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ABSTRACT Introduction and objectives: The optimal treatment of nonculprit angiographic intermediate lesions (diameter stenosis 40%-69%) in patients with ST-segment elevation myocardial infarction (STEMI) is still unknown. Lesions with fractional flow reserve (FFR) ≤ 0.80 are indicative of ischemia and benefit from revascularization. However, lesions with FFR > 0.80 and optical coherence tomography (OCT) findings of vulnerability have been hypothesized to cause adverse events during follow-up. The study aims to compare the efficacy of a preventive treatment with stent implantation plus optimal medical therapy vs optimal medical therapy alone for nonculprit intermediate lesions with FFR > 0.80 and OCT findings of plaque vulnerability in STEMI patients at 4 years of follow-up. Methods: This parallel-group, multicenter, controlled, single-blind, and 1:1 randomized trial will enroll a total of 600 STEMI patients with ≥ 1 intermediate nonculprit lesions with FFR > 0.80 and OCT findings of plaque vulnerability. The primary endpoint is target vessel failure, defined as the composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization. The study will include a parallel registry of patients with FFR > 0.80 but without OCT findings of vulnerability. Vulnerable plaques are defined as lipid-rich fibroathermas with plaque burden ≥ 70% and a thin fibrous cap (≤ 80 μm). Results: The VULNERABLE trial will reveal the role of preventive treatment with stent implantation for nonculprit and functionally nonsignificant vulnerable plaques in STEMI patients. Conclusions: This is the first randomized trial of OCT-guided treatment of vulnerables plaques. Registered at ClinicalTrials.gov (NCT05599061).

Introducción y objetivos: El tratamiento óptimo de las lesiones angiográficas intermedias (diámetro de estenosis 40-69%) no culpables en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) está por determinar. La reserva fraccional de flujo (RFF) permite diagnosticar lesiones causantes de isquemia (RFF ≤ 0,80) que se benefician de una revascularización. No obstante, las lesiones con RFF > 0,80 y criterios de vulnerabilidad por tomografía de coherencia óptica (OCT) también se ha hipotetizado que pueden causar eventos adversos en el seguimiento. El objetivo es comparar la eficacia del tratamiento preventivo con implantación de stent más tratamiento médico óptimo de lesiones intermedias no culpables con RFF > 0,80 y características de placa vulnerable frente a solo tratamiento médico óptimo en pacientes con IAMCEST a 4 años de seguimiento. Métodos: Estudio de grupos paralelos, multicéntrico, controlado, aleatorizado 1:1 y simple ciego. Se incluirán 600 pacientes con IAMCEST y al menos una lesión intermedia no culpable que presenten RFF > 0,80 y características de placa vulnerable por OCT. El objetivo primario se define como fallo del vaso diana, compuesto de muerte cardiaca, infarto del vaso diana y necesidad de revascularización del vaso diana. El estudio incluye un registro paralelo para pacientes con RFF > 0,80 sin características de placa vulnerable. Se define placa vulnerable como fibroateromas lipídicos con carga de placa ≥ 70% y capa fibrosa fina (≤ 80 µm). Resultados: El estudio VULNERABLE permitirá conocer el papel del tratamiento preventivo con stent de placas vulnerables no culpables funcionalmente no significativas en pacientes con IAMCEST. Conclusiones: Se trata del primer estudio aleatorizado para el tratamiento de placas vulnerables guiado por OCT. Registrado en ClinicalTrials.gov (NCT05599061).

Transcatheter heart valve embolization is a serious and rare complication of transcatheter aortic valve replacement. Having a strategy for promptly managing transcatheter heart valve embolization is crucial to avoid emergency conversion from transcatheter aortic valve replacement to open-heart surgery. Many cases of transcatheter heart valve embolization occurring with balloon-expandable prostheses such as the SAPIEN 3 (Edwards LifeSciences Corporation) valve and self-expandable prostheses such as the ACURATE neo (Boston Scientific Corporation) valve have been reported in the literature. Here, for the first time (to the authors’ knowledge), the case of a Myval (Meril Life Sciences Pvt Ltd) transcatheter heart valve embolization during transcatheter aortic valve replacement, which was treated percutaneously with favorable outcomes, is reported.

Sr. Editor: El uso de dispositivos de soporte circulatorio con oxigenador extracorpóreo de membrana (ECMO) en pacientes con parada cardiaca, shock o insuficiencia respiratoria refractaria secundaria a una tromboembolia pulmonar se está consolidando como una terapia eficaz y segura1-3. Con el objetivo de mejorar la situación hemodinámica y respiratoria de estos pacientes, es creciente el uso complementario de la trombectomía pulmonar percutánea mediante tromboaspiración4-6. En este caso, debemos considerar algunos aspectos técnicos que garanticen el éxito del procedimiento, y que eviten exponer al paciente a nuevos riesgos que puedan surgir como consecuencia de combinar ambas terapias. El ECMO está compuesto por una bomba centrífuga que, al girar a alta velocidad, genera una presión negativa en el eje central. Esto permite la aspiración de sangre a través de la cánula de inserción venosa (figura 1 del material adicional). Posteriormente, tras pasar por el ECMO, la sangre es expulsada a través de una segunda cánula, ya sea arterial o venosa, introduciéndola de nuevo en el sistema circulatorio del paciente. La estanqueidad es la cualidad de un sistema o compartimento que se encuentra aislado del resto, sin transferencias. En condiciones normales, el sistema vascular se considera estanco, ya que no hay pérdidas hemáticas ni entradas de...

To the Editor, The use of extracorporeal membrane oxygenation (ECMO) circulatory support devices in patients with cardiac arrest, shock, or refractory respiratory failure due to pulmonary thromboembolism is increasingly recognized as a safe and effective therapy.1-3 With the aim of improving the hemodynamic and respiratory status of these patients, the adjuvant use of transcatheter pulmonary thrombectomy through thrombus aspiration is increasingly common.4-6 However, combining these two therapies requires careful consideration of technical issues to ensure procedural success and prevent additional risks. ECMO consists of a centrifugal pump that rotates at high speed to create negative pressure in the central axis, allowing blood to be aspirated through the venous insertion cannula (figure 1 of the supplementary data). Subsequently, after passing through the ECMO, the blood is pumped through a second cannula—arterial or venous—to be reintroduced into the patient’s circulatory system. Figure 1. A: valve of a large-bore thrombus aspiration catheter. The asterisk shows the 2 buttons that, when pressed, allow the valve to open. B: opening of the valve by pressing the 2 buttons. Support needs to be reduced or stopped before opening this or any other valve in patients on extracorporeal membrane oxygenation (ECMO). Sealing refers to the quality of a system...

RESUMEN Introducción y objetivos: La Asociación de Cardiología Intervencionista de la Sociedad Española de Cardiología (ACI-SEC) y el Grupo de Trabajo de Hemodinámica de la Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas (GTH-SECPCC) presentan su informe anual de actividad hemodinámica en cardiopatías congénitas correspondiente al año 2022. Métodos: Se invitó a participar a los centros españoles con laboratorio de hemodinámica y actividad intervencionista en cardiopatías congénitas. La recogida de datos se realizó mediante un cuestionario telemático. Una empresa externa analizó los resultados, que fueron revisados por miembros de la ACI-SEC y el GTH-SECPCC. Resultados: Participaron en el registro 22 centros (19 públicos y 3 privados). Se incorporaron al análisis los datos de intervencionismo en cardiopatías congénitas del adulto aportados por otros 99 hospitales al Registro de Hemodinámica y Cardiología Intervencionista de la ACI-SEC del año 2022. Se registraron 1.141 estudios diagnósticos (un 4,3% más que en 2021) y 2.508 cateterismos intervencionistas (un 61,5% más que en 2021). Las técnicas con mayor casuística fueron el cierre de defectos interauriculares (1.135 casos), el cierre de ductus arterioso (262 casos) y la angioplastia de ramas pulmonares (234 casos). El incremento más significativo se comunicó en la valvuloplastia aórtica (48,9%), el cierre de defectos interauriculares (45,2%) y el cierre de comunicación interventricular (40,7%). La tasa de éxito en los procedimientos intervencionistas fue del 97,6%, con una tasa de complicaciones mayores del 1,4 % y una mortalidad intrahospitalaria del 0,2%. Conclusiones: El presente trabajo es la tercera publicación del Registro Español de Intervencionismo en Cardiopatías Congénitas. Se ha comunicado un aumento muy significativo de la mayoría de los procedimientos terapéuticos, destacando el incremento de la valvuloplastia aórtica, del cierre de defectos interauriculares y del cierre de comunicación interventricular. Todas las técnicas intervencionistas han comunicado excelentes datos de seguridad y eficacia.

