Eduardo Franco - Academia.edu (original) (raw)

Papers by Eduardo Franco

Heart Asia, 2014

Case 1: A 51-year-old man with diabetes was referred for primary angioplasty with the working dia... more Case 1: A 51-year-old man with diabetes was referred for primary angioplasty with the working diagnosis of inferior ST elevation infarction. He denied chest pain but presented with severe diarrhoea in the previous days with obnubilation. ECG showed widened QRS complexes followed by peaked Twaves with a shortened QT interval, P waves were not discernible (figure 1A). Blood analysis confirmed severe hyperkalaemia (K+ 9.4 mmol/L) due to acute renal failure (serum creatinine 15.7 mg/dL), without signs of ketoacidosis. Troponin I was normal. After infusion of calcium gluconate, higher heart rate and narrower QRS complexes were observed, whereas P waves were sill unnoticeable (figure 1B). Case 2: An 80-year-old woman was admitted for pacemaker lead infection treatment. Spironolactone was started due to mild heart failure. Infection was being controlled by antibiotic treatment, but 3 days later she started with progressive obnubilation. ECG showed pacemaker spikes followed by widened QRS complexes fused with tall T waves, similar to a sine wave pattern (figure 2A). 1 Potassium was 8.4 mmol/L and renal function was normal.

Las dehiscencias o “leaks” perivalvulares (LPV) son comunicaciones anómalas entre cavidades cardi... more Las dehiscencias o “leaks” perivalvulares (LPV) son comunicaciones anómalas entre cavidades cardiacas adyacentes, o entre éstas y los grandes vasos, que se forman a través del tejido circundante a una válvula protésica (1), de manera inmediata o diferida tras su implante (figura 1). Así pues, un LPV no es sino una de las complicaciones que pueden aparecer tras el implante de una prótesis valvular, y su repercusión funcional lógica es la aparición de regurgitación valvular de tipo perivalvular (RPV) con un mayor o menor grado de hemólisis asociada, con el deterioro clínico y pronóstico que ello puede implicar para los pacientes..

Value in Health, 2013

A535 Objectives: There are few studies in Spain about outcomes at six months in terms of health-r... more A535 Objectives: There are few studies in Spain about outcomes at six months in terms of health-related quality of life (HRQoL) in patients hospitalized by heart failure (HF). The objective of the study was to evaluate changes in HRQoL from baseline to six months post discharge in patients with HF through three questionnaires, SF-12, EQ-5D-3L and Minnesota Living with Heart Failure questionnaire (MLHFQ). MethOds: This is a prospective study with 976 patients admitted by HF. Patients completed questionnaires during their hospitalization and at six months. The MLHFQ is a specific instrument which has 21 items with an overall scale, physical (8 items) and emotional (5 items) subscales. MLHFQ items are scoring from 0 (best) to 5 (worse). Total score ranges from 0 to 105, physical domain from 0 to 40 and emotional from 0 to 25. SF-12 has two dimensions, Physical Summary Score (PCS) and Mental Summary Score (MSC) which scores range from 0 (worst) to 100 (best). EQ-5D has been measured according to the Spanish tariffs by time trade-off and the visual analogic scale. We used general linear model to study gains in each dimension adjusted by baseline score, age, gender and readmissions in the previous 6 months. Results: Mean age was 76.0 (SD= 10.4), there were a 53.3% of men and 33.1% of readmissions in the previous six months. Regarding all questionnaires and dimensions, baseline status influence in gains, the worse the baseline the more the gains. Likewise men have greater gains and patients readmitted lower in all domains. Age has an influence in all domains but emotional dimension of MLHFQ and MSC of SF-12. cOnclusiOns: Adjusted by baseline score and readmissions, men have greater improvements in all domains of MLHFQ, SF-12 and EQ-5D. On the other hand, the younger the patients the higher the improvement is, however age does not have any influence in psychological domains.

EP Europace, 2018

Background: and objective. Anterior mitral lines (AML) have been suggested as an alternative to m... more Background: and objective. Anterior mitral lines (AML) have been suggested as an alternative to mitral isthmus ablation for perimitral flutter (AFL) treatment. The aim of this study was to test the efficacy of AML (i.e.: the modified anterior line (MAL, figure, panel A), the anteroseptal line (ASL, panel B), and lines between scar tissue and anterior mitral annulus) for perimitral AFL ablation. Methods: From May 2014 to October 2017, all consecutive patients with perimitral AFL received AML and were included in the study. Activation and voltage mapping were used to define AFL circuits and substrate. After perimitral AFL was diagnosed, an AML (type depending on expected efficacy) was performed until AFL termination. Programmed atrial stimulation was repeated to test AFL inducibility, and any sustained induced atrial arrhythmia was ablated. Follow-up included visits with ECG and/or 24h Holter-ECG at 3 and 12 months, and a final telephone call. Results: 25 patients, 13 male (52%) 70.4 6 13.7 y/o, were included. Successful ablation with AML was achieved in 24 patients (96%), 1 patient developed cardiac tamponade with interruption of the procedure. After perimitral AFL termination, other AFL (15 patients) or atrial fibrillation (AF, 1 patient) were induced and successfully ablated in all cases except in 1 patient. At a mean follow-up of 7.4 6 8.2 months, 3 patients (12%) recurred with a perimitral AFL, 4 with AF and 5 with other AFL. During followup, 14 patients (56%) were free from recurrence, with a mean survival free from atrial arrhythmias of 0.87 years (95%CI: 0.2-1.5 years) (figure, panel C). Possible predictors of arrhythmia recurrence were analysed. Among clinical variables, there was no difference in left ventricular ejection fraction, indexed left atrial volume or history of cardiac surgery between patients with or without arrhythmia recurrence; nevertheless, history of AF was more frequent in the group with recurrence compared to the group without it (7 cases, 63.7%; versus 3 cases, 21.4%; p¼0.032), as it was the history of prior ablation procedures (7 cases, 63.7%; versus 2 cases, 14%; p¼0.011). Among procedural aspects, a trend towards lower use of contact force ablation catheter was noted in the group with arrhythmia recurrence compared to the group without it (1 case, 9%; versus 6 cases, 42.9%; p¼0.062). A trend was also noted towards higher use of ASL in the group without recurrence, compared to a higher use of MAL in the group with recurrence (1 MAL, 7.1%; 8 ASL, 57.1%; 5 scar-to-annulus line, 35.7%, in the former; 5 MAL, 45.4%; 4 ASL, 36.4%; 2 scar-to-annulus, 18.2%, in the latter; p¼0.082). Conclusion: AML were highly successful to terminate perimitral AFL, although recurrence of other atrial arrhythmias was frequent. History of AF and prior ablation procedures were more frequent in those with arrhythmia recurrence, while use of contact force ablation catheter and ASL was higher in those without it.

