Search

International audience; This cross-sectional study evaluates the association of major adverse cardiac events (MACE) integrated with fractional flow reserve as the management strategy for diabetes with outcomes in patients with ambiguous lesions who undergo angiography.Key PointsQuestionWhat are the usefulness, rate of major adverse cardiovascular events (MACE), and clinical outcomes of routinely integrating fractional flow reserve in the management strategy for patients with diabetes who undergo coronary angiography? FindingsIn this cross-sectional study of 1983 patients, overall reclassification by fractional flow rate was high and similar in patients with diabetes (41.2%) and patients without diabetes (37.5%); however, reclassification from medical treatment to revascularization was more frequent among patients with diabetes. The rate of 1-year MACE was similar in reclassified (9.7%) and nonreclassified (12.0%) patients with diabetes, and the rate of MACE of patients deferred based on fractional flow reserve was similar among those with and without diabetes. MeaningThe findings suggest that management strategies guided by fractional flow reserve, including revascularization deferral, may be useful for patients with diabetes.ImportanceApproximately one-third of patients considered for coronary revascularization have diabetes, which is a major determinant of clinical outcomes, often influencing the choice of the revascularization strategy. The usefulness of fractional flow reserve (FFR) to guide treatment in this population is understudied and has been questioned. ObjectiveTo evaluate the usefulness and rate of major adverse cardiovascular events (MACE) of integrating FFR in management decisions for patients with diabetes who undergo coronary angiography. Design, Setting, and ParticipantsThis cross-sectional study used data from the PRIME-FFR study derived from the merger of the POST-IT study (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease [March 2012-November 2013]) and R3F study (French Study of FFR Integrated Multicenter Registries Implementation of FFR in Routine Practice [October 2008-June 2010]), 2 prospective multicenter registries that shared a common design. A population of all-comers for whom angiography disclosed ambiguous lesions was analyzed for rates, patterns, and outcomes associated with management reclassification, including revascularization deferral, in patients with vs without diabetes. Data analysis was performed from June to August 2018. Main Outcomes and MeasuresDeath from any cause, myocardial infarction, or unplanned revascularization (MACE) at 1 year. ResultsAmong 1983 patients (1503 [77%] male; mean [SD] age, 65 [10] years), 701 had diabetes, and FFR was performed for 1.4 lesions per patient (58.2% of lesions in the left anterior descending artery; mean [SD] stenosis, 56% [11%]; mean [SD] FFR, 0.81 [0.01]). Reclassification by FFR was high and similar in patients with and without diabetes (41.2% vs 37.5%, P=.13), but reclassification from medical treatment to revascularization was more frequent in the former (142 of 342 [41.5%] vs 230 of 730 [31.5%], P=.001). There was no statistical difference between the 1-year rates of MACE in reclassified (9.7%) and nonreclassified patients (12.0%) (P=.37). Among patients with diabetes, FFR-based deferral identified patients with a lower risk of MACE at 12 months (25 of 296 [8.4%]) compared with those undergoing revascularization (47 of 257 [13.1%]) (P=.04), and the rate was of the same magnitude of the observed rate among deferred patients without diabetes (7.9%, P=.87). Status of insulin treatment had no association with outcomes. Patients (6.6% of the population) in whom FFR was disregarded had the highest MACE rates regardless of diabetes status. Conclusions and RelevanceRoutine integration of FFR for the management of coronary artery disease in patients with diabetes may be associated with a high rate of treatment reclassification. Management strategies guided by FFR, including revascularization deferral, may be useful for patients with diabetes.

Resumo: Introdução e objetivos: Foi nosso objetivo estudar as tendências da intervenção coronária percutânea entre 2004‐2013 e comparar Portugal com outros países europeus. Métodos: Análise dos procedimentos coronários efetuados entre 2004‐2013 com base num registo prospetivo, multicêntrico, voluntário, doente a doente – Registo Nacional de Cardiologia de Intervenção (RNCI) da Associação Portuguesa de Intervenção Cardiovascular da Sociedade Portuguesa de Cardiologia (APIC‐SPC) – e dos dados oficiais publicados pela Direção Geral de Saúde (DGS). Resultados: Em 2013 realizaram‐se 36 810 cateterismos diagnósticos (3529 coronariografias por milhão de habitantes), representando um aumento significativo de 34% relativamente ao ano de 2007 (p

Design and hierarchical control of three phase parallel Voltage Source Inverters are developed in this paper. The control scheme is based on synchronous reference frame and consists of primary and secondary control levels. The primary control consists of the droop control and the virtual output impedance loops. This control level is designed to share the active and reactive power correctly between the connected VSIs in order to avoid the undesired circulating current and overload of the connected VSIs. The secondary control is designed to clear the magnitude and the frequency deviations caused by the primary control. The control structure is validated through dynamics simulations.The obtained results demonstrate the effectiveness of the control structure.

Background— Fractional flow reserve (FFR) is not firmly established as a guide to treatment in patients with acute coronary syndromes (ACS). Primary goals were to evaluate the impact of integrating FFR on management decisions and on clinical outcome of patients with ACS undergoing coronary angiography, as compared with patients with stable coronary artery disease. Methods and Results— R3F (French FFR Registry) and POST-IT (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease), sharing a common design, were pooled as PRIME-FFR (Insights From the POST-IT and R3F Integrated Multicenter Registries - Implementation of FFR in Routine Practice). Investigators prospectively defined management strategy based on angiography before performing FFR. Final decision after FFR and 1-year clinical outcome were recorded. From 1983 patients, in whom FFR was prospectively used to guide treatment, 533 sustained ACS (excluding acute ST-segment–elevation myocardial infarction). In ACS, FFR was performed in 1.4 lesions per patient, mostly in left anterior descending (58%), with a mean percent stenosis of 58±12% and a mean FFR of 0.82±0.09. In patients with ACS, reclassification by FFR was high and similar to those with non-ACS (38% versus 39%; P =NS). The pattern of reclassification was different, however, with less patients with ACS reclassified from revascularization to medical treatment compared with those with non-ACS ( P =0.01). In ACS, 1-year outcome of patients reclassified based on FFR (FFR against angiography) was as good as that of nonreclassified patients (FFR concordant with angiography), with no difference in major cardiovascular event (8.0% versus 11.6%; P =0.20) or symptoms (92.3% versus 94.8% angina free; P =0.25). Moreover, FFR-based deferral to medical treatment was as safe in patients with ACS as in patients with non-ACS (major cardiovascular event, 8.0% versus 8.5%; P =0.83; revascularization, 3.8% versus 5.9%; P =0.24; and freedom from angina, 93.6% versus 90.2%; P =0.35). These findings were confirmed in ACS explored at the culprit lesion. In patients (6%) in whom the information derived from FFR was disregarded, a dire outcome was observed. Conclusions— Routine integration of FFR into the decision-making process of ACS patients with obstructive coronary artery disease is associated with a high reclassification rate of treatment (38%). A management strategy guided by FFR, divergent from that suggested by angiography, including revascularization deferral, is safe in ACS.

