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Heavily calcified coronary lesions increase the complexity of percutaneous coronary interventions (PCI) and represent a challenge for interventional cardiologists. They are an important cause of stent underexpansion and poor clinical outcome. Nowadays, there are different dedicated devices which enhance the chances of success. Rotational atherectomy is the first-line modality which permits to cross balloons or stents through severe calcified lesions. However, when circumferential deep calcium plaques exist may not be enough to achieve adequate expansion of these devices. In these cases, the complementary use of intracoronary lithotripsy ("RotaTripsy") can be an effective approach that further modifies the calcified plaque and enables optimal stent implantation. We present the first case series undergoing PCI using "RotaTripsy" technique.

Introduction and objectives Neoatherosclerosis is one of the causes of in-stent restenosis (ISR). Our objective was to evaluate the influence of neoatherosclerosis on prognosis and treatment response in patients with ISR. Methods This is a pooled analysis of the optical coherence tomography (OCT)-substudies of 2 multicenter, randomized clinical trials, RIBS IV and V, comparing treatment with paclitaxel-coated balloon vs everolimus-eluting stent in patients with ISR. OCT evaluation was performed at baseline and at 6 to 9 months. Neoatherosclerosis was defined in baseline OCT as neointima with calcified or lipid content. We evaluated the angiographic and OCT results at 6 to 9 months and the occurrence of major adverse cardiovascular events at 3 years of follow-up in patients with and without neoatherosclerosis treated with paclitaxel-coated balloon or everolimus-eluting stents. Results Sixty-four patients underwent OCT at the time of the index procedure. Neoatherosclerosis was documented in 23 (36%) lesions. Angiographic follow-up at 6 to 9 months showed no differences in restenosis [5 (24%) vs 6 (15%) P = .49], minimum lumen diameter (1.79 ± 0.7 vs 1.94 ± 0.6 mm; P = .41) or late loss (0.33 ± 0.7 vs 0.15 ± 0.5; P = .34) in patients with and without neoatherosclerosis, respectively. Follow-up OCT confirmed the absence of differences in quantitative parameters and the characteristics of tissue coverage between the 2 groups. At 3 years of follow-up, the major adverse cardiovascular events rate was 3 (13%) vs 5 (12%) in the neoatherosclerosis and nonneoatherosclerosis groups (HR, 0.94; 95%CI, 0.22-3.93; P = .93). Conclusions In this limited study population, OCT-defined neoatherosclerosis did not seem to influence acute and long-term outcomes in patients randomized to paclitaxel-coated balloon or everolimus-eluting stents for ISR.

INTRODUCTION: The concurrency of both, acute stroke and acute myocardial infarction in normal conditions, outside the pandemic is rare. Coagulopathy has been associated with the inflammatory phase of coronavirus disease (COVID-19) and might be involved in this concurrency. CASES REPORT: We describe 2 patients with previous mild or no symptoms of COVID-19, admitted for acute stroke with recent/simultaneous myocardial infarction in whom admission polymerase chain reaction was negative but serologic testing diagnosed COVID-19. In these patients, concurrent stroke and myocardial infarction could have been promoted by COVID-19 infection. Management and evolution are detailed, and their contacts to confirm the COVID-19 infection. Pathogenic analysis of possible hypercoagulation state is described suggesting the hypothesis of endothelial dysfunction as the strongest mechanism involved in thrombus formation after the acute phase of COVID-19 infection. CONCLUSIONS: Our experience with these cases suggests that patients with mild symptoms can also present thromboembolic complications once the acute phase of COVID-19 infection has passed.

Resumen Introduccion y objetivos La neoateroesclerosis es una de las causas de la reestenosis en el stent (RS). Nuestro objetivo es evaluar la influencia de la neoateroesclerosis en el pronostico y la respuesta al tratamiento de los pacientes con RS. Metodos Se trata de un analisis conjunto de los subestudios de tomografia de coherencia optica (OCT) de los RIBS IV y V, 2 ensayos clinicos aleatorizados y multicentricos que comparan el tratamiento con un balon recubierto con paclitaxel frente al stent liberador de everolimus en pacientes con RS. La evaluacion con OCT se realizo basalmente y a los 6-9 meses. La neoateroesclerosis se definio en la OCT basal como una neointima con contenido calcificado o lipidico. Se evaluaron los resultados angiograficos y por OCT a los 6-9 meses y la aparicion de eventos adversos cardiovasculares mayores a los 3 anos de seguimiento en pacientes con y sin neoateroesclerosis tratados con balon recubierto con paclitaxel o stent liberador de everolimus. Resultados Se estudio mediante OCT a 64 pacientes en el momento del procedimiento. Se documento neoateroesclerosis en 23 lesiones (36%). El seguimiento angiografico a los 6-9 meses no mostro diferencias entre los pacientes con y sin neoateroesclerosis en reestenosis (5 [24%] frente a 6 [15%]; p = 0,49), diametro luminal minimo (1,79 ± 0,7 frente a 1,94 ± 0,6 mm; p = 0,41) o perdida tardia (0,33 ± 0,7 frente a 0,15 ± 0,5; p = 0,34). El seguimiento con OCT confirmo la ausencia de diferencias en los parametros cuantitativos y las caracteristicas del tejido de recubrimiento entre los 2 grupos. A los 3 anos de seguimiento, la incidencia de eventos fue de 3 (13%) frente a 5 (12%) en los grupos con y sin neoateroesclerosis respectivamente (HR = 0,94; IC95%, 0,22-3,93; p = 0,93). Conclusiones En este estudio con una pequena muestra de pacientes aleatorizados a tratamiento con balon recubierto con paclitaxel o stent liberador de everolimus por RS, no parece que la presencia de neoateroesclerosis influya en los resultados agudo y a largo plazo.

Objectives The objective was to evaluate the results of valve-in-valve procedures performed with the Allegra device. Background Transcatheter aortic valve implantation to treat degenerated biological aortic valves (valve-in-valve) is an established procedure in most catheterization laboratories, but the results are poorer than procedures done in native aortic stenosis. The Allegra device (Biosensors, Morges, Switzerland) has an excellent design to treat these patients. Methods All patients with severely degenerated biological aortic valve treated with the Allegra device in centers from Spain until December 2020 were included (n = 29). Hemodynamic results and 30-day clinical outcomes were evaluated. The predominant hemodynamic failure was stenosis in 15, regurgitation in 11, and a combination of both in 3 cases. Time from aortic valve replacement to valve-in-valve procedure was 8.4 ± 3.9 years (range 3.3-22.1). Results After the procedure, maximum and mean trans-valvular gradients were 17.4 ± 12.3 and 8.4 ± 6.1 mmHg, respectively. Device success was obtained in 28 patients (96.6%). In one patient with a degenerated 19 mm prosthetic valve, mean gradient after the procedure was 22 mmHg. No patients had a para-valvular leak grade >1. There were no deaths during the hospitalization or at 30 days and one patient suffered a stroke. Conclusions The Allegra trans-catheter aortic valve offers optimal hemodynamic results in patients with severely degenerated biological aortic valve.

