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Resumen Introduccion y objetivos Se presentan los datos correspondientes a los implantes de desfibrilador automatico implantable (DAI) en Espana durante el ano 2020. Metodos Los datos provienen de los centros implantadores, que cumplimentaron voluntariamente una hoja de recogida de datos. Resultados En 2020 se recibieron 7.056 hojas de implante, frente a las 7.106 comunicadas por Eucomed (European Confederation of Medical Suppliers Associations), lo que implica que se han recogido datos del 99% de los dispositivos implantados en Espana. La cumplimentacion oscilo entre el 99,8% en el campo «nombre del hospital implantador» y el 2,6% en la variable «hospital de referencia». Los hospitales que realizaron implantes de DAI y participaron en el registro fueron 173, un numero similar al del ano 2019 (172). La tasa total de implantes registrados fue 149/millon de habitantes (150 segun Eucomed), lo que muestra una ligera disminucion de los implantes en Espana en 2020 como consecuencia del impacto de la pandemia de la COVID-19. Esta reduccion observada ha sido desigual entre las diferentes comunidades autonomas. Conclusiones El Registro Espanol de Desfibrilador Automatico Implantable del ano 2020 recoge una mejora en la tasa de implantes comunicados y una reduccion del numero de implantes de DAI, lo que reflejaria la reduccion de la actividad hospitalaria no relacionada con el tratamiento del paciente con COVID-19. De forma similar a los anos previos, el numero total de implantes en Espana sigue siendo muy inferior a la media de la Union Europea, con un aumento en las diferencias entre las comunidades autonomas espanolas.

La fibrilación auricular aumenta hasta en 5 veces el riesgo de ictus. Los ictus cardioembólicos habitualmente son más graves y tienen altas tasas de recurrencias y discapacidad permanente en comparación con los ictus de otras etiologías. En consecuencia, la reducción del riesgo de ictus mediante una adecuada anticoagulación es uno de los principales objetivos en el tratamiento de los pacientes con fibrilación auricular. Los antagonistas de la vitamina K han sido ampliamente superados por los anticoagulantes orales de acción directa, ya que tanto los resultados de los ensayos clínicos como los de los estudios de práctica clínica y, últimamente, estudios poblacionales han demostrado que los anticoagulantes orales de acción directa tienen mayores eficacia (menos ictus y muerte) y seguridad (menos hemorragias intracraneales) que los antagonistas de la vitamina K. Además, durante la pandemia de COVID-19, el empleo preferente de anticoagulantes orales de acción directa frente a los antagonistas de la vitamina K constituye una estrategia clave para garantizar una calidad óptima de la anticoagulación y una mejor protección del paciente contra el SARS-CoV-2, al no precisarse control de la razón internacional normalizada.

Pulmonary vein (PV) isolation is a well-established rhythm control therapy in atrial fibrillation (AF). Currently, there is no consensus on which ablation technique to use for the first procedure, cryoballoon (CB) or radiofrequency (RF). A retrospective cohort study was conducted on 1055 patients who underwent a first ablation, to assess both techniques based on the need for reablation. Patients with CB (n = 557) and RF (n = 498) ablations were clinically characterized and the need for reablation during a 30-month follow-up was used as the primary endpoint. Independent variables were analyzed to identify potential predictors. The need for reablation was significantly lower in the CB group than in the RF group (hazard ratio = 0.45 and 95% confident interval = 0.32–0.61; p < 0.001); in both paroxysmal and persistent AF, using a full-adjusted regression Cox model by age, sex, smoking, hypertension, diabetes mellitus, dyslipidemia, severe obstructive sleep apnea, dilated left atrium, persistent AF and early recurrence. RF ablation, dilated left atrium, persistent AF and early recurrence were identified as independent predictors of reablation. In addition, the CB-redo subgroup had a lower PV reconnection than the RF-redo subgroup. In conclusion, CB ablation suggests a reduction in the need for reablation and lower PV reconnection during the follow-up than RF ablation.

Resumen La fibrilacion auricular aumenta de manera marcada el riesgo de ictus. Multiples ensayos clinicos y estudios en practica clinica han demostrado que el tratamiento anticoagulante disminuye el riesgo de complicaciones tromboembolicas. Para este tratamiento, los anticoagulantes orales de accion directa (ACOD) ofrecen un mejor perfil de eficacia y seguridad que los antagonistas de la vitamina K. Estudios realizados en paises de nuestro entorno han objetivado en los ultimos anos una reduccion en la incidencia de ictus isquemico, lo que podria estar en relacion con una mayor prescripcion de anticoagulantes orales, sobre todo ACOD. En Espana hay muy poca informacion sobre este tema. Sin embargo, los datos disponibles indican que parece que tambien la mayor prescripcion de anticoagulantes orales, sobre todo ACOD, se asociaria con una significativa reduccion de las incidencias tanto de ictus isquemico como de hemorragias intracraneales. En consecuencia, se deberia recomendar un mayor empleo de los ACOD para los pacientes con fibrilacion auricular, lo que contribuiria no solo a reducir la incidencia de ictus isquemico y de hemorragias intracraneales, sino tambien la carga economica que esto conlleva.

