Search

RESUMEN Introducción y objetivos: El uso contemporáneo y los resultados de la aterectomía coronaria con láser Excímer (ELCA) en el intervencionismo coronario percutáneo (ICP) de lesiones coronarias gravemente calcificadas no están establecidos. El objetivo de este estudio fue evaluar la eficacia, seguridad y resultados a 1 año de ELCA en este escenario. Métodos: Se revisaron de forma retrospectiva las características clínicas y angiográficas, y los resultados de los procedimientos de revascularización de lesiones gravemente calcificadas tratadas con ICP asistido por ELCA en nuestro centro entre 2016 y 2022. Resultados: Se incluyeron 78 pacientes consecutivos (80 procedimientos) (edad media 71,2 ± 8,6 años, 80,5% varones). La presentación clínica fue enfermedad arterial coronaria estable en 45 (56,2%) pacientes y síndromes coronarios agudos en 33 (43,8%). Todas las lesiones presentaban calcificación grave. Además, el 40% eran lesiones incruzables, el 28,75% lesiones indilatables, el 2,5% reestenosis intrastent, el 6,25% infraexpansión del stent y el 7,5% oclusiones crónicas. La combinación de ≥ 2 de los escenarios anatómicos anteriores existió en el 12,5% de los procedimientos. La fluencia máxima fue de 73 ± 9,6 mJ/mm2 y la frecuencia máxima de 72,7 ± 10,4 Hz. ELCA con lavado con solución salina se utilizó inicialmente en todos los procedimientos y se utilizó contraste en 2 procedimientos. La tasa de éxito de ELCA y de éxito técnico fueron del 91,25 %. Fueron necesarias terapias adyuvantes de modificación de placa en 4 casos. La tasa de éxito clínico fue del 87,5%. Ocurrieron complicaciones relacionadas con ELCA en 2 (2,5%) procedimientos. Tras una mediana de seguimiento de 15,5 meses (IQR, 5,0-29,3), se produjeron eventos cardiovasculares adversos mayores (MACE) (nueva revascularización de la lesión diana, infarto de miocardio o muerte cardiaca) en 9 pacientes (11,25%). Conclusiones: A pesar de la complejidad de la ICP en lesiones gravemente calcificadas, ELCA demostró ser efectivo con una incidencia relativamente baja de complicaciones relacionadas con ELCA y MACE en el seguimiento.

ABSTRACT Introduction and objectives: No previous studies have established the contemporary use and outcomes of Excimer laser coronary atherectomy (ELCA) in percutaneous coronary intervention (PCI) of severely calcified coronary lesions. The aim of this study was to assess the safety, efficacy, and 1-year outcomes of ELCA in this setting. Methods: We retrospectively examined the clinical and angiographic characteristics and procedural outcomes of severely calcified lesions treated with ELCA-assisted PCI in our institution between 2016 and 2022. Results: Seventy-eight consecutive patients (80 procedures) were included (mean age 71.2 ± 8.6 years, 80.5% men). Clinical presentation was stable coronary artery disease in 45 patients (56.2%) and acute coronary syndromes in 33 (43.8%). All the lesions were severely calcified. In addition, 40% were uncrossable lesions, 28.75% were undilatable lesions, 2.5% showed in-stent restenosis, 6.25% showed stent underexpansion, and 7.5% were chronic total occlusions. The combination of ≥ 2 of the above anatomic settings was found in 12.5% of the procedures. The maximum fluence was 73 ± 9.6 mJ/mm2, and the maximum frequency was 72.7 ± 10.4 Hz. The saline flushing technique was initially used in all the procedures, while contrast was used in 2 procedures. The ELCA success and technical success rates were both 91.25%. Adjuvant plaque modification therapies were required in 4 patients. The clinical success rate was 87.5%. ELCA-related complications occurred in 2 procedures (2.5%). After a median follow-up of 15.5 months [IQR, 5.0-29.3], major adverse cardiac events (MACE) (target lesion revascularization, myocardial infarction or cardiac death) occurred in 9 patients (11.25%). Conclusions: Despite the complexity of PCI in severely calcified lesions, ELCA was effective with a relatively low incidence of ELCA-related complications and MACE during follow-up.