Eighty-five-year-old woman with unstable angina with serious and heavily calcified lesions in proximal right coronary arteries (figure 1A, asterisk) and proximal and mid left anterior descending coronary artery (figure 1B, asterisk). Rotational atherectomy was performed in the right coronary artery using the RotaPro system (Boston Scientific, United States) (figure 1C) and a drug-eluting stent was implanted with good results (figure 1D) as confirmed by the intracoronary ultrasound (figure 1E). Informed consent was obtained from the patient. Figure 1. After the catheterization of the left main coronary artery (LMCA) the left anterior descending coronary artery was crossed. A 1.5 mm olive-shaped burr was advanced in the DynaGlide mode towards the LMCA, which is when the guide catheter was extubated and an Ellis type III perforation occurred in the LMCA (figure 2A, asterisk; video 1 of the supplementary data); it is possible that an unnoticed deformation of the guidewire moved the burr towards the vessel wall. The patient showed cardiac tamponade that was treated with pericardiocentesis. A 4 × 15 mm PK-Papyrus covered coronary stent (Biotronik, Germany) was implanted in the LMCA without jailing the bifurcation (figure 2B). However, a discrete leak of contrast still occurred (figure 2C, asterisk). After postdilatation with a 4.5 mm...

Introduction and objectives Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome. The characteristics and in-hospital clinical course of patients with SCAD in Spain remain unknown. Methods We present data from consecutive patients included in the national prospective SCAD registry. Angiographic analysis was performed in a centralized core laboratory. Results Between June 2015 and April 2019, we included 318 patients with SCAD (358 lesions) from 31 centers. Median age was 53 years, and 88% were women. The most frequent presentation was non–ST-segment elevation acute myocardial infarction (53%). The most frequently involved artery was the left anterior descending coronary artery (44%), predominantly affecting the distal segments (39%) and secondary branches (54%). Most lesions (62%) appeared on angiography as intramural hematoma, without double lumen. Conservative management was selected as the initial approach in most patients (78%). During the index admission, 6% of patients had a major adverse event and 4 patients (1.3%) died. Independent predictors of adverse events were initial management with percutaneous coronary intervention (OR, 5.97; P = .004) and angiographic presentation as intramural hematoma (OR, 4.96; P = .028). Conclusions In Spain, SCAD affects mainly middle-aged women. In most patients, the initial management strategy was conservative with excellent in-hospital survival. Initial management with percutaneous coronary intervention and angiographic presentation as intramural hematoma were related to the presence of in-hospital adverse events. Registered at ClnicalTrials.gov (Identifier: NCT03607981).

BACKGROUND Spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS) constitute two relatively common nonatherosclerotic causes of acute coronary syndrome particularly frequent in women. METHODS This study sought to compare the baseline clinical and angiographic characteristics and in-hospital outcomes of patients from two large prospective registries on SCAD and TTS (the prospective nation-wide Spanish SCAD Registry and a prospective single-center TTS registry). RESULTS A total of 318 SCAD and 106 TTS consecutive patients were included. Most patients in both groups (88%) were women. Patients in the TTS group were older [74 (interquartile range, IQR 67-81) vs. 53 years-old (IQR 47-60), P < 0.001] and presented a higher prevalence of cardiovascular risk factors. Precipitating triggers were more frequent in TTS (56% vs. 42%, P = 0.009) but emotional stress was more common in the SCAD group (25% vs. 15%, P = 0.037). TTS patients showed a reduced release of cardiac biomarkers but had more severe left ventricular dysfunction (ejection fraction

Introduction and objectives: The Lotus Valve device (Boston Scientific) is a second-generation fully-retrievable and repositionable transcatheter aortic valve. We report the initial multicenter experience with the Lotus valve in the management of patients with severe aortic stenosis. Methods: Observational study that described the short and long-term results of implanting the Lotus valve in 8 Spanish and Portuguese centers from March 2014 through April 2016. Results: The study included 102 patients (mean age 80.4 ± 6.1 years; STS score 5.2% ± 3.3%) with severe symptomatic aortic stenosis (mean aortic valve area 0.66 ± 0.17 cm2, aortic gradients 74.3 / 45.6 mmHg). The valve was successfully implanted in 100 patients (98%), with significant improvement in both the peak and mean aortic valve gradients and with only one patient showing moderate paravalvular regurgitation. Upon hospital discharge, mortality rate was 3.9% while the stroke rate was 2.9%. No cases of valve embolization, ectopic valve deployment or additional valve implantation (valve-in-valve) were seen. Thirty-three patients (32.3%) received a permanent pacemaker. Conclusions: The Lotus Valve System is effective and safe for the management of patients with severe symptomatic aortic stenosis. In particular, considering the low rate of periprosthetic regurgitation and lack of complications like embolization or ectopic valve deployment; however at the expense of a high pacemaker implantation rate.

QUESTION: How often do you see nonrevascularizable patients with refractory angina today? ANSWER: Refractory angina is defined as chronic angina that cannot be controlled even with the use of optimal medical therapy and where all revascularization options have failed.1,2 It is a common entity whose prevalence is on the rise due to the ageing of population and the improved prognosis of ischemic heart disease. It is estimated that between 5% and 10% of the patients with chronic ischemic heart disease can develop refractory angina. Its annual incidence rate is between 50 000 and 100 000 cases in the United States and between 30 000 and 50 000 cases in Europe.1,2 On the other hand, we know that around 10% of all coronary angiographies performed indicate that it is not possible to give efficient options of revascularization. According to the activity registry in interventional cardiology in Spain from 2019,3 this figure would be up to 15 000 patients each year, and it is reasonable to think that a significant percentage can suffer refractory angina. These patients often remain asymptomatic which negatively impacts their quality of life and. Actually, to this day, we still do not have effective therapeutic options to offer. Multidisciplinary approach...

