Background: Drug-eluting stents (DESs) based on biodegradable polymers (BPs) have been introduced... more Background: Drug-eluting stents (DESs) based on biodegradable polymers (BPs) have been introduced to reduce the risk for late and very late stent thrombosis (ST), which were frequently observed with earlier generations of DES designs based on durable polymers (DPs); however, randomized controlled trials on these DES designs are scarce. The meriT-V trial is a randomized, active-controlled, noninferiority trial with a prospective, multicenter design that evaluated the 2-year efficacy of a novel third-generation, ultra-thin strut, BPbased BioMime sirolimus-eluting stent (SES) versus the DP-based XIENCE everolimus-eluting stent (EES) for the treatment of de novo lesions. Methods: The meriT-V is a randomized trial that enrolled 256 patients at 15 centers across Europe and Brazil. Here, we report the outcomes of the extended follow-up period of 2 years. The randomization of enrolled patients was in a 2:1 ratio; the enrolled patients received either the BioMime SES (n = 170) or the XIENCE EES (n = 86). The three-point major adverse cardiac event (MACE), defined as a composite of cardiac death, myocardial infarction (MI), or ischemiadriven target vessel revascularization (ID-TVR), was considered as the composite safety and efficacy endpoint. Ischemia-driven target lesion revascularization (ID-TLR) was evaluated as well as the frequency of definite/probable ST, based on the first Academic Research Consortium definitions. Results: The trial had a 2-year follow-up completion rate of 98.44% (n = 252/256 patients), and the clinical outcomes assessment showed a nonsignificant difference in the cumulative rate of three-point MACE between both arms (BioMime vs. XIENCE: 7.74% vs. 9.52%, P = 0.62). Even the MI incidences in the BioMime arm were insignificantly lower than those of the XIENCE arm (1.79% vs. 5.95%, P = 0.17). Late ST was observed in 1.19% cases of the XIENCE arm, while there were no such cases in the BioMime arm (P = 0.16). Conclusions: The objective comparisons between the novel BP-based BioMime SES and the well-established DP-based XIENCE EES in this randomized controlled trial show acceptable outcomes of both the devices in the cardiac deaths, MI, ID-TVR, and ST. Moreover, since there were no incidences of cardiac death in the entire study sample over the course of 2 years, we contend that the findings of the study are highly significant for both these DES designs. In this preliminary comparative trial, the device safety of BioMime SES can be affirmed to be acceptable, considering the lower three-point MACE rate and absence of late ST in the BioMime arm over the 2-year period.
We describe the case of a 61-year-old man who presented with chest pain and STsegment elevation i... more We describe the case of a 61-year-old man who presented with chest pain and STsegment elevation in the anterior precordial leads (V1-V5) due to proximal occlusion of the right ventricular branch of a codominant right coronary artery. Primary coronary angioplasty and stenting of this branch was performed resulting in resolution of the chest pain and STsegment elevation. Our description illustrates a case of isolated right ventricular infarction as an uncommon but important differential diagnosis of anterior ST-segment elevation. In addition, it highlights the value of careful review of the angiographic images in this context, as the culprit lesion may be a right ventricular branch occlusion. To the best of our knowledge, this is the first reported case of primary percutaneous coronary intervention treatment of a right ventricular branch occlusion causing isolated acute right ventricular myocardial infarction and anterior ST-segment elevation.
