Caracterización mediante resonancia magnética cardiaca de un modelo porcino de infarto agudo de miocardio a tórax cerrado = Characterization by cardiac magnetic resonance of a closed-chest porcine model of acute myocardial infarction

212Este estudio pretendía demostrar que nuestro modelo experimental animal de infarto agudo de miocardio, obtenido mediante un procedimiento intervencionista de isquemia-reperfusión (oclusión con balón de angioplastia en la arteria coronaria descendente anterior) es factible y reproducible, y, que la resonancia magnética cardíaca (RMC) permitía una adecuada caracterización de los parámetros anatómicos y funcionales del ventrículo izquierdo (VI) en la fase aguda y crónica del infarto. Se utilizaron animales hembra de entre 25 y 30 kg de peso. El modelo porcino percutáneo de infarto-reperfusión propuesto es factible y presenta baja mortalidad. El tamaño del infarto, así como la disminución de la FEVI, obtenidos son reproducibles y dependen del segmento ocluído en la arteria coronaria descendente anterior. El proceso de remodelado ventricular se activa con un aumento progresivo del volumen y de la masa ventriculares. La magnitud de estos cambios está en relación con el tamaño del infarto obtenido. No se producen cambios significativos en los volúmenes ni masa ventriculares durante el crecimiento normal de éstos animales. La administración de BrdU en animales sanos y del modelo experimental propuesto no afecta a ninguno de los parámetros anatómicos ni funcionales cardíacos estudiado

Instantaneous Wave-Free Ratio for the Assessment of Intermediate Left Main Coronary Artery Stenosis: Correlations With Fractional Flow Reserve/Intravascular Ultrasound and Prognostic Implications: The iLITRO-EPIC07 Study

Background: There is little information available on agreement between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in left main coronary artery (LMCA) intermediate stenosis. Besides, several meta-analyses support the use of FFR to guide LMCA revascularization, but limited information is available on iFR in this setting. Our aims were to establish the concordance between FFR and iFR in intermediate LMCA lesions, to evaluate with intravascular ultrasound (IVUS) in cases of FFR/iFR discordance, and to prospectively validate the safety of deferring revascularization based on a hybrid decision-making strategy combining iFR and IVUS. Methods: Prospective, observational, multicenter registry with 300 consecutive patients with intermediate LMCA stenosis who underwent FFR and iFR and, in case of discordance, IVUS and minimal lumen area measurements. Primary clinical end point was a composite of cardiovascular death, LMCA lesion-related nonfatal myocardial infarction, or unplanned LMCA revascularization. Results: FFR and iFR had an agreement of 80% (both positive in 67 and both negative in 167 patients); in case of disagreement (31 FFR+/iFR- and 29 FFR-/iFR+) minimal lumen area was & GE;6 mm(2) in 8.7% of patients with FFR+ and 14.6% with iFR+. Among the 300 patients, 105 (35%) underwent revascularization and 181 (60%) were deferred according to iFR and IVUS. At a median follow-up of 20 months, major adverse cardiac events incidence was 8.3% in the defer group and 13.3% in the revascularization group (hazard ratio, 0.71 [95% CI 0.30-1.72]; P=0.45). Conclusions: In patients with intermediate LMCA stenosis, a physiology-guided treatment decision is feasible either with FFR or iFR with moderate concordance between both indices. In case of disagreement, the use of IVUS may be useful to indicate revascularization. Deferral of revascularization based on iFR appears to be safe in terms of major adverse cardiac events

Incidence and prognostic implications of late bleeding events after percutaneous mitral valve repair

Objectives: MitraClip is an established therapy for patients with mitral regurgitation (MR) that are considered of high-risk or inoperable. However, late bleeding events (BE) after hospital discharge and their impact on prognosis in this cohort of patients have been poorly investigated. Our purpose is to address the incidence, related factors and clinical implications of BE after hospital discharge in patients treated with MitraClip. Methods: Prospective registry of all consecutive patients (n = 80) who underwent MitraClip implantation in our Institution between June 2014 and December 2017. BE were defined according to MVARC definitions. A combined clinical end-point including admission for heart failure (HF) and all-cause mortality was established to analyze prognostic implications of BE. Results: During a median follow up of 523.5 days, 41 BE were reported in 21 patients. Atrial fibrillation (AF, HR 4.54, CI95% 1.20–17.10) and combined antithrombotic therapy at discharge (HR 3.52, CI95% 1.03–11.34) were independently associated with BE. In the study period, 15 (18.8%) patients died, 20 (25%) were admitted for HF and 29 (36.3%) presented the combined end-point. After multivariable adjustment BE remained independently associated with an adverse outcome (HR 3.80, CI 95% 1.66–8.72). In the subgroup of patients with AF, HAS-BLED score was higher among subjects with BE (3.1 ± 1.3 vs 2.1 ± 0.9, p = 0.003). HAS-BLED score had a significant discrimination power for the occurrence BE (AUC: 0.677 [0.507–0.848]) in this subgroup. Conclusions: BE are common after MitraClip and are associated with an impaired outcome. Strategies to reduce bleeding events are paramount in this cohort of patients. Keywords: MitraClip, Atrial fibrillation, Bleeding event

