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Introduction and objectives Bone marrow stem cells may reconstruct infarcted myocardium through distinct mechanisms. However, little is known on the relationship between recovery of muscular and microvascular function after regenerative treatments. Our objective was to analyze the relationship between changes in left ventricular and microvascular function in patients with anterior acute myocardial infarction receiving regenerative treatment. Methods We performed a pooled analysis of 2 clinical trials and a pilot study evaluating stem cell therapy in 88 patients with revascularized acute anterior myocardial infarction. Coronary flow reserve and left ventricular function were analyzed with identical methods in all patients. Patients treated with regenerative treatment received intracoronary bone–marrow-derived mononuclear cell transplant (n = 40), subcutaneous administration of granulocyte colony-stimulating factor (n = 14), or a combination of both (n = 10). A control group of 24 patients was treated with conventional revascularization. Results Mean ejection fraction increased from 37% ± 8% to 46% ± 12%, (P Conclusions Left ventricular function shows favorable changes after regenerative treatment of infarction. However, no correlation was found between changes in microvascular and myocardial function after regenerative therapy.

Resumen Introduccion y objetivos Las celulas madre de medula osea pueden regenerar el miocardio infartado por distintos mecanismos. La relacion entre la recuperacion de la funcion muscular y microvascular despues del tratamiento regenerativo ha sido poco estudiada. El objetivo es analizar la relacion entre los cambios en funcion ventricular y funcion microvascular en pacientes con infarto agudo que reciben la terapia. Metodos Se analizo a 88 pacientes con infarto anterior revascularizado incluidos en 2 ensayos clinicos y 1 estudio piloto que evaluaban la eficacia de la terapia celular. El estudio de la reserva coronaria y la funcion ventricular se analizaron con la misma metodologia en todos ellos. Se administraron celulas mononucleares derivadas de medula osea autologa (n = 40), factor estimulante de colonias granulociticas (n = 14) o la combinacion de ambos (n = 10). Hubo un grupo control (n = 24) que solo recibio revascularizacion convencional. Resultados La media de fraccion de eyeccion se incremento del 37 ± 8% al 46 ± 12% (p Conclusiones Hay cambios favorables en el miocardio tras el tratamiento con terapia regenerativa despues de un infarto, aunque no se ha encontrado correlacion entre los cambios de funcion muscular y microvascular.

Objectives The aim of this study was to determine the prognosis and specific complications of patients with prosthetic mitral valves (PMVs) undergoing transcatheter aortic valve replacement (TAVR). Background TAVR is performed relatively often in patients with PMVs, but specific risks are not well described. Methods A multicenter analysis was conducted, including patients with severe symptomatic aortic stenosis who underwent TAVR at 10 centers. Patients’ clinical characteristics and outcomes were evaluated according to the presence of a PMV. Results The mean age of the study population (n = 2,414) was 81 ± 8 years, and 48.8% were men. A total of 91 patients (3.77%) had PMVs. They were more commonly women, younger, and had higher surgical risk. PMVs were implanted a median of 14 years before TAVR, and most patients had mechanical prostheses (73.6%). Eighty-six patients (94.5%) were on long-term vitamin K inhibitor therapy, and bridging antithrombotic therapy was administered in 59 (64.8%). TAVR device embolization occurred in 6.7% (vs. 3.3% in the non-PMV group; p = 0.127), in all instances when distance between the PMV and the aortic annulus was Conclusions TAVR presents similar mortality irrespective of the presence of a PMV. However, patients with PMVs had higher bleeding risk that was independently associated with higher mortality. Risk for valve embolization was relatively high, but it occurred only in patients with PMV–to–aortic annulus distances

Resumen Introduccion y objetivos La reestenosis coronaria tras implantar un armazon vascular bioabsorbible (AVB) es infrecuente. Hay poca informacion disponible sobre las principales caracteristicas de este tipo de lesiones. El objetivo de este estudio es caracterizar las reestenosis del AVB mediante tomografia de coherencia optica (OCT). Metodos Se estudio a 330 pacientes que recibieron 398 AVB para tratar 380 lesiones. Se evaluo a estos pacientes clinica y angiograficamente y, tras detectarse la reestenosis, mediante OCT. Resultados Tras un seguimiento de 19 ± 10 meses, se detectaron 18 casos de reestenosis en 17 pacientes (5,4%). La mayoria eran tardias o muy tardias (9 ± 4 meses). El patron angiografico mas frecuente fue la reestenosis focal en 12 (67%) y principalmente localizada en el borde proximal en 9 (75%), afectando o no la plataforma. El patron predominantemente homogeneo fue infrecuente en 3 (25%) y solo se visualizo en 3 de las 6 reestenosis situadas en el margen. La reestenosis focal localizada dentro del armazon presento en la OCT un patron heterogeneo o en capas. Finalmente se observo reestenosis difusa en 6 casos (33%), en los que se identifico un patron rico en lipidos o un patron en capas. Ademas, se identificaron microvasos y microcalcificaciones en algunos de ellos, lo que sugiere un proceso de neoateroesclerosis. Conclusiones La tasa de reestenosis tras una media de seguimiento de 19 meses fue del 5,4%. La presentacion angiografica mas frecuente fue focal, situada en el borde proximal. La reestenosis difusa ocurrio tardia o muy tardiamente y la mayoria de estos pacientes presentaban signos de neoateroesclerosis.

Introduction and objectives Coronary restenosis after bioresorbable vascular scaffold (BVS) implantation is infrequent and little information is available on the main characteristics of these lesions. The aim of this study was to assess restenotic lesions by using optical coherence tomography (OCT). Methods We studied 330 patients with coronary artery disease who received 398 BVS to treat 380 lesions. These patients were clinically and angiographically evaluated at follow-up and OCT was carried out on detection of restenosis. Results After a follow-up of 19 ± 10 months, 18 restenotic lesions were detected in 17 patients (5.4%). Depending on the time of presentation, most cases of restenosis were late or very late (9 ± 4 months). The most frequent angiographic pattern was focal restenosis in 12 (67%) patients, which was mainly located at the proximal border in 9 (75%) whether involving the scaffold or not. The homogeneous pattern was infrequent, occurring in 3 (25%) lesions and was only visualized in 3 out of 6 cases of restenosis located at the margin. When the focal restenosis was located in the platform, OCT showed a heterogeneous or layered pattern. Finally, diffuse restenosis was observed in 6 patients (33%). In diffuse restenosis, OCT revealed a lipid-laden or layered tissue structure and the presence of microvessels or microcalcification, potentially suggesting a neoatherosclerotic process. Conclusions After a mean follow-up of 19 months, the restenosis rate was 5.4%. Most restenotic lesions were focal, located at the proximal border. Diffuse restenosis mostly occurred late or very late and most showed signs suggestive of neoatherosclerosis.

