The aim of this study was to determine prognostic factors for the risk of new vascular events during the first 6 months after acute myocardial infarction (AMI) or atherothrombotic stroke (AS). We ...were interested in the prognostic role of endothelial progenitor cells (EPC) and circulating endothelial cells (CEC).
Between February 2009 and July 2012, 100 AMI and 50 AS patients were consecutively studied in three Spanish centres. Patients with previously documented coronary artery disease or ischemic strokes were excluded. Samples were collected within 24h of onset of symptoms. EPC and CEC were studied using flow cytometry and categorized by quartiles. Patients were followed for up to 6 months. NVE was defined as new acute coronary syndrome, transient ischemic attack (TIA), stroke, or any hospitalization or death from cardiovascular causes. The variables included in the analysis included: vascular risk factors, carotid intima-media thickness (IMT), atherosclerotic burden and basal EPC and CEC count. Multivariate survival analysis was performed using Cox regression analysis.
During follow-up, 19 patients (12.66%) had a new vascular event (5 strokes; 3 TIAs; 4 AMI; 6 hospitalizations; 1 death). Vascular events were associated with age (P = 0.039), carotid IMT≥0.9 (P = 0.044), and EPC count (P = 0.041) in the univariate analysis. Multivariate Cox regression analysis showed an independent association with EPC in the lowest quartile (HR: 10.33, 95%CI (1.22-87.34), P = 0.032 and IMT≥0.9 HR: 4.12, 95%CI (1.21-13.95), P = 0.023.
Basal EPC and IMT≥0.9 can predict future vascular events in patients with AMI and AS, but CEC count does not affect cardiovascular risk.
Atrial fibrillation (AF) is the most common arrhythmia worldwide. It is associated with increased mortality and morbidity, especially due to the increased risk of ischemic stroke and systemic ...embolism in these patients. For this reason, thromboembolism prevention is the cornerstone of managing AF, and oral anticoagulation is nowadays the first-line treatment. However, since most thrombi form in the left atrial appendage and anticoagulant therapy may have side effects and be contraindicated in some patients, surgical and percutaneous left atrial appendage occlusion (LAAO) have emerged as a non-pharmacological alternative. This review summarizes all existing evidence on surgical and percutaneous LAAO.
Background Hypothermia has been associated with therapeutic benefits including reduced mortality and better neurologic outcomes in survivors of cardiac arrest. However, undesirable side effects have ...been reported in patients undergoing coronary interventions. Using a large animal model of temperature management, we aimed to describe how temperature interferes with the coronary vasculature. Methods and Results Coronary hemodynamics and endothelial function were studied in 12 pigs at various core temperatures. Left circumflex coronary artery was challenged with intracoronary nitroglycerin, bradykinin, and adenosine at normothermia (38°C) and mild hypothermia (34°C), followed by either rewarming (38°C; n=6) or moderate hypothermia (MoHT; 32°C, n=6). Invasive coronary hemodynamics by Doppler wire revealed a slower coronary blood velocity at 32°C in the MoHT protocol (normothermia 20.2±11.2 cm/s versus mild hypothermia 18.7±4.3 cm/s versus MoHT 11.3±5.3 cm/s,
=0.007). MoHT time point was also associated with high values of hyperemic microvascular resistance (>3 mm Hg/cm per second) (normothermia 2.0±0.6 mm Hg/cm per second versus mild hypothermia 2.0±0.8 mm Hg/cm per second versus MoHT 3.4±1.6 mm Hg/cm per second,
=0.273). Assessment of coronary vasodilation by quantitative coronary analysis showed increased endothelium-dependent (bradykinin) vasodilation at 32°C when compared with normothermia (normothermia 6.96% change versus mild hypothermia 9.01% change versus MoHT 25.42% change,
=0.044). Results from coronary reactivity in vitro were in agreement with angiography data and established that endothelium-dependent relaxation in MoHT completely relies on NO production. Conclusions In this porcine model of temperature management, 34°C hypothermia and rewarming (38°C) did not affect coronary hemodynamics or endothelial function. However, 32°C hypothermia altered coronary vasculature physiology by slowing coronary blood flow, increasing microvascular resistance, and exacerbating endothelium-dependent vasodilatory response.