This study presents the functional model that provides net-load forecasts for each low-voltage (LV) node (including PV generation and self-consumption), developed for the UPGRID (real proven solutions to enable active demand and distributed generation flexible integration, through a fully controllable low-voltage and medium-voltage distribution grid) framework project. Several tests scenarios were simulated and the results regarding forecast accuracy and computational performance are given. Results demonstrate the applicability of the distribution in memory solution in a practical operational scenario, offering a highly scalable forecasting system for LV networks. Based on forecasts and available real-time information, an architecture for preventive control of LV grids is built upon chronological analysis capabilities of DPlan. An illustration on how such capabilities are used in the context of the foreseen UPGRID preventive control framework is provided.

MicroGrid (MG) is becoming an important system for a massive and reliable integration of renewable energy sources. Hence, due to its benefits, photovoltaic (PV) systems are the most suitable and widely used in MGs. However, for a reliable integration of PV panels, they must be interfaced by smart power electronics devices that allow the implementation of advanced control solutions. In addition to operating as active power generator with maximum power point tracking (MPPT), the new PV systems (PVS) should behave as ancillary services providers by participating to the grid regulation, such as frequency stabilization, voltage profile control, harmonics compensation and so forth. This paper aims at reviewing the control and operation of PVS in AC MG. Control structures, active power control, MPPT and inner loops are presented and discussed. Design, analysis and control of single-stage three phase PVS in AC MG that is able to operate at MPP or as a dispatchable source are made. The control structure is validated through dynamic simulations.

Acute heart failure in patients with severe aortic stenosis and left ventricular systolic dysfunction is well known for its dire prognosis and limited therapeutic options.The authors describe the case of a man admitted for non-ST-elevation myocardial infarction. Diagnostic exams revealed severe aortic stenosis, with good left ventricular systolic function, and two-vessel coronary artery disease. The development of cardiogenic shock with left ventricular systolic dysfunction on day four led to changes in the therapeutic strategy. Percutaneous aortic balloon valvuloplasty coupled with complete myocardial revascularization was performed with a view to future surgical intervention. After discharge, the patient was readmitted with cardiogenic shock after acute pulmonary edema and cardiopulmonary arrest. Ventilator weaning was not possible due to acute heart failure and so it was decided to administer levosimendan, which resulted in substantial clinical and echocardiographic improvement. The patient subsequently underwent successful aortic valve replacement.This case highlights the challenge that characterizes the management of patients with concomitant coronary artery disease, left ventricular systolic dysfunction and severe aortic stenosis. Percutaneous aortic balloon valvuloplasty and levosimendan were safe and effective in the treatment of acute heart failure, acting as a bridge to surgery. Resumo: A insuficiência cardíaca aguda na estenose aórtica grave com compromisso da função sistólica global tem um prognóstico reservado, com opções terapêuticas limitadas.Os autores descrevem o caso clínico de um doente admitido por enfarte agudo do miocárdio sem supradesnivelamento de ST, no qual o estudo complementar revelou estenose aórtica grave, com boa função ventricular esquerda, e doença coronária de 2 vasos. O desenvolvimento de choque cardiogénico, com compromisso grave da função sistólica global, ao quarto dia de internamento, alterou a estratégia terapêutica, optando-se por realizar valvuloplastia aórtica com balão e revascularização miocárdica percutânea completa, com vista a posterior referenciação para cirurgia valvular. Após a alta, apresentou novo quadro de choque cardiogénico em contexto de insuficiência cardíaca aguda e paragem cardiorrespiratória. Por dificuldade na extubação, iniciou perfusão de levosimendan, com franca melhoria clínica e ecocardiográfica. Posteriormente, o doente foi submetido com sucesso a implantação de prótese valvular aórtica.Este caso demonstra o desafio que caracteriza a estabilização e o tratamento destes doentes. A valvuloplastia aórtica com balão e o levosimendan foram eficazes e seguros no tratamento da insuficiência cardíaca aguda e permitiram estabelecer a ponte para a cirurgia. Keywords: Severe aortic stenosis, Cardiogenic shock, Aortic balloon valvuloplasty, Levosimendan, Palavras-chave: Estenose aórtica grave, Choque cardiogénico, Valvuloplastia aórtica com balão, Levosimendan

Within the Smart Grids paradigm, the future electricity distribution system will be characterized by more observability and controllability, offering the conditions for bidirectional control of Distributed Energy Resources (DER) with high penetration of Distributed Renewable Energy Resources (DRES). The flexibilities available in the network may be used to solve local technical problems such as under/overvoltage or branch congestion. They may be also used in order to meet regulatory restrictions and to avoid penalties or to offer flexibilities to the TSO. Today, in Germany, the scheduled operating point at the primary substation must fit in the TSO rules. Therefore, the DSO optimizes the scheduled operating point to avoid penalties and to find the minimum cost by using an optimal power flow (OPF). In the future, it is also in discussion whether the DSO should provide the TSO with a specific operating point as an additional service.

Photovoltaic systems (PVS) based MicroGrid (MG) should be able to operate at the maximum power point (MPP) in order to extract the maximum available power during atmospheric conditions changes. In addition to this, the PVSs should be able also to operate below the MPP in order to participate to the MG regulation such as grid frequency stabilization, voltage profile control and grid management support. This paper discusses the state of the art of operation and control of PVS in MG. Design and control of a single stage single phase PVS connected to a low voltage AC MG are presented and analyzed. A comparison between two current control methods, Proportional integral with grid voltage feed forward (PI+FF) and proportional resonant with selective harmonics compensation (PR+HC) is also made. The control structures are validated through dynamic simulation.

