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INTRODUCTION AND OBJECTIVES Many patients with nonvalvular atrial fibrillation are still left without protection due to a contraindication for anticoagulants. This study aimed to establish the occurrence of stroke and major bleeding events in patients with nonvalvular atrial fibrillation and left atrial appendage closure with long-term follow-up and to explore the factors associated with higher long-term mortality. METHODS Analysis of a multicenter single cohort prospectively recruited from 2009 to 2015. Thromboembolic and bleeding events were compared with those expected from CHA2DS2-VASc and HAS-BLED scores. Multivariate analysis examined variables associated with mortality during follow-up. RESULTS A total of 598 patients (1093 patient-years) with a contraindication for anticoagulants were recruited (median 75.4 years). The success rate of left atrial appendage closure device implantation was 95.8%. Thirty patients (5%) experienced periprocedural complications. The rate of events (per 100 patient-years) during follow-up (mean 22.9 months; median 16.1 months) was as follows: death 7.0%; ischemic stroke 1.6% (vs 8.5% expected according to CHA2DS2-VASc; P 24 months (mean follow-up 46.6 months, 683 patient-years) for severe bleeding 2.6% (vs 6.3% expected by HAS-BLED, P < .033). The factors significantly associated with higher mortality were age (HR, 1.1), intracranial hemorrhage (HR, 6.8), and stroke during follow-up (HR, 2.7). CONCLUSIONS Left atrial appendage closure significantly reduced the incidence of stroke and bleeding events and the benefit was maintained. Intracranial hemorrhage, age and stroke were associated with higher mortality.

Resumen Introduccion y objetivos Muchos pacientes con fibrilacion auricular no valvular tienen contraindicados los anticoagulantes orales. El objetivo es estimar la incidencia de eventos tromboembolicos y hemorragicos en pacientes con fibrilacion auricular no valvular y cierre de la orejuela izquierda con seguimiento a largo plazo, y determinar los factores asociados con mayor mortalidad a largo plazo. Metodos Cohorte prospectiva de pacientes reclutados desde 2009 a 2015. Se compararon los eventos tromboembolicos y hemorragicos con los esperados segun las escalas CHA2DS2-VASc y HAS-BLED. Se realizo un analisis multivariable para determinar las variables asociadas con la mortalidad. Resultados Se recluto a 598 pacientes (1.093 pacientes-ano) con contraindicacion de anticoagulantes (mediana de edad, 75,4 anos). La tasa de exito del cierre de la orejuela izquierda fue del 95,8%; 30 pacientes (5%) presentaron complicaciones. Las tasas de eventos (cada 100 pacientes-ano) durante el seguimiento (media, 22,9 meses; mediana, 16,1 meses) fueron: muerte, 7,0%; ictus isquemico, 1,6% (frente al 8,5% esperado segun CHA2DS2-VASc; p 24 meses (media, 46,6 meses; 683 pacientes-ano) para las hemorragias graves, el 2,6% (frente al 6,3% esperado por HAS-BLED; p Conclusiones El cierre de la orejuela izquierda redujo significativamente las incidencias de ictus y de eventos hemorragicos graves y el beneficio se mantuvo. La edad, las hemorragias intracraneales y el ictus se asociaron con mayor mortalidad.

Iodinated contrast media (CM) are the leading cause of acute renal failure of toxic origin. Between 21% and 50% of patients that receive them develop contrast-induced nephropathy (CIN). All prophylactic measures used so far have failed to provide effective prevention. Since oxidative stress is involved in the damage, a possible preventive strategy could be the administration of antioxidant substances, such as quercetin. This compound has shown renoprotective effects in experimental studies. The aim of this study was to evaluate whether quercetin may be helpful in preventing CIN in patients undergoing coronary catheterization. A clinical phase II study was conducted. Patients were distributed in two groups, namely, CM (patients who only received contrast media) and CM+Q (patients who were pretreated with quercetin orally for 3&ndash, 5 days). Results showed less incidence of CIN in the CM+Q group, possibly due to glomerular protection, evidenced by a lower increase in serum creatinine and albuminuria, and a lower decrease in the glomerular filtration rate (GFR). Furthermore, in this group, the relative risk of developing CIN observed in patients that received a high dose of contrast media was inferior. In conclusion, this is the first study that demonstrates that quercetin is a promising safe candidate in preventing CIN.

