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IntroductionComplex Percutaneous coronary intervention (PCI) for the treatment of ischemic heart disease has increased significantly. We aimed to evaluate sex-related differences in patients undergoing complex PCI.Methodssingle-center prospective observational study including patients undergoing complex PCI between 2017 and 2023. Baseline and procedural features, and mid-term outcomes were compared according to the gender distribution. The combined primary endpoint included stroke, myocardial infarction, need for a new coronary revascularization, and all-cause mortality. Propensity score (PS) matching with an inverse probability of treatment weight (IPW) approach was used to adjust for differences in baseline characteristics.Results1,283 patients were included, 983 (76.6%) male and 300 (23.4%) female. Median follow-up was 2.4 (IQR: 1–3.8) years. There was a higher rate of no-reflow phenomenon (4% vs. 1.8%, p = 0.03) among female patients. In the overall cohort, female patients had a greater risk for the combined primary endpoint (HR 1.28, 95% CI: 1.02–1.59). In the matched cohort, female patients exhibited a higher risk for the combined primary endpoint (HR 1.23, 95% CI: 1.06–1.42), as well as for myocardial infarction (HR 1.34, 95% CI 1.03–1.75), and all-cause mortality (HR 1.21, 95% CI 1.02–1.45), and a trend towards a higher risk for the need of a new coronary revascularization (HR 1.22, 95% CI 0.92–1.61).Conclusionsin a contemporary cohort of patients undergoing complex PCI procedures, female patients are associated with a higher risk of early complications.

Background Hypertrophic cardiomyopathy is an autosomal dominant cardiac disease. The mechanisms that determine its variable expressivity are poorly understood. Epigenetics could play a crucial role in bridging the gap between genotype and phenotype by orchestrating the interplay between the environment and the genome regulation. In this study we aimed to establish a possible correlation between the peripheral blood DNA methylation patterns and left ventricular hypertrophy severity in patients with hypertrophic cardiomyopathy, evaluating the potential impact of lifestyle variables and providing a biological context to the observed changes. Methods and Results Methylation data were obtained from peripheral blood samples (Infinium MethylationEPIC BeadChip arrays). We employed multiple pair‐matched models to extract genomic positions whose methylation correlates with the degree of left ventricular hypertrophy in 3 monozygotic twin pairs carrying the same founder pathogenic variant (MYBPC3 p.Gly263Ter). This model enables the isolation of the environmental influence, beyond age, on DNA methylation changes by removing the genetic background. Our results revealed a more anxious personality among more severely affected individuals. We identified 56 differentially methylated positions that exhibited moderate, proportional changes in methylation associated with left ventricular hypertrophy. These differentially methylated positions were enriched in regions regulated by repressor histone marks and tended to cluster at genes involved in left ventricular hypertrophy development, such as HOXA5, TRPC3, UCN3, or PLSCR2, suggesting that changes in peripheral blood may reflect myocardial alterations. Conclusions We present a unique pair‐matched model, based on 3 monozygotic twin pairs carrying the same founder pathogenic variant and different phenotypes. This study provides further evidence of the pivotal role of epigenetics in hypertrophic cardiomyopathy variable expressivity.

To the Editor, This is the case of a 67-year-old woman admitted due to a 6-month history of exertional angina. Stress echocardiography showed severe anterior wall ischemia. The patient was referred for coronary angiography that revealed the presence of a chronic total coronary occlusion of the proximal left anterior descending coronary artery (LAD) immediately before the bifurcation with the first diagonal branch (D1) from the septal collaterals of the right coronary artery (figure 1, video 1 of the supplementary data). The patient signed the written informed consent, and a chronic total coronary occlusion recanalization was performed 6 months after the index angiography. Figure 1. A: cranial view of chronic total coronary occlusion of proximal left anterior descending coronary artery (LAD). B: postoperative final angiographic result with a small non-flow limiting dissection in the mid-LAD treated conservatively. C: angiographic control at 6 months showed great outcomes using drug-eluting balloons. The distal vessel has increased its size with no signs of the small dissection whatsoever. Initial antegrade acess was planned given the lesion’s favorable characteristics (Japan-chronic total occlusion score of 1). An ultrasound-guided dual angiography was performed with a 7-Fr AL1 guiding catheter (Cordis, United States) via femoral access for the right coronary artery, and...

Sr. Editor: Presentamos el caso de una mujer de 67 años ingresada con un cuadro de angina de esfuerzo de 6 meses de evolución. La prueba de esfuerzo electrocardiográfica confirmó la presencia de isquemia grave de la pared anterior. Se derivó a la paciente para practicarle una coronariografía, que reveló la presencia de una oclusión coronaria total crónica en el segmento proximal de la descendente anterior (DA) inmediatamente antes de la bifurcación con la prime-ra rama diagonal (D1) perfundida por colaterales septales desde la coronaria derecha (figura 1A, vídeo 1 del material adicional). La paciente firmó el consentimiento informado para el procedimiento y la oclusión coronaria total crónica se recanalizó 6 meses después de la angiografía inicial. Figura 1. A: vista craneal de la oclusión coronaria total crónica localizada en el segmento proximal de la descendente anterior (DA). B: resultado final angiográfico posoperatorio con una pequeña disección no limitante del flujo en el segmento medio de la DA tratada de forma conservadora. C: el seguimien-to angiográfico a los 6 meses confirmó los excelentes resultados clínicos cosechados con los balones farmacoactivos. El vaso distal ha aumentado su tamaño sin rastro alguno de la pequeña disección. Inicialmente, teniendo en cuenta las características favorables de la...