Resumen Introduccion y objetivos La epidemiologia de la endocarditis infecciosa sobre valvula nativa izquierda (EIVNI) se ha modificado, consecuencia del aumento en la edad media de los pacientes. El objetivo de nuestro estudio es analizar la influencia de la edad y la presencia de una cardiopatia predisponente previa en el pronostico de estos pacientes. Metodos Analizamos 257 casos consecutivos de EIVNI en funcion de su edad, tanto en la serie global como en el subgrupo de pacientes sin cardiopatia predisponente. Resultados La edad media fue de 54,6 (18,6) anos. Existio un aumento en la proporcion de pacientes de edad igual o mayor a 70 anos entre 1987-2000 y 2001-2014 (9,8 frente a 34,8%, p Conclusiones Los pacientes que tienen una edad igual o mayor a 70 anos con un episodio de EIVNI son cada vez mas frecuentes y presentan peor pronostico, con una tasa menor de cirugia y mayores tasas de mortalidad hospitalaria.

Introduction and objectives The percutaneous mitral valve repair procedure (MitraClip) appears to reduce mitral annulus diameter in patients with functional mitral regurgitation, but the relationship between this and regurgitation severity has not been demonstrated. The aim of this study was to determine the effect of mitral annulus remodeling on the reduction of mitral regurgitation in patients with functional etiology. Methods The study included all patients with functional mitral regurgitation treated with MitraClip at our hospital until January 2015. Echocardiogram (iE33 model, Philips) was performed in all patients immediately after device positioning. Changes in the mitral annulus correlated with mitral regurgitation severity, as assessed using the effective regurgitant orifice area. Results The study included 23 patients (age, 65 ± 14 years; 74% men; left ventricular ejection fraction, 31% ± 13%; systolic pulmonary artery pressure, 47 ± 10 mmHg). After the procedure, the regurgitant orifice area decreased by 0.30 cm2 ± 0.04 cm2 (P Conclusions In patients with functional mitral regurgitation, the MitraClip device produces an immediate reduction in the anteroposterior diameter. This remodeling may be related to the reduction in mitral regurgitation.

Resumen Introduccion y objetivos El procedimiento de reparacion mitral percutanea (MitraClip) parece reducir los diametros del anillo mitral de pacientes con etiologia funcional, pero no se ha demostrado la relacion con la intensidad de la regurgitacion. El objetivo es evaluar si el remodelado del anillo mitral tiene algun impacto en la reduccion de la regurgitacion mitral en pacientes con insuficiencia mitral funcional. Metodos Se incluyo a todos los pacientes con etiologia funcional tratados con MitraClip en el centro hasta enero de 2015. Se les realizo ecocardiograma inmediatamente despues de la colocacion del dispositivo (equipo iE33, Philips). Los cambios en el anillo mitral se correlacionaron con la intensidad de la regurgitacion mitral evaluada por el orificio regurgitante efectivo. Resultados Se incluyo a 23 pacientes (edad, 65 ± 14 anos; el 74% varones; fraccion de eyeccion del ventriculo izquierdo, 31 ± 13%; presion sistolica de la arterial pulmonar, 47 ± 10 mmHg). Tras el procedimiento, el orificio regurgitante disminuyo en 0,30 ± 0,04 cm2 (p Conclusiones El dispositivo MitraClip produce una inmediata reduccion del diametro anteroposterior en pacientes con insuficiencia mitral funcional. Este remodelado podria relacionarse con la reduccion de la regurgitacion mitral.

Objectives The study sought to compare the safety (resistance to damage) and efficacy (ability to cross the side branch) of polymer-coated and non–polymer-coated guidewires in the jailed wire technique used during the percutaneous treatment of bifurcation lesions. Background The jailed wire technique is a useful strategy in the treatment of bifurcation lesions by provisional stenting. However, these wires can be damaged or even be broken during their removal. Methods We performed a randomized study in patients with bifurcation lesions treated by provisional stenting. The jailed wire technique was mandatory, and the types of guidewires, polymer-coated (n = 115) and non–polymer-coated (n = 120), were randomized. After the procedures, the wires were evaluated by stereoscopic microscopy. The induced damage in the wires was classified as follows: no damage, mild, moderate, or severe. Results The clinical characteristics were similar between patients treated with polymer-coated or non–polymer-coated wires. Polymer-coated wires were significantly (p Conclusions Jailed wires during interventional procedures of bifurcation lesions commonly showed microscopic damage. Polymer-coated wires were more resistant to retrieval damage and were more efficient in crossing the side branch ostium than non–polymer-coated wires. (Jailed Wire Technique in the Treatment of Coronary Bifurcations Lesions With Stent: Stereoscopic Microscopy Study; NCT02516891)

Data on long-term outcomes of percutaneous mitral valvuloplasty (PMV) are still scarce. In addition, the persistence of pulmonary hypertension (PH) after PMV is a complication for which mechanisms and prognostic implications are unclear. Our aims were (1) to report the long-term outcomes of patients with rheumatic mitral stenosis treated with PMV; (2) to determine the risk factors for long-term poor outcomes; and (3) to analyze the prevalence and predictors of persistent PH. We prospectively enrolled 532 patients who underwent PMV from 1987 to 2011 at 2 hospitals. The following end points were assessed after PMV: all-cause mortality, mitral reintervention, a composite end point of all-cause mortality and mitral reintervention, and PH persistence. Survival status was available for 97% patients; the median follow-up was 10 years (interquartile range 4 to 18 years). Procedural success was achieved in 85% patients. During the follow-up, 21% patients died and 27% required mitral reintervention. Before PMV, 74% patients had PH that persisted after PMV in 45% of patients (p0.001). Unfavorable valve anatomy (Wilkins score8) and post-PMV mean pulmonary arterial pressure (PAP) were independent predictors of all-cause mortality, mitral reintervention, and the composite end point. Post-PMV mean PAP was significantly correlated with a mitral valve area (MVA)2.5 cm(2) (p0.001); in addition, on the echocardiographic follow-up, MVA was an independent predictor of systolic PAP (p0.001). In conclusion, PMV represents an advantageous therapeutic option for patients with mitral stenosis in terms of long-term outcomes. Unfavorable valve anatomy and persistent PH were the most important predictors of long-term outcomes. The persistence of PH is associated with the MVA obtained after PMV.

