Vascular access approach for structural heart procedures

Vascular access is an essential part of all interventional procedures whether coronary or structural. Over the last 15 to 20 years, in coronary interventions, traditional femoral access has been mostly replaced by the radial approach. Nonetheless, the femoral approach through both artery and vein is still the main approach for structural heart procedures. Over the last few years, femoral access has evolved from a puncture guided by anatomical references to more accurate ultrasound-guided approaches. The relatively recent introduction of interventions such as transcatheter aortic valve replacement has conditioned the use of large introducers and ultimately the need for specific hemostatic systems, above all, percutaneous closure devices. This manuscript reviews different anatomical concepts, puncture techniques, diagnostic assessments, and closure strategies of the main arterial and venous approaches for the diagnosis and treatment of different structural heart procedures

Superioridad del índice de puntuación de movimiento parietal sobre la fracción de eyección del ventrículo izquierdo en la predicción de eventos cardiovasculares tras un infarto agudo de miocardio

Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Medicina, leída el 01-06-2015OBJETIVOS, MATERIAL Y MÉTODOS Estudio observacional prospectivo en el que se incluyeron 352 pacientes para comparar el valor pronóstico del índice de puntuación de movimiento parietal (IPMP) y de la fracción de eyección del ventrículo izquierdo (FEVI) tras un infarto agudo de miocardio (IAM) más allá de la fase hiperaguda. Dos ecocardiografistas expertos independientes analizaron los ecocardiogramas realizados más allá de las primeras 48 horas del ingreso y antes del alta. Se consideró como endpoint primario el compuesto de mortalidad por cualquier causa o reingreso por insuficiencia cardiaca (IC). RESULTADOS El 76% eran varones con una edad media de 63,4±13,6 años. El 50,4% fueron SCACEST y el 49,6% SCASEST. En un 40,8% estaba afectada la cara anterior y un 12,2% de los pacientes presentaron elevación de troponina T sin elevación de la CPK. Existió una alta concordancia interobservador en las mediciones del IPMP y de la FEVI. Durante una mediana de seguimiento de 30,5 meses (24,2-49,5), 41 pacientes (14,7%) presentaron el endpoint primario, 30 (10,9%) fallecieron y 17 (6,1%) fueron hospitalizados por IC. En el análisis de supervivencia por regresión de Cox, tener un IPMP > 1,8 fue el predictor más importante del endpoint combinado [HR 8,5; IC95% (3,7-18,8); p < 0,0001], de mortalidad [HR 12,4; IC95% (3,42-23,8); p < 0,0001] y de reingreso por IC [HR 5,6; IC 95% (1,2-10,8); p=0,001]. La FEVI también fue un predictor más débil del endpoint combinado y de mortalidad y no lo fue de reingreso por IC. En los subgrupos con menor daño miocárdico el IPMP fue el predictor independiente de eventos más importante, no siendo la FEVI un predictor independiente. CONCLUSIONES El IPMP es una técnica ecocardiográfica sencilla, reproducible y aplicable en la práctica clínica. Tanto la FEVI como el IPMP aportan una importante información pronóstica después de un primer IAM. Sin embargo, valorados más allá de la fase hiperaguda, el IPMP es un predictor pronóstico más potente, especialmente en los infartos con menor daño miocárdico.Depto. de MedicinaFac. de MedicinaTRUEunpu

Endoscopic Ultrasound for the Detection of Left Atrial Appendage Thrombus: A Useful Technique in Patients with Transesophageal Echocardiography Contraindication

Endoscopic ultrasound is a diagnostic and therapeutic technique used in specialized centers for patients that have undergone digestive procedures. This technique enables highly precise real-time imaging of the digestive tract wall and surrounding organs. Endoscopic ultrasound is also useful in patients with cardiovascular diseases such as atrial fibrillation. In patients with contraindication for transesophageal echocardiography due to high risk of esophageal bleeding or complications that may require immediate intervention, endoscopic ultrasound may be a safer option for visualizing atrial chambers to rule out the presence of left atrial appendage thrombi before cardioversion.S

Calcium Signaling Pathway Is Involved in the Shedding of ACE2 Catalytic Ectodomain: New Insights for Clinical and Therapeutic Applications of ACE2 for COVID-19

The angiotensin-converting enzyme 2 (ACE2) is a type I integral membrane that exists in two forms: the first is a transmembrane protein; the second is a soluble catalytic ectodomain of ACE2. The catalytic ectodomain of ACE2 undergoes shedding by a disintegrin and metalloproteinase domain-containing protein 17 (ADAM17), in which calmodulin mediates the calcium signaling pathway that is involved in ACE2 release, resulting in a soluble catalytic ectodomain of ACE2 that can be measured as soluble ACE2 plasma activity. The shedding of the ACE2 catalytic ectodomain plays a role in cardiac remodeling and endothelial dysfunction and is a predictor of all-cause mortality, including cardiovascular mortality. Moreover, considerable evidence supports that the ACE2 catalytic ectodomain is an essential entry receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Additionally, endotoxins and the pro-inflammatory cytokines interleukin (IL)-1&beta; and tumor necrosis factor-alpha (TNF&alpha;) all enhanced soluble catalytic ectodomain ACE2 shedding from the airway epithelia, suggesting that the shedding of ACE2 may represent a mechanism by which viral entry and infection may be controlled such as some types of betacoronavirus. In this regard, ACE2 plays an important role in inflammation and thrombotic response, and its down-regulation may aggravate COVID-19 via the renin-angiotensin system, including by promoting pathological changes in lung injury. Soluble forms of ACE2 have recently been shown to inhibit SARS-CoV-2 infection. Furthermore, given that vitamin D enhanced the shedding of ACE2, some studies reported that vitamin D treatment is associated with prognosis improvement in COVID-19. This is an updated review on the evidence, clinical, and therapeutic applications of ACE2 for COVID-19

Endoscopic Ultrasound for the Detection of Left Atrial Appendage Thrombus: A Useful Technique in Patients with Transesophageal Echocardiography Contraindication

Endoscopic ultrasound is a diagnostic and therapeutic technique used in specialized centers for patients that have undergone digestive procedures. This technique enables highly precise real-time imaging of the digestive tract wall and surrounding organs. Endoscopic ultrasound is also useful in patients with cardiovascular diseases such as atrial fibrillation. In patients with contraindication for transesophageal echocardiography due to high risk of esophageal bleeding or complications that may require immediate intervention, endoscopic ultrasound may be a safer option for visualizing atrial chambers to rule out the presence of left atrial appendage thrombi before cardioversion