Search

Background Data on Device-related Thrombus (DRT) after left atrial appendage closure (LAAC) remain scarce. This study aimed to investigate risk factors for DRT from centers reporting to the EUROC-DRT registry. Methods We included 537 patients (112 with DRT and 425 without DRT) who had undergone LAAC between 12/2008 and 04/2019. Baseline and implantation characteristics, anti-thrombotic treatment and clinical outcomes were compared between both groups in uni- and multivariate analyses. Additional propensity-score matching (PSM) was conducted to focus on the role of implantation characteristics. Results Patients with DRT showed higher rates of previous stroke/transient ischemic attack (TIA) (49.1% vs. 34.7%, p < 0.01), spontaneous echocardiographic contrast (SEC) (44.9% vs. 27.7%, p < 0.01) and lower left atrial appendage (LAA) peak emptying velocity (35.4 +/- 18.5 vs. 42.4 +/- 18.0 cm/s, p= 0.02). Occluders implanted in DRT patients were larger (25.5 +/- 3.8 vs. 24.6 +/- 3.5 mm, p =0.03) and implanted deeper in the LAA (mean depth: 7.6 +/- 4.7 vs. 5.7 +/- 4.7 mm, p

Left atrial appendage closure is an alternative to chronic oral anticoagulation to prevent embolic events related to nonvalvular atrial fibrillation. After device implantation, antithrombotic treatment is prescribed to prevent device-related thrombosis, a dreadful complication associated with an increased risk of ischemic events. However, the optimal antithrombotic treatment after left atrial appendage closure, effective on both device-related thrombus prevention and bleeding risk mitigation, remains to be determined. In more than 10 years experience with left atrial appendage closure, a wide range of antithrombotic treatments have been used, mostly in observational studies. In this review, we analyzed the body of evidence for each antithrombotic regimen after left atrial appendage closure to provide tools to guide the physician choice and describe future perspectives in the field.

Resumen Antecedentes El cierre percutaneo de la orejuela izquierda (CPOI) se ha propuesto como una alternativa al tratamiento anticoagulante en pacientes con fibrilacion auricular no valvular para disminuir el riesgo tromboembolico, evitando los riesgos de la anticoagulacion. Esta opcion puede ser atractiva en pacientes con fibrilacion auricular no valvular y enfermedad renal cronica (ERC), ya que presentan un alto riesgo tanto tromboembolico como hemorragico. Objetivo Determinar el papel pronostico de la presencia de ERC en pacientes con fibrilacion auricular sometidos a un CPOI periprocedimiento y durante el seguimiento comparado con los pacientes con funcion renal preservada. Metodos Estudio retrospectivo, observacional de muestreo consecutivo que incluyo 124 pacientes sometidos a CPOI por fibrilacion auricular en un hospital universitario y se compararon los resultados segun la funcion renal basal. Resultados La mediana de edad fue 75,5 anos (RIQ 67,6-80), el 62,1% eran hombres, la mediana de CHA2DS2-Vasc y HASBLED era de 4 (RIQ 3-4) para ambas escalas. El 57,3% de la muestra tenia ERC. Las caracteristicas basales eran similares entre ambos grupos, salvo una media de edad y un score de HASBLED superiores en los pacientes con ERC. Durante el procedimiento, no se observo ningun evento tromboembolico, de sangrado o muerte. Durante el tiempo de hospitalizacion y de seguimiento combinados, no hubo diferencias significativas entre grupos en la tasa anual de episodios tromboembolicos (0,97/100 pacientes-ano [100PA] vs. 4,06/100PA, p = 0,092), pero si se observo una mayor tasa de sangrados (5,67/100PA vs. 13,3/100PA, p = 0,033), y de mortalidad (6,50/100PA vs. 17,2/100PA, p = 0,009) en el grupo de ERC, con una odds ratio para mortalidad de 2,711 (IC95% 1,96-6,95). En el analisis multivariante, el FGe preservado se asocio independientemente con una menor mortalidad. Conclusiones El CPOI es una alternativa valida a la anticoagulacion oral en pacientes con ERC y fibrilacion auricular, con una baja tasa de eventos peri- y posprocedimiento. No obstante, los pacientes con ERC presentan mayor riesgo de sangrado y de mortalidad durante el seguimiento. Aunque estas mayores tasas no estan necesariamente relacionadas con el procedimiento.