European Heart Journal, 2018

In Echocardiographic data, LA volume was no significantly change in both groups, but LA-EF of 6-m... more In Echocardiographic data, LA volume was no significantly change in both groups, but LA-EF of 6-month after cryoballoon ablation was significantly improved in comparison with RF ablation. LA-Sa of 1 month after RF ablation was significantly lower than before. LA-Sa after cryoballoon ablation was improved 6-month after. Conclusions: The elevation of CK level after cryoballoon ablation might be reflected early damage of atrial muscle and the increasing of HANP secretion could be influenced recovery process of left atrium.

Introduction. Unstable reentrant atrial tachycardias (ATs) (i.e. those with frequent circuit modi... more Introduction. Unstable reentrant atrial tachycardias (ATs) (i.e. those with frequent circuit modification or conversion to atrial fibrillation) are challenging to ablate. We have tested a strategy to achieve arrhythmia stabilization into mappable stable ATs based on the detection and ablation of rotors. Methods and Results. From May 2017 to December 2019, 97 consecutive patients with reentrant ATs were ablated. Of these, 18 (18.6%) presented unstable circuits and were included. Mapping was performed using conventional high-density mapping catheters (IntellaMap ORION, PentaRay NAV or Advisor HD Grid). Rotors were subjectively identified as fractionated continuous (or quasi-continuous) electrograms on 1-2 adjacent bipoles of the mapping catheter, without dedicated software. 13 patients (72%) had detectable rotors (median 2 [1–3] rotors per patient); focal ablation achieved conversion into stable AT or sinus rhythm in 12 (92%). In the other 6 patients, sites with spatiotemporal dispers...

Heart, 2011

Background The circadian clock influences a number of cardiovascular (patho)physiological process... more Background The circadian clock influences a number of cardiovascular (patho)physiological processes including the incidence of acute myocardial infarction. A circadian variation in infarct size has recently been shown in rodents, but there is no clinical evidence of this finding. Objective To determine the impact of time-of-day onset of ST segment elevation myocardial infarction (STEMI) on infarct size. Methods A retrospective single-centre analysis of 811 patients with STEMI admitted between 2003 and 2009 was performed. Infarct size was estimated by peak enzyme release. The relationship between peak enzyme concentrations and time-of-day were characterised using multivariate regression splines. Time of STEMI onset was divided into four 6-hour periods in phase with circadian rhythms. Results Model comparisons based on likelihood ratio tests showed a circadian variation in infarct size across time-of-day as evaluated by peak creatine kinase (CK) and troponin-I (TnI) concentrations (p¼0.015 and p¼0.012, respectively). CK and TnI curves described similar patterns across time, with a global maximum in the 6:00enoon period and a local minimum in the noone18:00 period. Infarct size was largest in patients with STEMI onset in the dark-to-light transition period (6:00enoon), with an increase in peak CK and TnI concentrations of 18.3% (p¼0.031) and 24.6% (p¼0.033), respectively, compared with onset of STEMI in the 18:00emidnight period. Patients with anterior wall STEMI also had significantly larger infarcts than those with STEMI in other locations. Conclusions Significant circadian oscillations in infarct size were found in patients according to time-of-day of STEMI onset. The infarct size was found to be significantly larger with STEMI onset in the dark-to-light transition period (6:00enoon). If confirmed, these results may have a significant impact on the interpretation of clinical trials of cardioprotective strategies in STEMI. METHODS Study population and variables analysed Consecutive patients with STEMI admitted to the Coronary Care Unit of Hospital Clínico San Carlos between March 2003 and September 2009 were retrospectively analysed. Demographic and clinical variables were prospectively recorded in < Additional figures are published online only. To view these files please visit the journal online (http://heart.bmj. com).

European Heart Journal, 2018

index (LAVI) and an increase in the LA strain and the Global Longitudinal Strain (GLS) of the LV ... more index (LAVI) and an increase in the LA strain and the Global Longitudinal Strain (GLS) of the LV was found (15±4 months after PVI). Significant increase in right atrium (RA), right ventricle (RV) and LA-RA free wall strain was noticed. Moreover the RA area and RA major diameter significantly decreased. Conclusion: Successful PVI in patients with paroxysmal AF and preserved/midrange LV systolic function results in significant reverse structural remodeling not only within the LA but also in the LV, RA and RV.

Case Reports in Internal Medicine, 2014

Cardiac resynchronization therapy has demonstrated important benefits for selected patients suffe... more Cardiac resynchronization therapy has demonstrated important benefits for selected patients suffering from heart failure. Those benefits include clinical and/or echocardiography assessed improvement, as well as hospitalizations and all-cause mortality reduction. However, about 30% of patients do not benefit from the therapy. Suboptimal left ventricle lead position, post-implant lead dislodgements and undesired phrenic nerve stimulation are potential causes for not responding and it is not always possible to avoid them during the implant procedure. We report a case in which we used a novel left ventricle lead which is actively fixated to the cardiac vein or to the coronary sinus, by means of a helix, in a patient with very limited options to implant the lead. In this patient, a traditional, passively fixated lead would fail to get implanted. This design can help the implanting physician to implant the lead in the desired position, minimizing the possibility of dislodgement, even in very basal positions where traditional leads are more likely to dislodge.

