An unusual cause of myocardial infarction

Copyright © 2019 European Society of CardiologyBackground: In order to direct the treatment it, is well established that is fundamental to clarify the aetiology of heart failure and the cause of myocardial infarction (MI) with non obstructive coronary artery disease (MINOCA), with CMR being one of the methods of choice in both clinical situations. Case report: A 70 years-old male patient was admitted in our emergency department with complaints of irregular palpitations, progressive dyspnoea and fatigue on exertion, with two weeks of evolution; these symptoms were associated to retrosternal chest pain in the last twelve hours. He had a previous medical history of dyslipidemia, no other cardiovascular risk factors were known. On admission, his heart rate was 130bpm, with an irregularly irregular pulse and the pulmonary auscultation revealed bibasal crackles. The remaining physical examination was unremarkable. The ECG showed an atrial fibrillation rhythm, with a mild ST elevation and T wave inversion in inferior leads. The echocardiogram revealed a diffuse hypokinesia of left ventricle with an ejection fraction of 35-40%. The lab tests documented an elevation of troponin (hs-TnT 210ng/L) and NTproBNP (1945pg/ml). The coronary angiogram showed no lesions.info:eu-repo/semantics/publishedVersio

Right ventricular lead in cardiac resynchronization therapy : what is the most electrically favorable stimulation site?

© The European Society of Cardiology 2018. All rights reserved.Introduction: The most recent studies in cardiac resynchronization therapy (CRT) have been focused on attempts to improve response rate, such as the determination of the optimal placement of the left ventricular (LV) lead. The position of the LV lead guided by the site of latest electrical delay (ED), seems to be a promising strategy. The same strategy may be useful in assessing the ideal positioning of right ventricular (RV) lead in CRT. Purpose: To determine the most favorable position of the RV lead (septal versus apical) in CRT, by measuring the ED of the LV poles during septal or apical RV pacing in patients with triple-site CRT (TRIV). Methods: A single-center prospective study of consecutive patients (Oct. 2014 to Oct. 2017) submited to CRT device implantation (Quadra Allure MPTM, which allows post-implantation ED measurement) in TRIV mode - with a quadripolar lead in the LV, a RV lead positioned at the septum and a RV lead at the apex. In the follow-up, the lead position was confirmed and determined by fluoroscopic evaluation (anterior, lateral and postero-lateral in the short axis and basal, mid and apical on the long axis). The ED was measured at the 4-pole LV lead, during apical and septal RV pacing and the relation between the ED and lead position was evaluated. Results: Twenty two patients were included: 82% male, median age 78 years; 50% implanted CRT with defibrillator; 27% had ischemic heart disease and 73% non-ischemic etiology; all patients had permanent atrial fibrillation and the QRS duration was of 176±29ms. The position of the LE lead poles was classified as lateral in 44% and postero-lateral in 56%, basal in 28%, medial in 39% and apical in 34%. We evaluated 160 ED. The mean ED between the apical RV lead and the LV poles was significantly higher than the delay between septal RV lead and the LV poles [161±33ms vs 75±45ms (p<0.001)]. This difference remained significant in LV poles located in a lateral position (76±62 vs. 166±36ms; p<0.001) or in a postero-lateral position (74±30 vs. 157±31ms; p<0.001); the same ocurred for LV poles in a basal (99±62 vs. 179±24ms, p<0.001), mid (72±38 vs. 167±31ms, p<0.001) and apical location (57±24 vs. 140±32ms, p<0.001). Conclusion: The LV lead position is an important determinant of the success of CRT, but is conditioned by anatomical and technical characteristics. The optimization of CRT may then depend on the positioning of RV lead. This study demonstrated that the apical (vs. septal) RV lead positioning presents higher ED in relation to LV lead, regardless of the latter position.info:eu-repo/semantics/publishedVersio

Prognostic impact of invasive hemodynamic evaluation in patients with pulmonary arterial hypertension

