P = 0.003). Of the seven patients with preexisting right bundle branch block (RBBB), four (57.1%) required PPM implantation after TAVI. Conclusions: High-grade AV block requiring PPM implantation is a common complication following TAVI and could be predicted by a deeper implantation of the prosthesis. Patients with preexisting RBBB also seem to be at risk for the development of high-grade AV block and subsequent pacemaker implantation. (PACE 2010; 1364–1372)

Background A multiple-test strategy in often needed in the evaluation of patients (pts) with suspected coronary artery disease (CAD). Cardiac magnetic resonance (CMR) has potential advantages in this context allowing simultaneous evaluation of ventricular function, myocardial perfusion and scar detection with high spatial resolution and no ionizing radiation exposure. We aimed to compare the diagnostic accuracy of adenosine stress CMR myocardial perfusion imaging (CMR-MPI) with exercise treadmill test (ETT) for detection of CAD using invasive fractional flow reserve (FFR) as the reference standard, and to assess the best performing diagnostic algorithm using these tests in patients with suspected CAD.

Cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI) is considered a state-of-the-art non-invasive modality for ischemia detection but its additive value in a multiple-test strategy in patients with suspected coronary artery disease (CAD) is not fully validated. We aimed to evaluate CMR-MPI integration with exercise treadmill test (ETT) for the diagnostic workup of patients with suspected CAD, having invasive fractional flow reserve (FFR) as reference standard.In this prospective single-center study, patients with suspected CAD underwent sequential ETT, CMR-MPI and X-ray invasive coronary angiography (XA). Significant CAD was defined by the presence of stenosis40% with FFR ≤ 0.8 in vessels2 mm or ≥90% stenosis/occlusion.80 symptomatic patients (68% male, 61 ± 8 years) were enrolled. Compared to ETT, CMR-MPI showed similar sensitivity (81%) and higher specificity (93 vs. 58%, p0.001) for CAD detection (prevalence = 46%) translating into better diagnostic performance (AUC 0.87 vs. 0.70; p = 0.002). CMR-MPI improved accuracy independently of ETT in all patients with high pre-test probability and in intermediate-probability patients but those with a clearly positive-ETT (symptoms + ST-shift), in whom ETT correctly identified CAD. In the low-probability group CMR-MPI was useful as a gatekeeper for XA after a positive-ETT. The best integrating protocol achieved a global accuracy of 89% (AUC 0.88) and was clearly superior to an approach based solely in ETT (AUC 0.70, p0.001), yet similar to isolated CMR-MPI (AUC 0.87, p = ns).CMR-MPI has high sensitivity and specificity for CAD detection and may be combined with ETT in a diagnostic workflow aiming to increase accuracy and reduce the number of unnecessary catheterizations.

A permanent pacemaker (PPM) implantation is common after transcatheter aortic valve implantation (TAVI). We sought to evaluate requirements of pacing and incidence of pacemaker dependency during the first year after TAVI.From August 2007 until May 2011, 65 patients underwent TAVI with self-expandable prosthesis. Five patients paced at baseline and two procedure-related deaths were excluded. Evaluation of ventricular pacing percentage (VP%) and look for spontaneous rhythm were performed at 3, 6, and 12 months.PPM implantation was required in 19/58 patients (33%). Mean VP% decreased between assessments (59% at 3 months, 48% at 6 months, 50% at 12 months), but overall VP% at 1 year was high (57% ± 43%) and most patients were paced ≥10% of time. A favorable annulus-to-aorta angle was associated with lower pacing requirements (60% of patients paced ≤10% of time vs 10% of patients paced10% of time presented an angle ≤30⁰, P = 0.039). Pacemaker dependency was established in 27% of patients and could be predicted by the presence of porcelain aorta (odds ratio = 30, confidence interval 95% 1-638, P = 0.029). New postprocedural left bundle branch block (LBBB) had a negative impact on 1-year survival (58% vs 82% in non-LBBB group, P = 0.111). PPM implantation had no impact on 1-year survival.One third of patients required PPM after TAVI and full recovery of advanced conduction abnormalities seems unlikely. Unfavorable aortic root orientation may hinder the deployment of the valve and contribute to the continued impairment of the conduction system. Porcelain aorta was a strong predictor of pacemaker dependency.

