Papers by guillermo bastos fernandez
Revista Espanola De Cardiologia, Jul 1, 2020
Resumen Introduccion y objetivos El objetivo es evaluar el impacto del acceso vascular en las com... more Resumen Introduccion y objetivos El objetivo es evaluar el impacto del acceso vascular en las complicaciones hemorragicas tras una intervencion coronaria percutanea en pacientes con alto riesgo de sangrado (ARS) a los 30 dias y a los 2 anos. Metodos El presente estudio es un subanalisis predefinido del estudio LEADERS FREE, que incluyo a 2.432 pacientes con ARS y en el que el stent farmacoactivo Biolimus A9 resulto superior al stent convencional en seguridad y eficacia. Resultados El acceso radial (AR) se utilizo en 1.454 pacientes (59,8%) y el femoral (AF), en 978 (40,2%), ambos a eleccion del operador. La seguridad y los beneficios del stent farmacoactivo sobre el convencional fueron independientes del acceso vascular. A los 30 dias y a los 2 anos, habian sufrido un sangrado mayor el 2,4 y el 7,5% de los pacientes con AR y el 4,6 y el 10,9% de los pacientes con AF (p = 0,003), la mayoria en ambos grupos (el 2,1 y el 7,0% del de AR; el 3,2 y el 9,4% del de AF) no relacionados con el sitio de acceso vascular. El AR se asocio con una reduccion significativa en las tasas ajustadas de sangrado mayor tanto a 30 dias (HR = 1,98; IC95%, 1,25-3,11; p = 0,003) como a 2 anos de seguimiento (HR = 1,51; IC95%, 1,14-2,01; p = 0,003). Conclusiones Los operadores prefirieron el AR en la mayoria de los pacientes con ARS, lo cual se asocio con una reduccion significativa del sangrado mayor. Asimismo, un numero significativo de sangrados en el seguimiento de esta poblacion son no relacionados con el acceso vascular.
Journal of the American College of Cardiology, Oct 1, 2012
Thrombosis P valueء vents Under 30 Days: n47؍ n3292؍ Confirmed Discontinuation of Thienopyr... more Thrombosis P valueء vents Under 30 Days: n47؍ n3292؍ Confirmed Discontinuation of Thienopyridine 2/65 (3.08%) 54/2794 (1.93%) 0.37 Confirmed Discontinuation of Aspirin 3/65 (4.62%) 59/2789 (2.12%) 0.17 Confirmed Discontinuation of Thienopyridine or Aspirin 5/65 (7.69%) 106/2795 (3.79%) 0.11 Confirmed Discontinuation on Both Aspirin and Thienopyridine 0/60 (0%) 7/2696 (0.26%) 1 Events From 30 Days to 6 months: n51؍ n8092؍ Confirmed Discontinuation of Thienopyridine 5/13 (38.5%) 204/2704 (7.54%) 0.002 Confirmed Discontinuation of Aspirin 5/13 (38.5%) 65/2701 (2.41%) Ͻ0.0001 Confirmed Discontinuation of Thienopyridine or Aspirin 7/13 (53.8%) 250/2704 (9.25%) 0.0001 Confirmed Discontinuation on Both Aspirin and Thienopyridine 3/9 (33.3%) 19/2473 (0.77%) Ͻ0.0001
Jacc-cardiovascular Interventions, Oct 1, 2021
OBJECTIVES This study sought to evaluate the safety, feasibility, and outcomes of transcatheter p... more OBJECTIVES This study sought to evaluate the safety, feasibility, and outcomes of transcatheter pulmonary valve replacement (TPVR) in conduits #16 mm in diameter. BACKGROUND The Melody valve (Medtronic, Minneapolis, Minnesota) is approved for the treatment of dysfunctional right ventricular outflow tract (RVOT) conduits $16 mm in diameter at the time of implant. Limited data are available regarding the use of this device in smaller conduits. METHODS The study retrospectively evaluated patients from 9 centers who underwent percutaneous TPVR into a conduit that was #16 mm in diameter at the time of implant, and reported procedural characteristics and outcomes. RESULTS A total of 140 patients were included and 117 patients (78%; median age and weight 11 years of age and 35 kg, respectively) underwent successful TPVR. The median original conduit diameter was 15 (range: 9 to 16) mm, and the median narrowest conduit diameter was 11 (range: 4 to 23) mm. Conduits were enlarged to a median diameter of 19 mm (29% larger than the implanted diameter), with no difference between conduits. There was significant hemodynamic improvement post-implant, with a residual peak RVOT pressure gradient of 7 mm Hg (p < 0.001) and no significant pulmonary regurgitation. During a median follow-up of 2.0 years, freedom from RVOT reintervention was 97% and 89% at 2 and 4 years, respectively, and there were no deaths and 5 cases of endocarditis (incidence rate 2.0% per patient-year). CONCLUSIONS In this preliminary experience, TPVR with the Melody valve into expandable small diameter conduits was feasible and safe, with favorable early and long-term procedural and hemodynamic outcomes.