Background— Penetration of fractional flow reserve (FFR) in clinical practice varies extensively, and the applicability of results from randomized trials is understudied. We describe the extent to which the information gained from routine FFR affects patient management strategy and clinical outcome. Methods and Results— Nonselected patients undergoing coronary angiography, in which at least 1 lesion was interrogated by FFR, were prospectively enrolled in a multicenter registry. FFR-driven change in management strategy (medical therapy, revascularization, or additional stress imaging) was assessed per-lesion and per-patient, and the agreement between final and initial strategies was recorded. Cardiovascular death, myocardial infarction, or unplanned revascularization (MACE) at 1 year was recorded. A total of 1293 lesions were evaluated in 918 patients (mean FFR, 0.81±0.1). Management plan changed in 406 patients (44.2%) and 584 lesions (45.2%). One-year MACE was 6.9%; patients in whom all lesions were deferred had a lower MACE rate (5.3%) than those with at least 1 lesion revascularized (7.3%) or left untreated despite FFR≤0.80 (13.6%; log-rank P =0.014). At the lesion level, deferral of those with an FFR≤0.80 was associated with a 3.1-fold increase in the hazard of cardiovascular death/myocardial infarction/target lesion revascularization ( P =0.012). Independent predictors of target lesion revascularization in the deferred lesions were proximal location of the lesion, B2/C type and FFR. Conclusions— Routine FFR assessment of coronary lesions safely changes management strategy in almost half of the cases. Also, it accurately identifies patients and lesions with a low likelihood of events, in which revascularization can be safely deferred, as opposed to those at high risk when ischemic lesions are left untreated, thus confirming results from randomized trials. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01835808.

Introduction: There is disagreement regarding the best method for assessing renal dysfunction in patients with myocardial infarction (MI). This study aims to compare two commonly used formulas for measuring glomerular filtration rate (GFR) (Cockcroft–Gault [CG] and Modification of Diet in Renal Disease [MDRD]) in terms of predicting extent of coronary artery disease (CAD) and short- and long-term cardiovascular risk. Methods: We studied 452 patients admitted to a cardiac intensive care unit (ICU) with MI (age 69.01 ± 13.64 years; 61.7% male, 38.5% diabetic) and followed for two years. CG and MDRD GFR estimates were compared in terms of prediction of CAD extent, in-hospital mortality risk and cardiovascular risk during follow-up. Results: GFR

Introduction: Device closure of interatrial communications has become a well-established technique to treat left-to-right shunt associated with atrial septal defect (ASD) and to prevent paradoxical embolism in patients with patent foramen ovale (PFO). Guidance by transesophageal echocardiography (TEE) is the standard practice but intracardiac echocardiography (ICE) is a feasible and safe alternative for monitoring these procedures. Objectives: To report our experience in the percutaneous closure of ASD and PFO guided by ICE. Methods: We retrospectively reviewed all patients with ASD or PFO who underwent percutaneous closure guided exclusively by ICE between January 2008 and December 2010. All patients were followed clinically with regular echocardiographic evaluation (at discharge, one month, three, six and twelve months) to exclude residual shunt and device malposition. Results: A total of 127 patients (mean age 46.6±12.2 years; 71% female) underwent transcatheter device closure of ASD or PFO during the study period. Device deployment with ICE monitoring was 100% successful, with a low rate of complications and eliminating the need for additional imaging techniques. Conclusions: ICE provides anatomical detail of ASD/PFO and cardiac structures, facilitating congenital cardiac interventional procedures. It eliminates the major drawbacks associated with TEE and enables the interventional cardiologist to control all aspects of the procedure without relying on additional echocardiographic support. Resumo: Introdução: O encerramento percutâneo (EP) de defeitos do septo interauricular (SIA) é uma técnica comprovadamente eficaz para o tratamento da comunicação interauricular (CIA) e prevenção de embolia paradoxal em doentes com foramen ovale patente (FOP). A monitorização com ecocardiograma transesofágico (ETE) é o método habitualmente utilizado mas o ecocardiograma intracardíaco (EIC) constitui uma alternativa prática e segura para o controlo imagiológico destes procedimentos. Objetivo: Apresentar a experiência de um centro no EP de CIA e FOP guiado exclusivamente por EIC. Métodos: Analisámos retrospetivamente uma série de doentes consecutivos com CIA ou FOP submetidos a EP sob controlo por EIC no período de janeiro de 2008 a dezembro de 2010. Foram todos avaliados clínica, eletro e ecocardiograficamente à data da alta e após o 1.°, 3.°, 6.° e 12.° mês para excluir shunt residual (SR) e malaposição do dispositivo. Resultados: Um total de 127 doentes (46,6±12,2 anos; 71% de mulheres) foi submetido a EP de CIA ou FOP durante o referido período. A utilização do EIC durante o EP permitiu a colocação eficaz dos dispositivos em 100% dos casos, com uma reduzida taxa de complicações, dispensando a utilização adicional de outras técnicas de imagem durante os procedimentos. Conclusão: O EIC fornece informação anatómica detalhada da CIA/FOP e estruturas cardíacas adjacentes, facilitando assim os procedimentos de intervenção. Elimina os inconvenientes do ETE e possibilita ao cardiologista de intervenção controlar os vários aspetos do procedimento sem necessitar de apoio ecocardiográfico adicional. Keywords: Intracardiac echocardiography, Atrial septal defects, Transcatheter device closure, Palavras-chave: Ecocardiograma intracardíaco, Defeitos do septo interauricular, Encerramento percutâneo

