Search

Resumen Introduccion y objetivos Evaluar el tratamiento y aplicacion de las recomendaciones de las guias europeas del tratamiento de fibrilacion auricular (FA), en una cohorte contemporanea de pacientes con FA. Metodos REGUEIFA es un estudio observacional, prospectivo y multicentrico de pacientes con diagnostico primario o secundario de FA que residen en la comunidad autonoma de Galicia y son valorados por cardiologos. Resultados Se incluyeron 1.007 pacientes con una edad media de 67 anos y 32% mujeres. Un 50% de pacientes tenia enfermedad cardiovascular. La amiodarona fue el farmaco antiarritmico mas utilizado (24,5%). El riesgo tromboembolico fue de 2,3 ± 1,5 en la escala CHA2DS2-VASc y el riesgo hemorragico de 0,7 ± 0,7 en la escala HAS-BLED. Se prescribio tratamiento con anticoagulantes orales (ACO) en el 91,1%. Una mayor puntuacion en la escala CHA2DS2-VASc, y la ablacion de FA se identificaron como factores independientes asociados a ACO mientras que la forma paroxistica se asocio a no anticoagulacion. Se identificaron la edad y la insuficiencia renal como factores independientes de prescripcion de antagonistas de la vitamina K mientras que la cardioversion electrica y la ablacion de FA se asociaron de forma independiente a la prescripcion de ACO de accion directa. Conclusiones El estudio REGUEIFA proporciona informacion contemporanea del tratamiento cardiologico de pacientes con FA. La prescripcion de ACO fue del 91,1%. Se describen los factores independientes asociados a la prescripcion de ACO y de ACO de accion directa.

Introduction and objectives: This report presents the findings of the 2018 Spanish Catheter Ablation Registry. Methods: Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers. Results: Data sent by 100 centers were analyzed, with a total number of 16,566 ablation procedures performed (the highest historically reported in this registry) for a mean of 165.5 ± 127.9 and a median of 119 procedures per center. The ablation targets most frequently treated were atrial fibrillation (n = 4234; 25.6%), atrioventricular nodal re-entrant tachycardia (n = 3525; 21.3%) and cavotricuspid isthmus (n = 3425; 20.7%). A new peak was observed in the ablation of atrial fibrillation, increasing the distance from the other substrates. The overall success rate was 91%. The rate of major complications was 2.2%, and the mortality rate was 0.04%. A total of 2.1% of the ablations were performed in pediatric patients. Conclusions: The Spanish Catheter Ablation Registry systematically and continuously enrolls the ablation procedures performed in Spain, showing a progressive increase in the number of ablations over the years, with a high success rate and low percentage of complications.

Background: Leadless pacemakers (L-PM) are an emerging effective and safe technology that offer an alternative to conventional pacemakers (C-PM) for right ventricular stimulation. However, there is little information about their potential benefits for quality of life (QoL) in patients with L-PM. We compared QoL between patients with L-PM and C-PM. Methods: The study population comprised patients undergoing single chamber pacemaker implantation from December 2016 to March 2018. The SF-36 questionnaire was used to evaluate QoL at baseline and at 6 months of followup. We also used a questionnaire consisted of 10 specific questions related to the implant procedure. Results: A total of 106 patients (64 C-PM; 42 L-PM) were included. There were no differences in baseline characteristics between the groups (C-PM vs L-PM), except for age (81.5 vs 77.3 years; P = .012) and diabetes (38% vs 17%; P = .021). Baseline SF-36 scores did not differ between the groups. At 6 months followup, patients in the L-PM group scored significantly higher on physical function (63 vs 42; P < .001), physical role (64 vs 36; P = .004), and mental health (75 vs 65; P = .017), even after adjusting for covariates. Pacemaker-related discomfort and physical restrictions were significantly lower for the L-PM group. Conclusion: L-PM is associated with better QoL than C-PM in both physical and mental health. Patients undergoing L-PM implantation reported less procedure-related discomfort, physical restriction, and preoccupation.