RESUMEN Introducción y objetivos: La calcificación coronaria es uno de los principales factores que inciden negativamente en la seguridad y la eficacia del intervencionismo coronario percutáneo. Existen varias técnicas de modificación del calcio, pero falta evidencia de estudios aleatorizados sobre la terapia de elección en este escenario. Métodos: El ROLLERCOASTR es un estudio prospectivo, multicéntrico y aleatorizado, diseñado para comparar la seguridad y la eficacia de 3 técnicas de modificación de la placa en el contexto de calcificación coronaria moderada o grave: aterectomía rotacional (AR), aterectomía coronaria con láser láser excimer (ACLE) y litotricia intracoronaria (LIC). El objetivo primario es la expansión del stent evaluada mediante tomografía de coherencia óptica. Su análisis se hará por intención de tratar, con un α de 0,05 entre el grupo de referencia (AR) y cada uno de los otros grupos (ACLE y LIC). Se realizará también un análisis del objetivo primario por protocolo para mantener la coherencia. Si se confirma la hipótesis de no inferioridad, se realizará un análisis bilateral de superioridad. El comité de eventos clínicos y el laboratorio central independiente no conocerán la rama de tratamiento. Asumiendo un error α de 0,05, un error β de 0,2 (80% de potencia), un margen de irrelevancia (ε) del 7% y un 10% de pérdidas por dificultad de medición o imposibilidad de completar la intervención, se estima un tamaño de muestra de 56 casos en cada grupo. Los objetivos secundarios son el éxito del dispositivo, el éxito del procedimiento, la tasa de cruce entre técnicas y la presentación de eventos cardiovasculares adversos importantes al año de seguimiento. Conclusiones: El estudio ROLLERCOASTR evaluará y comparará la seguridad y la eficacia, en pacientes con estenosis coronaria calcificada, de 3 técnicas de modificación de placa: AR, ACLE y LIC. Este ensayo se ha registrado en Clinicaltrials.gov: NCT04181268.

ABSTRACT Introduction and objectives: Coronary calcification is one of the leading factors that affect negatively the safety and effectiveness of percutaneous coronary intervention. Several calcium modification techniques exist. However, there is a lack of randomized evidence on the therapy of choice in this scenario. Methods: The ROLLERCOASTR is a prospective, multicenter, randomized clinical trial designed to compare the safety and efficacy profile of 3 plaque modification techniques in the moderate-to-severe coronary calcification setting: rotational atherectomy (RA), excimer laser coronary angioplasty (ELCA), and intravascular lithotripsy (IVL). The study primary endpoint is stent expansion evaluated by optical coherence tomography. An intention-to-treat analysis will be conducted with an alpha coefficient of 0.05 between the reference group (RA) and the remaining 2 groups (ELCA and IVL). An analysis of the study primary endpoint per protocol will be conducted for consistency purposes. If the non-inferiority hypothesis is confirmed, a superiority 2-sided analysis will be conducted. Both the clinical events committee and the independent core laboratory will be blinded to the treatment arm. Assuming an α error of 0.05, an β error of 0.2 (80% power), a margin of irrelevance (ε) of 7, and losses of 10% due to measurement difficulty or impossibility to complete the intervention, we estimate a sample size of 56 cases per group. The study secondary endpoints are device success, procedural success, crossover rate among the different techniques used, and the occurrence of major adverse cardiovascular events at 1-year follow-up. Conclusions: The ROLLERCOASTR trial will evaluate and compare the safety and effectiveness of 3 plaque modification techniques: RA, ELCA, and IVL in patients with calcified coronary stenosis. This trial was registered at clinicaltrials.gov with identifier NCT04181268.

RESOLUCIÓN DEL CASO Ante la imposibilidad de retirar el Impella 5.0 (figura 1), y debido al riesgo quirúrgico (EuroSCORE II 48,9%, Society of Thoracic Surgeons score 16%), se decidió realizar una reparación mitral percutánea con un dispositivo MitraClip (Abbott Laboratories, Estados Unidos). Con el soporte de Impella 5.0 a 2 l/min y bajo control con ecocardiograma transesofágico, se implantó un MitraClip NTW a nivel de A3-P3 (mayor orificio de regurgitación), con lo que se logró una reducción del chorro de insuficiencia (vídeos 1 y 2 del material adicional), una mejoría del flujo en las venas pulmonares y un gradiente transmitral de 4 mmHg. Se reevaluó el resultado disminuyendo transitoriamente el soporte hemodinámico a 1 l/min y se observó un chorro central de grado III-IV. Se implantó un segundo clip NT a nivel de A2-P2 (vídeos 3 y 4 del material adicional). Durante su posicionamiento hubo dificultades por interferencia con el Impella 5.0, por lo que fueron necesarias maniobras de inversión del dispositivo hacia la aurícula. Finalmente se realizó captura o prensión, que fue eficaz y se confirmó la ausencia de insuficiencia mitral residual, aunque hubo un aumento del gradiente transmitral hasta 7 mmHg. Tras reducir el soporte hemodinámico a 0,5 l/min, el...

CASE RESOLUTION Given the impossibility to remove the Impella 5.0 device (figure 1) and due to the high surgical risk involved (EuroSCORE II, 48,9%; Society of Thoracic Surgeons score (STS), 16%), percutaneous mitral valve repair was attempted with a MitraClip device (Abbott Laboratories, United States). Figure 1. Normal position of the Impella device as seen on the transesophageal echocardiography. With support from an Impella 5.0 device at a rate of 2 L/min and under transesophageal echocardiography guidance the MitraClip NTW device was implanted at A3-P3 level (greater effective regurgitant orifice area), which resulted in a reduced regurgitant jet (videos 1 and 2 of the supplementary data), improved blood flow into the pulmonary veins, and a transmitral gradient of 4 mmHg. Result was reassessed by reducing hemodynamic support temporarily at 1 L/min. A grade III-IV central regurgitant jet was seen. A second MitraClip NT was implanted at A2-P2 level (videos 3 and 4 of the supplementary data). Difficulties during its positioning due to interference with the Impella 5.0 device were reported, which is why reversal maneuvers towards the atrium were performed. Finally, capture or grasping turned out effective, and the lack of residual mitral regurgitation was confirmed. However, although transmitral gradient increased up to...