Journal of the American College of Cardiology, Nov 1, 1999
The purpose of this study was to test the hypothesis that stent implantation in de novo coronary ... more The purpose of this study was to test the hypothesis that stent implantation in de novo coronary artery lesions would result in lower restenosis rates and better long-term clinical outcomes than balloon angioplasty. BACKGROUND Placement of an intracoronary stent, as compared with balloon angioplasty, has proven to reduce the rate of restenosis. However, the long-term clinical benefit of stenting over angioplasty has not been assessed in large randomized trials. METHODS We randomly assigned 452 patients with either stable (129 patients) or unstable (323 patients) angina pectoris to elective stent implantation (229 patients) or standard balloon angioplasty (223 patients). Coronary angiography was performed at baseline, immediately after the procedure and six months later. End points were the rate of restenosis at six months and a composite of death, myocardial infarction (MI) and target vessel revascularization over four years of follow-up. RESULTS Procedural success rate was achieved in 84% and 95% (balloon angioplasty vs. stent, respectively). The increase in the minimal luminal diameter was greater in the stent group both after the intervention (2.02 Ϯ 0.6 mm vs. 1.43 Ϯ 0.6 mm in the angioplasty group; p Ͻ 0.0001), and at six-month follow-up (1.98 Ϯ 0.7 mm vs. 1.63 Ϯ 0.7 mm; p Ͻ 0.001). The corresponding restenosis rates were 22% and 37%, respectively (p Ͻ 0.002). After four years, no differences in mortality (2.7% vs. 2.4%) and nonfatal MI (2.2% vs. 2.8%) were found between the stent and the angioplasty groups, respectively. However, the requirement for further revascularization procedures of the target lesions was significantly reduced in the stent group (12% vs. 25% in the angioplasty group; relative risk 0.49, 95% confidence interval 0.32 to 0.75, p ϭ 0.0006); most of the repeat procedures (84%) were carried out within six months of entry into the study. CONCLUSIONS Patients who received an intracoronary stent showed a lower rate of restenosis than those treated with conventional balloon angioplasty. The benefit of stenting was maintained four years after implantation, as manifested by a significant reduction in the need for repeat revascularization.
Brecha de género en las redes de atención al infarto 71 236 frente a 210 min, p < 0,001), más com... more Brecha de género en las redes de atención al infarto 71 236 frente a 210 min, p < 0,001), más complicaciones intrahospitalarias (20,6 frente a 17,4%, p = 0,031) y mortalidad intrahospitalaria, a 30 días y un año (4,8 frente a 2,6%, p = 0,001; 9,1 frente a 4,5%, p < 0,001; 14,0 frente a 8,3%, p < 0,001). Sin embargo, tras el análisis multivariado no hubo diferencias en mortalidad a 30 días y un año. Conclusiones: A pesar del peor perfil de riesgo y el peor tratamiento recibido, las mujeres presentaron similares resultados a 30 días y un año que sus homólogos masculinos atendidos por una red de atención al infarto.
AimsThe aim of this study was to evaluate the impact of pulmonary ridge (PR) coverage on both cli... more AimsThe aim of this study was to evaluate the impact of pulmonary ridge (PR) coverage on both clinical and imaging follow-up outcomes in patients undergoing left atrial appendage occlusion (LAAO).Methods and result: The study included consecutive patients with non-valvular atrial fibrillation who underwent LAAO with disc and lobe devices. Patients were classified into two groups according to the PR coverage. A total of 147 patients were included. Among these, the PR was covered in 109 (74%) and uncovered in 38 (26%). Successful implantation was achieved in 98.6%. No differences in procedural outcomes were observed between the groups. The rate of procedural major adverse events was 3% (only major bleedings and/or vascular access complications). No device embolisation, cardiac tamponade or in-hospital mortality was observed. After a mean follow-up of 1.77±2.2 years, the annualised ischaemic stroke and major bleeding rate was 1.3%/year and 6.5%/year, respectively, without differences between groups. At follow-up, patients with a covered PR presented a lower incidence of device-related thrombosis (DRT) (1%) than those with an uncovered PR (27%); p<0.001. In multivariable analysis, the presence of PR coverage emerged as an independent predictor of DRT.ConclusionsPulmonary ridge coverage was associated with a lower incidence of DRT after LAAO. Procedural and follow-up clinical outcomes did not differ between covered PR and uncovered PR patients.
European Heart Journal - Case Reports, Jan 12, 2019
Background Spontaneous coronary artery dissection (SCAD) is an infrequent and often misdiagnosis ... more Background Spontaneous coronary artery dissection (SCAD) is an infrequent and often misdiagnosis of a non-atherosclerotic cause of acute coronary syndrome (ACS). It is an important cause of ACS in young women, responsible for up to 25% of all cases in women <50 years of age without cardiovascular risk factors. Clinical presentation ranges from ST-segment-elevation myocardial infarction (MI) to ventricular fibrillation and sudden death. The treatment of patients with SCAD is a challenge and the ideal management strategy has yet to be determined.