Background Cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI) is considered a state of the art non-invasive modality for the detection of reversible ischemia. Recent studies have shown its utility in the diagnosis of coronary artery disease (CAD) and superiority over other established techniques. However, only a few studies compared CMR-MPI against the invasive standard including fractional flow reserve (FFR) and clinical validation in non-specialized centers is scarce. The aim of this study was to validate CMR-MPI in a real-world clinical environment and to test its diagnostic accuracy in symptomatic patients with suspected CAD versus FFR as the reference standard of functionally significant disease. Methods and results 103 symptomatic consecutive patients (62±8.0years, 66% males) with suspected CAD and intermediate or high probability of disease underwent sequential CMR and invasive coronary angiography (XA). The CMR protocol included stress-rest adenosine perfusion, SSFP cine imaging and late-enhancement imaging. Functionally significant CAD was defined as occlusive/sub-occlusive stenoses on XA or non-occlusive stenoses with a FFR measurement of 2mm. On a patient-based model, CMR-MPI had sensitivity, specificity, positive and negative predictive values of 89%, 88%, 85%, and 91%, respectively, with a global accuracy of 88%. On a vessel-based analysis, these values were 80%, 93%, 79% and 94%, respectively, with a global accuracy of 90%. Conclusions CMR-MPI had a very high accuracy for detection of functionally significant CAD as assessed by FFR in patients with intermediate to high pretest probability.

The Parachute is a novel left ventricular (LV) partitioning device that is deployed percutaneously in the left ventricle in patients with anteroapical regional wall motion abnormalities, dilated LV and systolic dysfunction after anterior myocardial infarction (MI). The implantable device is a partitioning membrane that isolates the dysfunctional region of the ventricle and decreases chamber volume.Data from the first-in-human clinical trial – the Percutaneous Ventricular Restoration in Chronic Heart Failure (PARACHUTE) trial– has shown that this new device is associated with significant and sustained LV volume reduction and improvement in LV hemodynamics and functional capacity in the 12 months after implantation, with a relatively low rate of clinical events, indicating that it may have a beneficial effect in the treatment of ischemic heart failure.We aim to describe our initial experience with implantation of the Parachute LV partitioning device and its short-term safety, defined as the successful delivery and deployment of the device. Resumo: O dispositivo Parachute é um dispositivo inovador, implantado percutaneamente no ápex do ventrículo esquerdo (VE) em doentes com discinésia ou acinésia antero-apical, dilatação e disfunção sistólica do VE, no decurso de um enfarte do miocárdio envolvendo a artéria descendente anterior esquerda. O dispositivo corresponde a uma membrana de partição, desenhada de forma a isolar a região acinética ou discinética e reduzir o volume do VE.O estudo piloto - the Percutaneous Ventricular Restoration in Chronic Heart Failure (PARACHUTE) trial - mostrou que o dispositivo está associado a uma redução significativa e sustentada do volume do VE, com melhoria hemodinâmica e da capacidade funcional. Estes resultados positivos mantiveram-se durante os 12 meses após a implantação, com uma taxa relativamente baixa de eventos adversos relacionados com o dispositivo. Estes dados indicam que o dispositivo Parachute poderá ser benéfico no tratamento de doentes com insuficiência cardíaca com dilatação e disfunção sistólica do VE secundária a cardiopatia isquémica.Os autores pretendem demonstrar a experiência inicial com a implantação do dispositivo, assim como a segurança do mesmo a curto-prazo relativamente à entrega e deposição do dispositivo no ápex do VE. Keywords: Heart failure, Left ventricular remodeling, Anterior myocardial infarction, Anteroapical wall motion dysfunction, Parachute left ventricular partitioning device, Palavras-chave: Insuficiência cardíaca, Remodelação ventricular, Enfarte agudo do miocárdio da parede anterior, Alterações cinética segmentar antero-apical, Dispositivo de partição ventricular