Sr. Editor: Se presenta el caso de un varón de 72 años con angina de esfuerzo e isquemia grave de la pared inferior confirmada tras exploración mediante tomografía computarizada por emisión de fotón único con Tc-99. Tras obtener el consentimiento informado y por escrito del paciente, se realizó una coronariografía que confirmó la presencia de oclusión coronaria total crónica (OTC) en la coronaria derecha (CD) proximal (figura 1A) con una puntuación en la escala J-CTO de 3 (punto de entrada romo, lesión > 20 mm y calcificación) y presencia de ramas colaterales septales desde la descendente anterior (DA) (figura 1B, vídeo 1 del material adicional). Inicialmente se usó el abordaje anterógrado, que hubo que cambiar rápidamente por el retrógrado debido a las características desfavorables de la lesión. Figura 1. A: oclusión total de CD proximal. B: ramas colaterales septales desde la descendente anterior. C: guía externalizada mediante abordaje retrograde desde las ramas colaterales septales franqueando la oclusión de la coronaria derecha. D: inserción de guía mediante abordaje retrógrado con ayuda de microcatéter colocado en coronaria derecha distal. E: resultado angiográfico tras predilatación de la oclusión e implante de stent con grado de flujo TIMI 1. F: tras el uso del balón farmacoativo,...

To the Editor, This is the case of a 72-year-old male examined due to exertional angina, and severe inferior wall ischemia through a single-photon emission computed tomography with Tc-99. After obtaining the patient’s written informed consent he was referred for a coronary angiography that confirmed the chronic total coronary occlusion (CTO) of the proximal right coronary artery (RCA) (figure 1A) with a J-CTO score of 3 (blunt entry shape, lesion > 20 mm, and calcification), and the presence of septal collaterals from the left anterior descending coronary artery (figure 1B, video 1 of the supplementary data). Initial antegrade approach was planned that quickly had to be changed for the retrograde approach due to the unfavorable characteristics of the lesion. Figure 1. A: total occlusion of proximal RCA. B: septal collaterals from the left anterior descending coronary artery. C: externalized retrograde wire from the septal collateral crossing the right coronary artery occlusion. D: antegrade wiring with the help of a microcatheter placed in the distal right coronary artery. E: angiographic result after occlusion predilatation and stenting with TIMI grade-1 flow. F: after drug-eluting balloon, TIMI grade-3 flow is achieved with a diseased distal vessel. After surfing across the septal collateral channels, the distal cap...

IntroductionMitral Regurgitation (MR) has a strong impact on quality of life and on mid-term survival. Transcatheter mitral valve replacement (TMVR) is rapidly expanding and a growing number of studies have been published recently.MethodsA systematic review of studies reporting on clinical data for patients with symptomatic severe MR undergoing TMVR was performed. Early- and mid-term outcomes (clinical and echocardiographic) were evaluated. Overall weighted means and rates were calculated. Risk ratios or mean differences were calculated for pre- and post-procedural comparisons.ResultsA total of 12 studies and 347 patients who underwent TMVR with devices clinically available or under clinical evaluation were included. Thirty-day mortality, stroke and major bleeding rates were 8.4%, 2.6%, and 15.6%, respectively. Pooled random-effects demonstrated a significant reduction of ≥ grade 3+ MR (RR: 0.05; 95% CI: 0.02–0.11; p

RESUMEN Introducción y objetivos: Los pacientes con estenosis en el tronco coronario izquierdo (TCI) han sido excluidos de los ensayos que apoyan la no inferioridad del cociente de presiones en el índice diastólico instantáneo sin ondas (iFR) respecto a la reserva fraccional de flujo (RFF) en la toma de decisiones sobre revascularización coronaria. El presente estudio propone valorar de manera prospectiva la concordancia entre los dos índices en lesiones del TCI y validar el valor de corte del iFR de 0,89 para su uso clínico. Métodos: Registro multicéntrico nacional, prospectivo, observacional, con la inclusión de 300 pacientes consecutivos con lesiones intermedias (estenosis angiográfica 25-60%) en el TCI. Se realizará un estudio con guía de presión y determinación de RFF e iFR. En caso de resultado concordante negativo (RFF > 0,80 / iFR > 0,89), no se realizará tratamiento; en caso de resultado concordante positivo (RFF ≤ 0,80 / iFR ≤ 0,89), se realizará revascularización; en caso de resultado discordante (RFF > 0,80 / iFR ≤ 0,89 o RFF ≤ 0,80 / iFR > 0,89), se realizará estudio con ecocardiografía intravascular y se considerará diferir la revascularización si el área luminal mínima es > 6 mm2. El criterio de valoración clínico primario será la incidencia del combinado de muerte cardiovascular, infarto no mortal relacionado con la lesión del TCI o necesidad de revascularización de la lesión del TCI a los 12 meses. Conclusiones: La demostración de la seguridad clínica en la toma de decisiones del iFR en pacientes con lesiones intermedias en el TCI tendría un impacto clínico importante y justificaría su uso sistemático para la decisión del tratamiento en estos pacientes de potencial alto riesgo. Registrado en ClinicalTrials.gov (identificador: NCT03767621).

