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BACKGROUND: Cardiac computed tomography angiography (CCTA) appears to be an appropriate imaging technique for device surveillance after left atrial appendage occlusion (LAAO). However, the available experience is limited. AIMS: The aim of this study was to determine the prevalence, mechanisms and clinical impact of left atrial appendage (LAA) patency and device-related thrombosis (DRT) following LAAO utilising a novel CCTA-based classification. METHODS: Consecutively enrolled patients who underwent LAAO with an AMPLATZER device were followed up with CCTA. Mechanisms and frequency of residual patency were evaluated and correlated with clinical events. Atrial-side device thrombus, device positioning and presence of signs of device stability were also analysed. RESULTS: A total of 137 patients were included. LAA patency was observed in 56.9% (n=78). Mechanisms and frequency of patency were: malapposition of proximal segment of the device lobe (55.1%), peri-device leak (PDL, 34.6%) and fabric permeability (5.8%). Lobe-LAA axis misalignment was the only independent predictor of device patency after LAAO (HR 38.3, 95% CI: 13.6-107.0; p

Introduction and objectives: Left atrial appendage occlusion (LAAO) can be an efficient treatment to prevent strokes in patients who suffer from atrial fibrillation, especially those at risk of bleeding. A non-negligible number of patients treated with LAAO develop device-related thrombosis (DRT) after device implantation. Our study aimed to identify the key blood flow characteristics leading to DRT using patient-specific flow simulations. Methods: Patients treated with LAAO between 2014 and 2019 at a single center with preoperative and follow-up computerized tomography images and ultrasound imaging (US) were used to create patient-specific flow simulations. Amulet LAAO devices were implanted in the study patients. Flow simulations were blindly assessed to discard the presence of DRT in the follow-up imaging. Results: A total of 6 patients were processed in this pivotal study, half of them with DRT at the follow-up according to the imaging analysis. After a comprehensive analysis of the simulations, the most relevant in silico indices associated with DRT were the presence of stagnant blood flow, recirculation with low flow velocities (< 0.20 m/s) next to the device surface, and regions with high flow complexity combined with low wall shear stress. Conclusions: Patient-specific flow simulations of LAAO were successfully used to predict blood flow patterns with different device configurations. The results show the potential of the present modelling and simulation approach to recommend optimal settings capable of minimizing the risk of DRT. Introducción y objetivos: El cierre de la orejuela izquierda (COI) puede ser una alternativa de tratamiento eficaz para prevenir eventos cardiovasculares en pacientes con fibrilación auricular, en especial en aquellos con alto riesgo de sangrado. Sin embargo, algunos de estos pacientes en los que se realiza COI desarrollan trombosis relacionada con el dispositivo (TRD). Este estudio presenta las características del flujo sanguíneo que son clave en la formación de TDR, a partir de simulaciones personalizadas para cada paciente. Métodos: Para crear las simulaciones personalizadas se incluyeron en el estudio pacientes intervenidos de COI entre 2014 y 2019 en un único centro, de quienes se disponía de imágenes de tomografía computarizada previas al procedimiento y de seguimiento, así como de control ecocardiográfico. Para el COI se utilizaron los dispositivos Amulet. Las simulaciones se analizaron de forma ciega al diagnóstico de TRD. Resultados: En total se estudiaron 6 pacientes, de los que la mitad presentaban TRD según las imágenes del seguimiento clínico. Tras analizar los resultados de las simulaciones, los índices hemodinámicos asociados con TRD fueron la presencia de flujo estancado, las recirculaciones de sangre a velocidades bajas (< 0,20 m/s) cerca de la superficie del dispositivo y las regiones con alta complejidad de flujo y baja tensión de cizallamiento en la pared. Conclusiones: Las simulaciones de flujo personalizadas en pacientes con COI predijeron correctamente el diagnóstico clínico de TRD en todos los casos analizados. Los resultados obtenidos demuestran el potencial de los modelos personalizados para recomendar configuraciones óptimas del dispositivo y minimizar el riesgo de TRD. This work was supported by the Spanish Ministry of Science, Innovation and Universities under the Retos I+D (RTI2018-101193-B-I00), the Maria de Maeztu Units of Excellence (MDM-2015-0502), the Formation of Doctors (PRE2018-084062) and the Recruitment of Talents (RYC-2015-18888) programmes.

