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Transcatheter heart valve embolization is a serious and rare complication of transcatheter aortic valve replacement. Having a strategy for promptly managing transcatheter heart valve embolization is crucial to avoid emergency conversion from transcatheter aortic valve replacement to open-heart surgery. Many cases of transcatheter heart valve embolization occurring with balloon-expandable prostheses such as the SAPIEN 3 (Edwards LifeSciences Corporation) valve and self-expandable prostheses such as the ACURATE neo (Boston Scientific Corporation) valve have been reported in the literature. Here, for the first time (to the authors’ knowledge), the case of a Myval (Meril Life Sciences Pvt Ltd) transcatheter heart valve embolization during transcatheter aortic valve replacement, which was treated percutaneously with favorable outcomes, is reported.

Background: Obstructive complications in the Fontan circulation pose significant risks to affected patients. Traditional management strategies may be insufficient, necessitating innovative treatment approaches. This case report discusses the use of the FlowTriever Retrieval System for percutaneous aspiration thrombectomy in a patient with a history of Fontan procedure who developed conduit obstruction due to thrombus formation. Case report: A 28-year-old male with a history of double inlet left ventricle and previous Fontan procedure presented with progressive dyspnea. Despite initial thrombectomy for high-risk pulmonary embolism, thrombi remained in the Fontan conduit and inferior vena cava. The patient remained hemodynamically unstable. Imaging confirmed thrombosis of the extracardiac conduit. An innovative percutaneous approach using the FlowTriever system successfully restored conduit flow and removed thrombus. Subsequent stenting addressed residual stenosis. Post-intervention, the patient showed remarkable clinical improvement. There were no procedure-related complications. He was discharged on an optimized anticoagulation regimen and remained asymptomatic during follow-up. Conclusion: This case demonstrates the efficacy of the FlowTriever Retrieval System in managing complex thrombotic obstructions in Fontan circulation, which not only effectively resolved the obstruction but also maintained haemodynamic stability, thus highlighting its potential to enhance current treatment modalities for such congenital heart conditions.

RESUMEN Introducción y objetivos: El uso contemporáneo y los resultados de la aterectomía coronaria con láser Excímer (ELCA) en el intervencionismo coronario percutáneo (ICP) de lesiones coronarias gravemente calcificadas no están establecidos. El objetivo de este estudio fue evaluar la eficacia, seguridad y resultados a 1 año de ELCA en este escenario. Métodos: Se revisaron de forma retrospectiva las características clínicas y angiográficas, y los resultados de los procedimientos de revascularización de lesiones gravemente calcificadas tratadas con ICP asistido por ELCA en nuestro centro entre 2016 y 2022. Resultados: Se incluyeron 78 pacientes consecutivos (80 procedimientos) (edad media 71,2 ± 8,6 años, 80,5% varones). La presentación clínica fue enfermedad arterial coronaria estable en 45 (56,2%) pacientes y síndromes coronarios agudos en 33 (43,8%). Todas las lesiones presentaban calcificación grave. Además, el 40% eran lesiones incruzables, el 28,75% lesiones indilatables, el 2,5% reestenosis intrastent, el 6,25% infraexpansión del stent y el 7,5% oclusiones crónicas. La combinación de ≥ 2 de los escenarios anatómicos anteriores existió en el 12,5% de los procedimientos. La fluencia máxima fue de 73 ± 9,6 mJ/mm2 y la frecuencia máxima de 72,7 ± 10,4 Hz. ELCA con lavado con solución salina se utilizó inicialmente en todos los procedimientos y se utilizó contraste en 2 procedimientos. La tasa de éxito de ELCA y de éxito técnico fueron del 91,25 %. Fueron necesarias terapias adyuvantes de modificación de placa en 4 casos. La tasa de éxito clínico fue del 87,5%. Ocurrieron complicaciones relacionadas con ELCA en 2 (2,5%) procedimientos. Tras una mediana de seguimiento de 15,5 meses (IQR, 5,0-29,3), se produjeron eventos cardiovasculares adversos mayores (MACE) (nueva revascularización de la lesión diana, infarto de miocardio o muerte cardiaca) en 9 pacientes (11,25%). Conclusiones: A pesar de la complejidad de la ICP en lesiones gravemente calcificadas, ELCA demostró ser efectivo con una incidencia relativamente baja de complicaciones relacionadas con ELCA y MACE en el seguimiento.