ABSTRACT Introduction and objectives: The Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) and the Interventional Working Group of the Spanish Society of Pediatric Cardiology (GTH-SECPCC) present their annual activity report for 2022. Methods: All Spanish centers with catheterization laboratories and interventional activity in congenital heart diseases were invited to participate. Data were collected online and analyzed by an external company, together with the members of the ACI-SEC and the GTH-SECPCC. Results: A total of 22 centers participated (19 public and 3 private). Interventional data on adult congenital diseases contributed by another 99 hospitals to the Registry of Cardiac Catheterization and Interventional Cardiology of the ACI-SEC in 2022 were incorporated into the analysis. A total of 1141 diagnostic studies (4.3% more than in 2021) and 2508 interventional catheterizations (61.5% more than in 2020) were registered. The most frequent procedures were atrial septal defect closure (1135 cases), percutaneous closure of patent ductus arteriosus (262 cases), and pulmonary branch artery angioplasty (234 cases). The most significant increases in volume were related to balloon aortic valvuloplasty (48.9%), atrial septal defect closure (45.2%), and ventricular septal defect closure (40.7%). Interventional procedures were successful in 97.6%, with major procedural complications occurring in 1.4% and in-hospital mortality in 0.2%. Conclusions: This report is the third publication of the Spanish Cardiac Catheterization in Congenital Heart Diseases Registry. Both diagnostic and interventional procedures substantially increased, particularly in balloon aortic valvuloplasty, atrial septal defect closure, and ventricular septal defect closure. Most interventional techniques continue to demonstrate excellent safety and effectiveness outcomes.

New remote-sensed biomass change products will transform our capacity to monitor and validate large-scale carbon dynamic in the next decade. In this study, we evaluated the use of multitemporal Airborne Laser Scanning (ALS) and the Climate Change Initiative (CCI) BIOMASS spaceborne mission to estimate AGB dynamics in different Mediterranean forest over an 8-year period (2010–2018). To do so, we evaluated different maps to estimate change in AGB, specifically indirect approach using forest-type specific ALS-based AGB maps using i) countrywide ALS coverage at 25 m resolution (2010–2018) and ii) the global, 100-m resolution CCI maps version 3 (2010–2018). The change in AGB (ΔAGB) was mapped across the study region to compute dynamics by forest type. Our results suggest that the indirect approach using ALS-model-based produced more accurate estimates in change of AGB than CCI when we compared with the design-based AGB estimation using Spanish National Forest Inventory (SNFI) at strata level. The spatial representation of the AGB change indicated that ΔAGB-ALS changes by forest type had an overall gain in biomass at regional level. The ΔAGB total and net annual changes by year and area (ΔAGB, Mg ha−1 year−1) were closed to the values obtained using SNFI at strata level. This study demonstrates the feasibility of enhancing carbon sequestration and stock capacity in Mediterranean forest using multitemporal ALS data and the limitations of global AGB maps at Regional Scale.

Background: Obstructive complications in the Fontan circulation pose significant risks to affected patients. Traditional management strategies may be insufficient, necessitating innovative treatment approaches. This case report discusses the use of the FlowTriever Retrieval System for percutaneous aspiration thrombectomy in a patient with a history of Fontan procedure who developed conduit obstruction due to thrombus formation. Case report: A 28-year-old male with a history of double inlet left ventricle and previous Fontan procedure presented with progressive dyspnea. Despite initial thrombectomy for high-risk pulmonary embolism, thrombi remained in the Fontan conduit and inferior vena cava. The patient remained hemodynamically unstable. Imaging confirmed thrombosis of the extracardiac conduit. An innovative percutaneous approach using the FlowTriever system successfully restored conduit flow and removed thrombus. Subsequent stenting addressed residual stenosis. Post-intervention, the patient showed remarkable clinical improvement. There were no procedure-related complications. He was discharged on an optimized anticoagulation regimen and remained asymptomatic during follow-up. Conclusion: This case demonstrates the efficacy of the FlowTriever Retrieval System in managing complex thrombotic obstructions in Fontan circulation, which not only effectively resolved the obstruction but also maintained haemodynamic stability, thus highlighting its potential to enhance current treatment modalities for such congenital heart conditions.

Sr. Editor: La aterectomía coronaria con láser excimer es una técnica que empezó su desarrollo a principios de los años 1980, pero no ha sido hasta estos últimos años cuando se ha producido una mejora en términos de seguridad y efectividad, lo que ha permitido su expansión a un número de salas de hemodinámica cada vez mayor. El mecanismo de acción de dicha técnica es triple: fotoquímico, fototérmico y fotocinético. Cuando se expone en un campo eléctrico de alto voltaje una mezcla de cloruro de hidrógeno y un gas noble como el xenón, se produce una unión extremadamente lábil de los átomos de cloro y xenón, cuya separación emite un fotón que, tras su amplificación, es el origen del láser de alta energía generado1. Se presentan los casos de 3 pacientes, 2 con lesiones incruzables y 1 con infraexpansión rebelde de stent, tratados en nuestra unidad. La aterectomía láser con infusión intracoronaria simultánea de solución salina fisiológica (con catéter ELCA 0,9 mm, Espectranetics, Estados Unidos) no tuvo éxito en un primer acto, dado que, después de la aplicación de la terapia, esta no permitió el avance de ningún otro dispositivo de angioplastia (balones de predilatación, microcatéteres de bajo perfil ni guía de...

To the Editor, The excimer laser coronary angioplasty technique was first developed in the early 1980s. However, its safety and effectiveness have only improved in recent years, allowing its integration in an increasing number of cath labs. The technique has a triple mechanism of action: photochemical, photothermal, and photokinetic. When a mixture of hydrogen chloride and a noble gas such as xenon is exposed to a high-voltage electric field, an extremely unstable bond of chlorine and xenon atoms occurs. The separation of these atoms emits a photon which, when amplified, creates a high-energy laser.1 We report the cases of 3 patients, 2 with uncrossable lesions and 1 with rebel stent underexpansion, treated in our unit. Laser atherectomy, along with simultaneous intracoronary infusion of a physiological saline solution (using a 0.9 mm ELCA catheter, Spectranetics, United States), was unsuccessful at the first attempt. This was because, after its application, no other angioplasty devices (predilatation balloons, low-profile microcatheters, or rotational atherectomy guidewires) could be advanced in any of the uncrossable lesions. In the patient with underexpansion, effective dilatation with high-pressure noncompliant balloons after lithotripsy was also unfeasible. These are the only cases treated in our unit with failed laser therapy and a new angioplasty...