Background: Left atrial appendage occlusion (LAAO) is an accepted strategy for cardioembolic events prevention in patients with non-valvular atrial fibrillation (AF) unsuitable for anticoagulation. However, uncertainties persist regarding the benefit of LAAO in highly-comorbid patients. The aim of this study was to assess the impact of the CHA(2)DS(2)-VASc score beyond thromboembolic risk in predicting clinical outcomes in patients undergoing LAAO. Methods: 160 patients who underwent LAAO were included and categorized into two groups according to their stroke risk (89 with CHA(2)DS(2)-VASc >4 vs. 71 with lower risk). The coprimary endpoints were death and stroke at follow-up. Thromboembolic and bleeding events were compared to those predicted from CHA(2)DS(2)-VASc and HAS-BLED scores. Results: Over a median follow-up of 679 days, CHA(2)DS(2)-VASc >4 was associated with increased all-cause mortality compared with patients with lower thromboembolic risk (HR: 3.23; 95% CI: 1.28-8.19; p < 0.001). However, the rates of stroke after LAAO were not significantly different between risk groups. The observed annual rates of stroke and major bleeding were lower than predicted. Conclusions: Despite increased long-term mortality in patients with CHA(2)DS(2)-VASc >4, LAAO remains beneficial in reducing stroke and bleeding events in high-risk AF patients unsuitable for anticoagulation. (C) 2020 Elsevier B.V. All rights reserved.

Background: Isolated atrial fibrillation can cause mitral regurgitation (MR) in patients with normal left ventricular systolic function and no organic disease of the mitral valve. Little information is available regarding outcomes of Mitraclip in patients with atrial functional mitral regurgitation (AFMR). We aimed to evaluate 12-month clinical and echocardiographic outcomes of transcatheter mitral valve repair (TMVR) with MitraClip in patients with AFMR compared to those with ventricular functional or degenerative/mixed MR. Methods: Registry-based analysis of all consecutive patients who underwent TMVR and were included in the Spanish Registry of Mitraclip. Changes in MR and NYHA functional class, and a combined endpoint including all-cause mortality and hospitalizations due to heart failure were the main outcomes. Results: Overall, 1074 (69.1% male, 73.3 +/- 10.2 years-old) patients were analyzed in this report. 48 patients (4.5%) presented AFMR. AFMR was significantly reduced after TMVR, with a procedural success rate of 91.7%, and this reduction persisted at 12-month (p < 0.001). Patients with AFMR showed a significant functional improvement at 6- and 12-month follow-up in our series (baseline: NYHA III 70.8% IV 18.8% vs. 1-year: NYHA III 21.7% IV 0%; p < 0.001). The probability of survival free of readmission for heart failure and all-cause mortality within the first year after TMVR was 74.9%. Procedural and clinical outcomes, as well as recurrent rates of MR were similar acutely and at 1-year compared to other etiologies. Conclusion: TMVR in patients with AFMR showed no significant differences compared to ventricular functional or degenerative/mixed MR regarding MR reduction or clinical outcomes.

