01 octubre 2013

JACC. Predictive Factors, Management, and Clinical Outcomes of Coronary Obstruction Following Transcatheter Aortic Valve Implantation. Insights From a Large Multicenter Registry

Henrique B. Ribeiro, MD∗; John G. Webb, MD†; Raj R. Makkar, MD‡; Mauricio G. Cohen, MD§; Samir R. Kapadia, MD‖; Susheel Kodali, MD¶; Corrado Tamburino, MD#; Marco Barbanti, MD†; Tarun Chakravarty, MD‡; Hasan Jilaihawi, MD‡; Jean-Michel Paradis, MD¶; Fabio S. de Brito, MD∗∗; Sergio J. Cánovas, MD††; Asim N. Cheema, MD‡‡; Peter P. de Jaegere, MD§§; Raquel del Valle, MD‖‖; Paul T.L. Chiam, MD¶¶; Raúl Moreno, MD##; Gonzalo Pradas, MD∗∗∗; Marc Ruel, MD†††; Jorge Salgado-Fernández, MD‡‡‡; Rogerio Sarmento-Leite, MD§§§; Hadi D. Toeg, MD†††; James L. Velianou, MD‖‖‖; Alan Zajarias, MD¶¶¶; Vasilis Babaliaros, MD###; Fernando Cura, MD∗∗∗∗; Antonio E. Dager, MD††††; Ganesh Manoharan, MD‡‡‡‡; Stamatios Lerakis, MD###; Augusto D. Pichard, MD§§§§; Sam Radhakrishnan, MD‖‖‖‖; Marco Antonio Perin, MD∗∗; Eric Dumont, MD∗; Eric Larose, MD∗; Sergio G. Pasian, MD∗; Luis Nombela-Franco, MD∗; Marina Urena, MD∗; E. Murat Tuzcu, MD‖; Martin B. Leon, MD¶; Ignacio J. Amat-Santos, MD¶¶¶¶; Jonathon Leipsic, MD†; Josep Rodés-Cabau, MD∗

Objectives: This study sought to evaluate the main baseline and procedural characteristics, management, and clinical outcomes of patients from a large cohort of patients undergoing transcatheter aortic valve implantation (TAVI) who suffered coronary obstruction (CO).

01 octubre 2013

JACC. Consideration of a New Definition of Clinically Relevant Myocardial Infarction After Coronary Revascularization. An Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions (SCAI)

Issam D. Moussa, MD∗; Lloyd W. Klein, MD†; Binita Shah, MD‡; Roxana Mehran, MD§; Michael J. Mack, MD‖; Emmanouil S. Brilakis, MD¶; John P. Reilly, MD#; Gilbert Zoghbi, MD∗∗; Elizabeth Holper, MD††; Gregg W. Stone, MD‡‡

Numerous definitions have been proposed for the diagnosis of myocardial infarction (MI) after coronary revascularization. The universal definition for MI designates post procedural biomarker thresholds for defining percutaneous coronary intervention (PCI)-related MI (type 4a) and coronary artery bypass grafting (CABG)-related MI (type 5), which are of uncertain prognostic importance. In addition, for both the MI types, cTn is recommended as the biomarker of choice, the prognostic significance of which is less well validated than CK-MB. Widespread adoption of a MI definition not clearly linked to subsequent adverse events such as mortality or heart failure may have serious consequences for the appropriate assessment of devices and therapies, may affect clinical care pathways, and may result in misinterpretation of physician competence. Rather than using an MI definition sensitive for small degrees of myonecrosis (the occurrence of which, based on contemporary large-scale studies, are unlikely to have important clinical consequences), it is instead recommended that a threshold level of biomarker elevation which has been strongly linked to subsequent adverse events in clinical studies be used to define a “clinically relevant MI.” The present document introduces a new definition for “clinically relevant MI” after coronary revascularization (PCI or CABG), which is applicable for use in clinical trials, patient care, and quality outcomes assessment.

