ABSTRACT Introduction and objectives: The COVID-19 epidemic and the declaration of the state of alarm have led to a decrease in healthcare activity in interventional cardiology units. The objective ...of this study is to quantify these changes in activity, with special interest in the treatment of patients with ST-segment elevation myocardial infarction (STEMI). Methods: A telematic survey of 81 centers involved in STEMI networks in the 17 autonomous communities of Spain. Information was collected on diagnostic activity, percutaneous coronary intervention (PCI), structural interventions, and PCI in STEMI on changes in the organization of STEMI networks, and on the prevalence of COVID-19 among interventional cardiologists. Data was compared for the week of February 24 through March 1 (before the outbreak) and for the week of March 16 through March 22 (during the outbreak). Results: Response has been obtained from 73 centers (90%). A very significant decrease in the number of diagnostic procedures (─56%), PCI (─48%), structural interventions (─81%) and PCI in STEMI (─40%) has been observed. A slight increase in the use of pharmacological thrombolysis has been reported, although primary angioplasty remains the leading reperfusion strategy. Up to 5% of interventional cardiologists (17) had COVID-19. Conclusions: An important reduction in the activity in interventional cardiology has been observed during the COVID-19 epidemic. Likewise, a great decrease has been detected in the number of patients treated in the STEMI networks, with the risk of increased morbidity and mortality that this represents. Scientific societies and health authorities have to promote that patients presenting STEMI compatible symptoms proceed with no delay to access the health system to receive reperfusion treatment in an appropriate way.
The aim of this study was to assess clinical and prognosis differences in patients with COVID-19 and STEMI.
Using a nationwide registry of consecutive patients managed within 42 specific STEMI care ...networks, we compared patient and procedure characteristics and in-hospital outcomes in two different cohorts, according to whether or not they had COVID-19. Among 1,010 consecutive STEMI patients, 91 were identified as having COVID-19 (9.0%). With the exception of smoking status (more frequent in non-COVID-19 patients) and previous coronary artery disease (more frequent in COVID-19 patients), clinical characteristics were similar between the groups, but COVID-19 patients had more heart failure on arrival (31.9% vs 18.4%, p=0.002). Mechanical thrombectomy (44% vs 33.5%, p=0.046) and GP IIb/IIIa inhibitor administration (20.9% vs 11.2%, p=0.007) were more frequent in COVID-19 patients, who had an increased in-hospital mortality (23.1% vs 5.7%, p<0.0001), that remained consistent after adjustment for age, sex, Killip class and ischaemic time (OR 4.85, 95% CI: 2.04-11.51; p<0.001). COVID-19 patients had an increase of stent thrombosis (3.3% vs 0.8%, p=0.020) and cardiogenic shock development after PCI (9.9% vs 3.8%, p=0.007).
Our study revealed a significant increase in in-hospital mortality, stent thrombosis and cardiogenic shock development after PCI in patients with STEMI and COVID-19 in comparison with contemporaneous non-COVID-19 STEMI patients.
In catheter-based procedures, acute kidney injury (AKI) is a frequent, serious complication ranging from 10% to 30%. In MitraClip (Abbott Vascular, Santa Clara, California), a usually contrast-free ...procedure, there is scarce data about its real incidence and impact.
This study aimed to evaluate incidence, predictive factors, and midterm outcomes of AKI in patients with significant mitral regurgitation (MR) undergoing transcatheter valve repair with MitraClip.
A total of 721 patients undergoing MitraClip were included. AKI was defined as an absolute or a relative increase in serum creatinine of >0.3 mg/dl or ≥50%, respectively, or the need for hemodialysis during index hospitalization.
The mean age of the patients was 72 ± 11 years (28.3% women). Median estimated glomerular filtration rate (eGFR) was 43.7 ml/min/1.73 m2 (interquartile range: 30.9 to 60.1 ml/min/1.73 m2), and was <60 ml/min/1.73 m2 in 74.9% of the patients. AKI after MitraClip occurred in 106 patients (14.7%). Baseline hemoglobin (<11 g/dl) (odds ratio OR: 1.97; p = 0.003), urgent procedure (OR: 3.44; p = 0.003), and absence of device success (OR: 3.37; p < 0.001) were independent predictors of AKI. Patients with AKI had worse outcomes compared to those without AKI, including a higher proportion of in-hospital bleeding events (3.8% vs. 0.8%; p = 0.011), 2-year all-cause mortality (40.5% vs. 18.7%; p <0.001), and major adverse cardiac events (63.6% vs. 23.5%; p <0.001). Combination of AKI with significant residual MR after the procedure conferred even worst outcomes (2-year all-cause mortality 50.0% vs. 19.6%; p = 0.001, and major adverse cardiac events 70.0% vs. 18.9%; p < 0.001).
Despite being a “zero-contrast” procedure, one-sixth of patients undergoing transcatheter mitral valve repair had AKI, linked to device failure or other severe conditions. The occurrence of AKI was associated with worse outcomes, highlighting the importance to detect and reduce this complication in high-risk population.