Producción Científica, Background: Transcatheter mitral valve repair (TMVR) is an effective therapy for high-risk patients with severe mitral regurgitation (MR) but heart failure (HF) readmissions and death remain substantial on mid-term follow-up. Recently, right ventricular (RV) to pulmonary arterial (PA) coupling has emerged as a relevant prognostic predictor in HF. In this study, we aimed to assess the prognostic value of tricuspid annular plane systolic excursion (TAPSE) to PA systolic pressure (PASP) ratio as a non-invasive measure of RV-to-PA coupling in patients undergoing TMVR with MitraClip (Abbott, CA, USA). Methods: Multicentre registry including 228 consecutive patients that underwent successful TMVR with MitraClip. The sample was divided in two groups according to TAPSE/PASP median value: 0.35. The primary combined endpoint encompassed HF readmissions and all-cause mortality. Results: Mean age was 72.5 ± 11.5 years and 154 (67.5%) patients were male. HF readmissions and all-cause mortality were more frequent in patients with TAPSE/PASP ≤ 0.35: Log-Rank 8.844, p = 0.003. On Cox regression, TAPSE/PASP emerged as a prognostic predictor of the primary combined endpoint, together with STS-Score. TAPSE/PASP was a better prognostic predictor than either TAPSE or PASP separately. Conclusions: TAPSE/PASP ratio appears as a novel prognostic predictor in patients undergoing MitraClip implantation that might improve risk stratification and candidate selection.

Background: Transcatheter mitral valve repair (TMVR) could improve survival in functional mitral regurgitation (FMR), but it is necessary to consider the influence of left ventricular ejection fraction (LVEF). Therefore, we compare the outcomes after TMVR with Mitraclip&reg, between two groups according to LVEF. Methods: In an observational registry study, we compared the outcomes in patients with FMR who underwent TMVR with and without LVEF &lt, 30%. The primary endpoint was the combined one-year all-cause mortality and unplanned hospital readmissions due to HF. The secondary end-points were New York Heart Association (NYHA) functional class and mitral regurgitation (MR) severity. Propensity-score matching was used to create two groups with the same baseline characteristics, except for baseline LVEF. Results: Among 535 FMR eligible patients, 144 patients with LVEF &lt, 30% (group 1) and 144 with LVEF &gt, 30% (group 2) had similar propensity scores and were included in the analyses. The primary study endpoint was significantlly higher in group 1 (33.3% vs. 9.4%, p = 0.002). There was a maintained improvement in secondary endpoints without significant differences among groups. Conclusion: FMR patients with LVEF &lt, 30% treated with MitraClip&reg, had higher mortality and readmissions than patients with LVEF &ge, 30% treated with the same device. However, both groups improved the NYHA functional class and MR severity.

BACKGROUND In catheter-based procedures, acute kidney injury (AKI) is a frequent, serious complication ranging from 10% to 30%. In MitraClip (Abbott Vascular, Santa Clara, California), a usually contrast-free procedure, there is scarce data about its real incidence and impact. OBJECTIVES This study aimed to evaluate incidence, predictive factors, and midterm outcomes of AKI in patients with significant mitral regurgitation (MR) undergoing transcatheter valve repair with MitraClip. METHODS A total of 721 patients undergoing MitraClip were included. AKI was defined as an absolute or a relative increase in serum creatinine of >0.3 mg/dl or >= 50%, respectively, or the need for hemodialysis during index hospitalization. RESULTS The mean age of the patients was 72 +/- 11 years (28.3% women). Median estimated glomerular filtration rate (eGFR) was 43.7 ml/min/1.73 m(2) (interquartile range: 30.9 to 60.1 ml/min/1.73 m(2)), and was