Sr. Editor: En la embolia de pulmón (EP), la terapia dirigida por catéter está indicada en pacientes de alto riesgo (EP-AR) si la trombólisis sistémica está contraindicada o ha fallado (indicación IIA, C), y como rescate en pacientes de intermedio-alto riesgo (EP-IAR) cuando sufren deterioro hemodinámico, como alternativa a la trombólisis sistémica (indicación IIA, C)1. Sin embargo, las guías de práctica clínica no especifican el tipo de terapia dirigida por catéter ideal. Esta puede ser trombólisis local, que consiste en la infusión directa en la arteria pulmonar (intratrombo) de dosis variables (alrededor del 20% de la dosis sistémica) de fármacos trombolíticos (alteplasa o tenecteplasa), o trombectomía mecánica por aspiración, que consiste en la extracción del trombo (con o sin fragmentación previa). Finalmente, se puede optar por una estrategia mecánico-farmacológica combinando las 2 técnicas de manera secuencial2. Se presenta la experiencia inicial de trombectomía mecánica por aspiración con el dispositivo FlowTriever (Inari, Estados Unidos) en 4 centros de España y Portugal. El Comité Ético del Hospital Clínico San Carlos aprobó el registro y se obtuvo el consentimiento informado de los participantes. Se trata de un sistema de tromboaspiración de 24 Fr con tubuladuras sobredimensionadas y accesorios para optimizar la extracción del trombo3,4. Son...

To the Editor, Catheter-directed therapy is indicated in high-risk patients (PE-HR) to treat pulmonary embolism (PE) when systemic thrombolysis is contraindicated or has failed (indication IIA, C). Also, as a bailout therapy in intermediate/high-risk patients (PE-IHR) with hemodynamic impairment as an alternative to systemic thrombolysis (indication IIA, C).1 However, clinical practice guidelines do not specify which is the optimal catheter-directed therapy that should be used. It can be local thrombolysis that consists of the direct infusion of variable doses (around 20% of systemic dose) of thrombolytic drugs (alteplase or tenecteplase) into the pulmonary artery (intra-thrombus) or else mechanical thrombectomy with direct aspiration catheter that consists of thrombus extraction (with or without previous fragmentation). Finally, a mechanical-pharmacological strategy with both techniques combined can be used sequentially.2 This is the early experience of mechanical thrombectomy with direct aspiration using the FlowTriever retrieval/aspiration system (Inari, United States) of 4 Spanish and Portuguese centers. The Hospital Clínico San Carlos ethics committee approved the registry and obtained the participants’ written informed consent. The FlowTriever is a 24-Fr thrombus aspiration system with an oversized tube and accessories to optimize thrombus extraction.3,4 These are 3 cases of PE-HR with contraindication for systemic thrombolysis and 7 cases of PE-IHR treated...

RESUMEN La calcificación coronaria es probablemente el mayor determinante de un mal resultado de la angioplastia y se asocia a mayores tasas de eventos adversos. En la actualidad existen distintas técnicas de modificación de la placa basadas en balones o en dispositivos específicos. El conocimiento de sus características y su uso adecuado son aspectos clave para el tratamiento óptimo de las lesiones calcificadas. Este artículo de posicionamiento, promovido desde la Asociación de Cardiología Intervencionista de la Sociedad Española de Cardiología (ACI-SEC), describe las técnicas de modificación de la placa existentes en la actualidad y propone un algoritmo para el tratamiento de la lesión calcificada.

ABSTRACT Introduction and objectives: The optimal time to perform a diagnostic coronary angiography in patients admitted due to non-ST-segment elevation acute coronary syndrome (NSTEACS) and start pretreatment with dual antiplatelet therapy is controversial. Our study aims to identify the current diagnostic and therapeutic approach, and clinical progression of patients with NSTEACS in our country. Methods: The IMPACT-TIMING-GO trial (Impact of time of intervention in patients with myocardial infarction with non-ST segment elevation. Management and outcomes) is a national, observational, prospective, and multicenter registry that will include consecutive patients from 24 Spanish centers with a clinical diagnosis of NSTEACS treated with diagnostic coronary angiography and with present unstable or causal atherosclerotic coronary artery disease. The study primary endpoint is to assess the level of compliance to clinical practice guidelines in patients admitted due to NSTEACS undergoing coronary angiography in Spain, describe the use of antithrombotic treatment prior to cardiac catheterization, and register the time elapsed until it is performed. Major adverse cardiovascular events will also be described like all-cause mortality, non-fatal myocardial infarction and non-fatal stroke, and the rate of major bleeding according to the BARC (Bleeding Academic Research Consortium) scale at 1- and 3-year follow-up. Results: This study will provide more information on the impact of different early management strategies in patients admitted with NSTEACS in Spain, and the degree of implementation of current recommendations into the routine clinical practice. It will also provide information on these patients’ baseline and clinical characteristics. Conclusions: This is the first prospective study conducted in Spain that will be reporting on the early therapeutic strategies—both pharmacological and interventional—implemented in our country in patients with NSTEACS after the publication of the 2020 European guidelines, and on the clinical short- and long-term outcomes of these patients.