Revista Portuguesa de Cardiologia (English Edition), 2014

Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infa... more Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infarction (STEMI) suggest prehospital activation of the cardiac catheterization team. In previous protocols in our center activation occurred once patients arrived at the hospital. In January 2011, we initiated a new primary angioplasty activation protocol from prehospital locations. Our objective was to quantify the influence of this change on reperfusion times. Methods: A total of 173 consecutive STEMI patients (n=73/100 before/after initiation of the new protocol), diagnosed in a prehospital setting within 12 hours of symptom onset, were analyzed. The time between the patient's arrival at the hospital and beginning of the angioplasty procedure was termed the cath lab activation delay. Results: The new protocol resulted in a 37-min reduction in system delay (166 [132-235] min before vs. 129 [105-166] min after, p<0.001), mostly driven by a 64% reduction in cath lab activation delay (55 [0-79] min before vs. 20 [0-54] min after, p=0.001). This reduction was mainly observed outside working hours. The percentage of patients treated with a system delay ≤120 min increased from 14.5% before the new protocol to 41.8% afterwards (p=0.001). Conclusions: Prehospital activation of the cardiac catheterization team resulted in earlier reperfusion of STEMI patients.

International journal of cardiology, Jan 5, 2015

IJC Heart & Vasculature, 2015

Introduction and objectives: Different percutaneous interventional procedures are needed to reach... more Introduction and objectives: Different percutaneous interventional procedures are needed to reach and maintain adequate anatomical and physiological conditions for the Fontan circulation. We aim to describe the experience gained at a children's hospital in such interventions, and to analyze the clinical outcomes. Methods: Retrospective study of all patients with Fontan circulation completed between 1995 and 2013. We analyzed the clinical characteristics and the different types of percutaneous interventions performed, considering three different periods of time: before Glenn surgery, between Glenn and Fontan surgeries, and after Fontan was completed. Survival and time to indication of percutaneous interventions in each period were analyzed, as well as the clinical situation at last follow-up. Results: Of the 91 patients analyzed, 46 (50.5%) required percutaneous interventions. The most frequent procedures were pulmonary artery angioplasty and angioplasty of the Fontan conduit. Estimated survival at 10, 20 and 30 years of age was 96.2%, 94.7% and 89.4%, respectively. There were no significant differences in survival of patients undergoing percutaneous interventions or not. Overall survival and time to indication of percutaneous interventions were significantly lower in the group of patients with right morphology systemic ventricle. Patients with fenestrated Fontan required interventions more frequently. At the end of follow-up, 66 patients (72.5%) were asymptomatic, without significant differences between patients who underwent or did not undergo percutaneous interventions. Conclusions: Interventional catheterization procedures are often necessary to reach and maintain the fragile Fontan circulation, mainly in patients with right morphology systemic ventricles and fenestrated Fontan conduits.

European Journal of Internal Medicine, 2011

Up to 15% of patients with NSTEMI present at admission with heart failure. Scientific evidence fo... more Up to 15% of patients with NSTEMI present at admission with heart failure. Scientific evidence for its management is limited but much progress has been made during the last years. Our purpose was to review the last data concerning heart failure in NSTEMI and perform an update on the subject, with the following findings as main highlights. As Killip classes III and IV, Killip class II onset in the context of NSTEMI has also proven bad prognosis significance. Beta-blocker therapy has proven benefit to patients with Killip class II in observational studies and small trials. Angiotensin-converting enzyme inhibitor therapy shows stronger evidence of benefit in patients with heart failure than in patients without it. Eplerenone is indicated for patients with left ventricular dysfunction and heart failure or diabetes mellitus. Implantable cardioverter defibrillators improve survival in patients with severe ventricular dysfunction after a myocardial infarction. Cardiac resynchronization therapy indications must be carefully assessed due to the high rate of implants that do not fulfill guidelines indications. In conclusion, heart failure during a NSTEMI is a common and meaningful situation which warrants careful management and further investigation to reach stronger evidence for clinical recommendations.

Revista Portuguesa de Cardiologia (English Edition), 2014

Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infa... more Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infarction (STEMI) suggest prehospital activation of the cardiac catheterization team. In previous protocols in our center activation occurred once patients arrived at the hospital. In January 2011, we initiated a new primary angioplasty activation protocol from prehospital locations. Our objective was to quantify the influence of this change on reperfusion times. Methods: A total of 173 consecutive STEMI patients (n=73/100 before/after initiation of the new protocol), diagnosed in a prehospital setting within 12 hours of symptom onset, were analyzed. The time between the patient's arrival at the hospital and beginning of the angioplasty procedure was termed the cath lab activation delay. Results: The new protocol resulted in a 37-min reduction in system delay (166 [132---235] min before vs. 129 [105---166] min after, p<0.001), mostly driven by a 64% reduction in cath lab activation delay (55 [0---79] min before vs. 20 [0---54] min after, p=0.001). This reduction was mainly observed outside working hours. The percentage of patients treated with a system delay ≤120 min increased from 14.5% before the new protocol to 41.8% afterwards (p=0.001). Conclusions: Prehospital activation of the cardiac catheterization team resulted in earlier reperfusion of STEMI patients. Angioplastia coronária; Enfarte do miocárdio; Tempo de isquemia; Atraso no tratamento Ativação pré-hospitalar da equipa de angioplastia primária no enfarte agudo miocárdio com elevação do segmento ST Resumo Introdução e objetivos: As atuais diretrizes clínicas aquando da ocorrência de um enfarte agudo miocárdio com elevação do segmento ST (STEMI) sugerem a ativação da equipa de angioplastia primária ao nível pré-hospitalar. Protocolos anteriores contemplam a ativação da referida equipa assim que os pacientes chegam ao hospital. Em janeiro de 2011, o nosso centro iniciou um novo protocolo de ativação da equipa de angioplastia primária em localização pré-hospitalar de modo a quantificar a influência de tal alteração nos tempos de reperfusão. Métodos: Foram analisados 173 pacientes consecutivos com STEMI, cujo diagnóstico se efetuou em local pré-hospitalar em 12 horas desde o início dos sintomas (n = 73/100 antes/ após início do novo protocolo). O tempo que decorreu entre a chegada do paciente ao hospital e o inicio do procedimento de angioplastia foi designado Cath Lab Activation Delay. Resultados: O novo protocolo refletiu uma redução de 37 minutos no System Delay (166 [132 ---235] antes versus 129 [105 ---166] minutos depois, p<0.001), que se deveu primordialmente à redução de 64% no Cath Lab Activation Delay (55 [0 ---79] minutos antes versus 20 [0 ---54] minutos depois, p = 0,001). Tal redução observou-se principalmente em horário pós-laboral. A percentagem de pacientes tratados com um System Delay ≤ 120 minutos aumentou de 14,5%, antes do início do novo protocolo, para 41,8% após (p = 0,001). Conclusões: A ativação da equipa de angioplastia primária ao nível pré-hospitalar permitiu uma maior celeridade no início da terapia de reperfusão em pacientes com STEMI.

