[Impact of COVID-19 on ST-segment elevation myocardial infarction care. The Spanish experience]. / Impacto de la COVID-19 en el tratamiento del infarto agudo de miocardio con elevación del segmento ST. La experiencia española.

INTRODUCTION AND OBJECTIVES: The COVID-19 outbreak has had an unclear impact on the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to assess changes in STEMI management during the COVID-19 outbreak. METHODS: Using a multicenter, nationwide, retrospective, observational registry of consecutive patients who were managed in 75 specific STEMI care centers in Spain, we compared patient and procedural characteristics and in-hospital outcomes in 2 different cohorts with 30-day follow-up according to whether the patients had been treated before or after COVID-19. RESULTS: Suspected STEMI patients treated in STEMI networks decreased by 27.6% and patients with confirmed STEMI fell from 1305 to 1009 (22.7%). There were no differences in reperfusion strategy (> 94% treated with primary percutaneous coronary intervention in both cohorts). Patients treated with primary percutaneous coronary intervention during the COVID-19 outbreak had a longer ischemic time (233 [150-375] vs 200 [140-332] minutes, P < .001) but showed no differences in the time from first medical contact to reperfusion. In-hospital mortality was higher during COVID-19 (7.5% vs 5.1%; unadjusted OR, 1.50; 95%CI, 1.07-2.11; P < .001); this association remained after adjustment for confounders (risk-adjusted OR, 1.88; 95%CI, 1.12-3.14; P = .017). In the 2020 cohort, there was a 6.3% incidence of confirmed SARS-CoV-2 infection during hospitalization. CONCLUSIONS: The number of STEMI patients treated during the current COVID-19 outbreak fell vs the previous year and there was an increase in the median time from symptom onset to reperfusion and a significant 2-fold increase in the rate of in-hospital mortality. No changes in reperfusion strategy were detected, with primary percutaneous coronary intervention performed for the vast majority of patients. The co-existence of STEMI and SARS-CoV-2 infection was relatively infrequent.

Impact of COVID-19 on ST-segment elevation myocardial infarction care. The Spanish experience.

INTRODUCTION AND OBJECTIVES: The COVID-19 outbreak has had an unclear impact on the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to assess changes in STEMI management during the COVID-19 outbreak. METHODS: Using a multicenter, nationwide, retrospective, observational registry of consecutive patients who were managed in 75 specific STEMI care centers in Spain, we compared patient and procedural characteristics and in-hospital outcomes in 2 different cohorts with 30-day follow-up according to whether the patients had been treated before or after COVID-19. RESULTS: Suspected STEMI patients treated in STEMI networks decreased by 27.6% and patients with confirmed STEMI fell from 1305 to 1009 (22.7%). There were no differences in reperfusion strategy (> 94% treated with primary percutaneous coronary intervention in both cohorts). Patients treated with primary percutaneous coronary intervention during the COVID-19 outbreak had a longer ischemic time (233 [150-375] vs 200 [140-332] minutes, P<.001) but showed no differences in the time from first medical contact to reperfusion. In-hospital mortality was higher during COVID-19 (7.5% vs 5.1%; unadjusted OR, 1.50; 95%CI, 1.07-2.11; P <.001); this association remained after adjustment for confounders (risk-adjusted OR, 1.88; 95%CI, 1.12-3.14; P=.017). In the 2020 cohort, there was a 6.3% incidence of confirmed SARS-CoV-2 infection during hospitalization. CONCLUSIONS: The number of STEMI patients treated during the current COVID-19 outbreak fell vs the previous year and there was an increase in the median time from symptom onset to reperfusion and a significant 2-fold increase in the rate of in-hospital mortality. No changes in reperfusion strategy were detected, with primary percutaneous coronary intervention performed for the vast majority of patients. The co-existence of STEMI and SARS-CoV-2 infection was relatively infrequent.