ABSTRACT Coronary artery calcification is probably the main determinant of the poor outcome of percutaneous coronary interventions and is associated with higher rates of adverse events. There are currently different balloon or specific device-based plaque modification techniques available. Knowing their characteristics and proper use is key for the optimal treatment of calcified lesions. This position paper—promoted by the Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC)—describes existing plaque modification techniques currently available and proposes an algorithm for the management of calcified lesions.

RESUMEN Introducción y objetivos: El momento óptimo para la realización de un cateterismo diagnóstico en pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST) y la necesidad de pretratamiento con doble antiagregación son motivo de controversia. Este estudio pretende conocer el abordaje diagnóstico y terapéutico actual, así como la evolución clínica de los pacientes con SCASEST en España. Métodos: El estudio IMPACT of Time of Intervention in patients with Myocardial Infarction with Non-ST seGment elevation. ManaGement and Outcomes (IMPACT-TIMING-GO) es un registro nacional observacional, prospectivo y multicéntrico, que incluirá pacientes consecutivos con diagnóstico de SCASEST tratados con coronariografía diagnóstica y que presenten enfermedad coronaria aterosclerótica inestable o causal en 24 centros españoles. El objetivo primario del estudio es conocer el grado de cumplimiento de las recomendaciones de las guías de práctica clínica en pacientes que ingresan por SCASEST tratados con coronariografía en España, describir el uso del tratamiento antitrombótico antes del cateterismo y determinar el tiempo hasta este en la práctica clínica real. Se describirán también los eventos adversos cardiovasculares mayores: mortalidad por cualquier causa, infarto no fatal e ictus no fatal, y también la incidencia de hemorragia mayor según la escala BARC (Bleeding Academic Research Consortium) durante el seguimiento a 1 y 3 años. Resultados: Este registro permitirá mejorar el conocimiento en relación con el abordaje terapéutico inicial en pacientes que ingresan por SCASEST en España. Contribuirá a conocer sus características basales y su evolución clínica, así como el grado de adherencia y cumplimiento de las recomendaciones de las que se dispone actualmente. Conclusiones: Se trata del primer estudio prospectivo realizado en España que permitirá conocer las estrategias terapéuticas iniciales, tanto farmacológicas como intervencionistas, que se realizan en nuestro país en pacientes con SCASEST tras la publicación de las guías europeas de 2020, y la evolución clínica de estos pacientes a corto y largo plazo.

ABSTRACT Vascular access is an essential part of all interventional procedures whether coronary or structural. Over the last 15 to 20 years, in coronary interventions, traditional femoral access has been mostly replaced by the radial approach. Nonetheless, the femoral approach through both artery and vein is still the main approach for structural heart procedures. Over the last few years, femoral access has evolved from a puncture guided by anatomical references to more accurate ultrasound-guided approaches. The relatively recent introduction of interventions such as transcatheter aortic valve replacement has conditioned the use of large introducers and ultimately the need for specific hemostatic systems, above all, percutaneous closure devices. This manuscript reviews different anatomical concepts, puncture techniques, diagnostic assessments, and closure strategies of the main arterial and venous approaches for the diagnosis and treatment of different structural heart procedures.

RESUMEN El acceso vascular es una parte esencial de cualquier procedimiento intervencionista coronario o estructural. En procedimientos coronarios, el acceso femoral tradicional prácticamente ha sido sustituido por el radial desde hace 15-20 años. No obstante, el acceso femoral, tanto arterial como venoso, sigue siendo la principal vía de abordaje para el intervencionismo estructural. El acceso femoral ha ido evolucionando con el paso del tiempo de una punción mediante referencias anatómicas a una punción mucho más precisa guiada por ecografía. La llegada de técnicas como el recambio valvular aórtico percutáneo ha condicionado el uso de introductores arteriales de gran tamaño y, por tanto, la necesidad de sistemas de control de la hemostasia, principalmente los sistemas percutáneos de cierre vascular. Este artículo revisa diversos conceptos anatómicos, técnicas de punción, evaluación diagnóstica y estrategias de cierre de las principales vías de acceso arterial y venoso utilizadas en el diagnóstico y el tratamiento de diferentes patologías estructurales.

