Definición de infarto agudo de miocardio en el perioperatorio de cirugía cardíaca valvular con troponina T ultrasensible

Los pacientes con infarto agudo de miocardio en el perioperatorio de cirugía cardíaca valvular presentan una curva enzimática de Tn T US con un valor pico de 2569 pg/ml (mediana) a las 16 horas después de la cirugía y una curva enzimática de CK-MB con un valor pico de 83,2 mg/dl a las 8 horas de la cirugía. Los puntos de corte de Tn T US y de CK-MB para diagnosticar IAM en el perioperatorio de cirugía cardíaca valvular se hallan muy por encima del LSR establecido por la Tercera Definición Universale de IM. Los puntos de corte de Tn T US y de CK-MB a la llegada a REA, a las 8h, 16 y 24h tras la cirugía valvular son más de 50 veces el p99 del LSR para la Tn T US y más de 20 veces el p99 del LSR para la CK-MB. Estos hallazgos actualizan la Tercera Definición Universal de IM estableciendo la definición de IAM en el perioperatorio de cirugía cardíaca valvular.Departamento de Biología Celular, Histología y FarmacologíaDoctorado en Investigación en Ciencias de la Salu

Cutoff for high-sensitivity cardiac troponin T is not arbitrary but according to usual clinical practice

Producción CientíficaWe were pleased to read a comment written by Bianchi regarding our article previously published in The Journal of Thoracic and Cardiovascular Surgery. Bianchi raised several important issues related to the use of high-sensitivity cardiac troponin T (hs-cTnT) for the diagnosis of acute myocardial infarction (MI). First, we shall respond to his comment on the electrocardiographic and transthoracic echocardiographic approach. The combination of biomarkers with electrocardiographic or transthoracic echocardiographic criteria to diagnose perioperative MI, as suggested by the “Third Universal Definition of Myocardial Infarction,” is more specific and has a high negative predictive value for the diagnosis of perioperative MI after heart valve surgery than the use of a single criterion

The natural history of QTc interval and its clinical impact in coronavirus disease 2019 survivors after 1 year

Background and objectiveProlonged QTc interval on admission and a higher risk of death in SARS-CoV-2 patients have been reported. The long-term clinical impact of prolonged QTc interval is unknown. This study examined the relationship in COVID-19 survivors of a prolonged QTc on admission with long-term adverse events, changes in QTc duration and its impact on 1-year prognosis, and factors associated with a prolonged QTc at follow-up.MethodsWe conducted a single-center prospective cohort study of 523 SARS-CoV-2-positive patients who were alive on discharge. An electrocardiogram was taken on these patients within the first 48 h after diagnosis and before the administration of any medication with a known effect on QT interval and repeated in 421 patients 7 months after discharge. Mortality, hospital readmission, and new arrhythmia rates 1 year after discharge were reviewed.ResultsThirty-one (6.3%) survivors had a baseline prolonged QTc. They were older, had more cardiovascular risk factors, cardiac disease, and comorbidities, and higher levels of terminal pro-brain natriuretic peptide. There was no relationship between prolonged QTc on admission and the 1-year endpoint (9.8% vs. 5.5%, p = 0.212). In 84% of survivors with prolonged baseline QTc, it normalized at 7.9 ± 2.2 months. Of the survivors, 2.4% had prolonged QTc at follow-up, and this was independently associated with obesity, ischemic cardiomyopathy, chronic obstructive pulmonary disease, and cancer. Prolonged baseline QTc was not independently associated with the composite adverse event at 1 year.ConclusionsProlonged QTc in the acute phase normalized in most COVID-19 survivors and had no clinical long-term impact. Prolonged QTc at follow-up was related to the presence of obesity and previously acquired chronic diseases and was not related to 1-year prognosis

Influence of renal dysfunction on the differential behaviour of procalcitonin for the diagnosis of postoperative infection in cardiac surgery

