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Introduction and objectives: Systemic coronary artery embolism is one of the mechanisms of acute myocardial infarction of nonatherosclerotic origin. However, the epidemiological, clinical, and angiographic profile of this entity has not been properly established yet. Our objective was to describe the clinical characteristics, angiographic features, and prognosis of acute coronary syndromes (ACS) due to systemic embolism (ACS-E), compare them to those due to coronary atherosclerosis (ACS-A), and identify predictive clinical factors of ACS-E. Methods: All consecutive patients with ACS—admitted to a tertiary hospital from 2003 through 2018—were classified as ACS-E (n = 40) or ACS-A (n = 4989), and prospectively recruited on a multipurpose database. Results: Patients with ACS-E were younger (27.5% vs 9.6% were < 45 years old, P < .001), more often women (42.5% vs 22.5%, P = .003), and had higher rates of atrial fibrillation (AF) (40.0% vs 5.3%, P < .001), previous stroke (15.0% vs 3.6%, P < .001), active neoplasms (17.5% vs 6.9%, P =.009), and previous valvular surgery (12.5% vs 0.5%, P < .001). Also, a higher proportion of them were on warfarin (27.5% vs 2.9%, P < .001). The most frequent culprit vessel was the left anterior descending coronary artery in both groups. A percutaneous coronary intervention was attempted in all patients with ACS-A, and in 75.0% of those with ACS-E (P < .001) being successful in 99.1% and 80.0%, respectively. The in-hospital all-cause mortality rate was 15.0% regarding ACS-E, and 4.0% in the control group (P < .001). A multivariate analysis was performed to study the independent predictors of ACS-E, identify AF, previous valvular surgery, and active neoplasms, younger age, and female sex. Conclusions: ACS-E and ACS-A have different clinical and angiographic characteristics. Atrial fibrillation, previous valvular surgery, active neoplasms, younger age, and female sex were all independent predictors of ACS-E., Introducción y objetivos: La embolia coronaria de origen sistémico representa uno de los mecanismos de infarto agudo de miocardio de causa no aterosclerótica. Sin embargo, el perfil epidemiológico, clínico y angiográfico de esta entidad no ha sido aún bien definido. Nuestro objetivo fue describir las características clínicas y angiográficas y el pronóstico de los síndromes coronarios agudos (SCA) de origen embólico (SCA-E), compararlos con aquellos debidos a aterosclerosis (SCA-A) e identificar predictores clínicos de SCA-E. Métodos: Todos los pacientes con SCA atendidos en un hospital terciario entre 2003 y 2018 se clasificaron en SCA-E (n = 40) o SCA-A (n = 4.989) e incluidos de forma prospectiva en un registro multipropósito. Resultados: Entre los pacientes con SCA-E existía mayor proporción de jóvenes (27,5 frente a 9,6% tenían menos de 45 años, p < 0,001), mujeres (42,5 frente a 22,5%, p = 0,003), fibrilación auricular (FA) (40,0 frente a 5,3%, p < 0,001), neoplasias activas (17,5 frente a 6,9%, p = 0,009), cirugía valvular previa (12,5 frente a 0,5%, p < 0,001) y una mayor proporción de los mismos se encontraba en tratamiento con warfarina (27,5 frente a 2,9%, p < 0,001). El vaso responsable con mayor frecuencia fue la descendente anterior en ambos grupos. En todos los pacientes con SCA-A se llevó a cabo una intervención coronaria percutánea, frente al 75,0% de los pacientes con SCA-E (p < 0,001), la cual se completó con éxito en el 99,1% y el 80,0% de los casos, respectivamente. La mortalidad por todas las causas en el grupo de SCA-E fue del 15,0% frente al 4,0% en el grupo control (p < 0,001). Se llevó a cabo un análisis multivariante para estudiar predictores independientes de SCA-E, identificando la FA, la cirugía valvular previa, la presencia de una neoplasia activa, una menor edad y el sexo femenino. Conclusiones: Los SCA-E y los SCA-A presentan características clínicas y angiográficas diferentes. La FA, la cirugía valvular previa, la presencia de una ne

