Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE) : a prospective, randomised, open-label, non-inferiority trial

Background Coronary artery bypass grafting (CABG) is the standard treatment for revascularisation in patients with left main coronary artery disease, but use of percutaneous coronary intervention (PCI) for this indication is increasing. We aimed to compare PCI and CABG for treatment of left main coronary artery disease. Methods In this prospective, randomised, open-label, non-inferiority trial, patients with left main coronary artery disease were enrolled in 36 centres in northern Europe and randomised 1: 1 to treatment with PCI or CABG. Eligible patients had stable angina pectoris, unstable angina pectoris, or non-ST-elevation myocardial infarction. Exclusion criteria were ST-elevation myocardial infarction within 24 h, being considered too high risk for CABG or PCI, or expected survival of less than 1 year. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCE), a composite of all-cause mortality, non-procedural myocardial infarction, any repeat coronary revascularisation, and stroke. Non-inferiority of PCI to CABG required the lower end of the 95% CI not to exceed a hazard ratio (HR) of 1 . 35 after up to 5 years of follow-up. The intention-to-treat principle was used in the analysis if not specified otherwise. This trial is registered with ClinicalTrials.gov identifier, number NCT01496651. Findings Between Dec 9, 2008, and Jan 21, 2015, 1201 patients were randomly assigned, 598 to PCI and 603 to CABG, and 592 in each group entered analysis by intention to treat. Kaplan-Meier 5 year estimates of MACCE were 29% for PCI (121 events) and 19% for CABG (81 events), HR 1 . 48 (95% CI 1 . 11-1 . 96), exceeding the limit for non-inferiority, and CABG was significantly better than PCI (p=0 . 0066). As-treated estimates were 28% versus 19% (1 . 55, 1 . 18-2 . 04, p= 0 . 0015). Comparing PCI with CABG, 5 year estimates were 12% versus 9% (1 . 07, 0 . 67-1 . 72, p= 0 . 77) for all-cause mortality, 7% versus 2% (2 . 88, 1 . 40-5 . 90, p= 0 . 0040) for non-procedural myocardial infarction, 16% versus 10% (1 . 50, 1 . 04-2 . 17, p= 0 . 032) for any revascularisation, and 5% versus 2% (2 . 25, 0 . 93-5 . 48, p= 0 . 073) for stroke. Interpretation The findings of this study suggest that CABG might be better than PCI for treatment of left main stem coronary artery disease.Peer reviewe

Outcome after Surgery for Iatrogenic Acute Type A Aortic Dissection

(1) Background: Acute Stanford type A aortic dissection (TAAD) may complicate the outcome of cardiovascular procedures. Data on the outcome after surgery for iatrogenic acute TAAD is scarce. (2) Methods: The European Registry of Type A Aortic Dissection (ERTAAD) is a multicenter, retrospective study including patients who underwent surgery for acute TAAD at 18 hospitals from eight European countries. The primary outcomes were in-hospital mortality and 5-year mortality. Twenty-seven secondary outcomes were evaluated. (3) Results: Out of 3902 consecutive patients who underwent surgery for acute TAAD, 103 (2.6%) had iatrogenic TAAD. Cardiac surgery (37.8%) and percutaneous coronary intervention (36.9%) were the most frequent causes leading to iatrogenic TAAD, followed by diagnostic coronary angiography (13.6%), transcatheter aortic valve replacement (10.7%) and peripheral endovascular procedure (1.0%). In hospital mortality was 20.5% after cardiac surgery, 31.6% after percutaneous coronary intervention, 42.9% after diagnostic coronary angiography, 45.5% after transcatheter aortic valve replacement and nihil after peripheral endovascular procedure (p = 0.092), with similar 5-year mortality between different subgroups of iatrogenic TAAD (p = 0.710). Among 102 propensity score matched pairs, in-hospital mortality was significantly higher among patients with iatrogenic TAAD (30.4% vs. 15.7%, p = 0.013) compared to those with spontaneous TAAD. This finding was likely related to higher risk of postoperative heart failure (35.3% vs. 10.8%, p < 0.0001) among iatrogenic TAAD patients. Five-year mortality was comparable between patients with iatrogenic and spontaneous TAAD (46.2% vs. 39.4%, p = 0.163). (4) Conclusions: Iatrogenic origin of acute TAAD is quite uncommon but carries a significantly increased risk of in-hospital mortality compared to spontaneous TAAD

