Search

Introduction and objectives Aortic self-expandable (SE) transcatheter aortic valve implantation (TAVI) devices are particularly useful for patients with aortic stenosis and small/tortuous vessels, small aortic annuli, or low coronary ostia. However, it is unclear whether the growing range of SE devices shows comparable hemodynamic and clinical outcomes. We aimed to determine the differential hemodynamic (residual valve area and regurgitation) and clinical outcomes of these devices in comparable scenarios. Methods All patients were enrolled from 4 institutions and were managed with 4 different SE TAVI devices. Baseline and follow-up clinical data were collected and echocardiographic tests blindly and centrally analyzed. Patients were compared according to valve type and a 1:1 matched comparison was performed according to degree of calcification, aortic annulus dimensions, left ventricular ejection fraction, and body surface area. Results In total, 514 patients were included (Evolut R/PRO, 217; ACURATE neo, 107; ALLEGRA, 102; Portico, 88). Surgical risk scores were comparable in the unmatched population. No differences were observed in the post-TAVI regurgitation rate and in in-hospital mortality (2.7%). The rate of pacemaker implantation at discharge was significantly different among devices (P=.049), with Portico showing the highest rate (23%) and ACURATE neo the lowest (9.5%); Evolut R/PRO and ALLEGRA had rates of 15.9% and 21.2%, respectively. The adjusted comparison showed worse residual TAVI gradients and aortic valve area with ACURATE neo vs ALLEGRA (P=.001) but the latter had higher risk of valve embolization and a tendency for more cerebrovascular events. Conclusions A matched comparison of 4 SE TAVI devices showed no differences regarding residual aortic regurgitation and in-hospital mortality.

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...

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.

Background Cangrelor, an intravenous, reversible P2Y12 antagonist, is approved for use in patients undergoing percutaneous coronary intervention (PCI). Objectives This study sought to evaluate the efficacy and safety of cangrelor compared with clopidogrel in subgroups that did and did not receive glycoprotein IIb/IIIa inhibitors (GPIs). Methods This pooled, patient-level analysis of the 3 CHAMPION (Cangrelor versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition) trials analyzed all randomized patients who underwent PCI and received the study drug (n = 24,902). Only bailout/rescue GPI use was permitted, except in CHAMPION PCI, in which routine or bailout/rescue GPI use was at the site investigator’s discretion. The primary efficacy endpoint was the composite of all-cause mortality, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 h after randomization. Results Overall, 3,173 patients (12.7%) received a GPI, most commonly eptifibatide (69.4%). Despite variation in indications for GPIs, baseline characteristics were well balanced between the cangrelor and clopidogrel arms in subsets receiving and not receiving GPIs. Rates of the primary composite endpoint were lower with cangrelor compared with clopidogrel in patients who did (4.9% vs. 6.5%; odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.55 to 1.01) or did not receive a GPI (3.6% vs. 4.4%; OR: 0.82; 95% CI: 0.72 to 0.94; Pint = 0.55). Cangrelor did not increase the primary safety endpoint, GUSTO-defined severe/life-threatening bleeding, in patients who did (0.4% vs. 0.5%; OR: 0.71; 95% CI: 0.25 to 1.99) or did not receive GPIs (0.2% vs. 0.1%; OR: 1.56; 95% CI: 0.80 to 3.04; Pint = 0.21). GPI use was associated with increased risk of bleeding in both treatment arms. Conclusions Cangrelor’s efficacy in reducing ischemic complications in patients undergoing PCI was maintained irrespective of GPI administration. GPI use was associated with substantially higher bleeding rates, regardless of the randomization to cangrelor or clopidogrel. (A Clinical Trial to Demonstrate the Efficacy of Cangrelor [PCI]: NCT00305162 ; Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition [PLATFORM]: NCT00385138 ; A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention [PCI] [CHAMPION PHOENIX] [CHAMPION]: NCT01156571 )