Resumen Introduccion y objetivos El tratamiento de lesiones coronarias con armazon vascular bioabsorbible ha demostrado ser eficaz. Hay poca informacion sobre su uso en bifurcaciones. El objetivo de este estudio es analizar la seguridad y la eficacia de esta plataforma en el tratamiento de bifurcaciones coronarias. Metodos Desde enero de 2012 hasta enero de 2015, se trato con plataforma bioabsorbible a 194 pacientes con 230 lesiones en bifurcaciones coronarias. Se analizo con tecnicas de imagen intracoronaria la geometria de 145 bifurcaciones (63%). El 78% de las lesiones se revaluaron angiograficamente (por tomografia computarizada, 138; por coronariografia, 41). Resultados La presentacion clinica mas habitual fue un sindrome coronario agudo (81%). El tipo de bifurcacion mas frecuente (34%) fue la 1,1,1. La estrategia simple fue de eleccion en 221 lesiones (96%). En 90 lesiones se posdilato la rama lateral a traves de las celdillas, y por tomografia de coherencia optica se observo fractura del dispositivo en 3 casos. Se obtuvo exito del procedimiento en todos los pacientes. En el primer mes se documento 1 trombosis subaguda y 1 muerte subita. El tiempo de seguimiento angiografico fue de 7,3 ± 1,6 meses y el del seguimiento clinico, 14 ± 6 meses. Se observaron 12 restenosis (5%). Durante el seguimiento, 2 pacientes (1%) tuvieron un infarto en otro territorio y otros 2 fallecieron (1%); los demas quedaron libres de sintomas. La tasa de trombosis fue del 1,3%. Conclusiones El tratamiento de lesiones en bifurcaciones coronarias con armazon vascular bioabsorbible provisional es seguro y eficaz. Al seguimiento, habia una tasa de eventos adversos baja.

ResumenIntroduccion y objetivos Con frecuencia se producen alteraciones en la conduccion tras el implante de una protesis CoreValve. Se pretende analizar que cambios se producen en la conduccion cardiaca de pacientes con estenosis aortica tratados con este tipo de protesis. Metodos Desde abril de 2008 hasta diciembre de 2013, se selecciono a 181 pacientes con estenosis aortica grave tratados con esta protesis y estudiados mediante electrocardiograma. Se estudio a un subgrupo de 137 pacientes consecutivos (75,7%) mediante electrocardiogramas intracavitarios antes y tras implante protesico. El objetivo principal del estudio es la necesidad de marcapasos definitivo en las primeras 72 h tras el implante protesico. Se analizaron numerosas variables para predecir esta eventualidad. Resultados Tras el implante, los intervalos PR y QRS se incrementaron de 173 ± 47 a 190 ± 52 ms (p

Conduction disturbances often occur after CoreValve transcatheter aortic valve implantation. The aim was to analyze which cardiac conduction changes occur in patients with aortic stenosis treated with this type of prosthesis.A total of 181 patients with severe aortic stenosis treated with this prosthesis and studied by electrocardiography between April 2008 and December 2013 were selected. A subgroup of 137 (75.7%) consecutive patients was studied by intracardiac electrocardiogram before and after prosthesis implantation. The primary endpoint of the study was the need for a permanent pacemaker within 72 hours after prosthesis implantation. Numerous variables to predict this possibility were analyzed.Following implantation, PR and QRS intervals were increased from 173±47 ms to 190±52ms (P.01) and from 98±22ms to 129±24 ms (P.01), whereas the A-H and H-V intervals were prolonged from 95±39ms to 108±41ms (P.01) and from 54±10ms to 66±23ms (P.01). A total of 89 (49%) patients had new-onset left bundle-branch block, and 33 (25%) required a pacemaker within the first 72hours. The independent predictors for a pacemaker were baseline right bundle-branch block and prosthetic depth. Intracardiac intervals had no predictive value. In addition, 13 patients required a pacemaker after 72 hours.CoreValve prosthesis implantation has a high incidence of conduction disturbance, with left bundle-branch block being the most common. A total of 25% of patients required a permanent pacemaker. The need for a pacemaker was related to baseline right bundle-branch block and prosthetic depth.

Introduction and objectives The use of the jailed guidewire technique is highly useful when treating bifurcation lesions by provisional stenting. However, at the time of withdrawal, the guidewire can suffer damage and even fracture. The aim of this study was to evaluate structural damage in both polymer-coated and nonpolymer-coated jailed guidewires. Methods Between January 2011 and December 2012, an observational study was conducted using stereoscopic microscopy to evaluate 135 jailed guidewires (45 nonpolymer-coated and 90 polymer-coated) previously used in the percutaneous treatment of bifurcation lesions. Damage after withdrawal was classified as mild, moderate, or severe. Results Age and sex distributions were similar in both groups of patients treated with polymer-coated and nonpolymer-coated guidewires. However, operators selected polymer-coated guidewires more frequently when treating more complex bifurcations and in diabetic patients. Some type of microscopic damage was observed in 25 of the guidewires analyzed (18%). Paradoxically, damage was more common in nonpolymer-coated guidewires (53.0% vs 1.1%; P Conclusions Coronary guidewires that are jailed during the treatment of bifurcations using provisional stenting often suffer nonsevere microscopic damage. Although polymer-coated guidewires were used in more complex bifurcation lesions, paradoxically, they were damaged less frequently.