Producción CientíficaBackground: procalcitonin is a valuable marker in the diagnosis of bacterial infections; however, the impairment of renal function can influence its diagnostic precision. The objective of this study is to evaluate the differential behaviour of procalcitonin, as well as its usefulness in the diagnosis of postoperative pulmonary infection after cardiac surgery, depending on the presence or absence of impaired renal function. Materials and methods: A total of 805 adult patients undergoing cardiac surgery with extracorporeal circulation (CBP) were prospectively recruited, comparing the behaviour of biomarkers between the groups with and without postoperative pneumonia and according to the presence or absence of renal dysfunction. Results: Pulmonary infection was diagnosed in 42 patients (5.21%). In total, 228 patients (28.32%) presented postoperative renal dysfunction. Procalcitonin was significantly higher in infected patients, even in the presence of renal dysfunction. The optimal procalcitonin threshold differed markedly in patients with renal dysfunction compared to patients without renal dysfunction (1 vs. 0.78 ng/mL p < 0.05). The diagnostic accuracy of procalcitonin increased significantly when the procalcitonin threshold was adapted to renal function. Conclusions: Procalcitonin is an accurate marker of postoperative infection in cardiac surgery, even in the presence of renal dysfunction. Renal function is an important determinant of procalcitonin levels and, therefore, its diagnostic thresholds must be adapted in the presence of renal dysfunction.Instituto de Salud Carlos III - (grant COV20/00491, PI18/01238, CIBERINFEC CB21/13/00051)Junta de Castilla y León - (grant VA321P18, GRS 1922/A/19, GRS 2057/A/19)Junta de Castilla y León, Consejería de Educación - (grant VA256P20)Fundación Ramón Areces - (grant CIVP19A5953)Instituto de Salud Carlos III y Fondo Europeo de Desarrollo Regional (FEDER)/Fondo Social Europeo - (grant CM20/00138

Influence of impairment in renal function on the accuracy of high-sensitivity cardiac troponin T for the diagnosis of perioperative myocardial infarction after heart valve surgery

Producción CientíficaWe aimed to assess the influence of impairment in renal function over the high-sensitivity cardiac troponin T (hs-cTnT) accuracy to diagnose perioperative myocardial infarction (MI) after heart valve surgery. Heart valve surgery was performed in 805 patients from June 2012 to January 2016. Patients with enzymatic curves of hs-cTnT suggestive of myocardial necrosis and electrocardiogram and/or transthoracic echocardiogram criteria were identified as patients with perioperative MI. Impairment in renal function was defined as a postoperative creatinine clearance 50 ml/min) and (ii) patients with impairment in renal function (creatinine clearance <50 ml/min). From a total of 805 patients undergoing heart valve surgery, 88 patients developed perioperative MI. When comparing receiver operating characteristic curves in patients with perioperative MI according to renal function, the optimal threshold of hs-cTnT at 16 h differed in patients with impairment in renal function (1303 vs 1095 pg/ml, P < 0.001). The diagnostic accuracy of hs-cTnT at 16 h was 93.4% [95% confidence interval (CI) 89.98–96.86], with an area under receiver operating characteristic curve (0.993, 95% CI 0.988–0.999 vs 0.972, 95% CI 0.952–0.992; P < 0.001). Renal function might influence in hs-cTnT levels. However, a hs-cTnT threshold of 1303 pg/ml at 16 h may be applied according to renal function to diagnose perioperative MI after cardiac surgery

Perioperative myocardial infarction after heart valve surgery, where are we going?

Producción CientíficaWe are pleased to provide a response to the letter to the Editor entitled “Cut-off for High-Sensitivity Cardiac Troponin T Not Arbitrarily but Accordingly to Usual Clinical Practice,” regarding our article previously published in the Journal. In this letter to the Editor, Cubero Gallego and colleagues raised several important issues related to the combination of biomarkers with electrocardiographic (ECG) or transthoracic echocardiographic criteria to diagnose perioperative myocardial infarction (MI), the mechanism of perioperative MI after heart valve surgery, and the requirement of a stable baseline of high-sensitivity cardiac troponin T (hs-cTnT) before surgery to distinguish an acute event from a recent index MI

Intracoronary imaging: review and clinical use

ABSTRACT Invasive coronary angiography is the standard approach in the routine clinical practice. Intracoronary imaging modalities provide real-time images of intracoronary anatomy. On this basis, optical coherence tomography and intravascular ultrasound have a positive impact on diagnosis and percutaneous coronary intervention. This summary provides an insight on these imaging modalities for the interventional and clinical cardiologist with the currently available evidence

Imagen intracoronaria: revisión y utilidad clínica

RESUMEN La coronariograf&#x00ED;a es el m&#x00E9;todo de elecci&#x00F3;n para el estudio de la anatom&#x00ED;a coronaria en la pr&#x00E1;ctica cl&#x00ED;nica diaria. Las diferentes modalidades de imagen intracoronaria permiten valorar en tiempo real la anatom&#x00ED;a de la pared arterial coronaria. Sobre esta base, la tomograf&#x00ED;a de coherencia &#x00F3;ptica y la ecograf&#x00ED;a intravascular tienen un impacto positivo en el diagn&#x00F3;stico y en el intervencionismo percut&#x00E1;neo. La presente revisi&#x00F3;n proporciona un resumen de las t&#x00E9;cnicas de imagen intracoronaria basadas en la evidencia actual disponible

