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Background Patients with aortic stenosis may continue to have an increased risk of heart failure, arrhythmias, and death after successful transcatheter aortic valve implantation. Renin‐angiotensin system inhibitors may be beneficial in this setting. We aimed to explore whether ramipril improves the outcomes of patients with aortic stenosis after transcatheter aortic valve implantation. Methods and Results PROBE (Prospective Randomized Open, Blinded Endpoint) was a multicenter trial comparing ramipril with standard care (control) following successful transcatheter aortic valve implantation in patients with left ventricular ejection fraction >40%. The primary end point was the composite of cardiac mortality, heart failure readmission, and stroke at 1‐year follow‐up. Secondary end points included left ventricular remodeling and fibrosis. A total of 186 patients with median age 83 years (range 79–86), 58.1% women, and EuroSCORE‐II 3.75% (range 3.08–4.97) were randomized to receive either ramipril (n=94) or standard treatment (n=92). There were no significant baseline, procedural, or in‐hospital differences. The primary end point occurred in 10.6% in the ramipril group versus 12% in the control group (P=0.776), with no differences in cardiac mortality (ramipril 1.1% versus control group 2.2%, P=0.619) but lower rate of heart failure readmissions in the ramipril group (3.2% versus 10.9%, P=0.040). Cardiac magnetic resonance analysis demonstrated better remodeling in the ramipril compared with the control group, with greater reduction in end‐systolic and end‐diastolic left ventricular volumes, but nonsignificant differences were found in the percentage of myocardial fibrosis. Conclusions Ramipril administration after transcatheter aortic valve implantation in patients with preserved left ventricular function did not meet the primary end point but was associated with a reduction in heart failure re‐admissions at 1‐year follow‐up. Registration URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03201185.

Background: Renal dysfunction in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) indicates a poor long-term prognosis. However, the prognostic value of the improvement or stabilisation of renal function during follow-up has not yet been assessed. This study aimed to investigate the long-term predictive impact of the improvement or stabilisation of renal function after one year of follow-up in patients with STEMI undergoing pPCI with renal dysfunction at discharge. Methods: This prospective, single-centre cohort study included 2170 consecutive patients with STEMI who underwent pPCI. The glomerular filtration rate (GFR) was determined at hospital discharge and one-year follow-up. The median clinical follow-up was 72 months. Results: Among the 2004 patients, 393 (19.6%) had a GFR

Abstract Deterioration is sometimes unexpected in SARS-CoV2 infection. The aim of our study is to establish laboratory predictors of mortality in COVID-19 disease which can help to identify high risk patients. All patients admitted to hospital due to Covid-19 disease were included. Laboratory biomarkers that contributed with significant predictive value for predicting mortality to the clinical model were included. Cut-off points were established, and finally a risk score was built. 893 patients were included. Median age was 68.2 ± 15.2 years. 87(9.7%) were admitted to Intensive Care Unit (ICU) and 72(8.1%) needed mechanical ventilation support. 171(19.1%) patients died. A Covid-19 Lab score ranging from 0 to 30 points was calculated on the basis of a multivariate logistic regression model in order to predict mortality with a weighted score that included haemoglobin, erythrocytes, leukocytes, neutrophils, lymphocytes, creatinine, C-reactive protein, interleukin-6, procalcitonin, lactate dehydrogenase (LDH), and D-dimer. Three groups were established. Low mortality risk group under 12 points, 12 to 18 were included as moderate risk, and high risk group were those with 19 or more points. Low risk group as reference, moderate and high patients showed mortality OR 4.75(CI95% 2.60–8.68) and 23.86(CI 95% 13.61–41.84), respectively. C-statistic was 0–85(0.82–0.88) and Hosmer–Lemeshow p-value 0.63. Covid-19 Lab score can very easily predict mortality in patients at any moment during admission secondary to SARS-CoV2 infection. It is a simple and dynamic score, and it can be very easily replicated. It could help physicians to identify high risk patients to foresee clinical deterioration.

