Impact of coronary calcium morphology on intravascular lithotripsy.

BACKGROUND: Coronary calcification negatively impacts optimal stenting. Intravascular lithotripsy (IVL) is a new calcium modification technique. AIMS: We aimed to assess the impact of different calcium morphologies on IVL efficacy. METHODS: This was a prospective, multicentre study (13 tertiary referral centres). Optical coherence tomography (OCT) was performed before and after IVL, and after stenting. OCT-defined calcium morphologies were concentric (mean calcium arc >180°) and eccentric (mean calcium arc ≤180°). The primary outcomes were angiographic success (residual stenosis <20%) and the presence of fracture by OCT in concentric versus eccentric lesions. RESULTS: Ninety patients were included with a total of 95 lesions: 47 concentric and 48 eccentric. The median number of pulses was 60 (p=1.00). Following IVL, the presence of fracture was not statistically different between groups (79.0% vs 66.0% for concentric vs eccentric; p=0.165). The number of fractures/lesion (4.2±4.4 vs 2.3±2.8; p=0.018) and ≥3 fractures/lesion (57.1% vs 34.0%; p=0.029) were more common in concentric lesions. Angiographic success was numerically but not statistically higher in the concentric group (87.0% vs 76.6%; p=0.196). By OCT, no differences were noted in final minimum lumen area (5.9±2.2 mm2 vs 6.2±2.1 mm2; p=0.570), minimum stent area (5.9±2.2 mm² vs 6.25±2.4 mm2; p=0.483), minimum stent expansion (80.9±16.7% vs 78.2±19.8%), or stent expansion at the maximum calcium site (100.6±24.2% vs 95.8±27.3%) (p>0.05 for all comparisons of concentric vs eccentric, respectively). Calcified nodules were found in 29.5% of lesions; these were predominantly non-eruptive (57%). At the nodule site, dissection was more common than fracture with stent expansion of 103.6±27.2%. CONCLUSIONS: In this prospective, multicentre study, the effectiveness of IVL followed by stenting was not significantly affected by coronary calcium morphology.

Cost-effectiveness analysis of the SAPIEN 3 transcatheter aortic valve implant in patients with symptomatic severe aortic stenosis.

INTRODUCTION AND OBJECTIVES: Transcatheter aortic valve implant has become a widely accepted treatment for inoperable patients with aortic stenosis and patients at high surgical risk. Its indications have recently been expanded to include patients at intermediate and low surgical risk. Our aim was to evaluate the efficiency of SAPIEN 3 vs conservative medical treatment (CMT) or surgical aortic valve replacement (SAVR) in symptomatic inoperable patients at high or intermediate risk. METHODS: We conducted a cost-effectiveness analysis of SAPIEN 3 vs SAVR/CMT, using a Markov model (monthly cycles) with 8 states defined by the New York Heart Association and a time horizon of 15 years, including major complications and management after hospital discharge, from the perspective of the National Health System. Effectiveness parameters were based on the PARTNER trials. Costs related to the procedure, hospitalization, complications, and follow-up were included (euros in 2019). An annual discount rate of 3% was applied to both costs and benefits. Deterministic and probabilistic sensitivity analyses (Monte Carlo) were performed. RESULTS: Compared with SAVR (high and intermediate risk) and CMT (inoperable), SAPIEN 3 showed better clinical results in the 3 populations and lower hospital stay. Incremental cost-utility ratios (€/quality-adjusted life years gained) were 5471 (high risk), 8119 (intermediate risk) and 9948 (inoperable), respectively. In the probabilistic analysis, SAPIEN 3 was cost-effective in more than 75% of the simulations in the 3 profiles. CONCLUSIONS: In our health system, SAPIEN 3 facilitates efficient management of severe aortic stenosis in inoperable and high- and intermediate-risk patients.