Isolated left ventricular noncompaction (LVNC) is a rare cardiomyopathy characterized by excessive and prominent trabeculations associated with deep recesses that communicate with the ventricular cavity. Determining the natural history of this condition has been hampered by differences in clinical features and prognosis in published series, which are partly the result of differing diagnostic criteria and the lack of management guidelines. This work aims to contribute to the characterization of isolated LVNC by analyzing an affected population in terms of clinical presentation, diagnosis, risk stratification, treatment and follow-up. We also discuss the most relevant data from the literature concerning this cardiomyopathy. Resumo: A não compactação isolada do ventrículo esquerdo (NCIVE) é uma cardiomiopatia rara, caracterizada pela presença de trabeculações miocárdicas proeminentes e recessos intertrabeculares profundos que comunicam com a cavidade ventricular. A existência de diferentes critérios de diagnóstico, bem como a ausência de recomendações consensuais relativas à sua terapêutica, têm contribuído para que sejam descritas séries de doentes com características clínicas e prognósticos distintos, o que dificulta o reconhecimento da verdadeira história natural desta patologia. Este trabalho tem por objetivo contribuir para a caracterização da NCIVE, através da descrição de uma população afetada, no que se refere à sua apresentação clínica, diagnóstico, estratificação de risco, terapêutica instituída e seguimento. A propósito da revisão dos casos, é feita uma discussão da literatura atual mais relevante acerca do tema. Keywords: Isolated left ventricular noncompaction, Cardiomyopathy, Diagnosis, Therapy, Prognosis, Palavras-chave: Não compactação isolada do ventrículo esquerdo, Cardiomiopatia, Diagnóstico, Terapêutica, Prognóstico

We report the case of a 77-year-old man with heart failure (NYHA class IV), angina (CCS class III) and multiple comorbidities. The evaluation showed severe aortic sten osis and left main coronary disease. Due to the very high perioperative risk, conventional surgery was denied. It was therefore decided to perform a combined percutaneous intervention. First, left main PCI was successfully performed. A few days later, a percutaneous aortic valve prosthesis was implanted via a femoral approach using the CoreValve ReValving system. Immediately after prosthesis implantation, the control angiogram showed severe paravalvular aortic regurgitation, which was corrected by implanting another percutaneous aortic prosthesis inside the first one (valve-in-valve procedure). During follow-up the patient experienced a remarkable improvement in hemodynamic and clinical status. We demonstrate that the combination of two different percutaneous interventions in severe aortic and coronary disease is feasible and can be a suitable alternative approach in high surgical risk patients.

Previous reports have suggested the occurrence of cardiac conduction disorders and permanent pacemaker (PPM) requirement after transcatheter aortic valve implantation (TAVI). Based on a single-center experience, we aim to assess the incidence of postprocedural conduction disorders, need for PPM, and its determinants after TAVI with a self-expanding bioprosthesis.From August 2007 to October 2009, 32 consecutive patients underwent TAVI with the Medtronic CoreValve (MCV) System (Medtronic Inc., Minneapolis, MN, USA). Three patients paced at baseline and two cases of procedure-related mortality were excluded. We analyzed the 12-lead electrocardiogram at baseline, immediately after procedure and at discharge. Requirements for PPM were documented and potential clinical, electrophysiological, echocardiographic, and procedural predictors of PPM requirement were studied.After TAVI, eight patients (29.6%) required PPM implantation due to high-grade atrioventricular (AV) block. The prevalence of left bundle branch block increased from 13.8% to 57.7% directly after implantation (P = 0.001). Need for PPM was correlated to the depth of prosthesis implantation (r = 0.590; P = 0.001). At a cutoff point of 10.1 mm, the likelihood of pacemaker could be predicted with 87.5% sensitivity and 74% specificity and a receiver operator characteristic curve area of 0.86 ± 0.07 (P = 0.003). Of the seven patients with preexisting right bundle branch block (RBBB), four (57.1%) required PPM implantation after TAVI.High-grade AV block requiring PPM implantation is a common complication following TAVI and could be predicted by a deeper implantation of the prosthesis. Patients with preexisting RBBB also seem to be at risk for the development of high-grade AV block and subsequent pacemaker implantation.

Background— Multislice computed tomography (MSCT) has shown high negative predictive value in ruling out obstructive coronary artery disease. Preliminary studies in patients with valvular heart disease (VHD) have demonstrated the potential of MSCT angiography (CTA) in such patients, precluding need for invasive angiography (XA). However, larger prospectively designed studies, including patients with atrial fibrillation and incorporating dose reduction algorithms, are needed. Methods and Results— To evaluate the clinical utility of 64-slice CT in the preoperative assessment in patients with VHD, we prospectively studied 452 consecutive patients undergoing routine cardiac catheterization for eligibility. Two hundred thirty-seven patients underwent both MSCT and XA. Segment-based, vessel-based, and patient-based agreement between CTA and XA was estimated assuming that “nonevaluable” segments were positive for significant coronary stenosis. In a patient-based analysis, sensitivity, specificity, positive predictive value, and negative predictive values of CTA were 95%, 89%, 66%, and 99%, respectively; in vessel-based analysis, 90%, 92%, 48%, and 99%, respectively; and in segment-based analysis, 89%, 97%, 38%, and 100%, respectively. No significant differences were found between patients with or without atrial fibrillation. A CAC value of 390 was the best cutoff for the identification of patients with positive or inconclusive CTA (which would not be exempted from XA in the clinical setting). Conclusions— In the preoperative assessment of patients with predominant VHD, the diagnostic accuracy of 64-slice CTA for ruling out the presence of significant coronary artery disease is very good even when including patients with irregular heart rhythm. Using this approach, CAC quantification before CTA can be successfully used to identify patients who should be referred directly to XA, sparing unnecessary exposure to radiation.