ABSTRACT Introduction and objectives: Patients with left main coronary artery (LMCA) stenosis have been excluded from the trials that support the non-inferiority of the instantaneous wave-free ratio (iFR) compared to the fractional flow reserve (FFR) in the decision-making process of coronary revascularization. This study proposes to prospectively assess the concordance between the two indices in LMCA lesions and to validate the iFR cut-off value of 0.89 for clinical use. Methods: National, prospective, and observational multicenter registry of 300 consecutive patients with intermediate lesions in the LMCA (angiographic stenosis, 25% to 60%. A pressure gudiewire study and determination of the RFF and the iFR will be performed: in the event of a negative concordant result (FFR > 0.80/iFR > 0.89), no treatment will be performed; in case of a positive concordant result (FFR ≤ 0.80/iFR ≤ 0.89), revascularization will be performed; In the event of a discordant result (FFR> 0.80/iFR ≤ 0.89 or FFR ≤ 0.80/iFR> 0.89), an intravascular echocardiography will be performed and revascularization will be delayed if the minimum lumen area is > 6 mm2. The primary clinical endpoint will be a composite of cardiovascular death, LMCA lesion-related non-fatal infarction or need for revascularization of the LMCA lesion at 12 months. Conclusions: Confirm that an iFR-guided decision-making process in patients with intermediate LMCA stenosis is clinically safe and would have a significant clinical impact. Also, justify its systematic use when prescribing treatment in these potentially high-risk patients. Registered at ClinicalTrials.gov ( Identifier: NCT03767621).

Abstract Paravalvular leakage (PVL) is yet a potential and serious complication after transcatheter aortic valve replacement. Percutaneous PVL closure may be the treatment of choice upon failure of balloon postdilation in patients with excessive surgical risk. If the retrograde approach fails, an antegrade strategy might provide the solution.

Background: Transcatheter aortic valve implantation has revolutionized the management of aortic stenosis and is currently an alternative to surgical aortic valve replacement. Some studies have found costs of percutaneous procedure to be greater than those of surgical replacement. However, these published studies are based on pooled data from clinical registries. The objective of the present study was to compare costs of both treatments during the hospital phase in a Spanish public hospital. Methods: A hospital phase cost study consisted of patients diagnosed and treated with aortic stenosis in a Spanish tertiary hospital between 1st January 2019 and 29th February 2020. An individual analysis was conducted in relation to real costs pertaining to materials, staffing and hospital stay. Several baseline characteristics were controlled for. Results: Mean costs per patient from procedure through to discharge were 26,684.1 € in the percutaneous group and 14,939.5 € in the surgical group (p

Background Malnutrition is associated with poor prognosis in several cardiovascular diseases. However, its prognostic impact in patients undergoing transcatheter edge‐to‐edge mitral valve repair (TEER) is not well known. This study sought to assess the prevalence, clinical associations, and prognostic consequences of malnutrition in patients undergoing TEER. Methods and Results A total of 892 patients undergoing TEER from the international MIVNUT (Mitral Valve Repair and Nutritional Status) registry were studied. Malnutrition status was assessed with the Controlling Nutritional Status score. The association of nutritional status with mortality was analyzed with multivariable Cox regression models, whereas the association with heart failure admission was assessed by Fine‐Gray models, with death as a competing risk. According to the Controlling Nutritional Status score, 74.4% of patients with TEER had any degree of malnutrition at the time of TEER (75.1% in patients with body mass index

The development of transcatheter therapies to treat valvular heart diseases has changed the rules of the game, particularly in the case of aortic stenosis and mitral regurgitation. In the last years, the tricuspid valve has also been the focus of these percutaneous techniques for several reasons: (1) tricuspid regurgitation is a frequent disease associated with poor clinical outcomes in spite of medical treatment, leading to end-stage right ventricular heart failure, (2) surgical tricuspid valve repair or replacement has been the treatment of choice for patients with tricuspid valve disease, but high mortality rates for isolated surgical tricuspid valve intervention have been reported in the literature, and (3) most patients with tricuspid pathology are ultimately denied cardiac surgery because of their comorbidity burden. Thus, in this context the development of less invasive catheter-based therapies would be of high clinical relevance. The present review provides an overview regarding the framework of chronic tricuspid regurgitation transcatheter therapeutic options, summarizes the transcatheter systems under clinical use or clinical evaluation with their technical features, and describes the updated current evidence in this challenging and evolving field.