Modelo experimental de insuficiencia mitral en modelo animal porcino

Introduction and objectives: There is great interest in the development of devices for the percutaneous management of mitral regurgitation (MR). For this reason, having an experimental model that reproduces the conditions of the disease is of great importance. Our objective was to validate an experimental model of MR in a porcine model. Methods: For the model creation phase 3, 2-month-old 25 ± 3 kg large white pigs were used. An acute myocardial infarction was caused in the circumflex artery territory that hampered the perfusion of the posteromedial papillary muscle. Then, volume overload was induced in the animal by creating an arteriovenous shunt and connecting the aorta and the pulmonary artery using a Dacron tube. Echocardiography and magnetic resonance imaging were performed before the intervention and on week 8. Afterwards, the animal was euthanized to conduct the pathological study. Results: One out of the 3 pigs died during the intervention due to ventricular fibrillation. The remaining 2 pigs survived the procedure and were euthanized as scheduled on week 8. In both cases a transmural infarction occurred, 1 at lateral level and the other one at posteroinferior level with moderate secondary mitral regurgitation. Ventricular dimensions and volumes increased and the overall contractility was maintained despite segmental alterations. Conclusions: The experimental model of chronic MR based on the ischemic damage of the posteromedial papillary muscle associated with volume overload is feasible, safe and reproducible. Also, it can be very useful to test the safety and efficacy of future devices for the management of this condition.Introducción y objetivos: Existe un creciente interés en el desarrollo de dispositivos para el tratamiento de la insuficiencia mitral (IM) de forma mínimamente invasiva. Para este propósito, disponer de un modelo experimental que reproduzca las condiciones de la enfermedad sería de gran utilidad. Nuestro objetivo fue validar un modelo experimental de IM en cerdos. Métodos: Para esta fase de creación del modelo se han utilizado 3 cerdos de raza large white, de 2 meses de edad y un peso de 25 ± 3 kg. Se provocó un infarto en el territorio de la arteria circunfleja que afectó la perfusión del músculo papilar posteromedial, y posteriormente se sometió al animal a una sobrecarga de volumen mediante creación de un shunt arteriovenoso, con la conexión de la aorta y la pulmonar mediante un tubo de dacrón. Se realizó análisis mediante ecocardiografía y resonancia magnética antes de la intervención y a las 8 semanas, y posteriormente el animal fue eutanasiado para realizar el estudio anatomopatológico. Resultados: De los 3 cerdos, 1 falleció durante la intervención por fibrilación ventricular y los otros 2 sobrevivieron al procedimiento y fueron eutanasiados como estaba previsto a las 8 semanas. En ambos se produjo un infarto transmural, uno lateral y otro posteroinferior, con IM moderada secundaria. Las dimensiones y los volúmenes ventriculares aumentaron, y la contractilidad global se mantuvo a pesar de las alteraciones segmentarias. Conclusiones: El modelo experimental de IM crónica basado en el daño isquémico del músculo papilar posteromedial asociado a una sobrecarga de volumen es factible, seguro y reproducible, y puede ser de gran utilidad para comprobar la seguridad y la eficacia de los futuros dispositivos para el tratamiento de esta afección

Instantaneous Wave-Free Ratio for the Assessment of Intermediate Left Main Coronary Artery Stenosis: Correlations With Fractional Flow Reserve/Intravascular Ultrasound and Prognostic Implications: The iLITRO-EPIC07 Study

Background: There is little information available on agreement between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in left main coronary artery (LMCA) intermediate stenosis. Besides, several meta-analyses support the use of FFR to guide LMCA revascularization, but limited information is available on iFR in this setting. Our aims were to establish the concordance between FFR and iFR in intermediate LMCA lesions, to evaluate with intravascular ultrasound (IVUS) in cases of FFR/iFR discordance, and to prospectively validate the safety of deferring revascularization based on a hybrid decision-making strategy combining iFR and IVUS. Methods: Prospective, observational, multicenter registry with 300 consecutive patients with intermediate LMCA stenosis who underwent FFR and iFR and, in case of discordance, IVUS and minimal lumen area measurements. Primary clinical end point was a composite of cardiovascular death, LMCA lesion-related nonfatal myocardial infarction, or unplanned LMCA revascularization. Results: FFR and iFR had an agreement of 80% (both positive in 67 and both negative in 167 patients); in case of disagreement (31 FFR+/iFR- and 29 FFR-/iFR+) minimal lumen area was ?6 mm2 in 8.7% of patients with FFR+ and 14.6% with iFR+. Among the 300 patients, 105 (35%) underwent revascularization and 181 (60%) were deferred according to iFR and IVUS. At a median follow-up of 20 months, major adverse cardiac events incidence was 8.3% in the defer group and 13.3% in the revascularization group (hazard ratio, 0.71 [95% CI 0.30-1.72]; P=0.45). Conclusions: In patients with intermediate LMCA stenosis, a physiology-guided treatment decision is feasible either with FFR or iFR with moderate concordance between both indices. In case of disagreement, the use of IVUS may be useful to indicate revascularization. Deferral of revascularization based on iFR appears to be safe in terms of major adverse cardiac events

Techniques and material used in the percutaneous treatment of chronic coronary occlusions. Data from the CIBELES study

0.525 JCR (2013) Q4, 119/125 Cardiac & cardiovascular system