Valoración geriátrica antes de la implantación valvular aórtica a través de catéter en pacientes ancianos / Geriatric assessment before transcatheter aortic valve implantation in elderly patients

No disponible

Modelo de intervención coronaria percutánea primaria en la Región de Murcia / The primary percutaneous coronary intervention program in Murcia

Antes de la implantación del programa, la intervención coronaria percutánea primaria era la excepción en el tratamiento del infarto agudo de miocardio, a pesar de que se reperfundía con fibrinolíticos a menos del 40% de los pacientes. Desde 1998 se comenzó a tratar con intervención coronaria percutánea primaria a todos los pacientes que acudían al Hospital Universitario Virgen de la Arrixaca. En el año 2000, se diseñó un programa de tratamiento del infarto agudo de miocardio con intervención coronaria percutánea primaria para toda la Región de Murcia, al que se denominó APRIMUR, estableciendo una primera fase que sólo incluía los tres hospitales de la capital. El programa se hizo extensible al resto de la Región en 2001. Se describe del programa sus primeras fases, el transporte, la metodología de trabajo, los objetivos primarios y secundarios, lo que consideramos puntos clave y su sostenibilidad. Se han realizado más de 3.500 intervenciones coronarias percutáneas primarias, con una media mensual actual de 40-45 casos. La mortalidad ha ido variando desde cifras anuales superiores al 10% a las más actuales del 6% en 2007 y el 6,6% en 2009. Hemos conseguido que, al menos en la mitad de la Región, las cifras de reperfusión superen el 90% y vayan aumentando anualmente en el resto de las comarcas (AU)

Before the primary percutaneous coronary intervention program was implemented, few acute myocardial infarction patients were treated using the technique, even though less than 40% were reperfused using thrombolytic agents. In 1988, we started to use primary percutaneous coronary intervention to treat all patients admitted with acute myocardial infarction to the Virgen de la Arrixaca University Hospital in Murcia, Spain. In 2000, we developed a program, APRIMUR, to treat acute myocardial infarction using primary percutaneous coronary intervention throughout the Murcia region. The first phase involved only three hospitals in the regional capital. The program was then extended to the rest of the region in 2001. This article describes the first phases of the program, including patient transport and work methodology, the primary and secondary aims of the program, what we regard as the program’s key features, and the sustainability of the program. More than 3500 primary percutaneous coronary interventions have now been performed, at a mean rate of 40-45 per month. Annual mortality ranged from more than 10% at the beginning of the program to, more recently, 6.0% in 2007 and 6.6% in 2009. We have achieved a reperfusion rate greater than 90% in at least half the region and the rate is increasing each year in the remaining districts (AU)

Percutaneous coronary intervention in heavily calcified lesions using rotational atherectomy and paclitaxel-eluting stents: outcomes at one year.

Heavily calcified lesions present a challenge for percutaneous coronary intervention. With rotational atherectomy, it is possible to treat these lesions and paclitaxel-eluting stents (PESs) reduce the risk of restenosis over the long term. This retrospective study investigated clinical outcomes with rotational atherectomy and PESs in 50 consecutive patients with heavily calcified lesions. Mortality and target lesion revascularization at 1 year (median, 14 months; interquartile range, 8.75-25.5 months) were recorded. Some 52% of patients were aged over 70 years, 68% were male, 52% had acute coronary syndrome, 80% had multivessel disease and 44% were receiving abciximab. Two patients died in hospital, three died during follow-up (one cardiac death) and 3 (6%) underwent target lesion revascularization. At 1 year, the survival rate free of cardiac death was 94% and the survival rate free of target lesion revascularization was 94%. These findings demonstrate that the combination of rotational atherectomy and PESs gives excellent results in heavily calcified lesions.

