A Piserra

Hospital Universitario Reina Sofía

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José Suárez de Lezo

Hospital Universitario Reina Sofía

Soledad Ojeda

Instituto Maimónides de Investigación Biomédica de Córdoba

Jorge Perea Armijo

Instituto Maimónides de Investigación Biomédica de Córdoba

Francisco Mazuelos

Hospital Universitario Reina Sofía

J Rodriguez-Nieto

Complejo Hospitalario de Salamanca

Manuel Pan

Hospital Universitario Reina Sofía

Francisco J. Hidalgo

Instituto de la Grasa

José M. Segura

Hospital Universitario Reina Sofía

Rafael González Manzanares

Hospital Universitario Reina Sofía

Miguel Romero

Hospital Universitario Reina Sofía

Cooperative Institutions

Hospital Universitario Reina Sofía

Instituto Maimónides de Investigación Biomédica de Córdoba

University of Córdoba

Centro de Investigación Biomédica en Red

Institute for Research in Biomedicine

Centro de Investigación en Red en Enfermedades Cardiovasculares

Instituto de Salud Carlos III

Marqués de Valdecilla University Hospital

Hospital Jerez Puerta del Sur

Hospital Universitario Virgen del Rocío

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Instantaneous wave-free ratio for the assessment of nonculprit lesions in patients with acute coronary syndrome

European Heart Journal (2021)

Rafael González Manzanares Francisco J. Hidalgo Soledad Ojeda A Piserra Jorge Perea Armijo

Abstract Background A physiological assessment with the fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) is strongly recommended by the European Guidelines of Revascularization to guide percutaneous coronary intervention (PCI) decision making in intermediate coronary stenosis. However, data supporting its use in the pro-inflammatory setting of ACS is weak. Purpose To analyze the usefulness of a physiological coronary evaluation with iFR of nonculprit lesions in patients with ACS. Methods Retrospective multicenter study including patients with ACS and underwent successful revascularization of the culprit vessel and had other nonculpritlesions physiologically evaluated with the iFR between January 2017 and December 2019. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction, stent thrombosis and new revascularization (MACEs). Results A total of 356 patients with 472 nonculprit lesions were included. The mean age was 66±11 years. The clinical presentation was non-ST-segment elevation myocardial infarction (NSTEMI) in 235 patients and ST-segment elevation myocardial infarction (STEMI) in 121 patients. After a mean follow-up period of 22±10 months, the primary endpoint occurred in 32 patients (9%). There were no differences in outcomes regarding iFR induced treatment strategy (patients with all lesions revascularized vs. patients with at least one lesion deferred for revascularization, 10.5 vs 8.4%, p=0.476). Conclusion The use of the iFR to guide percutaneous coronary intervention decision making in nonculprit lesions seems to be safe, with an acceptable percentage of MACEs at the mid-term follow-up. Funding Acknowledgement Type of funding sources: None. FlowchartSurvival curves by iFR and ACS group

Fractional Flow Reserve

Clinical endpoint

Culprit

Target lesion

10.1093/eurheartj/ehab724.1402

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Association between distance to tertiary hospital and cardiovascular outcomes in coronary artery disease patients

European Heart Journal (2021)

Rafael González Manzanares L Carmona-Artime M Ruíz-Moreno Jorge Perea Armijo A Piserra

Abstract Background The impact of distance from residence to Tertiary Referral Hospital and cardiovascular (CV) outcomes in patients with coronary artery disease (CAD) is unknow. Despite longer travel distances hinder access to healthcare and may worsen CV outcomes, we hypothesize that Mediterranean lifestyle and behaviors in distant rural areas may be associated with a reduced risk of CV death and events. Purpose To investigate the association between travel distance to Tertiary Hospital and mid-term cardiovascular outcomes in a population of CAD patients in Southern Spain. Methods Retrospective study including all patients discharged after percutaneous coronary intervention (PCI) at a high-volume center in Southern Spain during 2018. Those belonging to another healthcare area were excluded. One-way driving distances from residence to hospital were computed using Google Maps Distance Matrix API with R package “gmapsdistance”. Patients were stratified into tertiles according to travel distance (short, STD; intermediate, ITD; and long, LTD). Kaplan-Meier (KM) and Multivariable Cox regression (adjusted for age, sex, atrial fibrillation, cancer history, prior revascularization and clinical presentation) were used to assess the impact of travel distance on CV death and a composite outcome of MACE (Myocardial Infarction, unplanned PCI and CV death). Results Of 1005 patients discharged after PCI during the study period, 966 met the selection criteria. Flowchart and baseline characteristics by distance groups are presented in Figure 1. Median travel distance tertiles were 6.1 (STD), 41.7 (ITD) and 78.4 (LTD). During a median follow-up of 31 (IQR 28–35) months, 50 cardiovascular deaths [STD 27 (8.4%), ITD 13 (4%), LTD 10 (3.1%), p=0.006)] and 63 MACE occurred [STD 45 (13.9%), ITD 37 (11.5%), LTD 26 (8.1%), p=0.060)]. KM curves for the three distance groups are shown in Figure 2. In univariable and multivariable Cox models, longer travel distances were associated with better outcomes, as for every 10 Km increase, there was a 11% and 7% decrease in the hazards of CV death (HR adj: 0.89, CI 0.82–0.98, p=0.029) and of MACE (HR adj: 0.93, CI 0.87–0.99, p=0.025), respectively. Conclusion Travel distance was inversely associated with CV events in a population of CAD patients in Southern Spain. Patients in the first tertile of distance had a higher rate of CV death. Multicenter studies involving other Mediterranean regions are needed to confirm these findings and to look for explanations. Funding Acknowledgement Type of funding sources: None. Flowchart and baseline characteristicsSurvival curves by distance groups