Revista Portuguesa de Cardiologia (English Edition), 2014

Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infa... more Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infarction (STEMI) suggest prehospital activation of the cardiac catheterization team. In previous protocols in our center activation occurred once patients arrived at the hospital. In January 2011, we initiated a new primary angioplasty activation protocol from prehospital locations. Our objective was to quantify the influence of this change on reperfusion times. Methods: A total of 173 consecutive STEMI patients (n=73/100 before/after initiation of the new protocol), diagnosed in a prehospital setting within 12 hours of symptom onset, were analyzed. The time between the patient's arrival at the hospital and beginning of the angioplasty procedure was termed the cath lab activation delay. Results: The new protocol resulted in a 37-min reduction in system delay (166 [132---235] min before vs. 129 [105---166] min after, p<0.001), mostly driven by a 64% reduction in cath lab activation delay (55 [0---79] min before vs. 20 [0---54] min after, p=0.001). This reduction was mainly observed outside working hours. The percentage of patients treated with a system delay ≤120 min increased from 14.5% before the new protocol to 41.8% afterwards (p=0.001). Conclusions: Prehospital activation of the cardiac catheterization team resulted in earlier reperfusion of STEMI patients. Angioplastia coronária; Enfarte do miocárdio; Tempo de isquemia; Atraso no tratamento Ativação pré-hospitalar da equipa de angioplastia primária no enfarte agudo miocárdio com elevação do segmento ST Resumo Introdução e objetivos: As atuais diretrizes clínicas aquando da ocorrência de um enfarte agudo miocárdio com elevação do segmento ST (STEMI) sugerem a ativação da equipa de angioplastia primária ao nível pré-hospitalar. Protocolos anteriores contemplam a ativação da referida equipa assim que os pacientes chegam ao hospital. Em janeiro de 2011, o nosso centro iniciou um novo protocolo de ativação da equipa de angioplastia primária em localização pré-hospitalar de modo a quantificar a influência de tal alteração nos tempos de reperfusão. Métodos: Foram analisados 173 pacientes consecutivos com STEMI, cujo diagnóstico se efetuou em local pré-hospitalar em 12 horas desde o início dos sintomas (n = 73/100 antes/ após início do novo protocolo). O tempo que decorreu entre a chegada do paciente ao hospital e o inicio do procedimento de angioplastia foi designado Cath Lab Activation Delay. Resultados: O novo protocolo refletiu uma redução de 37 minutos no System Delay (166 [132 ---235] antes versus 129 [105 ---166] minutos depois, p<0.001), que se deveu primordialmente à redução de 64% no Cath Lab Activation Delay (55 [0 ---79] minutos antes versus 20 [0 ---54] minutos depois, p = 0,001). Tal redução observou-se principalmente em horário pós-laboral. A percentagem de pacientes tratados com um System Delay ≤ 120 minutos aumentou de 14,5%, antes do início do novo protocolo, para 41,8% após (p = 0,001). Conclusões: A ativação da equipa de angioplastia primária ao nível pré-hospitalar permitiu uma maior celeridade no início da terapia de reperfusão em pacientes com STEMI.

Journal of the American College of Cardiology, 2012

International Journal of Cardiology, 2014

Heart, 2011

Background The circadian clock influences a number of cardiovascular (patho)physiological process... more Background The circadian clock influences a number of cardiovascular (patho)physiological processes including the incidence of acute myocardial infarction. A circadian variation in infarct size has recently been shown in rodents, but there is no clinical evidence of this finding. Objective To determine the impact of time-of-day onset of ST segment elevation myocardial infarction (STEMI) on infarct size. Methods A retrospective single-centre analysis of 811 patients with STEMI admitted between 2003 and 2009 was performed. Infarct size was estimated by peak enzyme release. The relationship between peak enzyme concentrations and time-of-day were characterised using multivariate regression splines. Time of STEMI onset was divided into four 6-hour periods in phase with circadian rhythms. Results Model comparisons based on likelihood ratio tests showed a circadian variation in infarct size across time-of-day as evaluated by peak creatine kinase (CK) and troponin-I (TnI) concentrations (p¼0.015 and p¼0.012, respectively). CK and TnI curves described similar patterns across time, with a global maximum in the 6:00enoon period and a local minimum in the noone18:00 period. Infarct size was largest in patients with STEMI onset in the dark-to-light transition period (6:00enoon), with an increase in peak CK and TnI concentrations of 18.3% (p¼0.031) and 24.6% (p¼0.033), respectively, compared with onset of STEMI in the 18:00emidnight period. Patients with anterior wall STEMI also had significantly larger infarcts than those with STEMI in other locations. Conclusions Significant circadian oscillations in infarct size were found in patients according to time-of-day of STEMI onset. The infarct size was found to be significantly larger with STEMI onset in the dark-to-light transition period (6:00enoon). If confirmed, these results may have a significant impact on the interpretation of clinical trials of cardioprotective strategies in STEMI.