Muerte súbita isquémica: análisis crítico de los marcadores de riesgo

La enfermedad coronaria es responsable de un 75- 80% de los casos de muerte súbita en la mayoría de países industrializados. Los factores de riesgo de muerte súbita pueden dividirse en marcadores de enfermedad estructural cardíaca y marcadores de acontecimientos fisiológicos anormales. No están bien definidas las estrategias de prevención primaria de muerte súbita. El uso sistemático de marcadores de riesgo para identificar poblaciones en riesgo de muerte súbita podría ayudar a establecer medidas de prevención primaria en la práctica clínica diaria. En este artículo se revisan diferentes métodos de estratificación de riesgo mediante análisis de la fracción de eyección, arritmias ventriculares, variabilidad de frecuencia cardíaca, sensibilidad de barorreflejo, dispersión de la repolarización y estudios electrofisiológicos. Coronary artery disease is responsible for approximately 75-80% of sudden cardiac deaths in most industrialized countries. Risk factors can be divided in those which suggest structural heart disease and those reflecting abnormal physiological markers. Therapeutic strategies for primary prevention of sudden cardiac death require careful scrutiny. The systematic use of risk markers to identify and stratify high risk groups may be of help to establish primary prevention measures in daily practice. Different methods to stratify risk factors using ejection fraction, ventricular arrhythmias, heart rate variability, barofeflex sensitivity, and dispesrion of repolarization are discussed in this article

Multi-lag HRV analysis discriminates disease progression of post-infarct people with no diabetes versus diabetes

Diabetes mellitus is associated with multi-organ system dysfunction including the cardiovascular and autonomic nervous system. Although it is well documented that post-infarct patients are at higher risk of sudden cardiac death, diabetes adds an additional risk associated with autonomic neuropathy. However it is not known how the presence of diabetes in post-infarct patients affects cardiac rhythm. The majority of HRV algorithms for determining cardiac inter-beat interval changes describe only beat-to-beat variation determined over the whole heart rate recording and therefore do not consider the ability of a heart beat to influence a train of succeeding beats nor whether or how the temporal dynamics of the inter-beat intervals changes. This study used Poincaré Plot derived features and incorporated increased lag intervals to compare post-infarct patients with no history of prior infarct with or without diabetes and found that for the nondiabetic post-infarct patients only increased lag of short term correlation (SD1) predicted mortality, whereas in the diabetic post-infarct group only long-term correlations (SD2) significantly predicted mortality at a follow-up period of eight years. Temporal dynamics measured as a complex correlation measure (CCM) was also a significant predictor of mortality only in the diabetic post-infarct cohort. This study highlights the different pathophysiological progression and risk profile associated with presence of diabetes in a post-infarct patient population at eight year follow-up

Multi-lag HRV analysis discriminates disease progression of post-infarct people with no diabetes versus diabetes

Diabetes mellitus is associated with multi-organ system dysfunction including the cardiovascular and autonomic nervous system. Although it is well documented that post-infarct patients are at higher risk of sudden cardiac death, diabetes adds an additional risk associated with autonomic neuropathy. However it is not known how the presence of diabetes in post-infarct patients affects cardiac rhythm. The majority of HRV algorithms for determining cardiac inter-beat interval changes describe only beat-to-beat variation determined over the whole heart rate recording and therefore do not consider the ability of a heart beat to influence a train of succeeding beats nor whether or how the temporal dynamics of the inter-beat intervals changes. This study used Poincaré Plot derived features and incorporated increased lag intervals to compare post-infarct patients with no history of prior infarct with or without diabetes and found that for the nondiabetic post-infarct patients only increased lag of short term correlation (SD1) predicted mortality, whereas in the diabetic post-infarct group only long-term correlations (SD2) significantly predicted mortality at a follow-up period of eight years. Temporal dynamics measured as a complex correlation measure (CCM) was also a significant predictor of mortality only in the diabetic post-infarct cohort. This study highlights the different pathophysiological progression and risk profile associated with presence of diabetes in a post-infarct patient population at eight year follow-up

Patient-Prosthesis Mismatch Worsens Long-Term Survival : Insights From the FinnValve Registry

Background. The impact of patient-prosthesis mismatch (PPM) on long-term outcome after surgical aortic valve replacement (SAVR) is controversial. We sought to investigate the incidence of PPM and its impact on survival and reinterventions in a Finnish nationwide cohort. Methods. In the context of the nationwide FinnValve registry, we identified 4097 patients who underwent SAVR with a stented bioprosthesis with or without myocardial revascularization. The indexed effective orifice areas (EOAs) of surgical bioprostheses were calculated using literature-derived EOAs. PPM was graded as moderate (EOA 0.65-0.85 cm(2)/m(2)) or severe (EOA Results. The incidence of PPM was 46.0%. PPM was moderate in 38.8% (n = 1579) patients and severe in 7.2% (n = 297) patients. Time-trend analysis showed that the proportion of PPM decreased significantly from 74% in 2009 to 18% in 2017 (P < .01). Severe PPM was associated with increased 5-year all-cause mortality (adjusted hazard ratio [HR], 1.72; 95% confidence interval [CI], 1.07-2.76; P = .02). Severe PPM was not associated with an increased risk of repeat AVR (adjusted HR, 5.90; 95% CI, 0.95-36.5; P = .06). In a subanalysis of patients greater than or equal to 70 years of age, in comparison with no PPM, any PPM (adjusted HR, 1.23; 95% CI, 1.05-1.45; P = .01) and severe PPM (HR, 1.53; 95% CI, 1.17-2.00; P < 0.01) were associated with increased risk of 5-year mortality. Conclusions. Severe PPM after SAVR had a negative impact on survival. This study demonstrated that the effects of PPM should not be overlooked in elderly undergoing SAVR. (C) 2021 by The Society of Thoracic SurgeonsPeer reviewe