Resumen Introduccion y objetivos Se describen los resultados del Registro Espanol de Ablacion con Cateter correspondientes al ano 2017. Metodos La recogida de datos se llevo a cabo de forma retrospectiva con la cumplimentacion de un formulario de recogida de datos de cada uno de los centros participantes. Resultados El numero total de procedimientos de ablacion fue de 15.284 realizados en 98 centros (mayor numero de centros y de procedimientos de ablacion comunicados historicamente en este registro) con una media de 156 ± 126 y una mediana de 136 procedimientos. El sustrato abordado con mas frecuencia ha sido por primera vez en el registro la fibrilacion auricular (n = 3.457; 22,6%), seguida del istmo cavotricuspideo (n = 3.449; 22,5%) y la taquicardia intranodular (n = 3.429; 22,4%). La tasa total de exito fue del 87%; la de complicaciones mayores, del 2,6% y la mortalidad, del 0,09%. Se ha producido un aumento de los procedimientos realizados sin apoyo de fluoroscopia hasta suponer un 6% del total de las ablaciones. Un 2,3% de las ablaciones se realizo en pacientes pediatricos. Conclusiones El Registro Espanol de Ablacion con Cateter recoge sistematica e ininterrumpidamente los procedimientos de ablacion realizados en Espana, y esto nos ha permitido observar un aumento progresivo del numero de ablaciones y de centros que las realizan manteniendo una tasa de exito elevada y unos porcentajes de complicaciones bajos.

To analyze the clinical profile and therapeutic strategy in atrial fibrillation (AF) according to gender in a contemporaneous patient cohort a prospective, multicenter observational study was performed on consecutive patients diagnosed with AF and assessed by cardiology units in the region of Galicia (Spain). A total of 1007 patients were included, of which 32.3% were women. The mean age of the women was significantly greater than that of the men (71.6 versus 65.7 years, p &lt, 0.001), with a higher prevalence of hypertension (HTN) and valve disease. Women more often reported symptoms related to arrhythmia (28.2% in EHRA class I versus 36.4% in men), with a poorer level of symptoms (EHRA classes IIb and III). Thromboembolic risk was significantly higher among women (CHA2DS2-VASc 3 ± 1.3 versus 2 ± 1.5), in the same way as bleeding risk (HAS-BLED 0.83 ± 0.78 versus 0.64 ± 0.78) (p &lt, 0.001), and women more often received anticoagulation therapy (94.1% versus 87.6%, p = 0.001). Rhythm control strategies proved significantly less frequent in women (55.8% versus 66.6%, p = 0.001), with a lesser electrical cardioversion (ECV) rate (18.4% versus 27.3%, p = 0.002). Perceived health status was poorer in women. Women were older and presented greater comorbidity than men, with a greater thromboembolic and bleeding risk. Likewise, rhythm control strategies were less frequent than in men, despite the fact that women had poorer perceived quality of life and were more symptomatic.

Introduction Recurrences after atrial fibrillation (AF) ablation are still common. Among the reported clinical and imaging predictors of recurrences, diagnosis-to-ablation time (DAT) has been defined as a predictor of ablation outcome in single-center studies. We aimed to validate DAT in a multicenter real-life cohort. Methods This was a multicenter study including consecutive patients undergoing first paroxysmal and persistent AF ablation with radiofrequency or cryoballoon catheters during 2013. Cox proportional hazard regression models were performed to identify predictors of recurrence. Results In total, 309 patients were included across nine centers (71% men, 57 ± 10 years old, 46% with hypertension, and 66% with CHA2 DS2 -VASc ≤ 1). Most patients had paroxysmal AF (67%) and underwent radiofrequency ablation (68%) with a median DAT of 51 (43) months. Patients with DAT ≤ 1 year (16.6%) were less likely to have repeat procedures (4% vs 18%; P = .017). The adjusted proportional hazards Cox model identified hypertension (P = .005), heart failure (P = .011), nonparoxysmal AF (P = .038), DAT > 1 year (P = .007), and LA diameter (P = .026) as independent predictors for AF recurrence. DAT > 1 year was the only modifiable factor independently associated with recurrence (HR 4.2 [95% CI, 1.5-11.9]) CONCLUSION: Diagnosis-to-ablation time is a modifiable factor independently associated with recurrent arrhythmia and repeat ablation after first AF ablation. An early intervention strategy during the first year from AF diagnosis might improve outcomes.

