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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

ABSTRACT Introduction and objectives: The treatment of patients with non-valvular atrial fibrillation (NVAF) who need coronary stenting is challenging. The objective of the study was to determine whether left atrial appendage occlusion (LAAO) could be a feasible option and benefit these patients. To this end, we studied the impact of LAAO plus antiplatelet drugs vs oral anticoagulants (OAC) (including direct OAC) plus antiplatelet drugs in these patients’ long-term outcomes. Methods: The results of 207 consecutive patients with NVAF who underwent coronary stenting were analyzed. A total of 146 patients were treated with OAC (75 with acenocoumarol, 71 with direct OAC) while 61 underwent LAAO. The median follow-up was 35 months. Patients also received antiplatelet therapy as prescribed by their cardiologist. The study received the proper ethical oversight. Results: Age (mean 75.7 years), and the past medical history of stroke were similar in both groups. However, the LAAO group had more unfavorable characteristics (history of coronary artery disease [CHA2DS2-VASc], and significant bleeding [BARC ≥ 2] and HAS-BLED). The occurrence of major adverse events (death, stroke/transient ischemic events, major bleeding) and major cardiovascular events (cardiac death, stroke/transient ischemic attack, and myocardial infarction) were significantly higher in the OAC group compared to the LAAO group: 19.75% vs 9.06% (HR, 2.18; P.= .008) and 6.37% vs 1.91% (HR, 3.34; P.= .037), respectively. Conclusions: In patients with NVAF undergoing coronary stenting, LAAO plus antiplatelet therapy produced better long-term outcomes compared to treatment with OAC plus antiplatelet therapy despite the unfavorable baseline characteristics of the LAAO group.

RESUMEN Introducción y objetivos: Durante el confinamiento por la pandemia provocada por el coronavirus del síndrome respiratorio agudo grave de tipo 2 (SARS-CoV-2) se observó un descenso en los ingresos por síndrome coronario agudo (SCA). El objetivo de este estudio fue evaluar el impacto del confinamiento en la incidencia, la morbimortalidad y el manejo del SCA. Métodos: Estudio retrospectivo y multicéntrico, en el que se incluyeron los pacientes ingresados por SCA entre el 14 de febrero y el 24 de junio de 2020. Se excluyeron los pacientes con infarto agudo de miocardio y coronarias sin lesiones significativas. Se establecieron 3 grupos en función del periodo de ingreso: a) 1 mes antes del confinamiento; b) durante el confinamiento; y c) 1 mes después del confinamiento. Se evaluaron las diferencias en la mortalidad entre los 3 grupos, así como las diferencias temporales entre el inicio de los síntomas y el primer contacto médico. Resultados: Se incluyeron 634 pacientes (grupo A: 205; grupo B: 303; grupo C: 126). Se observó un descenso del 41% en los ingresos por SCA durante el primer mes del confinamiento respecto al mes previo, así como un retraso en el diagnóstico durante este mismo periodo: grupo A, 66 minutos (45-180); grupo B, 120 minutos (60-240); grupo C, 120 minutos (60-240) (p = 0,007). Sin embargo, no hubo mayor mortalidad durante el confinamiento (riesgo relativo, 1.26; intervalo de confianza del 95%, 0.53-2.97; p = 0,60). Conclusiones: Durante el confinamiento se produjo un marcado descenso en los ingresos por SCA y, a pesar de que se dilató el tiempo desde el inicio de los síntomas hasta el primer contacto médico en este periodo en los pacientes con SCA con elevación del segmento ST, la mortalidad fue similar en los 3 grupos estudiados.

ABSTRACT Introduction and objectives: During the lockdown due to the pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a decrease in the number of admissions due to acute coronary syndrome (ACS) was observed. The objective of our study was to evaluate the impact lockdown had on the incidence, morbidity and mortality, and management of ACS. Methods: A retrospective and multicenter study was conducted including patients admitted due to ACS from February 14 through June 24, 2020. Patients with acute myocardial infarction and coronary arteries without significant lesions were excluded. The following groups were established based on the period of admission: a) 1 month before lockdown; b) during lockdown; and c) 1 month after lockdown. The differences in mortality seen among the 3 groups were evaluated, as well as the temporal differences reported between symptom onset and the first medical contact (FMC). Results: a total of 634 patients were included (group a, 205; group b, 303, and group c, 126). A 41% decrease in the number of admissions due to ACS was observed during the first month of lockdown compared to the previous month, as well as diagnostic delay during this same period (group a, 66 minutes (45-180), group b, 120 minutes (60-240), and group c, 120 minutes (60-240), P = .007). However, a higher mortality rate during confinement was not reported (RR, 1.26; 95%CI, 0.53-2.97; P = .60). Conclusions: During lockdown, a remarkable decrease in the number of admissions due to ACS was observed, and although there was an increase in the time elapsed from symptom onset to the FCM in this period in patients with STEMI, the mortality rate was similar in the 3 groups studied.