European Journal of Internal Medicine, Oct 1, 2011
Objectives: To compare clinical presentation and short-term prognosis of acute coronary syndrome ... more Objectives: To compare clinical presentation and short-term prognosis of acute coronary syndrome (ACS) in HIV-infected and uninfected adults. Design: Retrospective analysis of a prospectively collected cohort. Methods: HIV-infected patients with myocardial infarction or unstable angina were identified by clinical history and specific characteristics of HIV infection were consecutively registered. Surviving patients were followed for at least one month after discharge. Risk factors for cardiovascular disease, clinical symptoms at admission, type of ACS, delivery of care, and factors associated with prognosis were compared between HIVinfected and uninfected adults. Results: Among 627 patients included, 44 (7%) were HIV-infected patients. HIV-infected patients were younger, more frequently men, and had higher prevalence of cardiovascular risk factors than uninfected patients. HIV-infected patients persisted frequently with less pain at Emergency Department (ED) (34% vs 82%, P b 0.001) and complained of dyspnea (2% vs 15%, P b 0.05) persisted in respect to HIV-uninfected patients. ST-elevation myocardial infarction was the most frequent ACS in HIV-infected patients (59% vs 24%) whereas non-ST-elevation myocardial infarction (23% vs 38%) and unstable angina (18% vs 38%) were the predominant ones in uninfected patients (P b 0.001). Catheterism was performed more commonly in HIVinfected patients (75% vs 62%, P b 0.01) and similarly admitted in the coronary care unit (38% vs 41%, P = 0.81). The evolution was similar in both groups. When HIV-infected patients were matched by age and sex with a subgroup of 88 HIV-uninfected patients, most of the differences disappeared. Conclusions: HIV-infected adults presenting with ACS are younger and have fewer symptoms than uninfected. Despite having a more established disease, short-term prognosis is similar.
A patient with ischemic myocardiopathy who had undergone resynchronization therapy was admitted t... more A patient with ischemic myocardiopathy who had undergone resynchronization therapy was admitted to the authors' institution with progressive dyspnea. Echocardiography demonstrated a left ventricular ejection fraction (LVEF) of 25%, with a massive mitral regurgitation (MR) secondary to anterior leaflet prolapse and posterior leaflet restriction. Despite intensive medical treatment, the patient developed cardiogenic shock and required mechanical ventilation, inotropic support and intra-aortic balloon pumping. The patient was rejected for surgery due to the high operative risk, but subsequently underwent a successful percutaneous repair with two MitraClip® devices. Immediately after the intervention there was a progressive improvement that allowed the patient to be discharged, such that the clinical outcome was favorable at the six-month follow up (NYHA class II/IV). This case report describes the benefits of minimally invasive therapy in selected patients who are at very high surgical risk and who, despite being in a critical condition and with low LVEF, experience an outstanding clinical improvement following the resolution of a massive MR.
Background Developed countries are facing a sustained increase in life expectancy. Elderly people... more Background Developed countries are facing a sustained increase in life expectancy. Elderly people represent the fastest growing portion of cardiovascular patients. However, nonagenarians with ST-segment elevation myocardial infarction (STEMI) are often underrepresented in clinical trials as prolonged follow-up may be compromised by limited life expectancy. The aim of this retrospective study is to analyse the clinical presentation, risk factors, co-morbidities, outcomes of nonagenarian patients presenting with STEMI. Methods We included all consecutive nonagenarians presenting with STEMI admitted in 2 academic centers between 2007 and 2017. There were no exclusion criteria. We collected demographic, clinical, and procedural data. All-cause mortality was assessed in-hospital, at 6 months and at 1-year follow-up. Results A total of 140 patients (mean age 91.6 years [91.3–92]; 59% females) were included. The number of patients increased over the years (from 6.5 cases per year before 2012 to 14.4 cases per year after 2012). One out of 5 patients presented disability or dependence for activities of daily living (ADL). Emergent catheterization was performed in 70% of our patients, and primary percutaneous coronary intervention (pPCI) in 57% (n=80). The use of bare metal stent was preponderant (72%) in this cohort. Successful revascularization of the culprit vessel was achieved in 90% of patients. Dual antiplatelet therapy with aspirin and clopidogrel was used in 97% of patients. Overall, in-hospital mortality was 22%, increased up to 27% at 6 months and up to 34% at 1-year follow-up. In-hospital mortality was lower in pPCI group than in conservative group (13.7% versus 31.6%, adjusted OR: 0.17, 95% CI: 0.04–0.67, P&amp;amp;amp;lt;0.01). One-year mortality was also lower in pPCI group than in conservative group (26% versus 45%, P&amp;amp;amp;lt;0.01). Multivariable analysis identified mechanical complications (adjusted OR: 28.1, 95% CI: 3.18–247.7, P&amp;amp;amp;lt;0.01), Killip class (III/IV) (adjusted OR: 4.19, 95% CI: 3.37–22.3, P&amp;amp;amp;lt;0.01) and pPCI (adjusted OR: 0.40, 95% CI: 0. 16- 0. 95, P&amp;amp;amp;lt;0.05) as independent predictors of all-cause mortality at 1 year. Conclusions STEMI in nonagenarians is becoming more and more common. pPCI may be also the preferred strategy in this high-risk cohort. The hemodynamic compromise (Killip class III/IV), the presence of complications related to myocardial infarction and early revascularization may be related to prognosis of these patients.