BACKGROUND Left atrial (LA) sphericity (LASP) is a new remodeling parameter based on LA shape analysis, with independent predictive value for recurrence after atrial fibrillation (AF) ablation. OBJECTIVES To evaluate the association between LASP and thromboembolic events (TE) in patients with AF. METHODS Twenty-nine AF patients and prior TE and 29 age- and gender-matched controls were included. LASP was calculated using a 3D-LA reconstruction. The LA appendage (LAA) volume and morphology were assessed. ROC curve analysis was performed for LASP, LA volume, LAA volume, and CHAD/CHA2 D-VASc scores (Stroke2 -the grouping variable-was excluded). RESULTS Mean age of the study population was 61 ± 11 years (79.3% males, 53.4% hypertension, 8.6% diabetes). Patients with prior TE had higher LASP than those without (82.5 ± 3.3% vs. 80.2 ± 3.1%, P = 0.008); there were no differences in CHAD or CHA2 D-VASc scores, LA volume, LAA volume, or LAA morphology. The C-statistic was higher for LASP (0.71) than for other tested variables (CHAD score = 0.58, CHA2 D-VASc score = 0.59, LA volume = 0.50, LAA volume = 0.46; P < 0.01 for all vs. LASP). The best cutoff value for LASP was 83.6% (sensitivity 0.52, specificity 0.90). Logistic regression analysis showed predictive value for LASP (OR 1.26 per each 1% increase [1.85-52.20], P = 0.013), but not for clinical risk scores. The addition of LASP to the CHAD and CHA2 D-VASc scores increased the predictive value over the risk scores alone (P = 0.004), and reclassified 45.5% of patients with CHAD = 0 (no anticoagulation indicated) to moderate-risk (anticoagulation indicated). CONCLUSION LA sphericity is associated with prior TE in AF patients and improves the performance of the CHAD and CHA2 D-VASc scores alone.

Resumen Introduccion y objetivos Existe escasa evidencia sobre la evolucion de los pacientes con miocardiopatia valvular remitidos para implante de desfibrilador por prevencion primaria. Se pretende describir la evolucion de este subgrupo particular. Metodos Estudio multicentrico retrospectivo en 15 centros espanoles que incluyo pacientes consecutivos remitidos para implante de desfibrilador en los anos 2010 y 2011, y en tres centros desde el 1 enero de 2008. Resultados De un total de 1.174 pacientes, 73 (6,2%) presentaron miocardiopatia valvular. Comparados con los pacientes con miocardiopatia isquemica (n = 659; 56,1%) o dilatada (n = 442; 37,6%), presentaron peor clase funcional, mayor anchura del QRS y antecedente de fibrilacion auricular. Durante un seguimiento de 38,1 ± 21,3 meses, 197 (16,7%) pacientes fallecieron por cualquier causa, sin diferencias significativas entre grupos (19,2% en miocardiopatia valvular, 15,8% en isquemica y 17,9% en miocardiopatia dilatada; p = 0,2). De estos, 136 murieron por causa cardiovascular (11,6%), sin diferencias significativas (12,3%; 10,5% y 13,1%, respectivamente; p = 0,1). Tampoco hubo diferencias en la proporcion de intervenciones apropiadas del desfibrilador (13,7%; 17,9% y 18,8%; p = 0,4), pero si en el de inapropiadas (8,2%; 7,1% y 12,0%, respectivamente; p = 0,03). Conclusiones Las tasas de mortalidad por cualquier causa y por causa cardiovascular en pacientes con miocardiopatia valvular fueron similares a las del resto de los pacientes remitidos para implante de desfibrilador. Tambien presentaron similares tasas de intervenciones apropiadas. Estos datos parecen indicar que el implante de un desfibrilador en este grupo confiere un beneficio similar al que obtienen los pacientes con miocardiopatia isquemica y miocardiopatia dilatada.

Introduction and objectives: This report describes the findings of the 2017 Spanish Catheter Ablation Registry. Methods: Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers. Results: A total of 15 284 ablation procedures were performed by 98 institutions (the highest number of ablations and institutions historically reported in this registry), with a mean of 156 ± 126 and a median of 136 procedures per center. For the first time, the most frequently treated ablation target was atrial fibrillation (n = 3457; 22.6%), followed by cavotricuspid isthmus (n = 3449; 22.5%) and atrioventricular nodal re-entrant tachycardia (n = 3429; 22.4%). The overall success rate was 87%. The rate of major complications was 2.6%, and the mortality rate was 0.09%. The percentage of procedures performed without fluoroscopic support increased to 6% of all ablations, and 2.3% of all ablations were performed in pediatric patients. Conclusions: The Spanish Ablation Catheter Registry systematically and uninterruptedly collects data on the ablation procedures performed in Spain, revealing that both the number of ablations and the number of centers performing them has progressively increased, while maintaining a high success rate and a low percentage of complications.

