Due to the energy requirements for various human activities, and the need for a substantial change in the energy matrix, it is important to research and design new materials that allow the availability of appropriate technologies. In this sense, together with proposals that advocate a reduction in the conversion, storage, and feeding of clean energies, such as fuel cells and electrochemical capacitors energy consumption, there is an approach that is based on the development of better applications for and batteries. An alternative to commonly used inorganic materials is conducting polymers (CP). Strategies based on the formation of composite materials and nanostructures allow outstanding performances in electrochemical energy storage devices such as those mentioned. Particularly, the nanostructuring of CP stands out because, in the last two decades, there has been an important evolution in the design of various types of nanostructures, with a strong focus on their synergistic combination with other types of materials. This bibliographic compilation reviews state of the art in this area, with a special focus on how nanostructured CP would contribute to the search for new materials for the development of energy storage devices, based mainly on the morphology they present and on their versatility to be combined with other materials, which allows notable improvements in aspects such as reduction in ionic diffusion trajectories and electronic transport, optimization of spaces for ion penetration, a greater number of electrochemically active sites and better stability in charge/discharge cycles.

OBJECTIVE:To assess the efficiency of Dyevert™ Power XT compared to the standard clinical practice when used for percutaneous coronary interventions (PCI).METHODS:A Markov model was developed to estimate, over 3-month cycles and a lifetime time horizon, the cumulative costs and health outcomes (life years gained [LYG] and quality-adjusted life years [QALY]) in a hypothetical cohort of 1,000 patients with chronic kidney disease (CKD) 3b-4 and an average age of 72 years. The incidence of contrast-induced acute kidney injury for these patients is 18.89% in routine practice and 7.78% with Dyevert. QALYs were estimated by applying utilities by health state. Transitions between states and utilities were obtained from the literature. Overall all-cause and state-specific mortality were considered. The total cost (€2,022) estimated with the National Health System perspective included cost of the procedure and of CKD management. The parameters were validated by a panel of experts. A discount rate (3% per year) was applied to costs and outcomes.RESULTS:The use of Dyevert yielded more health benefits (34.60 LYG and 5.69 QALYs) compared to the current standard practice (33.11 LYG and 5.38 QALYs). Lifetime cost accumulated at the end of the simulation resulted €30,211/patient with Dyevert and €33,895/patient with current standard clinical practice.CONCLUSIONS:The use of Dyevert™ Power XT resulted dominant option, due to its higher effectiveness and lower cost as compared to standard clinical practice and, therefore, a preferred option in patients with CKD stages 3b-4 undergoing PCI in Spain.

RESUMEN Introducción y objetivos: Los pacientes con estenosis en el tronco coronario izquierdo (TCI) han sido excluidos de los ensayos que apoyan la no inferioridad del cociente de presiones en el índice diastólico instantáneo sin ondas (iFR) respecto a la reserva fraccional de flujo (RFF) en la toma de decisiones sobre revascularización coronaria. El presente estudio propone valorar de manera prospectiva la concordancia entre los dos índices en lesiones del TCI y validar el valor de corte del iFR de 0,89 para su uso clínico. Métodos: Registro multicéntrico nacional, prospectivo, observacional, con la inclusión de 300 pacientes consecutivos con lesiones intermedias (estenosis angiográfica 25-60%) en el TCI. Se realizará un estudio con guía de presión y determinación de RFF e iFR. En caso de resultado concordante negativo (RFF > 0,80 / iFR > 0,89), no se realizará tratamiento; en caso de resultado concordante positivo (RFF ≤ 0,80 / iFR ≤ 0,89), se realizará revascularización; en caso de resultado discordante (RFF > 0,80 / iFR ≤ 0,89 o RFF ≤ 0,80 / iFR > 0,89), se realizará estudio con ecocardiografía intravascular y se considerará diferir la revascularización si el área luminal mínima es > 6 mm2. El criterio de valoración clínico primario será la incidencia del combinado de muerte cardiovascular, infarto no mortal relacionado con la lesión del TCI o necesidad de revascularización de la lesión del TCI a los 12 meses. Conclusiones: La demostración de la seguridad clínica en la toma de decisiones del iFR en pacientes con lesiones intermedias en el TCI tendría un impacto clínico importante y justificaría su uso sistemático para la decisión del tratamiento en estos pacientes de potencial alto riesgo. Registrado en ClinicalTrials.gov (identificador: NCT03767621).