Jacc-cardiovascular Interventions, 2019
OBJECTIVES The REAC-TAVI (Assessment of platelet REACtivity after Transcatheter Aortic Valve Impl... more OBJECTIVES The REAC-TAVI (Assessment of platelet REACtivity after Transcatheter Aortic Valve Implantation) trial enrolled patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) pre-treated with aspirin þ clopidogrel, aimed to compare the efficacy of clopidogrel and ticagrelor in suppressing high platelet reactivity (HPR) after TAVI. BACKGROUND Current recommendations support short-term use of aspirin þ clopidogrel for patients with severe AS undergoing TAVR despite the lack of compelling evidence. METHODS This was a prospective, randomized, multicenter investigation. Platelet reactivity was measured at 6 different time points with the VerifyNow assay (Accriva Diagnostics, San Diego, California). HPR was defined as (P2Y 12 reaction units (PRU) $208. Patients with HPR before TAVR were randomized to either aspirin þ ticagrelor or aspirin þ clopidogrel for 3 months. Patients without HPR continued with aspirin þ clopidogrel (registry cohort). The primary endpoint was non-HPR status (PRU <208) in $70% of patients treated with ticagrelor at 90 days post-TAVR. RESULTS A total of 68 patients were included. Of these, 48 (71%) had HPR (PRU 273 AE 09) and were randomized to aspirin þ ticagrelor (n ¼ 24, PRU 277 AE 08) or continued with aspirin þ clopidogrel (n ¼ 24, PRU 269 AE 49). The remaining 20 patients (29%) without HPR (PRU 133 AE 12) were included in the registry. Overall, platelet reactivity across all the study time points after TAVR was lower in patients randomized to ticagrelor compared with those treated with clopidogrel, including those enrolled in the registry (p < 0.001). The primary endpoint was achieved in 100% of patients with ticagrelor compared with 21% with clopidogrel (p < 0.001). Interestingly, 33% of clopidogrel responder patients at baseline developed HPR status during the first month after TAVR. CONCLUSIONS HPR to clopidogrel is present in a considerable number of patients with AS undergoing TAVR. Ticagrelor achieves a better and faster effect, providing sustained suppression of HPR to these patients.
PubMed, Apr 1, 2017
A 73-year-old man was admitted for non-ST segment elevation acute myocardial infarction. Coronary... more A 73-year-old man was admitted for non-ST segment elevation acute myocardial infarction. Coronary angiography suggested intrastent thrombosis as the etiology, but optical coherence tomography revealed a non-expanded stent, which was successfuly crushed and covered with a new stent.
Journal of the American College of Cardiology, Oct 1, 2017
Journal of the American College of Cardiology, Nov 1, 2016
Journal of the American College of Cardiology, Nov 1, 2016
BACKGROUND Transradial access (TRA) has been associated with reduced complication and mortality r... more BACKGROUND Transradial access (TRA) has been associated with reduced complication and mortality rate while the crossover rate and procedural time were increased in comparison with traditional transfemoral access (TFA). The differences are particularly significant for STEMI interventions. There is open question regarding usage of the rest wrist arteries for access (ulnar and contra lateral radial) rather than femoral. METHODS During four years from 2010 to 2013, in our Center 2624 consecutive all-comers STEMI patients underwent coronary intervention. TRA was used as first choice access strategy. We sought to assess crossover rate and safety of preferable access strategy. Crossover occurred according to operator's decision. Primary outcomes were: access site crossover rate and In Lab time, secondary outcomes were PCI time, X ray time, mortality and major adverse cardiovascular events rates (MACE: death, re infarction, stroke target vessel revascularization) at 30 days and 6 months. RESULTS Overall crossover rate from default radial was 5.4 % (144 out of 2624 patients). We treated 98.7 % (2589) patients by wrist access and only 1.3 % (35) patients with TFA. Crossover towards left radial occurred in 47.9 % (69 out of 144 patients), towards ulnar 27.8 % (40 patients) and towards TFA only 24.3 % (35 patients). Mean in Lab time 40.4 AE 17.7 minutes PCI time was 21.4 AE7.4 min. X ray time 9.2 AE 4.7 minutes. Survival outcomes at 30 days were: MACE rate of 6.6% (174 patients), mortality rate of 5.0% (131 patients). At six months MACE rate was 8.6% and mortality rate was 5.6%.