Resumo: Introdução: O encerramento percutâneo (EP) de defeitos do septo interauricular (SIA) é uma técnica comprovadamente eficaz para o tratamento da comunicação interauricular (CIA) e prevenção de embolia paradoxal em doentes com foramen ovale patente (FOP). A monitorização com ecocardiograma transesofágico (ETE) é o método habitualmente utilizado mas o ecocardiograma intracardíaco (EIC) constitui uma alternativa prática e segura para o controlo imagiológico destes procedimentos. Objetivo: Apresentar a experiência de um centro no EP de CIA e FOP guiado exclusivamente por EIC. Métodos: Analisámos retrospetivamente uma série de doentes consecutivos com CIA ou FOP submetidos a EP sob controlo por EIC no período de janeiro de 2008 a dezembro de 2010. Foram todos avaliados clínica, eletro e ecocardiograficamente à data da alta e após o 1.°, 3.°, 6.° e 12.° mês para excluir shunt residual (SR) e malaposição do dispositivo. Resultados: Um total de 127 doentes (46,6 ± 12,2 anos; 71% de mulheres) foi submetido a EP de CIA ou FOP durante o referido período. A utilização do EIC durante o EP permitiu a colocação eficaz dos dispositivos em 100% dos casos, com uma reduzida taxa de complicações, dispensando a utilização adicional de outras técnicas de imagem durante os procedimentos. Conclusão: O EIC fornece informação anatómica detalhada da CIA/FOP e estruturas cardíacas adjacentes, facilitando assim os procedimentos de intervenção. Elimina os inconvenientes do ETE e possibilita ao cardiologista de intervenção controlar os vários aspetos do procedimento sem necessitar de apoio ecocardiográfico adicional. Abstract: Introduction: Device closure of interatrial communications has become a well-established technique to treat left-to-right shunt associated with atrial septal defect (ASD) and to prevent paradoxical embolism in patients with patent foramen ovale (PFO). Guidance by transesophageal echocardiography (TEE) is the standard practice but intracardiac echocardiography (ICE) is a feasible and safe alternative for monitoring these procedures. Objectives: To report our experience in the percutaneous closure of ASD and PFO guided by ICE. Methods: We retrospectively reviewed all patients with ASD or PFO who underwent percutaneous closure guided exclusively by ICE between January 2008 and December 2010. All patients were followed clinically with regular echocardiographic evaluation (at discharge, one month, three, six and twelve months) to exclude residual shunt and device malposition. Results: A total of 127 patients (mean age 46.6±12.2 years; 71% female) underwent transcatheter device closure of ASD or PFO during the study period. Device deployment with ICE monitoring was 100% successful, with a low rate of complications and eliminating the need for additional imaging techniques. Conclusions: ICE provides anatomical detail of ASD/PFO and cardiac structures, facilitating congenital cardiac interventional procedures. It eliminates the major drawbacks associated with TEE and enables the interventional cardiologist to control all aspects of the procedure without relying on additional echocardiographic support. Palavras-chave: Ecocardiograma intracardíaco, Defeitos do septo interauricular, Encerramento percutâneo, Keywords: Intracardiac echocardiography, Atrial septal defects, Transcatheter device closure

Introduction: Percutaneous coronary intervention (PCI) of heavily calcified lesions is a challenge for the interventional cardiologist and is associated with a high rate of restenosis and target lesion revascularization (TLR). Adequate lesion preparation by rotational atherectomy followed by drug-eluting stent implantation has shown favorable results. Objective: To report the recent experience of our center with rotational atherectomy (RA) of complex and heavily calcified coronary lesions. Methods: We retrospectively analyzed consecutive patients who underwent PCI with RA in our center between January 2009 and December 2010. A total of 42 patients were included, 65% of whom had been previously refused for coronary artery bypass grafting due to unfavorable coronary anatomy or high surgical risk. RA was performed using the standard Boston Scientific Rotablator® system. The procedure was performed ad-hoc in 50% of patients and transradial access was used in 35%. Data were collected on immediate post-procedural events and major cardiac events during follow-up – cardiovascular death, myocardial infarction, TLR and recurrent angina. Results: Of 1650 PCIs performed in a 23-month period from January 2009, 42 (2.5%) involved RA; from a total of 42 patients (mean age 70.3 ± 10.1 years, 67% male, 55% diabetic), three had left main disease, six had three-vessel disease, 18 had two-vessel disease and the other 15 had single-vessel disease. Of the lesions treated, 71% were >20 mm long and classified in 69% of cases as type C according to the ACC/AHA lesion classification, 4% being chronic total occlusions. The left anterior descending artery was treated in 56% of the procedures. The mean number of burrs used per lesion was 1.3 and a total of 69 stents were implanted, 81% of which were drug-eluting. During follow-up three patients had recurrent angina, one required TLR and two died due to a cardiovascular event. There was significant clinical improvement in 83% of patients. Conclusions: This study demonstrates that rotational atherectomy followed by stenting in heavily calcified lesions can nowadays be performed with high success rates and few complications, extending the possibility of coronary revascularization to a greater number of patients. Resumo: Introdução: A intervenção coronária percutânea (ICP) de lesões gravemente calcificadas constitui um desafio para o cardiologista de intervenção, estando associada a maior taxa de reestenose e necessidade de reintervenção na lesão alvo. A preparação adequada das lesões pela técnica de aterectomia rotacional (AR), seguida da colocação de stent farmacoactivo, tem demonstrado resultados favoráveis. Objectivo: Reportar a experiência recente do nosso centro na utilização de AR para o tratamento de lesões coronárias complexas e calcificadas. Material e Métodos: Analisámos retrospectivamente uma série de doentes consecutivos submetidos a ICP com recurso a AR no período de Janeiro de 2009 a Dezembro de 2010. Foram incluídos 42 doentes (dts), dos quais 65% tinham sido recusados para cirurgia por apresentarem múltiplas comorbilidades ou anatomia coronária desfavorável. A AR foi realizada utilizando o sistema Rotablator® da Boston Scientific. O procedimento foi realizado ad-hoc em 50% dos casos e utilizou-se a via radial em 35% dos dts. Foi avaliada a ocorrência de eventos no pós procedimento imediato e realizado follow-up (FUP) com avaliação de eventos cardiovasculares major após a alta hospitalar – morte cardiovascular (MCV), enfarte agudo do miocárdio, reintervenção na lesão alvo (RLA) e recorrência de angina (RA). Resultados: De um total de 1650 ICP realizadas durante um período de 23 meses desde Janeiro de 2009, 42 (2,5%) envolveram a técnica de AR. Num total de 42 doentes submetidos a AR (70,3 ± 10,1 anos, 67% homens, 55% de diabéticos), três apresentavam doença (DC) de tronco comum (TC), seis dts DC de 3 vasos, 18 dts DC de 2 vasos e 15 dts DC de 1 vaso. As lesões tratadas (71% > 20 mm) classificaram-se como tipo C em 69% e oclusão total crónica em 4%. Intervencionou-se a descendente anterior em 56% dos casos. Utilizou-se uma média de 1,3 olivas por lesão e implantaram-se no total 69 stents, 81% dos quais eram farmacoactivos. Verificou-se RA em três dts, RLA em apenas um dt e MCV em dois dts. Em 83% dos doentes verificou-se melhoria da classe funcional. Conclusão: A utilização da AR na ICP de lesões gravemente calcificadas, seguida de colocação de stent, é um procedimento seguro e com uma elevada taxa de sucesso, permitindo a revascularização coronária a um maior número de doentes. Keywords: Coronary calcification, Percutaneous coronary intervention, Rotational atherectomy, Drug-eluting stents, Palavras-chave: Calcificação coronária, Intervenção coronária percutânea, Aterectomia rotacional, Stents farmacoactivos