Echocardiography (echo) has gained increasing importance in cardiology as technological developments have enabled progression from one-dimensional to two-dimensional imaging and the inclusion of physiological information with the Doppler principle. Although three-dimensional (3D) echo is not a new concept, its use has been limited by image artifacts and the need for time-consuming offline processing. Despite several improvements since its introduction in the 1990s, real-time 3D echo was until 2007 limited to transthoracic studies, but a real-time 3D transesophageal (TE) echo probe has recently become commercially available. The objective of this article is to describe our initial experience with this probe, to assess its ability to visualize different cardiac structures and to discuss its advantages and shortcomings.We performed 103 transesophageal studies between 08/05/2008 and 10/31/2009 using an iE33 ultrasound system with an X7-2t probe (Philips Medical Systems, Andover, Massachusetts, USA). Successful intubation was achieved in all patients. The 3D images obtained were exported to a workstation equipped with QLAB version 6.0 software for review and post-processing.Three-dimensional images were obtained in 73 studies, mostly for pre- or post-closure evaluation of atrial septal defects (ASD; 31.5%) and assessment of mitral valve disease or mitral prostheses (30%). Most of the images were acquired using 3D zoom mode. The additional information provided by 3D study was very useful for evaluation of mitral valve disease and mitral valve prostheses, enabling quick and reliable recognition of the cardiac anatomy and the pathological processes involved in each case. The interatrial septum was clearly visualized and the anatomical relations of defects were identified in most exams, in spite of the presence of dropouts in some cases. Imaging of more anterior cardiac structures, particularly the aortic, pulmonary and tricuspid valves, is generally suboptimal with this technique and good-quality images were obtained in only a few studies.After a relatively short training period and without prolonging the study time significantly, we were able to visualize the various components of the mitral valve clearly and identify its anatomical relations; in our initial experience, this was the major advantage of the technique, which will probably become the gold standard for preoperative evaluation of mitral valve disease. Programming and guiding ASD closure is another promising area for 3D TE echo. On the other hand, imaging of anterior cardiac structures is poor and needs refinement.

Previous studies have evaluated the prognostic impact of early invasive strategies in the management of non-ST elevation acute coronary syndromes (NSTEACS). There is, however, conflicting evidence about the advantages of such an approach. In some studies the benefits are dependent on gender or age, while time to angiography varies between studies.We performed a retrospective analysis of 222 patients admitted with NSTEACS between 1/1/2004 and 12/31/2004. The patients initially received intensive medical therapy and were divided into three groups according to the subsequent approach. In the early invasive strategy group (EIS; n = 62), angiography was performed in the first 48 hours; in delayed invasive strategy (DIS; n = 97), angiography was routinely performed but postponed beyond the first 48 hours; in the conservative strategy group (CS; n = 63), catheterization was performed only in cases of refractory angina or evidence of ischemia in non-invasive tests. We evaluated the occurrence of death or hospitalization due to cardiac cause during a mean follow-up of 549 days.The patients' mean age was 64.6 +/- 11.7 years and 66.7% were male. CS patients were older than the others (60.6 +/- 10.3 [EIS]; 63.2 +/- 11.2 [DIS]; 70.6 +/- 11.5 [CS]; p0.0005). The prevalence of cardiovascular risk factors was similar in the three groups. Ejection fraction (EF) at discharge was lower in the CS group (51.2% +/- 9.5; 51.3% +/- 7.4; 44.5% +/- 11.4; p0.0005). The primary endpoint occurred in 9.6%, 16.4% and 41.3% in the EIS, DIS and CS groups respectively. On multivariate analysis, after adjustment for age, EF and troponin I elevation, CS maintained the association with the endpoint (OR 5.17; 95% CI 1.64-16.32), while EF40% was inversely related to the endpoint.A conservative approach to NSTEACS was, in our population, associated with a worse prognosis. Delaying cardiac catheterization beyond the first 48 hours had no prognostic impact.