AimWhether Takotsubo syndrome (TTS) should be classified within myocardial infarction with non-obstructive coronary arteries (MINOCAs) is still controversial. The aim of this work was to evaluate the main differences between TTS and non-TTS MINOCAs.Methods and ResultsA cohort study based on two prospective registries: TTS from the RETAKO registry (N:1,015) and patients with non-TTS MINOCAs from contemporary records of acute myocardial infarction from five 5 national centers (N:1,080). Definitions and management recommended by the ESC were used. Survival analysis was based on the Cox regression analysis; propensity score matching (PS) was created to adjust prognostic variables. Takotsubo syndrome were more often women (85.9 vs. 51.9%; p < 0.001) and older (69.4 ± 12.5 vs. 64.5 ± 14.1 years; p < 0.001). Atrial fibrillation (AF) was more frequent in non-TTS MINOCAs (10.4 vs. 14.4%; p = 0.007). Psychiatric disorders were more prevalent in TTS (15.5 vs. 10.2%, p < 0.001). In-hospital mortality and complications were higher in TTS: 3.4 vs. 1.8%, (p = 0.015), and 25.8 vs. 11.5%, (p < 0.001). Global mortality before PS matching was 16.1% in non-TTS MINOCAs and 8.1% in TTS. Median follow-up was 32.4 months; after PS matching, TTS had fewer major adverse cardiovascular events (MACEs): hazard ratio (HR) 0.59; 95% CI 0.42–0.83. There were no differences in global mortality (HR 0.87; CI: 0.64–1.19), but TTS had lower cardiovascular mortality (HR 0.58; CI: 0.35–0.98).ConclusionCompared to the rest of MINOCAs, TTS presents a different patient profile and a more aggressive acute phase. However, its long-term cardiovascular prognosis is better. These results support that TTS should be considered a separate entity with unique characteristics and prognosis.

RESUMEN Introducción y objetivos: Las lesiones coronarias calcificadas pueden impedir una correcta expansión del stent que en ocasiones conduce a eventos adversos. La litotricia intracoronaria es una nueva herramienta de modificación de la placa, cuyas seguridad y viabilidad en pacientes con enfermedad coronaria estable han sido evaluadas en el ensayo Disrupt CAD II. Aunque su uso ha aumentado rápidamente, hasta el momento solo se han comunicado casos aislados en escenarios concretos. Se presentan los resultados en pacientes clínicamente complejos de la vida real con calcificación coronaria grave. Métodos: Entre octubre de 2018 y marzo de 2019 se trató a 25 pacientes (37 lesiones) en 2 centros españoles, lo que representa el 2,7% de los pacientes tratados con intervención coronaria percutánea. Resultados: Las tasas de éxito clínico y del dispositivo fueron del 84 y el 95%, y no se observaron complicaciones relacionadas con el procedimiento. En todos los casos se consiguió cruzar la lesión con el balón de litotricia intracoronaria, si bien en el 8% de los casos se rompió el balón durante el inflado. Se trataron con éxito lesiones complejas, como oclusiones coronarias totales y estenosis del tronco común. En comparación con el estudio Disrupt CAD II, nuestros pacientes eran más jóvenes, pero tenían peor escenario clínico, con mayor prevalencia de diabetes (68%) e insuficiencia renal (22%), y hasta el 76% se presentó como síndrome coronario agudo. En 3 de 4 pacientes con infraexpansión de stent tratados con litotricia intracoronaria no se consiguió una expansión adecuada tras el procedimiento. No hubo complicaciones ni mortalidad hospitalaria. Un paciente falleció por causa no cardiaca a los 30 días de seguimiento. Conclusiones: La litotricia intracoronaria se ha demostrado efectiva y segura en una cohorte de pacientes complejos de la vida real con lesiones calcificadas.