Introduction and objectives. Alcohol septal ablation is a therapeutic option for patients with hy... more Introduction and objectives. Alcohol septal ablation is a therapeutic option for patients with hypertrophic obstructive cardiomyopathy who remain symptomatic despite medical treatment. Our aim was to monitor clinical and echocardiographic progression in patients with hypertrophic obstructive cardiomyopathy treated by septal ablation at our center. Methods. Thirty-five septal ablations were performed in 34 patients (79% male) who had symptomatic hypertrophic obstructive cardiomyopathy despite optimum medical treatment. The procedure was successful in 32 (i.e., the reduction in left ventricular outflow tract pressure gradient, or LVOTPG, was >50%). During clinical and echocardiographic follow-up, New York Heart Association (NYHA) functional class and LVOTPG were monitored. Results. The patients' mean age was 63 (12) years. The mean follow-up period was 9 (3) months. Immediately after septal ablation, LVOTPG decreased significantly, from 74.2 (25.3) mm Hg to 26 (25) mm Hg (P<.001), and remained low throughout follow-up. Moreover, echocardiography showed that the interventricular septum thickness also decreased during follow-up, from 19 (3) mm to 15 (2) mm (P<.0001). A significant improvement in NYHA functional class (from 93% in class III-IV to 84% in class I-II) was also observed. Two deaths occurred within 48 hours after the procedure. The most frequent complication was complete heart block (20%; n=6). Conclusions. Alcohol septal ablation is effective in patients with hypertrophic obstructive cardiomyopathy who remain symptomatic despite medical treatment. However, the procedure is associated with a significant rate of complications and should, therefore, be reserved for selected patients, in particular for elderly patients and those with comorbid conditions.
Aims Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of a... more Aims Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD in old patients (>65 years of age) remain unknown. Methods and results The Spanish multicentre prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. Data were collected between June 2015 and April 2019. All angiograms were analysed in a centralized corelab. For the purposes of this study, patients were classified according to age in two groups <65 and ≥65 years old and in-hospital outcomes were analysed. Fifty-five patients (17%) were ≥65 years old (95% women). Older patients had more often hypertension (76% vs. 29%, P < 0.01) and dyslipidaemia (56% vs. 30%, P < 0.01), and less previous (4% vs. 18%, P < 0.001) or current smoking habit (4% vs. 33%, P < 0.001). An identifiable trigger was less often present in old patients (27% vs. 43%, P = 0.0...
Transcatheter aortic valve implantation (TAVI) is the treatment of choice for severe symptomatic ... more Transcatheter aortic valve implantation (TAVI) is the treatment of choice for severe symptomatic aortic stenosis in inoperable patients, and an alternative treatment for those at high risk. The coexistence of coronary artery disease (CAD) adds morbidity and mortality to the procedure. Prior percutaneous coronary intervention (PCI) has been suggested as safe and related to a better prognosis. However, PCI in the left main coronary artery (LMCA) prior to TAVI has been poorly represented in clinical trials and scarcely reported. Herein are presented three cases of a successful sequential approach by LMCA stenting and TAVI, underlining the importance of clinical and anatomic assessment by a multidisciplinary team. Future studies will be necessary to provide more evidence for this indication.