IAM por trombosis de aneurisma del seno de Valsalva / Thrombosis of a Valsalva sinus aneurysm causing AMI

No disponible

Drug-eluting vs. conventional balloon for side branch dilation in coronary bifurcations treated by provisional T stenting.

OBJECTIVE: The origin of the side branch (SB) is the most common site for restenosis in coronary bifurcations. The end-point is to compare the results of SB dilation with drug-eluting balloon (DEB group) versus conventional balloon (BAL group) in bifurcations treated with provisional T stenting. METHODS AND RESULTS: Each group included 50 patients. In DEB, the origin of SB was dilated with a Sequent(®) Please balloon. In both groups, a Taxus Liberté(®) stent was implanted in the main vessel, with kissing balloon postdilation. If the outcome for the SB was suboptimal, a Taxus stent was implanted in BAL and a bare stent in DEB group. An angiographic follow-up and IVUS were scheduled for 12 months later. Adverse events (MACE) were 24% in BAL versus 11% in DEB (P = 0.11), with greater revascularization (TLR) in the BAL group (22% vs. 12%, P = 0.16). At angiographic follow-up, there was a lower percentage of SB restenosis in the DEB group (20% vs. 7%, P = 0.08), with less late loss (0.40 mm vs. 0.09 mm, P = 0.01). CONCLUSION: Side branch dilation with a drug-eluting balloon resulted in better angiographic outcomes than with a conventional balloon, with less late loss and restenosis at the 12-month follow-up.

High-risk diabetic patients with unprotected left main coronary artery disease: characteristics and medium-term outcomes of percutaneous revascularization with drug-eluting stents.

Percutaneous coronary intervention with drug-eluting stents is an alternative for patients with high-risk unprotected left main coronary artery disease; those with diabetes mellitus are at even higher risk. Recent advances in percutaneous coronary intervention could lead to better results. The aim of this study was to evaluate medium-term results in a real-world sample of high-risk diabetic patients undergoing percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.From 3 tertiary hospitals, we retrospectively identified 334 high-risk patients, of whom 141 (42%) were diabetic and 193 (58%) were nondiabetic. The diabetes mellitus group showed a higher prevalence of peripheral vascular disease and left ventricular dysfunction. Angiographic and procedural characteristics did not differ significantly, with the exception of poor distal vessels in the diabetes mellitus group (44.5% vs 28.5%, P = 0.006). The use of intra-aortic balloon pumping and intravascular ultrasonography was low in both diabetic and nondiabetic patients. After a median follow-up of 22.4 months, cardiac death was higher in the diabetes mellitus group (16.2% vs 7.5%, P = 0.015), especially in insulin-dependent diabetic patients (25.8%). The incidence of major adverse cardiac events, including cardiac death, target-lesion revascularization, and myocardial infarction was similar in both groups (23.8% vs 18.3%, P = NS).High-risk diabetic patients who undergo percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease present with a worse clinical profile that carries a higher cardiac mortality rate in the medium term, especially in insulin-dependent diabetic patients.

Comparison of zotarolimus- versus everolimus-eluting stents in the treatment of coronary bifurcation lesions.

OBJECTIVES: To compare zotarolimus-eluting stent (Endeavor Sprint®; ZES-S) and the everolimus-eluting stent (Xience V®; EES) in the treatment of coronary bifurcation lesions. BACKGROUND: Both these stents have demonstrated good outcomes in the treatment of coronary lesions. However, the outcomes with respect to treatment of bifurcation lesions have yet to be conclusively demonstrated. METHODS: In this single centered, nonrandomized, open label study, we treated, between August 2006 and December 2008, 110 bifurcations with ZES-S and, in a second stage of the study, 129 bifurcations with EES. The primary end point was to compare the rate of major adverse cardiac events (MACE) (death, myocardial infarction, and new target lesion revascularization) in-hospital and at 12 months of follow-up. Provisional T stenting was the strategy used in the majority of cases. Angiographic follow-up was performed only in patients who presented signs or symptoms suggestive of angina or ischemia. RESULTS: There were no significant differences in in-hospital MACE between the groups (ZES-S: 8.1%; EES: 6.2%; P = 0.5). At 12 months, the ZES-S group had significantly more MACE than the EES group (23.1% vs. 4.5%; P < 0.001) and an elevated index of new revascularization of the bifurcation (17.5% vs. 3.2%; P < 0.001). There were no significant differences in mortality (four patients in ZES-S vs. one in EES; P = 0.14). CONCLUSION: The treatment of coronary bifurcation lesions using everolimus-eluting stents results in better outcomes at 12 months of follow-up than zotarolimus-eluting stents.