Evidence regarding redo percutaneous interventions for recurrent mitral regurgitation is scarce. We ought to evaluate procedural and clinical outcomes of repeated edge-to-edge transcatheter mitral valve repair (TMVR) interventions.This multicenter study collected individual data from eight high-volume TMVR Centers in Spain. Between 2012 and 2020, all patients undergoing a second edge-to-edge TMVR intervention (Redo) were included in the study.Among a total of 1028 procedures, 31 patients (3%) with residual MR ≥ 3 at follow-up underwent a second procedure (Redo). Redo intervention was mainly conducted between the first and second year after the first procedure. The most common cause of MR progression was partial detachment (46.7%) followed by LV remodeling (35.5%). Procedural success was achieved in 87% of cases. After a mean follow-up of 1.75 ± 1.54 years, all-cause and cardiovascular mortality were 48.1% and 25%, respectively. Nearly half of the patients (48.1%) required at least one hospital admission for CHF within the follow-up period. However, most of the patients presented symptomatic improvement as depicted by an NYHA class ≤2. Elective mitral surgery was conducted in only one patient at follow-up due to insufficient MR reduction.According to our findings, redo edge-to-edge TMVR interventions were feasible and safe with a high procedural success rate. Clinical and echocardiographic follow-up showed however modest long-term results in this specific setting.

PURPOSE: The present article aims to compare a novel sizing chart based on both maximum and minimum diameters (novel MATRIX) with the current sizing recommendation instructions for use (IFU) based on the maximum diameter.BACKGROUND: Current IFU with the Amulet device are still based on the maximum left atrial appendage (LAA) diameter, which might lead to inappropriate oversizing, especially in elliptic appendages.METHODS: This was a retrospective analysis of patients undergoing LAA occlusion in two high-volume centers. Two hundred patients were included (100 patients with baseline cardiac computed tomography angiography [CCTA] and 100 with baseline 2D and 3D-transesophageal echocardiography [TEE]). The degree of concordance between the predicted device size recommendation and the actual device selection was the primary outcome.RESULTS: The novel MATRIX showed a higher level of concordance between the predicted and implanted device size, regardless of imaging modalities. CCTA showed the strongest, and 2D-TEE the weakest concordance between the predicted and implanted device for both MATRIX and IFU charts. The percentage of patients in whom the disagreement among the predicted and implanted device represented >1 size was higher when using the IFU chart. In elliptical LAA anatomies, the differences favoring the use of MATRIX compared to the IFU in terms of predicted/implanted agreement were higher. Finally, no significant differences in clinical or imaging endpoints were observed between the two different sizing charts.CONCLUSIONS: Incorporating both the LAA maximum and minimum diameters, as opposed to just maximum diameter, appears to improve sizing accuracy. The proposed MATRIX sizing chart offered a higher level of concordance between predicted and implanted device compared to the current IFU.

AIMS The aim of this study was to evaluate the impact of pulmonary ridge (PR) coverage on both clinical and imaging follow-up outcomes in patients undergoing left atrial appendage occlusion (LAAO). METHODS AND RESULTS The study included consecutive patients with non-valvular atrial fibrillation who underwent LAAO with disc and lobe devices. Patients were classified into two groups according to the PR coverage. A total of 147 patients were included. Among these, the PR was covered in 109 (74%) and uncovered in 38 (26%). Successful implantation was achieved in 98.6%. No differences in procedural outcomes were observed between the groups. The rate of procedural major adverse events was 3% (only major bleedings and/or vascular access complications). No device embolisation, cardiac tamponade or in-hospital mortality was observed. After a mean follow-up of 1.77±2.2 years, the annualised ischaemic stroke and major bleeding rate was 1.3%/year and 6.5%/year, respectively, without differences between groups. At follow-up, patients with a covered PR presented a lower incidence of device-related thrombosis (DRT) (1%) than those with an uncovered PR (27%); p

