05 febrero 2013

CIRCULATION: CARDIOVASCULAR INTERVENTIONS. Structural Heart Disease. Atrial Fibrillation and Aortic Stenosis. Impact on Clinical Outcomes Among Patients Undergoing Transcatheter Aortic Valve Implantation

Stefan Stortecky, MD*, Lutz Buellesfeld, MD*, Peter Wenaweser, MD, Dik Heg, PhD, Thomas Pilgrim, MD, Ahmed A. Khattab, MD, Steffen Gloekler, MD, Christoph Huber, MD, Fabian Nietlispach, MD, Bernhard Meier, MD, Peter Jüni, MD and Stephan Windecker, MD

Background: Atrial fibrillation (AF) is an important risk factor for stroke and is common among elderly patients undergoing transcatheter aortic valve implantation. The aim of this study was to assess the impact of AF on clinical outcomes among patients undergoing transcatheter aortic valve implantation.

22 enero 2013

CIRCULATION: CARDIOVASCULAR INTERVENTIONS. Structural Heart Disease. Efficacy and Safety of Postdilatation to Reduce Paravalvular Regurgitation During Balloon-Expandable Transcatheter Aortic Valve Replacement

Benoit Daneault, MD, Elana Koss, MD, Rebecca T. Hahn, MD, Susheel Kodali, MD, Mathew R. Williams, MD, Philippe Généreux, MD, Jean-Michel Paradis, MD, Isaac George, MD, George R. Reiss, MD, Jeffrey W. Moses, MD, Craig R. Smith, MD and Martin B. Leon, MD

Background: Paravalvular regurgitation (PVR) is common after transcatheter aortic valve replacement (TAVR) and may be associated with adverse outcomes. Postdilatation (PD) has been proposed to treat PVR without being formally studied. We performed a study to evaluate the safety and efficacy of PD after balloon expandable TAVR.

01 febrero 2014

CIRCULATION: CARDIOVASCULAR INTERVENTIONS. Complete Revascularization in Contemporary Practice

Sripal Bangalore, MD, MHA

In patients with acute coronary syndrome (ACS), the pathophysiological process is not limited to a single coronary lesion but involves the entire coronary tree, with 30% to 60% patients presenting with multiple significant coronary lesions, with significant increase in cardiovascular morbidity and mortality in patients with multivessel coronary artery disease.1,2 In the Predictors of Events in the Coronary Tree trial, patients with ACS who underwent percutaneous coronary intervention (PCI), major adverse cardiovascular events occurring during follow-up were equally attributable to recurrence at the site of culprit lesions and to nonculprit lesions, which were frequently angiographically mild.3 In contrast, in the COURAGE trial in patients with stable coronary artery disease (CAD) on optimal medical therapy, the only angiographic predictor of future ACS was the number of lesions originally ≥50% that had not been revascularized.4 The above studies attest to the importance of both angiographically significant lesions as well as angiographically mild lesions on future events. These studies highlight the importance of a multipronged approach with the use of evidence-based aggressive medical management (to prevent progression of angiographically mild and also significant CAD), as well as judicious use of optimal revascularization strategies. Several surgical studies have shown that incomplete revascularization in patients undergoing coronary artery bypass graft surgery has worse prognosis with higher mortality, myocardial infarction (MI), and more angina.5–7 As a result, complete anatomic revascularization has become the standard of treatment for coronary artery bypass graft surgery. The concept has been adapted by interventionalist to patients undergoing PCI with several studies (nonrandomized), including an analysis from the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial8 showing substantial increase in cardiovascular events with incomplete revascularization. Similarly, in the Acute Catheterization and Urgent Intervention Triage Strategy trial of patients with nonST-segment elevation ACS, incomplete revascularization was associated with increased risk of major adverse cardiac events, MI, and numerically higher mortality when compared with patients with complete revascularization.9 In many of the above observational studies, patients who underwent incomplete revascularization were in a higher-risk group with lesions less amenable to PCI, and it is difficult to rule out the effect of baseline confounding on worse outcomes in this cohort. Moreover, recent data from surgical registries seem to suggest that a strategy of reasonably incomplete revascularization may be acceptable.10 Similarly, in the DEFER trial, patients with intermediate stenosis without functionally significant lesion (as measured by fractional flow reserve [FFR]), randomized to deferral of PCI had similar outcomes at 5 years, when compared with the patients randomized to the performance of PCI.11 These and other results therefore seem to suggest that complete anatomic revascularization may not be a necessity.

