Aortic Sinus Contrast Retention During TAVR : A Warning Sign Preceding a Potential Thrombotic Complication

Sinus contrast material retention after transcatheter aortic valve replacement (TAVR) is a rare phenomenon that may reflect an increased risk for thrombotic complications. We present 3 cases of persistent contrast agent retention in the sinus of Valsalva during the TAVR procedure that portend the occurrence of embolic stroke or bioprosthetic valve thrombosis. (Level of Difficulty: Advanced.

Hemolytic Anemia After Surgical Mitral Valve Repair Treated With Transcatheter Edge-to-Edge Device

An 80-year-old woman with mitral valve repair failure was admitted with hemolytic anemia secondary to the impact of a regurgitant jet on the annuloplasty ring. Transcatheter repair to treat both mitral regurgitation and hemolysis was favored because of surgical risk. Transcatheter edge-to-edge repair represents an alternative for treating hemolysis associated with mitral regurgitation. (Level of Difficulty: Advanced.

Myocardial remodelling and tissue characterisation by cardiovascular magnetic resonance (CMR) in endurance athletes

Our purpose was to evaluate by cardiovascular magnetic resonance (CMR) the presence of diffuse as well as focal MF in a series of high-performance veteran endurance athletes. Thirty-four veteran healthy male endurance athletes, still being in regular training, with more than 10 years of training underwent a CMR. A cardiopulmonary exercise test was also performed to assess their maximal physical performance. The control group consisted in 12 non-trained normal individuals. We found an increase in both, right and left ventricular (LV) volumes in the athlete's group when compared with controls. There was no increase in indexed LV myocardial mass despite of a significantly increased maximal myocardial wall thickness in comparison to controls. Native T1 values and extracellular volume (ECV) were normal in all cases. We did not find differences in native T1 values and ECV between both groups. In three athletes (9%), non-ischaemic late gadolinium enhancement (LGE) was observed. We did not find a correlation between total training volume and presence of LGE or with the ECV value. Our results show that the majority of veteran endurance athletes present with myocardial remodelling without MF as a physiological adaptive phenomenon. In the only three athletes with focal MF, the LGE pattern observed suggests an intercurrent event not related with the remodelling phenomenon

Validación de la utilidad de los parámetros de deformación miocárdica para excluir el rechazo agudo tras el trasplante cardiaco: un estudio multicéntrico

Multicenter study[Abstract] Introduction and objectives: Two-dimensional speckle-tracking echocardiography has emerged as a promising alternative to endomyocardial biopsy to rule out acute cellular rejection after orthotopic heart transplantation (OHT) in single center studies. In an original cohort, 15.5% and 17% of cutoff points for left ventricular global longitudinal strain (LVGLS) and free-wall right ventricular longitudinal strain, respectively, achieved 100% negative predictive value to exclude moderate or severe acute cellular rejection (ACR ≥ 2R). Our objective was to demonstrate the usefulness of speckle-tracking and validate these cutoff points in an external cohort. Methods: A prospective, multicenter study that included patients who were monitored during their first year after OHT was conducted. Echocardiographic studies analyzed by local investigators were compared with simultaneous paired endomyocardial biopsies samples. Results: A total of 501 endomyocardial biopsy-echocardiographic studies were included in 99 patients. ACR≥2R was present in 7.4% of samples. LVGLS and free-wall right ventricular longitudinal strain were significantly reduced during ACR≥2R on univariate analysis. On multivariate analysis, LVGLS was independently associated with the presence of ACR≥2R. The original cutoff points demonstrated a negative predictive value of 94.3% to exclude ACR≥2R. Conclusions: This study maintained a strong negative predictive value to exclude ACR≥2R after OHT and LVGLS was independently associated with the presence of ACR≥2R. We propose the use of speckle-tracking, especially LVGLS, as part of the noninvasive diagnosis and management of ACR.[Resumen] Introducción y objetivos. Algunos estudios indican que los parámetros de strain por speckle-tracking pueden ser una alternativa no invasiva a la biopsia endomiocárdica para excluir el rechazo celular agudo (RCA) moderado o grave (≥ 2 R) tras el trasplante cardiaco (TxC). En una cohorte inicial, unos puntos de corte del 15,5% para el strain longitudinal global del ventrículo izquierdo (SLGVI) y el 17% para el strain de pared libre del ventrículo derecho mostraron un valor predictivo negativo del 100% para excluir RCA ≥ 2 R. Nuestro objetivo es analizar la utilidad del strain y validar estos puntos de corte en una cohorte multicéntrica prospectiva externa. Métodos. Estudio multicéntrico y prospectivo que incluyó a pacientes con seguimiento el primer año tras el TC. Se compararon los resultados de biopsias electivas con ecocardiogramas realizados el mismo día. Resultados. Se incluyó a 99 pacientes y 501 pares de biopsias-ecocardiogramas. El RCA ≥ 2 R en las biopsias fue del 7,4%. El SLGVI y el strain longitudinal de pared libre del ventrículo derecho fueron menores durante los RCA ≥ 2 R en el análisis univariante. En el análisis multivariante, el SLGVI se asoció de manera independiente con el RCA ≥ 2 R. Los puntos de corte originales mostraron un valor predictivo negativo del 94,3% el RCA ≥ 2 R. Conclusiones. Este estudio mantiene un alto valor predictivo negativo para excluir RCA ≥ 2 R tras el TxC y el SLGVI se asoció de manera independiente con el RCA ≥ 2 R. El strain y, principalmente, el SLGVI pueden ser de utilidad en el diagnóstico y el tratamiento no invasivo del RCA