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The aims of this study were to determine the rate of noncentered coronary ostia and their risk for coronary overlap (CO) and to develop an improved orientation strategy for transcatheter aortic valve ...replacement (TAVR) devices taking into account anatomical cues to identify patients at risk for CO regardless of commissural alignment and compute an alternative, CO-free TAVR rotation angle for those patients.
Commissural alignment during TAVR reduces CO risk. However, eccentricity of coronary ostia from the center of the sinus of Valsalva may result in CO even after perfect alignment of TAVR commissures.
Baseline computed tomography from TAVR candidates helped identify distance from commissures to the right coronary artery (RCA) and the left coronary artery (LCA). Then, for each case, a virtual valve was simulated with ideal commissural or coronary alignment, and the degree of CO was determined. On the basis of the potential BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) efficacy, 3 groups were defined: no risk for CO (>35° from neocommissure to coronary ostia), moderate risk (20°-35°), and severe risk (≤20°).
Computed tomographic studies from 107 patients were included. After excluding 7 patients (poor quality or bicuspid valve), 100 patients were analyzed. The RCA showed greater eccentricity compared with the LCA (18.5° IQR: 3.3°-12.8° vs 6.5° IQR: 3.3°-12.8°; P < 0.001). The mean intercoronary angle was 140.0° ± 18.7° (95% CI: 136.3°-143.7°). Thirty-two patients had moderate to severe risk for CO (≤35°) despite ideal commissural alignment. Greater coronary eccentricity (cutoff for RCA, 24.5°; cutoff for LCA, 19°) and intercoronary angle >147.5° or <103° were associated with greater risk for moderate to severe CO despite commissural alignment (area under the curve: 0.97; 95% CI: 0.91-0.99). If optimal coronary alignment was simulated, this prevented severe CO in all cases and reduced moderate CO from 27% to 5% (P < 0.001).
One third of patients would have CO during TAVR-in-TAVR despite commissural alignment; a 6-fold decrease in this risk was achieved with optimized coronary alignment. Coronary eccentricity and intercoronary angle were the main predictors.
Abstract Introduction and objectives: Complete revascularization is recommended for the management of ST-segment elevation myocardial infarctions (STEMI). Although physiological evaluation is ...recommended for the assessment of nonculprit lesions, in this context, the use of fractional flow reserve (FFR) is limited. The quantitative flow ratio (QFR) is a new angiography-based tool for the assessment of functional severity. We evaluated the functional changes occurring in nonculprit lesions after the acute phase and the QFR/FFR correlation in non-infarct-related arteries. Methods: We recruited all patients with multivessel disease admitted to our institution due to STEMI from January 2016 through December 2017 who underwent staged interventions for the management of nonculprit lesions. We conducted a retrospective QFR assessment at both the index and the staged procedures and drew a comparison. Also, the QFR/FFR concordance and agreement were prospectively evaluated between January and May 2018 in a cohort of patients with STEMI and multivessel disease. Results: We analyzed a total of 131 lesions in 88 patients. During the initial procedure, 93.1% of the lesions were considered significant based on the angiography compared to only 56.3% studied through QFR (P ≤ .001). The QFR reassessment during the staged intervention brought this percentage down to 32.1%. All patients with QFR values ≥ 0.82 during the index procedure remained nonsignificant at the staged assessment. Both the FFR and the QFR were compared in 12 patients showing good agreement and a mean difference of 0.015 ± 0.02 (P > .1). Conclusions: The QFR-based physiological assessment of nonculprit lesions in STEMI patients led us to consider nonsignificant 40% of the lesions classified as significant by the angiography. Also, the QFR significantly increased from the acute phase to the staged procedure, indicative that in patients with QFR ≥ 0.82 in the acute phase a new coronary angiography procedure may be unnecessary.
ABSTRACT Introduction and objectives: Geographical and organizational differences between different autonomous communities (AC) can generate differences in care for ST-segment elevation myocardial ...infarction (STEMI). A total of 17 heart attack code programs have been compared in terms of incidence rate, clinical characteristics, reperfusion therapy, delay to reperfusion, and 30-day mortality. Methods: National prospective observational study (83 centers included in 17 infarction networks). The recruitment period was 3 months (April 1 to June 30, 2019) with clinical follow-up at 30 days. Results: 4366 patients with STEMI were included. The incidence rate was variable between different AC (P < .0001), as was gender (P = .003) and the prevalence of cardiovascular risk factors (P < .0001). Reperfusion treatment was primary angioplasty (range 77.5%-97.8%), fibrinolysis (range 0%-12.9%) or no treatment (range 2.2%- 13.5%). The analysis of the delay to reperfusion showed significant differences (P < .001) for all the intervals analyzed. There were significant differences in 30-days mortality that disappeared after adjusting for clinical and healthcare network characteristics. Conclusions: Large differences in STEMI care have been detected between the different AC, in terms of incidence rate, clinical characteristics, reperfusion treatment, delay until reperfusion, and 30-day mortality. The differences in mortality disappeared after adjusting for the characteristics of the patient and the care network.