Abstract Aim Patients with diabetes mellitus are at high risk of adverse events after percutaneous revascularization, with no differences in outcomes between most contemporary drug-eluting stents. The Cre8 EVO stent releases a formulation of sirolimus with an amphiphilic carrier from laser-dug wells, and has shown clinical benefits in diabetes. We aimed to compare Cre8 EVO stents to Resolute Onyx stents (a contemporary polymer-based zotarolimus-eluting stent) in patients with diabetes. Methods and results We did an investigator-initiated, randomized, controlled, assessor-blinded trial at 23 sites in Spain. Eligible patients had diabetes and required percutaneous coronary intervention. A total of 1175 patients were randomly assigned (1:1) to receive Cre8 EVO or Resolute Onyx stents. The primary endpoint was target-lesion failure, defined as a composite of cardiac death, target-vessel myocardial infarction, and clinically indicated target-lesion revascularization at 1-year follow-up. The trial had a non-inferiority design with a 4% margin for the primary endpoint. A superiority analysis was planned if non-inferiority was confirmed. There were 106 primary events, 42 (7.2%) in the Cre8 EVO group and 64 (10.9%) in the Resolute Onyx group [hazard ratio (HR): 0.65, 95% confidence interval (CI): 0.44–0.96; Pnon-inferiority < 0.001; Psuperiority = 0.030]. Among the secondary endpoints, Cre8 EVO stents had significantly lower rate than Resolute Onyx stents of target-vessel failure (7.5% vs. 11.1%, HR: 0.67, 95% CI: 0.46–0.99; P = 0.042). Probable or definite stent thrombosis and all-cause death were not significantly different between groups. Conclusion In patients with diabetes, Cre8 EVO stents were non-inferior to Resolute Onyx stents with regard to target-lesion failure composite outcome. An exploratory analysis for superiority at 1 year suggests that the Cre8 EVO stents might be superior to Resolute Onyx stents with regard to the same outcome. Clinical trial registration ClinicalTrials.gov: NCT03321032.

Background: We sought to investigate the antithrombotic regimens applied and their prognostic effects in patients over 75 years old with atrial fibrillation (AF) after revascularization with drug-eluting stents (DES). Methods: Retrospective registry in 20 centers including patients over 75 years with AF treated with DES. A primary endpoint of MACCE and a co-primary endpoint of major bleeding by ISTH criteria were considered at 12 months. Results: A total of 1249 patients (81.1 +/- 4.2 years, 33.1% women, 66.6% ACS, 30.6% complex PCI) were included. Triple antithrombotic therapy (TAT) was prescribed in 81.7% and dual antithrombotic therapy (DAT) in 18.3%. TAT was based on direct oral anticoagulants (DOAC) in 48.4% and maintained for only 1 month in 52.2%, and DAT included DOAC in 70.6%. Primary endpoint of MACCE was met in 9.6% and primary endpoint of major bleeding in 9.4%. TAT was significantly associated with more bleeding (10.2% vs. 6.1%, p = 0.04) but less MACCE (8.7% vs. 13.6%, p = 0.02) than DAT and the use of DOAC was significantly associated to less bleeding (8% vs. 11.1%, p = 0.03) and similar MACCE (9.8% vs. 9.4%, p = 0.8). TAT over 1 month or with VKA was associated with more major bleeding but comparable MACCE rates. Conclusions: Despite advanced age TAT prevails, but duration over 1 month or the use of other agent than Apixaban are associated with increased bleeding without additional MACCE prevention. DAT reduces bleeding but with a trade-off in terms of ischemic events. DOAC use was significantly associated to less bleeding and similar MACCE rates. (c) 2021 Elsevier B.V. All rights reserved.