Resumen: Introducción: en los procedimientos de extracción de electrodos, la vía femoral se usa cuando la vía superior ha fracasado. Objetivo: describir la incidencia, el éxito, las complicaciones y los predictores de uso de la vía femoral. Métodos: se realizó un análisis de la incidencia del uso de la vía femoral y los factores predictores en pacientes a quienes se les realizó extracción de electrodos entre noviembre de 2011 y noviembre de 2017. Resultados: se incluyeron 85 pacientes, con edad media de 62,36 ± 11,15 años. El 38,9% de los dispositivos eran marcapasos. Se extrajeron 135 electrodos, 59,3% de fijación pasiva. La mediana de tiempo desde el implante fue de 102 (60-174) meses. Se empleó la ruta femoral en el 25,9% de los procedimientos. Se obtuvo éxito clínico en el 92,9% de los pacientes. La extracción no fue exitosa en el 22,7% de los procedimientos cuando se usó la vía femoral, en comparación con el 1,6% cuando se usó la vía superior (p 0,004). La extracción no fue completa en el 36,4% de los procedimientos cuando se empleó la vía femoral en comparación con el 9,5% por vía superior (p 0,007).Los factores que predijeron el empleo de la ruta femoral fueron la presencia de electrodos de fijación pasiva [OR IC 95% 13,69 (3,06-62,5) p 0,001] y el tiempo desde el implante del electrodo [OR IC 95% por cada 10 meses 1,04 (1,00-1,09) p 0,044]. Conclusiones: se empleó la ruta femoral en el 25,9% de los procedimientos. No fue eficaz en el 22,7% de las intervenciones. Los factores que predijeron su utilización fueron la presencia de electrodos de fijación pasiva y el tiempo desde el implante del electrodo. Abstract: Introduction: The femoral route is used in electrode removal procedures when the upper route has failed. Objective: To describe the incidence, success rate, complications and predictive factors for the use of the femoral route. Methods: An analysis was performed on the incidence of use of the femoral route and the predictive factors in patients in whom electrode removal was carried out between November 2011 and November 2017. Results: The study included 85 patients with a mean age of 62.36 ± 11.5 years. Pacemakers made up 38.9% of the devices. A total of 135 electrodes, 59.3% of passive fixation, were removed. The median time since the implant was 102 (60-174) months. The femoral route was used in 25.9% of the procedures. Clinical success was achieved in 92.9% of the patients. The removal was not successful in 22.7% of the procedures when the femoral route was used, compared to 1.6% when the upper route was used (P = .004). The removal was not completed in 36.4% of the procedures when the femoral route was used, compared to 9.5% with the upper route (P = .007).The factors that predicted the use of the femoral route were the presence of passive-fixation electrodes (OR = 13.69: 95% CI; 3.06 – 62.5, P = .001), and the time since the electrodes were implanted (OR = 1.04, 95% CI; 1.00 – 1.09, P = .044, for every 10 months). Conclusions: The femoral route was employed in 25.9% of the procedures. It was not effective in 22.7% of the interventions. The factors that predicted its use were the presence of passive-fixation electrodes and the time since the electrode implant.

INTRODUCTION AND OBJECTIVES: Equal opportunities to access technical advances with recognized clinical value should be a priority of the publicly-funded health system. We analyzed variability among all the Spanish autonomous communities in the use of cardiovascular techniques with an established indication and its relationship with economic indicators, burden of disease, and hospital mortality. METHODS: The activity registries of various Associations of the Spanish Society of Cardiology from 2011 to 2019 were analyzed for coronary angiography, overall percutaneous coronary intervention (PCI), primary PCI, implantable cardioverter-defibrillators (ICD), cardiac resynchronization therapy, and transcatheter aortic valve replacement (TAVR). Economic indices (gross domestic product and per capita health care expenditure) were obtained from public sources and data on attendance rates and mortality from the Resources and Quality in Cardiology (RECALCAR) reports of the Spanish Society of Cardiology. We analyzed the coefficient of variation for activity and the correlation of activity with regional economic indices, attendance rates, and risk-adjusted rates of in-hospital mortality. RESULTS: We identified wide variability in the use of technologies, especially for primary PCI (18%), ICD (22%), cardiac resynchronization therapy (36%), and TAVR (42%). A certain correlation with attendance rates was seen only for overall PCI and ICD. In general, no significant correlation was found between the use of the techniques and the economic indices of wealth and expenditure. The correlation with in-hospital mortality showed no significant results, although this was the analysis with the greatest limitations because the impact of these techniques on survival is exerted more in the mid- and long-term. CONCLUSIONS: The results of this study, despite its inherent limitations, show marked variability between autonomous communities in the use of cardiovascular technologies, which is not explained by economic differences or by hospital attendance rates due to the corresponding diseases.

Introduction Previous studies have found sex differences in implantable cardiac defibrillator (ICD) implantation counseling, especially in primary prevention. Possible explanations to this phenomenon have been described: under-representation of women in clinical trials, patient's preferences, lower overall sudden cardiac death risk in women compared to men, higher prevalence of non-ischemic dilated cardiomyopathy (DCM) in women and better response to cardiac resynchronization therapy in this population. Nevertheless, this gap appears to narrow in most recent registries. Purpose Our aim is to asses if there is still sex discrimination in ICD counseling by comparing ICD implantation between men and women. Methods A single-centre retrospective registry of 160 patients with a reduced left ventricle ejection fraction (LVEF ≤35%) found in a routine transthoracic echocardiogram (TTE) from January 2019 to June 2020. Inclusion and exclusion flow chart is described in Picture 1. Data collected included demographic, clinical and echocardiographic characteristics. Date of heart disease diagnosis, earliest date of LVEF ≤35% diagnosis (with TTE or cardiac magnetic resonance) and date of death when applicable were recorded. Cardiac resynchronization devices with ICD function were also considered for the analysis. In ICD carriers, implantation date and type of prevention for indication were collected. ICD implants and deaths up to December 31, 2020 were included for the analysis. Results Basal characteristics are described in Picture 2. The mean age was 67.5 years and 24.4% of the population were women. Ischemic etiology was the most frequent etiology in the overall population and in the male group. In women, DCM was the most common etiology. Sixty-eight patients carried an ICD. No significant differences between both sexes, neither globally nor according to the implant indication (primary vs. secondary prevention) were observed. In the subgroup analysis of patients with ICD, there were no significant differences in the number of devices between men and women, neither in ischemic or non-ischemic etiology. In primary prevention, there was a non-significant trend towards earlier implantation of the device in women (1.4 years vs 3.4 years, p=0.008) since the diagnosis of LVEF ≤35%. In patients without ICD (n=92), the mean age was significantly higher (72.5 years vs. 60.8 years, p Conclusions Despite under representation of women in pur population, we could not find differences in ICD implantation decision based on gender, even considering differences in underlying cardiomyopathy. There was no delay in implantation depending on sex, and even the trend was towards earlier implantation in women. Funding Acknowledgement Type of funding sources: None. Inclusion and exclusion flow chartBasal characteristics

