um documento de posição da Associação Portuguesa de Intervenção Cardiovascular e do Grupo de Estudo de Cardio-Oncologia da Sociedade Portuguesa de Cardiologia

The field of Cardio-Oncology has grown significantly, especially during the last decade. While awareness of cardiotoxicity due to cancer disease and/or therapies has greatly increased, much of the attention has focused on myocardial systolic disfunction and heart failure. However, coronary and structural heart disease are also a common issue in cancer patients and encompass the full spectrum of cardiotoxicity. While invasive percutaneous or surgical intervention, either is often needed or considered in cancer patients, limited evidence or guidelines are available for dealing with coronary or structural heart disease. The Society for Cardiovascular Angiography and Interventions consensus document published in 2016 is the most comprehensive document regarding this particular issue, but relevant evidence has emerged since, which render some of its considerations outdated. In addition to that, the recent 2022 ESC Guidelines on Cardio-Oncology only briefly discuss this topic. As a result, the Portuguese Association of Cardiovascular Intervention and the Cardio-Oncology Study Group of the Portuguese Society of Cardiology have partnered to produce a position paper to address the issue of cardiac intervention in cancer patients, focusing on percutaneous techniques. A brief review of available evidence is provided, followed by practical considerations. These are based both on the literature as well as accumulated experience with these types of patients, as the authors are either interventional cardiologists, cardiologists with experience in the field of Cardio-Oncology, or both.proofepub_ahead_of_prin

Guideline-directed medical therapy assessment in heart failure patients undergoing percutaneous mitral valve repair.

AIMS Achieving optimized guideline-directed medical therapy (GDMT) is recommended prior to transcatheter mitral valve edge-to-edge repair (M-TEER) for secondary mitral regurgitation (SMR). We aimed to propose and validate an easy-to-use score for assessing the quality of GDMT in patients with heart failure with reduced ejection fraction (HFrEF) undergoing M-TEER. METHODS AND RESULTS Among the 1641 EuroSMR patients enrolled in the EuroSMR Registry who underwent M-TEER, a total of 1072 patients [median age 74, interquartile range (IQR) 67-79 years, 29% female] had complete data on GDMT and a left ventricular ejection fraction ≤ 40% and were included in the current study. We proposed a GDMT score that considers the dosage levels of three medication classes (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists), with a maximum score of 12 points indicating optimal GDMT. The primary outcome was all-cause mortality. The median GDMT score was 4 points (IQR 3-6). All three domains of the scoring system were associated with all-cause mortality (P < 0.05 for all). The overall GDMT score was associated with all-cause mortality (hazard ratio 0.90, 95% confidence interval 0.86-0.95 for each 1-point increase in the GDMT score). This association remained significant after adjusting for renal function and co-morbidities. CONCLUSIONS This study demonstrates the utility of a simple GDMT scoring system for assessing the adequacy of GDMT in HFrEF patients with relevant SMR undergoing M-TEER. The GDMT score has potential applications in guiding the design of future clinical trials and aiding clinical decision-making processes

Transcatheter mitral valve interventions for mitral regurgitation, with special focus on MitraClip: The position of Spanish, Portuguese and Italian interventional societies

Mitral regurgitation is a common valvular heart disease and its prevalence is expected to increase with population ageing. In the recent years we have witnessed the evolution of several transcatheter devices to correct mitral regurgitation in patients at high-risk for surgery. Most of the evidence of the safety and efficacy of this new therapy comes from MitraClip studies. However, new alternatives have emerged with promising results. The aim of this position paper is to review the current evidence regarding patient selection, expected results and timing for transcatheter mitral valve interventions from the perspective of three European interventional societies

Additive Value of Magnetic Resonance Coronary Angiography in a Comprehensive Cardiac Magnetic Resonance Stress-Rest Protocol for Detection of Functionally Significant Coronary Artery Disease:A Pilot Study

Background— Cardiovascular magnetic resonance (CMR) myocardial perfusion imaging (MPI) is a state-of-the-art noninvasive modality for detection of myocardial ischemia and coronary artery disease. Magnetic resonance coronary angiography (MRCA) allows visualization of the coronary tree, but its incremental value as part of a CMR protocol including MPI and late gadolinium enhancement (LGE) is not well established. We aimed to evaluate the additive diagnostic value of a 3-dimensional whole-heart MRCA integration into a 1.5T CMR-MPI/LGE protocol for the detection of functionally significant coronary artery disease. Methods and Results— Forty-three symptomatic patients (61±8.3 years; 65% men) with suspected coronary artery disease and intermediate/high-pretest probability underwent CMR (including CMR-MPI, MRCA, and LGE) and x-ray invasive coronary angiography (XA) with fractional flow reserve evaluation. Diagnostic performances of MRCA, CMR-MPI/LGE, and MRCA+CMR-MPI/LGE integration were determined having XA+fractional flow reserve as standard for coronary artery disease (≥90% stenosis/occlusion or fractional flow reserve≤0.80 in vessels&gt;2 mm). MRCA inclusion into the CMR protocol was associated with a mean increase of 7.9±4.69 (0–17.7) minutes in total examination duration (14%). On patient-based analysis, MRCA had 96% sensitivity, 68% specificity, positive predictive value of 79%, and negative predictive value of 93%. CMR-MPI/LGE had 79% sensitivity, 95% specificity, positive predictive value of 95%, and negative predictive value of 78%. Integration of MRCA with CMR-MPI/LGE further improved CMR performance to 96% sensitivity, 89% specificity, positive predictive value of 92%, and negative predictive value of 94%, with a global accuracy of 93%. Conclusions— In this intermediate/high-pretest population, integration of noncontrast-enhanced whole-heart MRCA nonsignificantly improved per-patient diagnostic accuracy of a comprehensive 1.5-T stress-rest CMR-MPI/LGE protocol at a cost of longer scanning times. </jats:sec