Journal of the American College of Cardiology, Oct 1, 2012
Background: Very late stent thrombosis (VLST) after bare-metal stent (BMS) implantation is a rare... more Background: Very late stent thrombosis (VLST) after bare-metal stent (BMS) implantation is a rare complication. There is emerging evidence suggesting that in-stent neoatherosclerosis may play a role, but data on clinical characteristics and prognosis of patients (p) are limited. The aim of this study was to evaluate the profile and outcome of VLST after BMS implantation treated with percutaneous coronary intervention (PCI). Methods: From January 2006 to May 2012 a total of 9,582 PCI were performed at our center. During this period we identified and retrospectively analyzed 30 consecutive p with angiographically confirmed VLST related to BMS. Minimum follow-up period of 1 year and 2 years was available in 25/30 and 23/30 p, respectively. Results: Mean age of p was 60Ϯ13 years, 93% were male, 53% active smokers, 20% diabetics, 77% had hyperlipidemia and 67% hypertension. Clinical presentation of VLST after BMS was ST-segment elevation myocardial infarction (STEMI) in 27 cases, and 3 p (10%) had non-STEMI. Right coronary artery was the most common location of VLST (57%). Median period from BMS implantation to VLST was 7.9 years (interquartile range, 6.0-9.9 years) and most of the p (70%) were receiving oral antiplatelet therapy at the time of VLST (67% aspirin alone, 3% dual antiplatelet). All p with VLST after BMS underwent successful PCI. Effective thrombus aspiration was achieved in 67% of p and a new stent was deployed in 83% of p (14 DES, 11 BMS). A significant deterioration of LVEF occurred in p with VLST related to BMS (64Ϯ6% to 50Ϯ9%; pϽ0.001). Major adverse cardiac events (cardiovascular death or myocardial infarction) rates were 7%, 20%, and 39% at 30 days, 1-year and 2-year follow-up, respectively. During the 2-year follow-up period 3 p died and 6 p had a non-fatal myocardial infarction (recurrent stent thrombosis in 3 p and myocardial infarction not related to prior VLST in 3 p). Conclusions: VLST after BMS implantation is an uncommon phenomenon, mainly presented as STEMI, and its treatment with a new PCI is feasible and effective. Nevertheless new major adverse cardiac events may occur in this group of p at short-and mid-term follow-up, related to both prior VLST and coronary disease progression.
Revista española de cardiología, Jul 1, 2020
INTRODUCTION AND OBJECTIVES The prognostic impact of bleeding in high bleeding risk (HBR) patient... more INTRODUCTION AND OBJECTIVES The prognostic impact of bleeding in high bleeding risk (HBR) patients depending on the location of bleeding and prognosis in nonaccess site bleeding is unknown. We aimed to assess the impact of vascular access site on bleeding complications after percutaneous coronary interventions for HBR patients at 30-day and 2-year follow-up. METHODS The LEADERS FREE trial included 2432 HBR PCI patients. A Biolimus A9 drug-coated stent was superior to a bare-metal stent for safety and efficacy. This is a predefined sub-analysis of the LEADERS FREE trial. RESULTS Transradial access (TRA) was used in 1454 patients (59.8%) and transfemoral access (TFA) in 978 (40.2%), according to operator preference. The safety and benefits of drug-coated stents over bare-metal stents were independent of vascular access. At 30 days and 2 years, major bleeding had occurred in 2.4% and 7.5% of TRA patients and 4.6% and 10.9% of TFA patients (P=.003), respectively. Most of these events in both groups (2.1% and 7.0% for TRA; 3.2% and 9.4% for TFA, respectively) were nonaccess site-related. TRA was associated with a significant reduction in adjusted rates of major bleeding both at 30 days (HR, 1.98; 95%CI, 1.25-3.11; P=.003) and at 2 years of follow-up (HR, 1.51; 95%CI, 1.14-2.01; P=.003). This difference was driven by both access and nonaccess bleeding. CONCLUSIONS Operators preferred TRA for most HBR patients, which was associated with a significant reduction in major bleeding events. However, most of these events in this population are unrelated to vascular access.
Frontiers in Cardiovascular Medicine
Since its conception, transcatheter aortic valve implantation (TAVI) has undergone important impr... more Since its conception, transcatheter aortic valve implantation (TAVI) has undergone important improvements both in the implantation technique and in transcatheter devices, allowing an enthusiastic adoption of this therapeutic approach in a wide population of patients previously without a surgical option and managed conservatively. Nowadays, patients with severe symptomatic aortic stenosis are typically managed with TAVI, regardless of their risk to surgery, improving the prognosis of patients and thus achieving an exponential global expansion of its use. However, thromboembolic and hemorrhagic complications remain a latent concern in TAVI recipients. Both complications can appear simultaneously in the periprocedural period or during the follow-up, and when minor, they resolved without apparent sequelae, but in a relevant percentage of cases, they are devastating, overshadowing the benefit achieved with TAVI. Our review outlines the etiology and incidence of thromboembolic complicatio...