Introduction and objectives: Transcatheter mitral valve repair (TMVR) with MitraClip is a therapeutic option for high surgical risk patients with severe mitral regurgitation (MR). The main objective of this study was to analyze differences in outcomes in patients with severe MR according to the cause of MR. Methods: Observational, multicenter, and prospective study with consecutive patient inclusion. The primary endpoint was the combination of all-cause mortality and new readmissions due to heart failure after 1 year. We compared clinical and procedural characteristics and the event rate for each MR group. We performed a multivariate analysis to identify predictive variables for the primary endpoint. Results: A total of 558 patients were included: 364 (65.2%) with functional etiology, 111 (19.9%) degenerative and 83 (14.9%) mixed. The mean age was 72.8 +/- 11.1 years and 70.3% of the sample were men. There were 95 (17%) events in the overall sample. No significant differences were found in the 3 groups in the number of primary outcome events: 11 (11.3%) in degenerative MR, 71 (21.3%) in functional MR, and 13 (18.1%) in mixed MR (P=.101). Independent predictors were functional class (P=.029), previous surgical revascularization (P=.031), EuroSCORE II (P=.003), diabetes mellitus (P=.037), and left ventricular ejection fraction (P=.015). Conclusions: This study confirms the safety and efficacy of TMVR with MitraClip irrespective of MR etiology in real-life data and shows the main factors related to prognosis during the first year of follow up. (C) 2019 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Multicenter study [Abstract] Introduction and objectives: Two-dimensional speckle-tracking echocardiography has emerged as a promising alternative to endomyocardial biopsy to rule out acute cellular rejection after orthotopic heart transplantation (OHT) in single center studies. In an original cohort, 15.5% and 17% of cutoff points for left ventricular global longitudinal strain (LVGLS) and free-wall right ventricular longitudinal strain, respectively, achieved 100% negative predictive value to exclude moderate or severe acute cellular rejection (ACR ≥ 2R). Our objective was to demonstrate the usefulness of speckle-tracking and validate these cutoff points in an external cohort. Methods: A prospective, multicenter study that included patients who were monitored during their first year after OHT was conducted. Echocardiographic studies analyzed by local investigators were compared with simultaneous paired endomyocardial biopsies samples. Results: A total of 501 endomyocardial biopsy-echocardiographic studies were included in 99 patients. ACR≥2R was present in 7.4% of samples. LVGLS and free-wall right ventricular longitudinal strain were significantly reduced during ACR≥2R on univariate analysis. On multivariate analysis, LVGLS was independently associated with the presence of ACR≥2R. The original cutoff points demonstrated a negative predictive value of 94.3% to exclude ACR≥2R. Conclusions: This study maintained a strong negative predictive value to exclude ACR≥2R after OHT and LVGLS was independently associated with the presence of ACR≥2R. We propose the use of speckle-tracking, especially LVGLS, as part of the noninvasive diagnosis and management of ACR. [Resumen] Introducción y objetivos. Algunos estudios indican que los parámetros de strain por speckle-tracking pueden ser una alternativa no invasiva a la biopsia endomiocárdica para excluir el rechazo celular agudo (RCA) moderado o grave (≥ 2 R) tras el trasplante cardiaco (TxC). En una cohorte inicial, unos puntos de corte del 15,5% para el strain longitudinal global del ventrículo izquierdo (SLGVI) y el 17% para el strain de pared libre del ventrículo derecho mostraron un valor predictivo negativo del 100% para excluir RCA ≥ 2 R. Nuestro objetivo es analizar la utilidad del strain y validar estos puntos de corte en una cohorte multicéntrica prospectiva externa. Métodos. Estudio multicéntrico y prospectivo que incluyó a pacientes con seguimiento el primer año tras el TC. Se compararon los resultados de biopsias electivas con ecocardiogramas realizados el mismo día. Resultados. Se incluyó a 99 pacientes y 501 pares de biopsias-ecocardiogramas. El RCA ≥ 2 R en las biopsias fue del 7,4%. El SLGVI y el strain longitudinal de pared libre del ventrículo derecho fueron menores durante los RCA ≥ 2 R en el análisis univariante. En el análisis multivariante, el SLGVI se asoció de manera independiente con el RCA ≥ 2 R. Los puntos de corte originales mostraron un valor predictivo negativo del 94,3% el RCA ≥ 2 R. Conclusiones. Este estudio mantiene un alto valor predictivo negativo para excluir RCA ≥ 2 R tras el TxC y el SLGVI se asoció de manera independiente con el RCA ≥ 2 R. El strain y, principalmente, el SLGVI pueden ser de utilidad en el diagnóstico y el tratamiento no invasivo del RCA.