01 octubre 2013

JACC. Outcomes After Complete Versus Incomplete Revascularization of Patients With Multivessel Coronary Artery Disease. A Meta-Analysis of 89,883 Patients Enrolled in Randomized Clinical Trials and Observational Studies

Santiago Garcia, MD∗; Yader Sandoval, MD‡; Henri Roukoz, MD, MS†; Selcuk Adabag, MD, MS∗; Mariana Canoniero, MD§; Demetris Yannopoulos, MD†; Emmanouil S. Brilakis, MD, PhD||

Objectives: This study sought to perform a systematic review and meta-analysis of studies comparing complete revascularization (CR) versus incomplete revascularization (IR) in patients with multivessel coronary artery disease.

01 octubre 2013

JACC. Computed Tomography Angiography and Myocardial Computed Tomography Perfusion in Patients With Coronary Stents

Matthias Rief, MD∗; Elke Zimmermann, MD∗; Fabian Stenzel, MD∗; Peter Martus, PhD†; Karl Stangl, MD‡; Johannes Greupner, MD∗; Fabian Knebel, MD‡; Anisha Kranz, MS∗; Peter Schlattmann, PhD§; Michael Laule, MD‡; Marc Dewey, MD∗

Objectives: This study sought to determine whether adding myocardial computed tomography perfusion (CTP) to computed tomography angiography (CTA) improves diagnostic performance for coronary stents.

01 octubre 2013

JACC. Computed Tomography Perfusion to Assess Physiological Significance of Coronary Stenosis in the Post-FAME Era (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation)

Andrew E. Arai, MD

Goldstein et al. 1 documented that it takes a severe coronary stenosis before myocardial perfusion is compromised. Both invasive and noninvasive cardiologists should consider a few lessons from the FAME (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) studies and other contemporary analyses. First, it is safer and better to manage a coronary stenosis based on physiological significance than angiographic severity, at least as determined by fractional flow reserve (FFR) (2). Second, when compared with optimal medical therapy, stenting reduces major adverse cardiac events when FFR is used to determine the physiological significance of stenoses (3). Third, too many patients underwent invasive coronary for stable angina without prior stress testing in the United States in 2004 4. Fourth, our most commonly selected stress tests (electrocardiography, single-photon emission computed tomography, and echocardiography) do not localize ischemia and do not quantify the severity of ischemia in a way that looks interchangeable with the invasive FFR stress test of specific coronary stenoses. This probably contributes to why interventional cardiologists have relied so heavily on severity of coronary stenosis for many years and have now developed FFR as their reference standard. However, if FFR is the new reference standard, one can expect that noninvasive imaging should be able to assess the physiological significance of stenosis and may someday replace invasive FFR.

01 octubre 2013

JACC. Role of Aspiration and Mechanical Thrombectomy in Patients With Acute Myocardial Infarction Undergoing Primary Angioplasty

Dharam J. Kumbhani, MD, SM∗; Anthony A. Bavry, MD, MPH†; Milind Y. Desai, MD‡; Sripal Bangalore, MD, MHA§; Deepak L. Bhatt, MD, MPH‖

Objectives: This meta-analysis was designed to update data on clinical outcomes with aspiration thrombectomy or mechanical thrombectomy before primary percutaneous coronary intervention (PCI) compared with conventional primary PCI alone.

09 diciembre 2014

CIRCULATION. Coronary Computed Tomographic Angiography. Its Role in Emergency Department Triage

Michael K. Cheezum, MD; Ron Blankstein, MD

Case presentation: A 55-year-old man presents to the emergency department (ED) after an episode of substernal chest discomfort that lasted 2 hours. His pain occurred at rest and was not positional, pleuritic, or postprandial. He has a history of hypertension and no known coronary artery disease (CAD). Vital signs and physical examination are unremarkable. His initial ECG, troponin, and serum creatinine are normal. How should this patient be evaluated?

30 septiembre 2013

CIRCULATION. Management and Outcomes of Major Bleeding During Treatment With Dabigatran or Warfarin

Ammar Majeed, MD; Hun-Gyu Hwang, MD; Stuart J. Connolly, MD; John W. Eikelboom, MD; Michael D. Ezekowitz, MD, ChB, Dphil; Lars Wallentin, MD, PhD; Martina Brueckmann, MD; Mandy Fraessdorf, PhD; Salim Yusuf, MD, Dphil; Sam Schulman, MD, PhD

Background: The aim of this study was to compare the management and prognosis of major bleeding in patients treated with dabigatran or warfarin.