Opciones actuales para el tratamiento de las lesiones calcificadas

Severe coronary calcium increases the complexity of percutaneous coronary interventions. It may affect the adequate preparation of the lesion, proper stent expansion and apposition and increase the risk of stent thrombosis and restenosis. The techniques available for the management of severe calcified lesions can be divided into 2 groups: non-balloon and balloon-based technologies. Rotational atherectomy has been the predominant technique to treat severe calcified lesions. As a matter of fact, there are new devices available that facilitate the modification of the plaque such as the new lithoplasty balloon that involves the use of highenergy mechanical pulses to crack coronary calcium. Coronary lithoplasty is an easy technique with a short learning curve that seems to be more effective on deep calcium by increasing luminal compliance. This may revolutionize the standard approach for the management of severe calcified coronary lesions. Also, the role of intravascular imaging is essential to select the most appropriate plaque-modification device and assess the optimal stent result. This review provides an overview of the techniques available and evidence on the currently approved devices to treat calcified lesions.El calcio coronario aumenta la complejidad del intervencionismo coronario percutáneo. La calcificación grave dificulta la preparación de la lesión, impide la adecuada expansión y la aposición del stent, y aumenta el riesgo de trombosis y de reestenosis. Las técnicas de modificación de placa se pueden dividir en 2 tipos según el tipo de dispositivo: sin balón y con balón. La aterectomía rotacional ha sido la técnica por excelencia para el tratamiento de lesiones gravemente calcificadas. Actualmente existen nuevos dispositivos que facilitan la preparación de la lesión, como el novedoso balón de litoplastia, que utiliza pulsos de alta energía mecánica para fragmentar el calcio coronario. La litoplastia coronaria es una técnica sencilla, con una curva de aprendizaje corta, que parece tener efecto sobre el calcio profundo y aumentar la distensibilidad luminal, lo que podría suponer un gran cambio en el enfoque del tratamiento de las lesiones calcificadas. Cabe destacar la relevancia de la imagen intravascular al seleccionar el dispositivo de modificación de placa más adecuado, así como para evaluar el resultado final del stent. Esta revisión proporciona una visión general sobre las técnicas disponibles y la evidencia de los dispositivos aprobados para el tratamiento de las lesiones calcificadas

Diagnosis of perioperative myocardial infarction after heart valve surgery with new cut-off point of high-sensitivity troponin T and new electrocardiogram or echocardiogram changes

Producción CientíficaObjective: Criteria for diagnosing myocardial infarction (MI) after heart valve surgery are not collected in the Third Universal Definition of MI. We aimed to define cut-offs for high-sensitivity cardiac troponin T (hs-cTnT) and creatine kinase-MB (CK-MB) for the diagnosis of perioperative MI after heart valve surgery according to perioperative MI determined by new alterations in electrocardiogram (ECG) and/or transthoracic echocardiogram (TTE). Secondary endpoints were incidence of perioperative MI, postoperative complications, 30-day mortality, and 2-year survival. Methods: Heart valve surgery was performed in 805 patients (June 2012-January 2016). hs-cTnT and CK-MB were measured at intensive care unit (ICU) admission and 8, 16, 24, 48, and 72 hours after surgery. Blind to outcomes, we analyzed ECGs and TTEs before and after surgery. Patients were divided into 2 groups: with ECG and/or TTE criteria after surgery (following the consensus statement) and without these changes. We conducted receiver operating characteristic analyses for hs-cTnT and CK-MB in the group with ECG and/or TTE criteria. Results: ECG and/or TTE criteria were observed in 88 patients. Receiver operating characteristic analyses in this group showed hs-cTnT levels of 732.3 pg/mL at ICU admission; 1008 pg/mL at 8 hours, 1057 pg/mL at 16 hours, and 958.3 pg/mL at 24 hours after surgery ( P < .001) and CK-MB levels of 26.78 mg/dL at ICU admission, 54.88 mg/dL at 8 hours, 38.98 mg/dL at 16 hours, and 18.4 mg/dL at 24 hours after surgery ( P < .001). Conclusions: Cut-offs for hs-cTnT and CK-MB to diagnose perioperative MI after heart valve surgery are well above upper reference limit. These findings update the Third Universal Definition providing cut-offs to diagnose perioperative MI after heart valve surgery