Drug-eluting stents for the treatment of bifurcation lesions: a randomized comparison between paclitaxel and sirolimus stents.

BACKGROUND: Drug-eluting stents have been shown to reduce restenosis in many types of lesions. The purpose of this article is to assess the efficacy of sirolimus- and paclitaxel-eluting stents in patients with bifurcation lesions. METHODS: Between June 2003 and October 2004, 205 patients were enrolled in a prospective randomized trial; 103 patients were assigned to sirolimus stents and 102 patients to paclitaxel stents. All patients were treated by provisional T-stenting. RESULTS: There were no differences between groups in terms of age, risk factors, clinical condition, location of the bifurcation lesion, or other technical factors. Angiographic data and immediate results were also similar in both groups. Three patients developed inhospital non-Q-wave acute myocardial infarction (2 from the sirolimus group and 1 from the paclitaxel group). Follow-up angiography was obtained in 109 patients (53%). In the sirolimus group, 5 patients developed restenosis (9%): 1 at the main vessel, 2 at the side branch, and 2 in both branches. In contrast, 16 patients from the paclitaxel group had restenosis (29%): 6 at the main vessel, 5 at the side branch, and 5 in both branches. Target lesion revascularization at 24 +/- 5 months post stenting occurred in 4 patients from the sirolimus group (4%) and in 13 from the paclitaxel group (13%) (P < .05). Late loss at the main vessel in the sirolimus group patients was 0.31 +/- 0.59 versus 0.60 +/- 0.77 mm in patients from the paclitaxel group (P < .05). CONCLUSIONS: Patients with bifurcation lesions treated by sirolimus showed significantly lower rates of late loss, restenosis and target lesion revascularization than patients treated with paclitaxel-eluting stents.

[Percutaneous transcatheter closure of ventricular septal defects using an Amplatz device]. / Cierre percutáneo de comunicación interventricular congénita mediante el dispositivo de Amplatz.

We carried out an analysis of our initial experience with using an Amplatz device for percutaneous closure of ventricular septal defects in 15 patients. The patient's ages ranged in from 1 to 44 years. Seven were infants with heart failure. In 4 patients, the ventricular septal defect was located in the muscular portion of the ventricular septum; in 11 patients, it was in the perimembraneous portion. The mean size of the Amplatz device selected was 11.2 (3.0) mm. Successful device implantation was achieved in 12 patients. In the other 3, stable occlusion could not be achieved, and the device was retrieved without complications. Immediate complete closure occurred in 11 of the 12 patients who underwent successful implantation. No complications were observed, either immediately or during follow-up. After a mean follow-up period of 9.2 (3.6) months, all patients remained free of symptoms. Follow-up Doppler echocardiography demonstrated complete closure in all patients.