Aims: To analyse the relationship among air pollutants, markers of inflammation and infarct size in patients with acute coronary syndrome (ACS). Methods: This was a prospective analysis of consecutive patients admitted to hospital because of ACS. Cardiac biomarkers were drawn. The daily mean values of the air pollutants from the day before until 7 days before admission were analysed. The study population was stratified according to infarct size, based on median peak troponin value. Results: Patients were divided into two groups of 108 subjects each, according to median peak troponin value. Patients with extensive MIs had a higher neutrophil:lymphocyte ratio and leukocyte and neutrophil counts than patients with smaller MIs. In addition, they were exposed to higher concentrations of sulphur dioxide (9.7 ± 4.1 versus 8.4 ± 3.1 μg/m3; p=0.009) and lower concentrations of ozone (33.8 ± 13.7 versus 38.6 ± 14.5 μg/m3; p=0.014). Multivariate analysis showed that sulphur dioxide levels (OR 1.12; 95% CI [1.031–1.21]; p=0.007) and neutrophil/lymphocyte ratio (OR 1.08; 95% CI [1.011–1.17]; p=0.024) were independent predictors of infarct size. Conclusion: Patients with extensive MIs had higher white cell inflammatory levels and had been exposed to higher sulphur dioxide concentrations in the ambient air.

Atherosclerosis is a chronic inflammatory disease. Several circulating inflammatory markers have been proposed for clinical use due to their ability to predict future cardiovascular events and may be useful for identifying people at high risk who might benefit from specific treatment to reduce this risk. Moreover, the identification of new therapeutic targets will allow the development of drugs that can help reduce the high residual risk of recurrence of cardiovascular events in patients with coronary artery disease. The clinical benefits of reducing recurrent major cardiovascular events recently shown by canakinumab and colchicine have renewed the cardiology community’s interest in inflammation as an aetiopathogenic mechanism for atherosclerosis. This review explores the use of C-reactive protein, which is the most frequently studied biomarker in this context; the concept of residual risk in primary and secondary cardiovascular prevention; and the current recommendations in international guidelines regarding the role of this inflammatory biomarker in cardiovascular risk stratification.

ABSTRACT The primary endpoint of the ISCHEMIA trial, whose results were presented at the American Heart Association congress back in 2019, was to determine whether an initial invasive strategy of cardiac catheterization and successful revascularization plus optimal medical treatment would reduce the primary composite endpoint of cardiovascular death or myocardial infarction in patients with chronic coronary syndrome compared to an initial conservative strategy of optimal medical treatment. Out of 5179 patients, 2588 were randomized to receive an invasive strategy and 2591 to receive conservative strategy. At the 4-year follow-up, the primary endpoint showed no significant differences between both groups revolutionizing mass media. In our opinion, we should be cautious when interpreting the results of a study that has not been published yet. There is no doubt, however, that the ISCHEMIA trial deals with an important matter, that the most powerful medical treatment was able to modify the natural history of this disease in patients with chronic coronary syndrome.

RESUMEN El estudio ISCHEMIA, cuyos resultados se presentaron en el congreso de la American Heart Association en 2019, tiene como objetivo principal determinar si una estrategia invasiva inicial de cateterización cardiaca y revascularización exitosa, junto con el tratamiento médico óptimo, reduce el objetivo primario combinado de muerte cardiovascular o infarto de miocardio en pacientes con síndrome coronario crónico, en comparación con una estrategia conservadora inicial de tratamiento médico óptimo. De 5.179 pacientes, se aleatorizaron 2.588 para seguir una estrategia invasiva y 2.591 para una estrategia conservadora. A los 4 años de seguimiento, el objetivo primario no mostró diferencias significativas entre ambos grupos, lo que generó un gran revuelo mediático. En nuestra opinión, debemos ser prudentes al interpretar los resultados de un estudio aún sin publicar. No obstante, es innegable que el estudio ISCHEMIA aborda la importante cuestión de que el tratamiento médico más potente en pacientes con síndrome coronario crónico ha demostrado modificar la evolución natural de la enfermedad.

ABSTRACT Introduction and objectives: The PSP (pre-dilation, sizing and post-dilation) score, derived from the GHOST-EU registry, has evaluated the relationship between the implantation technique of bioresorbable scaffolds and the clinical outcomes. The objective was to perform an external validation of the PSP technique and to determine its effect on adverse cardiac events in various clinical and anatomical scenarios. Methods: Data from the REPARA registry (2230 patients) were used for external validation, whereas a common database combining REPARA and GHOST-EU (3250 patients) data was used to evaluate the effect of PSP technique in various clinical and anatomical scenarios. PSP-1 and PSP-3 were used to score the appropriateness of pre-dilation, scaffold sizing, and post-dilation. The primary endpoint was 1-year device-oriented composite endpoint of cardiac death, target-vessel myocardial infarction, and target-lesion revascularization. The definite/probable scaffold thrombosis according to the Academic Research Consortium criteria was also evaluated. Results: A total of 303 (18.2%) patients were treated with an optimal PSP-1, and 182 (8.2%) with an optimal PSP-3. The external validation showed that PSP has a very high negative predictive value for device-oriented composite endpoint and scaffold thrombosis (91.8% and 89.1% for PSP-1; 98.4% and 97.3% for PSP-3, respectively). Patients with an optimal PSP-3 had a numerically lower rate of device-oriented composite endpoint and scaffold thrombosis compared to those without it (0.5% vs 2.9%; P = .085 and 0.5% vs 1.8%; P = .248, respectively). In the merged database, PSP benefits were seen on many scenarios, except in the ST-segment elevation myocardial infarction where a trend towards no benefit of an optimal PSP technique was present (Pinteraction = .100). Conclusions: In the REPARA registry, at 1-year follow-up, an optimal PSP technique was not associated with a lower rate of device-oriented composite endpoint. Further research is necessary to assess the impact of the PSP technique in longer follow-ups.