Ischemic heart disease is a major cause of heart failure in western societies. However, the factors that may influence left ventricular function (LVF) recovery after an acute coronary syndrome (ACS) are still unclear.To identify variables that may influence LVF evolution one year after ACS.104 patients hospitalized with ACS between 7/1/2001 and 12/31/2002 and with systolic dysfunction--defined as an echocardiographic ejection fraction (EF)or = 45%--were randomly allocated to a planned coronary follow-up program (FUP) or a general cardiology clinic (GC); patients from both groups were also randomly referred to a structured cardiac rehabilitation program (CRP). EF was re-assessed at one year. We compared differences between patients who recovered left ventricular function (EF45%; group 1) and those who did not (group 2).One year after discharge, 44.2% of the patients had recovered function. There were no significant differences between the groups in gender (77.7 vs. 76.5% male), age (56 vs. 59 years), hypertension, diabetes, dyslipidemia, smoking habits or family history. A previous history of cardiovascular events was more frequent in group 2 (11.1% vs. 35.3%, p = 0.03). Cardiac catheterization was performed before discharge in 88.8% and 88.2% in groups 1 and 2 respectively (p = NS); no differences were found in coronary anatomy between the two groups. Angioplasty was performed in 54.2% in group 1 and 50% in group 2 (p = NS). There were no differences in the use of angiotensin-converting enzyme inhibitors (83.3% vs. 87.5%), beta-blockers (87.5% vs. 87.5%), nitrates (37.5% vs. 33.3%), aspirin (95.8% vs. 95.8%), statins (79.1% vs. 75%) or diuretics (20.8% vs. 45.8%). There was no significant difference in LVF recovery between patients randomized to FUP or GC (38.5% vs. 54.5%). 87.5% of patients who completed the CRP had normal EF at one year compared to 32.7% of patients not referred to the program (p = 0.009). Although EF improved in both groups, this improvement was greater in patients who completed a CRP (EF 8% vs. 5%, p = 0.003).A previous cardiovascular event and completion of a CRP were the only variables that influenced LVF recovery. Thus, enrollment in a CRP, in addition to standard therapy, could be an important therapeutic measure in patients with systolic dysfunction after ACS; our data suggest that these programs should be more widely used.

In recent decades pre-hospital emergency plans have been developed in Portugal, in order to improve the quality and efficiency of medical care in acute situations. However, the real impact of these measures in the treatment of acute coronary patients has not been thoroughly studied.To evaluate the impact of pre-hospital emergency care (PHE) in the management and prognosis of patients admitted to hospital with acute myocardial infarction (AMI).Three hundred and eighty-one consecutive patients admitted to our hospital with AMI between 7/1/2001 and 12/31/2002.The patients referred to the Emergency Department (ED) after PHE care were prospectively compared with other patients admitted with AMI (controls), in terms of clinical and demographic characteristics, initial ECG, time of symptoms-to-ED, symptoms-to-ECG, and door-to-needle/balloon, Killip class, in-hospital morbidity and mortality, ejection fraction (EF) at discharge, morbidity and mortality during the first year and EF after one year.Of the 51 patients (mean age 66, 57% male) of the PHE group, 55% (mean age 66, 64% male) presented ST elevation on admission ECG. Of the 330 patients (mean age 63 years, 70% male) of the control group, ST elevation was present in 41% (p = 0.05), mean age 59 years (p0.02), 77% male (NS). There were no significant differences between the groups when cardiovascular risk factors, cardiac event history and comorbidity were studied. Time of symptoms-to-ED (124 vs. 256 min) and symptoms-to-ECG (138 vs. 292 min) were shorter in the PHE group (p0.005 and0.003, respectively). Door-to-ECG time was 14 min vs. 36 min in the control group (p0.02). In patients with ST elevation, door-to-needle (77 vs. 105 min) and door-to-balloon (79 vs. 132 min) times were shorter after PHE (NS, p = 0.08). Overall, the time of symptoms-to-reperfusion was shorter in the PHE group. There were no differences in Killip class, in-hospital mortality or one-year mortality/morbidity. The prevalence of EF45% was lower in the PHE group, both at discharge (39 vs. 58%, p = 0.08) and on the first year echocardiogram (8.3 vs. 46%, p0.04).Compared to other patients with AMI, those admitted to the ED after PHE are older and more frequently present ST elevation. PHE has a significant impact in reducing the time between first symptoms and admission to the ED, first ECG and reperfusion therapy. In patients with ST elevation at admission, the prevalence of heart failure after one year was found to be significantly lower in the PHE group, revealing the positive impact of PHE care in AMI that persists after one-year follow-up.

