Opciones actuales para el tratamiento de las lesiones calcificadas

Severe coronary calcium increases the complexity of percutaneous coronary interventions. It may affect the adequate preparation of the lesion, proper stent expansion and apposition and increase the risk of stent thrombosis and restenosis. The techniques available for the management of severe calcified lesions can be divided into 2 groups: non-balloon and balloon-based technologies. Rotational atherectomy has been the predominant technique to treat severe calcified lesions. As a matter of fact, there are new devices available that facilitate the modification of the plaque such as the new lithoplasty balloon that involves the use of highenergy mechanical pulses to crack coronary calcium. Coronary lithoplasty is an easy technique with a short learning curve that seems to be more effective on deep calcium by increasing luminal compliance. This may revolutionize the standard approach for the management of severe calcified coronary lesions. Also, the role of intravascular imaging is essential to select the most appropriate plaque-modification device and assess the optimal stent result. This review provides an overview of the techniques available and evidence on the currently approved devices to treat calcified lesions.El calcio coronario aumenta la complejidad del intervencionismo coronario percutáneo. La calcificación grave dificulta la preparación de la lesión, impide la adecuada expansión y la aposición del stent, y aumenta el riesgo de trombosis y de reestenosis. Las técnicas de modificación de placa se pueden dividir en 2 tipos según el tipo de dispositivo: sin balón y con balón. La aterectomía rotacional ha sido la técnica por excelencia para el tratamiento de lesiones gravemente calcificadas. Actualmente existen nuevos dispositivos que facilitan la preparación de la lesión, como el novedoso balón de litoplastia, que utiliza pulsos de alta energía mecánica para fragmentar el calcio coronario. La litoplastia coronaria es una técnica sencilla, con una curva de aprendizaje corta, que parece tener efecto sobre el calcio profundo y aumentar la distensibilidad luminal, lo que podría suponer un gran cambio en el enfoque del tratamiento de las lesiones calcificadas. Cabe destacar la relevancia de la imagen intravascular al seleccionar el dispositivo de modificación de placa más adecuado, así como para evaluar el resultado final del stent. Esta revisión proporciona una visión general sobre las técnicas disponibles y la evidencia de los dispositivos aprobados para el tratamiento de las lesiones calcificadas

Intracoronary lithotripsy for calcific neoatherosclerotic in-stent restenosis: a case report

Background: In-stent restenosis is a difficult percutaneous scenario if calcific neoatherosclerosis is the underlying aetiology. Case summary: A 69-year-old diabetic woman with a previous percutaneous coronary intervention on the left anterior descending coronary artery was readmitted for non-ST-elevation myocardial infarction. In-stent restenosis due to calcific neoatherosclerosis was observed by intracoronary imaging during the intervention. Intravascular lithotripsy was used successfully to fracture the underlying calcific plaque. However, the balloon ruptured during treatment although this did not damage the artery. Discussion: Intravascular lithotripsy is a promising tool for the treatment of extremely calcified lesions including calcific neoatherosclerosis of in-stent restenosis. Balloon rupture is a complication of this new percutaneous treatment that has not previously been described

Myocardial injury in COVID-19 and its implications in short- and long-term outcomes

COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is still a pandemic with high mortality and morbidity rates. Clinical manifestation is widely variable, including asymptomatic or mild respiratory tract illness to severe pneumonia and death. Myocardial injury is a significant pathogenic feature of COVID-19 and it is associated with worse in-hospital outcomes, mainly due to a higher number of hospital readmissions, with over 50% mortality. These findings suggest that myocardial injury would identify COVID-19 patients with higher risk during active infection and mid-term follow-up. Potential contributors responsible for myocardial damage are myocarditis, vasculitis, acute inflammation, type 1 and type 2 myocardial infarction. However, there are few data about cardiac sequelae and its long-term consequences. Thus, the optimal screening tool for residual cardiac sequelae, clinical follow-up, and the benefits of a specific cardiovascular therapy during the convalescent phase remains unknown. This mini-review explores the different mechanisms of myocardial injury related to COVID-19 and its short and long-term implications

Left atrial appendage closure with a new occluder device: efficacy, safety and mid-term performance

The LAmbreTM device is a novel system designed for left atrial appendage closure (LAAC). First registries showed a high rate of device implantation success. However, few mid-term results are available. We present our 1- and 12-month follow-up results for this device. This prospective, single-center registry included consecutive patients with nonvalvular atrial fibrillation who underwent LAAC with the LAmbreTM device. Transesophageal echocardiography (TEE) was performed at 1-month follow-up. In total, 55 patients were included. The population was elderly (75 ± 9.4 years), with a high proportion of comorbidities. The mean CHA2DS2-VASc and HAS-BLED scores were 4.6 ± 1.6 and 3.9 ± 1.0, respectively. Previous history of a major bleeding event was present in 37 patients (67.3%). Procedural success was achieved in 54 patients (98.2%). Device success was achieved in 100% of patients in whom device implantation was attempted (54 patients). Major in-hospital device-related complications included mortality of one patient (1.8%) and pericardial tamponade in two patients (3.6%); the incidence of stroke was 0%. No thrombus or significant leaks (≥5 mm) were observed on 1-month TEE. At 12 months, adverse events were overall death (1.8%), transient ischemic attack/ischemic stroke (1.8%), and major bleeding events (Bleeding Academic Research Consortium (BARC) 3a and 3c; 11%). In this high-risk population, the LAmbreTM device seems to be a safe and effective option for LAAC with a remarkable mid-term performance

The natural history of QTc interval and its clinical impact in coronavirus disease 2019 survivors after 1 year