Introduction and objectives: Patients with left main coronary artery (LMCA) stenosis have been excluded from the trials that support the non-inferiority of the instantaneous wave-free ratio (iFR) compared to the fractional flow reserve (FFR) in the decision-making process of coronary revascularization. This study proposes to prospectively assess the concordance between the two indices in LMCA lesions and to validate the iFR cut-off value of 0.89 for clinical use. Methods: National, prospective, and observational multicenter registry of 300 consecutive patients with intermediate lesions in the LMCA (angiographic stenosis, 25% to 60%. A pressure gudiewire study and determination of the RFF and the iFR will be performed: in the event of a negative concordant result (FFR > 0.80/iFR > 0.89), no treatment will be performed; in case of a positive concordant result (FFR <= 0.80/iFR <= 0.89), revascularization will be performed; In the event of a discordant result (FFR> 0.80/iFR <= 0.89 or FFR <= 0.80/iFR> 0.89), an intravascular echocardiography will be performed and revascularization will be delayed if the minimum lumen area is > 6 mm(2). The primary clinical endpoint will be a composite of cardiovascular death, LMCA lesion-related non-fatal infarction or need for revascularization of the LMCA lesion at 12 months. Conclusions: Confirm that an iFR-guided decision-making process in patients with intermediate LMCA stenosis is clinically safe and would have a significant clinical impact. Also, justify its systematic use when prescribing treatment in these potentially high-risk patients.

Aim Patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) remain at high risk of cardiovascular events despite the use of contemporary drug-eluting stents (DES). This trial aim to compare the clinical efficacy of 2 novel second-generation DES in patients with DM. Methods and results The Second-Generation Drug-Eluting Stents in Diabetes (SUGAR) trial (ClinicalTrials.gov NCT03321032) is an investigator-initiated, prospective, randomized, controlled, multicenter study conducted exclusively in patients with DM. This study allows inclusion of the entire spectrum of patients with DM undergoing PCI, and the only exclusion criteria are shock at presentation, inability to consent or a life expectancy <2 years. A total of 1164 patients will be randomized (1:1, no stratification) at 23 sites in Spain to treatment with polymer-free amphili m us (sirolimus formulated with an amphiphilic carrier) eluting stents versus Onyx-zotarolimus-eluting stents (Biolynx durable polymer and struts with platinum-iridium alloy core). Randomization will be patient-level, so in case of multivessel disease all lesions will be treated with the same stent. The primary end point is target lesion failure, a composite of cardiac death, target vessel-related myocardial infarction, or clinically indicated target lesion revascularization. First co-primary analysis will test non-inferiority at 1 year (80% power, a non-inferiority margin of 4% (1.5 RR) and a type-I-error of 0.05.) and second co-primary analysis will test superiority at 2 years (80% power, 0.05 alpha). Enrollment commenced in December 2017, and inclusion is expected to be completed by December 2019. Conclusions SUGAR is the first randomized head-to head trial comparing second-generation DES in an all-comer diabetic population undergoing PCI.

