Introduction and objectives To present the report on the trends in percutaneous coronary activity data in Portugal from the last decade (from 2014 to 2023). Methods Data were extracted from the Portuguese National Registry of Interventional Cardiology (RNCI) and the numbers in recent years were compared and complemented by information from the 2023 European Society of Cardiology Atlas in Interventional Cardiology (IC) survey, which was administered to the director of every IC department. Linear regression analysis was used to assess trends in activity over time. Results From 2014 to 2023, there were 160101 percutaneous coronary interventions reported in the RNCI. The number of annual PCI in the last decade remained constant (1360/million inhabitants in 2014 to 1322/million in 2023; R2=0.039, p=0.276). Importantly, there was a 22% increase in primary PCI (306/million inhabitants in 2014 to 374/million inhabitants in 2023; R2=0.759, p<0.001) and there was a decrease in the geographical disparities in primary PCI across Portugal. The following PCI trends were noted: a 43% increase in PCI performed by radial access (57.4% in 2014 to 82.1% in 2023; R2=0.908, p<0.001), a 27% increase in drug-eluting stents (78.4% in 2014 to 99.2% of all PCI with stents in 2023; R2=0.638, p=0.003), and a 47% decrease of thrombectomy in primary PCI (35.0% in 2014 to 18.6% in 2023; R2=0.649, p=0.003). There was a slight increase in the use of intracoronary diagnostic devices during PCI, with intravascular imaging and physiological assessments reaching 7.6% and 4.2%, respectively, in 2023. Conclusion The RNCI was able to depict changes in our practice along the study period. The annual PCI volume per million inhabitants remained stable, driven by an increase in primary PCI offset by a decrease in chronic coronary syndrome indications. The geographical asymmetries were markedly reduced due to the expansion on PCI capable centers, enabling a progress towards a more universal access to percutaneous coronary techniques.

Abstract Funding Acknowledgements None. Background Pre-infarct angina (PIA) has been demonstrated to reduce infarct size and improve prognosis in ST-elevation myocardial infarction (STEMI). However, the effects of ischemic preconditioning with aging are still controversial. Purpose We aimed at comparing the effect of pre-infarction angina (PIA) on infarct size between two age groups. Methods We retrospectively studied consecutive STEMI patients treated by primary percutaneous coronary intervention (PCI) from January 2008 to December 2017. PIA was diagnosed if a patient had arm, jaw, or chest pain in the preceding eight days. Peak creatine kinase (CK) concentration was used as a surrogate of infarct size. Patients were divided into two groups, based on the median age: ≤62 years and &gt;62 years. Multiple linear regression was used to identify independent predictors for infarct size that included total ischemic time and classic cardiovascular risk factors (hypertension, diabetes, dyslipidaemia, and smoking). Interaction between age and PIA was evaluated by 2-way factorial ANOVA. Results From the 1131 patients included in the study, 590 (52,2%) had ≤62 years and 541 (47,8%) had &gt;62 years. Older patients were more often women (17.2% vs 8.6%, p&lt;0.001) and had longer total ischemic time [4.6(3.0-9.0) vs 3.5(2.3-6.0) hours, p&lt;0.001]. They also had higher prevalence of hypertension (32.8% vs 22.8%, p&lt;0.001), diabetes (30.7% vs 18.7%, p&lt;0.001) and were less likely to be smokers (26.9% vs 71.4%, p&lt;0.001). The prevalence of PIA was similar across age groups (≤62Y 31.2% vs &gt;62Y 32.0%, p=0.668). In older patients, PIA was associated with smaller infarct size [1.29(0.72-2.33) vs. 1.76(0.97-2.91) U/Lx103, p&lt;0.001]. This difference was not observed for younger patients [1.72(0.95-3.40) vs. 1.81(0.94-3.37) U/Lx103, p=0.392]. There was no significant interaction between the existence of PIA and age on peak CK (p=0.280 for interaction) (Figure 1). In multivariate analysis, overall, PIA was associated with reduced peak CK (β=-0,320, p=0.011). On subgroup group analysis, PIA was a predictor of infarct size only in the older patients (β=-0,459, p=0.005), but not in the younger group (β=-0,182, p=0.394). Conclusion Older patients with PIA had significantly lower infarct size compared to patients in the same age group without PIA. After adjustment for risk factors and total ischemic time, PIA was a predictor of lower infarct size only for the older patients. These results suggest that the effect of pre-ischemic conditioning is not blunted by age, indicating that older patients should not be excluded from clinical trials investigation of cardioprotective strategies in STEMI patients.