PREGUNTA: Aunque vamos a comentar aspectos de dos técnicas de modificación de placa calcificada, explíquenos cuándo recurre a la imagen intravascular en casos de lesió con calcio y en qué le sirve, fundamentalmente, de ayuda. RESPUESTA: Las técnicas de imagen intracoronaria (tomografía de coherencia óptica [OCT] y ultrasonido intravascular [IVUS]) permiten optimizar la intervención coronaria percutánea y su uso en lesiones complejas mejora el pronóstico de los pacientes1. Facilitan los siguientes aspectos2: – Detección y evaluación de la calcificación: tienen unas mayores sensibilidad y especificidad que la angiografía para la detección del calcio3. Además, permiten evaluar las características de la calcificación y se han desarrollado distintas puntuaciones4,5 que integran las variables asociadas a la infraexpansión del stent. – Selección de técnicas de modificación de placa: los hallazgos de imagen intracoronaria influirán en la estrategia, siendo recomendable utilizar técnicas avanzadas cuando existen criterios de riesgo de infraexpansión del stent2. – Optimización de la implantación del stent: es especialmente relevante en lesiones calcificadas, que son las más asociadas a infraexpansión, el parámetro más relacionado con el fracaso del stent2. La adecuada aposición del stent y cobertura de la lesión y la ausencia de disección y de hematoma significativo en los bordes, son otros parámetros que deben...

QUESTION: Although we will discuss the aspects of 2 plaque modification techniques, please explain when you resort to intravascular imaging modalities in cases of calcified lesions and how that helps you. ANSWER: Intracoronary imaging modalities (optical coherence tomography [OCT] and intravascular ultrasound [IVUS]) allow us to optimize percutaneous coronary interventions, and their use in complex lesions improves the patient’s prognosis.1 They facilitate the following aspects:2 – Calcification detection and assessment: they have higher sensitivity and specificity than angiography for detecting calcium.3 Also, they allow the evaluation of calcification characteristics, and various scores4,5 have been developed that integrate variables associated with stent underexpansion. – Selection of plaque modification technique: intracoronary imaging findings have an impact on the strategy used, which is why the use of advanced imaging modalities is advised in the presence of risk criteria for stent underexpansion.2 – Optimization of stent deployment: this is especially relevant in calcified lesions, which are the lesions most frequently associated with stent underexpansion, the parameter most often associated with stent failure.2 Other parameters that should also be assessed are proper stent apposition, lesion coverage, the absence of dissection, and significant hematoma around the edges.6 Q.: In your opinion, what are the advantages and disadvantages of ablation, whether rotational...

RESUMEN Introducción y objetivos: El uso contemporáneo y los resultados de la aterectomía coronaria con láser Excímer (ELCA) en el intervencionismo coronario percutáneo (ICP) de lesiones coronarias gravemente calcificadas no están establecidos. El objetivo de este estudio fue evaluar la eficacia, seguridad y resultados a 1 año de ELCA en este escenario. Métodos: Se revisaron de forma retrospectiva las características clínicas y angiográficas, y los resultados de los procedimientos de revascularización de lesiones gravemente calcificadas tratadas con ICP asistido por ELCA en nuestro centro entre 2016 y 2022. Resultados: Se incluyeron 78 pacientes consecutivos (80 procedimientos) (edad media 71,2 ± 8,6 años, 80,5% varones). La presentación clínica fue enfermedad arterial coronaria estable en 45 (56,2%) pacientes y síndromes coronarios agudos en 33 (43,8%). Todas las lesiones presentaban calcificación grave. Además, el 40% eran lesiones incruzables, el 28,75% lesiones indilatables, el 2,5% reestenosis intrastent, el 6,25% infraexpansión del stent y el 7,5% oclusiones crónicas. La combinación de ≥ 2 de los escenarios anatómicos anteriores existió en el 12,5% de los procedimientos. La fluencia máxima fue de 73 ± 9,6 mJ/mm2 y la frecuencia máxima de 72,7 ± 10,4 Hz. ELCA con lavado con solución salina se utilizó inicialmente en todos los procedimientos y se utilizó contraste en 2 procedimientos. La tasa de éxito de ELCA y de éxito técnico fueron del 91,25 %. Fueron necesarias terapias adyuvantes de modificación de placa en 4 casos. La tasa de éxito clínico fue del 87,5%. Ocurrieron complicaciones relacionadas con ELCA en 2 (2,5%) procedimientos. Tras una mediana de seguimiento de 15,5 meses (IQR, 5,0-29,3), se produjeron eventos cardiovasculares adversos mayores (MACE) (nueva revascularización de la lesión diana, infarto de miocardio o muerte cardiaca) en 9 pacientes (11,25%). Conclusiones: A pesar de la complejidad de la ICP en lesiones gravemente calcificadas, ELCA demostró ser efectivo con una incidencia relativamente baja de complicaciones relacionadas con ELCA y MACE en el seguimiento.

ABSTRACT Introduction and objectives: No previous studies have established the contemporary use and outcomes of Excimer laser coronary atherectomy (ELCA) in percutaneous coronary intervention (PCI) of severely calcified coronary lesions. The aim of this study was to assess the safety, efficacy, and 1-year outcomes of ELCA in this setting. Methods: We retrospectively examined the clinical and angiographic characteristics and procedural outcomes of severely calcified lesions treated with ELCA-assisted PCI in our institution between 2016 and 2022. Results: Seventy-eight consecutive patients (80 procedures) were included (mean age 71.2 ± 8.6 years, 80.5% men). Clinical presentation was stable coronary artery disease in 45 patients (56.2%) and acute coronary syndromes in 33 (43.8%). All the lesions were severely calcified. In addition, 40% were uncrossable lesions, 28.75% were undilatable lesions, 2.5% showed in-stent restenosis, 6.25% showed stent underexpansion, and 7.5% were chronic total occlusions. The combination of ≥ 2 of the above anatomic settings was found in 12.5% of the procedures. The maximum fluence was 73 ± 9.6 mJ/mm2, and the maximum frequency was 72.7 ± 10.4 Hz. The saline flushing technique was initially used in all the procedures, while contrast was used in 2 procedures. The ELCA success and technical success rates were both 91.25%. Adjuvant plaque modification therapies were required in 4 patients. The clinical success rate was 87.5%. ELCA-related complications occurred in 2 procedures (2.5%). After a median follow-up of 15.5 months [IQR, 5.0-29.3], major adverse cardiac events (MACE) (target lesion revascularization, myocardial infarction or cardiac death) occurred in 9 patients (11.25%). Conclusions: Despite the complexity of PCI in severely calcified lesions, ELCA was effective with a relatively low incidence of ELCA-related complications and MACE during follow-up.

RESUMEN Introducción y objetivos: La calcificación coronaria es uno de los principales factores que inciden negativamente en la seguridad y la eficacia del intervencionismo coronario percutáneo. Existen varias técnicas de modificación del calcio, pero falta evidencia de estudios aleatorizados sobre la terapia de elección en este escenario. Métodos: El ROLLERCOASTR es un estudio prospectivo, multicéntrico y aleatorizado, diseñado para comparar la seguridad y la eficacia de 3 técnicas de modificación de la placa en el contexto de calcificación coronaria moderada o grave: aterectomía rotacional (AR), aterectomía coronaria con láser láser excimer (ACLE) y litotricia intracoronaria (LIC). El objetivo primario es la expansión del stent evaluada mediante tomografía de coherencia óptica. Su análisis se hará por intención de tratar, con un α de 0,05 entre el grupo de referencia (AR) y cada uno de los otros grupos (ACLE y LIC). Se realizará también un análisis del objetivo primario por protocolo para mantener la coherencia. Si se confirma la hipótesis de no inferioridad, se realizará un análisis bilateral de superioridad. El comité de eventos clínicos y el laboratorio central independiente no conocerán la rama de tratamiento. Asumiendo un error α de 0,05, un error β de 0,2 (80% de potencia), un margen de irrelevancia (ε) del 7% y un 10% de pérdidas por dificultad de medición o imposibilidad de completar la intervención, se estima un tamaño de muestra de 56 casos en cada grupo. Los objetivos secundarios son el éxito del dispositivo, el éxito del procedimiento, la tasa de cruce entre técnicas y la presentación de eventos cardiovasculares adversos importantes al año de seguimiento. Conclusiones: El estudio ROLLERCOASTR evaluará y comparará la seguridad y la eficacia, en pacientes con estenosis coronaria calcificada, de 3 técnicas de modificación de placa: AR, ACLE y LIC. Este ensayo se ha registrado en Clinicaltrials.gov: NCT04181268.