Sudden cardiac arrest (SCA) is an uncommon but devastating event among young adults. While inherited cardiomyopathies and channelopathies represent an important proportion of sudden deaths, coronary artery disease remains a significant contributor in this age group. ECG findings are essential to guide the first steps of diagnostic work‐up of SCA, but sometimes can overlap between different etiologies. In this article we present a 16‐year‐old female who experienced SCA during vigorous swimming whose ECG was compatible with long QT syndrome. However, evaluation of the coronary anatomy provided the diagnosis of Kawasaki disease., Sudden cardiac arrest is uncommon among young adults. Inherited cardiomyopathies and channelopathies are the most frequently identified cardiac etiologies. However, assessment of coronary artery anatomy is mandatory in order to rule out coronary artery anomalies.

Resumen Introduccion y objetivos Se describen los resultados en Espana de la segunda encuesta de la Sociedad Europea de Cardiologia sobre terapia de resincronizacion cardiaca (CRT-Survey II) y se comparan con los de los demas paises participantes. Metodos Pacientes a los que se implanto un dispositivo de terapia de resincronizacion cardiaca entre octubre de 2015 y diciembre de 2016 en 36 centros participantes. Se recogieron datos sobre las caracteristicas basales de los pacientes y del implante, y un seguimiento a corto plazo hasta el alta hospitalaria. Resultados La tasa de exito del implante fue del 95,9%. La mediana [intervalo intercuartilico] de implantes anuales/centro en Espana fue significativamente menor que en los demas paises participantes: 30 [21-50] frente a 55 [33-100] implantes/ano (p = 0,00003). En los centros espanoles hubo una menor proporcion de pacientes de edad ≥ 75 anos (el 27,9 frente al 32,4%; p = 0,0071), una mayor proporcion de pacientes en clase funcional II de la New York Heart Association (el 46,9 frente al 36,9%; p Conclusiones La encuesta CRT-Survey II muestra que en Espana hay una menor proporcion de pacientes de 75 o mas anos que reciben un dispositivo de terapia de resincronizacion cardiaca, una mayor proporcion de pacientes en clase funcional II de la New York Heart Association, con bloqueo completo de la rama izquierda del haz de His y con seguimiento a distancia, con estancias hospitalarias significativamente menores.

Resumen Introduccion y objetivos La Sociedad Espanola de Cardiologia/Fundacion Espanola del Corazon (SEC/FEC) realiza convocatorias anuales de becas para proyectos de investigacion cardiovascular. El objetivo es analizar la evolucion de estas inversiones y la produccion cientifica derivada en el periodo 2007-2012. Metodos Se ha realizado una busqueda de las publicaciones financiadas por SEC/FEC, segun los siguientes criterios de inclusion: publicacion en revista indexada en MEDLINE o EMBASE, fecha de publicacion posterior a la de la ayuda, estar firmadas por el investigador principal de la ayuda y reconocer la financiacion SEC/FEC. Se analizo el factor impacto y las citas posteriores de los articulos (Web of Science). Resultados Se han otorgado 235 becas (39/ano) con una dotacion de 3.854.300 euros (642.383 euros/ano), el 37% a mujeres. Hay 122 publicaciones derivadas de 88 proyectos (37%) de investigacion financiados SEC/FEC. Estas publicaciones han recibido hasta octubre de 2017 un total de 2.258 citas en estudios posteriores en la Web of Science, con una media de 18,5 y una mediana de 8 citas/estudio. Conclusiones Las becas concedidas por la SEC/FEC han crecido en numero y cuantia media en el periodo analizado, a pesar de la crisis economica. Las mujeres acceden a ellas en igualdad de condiciones que los varones. El impacto bibliometrico de los proyectos financiados es aceptable, aunque deben hacerse esfuerzos para mejorarlo.

Resumen Introduccion y objetivos El uso de dispositivos cardiacos implantables (DCI) se ha expandido en los ultimos anos. La infeccion relacionada con estos dispositivos es una de las principales complicaciones y se asocia con grandes morbilidad, mortalidad y costes. El objetivo del estudio es construir una puntuacion predictiva del riesgo de infeccion del DCI. Metodos Se diseno un estudio retrospectivo de casos y controles anidado. Tanto los casos como los controles pertenecian a una cohorte que incluia a todos los pacientes sometidos a un procedimiento relacionado con un DCI entre enero de 2009 y diciembre de 2015. Los casos se definieron como pacientes con infeccion, y se selecciono aleatoriamente a 3 controles de la cohorte por cada caso incluido. Resultados Durante el periodo de estudio, se realizaron 2.323 procedimientos. Se identificaron en total 33 infecciones relacionadas con el DCI. Se selecciono como controles a 99 pacientes. Se identificaron como factores de riesgo independientes el indice de Charlson (OR = 1,33; IC95%, 1,07-1,67), la anticoagulacion oral (OR = 3,51; IC95%, 1,44-8,54), la revision o el reemplazo de un dispositivo anterior (OR = 2,75; IC95%, 1,12-6,71) y la presencia de mas de 2 cables (OR = 3,42; IC95%, 1,25-9,37). Se genero una escala de riesgo predictivo y se denomino CIED-AI (indice de Charlson, mas de 2 cables/electrodos, revision/reemplazo del dispositivo, anticoagulacion oral, infeccion previa). Esta puntuacion presento un area bajo la curva receiver operating characteristic de 0,79 (IC95%, 0,71-0,88). Conclusiones La puntuacion CIED-AI puede ayudar a identificar a los pacientes con mayor riesgo de infeccion que serian candidatos a medidas de prevencion intensivas.