Background and objective: Prolonged QTc interval on admission and a higher risk of death in SARS-CoV-2 patients have been reported. The long-term clinical impact of prolonged QTc interval is unknown. This study examined the relationship in COVID-19 survivors of a prolonged QTc on admission with long-term adverse events, changes in QTc duration and its impact on 1-year prognosis, and factors associated with a prolonged QTc at follow-up. Methods: We conducted a single-center prospective cohort study of 523 SARS-CoV-2-positive patients who were alive on discharge. An electrocardiogram was taken on these patients within the first 48 h after diagnosis and before the administration of any medication with a known effect on QT interval and repeated in 421 patients 7 months after discharge. Mortality, hospital readmission, and new arrhythmia rates 1 year after discharge were reviewed. Results: Thirty-one (6.3%) survivors had a baseline prolonged QTc. They were older, had more cardiovascular risk factors, cardiac disease, and comorbidities, and higher levels of terminal pro-brain natriuretic peptide. There was no relationship between prolonged QTc on admission and the 1-year endpoint (9.8% vs. 5.5%, p = 0.212). In 84% of survivors with prolonged baseline QTc, it normalized at 7.9 ± 2.2 months. Of the survivors, 2.4% had prolonged QTc at follow-up, and this was independently associated with obesity, ischemic cardiomyopathy, chronic obstructive pulmonary disease, and cancer. Prolonged baseline QTc was not independently associated with the composite adverse event at 1 year.Conclusions: Prolonged QTc in the acute phase normalized in most COVID-19 survivors and had no clinical long-term impact. Prolonged QTc at follow-up was related to the presence of obesity and previously acquired chronic diseases and was not related to 1-year prognosis

Prognostic implications of chronic heart failure and utility of NT-proBNP levels in heart failure patients with SARS-CoV-2 infection

Background: The prevalence and prognostic value of chronic heart failure (CHF) in the setting of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection has seldom been studied. The aim of this study was to analyze the prevalence and prognosis of CHF in this setting. Methods: This single-center study included 829 consecutive patients with SARS-CoV-2 infection from February to April 2020. Patients with a previous history of CHF were matched 1:2 for age and sex. We analyze the prognostic value of pre-existing CHF. Prognostic implications of N terminal pro brain natriuretic peptide (NT-proBNP) levels on admission in the CHF cohort were explored. Results: A total of 129 patients (43 CHF and 86 non-CHF) where finally included. All-cause mortality was higher in CHF patients compared to non-CHF patients (51.2% vs. 29.1%, p = 0.014). CHF was independently associated with 30-day mortality (hazard ratio (HR) 2.3, confidence interval (CI) 95%: 1.26-2.4). Patients with CHF and high-sensitivity troponin T 2598 pg/mL on admission was associated with higher 30-day mortality in patients with CHF. Conclusions: All-cause mortality in CHF patients hospitalized due to SARS-CoV-2 infection was 51.2%. CHF was independently associated with all-cause mortality (HR 2.3, CI 95% 1.26-4.2). NT-proBNP levels could be used for stratification risk purposes to guide medical decisions if larger studies confirm this finding

Prolonged QT interval in SARS-CoV-2 infection: prevalence and prognosis

Background: The prognostic value of a prolonged QT interval in SARS-Cov2 infection is not well known. Objective: To determine whether the presence of a prolonged QT on admission is an independent factor for mortality in SARS-Cov2 hospitalized patients. Methods: Single-center cohort of 623 consecutive patients with positive polymerase-chain-reaction test (PCR) to SARS Cov2, recruited from 27 February to 7 April 2020. An electrocardiogram was taken on these patients within the first 48 h after diagnosis and before the administration of any medication with a known effect on QT interval. A prolonged QT interval was defined as a corrected QT (QTc) interval >480 milliseconds. Patients were followed up with until 10 May 2020. Results: Sixty-one patients (9.8%) had prolonged QTc and only 3.2% had a baseline QTc > 500 milliseconds. Patients with prolonged QTc were older, had more comorbidities, and higher levels of immune-inflammatory markers. There were no episodes of ventricular tachycardia or ventricular fibrillation during hospitalization. All-cause death was higher in patients with prolonged QTc (41.0% vs. 8.7%, p < 0.001, multivariable HR 2.68 (1.58-4.55), p < 0.001). Conclusions: Almost 10% of patients with COVID-19 infection have a prolonged QTc interval on admission. A prolonged QTc was independently associated with a higher mortality even after adjustment for age, comorbidities, and treatment with hydroxychloroquine and azithromycin. An electrocardiogram should be included on admission to identify high-risk SARS-CoV-2 patients

Myocardial injury as a prognostic factor in mid- and long-term follow-up of COVID-19 survivors

Myocardial injury, which is present in >20% of patients hospitalized for COVID-19, is associated with increased short-term mortality, but little is known about its mid- and long-term consequences. We evaluated the association between myocardial injury with one-year mortality and readmission in 172 COVID-19 patients discharged alive. Patients were grouped according to the presence or absence of myocardial injury (defined by hs-cTn levels) on admission and matched by age and sex. We report mortality and hospital readmission at one year after admission in all patients and echocardiographic, laboratory and clinical data at six months in a subset of 86 patients. Patients with myocardial injury had a higher prevalence of hypertension (73.3% vs. 50.0%, p = 0.003), chronic kidney disease (10.5% vs. 2.35%, p = 0.06) and chronic heart failure (9.3% vs. 1.16%, p = 0.03) on admission. They also had higher mortality or hospital readmissions at one year (11.6% vs. 1.16%, p = 0.01). Additionally, echocardiograms showed thicker walls in these patients (10 mm vs. 8 mm, p = 0.002) but without functional disorder. Myocardial injury in COVID-19 survivors is associated with poor clinical prognosis at one year, independent of age and sex, but not with echocardiographic functional abnormalities at six months