Percutaneous mitral valve repair : Outcome improvement with operator experience and a second-generation device

Background and aim: Recent randomized data comparing percutaneous mitral valve repair (PMVR) versus optimal medical treatment in patients with functional MR (FMR) seemed to highlight the importance of the learning curve not only for procedural outcomes but also for patient selection. The aim of the study was to compare a contemporary series of patients undergoing PMVR using a second-generation Mitraclip device (Mitraclip NT) with previous cohorts treated with a first-generation system. Methods: This multicenter study collected individual data from 18 centers between 2012 and 2017. The cohort was divided into three groups according to the use of the first-generation Mitraclip during the first (control-1) or second half (control-2) or the Mitraclip NT sys-tem. Results: A total of 545 consecutive patients were included in the study. Among all, 182 (33.3%), 183 (33.3%), and 180 (33.3%) patients underwent mitral repair in the control-1, control-2, and NT cohorts, respectively. Procedural success was achieved in 93.3% of patients without differences between groups. Major adverse events did not statistically differ among groups, but there was a higher rate of pericardial effusion in the control-1 group (4.3%, 0.6%, and 2.6%, respectively; p = 0.025). The composite endpoint of death, surgery, and admission for congestive heart failure (CHF) at 12 months was lower in the NT group (23.5% in control-1, 22.5% in control-2, and 8.3% in the NT group; p = 0.032). Conclusions: The present paper shows that contemporary clinical outcomes of patients undergoing PMVR with the Mitraclip system have improved over time

Patient-specific flow simulation analysis to predict device-related thrombosis in left atrial appendage occluders