Aims: Left atrial (LA) remodelling is a key determinant of atrial fibrillation (AF) ablation outcome. Optimal methods to assess this process are scarce. LA sphericity is a shape-based parameter shown to be independently associated to procedural success. In a multicentre study, we aimed to test the feasibility of assessing LA sphericity and evaluate its capability to predict procedural outcomes. Methods and results: This study included consecutive patients undergoing first AF ablation during 2013. A 3D model of the LA chamber, excluding pulmonary veins and LA appendage, was used to quantify LA volume (LAV) and LA sphericity (≥82.1% was considered spherical LA). In total, 243 patients were included across 9 centres (71% men, aged 56 ± 10 years, 44% with hypertension and 76% CHA2DS2-VASc ≤ 1). Most patients had paroxysmal AF (66%) and underwent radiofrequency ablation (60%). Mean LA diameter (LAD), LAV, and LA sphericity were 42 ± 6 mm, 100 ± 33 mL, and 82.6 ± 3.5%, respectively. Adjusted Cox models identified paroxysmal AF [hazard ratio (HR 0.54, P = 0.032)] and LA sphericity (HR 1.87, P = 0.035) as independent predictors for AF recurrence. A combined clinical-imaging score [Left Atrial Geometry and Outcome (LAGO)] including five items (AF phenotype, structural heart disease, CHA2DS2-VASc ≤ 1, LAD, and LA sphericity) classified patients at low (≤2 points) and high risk (≥3 points) of procedural failure (35% vs. 82% recurrence at 3-year follow-up, respectively; HR 3.10, P

Background: ICDs have been demonstrated to be highly effective in the primary prevention of sudden death, but inappropriate shocks (IS) occur frequently and represent one of the most important adverse effects of ICDs. The aim of this study was to analyze IS and identify the clinical predictors and prognostic implications of ISs in a real-world primary prevention ICD population. Methods: This multicenter retrospective study was performed in 13 centers with experience in the field of ICD implantation (at least 30 per year) and ICD follow-up in Spain. All consecutive patients who underwent ICD implantation for primary prevention between January 2008 and May 2014 were included. Results: One-thousand-sixteen patients were included, and 4 (0.39%) were lost to follow-up. Two-hundred-seventeen (21.4%) patients suffered from shock; 69 (6.8%) of these patients experienced IS, and 154 (15.4%) experienced appropriate shocks (AS). Age (

Background: A reverse left atrial (LA) remodelling after atrial fibrillation (AF) ablation has been reported and a relationship between diastolic function and AF is well known. However, there is little information about atrial remodelling and diastolic function after cavotricuspid isthmus (CTI) ablation. We aimed to evaluate long-term biatrial remodelling and diastolic function in patients undergoing CTI ablation.

Left atrial (LA) sphericity (LASP) is a new remodeling parameter based on LA shape analysis, with independent predictive value for recurrence after atrial fibrillation (AF) ablation.To evaluate the association between LASP and thromboembolic events (TE) in patients with AF.Twenty-nine AF patients and prior TE and 29 age- and gender-matched controls were included. LASP was calculated using a 3D-LA reconstruction. The LA appendage (LAA) volume and morphology were assessed. ROC curve analysis was performed for LASP, LA volume, LAA volume, and CHAD/CHA2 D-VASc scores (Stroke2 -the grouping variable-was excluded).Mean age of the study population was 61 ± 11 years (79.3% males, 53.4% hypertension, 8.6% diabetes). Patients with prior TE had higher LASP than those without (82.5 ± 3.3% vs. 80.2 ± 3.1%, P = 0.008); there were no differences in CHAD or CHA2 D-VASc scores, LA volume, LAA volume, or LAA morphology. The C-statistic was higher for LASP (0.71) than for other tested variables (CHAD score = 0.58, CHA2 D-VASc score = 0.59, LA volume = 0.50, LAA volume = 0.46; P0.01 for all vs. LASP). The best cutoff value for LASP was 83.6% (sensitivity 0.52, specificity 0.90). Logistic regression analysis showed predictive value for LASP (OR 1.26 per each 1% increase [1.85-52.20], P = 0.013), but not for clinical risk scores. The addition of LASP to the CHAD and CHA2 D-VASc scores increased the predictive value over the risk scores alone (P = 0.004), and reclassified 45.5% of patients with CHAD = 0 (no anticoagulation indicated) to moderate-risk (anticoagulation indicated).LA sphericity is associated with prior TE in AF patients and improves the performance of the CHAD and CHA2 D-VASc scores alone.