ABSTRACT Introduction and objectives: Complex calcified lesions can affect stent expansion and lead to stent failure and adverse outcomes. Intracoronary lithotripsy (ICL) has emerged as a new tool that enables calcium modification. The Disrupt CAD II clinical trial has recently evaluated the safety and feasibility of ICL in patients with stable coronary disease and calcified coronary lesions. Although its use has increased rapidly, the experience already reported with this new device is limited. We report the results in real-life complex patients with heavy coronary calcification. Methods: From October 2018 to March 2019, 25 patients (37 calcified lesions) were treated in 2 Spanish centers, which accounted for 2.7% of the patients treated with percutaneous coronary intervention. Results: The device and clinical success rates were 84% and 95%, respectively. No procedure-related complications were seen. The crossing rate of the ICL balloon was 100% and balloon rupture during inflation occurred in 8%. The ICL was performed in a subset of highly complex lesions like left main coronary artery lesions and chronic total coronary occlusions. Compared to the Disrupt CAD II trial, our patients were younger but their clinical scenario was worse with a higher prevalence of diabetes (68%), renal failure (22%), and up to 76% suffered from acute coronary syndrome. The ICL failed to reach proper expansion in 3 out of 4 cases of stent underexpansion. The procedure was performed safely, and clinical and device success were high with no in-hospital mortality. One patient died of non-cardiac causes at the 30-day follow-up. Conclusions: The ICL-assisted percutaneous coronary intervention was performed safely and effectively in a real-life cohort of patients with calcified and highly complex lesions.

Resumen Introducción y objetivos: La evidencia del beneficio en el pronóstico a largo plazo de los stents farmacoactivos (SFA) de nueva generación es limitada, en especial en los pacientes con angioplastia primaria. El objetivo de este trabajo fue comparar el impacto en el pronóstico a largo plazo de la implantación de SFA frente a stents metálicos (SM) en pacientes del mundo real tratados con angioplastia primaria. Métodos: Estudio de cohortes en el que incluyeron 1.499 pacientes ingresados de forma consecutiva con diagnóstico de infarto agudo de miocardio con elevación del segmento ST y sometidos a angioplastia primaria entre enero de 2008 y diciembre de 2015. El 24,9% recibió un SFA. Mediante un análisis de emparejamiento por puntuación de propensión se obtuvieron 2 grupos de 262 pacientes emparejados según la implantación de SFA o SM. Resultados: Durante el seguimiento (mediana de 1.015 días), los pacientes que recibieron SFA tuvieron tasas más bajas de mortalidad por todas las causas (6,5 frente a 12,2%; p = 0,049), así como en el objetivo combinado de eventos adversos mayores (16,4 frente a 25,2%; p = 0,049) y un objetivo combinado orientado al paciente que incluía muerte por cualquier causa, infarto de miocardio y revascularización en el seguimiento (12,6 frente a 22,5%; p = 0,017). No se observaron diferencias en cuanto a trombosis definitiva del stent. Conclusiones: En nuestro registro, en una población del mundo real de pacientes consecutivos tratados con ICP primaria, la utilización de SFA frente a SM se asoció a una mayor supervivencia y una reducción de los eventos clínicos en el seguimiento a largo plazo, sin observar diferencias en la trombosis del stent.

Abstract Introduction and objectives: Evidence of the long-term prognostic benefit of new generation drug-eluting stents (DES) is limited, especially in the context of primary percutaneous coronary interventions. The goal of this study was to compare the long-term prognostic impact of the implantation of DESs versus bare-metal stents (BMSs) in real-world patients undergoing primary percutaneous coronary interventions. Methods: A cohort study was conducted with 1499 consecutive patients diagnosed with ST-segment elevation myocardial infarction who underwent percutaneous coronary interventions between January 2008 and December 2015. A total of 24.9% of the patients received a DES. A matched propensity score analysis yielded 2 groups of 262 matched patients depending on whether they were treated with a DES or a BMS. Results: During follow-up (median 1015 days), the patients who received DES had a lower all-cause mortality rate (6.5% vs 12.2%; P = .049) a lower composite endpoint of major adverse cardiac events (16.4% vs 25.2%; P = .049) and a lower patient-oriented composite endpoint of death from any cause, myocardial infarction and revascularization at follow-up (12.6% vs 22.5%; P = .017). No differences were seen in the definite stent thrombosis rate. Conclusions: In our registry, in a real-world population of consecutive patients undergoing primary percutaneous coronary interventions, the use of DES versus BMS associated more survival and less clinically significant major adverse cardiac events and patient-oriented composite endpoints in a long-term follow-up, without any differences in stent thrombosis.