ABSTRACT Introduction and objectives: Distal embolization and no-reflow are common complications in primary angioplasty and the information available on the role played by the deflation speed of the stent delivery system is scarce. Our aim is to analyze how the deflation speed of the stent delivery system impacts the results of primary angioplasty. Methods: From December 2016 through February 2019, all consecutive patients with ST-segment elevation myocardial infarction undergoing urgent coronary angiography at our institution and who were eligible for thrombectomy, IIB-IIIA inhibitors, and direct stenting were randomized in a 1:1 ratio to rapid (group 1, n = 103) or slow deflation of the stent delivery system, at 1 atm/second, (group 2, n = 107). Pre- and postdilatation was not allowed per protocol. The primary outcomes were myocardial blush ≥ 2 and ST-segment resolution ≥ 70% while the size of myocardial damage, the ejection fraction both at discharge and at the 12-month follow-up, and the overall and 12-month cardiovascular mortality rates were the secondary outcomes. Results: The study was stopped prematurely with 50% of the estimated sample size due to futility. Myocardial blush ≥ 2 occurred in 77 (74.7%) vs 79 (75.2%) of the patients, P = .93, and ST-segment resolution ≥ 70% occurred in 54 (53.9%) vs 59 (55.5%) of the patients, P = .75 in groups 1 and 2, respectively without any differences being reported in any of the secondary endpoints. Conclusions: In our series, the deflation speed of the stent delivery system in primary angioplasty did not modify the myocardial blush ≥ 2, the ST-segment resolution ≥ 70% or impacted the clinical outcomes, the size of myocardial infarction according to the biomarkers or the ejection fraction.

RESUMEN Introducción y objetivos: La embolización distal y el fenómeno de no-reflow son complicaciones frecuentes de la angioplastia primaria. La información disponible sobre la influencia de la velocidad de desinflado del sistema de liberación del stent es escasa. Nuestro objetivo es analizar la influencia de este factor en los resultados de la angioplastia primaria. Métodos: Entre diciembre de 2016 y febrero de 2019, todos los pacientes consecutivos con infarto de miocardio con elevación del segmento ST sometidos a coronariografía urgente en nuestro centro y que eran susceptibles de trombectomía, inhibidores de IIB-IIIA e implante directo de stent fueron aleatorizados 1:1 a un desinflado rápido del sistema de liberación (grupo 1, n = 103) o a un desinflado lento a 1 atm/s (grupo 2, n = 107). Por protocolo, no se permitió la predilatación previa ni posterior. Los objetivos primarios fueron el grado de blush miocárdico ≥ 2 y la resolución del segmento ST ≥ 70%. Los objetivos secundarios fueron el tamaño del infarto, la fracción de eyección al alta y a los 12 meses, y las mortalidades total y cardiovascular a los 12 meses. Resultados: El estudio se detuvo prematuramente con el 50% del tamaño muestral calculado por futilidad. Se encontró blush ≥ 2 en 77 (74,7%) frente a 79 (75,2%) pacientes (p = 0,93) y resolución del segmento ST ≥ 70% en 54 (53,9%) frente a 59 (55,5%) pacientes (p = 0,75) en los grupos 1 y 2, respectivamente, sin diferencias en ninguno de los objetivos secundarios. Conclusiones: En nuestra serie, la velocidad de desinflado del sistema de liberación del stent en la angioplastia primaria no modificó el blush miocárdico ni la resolución del segmento ST, y tampoco demostró tener influencia en los resultados clínicos, el tamaño del infarto según los biomarcadores ni la fracción de eyección.

RESUMEN Introducción y objetivos: Existe un creciente interés en el desarrollo de dispositivos para el tratamiento de la insuficiencia mitral (IM) de forma mínimamente invasiva. Para este propósito, disponer de un modelo experimental que reproduzca las condiciones de la enfermedad sería de gran utilidad. Nuestro objetivo fue validar un modelo experimental de IM en cerdos. Métodos: Para esta fase de creación del modelo se han utilizado 3 cerdos de raza large white, de 2 meses de edad y un peso de 25 ± 3 kg. Se provocó un infarto en el territorio de la arteria circunfleja que afectó la perfusión del músculo papilar posteromedial, y posteriormente se sometió al animal a una sobrecarga de volumen mediante creación de un shunt arteriovenoso, con la conexión de la aorta y la pulmonar mediante un tubo de dacrón. Se realizó análisis mediante ecocardiografía y resonancia magnética antes de la intervención y a las 8 semanas, y posteriormente el animal fue eutanasiado para realizar el estudio anatomopatológico. Resultados: De los 3 cerdos, 1 falleció durante la intervención por fibrilación ventricular y los otros 2 sobrevivieron al procedimiento y fueron eutanasiados como estaba previsto a las 8 semanas. En ambos se produjo un infarto transmural, uno lateral y...

