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Introduction and objectives Despite evidence of a reduction in the incidence and mortality of acute coronary syndrome (ACS), some studies have highlighted differences in outcomes between men and women. We aimed to explore sex differences in the management and treatment of patients with ACS in Spain. Methods This ecological cross-sectional study combined ACS data from 10 Spanish registries (54 centres). Meta-regression analysis was performed using aggregated data of baseline characteristics, interventional procedures, treatments, and events that occurred during hospitalization and one-year follow-up. Results Aggregated data from 34 605 patients (75.1% men) was included. ST-segment elevation myocardial infarction was the most frequent diagnosis (58.9%) and almost 80% of patients were Killip Class I. Compared to men, women were older (mean age: 71.0 vs 63.3 years) and presented higher rates of hypertension (68.1% vs 51.7%) and diabetes (37.7% vs 26.5%). Women were also less likely to undergo percutaneous coronary interventions, revascularization surgery, and to receive drug-eluting stents during hospitalization. Regarding to antiplatelet therapy, even though indicated, 23.1% of women were not treated with P2Y12 inhibitors (vs 14.2% of men; P 60%). Significantly higher in-hospital (5.4% vs 3.7%) and 1-year (8.2% vs 4.9%) mortality was observed among women compared to men, which was mainly attributed to cardiovascular causes. Conclusions Despite older age and unfavourable risk profile, female ACS patients seem to be suboptimally treated with P2Y12 inhibitors. To reduce mortality associated with ACS, improved prevention and optimized therapeutic approaches are needed.

Resumen Introduccion La endocarditis infecciosa (EI) sobre transcatheter aortic valve implantation (TAVI) es una complicacion emergente. Existen datos incompletos y dispares sobre su incidencia. Se aporta la experiencia en nuestro centro sobre incidencia, mortalidad y factores asociados de la EI post-TAVI y se compara con datos de la literatura. Metodos Estudio retrospectivo observacional de los casos de EI diagnosticados en pacientes que habian recibido TAVI, entre el 1 de junio de 2009 y el 1 de noviembre de 2017, en un centro universitario tras una mediana de seguimiento de 15,3 meses (rango intercuartil [RIC] 9,1-36,2). Se analizaron la incidencia, los datos clinicos, microbiologicos y pronosticos, y los factores asociados a EI post-TAVI. Resultados Se detectaron 11 pacientes con EI de 200 TAVI. Incidencia global: 5,5% (2,77 casos por 100 anos-paciente). La mediana de tiempo hasta la EI post-TAVI fue de 112 dias (RIC 36-578), la tasa de mortalidad intrahospitalaria fue del 36,4% y la mortalidad al ano, del 54,5%. Todos los microorganismos identificados fueron grampositivos (4 Enterococcus faecalis, 3 Staphylococcus coagulasa negativo). Los pacientes con EI post-TAVI eran significativamente mas jovenes (mediana 78, RIC 73-80, frente a 82, RIC 79-84, p = 0,002), tenian un EuroSCORE mayor (5,1 ± 2,4 frente a 3,2 ± 1,2, p Conclusiones En nuestro medio, la incidencia de EI post-TAVI es mayor que la descrita en series multicentricas, lo que concuerda con la tendencia publicada en la literatura. Conlleva una elevada mortalidad y se asocia con una peor situacion clinica basal.

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.

Background: Both balloon-expandable (BE) and self-expandable (SE) valves for transcatheter aortic valve implantation (TAVI) are broadly used in clinical practice. However, adequately powered randomized controlled trials comparing these two valve designs are lacking. Methods: The CENTER-study included 12,381 patients undergoing transfemoral TAVI. Patients undergoing TAVI with a BE-valve (n = 4096) were compared to patients undergoing TAVI with an SE-valve (n = 4096) after propensity score matching. Clinical outcomes including one-year mortality and stroke rates were assessed. Results: In the matched population of n = 5410 patients, the mean age was 81 ± 3 years, 60% was female, and the STS-PROM predicted 30-day mortality was 6.2% (IQR 4.0–12.4). One-year mortality was not different between patients treated with BE- or SE-valves (BE: 16.4% vs. SE: 17.0%, Relative Risk 1.04, 95%CI 0.02–1.21, p = 0.57). One-year stroke rates were also comparable (BE: 4.9% vs. SE: 5.3%, RR 1.09, 95%CI 0.86–1.37, p = 0.48). Conclusion: This study suggests that one-year mortality and stroke rates were comparable in patients with severe aortic valve stenosis undergoing TAVI with either BE or SE-valves.