En este documento se ofrece evidencia sobre los aspectos macroeconomicos mas importantes de la politica fiscal en Colombia. En primer lugar, sobre su papel en la estabilizacion del ciclo economico en el corto plazo y sobre otros asuntos relacionados con la estabilizacion, como los impactos macro de la incertidumbre ocasionada por los cambios recurrentes en la tributacion y la interrelacion entre la politica fiscal y la politica monetaria. En segundo lugar, se evalua la sostenibilidad de la deuda publica y el espacio fiscal disponible en la economia, factores que son cruciales para conocer el margen de discrecionalidad del gobierno en el mediano y largo plazo. Los hallazgos del trabajo contribuiran al debate sobre el manejo futuro de la politica macroeconomica. En el frente fiscal, las acciones deberian encaminarse a alcanzar el doble objetivo de la sostenibilidad de la deuda publica y de estabilizar el ciclo economico. Sobre esta ultima cuestion, no se registran avances significativos a pesar de la regla fiscal estructural adoptada en 2011.

Aims This trial aimed to evaluate the safety and efficiency of a common and simplified protocol for the surveillance of cardiac implantable electronic devices based on remote monitoring (RM) in patients with pacemakers (PMs) and implantable cardiac defibrillators (ICDs) for at least 24 months. Methods and results The RM-ALONE is a multicentre prospective trial that randomly assigned 445 patients in two groups, both followed by RM: the home monitoring-only (HMo) based on RM + remote interrogations (RIs) every 6 months and the HM + IO that adds in-office evaluations every 6 months to RM. Four hundred and forty-five patients were enrolled in the study, 294 PMs and 151 ICDs recipients. In the HMo group, 20% of patients experienced ≥1 major adverse cardiac event (MACE) vs. 19.5% in HM + IO group (P = 0.006 for non-inferiority). The proportion of patients with a PM/ICD who experienced ≥1 MACE was 15.2/29.3% in HMo group and 16.1/26.3% in HM + IO group (hazard ratio 0.95/1.15, 95% confidence interval 0.53–1.70/0.62–2.10). There were 789 in-office evaluations (136 in the HMo and 653 in the HM + IO; P Conclusion The RM-ALONE protocol common for ICD and PM surveillance, consisting of RM + RI every 6 months has proven safe and efficient in reducing hospital visits and staff workload.

Funding Acknowledgements Type of funding sources: None. Introduction The most frequent complications of atrial fibrillation (AF) ablation procedures are those related to the vascular access site, which are associated with increased morbidity and length of hospital stay. Purpose: To assess the safety and efficacy of venous access site closure with a suture-mediated vascular closure device (SVD), as well as the feasibility of early mobilization and same-day discharge protocol after AF ablation procedures. Methods: We conducted a retrospective analysis of all consecutive AF ablation patients in whom a SVD was employed to achieve hemostasis after each venous puncture. The ablation was performed under conscious sedation, using 7 to 12-F introducer sheaths. Anticoagulation was uninterrupted but for the last dose prior to the procedure. Intraprocedural heparin was not reversed. Groin ultrasound was performed in the first 10 patients with adequate SVD deployment. Three conditions were required for the same-day discharge protocol application: 1) uncomplicated procedure, 2) successful SVD deployment and 3) adequate recovery. Recovery followed a three-phase protocol: bed rest (two hours), sitting (one hour) and ambulation. Follow-up included phone call and clinical examination. Patients were offered contact to the electrophysiologist if needed. Results: 63 ablation procedures with SVD closure were performed from May 2019 to October 2020, with a total of 132 access sites analysed. Patient characteristics are shown in the table. The SVD was successfully deployed in 125 (94.7%) and hemostasis immediately achieved. In the remaining 5.3%, failure was attributed to a deficient technique, which missed to advance the knot to the vein. First 10 patients were ultrasound evaluated 24 hours later (no early discharge), showing total absence of complications. 35 subsequent patients (55.6% of the remaining 53) were discharged the same day without ultrasound control. The remaining 18 stayed overnight for reasons not related to the access site (hemodynamic surveillance, initiation of antiarrhythmic drugs or loss of phrenic capture), allowing in any case early mobilization (three hours after the procedure). Mean follow-up was 272 ± 160 days, with no adverse events recorded. Conclusion: SVD are safe and effective in achieving rapid hemostasis, making the early mobilization and same-day discharge protocol after AF ablation feasible in selected patients. Age 63 (57-71) Male 46 (73%) Body mass index (kg/m²) 27,5 (24,2-31,6) Previous anticoagulation- Vitamin K antagonist- Direct oral anticoagulation 50 (79,4%)14 (28%)36 (72%)