ABSTRACT Introduction and objectives: There is great interest in the development of devices for the percutaneous management of mitral regurgitation (MR). For this reason, having an experimental model that reproduces the conditions of the disease is of great importance. Our objective was to validate an experimental model of MR in a porcine model. Methods: For the model creation phase 3, 2-month-old 25 ± 3 kg large white pigs were used. An acute myocardial infarction was caused in the circumflex artery territory that hampered the perfusion of the posteromedial papillary muscle. Then, volume overload was induced in the animal by creating an arteriovenous shunt and connecting the aorta and the pulmonary artery using a Dacron tube. Echocardiography and magnetic resonance imaging were performed before the intervention and on week 8. Afterwards, the animal was euthanized to conduct the pathological study. Results: One out of the 3 pigs died during the intervention due to ventricular fibrillation. The remaining 2 pigs survived the procedure and were euthanized as scheduled on week 8. In both cases a transmural infarction occurred, 1 at lateral level and the other one at posteroinferior level with moderate secondary mitral regurgitation. Ventricular dimensions and volumes increased and the overall contractility was maintained...

PREGUNTA: De forma sucinta, ¿qué evidencias tiene el cierre de la orejuela izquierda (COI) con respecto a la anticoagulación oral (ACO)? ¿Existen evidencias sobre los anticoagulantes de acción directa (ACOD)? RESPUESTA: El COI se ha comparado con la ACO en la prevención de eventos tromboembólicos en pacientes con fibrilación auricular no valvular (FANV) en 3 ensayos clínicos aleatorizados: PROTECT AF, PREVAIL y PRAGUE-17. Los dos primeros aleatorizaron 2:1 a 1.114 pacientes con FANV y CHADS2 ≥ 1 para recibir un dispositivo Watchman (Boston Scientific, Estados Unidos) o warfarina. En un metanálisis por intención de tratar de los datos individuales agregados de los dos estudios a 5 años de seguimiento no se encontraron diferencias entre ambas estrategias en el objetivo primario combinado de ictus, embolia sistémica y muerte de causa cardiovascular...

Abstract Aims The aim of this study is to evaluate changes in cardiopulmonary exercise test (CPET) after percutaneous mitral valve repair (PMVR) with MitraClip in patients with heart failure with reduced ejection fraction who are potentially candidates for heart transplantation or destination left ventricular assist device. Methods and results Prospective registry of all consecutive patients with heart failure with reduced ejection fraction and functional mitral regurgitation (MR) underwent elective PMVR between October 2015 and March 2018 in our institution. Patients with preserved or mid‐range left ventricular ejection fraction (>40%), advanced age (>75 years old), or severe co‐morbidities (end‐stage organ damage) were not included. Treadmill exercise testing with respiratory gas exchange analysis was carried out in 11 patients (male, 72.7%; median age, 67 years old) within the month prior to the procedure and at 6 month follow‐up. PMVR was successfully performed in all patients. At 6 month follow‐up, PMVR was associated with an improvement in New York Heart Association functional class (P = 0.021) and a reduction in MR severity (P = 0.013) and N‐terminal pro‐brain natriuretic peptide levels (2805 [1878–5022] vs. 1485 [654–3032] pg/mL; P = 0.012). All patients completed pre‐procedural and post‐procedural CPET, and all the studies showed a respiratory exchange ratio ≥1 and were consistent with sufficient exercise effort. Compared with pre‐procedural CPET, patients showed a significant increase in exercise time (295 [110–335] vs. 405 [261–540] s; P = 0.047), VO2 (9.8 [9.1–13.4] vs. 13.5 [12.1–16.8] mL/kg/min; P = 0.033), ventilatory anaerobic threshold (510 [430–950] vs. 850 [670–1070] mL/kg/min; P = 0.033), peak O2 pulse (7.2 [4.3–8.6] vs. 8.3 [6.2–11.8] mL/beat; P = 0.033), and workload (5 [3–6] vs. 6 [5–8] metabolic equivalents; P = 0.049). Conclusions Percutaneous mitral valve repair with MitraClip was associated with an enhancement in cardiopulmonary performance in patients with systolic heart failure and secondary MR.