ABSTRACT Introduction and objectives: Coronary calcification is one of the leading factors that affect negatively the safety and effectiveness of percutaneous coronary intervention. Several calcium modification techniques exist. However, there is a lack of randomized evidence on the therapy of choice in this scenario. Methods: The ROLLERCOASTR is a prospective, multicenter, randomized clinical trial designed to compare the safety and efficacy profile of 3 plaque modification techniques in the moderate-to-severe coronary calcification setting: rotational atherectomy (RA), excimer laser coronary angioplasty (ELCA), and intravascular lithotripsy (IVL). The study primary endpoint is stent expansion evaluated by optical coherence tomography. An intention-to-treat analysis will be conducted with an alpha coefficient of 0.05 between the reference group (RA) and the remaining 2 groups (ELCA and IVL). An analysis of the study primary endpoint per protocol will be conducted for consistency purposes. If the non-inferiority hypothesis is confirmed, a superiority 2-sided analysis will be conducted. Both the clinical events committee and the independent core laboratory will be blinded to the treatment arm. Assuming an α error of 0.05, an β error of 0.2 (80% power), a margin of irrelevance (ε) of 7, and losses of 10% due to measurement difficulty or impossibility to complete the intervention, we estimate a sample size of 56 cases per group. The study secondary endpoints are device success, procedural success, crossover rate among the different techniques used, and the occurrence of major adverse cardiovascular events at 1-year follow-up. Conclusions: The ROLLERCOASTR trial will evaluate and compare the safety and effectiveness of 3 plaque modification techniques: RA, ELCA, and IVL in patients with calcified coronary stenosis. This trial was registered at clinicaltrials.gov with identifier NCT04181268.

RESOLUCIÓN DEL CASO Ante la imposibilidad de retirar el Impella 5.0 (figura 1), y debido al riesgo quirúrgico (EuroSCORE II 48,9%, Society of Thoracic Surgeons score 16%), se decidió realizar una reparación mitral percutánea con un dispositivo MitraClip (Abbott Laboratories, Estados Unidos). Con el soporte de Impella 5.0 a 2 l/min y bajo control con ecocardiograma transesofágico, se implantó un MitraClip NTW a nivel de A3-P3 (mayor orificio de regurgitación), con lo que se logró una reducción del chorro de insuficiencia (vídeos 1 y 2 del material adicional), una mejoría del flujo en las venas pulmonares y un gradiente transmitral de 4 mmHg. Se reevaluó el resultado disminuyendo transitoriamente el soporte hemodinámico a 1 l/min y se observó un chorro central de grado III-IV. Se implantó un segundo clip NT a nivel de A2-P2 (vídeos 3 y 4 del material adicional). Durante su posicionamiento hubo dificultades por interferencia con el Impella 5.0, por lo que fueron necesarias maniobras de inversión del dispositivo hacia la aurícula. Finalmente se realizó captura o prensión, que fue eficaz y se confirmó la ausencia de insuficiencia mitral residual, aunque hubo un aumento del gradiente transmitral hasta 7 mmHg. Tras reducir el soporte hemodinámico a 0,5 l/min, el...

CASE RESOLUTION Given the impossibility to remove the Impella 5.0 device (figure 1) and due to the high surgical risk involved (EuroSCORE II, 48,9%; Society of Thoracic Surgeons score (STS), 16%), percutaneous mitral valve repair was attempted with a MitraClip device (Abbott Laboratories, United States). Figure 1. Normal position of the Impella device as seen on the transesophageal echocardiography. With support from an Impella 5.0 device at a rate of 2 L/min and under transesophageal echocardiography guidance the MitraClip NTW device was implanted at A3-P3 level (greater effective regurgitant orifice area), which resulted in a reduced regurgitant jet (videos 1 and 2 of the supplementary data), improved blood flow into the pulmonary veins, and a transmitral gradient of 4 mmHg. Result was reassessed by reducing hemodynamic support temporarily at 1 L/min. A grade III-IV central regurgitant jet was seen. A second MitraClip NT was implanted at A2-P2 level (videos 3 and 4 of the supplementary data). Difficulties during its positioning due to interference with the Impella 5.0 device were reported, which is why reversal maneuvers towards the atrium were performed. Finally, capture or grasping turned out effective, and the lack of residual mitral regurgitation was confirmed. However, although transmitral gradient increased up to...

Sr. Editor: En la embolia de pulmón (EP), la terapia dirigida por catéter está indicada en pacientes de alto riesgo (EP-AR) si la trombólisis sistémica está contraindicada o ha fallado (indicación IIA, C), y como rescate en pacientes de intermedio-alto riesgo (EP-IAR) cuando sufren deterioro hemodinámico, como alternativa a la trombólisis sistémica (indicación IIA, C)1. Sin embargo, las guías de práctica clínica no especifican el tipo de terapia dirigida por catéter ideal. Esta puede ser trombólisis local, que consiste en la infusión directa en la arteria pulmonar (intratrombo) de dosis variables (alrededor del 20% de la dosis sistémica) de fármacos trombolíticos (alteplasa o tenecteplasa), o trombectomía mecánica por aspiración, que consiste en la extracción del trombo (con o sin fragmentación previa). Finalmente, se puede optar por una estrategia mecánico-farmacológica combinando las 2 técnicas de manera secuencial2. Se presenta la experiencia inicial de trombectomía mecánica por aspiración con el dispositivo FlowTriever (Inari, Estados Unidos) en 4 centros de España y Portugal. El Comité Ético del Hospital Clínico San Carlos aprobó el registro y se obtuvo el consentimiento informado de los participantes. Se trata de un sistema de tromboaspiración de 24 Fr con tubuladuras sobredimensionadas y accesorios para optimizar la extracción del trombo3,4. Son...

To the Editor, Catheter-directed therapy is indicated in high-risk patients (PE-HR) to treat pulmonary embolism (PE) when systemic thrombolysis is contraindicated or has failed (indication IIA, C). Also, as a bailout therapy in intermediate/high-risk patients (PE-IHR) with hemodynamic impairment as an alternative to systemic thrombolysis (indication IIA, C).1 However, clinical practice guidelines do not specify which is the optimal catheter-directed therapy that should be used. It can be local thrombolysis that consists of the direct infusion of variable doses (around 20% of systemic dose) of thrombolytic drugs (alteplase or tenecteplase) into the pulmonary artery (intra-thrombus) or else mechanical thrombectomy with direct aspiration catheter that consists of thrombus extraction (with or without previous fragmentation). Finally, a mechanical-pharmacological strategy with both techniques combined can be used sequentially.2 This is the early experience of mechanical thrombectomy with direct aspiration using the FlowTriever retrieval/aspiration system (Inari, United States) of 4 Spanish and Portuguese centers. The Hospital Clínico San Carlos ethics committee approved the registry and obtained the participants’ written informed consent. The FlowTriever is a 24-Fr thrombus aspiration system with an oversized tube and accessories to optimize thrombus extraction.3,4 These are 3 cases of PE-HR with contraindication for systemic thrombolysis and 7 cases of PE-IHR treated...