Transcatheter aortic valve implantation (TAVI) now represents the mainstay of treatment for severe aortic stenosis. Owing to its exceptional procedural efficacy and safety, TAVI has been extended to ...include patients at lower surgical risk, thus now encompassing a diverse patient population receiving this treatment. Yet, long-term outcomes also depend on optimal medical therapy for secondary vascular prevention, with antithrombotic therapy serving as the cornerstone. Leveraging data from multiple randomized controlled trials, the current guidelines generally recommend single antithrombotic therapy, with either single antiplatelet therapy (SAPT) or oral anticoagulation (OAC) alone in those patients without or with atrial fibrillation, respectively. Yet, individualization of this pattern, as well as specific case uses, may be needed based on individual patient characteristics and concurrent procedures. This review aims to discuss the evidence supporting antithrombotic treatments in patients treated with TAVI, indications for a standardized treatment, as well as specific considerations for an individualized approach to treatment.
Hypertrophic cardiomyopathy (HCM) can cause symptoms due to the obstruction of the left ventricle outflow tract (LVOT). Although pharmacological therapy is the first step for treating this condition, ...many patients do not fully respond to the treatment, and an invasive approach is required to manage symptoms. Septal reduction therapies include septal myectomy (SM) and alcohol septal ablation (ASA). ASA consists of a selective infusion of high-grade alcohol into a septal branch supplying the basal interventricular septum to create an iatrogenic infarction with the aim of reducing LVOT obstruction. Currently, SM and ASA have the same level of indication; however, ASA is normally reserved for patients of advanced age, with comorbidities or when the surgical approach is not feasible. Recent data suggests that there are no differences in short- and long-term all-cause mortality, cardiovascular mortality and sudden cardiac death between ASA and SM. Despite the greater experience and refinement of the technique gained in recent years, the most common complication continues to be complete atrio-ventricular block, requiring a permanent pacemaker. Septal reduction therapies should be performed in experienced centres with comprehensive programs.
ABSTRACT Introduction and objectives: A systematic approach to patients with angina with no obstructed coronary arteries (ANOCA) or ischemia with no obstructed coronary arteries (INOCA) patients is ...not routinely implemented. Methods: All consecutive patients diagnosed with ANOCA/INOCA were referred to a designated outpatient clinic for a screening visit to assess their eligibility for a NOCA program. If eligible, patients underwent scheduled coronary angiograms with coronary function testing and intracoronary acetylcholine provocation testing. Medical therapy was optimized accordingly. All patients were then followed up at 1, 3, 6, and 12 months. Baseline and 3-month follow-up assessments included the Seattle Angina Questionnaire (SAQ) and EuroQol-5D questionnaire. Results: Of 77 patients screened, 23 (29.9%) were excluded and 54 (70.1%) were included (29 53.7% with INOCA and 25 46.3% with ANOCA). Microvascular angina was diagnosed in 19 (35.2%) patients, vasospastic angina in 12 (22.2%), both microvascular angina and vasospastic angina in 18 (33.3%), and noncoronary chest pain in 5 (9.3%). There was a notable increase in the use of beta-blockers, calcium channel blockers and nitrates. Complications occurred in 3 (5.5%) patients. Compared with baseline, there was no difference in the mean EQ-5D score at the 3-month follow-up, but there was a significant improvement in the SAQ score...