We present a case report of an 80-year-old frail woman with hemolytic anemia and cardiac failure secondary to mitral severe paravalvular regurgitation. Her clinical history was significant for mitral valve replacement that was complicated with a paravalvular leak two months after surgery. The leak was closed percutaneously with an Amplatzer Vascular Plug III single device. A year later she is readmitted with heart failure and the transesophageal echocardiogram revealed a severe paravalvular leak beside the Vascular Plug III device that seemed to be dislodged and rocking. During a new attempt of percutaneous leak closure, while trying to lasso the old device, it embolized to the iliac bifurcation. The old device could be removed from the right femoral artery and the leak could be closed with two new Vascular Plug III devices deployed simultaneously. To our knowledge this is the first reported case of a late embolization of a Vascular Plug III device. © 2013 Wiley Periodicals, Inc.

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Mitral regurgitation is the most prevalent valvular heart disease in the United States and the second most prevalent in Europe. Patients with severe mitral regurgitation have a poor prognosis with medical therapy once they become symptomatic or develop signs of significant cardiac dysfunction. However, as many as half of these patients are inoperable because of advanced age, ventricular dysfunction, or other comorbidities. Studies have shown that surgery increases survival in patients with organic mitral regurgitation due to valve prolapse but has no clinical benefit in those with functional mitral regurgitation. In this scenario, percutaneous repair for mitral regurgitation in native valves provides alternative management of valvular heart disease in patients at high surgical risk. Percutaneous repair for mitral regurgitation is a growing field that relies heavily on imaging techniques to diagnose functional anatomy and guide repair procedures.

Paciente varon de 46 anos con antecedentes de hipercolesterolemia y obesidad, que fue admitido en el servicio de urgencias del hospital con diagnostico de sindrome coronario agudo con elevacion del segmento ST en V1 y V2. Se realizo coronariografia invasiva emergente, que mostro lesion del 30% tanto en el origen de la arteria descendente anterior y como en el origen de la arteria descendente posterior. Ante dicho resultado, se decidio completar el estudio con cardiorresonancia magnetica, que mostro alteracion de la contractilidad segmentaria a nivel de camara de salida del ventriculo derecho (figura 1, flecha en panel superior), que coincidia con una zona de captacion de contraste tardia compatible con necrosis (figura 1, flechas en el panel inferior). Un posterior estudio por angiografia coronaria no invasiva por tomografia computarizada con multidetectores confirmo las lesiones objetivadas en el cateterismo y mostro, ademas, una rama conal de distribucion en el area infartada con oclusion trombotica en su origen (figuras 2A y B, flechas). Tal lesion habia pasado inadvertida en el cateterismo, pero en una de las proyecciones reanalizadas se visualizaba el munon correspondiente al origen de dicha rama conal ocluida (figura 2C, flecha). El caso ilustra la alta sensibilidad de la cardiorresonancia magnetica en la deteccion de areas de necrosis de cualquier localizacion, asi como la utilidad de combinar la tomografia computarizada con multidetectores para un analisis integral de la enfermedad arterial coronaria. Contraste tardio Sistole Diastole

A 78-year-old woman with a history of coronary artery bypass grafting underwent transapical transcatheter aortic valve replacement with a Sapien XT (Edwards, Irvine, California) prosthesis that was complicated by an apical left ventricular pseudoaneurysm (LVPA). Unsuccessful attempts at closure

Introduction and objectives Symptomatic mitral regurgitation has an unfavorable prognosis unless treated by surgery. However, the European registry of valvular heart disease reports that 49% of patients with this condition do not undergo surgery. Percutaneous treatment of mitral regurgitation with MitraClip ® has been proved a safe, efficient adjunct to medical treatment in patients with this profile. The objective of the present study is to describe initial experience of MitraClip ® therapy in Spain. Methods Retrospective observational study including all patients treated between November 2011 and July 2013 at the 4 Spanish hospitals recording the highest numbers of implantations. Results A total of 62 patients (77.4% men) were treated, mainly for restrictive functional mitral regurgitation (85.4%) of grade III (37%) or grade IV (63%), mean (standard deviation) ejection fraction 36% (14%), and New York Heart Association functional class III (37%) or IV (63%). Device implantation was successful in 98% of the patients. At 1 year, 81.2% had mitral regurgitation ≤ 2 and 90.9% were in New York Heart Association functional class ≤ II. One periprocedural death occurred (sepsis at 20 days post-implantation) and another 3 patients died during follow-up (mean, 9.1 months). Two patients needed a second implantation due to partial dehiscence of the first device and 2 others underwent heart transplantation. Conclusions In Spain, MitraClip ® therapy has principally been aimed at patients with functional mitral regurgitation, significant systolic ventricular dysfunction, and high surgical risk. It is considered a safe alternative treatment, which can reduce mitral regurgitation and improve functional capacity.