Sr. Editor: El foramen oval permeable (FOP) se encuentra presente en aproximadamente 1 de cada 4 personas, y para la gran mayoría de ellas no tiene consecuencias clínicas1; en otras, en cambio, puede favorecer la aparición de ictus, migrañas o síndrome de descompresión o desaturación con el ortostatismo (conocido como síndrome de platipnea-ortodesoxia)2. Una presentación todavía más infrecuente del FOP que se puede desarrollar en la edad adulta es la desaturación provocada por el ejercicio, descrita en pocas revisiones bibliográficas y con un término no totalmente acuñado3,4. Se presenta el caso de una mujer de 79 años con antecedentes de hipertensión y diabetes que es remitida a la unidad de rehabilitación cardiaca por disnea y pobre capacidad funcional. La paciente acudió con un estudio previo sin hallazgos significativos: ecocardiograma transtorácico, pruebas de función respiratoria, angiotomografía computarizada pulmonar y cateterismo coronario. En la exploración física destacaba una saturación de oxígeno del 98%. La analítica sanguínea era normal, con una fracción N-terminal del propéptido natriurético cerebral tipo B de 255 pg/ml. Cuando entró a la consulta refirió disnea de esfuerzo que apareció en el trayecto desde la sala de espera. Ante lo observado, se le colocó un pulsioxímetro y se salió a andar con ella....

To the Editor, The patent oval foramen (PFO) is present in nearly 1 out of every 4 people, and for the vast majority of them, it has no clinical implications.1 In others, however, it can trigger strokes, migraines or the orthostatic decompression or desaturation syndrome (known as platypnea-orthodeoxia syndrome).2 An even rarer presentation of PFO that can occur in the adult age is exercise-induced desaturation, which has been described in very few literature reviews and with a term not fully coined.3,4 This is the case of a 79-year-old woman with a past medical history of hypertension and diabetes referred to the cardiac rehabilitation unit due to dyspnea and poor functional capacity. The patient had previously undergone various tests including transthoracic echocardiography, pulmonary function tests, computed tomography pulmonary angiography, and coronary catheterization, all of which showed no significant findings. The physical examination revealed oxygen saturation levels around 98%, blood test results were normal, and N-terminal pro-brain natriuretic peptide levels, 255 pg/mL. Atthe office, she complained of exertional dyspnea that had just appeared after walking from the waiting room to the office. Then, a pulse oximeter was placed on her, and she was told to go for a walk. Oxygen saturation progressively dropped down to...

RESUMEN La calcificación coronaria es probablemente el mayor determinante de un mal resultado de la angioplastia y se asocia a mayores tasas de eventos adversos. En la actualidad existen distintas técnicas de modificación de la placa basadas en balones o en dispositivos específicos. El conocimiento de sus características y su uso adecuado son aspectos clave para el tratamiento óptimo de las lesiones calcificadas. Este artículo de posicionamiento, promovido desde la Asociación de Cardiología Intervencionista de la Sociedad Española de Cardiología (ACI-SEC), describe las técnicas de modificación de la placa existentes en la actualidad y propone un algoritmo para el tratamiento de la lesión calcificada.

ABSTRACT Introduction and objectives: The optimal time to perform a diagnostic coronary angiography in patients admitted due to non-ST-segment elevation acute coronary syndrome (NSTEACS) and start pretreatment with dual antiplatelet therapy is controversial. Our study aims to identify the current diagnostic and therapeutic approach, and clinical progression of patients with NSTEACS in our country. Methods: The IMPACT-TIMING-GO trial (Impact of time of intervention in patients with myocardial infarction with non-ST segment elevation. Management and outcomes) is a national, observational, prospective, and multicenter registry that will include consecutive patients from 24 Spanish centers with a clinical diagnosis of NSTEACS treated with diagnostic coronary angiography and with present unstable or causal atherosclerotic coronary artery disease. The study primary endpoint is to assess the level of compliance to clinical practice guidelines in patients admitted due to NSTEACS undergoing coronary angiography in Spain, describe the use of antithrombotic treatment prior to cardiac catheterization, and register the time elapsed until it is performed. Major adverse cardiovascular events will also be described like all-cause mortality, non-fatal myocardial infarction and non-fatal stroke, and the rate of major bleeding according to the BARC (Bleeding Academic Research Consortium) scale at 1- and 3-year follow-up. Results: This study will provide more information on the impact of different early management strategies in patients admitted with NSTEACS in Spain, and the degree of implementation of current recommendations into the routine clinical practice. It will also provide information on these patients’ baseline and clinical characteristics. Conclusions: This is the first prospective study conducted in Spain that will be reporting on the early therapeutic strategies—both pharmacological and interventional—implemented in our country in patients with NSTEACS after the publication of the 2020 European guidelines, and on the clinical short- and long-term outcomes of these patients.

ABSTRACT Coronary artery calcification is probably the main determinant of the poor outcome of percutaneous coronary interventions and is associated with higher rates of adverse events. There are currently different balloon or specific device-based plaque modification techniques available. Knowing their characteristics and proper use is key for the optimal treatment of calcified lesions. This position paper—promoted by the Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC)—describes existing plaque modification techniques currently available and proposes an algorithm for the management of calcified lesions.

RESUMEN Introducción y objetivos: El momento óptimo para la realización de un cateterismo diagnóstico en pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST) y la necesidad de pretratamiento con doble antiagregación son motivo de controversia. Este estudio pretende conocer el abordaje diagnóstico y terapéutico actual, así como la evolución clínica de los pacientes con SCASEST en España. Métodos: El estudio IMPACT of Time of Intervention in patients with Myocardial Infarction with Non-ST seGment elevation. ManaGement and Outcomes (IMPACT-TIMING-GO) es un registro nacional observacional, prospectivo y multicéntrico, que incluirá pacientes consecutivos con diagnóstico de SCASEST tratados con coronariografía diagnóstica y que presenten enfermedad coronaria aterosclerótica inestable o causal en 24 centros españoles. El objetivo primario del estudio es conocer el grado de cumplimiento de las recomendaciones de las guías de práctica clínica en pacientes que ingresan por SCASEST tratados con coronariografía en España, describir el uso del tratamiento antitrombótico antes del cateterismo y determinar el tiempo hasta este en la práctica clínica real. Se describirán también los eventos adversos cardiovasculares mayores: mortalidad por cualquier causa, infarto no fatal e ictus no fatal, y también la incidencia de hemorragia mayor según la escala BARC (Bleeding Academic Research Consortium) durante el seguimiento a 1 y 3 años. Resultados: Este registro permitirá mejorar el conocimiento en relación con el abordaje terapéutico inicial en pacientes que ingresan por SCASEST en España. Contribuirá a conocer sus características basales y su evolución clínica, así como el grado de adherencia y cumplimiento de las recomendaciones de las que se dispone actualmente. Conclusiones: Se trata del primer estudio prospectivo realizado en España que permitirá conocer las estrategias terapéuticas iniciales, tanto farmacológicas como intervencionistas, que se realizan en nuestro país en pacientes con SCASEST tras la publicación de las guías europeas de 2020, y la evolución clínica de estos pacientes a corto y largo plazo.