Aims To determine the spectral dynamics of early spontaneous polymorphic ventricular tachycardia and ventricular fibrillation (PVT/VF) in humans. Methods and results Fifty-eight self-terminated and 173 shock-terminated episodes of spontaneously initiated PVT/VF recorded by Medtronic implanted cardiac defibrillators (ICDs) in 87 patients with various cardiac pathologies were analyzed by short fast Fourier transform of shifting segments to determine the dynamics of dominant frequency (DF) and regularity index (RI). The progression in the intensity of DF and RI accumulations further quantified the time course of spectral characteristics of the episodes. Episodes of self-terminated PVT/VF lasted 8.6 s [95% confidence interval (CI): 8.1–9.1] and shock-terminated lasted 13.9 s (13.6–14.3) (P < 0.001). Recordings from patients with primarily electrical pathologies displayed higher DF and RI values than those from patients with primarily structural pathologies (P < 0.05) independently of ventricular function or antiarrhythmic drug therapy. Regardless of the underlying pathology, the average DF and RI intensities were lower in self-terminated than shock-terminated episodes [DF: 3.67 (4.04–4.58) vs. 4.32 (3.46–3.93) Hz, P < 0.001; RI: 0.53 (0.48–0.56) vs. 0.63 (0.60–0.65), P < 0.001]. In a multivariate analysis controlled by the type of pathology and clinical variables, regularity remained an independent predictor of self-termination [hazard ratio: 0.954 (0.928–0.980)]. Receiver operating characteristic (ROC) curve analysis of DF and RI intensities demonstrated increased predictability for self-termination in time with 95% CI above the 0.5 cut-off limit at about t = 8.6 s and t = 6.95 s, respectively. Conclusion Consistent with the notion that fast organized sources maintain PVT/VF in humans, reduction of frequency and regularity correlates with early self-termination. Our findings might help generate ICD methods aiming to reduce inappropriate shock deliveries.

Introduction and objectives: We present the data corresponding to implantable cardioverter-defibrillator (ICD) implants in Spain in 2020. Methods: The data in this registry were drawn from implantation centers, which voluntarily completed a data collection sheet. Results: In 2020, 7056 implant sheets were received compared with 7106 reported by Eucomed (European Confederation of Medical Suppliers Associations), indicating that data were collected from 99% of the devices implanted in Spain. Completion of the implant sheet ranged from 99.8% for the field ``name of the implanting hospital'' to 2.6% for the variable ``referral hospital''. A total of 173 hospitals performed ICD implants and participated in the registry, which is a similar figure to that in 2019 (n=172). The total rate of registered implants was 149/million inhabitants (150 according to Eucomed), revealing a slight reduction in implants in Spain in 2020 as a result of the impact of the COVID-19 pandemic. This reduction was uneven among the autonomous communities. Conclusions: The Spanish Implantable Cardioverter Defibrillator Registry for 2020 shows an improvement in the rate of implants reported and a reduction in the number of ICD implants, which likely reflects the decrease in hospital activity not related to the treatment of COVID-19 infection. Similar to previous years, the total number of implants in Spain is still much lower than the average for the European Union, with an increase in the differences between Spanish autonomous communities. (C) 2021 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Background Large‐scale studies describing modern populations using an implantable cardioverter‐defibrillator (ICD) are lacking. We aimed to analyze the incidence of arrhythmia, device interventions, and mortality in a broad spectrum of real‐world ICD patients with different heart disorders. Methods and Results The UMBRELLA study is a prospective, multicenter, nationwide study of contemporary patients using an ICD followed up by remote monitoring, with a blinded review of arrhythmic episodes. From November 2005 to November 2017, 4296 patients were followed up. After 46.6±27.3 months, 16 067 episodes of sustained ventricular arrhythmia occurred in 1344 patients (31.3%). Appropriate ICD therapy occurred in 27.3% of study population. Patients with ischemic cardiomyopathy (hazard ratio [HR], 1.51; 95% CI, 1.29–1.78), dilated cardiomyopathy (HR, 1.28; 95% CI, 1.07–1.53), and valvular heart disease (HR, 1.94; 95% CI, 1.43–2.62) exhibited a higher risk of appropriate ICD therapies, whereas patients with hypertrophic cardiomyopathy (HR, 0.72; 95% CI, 0.54–0.96) and Brugada syndrome (HR, 0.25; 95% CI, 0.14–0.45) showed a lower risk. All‐cause death was 13.4% at follow‐up. Ischemic cardiomyopathy (HR, 3.09; 95% CI, 2.58–5.90), dilated cardiomyopathy (HR, 3.33; 95% CI, 2.18–5.10), and valvular heart disease (HR, 3.97; 95% CI, 2.25–6.99) had the worst prognoses. Delayed high‐rate detection was enabled in 39.7% of patients, and single‐zone programming occurred in 52.6% of primary prevention patients. Both parameters correlated with lower risk of first appropriate ICD therapy, with no excess risk of mortality. The rate of inappropriate shocks at follow‐up was low (6%) and did not differ among type of ICD but was lower in SmartShock‐capable devices. Conclusions Irrespective of the cause, contemporary ICD patients with heart failure–related disorders had a similar risk of ICD life‐saving interventions and death. Current ICD programming recommendations still need to be implemented. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NTC01561144.