Abstract Funding Acknowledgements None. Background Women with ST-segment elevation myocardial infarction (STEMI) have been reported to have higher short-term mortality than men, especially in younger patients. However, data on long-term outcomes did not corroborate this association. Purpose We aimed to evaluate if sex was an independent predictor of major adverse cardio-cerebrovascular events (MACCE) at 1-year follow-up. A sub-analysis across different age subgroups was performed. Methods We retrospectively studied consecutive STEMI patients treated by primary percutaneous coronary intervention (PCI) from January 2008 to December 2017. Cox proportional hazard models were used to identify predictors of MACCE at 1-year follow-up (death, cerebrovascular accident, new myocardial infarction in any vessel, or target lesion revascularization). Patients were divided into four age groups, according to quartiles, for subgroup analysis (≤50, 51-60, 61-70, >71 years). Results Of the 1131 patients included in the study, 291 (25.7%) were women. Women were older [68.2 (±14.2) vs 60.6 (±12.2) years, p<0.001], more often non-smokers (21.5% vs 60.2%, p<0.001), and had a higher prevalence of diabetes (34,8% vs 20.9%, p<0.001) and hypertension (71.6% vs 50.2%, p<0.001). They also had lower haemoglobin [12.8 (±1.6) vs 14.5 (±1.7) g/dl, p<0.001] and lower creatinine clearance at admission [73.8 (±35.3) vs 92.6 (±35.2) ml/min, p<0.001], as well as longer door-to-balloon times [90 (60-166) vs 75(50-120) min, p=0.005]. However, total ischemic time was not significantly different between groups [250(175-480) vs 224(150-440) min, p=0.054]. Overall, women had a higher occurrence of MACCE (22.1% vs 15.4%; log-rank P = 0.008, Figure 1). On multivariate analysis, sex was not found to be an independent predictor of MACCE (HR 1.12; 95% CI, 0.77–1.65; P = 0.547). The risk of unfavourable outcomes was mainly driven by other comorbidities (namely, age, presence of peripheral arterial disease, lower haemoglobin concentration, lower systolic blood pressure on admission, a higher peak CK activity, and the utilization of a femoral approach). When MACCE was stratified by age, sex was not an independent predictor of MACCE in any age group (Figure 2). Conclusion Women with STEMI submitted to PCI had a higher rate of MACCE at 1-year follow-up compared with men, however, sex was not an independent predictor of these events on multivariate analysis, regardless of the age subgroups considered.

Calcified lesions are associated with higher rates of complications during percutaneous coronary intervention (PCI). Balloon shaft fracture and entrapment is a rare, but potentially severe complication of PCI. The resulting debris might lead to vessel occlusion and/or form a pro-thrombotic nidus, potentially leading to distal embolization, acute myocardial infarction, ventricular dysrhythmia, and even death. We report a case of balloon fracture and entrapment, where rotational atherectomy was essential in modifying the entrapped material, allowing the crossing of an otherwise uncrossable “balloon-lesion complex”, subsequently treated with crushing and jailing by stenting, with good angiographic result and outcome.

The percutaneous treatment of structural, valvular, and non-valvular heart disease (SHD) is rapidly evolving. The Core Curriculum (CC) proposed by the EAPCI describes the knowledge, skills, and attitudes that define competency levels required by newly trained SHD interventional cardiologists (IC) and provides guidance for training centres. SHD ICs are cardiologists who have received complete interventional cardiology training. They are multidisciplinary team specialists who manage adult SHD patients from diagnosis to follow-up and perform percutaneous procedures in this area. They are competent in interpreting advanced imaging techniques and master planning software. The SHD ICs are expected to be proficient in the aortic, mitral, and tricuspid areas. They may have selective skills in either the aortic area or mitral/tricuspid areas. In this case, they must still have common transversal competencies in the aortic, mitral, and tricuspid areas. Additional SHD domain competencies are optional. Completing dedicated SHD training, aiming for full aortic, mitral, and tricuspid competencies, requires at least 18 months. For full training in the aortic area, with basic competencies in mitral/tricuspid areas, the training can be reduced to 1 year. The same is true for training in the mitral/tricuspid area, with competencies in the aortic area. The SHD IC CC promotes excellence and homogeneous training across Europe and is the cornerstone of future certifications and patient protection. It may be a reference for future CC for national associations and other SHD specialities, including imaging and cardiac surgery.