Cardioneuropatía chagásica un modelo único de nervación autonómica

IP 6566-04-788-98Anexo: Perdida de la oscilacion caotica de la frecuencia cardiaca : un nuevo marcador de compromiso miocardio temprano en la cardiopatia chagasica / Angel maria Chavez, Hernando Leon, Manuel Alxander Lindarte, Juan Camilo Guzman, Tom A. Kuusela, Leonelo E. Bautista. Bautista.ARTICULO(S) EN REVISTA: Heart rate dynamics before tha spontaneous onset of ventricular tachyarrhythmias in;chagas' heart disease / Jorge O. Diaz, Timo H. Makikallio,Heikki V. Huikuri, Gustavo Lopera, Raul D. Mitrani,;Agustin Castellanos, Robert J. Myerburg, Pilar Rozo, FernandoPava and Carlos A. Morillo. -- En: The american;journal of cardiology. -- Vol. 87 (May. 2001); p. 1123-1125. --ARTICULO(S) EN REVISTA: Evaluacion de la;Funcion Cardiaca bajo estres en seropositivos asintomaticos paratrypanosoma cruzi / Carlos Arturo Morillo;Zarate. ... [et. al]. -- En: Revista Colombiana de Cardiologia.-- Vol. 7,no 6. (oct 1999); p. 317. -- Herat;rate dynamics before the spontaneous onset of ventriculartachyarrhythmiasin chagas Heart disease / Carlos;Arturo Morillo Zarate. ... [et. al]. -- En: The American Journalof Cardiology. -- Vol. 87. (May 2001); p.;1121-1124. -- Balloon valvuloplasty versus transventricular dilation for neonatal critical aortic stenosis /;Collin G. Cowley. ... [et. al]. -- En: The American Journal ofCardiology.-- Vol. 87. (May 2001); p.;1124-1125

Clinical outcomes with percutaneous coronary revascularization vs coronary artery bypass grafting surgery in patients with unprotected left main coronary artery disease:A meta-analysis of 6 randomized trials and 4,686 patients

Some but not all randomized controlled trials (RCT) have suggested that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative to coronary artery bypass grafting (CABG) surgery for the treatment of unprotected left main coronary artery disease (ULMCAD). We therefore aimed to compare the risk of all-cause mortality between PCI and CABG in patients with ULMCAD in a pairwise meta-analysis of RCT. METHODS: Randomized controlled trials comparing PCI vs CABG for the treatment of ULMCAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. RESULTS: Six trials including 4,686 randomized patients were identified. After a median follow-up of 39 months, there were no significant differences between PCI vs CABG in the risk of all-cause mortality (hazard ratio [HR] 0.99, 95% CI 0.76-1.30) or cardiac mortality. However, a significant interaction for cardiac mortality (Pinteraction= .03) was apparent between randomization arm and SYNTAX score, such that the relative risk for mortality tended to be lower with PCI compared with CABG among patients in the lower SYNTAX score tertile, similar in the intermediate tertile, and higher in the upper SYNTAX score tertile. Percutaneous coronary intervention compared with CABG was associated with a similar long-term composite risk of death, myocardial infarction, or stroke (HR 1.06, 95% CI 0.82-1.37), with fewer events within 30 days after PCI offset by fewer events after 30 days with CABG (Pinteraction < .0001). Percutaneous coronary intervention was associated with greater rates of unplanned revascularization compared with CABG (HR 1.74, 95% CI 1.47-2.07). CONCLUSIONS: In patients undergoing revascularization for ULMCAD, PCI was associated with similar rates of mortality compared with CABG at a median follow-up of 39 months, but with an interaction effect suggesting relatively lower mortality with PCI in patients with low SYNTAX score and relatively lower mortality with CABG in patients with high SYNTAX score. Both procedures resulted in similar long-term composite rates of death, myocardial infarction, or stroke, with PCI offering an early safety advantage and CABG demonstrating greater durability