Background: Drug-eluting stents (DESs) based on biodegradable polymers (BPs) have been introduced... more Background: Drug-eluting stents (DESs) based on biodegradable polymers (BPs) have been introduced to reduce the risk for late and very late stent thrombosis (ST), which were frequently observed with earlier generations of DES designs based on durable polymers (DPs); however, randomized controlled trials on these DES designs are scarce. The meriT-V trial is a randomized, active-controlled, noninferiority trial with a prospective, multicenter design that evaluated the 2-year efficacy of a novel third-generation, ultra-thin strut, BPbased BioMime sirolimus-eluting stent (SES) versus the DP-based XIENCE everolimus-eluting stent (EES) for the treatment of de novo lesions. Methods: The meriT-V is a randomized trial that enrolled 256 patients at 15 centers across Europe and Brazil. Here, we report the outcomes of the extended follow-up period of 2 years. The randomization of enrolled patients was in a 2:1 ratio; the enrolled patients received either the BioMime SES (n = 170) or the XIENCE EES (n = 86). The three-point major adverse cardiac event (MACE), defined as a composite of cardiac death, myocardial infarction (MI), or ischemiadriven target vessel revascularization (ID-TVR), was considered as the composite safety and efficacy endpoint. Ischemia-driven target lesion revascularization (ID-TLR) was evaluated as well as the frequency of definite/probable ST, based on the first Academic Research Consortium definitions. Results: The trial had a 2-year follow-up completion rate of 98.44% (n = 252/256 patients), and the clinical outcomes assessment showed a nonsignificant difference in the cumulative rate of three-point MACE between both arms (BioMime vs. XIENCE: 7.74% vs. 9.52%, P = 0.62). Even the MI incidences in the BioMime arm were insignificantly lower than those of the XIENCE arm (1.79% vs. 5.95%, P = 0.17). Late ST was observed in 1.19% cases of the XIENCE arm, while there were no such cases in the BioMime arm (P = 0.16). Conclusions: The objective comparisons between the novel BP-based BioMime SES and the well-established DP-based XIENCE EES in this randomized controlled trial show acceptable outcomes of both the devices in the cardiac deaths, MI, ID-TVR, and ST. Moreover, since there were no incidences of cardiac death in the entire study sample over the course of 2 years, we contend that the findings of the study are highly significant for both these DES designs. In this preliminary comparative trial, the device safety of BioMime SES can be affirmed to be acceptable, considering the lower three-point MACE rate and absence of late ST in the BioMime arm over the 2-year period.
We describe the case of a 61-year-old man who presented with chest pain and STsegment elevation i... more We describe the case of a 61-year-old man who presented with chest pain and STsegment elevation in the anterior precordial leads (V1-V5) due to proximal occlusion of the right ventricular branch of a codominant right coronary artery. Primary coronary angioplasty and stenting of this branch was performed resulting in resolution of the chest pain and STsegment elevation. Our description illustrates a case of isolated right ventricular infarction as an uncommon but important differential diagnosis of anterior ST-segment elevation. In addition, it highlights the value of careful review of the angiographic images in this context, as the culprit lesion may be a right ventricular branch occlusion. To the best of our knowledge, this is the first reported case of primary percutaneous coronary intervention treatment of a right ventricular branch occlusion causing isolated acute right ventricular myocardial infarction and anterior ST-segment elevation.