Background: QTc prolongation is an adverse effect of COVID-19 therapies. The use of a handheld device in this scenario has not been addressed. Objectives: To evaluate the feasibility of QTc monitoring with a smart device in COVID-19 patients receiving QTc-interfering therapies. Methods: Prospective study of consecutive COVID-19 patients treated with hydroxychloroquine ± azithromycin ± lopinavir-ritonavir. ECG monitoring was performed with 12-lead ECG or with KardiaMobile-6L. Both registries were also sequentially obtained in a cohort of healthy patients. We evaluated differences in QTc in COVID-19 patients between three different monitoring strategies: 12-lead ECG at baseline and follow-up (A), 12-lead ECG at baseline and follow-up with the smart device (B), and fully monitored with handheld 6-lead ECG (group C). Time needed to obtain an ECG registry was also documented. Results: One hundred and eighty-two COVID-19 patients were included (A: 119(65.4%); B: 50(27.5%); C: 13(7.1%). QTc peak during hospitalization did significantly increase in all groups. No differences were observed between the three monitoring strategies in QTc prolongation (p = 0.864). In the control group, all but one ECG registry with the smart device allowed QTc measurement and mean QTc did not differ between both techniques (p = 0.612), displaying a moderate reliability (ICC 0.56 [0.19–0.76]). Time of ECG registry was significantly longer for the 12-lead ECG than for handheld device in both cohorts (p < 0.001). Conclusion: QTc monitoring with KardiaMobile-6L in COVID-19 patients was feasible. Time of ECG registration was significantly lower with the smart device, which may offer an important advantage for prevention of virus dissemination among healthcare providers.

Sr. Editor: La disección coronaria espontánea (DCE) es una afección infradiagnosticada de creciente interés que constituye una causa de síndrome coronario agudo y muerte súbita, especialmente en las mujeres menores de 50 años, en las que constituye el 30% de todos los casos de dicho síndrome1. Solo en torno a un 10-15% de las DCE son diagnosticadas en varones.

To the Editor, Spontaneous coronary artery dissection (SCAD) is a misdiagnosed condition that has emerged as an important cause of acute coronary syndrome and sudden death, especially in women under 50. In these patients it is responsible for 30% of all the cases of such syndrome.1 However, only between 10% and 15% of all SCADs are diagnosed in male patients.

Objectives: MitraClip is an established therapy for patients with mitral regurgitation (MR) that are considered of high-risk or inoperable. However, late bleeding events (BE) after hospital discharge and their impact on prognosis in this cohort of patients have been poorly investigated. Our purpose is to address the incidence, related factors and clinical implications of BE after hospital discharge in patients treated with MitraClip. Methods: Prospective registry of all consecutive patients (n = 80) who underwent MitraClip implantation in our Institution between June 2014 and December 2017. BE were defined according to MVARC definitions. A combined clinical end-point including admission for heart failure (HF) and all-cause mortality was established to analyze prognostic implications of BE. Results: During a median follow up of 523.5 days, 41 BE were reported in 21 patients. Atrial fibrillation (AF, HR 4.54, CI95% 1.20–17.10) and combined antithrombotic therapy at discharge (HR 3.52, CI95% 1.03–11.34) were independently associated with BE. In the study period, 15 (18.8%) patients died, 20 (25%) were admitted for HF and 29 (36.3%) presented the combined end-point. After multivariable adjustment BE remained independently associated with an adverse outcome (HR 3.80, CI 95% 1.66–8.72). In the subgroup of patients with AF, HAS-BLED score was higher among subjects with BE (3.1 ± 1.3 vs 2.1 ± 0.9, p = 0.003). HAS-BLED score had a significant discrimination power for the occurrence BE (AUC: 0.677 [0.507–0.848]) in this subgroup. Conclusions: BE are common after MitraClip and are associated with an impaired outcome. Strategies to reduce bleeding events are paramount in this cohort of patients. Keywords: MitraClip, Atrial fibrillation, Bleeding events

QUESTION: Briefly, what is the evidence behind the percutaneous left atrial appendage closure (LAAC) regarding oral anticoagulation (OA)? Is there any evidence on direct-acting oral anticoagulants (DAOAs)? ANSWER: The main clinical evidence published on this regard comes from 3 randomized clinical trials (2 vs anti-vitamin K and 1 vs DAOAs), registries, and case series. The PROTECT AF clinical trial1 included 707 patients with atrial fibrillation (AF) and CHADS2 scores ≥ 1 who were randomized on a 2:1 ratio to receive the Watchman device (Boston Scientific, United States) or warfarin. The composite endpoint (stroke, cardiovascular death, and systemic embolism) was less prevalent in patients with the Watchman device (relative risk [RR], 0.62; 95% confidence interval [95%CI], 0.35-1.25); however, adverse events were more common in the device group (RR, 1.69; 95%CI, 1.01-3.19) mainly due to periprocedural complications. These increased adverse events ...

Introduction: Coronary vessel perforation is one of the most feared complications of coronary angioplasty. The treatment of this complication relies mostly on the implantation of covered stents. However, due to their design, covered stents are difficult to advance in a tortuous or calcified vessel. Case Presentation: We present a case of a grade III coronary perforation in which the double guiding catheter technique helped us to deliver the graft stent. Conclusions: The double-guiding technique is useful in emergency situations to increase the safety and efficacy of sealing a coronary perforation.