ABSTRACT Introduction and objectives: No previous studies have established the contemporary use and outcomes of Excimer laser coronary atherectomy (ELCA) in percutaneous coronary intervention (PCI) of severely calcified coronary lesions. The aim of this study was to assess the safety, efficacy, and 1-year outcomes of ELCA in this setting. Methods: We retrospectively examined the clinical and angiographic characteristics and procedural outcomes of severely calcified lesions treated with ELCA-assisted PCI in our institution between 2016 and 2022. Results: Seventy-eight consecutive patients (80 procedures) were included (mean age 71.2 ± 8.6 years, 80.5% men). Clinical presentation was stable coronary artery disease in 45 patients (56.2%) and acute coronary syndromes in 33 (43.8%). All the lesions were severely calcified. In addition, 40% were uncrossable lesions, 28.75% were undilatable lesions, 2.5% showed in-stent restenosis, 6.25% showed stent underexpansion, and 7.5% were chronic total occlusions. The combination of ≥ 2 of the above anatomic settings was found in 12.5% of the procedures. The maximum fluence was 73 ± 9.6 mJ/mm2, and the maximum frequency was 72.7 ± 10.4 Hz. The saline flushing technique was initially used in all the procedures, while contrast was used in 2 procedures. The ELCA success and technical success rates were both 91.25%. Adjuvant plaque modification therapies were required in 4 patients. The clinical success rate was 87.5%. ELCA-related complications occurred in 2 procedures (2.5%). After a median follow-up of 15.5 months [IQR, 5.0-29.3], major adverse cardiac events (MACE) (target lesion revascularization, myocardial infarction or cardiac death) occurred in 9 patients (11.25%). Conclusions: Despite the complexity of PCI in severely calcified lesions, ELCA was effective with a relatively low incidence of ELCA-related complications and MACE during follow-up.

RESUMEN Introducción y objetivos: La calcificación coronaria es uno de los principales factores que inciden negativamente en la seguridad y la eficacia del intervencionismo coronario percutáneo. Existen varias técnicas de modificación del calcio, pero falta evidencia de estudios aleatorizados sobre la terapia de elección en este escenario. Métodos: El ROLLERCOASTR es un estudio prospectivo, multicéntrico y aleatorizado, diseñado para comparar la seguridad y la eficacia de 3 técnicas de modificación de la placa en el contexto de calcificación coronaria moderada o grave: aterectomía rotacional (AR), aterectomía coronaria con láser láser excimer (ACLE) y litotricia intracoronaria (LIC). El objetivo primario es la expansión del stent evaluada mediante tomografía de coherencia óptica. Su análisis se hará por intención de tratar, con un α de 0,05 entre el grupo de referencia (AR) y cada uno de los otros grupos (ACLE y LIC). Se realizará también un análisis del objetivo primario por protocolo para mantener la coherencia. Si se confirma la hipótesis de no inferioridad, se realizará un análisis bilateral de superioridad. El comité de eventos clínicos y el laboratorio central independiente no conocerán la rama de tratamiento. Asumiendo un error α de 0,05, un error β de 0,2 (80% de potencia), un margen de irrelevancia (ε) del 7% y un 10% de pérdidas por dificultad de medición o imposibilidad de completar la intervención, se estima un tamaño de muestra de 56 casos en cada grupo. Los objetivos secundarios son el éxito del dispositivo, el éxito del procedimiento, la tasa de cruce entre técnicas y la presentación de eventos cardiovasculares adversos importantes al año de seguimiento. Conclusiones: El estudio ROLLERCOASTR evaluará y comparará la seguridad y la eficacia, en pacientes con estenosis coronaria calcificada, de 3 técnicas de modificación de placa: AR, ACLE y LIC. Este ensayo se ha registrado en Clinicaltrials.gov: NCT04181268.

ABSTRACT Introduction and objectives: Coronary calcification is one of the leading factors that affect negatively the safety and effectiveness of percutaneous coronary intervention. Several calcium modification techniques exist. However, there is a lack of randomized evidence on the therapy of choice in this scenario. Methods: The ROLLERCOASTR is a prospective, multicenter, randomized clinical trial designed to compare the safety and efficacy profile of 3 plaque modification techniques in the moderate-to-severe coronary calcification setting: rotational atherectomy (RA), excimer laser coronary angioplasty (ELCA), and intravascular lithotripsy (IVL). The study primary endpoint is stent expansion evaluated by optical coherence tomography. An intention-to-treat analysis will be conducted with an alpha coefficient of 0.05 between the reference group (RA) and the remaining 2 groups (ELCA and IVL). An analysis of the study primary endpoint per protocol will be conducted for consistency purposes. If the non-inferiority hypothesis is confirmed, a superiority 2-sided analysis will be conducted. Both the clinical events committee and the independent core laboratory will be blinded to the treatment arm. Assuming an α error of 0.05, an β error of 0.2 (80% power), a margin of irrelevance (ε) of 7, and losses of 10% due to measurement difficulty or impossibility to complete the intervention, we estimate a sample size of 56 cases per group. The study secondary endpoints are device success, procedural success, crossover rate among the different techniques used, and the occurrence of major adverse cardiovascular events at 1-year follow-up. Conclusions: The ROLLERCOASTR trial will evaluate and compare the safety and effectiveness of 3 plaque modification techniques: RA, ELCA, and IVL in patients with calcified coronary stenosis. This trial was registered at clinicaltrials.gov with identifier NCT04181268.