Introduction and objectives We present the data corresponding to implantable cardioverter-defibrillator (ICD) implants in Spain in 2019. Methods The data were drawn from implant centers voluntarily completing a data collection sheet. Results In 2019, 7003 implant sheets were received compared with the 7389 reported by Eucomed (European Confederation of Medical Suppliers Associations), indicating that data were collected from 94.8% of the devices implanted in Spain. Completion of the implant sheet ranged from 99.7% in the field “name of the implanting hospital” to 17.8% in the variable “reference hospital”. In 2019, 172 hospitals performed ICD implants and participated in the registry, a figure similar to that of 2018 (173). The total rate of registered implants was 149/million inhabitants; the rate reported by Eucomed was 157. Although this value represents the highest in the historical series, it is still much lower than the average rate of ICD implants in Europe (303). Conclusions The Spanish Implantable Cardioverter-Defibrillator Registry for 2019 reflects a growth in the number of ICD implants and is the year with the highest number of ICD implants in Spain. However, similar to previous years, the total number of implants in Spain is still much lower than the European Union average, with substantial differences between Spanish autonomous communities.

Resumen: Objetivo: El bloqueo interauricular (BIA) es una entidad asociada con un mayor riesgo de presentar fibrilación auricular (FA), constituyendo el denominado síndrome de Bayés. El objetivo de nuestro estudio fue definir la prevalencia de BIA en pacientes menores de 65 años sometidos a cirugía cardiaca y determinar si existe una asociación entre la presencia de BIA y la aparición de FA postoperatoria. Método: Se incluyeron un total de 207 pacientes. Se definió BIA parcial como onda P > 120 ms. Se definió BIA avanzado como onda P > 120 ms con morfología bifásica en derivaciones inferiores. Se determinó la frecuencia de aparición de FA postoperatoria y se realizó un análisis comparativo entre los pacientes que presentaron y los que no presentaron esta arritmia. Resultados: La prevalencia de BIA fue del 78.3% (parcial, 66.2%; avanzado, 12.1%). La frecuencia de aparición de FA fue del 28.5% de forma global, siendo mayor en los pacientes con BIA avanzado (44%) comparado con pacientes con BIA parcial (27.7%) y sin BIA (24.4%). Los pacientes que presentaron FA fueron significativamente mayores, con niveles más elevados de NTproBNP y presentaron mayor prevalencia de dilatación auricular y de patología tiroidea. El análisis multivariable demostró una asociación independiente entre BIA avanzado y FA postoperatoria. Conclusiones: El BIA es una entidad frecuente en pacientes sometidos a cirugía cardiaca. En nuestro estudio, el BIA avanzado se asocia de forma independiente con una mayor frecuencia de FA postoperatoria en pacientes menores de 65 años sometidos a cirugía cardiaca. Abstract: Objective: Interatrial block (IAB) is a well-known entity that is associated with an increased risk of atrial fibrillation (AF). This association is called Bayes’ syndrome. The aim of our study was to define the prevalence of IAB among patients younger than 65 years undergoing cardiac surgery and determine whether there is an association between the presence of interatrial conduction delay and postoperative atrial fibrillation (POAF). Method: A total of 207 patients were enrolled. Partial IAB was defined as P-wave > 120 ms. Advanced IAB was defined as P-wave > 120 ms + biphasic morphology in the inferior leads. Ocurrence of POAF was assessed and a comparative analysis was conducted between patients that did and did not develop AF. Results: IAB prevalence was 78.3% (partial 66.2%, advanced 12.1%). POAF occurred in 28.5% of all patients, and was more frequent among patients with advanced IAB (44%) compared to 27.7% and 24.4% of POAF among patients with partial IAB and without IAB, respectively. Patients who developed POAF were significantly older, had significantly higher NTproBNP, higher prevalence of atrial enlargement and thyroid disease. After multivariate analysis, advanced IAB was found to be independently associated with POAF. Conclusions: IAB is a frequent finding among patients undergoing cardiac surgery. According to our results, advanced IAB is independently associated with POAF in younger patients (

Resumen Introduccion y objetivos El Registro Espanol de Desfibrilador Automatico aporta datos de actividad desde el ano 2002. Metodos Los datos de este registro provienen de los centros implantadores, que cumplimentaron voluntariamente una hoja de recogida de datos. Resultados Durante 2017 se han recibido 6.273 hojas de implante, frente a las 6.429 comunicadas por Eucomed (European Confederation of Medical Suppliers Associations); por lo tanto, se han recogido datos del 97,6% de los dispositivos implantados en Espana. El cumplimiento oscilo entre el 99,7% en el campo «nombre del hospital implantador» y el 46,1% en la variable «clase funcional de la New York Heart Association». Comunicaron sus datos al registro 181 hospitales, lo que supone un aumento respecto a los que participaron en 2016 (177) y anos anteriores (169 en 2015, 162 en 2014, 154 en 2013 o 153 en 2012). Conclusiones Despues de varios anos de crecimiento en el numero de implantes por millon de habitantes, este ano se ha reducido. Como en los anos previos, el numero total de implantes en Espana sigue siendo muy inferior a la media de la Union Europea, y la diferencia continua aumentando, al igual que persisten las importantes diferencias entre comunidades autonomas espanolas.

Resumen En cardiologia, es esencial disponer de tecnologia adecuada, actualizada y en buenas condiciones de funcionamiento. En Espana, el marco economico ha impactado fuertemente en los programas de renovacion de tecnologia y la obsolescencia es un problema creciente. El actual informe trata de dar respuesta al momento y las condiciones que deben concurrir para plantear la actualizacion, el reemplazo o la adopcion de nuevas tecnologias en el ambito de la cardiologia.