Time-resolved, 3-dimensional phase-contrast magnetic resonance imaging (3D+t PCMRI) is employed to obtain complete spatial and temporal coverage of the vessels blood combined with spatially registered 3-directional pulsatile blood flow velocities[1][2]. Recent studies have reported that Wall Shear Stress (WSS) quantification from PCMRI are able to use the WSS as biomarkers for different aortas pathologies [3]. Figure [1] shows the pathline visualization of blood flow during one cardiac cycle in the heart of a healthy patient at peak early LV filling, diastasis, peak atrial contraction, and peak systole.

Myocardium deformation and displacement analysis by echocardiography has proven useful to evaluate the synchrony of myocardial mechanics. The aim of our study was to evaluate the mean standard deviation of time to longitudinal peak displacement in 16 cardiac segments by 3D echo wall motion Speckle Tracking analysis. We studied 15 patients with ventricular dyssynchrony-defined by a QRS > 120 ms in the ECG. We obtained the differences between time peaks of endocardial longitudinal displacement for 16 segments of the heart by 3D echo Speckle Tracking. We compared the temporal dispersion of these peaks with results obtained in a control group of 13 healthy individuals without dyssynchrony. The results showed a significant difference (p < 0,001) between the dispersion of standard deviation in the 13 patients in the control group (34 ms +/- A 19) and the 15 patients in the dyssynchrony group (117 ms +/- A 57). We describe a new parameter obtained by 3D echo wall motion Speckle Tracking analysis for the detection of dyssynchrony. It can be useful to identify dyssynchrony of left ventricular myocardial mechanics, to indicate the resynchronization therapy, to optimize the parameters of the device and to achieve a less operator-dependent evaluation.

Un varon de 84 anos sin antecedentes patologicos de interes previos, consulto por un infarto inferoposterior de mas de 24 h de evolucion. Se le practico una coronariografia, que mostro una oclusion de la rama posterolateral, con trombo organizado, que no se pudo revascularizar, y quedo con un flujo TIMI I. El paciente se mantuvo asintomatico y estable, hasta que 4 dias mas tarde sufrio un nuevo dolor opresivo asociado a hipotension; en la ecocardiografia se observaba una comunicacion interventricular (CIV) septoinferomedial (figura A). Se desestimo la opcion quirurgica por un EuroSCORE de mortalidad > 20% y, con vistas a la reparacion transcateter, se realizo una tomografia computarizada (TC) cardiaca. Mostro una CIV de 22 mm con un septum desflecado hacia el ventriculo derecho (figura B). Con estos hallazgos, se decidio cerrar la CIV realizando un asa venovenosa femoroyugular (femoral derecha-transeptal-auricula izquierdaventriculo izquierdo-ventriculo derecho-auricula derecha-vena yugular) que permitiera liberar primero el disco en el ventriculo derecho y atraer todo el tejido desflecado alineando el septum. Mediante esta tecnica se implanto con exito un dispositivo para oclusion de CIV tras infarto Amplatzer de 24 mm (figuras C y D). El paciente evoluciono satisfactoriamente y en el seguimiento a los 16 meses seguia vivo, en clase funcional II y con un QP/QS residual de 1,8. Este caso demuestra la gran utilidad de la TC para perfilar el septo interventricular y determinar el tamano del defecto, los bordes y la anfractuosidad de las CIV tras infarto aportando informacion esencial para las estrategias de cierre transcateter.

A 70-year-old male diagnosed with idiopathic pulmonary artery dilatation at 23. The patient was asymptomatic until the age of 68, when he started with exertional dyspnoea and was found to have a chronic pulmonary artery dissection with …