Intervencionismo coronario en lesiones severamente calcificadas mediante aterectomía rotacional y stent liberador de paclitaxel: resultados tras un año de seguimiento / Percutaneous coronary intervention in heavily calcified lesions using rotational atherectomy and paclitaxel-eluting stents: outcomes at one year

Las lesiones severamente calcificadas dificultan el intervencionismo coronario. La aterectomía rotacional permite tratar estas lesiones y los stents liberadores de paclitaxel (SLP) reducen la reestenosis a largo plazo. Se evaluó retrospectivamente el resultado de la aterectomía rotacional y los SLP en lesiones severamente calcificadas en 50 pacientes consecutivos. Se estudió la mortalidad y la revascularización de la lesión tratada tras 1 año (mediana, 14 meses; intervalo intercuartílico, 8,75-25,5). El 52% eran mayores de 70 años; el 68%, varones; el 52% tenía síndrome coronario agudo; el 80%, enfermedad multivaso y un 44% recibió abciximab. Hubo 2 muertes intrahospitalarias, 3 en el seguimiento (una cardiaca) y 3 (6%) casos de revascularización de la lesión tratada. A 1 año, la supervivencia libre de muerte cardiaca fue del 94% y la supervivencia libre de revascularización de la lesión tratada, del 94%; esto muestra que la estrategia de SLP y aterectomía rotacional en lesiones severamente calcificadas proporciona excelentes resultados (AU)

Heavily calcified lesions present a challenge for percutaneous coronary intervention. With rotational atherectomy, it is possible to treat these lesions and paclitaxel-eluting stents (PESs) reduce the risk of restenosis over the long term. This retrospective study investigated clinical outcomes with rotational atherectomy and PESs in 50 consecutive patients with heavily calcified lesions. Mortality and target lesion revascularization at 1 year (median, 14 months; interquartile range, 8.75-25.5 months) were recorded. Some 52% of patients were aged over 70 years, 68% were male, 52% had acute coronary syndrome, 80% had multivessel disease and 44% were receiving abciximab. Two patients died in hospital, three died during follow-up (one cardiac death) and 3 (6%) underwent target lesion revascularization. At 1 year, the survival rate free of cardiac death was 94% and the survival rate free of target lesion revascularization was 94%. These findings demonstrate that the combination of rotational atherectomy and PESs gives excellent results in heavily calcified lesions (AU)

Emergency percutaneous coronary intervention in unprotected left main coronary arteries. Predictors of mortality and impact of cardiogenic shock.

INTRODUCTION AND OBJECTIVES: Percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease may be essential following acute myocardial infarction (AMI). However, few data are available on the use of emergency PCI in unprotected LMCAs outside of clinical trials. The objective of this study was to determine the frequency of in-hospital mortality, its predictors and its association with cardiogenic shock, and long-term outcomes in patients with unprotected LMCA disease who undergo emergency PCI because of AMI. METHODS: The study included 71 consecutive patients who underwent emergency angioplasty of the LMCA and who were followed up clinically. RESULTS: Overall, 42 patients (59%) had ST-elevation AMI and 47 (66%) had cardiogenic shock or developed it during PCI. Eleven patients (16%) died in the catheterization laboratory and 33 (47%) died during hospitalization. Inhospital mortality was similar in those with and without evidence of ST-segment elevation on ECG (48% vs. 45%; P=1). Multivariate analysis showed that the predictors of in-hospital mortality were cardiogenic shock (odds ratio [OR]=4.5; 95% confidence interval [CI], 1.1-18) and incomplete revascularization (OR=5.1; 95% CI, 1.0-26). After discharge, 39 patients were followed up for a median of 32 months. Mortality in the first year was 10%. CONCLUSIONS: Emergency PCI is a viable therapeutic option for AMI due to unprotected LMCA disease. However, in-hospital mortality is high, regardless of ST-segment elevation, particularly if there is cardiogenic shock or complete revascularization has not been achieved.