Introduction and objectives: There is current controversy regarding the benefits of percutaneous recanalization (PCI) of chronic total coronary occlusions (CTO). Our aim was to determine acute and follow-up outcomes in our setting. Methods: Two-year prospective registry of consecutive patients undergoing PCI of CTO in 24 centers. Results: A total of 1000 PCIs of CTO were performed in 952 patients. Most were symptomatic (81.5%), with chronic ischemic heart disease (59.2%). Previous recanalization attempts had been made in 15%. The mean SYNTAX score was 19.5 +/- 10.6 and J-score was > 2 in 17.3%. A retrograde procedure was performed in 92 patients (9.2%). The success rate was 74.9% and was higher in patients without previous attempts (82.2% vs 75.2%; P = .001), those with a J-score 20 mm, and blunt proximal cap were independent predictors of failed recanalization. The rate of procedural complications was 7.1%, including perforation (3%), myocardial infarction (1.3%), and death (0.5%). At 1-year of follow-up, 88.2% of successfully revascularized patients showed clinical improvement (vs 34.8%, P < .001), which was associated with lower mortality. At 1-year of follow-up, the mortality rate was 1.5%. Conclusions: Compared with other national registries, patients in the Iberian registry undergoing PCI of a CTO showed similar complexity, success rate, and complications. Successful recanalization was strongly associated with functional improvement, which was related to lower mortality. (C) 2018 Published by Elsevier Espana, S.L.U. on behalf of Sociedad Espanola de Cardiologia.

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

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

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.

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

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

Of 12 patients with sudden death and a high probability of coronary artery disease who underwent cardiac catheterization, 4 (25%) showed coronary arteries without significant obstructive lesions or angiographic signs of instability. The study protocol included an invasive study of coronary vasoreactivity and an intracoronary imaging study with intravascular ultrasound. The coronary reactivity study showed coronary vasospasm in 1 patient. Intravascular ultrasound showed active coronary plaques with images suggesting intraluminal thrombus in all patients. The diagnosis reached was sudden death secondary to ventricular arrhythmias in the context of acute coronary syndrome; the use of an implantable cardioverter-defibrillator was therefore not indicated. In conclusion, in patients with sudden death with a high probability of coronary artery disease but with coronary arteries lacking significant lesions, intracoronary imaging (eg, by intravascular ultrasound) may be essential to establish a diagnosis and appropriate treatment, even in patients with induced coronary vasospasm.

AIMS Data on primary percutaneous coronary intervention for ST-segment elevation in nonagenarian patients are very limited. Our aim was to evaluate the results of primary percutaneous coronary intervention in patients ≥ 90 years old with ST-segment elevation acute myocardial infarction. METHODS AND RESULTS We conducted a multicentre registry focused on nonagenarians treated with percutaneous coronary interventions, gathering data from five tertiary centres in Spain. We included 38 patients with ST-segment elevation acute myocardial infarction who presented within 12 hours after symptoms onset and who were treated with primary percutaneous intervention. Mean age was 91.5 (90-98). Angiographic success was achieved in 90%, and TIMI 3 flow in 76% of cases. In-hospital mortality was 34.2%, concentrated in patients with major bleeding (100% vs. 31.4%), final TIMI flow grade I at admission (53.3% vs. 21.7%). CONCLUSIONS Primary percutaneous coronary intervention in nonagenarians with ST-segment elevation acute myocardial infarction is associated with high rate of successful recanalisation of the infarct-related artery. Mortality is concentrated in patients with severe bleeding during hospitalisation, heart failure at admission, and final TIMI flow

The use of drug-eluting stents (DES) in unfavourable patients has been associated with higher rates of clinical complications and stent thrombosis, and because of that concerns about the use of DES in high-risk settings have been raised.This study sought to demonstrate that the clinical benefit of DES increases as the risk profile of the patients increases.A meta-regression analysis from 31 randomized trials that compared DES and bare-metal stents, including overall 12,035 patients, was performed. The relationship between the clinical benefit of using DES (number of patients to treat [NNT] to prevent one episode of target lesion revascularization [TLR]), and the risk profile of the population (rate of TLR in patients allocated to bare-metal stents) in each trial was evaluated.The clinical benefit of DES increased as the risk profile of each study population increased: NNT for TLR=31.1-1.2 (TLR for bare-metal stents); p0.001. The use of DES was safe regardless of the risk profile of each study population, since the effect of DES in mortality, myocardial infarction, and stent thrombosis, was not adversely affected by the risk profile of each study population (95% confidence interval for β value 0.09 to 0.11, -0.12 to 0.19, and -0.03 to-0.15 for mortality, myocardial infarction, and stent thrombosis, respectively).The clinical benefit of DES increases as the risk profile of the patients increases, without affecting safety.