espanolIntroduccion y objetivos: El objetivo del estudio fue investigar si la evaluacion no invasiva del indice de calcificacion coronaria mediante tomografia computarizada cardiaca multidetector (TCMD) puede predecir la necesidad de una aterectomia rotacional (AR) electiva durante la intervencion coronaria percutanea. Metodos: Se incluyeron pacientes diagnosticados de estenosis coronaria grave con placas moderadamente o gravemente calcificadas durante la angiografia coronaria. Esos pacientes se sometieron a la cuantificacion del indice de calcificacion coronaria con la escala de Agatston utilizando TCMD y posteriormente a intervencion percutanea. Solo fueron tratadas con AR las lesiones que se consideraba que no era posible cruzar ni dilatar, segun un protocolo de revascularizacion predisenado. Ninguno de los operadores conocia de antemano los resultados de la TCMD. Segun el protocolo del estudio, en el analisis estadistico se incluyeron variables clinicas, angiograficas y relacionadas con la puntuacion Agatston. Durante el seguimiento se estudiaron los resultados a corto y largo plazo en ambos grupos. Resultados: Se analizaron 40 pacientes: 20 que recibieron AR y 20 con intervencion coronaria percutanea convencional. La mayoria se incluyo despues de un sindrome coronario agudo y tenian una anatomia coronaria compleja (puntuacion media de la escala Syntax de 25 puntos). La creatinina y la puntuacion de Agatston por lesion fueron los unicos factores predictivos de la AR. No se observaron diferencias significativas en el pronostico dentro del hospital o a largo plazo. Un nuevo parametro, el indice CAC-Cre, fue util para predecir la necesidad de AR. Conclusiones: El analisis de la calcificacion de las arterias coronarias mediante la puntuacion de Agatston mejora la evaluacion no invasiva de las placas coronarias complejas antes de la intervencion coronaria percutanea. La puntuacion de Agatston por lesion, la creatinina serica y el indice CAC-Cre son parametros utiles para predecir la necesidad de una AR electiva durante la intervencion coronaria percutanea. EnglishIntroduction and objectives: This study aims to investigate if the non-invasive assessment of coronary calcium score using multislice cardiac computerized tomography (MSCT) may anticipate the need for elective rotational atherectomy (RA) during percutaneous coronary intervention. Methods: Patients were considered eligible for the study after receiving a diagnosis of severe coronary stenosis with moderate or severely calcified plaques during index coronary angiography. Those patients underwent the Agatston coronary artery calcium (CAC) score quantification using the MSCT and then underwent percutaneous intervention. Only those lesions considered non-crossable or non-dilatable according to a pre-specified revascularization protocol were treated with RA. All operators were blinded to the MSCT results. According to the study protocol, clinical, angiographic and Agatston-related variables were included in the statistical analysis. Short and long-term outcomes were investigated in both treatment groups during follow-up. Results: A total of 40 patients were included in the analysis: 20 underwent RA and 20 conventional percutaneous coronary interventions. Most patients were included after suffering from an acute coronary syndrome and had complex coronary anatomy (mean Syntax score, 25 points). The logistic regression analysis showed that creatinine levels and the per-lesion Agatston score were the only predictors of RA. No significant differences were observed regarding in-hospital or long-term procedural outcomes. A novel parameter, the CAC-Cre index, was found to be useful to anticipate the need for RA. Conclusions: Coronary artery calcification analysis using the Agatston score is a simple technique that improves the non-invasive assessment of complex coronary plaques prior to percutaneous coronary intervention. The per-lesion Agatston score, serum creatinine levels, and the CAC-Cre index may become useful parameters to anticipate the need for elective RAs during percutaneous coronary intervention.

Introduction and objectives: This study aims to investigate if the non-invasive assessment of coronary calcium score using multislice cardiac computerized tomography (MSCT) may anticipate the need for elective rotational atherectomy (RA) during percutaneous coronary intervention. Methods: Patients were considered eligible for the study after receiving a diagnosis of severe coronary stenosis with moderate or severely calcified plaques during index coronary angiography. Those patients underwent the Agatston coronary artery calcium (CAC) score quantification using the MSCT and then underwent percutaneous intervention. Only those lesions considered non-crossable or non-dilatable according to a pre-specified revascularization protocol were treated with RA. All operators were blinded to the MSCT results. According to the study protocol, clinical, angiographic and Agatston-related variables were included in the statistical analysis. Short and long-term outcomes were investigated in both treatment groups during follow-up. Results: A total of 40 patients were included in the analysis: 20 underwent RA and 20 conventional percutaneous coronary interventions. Most patients were included after suffering from an acute coronary syndrome and had complex coronary anatomy (mean Syntax score, 25 points). The logistic regression analysis showed that creatinine levels and the per-lesion Agatston score were the only predictors of RA. No significant differences were observed regarding in-hospital or long-term procedural outcomes. A novel parameter, the CAC-Cre index, was found to be useful to anticipate the need for RA. Conclusion: Coronary artery calcification analysis using the Agatston score is a simple technique that improves the non-invasive assessment of complex coronary plaques prior to percutaneous coronary intervention. The per-lesion Agatston score, serum creatinine levels, and the CAC-Cre index may become useful parameters to anticipate the need for elective RAs during percutaneous coronary intervention.

espanolIntroduccion y objetivos: El dispositivo Lotus (Boston Scientific, Estados Unidos) es una protesis valvular aortica transcateter de segunda generacion, completamente recuperable y reposicionable. Se presenta la experiencia inicial con la protesis Lotus en un registro multicentrico. Metodos: Estudio observacional que reporta los resultados a corto y largo plazo del implante transfemoral de protesis Lotus entre marzo de 2014 y abril de 2016 en 8 centros de Espana y Portugal. Resultados: Se incluyeron 102 pacientes (edad media 80,4 ± 6,1 anos, indice STS medio 5,2% ± 3,3%) con estenosis aortica grave sintomatica (area valvular media 0,66 ± 0,17 cm2, gradientes 74,3/45,6 mmHg). Se implanto con exito el dispositivo en 100 pacientes (98%), con mejoria significativa de los gradientes maximo y medio valvular, y un solo caso de regurgitacion periprotesica moderada. No hubo ninguna embolizacion ni necesidad de implante de una nueva protesis intravalvular. Hasta el alta hospitalaria, la mortalidad fue del 3,9% y la tasa de ictus fue del 2,9%. En 33 pacientes (32,3%) fue necesario el implante de marcapasos definitivo. Conclusiones: La valvula Lotus es eficaz y segura para el tratamiento de pacientes con estenosis aortica grave sintomatica. Destacan la escasa tasa de insuficiencia periprotesica y la ausencia de complicaciones derivadas del mal posicionamiento o la embolizacion de la protesis, a costa de un alta incidencia de implante de marcapasos. EnglishIntroduction and objectives: The Lotus Valve device (Boston Scientific) is a second-generation fully-retrievable and repositionable transcatheter aortic valve. We report the initial multicenter experience with the Lotus valve in the management of patients with severe aortic stenosis. Methods: Observational study that described the short and long-term results of implanting the Lotus valve in 8 Spanish and Portuguese centers from March 2014 through April 2016. Results: The study included 102 patients (mean age 80.4 ± 6.1 years; STS score 5.2% ± 3.3%) with severe symptomatic aortic stenosis (mean aortic valve area 0.66 ± 0.17 cm2, aortic gradients 74.3 / 45.6 mmHg). The valve was successfully implanted in 100 patients (98%), with significant improvement in both the peak and mean aortic valve gradients and with only one patient showing moderate paravalvular regurgitation. Upon hospital discharge, mortality rate was 3.9% while the stroke rate was 2.9%. No cases of valve embolization, ectopic valve deployment or additional valve implantation (valve-in-valve) were seen. Thirty-three patients (32.3%) received a permanent pacemaker. Conclusions: The Lotus Valve System is effective and safe for the management of patients with severe symptomatic aortic stenosis. In particular, considering the low rate of periprosthetic regurgitation and lack of complications like embolization or ectopic valve deployment; however at the expense of a high pacemaker implantation rate.