Abstract Funding Acknowledgements None. Background Differences in women’s prognosis have been described for both ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (CS). These might reflect asymmetries in clinical management, but also gender-specific comorbidities and pathologic mechanisms. Purpose We aimed to evaluate the risk of in-hospital complications and mid-term outcomes of women with CS following STEMI. Methods We retrospectively studied STEMI patients treated by primary percutaneous coronary intervention (PCI) from 2008 to 2017 in a tertiary care centre, presenting or evolving in Killip class IV (defined as cardiogenic shock or hypotension and organ hypoperfusion). Clinical and demographic characteristics, as well as complications and outcomes, were collected. Major adverse cardio-cerebrovascular events (MACCE) at 1-year follow-up was a composite of death, cerebrovascular accident, new myocardial infarction in any vessel, or target lesion revascularization. Results Among 1131 patients presenting with STEMI, our study included 117 (10.3%) patients in CS, of which 40 (34.2%) were women. Women were older [71.8(±13.4) vs 64.6(±11.72) years, p=0.002] and less frequently smokers (25.0% vs 50.7%, p=0.008). Prevalence of classic cardiovascular risk factors, namely diabetes (34,1% vs 39.2%, p=0.860), hypertension (71.5% vs 60.8%, p=0.212), and dyslipidaemia (47.5% vs 70.0%, p=0.799), was the same for both groups. Body mass index was also similar [26.6(±5.2) vs 26.1(±3.4) kg/m2, p=0.539]. Women had lower haemoglobin [12.4(±1.9) vs 13.8(±1.9) g/dl, p&lt;0.001] and lower creatinine clearance at admission [52.4(±30.6) vs 67.3(±29.4) ml/min, p=0.017]. Door-to-balloon times [80(59-180) vs 68(48-105) min, p=0.302], total ischemic time [210(120-360) vs 203(120-476) min, p=0.302] and prevalence of anterior STEMI (35.0% vs 50.0%, p=0.123) were not significantly different between sexes. The prevalence of in-hospital complications was generally similar for both sexes (Table 1), except for the risk of advanced atrioventricular (AV) block that was higher in women (32.5% vs 10.7%, p=0.004). Also, haemoglobin nadir was lower in women [10.6(±2.1) vs 11.7(±2.1) g/dl, p=0.023]. In a 1-year follow-up, the occurrence of MACCE was similar for both sexes (60.0% vs 59.7%, log-rank P 0.734) (Figure 1). Conclusion Women with STEMI complicated by CS submitted to PCI had a similar prevalence of in-hospital complications as men. Also, mid-term outcomes, assessed by MACCE at 1 year, did not differ between groups.

AbstractAimsAcute myocardial infarction (AMI) resulting from unprotected left main coronary artery (LMCA) occlusion and subtotal occlusion is a life‐threatening condition. Although AMI management has improved in the past two decades, there is limited information on recent trends in patient characteristics, management, and outcomes for acute unprotected LMCA‐related AMI. This study aims to assess such trends over a 12 year period.Methods and resultsThis retrospective multicentre study includes patients with unprotected LMCA occlusion/subtotal occlusion admitted to three tertiary hospitals between 2008 and 2020. The patients were divided into two groups based on the chronology of presentation: a ‘past group’ (January 2008 to December 2014) and a ‘contemporary group’ (January 2015 to December 2020). The study compares clinical characteristics, management approaches, and outcomes between the two groups. The study includes 128 patients, with 51 (40%) in the ‘past group’ and 77 (60%) in the ‘contemporary group’. Baseline risk factors did not show statistically significant differences between the two groups, except for hypertension (49% vs. 74%; P = 0.005). Chest pain was more frequent in the ‘past group’ (98% vs. 89%; P = 0.014), and a trend towards more cardiac arrests was observed in the ‘contemporary group’ (18% vs. 31%; P = 0.087). Revascularization type did not differ significantly (P = 0.419), but manual thrombectomy was less frequently used (41% vs. 23%; P = 0.032) and stent implantation showed a trend towards higher rates (66% vs. 78%; P = 0.150) in the ‘contemporary cohort’. There was a gradual shift from bare‐metal to drug‐eluting stents, with a significantly higher percentage of ticagrelor/prasugrel loading in the ‘contemporary cohort’ (5% vs. 79%; P < 0.001). The use of mechanical circulatory support (MCS), although not statistically significant, was higher among patients in the ‘past group’ (67% vs. 51%; P = 0.073). The type of MCS differed significantly between groups, with a decrease in intra‐aortic balloon pump use (67% vs. 42%; P = 0.005) and an increase in veno‐arterial extracorporeal membrane oxygenation (4% vs. 22%; P = 0.005) and Impella system (0% vs. 3%) over time. Survival analysis showed no significant differences (P = 0.599; log‐rank test) in all‐cause mortality between the different time groups, with the long‐term survival rate being approximately 30%.ConclusionsIn our real‐world population, despite the progressive use of newer drugs and more advanced devices over time, patients with unprotected LMCA occlusion/subtotal occlusion remain a subpopulation with poor prognosis.