BackgroundThird generation drug-eluting stents (DES) potentially offer better technical performance and reduced neointimal proliferation than previous generation DES. The XLIMIT non-inferiority trial evaluated the performance of the Xlimus (a novel sirolimus-eluting coronary stent system) in terms of endothelialization and tissue healing compared to the bioresorbable polymer Synergy DES.MethodsA total of 177 patients undergoing percutaneous coronary intervention (PCI) were randomized in a 2:1 ratio (2 Xlimus: 1 Synergy). The primary endpoints, defined as the in-stent neointimal volume weighted by the sum of the lengths of the implanted stent (ISNV) and the in-stent neointimal percent volume obstruction (%VO) were evaluated at 6–9 months by means of optical coherence tomography (OCT). Additional OCT parameters as well as clinical endpoints were also collected.ResultsMost of the patients were males (77.4%), and the mean age was 64 years. One third of the population had stable angina/silent ischemia. A total of 300 stents (237 lesions) were analyzed: 198 (152 lesions) were in the Xlimus group, and 102 (85 lesions) in the Synergy group. The ISNV in the Xlimus group was 30.7 ± 24.5 mm3 while in the Synergy group it was 26.5 ± 26.7 mm3: the difference between the two means was 0.08 (−0, 04–0, 45), p = 0.018, thus meeting the non-inferiority hypothesis. The %VO was 16.3% ± 10.4% and 13.3% ± 10.8% in the Xlimus and Synergy groups, respectively: the difference between the two means was 3.0 (−0, 06–4, 2), (p = 0.01), thus meeting the non-inferiority hypothesis. No difference was found with respect to the secondary OCT endpoints as well as for clinical endpoints.ConclusionsThe study results confirm that the biological interaction of the Xlimus and Synergy DES with the coronary artery is comparable, and that translates in very reassuring OCT parameters at follow-up: as such, the Xlimus is non-inferior to the Synergy.Clinical Trial RegistrationClinicalTrials.gov, identifier (NCT03745053).

Abstract Background Since the last century, the electrocardiogram (ECG) remains the non‐invasive test, that is, most easily accessible, feasible, and inexpensive for cardiology assessment. In past years, many novel ECG indexes and patterns have been published that allow for a more advanced evaluation of what is currently being done, especially based on subtle QRS changes and patterns. Objective The objective of the study was to provide an update on the evidence and clinical applications of these ECG subtle QRS changes and patterns associated with heart disease. Methods Through the literature review, we will highlight the subtle QRS changes and patterns associated with heart disease, mainly focusing on QRS duration, voltage, morphology, axis, and QT interval. Results Small increases in QRS duration are associated with a reduction in left ventricular ejection fraction (EF), increased cardiac chamber dimensions, and risk for incident heart failure (HF). Moreover, fragmentation of the QRS complex is associated with myocardial fibrosis and is a substrate for developing arrhythmic events. Besides, low amplitude QRS voltage is associated with congestive HF, and an increase in the voltage of the QRS complexes is associated with the effectiveness of diuresis treatment. Furthermore, small increases in QT interval are associated with diastolic dysfunction due to impaired sarcoplasmic reticulum calcium handling as occurs in myocardial ischemia, hypertension, or diabetes. On the other hand, in patients with left ventricular dysfunction, the QRS area is associated with clinical and echocardiographic response to cardiac resynchronization therapy regardless of the type of bundle branch block. In addition, subtle ECG changes and patterns in the left bundle branch block are associated with concomitant right ventricular dilation, mostly based on the QRS axis and voltage. Notwithstanding, to identify these subtle changes in QRS require exact manual measurements that can take time. In this regard, applying artificial intelligence (AI) to the ECG can make a quicker and more complete assessment, as well as provide a low cost when applied to large populations. Conclusion We provided an update on the evidence and clinical applications of these subtle QRS changes and patterns associated with diastolic dysfunction, reduced EF, and HF development and therapy responsiveness, as well as their applications for AI to ECG.