Remotely sensed data are increasingly used together with National Forest Inventory (NFI) data to improve the spatial precision of forest variable estimates. In this study, we combined data from the 4th Spanish National Forest Inventory (SNFI-4) and from the 2nd nationwide Airborne Laser Scanning (ALS) survey to develop predictive forest inventory variables (total over bark volume (V), basal area (G), and annual increase in total volume (IAVC)) and aboveground biomass (AGB) models for the eight major forest strata in the region of Extremadura that are included in the Spanish Forest Map (SFM). We generated maps at 25 m resolution by applying an area‐based approach (ABA) and 758 sample plots measured with good positional accuracy within the SNFI-4 in Extremadura (Spain). Inventory performance is mainly influenced by spatial scale and vegetation structure. Therefore, in this study, we conducted a comparative analysis of statistical inference methods that can characterize forest inventory variables and AGB uncertainty across multiple spatial scales and types of vegetation structure. Predictions at pixel level were used to produce county, provincial, and regional model-based estimates, which were then compared with design-based estimates at different scales for different types of forest. We developed and tested both methods for forested area (cover, 19,744.15 km2), one province (9126.78 km2), and two counties (1594.42 km2 and 2076.76 km2, respectively) in Extremadura. The resulting relative standard error (SE) for regional level forest type-specific model-based estimates of V, G, IAVC, and AGB ranged from 3.34%–14.46%, 3.22%–12.50%, 4.46%–16.67%, and 3.63%–12.58%, respectively. The performance of the model-based approach, as assessed by the relative SE, was similar to that of the design-based approach at regional and provincial levels. However, the precision of SNFI model-based estimates was higher than that of estimates based on only the plot observations in small areas (e.g. at county level). The standard errors (SE) for model-based inferences were stable across the different scales, while SNFI design-based errors were higher due to the small sample sizes available for small areas. The findings indicate that SNFI-model based maps could be used directly to estimate forest inventory variables and AGB in the major forest strata included in the Spanish Forest Map, leading to potentially large economic savings.

ABSTRACT Vascular access is an essential part of all interventional procedures whether coronary or structural. Over the last 15 to 20 years, in coronary interventions, traditional femoral access has been mostly replaced by the radial approach. Nonetheless, the femoral approach through both artery and vein is still the main approach for structural heart procedures. Over the last few years, femoral access has evolved from a puncture guided by anatomical references to more accurate ultrasound-guided approaches. The relatively recent introduction of interventions such as transcatheter aortic valve replacement has conditioned the use of large introducers and ultimately the need for specific hemostatic systems, above all, percutaneous closure devices. This manuscript reviews different anatomical concepts, puncture techniques, diagnostic assessments, and closure strategies of the main arterial and venous approaches for the diagnosis and treatment of different structural heart procedures.

RESUMEN El acceso vascular es una parte esencial de cualquier procedimiento intervencionista coronario o estructural. En procedimientos coronarios, el acceso femoral tradicional prácticamente ha sido sustituido por el radial desde hace 15-20 años. No obstante, el acceso femoral, tanto arterial como venoso, sigue siendo la principal vía de abordaje para el intervencionismo estructural. El acceso femoral ha ido evolucionando con el paso del tiempo de una punción mediante referencias anatómicas a una punción mucho más precisa guiada por ecografía. La llegada de técnicas como el recambio valvular aórtico percutáneo ha condicionado el uso de introductores arteriales de gran tamaño y, por tanto, la necesidad de sistemas de control de la hemostasia, principalmente los sistemas percutáneos de cierre vascular. Este artículo revisa diversos conceptos anatómicos, técnicas de punción, evaluación diagnóstica y estrategias de cierre de las principales vías de acceso arterial y venoso utilizadas en el diagnóstico y el tratamiento de diferentes patologías estructurales.

Un varón de 78 años con enfermedad coronaria revascularizada 10 años antes (descendente anterior y circunfleja) ingresa en el hospital por síndrome coronario agudo sin elevación del segmento ST. Por angiografía se detecta una imagen en la descendente anterior proximal inusual que parece originar una estenosis angiográficamente significativa (figura 1A,B). Para confirmar el diagnóstico, se intenta avanzar el catéter de tomografía de coherencia óptica (OCT) a través de una guía polimérica, sin conseguir atravesar la zona más estenótica. Se reintenta la maniobra tras predilatar en dos ocasiones (con balones de 1,5 y 2,5 mm de diámetro), sin resultado. Posteriormente, se decide avanzar un catéter de extensión de guía (figura 1D) que consigue atravesar la lesión y realizar la OCT, la cual muestra un stent no expandido, totalmente endotelizado, con un posible trombo adherido (figura 1C). Ante la sospecha de que esta sea la lesión culpable, se decide tratarla. Con el objetivo de aplastar el stent no expandido contra la luz del propio vaso (crush), primero se predilata con un balón de 3,5 × 12 mm sin dificultad y a continuación se implanta un stent farmacoactivo de 3,5 × 15 mm, con buen resultado angiográfico (figura 1E). Una nueva OCT...

This is the case of a 78-year-old man with revascularized coronary artery disease 10 years ago (left anterior descending coronary artery and left circumflex artery) who was admitted to the hospital with signs of ST-segment elevation acute coronary syndrome. The angiography shows an unusual image on the proximal left anterior descending coronary artery that seems to be causing an angiographically significant stenosis (figure 1A,B). To confirm diagnosis, a catheter is unsuccessfully advanced with optical coherence tomography (OCT) guidance through a polymeric guidewire while trying to cross the most stenotic region. Two attempts are made after predilatation (with balloons of 1.5 mm and 2.5 mm in diameter) that prove unsuccessful. Afterwards, a guide catheter extension system is advanced (figure 1D) that successfully crosses the lesion facilitating the OCT that reveals the presence of an underexpanded coronary stent with complete endothelization, and a possible thrombus attached to it (figure 1C). Upon suspicion that this is the culprit lesion, decision is made to treat it. To crush the underexpanded stent against the lumen of the vessel, it is first effortlessly predilated using a 3.5 mm x 12 mm balloon. Afterwards, a 3.5 mm x 15 mm drug-eluting stent is implanted with good angiographic...

Abstract Background Since the last century, the electrocardiogram (ECG) remains the non‐invasive test, that is, most easily accessible, feasible, and inexpensive for cardiology assessment. In past years, many novel ECG indexes and patterns have been published that allow for a more advanced evaluation of what is currently being done, especially based on subtle QRS changes and patterns. Objective The objective of the study was to provide an update on the evidence and clinical applications of these ECG subtle QRS changes and patterns associated with heart disease. Methods Through the literature review, we will highlight the subtle QRS changes and patterns associated with heart disease, mainly focusing on QRS duration, voltage, morphology, axis, and QT interval. Results Small increases in QRS duration are associated with a reduction in left ventricular ejection fraction (EF), increased cardiac chamber dimensions, and risk for incident heart failure (HF). Moreover, fragmentation of the QRS complex is associated with myocardial fibrosis and is a substrate for developing arrhythmic events. Besides, low amplitude QRS voltage is associated with congestive HF, and an increase in the voltage of the QRS complexes is associated with the effectiveness of diuresis treatment. Furthermore, small increases in QT interval are associated with diastolic dysfunction due to impaired sarcoplasmic reticulum calcium handling as occurs in myocardial ischemia, hypertension, or diabetes. On the other hand, in patients with left ventricular dysfunction, the QRS area is associated with clinical and echocardiographic response to cardiac resynchronization therapy regardless of the type of bundle branch block. In addition, subtle ECG changes and patterns in the left bundle branch block are associated with concomitant right ventricular dilation, mostly based on the QRS axis and voltage. Notwithstanding, to identify these subtle changes in QRS require exact manual measurements that can take time. In this regard, applying artificial intelligence (AI) to the ECG can make a quicker and more complete assessment, as well as provide a low cost when applied to large populations. Conclusion We provided an update on the evidence and clinical applications of these subtle QRS changes and patterns associated with diastolic dysfunction, reduced EF, and HF development and therapy responsiveness, as well as their applications for AI to ECG.