Paravalvular leak (PVL) is an uncommon yet serious complication associated with the implantation of mechanical or bioprosthetic surgical valves and more recently recognized with transcatheter aortic valves implantation (TAVI). A significant number of patients will present with symptoms of congestive heart failure or haemolytic anaemia due to PVL and need further surgical or percutaneous treatment. Until recently, surgery has been the only available therapy for the treatment of clinically significant PVLs despite the significant morbidity and mortality associated with re-operation. Percutaneous treatment of PVLs has emerged as a safe and less invasive alternative, with low complication rates and high technical and clinical success rates. However, it is a complex procedure, which needs to be performed by an experienced team of interventional cardiologists and echocardiographers. This review discusses the current understanding of PVLs, including the utility of imaging techniques in PVL diagnosis and treatment, and the principles, outcomes and complications of transcatheter therapy of PVLs.

Objectives The aims of this registry were to determine the incidence, predictors, and prognostic value of periprocedural acute kidney injury (AKI) after left atrial appendage closure (LAAC). Background No data exist on the occurrence of AKI after LAAC. Methods A total of 355 patients undergoing LAAC were included in the study. AKI was defined as an absolute or a relative increase in serum creatinine of >0.3 mg/dl or ≥50%, respectively, after the procedure or the need for hemodialysis during index hospitalization. Results The incidence of AKI was 9%, and patients with worse baseline renal function were at higher risk for developing AKI (odds ratio: 1.32; 95% confidence interval [CI]: 1.09 to 1.61; p = 0.004 for each 10 ml/min decrease in glomerular filtration rate). In-hospital bleeding events occurred more frequently in the AKI group (5.3% vs. 15.6%; p = 0.037). After a median follow-up period of 18 months, patients in the AKI group had higher mortality (hazard ratio [HR]: 2.59; 95% CI: 1.36 to 4.92; p = 0.004), more embolic events (HR: 6.14; 95% CI: 2.23 to 16.92; p = 0.001) and major bleeding events (HR: 2.36; 95% CI: 0.89 to 6.24; p = 0.083). The occurrence of AKI was an independent predictor of midterm mortality (HR: 2.00; 95% CI: 1.02 to 3.91; p = 0.044). Conclusions The occurrence of AKI was relatively frequent following LAAC, and patients with lower renal glomerular filtration rates were at high risk for developing this complication. AKI identified a group of patients with worse midterm outcomes, highlighting the importance of further preventive strategies in this population.

Resumen Introduccion y objetivos El cierre percutaneo de las fugas periprotesicas presenta tasas de exito variables, la falta de dispositivos especificamente disenados para este procedimiento ha limitado sus resultados. El Amplatzer Vascular Plug III , por sus caracteristicas, parece un dispositivo ideal para este procedimiento, pero los datos disponibles se limitan a casos aislados o pequenas series. El proposito de este estudio es analizar la factibilidad y la eficacia del cierre percutaneo de fugas periprotesicas con este dispositivo. Metodos Se analizan resultados de seguridad y eficacia durante el procedimiento y a 90 dias de las fugas periprotesicas mitrales y aorticas cerradas percutaneamente con este dispositivo en nuestro centro. Resultados Se trataron 34 fugas periprotesicas, 7 a nivel aortico y 27 a nivel mitral, correspondientes a 33 pacientes. El exito tecnico fue del 93,9% (en 2 pacientes se realizo un segundo procedimiento programado) y el exito del procedimiento (reduccion ≥ 1 grado de regurgitacion) en el 90,9%. En 4 pacientes se observaron complicaciones relacionadas con el procedimiento (transfusion en 3 pacientes y cirugia por interferencia con los discos en 1 paciente). No se observo ningun caso de muerte, infarto de miocardio o accidente cerebrovascular periprocedimiento. A 90 dias la supervivencia fue del 100%, y en el 90,3% de los pacientes mejoro la clase funcional; 4 pacientes sufrieron complicaciones vasculares (seudoaneurisma) en el seguimiento. Conclusiones El cierre percutaneo de la fugas periprotesicas con el Amplatzer Vascular Plug III es un procedimiento factible, seguro y con elevadas tasas de exito clinico y ecocardiografico.

Objectives The aim of this study was to compare the acute performance of the PLLA ABSORB bioresorbable vascular scaffold (BVS) (Abbott Vascular, Santa Clara, California) with second-generation metal drug-eluting stents (DES) in complex coronary artery lesions. Background Thick polymer-based BVS have different mechanical properties than thin second-generation DES. Data on the acute performance of BVS are limited to simple coronary lesions treated in trials with strict inclusion criteria. Methods Fifty complex coronary lesions (all type American College of Cardiology/American Heart Association B2-C) treated with a BVS undergoing a final optical coherence tomography (OCT) examination were compared with an equal number of matched lesions treated with second-generation DES. The following stent performance indexes were assessed with OCT: mean and minimal area, residual area stenosis (RAS), incomplete strut apposition (ISA), tissue prolapse, eccentricity index, symmetry index, strut fracture, and edge dissection. Results One hundred lesions from 73 patients were analyzed. A higher balloon diameter/reference vessel diameter ratio was used for predilation in the BVS group (p Conclusions Based on OCT, the BVS showed similar post-procedure area stenosis, minimal lumen area, and eccentricity index as second-generation DES. The different approach for lesion preparation and routine use of OCT guidance during BVS expansion may have contributed to these results.