Se presenta el caso de un varón de 74 años ingresado por síndrome coronario agudo sin elevación del segmento ST. La coronariografía realizada mostró una estenosis de la arteria coronaria derecha con un aneurisma coronario (AC) gigante y alta carga trombótica (figura 1A). Se recomendó doble antiagregación y anticoagulación oral para excluir el AC en un segundo tiempo. Tras confirmar la reducción del trombo (figura 1B), se predilató y se midió la longitud del AC (40 mm) y de la zona de aterrizaje mediante ecografía intravascular (IVUS) (figura 1C). Se implantaron 2 stents coronarios recubiertos PK-Papyrus (SCR) de 5 × 26 mm (Biotronik, Suiza) de proximal a distal. La zona de solapamiento de ambos stents se confirmó mediante StentBoost (Philips Medical Systems, Países Bajos) (figura 1D). El stent se implantó bajo fluoroscopia y en ausencia de movimientos respiratorios. La siguiente angiografía reveló la exclusión incompleta del AC (figura 1E) a pesar de posdilatación con un balón no compliante (BNC) de 5,5 mm. El IVUS confirmó la existencia de un gap entre ambos stents debido al acortamiento de los mismos (E2, figura 1E y vídeo 1 del material adicional). Se implantó otro SCR de 5 × 15 mm y se posdilató...

Seventy-four-year-old male patient admitted with non-ST-elevation acute myocardial infarction. The coronary angiography performed revealed the presence of right coronary artery stenosis with a giant coronary artery aneurysm (CAA) and high thrombus burden (figure 1A). Dual antiplatelet and anticoagulation therapies were recommended for its exclusion in a staged procedure. After confirmation of thrombus reduction (figure 1B), predilatation was attempted and both the length of the CAA (40 mm) and the landing zone were measured on the intravascular ultrasound (IVUS) (figure 1C). From proximal to distal, two 5 mm x 26 mm-PK-Papyrus covered coronary stents (PCS) (Biotronik, Switzerland) were deployed. The overlapping stent zone was confirmed using the StentBoost imaging modality (Philips Medical Systems, Nederland) (figure 1D) and the stent was deployed under fluoroscopic guidance in the absence of any respiratory movements. The subsequent angiography performed revealed an incomplete CAA exclusion (figure 1E) despite postdilatation with a 5.5 mm noncompliant balloon (NCB). The IVUS confirmed the existence of a gap between both stents due to stent shortening (E2, figure 1E and video 1 of the supplementary data). Another 5 mm × 15 mm PCS was deployed followed by postdilatation with a 5.5 mm NCB. Both the angiography and the IVUS confirmed the...

The angiotensin-converting enzyme 2 (ACE2) is a type I integral membrane that exists in two forms: the first is a transmembrane protein; the second is a soluble catalytic ectodomain of ACE2. The catalytic ectodomain of ACE2 undergoes shedding by a disintegrin and metalloproteinase domain-containing protein 17 (ADAM17), in which calmodulin mediates the calcium signaling pathway that is involved in ACE2 release, resulting in a soluble catalytic ectodomain of ACE2 that can be measured as soluble ACE2 plasma activity. The shedding of the ACE2 catalytic ectodomain plays a role in cardiac remodeling and endothelial dysfunction and is a predictor of all-cause mortality, including cardiovascular mortality. Moreover, considerable evidence supports that the ACE2 catalytic ectodomain is an essential entry receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Additionally, endotoxins and the pro-inflammatory cytokines interleukin (IL)-1β and tumor necrosis factor-alpha (TNFα) all enhanced soluble catalytic ectodomain ACE2 shedding from the airway epithelia, suggesting that the shedding of ACE2 may represent a mechanism by which viral entry and infection may be controlled such as some types of betacoronavirus. In this regard, ACE2 plays an important role in inflammation and thrombotic response, and its down-regulation may aggravate COVID-19 via the renin-angiotensin system, including by promoting pathological changes in lung injury. Soluble forms of ACE2 have recently been shown to inhibit SARS-CoV-2 infection. Furthermore, given that vitamin D enhanced the shedding of ACE2, some studies reported that vitamin D treatment is associated with prognosis improvement in COVID-19. This is an updated review on the evidence, clinical, and therapeutic applications of ACE2 for COVID-19.

Mujer de 85 años con angina inestable que presentaba lesiones graves y muy calcificadas en las arterias coronaria derecha proximal (figura 1A, asterisco) y descendente anterior proximal-media (figura 1B, asterisco). Figura 1. Se realizó aterectomía rotacional con el sistema RotaPro (Boston Scientific, EE.UU.) en la coronaria derecha (figura 1C) y se implantó un stent farmacoactivo, con buen resultado (figura 1D) confirmado mediante ecografía intracoronaria (figura 1E). Se obtuvo el consentimiento informado de la paciente. Tras sondar el tronco coronario izquierdo (TCI) se cruzó la guía a la descendente anterior. Se avanzó una oliva de 1,5 mm en modo dynaglide hasta el TCI, momento en que el catéter guía se extubó y se produjo una perforación Ellis-III en el TCI (figura 2A, asterisco; vídeo 1 del material adicional); es posible que una deformación inadvertida de la guía dirigiera la oliva hacia la pared del vaso. La paciente presentó taponamiento cardiaco, que fue tratado con pericardiocentesis. Se implantó un stent recubierto PK-Papyrus (Biotronik, Alemania) de 4 × 15 mm en el TCI sin enjaular la bifurcación (figura 2B). Sin embargo, se mantenía una discreta fuga de contraste (figura 2C, asterisco). Tras posdilatar con balón de 4,5 mm, la perforación quedó sellada (figura 2D; vídeo 2...