Coronary disease in its various forms of presentation is associated with a reduction in the patients' own perception of their quality of life (QoL). QoL is an important measure of effectiveness of treatment; however, the predictors of QoL after admission for acute coronary syndrome (ACS) are not completely clear.To identify the clinical, demographic and psychosocial characteristics of patients admitted for ACS that were predictive of QoL in clinical follow-up.Physical and mental QoL were prospectively evaluated in 278 patients admitted for ACS, using Short Form-36 v2 physical (PCS) and mental (MCS) component summary scales. Based on the median PCS (55) and MCS (56) scores, the population was divided into two groups. Depressive symptoms were assessed using the Beck Depression Inventory.The patients with a better QoL perception were male, young, smokers and had more than 12 years' education. A greater proportion of patients with PCS and MCS below the median score presented prior cardiovascular events and depressive symptoms. A worse physical QoL perception was more common in unmarried, hypertensive and diabetic patients. There was no association between clinical evolution or in-hospital complications and baseline QoL scores. Baseline PCS and MCS were 55 +/- 24 and 55 +/- 27 and at 16 months, 63 +/- 25 and 66 +/- 29. Clinical follow-up was achieved in 181 patients. A worse mental QoL perception at follow-up was related to female gender, baseline MCS56 and depressive symptoms. A PCS below median score at follow-up was more frequent in women and in patients with prior cardiovascular events, hypertension, diabetes, dyslipidemia and a lower level of education. Patients with better physical QoL at follow-up were smokers, presented higher baseline PCS and MCS, and had fewer depressive symptoms. Percutaneous myocardial revascularization was associated with a better physical QoL. In a logistic regression model the independent predictors of PCS were: gender, baseline PCS, level of education and prior cardiovascular events. Gender and depressive symptoms were independent predictors of MCS.In the study population, baseline clinical and psychosocial characteristics were the most important predictors of QoL after ACS. Depression was associated with worse mental QoL. In-hospital evolution and treatment did not appear to strongly affect patients' follow-up perceptions of QoL.

Left ventricular (LV) systolic function is an important prognostic factor in coronary heart disease. Left ventricular ejection fraction (LVEF) should be assessed in all patients after acute myocardial infarction (AMI). Although reperfusion therapy has been found effective in the reduction of complications of AMI, LVEF impairment is a common consequence of an acute coronary event. The aim of this study was to estimate the incidence of LVEF depression after ST-elevation myocardial infarction (STEMI) and to evaluate the effect of previous cardiovascular risk factors on the risk of LV dysfunction.One hundred and forty-seven consecutive patients with a first STEMI were included in this study. Most patients were male (70.7%) and mean age was 60.7 years. LVEF was assessed by echocardiography (using the single-plane area-length method and automatic border detection). LV systolic function was considered depressed when ejection fraction was less than 45 %. The chi-square test was used in the statistical analysis to compare proportions and a logistic regression model was fitted to assess the independent effect of each variable.Incidence of LV dysfunction was 55.8% in STEMI patients. No association was found between gender or age and LVEF impairment. The proportion of patients with diabetes was higher in the impaired LVEF group than in normal LVEF patients (44.7% vs. 31.7%, p = 0.12); the prevalence of smoking was also higher in patients with LV dysfunction (46.9% vs. 33.8%, p = 0.11). On the other hand, dyslipidemia was less common in patients with depressed LV function (35.4% vs. 56.9%, p = 0.01). Hypertension was not associated with impaired LVEF. After adjustment for ST-elevation location and number of vessels with critical stenosis, diabetes and smoking were associated with a significantly higher risk of LVEF impairment (diabetes: OR = 3.73, 95% CI 1.25-11.16; smoking: OR = 3.9, 95% CI 1.37-11.07) and dyslipidemia with a significantly lower risk of LV dysfunction (OR: 0.37, 95% CI 0.15-0.88).In STEMI patients, previous cardiovascular risk factors have a significant impact on the likelihood of LV dysfunction and hence could influence long-term prognosis.

