Intervencionismo coronario percutáneo en Navarra. Resultados de un centro de bajo volumen intervencionista

Fundamento. El intervencionismo coronario percutáneo (PCI) es una opción terapéutica fundamental en pacientes con enfermedad coronaria. Para realizarla los especialistas deben formarse y acreditarse. Se sabe que el número de procedimientos realizados al año influye en los resultados. Pretendemos mostrar que con un bajo volumen de PCI algunos centros obtienen buenos resultados. Método. Análisis prospectivo de las características clínicas y resultados inmediatos obtenidos en nuestro centro con el PCI entre 2006 y 2012 y análisis retrospectivo de la supervivencia global, supervivencia libre de eventos y reestenosis de los PCI realizados entre 2006 y 2009. Se compararon las características clínicas, los eventos agudos y a largo plazo (complicaciones, supervivencia y mortalidad) entre nuestros pacientes y los de algunos trabajos publicados. Resultados. Nuestra probabilidad de tener cualquier complicación en un PCI fue del 9% con una mortalidad global del 2%. La mortalidad del PCI en situación estable fue del 0,43% y en el síndrome coronario agudo del 6,25%. Las complicaciones en el lugar del acceso vascular fueron del 1,44% y la incidencia de reestenosis a los nueve meses, en pacientes sometidos por primera vez a PCI, fue del 5,2%. Conclusiones. Aunque el alto volumen intervencionista ha demostrado ser importante para tener una baja tasa de complicaciones y una buena evolución a largo plazo, hay centros con bajo volumen intervencionista que por sus características pueden obtener resultados equiparables a los de alto volumen.Background. Percutaneous coronary intervention (PCI) is currently a basic therapeutic option in patients with coronary artery disease. To carry this out specialists must be trained and accredited. It is known that the number of procedures performed each year influences results. We suggest that some low volume centres may also get good results. Methods. Prospective analysis of clinical features and immediate results obtained in our centre following PCI performed between 2006 and 2012 and retrospective analysis of overall survival, outcome-free survival and restenosis in patients treated between 2006 and 2009. The clinical features, acute and long-term events (complications, survival and mortality) of our group were compared with other published studies. Results. In our centre the likelihood of complications in a PCI was 9% with an overall mortality of 2%. PCI mortality in stable coronary disease was 0.43% and in acute coronary syndrome 6.25%. Complications at the vascular access site was 1.44% and restenosis at nine months, in patients undergoing PCI for the first time, was 5.2%. Conclusions. Although a high interventionist volume has been shown to reduce the rate of complications and improve long-term evolution, some low volume interventional centres can obtain similar results to those of high volume interventional centres

Características y resultados del retransplante cardíaco en España: Análisis del Registro Nacional de Trasplante Cardíaco

Introducción y objetivos: El retrasplante cardiaco (ReTC) supone tanto un reto científico como un dilema ético en la práctica clínica, donde el número de donantes no es suficiente para todos los pacientes incluidos en lista de espera. El objetivo de este trabajo fue describir las características y analizar la supervivencia de los pacientes retrasplantados en nuestro país. Métodos: Se trata de un estudio retrospectivo del Registro Español de Trasplante Cardiaco (RETC) en el que se incluyeron los trasplante realizados desde 1984 hasta 2018. Se recogieron variables del receptor, donante, procedimiento quirúrgico, tratamiento inmunosupresor y supervivencia. Se determinaron las características de los pacientes retrasplantados, las indicaciones para el ReTC así como su supervivencia. Se estudiaron además, diferencias en supervivencia según la indicación para el ReTC y el intervalo de tiempo entre trasplantes. Resultados: Se estudiaron en total 7592 trasplantes cardiacos (TC) y 173 ReTC (que supone el 2,3% de todos los trasplantes) con una mediana de edad de 55,0 y 52,0 años respectivamente. El grupo ReTC se caracterizó por más pacientes con insuficiencia renal (46,8%), hipertensión (42,2%), ventilación mecánica (29,5%), necesidad de soporte circulatorio (34,1%) y mayor tiempo de isquemia fría (mediana 3,3 horas; RIQ, 2,6-4,0). La enfermedad vascular del injerto fue la indicación más frecuente para el ReTC (42,2%) y 59 pacientes (80,8%) se retrasplantaron más allá de 5 años tras el primer TC. El rechazo agudo (RA) y el fallo primario del injerto (FPI) disminuyeron en frecuencia como indicaciones para ReTC a lo largo del periodo estudiado (RA 68,8 % y FPI 58,5% en 1984-1999 vs RA 31,2% y FPI 41,5% en 2000- 2018). La mediana de seguimiento del ReTC fue 5,8 años. El ReTC se asoció con peor supervivencia que el TC (HR ajustado, 1,43; IC95%, 1,17-1,44; p < 0,001). El rechazo agudo (HR ajustado, 2,49; IC95%, 1,45-4,27; p < 0,001) 19 fue la indicación de mayor mortalidad así como el intervalo de 1-5 años (HR ajustado, 2,07; IC95%, 1,39-3,07; p < 0,001). El ReTC tardío presenta una supervivencia similar al TC primario (HR ajustado, 1,14; IC95%, 0,86-1,50; p < 0,001). Conclusiones: El ReTC se asoció con una mayor mortalidad que el TC, especialmente cuando el retrasplante es por RA. El ReTC realizado en el intervalo de 1-5 años se relacionó con mayor mortalidad. En cambio, el pronóstico del retrasplante realizado en un intervalo de tiempo superior a 5 años es similar al del TC primario