Resumen Introduccion y objetivos La tecnica de la guia encarcelada resulta de gran utilidad en el tratamiento de lesiones bifurcadas mediante la tecnica de stent condicional. Sin embargo, esta guia puede sufrir dano e incluso fracturarse en el momento de la retirada. El objetivo de este estudio es evaluar la aparicion de dano estructural en las guias encarceladas, tanto polimericas como no polimericas. Metodos Entre enero de 2011 y diciembre de 2012 se realizo un estudio observacional en el que se evaluaron mediante microscopia estereoscopica 135 guias (45 no polimericas y 90 polimericas) utilizadas previamente en el tratamiento percutaneo de bifurcaciones y que resultaron encarceladas. El dano tras la extraccion se valoro como leve, moderado o grave. Resultados Las distribuciones de edad y sexo fueron similares en los dos grupos de pacientes tratados con guias polimericas y no polimericas. Sin embargo, los operadores seleccionaron las guias polimericas con mas frecuencia en bifurcaciones mas complejas y en pacientes diabeticos. Se observo algun tipo de dano microscopico en 25 de las guias analizadas (18%). Paradojicamente, estas alteraciones fueron mas frecuentes en el grupo de guias no polimericas (el 53,0 frente al 1,1%; p Conclusiones Las guias coronarias que se encarcelan durante el tratamiento de las bifurcaciones con stent condicional presentan a menudo dano microscopico no grave. Aunque las guias polimericas se utilizaron en bifurcaciones mas complejas, paradojicamente se danaron con menos frecuencia.

The possibility of strut fractures after bioresorbable vascular scaffold (BVS) treatment is a new problem associated with the use of this novel technology. There is little in vivo information regarding the effects of lateral dilation on BVS. The present study aimed to evaluate the effects of lateral balloon dilation after bioresorbable vascular scaffold implantation in the treatment of bifurcation lesions. From January 2012 to February 2015, 49 patients with bifurcation lesions who had been treated with BVS required balloon dilation of the side branch (SB). Optical coherence tomographic studies were performed in each of these patients. In 3 patients (6%), the optical coherence tomographic results met the criteria for rupture. Prolonged inflation using a noncompliant balloon with a diameter within the expansion limits of the device resolved the complication in all patients. The clinical course was favorable in all patients, and there were no inhospital deaths or myocardial infarctions. At 14 ± 8 months of follow-up, 2 patients with integrity of the BVS presented target lesion revascularization (4%). Another patient (2%) suffered a probable stent thrombosis 11 months after the procedure (myocardial infarction and death at home). The patients with the BVS rupture at the index procedure had a favorable clinical outcome, and the 6-month computed tomographic scan revealed maintenance of the initial good results. In conclusion, minor BVS rupture after 2.5-mm lateral balloon dilation may occur but is infrequent (6%). Prolonged balloon inflation of the main vessel may partially restore the geometry of the BVS.

Objectives To analyze the feasibility and safety of direct bioresorbable vascular scaffold (BVS) implantation without previous balloon dilation. Background Lesion preparation through predilation is recommended before BVS implantation. There is no information on the routine use of direct BVS implantation. Methods and Results One hundred fifty-three patients with a total of 200 coronary lesions, were treated with BVS. A baseline intravascular ultrasound study (IVUS) was performed in 171 lesions (86%), and after BVS implantation, the quality of scaffolding was assessed with an additional IVUS (83, 41%) or optical coherence tomography (77, 38%). Elective predilation was conducted in 50 lesions. In 150 lesions, direct BVS implantation was attempted. In 129 lesions (86%), the BVS was implanted successfully, and in the remaining 21 (14%), direct implantation failed. In these cases, the scaffolds were retrieved and successfully implanted after balloon angioplasty. Longer and C-type lesions, and a larger plaque burden, were associated with failure to directly cross the lesion. Balloon postdilation was needed in 34% of the lesions. Ten patients (6.6%) had a periprocedural myocardial infarction. One patient (0.6%) died 60 days after BVS implantation due to thrombosis of the scaffold. At follow-up, target lesion revascularisation was needed in eight patients (5%). After 12 ± 3 months, the remaining patients were symptom-free. Conclusions Direct BVS implantation is safe and feasible in most soft coronary plaques. © 2015 Wiley Periodicals, Inc.

Resumen Introduccion y objetivos La regurgitacion mitral sintomatica tiene un pronostico desfavorable sin tratamiento quirurgico. Sin embargo, segun el registro europeo de enfermedad cardiaca valvular, no se intervino al 49% de los pacientes en esa situacion. El tratamiento percutaneo de la regurgitacion mitral con MitraClip® se ha demostrado seguro y eficaz anadido al tratamiento medico en este perfil de pacientes. El objetivo de este trabajo es describir la experiencia inicial con MitraClip® en Espana. Metodos Estudio observacional retrospectivo que incluye a todos los pacientes tratados desde noviembre 2011 hasta julio 2013 por los cuatro hospitales espanoles con mayor numero de implantes. Resultados Se trato a 62 pacientes (el 77,4% varones), principalmente con regurgitacion mitral funcional restrictiva (85,4%), de gravedad grado III (37%) o IV (63%), fraccion de eyeccion media del 36 ± 14% y clase funcional de la New York Heart Association III (37%) o IV (63%). En el 98% de los pacientes, se implanto con exito el dispositivo. Al ano, el 81,2% tenia regurgitacion mitral ≤ 2 y el 90,9% en clase funcional de la New York Heart Association ≤ II . Hubo un solo caso de mortalidad periprocedimiento (sepsis 20 dias despues del implante) y otros 3 fallecimientos en el seguimiento (media, 9,1 meses). Fue necesario implantar un nuevo dispositivo por dehiscencia parcial del previo a 2 pacientes y se sometio a trasplante cardiaco a otros 2. Conclusiones El tratamiento con MitraClip® en Espana se ha dirigido principalmente a pacientes con insuficiencia mitral funcional, disfuncion ventricular sistolica significativa y elevado riesgo quirurgico, y se perfila como una opcion segura de tratamiento con capacidad de reducir la regurgitacion mitral y mejorar la capacidad funcional.