To evaluate the impact of cardiac rehabilitation programs (CRP) on quality of life (QL) and depression at one-year follow-up after acute coronary syndrome (ACS).Two hundred and three patients, without previous cardiological follow-up and referred to the outpatient clinic after hospitalization for ACS between 9/1/2001 and 12/31/2002, were randomly allocated to a 12-week, 3-times-a-week CRP or standard cardiology follow-up only, after giving their informed consent. Baseline population characteristics were recorded and, in patients with more than 4 years' education, QL and depression were evaluated during hospitalization and at one-year follow-up by self-reported responses to the SF-36 QL survey and the Beck Depression Inventory (BDI) respectively. Analysis was by intention-to-treat.31 patients randomized to CRP, mean age 56 years (31-80), 84% male (group A) and 95 patients, mean age 58 years (33-86), 83 % male, allocated to standard follow-up (group B), responded to the questionnaires. There were no significant differences between the two groups in any of the variables evaluated by the questionnaires during hospitalization. At one-year evaluation, the average BDI score was lower in the CRP group (8 vs. 11, p = 0.05). The prevalence of depressive symptoms (37.5 vs. 56.1%) or severe depression (3.1% vs. 12.2%) was also lower, in this group, although not significantly. SF-36 found significant differences in the evaluation of Vitality (average 62 points in A vs. 47 in B, p0.02) and General Health (57 points in A vs. 46 points in B, p0.02); there were no differences in the other parameters evaluated. When the physical and mental health components were analyzed, a significant difference favoring CRP was found in mental health (70.6 vs. 56.9, p = 0.02) but not in physical health (62.9 in A vs. 56.4 in B, NS).Despite the small sample size, significant differences favorable to CRP after ACS were found. After one-year follow-up, patients referred to CRP have a better BDI score; the Vitality and General Health parameters, as well as the mental health component evaluated by SF-36, are also significantly improved after CRP.

Clinical depression is associated with poor compliance in risk reduction recommendations and has been suggested as an independent risk factor for increased postmyocardial infarction morbidity and mortality.To determine the prevalence of depressive symptoms, their main determinants and their influence on clinical evolution in acute coronary syndromes (ACS) patients.We studied depressive symptoms, sociodemographic variables, cardiovascular status and therapeutic procedures in 240 consecutive patients admitted for ACS. Depressive symptoms were assessed using the Beck Depression Inventory (BDI) after clinical stabilization, in patients with more than 4 years' education.The majority of the patients were male (203); their average age was 59.4 +/- 13 yrs; 31.8% were admitted for unstable angina, 33.1% for acute myocardial infarction with ST elevation and 31.8% without ST elevation. Depressive symptoms (BDIor =10) were present in 100 patients (41.6%). Depressed patients were older (61.1 vs. 58.2 years, p = 0.06) and had a history of previous cardiovascular events /47.5 vs. (34.8% p = 0.05). The proportion of female was higher in the group of patients with BDIor =10 (24% vs. 9.3%, p = 0.02). Traditional cardiovascular risk factors were not associated with depressive symptoms. There were no statistically significant differences between the depressed and non-depressed patients in admission diagnosis, in-hospital clinical evolution and treatment. There were 35 patients (14.6%) with moderate/severe depression (BDIor =19), 12 of whom were women (OR = 3.8, p = 0.001); no relation was established between age and previous cardiac events. These scores were less frequent in patients with a higher level of education (OR = 0.28, p = 0.09) and married (OR = 0.31 vs. not married, p = 0.03). Clinical follow-up of 158 patients was achieved (16 +/- 4 months), in patients with BDIor =19, the presence of cardiovascular symptoms (angina, congestive heart failure) was higher (46% vs. 23%, OR = 2.8, p = 0.03), even after adjustment for age (OR = 2.5; p = 0.06). However, there was no association between the presence of depressive symptoms and readmission and/or fatal events.Depression is a common finding after hospital admission for ACS, particularly in women, and is mainly associated with prehospital factors. In our group of patients, the presence of depressive symptoms was closely related to clinical status during follow-up.