An 85-year-old patient with permanent atrial fibrillation with a DDD pacemaker, and with indication for left atrial appendage occlusion (LAAO). Sent for LAAO due to recurrent gastrointestinal bleedings even on apixaban and with a CHA 2 DS 2 VASc and HAS-BLED scores of 4 and 3 respectively.

Objectives To compare the safety and efficacy of the new cobalt-chromium bioactive stent Titan Optimax® (Hexacath, France) with its predecessor, Titan-2®. Background The TIOMAX registry includes 784 patients who underwent percutaneous coronary intervention with these stents in 21 Spanish hospitals. Methods Analysis of all patients in the registry without exclusion criteria, candidates for revascularization (March-2013/July-2014). Initially 273 patients received Titan-2®, and the next 511 received the Optimax® after its launch. Results Mean age was 65.8 ± 13.0 (78.1% men); 49.2% were STEACS patients (n = 322), 29.8% NSTEACS, and 27.3% had stable angina or silent ischemia. Most STEACS patients (76.4% of n = 322) were treated

An 81-year-old man was referred for left atrial appendage (LAA) closure because of nonvalvular atrial fibrillation and recurrent gastrointestinal bleeds with 2 direct oral anticoagulants. He had a CHA2DS2-VASc score of 4 and a HAS-BLED score of 3. A 25-mm Amplatzer Amulet device (St. Jude Medical

Background Fractional flow reverse (FFR) is the gold standard assessment of the hemodynamic significance of coronary stenoses. However, it requires the catheterization of the coronary artery to determine the pressure waveforms proximal and distal to the stenosis. On the contrary, computational fluid dynamics enables the calculation of the FFR value from relatively non-invasive computed tomography angiography (CTA). Methods We analyze the flow across idealized highly-eccentric coronary stenoses by solving the Navier–Stokes equations. We examine the influence of several aspects (approximations) of the simulation method on the calculation of the FFR value. We study the effects on the FFR value of errors made in the segmentation of clinical images. For this purpose, we compare the FFR value for the nominal geometry with that calculated for other shapes that slightly deviate from that geometry. This analysis is conducted for a range of stenosis severities and different inlet velocity and pressure waveforms. Results and conclusions The errors made in assuming a uniform velocity profile in front of the stenosis, as well as those due to the Newtonian and laminar approximations, are negligible for stenosis severities leading to FFR values around the threshold 0.8. The limited resolution of the stenosis geometry reconstruction is the major source of error when predicting the FFR value. Both systematic errors in the contour detection of just 1-pixel size in the CTA images and a low-quality representation of the stenosis surface (coarse faceted geometry) may yield wrong outcomes of the FFR assessment for an important set of eccentric stenoses. On the contrary, the spatial resolution of images acquired with optical coherence tomography may be sufficient to ensure accurate predictions for the FFR value.

AIMS: The aim of this study was to observe the percentage of thromboembolic and haemorrhagic events over a 2-year follow-up in patients with non-valvular atrial fibrillation (NVAF) undergoing closure of the left atrial appendage (LAA) with an occlusion device. Observed events and CHADS2 (congestive heart failure, hypertension, age, diabetes, stroke history), CHA2DS2-VASc (also adding: vascular disease and sex) and HAS-BLED (hypertension, abnormal liver/renal function, stroke history, bleeding predisposition, labile international normalised ratios, elderly, drugs/alcohol use)-predicted events were compared. METHODS: LAA closure with an occlusion device was performed in 167 NVAF patients contraindicated for oral anticoagulants and recruited from 12 hospitals between 2009 and 2013. At least two transoesophageal echocardiograms were performed in the first 6 months postimplantation. Antithrombotics included clopidogrel and aspirin. Patients were monitored for death, stroke, major and relevant bleeding and hospitalisation for concomitant conditions. Mean age was 74.68±8.58, median follow-up was 24 months, 5.38% had intraoperative complications and implantation was successful in 94.6% of subjects. Mortality during follow-up was 10.8%, mostly (9.5%) non-cardiac related. Bleeding occurred in 10.1% of subjects, 5.7% major and 4.4% minor though relevant, and 4.4% suffered stroke. Major bleeding and stroke/transient ischaemic attack events within 2 years (annual event rates, 290 patients/year) were less frequent than expected from CHADS2 (2.4% vs 9.6%), CHA2DS2-VASc (2.4% vs 8.3%) and HAS-BLED (3.1% vs 6.6%) risk scores (p