Calcified coronary artery disease poses a number of challenges to the interventional cardiologist when performing percutaneous coronary interventions, and patients with calcified coronary artery disease continue to have poorer outcomes at both the short and the long-term follow up. Stent underexpansion is the most feared outcome when performing percutaneous coronary interventions in these patients and is a strong predictor of stent failure. Therefore, intracoronary imaging to guide calcium modification is an important step in the treatment of this disease. The following review outlines a stepwise approach using intracoronary imaging in the assessment of coronary calcification, and in the selection of the appropriate calcium modification tool. Additionally, we describe current calcium modification techniques available, the evidence behind their use, their mechanism of action, and the typical results seen on intracoronary imaging., Las intervenciones coronarias percutáneas en enfermedad arterial coronaria calcificada representan un desafío para el cardiólogo intervencionista. Además, los pacientes con enfermedad arterial coronaria calcificada tienden a tener peores resultados en el seguimiento a corto y largo plazo. La infraexpansión del stent es el resultado más temido cuando se realiza una intervención coronaria percutánea en estos pacientes y es un gran predictor de falla del stent. Por lo tanto, la modificación del calcio guiada por imágenes intracoronarias, es un paso importante en el tratamiento de esta enfermedad. La siguiente revisión describe el uso «paso a paso» de imágenes intracoronarias en la evaluación de la calcificación coronaria y en la selección de una técnica de modificación de calcio adecuada. Además, se describen las técnicas actuales de modificación de calcio disponibles, la evidencia para su uso, su mecanismo de acción y los resultados típicos que se observan en las imágenes intracoronarias.

Background: The mean age of transcatheter aortic valve implantation (TAVI) patients is steadily decreasing. Aims: The aim of the study was to describe the characteristics, the indications for and the outcomes of TAVI in patients <70 years old. Methods: All patients patients undergoing TAVI (n=8,626) from the 18 participating centres between January 2007 dune 2020 were stratified by age (70). For patients <70, the indications for TAVI were extracted from Heart Team discussions and the baseline characteristics and mortality were compared between the two groups. Results: Overall, 640 (7.4%) patients were <70 (9.1% during 2018-2020, p<0.001); the mean age was 65.0 +/- 2.3 years. The younger patients were more often male, with bicuspid valves or needing valve-in-valve procedures. They had a higher prevalence of lung disease and diabetes. In 80.7% of cases, the Heart Team estimated an increased surgical risk and TAVI was selected, reflected by an STS score >4% in 20.4%. Five-year mortality was similar (29.4 vs 29.8%, HR 0.95, p=0.432) in the <70 and >70 groups. In the <70 group, mortality was higher for those referred for TAVI due to an increased surgical risk compared to those referred for other reasons (31.6 vs 24.5%, HR 1.23, p=0.021). Mortality was similar regardless of the STS stratum in patients judged by the Heart Team to be at increased surgical risk (32.6 vs 30.4%, HR 0.98, p=0.715). Conclusions: Use of TAVI in patients <70 is becoming more frequent. The main reason for choosing TAVI is due to an increased surgical risk not adequately represented by the STS score. The outcomes for these patients are similar to those for older TAVI patients. Dedicated trials of TAVI/SAVR in younger patients are needed to guide decisions concerning expansion of TAVI indications.

OBJECTIVE: Left atrial appendage (LAA) thrombus has heretofore been considered a contraindication to percutaneous LAA closure (LAAC). Data regarding its management are very limited. The aim of this study was to analyse the medical and invasive treatment of patients referred for LAAC in the presence of LAA thrombus. METHODS: This multicentre observational registry included 126 consecutive patients referred for LAAC with LAA thrombus on preprocedural imaging. Treatment strategies included intensification of antithrombotic therapy (IAT) or direct LAAC. The primary and secondary endpoints were a composite of bleeding, stroke and death at 18 months, and procedural success, respectively. RESULTS: IAT was the preferred strategy in 57.9% of patients, with total thrombus resolution observed in 60.3% and 75.3% after initial and subsequent IAT, respectively. Bleeding complications and stroke during IAT occurred in 9.6% and 2.9%, respectively, compared with 3.8% bleeding and no embolic events in the direct LAAC group before the procedure. Procedural success was 90.5% (96.2% vs 86.3% in direct LAAC and IAT group, respectively, p=0.072), without cases of in-hospital thromboembolic complications. The primary endpoint occurred in 29.3% and device-related thrombosis was found in 12.8%, without significant difference according to treatment strategy. Bleeding complications at 18 months occurred in 22.5% vs 10.5% in the IAT and direct LAAC group, respectively (p=0.102). CONCLUSION: In the presence of LAA thrombus, IAT was the initial management strategy in half of our cohort, with initial thrombus resolution in 60% of these, but with a relatively high bleeding rate (~10%). Direct LAAC was feasible, with high procedural success and absence of periprocedural embolic complications. However, a high rate of device-related thrombosis was detected during follow-up.