Aims Because of the reduction in the rate events related with in-stent restenosis, most events after drug-eluting stent implantation occur shortly after coronary stenting. Cobalt-chromium alloys allow to reduce strut thickness and improve flexibility and deliverability of coronary stent platforms, and thus could be associated with lower short-term events after stenting. The aim of this study was to test the hypothesis that drug-eluting coronary stents with a cobalt-chromium platform reduce the incidence of periprocedural (30-day) myocardial infarction in comparison with stainless steel drug-eluting coronary stents. Methods and results A meta-analysis from nine randomised trials comparing cobalt-chromium and stainless steel drug-eluting coronary stents that overall included 11,313 patients was performed. The incidence of myocardial infarction, stent thrombosis, and cardiac death at 30 days was compared between both types of stents. At 30 days, the incidence of acute myocardial infarction was significantly lower in patients allocated to cobalt-chromium drug-eluting stents (2.3% vs. 3.9%, respectively; p=0.006; odds ratio 0.72, 95% confidence interval 0.58-0.91), due to a significant reduction in the rate of non-Q-wave myocardial infarction (odds ratio 0.67, 95% confidence interval 0.51-0.88). The incidence of stent thrombosis was similar between both groups of patients, (0.5% vs. 0.5%, p=0.76; odds ratio 1.09, 95% confidence interval 0.63-1.89). Conclusions Drug-eluting coronary stents that use cobalt-chromium stent platforms have a better safety profile at 30 days in comparison with stainless steel drug-eluting stents, due to a significant reduction in the rate of myocardial infarction.

An 83-year-old woman with chronic atrial fibrillation and hypertension underwent left atrial appendage occlusion at another center with a 22-mm Amplatzer cardiac plug (St. Jude Medical, Minneapolis, Minnesota) after embolic central retinal artery occlusion while receiving treatment with dabigatran.

Chronic total coronary occlusions constitute a sub-group of lesions at very high risk of restenosis after successful percutaneous coronary intervention. The sirolimus-eluting coronary stent is the only drugeluting stent that has demonstrated to reduce angiographic restenosis and the need for new revascularisation procedures in comparison with bare-metal stents in randomised clinical trials focusing on these lesions. Everolimus-eluting stents have shown to offer optimal angiographic and clinical outcomes in comparison with bare-metal stents and paclitaxel-eluting stents, but no randomised trials have tested the device in chronic total occlusions. The CIBELES (non-acute Coronary occlusIon treated By EveroLimus- Eluting Stent) will randomise 208 patients with chronic total coronary occlusions in 13 centres from Portugal and Spain to receive everolimus- or sirolimus-eluting coronary stents. The primary endpoint will be angiographic in-stent late loss.

Aims The aim of this study was to evaluate whether there is any relationship between in-stent late loss (ISLL) and the risk of stent thrombosis (ST) in patients treated with drug eluting stents (DES). The benefit of DES in reducing binary angiographic restenosis and the need for new revascularisation procedures is due to a reduction on ISLL. It has been hypothesised, however, that neointimal hyperplasia could preclude ST, and thus a very low ISLL could increase the risk of ST. Methods and results We selected 26 randomised clinical trials comparing bare metal stents and DES or different DES types, and including clinical and angiographic follow-up. In order to evaluate the association between risk of ST and ISLL, meta-regression analyses were conducted, weighting for the number of patients of each study. Twenty-six studies were included, retrieving 36 subgroups for analysis and 8,971 patients treated with DES. The incidence for ST and LST was 0.81% and 0.17%. Using meta-regression techniques, neither the risk of ST nor the risk of LST were found to be significantly associated with ISLL, accounting for -0.82 and -0.002 meta-regression estimates respectively (IC 95%: -1.92 to 0.28 for ST and -0.008 to 0.003 for LST). Conclusions The risk of ST and LST after DES implantation is not related with ISLL values. A very low mean value of ISLL is nor associated with a higher risk of ST.

The no-reflow phenomenon (NRP) is characterized by an inadequate myocardial tissue perfusion in the presence of a patent epicardial coronary artery. It generally occurs after temporary occlusion of the artery causing myocardial ischemia and necrosis that persist after relief of the vessel occlusion, without evidence of epicardial mechanical obstruction. Currently, the main scenario of NRP is the setting of percutaneous coronary interventions (PCI), especially in patients with acute myocardial infarction or saphenous vein graft disease, and its occurrence is associated with adverse clinical outcomes. Pathophysiology of NRP is not fully understood but it seems to be related with microvascular damage. Several mechanisms have been involved, such as distal microembolization, interstitial and intracellular edema, coronary spasm and capillary plugging. Diagnosis of NRP is generally based on clinical and angiographic data. Several methods have been proposed for the assessment of NRP, such as electrocardiography, myocardial contrast echocardiography, contrast-enhanced magnetic resonance imaging, nuclear imaging or positron emission tomography, that have demonstrated additional prognostic value over angiography. There are different pharmacological and mechanical approaches for the prevention of NRP but none of them have demonstrated a clear efficacy. The treatment of established NRP is mainly based on the administration of coronary vasodilators, like adenosine, verapamil or nitroprusside, but clinical results are frequently disappointing. The objective of this review is to describe the state of the art of the pathophysiology, diagnosis and pharmacological management of NRP.