Resumen Fundamentos y objetivo El sindrome de Tako-tsubo (SmT) es una miocardiopatia aguda reversible que simula un infarto. Analizamos los 60 pacientes ingresados con SmT en nuestro centro. Pacientes y metodo El 73,3% eran mujeres (edad media [DE] de 70,6 [8,11] anos). El 83,3% tenia algun factor de riesgo cardiovascular, el 25% tenia trastorno ansiosodepresivo y en el 58,3% se identifico algun desencadenante, siendo el estres emocional el mas frecuente. El 15,3% mostro bloqueo completo de rama izquierda (BCRI). En el 23,3% las alteraciones de la contractilidad respetaban el apex (formas medioventriculares o diafragmaticas). Resultados La arteria descendente anterior mostro lesiones no significativas en el 35% de los pacientes, y en el 68,3% tenia trayecto diafragmatico. El 40% desarrollo insuficiencia cardiaca (ICC) y el 18,3% shock cardiogenico (SC). La mortalidad hospitalaria global fue del 3,3%, siendo del 8,3% entre aquellos que desarrollaron ICC. La incidencia de SC fue mayor entre los pacientes con BCRI (44,4 frente a 13,7%; p = 0,05) y los varones (43,8 frente a 9,1%; p = 0,005). Conclusiones Aunque la mortalidad hospitalaria del SmT es baja, un porcentaje importante de pacientes desarrollan ICC, siendo la mortalidad de este subgrupo elevada. Los pacientes varones y aquellos con BCRI presentaron mayor morbilidad hospitalaria.

Introduccion y objetivos Hasta un 25% de los pacientes sometidos a intervencionismo coronario percutaneo presentan alguna limitacion para la utilizacion de los stents farmacoactivos. Nuestro objetivo es evaluar si el stent bioactivo de titanio y oxido nitrico podia ser una buena alternativa al stent de everolimus para pacientes diabeticos. Metodos Se aleatorizo a 173 pacientes diabeticos con lesiones de riesgo de reestenosis intermedio (criterios de exclusion: diametro 28 mm en vasos < 3 mm, oclusion cronica): 83 pacientes en el grupo con titanio y 90 en el grupo con everolimus. Resultados Las variables basales estaban bien equilibradas, el 28,3% eran insulinodependientes. Al ano, las incidencias de eventos adversos cardiacos mayores (muerte, infarto de miocardio no fatal, ictus o nueva revascularizacion del vaso tratado) eran significativamente mas frecuente en el grupo con titanio que en el grupo con everolimus (total, el 14,5 frente al 4,4%; p = 0,02; subgrupo no insulinodependiente, el 9,7 frente al 3,2%; p = 0,14; insulinodependiente, el 28,6 frente al 7,1%; p = 0,04) y de muerte, infarto de miocardio no fatal, ictus o cualquier revascularizacion, del 16,9% en el grupo con titanio y el 7,8% en el grupo con everolimus (p = 0,06). La revascularizacion de la lesion diana se produjo en el 8,4 frente al 3,3% (p = 0,15), y la del vaso tratado, el 13,3 frente al 3,3% (p = 0,01). El seguimiento angiografico a 9 meses mostro una perdida luminal tardia significativamente menor en el grupo con everolimus (en el segmento, 0,52 ± 0,58 frente a �0,05 ± 0,32 mm; en el stent, 0,76 ± 0,54 frente a 0,13 ± 0,31 mm; p < 0,0001). Conclusiones El stent de everolimus fue superior al titanio en pacientes diabeticos incluso con lesiones de riesgo de eventos clinicos y angiograficos intermedio.