Background: Healthcare systems are under prominent stress due to the COVID-19 pandemic. A fast and simple triage is mandatory to screen patients who will benefit from early hospitalization, from those that can be managed as outpatients. There is a lack of all-comers scores, and no score has been proposed for western-world population. Aims: To develop a fast-track risk score valid for every COVID-19 patient at diagnosis. Methods: Single-center, retrospective study based on all the inhabitants of a healthcare area. Logistic regression was used to identify simple and wide-available risk factors for adverse events (death, intensive care admission, invasive mechanical ventilation, bleeding > BARC3, acute renal injury, respiratory insufficiency, myocardial infarction, acute heart failure, pulmonary emboli, or stroke). Results: Of the total healthcare area population, 447.979 inhabitants, 965 patients (0.22%), were diagnosed with COVID-19. A total of 124 patients (12.85%) experienced adverse events. The novel SODA score (based on sex, peripheral O2 saturation, presence of diabetes, and age) demonstrated good accuracy for adverse events prediction (area under ROC curve 0.858, CI: 0.82–0.98). A cut-off value of ≤2 points identifies patients with low risk (positive predictive value [PPV] for absence of events: 98.9%) and a cut-off of ≥5 points, high-risk patients (PPV 58.8% for adverse events). Conclusions: This quick and easy score allows fast-track triage at the moment of diagnosis for COVID-19 using four simple variables: age, sex, SpO2, and diabetes. SODA score could improve preventive measures taken at diagnosis in high-risk patients and also relieve resources by identifying very low-risk patients.

Background The clinical significance of conduction disturbances after transcatheter aortic valve implantation has been described; however, little is known about the influence of baseline ECGs in the prognosis of these patients. Our aim was to study the influence of baseline ECG parameters, including interatrial block (IAB), in the prognosis of patients treated with transcatheter aortic valve implantation. Methods and Results The BIT (Baseline Interatrial Block and Transcatheter Aortic Valve Implantation) registry included 2527 patients with aortic stenosis treated with transcatheter aortic valve implantation. A centralized analysis of baseline ECGs was performed. Patients were divided into 4 groups: normal P wave duration (

Presentación del caso Se presenta el caso de un varón de 83 años, hipertenso, diabético, con estenosis aórtica grave sintomática, función ventricular conservada e insuficiencia mitral ligera y sin enfermedad coronaria. Presentaba un riesgo quirúrgico bajo-intermedio (puntuación de la Society of Thoracic Surgeons del 3,1%) y en sesión médico-quirúrgica se decidió realizar el reemplazo quirúrgico de la válvula aórtica. Se implantó una bioprótesis aórtica sin suturas Perceval (Perceval Sutureless Aortic Heart Valve, Sorin) de tamaño L. El ecocardiograma de seguimiento previo al alta mostró un gradiente transvalvular aórtico de 22/11 mmHg y 2 chorros de regurgitación periprotésicos que sugerían insuficiencia aórtica de ligera a moderada, con una presión sistólica de la arteria pulmonar de 40 mmHg. Cinco meses después del reemplazo valvular, el paciente ingresó por insuficiencia cardiaca aguda con edema agudo de pulmón. En la exploración física, la auscultación mostró un soplo sugestivo de regurgitación aórtica de grado III/IV y estertores pulmonares bilaterales. El ecocardiograma reveló insuficiencia aórtica grave secundaria a la ausencia de cobertura del stent de la bioprótesis aórtica a nivel del anillo aórtico en la zona correspondiente al seno no coronariano y la mayor parte del seno coronariano derecho, que condicionaba 2 chorros de regurgitación hacia el ventrículo izquierdo, el cual...