Background: Data on Device-related Thrombus (DRT) after left atrial appendage closure (LAAC) remain scarce. This study aimed to investigate risk factors for DRT from centers reporting to the EUROC-DRT registry. Methods: We included 537 patients (112 with DRT and 425 without DRT) who had undergone LAAC between 12/2008 and 04/2019. Baseline and implantation characteristics, anti-thrombotic treatment and clinical outcomes were compared between both groups in uni- and multivariate analyses. Additional propensity-score matching (PSM) was conducted to focus on the role of implantation characteristics. Results: Patients with DRT showed higher rates of previous stroke/transient ischemic attack (TIA) (49.1% vs. 34.7%, p < 0.01), spontaneous echocardiographic contrast (SEC) (44.9% vs. 27.7%, p < 0.01) and lower left atrial appendage (LAA) peak emptying velocity (35.4 ± 18.5 vs. 42.4 ± 18.0 cm/s, p = 0.02). Occluders implanted in DRT patients were larger (25.5 ± 3.8 vs. 24.6 ± 3.5 mm, p = 0.03) and implanted deeper in the LAA (mean depth: 7.6 ± 4.7 vs. 5.7 ± 4.7 mm, p < 0.01). Coverage of the appendage ostium was achieved less often in DRT patients (69.5% vs. 81.5%, p < 0.01), while DRT patients were less frequently on oral anticoagulation (7.1% vs. 16.7%, p < 0.01). Multivariate analysis identified age, prior stroke/TIA and SEC as independent risk factors for DRT. After PSM, implantation depth was found to be predictive. Rates of stroke/TIA were higher in DRT patients (13.5% vs. 3.8%, Hazard Ratio: 4.21 [95%-confidence interval: 1.88–9.49], p < 0.01). Conclusions: DRT after LAAC is associated with adverse outcome and appears to be of multifactorial origin, depending on patient characteristics, anticoagulation regimen and device position. Graphical abstract: [Figure not available: see fulltext.].

Background: The mean age of transcatheter aortic valve implantation (TAVI) patients is steadily decreasing. Aims: The aim of the study was to describe the characteristics, the indications for and the outcomes of TAVI in patients <70 years old. Methods: All patients undergoing TAVI (n=8,626) from the 18 participating centres between January 2007 and June 2020 were stratified by age (70). For patients <70, the indications for TAVI were extracted from Heart Team discussions and the baseline characteristics and mortality were compared between the two groups. Results: Overall, 640 (7.4%) patients were <70 (9.1% during 2018-2020, p<0.001); the mean age was 65.0±2.3 years. The younger patients were more often male, with bicuspid valves or needing valve-in-valve procedures. They had a higher prevalence of lung disease and diabetes. In 80.7% of cases, the Heart Team estimated an increased surgical risk and TAVI was selected, reflected by an STS score >4% in 20.4%. Five-year mortality was similar (29.4 vs 29.8%, HR 0.95, p=0.432) in the <70 and >70 groups. In the <70 group, mortality was higher for those referred for TAVI due to an increased surgical risk compared to those referred for other reasons (31.6 vs 24.5%, HR 1.23, p=0.021). Mortality was similar regardless of the STS stratum in patients judged by the Heart Team to be at increased surgical risk (32.6 vs 30.4%, HR 0.98, p=0.715). Conclusions: Use of TAVI in patients <70 is becoming more frequent. The main reason for choosing TAVI is due to an increased surgical risk not adequately represented by the STS score. The outcomes for these patients are similar to those for older TAVI patients. Dedicated trials of TAVI/SAVR in younger patients are needed to guide decisions concerning expansion of TAVI indications.