25 febrero 2014

CIRCULATION. Images in Cardiovascular Medicine. Traumatic Coronary Artery Dissection. Potential Cause of Sudden Death in Soccer.

Nicolas M. Van Mieghem, MD; Sander van Weenen, BSc; Gijs Nollen, MD; Jurgen Ligthart, BSc; Evelyn Regar, MD, PhD; Robert-Jan van Geuns, MD, PhD

A 33-year-old male soccer player started to experience chest discomfort briefly after taking a blow from an opponent’s knee into his chest during a dribbling maneuver on the pitch. He completed the game but then consulted a referring hospital because of waxing and waning chest complaints irradiating to his left arm. The ECG demonstrated ST-T–segment changes compatible with inferoposterior ischemia (Figure 1). Cardiac enzyme markers were elevated. Echocardiography confirmed inferior wall hypokinesis. The patient was loaded with aspirin and clopidogrel. He subsequently underwent transradial invasive coronary angiography, which demonstrated Thrombolysis In Myocardial Infarction (TIMI) 2 flow in the right coronary artery and a dissection-suspect lesion in its proximal segment (online-only Data Supplement Movie I and Figure 2). Invasive imaging of the right coronary artery by means of optical coherence tomography confirmed mild atherosclerotic disease and unequivocally pointed toward dissection in the proximal segment surrounded by significant thrombus burden (Figure 3 and online-only Data Supplement Movie II). It is noteworthy that the size of the right coronary artery exceeded 5 mm in diameter.

25 febrero 2014

CIRCULATION. New Drugs and Technologies. Paravalvular Aortic Leak After Transcatheter Aortic Valve Replacement

Stamatios Lerakis, MD; Salim S. Hayek, MD; Pamela S. Douglas, MD

Transcatheter aortic valve replacement (TAVR) is now well-established as the standard of care for patients with severe symptomatic aortic stenosis who are deemed inoperable,1 and is seen as an alternative treatment option to surgical aortic valve replacement (SAVR) in a subset of patients with high postoperative mortality.2 The native valve is typically not removed but instead crushed by the superimposed bioprosthesis, which can result in an incomplete seal of the bioprosthetic valve and aortic annulus, with subsequent occurrence of paravalvular leak (PVL). Two types of Transcatheter Heart Valves (THV) that have been widely used, the balloon-expandable Edwards valve (Cribier-Edwards, Edwards SAPIEN and Edwards SAPIEN XT) by Edwards Lifesciences, and the self-expandable CoreValve by Medtronic, have been described in detail elsewhere.3,4 Despite the evolving technology of transcatheter valves, PVL post-TAVR is common, with a wide range of reported incidences (Table 1). Most importantly, PVL has been associated with increased short- and long-term mortality post-TAVR, and is seen as a barrier to more widespread use of this promising technique.5–13 This article describes the incidence, causes, and predictors of PVL, as well as its impact on clinical outcomes. Methods of prevention, diagnosis, and treatment of PVL are also reviewed.

30 diciembre 2012

CIRCULATION. Interventional Cardiology. The Impact of a Statewide Pre-Hospital STEMI Strategy to Bypass Hospitals Without Percutaneous Coronary Intervention Capability on Treatment Times

Emil L. Fosbol, MD, PhD; Christopher B. Granger, MD; James G. Jollis, MD; Lisa Monk, RN, MSN; Li Lin, MS; Barbara L. Lytle, MS; Ying Xian, MD, PhD; J. Lee Garvey, MD; Greg Mears, MD; Claire C. Corbett, MMS, NREMT-P; Eric D. Peterson, MD, MPH; Seth W. Glickman, MD

Background: The ultimate treatment goal for ST-segment elevation myocardial infarction (STEMI) is rapid reperfusion via primary percutaneous intervention (PCI). North Carolina has adopted a statewide STEMI referral strategy that advises paramedics to bypass local hospitals and transport STEMI patients directly to a PCI-capable hospital, even if a non-PCI-capable hospital is closer.