Intervencionismo percutáneo urgente sobre el tronco coronario izquierdo no protegido. Factores predictores de mortalidad y análisis del shock cardiogénico / Emergency percutaneous coronary intervention in unprotected left main coronary arteries. Predictors of mortality and impact of cardiogenic shock

Introducción y objetivos. El intervencionismo coronario percutáneo (ICP) de la enfermedad de tronco coronario izquierdo (TCI) no protegido puede ser necesaria en el infarto agudo de miocardio (IAM). Sin embargo, la evidencia del ICP urgente en el TCI fuera de ensayos clínicos no es muy amplia. El objetivo del estudio es evaluar la mortalidad intrahospitalaria, sus predictores y su asociación con shock, así como eventos a largo plazo en pacientes con enfermedad de TCI tratado con ICP urgente debido a un IAM. Métodos. Se incluyó a 71 pacientes consecutivos en los que se realizó una angioplastia urgente sobre el TCI y seguimiento clínico posterior. Resultados. Presentaron IAM con elevación del ST 42 (59%) y presentaban shock cardiogénico o lo desarrollaron durante el procedimiento 47 (66%). Murieron en la sala de hemodinámica 11 (16%) y 33 (47%) durante la hospitalización. La mortalidad intrahospitalaria fue independiente de la elevación del ST en el ECG (el 45 frente al 48%; p = 1). Los predictores multivariables de mortalidad intrahospitalaria fueron el shock cardiogénico (4,5; intervalo de confianza [IC], 1,1-18) y la revascularización incompleta (odds ratio [OR] = 5,1; IC, 1-26). Tras el alta hospitalaria se siguió a 39 pacientes durante una mediana de 32 meses. La mortalidad durante el primer año de seguimiento fue del 10%. Conclusiones. El ICP es una opción terapéutica en el seno del IAM debido a enfermedad de TCI. Sin embargo, la mortalidad intrahospitalaria es elevada independientemente de la elevación del ST en el ECG y especialmente cuando se asocia a shock cardiogénico y no se logra una revascularización completa (AU)

Introduction and objectives. Percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease may be essential following acute myocardial infarction (AMI). However, few data are available on the use of emergency PCI in unprotected LMCAs outside of clinical trials. The objective of this study was to determine the frequency of in-hospital mortality, its predictors and its association with cardiogenic shock, and long-term outcomes in patients with unprotected LMCA disease who undergo emergency PCI because of AMI. Methods. The study included 71 consecutive patients who underwent emergency angioplasty of the LMCA and who were followed up clinically. Results. Overall, 42 patients (59%) had ST-elevation AMI and 47 (66%) had cardiogenic shock or developed it during PCI. Eleven patients (16%) died in the catheterization laboratory and 33 (47%) died during hospitalization. Inhospital mortality was similar in those with and without evidence of ST-segment elevation on ECG (48% vs. 45%; P=1). Multivariate analysis showed that the predictors of in-hospital mortality were cardiogenic shock (odds ratio [OR]=4.5; 95% confidence interval [CI], 1.1-18) and incomplete revascularization (OR=5.1; 95% CI, 1.0-26). After discharge, 39 patients were followed up for a median of 32 months. Mortality in the first year was 10%. Conclusions. Emergency PCI is a viable therapeutic option for AMI due to unprotected LMCA disease. However, in-hospital mortality is high, regardless of ST-segment elevation, particularly if there is cardiogenic shock or complete revascularization has not been achieved (AU)

[Transient cortical blindness following cardiac catheterization: an alarming but infrequent complication with a good prognosis]. / Ceguera cortical transitoria como complicación del cateterismo cardiaco: alarmante, pero infrecuente y de buen pronóstico.

Transient cortical blindness is a rare complication of using an angiographic contrast agent. Its incidence following cardiac catheterization is low and has been studied scarcely. This article describes our experience with this condition and compares it with the findings of a review of published reports. Although the clinical characteristics of the onset and development of the condition are well-defined, its occurrence usually causes great alarm, in both patients and interventional cardiologists. It occurs more frequently in patients with an internal mammary artery graft and in those undergoing extended procedures. Etiologically, it appears to be related to the direct toxic effects of an accumulation of contrast in lower body areas during prolonged supination. Contrast can leak through the vertebral arteries during internal mammary artery catheterization. The condition resolves completely within a few days. Further investigations using contrast are not contraindicated.