Abstract Background Since the last century, the electrocardiogram (ECG) remains the non‐invasive test, that is, most easily accessible, feasible, and inexpensive for cardiology assessment. In past years, many novel ECG indexes and patterns have been published that allow for a more advanced evaluation of what is currently being done, especially based on subtle QRS changes and patterns. Objective The objective of the study was to provide an update on the evidence and clinical applications of these ECG subtle QRS changes and patterns associated with heart disease. Methods Through the literature review, we will highlight the subtle QRS changes and patterns associated with heart disease, mainly focusing on QRS duration, voltage, morphology, axis, and QT interval. Results Small increases in QRS duration are associated with a reduction in left ventricular ejection fraction (EF), increased cardiac chamber dimensions, and risk for incident heart failure (HF). Moreover, fragmentation of the QRS complex is associated with myocardial fibrosis and is a substrate for developing arrhythmic events. Besides, low amplitude QRS voltage is associated with congestive HF, and an increase in the voltage of the QRS complexes is associated with the effectiveness of diuresis treatment. Furthermore, small increases in QT interval are associated with diastolic dysfunction due to impaired sarcoplasmic reticulum calcium handling as occurs in myocardial ischemia, hypertension, or diabetes. On the other hand, in patients with left ventricular dysfunction, the QRS area is associated with clinical and echocardiographic response to cardiac resynchronization therapy regardless of the type of bundle branch block. In addition, subtle ECG changes and patterns in the left bundle branch block are associated with concomitant right ventricular dilation, mostly based on the QRS axis and voltage. Notwithstanding, to identify these subtle changes in QRS require exact manual measurements that can take time. In this regard, applying artificial intelligence (AI) to the ECG can make a quicker and more complete assessment, as well as provide a low cost when applied to large populations. Conclusion We provided an update on the evidence and clinical applications of these subtle QRS changes and patterns associated with diastolic dysfunction, reduced EF, and HF development and therapy responsiveness, as well as their applications for AI to ECG.

ABSTRACT The current COVID-19 outbreak is forcing healthcare workers to continuously reconsider the proper indications for cardiac catheterization. Human and material resources optimization, infection prevention for patients and healthcare workers, and transfer times force a rethink of the previously established protocols. This article is a consensus statement of the Interventional Cardiology Association and the Ischemic Heart Disease Association of the Spanish Society of Cardiology, and aims to provide information to healthcare workers on the indications of diagnostic or therapeutic cardiac catheterization during the current COVID-19 pandemic.

El brote actual de COVID-19 está obligando a los profesionales sanitarios a replantear de forma continua las indicaciones de cateterismo cardiaco. La optimización de recursos materiales y humanos, la prevención de contagios a profesionales y pacientes, así como la gestión de los tiempos de traslado, hace totalmente necesario reformular los protocolos previamente establecidos. El presente texto es un documento de consenso de la Asociación de Cardiología Intervencionista y la Asociación de Cardiopatía Isquémica y Cuidados Agudos Cardiovasculares de la Sociedad Española de Cardiología que pretende dar información al personal sanitario sobre las indicaciones de cateterismo diagnóstico o terapéutico durante la pandemia actual de COVID-19.

RESUMEN Introducción y objetivos: Tras los resultados de varios estudios aleatorizados, la tromboaspiración (TA) sistemática ha sido relegada a un segundo plano por no mejorar el pronóstico de los pacientes con infarto agudo de miocardio con elevación del segmento ST e incluso aumentar sus complicaciones. El objetivo de este trabajo fue evaluar el impacto de la TA selectiva durante la angioplastia primaria (ICPp), su seguridad y sus beneficios clínicos tras 1 año de seguimiento. Métodos: El registro TAPER (eficacia y seguridad de la tromboaspiración selectiva en la práctica clínica real) incluyó retrospectivamente pacientes con infarto de miocardio con elevación del segmento ST tratados con ICPp. Se evaluaron las características clínicas y de los procedimientos, así como la presentación del evento combinado de muerte cardiovascular, infarto de miocardio no fatal, trombosis de stent, necesidad de revascularización de la lesión tratada o ictus tras 1 año de seguimiento. Resultados: Se analizaron 687 pacientes (76,9% varones, 64 ± 12 años). La TA se realizó en el 40,3% de los casos (89,9% como estrategia inicial y 10,1% como rescate) y fue exitosa en el 93,8%. El predictor más importante de uso de TA fue un alto grado de trombo inicial según la escala TIMI (Thrombolysis in Myocardial Infarction) (odds ratio = 3,2; intervalo de confianza del 95%, 2,5-3,9; p < 0,0001). La TA consiguió una mejora significativa del flujo de 2,4 puntos en la escala TIMI de flujo y una reducción significativa del grado de trombo de 2,6 puntos en la escala TIMI de trombo. En 1 año de seguimiento no se observó ningún ictus en el grupo de TA y la tasa del evento combinado fue similar en ambos grupos (grupo de TA 8% y grupo de no-TA 5,7%; p = 0,24). Conclusiones: La TA selectiva se usa con frecuencia en la práctica clínica actual, con una alta tasa de éxito y pocas complicaciones asociadas. La TA selectiva reduce significativamente la carga de trombo y mejora el flujo coronario. Tras 1 año de seguimiento, se observó una tasa similar de eventos adversos en los pacientes a quienes se realizó ICPp con independencia del uso de TA.