Background Acute coronary syndrome (ACS) remains one of the leading causes of mortality for women, increasing with age. There is an unmet need regarding this condition in a fast‐growing and predominantly female population, such as nonagenarians. Hypothesis Our aim is to compare sex‐based differences in ACS management and long‐term clinical outcomes between women and men in a cohort of nonagenarians. Methods We included consecutive nonagenarian patients with ACS admitted at four academic centers between 2005 and 2018. The study was approved by the Ethics Committee of each center. Results A total of 680 nonagenarians were included (59% females). Of them, 373 (55%) patients presented with non‐ST‐segment elevation ACS and 307 (45%) with ST‐segment elevation myocardial infarction (STEMI). Men presented a higher disease burden compared to women. Conversely, women were frailer with higher disability and severe cognitive impairment. In the STEMI group, women were less likely than men to undergo percutaneous coronary intervention (PCI) (60% vs. 45%; p = .01). Overall mortality rates were similar in both groups but PCI survival benefit at 1‐year was greater in women compared to their male counterparts (82% vs. 68%; p = .008), persisting after sensitivity analyses using propensity‐score matching (80% vs. 64%; p = .03). Conclusion Sex‐gender disparities have been observed in nonagenarians. Despite receiving less often invasive approaches, women showed better clinical outcomes. Our finding may help increase awareness and reduce the current gender gap in ACS management at any age.

Introduction: Infection remains a major complication among heart transplant (HT) recipients, causing approximately 20% of deaths in the first year after transplantation. In this population, Aspergillus spp. can have various clinical presentations including invasive pulmonary aspergillosis (IPA), with high mortality (53-78%). Objectives: To establish the characteristics of IPA infection in HT recipients and their outcomes in our center. Methods: Among 328 HTs performed in our center between 1998 and 2016, we identified five cases of IPA. Patient medical records were examined and clinical variables were extracted. Results: All cases were male, and mean age was 62 years. The most common indication for HT was non-ischemic dilated cardiomyopathy. Productive cough was reported as the main symptom. The radiological assessment was based on chest X-ray and chest computed tomography. The most commonly reported radiographic abnormality was multiple nodular opacities in both techniques. Bronchoscopy was performed in all patients and Aspergillus fumigatus was isolated in four cases on bronchoalveolar lavage culture. Treatment included amphotericin in four patients, subsequently changed to voriconazole in three, and posaconazole in one patient, with total treatment lasting an average of 12 months. Neutropenia was found in only one patient, renal failure was observed in two patients, and concurrent cytomegalovirus infection in three patients. All patients were alive after a mean follow-up of 18 months. Conclusions: IPA is a potentially lethal complication after HT. Early diagnosis and prompt initiation of aggressive treatment are the cornerstone of better survival. Resumo: Introdução: A infeção continua a ser uma complicação major nos recipientes para transplante cardíaco (TC), causando cerca de 20% de mortes no primeiro ano após o transplante. Nestes doentes, o Aspergillus species pode levar a várias apresentações clínicas incluindo a aspergilose pulmonar invasiva (API), com uma mortalidade elevada (53% a 78%). Objetivos: Estabelecer as características da infeção por API nos recipientes para TC e os respetivos resultados no nosso serviço. Métodos: Dos 328 transplantes cardíacos realizados no nosso centro entre 1998 e 2016, identificámos cinco casos de API. Foram examinados os registos dos doentes e foram identificadas variáveis clínicas. Resultados: Em todos os casos os doentes eram do sexo masculino com idade média de 62 anos. A indicação mais comum para TC foi a miocardiopatia não isquémica dilatada. O principal sintoma foi tosse produtiva. A avaliação radiológica baseou-se na radiografia e na TAC torácicas. A alteração radiológica mais comum foi a densidade nodular múltipla em ambas as técnicas. A broncoscopia foi realizada em todos os doentes e o Aspergillus fumigatus foi isolado em quatro casos de cultura BAL. O tratamento incluiu anfotericina em quatro doentes com alteração subsequente para voriconazol em três doentes e posaconazol num doente, tendo o tratamento durado uma média de 12 meses. A neutropenia foi encontrada num doente apenas, a insuficiência renal foi observada em dois doentes e a infeção por CMV ocorreu em três doentes. Todos os doentes sobreviveram após seguimento de 18 meses. Conclusão: A API representa uma complicação potencialmente mortal após o TC. Um diagnóstico precoce e a iniciação de um tratamento rapidamente agressivo constituem a pedra angular para uma melhor sobrevivência. Keywords: Heart transplantation, Invasive pulmonary aspergillosis, Immunosuppression, Palavras-chave: Transplante cardíaco, Aspergilose pulmonar invasiva, Imunossupressão