Direct comparison of cardiac magnetic resonance and multidetector computed tomography stress-rest perfusion imaging for detection of coronary artery disease

ObjectivesThis study sought to compare the diagnostic performance of a multidetector computed tomography (MDCT) integrated protocol (IP) including coronary angiography (CTA) and stress-rest perfusion (CTP) with cardiac magnetic resonance myocardial perfusion imaging (CMR-Perf) for detection of functionally significant coronary artery disease (CAD).BackgroundMDCT stress-rest perfusion methods were recently described as adjunctive tools to improve CTA accuracy for detection of functionally significant CAD. However, only a few studies compared these MDCT-IP with other clinically validated perfusion techniques like CMR-Perf. Furthermore, CTP has never been validated against the invasive reference standard, fractional flow reserve (FFR), in patients with suspected CAD.Methods101 symptomatic patients with suspected CAD (62 ± 8.0 years, 67% males) and intermediate/high pre-test probability underwent MDCT, CMR and invasive coronary angiography. Functionally significant CAD was defined by the presence of occlusive/subocclusive stenoses or FFR measurements ≤0.80 in vessels >2mm.ResultsOn a patient-based model, the MDCT-IP had a sensitivity, specificity, positive and negative predictive values of 89%, 83%, 80% and 90%, respectively (global accuracy 85%). These results were closely related with those achieved by CMR-Perf: 89%, 88%, 85% and 91%, respectively (global accuracy 88%). When comparing test accuracies using noninferiority analysis, differences greater than 11% in favour of CMR-Perf can be confidently excluded.ConclusionsMDCT protocols integrating CTA and stress-rest perfusion detect functionally significant CAD with similar accuracy as CMR-Perf. Both approaches yield a very good accuracy. Integration of CTP and CTA improves MDCT performance for the detection of relevant CAD in intermediate to high pre-test probability populations

A comparison of in-hospital acute myocardial infarction management between Portugal and the United States : 2000–2010

© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: [email protected]: To compare healthcare in acute myocardial infarction (AMI) treatment between contrasting health systems using comparable representative data from Europe and USA. Design: Repeated cross-sectional retrospective cohort study. Setting: Acute care hospitals in Portugal and USA during 2000-2010. Participants: Adults discharged with AMI. Interventions: Coronary revascularizations procedures (percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery). Main Outcome Measures: In-hospital mortality and length of stay. Results: We identified 1 566 601 AMI hospitalizations. Relative to the USA, more hospitalizations in Portugal presented with elevated ST-segment, and fewer had documented comorbidities. Age-sex-adjusted AMI hospitalization rates decreased in USA but increased in Portugal. Crude procedure rates were generally lower in Portugal (PCI: 44% vs. 47%; CABG: 2% vs. 9%, 2010) but only CABG rates differed significantly after standardization. PCI use increased annually in both countries but CABG decreased only in the USA (USA: 0.95 [0.94, 0.95], Portugal: 1.04 [1.02, 1.07], odds ratios). Both countries observed annual decreases in risk-adjusted mortality (USA: 0.97 [0.965, 0.969]; Portugal: 0.99 [0.979, 0.991], hazard ratios). While between-hospital variability in procedure use was larger in USA, the risk of dying in a high relative to a low mortality hospital (hospitals in percentiles 95 and 5) was 2.65 in Portugal when in USA was only 1.03. Conclusions: Although in-hospital mortality due to an AMI improved in both countries, patient management in USA seems more effective and alarming disparities in quality of care across hospitals are more likely to exist in Portugal.This paper was funded by the Harvard Medical School—Portugal Program [HMSP-ICT/0013/2011]. Armando Teixeira-Pinto was partially supported by National Health and Medical Research Council through the Screening & Test Evaluation Program [grant number 633003]. Project Macro-to-Nano human sensing: towards integrated multimodal health monitoring and analytics (NanoSTIMA) [NORTE-01-0145-FEDER-000016] is financed by the North Portugal Regional Operational Programme (NORTE 2020), under the PORTUGAL 2020 Partnership Agreement, and through the European Regional Development Fund (ERDF).info:eu-repo/semantics/publishedVersio

