Secondary tricuspid valve regurgitation : a forgotten entity

The tricuspid valve was virtually ignored for a long time in the past. However, the incidence of tricuspid insufficiency associated with left valvular disease is quite significant, ranging from 8% to 35% of cases. This is most common in conjunction with mitral valve disease but association with aortic valve pathology is not uncommon. It is most frequently related to rheumatic valve disease and much rarer in association with degenerative mitral valve disease. In most cases, the tricuspid regurgitation (TR) is so-called 'functional', corresponding to dilatation of the annulus, as a consequence of RV dilatation secondary to pulmonary hypertension. In 15-20% of cases, however, the injury can be organic, generally of rheumatic origin, but for the purposes of this work we will restrict our analysis to secondary (terminology now preferred over functional) TR. Originally, it was thought that in most patients with secondary TR, surgical treatment of the mitral valve disease would correct the problems of the right side and, hence, a conservative (no touch) approach to the tricuspid valve was recommended. More recently, however, it has become evident that in a significant number of cases secondary TR does not regress after appropriate correction of the left-side valvulopathy. Thus, the indications for surgery of the TR have moved towards a progressively more interventional attitude. Today, it is evident that we must intervene on the tricuspid valve in cases of obviously severe tricuspid insufficiency and in cases where perioperative detection of a more significant TR than expected is made, especially when triggered by increasing load conditions. In this work, we intend to review the current concepts on the anatomy, physiopathology, natural history, diagnosis and treatment of secondary TR

Desarrollo de indicaciones de uso apropiado del implante transcateter de protesis valvular aortica en el tratamiento de la estenosis aortica grave sintomatica

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Impact of Triple Therapy in Elderly Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Background and purpose: Selecting an ideal antithrombotic therapy for elderly patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) can be challenging since they have a higher thromboembolic and bleeding risk than younger patients. The current study aimed to assess the efficacy and safety of triple therapy (TT: oral anticoagulation plus dual antiplatelet therapy: aspirin plus clopidogrel) in patients ≥75 years of age with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). Methods: A prospective multicenter study was conducted from 2003 to 2012 at 6 Spanish teaching hospitals. A cohort study of consecutive patients with AF undergoing PCI and treated with TT or dual antiplatelet therapy (DAPT) was analyzed. All outcomes were evaluated at 1-year of follow-up. RESULTS: Five hundred and eighty-five patients, 289 (49%) of whom were ≥75 years of age (79.6±3.4 years; 33% women) were identified. TT was prescribed in 55.9% of patients at discharge who had a higher thromboembolic risk (CHA2DS2VASc score: 4.23±1.51 vs 3.76±1.40, p = 0.007 and a higher bleeding risk (HAS-BLED ≥3: 88.6% vs 79.2%, p = 0.02) than those on DAPT. Therefore, patients on TT had a lower rate of thromboembolism than those on DAPT (0.6% vs 6.9%, p = 0.004; HR 0.08, 95% CI: 0.01-0.70, p = 0.004). Major bleeding events occurred more frequently in patients on TT than in those on DAPT (11.7% vs 2.4%, p = 0.002; HR 5.2, 95% CI: 1.53-17.57, p = 0.008). The overall mortality rate was similar in both treatment groups (11.9% vs 13.9%, p = 0.38); however, after adjustment for confounding variables, TT was associated with a reduced mortality rate (HR 0.33, 95% CI: 0.12-0.86, p = 0.02). Conclusions: In elderly patients with AF undergoing PCI, the use of TT compared to DAPT was associated with reduced thromboembolism and mortality rates, although a higher rate of major bleeding