Moderate to severe paravalvular-leak (PVL) regurgitation after surgical aortic-valve replacement or after transcatheter valve implantation represents a well-known complication associated with symptoms related to heart failure, hemolysis, or both in patients with multiple comorbidities and with poor prognostic outcomes. The transcatheter closure of aortic paravalvular leaks (APVLs) is currently considered a valid alternative to cardiac surgery. Nevertheless, careful patient selection, optimal cardiac imaging for intraprocedural guidance, and expert operators are key for success. Although technically demanding, particularly in APVLs after transcatheter valve implantation, catheter-based closure is an effective, less invasive, and often the only option for high-risk patients with symptomatic PVL regurgitation.

BACKGROUND Chronic total occlusion (CTO) is common in patients with diabetes mellitus. Data on the long-term outcomes after treatment of CTOs in this high-risk population are scarce. AIM To compare the long-term clinical outcomes of CTO revascularization either by coronary artery bypass graft (CABG) or successful percutaneous coronary intervention (PCI) versus optimal medical treatment (MT) alone in patients with diabetes. METHODS AND RESULTS A total of 538 consecutive patients with diabetes and at least one CTO were identified from 2010 to 2014 in our center. In the present analysis, patients were stratified according to the CTO treatment strategy that was selected. MT was selected in 61% of patients whereas revascularization in the remaining 39%. Patients undergoing revascularization were younger, had higher left ventricular ejection fraction (LVEF), lower ACEF score, and more positive myocardial ischemia detection results compared to the MT group (p

This is the case of an 84-year-old woman with a past medical history of ST-segment elevation myocardial infarction (STEMI) due to thrombotic occlusion of the right coronary artery treated at a different center with a bare-metal stent. The transthoracic echocardiography and thoracic computed tomography scan performed showed a rounded calcified mass at the posterior portion of the mitral annulus that induced mild mitral regurgitation (figure 1A, black arrow). Figure 1. A month later the patient was admitted to our center with recurrent inferior STEMI with total occlusion of the right coronary artery (figure 1B). We performed mechanical thrombus aspiration—that resulted in postprocedural TIMI flow grade 3—and obtained a white fibrous substance (figure 1C). We thought the occluding substance was not just a thrombus but rather a caseous degenerative material from the posterior mitral mass. Therefore, we decided to send it to the pathology laboratory. The pathological examination of the material showed thrombosis and microcalcifications of caseous appearance (figure 1D, red arrow). Therefore, the current STEMI was possibly associated with a coronary embolism due to caseous calcification of the mitral valve (CCMA). CCMA is a rare evolution of a calcified mitral annulus due to the caseous transformation of the inner material. It is often an...

Figure 1. Se presenta el caso de una mujer de 84 años con historia clínica de infarto agudo de miocardio con elevación del segmento ST (IAMCEST) por oclusión trombótica de coronaria derecha tratada en otro centro con un stent metálico. Tanto la ecocardiografía transtorácica como la tomografía computarizada torácica realizadas revelaron la presencia de una masa calcificada redondeada en la porción posterior del anillo mitral causante de la insuficiencia mitral leve (figura 1A, flecha negra). Un mes después, la paciente ingresó en nuestro centro con un IAMCEST inferior recurrente y oclusión total de coronaria derecha (figura 1B). Se llevó a cabo tromboaspiración con recuperación de flujo TIMI3 y se obtuvo una sustancia fibrosa blanquecina (figura 1C). Ante la posibilidad de que la sustancia oclusora no fuese solo un trombo sino material degenerativo caseoso procedente de la masa mitral posterior, se optó por enviar la muestra al laboratorio de anatomía patológica. El análisis patológico del material reveló trombosis y microcalcificaciones de apariencia caseosa (figura 1D, flecha roja). El IAMCEST en cuestión posiblemente estuviese asociado a una embolia coronaria debido a la calcificación caseosa del anillo mitral (CCAM). La CCAM es una rara evolución del anillo mitral calcificado que se debe a la transformación caseosa del...