RESUMEN Introducción y objetivos: La epidemia de COVID-19 y la declaración del estado de alarma han propiciado una disminución en la actividad en la cardiología intervencionista. El objetivo de este ...estudio es cuantificar esta disminución, con especial interés en el funcionamiento del código infarto. Métodos: Se realizó una encuesta telemática a 81 centros de las 17 comunidades autónomas españolas con procedimientos de código infarto. Se recogió información sobre la actividad diagnóstica, el intervencionismo coronario, el intervencionismo estructural y el intervencionismo en el seno del infarto agudo de miocardio con elevación del segmento ST (IAMCEST) sobre cambios en la organización de las redes del infarto y sobre la afección por COVID-19 de las plantillas de cardiología intervencionista. Se compararon 2 periodos: uno entre el 24 de febrero y el 1 de marzo (antes del inicio de la pandemia en España) y el otro entre el 16 y el 22 de marzo (durante la pandemia). Resultados: Se obtuvo respuesta de 73 centros (90%) que evidenció una disminución significativa en el número de procedimientos diagnósticos (─56%), terapéuticos coronarios (─48%), terapéuticos estructurales (─81%) y en el seno del IAMCEST (─40%). Se indicó un leve incremento en el uso de trombolisis. Se diagnosticó infección por COVID-19 en 17 cardiólogos intervencionistas (5%). Conclusiones: Se observó una reducción importante de la actividad asistencial durante la epidemia de COVID-19 y una gran disminución en el número de pacientes tratados con IAMCEST, con el riesgo de incremento de morbimortalidad que esto supone. Las sociedades científicas y autoridades sanitarias deberían promover que los pacientes con síntomas compatibles con IAMCEST demanden asistencia al sistema sanitario para poder recibir el tratamiento de reperfusión de forma adecuada.
Transcatheter edge-to-edge repair (TEER) should be considered in patients with heart failure and secondary mitral regurgitation (MR). Angiotensin receptor-neprilysin inhibitors (ARNIs) have been ...demonstrated to improve prognosis in heart failure. We aimed to evaluate the impact ARNIs on patient selection and outcomes.
The population of the Spanish TEER prospective registry (March 2012 to January 2021) was divided into 2 groups: a) TEER before the ARNI era (n=450) and b) TEER after the recommendation of ARNIs by European Guidelines (n=639), with further analysis according to intake (n=52) or not (n=587) of ARNIs.
A total of 1089 consecutive patients underwent TEER for secondary MR. In the ARNI era, there was a reduction in left ventricle dilation (82mL vs 100mL, P=.025), and better function (35% vs 38%, P=.011). At 2 years of follow-up, mortality (10.6% vs 17.3%, P <.001) and heart failure readmissions (16.6% vs 27.8%, P <.001) were lower in the ARNI era, but not recurrent MR. In the ARNI era, 1- and 2-year mortality were similar irrespective of ARNI intake but patients on ARNIs had a lower risk of readmission+mortality at 2 years (OR, 0.369; 95%CI, 0.137-0.992; P=.048), better NYHA class, and lower recurrence of MR III-IV (1.9% vs 14.3%, P=.011).
Better patient selection for TEER has been achieved in the last few years with a parallel improvement in outcomes. The use of ARNIs was associated with a significant reduction in overall events, better NYHA class, and lower MR recurrence.
En insuficiencia cardiaca persistente con insuficiencia mitral (IM) secundaria se debe considerar la reparación transcatéter borde-a-borde (TEER) de la válvula mitral. Los inhibidores de neprilisina (ARNIs) demostraron mejorar el pronóstico en insuficiencia cardiaca. Nuestro objetivo fue evaluar el impacto de los ARNIs en la selección y resultados.
La población del registro nacional de TEER (marzo/2012-enero/2021) se dividió en 2 grupos: a) TEER pre-ARNI (n=450) y b) TEER una vez que los ARNIs se recomendaron en guías europeas (n=639), teniendo en cuenta si se prescribieron (n=52) o no (n=587).
Un total de 1.089 pacientes consecutivos se sometieron a TEER para el tratamiento de la IM. Presentaron menor tamaño ventricular izquierdo (100 frente a 82mL, p=0,025) y mejor función (35 frente a 38%, p=0,011) en la era ARNI. A los 2 años, la mortalidad (10,6 frente a 17,3%, p <0,001) y los ingresos por insuficiencia cardiaca (16,6 frente a 27,8%, p <0,001) fueron menores, pero no la recurrencia de IM. En la era ARNI, la mortalidad fue comparable independientemente de la prescripción de ARNIs, pero tuvieron menor tasa de muerte+re-hospitalización a 2 años (OR=0,369, IC95%, 0,137-0,992, p=0,048), mejor NYHA y menor recurrencia de IM (1,9 frente al 14,3%, p=0,011).
Se observó una mejor selección y resultados en candidatos a TEER en la era ARNI y su prescripción se asoció a una reducción significativa de eventos globales, mejor NYHA y menor recurrencia de la IM.
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