ABSTRACT Introduction and objectives: After the results of several randomized trials, routine thrombus aspiration (TA) has remained out of the spotlight after not improving the prognosis of patients with ST-segment elevation myocardial infarction and even increasing their complications. The goal here was to assess the impact of selective TA during primary percutaneous coronary intervention (pPCI), its safety and clinical benefits at 1-year follow-up. Methods: The TAPER registry (efficacy and safety of selective Thrombus Aspiration in Real clinical Practice) retrospectively included patients with ST-segment elevation myocardial infarction treated with pPCI. The clinical and procedural characteristics and the composite endpoint of cardiovascular mortality, non-fatal myocardial infarction, stent thrombosis, target lesion revascularization or stroke were evaluated after at 1-year follow-up. Results: 687 patients (76.9% males, 64 ± 12 years) were analyzed. The TA was performed in 40.3% of cases (in 89.9% as the initial strategy and in 10.1% as the bailout strategy) and it was successful in 93.8% of them. The most important predictor of TA use was a higher initial Thrombolysis in Myocardial Infarction (TIMI) thrombus grade (OR, 3.2; 95%CI, 2.5-3.9; P < .0001). TA achieved a significant improvement of TIMI-flow (2.4 points) and a significant reduction of the TIMI thrombus grade (2.6 points). At 1-year follow-up, no stroke was observed in the TA-group and the rate of the composite endpoint (cardiovascular mortality, non-fatal myocardial infarction, stent thrombosis, target lesion revascularization or stroke) was similar in both groups (TA-group 8% vs non-TA-group 5.7%; P = .24). Conclusions: Selective TA is frequently used in the current clinical practice with a high success rate and a low rate of associated complications. It significantly reduces thrombotic burden and improves coronary flow. At 1-year follow-up, a similar rate of adverse events was observed regardless of the use of TA.

Se presenta el caso de un varón de 74 años ingresado por síndrome coronario agudo sin elevación del segmento ST. La coronariografía realizada mostró una estenosis de la arteria coronaria derecha con un aneurisma coronario (AC) gigante y alta carga trombótica (figura 1A). Se recomendó doble antiagregación y anticoagulación oral para excluir el AC en un segundo tiempo. Tras confirmar la reducción del trombo (figura 1B), se predilató y se midió la longitud del AC (40 mm) y de la zona de aterrizaje mediante ecografía intravascular (IVUS) (figura 1C). Se implantaron 2 stents coronarios recubiertos PK-Papyrus (SCR) de 5 × 26 mm (Biotronik, Suiza) de proximal a distal. La zona de solapamiento de ambos stents se confirmó mediante StentBoost (Philips Medical Systems, Países Bajos) (figura 1D). El stent se implantó bajo fluoroscopia y en ausencia de movimientos respiratorios. La siguiente angiografía reveló la exclusión incompleta del AC (figura 1E) a pesar de posdilatación con un balón no compliante (BNC) de 5,5 mm. El IVUS confirmó la existencia de un gap entre ambos stents debido al acortamiento de los mismos (E2, figura 1E y vídeo 1 del material adicional). Se implantó otro SCR de 5 × 15 mm y se posdilató...

Seventy-four-year-old male patient admitted with non-ST-elevation acute myocardial infarction. The coronary angiography performed revealed the presence of right coronary artery stenosis with a giant coronary artery aneurysm (CAA) and high thrombus burden (figure 1A). Dual antiplatelet and anticoagulation therapies were recommended for its exclusion in a staged procedure. After confirmation of thrombus reduction (figure 1B), predilatation was attempted and both the length of the CAA (40 mm) and the landing zone were measured on the intravascular ultrasound (IVUS) (figure 1C). From proximal to distal, two 5 mm x 26 mm-PK-Papyrus covered coronary stents (PCS) (Biotronik, Switzerland) were deployed. The overlapping stent zone was confirmed using the StentBoost imaging modality (Philips Medical Systems, Nederland) (figure 1D) and the stent was deployed under fluoroscopic guidance in the absence of any respiratory movements. The subsequent angiography performed revealed an incomplete CAA exclusion (figure 1E) despite postdilatation with a 5.5 mm noncompliant balloon (NCB). The IVUS confirmed the existence of a gap between both stents due to stent shortening (E2, figure 1E and video 1 of the supplementary data). Another 5 mm × 15 mm PCS was deployed followed by postdilatation with a 5.5 mm NCB. Both the angiography and the IVUS confirmed the...