Campinas, Andreia Filipa Oliveira; Brochado, Bruno F.; Santos, Raquel B.; Costa, Ricardo F.; de Frias, André D.; Alexandre, André M.; Couto, David S.; Gomes, Catarina P.; Luz, André C.; da Silveira, João B.; Torres, Severo B. Author Information

Background Atrial septal defect (ASD) can often remain asymptomatic until adulthood. It still remains unclear whether large ASD closure in senior people should be performed or not. Temporary ASD balloon occlusion test has been suggested as a tool to assess the risk of acute left ventricular heart failure post-ASD closure, and it allows to better distinguish responders from non-responders. Case presentation An 83-year-old man with a long-standing uncorrected secundum ASD was admitted for recently decompensated right-sided heart failure. During hospitalization, this patient was studied with trans-esophageal echocardiography, cardiac magnetic resonance imaging, and right heart catheterization, showing high Qp:Qs ratio and favorable anatomical conditions for percutaneous closure. Because of patient’s increasing need for intravenous diuretics and worsening renal function, it was considered that transcatheter ASD closure could improve symptoms, hence it was performed an attempt of percutaneous closure of the ASD with a fenestrated device. Unfortunately, irrespective of ASD being hemodynamically significant, it was found a very significant increase in pulmonary capillary wedge pressure during the temporary balloon occlusion test, supporting the existence of concealed left ventricular diastolic dysfunction. As a result, it was decided to abandon the procedure and not to close the ASD. Conclusion This clinical case illustrates the value of temporary balloon occlusion test before permanent percutaneous closure of ASD in elderly patients, regardless of left ventricular (systolic or diastolic) dysfunction.

The clinical presentation of pulmonary embolism (PE) and acute coronary syndrome can be similar. We report a case of a patient presenting with antero-septal ST-segment elevation after cardiac arrest, found to have acute-PE-mimicking ST-segment elevation myocardial infarction (STEMI), treated with aspiration thrombectomy and catheter-directed thrombolysis (CDT). A 78-year-old man was admitted with dyspnea, chest pain and tachycardia. During evaluation, cardiac arrest in pulseless electrical activity was documented. Advanced life support was started immediately. ECG post-ROSC revealed ST-segment elevation in V1–V4 and aVR. Echocardiography showed normal left ventricular function but right ventricular (RV) dilation and severe dysfunction. The patient was in shock and was promptly referred to cardiac catheterization that excluded significant CAD. Due to the discordant ECG and echocardiogram findings, acute PE was suspected, and immediate invasive pulmonary angiography revealed bilateral massive pulmonary embolism. Successful aspiration thrombectomy was performed followed by local alteplase infusion. At the end of the procedure, mPAP was reduced and blood pressure normalized allowing withdrawal of vasopressor support. Twenty-four-hour echocardiographic reassessment showed normal-sized cardiac chambers with preserved biventricular systolic function. Bedside echocardiography in patients with ST-segment elevation post-ROSC is instrumental in raising the suspicion of acute PE. In the absence of a culprit coronary lesion, prompt pulmonary angiography should be considered if immediately feasible. In these cases, CDT and aspiration in high-risk acute PE seem safe and effective in relieving obstructive shock and restoring hemodynamics.