Abstract Transcarotid transcatheter aortic valve replacement (TAVR) is a new alternative in patients with contraindications to other approaches. We report results in 5 patients who underwent TAVR ...using the common carotid artery approach. Intraprocedural evaluation of the integrity of the circle of Willis was performed by measuring backflow pressure and cerebral oximetry. All patients underwent successful TAVR, without any cerebrovascular or access-related complications. Patient mobilization occurred early postprocedure and 4 of the 5 patients were discharged 3 days after the TAVR procedure. In conclusion, these results suggest that transcarotid access is a safe and feasible secondary TAVR approach.
Transcatheter tricuspid valve repair (TTVr) has emerged as an alternative for the treatment of severe tricuspid regurgitation (TR). We report our initial experience with an edge-to-edge TTVr system ...in a high-volume institution. Methods: We included consecutive patients who underwent edge-to-edge TTVr systems. The primary efficacy endpoint was a reduction in the TR of at least one grade. The primary safety endpoint was procedure-related clinical serious adverse events. Results: A total of 28 patients underwent TTVr with edge-to-edge systems. All patients presented with at least severe TR with a high impact on quality of life (82% of patients in NYHA class ≥ III). The Triclip system was the most used device (89%). The primary efficacy endpoint was met in all patients. Only one patient experienced a procedural complication (femoral pseudoaneurysm). At three-month follow-up, 83% of patients were in NYHA I or II (18% baseline vs. 83% 3 months follow-up; p < 0.001). Echocardiography follow-up showed residual TR ≤ 2 in 79% of patients (paired p < 0.001). At the maximum follow-up (median follow up = 372 days), no patients had died. Conclusions: Edge-to-edge TTVr systems seem to represent a very valid alternative to prevent morbidity and mortality associated with TR as depicted by the favorable efficacy and safety.
Current European guidelines support transcatheter aortic valve implantation (TAVI) in intermediate-to-low-risk patients ≥75 years-old, but its prognostic relevance is unknown.
...Intermediate-to-low-risk (The Society of Thoracic Surgeons score <8%) patients enrolled in the HORSE registry were included. We compared the populations aged under 75 with those over 75. The primary endpoint was all-cause mortality.
A total of 2685 patients were included: 280 (8.6%) < 75 and 2405 ≥ 75 years. Through a mean follow-up of 437 ± 381 days, 198 (8.2%) and 23 (8.2%) patients died in the two arms without statistically significant differences (log-rank
= 0.925). At Cox regression analysis, age did not predict the occurrence of all-cause death, neither as a continuous variable (HR 1.01, 95% CI 0.99-1.04,
= 0.294) nor dichotomizing according to the prespecified cutoff of 75 years (HR 0.97, 95% CI 0.63-1.51,
= 0.924). Time-to-event ROC curves showed low accuracy of age to predict all-cause mortality (area under the curve of 0.54 for both 1-year and 2-year outcomes).
TAVI has comparable benefits across age strata for intermediate-to-low-risk patients. The age cutoff suggested by the current guidelines is not predictive of the risk of adverse events during hospital stays or of all-cause mortality through a mid-term follow-up.
While transcatheter aortic valve implantation (TAVI) has rapidly evolved as an acceptable alternative to conventional surgical aortic valve replacement in elderly, high-risk surgical candidates with ...critical aortic stenosis, thrombotic and bleeding complications remain relatively frequent and potentially life-threatening. Thrombotic events during and following TAVI relate to the dynamic interplay between the systemic burden of atherosclerotic disease, atrial arrhythmias, device and native aortic valve interactions, as well as platelet and coagulation cascade activation. Bleeding in the acute setting relates primarily to access site vascular complications, but also appears related to pre-existing renal impairment and anemia. Current pre-, peri- and post-procedural anti-thrombotic regimens are empirical, based on expert consensus following extrapolation from the wealth of experience gleaned following percutaneous coronary intervention. However the complexities of the TAVI procedure, the high-risk clinical substrate and competing effects of anti-thrombotic regimens and bleeding risk are yet to be prospectively assessed in randomized clinical trials for defining evidence-based anti-thrombotic strategies.
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