Resumen Introduccion y objetivos Se presentan los resultados del Registro Espanol de Desfibrilador Automatico Implantable de 2016, elaborado por la Seccion de Electrofisiologia y Arritmias de la Sociedad Espanola de Cardiologia. Metodos Se envio de forma prospectiva a la Sociedad Espanola de Cardiologia la hoja de recogida de datos cumplimentada voluntariamente por cada equipo implantador. Resultados El numero de implantes comunicados fue 5.673 (el 85% del total de implantes estimado). La tasa de implantes fue 122 por millon de habitantes y la estimada, 143. Los primoimplantes fueron el 66,8%. Se obtuvieron datos de 177 hospitales (8 mas que en 2015). La mayoria de los implantes (81,9%) se realizaron en varones. La media de edad fue 62,7 ± 13,4 anos. La mayoria de los pacientes presentaban una disfuncion ventricular grave o grave-moderada y clase funcional II de la New York Heart Association . La cardiopatia mas frecuente fue la isquemica, seguida de la dilatada. Las indicaciones por prevencion primaria han sido el 62%. Los implantes realizados por electrofisiologos fueron el 81,2%. Conclusiones El Registro Espanol de Desfibrilador Automatico Implantable de 2016 recoge informacion del 85% de los implantes realizados en Espana. El numero de implantes ha crecido respecto a los datos de los ultimos anos. El porcentaje de indicacion por prevencion primaria ha aumentado con respecto al registro anterior.

Our paper proposes an empirical model to forecast banking fragility episodes using information from the credit funding sources. We predict the probability of occurrence of such events 3 and 6 months ahead, employing a Bayesian Model Averaging on logistic regressions. We perform prediction exercises for nine emerging economies under a broad set of prior specifications, whose results are evaluated using predictive ability tests and the signaling analysis approach. Our findings indicate that the increasing use of wholesale funds provide signals of banking frailness. Moreover, pseudo out-of-sample predictions show that our warning tool is able to forecast financial fragility events.

This paper provides evidence for the positive effects of fiscal decentralization on regional economic growth in Colombia since the enactment of the Political Constitution of 1991. The empirical strategy involved choosing a suitable estimator for the panel data approach, the augmented mean group (amg) estimator, that enabled unobserved determinants suggested by the literature to be added to traditional long-term explanatory factors. The strategy was supplemented with exercises that provided support for the results from (i) cross-sectional models for different periods and various control variables; (ii) a test of the hypothesis of complementarity between public goods provided by different jurisdictions (spillover effects), and (iii) an assessment of unconditional convergence in regional income differences.

Objectives This study sought to evaluate the incidence and clinical effect of coronary chronic total occlusions (CTOs) in patients with ischemic cardiomyopathy receiving an implantable cardioverter-defibrillator (ICD) for secondary prevention of sudden cardiac death (SCD). Background CTOs are common in patients with ischemic cardiomyopathy, which is the major cause of SCD. However, the impact of CTO in SCD survivors receiving an ICD is unknown. Methods A total of 425 patients who had survived an episode of ventricular arrhythmias and underwent ICD implantation for secondary prevention in 8 centers were included. Coronary angiogram, CTO angiographic characteristics, and ventricular arrhythmia pattern were centrally analyzed. Primary and secondary endpoints were appropriate ICD therapies and mortality during a median follow-up of 4.1 years, according to the presence of CTO in the baseline angiogram. Results Appropriate ICD therapies were higher in patients with CTO (51.7% vs. 36.3%; p = 0.001 at 4 years). Left ventricular ejection fraction (LVEF) (p = 0.015) and CTO (p = 0.001) were independent predictors of appropriate ICD therapy. Ventricular arrhythmia onset was associated to a shorter coupling interval and lower prematurity index in CTO patients. Defibrillator therapies were independently associated with worse LVEF (p = 0.046) and renal dysfunction (p = 0.023) among patients with CTO, and a tendency was observed in patients with better collateral flow (p = 0.093). Patients with poorer renal function (p = 0.029), LVEF (p = 0.041), and CTO (p = 0.033) experienced higher mortality rate. Conclusions Among ICD recipients for secondary prevention of SCD, coronary CTO conferred a higher risk of VA recurrence and mortality in long-term follow-up. Angiographic and VA patterns could provide insights into the mechanisms of SCD and may have implications for the use of interventions designed to limit ICD shocks in this high-risk population.

Background NYHA functional class (FC) is used for selection of heart failure (HF) patients who are candidates to primary prevention (PP) implantable cardioverter defibrillator (ICD) therapy. However, FC is subjectively estimated and concerns about its real prognostic value are still present in this setting. Purpose To compare whether mortality and arrhythmic risk are different, in a cohort of HF patients undergoing PP ICD-only implant, according to their FC. Methods All HF patients with left ventricle ejection fraction (LVEF) ≤35%, undergoing first prophylactic ICD-only implant were collected from the UMBRELLA nationwide registry (2006–2015). The sample was divided into three groups: no symptoms (NYHA I), mildly symptomatic patients (NYHA II) and severely symptomatic (NYHA III) patients. Outcomes were studied as follow: all-cause death, cardiovascular mortality and arrhythmia free survival (surrogate marker of sudden cardiac death) defined as survival free of first appropriate ICD therapy delivered in ventricular fibrillation (VF) window. Arrhythmic events were collected by remote monitoring and reviewed by a committee of experts. Results Six hundred and twenty one patients were identified (61.1±11.4 years, 87.3% male). Distribution of study groups was as follow: 101 patients in NYHA I; 411 in NYHA II; and 109 in NYHA III. More symptomatic patients were older and had higher prevalence of atrial fibrillation (AF) and chronic kidney disease (CKD). Higher rates of optimal medical treatment were present among study groups (beta-blockers: 92.1%; ACEI or ARB: 86.8%; aldosterone antagonists: 60.2%). After a median follow-up of 4.2 years (IQR, 2.7–5.7 years) 126 patients died (event rate: 20.3%). All-cause mortality was higher in patients with worse FC (13.9% vs. 18.3% vs. 32.9% for NYHA I, II and III respectively; p Figure 1 Conclusions In HF patients, prophylactic ICD seems to be useful in preventing death due to life threatening arrhythmias, regardless of the baseline FC. Nevertheless, the combination of NYHA class with other comorbidities may be useful to select those ICD candidates who obtain less survival benefit.