Presentation of the case We hereby present the case of an 83 year old hypertense, diabetic male patient with asymptomatic severe aortic stenosis, preserved ventricular function, mild mitral regurgitation and no coronary artery disease. He had low-intermediate surgical risk (3.1% in the Society of Thoracic Surgeons scoring system) and, in medical-surgical session, it was decided to proceed with the surgical replacement of his aortic valve. Perceval Sutureless Aortic Heart Valve, Sorin size L was implanted. The follow-up echocardiogram prior to hospital discharge showed an aortic transvalvular gradient of 22/11 mmHg and 2 periprosthetic regurgitation jets indicative of mild-to-moderate aortic failure with pulmonary artery systolic pressure of 40 mmHg. Five months after valvular replacement, the patient was hospitalized due to acute heart failure with acute pulmonary edema. During the physical examination, the auscultation showed murmurs indicative of grade III/IV aortic regurgitation and bilateral pulmonary rales. The echorcardiogram showed severe aortic failure due to the lack of stent coverage of the aortic bioprosthesis at the level of the aortic annulus and in the area corresponding to the non-coronary sinus and most of the right coronary sinus which conditioned 2 regurgitation jets towards the left ventricle that appeared slightly dilated. The left ventricular ejection fraction was somehow...

Resolución del caso Con una puntuación de la Society of Thoracic Surgeons de un 8,5% para mortalidad, se decidió implantar una prótesis Evolut PRO transfemoral sobre una bioprótesis infraexpandida. Se realizó tomografía computarizada y se observó la ausencia de cobertura del stent de la bioprótesis sobre el anillo aórtico a nivel de los senos de Valsalva, no coronariano y coronariano derecho (figura 1), que sugería como mecanismo de la insuficiencia periprotésica el recoil del stent que alojaba los velos de la bioprótesis provocando la falta de aposición con el anillo aórtico. El perímetro del anillo aórtico era de 79,3 mm (diámetro mínimo: 22 mm; diámetro máximo: 25 mm). Se eligió una prótesis autoexpandible con velos a nivel supraanular, ya que está demostrado que en los procedimientos valve-in-valve el resultado hemodinámico es mejor que con aquellas de implantación anular que dejan un mayor gradiente transprotésico. Además, la posición de la prótesis dentro de la prótesis debe ser óptima, y por ello la posibilidad de recaptura y reposicionamiento de la prótesis Evolut R es idónea para este procedimiento. La selección del tamaño de la prótesis que se debía implantar se basó en el diámetro interno verdadero de la válvula Perceval L de 25 mm, que...

Case Resolution With an 8.5% score in the Society of Thoracic Surgeons risk score for mortality rate, we decided to implant one Evolut PRO transfemoral bioprostheis on an underexpanded bioprosthesis. The computed tomography confirmed the lack of coverage of the bioprosthetic stent over the aortic annulus at the level of the Valsava, non-coronary and right coronary sinuses (figure 1), indicative of stent recoil of the stent harboring the bioprosthetic leaflets as the possible mechanism of periprosthetic failure and causing malapposition with the aortic annulus. The perimeter of the aortic annulus was 79.3 mm (minimum diameter: 22 mm; maximum diameter: 25 mm). Figure 1. Lack of coverage of the bioprosthetic stent over the aortic annulus at the level of the Valsava, non-coronary and right coronary sinuses (asterisk). The colored dots are indicative of the location of coronary sinuses. One self-expandable prosthesis was selected with leaflets at the supra-annular level, since it has already been confirmed that in valve-in-valve procedures, the hemodynamic outcome is better compared to the annular implantation that leaves a more significant trans-prosthetic gradient. Also, the position of the prosthesis inside the prosthesis needs to be optimal, which makes the Evolut R the perfect device for this kind of procedure for its...