Background. - The Ross procedure is used in the treatment of selected patients with aortic valve disease. Pulmonary graft stenosis can appear in the long-term follow-up after the Ross intervention, but the factors involved and its clinical implications are not fully known. Aim. To describe the incidence, clinical impact and predictors of homograft stenosis and reintervention after the Ross procedure in a prospective series in a tertiary referral hospital.Methods. - From 1997 to 2009, 107 patients underwent the Ross procedure (mean age: 30 +/- 11 years; 69% men; 21 aged 36 mmHg) and surgical or percutaneous homograft reintervention.Results. - After 15 years of follow-up (median: 11 years), echocardiographic and clinical data were available in 91 (85%) and 104 (98%) patients, respectively: 26/91 (29%) patients developed homograft stenosis; 10/104 (10%) patients underwent 13 homograft reintervention procedures (three patients underwent surgical replacement, three received a percutaneous pulmonary valve and one needed stent implantation). The other three patients underwent two consecutive procedures in follow-up; one died because of a procedure-related myocardial infarction. Rates of survival free from homograft stenosis and reintervention at 1, 5 and 10 years were 96%, 82% and 75% and 99%, 94% and 91%, respectively. Paediatric patients had worse survival free from homograft stenosis (hazard ratio [HR] 3.50, 95% confidence interval [CI]: 1.56-7.90; P=0.002), although there were no significant differences regarding reintervention (HR: 2.01, 95% CI: 0.52-7.78; P=0.31). Younger age of homograft donor was also a stenosis predictor (HR: 0.97, 95% CI: 0.94-0.99; P=0.046).Conclusions. - The probabilities of homograft stenosis and reintervention 10 years after the Ross procedure were 29% and 10%, respectively; only one patient had a reintervention-related death. Younger donor and recipient age were associated with a higher rate of stenosis. (C) 2016 Elsevier Masson SAS. All rights reserved.

There is little evidence on the optimal strategy for bifurcation lesions in the context of a coronary chronic total occlusion (CTO). This study compared the procedural and mid-term outcomes of patients with bifurcation lesions in CTO treated with provisional stenting vs 2-stent techniques in a multicenter registry.Between January 2012 and June 2016, 922 CTO were recanalized at the 4 participating centers. Of these, 238 (25.8%) with a bifurcation lesion (side branch ≥ 2mm located proximally, distally, or within the occluded segment) were treated by a simple approach (n=201) or complex strategy (n=37). Propensity score matching was performed to account for selection bias between the 2 groups. Major adverse cardiac events (MACE) consisted of a composite of cardiac death, myocardial infarction, and clinically-driven target lesion revascularization.Angiographic and procedural success were similar in the simple and complex groups (94.5% vs 97.3%; P=.48 and 85.6% vs 81.1%; P=.49). However, contrast volume, radiation dose, and fluoroscopy time were lower with the simple approach. At follow-up (25 months), the MACE rate was 8% in the simple and 10.8% in the complex group (P=.58). There was a trend toward a lower MACE-free survival in the complex group (80.1% vs 69.8%; P=.08). After propensity analysis, there were no differences between the groups regarding immediate and follow-up results.Bifurcation lesions in CTO can be approached similarly to regular bifurcation lesions, for which provisional stenting is considered the technique of choice. After propensity score matching, there were no differences in procedural or mid-term clinical outcomes between the simple and complex strategies.

Aims Percutaneous pulmonary valve implantation (PPVI) is used to treat patients with dysfunctional pulmonary valve conduits. Short- and longer-term results from multiple trials have outlined haemodynamic improvements. Our aim was to report the long-term results, including quality of life, from a multicentre trial in Europe and Canada. Methods and results From October 2007 to April 2009, 71 patients (24 female; median age 19.0 [IQR: 14.0 to 25.0] years) were enrolled in a prospective cohort study. PPVI was performed successfully in 63 patients. At five-year follow-up four patients had died. Moderate and severe pulmonary regurgitation were completely resolved in all except one patient, who needed re-PPVI. Outflow tract obstruction improved significantly from a mean pressure gradient of 37.7±12.1 mmHg before PPVI to 17.3±9.7 mmHg at five-year follow-up; however, 11 patients needed treatment for restenosis. The EQ-5D quality of life utility index and visual analogue scale scores were both significantly improved six months post PPVI and remained so at five years. Conclusions Five-year results following PPVI demonstrate resolved moderate or severe pulmonary regurgitation, improved right ventricular outflow tract obstruction, and improved quality of life.

Resumen Introduccion y objetivos Comparar la incidencia en 3 anos de eventos mayores en pacientes con lesiones de bifurcacion tratados con implante condicional de stents liberadores de sirolimus frente a stents liberadores de everolimus. Metodos Se llevo a cabo un analisis combinado de dos ensayos prospectivos y aleatorizados de metodologia similar (SEAside y CORpal). En dichos ensayos, se asigno aleatoriamente a 443 pacientes con lesiones de bifurcacion a tratamiento con stents liberadores de sirolimus o everolimus. El seguimiento clinico se amplio a 3 anos para evaluar los eventos adversos cardiovasculares mayores (muerte o infarto agudo de miocardio o revascularizacion de vaso diana). Resultados A los 3 anos, la supervivencia libre de eventos adversos cardiovasculares mayores fue del 93,2 y el 91,3% en los grupos de stents liberadores de everolimus y sirolimus respectivamente (p = 0,16). El analisis exploratorio de referencia para los eventos tardios (aparecidos despues de los primeros 12 meses) mostro una frecuencia de eventos adversos cardiovasculares mayores significativamente inferior en el grupo de stents liberadores de everolimus: el 1,4 frente al 5,4% en el grupo de stents liberadores de sirolimus (p = 0,02). Conclusiones El implante de stents liberadores de sirolimus o everolimus en lesiones de bifurcacion se asocia a unas tasas bajas de eventos adversos mayores a los 3 anos de seguimiento. Los resultados de un subanalisis de los eventos que se produjeron despues del primer ano indican una tasa de eventos con los stents liberadores de everolimus inferior que con los liberadores de sirolimus, lo cual indica que esta justificado realizar estudios exploratorios del beneficio clinico a largo plazo obtenido con los stents liberadores de farmacos de ultima generacion.