Resumen: La taquicardia ventricular polimórfica catecolaminérgica es una enfermedad caracterizada por arritmias ventriculares desencadenadas por estrés o actividad física. Existen casos descritos de taquicardia ventricular polimórfica catecolaminérgica asociada a ventrículo izquierdo no compactado, en relación con mutaciones del gen RYR2 localizadas en el exón 3. Se expone el caso clínico de una paciente joven que debutó con clínica de síncopes recurrentes asociados a estrés físico o emocional. En el estudio posterior se descubrió taquicardia ventricular polimórfica catecolaminérgica, con áreas de miocardio no compactado y una nueva variante genética posiblemente asociada a la enfermedad. Abstract: Catecholaminergic polymorphic ventricular tachycardia is disease characterised by ventricular arrhythmias triggered by stress or physical activity. There are some cases of catecholaminergic polymorphic ventricular tachycardia described that are associated with non-compacted left ventricle in relation to mutations of the RYR2 gene located in exon 3. A case is presented of a young patient in whom the clinical signs started with recurrent syncope associated with physical or emotional stress. In the subsequent study, catecholaminergic polymorphic ventricular tachycardia was discovered, with areas of non-compacted myocardium and new genetic variant possibly associated with the disease.

Resumen: Objetivo: encontrar una relación entre los niveles de proteína C reactiva (PCR) y fibrinógeno, y la extensión de la aterosclerosis en el síndrome coronario agudo. Métodos: estudio observacional prospectivo, en el que se incluyeron 873 pacientes con síndrome coronario atendidos en un hospital entre 2016 y 2018. Se analizaron niveles de PCR y fibrinógeno, marcadores metabólicos y extensión de la aterosclerosis coronaria. Resultados: no se halló correlación positiva entre los niveles de PCR y fibrinógeno y los marcadores metabólicos, así como tampoco con enfermedad de uno, dos y tres vasos (p 0,829; p 0,810). Conclusiones: los niveles sanguíneos de PCR y fibrinógeno se relacionan con la tasa de eventos cardiovasculares, pero no se ha podido demostrar que exista relación entre estos y la severidad de la aterosclerosis coronaria. Abstract: Objective: To determine whether there is a relationship between C - reactive protein and fibrinogen levels and the extent of atherosclerosis in acute coronary syndrome. Methods: A prospective observational study was conducted that include 873 patients with coronary syndrome treated in a hospital between the years 2016 and 2018. An analysis was made that included C - reactive protein and fibrinogen levels, metabolic markers, extent of coronary atherosclerosis. Results: No positive correlation was found between the C - reactive protein and fibrinogen levels and the metabolic markers, nor with one, two, or three vessel disease (P = .829; P = .810). Conclusions: Although blood C-Reactive Protein and fibrinogen levels are associated with the rate of cardiovascular events, this study was unable to demonstrate whether there is a relationship between these and the severity of the coronary atherosclerosis.

Resumen: Es frecuente la relación entre la adrenalina administrada por vía intramuscular y el desarrollo de cardiopatía isquémica. La adrenalina potencia las hemostasias primaria y secundaria —puede producir trombosis intracoronaria— y causa vasoconstricción transitoria arteriolar. Se presenta un caso clínico de una paciente que acudió a urgencias por dolor torácico pocas horas después de una intervención dentaria. En el estudio posterior se descubrió un infarto de miocardio por trombosis intracoronaria de la descendente anterior distal. Abstract: There is a relationship between adrenaline administered intramuscularly and the development of ischaemic heart disease. Adrenaline promotes primary and secondary haemostasis, which can produce a coronary thrombosis and cause a transient arteriolar vasoconstriction. A case is presented of a patient who was seen in the Emergency Department with chest pain a few hours after dental treatment. In the subsequent work-up, it was discovered that she had a myocardial infarction due to a coronary thrombosis of the left anterior distal artery.

ABSTRACT The current COVID-19 outbreak is forcing healthcare workers to continuously reconsider the proper indications for cardiac catheterization. Human and material resources optimization, infection prevention for patients and healthcare workers, and transfer times force a rethink of the previously established protocols. This article is a consensus statement of the Interventional Cardiology Association and the Ischemic Heart Disease Association of the Spanish Society of Cardiology, and aims to provide information to healthcare workers on the indications of diagnostic or therapeutic cardiac catheterization during the current COVID-19 pandemic.

El brote actual de COVID-19 está obligando a los profesionales sanitarios a replantear de forma continua las indicaciones de cateterismo cardiaco. La optimización de recursos materiales y humanos, la prevención de contagios a profesionales y pacientes, así como la gestión de los tiempos de traslado, hace totalmente necesario reformular los protocolos previamente establecidos. El presente texto es un documento de consenso de la Asociación de Cardiología Intervencionista y la Asociación de Cardiopatía Isquémica y Cuidados Agudos Cardiovasculares de la Sociedad Española de Cardiología que pretende dar información al personal sanitario sobre las indicaciones de cateterismo diagnóstico o terapéutico durante la pandemia actual de COVID-19.

RESUMEN Introducción y objetivos: Tras los resultados de varios estudios aleatorizados, la tromboaspiración (TA) sistemática ha sido relegada a un segundo plano por no mejorar el pronóstico de los pacientes con infarto agudo de miocardio con elevación del segmento ST e incluso aumentar sus complicaciones. El objetivo de este trabajo fue evaluar el impacto de la TA selectiva durante la angioplastia primaria (ICPp), su seguridad y sus beneficios clínicos tras 1 año de seguimiento. Métodos: El registro TAPER (eficacia y seguridad de la tromboaspiración selectiva en la práctica clínica real) incluyó retrospectivamente pacientes con infarto de miocardio con elevación del segmento ST tratados con ICPp. Se evaluaron las características clínicas y de los procedimientos, así como la presentación del evento combinado de muerte cardiovascular, infarto de miocardio no fatal, trombosis de stent, necesidad de revascularización de la lesión tratada o ictus tras 1 año de seguimiento. Resultados: Se analizaron 687 pacientes (76,9% varones, 64 ± 12 años). La TA se realizó en el 40,3% de los casos (89,9% como estrategia inicial y 10,1% como rescate) y fue exitosa en el 93,8%. El predictor más importante de uso de TA fue un alto grado de trombo inicial según la escala TIMI (Thrombolysis in Myocardial Infarction) (odds ratio = 3,2; intervalo de confianza del 95%, 2,5-3,9; p < 0,0001). La TA consiguió una mejora significativa del flujo de 2,4 puntos en la escala TIMI de flujo y una reducción significativa del grado de trombo de 2,6 puntos en la escala TIMI de trombo. En 1 año de seguimiento no se observó ningún ictus en el grupo de TA y la tasa del evento combinado fue similar en ambos grupos (grupo de TA 8% y grupo de no-TA 5,7%; p = 0,24). Conclusiones: La TA selectiva se usa con frecuencia en la práctica clínica actual, con una alta tasa de éxito y pocas complicaciones asociadas. La TA selectiva reduce significativamente la carga de trombo y mejora el flujo coronario. Tras 1 año de seguimiento, se observó una tasa similar de eventos adversos en los pacientes a quienes se realizó ICPp con independencia del uso de TA.