Resumo: Introdução: A intervenção coronária percutânea (ICP) de lesões gravemente calcificadas constitui um desafio para o cardiologista de intervenção, estando associada a maior taxa de reestenose e necessidade de reintervenção na lesão alvo. A preparação adequada das lesões pela técnica de aterectomia rotacional (AR), seguida da colocação de stent farmacoativo, tem demonstrado resultados favoráveis. Objectivo: Reportar a experiência recente do nosso centro na utilização de AR para o tratamento de lesões coronárias complexas e calcificadas. Material e métodos: Analisámos retrospetivamente uma série de doentes consecutivos submetidos a ICP com recurso a AR no período de Janeiro de 2009 a Dezembro de 2010. Foram incluídos 42 doentes (dts), dos quais 65% tinham sido recusados para cirurgia por apresentarem múltiplas comorbilidades ou anatomia coronária desfavorável. A AR foi realizada utilizando o sistema Rotablator® da Boston Scientific. O procedimento foi realizado ad-hoc em 50% dos casos e utilizou-se a via radial em 35% dos doentes. Foi avaliada a ocorrência de eventos no pós-procedimento imediato e realizado follow-up (FUP) com avaliação de eventos cardiovasculares major após a alta hospitalar – morte cardiovascular (MCV), enfarte agudo do miocárdio, reintervenção na lesão alvo (RLA) e recorrência de angina (RA). Resultados: De um total de 1650 ICP realizadas durante um período de 23 meses desde Janeiro de 2009, 42 (2,5%) envolveram a técnica de AR. Num total de 42 doentes submetidos a AR (70,3 ± ,1 anos, 67% homens, 55% de diabéticos), 3 apresentavam doença (DC) de tronco comum (TC), 6 dts DC de 3 vasos, 18 dts DC de 2 vasos e 15 dts DC de um vaso. As lesões tratadas (71% > 20 mm) classificaram-se como tipo C em 69% e oclusão total crónica em 4%. Intervencionou-se a descendente anterior em 56% dos casos. Utilizou-se uma média de 1,3 olivas por lesão e implantaram-se no total 69 stents, 81% dos quais eram farmacoativos. Verificou-se RA em 3 dts, RLA em apenas um dt e MCV em 2 dts. Em 83% dos doentes verificou-se melhoria da classe funcional. Conclusão: A utilização da AR na ICP de lesões gravemente calcificadas, seguida de colocação de stent, é um procedimento seguro e com uma elevada taxa de sucesso, permitindo a revascularização coronária a um maior número de doentes. Abstract: Introduction: Percutaneous coronary intervention (PCI) of heavily calcified lesions is a challenge for the interventional cardiologist and is associated with a high rate of restenosis and target lesion revascularization (TLR). Adequate lesion preparation by rotational atherectomy followed by drug-eluting stent implantation has shown favorable results. Objective: To report the recent experience of our center with rotational atherectomy (RA) of complex and heavily calcified coronary lesions. Methods: We retrospectively analyzed consecutive patients who underwent PCI with RA in our center between January 2009 and December 2010. A total of 42 patients were included, 65% of whom had been previously refused for coronary artery bypass grafting due to unfavorable coronary anatomy or high surgical risk. RA was performed using the standard Boston Scientific Rotablator® system. The procedure was performed ad-hoc in 50% of patients and transradial access was used in 35%. Data were collected on immediate post-procedural events and major cardiac events during follow-up – cardiovascular death, myocardial infarction, TLR and recurrent angina. Results: Of 1650 PCIs performed in a 23-month period from January 2009, 42 (2.5%) involved RA, a total of 42 patients (mean age 70.3±10.1 years, 67% male, 55% diabetic), three of whom had left main disease, six had three-vessel disease, 18 had two-vessel disease and the other 15 had single-vessel disease. Of the lesions treated, 71% were >20 mm long and classified in 69% of cases as type C according to the ACC/AHA lesion classification, 4% being chronic total occlusions. The left anterior descending artery was treated in 56% of the procedures. The mean number of burrs used per lesion was 1.3 and a total of 69 stents were implanted, 81% of which were drug-eluting. During follow-up three patients had recurrent angina, one required TLR and two died due to a cardiovascular event. There was significant clinical improvement in 83% of patients. Conclusions: This study demonstrates that rotational atherectomy followed by stenting in heavily calcified lesions can nowadays be performed with high success rates and few complications, extending the possibility of coronary revascularization to a greater number of patients. Palavras-chave: Calcificação coronária, Intervenção coronária percutânea, Aterectomia rotacional, Stents farmacoativos, Keywords: Coronary calcification, Percutaneous coronary intervention, Rotational atherectomy, Drug-eluting stents