Eighty-five-year-old woman with unstable angina with serious and heavily calcified lesions in proximal right coronary arteries (figure 1A, asterisk) and proximal and mid left anterior descending coronary artery (figure 1B, asterisk). Rotational atherectomy was performed in the right coronary artery using the RotaPro system (Boston Scientific, United States) (figure 1C) and a drug-eluting stent was implanted with good results (figure 1D) as confirmed by the intracoronary ultrasound (figure 1E). Informed consent was obtained from the patient. Figure 1. After the catheterization of the left main coronary artery (LMCA) the left anterior descending coronary artery was crossed. A 1.5 mm olive-shaped burr was advanced in the DynaGlide mode towards the LMCA, which is when the guide catheter was extubated and an Ellis type III perforation occurred in the LMCA (figure 2A, asterisk; video 1 of the supplementary data); it is possible that an unnoticed deformation of the guidewire moved the burr towards the vessel wall. The patient showed cardiac tamponade that was treated with pericardiocentesis. A 4 × 15 mm PK-Papyrus covered coronary stent (Biotronik, Germany) was implanted in the LMCA without jailing the bifurcation (figure 2B). However, a discrete leak of contrast still occurred (figure 2C, asterisk). After postdilatation with a 4.5 mm...

Introduction and Objectives: To investigate the incidence and clinical relevance of the presence of mobile echogenic images (MEI) during transesophageal echocardiography (TEE) for monitoring of transcatheter aortic valve implantation (TAVI). Methods: Consecutive patients referred to our center for transfemoral or transapical TAVI were included. The procedure was monitored by three-dimensional (3D) TEE and images were analyzed by two independent experts. In-hospital follow-up was carried out and correlated with imaging findings. Results: A total of 104 patients were included. MEI were visualized in 11 patients during the procedure (11%) and in over 50% of cases were identified as thrombi, however no differences in periprocedural stroke were found in follow-up. Conclusions: Visualization of MEI during 3D TEE monitoring of TAVI is relatively common (11%) and in over 50% of cases they are identified as thrombi. The clinical implications of this finding are uncertain, as despite their frequency, the incidence of clinical stroke in this patient population was no higher. 3D TEE is a useful tool for diagnosis of MEI and can alert the operator to their presence. Resumo: Introdução e objetivos: Investigar a incidência e relevância clínica da presença de imagens ecogénicas móveis (IEM), através de ecocardiografia transesofágica (ETE) durante a implantação valvular aórtica percutânea (TAVI). Métodos: Foram incluídos doentes consecutivos referenciados para o nosso centro para realização de TAVI por via transapical ou transfemoral. Foi realizada a monitorização da ETE 3 D e as imagens foram analisadas por dois peritos individualmente. O seguimento foi realizado no hospital e foi correlacionado com achados de imagem. Resultados: Foram definitivamente incluídos 104 doentes. Durante o procedimento foram visualizadas IEM em 11 pacientes (11%) e,em mais de 50% dos casos, foram identificadas como trombos, não tendo, no entanto, sido encontradas diferenças no seguimento dos doentes. Conclusões: A visualização das IEM através da monitorização por ETE 3 D durante a TAVI é relativamente comum (11%) e, em mais de 50% dos casos, são identificadas como trombos. As implicações clínicas deste achado são incertas, porque apesar da sua frequência não há maior incidência de acidente vascular cerebral clínico nesta população de doentes. A ETE é uma ferramenta útil para o diagnóstico e pode alertar o operador da sua presença. Keywords: Transcatheter aortic valve implantation, Three-dimensional, Aortic stenosis, Transaortic valve, Palavras-chave: Implantação valvular aórtica percutânea, 3 D, Estenose aórtica, Válvula transaórtica