Hypertension is an important risk factor for cardiovascular events. Although several anti-hypertensive agents have shown to be effective in the treatment of hypertension, adequate blood pressure control is not frequent in most populations. The aim of this study was to evaluate the effect of a structured intensive follow-up program (SIFUP) on the control of blood pressure in coronary patients.we performed a prospective, randomized study including 237 patients admitted to the Cardiology Department for acute coronary syndrome. Patients were randomly assigned to a SIFUP (n=129) or to the general cardiology outpatient department (COD) (n=108). An experienced doctor performed a blind assessment of blood pressure in 157 randomised patients, 9 to 18 months after discharge. In statistical analysis, the chi-square test was used to compare proportions and the Student's t test to compare means.Both groups were predominantly male and mean age was similar. The proportion of patients with known hypertension randomised to the SIFUP and the COD did not differ. At the 9 to 18-month assessment there was no statistical significant difference in the proportion of patients with blood pressure under target values (57.5% in SIFUP and 48.5% in COD, p=NS). However, in hypertensive patients, the proportion of controlled patients was significantly higher in the SIFUP than in the COD (44.8% vs. 24.2%, p=0.05) and systolic and mean blood pressure were significantly lower in the SIFUP (respectively 139.0 vs. 148.8 mmHg, p=0.04 and 98.7 vs. 103.9 mmHg, p=0.03); diastolic blood pressure was also lower in SIFUP (78.5 vs. 81.5 mmHg, p=NS).The SIFUP has shown to be effective in lowering blood pressure in hypertensive coronary patients. The proportion of patients with controlled blood pressure was consistently higher in the SIFUP.

The individual awareness of one's own disease, the so called labeling effect, may result in a reduction of one's sense of perceived health. In patients submitted to coronary artery bypass surgery it has been reported that the diagnosis of depression is associated with a higher rate of hospitalization and it's an independent risk factor for cardiac events. The aim of this study was to evaluate the modification of depressive symptoms induced by the information of medical indication for myocardial revascularization surgery.We studied the presence of depressive symptoms, socio-demographic variables, cardiovascular status and therapeutic procedures in two groups of consecutive patients admitted for acute coronary syndrome. In the labeled group the BDI-1 was performed after clinical stabilization and the BDI-2 after the information of myocardial revascularization surgery need. In the control group the BDI-1 was answered after clinical stabilization and the BDI-2 48-72 hours later. The Mann-Whitney test was used to compare the difference of depressive symptoms between the groups.Distribution by age, marital status and education level was similar between the two groups. The cardiovascular risk profile was alike. The difference between BDI-1 and BDI-2 was significantly higher in the labeled group (4.6-/+4.2 vs 0.8-/+3.2; p=0.005). There were no significant differences between the final diagnosis (unstable angina in the labeled group 50% vs control group 45.5%; AMI without Q wave 30% vs 27.3%; AMI with Q wave 20% vs 27.3%) and in hospital clinical evolution.The individual awareness of the need to coronary bypass surgery was associated with a clinical and statistical significant increase of depressive symptoms. Hence, routine evaluation of depressive symptoms as a part of a preoperative protocol, may allow identification of the patients, who may benefit from therapeutic intervention.

Acute coronary syndromes (ACS) in young women are relatively unusual. This subgroup of patients presents a premature risk of death and disability, with significant social repercussions.This retrospective study was undertaken to define risk factors, symptoms and signs at presentation, electrocardiographic and angiographic characteristics, treatment and complications, in pre-menopausal women younger than fifty years old, admitted to the Coronary Care Unit between 1991 and 2002.We evaluated 33 patients (mean age 43.0 years). The most frequent risk factors were hypertension (48.5%) and smoking (45.5%). Typical chest pain (78.7%) and tachycardia (34.1%) were the most prevalent symptom and sign respectively. A history of previous angina was present in 18% of the patients. The most common presenting electrocardiographic finding was ST segment elevation (45.5%). Critical coronary lesions were present in 78.7%, mainly in the left anterior descending (LAD) (54.5%). Single-vessel disease was more frequent than multi-vessel disease (57.6% vs. 18.2%). Coronary arteries were angiographically normal in 9.1%. Left ventricular dysfunction assessed by echocardiography was present in 63.6%. Recurrent angina was the most common complication (24.2%). No fatal cases were recorded. Acute reperfusion therapy was indicated in fifteen patients: direct angioplasty in six, thrombolysis in six and none in three. Elective revascularization was performed in seventeen patients (angioplasty in ten and coronary artery bypass graft in seven). Secondary prevention included platelet antiaggregants in 100%, beta-blockers in 81.5%, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in 42.2%, and statins in 42.2%. Diagnosis at discharge was Q-wave myocardial infarction (anterior--36.3% and inferior--15.2%), non-Q wave myocardial infarction (27.2%), and unstable angina (21.2%).This study shows that atherosclerosis was the principal etiopathogenic factor in young women with ACS. Hypertension and smoking were the commonest risk factors. Critical LAD stenosis, Q-wave myocardial infarction (mostly anterior) and left ventricular dysfunction were common.