Heart Asia, 2014

Case 1: A 51-year-old man with diabetes was referred for primary angioplasty with the working dia... more Case 1: A 51-year-old man with diabetes was referred for primary angioplasty with the working diagnosis of inferior ST elevation infarction. He denied chest pain but presented with severe diarrhoea in the previous days with obnubilation. ECG showed widened QRS complexes followed by peaked Twaves with a shortened QT interval, P waves were not discernible (figure 1A). Blood analysis confirmed severe hyperkalaemia (K+ 9.4 mmol/L) due to acute renal failure (serum creatinine 15.7 mg/dL), without signs of ketoacidosis. Troponin I was normal. After infusion of calcium gluconate, higher heart rate and narrower QRS complexes were observed, whereas P waves were sill unnoticeable (figure 1B). Case 2: An 80-year-old woman was admitted for pacemaker lead infection treatment. Spironolactone was started due to mild heart failure. Infection was being controlled by antibiotic treatment, but 3 days later she started with progressive obnubilation. ECG showed pacemaker spikes followed by widened QRS complexes fused with tall T waves, similar to a sine wave pattern (figure 2A). 1 Potassium was 8.4 mmol/L and renal function was normal.

Las dehiscencias o “leaks” perivalvulares (LPV) son comunicaciones anómalas entre cavidades cardi... more Las dehiscencias o “leaks” perivalvulares (LPV) son comunicaciones anómalas entre cavidades cardiacas adyacentes, o entre éstas y los grandes vasos, que se forman a través del tejido circundante a una válvula protésica (1), de manera inmediata o diferida tras su implante (figura 1). Así pues, un LPV no es sino una de las complicaciones que pueden aparecer tras el implante de una prótesis valvular, y su repercusión funcional lógica es la aparición de regurgitación valvular de tipo perivalvular (RPV) con un mayor o menor grado de hemólisis asociada, con el deterioro clínico y pronóstico que ello puede implicar para los pacientes..

Value in Health, 2013

A535 Objectives: There are few studies in Spain about outcomes at six months in terms of health-r... more A535 Objectives: There are few studies in Spain about outcomes at six months in terms of health-related quality of life (HRQoL) in patients hospitalized by heart failure (HF). The objective of the study was to evaluate changes in HRQoL from baseline to six months post discharge in patients with HF through three questionnaires, SF-12, EQ-5D-3L and Minnesota Living with Heart Failure questionnaire (MLHFQ). MethOds: This is a prospective study with 976 patients admitted by HF. Patients completed questionnaires during their hospitalization and at six months. The MLHFQ is a specific instrument which has 21 items with an overall scale, physical (8 items) and emotional (5 items) subscales. MLHFQ items are scoring from 0 (best) to 5 (worse). Total score ranges from 0 to 105, physical domain from 0 to 40 and emotional from 0 to 25. SF-12 has two dimensions, Physical Summary Score (PCS) and Mental Summary Score (MSC) which scores range from 0 (worst) to 100 (best). EQ-5D has been measured according to the Spanish tariffs by time trade-off and the visual analogic scale. We used general linear model to study gains in each dimension adjusted by baseline score, age, gender and readmissions in the previous 6 months. Results: Mean age was 76.0 (SD= 10.4), there were a 53.3% of men and 33.1% of readmissions in the previous six months. Regarding all questionnaires and dimensions, baseline status influence in gains, the worse the baseline the more the gains. Likewise men have greater gains and patients readmitted lower in all domains. Age has an influence in all domains but emotional dimension of MLHFQ and MSC of SF-12. cOnclusiOns: Adjusted by baseline score and readmissions, men have greater improvements in all domains of MLHFQ, SF-12 and EQ-5D. On the other hand, the younger the patients the higher the improvement is, however age does not have any influence in psychological domains.

EP Europace, 2018

Background: and objective. Anterior mitral lines (AML) have been suggested as an alternative to m... more Background: and objective. Anterior mitral lines (AML) have been suggested as an alternative to mitral isthmus ablation for perimitral flutter (AFL) treatment. The aim of this study was to test the efficacy of AML (i.e.: the modified anterior line (MAL, figure, panel A), the anteroseptal line (ASL, panel B), and lines between scar tissue and anterior mitral annulus) for perimitral AFL ablation. Methods: From May 2014 to October 2017, all consecutive patients with perimitral AFL received AML and were included in the study. Activation and voltage mapping were used to define AFL circuits and substrate. After perimitral AFL was diagnosed, an AML (type depending on expected efficacy) was performed until AFL termination. Programmed atrial stimulation was repeated to test AFL inducibility, and any sustained induced atrial arrhythmia was ablated. Follow-up included visits with ECG and/or 24h Holter-ECG at 3 and 12 months, and a final telephone call. Results: 25 patients, 13 male (52%) 70.4 6 13.7 y/o, were included. Successful ablation with AML was achieved in 24 patients (96%), 1 patient developed cardiac tamponade with interruption of the procedure. After perimitral AFL termination, other AFL (15 patients) or atrial fibrillation (AF, 1 patient) were induced and successfully ablated in all cases except in 1 patient. At a mean follow-up of 7.4 6 8.2 months, 3 patients (12%) recurred with a perimitral AFL, 4 with AF and 5 with other AFL. During followup, 14 patients (56%) were free from recurrence, with a mean survival free from atrial arrhythmias of 0.87 years (95%CI: 0.2-1.5 years) (figure, panel C). Possible predictors of arrhythmia recurrence were analysed. Among clinical variables, there was no difference in left ventricular ejection fraction, indexed left atrial volume or history of cardiac surgery between patients with or without arrhythmia recurrence; nevertheless, history of AF was more frequent in the group with recurrence compared to the group without it (7 cases, 63.7%; versus 3 cases, 21.4%; p¼0.032), as it was the history of prior ablation procedures (7 cases, 63.7%; versus 2 cases, 14%; p¼0.011). Among procedural aspects, a trend towards lower use of contact force ablation catheter was noted in the group with arrhythmia recurrence compared to the group without it (1 case, 9%; versus 6 cases, 42.9%; p¼0.062). A trend was also noted towards higher use of ASL in the group without recurrence, compared to a higher use of MAL in the group with recurrence (1 MAL, 7.1%; 8 ASL, 57.1%; 5 scar-to-annulus line, 35.7%, in the former; 5 MAL, 45.4%; 4 ASL, 36.4%; 2 scar-to-annulus, 18.2%, in the latter; p¼0.082). Conclusion: AML were highly successful to terminate perimitral AFL, although recurrence of other atrial arrhythmias was frequent. History of AF and prior ablation procedures were more frequent in those with arrhythmia recurrence, while use of contact force ablation catheter and ASL was higher in those without it.