Seventy-four-year-old male patient admitted with non-ST-elevation acute myocardial infarction. The coronary angiography performed revealed the presence of right coronary artery stenosis with a giant coronary artery aneurysm (CAA) and high thrombus burden (figure 1A). Dual antiplatelet and anticoagulation therapies were recommended for its exclusion in a staged procedure. After confirmation of thrombus reduction (figure 1B), predilatation was attempted and both the length of the CAA (40 mm) and the landing zone were measured on the intravascular ultrasound (IVUS) (figure 1C). From proximal to distal, two 5 mm x 26 mm-PK-Papyrus covered coronary stents (PCS) (Biotronik, Switzerland) were deployed. The overlapping stent zone was confirmed using the StentBoost imaging modality (Philips Medical Systems, Nederland) (figure 1D) and the stent was deployed under fluoroscopic guidance in the absence of any respiratory movements. The subsequent angiography performed revealed an incomplete CAA exclusion (figure 1E) despite postdilatation with a 5.5 mm noncompliant balloon (NCB). The IVUS confirmed the existence of a gap between both stents due to stent shortening (E2, figure 1E and video 1 of the supplementary data). Another 5 mm × 15 mm PCS was deployed followed by postdilatation with a 5.5 mm NCB. Both the angiography and the IVUS confirmed the...

The angiotensin-converting enzyme 2 (ACE2) is a type I integral membrane that was discovered two decades ago. The ACE2 exists as a transmembrane protein and as a soluble catalytic ectodomain of ACE2, also known as the soluble ACE2 that can be found in plasma and other body fluids. ACE2 regulates the local actions of the renin-angiotensin system in cardiovascular tissues, and the ACE2/Angiotensin 1-7 axis exerts protective actions in cardiovascular disease. Increasing soluble ACE2 has been associated with heart failure, cardiovascular disease, and cardiac remodelling. This is a review of the molecular structure and biochemical functions of the ACE2, as well we provided an updated on the evidence, clinical applications, and emerging potential therapies with the ACE2 in heart failure, cardiovascular disease, lung injury, and COVID-19 infection.

Background Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Clinical features, angiographic findings, management and outcomes of SCAD in elderly patients remain unknown. Methods The Spanish multicenter prospective SCAD registry included 318 consecutive patients with SCAD diagnosis. Patients were classified according to age in two groups: Results A total of 55 patients (17%) were 65 or older (Table). Elderly patients had more often hypertension (29% vs 76%, p Conclusions Elderly patients with SCAD show different clinical and angiographic characteristics and they receive distinct management. Short-term outcomes do not significantly differ from those seen in younger patients. Funding Acknowledgement Type of funding source: None

Introduction and objectives The COVID-19 outbreak has had an unclear impact on the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to assess changes in STEMI management during the COVID-19 outbreak. Methods Using a multicenter, nationwide, retrospective, observational registry of consecutive patients who were managed in 75 specific STEMI care centers in Spain, we compared patient and procedural characteristics and in-hospital outcomes in 2 different cohorts with 30-day follow-up according to whether the patients had been treated before or after COVID-19. Results Suspected STEMI patients treated in STEMI networks decreased by 27.6% and patients with confirmed STEMI fell from 1305 to 1009 (22.7%). There were no differences in reperfusion strategy (> 94% treated with primary percutaneous coronary intervention in both cohorts). Patients treated with primary percutaneous coronary intervention during the COVID-19 outbreak had a longer ischemic time (233 [150-375] vs 200 [140-332] minutes, P

Heavy calcification remains one of the greatest challenges in the treatment of coronary artery disease (CAD), especially in subjects with an acute coronary syndrome (ACS). In the present case series study of high-risk patients with ACS, including both STEMI and NSTEMI, we performed a rota-lithotripsy—a combination of rotational atherectomy with subsequent intravascular lithotripsy—as a novel bail-out strategy to facilitate stent delivery in a tortuous calcified coronary artery.

A 76-year-old patient underwent coronary angiography due to progressive angina. He presented a severely calcified diffuse disease at proximal-mid left anterior descending artery ([Figure 1A][1]). ![Figure 1][2] Figure 1 Initial Angiographic and Intravascular Ultrasound Findings

Introduction and objectives Malignant pericardial effusion has a high recurrence rate after pericardiocentesis. We sought to confirm the efficacy and feasibility of percutaneous balloon pericardiotomy (PBP) as the initial treatment of choice for these effusions. Methods Retrospective analysis of the clinical, echocardiographic, and follow-up characteristics of a consecutive series of PBP carried out in a single-center in patients with advanced cancer. Results Forty PBPs were performed in 35 patients with a mean age of 61.8years (55% females). Thirty-four patients had pathologically confirmed metastatic neoplastic disease (26 patients with tumoral cells in the pericardial liquid), 7 had previously required pericardiocentesis, and in the remaining patients PBP was the first treatment for the effusion. All patients had a severe circumferential effusion (29mm by mean on transthoracic echocardiography [TTE]), and most presented evidence of hemodynamic compromise on TTE. In all cases, the procedure was successful, there were no acute complications, and it was well tolerated at the first attempt. There were no infectious complications during follow-up. One patient developed a pseudoaneurysm in the right ventricle, even though no further treatment was required. Eight patients needed a new pericardial procedure: 3 had elective pericardial window surgeries and 5 had a second PBP. Eighty percent of patients died during follow-up (57days by mean from the PBP) regarding their oncological disease. Conclusion PBP is a simple and safe technique that can be effective in the prevention of recurrence in many patients with severe malignant pericardial effusion. The characteristics of this procedure make it particularly useful in this group of patients to avoid more aggressive, poorly tolerated approaches, since they have a very poor prognosis regarding to their oncological disease.