Introduction: A permanent pacemaker is frequently needed after transcatheter aortic valve implantation, but the available data are mainly on the CoreValve system. Objective: To evaluate the need for new permanent pacemaker after implantation of the Edwards Sapien device, as well as related factors. Methods: We included the first 100 patients treated with the Edwards Sapien device at our institution. Of these, 12 had a permanent pacemaker before the procedure, and thus our study population was the remaining 88 patients. Results: A permanent pacemaker was indicated in eight patients (9.1%) during hospitalization or at 30 days. After discharge, another four patients needed a pacemaker (at 42 days and three, 18, and 30 months). Two variables were associated with the need for pacemaker during hospitalization: previous dialysis (13% vs. 1%, p=0.042) and complete right bundle branch block before the procedure (25% vs. 5%, p=0.032). More than one month after the procedure, the characteristics associated with the need for pacemaker were plasma creatinine level (2.5±1.7 vs. 1.3±0.6 mg/dl, p=0.001) and previous myocardial infarction (50% vs. 10%, p=0.013). Conclusion: The rate of pacemaker implantation with the Edwards Sapien device was 9.1%. Right bundle branch block and dialysis were associated with this complication. Resumo: Introdução: A necessidade de um pacemaker permanente após implantação percutânea da válvula aórtica é frequente, embora os dados disponíveis estejam principalmente associados ao sistema CoreValve. Objetivos: O objetivo foi avaliar o índice do novo pacemaker permanente, bem como todos os fatores relacionados, após a implantação do dispositivo Edwards-Sapiens. Métodos: Incluímos os primeiros 100 doentes tratados com o dispositivo Edwards-Sapiens no nosso hospital. Destes, 12 já tinham pacemaker permanente antes do procedimento, pelo que a população do estudo corresponde aos restantes 88 doentes. Resultados: O pacemaker permanente foi indicado em oito doentes (9,1%) durante o internamento ou a 30 dias. Após a alta hospitalar, outros quatro doentes necessitaram de colocar o pacemaker (aos 42 dias e aos três, 18 e 30 meses). Duas variáveis foram relacionadas com a necessidade de colocação de pacemaker durante o internamento: diálise prévia (13 versus 1%, p=0,042) e bloqueio completo do ramo direito antes do procedimento (25 versus 5%, p=0,032). Mais do que um mês após o procedimento, as características, que foram relacionadas com a necessidade de colocação de pacemaker, foram os níveis da creatinina plasmática (2,5±1,7 versus 1,3±0,6 mg/dl, p=0,001) e enfarte do miocárdio prévio (50 versus 10%, p=0,013). Conclusão: A necessidade de colocação de pacemaker após a implantação do dispositivo de Edwards-Sapiens foi de 9,1%. O bloqueio completo do ramo direito e a diálise foram associados a esta complicação. Keywords: Pacemaker, Transcatheter aortic valve implantation, Long term, Palavras-chave: Pacemaker, Implantação valvular aórtica percutânea, Longo prazo

Objective: To analyze long-term survival and predictors of mortality in patients evaluated for transcatheter aortic valve implantation (TAVI) depending on the decision taken by the heart team. Methods: All patients with severe aortic stenosis and high surgical risk evaluated for TAVI between June 2008 and June 2012 were included. Patients were grouped according to the therapeutic strategy decided by the heart team. Mean follow-up was 16.6 months (maximum 55.3). Results: A total of 149 patients were evaluated: 79 were accepted for TAVI, 12 had no current indication for valve replacement and were deferred, 13 were redirected to conventional surgery and 45 received medical treatment. The evaluated patients had a mean age of 83.7 years and a mean EuroSCORE of 19.8±12.3. Median survival free from all-cause death was 34.7 months (95% CI 27.1–42.3) in the TAVI group, 47.4 months (95% CI 0–97.4) in the deferred intervention group, not available in the surgery group and 8.2 months (95% CI 5.6–10.9) in the medical treatment group (log-rank p

Resumo: Neste artigo fazemos referência a um caso de reestenose muito tardia de um stent convencional que, através de duas técnicas de diagnóstico intracoronário, ultrassonografia intravascular (IVUS) e tomografia de coerência ótica (OCT), permite dar a conhecer o seu mecanismo subjacente (neoaterosclerose) e facilita o seu tratamento percutâneo (stent convencional direto intrasent). Aproveitamos também a ocasião para fazer uma breve descrição das vantagens e limitações de ambas as técnicas neste tipo de patologia. Abstract: We report a case of very late bare-metal stent restenosis, in which assessment by two intracoronary imaging techniques (intravascular ultrasound and optical coherence tomography) revealed the underlying mechanism (neoatherosclerosis) and facilitated percutaneous treatment (direct bare-metal stent-in-stent). We also take the opportunity to briefly describe the advantages and limitations of both techniques in this pathology. Palavras-chave: Neoaterosclerose, Intervenção coronária percutânea, Ultrassonografia intravascular, Tomografia de coerência ótica, Keywords: Neoatherosclerosis, Percutaneous coronary intervention, Intravascular ultrasound, Optical coherence tomography

Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are imaging methods used in the diagnosis of coronary lesions. IVUS is widely used in interventional cardiology laboratories, but OCT is now increasingly used. Conventional coronary angiography can identify different types of coronary lesions but sometimes is unable to diagnose them correctly. Both intravascular imaging methods are useful for better interpretation of these lesions, and can accurately diagnose ruptured plaques, thrombosis, stent restenosis and hazy images. However, the resolution of OCT is ten times higher than IVUS, and so an accurate diagnosis cannot always be achieved with ultrasound imaging. We present three cases in which IVUS was unable to identify the lesion causing the condition and OCT was required to obtain clearer images that helped to confirm the diagnosis. The advantages and disadvantages of each method are then discussed. Resumo: A tomografia de coerência ótica (TCO) e o ultrassom intravascular (USIV) são métodos de imagem geralmente utilizados nos serviços de cardiologia de intervenção. O USIV é um sistema de imagem intravascular, muito utilizado nos laboratórios de cardiologia de intervenção. A utilização de TCO começou mais tarde a ser divulgada na prática diagnóstica intracoronária. A angiografia coronária convencional pode identificar diferentes tipos de lesões coronárias que por vezes não são devidamente diagnosticadas. Os métodos de imagem são também utilizados para uma melhor interpretação destas lesões. As roturas de placas, trombose, reestenose de stent e outras imagens nebulosas podem ser diagnosticadas fielmente através da sua utilização. No entanto, a resolução da TCO é 10 vezes superior à do USIV. Portanto não é possível obter sempre um diagnóstico fiel com uma imagem ultra-som. Este artigo apresenta três casos em que a utilização de USIV não foi suficiente para identificar a lesão, tendo sido necessário recorrer à TOC para obter imagens mais claras que ajudaram a confirmar o diagnóstico. Segue-se a discussão das vantagens e desvantagens de cada método. Keywords: Optical coherence tomography, Intravascular ultrasound, Coronary restenosis, Coronary calcification, Coronary thrombosis, Palavras-chave: Tomografia de coerência ótica, Ultrasonografia intravascular, Reestenose coronária, Calcificação coronária, Trombose coronária

Background: Percutaneous septal ablation by alcohol-induced septal branch occlusion was introduced as a new treatment option in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Our aim was to evaluate procedural and long-term clinical and echocardiographic outcomes in patients with HOCM treated by alcohol septal ablation (ASA) at our center. Methods: This single-center retrospective study included 14 consecutive HOCM patients undergoing percutaneous ASA (66.4 ± 12.1 years, 71.4% female). At baseline all patients presented persistent symptoms despite optimized medical treatment, left ventricular outflow tract (LVOT) obstruction with a peak gradient >50 mmHg, systolic anterior motion of the mitral valve, and ventricular septal thickness ≥15 mm. ASA was considered successful when the LVOT pressure gradient fell to less than 50% of baseline value. All patients had echocardiographic evaluation at baseline, intraprocedure and at follow-up, and a long-term clinical follow-up (25 ± 38 months) with evaluation of functional class and occurrence of symptoms or cardiovascular events. Results: Percutaneous ASA achieved a 71.4% acute and 85.7% long-term success rate. Peak LVOT gradient decreased from 104 ± 40 mmHg at baseline to 58 ± 30 mmHg intraprocedure (p = 0.03) and 35 ± 26 mmHg at follow-up (p = 0.001); total gradient decrease was 75 ± 43 mmHg. Ventricular septal thickness and mitral regurgitation also presented significant decreases during follow-up (from 24 ± 5 mm to 18 ± 4 mm, p = 0.02, and from grade 2.4 ± 0.6 to 1.4 ± 0.5, p 50 mmHg, movimento sistólico anterior da válvula mitral e espessura do septo interventricular ≥15 mm. A ASA foi considerada bem sucedida quando o gradiente do LVOT diminuiu para menos de 50% do valor inicial. Todos os doentes foram submetidos a avaliação clínica e ecocardiográfica basal, intraprocedimento e durante o seguimento, com avaliação da classe funcional e ocorrência de sintomas ou eventos cardiovasculares a longo-prazo (25 ± 38 meses). Resultados: A ASA percutânea obteve uma taxa de sucesso de 71,4% e 85,7%, respetivamente aguda e a longo-prazo. O gradiente máximo do LVOT diminuiu de 104 ± 40 mmHg basais para 58 ± 30 mmHg intraprocedimento (p = 0,03) e 35 ± 26 mmHg a longo-prazo (p = 0,001); o decréscimo total do gradiente foi de 75 ± 43 mmHg. Também a espessura do septo interventricular e a regurgitação mitral apresentaram uma diminuição significativa durante o seguimento (de 24 ± 5 mm para 18 ± 4 mm, p = 0,02, e de grau 2,4 ± 0,6 para 1,4 ± 0,5, p