Coronary Artery Disease, 2011
European Heart Journal, 2020
European Heart Journal, 2013
Background: The aim of the study is to explore the influence of end-procedural ischemia (detected... more Background: The aim of the study is to explore the influence of end-procedural ischemia (detected with intracoronary electrocardiography (icECG)) and occlusion of secondary side branches arising in the reigion of coronary bifurcation stenosis (but not assessed as significant side branches) on revascularization rates (TLR) and cumulative MACE (death, myocardial infarction, TLR, rehospitalization) rates at 9-12 months after PCI. Methods: After placement of intracoronary guidewires in main branch (MB) and side branch (SB) an uninsulated proximal ends of wires were connected to unipolar V leads. Intracoronary unipolar ECGs (icECG) were recorded before, during and after stent placement and at the end of procedure. The maximal ST-segment elevation during intervention and 5 min after the procedure was recorded in SB and MB. At the end, the coronary wire was placed in every distal vessels with reference caliber >1.0mm, as well as in MB just below the stent, "mapping" the zones for ischemia presence and distribution. Provisional T-stenting was a default strategy. Results: The patient population consists from 91 patients with stable/unstable angina: 72% were males, mean age 66±8, diabetics 34%; 43% had previous myocardial infarction, 41% previous PCI and 58% had multivessel disease. The main treated vessel was LAD (72%). True bifurcation lesions (Medina xx1) were 51%. The maximal ST-segment elevation on icECG () was 12±9 mm in MB and 8±7 mm in SB (p=0.044). At the end of the procedure the distribution of icECG changes was as follows: 23% SB only, 21% MB only, 27% in both, 12% ST depression in SB or MB, 1.5% with SB ST-depression and MB STelevation, 1.5% with ST-depression in both branches. Changes on icECG have 78% sensitivity, 97% specificity for detection of post-procedural troponin elevation. At 10±4 months follow-up there were 6 (6.5%) TLR and 14 (15.3%) MACEs. The rate of small branch occlusion was 33% in group with TLR vs. 4.8% in group without (p<0.001). The only independent predictor of MACE on multivariate analysis is i.c. ECG ST changes at the end of PCI or occlusion of secondary branch: OR 2.606, CI 1.127-5.878, p=0.016. Conclusion: The end-PCI intracoronary ECG ST-segment changes combined with occurrence of secondary branch occlusion could predict future adverse events after single stenting of coronary bifurcation lesions.
Journal of the American College of Cardiology, 2012
The Journal of invasive cardiology, 2020
OBJECTIVES Ticagrelor has proven more effective than clopidogrel at attaining a maintained suppre... more OBJECTIVES Ticagrelor has proven more effective than clopidogrel at attaining a maintained suppression of high platelet reactivity (HPR) in aortic stenosis patients undergoing transcatheter aortic valve implantation (TAVI). This study aims to assess the influence of implanted valve type on the degree of platelet reactivity (PR) after TAVI. METHODS This study is a prespecified analysis of REAC-TAVI, a prospective, multicenter study that included patients on dual-antiplatelet therapy with aspirin and clopidogrel before TAVI. Patients with HPR (n = 48) were randomized to aspirin and clopidogrel or aspirin and ticagrelor for 3 months, while those without HPR (n = 20) were continued on aspirin and clopidogrel. PR was measured 6 hours, 24 hours, 5 days, 30 days, and 90 days after TAVI with VerifyNow assay. Bioprosthetic valves were classified as balloon-expandable valve (BEV), self-expandable valve (SEV), or other. RESULTS Sixty-eight patients comprising 32 BEVs, 28 SEVs, and 8 other valv...
Journal of the American College of Cardiology, 2014
(TF) access site groups. Secondary endpoints were major adverse cardiovascular events (MACE), ste... more (TF) access site groups. Secondary endpoints were major adverse cardiovascular events (MACE), stent thrombosis and major and minor bleedings. Results: The database included 1330 patients, 836 treated with a TR and 494 with a TF approach. After a propensity matched analysis performed to exclude possible confounders we identified 450 matched patients (225 TR and 225 TF). The incidence of AKI in the 2 matched groups was lower in patients treated with TR primary PCI (8.4% vs. 16.9%, p¼0.007). MACE and stent thrombosis were not different among study groups, whereas major bleedings were more often seen in the TF group. At multivariate analysis, femoral access was an independent predictor of AKI (OR 1.559, 95% CI 1.015-2.394, p¼0.042).
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Papers by guillermo bastos fernandez