Introduction and Objectives: To investigate the incidence and clinical relevance of the presence of mobile echogenic images (MEI) during transesophageal echocardiography (TEE) for monitoring of transcatheter aortic valve implantation (TAVI). Methods: Consecutive patients referred to our center for transfemoral or transapical TAVI were included. The procedure was monitored by three-dimensional (3D) TEE and images were analyzed by two independent experts. In-hospital follow-up was carried out and correlated with imaging findings. Results: A total of 104 patients were included. MEI were visualized in 11 patients during the procedure (11%) and in over 50% of cases were identified as thrombi, however no differences in periprocedural stroke were found in follow-up. Conclusions: Visualization of MEI during 3D TEE monitoring of TAVI is relatively common (11%) and in over 50% of cases they are identified as thrombi. The clinical implications of this finding are uncertain, as despite their frequency, the incidence of clinical stroke in this patient population was no higher. 3D TEE is a useful tool for diagnosis of MEI and can alert the operator to their presence. Resumo: Introdução e objetivos: Investigar a incidência e relevância clínica da presença de imagens ecogénicas móveis (IEM), através de ecocardiografia transesofágica (ETE) durante a implantação valvular aórtica percutânea (TAVI). Métodos: Foram incluídos doentes consecutivos referenciados para o nosso centro para realização de TAVI por via transapical ou transfemoral. Foi realizada a monitorização da ETE 3 D e as imagens foram analisadas por dois peritos individualmente. O seguimento foi realizado no hospital e foi correlacionado com achados de imagem. Resultados: Foram definitivamente incluídos 104 doentes. Durante o procedimento foram visualizadas IEM em 11 pacientes (11%) e,em mais de 50% dos casos, foram identificadas como trombos, não tendo, no entanto, sido encontradas diferenças no seguimento dos doentes. Conclusões: A visualização das IEM através da monitorização por ETE 3 D durante a TAVI é relativamente comum (11%) e, em mais de 50% dos casos, são identificadas como trombos. As implicações clínicas deste achado são incertas, porque apesar da sua frequência não há maior incidência de acidente vascular cerebral clínico nesta população de doentes. A ETE é uma ferramenta útil para o diagnóstico e pode alertar o operador da sua presença. Keywords: Transcatheter aortic valve implantation, Three-dimensional, Aortic stenosis, Transaortic valve, Palavras-chave: Implantação valvular aórtica percutânea, 3 D, Estenose aórtica, Válvula transaórtica

HOW WOULD I APPROACH IT? The case presented here is very representative of a certain complication that luckily, we rarely find nowadays: vessel acute occlusion following a coronary intervention. In this context, the use of intracoronary imaging modalities is essential to determine the mechanisms underlying this occlusion and to guide the treatment. Probably the most widely known mechanisms have to do with stent thrombosis such as the infra-expansion or dissection of stent edges, but in this case, there is a less common cause: the distal progression of a coronary intramural hematoma.

Resumen Introduccion y objetivos El implante percutaneo de valvula aortica se utiliza como alternativa a la sustitucion valvular quirurgica para pacientes con estenosis aortica grave de alto riesgo quirurgico o inoperables. Dos de las principales areas de incertidumbre son la durabilidad de la valvula y la supervivencia a largo plazo. Metodos Registro unicentrico prospectivo de un hospital terciario que incluyo consecutivamente todos los implantes percutaneos de valvula aortica entre 2008 y 2012. Se realizo seguimiento clinico durante un minimo de 2,5 anos y un maximo de 6,5 anos. Se utilizaron definiciones Valve Academic Research Consortium-2. Resultados Se incluyo a 79 pacientes, con un exito inmediato del 94,9%. La mediana de supervivencia fue de 47,6 (intervalo de confianza del 95%, 37,4-57,9) meses, es decir, 4 anos. Un cuarto de las muertes sucedieron en el primer mes, la mayoria de causa cardiovascular. Despues del primer mes, la causa mas frecuente fue no cardiovascular. Los valores medios de gradientes valvulares no se incrementaron en el seguimiento. La tasa acumulada de disfuncion protesica fue del 15,3%, sin ningun caso de resustitucion valvular. Conclusiones La mitad de los pacientes con estenosis aortica intervenidos mediante implante percutaneo de valvula aortica sobreviven 4 anos despues del procedimiento. Se detecto un 15,3% de disfuncion protesica en el seguimiento acumulado, sin casos de resustitucion valvular.

Objective: To analyze long-term survival and predictors of mortality in patients evaluated for transcatheter aortic valve implantation (TAVI) depending on the decision taken by the heart team. Methods: All patients with severe aortic stenosis and high surgical risk evaluated for TAVI between June 2008 and June 2012 were included. Patients were grouped according to the therapeutic strategy decided by the heart team. Mean follow-up was 16.6 months (maximum 55.3). Results: A total of 149 patients were evaluated: 79 were accepted for TAVI, 12 had no current indication for valve replacement and were deferred, 13 were redirected to conventional surgery and 45 received medical treatment. The evaluated patients had a mean age of 83.7 years and a mean EuroSCORE of 19.8±12.3. Median survival free from all-cause death was 34.7 months (95% CI 27.1–42.3) in the TAVI group, 47.4 months (95% CI 0–97.4) in the deferred intervention group, not available in the surgery group and 8.2 months (95% CI 5.6–10.9) in the medical treatment group (log-rank p