Candidate Selection, Determinant Factor for a Good Result in Cardiac Retransplantation: our Experience

Abstract Introduction: Cardiac retransplantation is the standard treatment for patients with advanced graft vasculopathy. It remains controversial due to the scarcity of donors and poor results when compared with the novo transplant. Despite all the factors studied to ensure a good result, when to make a new transplant, is still a question based on the experience of each institution as their protocols. This lack of clear information in the literature complicates the proper selection of candidates. We present our experience trying to answer some of these questions. Methods: Retrospective study of all cardiac retransplantation performed at our centre was made. Data of recipients and donors, surgical aspects and results of diagnostic tests were collected. The survival of the first and second graft was compared, as well as the survival according to the indication for retransplantation. Statistical analysis was performed using SPSS V21. Results: 14 retransplant (5%) and two third transplants (0.7%) were performed. The most common cause for retransplantation was graft vascular disease (10 cases (72%)). Operative mortality was 14%, with a survival group of 65 ± 61 months (median 62). Second graft survival was similar to the first (median 87 months first graft vs 74 months of the second, p = 0.851). Poor result was achieved when indication for retrasplantation was acute rejection or primary graft failure, with a mortality of 67% (median survival for acute rejection and primary failure group 6 days vs 106 months graft vascular disease; p = 0.000). Conclusion: Cardiac retransplantation is a valid alternative in selected patients with severe dysfunction of the graft secondary to graft vasculopathy

Intervencionismo coronario percutáneo en Navarra. Resultados de un centro de bajo volumen intervencionista

Fundamento. El intervencionismo coronario percutáneo (PCI) es una opción terapéutica fundamental en pacientes con enfermedad coronaria. Para realizarla los especialistas deben formarse y acreditarse. Se sabe que el número de procedimientos realizados al año influye en los resultados. Pretendemos mostrar que con un bajo volumen de PCI algunos centros obtienen buenos resultados. Método. Análisis prospectivo de las características clínicas y resultados inmediatos obtenidos en nuestro centro con el PCI entre 2006 y 2012 y análisis retrospectivo de la supervivencia global, supervivencia libre de eventos y reestenosis de los PCI realizados entre 2006 y 2009. Se compararon las características clínicas, los eventos agudos y a largo plazo (complicaciones, supervivencia y mortalidad) entre nuestros pacientes y los de algunos trabajos publicados. Resultados. Nuestra probabilidad de tener cualquier complicación en un PCI fue del 9% con una mortalidad global del 2%. La mortalidad del PCI en situación estable fue del 0,43% y en el síndrome coronario agudo del 6,25%. Las complicaciones en el lugar del acceso vascular fueron del 1,44% y la incidencia de reestenosis a los nueve meses, en pacientes sometidos por primera vez a PCI, fue del 5,2%. Conclusiones. Aunque el alto volumen intervencionista ha demostrado ser importante para tener una baja tasa de complicaciones y una buena evolución a largo plazo, hay centros con bajo volumen intervencionista que por sus características pueden obtener resultados equiparables a los de alto volumen.Background. Percutaneous coronary intervention (PCI) is currently a basic therapeutic option in patients with coronary artery disease. To carry this out specialists must be trained and accredited. It is known that the number of procedures performed each year influences results. We suggest that some low volume centres may also get good results. Methods. Prospective analysis of clinical features and immediate results obtained in our centre following PCI performed between 2006 and 2012 and retrospective analysis of overall survival, outcome-free survival and restenosis in patients treated between 2006 and 2009. The clinical features, acute and long-term events (complications, survival and mortality) of our group were compared with other published studies. Results. In our centre the likelihood of complications in a PCI was 9% with an overall mortality of 2%. PCI mortality in stable coronary disease was 0.43% and in acute coronary syndrome 6.25%. Complications at the vascular access site was 1.44% and restenosis at nine months, in patients undergoing PCI for the first time, was 5.2%. Conclusions. Although a high interventionist volume has been shown to reduce the rate of complications and improve long-term evolution, some low volume interventional centres can obtain similar results to those of high volume interventional centres