Background Our objective was to evaluate the impact of asymptomatic acute cellular rejection (ACR) in left ventricular myocardial strain in heart transplant (HT) recipients by means of two-dimensional speckle tracking echocardiography (2DSTE). Methods From September 1, 2009 to December 15, 2010 a conventional echocardiography and 2DSTE exam was performed on all consecutive HT recipients in their first year posttransplantation within 3 hours of the surveillance endomyocardial biopsies, as well as on 14 healthy controls. The association of strain echocardiographic variables with different grades of ACR was investigated. Results Of the 78 studies performed 4 ± 3 months after HT in 20 patients, 32 studies were coincident with grade 0R rejection, 41 with grade 1R, and 5 with grade 2R. Significantly lower values of average radial strain were found with higher grades of ACR (29.1 ± 7.7%, 23.2 ± 8.5%, and 14.3 ± 8.8% for grades 0R, 1R, and 2R of ACR, P = 0.001). Average deformation was similar for controls versus transplanted patients, in the absence of acute rejection: radial 29.1 ± 10.0% versus 29.1 ± 7.7%, P = 0.98; circumferential −19.3 ± 3.2% versus −20.2 ± 5.9%, P = 0.62; and longitudinal −20.7 ± 4.1% versus −18.5 ± 5.4%, P = 0.19. An average radial strain

Resumen Objetivos Comprobar si existen diferencias en la presentacion clinica, microbiologia y morbimortalidad intrahospitalaria de la endocarditis infecciosa entre 2 centros espanoles, uno peninsular y con cirugia cardiaca y otro en Canarias que debe derivar a los pacientes quirurgicos. Metodo Estudio retrospectivo de 229 pacientes con endocarditis, incluidos pediatricos, ingresados de forma consecutiva en los hospitales Reina Sofia de Cordoba (n = 119) y Nuestra Senora de Candelaria, en Tenerife (n = 110), entre 2005 y 2012. Se compararon las variables clinicas, microbiologicas y ecocardiograficas y se analizaron las diferencias de mortalidad mediante un analisis de regresion logistica binaria. Resultados No hubo diferencias en la cardiopatia predisponente, en la proporcion de casos intervenidos ni en el perfil microbiologico. En el hospital canario la proporcion de infecciones por cateter fue mayor (13,6% vs 3,4%), asi como la mortalidad global (31,8% vs 18,5%; p = 0,020). Esta diferencia de mortalidad entre hospitales dejo de resultar significativa en el analisis multivariable (OR = 1,85; IC 95%, 0,70-4,87; p = 0,213), siendo la edad (OR por ano = 1,04; IC 95%, 1,01-1,07; p = 0,006), las complicaciones cardiacas (OR = 5,05; IC 95%, 1,78-14,34; p = 0,002), la sepsis persistente (OR = 4,89; IC 95%, 2,09-11,46; p Conclusiones Existen diferencias en la presentacion de la endocarditis entre 2 hospitales espanoles distantes. La ausencia de servicio quirurgico no puede relacionarse directamente con la distinta evolucion intrahospitalaria.

Resumen El avance en el intervencionismo en las cardiopatias congenitas ha sido tan importante en los ultimos 30 anos que permite hoy dia su sistematizacion. En el primer articulo tratamos de las obstrucciones a la salida de ambos ventriculos. En esta segunda parte analizaremos el cierre percutaneo de defectos cardiacos. Entre los cortocircuitos izquierda-derecha, el cierre percutaneo de comunicacion interauricular, interventricular y ductus persistente suponen en la actualidad un excelente arsenal terapeutico para estas patologias. Las fistulas arteriovenosas centrales y las sistemico-pulmonares pueden tambien ser cerradas percutaneamente con dispositivos vasculares. Entre los cortocircuitos derecha-izquierda el cierre percutaneo de foramen oval y de fenestraciones posquirurgicas tambien supone un enfoque terapeutico muy util. Por ultimo, la terapia celular en cardiopatias con disfuncion ventricular severa en la infancia comienza a perfilarse como un tratamiento muy esperanzador.

Introduction and objectives Hospitalized patients with heart failure who are malnourished present a worse prognosis than those with an adequate nutritional status. It is unknown whether a nutritional intervention can modify the prognosis of these patients. The aim of this study is to assess the efficacy of a nutritional intervention on morbidity and mortality in hospitalized patients with heart failure who are malnourished. Methods PICNIC is a multicentre, randomized, controlled trial in which hospitalized patients with heart failure and malnutrition, as defined by the Mini Nutritional Assessment, are randomly assigned to conventional management of heart failure or conventional management of heart failure and an individualized nutritional intervention consisting of 3 points: optimization of diet, specific recommendations, and prescription, if deemed necessary, of nutritional supplements. A sample size of 182 patients for a maximum follow-up of 12 months has been estimated. The primary endpoint is time to death from any cause or rehospitalization because of heart failure. Analysis is by intention to treat. Conclusions PICNIC study will determine the prognostic impact of a nutritional intervention in hospitalized patients with heart failure who are malnourished.

Resumen Introduccion y objetivos Los pacientes hospitalizados por insuficiencia cardiaca en estado de desnutricion tienen un pronostico mas desfavorable que los que estan en adecuado estado nutricional. Se desconoce si una intervencion nutricional puede modificar el pronostico de estos pacientes. El objetivo de este estudio es evaluar si una intervencion nutricional sobre pacientes hospitalizados con insuficiencia cardiaca desnutridos produce beneficio en su morbimortalidad. Metodos PICNIC es un ensayo clinico multicentrico, aleatorizado y controlado, en el que se asigna aleatoriamente a los pacientes hospitalizados por insuficiencia cardiaca aguda que ademas esten en estado de desnutricion, definido segun la puntuacion de la encuesta Mini Nutritional Assessment, a tratamiento convencional de la insuficiencia cardiaca o a tratamiento convencional de la insuficiencia cardiaca mas una intervencion nutricional individualizada que consta de tres puntos: optimizacion de la dieta, recomendaciones especificas y prescripcion, si se estima necesario, de suplementos nutricionales. Se ha estimado un tamano muestral de 182 pacientes para un periodo maximo de seguimiento de 12 meses. La variable principal del estudio sera el tiempo hasta la muerte por cualquier causa o reingreso por insuficiencia cardiaca. El analisis se realiza por intencion de tratar. Conclusiones El estudio PICNIC determinara el impacto pronostico de una intervencion nutricional en pacientes hospitalizados con insuficiencia cardiaca desnutridos.