Objectives This study sought to compare the in-hospital prognostic values of the original and updated GRACE (Global Registry of Acute Coronary Events) risk score (RS) and the AR-G (ACTION [Acute Coronary Treatment and Intervention Outcomes Network] Registry and the GWTG [Get With the Guidelines] Database) RS in acute coronary syndromes (ACS). To evaluate the utility of recalculating risk after percutaneous coronary intervention (PCI) with newer RS models (NCDR [National Cardiovascular Data Registry] and EHS [EuroHeart Score] RS). Background Defined in 2003, GRACE is among the most popular systems of risk stratification in ACS. An updated version of GRACE has since appeared and new RS have been developed, aiming to improve risk prediction. Methods From 2004 to 2010, 4,497 consecutive patients admitted to a single center in Spain with an ACS were included (32.1% ST-segment elevation myocardial infarction, 19.2% unstable angina). Discrimination (C-statistic) and calibration (Hosmer-Lemeshow [HL]) indexes were used to assess performance of each RS. A comparative analysis of RS designed to predict post-PCI mortality NCDR and EHS RS versus the GRACE and AR-G RS was performed in a subgroup of 1,113 consecutive patients included in the study. Results There were 265 in-hospital deaths (5.9%). Original and updated GRACE RS and the AR-G RS all demonstrated good discrimination for in-hospital death (C-statistics: 0.91, 0.90 and 0.90, respectively) with optimal calibration (HL p: 0.42, 0.50, and 0.47, respectively) in all spectra of ACS, according to different managements (PCI vs. conservative) and without significant differences between the 3 different RS. In patients undergoing PCI, EHS and NCDR RS (C-statistic = 0.80 and 0.84, respectively) were not superior to GRACE RS (C-statistic = 0.91), albeit in the subgroup of patients undergoing PCI who were categorized as high risk using the GRACE RS, both EHS and NCDR have contributed to decrease the false positive rate generated by using the GRACE RS. Conclusions Despite having been developed over 8 years ago, the GRACE RS still maintains its excellent performance for predicting in-hospital risk of death among ACS patients.

La aterotrombosis es un proceso sistemico, progresivo, con una etiopatogenia comun que afecta a diferentes lechos vasculares y cuyas principales manifestaciones clinicas dependen del territorio mas gravemente afectado. Sin embargo, la practica clinica confirma el caracter multisistemico de la enfermedad, y es frecuente encontrar en el mismo sujeto (sintomatico o no) manifestaciones clinicas o subclinicas de enfermedad vascular en otro territorio. La cardiopatia isquemica, la enfermedad cerebrovascular y la enfermedad arterial periferica representan los tres frentes de presentacion principales y la importante relevancia pronostica de su coexistencia justifica la valoracion vascular integral del paciente. Al tratarse de una enfermedad sistemica con factores de riesgo comunes, el tratamiento con antiagregantes plaquetarios, inhibidores de la enzima de conversion de angiotensina, antagonistas de los receptores de angiotensina II y estatinas ha confirmado sus ventajas pronosticas con independencia del territorio afecto.

Introduction and objectives: Few data exist on the outcomes of valvular cardiomyopathy patients referred for defibrillator implantation for primary prevention. The aim of the present study was to describe the outcomes of this cardiomyopathy subgroup. Methods: This multicenter retrospective study included consecutive patients referred for defibrillator implantation to 15 Spanish centers in 2010 and 2011, and to 3 centers after 1 January 2008. Results: Of 1174 patients, 73 (6.2%) had valvular cardiomyopathy. These patients had worse functional class, wider QRS, and a history of atrial fibrillation vs patients with ischemic (n = 659; 56.1%) or dilated (n = 442; 37.6%) cardiomyopathy. During a follow-up of 38.1 +/- 21.3 months, 197 patients (16.7%) died, without significant differences among the groups (19.2% in the valvular cardiomyopathy group, 15.8% in the ischemic cardiomyopathy group, and 17.9% in the dilated cardiomyopathy group; P = .2); 136 died of cardiovascular causes (11.6%), without significant differences among the groups (12.3%, 10.5%, and 13.1%, respectively; P = .1). Although there were no differences in the proportion of appropriate defibrillator interventions (13.7%, 17.9%, and 18.8%; P = .4), there was a difference in inappropriate interventions (8.2%, 7.1%, and 12.0%, respectively; P = .03). Conclusions: All-cause and cardiovascular mortality in patients with valvular cardiomyopathy were similar to those in other patients referred for defibrillator implantation. They also had similar rates of appropriate interventions. These data suggest that defibrillator implantation in this patient group confers a similar benefit to that obtained by patients with ischemic or dilated cardiomyopathy. (C) 2015 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Background: A reverse left atrial (LA) remodelling after atrial fibrillation (AF) ablation has been reported and a relationship between diastolic function and AF is well known. However, there is little information about atrial remodelling and diastolic function after cavotricuspid isthmus (CTI) ablation. We aimed to evaluate long-term biatrial remodelling and diastolic function in patients undergoing CTI ablation.