AIM: To investigate key aspects of the problem of myocardial revascularization failure (MRF) and repeat or secondary myocardial revascularization (SR) in contemporary practice.; METHODS: The registry of secondary revascularization (REVASEC) is an investigator-initiated, multicenter, prospective registry enhanced with data monitoring and independent event adjudication (ClinicalTrials.govNCT03349385). It includes patients with prior revascularization referred to coronary angiography for suspected MRF with broad inclusion criteria. The main objectives are to describe the characteristics of patients with prior revascularization referred for repeat angiography, to describe and the rate and mechanisms of MRF (stent or graft failure, coronary artery disease progression or residual coronary artery disease); to evaluate the management including medical treatment and SR of these patients; and to assess the prognosis according to the outlined causative mechanisms. The registry has one year follow up for the primary endpoint (Patient-oriented composite endpoint including all-cause death, any myocardial infarction or any new unplanned revascularization according to subsets of MRF), but extended follow-up will be carried out up to 5years.; CONCLUSION: The REVASEC Registry will provide updated data on the characteristics, patterns of treatment, and 1-year outcomes of patients with MRF and SR in contemporary clinical practice. Copyright © 2021. Published by Elsevier Inc.

Sodium restriction is recommended for patients with heart failure (HF) despite the lack of solid clinical evidence from randomized controlled trials. Whether or not sodium restrictions provide beneficial cardiac effects is not known.The present study is a randomized, double-blind, controlled trial of stable HF patients with ejection fraction ≤ 40%. Patients were allocated to sodium restriction (2 g of sodium/day) vs. control (3 g of sodium/day). The primary outcome was change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) at 20 weeks. Secondary outcomes included quality of life and adverse safety events (HF readmission, blood pressure or electrolyte abnormalities).Seventy patients were enrolled. Median baseline sodium consumption was 3268 (2225-4537) mg/day. Adherence to the intervention based on 24-hour urinary sodium was 32%. NT-proBNP and quality of life did not significantly change between groups (p0.05 for both). Adverse safety events were not significantly different between the arms (p0.6 for all). In the per protocol analysis, patients who achieved a sodium intake2500 mg/day at the intervention conclusion showed improvements in NT-proBNP levels (between-group difference: -55%, 95% confidence interval -27 to -73%; p = 0.002) and quality of life (between-group difference -11 ± 5 points; p = 0.04). Blood pressure decreased in patients with lower sodium intake (between-group difference -9 ± 5 mmHg; p = 0.05) without significant differences in symptomatic hypotension or other safety events (p0.3 for all).Adherence assessed by 24-hour natriuresis and by the nutritionist was poor. The group allocated to sodium restriction did not show improvement in NT-proBNP. However, patients who achieved a sodium intake2500 mg/day appeared to have improvements in NT-proBNP and quality of life without any adverse safety signals. ClinicalTrials.gov Identifier: NCT03351283.

Chronic total occlusions (CTOs) are present in more than one third of older patients with myocardial ischemia, but controversy remains about the best therapeutic approach.To compare long-term survival after CTO revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG]) versus medical treatment (MT) alone in patients aged 75 and older.A total of 1,252 consecutive patients with at least one CTO were identified from 2010 to 2014 in our center. Patients were stratified by age (75 years vs. ≥75 years) in the present analysis. All-cause and cardiac mortality were assessed at a median follow-up of 3.5 years. In the older subgroup (26%), patients were more likely to be treated with MT alone (71% vs. 43% of younger patients; p 0.001). Patients undergoing revascularization were younger and had higher left ventricular ejection fraction (LVEF) and lower age, creatinine, ejection fraction (ACEF) score (age/LVEF +1 if creatinine2.0 mg/dL), compared to the MT group (p 0.05). As compared to MT, revascularization predicted lower rates of cardiac mortality and all-cause mortality in older patients, both in the subgroups treated with CABG (hazard ratio [HR] 0.35, 95% confidence interval [CI] 0.17-0.71; HR 0.39, 95%CI 0.18-0.81) and PCI (HR 0.57, 95%CI 0.33-0.98; HR 0.59, 95%CI 0.28-1.2). No differences in mortality were observed according to type of revascularization procedure.Among patients aged at least 75 years with a CTO, revascularization (PCI or CABG) rather than MT alone may portend a better outcome in terms of all-cause and cardiac mortality.