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

Resumen Introduccion y objetivos El cierre del apendice auricular izquierdo puede ser una opcion terapeutica atractiva para pacientes con fibrilacion auricular no valvular y contraindicacion para tomar anticoagulantes orales, siempre que se obtengan buenos resultados durante la implantacion y en el seguimiento. Metodos Se analizo a 35 pacientes consecutivos y no elegibles para los estudios aleatorizados con anticoagulantes orales a los que se implanto el dispositivo oclusor Amplatzer. Tras los primeros 5 casos, se incorporo una tecnica de imagen 3D. Se analizaron los resultados de la implantacion y de seguimiento durante 1 ano. Resultados La media de edad era 74,65 ± 7,61 anos, con un CHADS2 de 2,41 ± 1,53 y un CHA2DS2-VASc de 3,17 ± 1,60. No se pudo implantar el dispositivo en 1 caso y en 5 fue necesario cambiar la medida seleccionada. No hubo ninguna complicacion cardiaca durante la implantacion ni durante la estancia hospitalaria. Hubo una complicacion vascular (fistula arteriovenosa). Se realizo seguimiento con ecocardiografia transesofagica a las 24 h y tras 1, 3, 6 y 12 meses; se documentaron 5 trombos, que se resolvieron con heparina. En el seguimiento de 21,14 ± 10,09 meses, hubo 3 muertes de pacientes mayores de 80 anos, ninguna de ellas cardiologica, y un accidente isquemico transitorio sin secuelas. Conclusiones El cierre del apendice auricular izquierdo por un operador con cierta experiencia puede ser una opcion terapeutica con pocas complicaciones y con resultados a mas de 1 ano eficaces en la reduccion de complicaciones tromboembolicas y hemorragicas, incluso en poblaciones de muy alto riesgo.

Introduction and objectives Left atrial appendage closure can be an attractive option for patients with nonvalvular atrial fibrillation and a contraindication to oral anticoagulants, provided that satisfactory results can be achieved during implantation and follow-up. Methods Thirty-five consecutive patients, not eligible for randomized trials with oral anticoagulants, had an Amplatzer occlusion device implanted under general anesthesia. After the first 5 patients, 3-dimensional imaging was incorporated. The results of the implantation and the follow-up were analyzed over a 1-year period. Results The mean age was 74.65 (7.61) years, with a CHADS2 score of 2.41 (1.53) and a CHA2DS2-VASc score of 3.17 (1.60). Implantation failed in 1 patient and 5 needed a change in the selected plug size. There were no cardiac complications during the implantation or hospital stay. There was 1 vascular complication (arteriovenous fistula). Transesophageal echocardiography monitoring was performed at 24 h, 1, 3, 6, and 12 months and we found 5 thrombi which were resolved with heparin. In the follow-up period of 21.14 (10.09) months, 3 patients aged>80 years died, none of them due to heart problems, and one transient ischemic stroke without further consequences. Conclusions Left atrial appendage closure by an experienced operator can be a treatment option with few complications and with efficient results at>1 year in reducing thromboembolic and hemorrhagic complications, even in very high-risk groups.

We present a case of a 52 year old female who suffered from a sudden syncope. A coronariography was performed and spontaneous coronary dissection was diagnosed in the posterior descending artery after an optical coherence tomography (OCT) was performed. A conservative management was decided. During hospitalization the patient presented with an episode of chest pain with an anterior ST elevation on ECG. Coronariography showed total occlusion of the left descending artery and again a dissection was diagnosed by OCT. This time, 2 stents were implanted in the affected artery. The hypothesis that the coronary adventitial volume of vasa vasorum is higher in patients with spontaneous coronary artery dissection has been demonstrated in a recent small study and it was observed in this patient. Conservative management is preferred in most cases, proceeding to revascularization for patients with ongoing chest pain, hemodynamic instability and ST elevation, mostly if it affects major arteries.

Transcatheter aortic valve replacement (TAVR) is an increasingly common procedure for the treatment of aortic stenosis in elderly patients with comorbidities that prevent the use of standard surgery. It has been shown that implantation without aortic regurgitation is related to lower mortality. Mild paravalvular regurgitation is inevitable in some cases due to calcification of the aortic annulus and its usually somewhat elliptical shape. Central regurgitation is less common, but has been associated with valve overdilatation in cases in which reduction of paravalvular regurgitation was attempted after the initial inflation. However, there are no reported cases of central prosthetic aortic regurgitation due to acute LV dysfunction. We report a case in which central aortic regurgitation occurred due to transient ventricular dysfunction secondary to occlusion of the right coronary artery by an embolus. The regurgitation disappeared after thrombus aspiration and normal ventricular function was immediately recovered. Resumo: A substituição percutânea de válvula aórtica (transcatheter aortic valve replacement – TAVR) tem-se tornado cada vez mais frequente para o tratamento da estenose aórtica em pacientes idosos com doenças associadas, para evitar a cirurgia convencional. Sabe-se que, não havendo refluxo aórtico após o implante, a mortalidade será mais baixa. Em alguns casos, contudo, um refluxo paravalvular moderado é inevitável, devido à calcificação do ânulo-aórtico e à sua configuração geralmente elíptica. O refluxo central é mais raro, tendo sido associado à excessiva dilatação da válvula em casos em que se tentou redução do refluxo paravalvular, após a inflação inicial. Entretanto, não foram referidos casos de refluxo aórtico central por disfunção ventricular esquerda aguda. Referimos um caso em que ocorreu refluxo aórtico central por disfunção ventricular transitória, secundária à oclusão da artéria coronária direita por êmbolo. O refluxo desapareceu após aspiração do trombo, sendo recuperada imediatamente a função ventricular normal. Keywords: Aortic regurgitation, Transcatheter aortic valve replacement, Coronary occlusion, Palavras-chave: Insuficiência aórtica, Substituição percutânea de válvula aórtica, Oclusâo coronária