Abstract Funding Acknowledgements Type of funding sources: None. Background and purpose In ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (MVCAD), remote-vessel percutaneous coronary intervention (PCI) has been associated with a reduction in the incidence of reinfarction when compared to a culprit-only revascularization strategy. Overall effects on long-term all-cause mortality are still unclear. Methods Between 2008 and 2013, a total of 584 consecutive patients were admitted with STEMI. 535 survived to discharge, from which 302 (56,5%) had MVCAD and were included in the analysis. We stratified the patients according to the revascularization strategy in two groups: culprit-lesion-only PCI and PCI of non-culprit vessels with angiographic significant stenosis. Patients were followed for 8 years. The primary endpoints were reinfarction in any vessel and all-cause death. Secondary endpoints included target vessel failure (TVF) (any repeat revascularization in the index culprit vessel), heart failure (HF) hospitalization and stroke. Results Of the 302 cases, 217 (74.2%) were men and the median age was 63 years. 150 (49.7%) had 2-vessel, 152 (50.3%) had 3-vessel disease and 104 (34.4%) underwent non-culprit vessel PCI. The mean follow-up time was 6.95 (± 2.29) years. Overall, the culprit-lesion-only group was older (median: 66 vs 59.5 years; p < 0.001) and had a lower proportion of smokers (41.9% vs 59.6%; p = 0.003). There were no significant differences between the groups’ other main comorbidities. The culprit-lesion-only group had a shorter hospital stay (median: 7.0 vs 7.5; p = 0.013), despite presenting at higher Killip class (24.4% vs 10.6% in Killip II-IV; p = 0.004). Regarding index PCI, no-reflow phenomenon was more common in the culprit-lesion-only group (7.1% vs 1.0%; p = 0.020), where the use of drug-eluted stents was more prevalent in the remote-vessel PCI group (69.2% vs 47.0%; p = 0.001). There was a higher risk of reinfarction (Adjusted hazard ratio (HR) 2.46; 95% CI [1.12 – 5.38]; p = 0.008) and TVF (Adjusted HR 2.37; 95% CI [1.02 – 5.48]; p = 0.044) in the culprit-lesion-only PCI group after relevant variable adjustment, with no significant differences in all-cause mortality. There were no significant differences in any of the remaining secondary outcomes. Conclusions Randomized trials and successive metanalysis have demonstrated benefit in complete revascularization after STEMI regarding the incidence of reinfarction and cardiovascular death. However, the long term impact on all-cause death is still unclear. This study corroborates the main findings in the literature, while suggesting lack of effect on overall mortality on a long-term follow-up.

Abstract Funding Acknowledgements Type of funding sources: None. Background and purpose Left anterior descending (LAD) coronary artery occlusion has been associated with worse short-term outcomes and overall worse prognosis, there is still unclear data about the long-term risk of reinfarction in relation to the index culprit vessel. Methods In this retrospective cohort study, between 2008 and 2013, a total of 584 patients were admitted with STEMI and were subject to emergent percutaneous coronary intervention (PCI). Of those, 535 (91.6%) were alive at hospital discharge, from which 532 were considered for the analysis, after excluding the missing cases. We stratified the individuals according to the culprit vessel in two groups: anterior myocardial infarction (MI) (LAD or left main stem (LM)), and non-anterior MI (circumflex (CX) or right coronary artery (RCA)). We followed the cases for a maximum of 8 years, censoring every event beyond. The primary endpoints were reinfarction and target vessel failure (TVF). Secondary endpoints included all-cause mortality, heart failure (HF) hospitalization and stroke. Mann-Whitney-U and Chi-square tests were used to compare baseline characteristics. Kaplan-Meyer survival analysis was used to obtain the survival curves. Univariate and multivariate analysis were done using Cox regression models. Results Of the 532 individuals included in the analysis, 395 (74.2%) were men and the median age was 61 (+/- 19.8) years. The most common culprit vessel was RCA (45.5%), followed by LAD (41.2%), CX (13.2%), and lastly LM (0.20%). The median follow-up time was 6.94 (+/- 2.38) years. Overall, the anterior MI group presented at a higher Killip class (20.0% vs 14.8% in Killip class II-IV; p = 0.046) and had higher peak plasma level of high-sensitivity troponin T (6.16 vs 3.66 ng/ml; p < 0.001), suggesting larger infarct area. Left ventricle ejection fraction (LVEF) at discharge was also lower in the anterior MI group (reduced in 78,3% vs 43.4%; p < 0.001). Multivessel disease was more common in the non-anterior MI group (49.5% vs 60.9%; p = 0.005), as was PCI of non-culprit vessels (15.5% vs 22.8%; p = 0.037) and the use of bare-metal stents (20.0 vs 51.6%; p < 0.001). There were no significant differences between the groups regarding the main comorbidities, except for peripheral artery disease, more common in the non-anterior MI group (4.10 vs 10.0%; p = 0.011). There was a higher risk of reinfarction in the non-anterior MI group which persisted after relevant variable adjustment (Adjusted hazard ratio 1.96; 95% CI [1.08 – 3.67]; p = 0.027) (Figure 1). There were no significant differences regarding the risk of TVF or any of the secondary outcomes. Conclusions Although LAD/LM occlusion is thought to carry a worse short-term prognosis, non-anterior STEMI appears to be associated with a higher long-term risk of reinfarction. Despite higher rates of reinfarction, non-anterior STEMI patients have not been shown to have an excess mortality of HF hospitalizations in this cohort.