Introduction and objectives Transcatheter aortic valve implantation is used as an alternative to surgical valve replacement in patients with severe aortic stenosis who are considered high-surgical-risk or inoperable. Two of the main areas of uncertainty in this field are valve durability and long-term survival. Methods This prospective single-center registry study from a tertiary hospital included all consecutive patients who underwent percutaneous aortic valve implantation between 2008 and 2012. Clinical follow-up lasted a minimum of 2.5 years and a maximum of 6.5 years. Valve Academic Research Consortium-2 definitions were used. Results Seventy-nine patients were included, with an immediate success rate of 94.9%. The median survival was 47.6 months (95% confidence intervals, 37.4-57.9 months), ie, 4 years. One quarter of deaths occurred in the first month, and most were of cardiovascular cause. After the first month, most deaths were due to noncardiovascular causes. The mean values of valve gradients did not increase during follow-up. The cumulative rate of prosthetic valve dysfunction was 15.3%, with no cases of repeat valve replacement. Conclusions Half of the patients with aortic stenosis who underwent transcatheter aortic valve implantation were alive 4 years after the procedure. There was a 15.3% prosthetic valve dysfunction rate in cumulative follow-up, with no cases of repeat valve replacement.

Fully repositionable trans-catheter aortic valve devices (TAVR) facilitate precise positioning and minimize paravalvular regurgitation. However, the occurrence of some periprocedural complications remains a concern, and the need for permanent pacemaker implantation (PPI) after the procedure is

Clinical trials have shown that functional assessment of coronary stenosis by fractional flow reserve (FFR) improves clinical outcomes. Intravascular ultrasound (IVUS) complements conventional angiography, and is a powerful tool to assess atherosclerotic plaques and to guide percutaneous coronary intervention (PCI). Computational fluid dynamics (CFD) simulation represents a novel method for the functional assessment of coronary flow. A CFD simulation can be calculated from the data normally acquired by IVUS images. A case of coronary heart disease studied with FFR and IVUS, before and after PCI, is presented. A three-dimensional model was constructed based on IVUS images, to which CFD was applied. A discussion of the literature concerning the clinical utility of CFD simulation is provided. Resumo: Estudos clínicos demonstraram que a avaliação funcional da doença coronária com fio de pressão e determinação da reserva fracionada de fluxo (fractional flow reserve - FFR) melhora a evolução clínica. O estudo por ultra-som intravascular (IVUS) complementa a angiografia convencional, e é uma ferramenta poderosa para a avaliação das placas ateroscleróticas orientando a intervenção coronária percutânea (ICP). A simulação computorizada da dinâmica de fluidos (CFD), representa um novo método que permite avaliar funcionalmente o fluxo coronário. A CFD pode ser calculada a partir dos dados normalmente obtidos por IVUS. É apresentado um caso de doença coronária estudada com FFR e IVUS, antes e após a ICP. Foi construído um modelo tridimensional com base nas imagens obtidas por IVUS e avaliado com a técnica de CFD. É apresentada uma discussão bibliográfica sobre a utilidade clínica da simulação com CFD. Keywords: Coronary artery disease, Myocardial fractional flow reserve, Intravascular ultrasound, Fluid dynamics, Computer simulation, Palavras-chave: Doença cardíaca coronária, Reserva fracionada de fluxo miocárdico, Ultra-sonografia intravascular, Dinâmica de fluidos, Simulação computorizada