Objectives The goal of this study was to assess the immediate and long-term outcomes in patients undergoing percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) in an unprotected distal left main coronary artery (UDLM). Background PCI for UDLM-ISR can be complex. Limited information is available on procedural and clinical outcomes. Methods Between May 2002 and February 2011, UDLM-ISR after drug-eluting stent implantation was observed in 79 of 1,102 patients (7%). Seventy-five were treated by repeat PCI using a simple approach (balloon/in-stent implantation) or a complex strategy (additional stent/double-stenting technique). A diagnosis of mild or severe restenosis was considered depending on the number of bifurcation segments affected (1 vs. >1). Major adverse cardiac events (MACE) were defined as cardiac death, target lesion revascularization, and myocardial infarction. Results ISR treatment was performed using a simple approach in 44 (58%) patients, and using a complex strategy in 31 (42%). After 46 ± 26 months, the MACE rate was 22%. Patients treated with a simple approach had a lower incidence of MACE at follow-up compared with patients treated with a complex strategy, regardless of the restenosis extent (mild restenosis: 93% vs. 67%, p Conclusions PCI for UDLM-ISR is safe and feasible, with a high rate of procedural success and an acceptable long-term MACE rate. A simple strategy, when applicable, appears to be a good treatment option, associated with a lower event rate at follow-up.

Objectives To compare strut coverage patterns between everolimus-eluting stent (EES) and first-generation drug-eluting stents (DES) at more than 12 months after successful implantation, using optical coherence tomography (OCT). Background No sufficient OCT data has been reported comparing late strut coverage patterns between EES and first-generation DES. The favorable late results after EES implantation could be related to lower rates of uncovered and malapposed struts. Methods A total of 66 DES (21 EES, 23 SES, and 22 PES) that were implanted at least 1 year in advance in 40 patients and met good late angiographic results were evaluated by OCT. The percentage of uncovered and malapposed struts, calculated as the ratio of uncovered or malapposed struts to total struts in all cross-sectional images per stent, was compared among the three groups. Results A total of 35,061 struts were analyzed: 11,967 from EES, 11,855 from SES, and 11m239 from PES. The average tissue coverage thickness of the struts per stent was greater in EES than in SES and PES (109 ± 40 µm vs. 72 ± 27 µm and 83 ± 26 µm, respectively; P = 0.001). The percentage of uncovered struts (1.9 ± 4.1% in EES vs. 11.6 ± 12.7% in SES, P = 0.01 and vs. 7.1 ± 5.2% in PES, P

Resumen El avance en el intervencionismo en las cardiopatias congenitas ha sido tan importante en los ultimos 30 anos que permite hoy dia su sistematizacion. El objetivo de este articulo es el de intentar dicha sistematizacion. En esta primera parte abordaremos las obstrucciones al tracto de salida de ambos ventriculos. De entre las obstrucciones al tracto de salida de ventriculo izquierdo, la coartacion de aorta es la mas frecuente y el implante de stent para su reparacion constituye hoy dia el tratamiento de eleccion. En la estenosis supraaortica el tratamiento actual es quirurgico, pero en algunos casos particulares el tratamiento puede ser percutaneo mediante el implante de stent. La valvuloplastia percutanea para la estenosis aortica congenita tambien resulta una opcion terapeutica actual de valor. Igualmente, en casos seleccionados de estenosis subaortica de membrana la rotura de la membrana con balon resulta una opcion atractiva. Entre las obstrucciones al tracto de salida del ventriculo derecho, la estenosis valvular pulmonar puede ser tratada mediante valvuloplastia percutanea, siendo en la actualidad el tratamiento de eleccion. En los ultimos anos se ha introducido el implante de valvula pulmonar percutanea (Melody), aunque de momento su indicacion queda reservada a los homoinjertos degenerados. El implante de stents para las estenosis de ramas pulmonares tambien se ha consolidado como el tratamiento ideal para esta patologia congenita o posquirurgica.

Different studies have shown improvement in patients with idiopathic nonischemic dilated cardiomyopathy treated with cell-therapy. However, factors influencing responsiveness are not well known. This trial investigates functional changes and factors influencing the 6-month gain in ejection fraction in 27 patients with dilated cardiomiopathy treated with intracoronary cell-therapy.Patients received intracoronary infusion of autologous bone-marrow mononuclear cells (mean infused, 10.2 [2.9]×10(8)). Flow cytometry and functional analyses of the cells were also performed.The 6-month angiographic gain in ejection fraction ranged from -9% to 34% (mean, 9%). These changes were distinguished into 2 groups: 21 patients (78%) with a significant improvement at the 6-month evaluation (mean gain, 14 [7]%), and 6 patients who had no response (mean gain, -5 [3]%). The responders were younger as compared to the nonresponders (50 [12] years vs 62 [9] years; P.04). There was an inverse correlation (r=-0.41; P.003) between the gain in ejection fraction and the high density lipoprotein level, suggesting higher functional gain with low high density lipoprotein levels. The 24 h migratory capability of the infused cells was significantly reduced in the responders' group (5.4 [1.7]×10(8) vs 8.1 [2.3]×10(8); P.009 for vascular endothelial growth factor and 5.8 [1.7]×10(8) vs 8.4 [2.9]×10(8); P.002 for stromal cell-derived factor-1).Younger patients with dilated cardiomiopathy and lower plasma high density lipoprotein levels gain greater benefit from intracoronary cell-therapy. Functional improvement also seems to be enhanced by a lower migratory capacity of the infused cells.

Introduccion y objetivos Diferentes estudios han mostrado mejoria funcional en pacientes con miocardiopatia dilatada no isquemica tratada con terapia celular. Sin embargo, los factores que influyen en la respuesta no son bien conocidos. El presente estudio investiga los cambios funcionales y los factores que influyen en la mejora de la fraccion de eyeccion a los 6 meses en 27 pacientes con miocardiopatia dilatada tratados con terapia celular intracoronaria. Metodos Los pacientes recibieron una infusion intracoronaria de celulas mononucleares autologas de la medula osea (media de celulas infundidas, 10,2±2,9 × 108). En todos se efectuo analisis funcional y citometria de flujo de las celulas infundidas. Resultados La ganancia en fraccion de eyeccion observada a los 6 meses oscilo entre el ?9 y el 34% (media, 9%). Estos cambios formaron dos grupos de pacientes: 21 (78%) que mostraron una mejora significativa (ganancia media, 14±7%), frente a 6 (22%) que no mostraron respuesta (ganancia media, ?5±3%). Los respondedores eran mas jovenes (50±12 frente a 62±9 anos; p