A divisão atlântica na doença coronária : epidemiologia e cuidados de saúde nos Estados Unidos e Portugal

© 2017 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. All rights reserved.Introduction and Objectives: We aimed to compare access to new health technologies to treat coronary heart disease (CHD) in the health systems of Portugal and the US, characterizing the needs of the populations and the resources available. Methods: We reviewed data for 2000 and 2010 on epidemiologic profiles of CHD and on health care available to patients. Thirty health technologies (16 medical devices and 14 drugs) introduced during the period 1980-2015 were identified by interventional cardiologists. Approval and marketing dates were compared between countries. Results: Relative to the US, Portugal has lower risk profiles and less than halfthe hospitalizations per capita, but fewer centers per capita provide catheterization and cardiothoracic surgery services. More than 70% of drugs were available sooner in the US, whereas 12 out of 16 medical devices were approved earlier in Portugal. Nevertheless, at least five of these devices were adopted first or diffused fasterin the US. Mortality due to CHD and myocardial infarction (MI) was lower in Portugal (CHD: 72.8 vs. 168 and MI: 48.7 vs. 54.1 in Portugal and the US, respectively; age- and gender-adjusted deaths per 100 000 population, 2010); but only CHD deaths exhibited a statistically significant difference between the countries. Conclusions: Differences in regulatory mechanisms and price regulations have a significant impact on the types of health technologies available in the two countries. However, other factors may influence their adoption and diffusion, and this appears to have a greater impact on mortality, due to acute conditions.Introdução e objetivos: O objetivo deste estudo é comparar o acesso a novas tecnologias em saúde no tratamento da doença coronária (CHD), entre os sistemas de saúde de Portugal e dos Estados Unidos (US), caracterizando as necessidades das populações e disponibilidade de recursos. Métodos:Foram comparados dados (2000 e 2010) de Portugal e US para descrever perfis epidemiológicos e recursos disponíveis na prestação cuidados de saúde na CHD. Trinta tecnologias de saúde (16 dispositivos médicos e 14 medicamentos), introduzidas durante 1980-2015, foram identificadas por cardiologistas de intervenção e calcularam-se as diferenças entre as datas de autorização de introdução no mercado/comercialização nos dois países. Resultados: Relativamente aos US, Portugal apresenta perfis de risco mais baixos, menos hospitalizações per capita, menor número de centros per capita com valência para cateterismo coronário e cirurgia cardiotorácica. Mais de 70% dos medicamentos foram comercializados mais cedo nos US, enquanto 12 dos 16 dispositivos médicos obtiveram autorização para comercialização mais cedo em Portugal. Contudo, pelo menos cinco destes dispositivos foram adotados primeiro ou sofreram uma difusão mais rápida nos US. A mortalidade por CHD e enfarte agudo do miocárdio (EAM) foi inferior em Portugal (CHD: 72,8 [Portugal] versus 168 [US]; AMI: 48,7 [Portugal] versus 54,1 [US]; mortes por 100 000 habitantes, padronizada por idade e sexo, 2010), tendo-se apenas verificado uma diferença significativa entre os países na mortalidade por CHD. Conclusões: Diferenças nos mecanismos de regulação e controlo de preços têm um impacto significativo no tipo de tecnologias disponíveis nos dois países. Contudo, outros fatores influenciam a sua adoção e difusão, tendo um maior impacto na mortalidade em condições mais agudas.This work was supported by the Harvard Medical School - Portugal Program (HMSP-ICT/0013/2011). Armando Teixeira-Pinto was partially supported by National Health and Medical Research Council program grant 633003 to the Screening and Test Evaluation Program (STEP).info:eu-repo/semantics/publishedVersio

Qualitative monitoring of SARS-CoV-2 mRNA vaccination in humans using droplet microfluidics

International audienceSARS-CoV-2 mRNA vaccination generates protective B cell responses targeting the SARS-CoV-2 spike glycoprotein. Whereas anti-spike memory B cell responses are long-lasting, the anti-spike humoral antibody response progressively wanes, making booster vaccinations necessary for maintaining protective immunity. Here we investigated qualitatively the plasmablast responses by measuring from single cells within hours of sampling the affinity of their secreted antibody for the SARS-CoV-2 spike receptor binding domain in cohorts of BNT162b2-vaccinated naive and COVID-19-recovered individuals. Using a unique droplet microfluidic and imaging approach, we analyzed >4,000 single IgG-secreting cells revealing high inter-individual variability in affinity for RBD with variations over 4 logs. High-affinity plasmablasts were induced by BNT162b2 vaccination against Hu-1 and Omicron RBD but disappeared quickly thereafter, whereas low-affinity plasmablasts represented >65% of the plasmablast response at all timepoints. Our droplet-based method thus proves efficient at fast and qualitative immune monitoring and should be helpful for optimization of vaccination protocols