Combined catheter ablation and left atrial appendage closure as a hybrid procedure for the treatment of atrial fibrillation

Aims: Left atrial appendage (LAA) is the source of thrombi in up to 90% of patients with non-valvular atrial fibrillation (AF). Catheter ablation (CA) is an effective treatment for symptomatic AF and, in selected cases, LAA occlusion devices have been introduced as an alternative to oral anticoagulants (OACs). The safety and feasibility of combining CA and percutaneous LAA closure (LAAC) are unknown. Methods and results: Patients with symptomatic drug-refractory AF, CHADS2 score of ≥1, and CHA2DS2-VASc score ≥2 were included. Catheter ablation consisted in pulmonary vein isolation with or without roof line with radiofrequency and LAA was occluded with the Watchman or Amplatzer Cardiac Plug (ACP) devices guided by angiography and transoesophageal echocardiography. A total of 35 patients were included (71% male; 70 years). Median score was 3 on both CHA2DS2-VASc and HAS-BLED, 9% had prior stroke under OAC, and 48% had bleeding complications. Successful CA and device implantation were achieved in 97% of cases. The Watchman device was used in 29 patients and ACP in 6 patients. Periprocedural complications included three cases of cardiac tamponade. At 3 months, all patients met the criteria for successful sealing of the LAA. After a mean follow-up of 13 months (3-75), 78% of patients were free of arrhythmia recurrences and OAC was withheld in 97% of patients. Conclusions: The combination of CA and percutaneous LAAC in a single procedure is technically feasible in patients with symptomatic drug-refractory AF, high risk of stroke, and contraindications to OACs, although it is associated with a significant risk of major complications

Global circumferential and radial strain among patients with immune checkpoint inhibitor myocarditis

BACKGROUND Global circumferential strain (GCS) and global radial strain (GRS) are reduced with cytotoxic chemotherapy. There are limited data on the effect of immune checkpoint inhibitor (ICI) myocarditis on GCS and GRS. OBJECTIVES This study aimed to detail the role of GCS and GRS in ICI myocarditis. METHODS In this retrospective study, GCS and GRS from 75 cases of patients with ICI myocarditis and 50 ICI-treated patients without myocarditis (controls) were compared. Pre-ICI GCS and GRS were available for 12 cases and 50 controls. Measurements were performed in a core laboratory blinded to group and time. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiogenic shock, cardiac arrest, complete heart block, and cardiac death. RESULTS Cases and controls were similar in age (66 15 years vs 63 12 years; P ¼ 0.20), sex (male: 73% vs 61%; P ¼ 0.20) and cancer type (P ¼ 0.08). Pre-ICI GCS and GRS were also similar (GCS: 22.6% 3.4% vs 23.5% 3.8%; P ¼ 0.14; GRS: 45.5% 6.2% vs 43.6% 8.8%; P ¼ 0.24). Overall, 56% (n ¼ 42) of patients with myocarditis presented with preserved left ventricular ejection fraction (LVEF). GCS and GRS were lower in myocarditis compared with on-ICI controls (GCS: 17.5% 4.2% vs 23.6% 3.0%; P < 0.001; GRS: 28.6% 6.7% vs 47.0% 7.4%; P < 0.001). Over a median follow-up of 30 days, 28 cardiovascular events occurred. A GCS (HR: 4.9 [95% CI: 1.6-15.0]; P ¼ 0.005) and GRS (HR: 3.9 [95% CI: 1.4-10.8]; P ¼ 0.008) below the median was associated with an increased event rate. In receiveroperating characteristic (ROC) curves, GCS (AUC: 0.80 [95% CI: 0.70-0.91]) and GRS (AUC: 0.76 [95% CI: 0.64-0.88]) showed better performance than cardiac troponin T (cTnT) (AUC: 0.70 [95% CI: 0.58-0.82]), LVEF (AUC: 0.69 [95% CI: 0.56-0.81]), and age (AUC: 0.54 [95% CI: 0.40-0.68]). Net reclassification index and integrated discrimination improvement demonstrated incremental prognostic utility of GRS over LVEF (P ¼ 0.04) and GCS over cTnT (P ¼ 0.002). CONCLUSIONS GCS and GRS are lower in ICI myocarditis, and the magnitude of reduction has prognostic significance. (J Am Coll Cardiol Img 2022;15:1883–1896) © 2022 the American College of Cardiology Foundation. Published by Elsevier. All rights reserved

Myocardial T1 and T2 mapping by magnetic resonance in patients with immune checkpoint inhibitor–associated myocarditis