Cierre percutáneo de comunicación interventricular congénita mediante el dispositivo de Amplatz / Percutaneous transcatheter closure of ventricular septal defects using an amplatz device

El presente estudio analiza nuestra experiencia inicial en 15 pacientes con comunicación interventricular (CIV) en los que se intentó el cierre percutáneo mediante la implantación de un dispositivo de Amplatz. La edad media fue de 14 ± 14 años. Siete eran lactantes con síntomas de insuficiencia cardiaca. Cuatro pacientes presentaban un defecto muscular y 11 perimembranoso. El tamaño medio del dispositivo seleccionado fue de 11,2 ± 3,0 mm. Se consiguió la implantación correcta del dispositivo en 12 pacientes; en los 3 restantes no se pudo estabilizar el oclusor y fue retirado sin incidencias. Se produjo un cierre completo inicial de la CIV en 11 de los 12 pacientes con éxito en la implantación. No hubo complicaciones mayores inmediatas ni en el seguimiento. A los 9,2 ± 3,6 meses de seguimiento clínico todos los pacientes permanecieron libres de síntomas y no hubo incidencia de endocarditis o embolismo. El estudio eco-Doppler al seguimiento mostró cierre completo en todos los pacientes (AU)

We carried out an analysis of our initial experience with using an Amplatz device for percutaneous closure of ventricular septal defects in 15 patients. The patient's ages ranged in from 1 to 44 years. Seven were infants with heart failure. In 4 patients, the ventricular septal defect was located in the muscular portion of the ventricular septum; in 11 patients, it was in the perimembraneous portion. The mean size of the Amplatz device selected was 11.2 (3.0) mm. Successful device implantation was achieved in 12 patients. In the other 3, stable occlusion could not be achieved, and the device was retrieved without complications. Immediate complete closure occurred in 11 of the 12 patients who underwent successful implantation. No complications were observed, either immediately or during follow-up. After a mean follow-up period of 9.2 (3.6) months, all patients remained free of symptoms. Follow-up Doppler echocardiography demonstrated complete closure in all patients (AU)

[Six-month intravascular ultrasound follow-up of coronary bifurcation lesions treated with rapamycin-eluting stents: technical considerations]. / Ecografía intracoronaria durante el seguimiento en la valoración de stents liberadores de rapamicina para el tratamiento de las lesiones en bifurcación: implicaciones técnicas.

INTRODUCTION AND OBJECTIVES: In vitro studies show that stents deform when dilated laterally to access a side branch. This phenomenon may be avoided by use of a kissing balloon at the end of the procedure. However, to date, no in vivo data are available. Our objectives were to investigate the main vessel stent using intravascular ultrasound (IVUS) at six-month follow-up in 55 patients with bifurcation lesions treated using rapamycin-eluting stents and to examine the effect of technical factors. PATIENTS AND METHOD: All patients were treated using provisional or T stents. At 6 months, IVUS measurements were made in the main vessel at both proximal and distal ends of the stent, in reference segments, immediately below the side branch ostium, and at the points where the lumen was smallest and where stent expansion was greatest. RESULTS: The lumen area immediately below the side branch ostium was significantly smaller than that at the point of maximum stent expansion (6.7 [1.8] vs 5.1 [1.3] mm2; P<.05). Underexpansion was not influenced by use of a kissing balloon (stent area immediately under the side branch ostium: 5.5 [0.9] vs 5.6 [1.6] mm2; P=NS) and only one patient experienced restenosis at this point. The lumen areas at the proximal and distal edges of the stent were almost identical in patients who did or did not undergo balloon dilation beyond the ends of the stent. CONCLUSIONS: Stent underexpansion below the side branch ostium was frequently found following provisional or T stenting of bifurcation lesions. This minor stent deformity was not prevented by use of a kissing balloon nor by any specific side branch treatment and had no significant impact on the restenosis rate.

Ecografía intracoronaria durante el seguimiento en la valoración de stents liberadores de rapamicina para el tratamiento de las lesiones en bifurcación: implicaciones técnicas / Six-month intravascular ultrasound follow-up of coronary bifurcation lesions treated with rapamycin-eluting stents: technical considerations