El tratamiento quirurgico de la coartacion aortica presenta una alta tasa de exito; sin embargo, independientemente de la tecnica utilizada, un porcentaje significativo de los pacientes desarrolla complicaciones tardias relacionadas con la pared aortica. La reintervencion quirurgica para la reparacion de estas complicaciones es un procedimiento complicado y se asocia a una mortalidad elevada. El abordaje endovascular se ha propuesto recientemente como una alternativa prometedora para el manejo de estos casos. Presentamos una serie compuesta por 4 pacientes, 3 con desarrollo de aneurismas aorticos y 1 paciente con recoartacion, anos despues de ser sometidos a cirugia de coartacion aortica. Todos ellos fueron tratados por via endovascular de forma satisfactoria y sin complicaciones. Describimos nuestra experiencia y discutimos diversos aspectos tecnicos relacionados con estos complejos procedimientos: acceso vascular, oclusion de troncos supraaorticos y utilizacion de ecografia intravascular.

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

Fundamento y objetivo El dolor toracico agudo (DTA) es un sintoma inespecifico que puede ser expresion de cardiopatia isquemica (CI). La arteriosclerosis frecuentemente esta presente en mas de un territorio vascular. El indice tobillo-brazo (ITB) es una herramienta util en el diagnostico de enfermedad arterial periferica (EAP). Nuestro objetivo fue evaluar la utilidad del ITB en pacientes con DTA en los que se sospecha CI. Pacientes y metodo Estudio transversal de 94 pacientes consecutivos, con una edad media (DE) de 57,4 (12,2) anos, ingresados por DTA con sospecha de CI, en los que se determino el ITB y se investigo la presencia de CI. Resultados La CI estuvo presente en 22 pacientes (23,4%) y estuvo ausente en 72 pacientes (76,6%). La EAP asintomatica (ITB=0,9) estuvo presente en 6 pacientes (27,2%) en el grupo con CI y en 7 pacientes (9,7%) en el grupo sin CI. Encontramos diferencias significativas en el ITB segun la presencia o no de CI (0,9 [0,23] frente a 1,17 [0,15]; p

Introduccion y objetivos La diseccion retrograda aortocoronaria es una complicacion poco frecuente que sigue a la angioplastia coronaria. Nuestro estudio proporciona nuevos detalles estructurales de los senos aorticos y la porcion proximal de las arterias coronarias para un mejor entendimiento de aspectos relacionados con esta complicacion. Metodos Hemos analizado mediante tecnicas de diseccion, histologicas y de microscopia electronica de barrido los senos aorticos de 8 especimenes con cardiopatia isquemica estructural y se comparan con 8 especimenes control. Resultados Hemos observado las siguientes caracteristicas: a) el diametro de la arteria coronaria izquierda en 10 especimenes (71%) fue mayor que el de la derecha; b) el angulo que forma la coronaria izquierda con la aorta ascendente es agudo, mientras que el de la coronaria derecha tiende a ser recto, por lo que puede presentar un mejor abordaje para la cateterizacion; c) la pared periostial y la union sinotubular de la coronaria izquierda contiene, a diferencia de la derecha, mas celulas musculares lisas y una densa matriz de colageno tipo I, y d) los senos aorticos y coronarias de los especimenes con cardiopatia estructural presentan alteraciones estructurales que alteran la tunica media aortica y la distribucion del colageno de la union sinotubular. Conclusiones Las diferencias morfologicas y estructurales observadas indican que el seno aortico izquierdo es mas resistente a las tracciones y, por lo tanto, menos propenso a la diseccion iatrogenica. La cardiopatia isquemica estructural es un factor de riesgo que incrementa la predisposicion a la diseccion aortocoronaria.