Introduction: Patients with coronary artery disease (CAD) are at increased risk of stroke. The aim of this study was to analyze the prognostic accuracy of selected clinical and laboratory variables in stroke risk prediction following discharge after myocardial infarction (MI). Methods: we analyzed 404 consecutive patients (aged 68.1 ± 13.7 years; 63.4% male; 37.4% with diabetes) without previous stroke who were discharged in sinus rhythm after being admitted for MI. The following data were collected: cardiovascular risk factors, admission blood glucose (BG), HbA1c, creatinine, peak troponin levels; glomerular filtration rate (GFR) by the MDRD formula; maximum Killip class; GRACE score for in-hospital and 6-month mortality; and extent of CAD. Patients were followed for two years and each variable was tested as a possible predictor of cerebrovascular events (stroke or transient ischemic attack [TIA]). Results: During follow-up, 27 patients were admitted for stroke or TIA. The presence of diabetes, hypertension, dyslipidemia and previously known CAD, type of MI (STEMI vs NSTEMI) and extent of CAD did not predict cerebrovascular risk. The following variables were associated with higher stroke risk: GFR 1 (p = 0.025, OR 2.71, 95% CI 1.10-6.69); GRACE in-hospital mortality > 180 (p = 0.001, OR 4.09, 95% CI 1.64-10.22); admission BG > 140 mg/dl (p = 0.001, OR 5.74, 95% CI 1.87-17.58); GRACE 6–month mortality > 150 (p = 0.001, OR 4.50, 95% CI 1.80-6.27); and peak troponin > 42 ng/ml (p = 0.032, OR 2.64, 95% CI 1.06-6.59). Logistic regression analysis produced a model with the predictors GRACE 6-month mortality > 150 (OR 3.26; p = 0.014) and admission BG > 7.7 mmol/l (OR 4.09; p = 0.017) that fitted the data well (Hosmer-Lemeshow: p=0.916). Discussion/Conclusions: In patients with MI, variables known to be predictors of in-hospital mortality, including admission BG, renal function, acute heart failure and GRACE score, were found to be useful predictors of stroke during 2-year follow-up. While both GRACE score for 6-month mortality > 150 and admission BG > 7.7 mmol/l were independent predictors of stroke, CV risk factors, previously known CAD, and extent of CAD assessed by coronary angiography did not improve stroke risk prediction. This study highlights the need for even more aggressive secondary prevention in patients most at risk. Resumo: Introdução: Doentes com doença coronária (DC) têm risco aumentado de acidente vascular cerebral (AVC). O objectivo deste estudo foi analisar o poder prognóstico de determinadas variáveis clínicas e analíticas na predição do risco de evento cerebrovascular (CBV) após enfarte agudo do miocárdio (EAM). População e métodos: 404 doentes consecutivos (idade média 68,1 ± 13,7, 63,5% do sexo masculino, 37,4% com diabetes mellitus [DM]) sem antecedentes de AVC admitidos com o diagnóstico de EAM e que sobreviveram ao internamento. Dados recolhidos: factores de risco cardiovascular (CV), glicemia na admissão (GlicAd), HbA1c, creatinina, níveis máximos de troponina I (MaxTrop), taxa de filtração glomerular (TFG) calculada pelas fórmulas MDRD e Cockcroft-Gault, GRACE score para mortalidade intra-hospitalar e aos 6 meses (MIH e M6M, respectivamente), Killip Class máximo (KCm) e extensão da coronariopatia. Os doentes tiveram alta em ritmo sinusal, foram seguidos por dois anos e cada variável avaliada como possível preditor de AVC ou acidente isquémico transitório (AIT). Resultados: Durante o follow-up, 27 doentes foram admitidos por evento cerebrovascular. A presença de DM, hipertensão, dislipidemia e DC prévia, o tipo de EAM (STEMI versus NSTEMI) e a extensão da coronariopatia não ajudaram a prever o risco de AVC/AIT. As seguintes variáveis associaram-se a maior risco de AVC/AIT: TFG 1 (p = 0,025, OR 2,71, CI95% 1,10–6,69); GRACE MIH > 180 (p = 0,001, OR 4,09, CI95% 1,64–10,22); GRACE M6M > 150 (p = 0,001, OR 4,50, CI95% 1,80–6,27); GlicAd > 140 mg/dL (p = 0,001, OR 5,74, CI95% 1,87–17,58); MaxTrop > 42 ng/mL (p = 0,032, OR 2,64, CI95% 1,06–6,59). Regressão Logística obteve um modelo com os preditores GRACE M6M > 150 (OR 3,26, p = 0,014) e GlicAd > 7,7 mmol/L (OR 4,09, p = 0,017) que se ajustou bem aos dados (Hosmer-Lemeshow: p = 0,969). Discussão/conclusões: Em doentes com EAM, varáveis habitualmente úteis na predição do risco de MIH, como GlicAd e função renal, insuficiência cardíaca aguda e o score de GRACE mostraram valor como preditores de AVC/AIT durante um follow-up de 2 anos. Enquanto um valor do Score de GRACE M6M > 150 e GlicAd > 7,7 mmol/L se assumiram como preditores independentes de AVC/AIT, os factores de risco CV, a presença de CAD prévia e a extensão da coronariopatia não acrescentaram valor preditivo. Este estudo reforça a necessidade de uma prevenção secundária ainda mais agressiva em doentes com GRACE e GlicAD na admissão mais altos e com maior grau de disfunção renal. Keywords: Cerebrovascular disorders, Acute myocardial infarction, Risk prediction, Vascular events, Palavras-chave: Acidente vascular cerebral, Enfarte agudo do miocárdio, Predição de risco, Eventos vasculares

Penetration of fractional flow reserve (FFR) in clinical practice varies extensively, and the applicability of results from randomized trials is understudied. We describe the extent to which the information gained from routine FFR affects patient management strategy and clinical outcome.Nonselected patients undergoing coronary angiography, in which at least 1 lesion was interrogated by FFR, were prospectively enrolled in a multicenter registry. FFR-driven change in management strategy (medical therapy, revascularization, or additional stress imaging) was assessed per-lesion and per-patient, and the agreement between final and initial strategies was recorded. Cardiovascular death, myocardial infarction, or unplanned revascularization (MACE) at 1 year was recorded. A total of 1293 lesions were evaluated in 918 patients (mean FFR, 0.81±0.1). Management plan changed in 406 patients (44.2%) and 584 lesions (45.2%). One-year MACE was 6.9%; patients in whom all lesions were deferred had a lower MACE rate (5.3%) than those with at least 1 lesion revascularized (7.3%) or left untreated despite FFR≤0.80 (13.6%; log-rank P=0.014). At the lesion level, deferral of those with an FFR≤0.80 was associated with a 3.1-fold increase in the hazard of cardiovascular death/myocardial infarction/target lesion revascularization (P=0.012). Independent predictors of target lesion revascularization in the deferred lesions were proximal location of the lesion, B2/C type and FFR.Routine FFR assessment of coronary lesions safely changes management strategy in almost half of the cases. Also, it accurately identifies patients and lesions with a low likelihood of events, in which revascularization can be safely deferred, as opposed to those at high risk when ischemic lesions are left untreated, thus confirming results from randomized trials.URL: http://www.clinicaltrials.gov. Unique identifier: NCT01835808.