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: [email protected]: Invasive hemodynamic evaluation is a fundamental diagnostic method in patients with pulmonary hypertension (PH). However, its prognostic value in this group of patients is not fully established. Purpose: To assess the prognostic impact of hemodynamic parameters of right catheterization in patients with PH. Methods: Prospective observational study of patients with PH undergoing right and left catheterization for diagnostic confirmation and functional evaluation during vasoreactivity test. Only patients with mean pulmonary arterial pressure (PAP) >25 mmHg considered not secondary to left heart disease were included. A basal evaluation of the conventional hemodynamic parameters, left and right ventricular function indexes, pulmonary and systemic vascular resistance indexes were performed and they were re-evaluated during vasoreactivity test. The parametres were analysed and related with overall mortality and with cardiac death or hospitalization during clinical follow-up by Multivariate regression analysis of Cox. Results: A total of 68 patients were included (71% females, mean age 53±17 years), 81% of whom were from group 1 (NICE) and 15% from group IV. The mean value of mean pulmonary artery pressure was 47±16mmHg and mean right atrial pressure was 11±7mmHg. During a median follow-up of 34 months, 7 patients (10%) died and 25 (37%) were hospitalized for heart failure. Of all hemodynamic parameters, the only independent predictor of mortality was the mean right atrial pressure, for each 1mmHg rise, mortality risk increased by 12% (hazard ratio (HR): 1, 12; 95% CI 1.02–1.23; p=0.018) and the risk of death or hospitalization for cardiac causes was 17% (HR: 1.17, 95% CI: 1.00–1.37, P=0.050). The prognosis was not influenced by the demonstration of pulmonary arterial vasoreactivity, magnitude of PAP elevation or pulmonary vascular resistance. Conclusion: In patients with PH, invasive hemodynamic evaluation offers an addictional value in prognostic stratification. In particular, measurement of mean right atrial pressure has been shown to be an independent predictor of mortality. On the other hand, other parameters such as pulmonary arterial vasoreactivity, although important in the definition of the therapeutic strategy, did not have an impact on the risk of death or hospitalization.info:eu-repo/semantics/publishedVersio

Implantation of ICD and CRT-D in the elderly population : will it be a limiting factor?

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017Introduction: Implantable cardioverter defibrillator (ICD) and cardiac resynchronization (CRT-D) implantation in elderly patients is effective in preventing sudden death, although limited by the natural shorter life expectancy. The different device brands present very variable survival estimates and it has been discussed the availability of less expensive, less longevity generators for the elderly population. Purpose: To determine if the expected survival rate in the elderly patient population (≥75 years) should influence the selection of the desired longevity of the devices. Methods: A retrospective single-center study of consecutive patients who underwent implantation of ICD or CRT-D after November 1995. The mean survival of patients undergoing 1st implant or generator replacement at an advanced age (≥75 years) was evaluated and compared to the effective longevity of the generators. Cumulative survival analyzes using the Kaplan Meier method were used. Results: A total of 1312 cardiac devices were implanted, of which 163 generators in elderly patients (53% CDI and 47% CRT-D). Of these, 77% corresponded to the 1st implant. The median survival after implantation of the elderly patients was 6.8 years, not differing according to the type of device (Log-rank P = NS). The median longevity of CDI generators was 6.9 years, in line with the expected survival of elderly patients. Conversely, the median CRT-D longevity was 5.8 years, lower than the average survival of the elderly. For this reason, 21% of these CRT-D carriers were subsequently subjected to generator replacement, due to battery exhaustion. Conclusion: The effective longevity of ICDs is in agreement with an expected survival of elderly patients, for which it will not make sense to provide generators of shortened longevity for this population. The effective longevity of the CRTs is lower than the survival expectancy of the treatments, so that, paradoxically, generators with increased longevity should be favored.info:eu-repo/semantics/publishedVersio

Atrial fibrillation ablation : the added value of adenosine test in confirming pulmonary vein isolation