European Heart Journal, 2018

In Echocardiographic data, LA volume was no significantly change in both groups, but LA-EF of 6-m... more In Echocardiographic data, LA volume was no significantly change in both groups, but LA-EF of 6-month after cryoballoon ablation was significantly improved in comparison with RF ablation. LA-Sa of 1 month after RF ablation was significantly lower than before. LA-Sa after cryoballoon ablation was improved 6-month after. Conclusions: The elevation of CK level after cryoballoon ablation might be reflected early damage of atrial muscle and the increasing of HANP secretion could be influenced recovery process of left atrium.

Introduction. Unstable reentrant atrial tachycardias (ATs) (i.e. those with frequent circuit modi... more Introduction. Unstable reentrant atrial tachycardias (ATs) (i.e. those with frequent circuit modification or conversion to atrial fibrillation) are challenging to ablate. We have tested a strategy to achieve arrhythmia stabilization into mappable stable ATs based on the detection and ablation of rotors. Methods and Results. From May 2017 to December 2019, 97 consecutive patients with reentrant ATs were ablated. Of these, 18 (18.6%) presented unstable circuits and were included. Mapping was performed using conventional high-density mapping catheters (IntellaMap ORION, PentaRay NAV or Advisor HD Grid). Rotors were subjectively identified as fractionated continuous (or quasi-continuous) electrograms on 1-2 adjacent bipoles of the mapping catheter, without dedicated software. 13 patients (72%) had detectable rotors (median 2 [1–3] rotors per patient); focal ablation achieved conversion into stable AT or sinus rhythm in 12 (92%). In the other 6 patients, sites with spatiotemporal dispers...

Heart, 2011

Background The circadian clock influences a number of cardiovascular (patho)physiological process... more Background The circadian clock influences a number of cardiovascular (patho)physiological processes including the incidence of acute myocardial infarction. A circadian variation in infarct size has recently been shown in rodents, but there is no clinical evidence of this finding. Objective To determine the impact of time-of-day onset of ST segment elevation myocardial infarction (STEMI) on infarct size. Methods A retrospective single-centre analysis of 811 patients with STEMI admitted between 2003 and 2009 was performed. Infarct size was estimated by peak enzyme release. The relationship between peak enzyme concentrations and time-of-day were characterised using multivariate regression splines. Time of STEMI onset was divided into four 6-hour periods in phase with circadian rhythms. Results Model comparisons based on likelihood ratio tests showed a circadian variation in infarct size across time-of-day as evaluated by peak creatine kinase (CK) and troponin-I (TnI) concentrations (p¼0.015 and p¼0.012, respectively). CK and TnI curves described similar patterns across time, with a global maximum in the 6:00enoon period and a local minimum in the noone18:00 period. Infarct size was largest in patients with STEMI onset in the dark-to-light transition period (6:00enoon), with an increase in peak CK and TnI concentrations of 18.3% (p¼0.031) and 24.6% (p¼0.033), respectively, compared with onset of STEMI in the 18:00emidnight period. Patients with anterior wall STEMI also had significantly larger infarcts than those with STEMI in other locations. Conclusions Significant circadian oscillations in infarct size were found in patients according to time-of-day of STEMI onset. The infarct size was found to be significantly larger with STEMI onset in the dark-to-light transition period (6:00enoon). If confirmed, these results may have a significant impact on the interpretation of clinical trials of cardioprotective strategies in STEMI. METHODS Study population and variables analysed Consecutive patients with STEMI admitted to the Coronary Care Unit of Hospital Clínico San Carlos between March 2003 and September 2009 were retrospectively analysed. Demographic and clinical variables were prospectively recorded in < Additional figures are published online only. To view these files please visit the journal online (http://heart.bmj. com).

European Heart Journal, 2018

index (LAVI) and an increase in the LA strain and the Global Longitudinal Strain (GLS) of the LV ... more index (LAVI) and an increase in the LA strain and the Global Longitudinal Strain (GLS) of the LV was found (15±4 months after PVI). Significant increase in right atrium (RA), right ventricle (RV) and LA-RA free wall strain was noticed. Moreover the RA area and RA major diameter significantly decreased. Conclusion: Successful PVI in patients with paroxysmal AF and preserved/midrange LV systolic function results in significant reverse structural remodeling not only within the LA but also in the LV, RA and RV.

Case Reports in Internal Medicine, 2014

Cardiac resynchronization therapy has demonstrated important benefits for selected patients suffe... more Cardiac resynchronization therapy has demonstrated important benefits for selected patients suffering from heart failure. Those benefits include clinical and/or echocardiography assessed improvement, as well as hospitalizations and all-cause mortality reduction. However, about 30% of patients do not benefit from the therapy. Suboptimal left ventricle lead position, post-implant lead dislodgements and undesired phrenic nerve stimulation are potential causes for not responding and it is not always possible to avoid them during the implant procedure. We report a case in which we used a novel left ventricle lead which is actively fixated to the cardiac vein or to the coronary sinus, by means of a helix, in a patient with very limited options to implant the lead. In this patient, a traditional, passively fixated lead would fail to get implanted. This design can help the implanting physician to implant the lead in the desired position, minimizing the possibility of dislodgement, even in very basal positions where traditional leads are more likely to dislodge.