RESUMEN Introducción y objetivos: La escala de puntuación PSP (pre-dilation, sizing and post-dilation), derivada del registro GHOST-EU, evalúa la relación entre la técnica de implante de los armazones bioabsorbibles y los resultados clínicos. El objetivo fue realizar una validación externa de la escala PSP y determinar su efecto en eventos adversos cardiacos en diversos escenarios clínicos y anatómicos. Métodos: Para la validación externa se emplearon los datos del registro REPARA (2.230 pacientes), mientras que se utilizó una base de datos común que combina datos de REPARA y GHOST-EU (3.250 pacientes) para evaluar el efecto de la técnica PSP en varios escenarios clínicos y anatómicos. Se usó PSP-1 y PSP-3 para calificar la calidad de la predilatación, el dimensionamiento de los armazones y la posdilatación. El objetivo primario fue la variable compuesta orientada al dispositivo (muerte cardiaca, infarto de miocardio del vaso diana y revascularización de la lesión diana) a 1 año. También se evaluó la trombosis definitiva o probable del armazón según los criterios del Academic Research Consortium. Resultados: Se trató a 303 (18,2%) pacientes con una PSP-1 óptima y a 182 (8,2%) con una PSP-3 óptima. La validación externa mostró que la escala PSP tiene un valor predictivo negativo muy alto para el objetivo primario compuesto orientado al dispositivo y la trombosis del armazón (91,8 y 89,1% para PSP-1; 98,4 y 97,3% para PSP-3, respectivamente). En pacientes con PSP-3 óptimo, el objetivo primario compuesto orientado al dispositivo y la trombosis del armazón fueron numéricamente inferiores en comparación con los pacientes sin PSP-3 óptimo (0,5 frente a 2,9%; p = 0,085; y 0,5 frente a 1,8%; p = 0,248, respectivamente). En la base de datos combinada, los beneficios de la escala PSP se observaron en diversos escenarios, excepto en el de infarto de miocardio con elevación del segmento ST, en el que se observó una tendencia hacia laausencia de beneficios de una técnica de PSP óptima (pinteracción = 0,100). Conclusiones: Una técnica de PSP óptima no se asoció con una tasa más baja del objetivo primario compuesto orientado al dispositivo. Se necesitan nuevos estudios para evaluar el impacto de la técnica de PSP con un seguimiento más prolongado.

Abstract Introduction and objectives: Mitral regurgitation is one society’s most prevalent valvular diseases. Transcatheter mitral valve repair with the MitraClip system has become more widely used for the management of this condition. The endpoints of the study were the changes in the mitral annular morphology, the recurrent grade III-IV mitral valve regurgitation, and a composite endpoing of heart failure readmission and all-cause mortality. Methods: Single-centre, prospective and observational study. We included patients admitted due to transcatheter mitral valve repair between October 2015 and October 2018. The three-dimensional analysis of the mitral valve annulus was performed using the MVQ QLAB mitral valve quantification software (Philips; Amsterdam, The Netherlands). Results: Fifty procedures were performed on 48 patients. A significant decrease of both annular diameters, perimeter and area was observed after the procedure. The antero-posterior diameter reduction was more significant in patients with functional mitral regurgitation compared to patients with organic mitral regurgitation (13.2 ± 8.8 vs 8.6 ± 7.5; P = .05). The posterior leaflet grasping was the only parameter associated with less chances of significant recurrent mitral regurgitation (OR = 0.89; 95CI%, 0.79-0.98). Conclusions: Mitral annular morphological changes occur after MitraClip implantation. The magnitude of these changes varies depending on the etiology of mitral regurgitation. Posterior leaflet grasping is the main factor associated with these changes and prevents the recurrence of significant mitral regurgitation.

Resumen Introducción y objetivos: La insuficiencia mitral es una de las enfermedades valvulares más prevalentes en nuestro medio. La reparación mitral transcatéter con el sistema MitraClip es un procedimiento cada vez más utilizado en este contexto. Los objetivos del estudio fueron evaluar los cambios morfológicos anulares, la recurrencia de la insuficiencia mitral significativa y un objetivo combinado de reingreso por insuficiencia cardiaca y mortalidad global. Métodos: Estudio prospectivo, observacional y unicéntrico. Se incluyeron pacientes tratados con reparación mitral transcatéter entre octubre de 2015 y octubre de 2018. Se realizó un análisis tridimensional del anillo con el software de cuantificación mitral MVQ QLAB 10.0 (Philips; Amsterdam, Países Bajos). Resultados: Se realizaron 50 procedimientos en 48 pacientes. Tras el procedimiento se observó una disminución significativa de ambos diámetros anulares, así como del perímetro y del área, y una mayor reducción del diámetro anteroposterior en los pacientes con insuficiencia mitral funcional con respecto a aquellos con insuficiencia mitral orgánica (13,2 ± 8,8 frente a 8,6 ± 7,5; p = 0,05). El porcentaje de grasping sobre el velo posterior fue el único parámetro que se asoció estadísticamente a una menor probabilidad de desarrollar insuficiencia mitral significativa (OR = 0,89; IC95%, 0,79-0,98). Conclusiones: Tras el implante de MitraClip se producen cambios morfológicos en el anillo mitral. La magnitud de estos cambios es diferente según la etiología de la insuficiencia mitral. El grasping del velo posterior es el principal factor asociado a dichos cambios y previene la recurrencia de la insuficiencia mitral significativa.