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Acute myocardial infarction (AMI) due to unprotected left main coronary artery (LMCA) occlusion is a potentially life-threatening disease. AMI management has evolved over the past two decades, and mortality has decreased considerably. Though, little information on patient characteristics, management, and mortality trends in the most recent years is available regarding acute unprotected LMCA occlusion. Purpose We aimed to assess trends in patient characteristics, management, and outcomes for acute myocardial infarction due to LMCA occlusion between 2008 and 2020. Methods We conducted a retrospective multicentre registry of patients with AMI with unprotected LMCA occlusion admitted in three tertiary hospitals between 2008 and 2020. Patients were divided according to timeline of presentation, and we sought to compare clinical characteristics, management, and outcomes between a past group (from January 2008 to December 2012) and a contemporary group (from January 2017 to December 2020). Results Of 128 patients with AMI from unprotected LMCA occlusion, 28 were included in the past group [from January 2008 to December 2012 (group 1)] and 48 were included in the contemporary group [from January 2017 to December 2020 (group 2)]. No statistically significant differences in baseline risk factors were found between the two groups, except for hypertension (50.0% in group 1 vs 75.0% in group 2, p=0.027). There was no difference regarding presentation with cardiogenic shock (57.1% vs 64.6%, p=0.520). Median symptom-to-balloon time was high but similar in both groups [180 min (120-300) vs 210 min (120-420), p=0.640]. Radial access was more frequent used in the contemporary group (33.0% vs 10.7%, p=0.028), as well as the administration of glycoprotein IIb/IIIa inhibitors (14.6% vs 12.0%, p=0.004) and the implantation of drug-eluting stents (100% vs 63.2%, p=0.010). The use of mechanical circulatory support device was surprisingly higher in group 1 (82% vs 46%, p=0.002), but the intra-aortic pump balloon (IABP) was the only device available in that group. In the contemporary group, the use of IABP, Impella device, and extracorporeal membrane oxygenation was 37.5%, 20.8%, and 2.1%, respectively. The second antiplatelet agent was also different between groups, with a higher percentage of ticagrelor loading in the contemporary group. In-hospital mortality (46.4% in group 1 vs. 54.2% in group 2, p=0.520) and 1-year cumulative mortality (60.7% vs 60.4%, p=0.741) were high in both groups, but no statistically significant difference was found in survival analysis (p=0.794; log-rank test). Conclusion In our real-world population, despite the use of newer drugs and more advanced devices being more common in the contemporary group, patients with AMI due to LMCA occlusion are still a subpopulation with poor prognosis. Innovative strategies are needed to make a difference.

INTRODUCTION:Ticagrelor might reduce infarct size by exerting a more potent antiplatelet effect or by promoting a potential conditioning stimulus in ST-elevation myocardial infarction (STEMI) patients. Pre-infarction angina (PIA) is an effective preconditioning stimulus that reduces ischemia-reperfusion injury. Because little is known on the interaction of PIA in STEMI-patients loaded with ticagrelor, we sought to determine if patients loaded with ticagrelor had improved clinical outcomes as compared to clopidogrel and to study if it is modulated by the presence of PIA.METHODS:From 1272 STEMI patients submitted to primary percutaneous coronary intervention and treated with clopidogrel or ticagrelor from January 2008 to December 2018, 826 were analyzed after propensity score matching. Infarct size was estimated using peak creatine kinase (CK) and troponin T (TnT), and clinical impact was evaluated through cumulative major cardiac and cerebrovascular events (MACCE) at 1-year follow-up. Matched patients and their interaction with PIA were analyzed.RESULTS:Patients loaded with ticagrelor had lower peak CK [1405.50 U/L (730.25-2491.00), P < .001] and TnT [3.58 ng/mL (1.73-6.59), P < .001)], regardless of PIA. The presence of PIA was associated with lower CK (P = .030), but not TnT (P = .097). There was no interaction between ticagrelor loading and PIA (P = .788 for TnT and P = .555 for CK). There was no difference in MACCE incidence between clopidogrel or ticagrelor loading (P = .129). Cumulative survival was also similar between clopidogrel or ticagrelor, regardless of PIA (P = .103).CONCLUSION:Ticagrelor reduced infarct sizes independently and without a synergic effect with PIA. Despite reducing infarct size, clinical outcomes were similar across both groups.