Journal of the American College of Cardiology, Nov 1, 1999
The purpose of this study was to test the hypothesis that stent implantation in de novo coronary ... more The purpose of this study was to test the hypothesis that stent implantation in de novo coronary artery lesions would result in lower restenosis rates and better long-term clinical outcomes than balloon angioplasty. BACKGROUND Placement of an intracoronary stent, as compared with balloon angioplasty, has proven to reduce the rate of restenosis. However, the long-term clinical benefit of stenting over angioplasty has not been assessed in large randomized trials. METHODS We randomly assigned 452 patients with either stable (129 patients) or unstable (323 patients) angina pectoris to elective stent implantation (229 patients) or standard balloon angioplasty (223 patients). Coronary angiography was performed at baseline, immediately after the procedure and six months later. End points were the rate of restenosis at six months and a composite of death, myocardial infarction (MI) and target vessel revascularization over four years of follow-up. RESULTS Procedural success rate was achieved in 84% and 95% (balloon angioplasty vs. stent, respectively). The increase in the minimal luminal diameter was greater in the stent group both after the intervention (2.02 Ϯ 0.6 mm vs. 1.43 Ϯ 0.6 mm in the angioplasty group; p Ͻ 0.0001), and at six-month follow-up (1.98 Ϯ 0.7 mm vs. 1.63 Ϯ 0.7 mm; p Ͻ 0.001). The corresponding restenosis rates were 22% and 37%, respectively (p Ͻ 0.002). After four years, no differences in mortality (2.7% vs. 2.4%) and nonfatal MI (2.2% vs. 2.8%) were found between the stent and the angioplasty groups, respectively. However, the requirement for further revascularization procedures of the target lesions was significantly reduced in the stent group (12% vs. 25% in the angioplasty group; relative risk 0.49, 95% confidence interval 0.32 to 0.75, p ϭ 0.0006); most of the repeat procedures (84%) were carried out within six months of entry into the study. CONCLUSIONS Patients who received an intracoronary stent showed a lower rate of restenosis than those treated with conventional balloon angioplasty. The benefit of stenting was maintained four years after implantation, as manifested by a significant reduction in the need for repeat revascularization.
Brecha de género en las redes de atención al infarto 71 236 frente a 210 min, p < 0,001), más com... more Brecha de género en las redes de atención al infarto 71 236 frente a 210 min, p < 0,001), más complicaciones intrahospitalarias (20,6 frente a 17,4%, p = 0,031) y mortalidad intrahospitalaria, a 30 días y un año (4,8 frente a 2,6%, p = 0,001; 9,1 frente a 4,5%, p < 0,001; 14,0 frente a 8,3%, p < 0,001). Sin embargo, tras el análisis multivariado no hubo diferencias en mortalidad a 30 días y un año. Conclusiones: A pesar del peor perfil de riesgo y el peor tratamiento recibido, las mujeres presentaron similares resultados a 30 días y un año que sus homólogos masculinos atendidos por una red de atención al infarto.
AimsThe aim of this study was to evaluate the impact of pulmonary ridge (PR) coverage on both cli... more AimsThe aim of this study was to evaluate the impact of pulmonary ridge (PR) coverage on both clinical and imaging follow-up outcomes in patients undergoing left atrial appendage occlusion (LAAO).Methods and result: The study included consecutive patients with non-valvular atrial fibrillation who underwent LAAO with disc and lobe devices. Patients were classified into two groups according to the PR coverage. A total of 147 patients were included. Among these, the PR was covered in 109 (74%) and uncovered in 38 (26%). Successful implantation was achieved in 98.6%. No differences in procedural outcomes were observed between the groups. The rate of procedural major adverse events was 3% (only major bleedings and/or vascular access complications). No device embolisation, cardiac tamponade or in-hospital mortality was observed. After a mean follow-up of 1.77±2.2 years, the annualised ischaemic stroke and major bleeding rate was 1.3%/year and 6.5%/year, respectively, without differences between groups. At follow-up, patients with a covered PR presented a lower incidence of device-related thrombosis (DRT) (1%) than those with an uncovered PR (27%); p<0.001. In multivariable analysis, the presence of PR coverage emerged as an independent predictor of DRT.ConclusionsPulmonary ridge coverage was associated with a lower incidence of DRT after LAAO. Procedural and follow-up clinical outcomes did not differ between covered PR and uncovered PR patients.
European Heart Journal - Case Reports, Jan 12, 2019
Background Spontaneous coronary artery dissection (SCAD) is an infrequent and often misdiagnosis ... more Background Spontaneous coronary artery dissection (SCAD) is an infrequent and often misdiagnosis of a non-atherosclerotic cause of acute coronary syndrome (ACS). It is an important cause of ACS in young women, responsible for up to 25% of all cases in women <50 years of age without cardiovascular risk factors. Clinical presentation ranges from ST-segment-elevation myocardial infarction (MI) to ventricular fibrillation and sudden death. The treatment of patients with SCAD is a challenge and the ideal management strategy has yet to be determined.