Hypertrophic cardiomyopathy (HCM) is a monogenic disease with autosomal dominant inheritance. Genotype–phenotype relationships are complex, with variable penetrance even within the same family. The involvement of other modulating genetic and environmental factors is unknown. We aimed to analyze the HCM in monozygotic twins, carriers of the same founder pathogenic variant MYBPC3 p.G263*. The relationship was verified using the PowerPlex 16 HS System kit. Phenotypic differences and environmental differences (overloading conditions, coexistence and location, lifestyle, sport, and intensity) were analyzed. Three pairs of twins genetically identical for all markers and carriers of MYBPC3 G263* were identified. No environmental differences were identified. One of the 89-year-old twins had symptomatic severe obstructive HCM that required septal ablation, while her twin has remained asymptomatic with mild phenotype >80 years. A 49-year-old twin had a severe phenotype of obstructive HCM and pending myectomy, while his twin had a mild asymptomatic phenotype. In the last pair of twins, one presented a much larger left ventricular hypertrophy than his identical twin. In summary, we present three pairs of HCM twin patients sharing not only the genetic cause of the inherited disease but the entire genetic background. Despite identical genetic information and the absence of other known clinical, environmental, or lifestyle differences, the severity of the HCM phenotype is strikingly different. These unexplained differences should prompt the study of other unknown modulating factors, either epigenetic or environmental.

Resumen: Objetivo: Durante el período de formación, el residente de cardiología ha de entrenarse en todo lo relacionado con la indicación, la interpretación y realización de imágenes en cardiología nuclear que usan la tomografía computarizada por emisión de fotón simple (SPECT). El objetivo del presente estudio fue analizar la relación existente entre la adecuación de las indicaciones del gated-SPECT de perfusión miocárdica y los años de experiencia desde la finalización de la residencia de cardiología. Método: Registro descriptivo, retrospectivo y unicéntrico, en el que se analizaron las indicaciones (uso adecuado e inadecuado), según las guías de la gated-SPECT de perfusión miocárdica, prescritas por cardiólogos de un hospital universitario. Resultados: Se analizaron un total de 950 pruebas de gated-SPECT de acuerdo a la indicación adecuada e inadecuada y se distribuyeron por cuartiles los años de finalización de la residencia del cardiólogo prescriptor. Los cardiólogos de menos de 10 años de experiencia clínica indican de forma inadecuada una mayor proporción de pruebas de gated-SPECT que los cardiólogos de mayor experiencia (87,6 vs. 9,3%: p

Myocardial ischemia/reperfusion (IR) injury represents a critical problem associated with interventional approaches for coronary reperfusion. Pharmacological cardioprotective interventions are advocated to ameliorate IR injury. Melatonin is an anti-inflammatory and antioxidant agent with a wide range of therapeutic properties that may contribute to its cardioprotective effects. No systematic review or meta-analysis has compared melatonin vs. placebo as a cardioprotective agent in humans. The present study, based on a systematic review and meta-analysis, was carried out to assess melatonin's efficacy as a cardioprotective treatment. We performed a systematic review of the available literature. Randomized controlled trials (RCTs) were identified and information was extracted using predefined data extraction forms. The primary outcomes were (a) left ventricular ejection fraction (LVEF) and (b) blood troponin levels in patients who underwent myocardial revascularization and were randomized to melatonin or placebo. The inverse-variance random-effects method was used to pool the estimates. Heterogeneity and publication bias were assessed. Weighted mean differences or standardized mean differences were calculated. A total of 283 records were screened and seven RCTs met all the inclusion criteria. After the pooled analysis, the results on LVEF were consistent across all studies, and a significant heterogeneity was found in the results on troponin levels. The melatonin-treated patients had on average higher LVEF than the placebo-treated individuals with a weighted mean difference = 3.1% (95% CI 0.6–5.5, p = 0.01). Five works compared the levels of troponin after melatonin or placebo treatment. The melatonin-treated patients had lower levels of troponin with a standardized mean difference = −1.76 (95% CI −2.85 to −0.67, p = 0.002). The findings of this meta-analysis revealed that melatonin administration in humans as a cardioprotective agent attenuated heart dysfunction with a favorable effect on the LVEF.