27 diciembre 2012

CIRCULATION. Vascular Medicine. Concomitant Use of Antiplatelet Therapy with Dabigatran or Warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) Trial

Antonio L. Dans, MD, MSc; Stuart J. Connolly, MD; Lars Wallentin, MD, PhD; Sean Yang, MSc; Juliet Nakamya, PhD; Martina Brueckmann, MD; Michael Ezekowitz, MBChB, DPhil; Jonas Oldgren, MD, PhD; John W. Eikelboom, MD; Paul A. Reilly, PhD; Salim Yusuf, DPhil, FRCPC, FRSC

Background: The Randomized Evaluation of Long-term Anticoagulation Therapy (RE-LY) trial showed that dabigatran etexilate 150 mg BID was superior and dabigatran etexilate 110 mg BID was noninferior to warfarin in preventing stroke and systemic embolism in patients with atrial fibrillation. In this subgroup analysis, we assess the efficacy and safety of dabigatran in patients who did and did not receive concomitant antiplatelets.

31 diciembre 2012

CIRCULATION. Coronary Heart Disease. Reduction in First and Recurrent Cardiovascular Events With Ticagrelor Compared With Clopidogrel in the PLATO Study

Payal Kohli, MD; Lars Wallentin, MD, PhD; Eric Reyes, PhD; Jay Horrow, MD; Steen Husted, MD, DSc; Dominick J. Angiolillo, MD, PhD; Diego Ardissino, MD; Gerald Maurer, MD; Joao Morais, MD; José C. Nicolau, MD, PhD; Ali Oto, MD; Robert F. Storey, MD; Stefan K. James, MD, PhD; Christopher P. Cannon, MD

Background: We sought to evaluate the effect of potent platelet inhibition after acute coronary syndrome on total (ie, first and recurrent) occurrences of any of the primary outcome events (eg, cardiovascular death, myocardial infarction, and stroke) as well as on other ischemic events, such as urgent revascularization, (severe) recurrent ischemia, transient ischemic attacks, and arterial thrombotic events.

31 diciembre 2012

CIRCULATION. Frequency of Myocardial Infarction and Its Relationship to Angiographic Collateral Flow in Territories Supplied by Chronically Occluded Coronary Arteries

Jin-Ho Choi, MD, PhD; Sung-A Chang, MD, PhD; Jin-Oh Choi, MD, PhD; Young Bin Song, MD, PhD; Joo-Yong Hahn, MD, PhD; Seung Hyuk Choi, MD, PhD; Sang-Chol Lee, MD, PhD; Sang-Hoon Lee, MD, PhD; Jae K. Oh, MD; YeonHyeon Choe, MD, PhD; Hyeon-Cheol Gwon, MD, PhD

Background: Despite complete interruption of antegrade coronary artery flow in the setting of a chronic total occlusion (CTO), clinical recognition of myocardial infarction is often challenging. Using cardiac MRI, we investigated the frequency and extent of myocardial infarction in patients with CTO, and assessed their relationship with regional systolic function and the extent of angiographic collateral flow.

16 enero 2013

CIRCULATION. Percutaneous Left Atrial Appendage Closure for Stroke Prophylaxis in Patients With Atrial Fibrillation. 2.3-Year Follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) Trial

Vivek Y. Reddy, MD; Shephal K. Doshi, MD; Horst Sievert, MD; Maurice Buchbinder, MD; Petr Neuzil, MD, PhD; Kenneth Huber, MD; Jonathan L. Halperin, MD; David Holmes, MD; on behalf of the PROTECT AF Investigators

Background: The multicenter PROTECT AF study (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) was conducted to determine whether percutaneous left atrial appendage closure with a filter device (Watchman) was noninferior to warfarin for stroke prevention in atrial fibrillation.