Introduction and objectives. Retrograde aortocoronary dissection is an unusual complication of coronary angioplasty. Our study provides new structural details of the aortic sinuses and the proximal portions of the coronary arteries, which enable better understanding of several clinical features associated with this complication. Methods. We studied eight aortic sinus specimens from patients with structural ischemic heart disease using dissection, histologic analysis, and scanning electron microscopy, and compared findings with those in eight control specimens. Results. We observed the following features: a) in 10 specimens (71%), the left coronary artery diameter was greater than the right; b) the angle that the ascending aorta made with the left coronary artery was acute, whereas that with the right coronary artery was closer to a right angle, thereby possibly providing a better approach for catheterization; c) in contrast to those of the right coronary artery, the periostial wall and sinotubular junction of the left coronary artery were formed by more smooth muscle cells and by a dense matrix of collagen type-I fibers; and d) the aortic sinuses and coronary arteries in structural ischemic heart disease specimens displayed structural alterations that affected the aortic tunica media and the collagen distribution at the sinotubular junction. Conclusions. The morphological and structural differences observed between right and left sides suggest that the left aortic sinus is more resistant to traction and is, therefore, less prone to iatrogenic dissection. Structural ischemic heart disease is a risk factor that increases the likelihood of aortocoronary dissection.

The adequate device size selection for left atrial appendage closure is crucial to ensuring adequate implantation and for avoiding the need for multiple attempts that increase the risk of complications. Our aim was to evaluate the information obtained using different imaging techniques to select the size of the closure device in a clinical environment.Thirty-seven patients who consecutively underwent implantation of Amplatzer cardiac plug (ACP) devices were studied. All patients were examined using computed tomography (CT) prior to intervention. Measurements were compared to those obtained using intraoperative transesophageal echocardiography (IOTEE) and angiography. Size was determined by the longest axis of the appendage ostium. The influence of all techniques on the correct selection of final size was assessed.The measurements taken using the three techniques agreed in only 21.6% of the cases, leading to accurate selection of device size. Two techniques coincided as follows: IOTEE-CT in 45.9%, angiography-CT in 35.13%, and angiography-IOTEE in 24.3%. Measurements using CT were definitive for ACP selection in 75.7% of cases, angiography in 48.6%, and echocardiography in 51.4%. Device size was undermeasured with angiography in 35.1% of cases, and with IOTEE in 24.3%; CT overmeasured 21.6% of cases. The combination of angiography-CT was the most accurate for selection of device size.CT most often predicts the appropriate device size. If it fails, it usually overestimates the size. Agreement of measurements with all three techniques is the most accurate situation; when two agree, the most accurate combination is angiography and CT.

Aims: Paclitaxel drug-eluting balloons (pDEB) could be an attractive option to minimise side branch (SB) restenosis in bifurcated coronary lesions. We compared angiographic and clinical outcomes with pDEB plus bare metal stent (BMS) versus drug-eluting stents (DES) in de novo bifurcated lesions. Methods and results: This multicentre randomised trial included 108 patients. Sequential main branch (MB)/SB dilatation with pDEB, with provisional T-stenting with BMS in the MB was performed in the pDEB group, and with everolimus DES in the DES group. The primary endpoint was late lumen loss (LLL) at nine months. The secondary endpoint was the incidence of major adverse cardiac events (MACE: death, myocardial infarction, or target lesion revascularisation). In-segment MB LLL was 0.31±0.48 mm in the pDEB group, and 0.16±0.38 mm in the DES group (p=0.15); mean difference was 0.15 mm (upper limit one-sided 95% CI: 0.27 mm; p=0.001; non-inferiority test). LLL in SB was –0.04±0.76 mm in the pDEB group and –0.03±0.51 mm in the DES group (p=0.983). MACE and TLR were higher in the pDEB group (17.3% vs. 7.1%; p=0.105, and 15.4% vs. 3.6%; p=0.045), due to higher MB restenosis (13.5% vs. 1.8%; p=0.027). Conclusions: pDEB bifurcation pretreatment with BMS implantation in MB showed greater LLL (ns) and increased incidence of MACE compared to everolimus DES. Both strategies showed similar results in the SB.