Efficacy and safety of dronedarone was shown in the ATHENA trial for paroxysmal or persistent atrial fibrillation (AF) patients. Further trials revealed safety concerns in patients with heart failure and permanent AF. This review summarizes insights from recent real-world studies and meta-analyses, including reports on efficacy, with focus on liver safety, mortality risk in patients with paroxysmal/persistent AF, and interactions of dronedarone with direct oral anticoagulants. Reports of rapidly progressing liver failure in dronedarone-prescribed patients in 2011 led to regulatory cautions about potential liver toxicity. Recent real-world evidence suggests dronedarone liver safety profile is similar to other antiarrhythmics and liver toxicity could be equally common with many Class III antiarrhythmics. Dronedarone safety concerns (increased mortality in patients with permanent AF) were raised based on randomized controlled trials (RCT) (ANDROMEDA and PALLAS), but comedication with digoxin may have increased the mortality rates in PALLAS, considering the dronedarone–digoxin pharmacokinetic (PK) interaction. Real-world data on apixaban–dronedarone interactions and edoxaban RCT observations suggest no significant safety risks for these drug combinations. Median trough plasma concentrations of dabigatran 110 mg during concomitant use with dronedarone are at acceptable levels, while PK data on the rivaroxaban–dronedarone interaction are unavailable. In RCTs and real-world studies, dronedarone significantly reduces AF burden and cardiovascular hospitalizations, and demonstrates a low risk for proarrhythmia in patients with paroxysmal or persistent AF. The concerns on liver safety must be balanced against the significant reduction in hospitalizations in patients with non-permanent AF and low risk for proarrhythmias following dronedarone treatment.

This article presents the data corresponding to automated implantable cardioverter-defibrillator (ICD) implants in Spain reported to the Spanish Registry in 2018.The data in this registry include both primary implants and generator replacements and were gathered from a data collection sheet voluntarily completed by implantation centers.In 2018, 6421 implant sheets were received compared with 7077 reported by Eucomed (European Confederation of Medical Suppliers Associations). This represents data on 90.7% of the devices implanted in Spain. Compliance ranged between 99.6% for the field "name of the implanting hospital" and 12.4% for "population of residence". A total of 173 hospitals reported their data to the registry, representing a slight decrease compared with hospitals participating in 2017 (n=181).After the reduction in ICD implants in 2017, the number of implants increased in 2018, with the highest number of ICDs implanted in Spain. The total number of implants remains much lower than the European Union average, with substantial differences between autonomous communities.

Background: Concerns about the efficacy of prophylactic ICD in non-ischemic cardiomyopathy (NICM) heart failure (HF) patients are still present. We aimed to assess whether survival and arrhythmic risk were different among ischemic cardiomyopathy (ICM) and NICMICD-only patients, along with specific predictors for mortality. Methods: HF patients undergoing ICD-only implant were extracted from the nationwide multicenter UMBRELLA registry. Arrhythmic events were collected by remote monitoring and reviewed by a committee of experts. Results: 782 patients (556 ICM; 226 NICM) were recruited: mean ejection fraction of 26.6%; 83.4% in NYHA class II-III; mean QRS duration of 108.9 ms (only 14.9% with QRS > 130 ms). After 4.35 years of mean follow-up, all-cause mortality rate was 4.2%/year. In propensity-score (PS) analysis no survival differences between ICM and NICM subgroups appeared (mortality rates: 19.4% vs. 20%, p = 0.375). Age (hazard ratio [HR] = 1.02, p = 0.009), diabetes (HR = 2.61, p = 0.001), chronic obstructive pulmonary disease (HR = 2.13, p = 0.002), and previous HF (HR = 2.28, p = 0.027) correlated with increased mortality for the entire population, however atrial fibrillation (AF) (HR = 2.68, p = 0.002) and chronic kidney disease (HR = 3.74, p = 0.001) emerged as specific predictors in NICM patients. At follow-up, 134 patients (17.1%) were delivered a first appropriate ICD therapy (5.1%/year) without significant differences between ICM and NICM patients in the PS analysis (17.6% vs. 15.8%, p = 0.968). ICD shocks were associated with a higher mortality (HR = 2.88, p < 0.001) but longer detection windows (HR = 0.57, p = 0.042) correlated with fewer appropriate therapies. Conclusions: Mortality and arrhythmia free survival is similar among ICM and NICMHF patients undergoing ICD-only implant for primary prevention strategy. (c) 2018 Elsevier B.V. All rights reserved.

Purpose Comparisons of the efficacy of dual- vs. single-chamber implantable cardioverter defibrillators (ICDs) in preventing inappropriate shocks have had contradictory results. We investigated whether dual-chamber devices have a lower risk of inappropriate shocks and the specific role of supraventricular tachycardia (SVT) discriminators. Methods All heart failure (HF) patients without an indication for pacing and implanted with a prophylactic ICD were recruited from the nationwide multicenter UMBRELLA registry. Arrhythmic events were collected by remote monitoring and reviewed by a committee of experts. Results Among 782 patients, single-chamber ICDs were implanted in 537 (68.7%) and dual-chamber devices in 245 (31.3%). During a mean follow-up of 52.224.5months, 109 inappropriate shocks were delivered in 49 patients (6.2%). In the propensity-score-matched analysis, dual-chamber ICDs were related to lower rates of inappropriate shocks as compared to single-chamber devices (0.9% vs. 11.8%, p=200bpm emerged as protective factors.