31 diciembre 2012

CIRCULATION. A History of Stroke/Transient Ischemic Attack Indicates High Risks of Cardiovascular Event and Hemorrhagic Stroke in Patients With Coronary Artery Disease

Gregory Ducrocq, MD; Pierre Amarenco, MD; Julien Labreuche, BST; Mark J. Alberts, MD; Jean-Louis Mas, MD; E. Magnus Ohman, MD; Shinya Goto, MD; Philippa Lavallée, MD; Deepak L. Bhatt, MD, MPH; Ph. Gabriel Steg, MD

Background: Randomized trials of antithrombotics in coronary artery disease have identified previous stroke/transient ischemic attack (TIA) as a marker of increased intracranial bleeding risk. We aimed to further characterize the risk of ischemic and bleeding events associated with a history of stroke/TIA in patients with coronary artery disease.

16 enero 2013

CIRCULATION. Coronary Heart Disease. Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Prevention of Spontaneous Myocardial Infarction in Subjects With Stable Ischemic Heart Disease

Sripal Bangalore, MD, MHA; Seema Pursnani, MD, MPH; Sunil Kumar, MD; Pantelis G. Bagos, PhD

Background: Contemporary studies have shown that spontaneous but not procedural myocardial infarction (MI) is related to subsequent mortality. Whether percutaneous coronary intervention (PCI) reduces spontaneous (nonprocedural) MI is unknown.

31 diciembre 2012

CIRCULATION. Interventional Cardiology. Cost-Effectiveness of Percutaneous Coronary Intervention With Drug Eluting Stents Versus Bypass Surgery for Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease

Elizabeth A. Magnuson, ScD; Michael E. Farkouh, MD, MSc; Valentin Fuster, MD, PhD; Kaijun Wang, PhD; Katherine Vilain, MPH; Haiyan Li, MS; Jaime Appelwick, BA; Victoria Muratov, MD, MPH; Lynn A. Sleeper, ScD; Robin Boineau, MD, MA; Mouin Abdallah, MD, MSc; David J. Cohen, MD, MSc; on behalf of the FREEDOM Trial Investigators

Background: Studies from the balloon angioplasty and bare metal stent eras have demonstrated that coronary artery bypass grafting (CABG) is cost-effective compared with percutaneous coronary intervention (PCI) for patients undergoing multivessel coronary revascularization—particularly among patients with complex coronary artery disease or diabetes mellitus. Whether these results apply in the drug-eluting stent (DES) era is unknown.

04 febrero 2013

CIRCULATION. Congenital Heart Disease. Abnormal Lung Function in Adults With Congenital Heart Disease: Prevalence, Relation to Cardiac Anatomy, and Association With Survival

Rafael Alonso-Gonzalez, MD, MSc*; Francesco Borgia, MD*; Gerhard-Paul Diller, MD, MSc, PhD; Ryo Inuzuka, MD; Aleksander Kempny, MD; Ana Martinez-Naharro, MD; Oktay Tutarel, MD; Philip Marino, MD; Kerstin Wustmann, MD; Menelaos Charalambides, MD; Margarida Silva, MD; Lorna Swan, MB, ChB, FRCP, MD; Konstantinos Dimopoulos, MD, MSc, PhD; Michael A. Gatzoulis, MD, PhD

Background: Restrictive lung defects are associated with higher mortality in patients with acquired chronic heart failure. We investigated the prevalence of abnormal lung function, its relation to severity of underlying cardiac defect, its surgical history, and its impact on outcome across the spectrum of adult congenital heart disease.

01 enero 2014

CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS. Efficacy and safety of transulnar coronary angiography and interventions. A single center experience

Anand R. Deshmukh MD*, Manu Kaushik MD, Ahmed Aboeata MBBCH, Jamil Abuzetun MD, Tammy L. Burns PHARMD, Caroline A. Nubel BS, Michael D. White MD, FACC, Thomas J. Lanspa MD, FACC, Claire B. Hunter MD, FACC, Aryan N. Mooss MD, FACC, Dennis J. Esterbrooks MD, FACC

Objectives: To evaluate the efficacy and long-term safety of transulnar approach in complex coronary interventions.