Introduction and Objectives: The aim of this study was to analyze the incidence of drug-eluting stent thrombosis (sirolimus or everolimus) in patients with chronic total coronary occlusions (CTO) and to determine its clinical implications and related factors. Methods: Data from the 12-month follow-up of the 207 patients included in the CIBELES trial with CTO were analyzed. Results: Stent thrombosis occurred in three patients, two definite and one probable (overall thrombosis rate: 1.4%). However, there were no cases of death or Q-wave myocardial infarction. In univariate analysis, patients with a higher incidence of stent thrombosis were those in whom the target vessel was the left anterior descending, who had single-vessel disease, were assigned to treatment with sirolimus-eluting stents, and those with smaller minimum luminal diameter immediately after the procedure. In multivariate analysis, the only independent predictor of stent thrombosis was minimal luminal diameter immediately after the procedure. Conclusions: The rate of drug-eluting stent thrombosis in patients with CTO is relatively low (1.4%). The only independent predictor of stent thrombosis in this context was minimal luminal diameter after the procedure and the clinical presentation was in all cases relatively benign. Resumo: Introdução e objetivos: o objetivo do nosso estudo foi analisar a incidência de trombose de stent com eluição de fármaco (sirolimus ou everolimus) em pacientes com oclusões coronárias crónicas e identificar as suas implicações clínicas e fatores relacionados. Métodos: 12 meses de acompanhamento dos 207 pacientes incluídos no ensaio Cibeles com oclusão total coronária crónica. Resultados: a trombose de stent ocorreu em três doentes: duas definitivas e uma provável (taxa global de trombose 1,4%). No entanto, não surgiu nenhum caso de morte ou enfarte do miocárdio com onda Q. Na análise univariada, os doentes com maior incidência de trombose de stent foram aqueles em que o vaso-alvo foi a descendente anterior, os que tinham a doença de um vaso, os que foram considerados para tratamento com stent com sirolimus, e aqueles com diâmetro luminal mínimo menor imediatamente após o procedimento. Na análise multivariada, o único preditor independente de trombose do stent foi o diâmetro luminal mínimo imediatamente após o procedimento. Conclusões: a taxa de trombose de stent farmacológico em pacientes com oclusão coronária crónica foi relativamente baixa (1,4%).O único preditor independente de trombose de stent neste contexto foi o diâmetro luminal mínimo após o procedimento, tendo a apresentação clínica em todos os casos sido relativamente benigna. Keywords: Stent, Thrombosis, Everolimus, Sirolimus, Chronic total coronary occlusion, Palavras-chave: Stent, Trombose, Everolimus, Sirolimus, Oclusão coronária crónica total

Resumen Introduccion y objetivos El cierre percutaneo de dehiscencias paravalvulares es una alternativa a la cirugia en pacientes de alto riesgo, pero la falta de dispositivos especificos ha limitado su uso. Recientemente se han desarrollado dispositivos mas adecuados, como el Amplatzer Vascular Plug III , pero actualmente hay poca informacion de su eficacia y su seguridad. El objetivo es estudiar el resultado a medio plazo del cierre de dehiscencias paravalvulares con este dispositivo. Metodos Se analizo la evolucion clinica y ecocardiografica tanto hospitalaria como a medio plazo (13 ± 9 meses) de una serie de 20 pacientes consecutivos (edad, 68 anos; EuroSCORE logistico, 29) con dehiscencias paravalvulares e intento de cierre percutaneo. Resultados Se intento el cierre de 23 dehiscencias (17 mitrales y 6 aorticas) durante 22 procedimientos en 20 pacientes. Se logro el exito del implante en el 87% de las dehiscencias y el exito del procedimiento con una reduccion de ≥ 1 grado de la insuficiencia en el 83%. La supervivencia al ano fue del 64,7% y la supervivencia libre de muerte/cirugia, del 58,8%. El grado de insuficiencia valvular residual no se relaciono con la mortalidad, pero si con el grado funcional. Entre los supervivientes se observo una mejora significativa en la clase funcional. Conclusiones El cierre percutaneo de dehiscencias con el Amplatzer Vascular Plug III es seguro y eficaz a medio plazo, aunque la mortalidad de los pacientes de alto riesgo es alta independientemente del grado de insuficiencia residual, lo que indica que se realiza en un estadio avanzado de la cardiopatia.

Introduction and objectives Percutaneous closure of paravalvular leakage is an alternative to surgery in high-risk patients, but its use has been limited by a lack of specific devices. More appropriate devices—like the Amplatzer Vascular Plug III —have recently been developed, but information about their efficacy and safety is still scarce. The objective of the present study was to assess the mid-term results of paravalvular leakage closure with this device. Methods We analyzed the clinical and echocardiographic course both in-hospital and mid-term (13 [9] months) in a series of 20 consecutive patients (age, 68 years; logistic EuroSCORE, 29) with paravalvular leakage and attempted percutaneous closure. Results Closure was attempted for 23 leaks (17 mitral and 6 aortic) during 22 procedures in 20 patients. Implantation was successful in 87% of the leaks and the procedure was successful in 83%—with success being defined as a reduction in regurgitation of ≥ 1 degree. Survival at 1 year was 64.7% and survival free of the composite event of death/surgery was 58.8%. The degree of residual regurgitation was not associated with mortality but was associated with functional status. Survivors showed significant improvement in functional class. Conclusions Percutaneous closure of leakage with the Amplatzer Vascular Plug III is safe and efficient in the mid-term. However, mortality among high-risk patients is high independently of the degree of residual regurgitation, indicating that these procedures are performed when heart disease has reached an advanced stage.

A 75-year-old man admitted with unstable angina underwent coronary angiography demonstrating tandem in-stent restenosis in the proximal-segment of the left anterior descending artery. Optical coherence tomography (OCT) detected underoptimal stent implantation within circumferential atherosclerotic

We report a case of very late bare-metal stent restenosis, in which assessment by two intracoronary imaging techniques (intravascular ultrasound and optical coherence tomography) revealed the underlying mechanism (neoatherosclerosis) and facilitated percutaneous treatment (direct bare-metal stent-in-stent). We also take the opportunity to briefly describe the advantages and limitations of both techniques in this pathology. Resumo: Neste artigo fazemos referência a um caso de reestenose muito tardia de um stent convencional que, através de duas técnicas de diagnóstico intracoronário, ultrassonografia intravascular (IVUS) e tomografia de coerência ótica (OCT), permite dar a conhecer o seu mecanismo subjacente (neoaterosclerose) e facilita o seu tratamento percutâneo (stent convencional direto intrasent). Aproveitamos também a ocasião para fazer uma breve descrição das vantagens e limitações de ambas as técnicas neste tipo de patologia. Keywords: Neoatherosclerosis, Percutaneous coronary intervention, Intravascular ultrasound, Optical coherence tomography, Palavras-chave: Neoaterosclerose, Intervenção coronária percutânea, IVUS, OCT

Resumo: Neste artigo fazemos referência a um caso de reestenose muito tardia de um stent convencional que, através de duas técnicas de diagnóstico intracoronário, ultrassonografia intravascular (IVUS) e tomografia de coerência ótica (OCT), permite dar a conhecer o seu mecanismo subjacente (neoaterosclerose) e facilita o seu tratamento percutâneo (stent convencional direto intrasent). Aproveitamos também a ocasião para fazer uma breve descrição das vantagens e limitações de ambas as técnicas neste tipo de patologia. Abstract: We report a case of very late bare-metal stent restenosis, in which assessment by two intracoronary imaging techniques (intravascular ultrasound and optical coherence tomography) revealed the underlying mechanism (neoatherosclerosis) and facilitated percutaneous treatment (direct bare-metal stent-in-stent). We also take the opportunity to briefly describe the advantages and limitations of both techniques in this pathology. Palavras-chave: Neoaterosclerose, Intervenção coronária percutânea, Ultrassonografia intravascular, Tomografia de coerência ótica, Keywords: Neoatherosclerosis, Percutaneous coronary intervention, Intravascular ultrasound, Optical coherence tomography

Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are imaging methods used in the diagnosis of coronary lesions. IVUS is widely used in interventional cardiology laboratories, but OCT is now increasingly used. Conventional coronary angiography can identify different types of coronary lesions but sometimes is unable to diagnose them correctly. Both intravascular imaging methods are useful for better interpretation of these lesions, and can accurately diagnose ruptured plaques, thrombosis, stent restenosis and hazy images. However, the resolution of OCT is ten times higher than IVUS, and so an accurate diagnosis cannot always be achieved with ultrasound imaging. We present three cases in which IVUS was unable to identify the lesion causing the condition and OCT was required to obtain clearer images that helped to confirm the diagnosis. The advantages and disadvantages of each method are then discussed. Resumo: A tomografia de coerência ótica (TCO) e o ultrassom intravascular (USIV) são métodos de imagem geralmente utilizados nos serviços de cardiologia de intervenção. O USIV é um sistema de imagem intravascular, muito utilizado nos laboratórios de cardiologia de intervenção. A utilização de TCO começou mais tarde a ser divulgada na prática diagnóstica intracoronária. A angiografia coronária convencional pode identificar diferentes tipos de lesões coronárias que por vezes não são devidamente diagnosticadas. Os métodos de imagem são também utilizados para uma melhor interpretação destas lesões. As roturas de placas, trombose, reestenose de stent e outras imagens nebulosas podem ser diagnosticadas fielmente através da sua utilização. No entanto, a resolução da TCO é 10 vezes superior à do USIV. Portanto não é possível obter sempre um diagnóstico fiel com uma imagem ultra-som. Este artigo apresenta três casos em que a utilização de USIV não foi suficiente para identificar a lesão, tendo sido necessário recorrer à TOC para obter imagens mais claras que ajudaram a confirmar o diagnóstico. Segue-se a discussão das vantagens e desvantagens de cada método. Keywords: Optical coherence tomography, Intravascular ultrasound, Coronary restenosis, Coronary calcification, Coronary thrombosis, Palavras-chave: Tomografia de coerência ótica, Ultrasonografia intravascular, Reestenose coronária, Calcificação coronária, Trombose coronária

Resumen Introduccion y objetivos El derrame pericardico tumoral presenta una elevada tasa de recurrencia tras la pericardiocentesis. Se busca confirmar la eficacia de la pericardiotomia percutanea con balon como tratamiento inicial de eleccion de estos derrames. Metodos Analisis retrospectivo de las caracteristicas clinicas, ecocardiograficas y evolutivas de una serie monocentrica y consecutiva de pericardiotomias percutaneas con balon en pacientes con enfermedad oncologica avanzada. Resultados Se han realizado 17 pericardiotomias percutaneas con balon en 16 pacientes (media de edad, 66,2 ± 15,2 anos); 14 pacientes tenian confirmacion anatomopatologica de enfermedad neoplasica metastasica; 3 habian requerido una pericardiocentesis previa, mientras que en los restantes la pericardiotomia percutanea con balon fue la primera intervencion sobre el derrame. Todos los casos presentaban derrame circunferencial grave, y la mayoria tenian datos ecocardiograficos de compromiso hemodinamico. El exito inicial se logro sin complicaciones agudas y con buena tolerancia en un primer intento. Durante el seguimiento (mediana, 44 [intervalo intercuartilico, 36-225] dias) tampoco hubo complicaciones infecciosas. En 1 paciente se demostro la aparicion de un derrame pleural significativo, que no preciso tratamiento. Fue necesario realizar una reintervencion sobre el pericardio en 3 pacientes: dos ventanas pericardicas quirurgicas programadas y una segunda pericardiotomia percutanea con balon. Conclusiones La pericardiotomia percutanea con balon es un tecnica sencilla y segura que puede resultar eficaz en un gran numero de pacientes con derrame pericardico tumoral grave para evitar que recurra. Por sus caracteristicas, resultaria de especial utilidad en este grupo de pacientes para evitar abordajes mas agresivos y peor tolerados.

Although its use in daily practice is not common, optical coherence tomography (OCT) is a powerful research tool in invasive cardiology. This report describes a hazy angiography image after percutaneous coronary intervention that has been assessed using OCT. Based on the results of the OCT, the patient underwent an elective coronary angioplasty with standard anticoagulation. After implantation of the stent, an intracoronary hazy image was seen on angiography. The use of OCT permitted a correct diagnosis and a successful treatment. This paper provides a discussion of the advantages and disadvantages of OCT, and a comparison with intravascular ultrasound.

The no-reflow phenomenon (NRP) is defined as the lack of adequate myocardial tissue perfusion despite a patent epicardial coronary artery. The incidence of NRP varies between 2-5% of elective percutaneous coronary interventions (PCI) and 30% in primary PCI. Clinically, it is an independent predictor of myocardial infarction, in-hospital mortality, and long-term mortality. It may be categorized in interventional (after PCI, especially in saphenous venous grafts) or reperfusion NRP (after re-opening of a totally occluded coronary artery, usually during primary PCI or thrombolysis). There are many physiopathological factors implicated: distal microembolization, interstitial and intracellular edema, coronary spasm and capillary plugging. Although reperfusion and no reflow is a field of intense research, no single mechanical or pharmacological therapy has demonstrated a clear efficacy against NRP, probably due to its multifactorial nature. Once established, the treatment of NRP is based on vasodilators like adenosine, verapamil, nitroprusside or nicorandil. However, the efficacy of these measures is poor, so every effort should be made to prevent the apparition of NRP. The objective of this report is to provide an update of the pharmacological armamentarium available for the prevention and treatment of NRP, and suggest a systematic approach of the management of NRP according to the different possible clinical scenarios.