The angiotensin-converting enzyme 2 (ACE2) is a type I integral membrane that exists in two forms: the first is a transmembrane protein; the second is a soluble catalytic ectodomain of ACE2. The catalytic ectodomain of ACE2 undergoes shedding by a disintegrin and metalloproteinase domain-containing protein 17 (ADAM17), in which calmodulin mediates the calcium signaling pathway that is involved in ACE2 release, resulting in a soluble catalytic ectodomain of ACE2 that can be measured as soluble ACE2 plasma activity. The shedding of the ACE2 catalytic ectodomain plays a role in cardiac remodeling and endothelial dysfunction and is a predictor of all-cause mortality, including cardiovascular mortality. Moreover, considerable evidence supports that the ACE2 catalytic ectodomain is an essential entry receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Additionally, endotoxins and the pro-inflammatory cytokines interleukin (IL)-1β and tumor necrosis factor-alpha (TNFα) all enhanced soluble catalytic ectodomain ACE2 shedding from the airway epithelia, suggesting that the shedding of ACE2 may represent a mechanism by which viral entry and infection may be controlled such as some types of betacoronavirus. In this regard, ACE2 plays an important role in inflammation and thrombotic response, and its down-regulation may aggravate COVID-19 via the renin-angiotensin system, including by promoting pathological changes in lung injury. Soluble forms of ACE2 have recently been shown to inhibit SARS-CoV-2 infection. Furthermore, given that vitamin D enhanced the shedding of ACE2, some studies reported that vitamin D treatment is associated with prognosis improvement in COVID-19. This is an updated review on the evidence, clinical, and therapeutic applications of ACE2 for COVID-19.

Mujer de 85 años con angina inestable que presentaba lesiones graves y muy calcificadas en las arterias coronaria derecha proximal (figura 1A, asterisco) y descendente anterior proximal-media (figura 1B, asterisco). Figura 1. Se realizó aterectomía rotacional con el sistema RotaPro (Boston Scientific, EE.UU.) en la coronaria derecha (figura 1C) y se implantó un stent farmacoactivo, con buen resultado (figura 1D) confirmado mediante ecografía intracoronaria (figura 1E). Se obtuvo el consentimiento informado de la paciente. Tras sondar el tronco coronario izquierdo (TCI) se cruzó la guía a la descendente anterior. Se avanzó una oliva de 1,5 mm en modo dynaglide hasta el TCI, momento en que el catéter guía se extubó y se produjo una perforación Ellis-III en el TCI (figura 2A, asterisco; vídeo 1 del material adicional); es posible que una deformación inadvertida de la guía dirigiera la oliva hacia la pared del vaso. La paciente presentó taponamiento cardiaco, que fue tratado con pericardiocentesis. Se implantó un stent recubierto PK-Papyrus (Biotronik, Alemania) de 4 × 15 mm en el TCI sin enjaular la bifurcación (figura 2B). Sin embargo, se mantenía una discreta fuga de contraste (figura 2C, asterisco). Tras posdilatar con balón de 4,5 mm, la perforación quedó sellada (figura 2D; vídeo 2...

Eighty-five-year-old woman with unstable angina with serious and heavily calcified lesions in proximal right coronary arteries (figure 1A, asterisk) and proximal and mid left anterior descending coronary artery (figure 1B, asterisk). Rotational atherectomy was performed in the right coronary artery using the RotaPro system (Boston Scientific, United States) (figure 1C) and a drug-eluting stent was implanted with good results (figure 1D) as confirmed by the intracoronary ultrasound (figure 1E). Informed consent was obtained from the patient. Figure 1. After the catheterization of the left main coronary artery (LMCA) the left anterior descending coronary artery was crossed. A 1.5 mm olive-shaped burr was advanced in the DynaGlide mode towards the LMCA, which is when the guide catheter was extubated and an Ellis type III perforation occurred in the LMCA (figure 2A, asterisk; video 1 of the supplementary data); it is possible that an unnoticed deformation of the guidewire moved the burr towards the vessel wall. The patient showed cardiac tamponade that was treated with pericardiocentesis. A 4 × 15 mm PK-Papyrus covered coronary stent (Biotronik, Germany) was implanted in the LMCA without jailing the bifurcation (figure 2B). However, a discrete leak of contrast still occurred (figure 2C, asterisk). After postdilatation with a 4.5 mm...

Las redes sociales e internet han modificado nuestra forma de comunicarnos. Nunca se ha tenido tanta información sobre cualquier tema y de una forma tan directa, rápida y global. Sin embargo, esta nueva era también entraña ciertos riesgos, ya que al ser cualquier usuario un potencial creador de contenidos, la información nunca ha estado tan expuesta a sesgos y demagogia. La capacidad de las redes sociales para circular rápidamente información y generar debate entre sus usuarios ha dado lugar a su aplicación en ámbitos como la política, los negocios, la radiodifusión y el mundo académico1. La medicina no ha escapado a esta renovación tecnológica y podemos decir que hoy ya predominan los médicos educados en la cultura digital. La cardiología, como en tantos otros aspectos, se encuentra en la primera línea de esta tendencia. Además de la formación práctica y las habilidades técnicas, esenciales para los cardiólogos intervencionistas, la formación teórica y la actualización constante son imprescindibles. Las materias que componen nuestro core curriculum son cada vez más difíciles de abarcar, ya que no solo comprenden las correspondientes a la cardiología general, sino también las específicas como intervencionistas: fisiología e imagen coronaria, hemodinámica, técnicas de tratamiento percutáneo de lesiones coronarias (cada vez...