The renin–aldosterone–angiotensin system (RAAS) plays an important role in the pathogenesis of coronavirus disease 2019 (COVID-19), which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Angiotensin-converting enzyme 2 (ACE2) is the cellular receptor for SARS-CoV-2 and the host’s expression of this membrane-bound protein could affect susceptibility to infection. The RAAS is an important regulator of cardiovascular physiology and ACE2 has an essential role. People with hypertension and other traits have shown to have an imbalance in ACE/ACE2 levels and reduced levels of ACE2 could enhance the risk of adverse outcome in patients with COVID-19. It has been hypothesised that the RAAS may mediate the interplay between cardiovascular disease and COVID-19 severity. Evidence shows that antihypertensive drugs that target the RAAS have no significant effect on the risk of infection and disease outcome. Variations in RAAS genes have been associated with the risk of developing hypertension and cardiovascular disease and could partly explain the heterogenous response to SARS-CoV-2 infection. This article explores the interplay between the RAAS and COVID-19, with emphasis on the possible relationship between genetic variations and disease severity.

Objetivo: Determinar la percepción de los médicos internos residentes (MIR) de cardiología de España sobre el efecto de la pandemia por COVID-19 en su formación y la adaptación realizada por sus servicios. Métodos: Estudio de corte transversal a través de una plataforma de encuesta digital con el objetivo de conocer la opinión individual de los MIR de cardiología sobre la influencia de la pandemia en su formación. Se realiza un análisis estadístico para determinar los factores que influyeron en la percepción de la formación afectada. Resultados: Participó un total de 180 MIR de las 17 comunidades autónomas (CA). Los MIR de tercer año fueron los más afectados, junto con los que rotaban en imagen cardíaca. Los residentes de las CA con una prevalencia >5 casos/1,000 habitantes fueron los que mayor probabilidad tuvieron de ser desplazados de sus servicios. Conclusiones: Según la opinión de los participantes, el efecto de la pandemia por COVID-19 en su formación fue más negativa en los residentes de tercer año y los que rotaban en imagen cardíaca.

An 84-year-old female with severe aortic stenosis and previous non-disabling stroke was referred to undergo transcatheter aortic valve replacement (TAVR). The 3D computed tomography performed revealed the presence of a type 9 aortic arch with severe tortuosity (figure 1A). It was decided to protect the supra-aortic branches with suitable diameters to be able to use the Sentinel Cerebral Protection System (Boston Scientific, Marlborough, MA, United States). Manipulation length in the left common carotid artery (LCCA) was of, at least, 8 cm which is the distance between the proximal filter and the Sentinel distal edge. Figure 1B: yellow arrow: brachiocephalic trunk, 12 mm-diameter. White arrow: LCCA, 7 mm-diameter. This cerebral protection device (CPD) has a proximal filter for brachiocephalic trunk diameters between 9.0 mm and 15 mm and a distal filter for LCCA diameters between 6.5 mm and 10 mm. The angiography of the aortic arch is shown on figure 1C. This dual-system-filter basket was tried unsuccessfuly over a 0.014 in guidewire despite the use of an articulating sheath (figure 1D-F). After several attempts, a multipurpose catheter was used to engage the LCCA (figure 1G). Using a 300 cm 0.014 in guidewire, the multipurpose catheter was exchanged for the CPD which...

Una mujer de 84 años con estenosis aórtica grave y antecedentes de accidente cerebrovascular no discapacitante fue derivada para implante transcatéter de prótesis valvular aórtica (TAVI). La tomografía computarizada tridimensional realizada confirmó la presencia de un arco aórtico tipo 9 con acentuada tortuosidad (figura 1A). Se optó por proteger las ramas supraaórticas que presentaban diámetros apropiados para poder emplear el sistema de protección embolica cerebral Sentinel (Boston Scientific, Estados Unidos). La longitud de manipulación en la arteria carótida común izquierda (ACCI) fue de al menos 8 cm, que es la distancia entre el filtro proximal y el extremo distal del Sentinel. Figura 1B: flecha amarilla: tronco braquiocefálico, diámetro de 12 mm. Flecha blanca: ACCI, diámetro de 7 mm. Este dispositivo de protección cerebral (DPC) tiene un filtro proximal para diámetros del tronco braquiocefálico de entre 9,0 y 15 mm y un filtro distal para diámetros de la ACCI de entre 6,5 y 10 mm. La angiografía del arco aórtico se muestra en la figura 1C. Se intentó avanzar esta cesta con sistema de doble filtro sobre una guía de 0,014 pulgadas, sin éxito a pesar del uso de una vaina articulada (figura 1D-F). Tras varios intentos, se empleó un catéter...

A 59-year old male with severe left ventricular dysfunction, slow ventricular tachycardia and previously treated with cardiac resynchronization therapy was referred for percutaneous coronary intervention (PCI) of the left anterior descending coronary artery (LAD). The patient had 2 severely calcified lesions at mid-LAD level. Because it was a high-risk PCI, the heart team decided to perform this procedure using percutaneous left ventricular support using the Impella CP device (Abiomed, United States). The patient had a past medical history of right femoral-popliteal bypass surgery and a severely calcified stenosis in his left external iliac artery (figure 1A, arrow). The computed tomography performed on the supraaortic arteries revealed subclavian and axillary arteries with diameters < 5mm (figure 1B). The Impella CP device (14-Fr)—that requires a minimal vessel diameter of 5mm—was implanted using the left femoral access after revascularization of left external iliac artery. Predilation was performed using a 5 x 40 mm Mustang PTA balloon catheter (Boston Scientific, United States) (figure 1C); afterwards a 6 x 38 mm balloon expandable covered stent Advanta V12 (Atrium Medical Corporation, United States) was implanted (figure 1D,E). The Impella CP device was advanced through the stent (figure 1F). The PCI of the mid-LAD was performed using...