Resumo: Introdução: A implantação da válvula aórtica transcateter (TAVI) é uma alternativa à substituição valvular aórtica cirúrgica convencional para doentes com estenose aórtica (EA) grave e risco cirúrgico inaceitável. Métodos: Apresentamos a experiência com TAVI no nosso centro durante os primeiros anos, desde o seu início. De 76 doentes com EA avaliados para eventual TAVI, realizou-se o procedimento em 23 dos mesmos, que apresentavam um Euroscore médio de 22,4% e uma idade média de 81,5 anos. Estes 23 doentes foram seguidos de modo prospetivo durante 12,9 ± 11 meses. Resultados: A prótese foi implantada com êxito em todos os doentes. A mortalidade aos 30 dias foi de 4%. As complicações mais frequentes foram as vasculares e a necessidade de transfusão (22%) seguida de colocação de pace-maker definitivo (9%). Após um follow-up médio de 30 meses não se registou nenhum caso de disfunção protésica nem de morte cardiovascular. Conclusões: Dois anos após o início de um programa de TAVI no nosso centro, a TAVI evidencia-se como uma alternativa eficaz para doentes com EA grave inoperáveis por risco cirúrgico elevado. Abstract: Introduction: Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement in patients with severe aortic stenosis (AS) and unacceptably high surgical risk. Methods: We present our first two years’ experience with TAVI. A total of 76 AS patients were evaluated for TAVI and 23 of them underwent a TAVI procedure. These patients had a mean EuroSCORE of 22.4% and a mean age of 81.5 years, and were prospectively followed for a mean of 12.9 ± 11 months. Results: The percutaneous aortic valve was successfully implanted in 100% of the patients. Mortality at 30 days was 4%. The most common complications were access site-related bleeding and transfusion (22%), followed by new permanent pacemaker implantation (9%). After a mean follow-up of 12.9 months, survival was 87%. In a maximum follow-up of 30 months there were no cases of prosthesis dysfunction or cardiovascular death. Conclusions: Two years after the introduction of a TAVI program in our center, the procedure has established itself as a safe and effective alternative for patients with severe AS and unacceptably high surgical risk. Palavras-chave: Estenose aórtica grave, Prótese valvular cardíaca, Prótese aórtica transcateter, Intervenção cardíaca não coronária, Substituição valvular aórtica, Keywords: Aortic valve stenosis, Heart valve prosthesis, Transcatheter aortic valve implantation, Non-coronary intervention, Aortic valve replacement

Clinical trials have shown that functional assessment of coronary stenosis by fractional flow reserve (FFR) improves clinical outcomes. Intravascular ultrasound (IVUS) complements conventional angiography, and is a powerful tool to assess atherosclerotic plaques and to guide percutaneous coronary intervention (PCI). Computational fluid dynamics (CFD) simulation represents a novel method for the functional assessment of coronary flow. A CFD simulation can be calculated from the data normally acquired by IVUS images. A case of coronary heart disease studied with FFR and IVUS, before and after PCI, is presented. A three-dimensional model was constructed based on IVUS images, to which CFD was applied. A discussion of the literature concerning the clinical utility of CFD simulation is provided. Resumo: Estudos clínicos demonstraram que a avaliação funcional da doença coronária com fio de pressão e determinação da reserva fracionada de fluxo (fractional flow reserve - FFR) melhora a evolução clínica. O estudo por ultra-som intravascular (IVUS) complementa a angiografia convencional, e é uma ferramenta poderosa para a avaliação das placas ateroscleróticas orientando a intervenção coronária percutânea (ICP). A simulação computorizada da dinâmica de fluidos (CFD), representa um novo método que permite avaliar funcionalmente o fluxo coronário. A CFD pode ser calculada a partir dos dados normalmente obtidos por IVUS. É apresentado um caso de doença coronária estudada com FFR e IVUS, antes e após a ICP. Foi construído um modelo tridimensional com base nas imagens obtidas por IVUS e avaliado com a técnica de CFD. É apresentada uma discussão bibliográfica sobre a utilidade clínica da simulação com CFD. Keywords: Coronary artery disease, Myocardial fractional flow reserve, Intravascular ultrasound, Fluid dynamics, Computer simulation, Palavras-chave: Doença cardíaca coronária, Reserva fracionada de fluxo miocárdico, Ultra-sonografia intravascular, Dinâmica de fluidos, Simulação computorizada

We present the case report of a patient presenting with ST segment elevation myocardial infarction due to a subacute drug-eluting stent trombosis within the proximal segment of the left circumflex artery (LCX). Six days before a total chronic occlusion was treated at the mid segment of the LCX by overlapping two drug-eluting stents. Optical coherence tomography (OCT) was helpful to demonstrate stent underexpansion of the overlaping segment as the main mechanism of early stent thrombosis. This case is illustrative about the potential role of OCT to identify the mechanisms of ST and thus guiding the PCI procedure. Moreover, our case shows the capability of the Imagewire to cross a severe stenosis due to stent underexpansion that could not be crossed by the IVUS catheter.