BACKGROUND Data on the impact of chronic kidney disease (CKD) on clinical outcomes in chronic total occlusion (CTO) patients is scarce, and the optimal treatment strategy for this population is not well established. This study aims to compare differences in CTO management and long-term clinical outcomes, including all-cause and cardiac mortalities, according to baseline glomerular filtration rate (GFR). METHODS All patients with at least one CTO diagnosed in our center between 2010 and 2014 were included. Demographic and clinical data were registered. All-cause and cardiac mortalities were assessed during a median follow-up of 4.03 years (IQR 2.6-4.8). Clinical outcomes were compared between patients with CKD (GFR < 60 mL/min/1.73 m2) and without CKD (GFR ≥ 60 mL/min/1.73 m2). RESULTS A total of 1248 patients (67.3 ± 10.9 years; 32% CKD) were identified. CKD patients were older and had a higher prevalence of hypertension, type 2 diabetes, peripheral arterial disease, and severe left ventricular dysfunction compared to patients with normal renal function (p < 0.05). Subjects with renal dysfunction were more often treated with MT alone, compared to patients without CKD (63% vs 45%; p < 0.001), who were more likely to undergo PCI or surgery. During follow-up, 386 patients [31%] died. CKD patients had a higher rate of all-cause and cardiac mortalities compared to patients without CKD (p < 0.001). The independent predictors for all-cause mortality were age, GFR < 60 mL/min/1.73 m2, Syntax Score I, and successful revascularization of the CTO (CABG or PCI-CTO). Among patients with CKD, advanced age, eGFR

OBJECTIVES: To describe imaging assessment, procedural and follow-up outcome of patients undergoing left atrial appendage (LAA) occlusion (LAAO) using a "sandwich" technique.BACKGROUND: The presence of a LAA with chicken wing morphology constitutes a challenge that sometimes requires specific occlusion strategies like the "sandwich" technique. However, procedural and follow-up data focusing on this implanting strategy is scarce.METHODS: This multicenter study collected individual data from eight centers between 2012 and 2019. Consecutive patients with chicken-wing LAAs defined as an early (90°) who underwent LAAO with Amplatzer devices and using the "sandwich" technique were included in the analysis.RESULTS: Overall, 190 subjects were enrolled in the study. Procedures were done with the Amulet device (85%) and the Amplatzer Cardiac Plug (15%). Successful implantation was achieved in 99.5% with ≤1 partial recapture in 80% of cases. Single (46.2%) and dual antiplatelet therapy (39.4%) were the most used antithrombotic therapies after LAAO. In-hospital major adverse events rate was 1.5% with no deaths. One patient (0.5%) had cardiac tamponade requiring percutaneous drainage. With a mean follow-up of 19.6 ± 14.8 months, the mortality and stroke rates were 7.7%/year and 2.5%/year, respectively. Follow-up transesophageal echocardiography (TEE) at 2-3 months showed device-related thrombosis in 2.8% and peri-device leak ≥3 mm in 1.2% of patients.CONCLUSIONS: In a large series of patients with chicken wing LAA anatomies undergoing LAAO, the use of the "sandwich" technique was feasible and safe. Preprocedural imaging was a key-factor to determine specific measurements.