Introducción y objetivos. Los estudios in vitro han mostrado que el stent se deforma cuando se dilata lateralmente para acceder a un ramo colateral. Así, se han propuesto algunas técnicas para evitar este fenómeno; sin embargo, no hay información in vivo disponible. El objetivo es investigar los hallazgos ultrasónicos a los 6 meses en 55 pacientes con lesiones localizadas en bifurcación tratados mediante stents de rapamicina.Pacientes y método. Todos los pacientes fueron tratados con stent en el vaso principal y stent o dilatación con balón en el ramo colateral. Se analizaron los bordes del stent, los segmentos de referencia, el diámetro mínimo de la luz, el punto inmediatamente tras la salida del ramo colateral y el stent en el punto de máxima expansión.Resultados. El área de la luz en el punto inmediatamente tras la salida del ramo colateral fue significativamente más pequeña que en el punto de máxima expansión (6,7 ± 1,8 frente a 5,1 ± 1,3 mm²; p < 0,05). Esta inexpansión del stent no estuvo influida por el uso del inflado simultáneo de balones al final del procedimiento (área del stent inmediatamente bajo el origen del ramo colateral, 5,5 ± 0,9 frente a 5,6 ± 1,6 mm²; p = NS). El área de la luz en los bordes fue prácticamente idéntica entre pacientes con y sin inflado de balón más allá de los límites del stent.Conclusiones. Cierto grado de inexpansión del stent inmediatamente después de la salida del ramo colateral fue un hallazgo frecuente en pacientes con bifurcaciones tratados con stents en el ramo principal y stent provisional en el ramo colateral. Esta deformidad no fue prevenida por variables técnicas y no tuvo un impacto significativo en la incidencia de reestenosis

Introduction and objectives. In vitro studies show that stents deform when dilated laterally to access a side branch. This phenomenon may be avoided by use of a kissing balloon at the end of the procedure. However, to date, no in vivo data are available. Our objectives were to investigate the main vessel stent using intravascular ultrasound (IVUS) at six-month follow-up in 55 patients with bifurcation lesions treated using rapamycin-eluting stents and to examine the effect of technical factors.Patients and method. All patients were treated using provisional or T stents. At 6 months, IVUS measurements were made in the main vessel at both proximal and distal ends of the stent, in reference segments, immediately below the side branch ostium, and at the points where the lumen was smallest and where stent expansion was greatest.Results. The lumen area immediately below the side branch ostium was significantly smaller than that at the point of maximum stent expansion (6.7 [1.8] vs 5.1 [1.3] mm²; P<.05). Underexpansion was not influenced by use of a kissing balloon (stent area immediately under the side branch ostium: 5.5 [0.9] vs 5.6 [1.6] mm²; P=NS) and only one patient experienced restenosis at this point. The lumen areas at the proximal and distal edges of the stent were almost identical in patients who did or did not undergo balloon dilation beyond the ends of the stent.Conclusions. Stent underexpansion below the side branch ostium was frequently found following provisional or T stenting of bifurcation lesions. This minor stent deformity was not prevented by use of a kissing balloon nor by any specific side branch treatment and had no significant impact on the restenosis rate

Sirolimus-eluting stents for treatment of in-stent restenosis: immediate and late results.

We analyzed the clinical, angiographic, and late intravascular ultrasonographic findings from 140 patients whose in-stent restenosis was treated with sirolimus-eluting stents. In-stent restenosis remains the main limitation to percutaneous coronary revascularization and has a high recurrence rate after bare stent implantation. From May 2002 through July 2003, we studied 140 patients with clinical restenosis after bare-stent treatment. In 107 patients, in-stent restenosis occurred de novo; in 28 patients, this was the 2nd restenosis; and in another 5, it was the 3rd occurrence. A sirolimus-eluting stent was implanted directly after angiographic evaluation of the in-stent restenosis in 79 patients and after pre-dilation in 61 patients. All patients were given the following antithrombotic regimen: low-molecular-weight heparin, ticlopidine, and aspirin for 1 month, followed by clopidogrel and aspirin for 1 year. Primary success was achieved in 137 patients. Three patients had a non-Q wave myocardial infarction. At the 1-month evaluation, 2 patients had died: 1 due to subacute stent thrombosis and another due to acute mesenteric ischemia. After a mean follow-up of 16 +/- 4 months, the major adverse cardiac events were acute myocardial infarction due to late stent thrombosis in 2 patients and the need for target lesion revascularization in 15 patients. Late angiographic evaluation was performed in 97 patients (69%), 16 of whom had new restenosis: 14 of the restenoses were intrastent, and 2 were at the edges of the stent. Our results suggest that sirolimus-eluting stents are effective in the prevention of in-stent restenosis and, therefore, may become the leading treatment alternative for patients with in-stent restenosis.

Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: a randomized comparison of a simple versus complex strategy.

BACKGROUND: Rapamycin-eluting stents (RES) have been shown to reduce restenosis in many types of lesions. However, the ideal strategy for the treatment of coronary bifurcated lesions has not been established to date. This randomized study compares 2 strategies for the RES treatment of bifurcation lesions: a simple approach (stenting the main vessel and balloon dilatation for the side branch [SB]) versus a complex approach (stents for both vessels). METHODS: To compare both strategies, a randomized study was conducted in 91 patients with true coronary bifurcation lesions. All patients received an RES at the main vessel, covering the SB. Patients from group A (n = 47) were assigned to balloon dilation of the involved SB (simple strategy); patients in group B (n = 44) were randomized to receive a second stent at the SB origin (complex strategy). There were no differences between groups regarding baseline clinical and angiographic data. RESULTS: Major adverse cardiac events occurred in 3 patients from group A (2 non-Q-wave myocardial infarctions and 1 target lesion revascularization). Six-month angiographic reevaluation was obtained in 80 patients (88%). Restenosis of the main vessel was observed in 1 (2%) patient from group A and in 4 (10%) from group B. Restenosis of the SB appeared in 2 (5%) patients from group A and in 6 (15%) from group B. CONCLUSIONS: Both strategies are effective in reducing the restenosis rate, with no differences in terms of clinical outcome. Elective SB stenting seems to provide no advantages over the simpler stent jail followed by SB balloon dilation.

Rapamycin-eluting stents for the treatment of unprotected left main coronary disease.

BACKGROUND: Conventional bare stents have been used to treat unprotected left main (LM) coronary artery stenosis. However, restenosis remains the main limitation. Since rapamycin-eluting stents (RES) appear to inhibit neointimal proliferation, their application to this specific site seems promising. METHODS: Since May 2002, we have studied a series of 52 patients with LM lesions treated with RES. Forty-seven patients presented with de novo stenoses, and 5 had in-stent restenosis; 19 patients required combined stent treatment for other remote lesions in the coronary tree, 6 of them at the level of proximal right coronary artery. The RES was implanted directly at the LM in 39 patients; 13 others needed predilation. Once deployed, the RES was overexpanded with short balloons adjusted to the LM length in 44 patients. Quantitative coronary angiograms were analyzed in the same view before and immediately after treatment and at follow-up. Patients were followed-up closely and new cardiac catheterization was scheduled at 6-month evaluation or earlier in the presence of symptoms. At follow-up study, quantitative coronary angiography and motorized intravascular ultrasound analyses were performed in 35 (67%) patients. RESULTS: Primary success was obtained in 50 patients (96%). Two patients (4%) developed a non-Q-wave myocardial infarction. All patients were symptom-free at discharge. After a mean follow-up of 12 +/- 4 months, 50 patients (96%) remain asymptomatic. No late death or acute thrombosis have been recorded. Two patients became symptomatic 2 and 4 months after treatment, respectively. One had restenosis at a remote site, while the other had in-segment restenosis. None of the remaining 33 angiographically evaluated patients developed restenosis at any site. Target lesion revascularization was 1/52 (2%). CONCLUSIONS: Although longer-term follow-up studies are needed, the tailored treatment of coronary lesions located at the LM by overexpanded RES is feasible and safe. Midterm results seem promising, which might help to shift the orientation of patient management from surgical to percutaneous revascularization.