Aims: Characterization of neointimal tissue is essential to understand the pathophysiology of in-stent restenosis (ISR) after drug eluting stent (DES) implantation. Using optical coherence tomography (OCT), we compared the morphologic characteristics of ISR between first and second generation DES. Methods and Results: OCT was performed in 66 DES-ISR, defined as >. 50% angiographic diameter stenosis within the stented segment. Patients with ISR of first generation sirolimus-eluting stents (SES), paclitaxel eluting stents (PES) and second generation zotarolimus-eluting stents (ZES), everolimus-eluting stents (EES) and biolimus-eluting stents (BES) were enrolled. Quantitative and qualitative ISR tissue analysis was performed at 1-mm intervals along the entire stent, and categorised as homogeneous, heterogeneous and neo-atherosclerosis. The presence of microvessels and peri-strut low intensity area (PSLIA) was determined in all ISR. Neoatherosclerosis was identified by lipid, calcium and thin-cap fibro-atheroma (TCFA) like lesions. We compared the two DES generations at both early (. 1. year) follow-ups.In second generation DES a heterogeneous pattern was prevalent both before and after 1. year (57.1% and 58.6% respectively). Neo-atherosclerosis was more common in the early period in first generation DES (19.4% vs 11.7%, p.

The elderly is a sub-group of patients with an increased risk of bleeding events. We explored whether age affects the risk of gastrointestinal (GI) and major bleeding in non-valvular atrial fibrillation patients undergoing left atrial appendage closure (LAAC). The II Iberian Registry compared two

Optical coherence tomography (OCT) is a light based technology that provides very high spatial resolution images. OCT has been initially employed as a research tool to investigate plaque morphology and stent strut coverage. The introduction of frequency domain OCT, allowing fast image acquisition during a prolonged contrast injection via the guiding catheter, has made OCT applicable for guidance of coronary interventions. In this manuscript the various applications of OCT are reviewed, from assessment of plaque vulnerability and severity to characteristics of unstable lesions and thrombus burden to stent optimization and evaluation of late results.

Paravalvular leak (PVL) is a serious complication after surgical valve replacement or after transcatheter aortic valve replacement. Approximately 1–5% of PVLs can lead to serious clinical consequences, including congestive heart failure and/or haemolytic anaemia. For years, surgical re-intervention has been considered the treatment of choice for symptomatic patients with PVLs. However, surgical re-intervention is associated with a high risk of morbidity and mortality. Transcatheter PVL (TPVL) closure is a less invasive alternative to surgical re-intervention. The safety and feasibility of TPVL closure has been confirmed in several registries and a meta-analysis. In this review, we discuss the clinical implications and diagnosis of PVLs, technical considerations for TPVL, execution of the procedure and assessment of the results.

Background Mitral paravalvular leak (PVL) is a potential complication of surgical valve replacement procedures. Real-time 3D transesophageal echocardiography (RT-3DTEE) has emerged as an efficient tool for providing essential information about the anatomy of mitral PVLs compared with 2DTEE findings. The purpose of this study was to evaluate the utility of RT-3DTEE in the assessment of mitral PVLs. Methods and results The 3D characteristics of PVLs were recorded and compared with 2D findings. We included 34 consecutive patients with clinical suspicion of mitral PVL in the study. Mitral PVLs were detected in 26 patients (76%); 26 PVLs were identified by 2DTEE and 37 by RT-3DTEE. Moderate or severe mitral regurgitation was present in 23 patients (88%). The most common PVL locations were the septal and posterior regions. The median PVL size measured by RT-3DTEE was 7 mm long×4 mm wide. The median vena contracta of defect measured by 2DTEE and RT-3DTEE was 5 mm and 4 mm, respectively. The median effective regurgitant orifice area of defect measured by RT-3DTEE was 0.36 cm(2). The defect types were "oval" (54%), "round" (35%), "crescentic" (8%) and highly irregular (3%). Conclusions Compared with 2DTEE, RT-3DTEE provided detailed descriptions of the number, location, size and morphology of PVLs, which is essential for planning and guiding the potential corrective techniques. (Circ J 2016; 80: 738-744).