Nonagenarians are a fast-growing age group among cardiovascular patients, but data about their management and prognosis after an acute coronary syndrome (ACS) is scarce. This study aimed to analyze characteristics of nonagenarian patients with ACS and to compare in-hospital and 1-year clinical outcomes between those treated with medical treatment (MT) alone and those receiving percutaneous coronary intervention (PCI).Multicenter observational study.We included consecutive nonagenarian patients with ACS admitted at 4 academic centers between 2005 and 2018. Only patients with type 1 myocardial infarction were included.Standardized definitions of all patient-related variables, clinical diagnoses, and hospital complications and outcomes were used. The primary endpoint was 1-year all-cause mortality. Long-term survival was compared between patients undergoing PCI and those managed with MT alone. Given differences in baseline characteristics could substantially interfere in outcomes, 3 sensitivity analyses were performed to adjust for confounders.A total of 680 nonagenarians were included (59% females). Of them, 373 (55%) patients presented with non-ST-segment elevation ACS (NSTE-ACS) and 307 (45%) with ST-segment elevation myocardial infarction (STEMI). A coronary angiogram was performed in 115 (31%) of NSTE-ACS and in 182 (60%) of STEMI patients with subsequent PCI in 81 (22%) and 156 (51%), respectively. Overall mortality rates were 17% in-hospital and 39% at 1-year follow-up. PCI was independently associated with a decreased risk of 1-year all-cause death [hazard ratio (HR) 0.57, 95% confidence interval (CI) 0.35, 0.95; P.05], mainly observed in those patients without disability (HR 0.59, 95% CI 0.37, 0.94; P.01) and lower Killip class (HR 0.50, 95% CI 0.28, 0.89; P.001).The prognosis of nonagenarians after an ACS was associated with comorbidities and the therapeutic approach. Although PCI appeared to be a safe and effective strategy, it is still necessary to refine the decision-making process in this high-risk population group.

Chronic total occlusions (CTOs) are prevalent angiographic findings in patients with suspected coronary artery disease. Conflicting results of randomized controlled trials and registries have not clarified the therapeutic approach for patients with CTO in clinical practice. Therefore, we sought to analyze variables influencing the decision-making process and their relationship with clinical outcomes according to the type of selected therapy.A total of 1248 consecutive patients with at least 1 CTO were identified between 2010 and 2014 at our institution. Clinical and angiographic variables were collected to allow the calculation of several predictive scores. Primary outcome was all-cause death at the longest follow-up available. Other endpoints of interest included cardiac mortality and myocardial infarction. Medical therapy (MT) alone was indicated in 719 patients (58%), whereas percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) were used in 240 (19%) and 298 (24%), respectively. Age, acute myocardial infarction, previous CABG, and age, creatinine, ejection fraction (ACEF) score were independently associated with the decision for MT alone. Conversely, the presence of multivessel disease, left main coronary artery involvement, and high SYNTAX score favored the decision for CABG. At a median follow-up of 4.3 years, revascularization strategies were independently associated with all-cause mortality and cardiac mortality (hazard ratio [HR], 0.42; 95% confidence interval [CI] 0.27-0.65; P.001 and HR, 0.32; 95% CI, 0.17-0.60; P.001, respectively) for PCI and (HR, 0.39; 95% CI, 0.26-0.58 and HR, 0.51; 95% CI, 0.32-0.81; P.01, respectively) for CABG.Several clinical and angiographic parameters influence the decision-making process of patients with CTO. CTO revascularization with either PCI or CABG appeared to be associated with improved clinical outcomes at long-term follow-up as compared with MT alone.

Background A gender gap has been known to exist in the clinical presentation, management and outcomes of coronary artery disease. Nevertheless, it is not well described how these differences pertain to the management of chronic total occlusion (CTO) of coronary arteries. The aim of this study was to compare sex-based differences in CTO management and long-term outcomes. Methods We included all consecutive patients with CTO diagnosed in an academic center between 2010 to 2014. There were no exclusion criteria. We collected demographic, clinical, and management data. All-cause and cardiac mortality were assessed during a median follow-up of 4.03 years (IQR 2.6–4.8). Results A total of 1248 consecutive patients (mean age 67.3±10.9 years; 23,5% females) with at least one CTO receiving either revascularization or optimal medical treatment (MT) were identified. The female group included 198 patients (23.5%). Women were older, had a higher prevalence of type 2 DM and a lower ventricle ejection fraction compared to their male counterparts (p Conclusions In our cohort, female patients with a CTO were significantly older and presented more prevalence of diabetes mellitus. Women with CTO were more often treated with MT alone, compared to their male counterparts, who were more likely to undergo invasive strategies - PCI or surgery. Female gender was associated with higher cardiac mortality on our cohort regardless of CTO treatment in a long-term follow-up. Figure 1 Cardiac Survival Rates Funding Acknowledgement Type of funding source: None