Flecainide is an antiarrhythmic considered safe in patients who have no structural cardiopathy, and frequently used in the prevention of atrial fibrillation. However, in patients with a history of infarction and/or severe conduction disorders, its proarrhythmicity may be lethal. Torsade-de-pointes type tachycardia is not included as one of these proarrhythmic effects, since the drug's scant action on ventricular repolarization makes this adverse effect very unlikely. We present the case of a patient who, shortly after beginning treatment with flecainide, was admitted because of syncope related to bradyarrhythmias, long QT, and torsade-de-pointes. There have been very few published cases in which one finds such an association between flecainide and this infrequent arrhythmia.

Los sintomas que presentan los pacientes con cancer de pulmon pueden ser la consecuencia de una enfermedad broncopulmonar local (tos, hemoptisis, etc.), deberse a la extension del tumor hacia las estructuras circundantes, a metastasis a distancia, a efectos sistemicos inespecificos (anorexia, astenia, perdida de peso) o a sindromes paraneoplasicos secundarios a la produccion de determinadas hormonas por el tumor. En torno al 10% de los pacientes se encuentran asintomaticos en el momento del diagnostico. Presentamos el caso de un paciente varon de 77 anos de edad, que presentaba disnea, dolor toracico de tipo pleuritico y edemas en los miembros inferiores. Su evolucion fue fatal, falleciendo al cabo de pocos dias. La causa de la clinica era la existencia de pericarditis constrictiva secundaria a metastasis de carcinoma pulmonar.

Symptoms such as cough and hemoptysis in patients with lung cancer can be the consequence of local bronchopulmonary disease, tumor growth that leads to compression of surrounding structures, distant metastases, diverse systemic effects (anorexia, asthenia, weight loss), or paraneoplastic syndromes associated with tumor production of certain hormones. Approximately 10% of patients are asymptomatic at diagnosis. We report the case of a 77-year-old man with dyspnea, pleuritic chest pain, and lower limb edema. The patient died within a few days. The cause of the clinical picture was constrictive pericarditis secondary to metastases from lung carcinoma.

The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis between a primary cardiac tumour (with myxoma being the most frequent), invasion of an extracardiac tumour, vegetations on the tricuspid valve, and an atrial thrombus. We describe the case of a patient who was admitted to our service with a diagnosis of suspected myxoma based on the chance transthoracic echocardiographic discovery of a right atrial mass. A transesophageal echocardiogram showed the process to be extracardiac, and magnetic resonance imaging showed it to originate at the renal level extending via the inferior vena cava to the right atrium. Tumour extension with thrombosis of the vena cava is a relatively frequent complication of renal carcinoma, but only exceptionally does it reach the right atrium. It is also exceptional that this was a chance finding in an asymptomatic patient.

The Tako-tsubo syndrome (TS) is a reversible acute cardiomyopathy simulating an infarction. We analyzed 60 patients admitted with TS in our center.A percentage of 73.3 were women (mean age: 70.6 ± 11.8 years); 83.3% had some cardiovascular risk factor, 25% had an anxiety-depressive disorder and in 58.3% a precipitating factor was identified, emotional stress being the most frequent. A percentage of 15.3 showed complete left bundle branch block (LBBB). In 23.3% of patients, contractile abnormalities respected the apex (mid ventricular or diaphragmatic types).The anterior descending artery showed no significant lesions in 35% of patients and in 68.3% it had a diaphragmatic segment. Forty percent of patients developed heart failure (HF) and 18.3% cardiogenic shock (CS). The overall in-hospital mortality was 3.3%, while it was 8.3% among those patients who developed HF. The incidence of CS was higher among patients with LBBB (44.4 vs. 13.7%, P=.05) and males (43.8 vs. 9.1%, P=.005).Although in-hospital mortality in patients admitted due to TS is low, a significant percentage of these patients develop HF with a high mortality in this subgroup. Males and patients with LBBB had higher in-hospital morbidity.

Summary We present two cases of right coronary artery occlusion in which MGuard® stent implantation failed for different causes, leading to a retrieval procedure adapted to the situation. Complete retrieval was possible in both cases. These cases illustrate the need for careful selection of the lesions that are going to be treated with this type of stent, for which pre-dilatation is recommended in severe lesions located just after an acute vessel angle, the evaluation of proximal angulation and calcification, as well as strategies for complete retrieval in case of implantation failure.