Revista Portuguesa de Cardiologia (English Edition), 2014

Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infa... more Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infarction (STEMI) suggest prehospital activation of the cardiac catheterization team. In previous protocols in our center activation occurred once patients arrived at the hospital. In January 2011, we initiated a new primary angioplasty activation protocol from prehospital locations. Our objective was to quantify the influence of this change on reperfusion times. Methods: A total of 173 consecutive STEMI patients (n=73/100 before/after initiation of the new protocol), diagnosed in a prehospital setting within 12 hours of symptom onset, were analyzed. The time between the patient's arrival at the hospital and beginning of the angioplasty procedure was termed the cath lab activation delay. Results: The new protocol resulted in a 37-min reduction in system delay (166 [132-235] min before vs. 129 [105-166] min after, p<0.001), mostly driven by a 64% reduction in cath lab activation delay (55 [0-79] min before vs. 20 [0-54] min after, p=0.001). This reduction was mainly observed outside working hours. The percentage of patients treated with a system delay ≤120 min increased from 14.5% before the new protocol to 41.8% afterwards (p=0.001). Conclusions: Prehospital activation of the cardiac catheterization team resulted in earlier reperfusion of STEMI patients.

International journal of cardiology, Jan 5, 2015

IJC Heart & Vasculature, 2015

Introduction and objectives: Different percutaneous interventional procedures are needed to reach... more Introduction and objectives: Different percutaneous interventional procedures are needed to reach and maintain adequate anatomical and physiological conditions for the Fontan circulation. We aim to describe the experience gained at a children's hospital in such interventions, and to analyze the clinical outcomes. Methods: Retrospective study of all patients with Fontan circulation completed between 1995 and 2013. We analyzed the clinical characteristics and the different types of percutaneous interventions performed, considering three different periods of time: before Glenn surgery, between Glenn and Fontan surgeries, and after Fontan was completed. Survival and time to indication of percutaneous interventions in each period were analyzed, as well as the clinical situation at last follow-up. Results: Of the 91 patients analyzed, 46 (50.5%) required percutaneous interventions. The most frequent procedures were pulmonary artery angioplasty and angioplasty of the Fontan conduit. Estimated survival at 10, 20 and 30 years of age was 96.2%, 94.7% and 89.4%, respectively. There were no significant differences in survival of patients undergoing percutaneous interventions or not. Overall survival and time to indication of percutaneous interventions were significantly lower in the group of patients with right morphology systemic ventricle. Patients with fenestrated Fontan required interventions more frequently. At the end of follow-up, 66 patients (72.5%) were asymptomatic, without significant differences between patients who underwent or did not undergo percutaneous interventions. Conclusions: Interventional catheterization procedures are often necessary to reach and maintain the fragile Fontan circulation, mainly in patients with right morphology systemic ventricles and fenestrated Fontan conduits.

European Journal of Internal Medicine, 2011

Up to 15% of patients with NSTEMI present at admission with heart failure. Scientific evidence fo... more Up to 15% of patients with NSTEMI present at admission with heart failure. Scientific evidence for its management is limited but much progress has been made during the last years. Our purpose was to review the last data concerning heart failure in NSTEMI and perform an update on the subject, with the following findings as main highlights. As Killip classes III and IV, Killip class II onset in the context of NSTEMI has also proven bad prognosis significance. Beta-blocker therapy has proven benefit to patients with Killip class II in observational studies and small trials. Angiotensin-converting enzyme inhibitor therapy shows stronger evidence of benefit in patients with heart failure than in patients without it. Eplerenone is indicated for patients with left ventricular dysfunction and heart failure or diabetes mellitus. Implantable cardioverter defibrillators improve survival in patients with severe ventricular dysfunction after a myocardial infarction. Cardiac resynchronization therapy indications must be carefully assessed due to the high rate of implants that do not fulfill guidelines indications. In conclusion, heart failure during a NSTEMI is a common and meaningful situation which warrants careful management and further investigation to reach stronger evidence for clinical recommendations.

Revista Portuguesa de Cardiologia (English Edition), 2014

Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infa... more Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infarction (STEMI) suggest prehospital activation of the cardiac catheterization team. In previous protocols in our center activation occurred once patients arrived at the hospital. In January 2011, we initiated a new primary angioplasty activation protocol from prehospital locations. Our objective was to quantify the influence of this change on reperfusion times. Methods: A total of 173 consecutive STEMI patients (n=73/100 before/after initiation of the new protocol), diagnosed in a prehospital setting within 12 hours of symptom onset, were analyzed. The time between the patient's arrival at the hospital and beginning of the angioplasty procedure was termed the cath lab activation delay. Results: The new protocol resulted in a 37-min reduction in system delay (166 [132---235] min before vs. 129 [105---166] min after, p<0.001), mostly driven by a 64% reduction in cath lab activation delay (55 [0---79] min before vs. 20 [0---54] min after, p=0.001). This reduction was mainly observed outside working hours. The percentage of patients treated with a system delay ≤120 min increased from 14.5% before the new protocol to 41.8% afterwards (p=0.001). Conclusions: Prehospital activation of the cardiac catheterization team resulted in earlier reperfusion of STEMI patients. Angioplastia coronária; Enfarte do miocárdio; Tempo de isquemia; Atraso no tratamento Ativação pré-hospitalar da equipa de angioplastia primária no enfarte agudo miocárdio com elevação do segmento ST Resumo Introdução e objetivos: As atuais diretrizes clínicas aquando da ocorrência de um enfarte agudo miocárdio com elevação do segmento ST (STEMI) sugerem a ativação da equipa de angioplastia primária ao nível pré-hospitalar. Protocolos anteriores contemplam a ativação da referida equipa assim que os pacientes chegam ao hospital. Em janeiro de 2011, o nosso centro iniciou um novo protocolo de ativação da equipa de angioplastia primária em localização pré-hospitalar de modo a quantificar a influência de tal alteração nos tempos de reperfusão. Métodos: Foram analisados 173 pacientes consecutivos com STEMI, cujo diagnóstico se efetuou em local pré-hospitalar em 12 horas desde o início dos sintomas (n = 73/100 antes/ após início do novo protocolo). O tempo que decorreu entre a chegada do paciente ao hospital e o inicio do procedimento de angioplastia foi designado Cath Lab Activation Delay. Resultados: O novo protocolo refletiu uma redução de 37 minutos no System Delay (166 [132 ---235] antes versus 129 [105 ---166] minutos depois, p<0.001), que se deveu primordialmente à redução de 64% no Cath Lab Activation Delay (55 [0 ---79] minutos antes versus 20 [0 ---54] minutos depois, p = 0,001). Tal redução observou-se principalmente em horário pós-laboral. A percentagem de pacientes tratados com um System Delay ≤ 120 minutos aumentou de 14,5%, antes do início do novo protocolo, para 41,8% após (p = 0,001). Conclusões: A ativação da equipa de angioplastia primária ao nível pré-hospitalar permitiu uma maior celeridade no início da terapia de reperfusão em pacientes com STEMI.