Background Myocardial infarction (MI) in nonagenarians is associated with high morbidity and mortality. Nonetheless, this population has typically been underrepresented in cardiovascular clinical trials. Objective The aim of this study was to evaluate outcomes of nonagenarian patients presenting with MI who underwent either conservative or invasive management. Methods We retrospectively included all consecutive patients equal to or older than 90yo admitted with non-ST segment elevation (NSTEMI) or ST segment elevation MI (STEMI) in four tertiary care centers between 2005 and 2018. Patients with type 2 myocardial infarction were excluded. We collected patients' baseline characteristic and procedural data. In-hospital and at 1-year follow-up all-cause mortality and major adverse cardiovascular events were assessed. Results 523 patients (mean age 92.6±2 years; 60% females) were analyzed. Overall, 184 patients (35.2%) underwent percutaneous coronary intervention (PCI), increasing over the years, mostly in STEMI group (from 16% of patients in 2005 to 75% in 2018). PCI was preferred in those subjects with less prevalence of disability for activities of daily living (p Conclusion An invasive approach was performed in over a third of nonagenarian patients, carrying prognostic implications and with a few numbers of complications. PCI seems to be the preferred strategy for STEMI in this high-risk population in spite of age. Figure 1 Funding Acknowledgement Type of funding source: None

Percutaneous left atrial appendage closure (LAAC) has been proposed as an alternative to anticoagulation therapy in patients with nonvalvular atrial fibrillation to decrease the thromboembolic risk, while avoiding the risks of chronic anticoagulation. This option may be attractive in patients with nonvalvular atrial fibrillation and chronic kidney disease (CKD), since they exhibit both high-thromboembolic and bleeding risks.To evaluate the prognostic impact of the presence of CKD in patients with atrial fibrillation undergoing LAAC peri-procedure and during the follow-up as compared with patients with preserved renal function.Retrospective, observational study that included 124 consecutive patients with atrial fibrillation undergoing LAAC in a university hospital, and the results were evaluated according to the baseline renal function of the patients.The median age was 75.5 years (IQR 67.6-80) and 62.1% were men, the median of CHALAAC is a valid alternative to oral anticoagulation in patients with CKD and atrial fibrillation, with a low-rate of peri- and post-procedure complications, although CKD patients exhibited a higher risk of bleeding and mortality during the follow-up. However, these higher rates may not be necessarily related to the procedure.

Sex differences in coronary artery disease presentation and outcomes have been described. The aim of this study was to compare sex disparities in chronic total occlusion (CTO) management and long-term outcomes.All consecutive patients with at least one CTO diagnosed in our center between 2010 and 2014 were included. Demographic and clinical data were registered. All-cause and cardiac mortality were assessed during a median follow-up of 4.03 years (IQR 2.6-4.8).A total of 1248 patients (67.3 ± 10.9 years; 16% female) were identified. Women were older, had a higher prevalence of type 2 DM and a lower ventricle ejection fraction compared to men (p .05). Although women had major proportion of positive result for severe ischemia-viability test (86% vs. 74%; p = .01), they were more often treated with MT alone compared to male (57% vs 51%; p = .02). During follow-up, 386 patients (31%) died. Women presented a higher rate of all-cause and cardiac mortality, and hospitalizations for heart failure independently of treatment strategy, compared to men (p .001). In multivariable analysis female sex was associated with higher cardiac mortality [HR 1.67, 95% CI 1.10-2.57; p .001]. Among women, the independent predictors for all-cause and cardiac mortalities were age, MT of the CTO and ACEF (age, creatinin and ejection fraction) score.A significant sex gap regarding CTO treatment was observed. Female sex was an independent predictor for cardiac mortality at long-term follow-up. More data are needed to support these findings.