Abstract A 38-year-old woman with a 32-week gestation was admitted in the emergency department complaining of acute lower limb pain. She had history of smoking, 1 voluntary interruption of pregnancy, 1 miscarriage at age 34, and family history of antiphospholipid syndrome (APS). At admission, bilateral acute limb ischemia and foetal death were diagnosed. CT angiography revealed acute bilateral thrombotic occlusion of the iliac arteries, left renal artery thrombosis with extension to the distal abdominal aorta, deep vein thrombosis (DVT) of the left iliac vein and distal inferior vena cava, and bilateral pulmonary embolism. The patient started on anticoagulation and underwent caesarean section and axillobifemoral bypass. Plasmapheresis and rituximab were attempted due to high clinical suspicion of catastrophic APS. Immunological and neoplastic study were repeatedly negative. The patient was ultimately discharged on vitamin K antagonist (VKA). Further investigation revealed a patent foramen ovale (PFO) with spontaneous right-to-left shunt. Given the risk of paradoxical embolism in this thrombophilic setting of unclear cause, she was referred for percutaneous PFO closure using a GORE® CARDIOFORM 25 mm device. Post-procedure maintenance of antithrombotic therapy with VKA was decided by a multidisciplinary team. Since the event, she had no recurrence of thromboembolic events and continues under investigation in autoimmune disease outpatient clinic. Although simultaneous arterial and venous thrombosis cannot be ruled out, we suspect of left paradoxical embolism following DVT. PFO closure in this setting might be useful for reduction of paradoxical arterial embolism risk on top of systemic anticoagulation. Figure 1Panels A and B show the presence of patent foramen ovale (PFO). Panels C and D show the final result after percutaneous PFO closure using a GORE® CARDIOFORM 25 mm device.

Introduction Platypnoea orthodeoxia syndrome (POS) is an uncommon condition characterised by dyspnoea and arterial desaturation induced by an upright position and relieved in the supine position, usually due to a patent foramen ovale (PFO). Percutaneous closure of a PFO is the preferred treatment to cure POS. This study aimed to evaluate the clinical and gasometrical characteristics and to describe the long-term outcomes of percutaneous PFO closure in a group of patients with POS. Methods Patients with POS and a PFO treated by percutaneous intervention from 2010-2020 were reviewed. The primary efficacy outcome was the arterial oxygen pressure to fraction of inspired oxygen (PaO2/FiO2) ratio before and 24 hours after the procedure. Total clinical success was considered if the arterial oxygen saturation measured by pulse oximetry (SpO(2)) improved to.94% in the supine and sitting positions without supplemental oxygen, while partial success was considered if SpO(2) improved from baseline but still required oxygen to achieve.94%. Secondary outcomes were an absolute improvement in SpO(2) and sense of dyspnoea, without significant residual shunt on transthoracic echocardiography (TTE) at follow-up. Results Of 168 patients undergoing PFO or atrial septal defect closure, 14 had POS (8.3%). Percutaneous PFO closure was successfully performed in all patients with a single device. Twelve of 14 patients had total clinical success (86%) and one patient had partial success. The PaO2/FiO(2) ratio increased from 155.9650.6 to 318.3673.4 after PFO closure (p=0.002). All patients with total clinical success had a successful secondary efficacy outcome with an absolute improvement in SpO(2) and complete resolution of dyspnoea, which was maintained at follow-up (37620 months; range, 11 months to 6 years). None had a significant residual shunt between 12 and 24 months of follow-up. Conclusion The PFO percutaneous closure was a successful, durable and safe method for patients presenting with POS; it achieved major improvements in both gasometrical parameters and quality of life.