ABSTRACT Introduction and objectives: After the results of several randomized trials, routine thrombus aspiration (TA) has remained out of the spotlight after not improving the prognosis of patients with ST-segment elevation myocardial infarction and even increasing their complications. The goal here was to assess the impact of selective TA during primary percutaneous coronary intervention (pPCI), its safety and clinical benefits at 1-year follow-up. Methods: The TAPER registry (efficacy and safety of selective Thrombus Aspiration in Real clinical Practice) retrospectively included patients with ST-segment elevation myocardial infarction treated with pPCI. The clinical and procedural characteristics and the composite endpoint of cardiovascular mortality, non-fatal myocardial infarction, stent thrombosis, target lesion revascularization or stroke were evaluated after at 1-year follow-up. Results: 687 patients (76.9% males, 64 ± 12 years) were analyzed. The TA was performed in 40.3% of cases (in 89.9% as the initial strategy and in 10.1% as the bailout strategy) and it was successful in 93.8% of them. The most important predictor of TA use was a higher initial Thrombolysis in Myocardial Infarction (TIMI) thrombus grade (OR, 3.2; 95%CI, 2.5-3.9; P < .0001). TA achieved a significant improvement of TIMI-flow (2.4 points) and a significant reduction of the TIMI thrombus grade (2.6 points). At 1-year follow-up, no stroke was observed in the TA-group and the rate of the composite endpoint (cardiovascular mortality, non-fatal myocardial infarction, stent thrombosis, target lesion revascularization or stroke) was similar in both groups (TA-group 8% vs non-TA-group 5.7%; P = .24). Conclusions: Selective TA is frequently used in the current clinical practice with a high success rate and a low rate of associated complications. It significantly reduces thrombotic burden and improves coronary flow. At 1-year follow-up, a similar rate of adverse events was observed regardless of the use of TA.

Se presenta el caso de un varón de 74 años ingresado por síndrome coronario agudo sin elevación del segmento ST. La coronariografía realizada mostró una estenosis de la arteria coronaria derecha con un aneurisma coronario (AC) gigante y alta carga trombótica (figura 1A). Se recomendó doble antiagregación y anticoagulación oral para excluir el AC en un segundo tiempo. Tras confirmar la reducción del trombo (figura 1B), se predilató y se midió la longitud del AC (40 mm) y de la zona de aterrizaje mediante ecografía intravascular (IVUS) (figura 1C). Se implantaron 2 stents coronarios recubiertos PK-Papyrus (SCR) de 5 × 26 mm (Biotronik, Suiza) de proximal a distal. La zona de solapamiento de ambos stents se confirmó mediante StentBoost (Philips Medical Systems, Países Bajos) (figura 1D). El stent se implantó bajo fluoroscopia y en ausencia de movimientos respiratorios. La siguiente angiografía reveló la exclusión incompleta del AC (figura 1E) a pesar de posdilatación con un balón no compliante (BNC) de 5,5 mm. El IVUS confirmó la existencia de un gap entre ambos stents debido al acortamiento de los mismos (E2, figura 1E y vídeo 1 del material adicional). Se implantó otro SCR de 5 × 15 mm y se posdilató...

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...

BackgroundWe aimed to compare the performance of the recent CASTLE score to J-CTO, CL and PROGRESS CTO scores in a comprehensive database of percutaneous coronary intervention of chronic total occlusion procedures.MethodsScores were calculated using raw data from 1,342 chronic total occlusion procedures included in REBECO Registry that includes learning and expert operators. Calibration, discrimination and reclassification were evaluated and compared.ResultsMean score values were: CASTLE 1.60±1.10, J-CTO 2.15±1.24, PROGRESS 1.68±0.94 and CL 2.52±1.52 points. The overall percutaneous coronary intervention success rate was 77.8%. Calibration was good for CASTLE and CL, but not for J-CTO or PROGRESS scores. Discrimination: the area under the curve (AUC) of CASTLE (0.633) was significantly higher than PROGRESS (0.557) and similar to J-CTO (0.628) and CL (0.652). Reclassification: CASTLE, as assessed by integrated discrimination improvement, was superior to PROGRESS (integrated discrimination improvement +0.036, pConclusionProcedural percutaneous coronary intervention difficulty is not consistently depicted by available chronic total occlusion scores and is influenced by the characteristics of each chronic total occlusion cohort. In our study population, including expert and learning operators, the CASTLE score had slightly better overall performance along with CL score. However, we found only intermediate performance in the c-statistic predicting chronic total occlusion success among all scores.

The angiotensin-converting enzyme 2 (ACE2) is a type I integral membrane that exists in two forms: the first is a transmembrane protein; the second is a soluble catalytic ectodomain of ACE2. The catalytic ectodomain of ACE2 undergoes shedding by a disintegrin and metalloproteinase domain-containing protein 17 (ADAM17), in which calmodulin mediates the calcium signaling pathway that is involved in ACE2 release, resulting in a soluble catalytic ectodomain of ACE2 that can be measured as soluble ACE2 plasma activity. The shedding of the ACE2 catalytic ectodomain plays a role in cardiac remodeling and endothelial dysfunction and is a predictor of all-cause mortality, including cardiovascular mortality. Moreover, considerable evidence supports that the ACE2 catalytic ectodomain is an essential entry receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Additionally, endotoxins and the pro-inflammatory cytokines interleukin (IL)-1β and tumor necrosis factor-alpha (TNFα) all enhanced soluble catalytic ectodomain ACE2 shedding from the airway epithelia, suggesting that the shedding of ACE2 may represent a mechanism by which viral entry and infection may be controlled such as some types of betacoronavirus. In this regard, ACE2 plays an important role in inflammation and thrombotic response, and its down-regulation may aggravate COVID-19 via the renin-angiotensin system, including by promoting pathological changes in lung injury. Soluble forms of ACE2 have recently been shown to inhibit SARS-CoV-2 infection. Furthermore, given that vitamin D enhanced the shedding of ACE2, some studies reported that vitamin D treatment is associated with prognosis improvement in COVID-19. This is an updated review on the evidence, clinical, and therapeutic applications of ACE2 for COVID-19.

Mujer de 85 años con angina inestable que presentaba lesiones graves y muy calcificadas en las arterias coronaria derecha proximal (figura 1A, asterisco) y descendente anterior proximal-media (figura 1B, asterisco). Figura 1. Se realizó aterectomía rotacional con el sistema RotaPro (Boston Scientific, EE.UU.) en la coronaria derecha (figura 1C) y se implantó un stent farmacoactivo, con buen resultado (figura 1D) confirmado mediante ecografía intracoronaria (figura 1E). Se obtuvo el consentimiento informado de la paciente. Tras sondar el tronco coronario izquierdo (TCI) se cruzó la guía a la descendente anterior. Se avanzó una oliva de 1,5 mm en modo dynaglide hasta el TCI, momento en que el catéter guía se extubó y se produjo una perforación Ellis-III en el TCI (figura 2A, asterisco; vídeo 1 del material adicional); es posible que una deformación inadvertida de la guía dirigiera la oliva hacia la pared del vaso. La paciente presentó taponamiento cardiaco, que fue tratado con pericardiocentesis. Se implantó un stent recubierto PK-Papyrus (Biotronik, Alemania) de 4 × 15 mm en el TCI sin enjaular la bifurcación (figura 2B). Sin embargo, se mantenía una discreta fuga de contraste (figura 2C, asterisco). Tras posdilatar con balón de 4,5 mm, la perforación quedó sellada (figura 2D; vídeo 2...

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...

This paper proposes a new vibration-based structural health monitoring method for the identification of delamination defects in composite bulkheads used in small-length fiber-based ships. The core of this work is to find out if the variations of vibration energy can be efficiently used as a key performance indicator for the detection and quantification of delamination defects in marine composite bulkheads. For this purpose, the changes of vibrational energy exerted by delamination defects in sandwich and monolithic composite panel bulkheads with different types of delamination phenomenon are investigated using a non-destructive test. Experiments show that the overall vibration energy of the bulkheads is directly dependent on the damage conditions of the specimens and therefore, the variations of this parameter are a good indicator of the incorporation of delamination defects in composite bulkheads. Additionally, the overall vibration energy changes also give interesting information about the severity of the delamination defect in the panels. Hence, this methodology based on vibratory energy can be used to accurately determine delamination defects in medium-sized composite bulkheads with the advantages of being a simple and cost-effective approach. The findings of this research possess important applications for the identification of delamination failures in composite components such as bulkheads, turbine blades, and aircraft structures, among others.