Mitral stenosis (MS) is frequently associated with the development of atrial fibrillation (AF) as a consequence of hemodynamic and inflammatory changes in the left atrium. Both conditions predispose to thrombus formation, with frequent involvement of the left atrial appendage (LAA), and consequent increase in the incidence of systemic thromboembolic events. Percutaneous mitral valvuloplasty (PMV) reduces the risk of thromboembolism in patients with significant mitral stenosis. Percutaneous LAA closure is also associated with a reduction in thromboembolic risk in patients with AF, but there are no data regarding the use of this technique in patients with significant mitral valve disease. We report the case of a 57-year-old-woman with significant MS and permanent AF, in New York Heart Association functional class II, who despite adequate oral anticoagulation with acenocoumarol, presented several clinical episodes of systemic thromboembolism in the last four years. It was decided to perform a combined percutaneous procedure, including both PMV and percutaneous LAA closure with the Amplatzer Cardiac Plug device. No significant acute complications occurred and the patient was discharged on indefinite treatment with acenocoumarol associated with aspirin 100 mg/d for three months. After a one-year follow-up, there have been no new embolic episodes or other complications. Resumo: A estenose mitral (EM) é frequentemente associada ao desenvolvimento de fibrilhação auricular (FA) como consequência de alterações hemodinâmicas e inflamatórias na aurícula esquerda. Ambas as condições predispõem à formação de trombos, com frequente envolvimento do apêndice auricular, e consequente aumento da incidência de eventos tromboembólicos sistémicos. A valvuloplastia mitral percutânea (VMP) reduz o risco de tromboembolismo em doentes com EM significativa. O encerramento percutâneo do apêndice auricular esquerdo (PCLAA) na FA também está associado a uma redução de risco de tromboembolismo em pacientes com FA, mas não existem dados sobre a utilização desta técnica em doentes com MS. Relatamos o caso de uma mulher de 57 anos de idade com significativa EM e FA permanente, em classe funcional II, que, apesar de anticoagulação oral adequada com acenocumarol, apresentou nos últimos quatro anos vários episódios clínicos de tromboembolismo sistémico. Foi decidido realizar um procedimento percutâneo combinado de PMV e PCLAA com dispositivo Amplatzer Cardiac Plug. Não se verificaram complicações agudas significativas e o paciente recebeu alta com acenocumarol de forma indefinida, associado com aspirina 100 mg/d durante três meses. Depois de um ano de follow-up, não houve novos episódios embólicos ou outras complicações. Keywords: Percutaneous left atrial appendage closure, Percutaneous mitral valvuloplasty, Mitral stenosis, Atrial fibrillation, Palavras-chave: Encerramento percutâneo do apêndice arterial esquerdo, Valvuloplastia mitral percutânea, Estenose mitral, Fibrilhação auricular

AIMS Controversy exists about the safety and efficacy of drug-eluting stents (DES) in saphenous vein bypass grafts (SVGs). The aim of this study was to perform a meta-analysis of all published studies comparing DES and bare-metal stents (BMS) in patients with SVGs disease. METHODS AND RESULTS We included 22 studies comparing DES versus BMS in 5,543 patients with SVGs disease. The primary efficacy endpoint was target vessel revascularisation (TVR). The primary safety endpoint was mortality. Other outcomes of interest were cardiac mortality, myocardial infarction, target lesion revascularisation (TLR), stent thrombosis and a combined of major adverse cardiac events (MACE). DES significantly reduced the risk of TVR, OR=0.56 (95% CI, 0.41-0.76, p=0.0003) and TLR, OR=0.58 (95% CI, 0.41-0.81; p=0.001). Total mortality and cardiac mortality were significantly lower in DES versus BMS, OR=0.69 (95% CI, 0.49-0.98, p=0.04) and OR=0.71 (95% CI, 0.51-0.99; p=0.04), respectively. The overall risk of stent thrombosis, and myocardial infarction were not significantly different for patients receiving DES vs. BMS. Total MACE were significantly lower in patients receiving DES, OR=0.55 (95% CI, 0.42-0.71; p

Endothelial dysfunction is characterized by an impairment of endothelium-dependent vasodilatation. It has been linked to each of the known atherogenic risk factors, including diabetes mellitus, hypertension, dyslipidaemia, cigarette smoking, menopause, etc. A number of recent studies have shown that the severity of endothelial dysfunction correlates with the development of coronary artery disease and predicts future cardiovascular events. Therefore, these findings strengthen the hypothesis that endothelial dysfunction may be an early stage of coronary atherosclerosis. This phenomenon primarily reflects an imbalance between the vasodilating (nitric oxide) and vasoconstrictor agents (endothelin-1). Several invasive (intracoronary or intrabrachial infusions of vasoacting agents) and non-invasive techniques (assessment of flow mediated vasodilatation in the brachial artery by ultrasound) have been developed during the last few years to evaluate endothelial function in the coronary and peripheral circulation. This new methodology has allowed assessing the severity of the abnormalities in vascular function and their regression by several pharmacological and non-pharmacological interventions. It is likely that restoration of endothelial function can regress the atherosclerotic disease process and prevent future cardiovascular events. Most pharmacological interventions attempting to improve endothelial dysfunction targeted the risk factors linked to endothelial dysfunction: hypertension (ACE-inhibitors, calcium antagonists), dyslipidaemia (lipid-lowering agents) and menopause (estrogens). Nevertheless, several pharmacological agents have been suggested to achieve vascular protection through different mechanisms beyond their primary therapeutic actions: ACE-inhibitors, statins, third generation of beta-blockers (nebivolol), endothelium-derived nitric oxide synthesis (tetrahydrobiopterin, BH4) and antioxidants agents. In this review we will focus on the current pharmacological management of the endothelial dysfunction.