Revista Portuguesa de Cardiologia (English Edition), 2014

Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infa... more Introduction and Objectives: Current clinical guidelines for ST-segment elevation myocardial infarction (STEMI) suggest prehospital activation of the cardiac catheterization team. In previous protocols in our center activation occurred once patients arrived at the hospital. In January 2011, we initiated a new primary angioplasty activation protocol from prehospital locations. Our objective was to quantify the influence of this change on reperfusion times. Methods: A total of 173 consecutive STEMI patients (n=73/100 before/after initiation of the new protocol), diagnosed in a prehospital setting within 12 hours of symptom onset, were analyzed. The time between the patient's arrival at the hospital and beginning of the angioplasty procedure was termed the cath lab activation delay. Results: The new protocol resulted in a 37-min reduction in system delay (166 [132---235] min before vs. 129 [105---166] min after, p<0.001), mostly driven by a 64% reduction in cath lab activation delay (55 [0---79] min before vs. 20 [0---54] min after, p=0.001). This reduction was mainly observed outside working hours. The percentage of patients treated with a system delay ≤120 min increased from 14.5% before the new protocol to 41.8% afterwards (p=0.001). Conclusions: Prehospital activation of the cardiac catheterization team resulted in earlier reperfusion of STEMI patients. Angioplastia coronária; Enfarte do miocárdio; Tempo de isquemia; Atraso no tratamento Ativação pré-hospitalar da equipa de angioplastia primária no enfarte agudo miocárdio com elevação do segmento ST Resumo Introdução e objetivos: As atuais diretrizes clínicas aquando da ocorrência de um enfarte agudo miocárdio com elevação do segmento ST (STEMI) sugerem a ativação da equipa de angioplastia primária ao nível pré-hospitalar. Protocolos anteriores contemplam a ativação da referida equipa assim que os pacientes chegam ao hospital. Em janeiro de 2011, o nosso centro iniciou um novo protocolo de ativação da equipa de angioplastia primária em localização pré-hospitalar de modo a quantificar a influência de tal alteração nos tempos de reperfusão. Métodos: Foram analisados 173 pacientes consecutivos com STEMI, cujo diagnóstico se efetuou em local pré-hospitalar em 12 horas desde o início dos sintomas (n = 73/100 antes/ após início do novo protocolo). O tempo que decorreu entre a chegada do paciente ao hospital e o inicio do procedimento de angioplastia foi designado Cath Lab Activation Delay. Resultados: O novo protocolo refletiu uma redução de 37 minutos no System Delay (166 [132 ---235] antes versus 129 [105 ---166] minutos depois, p<0.001), que se deveu primordialmente à redução de 64% no Cath Lab Activation Delay (55 [0 ---79] minutos antes versus 20 [0 ---54] minutos depois, p = 0,001). Tal redução observou-se principalmente em horário pós-laboral. A percentagem de pacientes tratados com um System Delay ≤ 120 minutos aumentou de 14,5%, antes do início do novo protocolo, para 41,8% após (p = 0,001). Conclusões: A ativação da equipa de angioplastia primária ao nível pré-hospitalar permitiu uma maior celeridade no início da terapia de reperfusão em pacientes com STEMI.

Journal of the American College of Cardiology, 2012

International Journal of Cardiology, 2014

Heart, 2011

Background The circadian clock influences a number of cardiovascular (patho)physiological process... more Background The circadian clock influences a number of cardiovascular (patho)physiological processes including the incidence of acute myocardial infarction. A circadian variation in infarct size has recently been shown in rodents, but there is no clinical evidence of this finding. Objective To determine the impact of time-of-day onset of ST segment elevation myocardial infarction (STEMI) on infarct size. Methods A retrospective single-centre analysis of 811 patients with STEMI admitted between 2003 and 2009 was performed. Infarct size was estimated by peak enzyme release. The relationship between peak enzyme concentrations and time-of-day were characterised using multivariate regression splines. Time of STEMI onset was divided into four 6-hour periods in phase with circadian rhythms. Results Model comparisons based on likelihood ratio tests showed a circadian variation in infarct size across time-of-day as evaluated by peak creatine kinase (CK) and troponin-I (TnI) concentrations (p¼0.015 and p¼0.012, respectively). CK and TnI curves described similar patterns across time, with a global maximum in the 6:00enoon period and a local minimum in the noone18:00 period. Infarct size was largest in patients with STEMI onset in the dark-to-light transition period (6:00enoon), with an increase in peak CK and TnI concentrations of 18.3% (p¼0.031) and 24.6% (p¼0.033), respectively, compared with onset of STEMI in the 18:00emidnight period. Patients with anterior wall STEMI also had significantly larger infarcts than those with STEMI in other locations. Conclusions Significant circadian oscillations in infarct size were found in patients according to time-of-day of STEMI onset. The infarct size was found to be significantly larger with STEMI onset in the dark-to-light transition period (6:00enoon). If confirmed, these results may have a significant impact on the interpretation of clinical trials of cardioprotective strategies in STEMI.