European Journal of Internal Medicine, Oct 1, 2011
Objectives: To compare clinical presentation and short-term prognosis of acute coronary syndrome ... more Objectives: To compare clinical presentation and short-term prognosis of acute coronary syndrome (ACS) in HIV-infected and uninfected adults. Design: Retrospective analysis of a prospectively collected cohort. Methods: HIV-infected patients with myocardial infarction or unstable angina were identified by clinical history and specific characteristics of HIV infection were consecutively registered. Surviving patients were followed for at least one month after discharge. Risk factors for cardiovascular disease, clinical symptoms at admission, type of ACS, delivery of care, and factors associated with prognosis were compared between HIVinfected and uninfected adults. Results: Among 627 patients included, 44 (7%) were HIV-infected patients. HIV-infected patients were younger, more frequently men, and had higher prevalence of cardiovascular risk factors than uninfected patients. HIV-infected patients persisted frequently with less pain at Emergency Department (ED) (34% vs 82%, P b 0.001) and complained of dyspnea (2% vs 15%, P b 0.05) persisted in respect to HIV-uninfected patients. ST-elevation myocardial infarction was the most frequent ACS in HIV-infected patients (59% vs 24%) whereas non-ST-elevation myocardial infarction (23% vs 38%) and unstable angina (18% vs 38%) were the predominant ones in uninfected patients (P b 0.001). Catheterism was performed more commonly in HIVinfected patients (75% vs 62%, P b 0.01) and similarly admitted in the coronary care unit (38% vs 41%, P = 0.81). The evolution was similar in both groups. When HIV-infected patients were matched by age and sex with a subgroup of 88 HIV-uninfected patients, most of the differences disappeared. Conclusions: HIV-infected adults presenting with ACS are younger and have fewer symptoms than uninfected. Despite having a more established disease, short-term prognosis is similar.
A patient with ischemic myocardiopathy who had undergone resynchronization therapy was admitted t... more A patient with ischemic myocardiopathy who had undergone resynchronization therapy was admitted to the authors' institution with progressive dyspnea. Echocardiography demonstrated a left ventricular ejection fraction (LVEF) of 25%, with a massive mitral regurgitation (MR) secondary to anterior leaflet prolapse and posterior leaflet restriction. Despite intensive medical treatment, the patient developed cardiogenic shock and required mechanical ventilation, inotropic support and intra-aortic balloon pumping. The patient was rejected for surgery due to the high operative risk, but subsequently underwent a successful percutaneous repair with two MitraClip® devices. Immediately after the intervention there was a progressive improvement that allowed the patient to be discharged, such that the clinical outcome was favorable at the six-month follow up (NYHA class II/IV). This case report describes the benefits of minimally invasive therapy in selected patients who are at very high surgical risk and who, despite being in a critical condition and with low LVEF, experience an outstanding clinical improvement following the resolution of a massive MR.
Background Developed countries are facing a sustained increase in life expectancy. Elderly people... more Background Developed countries are facing a sustained increase in life expectancy. Elderly people represent the fastest growing portion of cardiovascular patients. However, nonagenarians with ST-segment elevation myocardial infarction (STEMI) are often underrepresented in clinical trials as prolonged follow-up may be compromised by limited life expectancy. The aim of this retrospective study is to analyse the clinical presentation, risk factors, co-morbidities, outcomes of nonagenarian patients presenting with STEMI. Methods We included all consecutive nonagenarians presenting with STEMI admitted in 2 academic centers between 2007 and 2017. There were no exclusion criteria. We collected demographic, clinical, and procedural data. All-cause mortality was assessed in-hospital, at 6 months and at 1-year follow-up. Results A total of 140 patients (mean age 91.6 years [91.3–92]; 59% females) were included. The number of patients increased over the years (from 6.5 cases per year before 2012 to 14.4 cases per year after 2012). One out of 5 patients presented disability or dependence for activities of daily living (ADL). Emergent catheterization was performed in 70% of our patients, and primary percutaneous coronary intervention (pPCI) in 57% (n=80). The use of bare metal stent was preponderant (72%) in this cohort. Successful revascularization of the culprit vessel was achieved in 90% of patients. Dual antiplatelet therapy with aspirin and clopidogrel was used in 97% of patients. Overall, in-hospital mortality was 22%, increased up to 27% at 6 months and up to 34% at 1-year follow-up. In-hospital mortality was lower in pPCI group than in conservative group (13.7% versus 31.6%, adjusted OR: 0.17, 95% CI: 0.04–0.67, P&amp;amp;amp;lt;0.01). One-year mortality was also lower in pPCI group than in conservative group (26% versus 45%, P&amp;amp;amp;lt;0.01). Multivariable analysis identified mechanical complications (adjusted OR: 28.1, 95% CI: 3.18–247.7, P&amp;amp;amp;lt;0.01), Killip class (III/IV) (adjusted OR: 4.19, 95% CI: 3.37–22.3, P&amp;amp;amp;lt;0.01) and pPCI (adjusted OR: 0.40, 95% CI: 0. 16- 0. 95, P&amp;amp;amp;lt;0.05) as independent predictors of all-cause mortality at 1 year. Conclusions STEMI in nonagenarians is becoming more and more common. pPCI may be also the preferred strategy in this high-risk cohort. The hemodynamic compromise (Killip class III/IV), the presence of complications related to myocardial infarction and early revascularization may be related to prognosis of these patients.