Introduction and objectives: Left atrial appendage occlusion (LAAO) can be an efficient treatment to prevent strokes in patients who suffer from atrial fibrillation, especially those at risk of bleeding. A non-negligible number of patients treated with LAAO develop device-related thrombosis (DRT) after device implantation. Our study aimed to identify the key blood flow characteristics leading to DRT using patient-specific flow simulations. Methods: Patients treated with LAAO between 2014 and 2019 at a single center with preoperative and follow-up computerized tomography images and ultrasound imaging (US) were used to create patient-specific flow simulations. Amulet LAAO devices were implanted in the study patients. Flow simulations were blindly assessed to discard the presence of DRT in the follow-up imaging. Results: A total of 6 patients were processed in this pivotal study, half of them with DRT at the follow-up according to the imaging analysis. After a comprehensive analysis of the simulations, the most relevant in silico indices associated with DRT were the presence of stagnant blood flow, recirculation with low flow velocities (< 0.20 m/s) next to the device surface, and regions with high flow complexity combined with low wall shear stress. Conclusions: Patient-specific flow simulations of LAAO were successfully used to predict blood flow patterns with different device configurations. The results show the potential of the present modelling and simulation approach to recommend optimal settings capable of minimizing the risk of DRT.Introducción y objetivos: El cierre de la orejuela izquierda (COI) puede ser una alternativa de tratamiento eficaz para prevenir eventos cardiovasculares en pacientes con fibrilación auricular, en especial en aquellos con alto riesgo de sangrado. Sin embargo, algunos de estos pacientes en los que se realiza COI desarrollan trombosis relacionada con el dispositivo (TRD). Este estudio presenta las características del flujo sanguíneo que son clave en la formación de TDR, a partir de simulaciones personalizadas para cada paciente. Métodos: Para crear las simulaciones personalizadas se incluyeron en el estudio pacientes intervenidos de COI entre 2014 y 2019 en un único centro, de quienes se disponía de imágenes de tomografía computarizada previas al procedimiento y de seguimiento, así como de control ecocardiográfico. Para el COI se utilizaron los dispositivos Amulet. Las simulaciones se analizaron de forma ciega al diagnóstico de TRD. Resultados: En total se estudiaron 6 pacientes, de los que la mitad presentaban TRD según las imágenes del seguimiento clínico. Tras analizar los resultados de las simulaciones, los índices hemodinámicos asociados con TRD fueron la presencia de flujo estancado, las recirculaciones de sangre a velocidades bajas (< 0,20 m/s) cerca de la superficie del dispositivo y las regiones con alta complejidad de flujo y baja tensión de cizallamiento en la pared. Conclusiones: Las simulaciones de flujo personalizadas en pacientes con COI predijeron correctamente el diagnóstico clínico de TRD en todos los casos analizados. Los resultados obtenidos demuestran el potencial de los modelos personalizados para recomendar configuraciones óptimas del dispositivo y minimizar el riesgo de TRD.This work was supported by the Spanish Ministry of Science, Innovation and Universities under the Retos I+D (RTI2018-101193-B-I00), the Maria de Maeztu Units of Excellence (MDM-2015-0502), the Formation of Doctors (PRE2018-084062) and the Recruitment of Talents (RYC-2015-18888) programmes

Cierre percutáneo de seudoaneurisma ventricular izquierdo

PRESENTACI&#x00D3;N DEL CASO Se presenta el caso de una paciente de 72 a&#x00F1;os, con antecedentes de fibrilaci&#x00F3;n auricular permanente en tratamiento con acenocumarol e historia de cardiopat&#x00ED;a valvular reum&#x00E1;tica en forma de doble lesi&#x00F3;n mitral en rango grave e insuficiencia tricusp&#x00ED;dea grave por dilataci&#x00F3;n del anillo, sintom&#x00E1;tica para disnea. Se completa el estudio cardiol&#x00F3;gico previo a planificar cirug&#x00ED;a de recambio valvular, que descarta la existencia de lesiones coronarias. Se presenta en el comit&#x00E9; m&#x00E9;dico-quir&#x00FA;rgico y es aceptada para sustituci&#x00F3;n valvular mitral y anuloplastia tricusp&#x00ED;dea. Se realiz&#x00F3; la intervenci&#x00F3;n de forma electiva y se implant&#x00F3; una pr&#x00F3;tesis mitral mec&#x00E1;nica On-X 25 mm (Life Technologies, EE.UU.), realizando anuloplastia tricusp&#x00ED;dea con anillo prot&#x00E9;sico. A la salida de la bomba de circulaci&#x00F3;n extracorp&#x00F3;rea se observ&#x00F3; hemorragia por rotura del surco auriculoventricular en la proximidad con la orejuela izquierda, que fue reparado con puntos apoyados en el pericardio y tefl&#x00F3;n hasta conseguir la hemostasia. En este contexto, la paciente present&#x00F3; deterioro hemodin&#x00E1;mico y ca&#x00ED;da de la funci&#x00F3;n ventricular, que precis&#x00F3; escalada de inotr&#x00F3;picos e implante de bal&#x00F3;n de contrapulsaci&#x00F3;n a&#x00F3;rtico. El posoperatorio en la unidad de cuidados cr&#x00ED;ticos fue t&#x00F3;rpido. Al quinto d&#x00ED;a de la cirug&#x00ED;a present&#x00F3; fiebre en el contexto de una neumon&#x00ED;a asociada a ventilaci&#x00F3;n mec&#x00E1;nica...