02 octubre 2013

CIRCULATION. Interplay Between Mitral Regurgitation and Transcatheter Aortic Valve Replacement With the CoreValve Revalving System

Francesco Bedogni, MD; Azeem Latib, MD; Federico De Marco, MD; Mauro Agnifili, MD; Jacopo Oreglia, MD; Samuele Pizzocri, MD; Roberto A. Latini, MD; Stefania Lanotte, MD; Anna Sonia Petronio, MD; Marco De Carlo, MD; Federica Ettori, MD; Claudia Fiorina, MD; Arnaldo Poli, MD; Silvia Cirri, MD; Stefano De Servi, MD; Angelo Ramondo, MD; Giuseppe Tarantini, MD; Antonio Marzocchi, MD; Rosario Fiorilli, MD; Silvio Klugmann; Gian Paolo Ussia, MD; Corrado Tamburino, MD; Francesco Maisano, MD; Nedy Brambilla, MD; Antonio Colombo, MD; Luca Testa, MD, PhD

Background: Little is known of the prognostic significance of mitral regurgitation (MR) on transcatheter aortic valve replacement (TAVR), the impact of TAVR on MR severity, and the variables associated with possible post-TAVR improvement in MR. We evaluated these issues in a multicenter registry of patients undergoing CoreValve Revalving System–TAVR.

02 octubre 2013

CIRCULATION. Mitral Regurgitation in Transcatheter Aortic Valve Replacement. The Complexity of Multivalvular Disease

Alexandra Gonçalves, MD, PhD; Scott D. Solomon, MD

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative treatment for patients with symptomatic aortic stenosis (AS) who are at an unacceptably high risk for conventional surgical aortic valve replacement (AVR).1,2 Approximately 60 000 patients worldwide have undergone TAVR in the 11 years since it was introduced.3 Although good procedural success and favorable clinical outcomes have been reported,4,5 issues remain regarding the best patient selection for the procedure. Risk calculators commonly used to estimate the risk of valvular surgery, such as the logistic EuroSCORE and the Society of Thoracic Surgeons model, are not considered accurate in patients undergoing TAVR because they do not account for all clinical characteristics that may significantly affect procedural and postprocedural mortality. The current selection criteria are based on those used in randomized trials, and, in conjunction with the clinical evaluation, echocardiography is a mainstay in the assessment of candidates for this procedure. Beyond the clinical and anatomic exclusion criteria, severe pulmonary hypertension with right ventricular dysfunction, very severe left ventricular (LV) systolic dysfunction (ejection fraction <20%), and severe mitral regurgitation (MR) are among the echocardiographic exclusions.6 Moreover, each of the commercially available prosthesis manufacturers presents its own recommendations for the procedure, with the CoreValve being more restrictive with respect to concomitant valvular disease.

25 septiembre 2013

CIRCULATION. Postconditioning During Percutaneous Coronary Intervention in Acute Myocardial Infarction

Warren K. Laskey, MD, MPH; Alex Schevchuck, MD

“Delaying the postconditioning intervention for even a few minutes while changing balloon catheters, or while allowing balloons to remain deflated beyond the period of time suggested by the algorithm, may abrogate the cardioprotective advantage of postconditioning,” from Kin et al

11 septiembre 2013

CIRCULATION. Health Services and Outcomes Research- Risk of Lower and Upper Gastrointestinal Bleeding, Transfusions, and Hospitalizations With Complex Antithrombotic Therapy in Elderly Patients

Neena S. Abraham, MD, MSCE; Christine Hartman, PhD; Peter Richardson, PhD; Diana Castillo, BA; Richard L. Street Jr, PhD; Aanand D. Naik, MD

Background: Complex antithrombotic therapy (CAT) prescribed to elderly patients increases the risk of gastrointestinal bleeding. We quantified upper (UGIE) and lower gastrointestinal (LGIE) events, transfusions, and hospitalizations in a national cohort of elderly veterans prescribed CAT.