Assessment of renal function is important for bleeding risk stratification in acute coronary syndrome (ACS). There are three formulas routinely used to assess renal function: the Cockroft-Gault (C-G) formula, the MDRD-4 formula and the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Our aim was to compare the ability of these formulas to predict the risk of in-hospital bleeding in patients with ACS.The study included 3270 patients with ACS. The performance of each formula with respect to in-hospital TIMI (Thrombolysis In Myocardial Infarction) major or TIMI minor bleeding were assessed using continuous data and by dividing patients into four subgroups according to the estimated glomerular filtration rate (eGFR): ≥90, 89-60, 30-59 and30 ml/min/1.73 m(2).Bleeding predictive ability was significantly higher for the C-G formula than for MDRD-4 and CKD-EPI formulas, as evaluated by the area under the curve (AUC); continuous eGFR AUCs: 0.73, 0.69 and 0.71, respectively; categorical eGFR AUCs: 0.71, 0.66 and 0.68, respectively. Net reclassification improvement based on the eGFR categories was significantly positively favored C-G: 9.5% (95% confidence interval (CI) 1.8-17.2%) and 19.1% (95% CI 11.3-26.9%) compared with CKD-EPI and MDRD-4, respectively. After multivariable adjustment, the C-G formula predicted in-hospital bleeding better than MDRD-4 formula (severe renal dysfunction vs. normal renal function: odds ratio 7.98, 95% CI 2.61-24.38 with C-G; odds ratio 3.76, 95% CI 1.63-8.69 with MDRD-4; and odds ratio 5.77, 95% CI 2.18-15.24 with CKD-EPI.Our findings suggest that the C-G eGFR may improve risk prediction of in-hospital bleeding more than the MDRD-4 equation and the new CKD-EPI equation in patients with ACS.

Objectives The aim of this study was to test the feasibility and usefulness of a new delayed-enhancement cardiac magnetic resonance (DE-CMR)–guided approach to ablate gaps in redo procedures. Background Recurrences of atrial fibrillation (AF) after pulmonary vein isolation (PVI) may be related to gaps at the ablation lines. DE-CMR allows identification of radiofrequency lesions and gaps (CMR gaps). Methods Fifteen patients undergoing repeated AF ablations were included (prior procedure was PVI in all patients and roof-line ablation in 8 patients). Pre-procedure 3-dimensional (3D) DE-CMR was performed with a respiratory-navigated (free-breathing) and electrocardiographically gated inversion-recovery gradient-echo sequence (voxel size 1.25 × 1.25 × 2.5 mm). Endocardium and epicardium were manually segmented to create a 3D reconstruction (DE-CMR model). A pixel signal intensity map was projected on the DE-CMR model and color-coded (thresholds 40 ± 5% and 60 ± 5% of maximum intensity). The DE-CMR model was imported into the navigation system to guide the ablation of CMR gaps, with the operator blinded to electrical data. Fifteen conventional procedures were used as controls to compare procedural duration, radiofrequency, and fluoroscopy times. Results Fifteen patients (56 pulmonary veins [PVs]; 57 ± 8 years of age; 9 with paroxysmal AF) were analyzed. In total, 67 CMR gaps were identified around PVs (mean 4.47 gaps/patient; median length 13.33 mm/gap) and 9 at roof line. All of the electrically reconnected PVs (87.5%) had CMR gaps. The site of electrical PV reconnection (assessed by circular mapping catheter) matched with a CMR gap in 79% of PVs. CMR-guided ablation led to reisolation of 95.6% of reconnected PVs (median radiofrequency time of 13.3 [interquartile range: 7.5 to 21.7] min/patient) and conduction block through the roof line in all patients (1.4 [interquartile range: 0.7 to 3.1] min/patient). Compared with controls, the CMR-guided approach shortened radiofrequency time (1,441 ± 915 s vs. 930 ± 662 s; p = 0.026) but not the procedural duration or fluoroscopy time. Conclusions DE-CMR can successfully guide repeated PVI procedures by accurately identifying and localizing gaps and may reduce procedural duration and radiofrequency application time.