Background: Percutaneous septal ablation by alcohol-induced septal branch occlusion was introduced as a new treatment option in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Our aim was to evaluate procedural and long-term clinical and echocardiographic outcomes in patients with HOCM treated by alcohol septal ablation (ASA) at our center. Methods: This single-center retrospective study included 14 consecutive HOCM patients undergoing percutaneous ASA (66.4 ± 12.1 years, 71.4% female). At baseline all patients presented persistent symptoms despite optimized medical treatment, left ventricular outflow tract (LVOT) obstruction with a peak gradient >50 mmHg, systolic anterior motion of the mitral valve, and ventricular septal thickness ≥15 mm. ASA was considered successful when the LVOT pressure gradient fell to less than 50% of baseline value. All patients had echocardiographic evaluation at baseline, intraprocedure and at follow-up, and a long-term clinical follow-up (25 ± 38 months) with evaluation of functional class and occurrence of symptoms or cardiovascular events. Results: Percutaneous ASA achieved a 71.4% acute and 85.7% long-term success rate. Peak LVOT gradient decreased from 104 ± 40 mmHg at baseline to 58 ± 30 mmHg intraprocedure (p = 0.03) and 35 ± 26 mmHg at follow-up (p = 0.001); total gradient decrease was 75 ± 43 mmHg. Ventricular septal thickness and mitral regurgitation also presented significant decreases during follow-up (from 24 ± 5 mm to 18 ± 4 mm, p = 0.02, and from grade 2.4 ± 0.6 to 1.4 ± 0.5, p 50 mmHg, movimento sistólico anterior da válvula mitral e espessura do septo interventricular ≥15 mm. A ASA foi considerada bem sucedida quando o gradiente do LVOT diminuiu para menos de 50% do valor inicial. Todos os doentes foram submetidos a avaliação clínica e ecocardiográfica basal, intraprocedimento e durante o seguimento, com avaliação da classe funcional e ocorrência de sintomas ou eventos cardiovasculares a longo-prazo (25 ± 38 meses). Resultados: A ASA percutânea obteve uma taxa de sucesso de 71,4% e 85,7%, respetivamente aguda e a longo-prazo. O gradiente máximo do LVOT diminuiu de 104 ± 40 mmHg basais para 58 ± 30 mmHg intraprocedimento (p = 0,03) e 35 ± 26 mmHg a longo-prazo (p = 0,001); o decréscimo total do gradiente foi de 75 ± 43 mmHg. Também a espessura do septo interventricular e a regurgitação mitral apresentaram uma diminuição significativa durante o seguimento (de 24 ± 5 mm para 18 ± 4 mm, p = 0,02, e de grau 2,4 ± 0,6 para 1,4 ± 0,5, p

Introduction: Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement in patients with severe aortic stenosis (AS) and unacceptably high surgical risk. Methods: We present our first two years’ experience with TAVI. A total of 76 AS patients were evaluated for TAVI and 23 of them underwent a TAVI procedure. These patients had a mean EuroSCORE of 22.4% and a mean age of 81.5 years, and were prospectively followed for a mean of 12.9±11 months. Results: The percutaneous aortic valve was successfully implanted in 100% of the patients. Mortality at 30 days was 4%. The most common complications were access site-related bleeding and transfusion (22%), followed by new permanent pacemaker implantation (9%). After a mean follow-up of 12.9 months, survival was 87%. In a maximum follow-up of 30 months there were no cases of prosthesis dysfunction or cardiovascular death. Conclusions: Two years after the introduction of a TAVI program in our center, the procedure has established itself as a safe and effective alternative for patients with severe AS and unacceptably high surgical risk. Resumo: Introdução: A implantação da válvula aórtica transcateter (TAVI) é uma alternativa à substituição valvular aórtica cirúrgica convencional para doentes com estenose aórtica (EA) grave e risco cirúrgico inaceitável. Métodos: Apresentamos a experiência com TAVI no nosso centro durante os primeiros anos, desde o seu início. De 76 doentes com EA avaliados para eventual TAVI, realizou-se o procedimento em 23 dos mesmos, que apresentavam um Euroscore médio de 22,4% e uma idade média de 81,5 anos. Estes 23 doentes foram seguidos de modo prospectivo durante 12,9±11 meses. Resultados: A prótese foi implantada com êxito em todos os doentes. A mortalidade aos 30 dias foi de 4%. As complicações mais frequentes foram as vasculares e a necessidade de transfusão (22%) seguida de colocação de pace-maker definitivo (9%). Após um follow-up médio de 30 meses não se registou nenhum caso de disfunção protésica nem de morte cardiovascular. Conclusões: Dois anos após o início de um programa de TAVI no nosso centro, a TAVI evidencia-se como uma alternativa eficaz para doentes com EA grave inoperáveis por risco cirúrgico elevado. Keywords: Aortic valve stenosis, Heart valve prosthesis, Transcatheter aortic valve implantation, Non-coronary intervention, Aortic valve replacement, Palavras-chave: Estenose aórtica grave, Prótese valvular cardíaca, Prótese aórtica transcateter, Intervenção cardíaca não coronária, Substituição valvular aórtica

Resumo: Introdução: A implantação da válvula aórtica transcateter (TAVI) é uma alternativa à substituição valvular aórtica cirúrgica convencional para doentes com estenose aórtica (EA) grave e risco cirúrgico inaceitável. Métodos: Apresentamos a experiência com TAVI no nosso centro durante os primeiros anos, desde o seu início. De 76 doentes com EA avaliados para eventual TAVI, realizou-se o procedimento em 23 dos mesmos, que apresentavam um Euroscore médio de 22,4% e uma idade média de 81,5 anos. Estes 23 doentes foram seguidos de modo prospetivo durante 12,9 ± 11 meses. Resultados: A prótese foi implantada com êxito em todos os doentes. A mortalidade aos 30 dias foi de 4%. As complicações mais frequentes foram as vasculares e a necessidade de transfusão (22%) seguida de colocação de pace-maker definitivo (9%). Após um follow-up médio de 30 meses não se registou nenhum caso de disfunção protésica nem de morte cardiovascular. Conclusões: Dois anos após o início de um programa de TAVI no nosso centro, a TAVI evidencia-se como uma alternativa eficaz para doentes com EA grave inoperáveis por risco cirúrgico elevado. Abstract: Introduction: Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement in patients with severe aortic stenosis (AS) and unacceptably high surgical risk. Methods: We present our first two years’ experience with TAVI. A total of 76 AS patients were evaluated for TAVI and 23 of them underwent a TAVI procedure. These patients had a mean EuroSCORE of 22.4% and a mean age of 81.5 years, and were prospectively followed for a mean of 12.9 ± 11 months. Results: The percutaneous aortic valve was successfully implanted in 100% of the patients. Mortality at 30 days was 4%. The most common complications were access site-related bleeding and transfusion (22%), followed by new permanent pacemaker implantation (9%). After a mean follow-up of 12.9 months, survival was 87%. In a maximum follow-up of 30 months there were no cases of prosthesis dysfunction or cardiovascular death. Conclusions: Two years after the introduction of a TAVI program in our center, the procedure has established itself as a safe and effective alternative for patients with severe AS and unacceptably high surgical risk. Palavras-chave: Estenose aórtica grave, Prótese valvular cardíaca, Prótese aórtica transcateter, Intervenção cardíaca não coronária, Substituição valvular aórtica, Keywords: Aortic valve stenosis, Heart valve prosthesis, Transcatheter aortic valve implantation, Non-coronary intervention, Aortic valve replacement