Introduction and objectives. Alcohol septal ablation is a therapeutic option for patients with hy... more Introduction and objectives. Alcohol septal ablation is a therapeutic option for patients with hypertrophic obstructive cardiomyopathy who remain symptomatic despite medical treatment. Our aim was to monitor clinical and echocardiographic progression in patients with hypertrophic obstructive cardiomyopathy treated by septal ablation at our center. Methods. Thirty-five septal ablations were performed in 34 patients (79% male) who had symptomatic hypertrophic obstructive cardiomyopathy despite optimum medical treatment. The procedure was successful in 32 (i.e., the reduction in left ventricular outflow tract pressure gradient, or LVOTPG, was >50%). During clinical and echocardiographic follow-up, New York Heart Association (NYHA) functional class and LVOTPG were monitored. Results. The patients' mean age was 63 (12) years. The mean follow-up period was 9 (3) months. Immediately after septal ablation, LVOTPG decreased significantly, from 74.2 (25.3) mm Hg to 26 (25) mm Hg (P<.001), and remained low throughout follow-up. Moreover, echocardiography showed that the interventricular septum thickness also decreased during follow-up, from 19 (3) mm to 15 (2) mm (P<.0001). A significant improvement in NYHA functional class (from 93% in class III-IV to 84% in class I-II) was also observed. Two deaths occurred within 48 hours after the procedure. The most frequent complication was complete heart block (20%; n=6). Conclusions. Alcohol septal ablation is effective in patients with hypertrophic obstructive cardiomyopathy who remain symptomatic despite medical treatment. However, the procedure is associated with a significant rate of complications and should, therefore, be reserved for selected patients, in particular for elderly patients and those with comorbid conditions.
Aims Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of a... more Aims Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD in old patients (>65 years of age) remain unknown. Methods and results The Spanish multicentre prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. Data were collected between June 2015 and April 2019. All angiograms were analysed in a centralized corelab. For the purposes of this study, patients were classified according to age in two groups <65 and ≥65 years old and in-hospital outcomes were analysed. Fifty-five patients (17%) were ≥65 years old (95% women). Older patients had more often hypertension (76% vs. 29%, P < 0.01) and dyslipidaemia (56% vs. 30%, P < 0.01), and less previous (4% vs. 18%, P < 0.001) or current smoking habit (4% vs. 33%, P < 0.001). An identifiable trigger was less often present in old patients (27% vs. 43%, P = 0.0...
Transcatheter aortic valve implantation (TAVI) is the treatment of choice for severe symptomatic ... more Transcatheter aortic valve implantation (TAVI) is the treatment of choice for severe symptomatic aortic stenosis in inoperable patients, and an alternative treatment for those at high risk. The coexistence of coronary artery disease (CAD) adds morbidity and mortality to the procedure. Prior percutaneous coronary intervention (PCI) has been suggested as safe and related to a better prognosis. However, PCI in the left main coronary artery (LMCA) prior to TAVI has been poorly represented in clinical trials and scarcely reported. Herein are presented three cases of a successful sequential approach by LMCA stenting and TAVI, underlining the importance of clinical and anatomic assessment by a multidisciplinary team. Future studies will be necessary to provide more evidence for this indication.
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