impacts on myocardial infarction deaths in the Athens territory: the CLIMATE study. Heart 2006;92:1747–51. [32] Chang CL, Shipley M, Marmot M, Poulter N. Lower ambient temperature was associated with an increased risk of hospitalization for stroke and acute myocardial infarction in young women. J Clin Epidemiol 2004;57:749–57. [33] Woodhouse PR, Khaw KT, Plummer M, Foley A, Meade TW. Seasonal variations of plasma fibrinogen and factor VII activity in the elderly: winter infections and death from cardiovascular disease. Lancet 1994;343:435–9. [34] Hertig BA, Beldings HS, Kraning KK, Batterton DL, Smith CR, Sargent II F. Artificial acclimatization of women to heat. J Appl Physiol 1963;18:383–6. [35] McArdleWD, Magel JR, Spina RJ, Gergley TJ, Toner MM. Thermal adjustment to coldwater exposure in exercising men and women. J Appl Physiol 1984;56:1572–7. [36] Anderson GS, Ward R, Mekjavic IB. Gender differences in physiological reactions to thermal stress. Eur J Appl Physiol 1995;71:95–101. [37] Fox RH, Lofstedt BE, Woodward PM, Eriksson E, Werkstrom B. Comparison of thermoregulatory function in men and women. J Appl Physiol 1969;26:444–53. [38] Miller JM, Zipes DP. Therapy for cardiac arrhythmias. In: Libby P, BonowRO,MannDL, Zipes DP, editors. Braunwald's heart disease: a textbook of cardiovascular medicine. 8th ed. Philadelphia: Saunders, Elsevier; 2008. p. 791–823. [39] Ghio AJ, Bassett M, Montilla T, et al. Case report: supraventricular arrhythmia after exposure to concentrated ambient air pollution particles. Environ Health Perspect 2012;120:275–7. [40] Berger A, Zareba W, Schneider A, et al. Runs of ventricular and supraventricular tachycardia triggered by air pollution inpatientswith coronary heart disease. J Occup Environ Med 2006;48:1149–58.

Haemorrhagic complications are strongly linked with adverse outcomes in acute coronary syndrome (ACS) patients. Various risk scores (RS) are available to predict bleeding risk in these patients. We compared the performance of three contemporary bleeding RS in ACS.We studied 4500 consecutive patients with ACS. We calculated the ACTION, CRUSADE, and Mehran et al. (2010) bleeding RS, and evaluated their performance for predicting their own major bleeding events and TIMI serious (major or minor) bleeding episodes, in patients with either non-ST-elevation ACS (NSTEACS) or ST-elevation myocardial infarction (STEMI). Calibration (Hosmer-Lemeshow test, HL) and discrimination (c-statistic) for the three RS were computed and compared.For RS-specific major bleeding, ACTION and CRUSADE showed the best prognostic discrimination in STEMI (c=0.734 and 0.791, respectively; p=0.04), and in NSTEACS (c=0.791 and 0.810; p=0.4); being CRUSADE significantly superior to Mehran et al. in both ACS types (p0.05). All RS performed well in patients undergoing coronary arteriography using either a radial or femoral approach (all c≥0.718); however, their discriminative capacity was modest in patients not undergoing coronary arteriography and in those previously on oral anticoagulant (all c0.70). For TIMI serious bleeding, ACTION and CRUSADE displayed the highest c-index values in both STEMI (0.724 and 0.703, respectively; p=0.3) and NSTEACS (c=0.733 and 0.744, respectively; p=0.6); however, calibration of ACTION was poor in both ACS types (HL p0.05).Of contemporary bleeding RS, the CRUSADE score was found to be the most accurate quantitative tool for NSTEACS and STEMI patients undergoing coronary arteriography.

This study sought to compare the in-hospital prognostic values of the original and updated GRACE (Global Registry of Acute Coronary Events) risk score (RS) and the AR-G (ACTION [Acute Coronary Treatment and Intervention Outcomes Network] Registry and the GWTG [Get With the Guidelines] Database) RS in acute coronary syndromes (ACS). To evaluate the utility of recalculating risk after percutaneous coronary intervention (PCI) with newer RS models (NCDR [National Cardiovascular Data Registry] and EHS [EuroHeart Score] RS).Defined in 2003, GRACE is among the most popular systems of risk stratification in ACS. An updated version of GRACE has since appeared and new RS have been developed, aiming to improve risk prediction.From 2004 to 2010, 4,497 consecutive patients admitted to a single center in Spain with an ACS were included (32.1% ST-segment elevation myocardial infarction, 19.2% unstable angina). Discrimination (C-statistic) and calibration (Hosmer-Lemeshow [HL]) indexes were used to assess performance of each RS. A comparative analysis of RS designed to predict post-PCI mortality NCDR and EHS RS versus the GRACE and AR-G RS was performed in a subgroup of 1,113 consecutive patients included in the study.There were 265 in-hospital deaths (5.9%). Original and updated GRACE RS and the AR-G RS all demonstrated good discrimination for in-hospital death (C-statistics: 0.91, 0.90 and 0.90, respectively) with optimal calibration (HL p: 0.42, 0.50, and 0.47, respectively) in all spectra of ACS, according to different managements (PCI vs. conservative) and without significant differences between the 3 different RS. In patients undergoing PCI, EHS and NCDR RS (C-statistic = 0.80 and 0.84, respectively) were not superior to GRACE RS (C-statistic = 0.91), albeit in the subgroup of patients undergoing PCI who were categorized as high risk using the GRACE RS, both EHS and NCDR have contributed to decrease the false positive rate generated by using the GRACE RS.Despite having been developed over 8 years ago, the GRACE RS still maintains its excellent performance for predicting in-hospital risk of death among ACS patients.