Many patients with non-valvular atrial fibrillation (NVAF) are still left without protection due to a contraindication for anticoagulants (OACs). Although closure of left atrial appendage (LAA) can reduce the thromboembolic/bleeding events and mortality in these patients, a better understanding of

Pulmonary vein (PV) stenosis (PVS) is a known complication of PV isolation procedures for AF (atrial fibrillation). PV angioplasty and stenting have been used as an effective therapy for PVS, yet high rates of restenosis are common. Experience with intravascular ultrasound (IVUS) in evaluating the PVS morphological characteristics and appropriate stent deployment is very limited. Furthermore, the use of IVUS could minimise the risk of restenosis. We describe the case of a patient with sub-occlusion of the left superior PV and total occlusion of the left inferior PV following catheter ablation for AF treated by stenting with IVUS guidance.

A 66-year-old woman with a history of atrial fibrillation and previous mitral valve replacement (MVR) underwent new MVR because of dysfunction. After surgery, she was admitted because of recurrent cardioembolic strokes despite optimal treatment with warfarin. Aspirin was added, but the patient had a

The most common etiology of tricuspid stenosis is rheumatic, and in most cases it is associated with valvular regurgitation. Interestingly, there have been reports of tricuspid stenosis without associated valvular regurgitation, mostly related to pacemaker leads. Percutaneous tricuspid valvuloplasty may be a therapeutic alternative to surgery in cases of pure tricuspid stenosis without other concomitant valvulopathies. We report the case of a 52-year-old woman with pacemaker lead-related tricuspid stenosis successfully treated with percutaneous valvuloplasty guided by 3D echocardiography. Resumo: A causa mais comum da estenose tricúspide é reumática, e na maioria dos casos está associada com insuficiência valvular. Curiosamente, tem havido relatos de estenose tricúspide sem insuficiência associada, sendo a maioria associados com electrocateteres de pacemaker. A plastia da valva tricúspide pode ser uma alternativa em casos de estenose valvular tricúspide pura, sem outras valvulopatias concomitantes. Relatamos o caso de uma mulher de 52 anos com estenose tricúspide associada a electrocateter de pacemaker tratada com sucesso com valvuloplastia percutânea guiada por ecocardiografia 3D. Keywords: Tricuspid stenosis, Pacemaker, Balloon valvuloplasty, 3D echocardiography, Palavras-chave: Estenose tricúspide, Pacemaker, Valvuloplastia com balão, Ecocardiografia 3D

We present the case of a 73-year-old woman scheduled for renal angiography for severe recurrent refractory arterial hypertension 2 months after sympathetic renal denervation with the EnligHTN multielectrode catheter system (St Jude Medical, Saint Paul, Minnesota). The angiogram confirmed right

A 73-year-old man with permanent atrial fibrillation, coronary artery disease revascularized with coronary artery bypass grafting, mitral valve repair with a 30-mm Carpentier Physio ring (Edwards Lifesciences, Irvine, California), tricuspid valve repair with a 34-mm Edwards MC3 ring (Edwards

Introduction and objectives Percutaneous paravalvular leak closure is a complex procedure with varying success rates; the lack of closure devices specifically designed for this purpose has hampered this technique. The characteristics of the Amplatzer Vascular Plug III appear to be well suited for paravalvular leak closures; however, the available data are limited to case reports or small series of patients. The aim of this study was to analyze the feasibility and efficacy of paravalvular leak with this device. Methods The immediate and 90-day safety and efficacy of mitral and aortic paravalvular leak closures performed with this device at our hospital were analyzed. Results Percutaneous repair of 34 paravalvular leaks (27 mitral, 7 aortic) was attempted in 33 patients. The device was successfully implanted in 93.9% (in 2 patients, a second planned procedure was needed), and successful closure (defined as regurgitation reduction ≥ 1 grade) was achieved in 90.9% of patients. Complications included emergency surgery due to disc interference (n = 1) and blood transfusion (n = 3). There were no reports of procedure-related death, myocardial infarction, or stroke. At 90 days, survival was 100%, and 90.3% of patients showed significant clinical improvement; 4 patients developed vascular complications (pseudoaneurysm). Conclusions Mitral and aortic paravalvular leak closure with the Amplatzer Vascular Plug III is feasible and safe, with high clinical and echocardiographic success rates.

Fully bioresorbable vascular scaffolds (BVS) are a new approach to the percutaneous treatment of coronary artery disease. The BVS have not yet been fully tested in complex lesions, including chronic total occlusion (CTO). We report a CTO case successfully treated with a second-generation bioabsorbable drug-eluting scaffold.

Mechanical aortic valve prostheses are considered a limiting factor when contemplating percutaneous closure of mitral paravalvular leaks using a retrograde approach. However, transfemoral artery access and a retrograde approach have advantages over a trans-septal anterograde approach when the paravalvular defect is large with a significant gradient or when the defect is medial to the mitral valve. We describe a novel technique of mitral paravalvular leak closure in the presence of a mechanical aortic valve prosthesis, which we performed successfully in 3 patients. The technique uses a retrograde approach and arteriovenous wire loop.