The smart grid concept increases the observability and controllability of the distribution system, which creates conditions for bi-directional control of Distributed Energy Resources (DER). The high penetration of Renewable Energy Resources (RES) in the distribution grid may create technical problems (e.g., voltage problems, branch congestion) in both transmission and distribution systems. The flexibility from DER can be explored to minimize RES curtailment and increase its hosting capacity. This paper explores the use of the Monte Carlo Simulation to estimate the flexibility range of active and reactive power at the boundary nodes between transmission and distribution systems, considering the available flexibility at the distribution grid level (e.g., demand response, on-load tap changer transformers). The obtained results suggest the formulation of an optimization problem in order to overcome the limitations of the Monte Carlo Simulation, increasing the capability to find extreme points of the flexibility map and reducing the computational effort.

Introduction and Objectives: The aim of the present paper is to report trends in Portuguese interventional cardiology from 2004 to 2013 and to compare them with other European countries. Methods: Based on the Portuguese National Registry of Interventional Cardiology and on official data from the Directorate-General of Health, we give an overview of developments in coronary interventions from 2004 to 2013. Results: In 2013, 36 810 diagnostic catheterization procedures were performed, representing an increase of 34% compared to 2007 and a rate of 3529 coronary angiograms per million population. Coronary interventions increased by 65% in the decade from 2004 to 2013, with a total of 13 897 procedures and a rate of 1333 coronary interventions per million population in 2013. Primary percutaneous coronary intervention (PCI) increased by 265% from 2004 to 2013 (1328 vs. 3524), an adjusted rate of 338 primary PCIs per million, representing 25% of total angioplasties. Stents were the most frequently used devices, drug-eluting stents being used in 73% in 2013. Radial access increased from 4.1% in 2004 to 57.9% in 2013. Conclusion: Interventional cardiology in Portugal has been expanding since 2004. We would emphasize the fact that in 2013 all Portuguese interventional cardiology centers were participating in the National Registry of Interventional Cardiology, as well as the growth in primary PCI and increased use of radial access. Resumo: Introdução e objetivos: Foi nosso objetivo estudar as tendências da intervenção coronária percutânea entre 2004-2013 e comparar Portugal com outros países europeus. Métodos: Análise dos procedimentos coronários efetuados entre 2004-2013 com base num registo prospetivo, multicêntrico, voluntário, doente a doente – Registo Nacional de Cardiologia de Intervenção (RNCI) da Associação Portuguesa de Intervenção Cardiovascular da Sociedade Portuguesa de Cardiologia (APIC-SPC) – e dos dados oficiais publicados pela Direção Geral de Saúde (DGS). Resultados: Em 2013 realizaram-se 36 810 cateterismos diagnósticos (3529 coronariografias por milhão de habitantes), representando um aumento significativo de 34% relativamente ao ano de 2007 (p

This paper describes the main developments of the LV SCADA project and addresses the technical challenges to be tackled when managing LV grids. This project entails the development of technological solutions that contribute for an effective Smart Grid implementation, creating flexible solutions allowing the anticipation of future trends, supporting the introduction of new technical, commercial and regulatory solutions to improve operation efficiency. This paper includes a description of the architecture, main functionalities and control capabilities associated to a new advanced LV SCADA that benefits from the AMI data available, allowing more precise network characterization without requiring widespread real-time information acquisition.

In order to allow large scale integration of Distributed Energy Resources in a secure and efficient way, the EU Project SuSTAINABLE designed a reference architecture for management and control of the distribution system as a whole. This novel architecture is based on the hierarchical architecture already deployed in the InovGrid test site in Évora, Portugal InovCity. This will require the development of specific algorithms and tools to support distribution system operation that are able to exploit distributed intelligence in several network components. These advanced control functionalities are summarily described and include: state estimation, load and renewable energy forecasting and voltage control.

Resumo: A angioplastia carotídea constitui uma opção terapêutica eficaz para o tratamento da doença carotídea aterosclerótica significativa, estando por vezes associada a alterações hemodinâmicas transitórias que influenciam a pressão arterial. Apresenta-se o caso clínico de uma mulher de 73 anos de idade com hipertensão arterial crónica refractária, que após ser submetida a angioplastia carotídea bilateral permaneceu normotensa durante um follow up de três anos. Abstract: Carotid artery angioplasty with stenting is an effective treatment for carotid artery stenosis, but is frequently associated with acute transient hemodynamic changes. We present the case of a 73-year-old female patient with long-standing refractory hypertension who remained normotensive during a three-year follow-up after undergoing staged bilateral carotid angioplasty. Palavras-chave: Hipertensão arterial refractária, Angioplastia carotídea bilateral, Keywords: Refractory hypertension, Bilateral carotid angioplasty

Carotid artery angioplasty with stenting is an effective treatment for carotid artery stenosis, but is frequently associated with acute transient hemodynamic changes. We present the case of a 73-year-old female patient with long-standing refractory hypertension who remained normotensive during a three-year follow-up after undergoing staged bilateral carotid angioplasty. Resumo: A angioplastia carotídea constitui uma opção terapêutica eficaz para o tratamento da doença carotídea aterosclerótica significativa, estando por vezes associada a alterações hemodinâmicas transitórias que influenciam a pressão arterial. Apresenta-se o caso clínico de uma mulher de 73 anos de idade com hipertensão arterial crónica refractária, que após ser submetida a angioplastia carotídea bilateral permaneceu normotensa durante um follow up de três anos. Keywords: Refractory hypertension, Bilateral carotid angioplasty, Palavras-chave: Hipertensão arterial refractária, Angioplastia carotídea bilateral

Smart Grids are the cornerstone for Distribution System Operators transformation. Having new solutions to deal with historical and future problems is key to ensure a smooth transition to an advanced power system that not only integrate a large share of renewables and distributed energy resources (e.g. storage, electrical vehicles), but also requires efficient operation, better planning and exceptional customer service. EDP Distribuição is at the forefront of this transformation, as it is developing Inovgrid, a smart grid project in Évora city (Portugal), where a smart grid infrastructure was deployed, and new data is now available to incorporate in planning and access tools and procedures, hence contributing to a Smarter Grid. This paper discusses the results that EDP Distribuição has attained so far in these areas of the smart grid development, as well as the projected evolution of these innovative approaches to the future of the distribution grid, which are being developed in European projects like SuSTAINABLE (www.sustainableproject.eu).