A B S T R A C T Introduction and objectives: The purpose of the present study is to determine the structural and functional cardiac changes that occur in patients at 1-year follow-up after ablation of typical atrial flutter. Methods: We enrolled 95 consecutive patients referred for cavotricuspid isthmus ablation. Echocardiography was performed at � 6 h post-procedure and 1-year follow-up. Results: Of 95 patients initially included, 89 completed 1-year follow-up. Hypertensive cardiopathy was the most frequently associated condition (39%); 24% of patients presented low baseline left ventricular systolic dysfunction. We observed a significant reduction in right and left atrial areas, end-diastolic and end-systolic left ventricular diameters, and interventricular septum. We observed substantial improvement in right atrium contraction fraction and left ventricular ejection fraction, and a reduction in pulmonary hypertension. Changes in diastolic dysfunction pattern were observed: 60% of patients progressed from baseline grade III to grade I; at 1-year follow-up, this improvement was found in 81%. We found no structural differences between paroxysmal and persistent atrial flutter at baseline and 1-year follow-up, exception for basal diastolic function. Conclusions: In patients with typical atrial flutter undergoing cavotricuspid isthmus catheter ablation, we found inverse structural and functional cardiac remodeling at 1-year follow-up with much improved left ventricular ejection fraction, right atrium contraction fraction, and diastolic dysfunction pattern.

Resumen Introduccion y objetivos El proposito de este trabajo es evaluar los cambios cardiacos estructurales y funcionales que se producen tras 1 ano de seguimiento de pacientes sometidos a ablacion del aleteo auricular tipico. Metodos Se ha analizado de manera consecutiva a 95 pacientes remitidos para ablacion del istmo cavotricuspideo. Se realizo un ecocardiograma en las 6 h posteriores al procedimiento y al cabo de 1 ano de seguimiento. Resultados Completaron el estudio 89 pacientes. La cardiopatia hipertensiva fue la asociada mas frecuentemente (39%). Presentaban disfuncion sistolica ventricular izquierda el 24% de los pacientes. Se observo una reduccion estadisticamente significativa en el area de la auricula derecha, el area de la auricula izquierda, los diametros telediastolico y telesistolico del ventriculo izquierdo y el septo interventricular. Hubo una mejoria significativa en la fraccion de contraccion de la auricula derecha y la fraccion de eyeccion del ventriculo izquierdo, asi como en la reduccion de hipertension pulmonar. Se observo un cambio significativo en el patron de disfuncion diastolica, que paso de grado III (60% basal) a grado I (el 81% en el seguimiento). No se encontraron diferencias estructurales basales ni en el seguimiento entre los pacientes con aleteo auricular paroxistico o persistente, excepto en la funcion diastolica basal. Conclusiones La ablacion con cateter del istmo cavotricuspideo en el aleteo auricular tipico produjo al cabo de 1 ano de seguimiento un remodelado cardiaco inverso estructural y funcional, con mejoria de la fraccion de eyeccion del ventriculo izquierdo, la fraccion de contraccion de la auricula derecha y el patron de disfuncion diastolica.

Background Cavotricuspid isthmus (CTI) ablation is the treatment of choice in preventing recurrences of typical atrial flutter (AFl). However, little is known about long-term quality of life (QoL) after CTI ablation. Methods and results From 01/2003 to 05/2005, 94 patients who consecutively underwent typical AFl ablation were included in the study. An SF-36 health questionnaire was self-administered before ablation and at follow-up. Transformed scores were calculated, adjusted for age and sex and then normalized and standardized for the Spanish population. Additionally, the minimal important differences (MID) were calculated to assess the smallest change in QoL that patients perceived as positive. A linear regression model was constructed to assess long-term QoL predictors. All SF-36 scales were lower than Spanish population scores. After a mean (SD) follow-up of 6.25 (0.5) years, all scales, except Bodily Pain, were higher than baseline. There was a significant difference for Physical Role (46.4 vs. 38.6, p