Social media and the internet have changed the way we communicate with each other. We have never had so much information on this or that topic and never in such a direct, fast and global way. However, this new era does not come without risks and because everybody can be a potential creator of content, information itself has never been so susceptible to bias and demagogy. The capacity of social media to expose information quickly and generate discussion among users has given rise to its application in the world of policy, business, radio broadcasts and academia world.1 Medicine is no stranger to this technological renewal and today we have doctors who are media-savvy. As it happens in many other aspects, cardiology is at the frontline of this trend. As well as practical training and technical skills, essential for interventional cardiologists, theoretical training and constant update are also indispensable. The subjects covered in our core curriculum are increasingly difficult to apprehend since they include topics not only from general cardiology but also from interventional cardiology: physiology and coronary imaging, hemodynamics, techniques for the percutaneous treatment of coronary lesions (more and more complex) and structural cardiomyopathies, knowledge of devices and technical development, etc. An ideal...

A single coronary artery is one of the most rarely seen coronary artery anomalies. In addition, the specific subtype (Lipton RII-A) that our patient presented is one of the least common, and its clinical presentation as myocardial infarction and cardiac arrest has not been described in the literature. The case shows that although it is essential to exclude a malignant interarterial course of the vessel, cardiac arrest is a possible clinical presentation produced by myocardial ischemia in the context of acute myocardial infarction and should be managed according to clinical practice guidelines. Resumo: Uma artéria coronária única é uma das anomalias mais raras das artérias coronárias. Além disso, o subtipo específico (Lipton R-IIA) presente no nosso doente é um dos menos frequentes e a sua apresentação clínica como enfarte do miocárdio e como paragem cardíaca não foi ainda descrita na literatura. O caso mostra que, embora o descarte de um percurso interarterial maligno do vaso seja essencial, a paragem cardíaca é uma apresentação clínica possível causada por isquemia do miocárdio no cenário de um enfarte agudo do miocárdio, que deverá ser tratada de acordo com as recomendações práticas clínicas. Keywords: Single coronary artery, Myocardial infarction, Cardiac arrest, Multislice computed tomography, Palavras chave: Artéria coronária única, Enfarte do miocárdio, Paragem cardíaca, Tomografia computorizada multislice

Poisoning by ingestion of ‘Jamaican Stone’, a kind of cardioactive steroid, is extremely rare. However, mortality is very high. For this reason, when it occurs, an early and accurate diagnosis represents a critical challenge for clinicians. We present an unusual case of electrical storm caused by this substance. Resumo: O envenenamento por ingestão de «pedra jamaicana», um tipo de esteroide cardioativo, é extremamente raro. Contudo, dado esta situação se associar a uma mortalidade muito elevada, o diagnóstico precoce e rigoroso desta situação pode ser clinicamente crucial. É retratado um caso pouco comum de tempestade arrítmica causada por esta substância. Keywords: Jamaican Stone, Cardenolides, Bufadienolides, Cardioactive steroids, Palavras-chave: Pedra jamaicana, Cardenolídeos, Bufadienolídeos, Esteroides cardioativos

Endoscopic ultrasound is a diagnostic and therapeutic technique used in specialized centers for patients that have undergone digestive procedures. This technique enables highly precise real-time imaging of the digestive tract wall and surrounding organs. Endoscopic ultrasound is also useful in patients with cardiovascular diseases such as atrial fibrillation. In patients with contraindication for transesophageal echocardiography due to high risk of esophageal bleeding or complications that may require immediate intervention, endoscopic ultrasound may be a safer option for visualizing atrial chambers to rule out the presence of left atrial appendage thrombi before cardioversion.

Coronary artery perforation (CAP) is a rare but potentially fatal complication of percutaneous coronary intervention. Polytetrafluoroethylene-covered stents prevent blood leakage between struts with a high rate of success. However, they lack elasticity and rapid and correct deployment is difficult. They have also a higher rate of stent restenosis and thrombosis. For these reasons, optimal deployment is essential.Although severe CAP needs an emergent solution, after stabilizing the patient, intracoronary imaging techniques may be useful to ensure correct expansion and reduce further adverse events.We present a case that shows the potential role of intravascular ultrasound in the resolution of a CAP. Resumo: A perfuração da artéria coronária (PAC) é uma complicação rara, mas potencialmente fatal da intervenção coronária percutânea (ICP). Os stents revestidos com politetrafluoroetileno impedem o leakage do sangue entre os suportes com uma elevada taxa de sucesso. No entanto, a falta de elasticidade e o posicionamento rápido e correto são difíceis. Apresentam também uma taxa mais elevada de reestenose de stent e de trombose. Por este motivo, é fundamental um posicionamento otimizado.Embora a PAC necessite de uma solução emergente, após estabilizar o doente, as técnicas intracoronárias imageológicas podem ser úteis para assegurar a expansão correta e reduzir eventos adversos adicionais.Apresentamos um caso que revela o papel potencial da ultrassonografia intravenosa na resolução de uma PAC. Keywords: Coronary artery perforation, Covered stents, Intravascular ultrasound, Palavras-chave: Perfuração da artéria coronária, Stents revestidos, Ultrassonografia intravenosa