© The European Society of Cardiology 2018. All rights reserved.Introduction: Adenosine test has been increasingly used to confirm pulmonary vein isolation (PVI) in patients undergoing ablation of atrial fibrillation (AF). However, its impact on the success of ablation remains unknown. Purposes: To evaluate the results of the adenosine triphosphate (ATP) test in patients undergoing PVI and assess the success of ablation related to the use of this test (adenosine-guided PVI versus conventional PVI). Methods: Single-center prospective study of consecutive patients undergoing first AF ablation procedure, started at January 2013. After ablation, the persistence of PVI was tested with adenosine triphosphate administration (15–30mg by intravenous route). When adenosine triphosphate-induced pulmonary vein conduction (termed as reconduction) was observed, additional energy applications of radiofrequency were applied to obtain persistent isolation on retesting. Cardiac event recorder was performed at 7 days, 3, 6 and 12 months after ablation and annually from the 2nd year. The adenosine triphosphate-induced reconduction rate was evaluated depending on the pulmonary vein involved. The impact of adenosine test implementation in the success of the ablation at 365 days (recurrence of AF or supraventricular tachycardia) was determined by analysis of overall survival using Kaplan-Meier method. Results: Adenosine test was performed on 151 patients, with reconduction detected on at least one of the pulmonary veins in 11 patients (33.8%) and in 17.6% of the 641 pulmonary veins evaluated, with no statistically significant difference between the different veins. The overall success rate of AF ablation at 365 days was 72% and did not differ significantly between adenosine-guided PVI versus conventional PVI (74.3% versus 70.8%, P = NS), although the duration of follow-up had been shorter in the first group (median of 13.0 vs. 38.3 months; p<0.001). Conclusion: The adenosine-induced reconduction occurs in about one third of the patients. However, the additional adenosine-guided energy applications do not seem to increase the overall success of ablation. We found no significant reduction in the 1 year incidence of recurrent atrial tachyarrhythmias by ATP-guided PVI compared with conventional PVI.info:eu-repo/semantics/publishedVersio

Structural Volatility in Chile: A Policy Report

This paper identifies Chile`s economic weaknesses and offers policy recommendations for increasing stability. Current problems include weak international financial links, a Central Bank mandate that is ill-designed to deal with terms of trade shocks, a propensity to waste scarce liquidity in the banking system; and limited development of financial markets. The paper`s policy recommendations include improving external financial links, molding terms of trade contingencies into anti-cyclical policies, Improving liquidity aggregation through and within the banking sector during crises, and improving the liquidity and immediacy of domestic financial instruments

An Evaluation of the Contractionary Devaluation Hypothesis

Recent empirical and theoretical literature on the impact of real exchange rate devaluations on economic performance questions the traditional expansionary effect generated within standard Mundell-Fleming models. Contractionary devaluations may arise when firms face maturity or currency mismatches that, when faced with real exchange rate depreciations, lead to balance-sheet effects that erode firms' wealth and lead to an output contraction. While some authors show that the standard Mundell-Fleming result may hold even in the presence of currency mismatches, others point out that, if the balance sheet effect is large enough, devaluations can be contractionary. Using a large panel of 57 countries across the world and various newly constructed measures of dollarization, we test whether the balance sheet effect hypothesis has been relevant during the past decades in explaining economic downturns. Additionally, we explore the channels through which devaluations can be contractionary; in particular, we explore whether investment and consumption decisions are negatively affected by exchange rate devaluations under currency mismatches

Elevated circulating levels of succinate in human obesity are linked to specific gut microbiota

Gut microbiota-related metabolites are potential clinical biomarkers for cardiovascular disease (CVD). Circulating succinate, a metabolite produced by both microbiota and the host, is increased in hypertension, ischemic heart disease, and type 2 diabetes. We aimed to analyze systemic levels of succinate in obesity, a major risk factor for CVD, and its relationship with gut microbiome. We explored the association of circulating succinate with specific metagenomic signatures in cross-sectional and prospective cohorts of Caucasian Spanish subjects. Obesity was associated with elevated levels of circulating succinate concomitant with impaired glucose metabolism. This increase was associated with specific changes in gut microbiota related to succinate metabolism: a higher relative abundance of succinate-producing Prevotellaceae (P) and Veillonellaceae (V), and a lower relative abundance of succinate-consuming Odoribacteraceae (O) and Clostridaceae (C) in obese individuals, with the (P + V/O + C) ratio being a main determinant of plasma succinate. Weight loss intervention decreased (P + V/O + C) ratio coincident with the reduction in circulating succinate. In the spontaneous evolution after good dietary advice, alterations in circulating succinate levels were linked to specific metagenomic signatures associated with carbohydrate metabolism and energy production with independence of body weight change. Our data support the importance of microbe-microbe interactions for the metabolite signature of gut microbiome and uncover succinate as a potential microbiota-derived metabolite related to CVD risk