Ceguera cortical transitoria como complicación del cateterismo cardiaco: alarmante, pero infrecuente y de buen pronóstico / Transient cortical blindness following cardiac catheterization: an alarming but infrequent complication with a good prognosis

La ceguera cortical transitoria es una complicación infrecuente de las exploraciones con contraste. Su incidencia en el cateterismo cardiaco es baja y apenas ha sido descrita. En este artículo describimos nuestra experiencia sobre este trastorno y la comparamos con una revisión de las publicaciones al respecto. Es un cuadro clínico, bien diferenciado en instauración y evolución, que suele crear gran alarma tanto en el paciente como en el operador. Se produce con mayor frecuencia en pacientes con injerto de arteria mamaria interna y procedimientos prolongados. Su etiología parece estar relacionada con la toxicidad directa del contraste acumulado en las zonas más bajas, facilitado por el paso a través de las arterias vertebrales durante la cateterización de la arteria mamaria. Su resolución suele ser completa en el curso de varios días y no contraindica nuevas exploraciones con contraste (AU)

Transient cortical blindness is a rare complication of using an angiographic contrast agent. Its incidence following cardiac catheterization is low and has been studied scarcely. This article describes our experience with this condition and compares it with the findings of a review of published reports. Although the clinical characteristics of the onset and development of the condition are well-defined, its occurrence usually causes great alarm, in both patients and interventional cardiologists. It occurs more frequently in patients with an internal mammary artery graft and in those undergoing extended procedures. Etiologically, it appears to be related to the direct toxic effects of an accumulation of contrast in lower body areas during prolonged supination. Contrast can leak through the vertebral arteries during internal mammary artery catheterization. The condition resolves completely within a few days. Further investigations using contrast are not contraindicated (AU)

[Imbalance between the supply and demand for cardiologists in Spain. Analysis of the current situation, future prospects, and possible solutions]. / Desequilibrio entre la oferta y las necesidades de cardiólogos en España. Análisis de la situación actual, previsiones futuras y propuestas de solución.

Planning cardiology provision in Spain requires knowledge of the resources available and the demand, both now and in the future. In this report, we present the results of a study carried out by the Spanish Society of Cardiology on the availability of and demand for cardiologists in the country. The current situation is characterized by an imbalance of around 14% between the number of active cardiologists and the estimated number required. The demographic distribution of cardiologists shows that they are predominantly male and middle-aged. Expectations are that the situation will get worse until the year 2020. To correct this imbalance, alternative forms of training or clinical department organization, or both, are required. Some possible alternatives are presented in the final part of this document, as proposals for open discussion.

Desequilibrio entre la oferta y las necesidades de cardiólogos en España. Análisis de la situación actual, previsiones futuras y propuestas de solución / Imbalance between the supply and demand for cardiologists in Spain. Analysis of the current situation, future prospects, and possible solutions

La planificación de la cardiología en España requiere el conocimiento de los recursos disponibles y las necesidades, no sólo presentes, sino también futuras. En el presente informe se recogen los resultados de un estudio llevado a cabo por la Sociedad Española de Cardiología sobre la necesidad y la disponibilidad de cardiólogos. La situación actual en España presenta un desequilibrio entre el número de cardiólogos en activo y los que serían necesarios, desequilibrio que oscila en torno al 14%. La pirámide poblacional refleja una población envejecida y mayoritariamente masculina. Las previsiones futuras indican que la situación empeorará desde ahora hasta el año 2020. La corrección de este desequilibrio requiere el desarrollo de alternativas diferentes de las actuales en formación y/o organización de los servicios asistenciales. Algunas de estas alternativas se recogen en la parte final de este documento, en forma de propuestas abiertas al debate

Planning cardiology provision in Spain requires knowledge of the resources available and the demand, both now and in the future. In this report, we present the results of a study carried out by the Spanish Society of Cardiology on the availability of and demand for cardiologists in the country. The current situation is characterized by an imbalance of around 14% between the number of active cardiologists and the estimated number required. The demographic distribution of cardiologists shows that they are predominantly male and middle-aged. Expectations are that the situation will get worse until the year 2020. To correct this imbalance, alternative forms of training or clinical department organization, or both, are required. Some possible alternatives are presented in the final part of this document, as proposals for open discussion