Un varón de 59 años con disfunción ventricular izquierda grave, taquicardia ventricular lenta y previamente tratado con resincronización cardiaca fue derivado para intervención coronaria percutánea (ICP) de la descendente anterior izquierda (DA). El paciente presentaba 2 lesiones extensamente calcificadas en la porción media de la DA. Al tratarse de una ICP de alto riesgo, el equipo multidisciplinar optó por realizar la intervención con soporte ventricular izquierdo percutáneo con el dispositivo Impella CP (Abiomed, Estados Unidos). Al paciente ya se le había realizado una cirugía de derivación fémoropoplítea derecha y presentaba una estenosis muy calcificada en la arteria ilíaca externa izquierda (figura 1A, flecha). La tomografía computarizada realizada en las arterias supraaórticas confirmó la presencia de arterias subclavia y axilar con diámetros < 5mm (figura 1B). El dispositivo Impella CP (14 Fr), que requiere un diámetro mínimo del vaso de 5 mm, se implantó mediante abordaje femoral izquierdo tras angioplastia de la arteria ilíaca externa izquierda. Para la predilatación se usó un catéter balón Mustang para ATP de 5 x 40 mm (Boston Scientific, Estados Unidos) (figura 1C); después se implantó un stent recubierto expandible por balón Advanta V12 de 6 x 38 mm (Atrium Medical Corporation, Estados Unidos) (figura 1D-E)....

¿Cómo lo haría? Los autores presentan un caso clínico de un varón octogenario con estenosis aórtica grave sintomática, función ventricular preservada e insuficiencia mitral ligera y sin enfermedad coronaria. Presentaba un riesgo quirúrgico bajo (puntuación de la Society of Thoracic Surgeons: 3,1%) y en sesión médico-quirúrgica se decidió realizar un recambio valvular aórtico quirúrgico, que se hizo con una bioprótesis aórtica sin suturas Perceval (Perceval Sutureless Aortic Heart Valve, Sorin) de tamaño L. El ecocardiograma de seguimiento previo al alta mostró ausencia de gradiente transvalvular aórtico significativo y dos chorros de regurgitación periprotésicos que sugerían insuficiencia aórtica de ligera a moderada. Cinco meses después del reemplazo valvular, el paciente ingresó por edema agudo de pulmón y el ecocardiograma mostró una insuficiencia aórtica grave secundaria a la ausencia de cobertura del stent de la bioprótesis aórtica a nivel del anillo aórtico en la zona correspondiente al seno no coronariano y la mayor parte del seno coronario derecho con 2 chorros de regurgitación hacia el ventrículo izquierdo, el cual se encontraba algo dilatado. La fracción de eyección del ventrículo izquierdo estaba ligeramente deprimida. Antes de plantear cualquier actitud terapéutica en un paciente con insuficiencia aórtica tras un implante valvular debemos conocer 3 datos fundamentales:...

HOW WOULD I APPROACH IT? The authors hereby present the clinical case of an 80-year old male with symptomatic severe aortic stenosis, preserved ventricular function, mild mitral regurgitation and no coronary heart disease. He had low surgical risk (3.1% score in the Society of Thoracic Surgeons risk scale) and, in medical-surgical session, it was decided to proceed with a surgical aortic valvular replacement using the Perceval Sutureless Aortic Heart Valve, Sorin – size L. The follow-up echocardiogram prior to the patient’s discharge showed lack of sig- nificant aortic transvalvular gradient and periprosthetic regurgitation jets indicative of mild-to-moderate aortic regurgitation. Five months after the implantation of the valve, the patient was admitted to the hospital due to acute pulmonary edema. The echocardiogram showed severe aortic regurgitation due to the lack of stent coverage of the aortic bioprosthesis at the level of the aortic annulus and in the area of the non-coronary sinus and most of the right coronary sinus with two regurgitation jets towards the left dilated ventricle. The left ventricular ejection fraction was slightly depressed. Before considering any therapeutic approaches in a patient with aortic regurgitation following a valvular implantation there are 3 fundamental issues we should all be aware of: 1)...

Among the numerous emerging biomarkers, high-sensitivity C-reactive protein (hsCRP) and growth-differentiation factor-15 (GDF-15) have received widespread interest, with their potential role as predictors of cardiovascular risk. The concentrations of inflammatory biomarkers, however, are influenced, among others, by physiological variations, which are the natural, within-individual variation occurring over time. The aims of our study are: (a) to describe the changes in hsCRP and GDF-15 levels over a period of time and after an episode of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and (b) to examine whether the rate of change in hsCRP and GDF-15 after the acute event is associated with long-term major cardiovascular adverse events (MACE). Two hundred and Fifty five NSTE-ACS patients were included in the study. We measured hsCRP and GDF-15 concentrations, at admission and again 36 months after admission (end of the follow-up period). The present study shows that the change of hsCRP levels, measured after 36 months, does not predict MACE in NSTEACS-patients. However, the level of GDF-15 measured, after 36 months, was a stronger predictor of MACE, in comparison to the acute unstable phase.