Transcatheter aortic valve implantation is being established as an alternative treatment for some patients with symptomatic severe aortic stenosis who are not considered suitable for surgical aortic valve replacement because of prohibitive surgical risk. 1–3 One of the potential complications is complete atrioventricular block requiring definitive pacemaker implantation. This complication occurs in 4% to 5% with the Edwards-Sapiens prosthesis (Edwards Lifesciences, Irvine, Calif), 1 and in 30% with the CoreValve system (Medtronic CV, Luxembourg),3 but it also occurs in 5% of patients after percutaneous aortic valvuloplasty4 or surgical aortic valve replacement. 5 The cause of complete atrioventricular block after transcatheter aortic valve implantation is unknown. Apart from traumatic lesions produced by aortic valve prosthesis expansion, ischemia of the conduction pathways resulting from insufficient myocardial protection might play a role. Here, necropsy findings in a patient with complete atrioventricular block after transcatheter aortic valve implantation are presented for the first time, showing the physiopathology of this complication. A 79-year-old woman with symptomatic severe aortic stenosis and prohibitive surgical risk was referred for transcatheter aortic valve implantation. A 26-mm EdwardsSapiens prosthetic valve was implanted without complications except complete atrioventricular block requiring transvenous pacemaker stimulation. Three days after transcatheter aortic valve implantation, the patient suffered sudden cardiac death that could not be resolved with resuscitation. Necropsy was performed to evaluate the status of the pros

Restenosis is an important limitation of percutaneous coronary interventions (PCI). In-stent restenosis is mainly due to neointimal hyperplasia, a proliferative process modulated by inflammatory mechanisms. Numerous technical and pharmacological means have been tested to reduce restenosis rates, with frequently disappointing clinical results. Drug-eluting stents (DES) have demonstrated a high efficacy in reducing restenosis, but there are some associated problems that limit its generalized utilization. Glucocorticoids (GC), as potent anti-inflammatory agents, may exert beneficial effects on neointimal proliferation. Clinical studies with oral and intracoronary GC therapy have demonstrated reduction in restenosis rates in selected patients. Although further investigations are warranted, GC might have a potential role for restenosis prevention in selected cases.

The only clinical benefit of drug-eluting stents (DESs) over bare metal stents (BMSs) is a significant decrease in the need for new revascularization procedures. We evaluated whether DESs also decrease the incidence of myocardial infarction at midterm. We performed a meta-analysis from 25 randomized trials comparing commercially available DESs with BMSs that included 9,791 patients overall. There was no heterogeneity across the trials included (Q test for heterogeneity, p = 0.68). Of the 9,791 patients included in all the trials, 364 developed an acute myocardial infarction during follow-up (6 to 12 months). The risk of myocardial infarction was significantly lower in patients allocated to DESs (3.3% vs 4.2% in those allocated to BMSs, odds ratio 0.79, 95% confidence interval 0.64 to 0.97, p = 0.03). In conclusion, the significant decrease in angiographic restenosis associated with the use of DESs leads not only to a decreased need for subsequent revascularization procedures but also a decreased incidence of myocardial infarction during the first 12 months after stent implantation.

We report a case of a 58-year-old woman with rheumatic mitral stenosis scheduled for percutaneous valvuloplasty. Prior left and right ventricular angiograms showed multiple diverticula at left ventricular apical and diaphragmatic walls and right ventricular diaphragmatic wall. Chest x-ray and echocardiogram were normal. Magnetic resonance imaging was concordant with catheterization findings and ruled out other cardiac malformations. The risk of ventricular perforation changed our indication of percutaneous valvuloplasty in favor of open heart commissurotomy.

We read with interest the paper by Amat-Santos et al. ([1][1]) describing the importance of new-onset atrial fibrillation (NOAF) after transcatheter aortic valve implantation (TAVI). They describe an association between NOAF and embolic events (EE), suggesting that NOAF may be a mechanism for late