25 septiembre 2013

CIRCULATION. Interventional Cardiology. Ischemic Postconditioning During Primary Percutaneous Coronary Intervention

Joo-Yong Hahn, MD*; Young Bin Song, MD*; Eun Kyoung Kim, MD; Cheol Woong Yu, MD; Jang-Whan Bae, MD; Woo-Young Chung, MD; Seung-Hyuk Choi, MD; Jin-Ho Choi, MD; Jang-Ho Bae, MD; Kyung Joo An, MD; Jong-Seon Park, MD; Ju Hyeon Oh, MD; Sang-Wook Kim, MD; Jin-Yong Hwang, MD; Jae Kean Ryu, MD; Hun Sik Park, MD; Do-Sun Lim, MD; Hyeon-Cheol Gwon, MD

Background: Ischemic postconditioning has been reported to reduce infarct size in patients with ST-segment–elevation myocardial infarction. However, cardioprotective effects of postconditioning have not been demonstrated in a large-scale trial.

18 septiembre 2013

CIRCULATION. Paradoxical Low-Flow, Low-Gradient Aortic Stenosis. New Evidence, More Questions

Philippe Pibarot, DVM, PhD, FAHA; Jean G. Dumesnil, MD, FRCP(C)

In the American Heart Association/American College of Cardiology and European Society of Cardiology/European Association of Cardiothoracic Surgery guidelines,1,2 severe aortic stenosis (AS) is defined as a peak aortic jet velocity >4.0 m/s, a mean gradient >40 mm Hg, or an aortic valve area (AVA) <1.0 cm2, and it is considered a Class I indication for aortic valve replacement (AVR) if the patient has symptoms or left ventricular (LV) systolic dysfunction defined as LV ejection fraction (LVEF) <50%. However, the cardiologist is often confronted with patients with discordant echocardiographic findings, the most frequent being the combination of a small calculated AVA (<1.0 cm2) consistent with the presence of severe AS with a low mean gradient (<40 mm Hg), suggesting the presence of moderate AS. This type of discordance may raise uncertainty about the actual severity of the AS and thus about the therapeutic management, particularly if the patient is symptomatic. Such AVA-gradient discordance is often related to the presence of low LV outflow, which may, even if modest, lead to an important reduction in gradient and thus to underestimation of AS severity. A low-flow state is generally defined as a stroke volume index <35 mL/m2, and it may occur not only in patients with reduced LVEF (i.e., classical low-flow) but also in those with preserved LVEF.3 This latter entity was first described in 2007 by Hachicha et al4 and was named “paradoxical” low-flow AS. Subsequently, Dumesnil et al5 proposed a new classification whereby patients with a priori severe AS on the basis of AVA and a preserved LVEF (i.e., >50%) are separated into 4 groups according to flow (stroke volume index <35 or ≥35 mL/m2) and gradient (<40 or ≥40 mm Hg) as follows: (1) normal-flow, high-gradient; (2) normal-flow, low-gradient (NF/LG); (3) low-flow, high-gradient; and (4) low-flow, low-gradient (LF/LG). In this issue of Circulation, Eleid et al6 report the characteristics, outcomes, and impact of therapy in a large series of 1704 patients stratified according to this classification. The main findings of this elegant study include the following. (1) Among patients with AVA <1.0 cm2 and LVEF ≥50%, those with LF/LG have lower survival compared with patients with the other flow/gradient patterns, but, nevertheless, the outcome of these patients is markedly improved by AVR. (2) Patients with NF/LG have favourable survival with medical management, and the effect of AVR on their outcome is neutral, thereby suggesting that these patients are likely at a less advanced stage of their disease than patients with other flow/gradient patterns.

18 septiembre 2013

CIRCULATION. Valvular Heart Disease. Flow-Gradient Patterns in Severe Aortic Stenosis With Preserved Ejection Fraction

Mackram F. Eleid, MD; Paul Sorajja, MD; Hector I. Michelena, MD; Joseph F. Malouf, MD; Christopher G. Scott, MS; Patricia A. Pellikka, MD

Background: Among patients with severe aortic stenosis (AS) and preserved ejection fraction, those with low gradient (LG) and reduced stroke volume may have an adverse prognosis. We investigated the prognostic impact of stroke volume using the recently proposed flow-gradient classification