The occurrence of hemopericardium with cardiac tamponade is a complication of percutaneous balloon mitral valvuloplasty (BMV) which, although uncommon, may have severe maternal and fetal consequences. This article describes a case of cardiac tamponade following BMV in a 28-year-old woman with severe rheumatic mitral stenosis in the 20th week of gestation.

This paper presents an innovative Power System Restoration (PSR) that exploits the flexibility offered by large offshore wind parks, in particular with HVDC connection with Voltage Source converter (VSC) technology, to support restoration following a black out in a typical transmission grid. Restoration sequences comparing different strategies in a VHV AC network with conventional generation (thermal units and hydro units) were implemented for two cases: with and without the participation of a large offshore wind farm in the restoration plan. In order to evaluate the benefit of using Utility scale Wind Parks to support PSR, a typical transmission network with all its models (including HVDC link with DC converter) was implemented in EUROSTAG simulation platform.

Current electrical distribution systems are facing significant challenges due to the widespread deployment of Distributed Energy Resources (DER), particularly the integration of variable Renewable Energy Sources (RES). This requires a change in the paradigm of distribution grids from a purely passive perspective into fully active networks within the smart grid vision. This new paradigm involves new control and management architectures as well as advanced planning methods and operational tools for distribution systems exploiting a smart metering infrastructure. This infrastructure will enable leveraging data from smart meters and short-term forecasts of load demand and RES in order to manage the distribution system in a more efficient and cost-effective way, thus enabling large scale integration of RES. Future tests to be carried out in a new, state of the art laboratory environment will bring additional added-value to the validation of the proposed concepts and tools.

The hierarchical control scheme for three phase parallel connected voltage source inverters (VSI), forming a low voltage AC MicroGrid (MG)is presented and analyzed in this paper. The proposed control scheme consists of two controllers, a local controller and a centralized controller. The local controller consists of inner control loops that are composed by a voltage and current proportional resonant controllers with selective harmonics compensation, and the power sharing controller that includes the droop control and the virtual output impedance loops in order to share properly the active and reactive power between the connected VSIs. In this system, the centralized controller is designed to restore the magnitude and the frequency deviations of the AC bus voltage produced by the power sharing controller. Simulation results for three parallel connected VSIs forming a low voltage AC MG that operates in islanded mode are provided to show the effectiveness of the proposed control scheme. Active and reactive power are properly shared as well as good harmonics compensation is achieved when both linear and non-linear loads are connected to the load bus.

A 76-year-old female patient was referred to our institution because of typical chest pain. A continuous murmur was audible at the lower sternal border. A transthoracic echocardiogram showed non-dilated right and left ventricles with mild left ventricular inferior wall hypokinesia and an exercise stress test was positive for myocardial ischemia. A coronary angiogram showed no signs of atherosclerotic coronary artery disease, but it revealed a voluminous fistula between the proximal segment of the right coronary artery and a branch of the pulmonary artery, which was percutaneously closed using 3 embolization coils. Such late presentation of a voluminous coronary fistula is extremely rare and, to the best of our knowledge, very few case reports like this have been published.

Ischemic Mitral Regurgitation (MR) has early prognostic impact in Myocardial Infarction (MI). Its medium-term importance, especially of mild MR, has not been established.to determine new clinical/analytical predictors of MR in MI-patients and establish its prognostic value during two-year follow-up [endpoints: mortality, decompensated heart failure (dHF)].796 patients admitted for MI (age 68.8±13.4, 63.2% males, 44.6% STEMI).Admission analytical study, risk scores, coronariography, pre-discharge echocardiogram. Patients followed for two years. Clinical/analytical predictors of pre-discharge MR assessed. Predictive model for presence of pre-discharge MR included GRACE for intra-hospital mortality [IHM](OR=1.008, p0.001), glomerular filtration rate (GFR)[OR=0.993, p=0.048], admission haemoglobin (OR=0.84, p=0.003). In univariate analysis, moderate-severe MR predicted 2-year mortality (OR=3.32, p0.001), but not dHF. Two year mortality rate was proportional to severity of pre-discharge MR. Mild MR (vs. no MR) associated with higher risk for 2-year mortality (OR=2.04, p=0.014) and re-admission for dHF (OR=2.55, p=0.001). Predictive model for 2-year mortality included MR severity (OR=1.42, p=0.033) and GRACE for IHM (OR=1.023, p0.001).GRACE score for IHM, GFR and admission haemoglobin independently predicted risk for pre-discharge MR. MR, including its milder form, was an independent predictor of 2-year mortality, adding prognostic power to GRACE score.

The deployment of the smart grid concept requires more automation and control in electrical distribution systems in order to be able to accommodate Distributed Energy Resources (DER), particularly those based on Renewable Energy Sources (RES). This paper presents a hierarchical control architecture designed for electrical distribution system comprising two main control layers. This structure enables the implementation of advanced functionalities such as coordinated voltage control between the MV and LV levels, exploiting Distributed Generation (DG) capabilities together with traditional voltage control techniques. The performance of the proposed voltage control algorithm is illustrated based on simulation results using real distribution networks. (4 pages)

This paper addresses the problem of providing frequency control services, including inertia emulation and primary frequency control, from offshore wind farms connected through a multiterminal HVDC network. The proposed strategy consists of a cascading control mechanism based on dc voltage regulation at the onshore converters and frequency regulation at the offshore converters. The control scheme involves only local measurements and actions avoiding security and reliability issues of control structures based on remote information. The effectiveness of the proposed strategy is illustrated in a test system that consists of two nonsynchronous areas linked by a multiterminal HVDC grid where two offshore wind farms are also connected.

This paper addresses the problematic of operating isolated networks with large penetration of intermittent renewable power sources, as well as the benefits that electric vehicles might bring to these systems. A small island's network was used as case study and a 100% renewable dispatch for a valley period, only with hydro and wind generation, was tested in a dynamic simulation platform developed in Eurostag. Two distinct wind speed disturbances were simulated and, for both, the impact in the network's frequency was evaluated considering two different situations: electric vehicles only in charging mode and electric vehicles participating in primary frequency control. It was assumed the existence of 575 electric vehicles in the island. The impact of having electric vehicles performing primary frequency control in the expected batteries state of charge was also evaluated.