BACKGROUND Myocarditis is a potentially fatal complication of immune checkpoint inhibitor (ICI) therapy. Data on the utility of cardiovascular magnetic resonance (CMR) T1 and T2 mapping in ICI myocarditis are limited. OBJECTIVES This study sought to assess the value of CMR T1 and T2 mapping in patients with ICI myocarditis. METHODS In this retrospective study from an international registry of patients with ICI myocarditis, clinical and CMR findings (including T1 and T2 maps) were collected. Abnormal T1 and T2 were defined as 2 SD above site (vendor/field strength specific) reference values and a z-score was calculated for each patient. Major adverse cardiovascular events (MACE) were a composite of cardiovascular death, cardiogenic shock, cardiac arrest, and complete heart block. RESULTS Of 136 patients with ICI myocarditis with a CMR, 86 (63%) had T1 maps and 79 (58%) also had T2 maps. Among the 86 patients (66.3 13.1 years of age), 36 (41.9%) had a left ventricular ejection fraction <55%. Across all patients, mean z-scores for T1 and T2 values were 2.9 1.9 (p < 0.001) and 2.2 2.1 (p < 0.001), respectively. On Siemens 1.5-T scanner (n ¼ 67), native T1 (1,079.0 55.5 ms vs. 1,000.3 22.1 ms; p < 0.001) and T2 (56.2 4.9 ms vs. 49.8 2.2 ms; p < 0.001) values were elevated compared with reference values. Abnormal T1 and T2 values were seen in 78% and 43% of the patients, respectively. Applying the modified Lake Louise Criteria, 95% met the nonischemic myocardial injury criteria and 53% met the myocardial edema criteria. Native T1 values had excellent discriminatory value for subsequent MACE, with an area under the curve of 0.91 (95% confidence interval: 0.84 to 0.98). Native T1 values (for every 1-unit increase in z-score, hazard ratio: 1.44; 95% confidence interval: 1.12 to 1.84; p ¼ 0.004) but not T2 values were independently associated with subsequent MACE. CONCLUSIONS The use of T1 mapping and application of the modified Lake Louise Criteria provides important diagnostic value, and T1 mapping provides prognostic value in patients with ICI myocarditis. (J Am Coll Cardiol 2021;77:1503–16) © 2021 by the American College of Cardiology Foundation

Correction: Epidemiology and outcomes of early-onset AKI in COVID-19-related ARDS in comparison with non-COVID-19-related ARDS: insights from two prospective global cohort studies (Critical Care, (2023), 27, 1, (3), 10.1186/s13054-022-04294-5)

Following publication of the original article [1], the authors identified that the collaborating authors part of the collaborating author group CCCC Consortium was missing. The collaborating author group is available and included as Additional file 1 in this article

Early short course of neuromuscular blocking agents in patients with COVID-19 ARDS: a propensity score analysis

Background: The role of neuromuscular blocking agents (NMBAs) in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) is not fully elucidated. Therefore, we aimed to investigate in COVID-19 patients with moderate-to-severe ARDS the impact of early use of NMBAs on 90-day mortality, through propensity score (PS) matching analysis. Methods: We analyzed a convenience sample of patients with COVID-19 and moderate-to-severe ARDS, admitted to 244 intensive care units within the COVID-19 Critical Care Consortium, from February 1, 2020, through October 31, 2021. Patients undergoing at least 2&nbsp;days and up to 3 consecutive days of NMBAs (NMBA treatment), within 48&nbsp;h from commencement of IMV were compared with subjects who did not receive NMBAs or only upon commencement of IMV (control). The primary objective in the PS-matched cohort was comparison between groups in 90-day in-hospital mortality, assessed through Cox proportional hazard modeling. Secondary objectives were comparisons in the numbers of ventilator-free days (VFD) between day 1 and day 28 and between day 1 and 90 through competing risk regression. Results: Data from 1953 patients were included. After propensity score matching, 210 cases from each group were well matched. In the PS-matched cohort, mean (± SD) age was 60.3 ± 13.2&nbsp;years and 296 (70.5%) were male and the most common comorbidities were hypertension (56.9%), obesity (41.1%), and diabetes (30.0%). The unadjusted hazard ratio (HR) for death at 90&nbsp;days in the NMBA treatment vs control group was 1.12 (95% CI 0.79, 1.59, p = 0.534). After adjustment for smoking habit and critical therapeutic covariates, the HR was 1.07 (95% CI 0.72, 1.61, p = 0.729). At 28&nbsp;days, VFD were 16 (IQR 0–25) and 25 (IQR 7–26) in the NMBA treatment and control groups, respectively (sub-hazard ratio 0.82, 95% CI 0.67, 1.00, p = 0.055). At 90 days, VFD were 77 (IQR 0–87) and 87 (IQR 0–88) (sub-hazard ratio 0.86 (95% CI 0.69, 1.07; p = 0.177). Conclusions: In patients with COVID-19 and moderate-to-severe ARDS, short course of NMBA treatment, applied early, did not significantly improve 90-day mortality and VFD. In the absence of definitive data from clinical trials, NMBAs should be indicated cautiously in this setting