The presence of a bifurcation (BL) in the context of a coronary chronic total occlusion (CTO) represents an additional difficulty. This study analyzes the incidence of BLs in CTO recanalization, the treatment, predictors of bifurcation technical success and their clinical impact.BLs with a side branch (SB) ≥2.0mm located proximally, distally or within the occluded segment were observed in 130 (33%) of 391 CTO. Provisional stenting was the strategy more frequently used (94%). Bifurcation success (stenosis30% in main vessel and TIMI flow III in both branches) was achieved in 105 patients (81%). In the remaining 25 (19%), the TIMI flow at the SB wasIII. Predictors of bifurcation success were baseline SB wiring (OR 0.01, 95% CI: 0.001-0.09; p0.01), the absence of dissection across the bifurcation (OR 0.10, 95% CI: 0.02-0.49; p0.01) and non-true BLs (OR 0.16, 95% CI: 0.04-0.68; p0.05). Regarding in-hospital results, patients with final TIMI flowIII at the SB had a higher incidence of periprocedural MI (32% vs 4.8%; p0.01). Subsequently, the rate of MI was higher in patients with CTO-BLs than in those without BLs. At follow-up, there were no differences in the event rate between CTO-BLs and non CTO-BLs (7.7% vs 9.5%, p=ns) CONCLUSIONS: BLs in CTO is a frequent finding and could be approached as regular bifurcations. The primary success was low and this was associated with a higher incidence of periprocedural MI. Baseline SB wiring was a powerful predictor of technical success.

New-onset conduction disturbances are common after transcatheter aortic valve implantation (TAVI). The most common complication is left bundle branch block (LBBB). The clinical impact of new-onset LBBB after TAVI remains controversial. The aim of this study was to analyze the clinical impact of new-onset LBBB in terms of mortality and morbidity (need for pacemakers and admissions for heart failure) at long-term follow-up. From April 2008 to December 2014, 220 patients who had severe aortic stenosis were treated with the implantation of a CoreValve prosthesis. Sixty-seven of these patients were excluded from the analysis, including 22 patients with pre-existing LBBB and 45 with a permanent pacemaker, implanted previously or within 72 hours of implantation. The remaining 153 patients were divided into 2 groups: group 1 (n = 80), those with persistent new-onset LBBB, and group 2 (n = 73), those without conduction disturbances after treatment. Both groups were followed up at 1 month, 6 months, 12 months, and yearly thereafter. Persistent new-onset LBBB occurred in 80 patients (36%) immediately after TAVI; 73 patients (33%) did not develop conduction disturbances. The mean follow-up time of both groups was 32 ± 22 months (range 3 to 82 months), and there were no differences in time between the groups. There were no differences in mortality between the groups (39% vs 48%, p = 0.58). No differences were observed between the groups in re-hospitalizations for heart failure (11% vs 16%, p = 0.55). Group 1 did not require pacemaker implantation more often at follow-up (10% vs 13%, p = 0.38) than group 2. In conclusion, new-onset LBBB was not associated with a higher incidence of late need for a permanent pacemaker after CoreValve implantation. In addition, it was not associated with a higher risk of late mortality or re-hospitalization.

Left-sided native valve infective endocarditis (LNVIE) epidemiology has been modified as a result of the increase in average age. The aim of our study is to analyze the influence of age and the presence of predisposing heart disease in the prognosis of these patients.We analyzed a series of 257 cases of LNVIE depending on their age (greater than or equal to 70 years old), both in the overall series and in the subgroup of patients without predisposing heart disease.Mean age was 54.6 (18.6) years. There was an increase in the percentage of cases of older patients between 1987-2000 and 2001-2014 (9.8 vs. 34.8%, P.001). These patients present higher prevalence of degenerative valves (50 vs. 22.8%) or not predisposing heart disease (50 vs. 39.9%), P.001, health-care associated episodes (41.8 vs. 23.6%, P=.016), lower rate of surgery (43.7 vs. 63.8%, P=.005) and higher in-hospital mortality (39.1 vs. 20.7%, P=.003), with no differences in comorbidities. Older patients who did not have predisposing heart disease also suffered higher in-hospital mortality (47 vs. 22%, P=.01). Age greater than or equal to 70 years old is an independent predictor of mortality in patients with LNVIE (OR 2.53, 95% CI 1.24-5.15, P=.011), as in those without previous heart disease (OR 3.98, 95% CI 1.49-10.62, P=.006).Patients of age greater than or equal to 70 years old and who suffer an LNVIE are becoming more frequent and have a worse prognosis with a lower rate of surgery and higher rates of in-hospital mortality.

The behaviour of side branches (SBs) covered by a bioresorbable vascular scaffold (BVS) is not well known. This study analysed the rate of side branch occlusion (SBO) immediately after BVS implantation, its clinical impact, predictors of SBO and the fate of such SBs at follow-up.We assessed 140 patients with 346 jeopardised SBs divided into three groups: small (1 mm, n=181), intermediate (1-2 mm, n=102) and large (2 mm, n=63). SBO was defined as a TIMI flow 0 or 1. Computed tomography was scheduled at six months for patients with jailed SBs1 mm. Immediate occlusion occurred in 31 (9%) SBs: 22 (12%) small, 8 (8%) intermediate and one (1.6%) large, while post-procedural SBO was 5.5%. In-hospital events included one thrombosis (0.7%) and eight non-Q-wave myocardial infarctions (6%). After 17±3 months, one patient died (0.7%) and six patients needed repeat revascularisation (4%). Re-evaluation showed no late SBO at 7±3 months. Predictors of SBO were: small SBs (OR 2.06, 95% CI: 1.08-4.63; p0.05) and stenosis50% at the origin (OR 17.22, 95% CI: 7.79-38.10; p0.01).The incidence of SBO and its clinical impact were low when SBs1 mm were covered. These favourable results were maintained at midterm.

Background: To assess changes in myocardial deformation and ejection fraction (EF) by two-dimensional speckle tracking echocardiography (2DSTE) after transcatheter aortic valve implantation (TAVI). Methods: A total of 24 patients (50% males, age 78 ± 4 years) were selected for TAVI because of severe aortic stenosis. A comprehensive echocardiographic study was performed before TAVI, at discharge, and after 1-month follow-up. EF was assessed by 2D conventional echocardiography with Simpson method and by 2DSTE. Radial and circumferential strains were evaluated in six segments in the short-axis view at the level of the papillary muscles, and longitudinal strain in six segments in the four-chamber apical view, by means of 2DSTE. All studies were performed with an iE-33 echocardiography device (Philips). Results: At discharge, the mean EF estimated by 2DSTE improved significantly when compared with the basal one (56 ± 7% vs. 51 ± 8%, P