Mace

10.1093/eurheartj/ehab724.1109

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Bleeding risk and selective serotonin reuptake inhibitors treatment after percutaneous coronary intervention: a propensity-matched study

European Heart Journal (2021)

Rafael González Manzanares M Ruíz-Moreno L Carmona-Artime J Rodriguez-Nieto A Piserra

Abstract Background Cardiovascular disease and mental disorders frequently coexist. Selective serotonin reuptake inhibitors (SSRIs) are often used to treat depressive and anxiety disorders but have been associated with an increased risk of bleeding due to platelet dysfunction. Up to 10% of patients with coronary artery disease are concomitantly treated with dual antiplatelet therapy (DAPT) and SSRI. Previous studies have assessed the risk of bleeding in patients treated with SSRI and clopidogrel-based DAPT, with contradictory results. However, there is no data regarding the use of SSRI and potent P2Y12 inhibitors (ticagrelor, prasugrel) or triple antithrombotic therapy (TAT). Purpose To evaluate the bleeding outcomes in a real-world population of patients undergoing percutaneous coronary intervention (PCI) treated with SSRI and DAPT or TAT after a year follow-up. Methods We conducted a retrospective study including all patients undergoing PCI at a high-volume center during 2018. Patients taking SSRI were propensity-score-matched (PSM) 1:1 using nearest neighbor matching with patients not taking SSRI. The primary endpoint was major bleeding as defined by the International Society on Thrombosis and Haemostasis (ISTH) at 1 year. Kaplan-Meier and Cox regression were used to compare outcomes between treatment groups. Results Of 1063 patients that underwent PCI during the study period, 1002 met the inclusion criteria and 139 (13.9%) were receiving SSRI. Propensity score distributions, baseline characteristics and standardized mean differences (SMD) of the covariates used for PSM before and after adjustment are shown in Figure 1. In matched survival analysis, there was no significant difference in the primary endpoint at 1 year follow-up: mayor bleeding occurred in 2.9% of patients who received SSRI and in 2.9% of those with no SSRI (HR 1.01; CI 0.25 to 4.03; p=0.991) (Figure 2). Conclusion In routine clinical care, patients treated with SSRI and DAPT or TAT after PCI did not have a higher risk of bleeding after a year follow-up. Funding Acknowledgement Type of funding sources: None. Figure 1. Baseline characteristicsFigure 2. Survival curves by SSRI treatment

Clinical endpoint

10.1093/eurheartj/ehab724.2748

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Role of three-dimensional imaging techniques in the management of transcatheter closure of complex atrial septal defects

European Heart Journal - Cardiovascular Imaging (2022)

Dominik Wulf Ana Almodóvar Jesús Rodríguez Nieto Martín Ruiz Ortiz Jorge Perea Armijo

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitario Reina Sofia. Instituto de investigación biomédica Maimonides Introduction Percutaneous closure is nowadays considered the treatment of choice of ostium secundum atrial septal defects (ASD) but complex defects may be a challenging. In the last years, the imaging techniques used for ASD assessment have improved considerably, allowing therapeutic approaches in patients with complex morphological features particularly in those with absence of rims. However, there are no studies about the impact of 3D imaging techniques on transcatheter closure of ASD as compared with 2D imaging along time . Purpose To compare the impact of real time 3D Transesophageal echocardiography (3D-RT TEE) and cardiac computed tomography (CCT) on the profile as well as on the success rate of transcatheter closure of complex ASD as compared to 2D imaging. Methods We selected 106 adults patients suffering from ASD of complex anatomy (large≥30 mm, multiple, multifenestrated, aneurysmal, or deficiency of posterior or inferior rims) from 1998 to 2020. Along this time, we compared closure success rate, morphological characteristics, and procedure complications after ASD transcatheter closure. We defined closure success rate as a complete closure without complications. In our study, ASD assessment and further intervention was performed by two-dimensional transesophageal echocardiography (2D-TEE) from 1998 to 2007 (n = 66), whereas 3D-RT TEE and CCT was performed from 2008 to 2020 (n= 40). Results The type of ASD complexity was different between the two diagnostic approaches. Thus, those patients management by 2D-TEE showed more number in large ASD (40,9%), multiple-ASD (34,8%), fenestrated (10,6%), aneurysmal (7,6%) and with lower ring deficiency (6,1%) as compared to those with 3D-RT TEE and CCT (10%, 25%, 15%, 15%, and 35%, respectively, p < 0,05). Although no significant differences were observed, patients from the 2D group needed a second surgical closure more frequently than those treated with 3D-RT TEE and CCT (12,1% vs 5%, p = 0.31). In our study, there were few complications (10 (9,4%), with no significant differences according to the imaging technic used (2D-TEE group: 3 device embolisms, 2 cardiac tamponade, 2 complications of the femoral access; 3D-RT TEE and CCT group: 2 device embolisms and 1 complication of the femoral access. All of them were resolved intraprocedure. Importantly, closure success was higher in those patients manage by 3D-RT TEE and CCT in comparison to 2D-TEE (88% vs. 67%, respectively, p <0.05). Conclusion Transcatheter closure of complex ASD is a secure procedure. However, the use of 3D TEE and cardiac CT improves the success rate of this approach as compared to 2D-TEE and changes the profile of complex ASD treated by transcatheter closure in favor of those with absence of some rims

Closure (psychology)

Septum secundum

10.1093/ehjci/jeab289.283

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