Objectives: We sought to evaluate clinical outcomes in patients treated with the drug-eluting stent ihtDEStiny BD. Background: The ihtDEStiny BD stent is a metallic sirolimus eluting stent with a biodegradable polymer with both drug and polymer coating the abluminal surface of the stent and balloon. Methods: In this study, the clinical outcomes of a multicenter prospective registry of patients treated with this stent (DEStiny group) were analyzed and compared with those of a control group of patients treated with durable polymer everolimus or zotarolimus eluting stents (CONTROL group) paired by propensity score matching. Primary outcome was the target vessel failure (TVF) at 12 months defined as a composite of cardiac death, target vessel myocardial infarction (TV-MI) and target vessel revascularization (TVR). Results: A total of 350 patients were included in the DESTtiny group. The control group consisted initially of 1368 patients, but aftermatching (1:1) 350 patients were selected as CONTROL group. The baseline clinical, angiographic and procedural characteristics were quite comparable in both groups. At 12 months follow up the TVF was 6.6% in DEStiny group and 6.3% in CONTROL group (p=0.8). No differences were observed for any of the individual components of the primary endpoint: cardiac death 1.1% vs. 1.4%, TV-MI 3.4% vs. 3.7% and TVR 2.6% vs. 2.3% respectively. Conclusions: The use of ihtDEStiny stent in real practice is associated with a clinical performance at 12 months follow up that appears to be non-inferior to the most widely used and largely evidence supported durable polymer drug eluting stents. A longer follow up is warranted. (C) 2020 Elsevier Inc. All rights reserved.

underwent IVUS were less likely to receive a second stent as part of thrombosis management, but no differences in mortality or rethrombosis were observed. However, IVUS was more often used in early than late thrombosis, which could overestimate the value of IVUS in preventing implantation of a second stent. IVUS is highly useful for investigating the causal mechanism of thrombosis symptoms, as it reveals pathophysiologic factors underestimated by conventional angiography and identifies patients who may benefit from implantation of an additional stent.

Introduction and objectives: The PSP ( pre-dilation, sizing and post-dilation) score, derived from the GHOST-EU registry, has evaluated the relationship between the implantation technique of bioresorbable scaffolds and the clinical outcomes. The objective was to perform an external validation of the PSP technique and to determine its effect on adverse cardiac events in various clinical and anatomical scenarios. Methods: Data from the REPARA registry (2230 patients) were used for external validation, whereas a common database combining REPARA and GHOST-EU (3250 patients) data was used to evaluate the effect of PSP technique in various clinical and anatomical scenarios. PSP-1 and PSP-3 were used to score the appropriateness of pre- dilation, scaffold sizing, and post-dilation. The primary endpoint was 1-year device-oriented composite endpoint of cardiac death, target-vessel myocardial infarction, and target-lesion revascularization. The definite/probable scaffold thrombosis according to the Academic Research Consortium criteria was also evaluated. Results: A total of 303 (18.2%) patients were treated with an optimal PSP-1, and 182 (8.2%) with an optimal PSP-3. The external validation showed that PSP has a very high negative predictive value for device- oriented composite endpoint and scaffold thrombosis (91.8% and 89.1% for PSP-1; 98.4% and 97.3% for PSP-3, respectively). Patients with an optimal PSP-3 had a numerically lower rate of device-oriented composite endpoint and scaffold thrombosis compared to those without it (0.5% vs 2.9%; P =.085 and 0.5% vs 1.8%; P =.248, respectively). In the merged database, PSP benefits were seen on many scenarios, except in the ST-segment elevation myocardial infarction where a trend towards no benefit of an optimal PSP technique was present (P interaction =.100). Conclusions: In the REPARA registry, at 1-year follow- up, an optimal PSP technique was not associated with a lower rate of device-oriented composite endpoint. Further research is necessary to assess the impact of the PSP technique in longer follow-ups.

RESUMEN Introducción y objetivos: La escala de puntuación PSP (pre-dilation, sizing and post-dilation), derivada del registro GHOST-EU, evalúa la relación entre la técnica de implante de los armazones bioabsorbibles y los resultados clínicos. El objetivo fue realizar una validación externa de la escala PSP y determinar su efecto en eventos adversos cardiacos en diversos escenarios clínicos y anatómicos. Métodos: Para la validación externa se emplearon los datos del registro REPARA (2.230 pacientes), mientras que se utilizó una base de datos común que combina datos de REPARA y GHOST-EU (3.250 pacientes) para evaluar el efecto de la técnica PSP en varios escenarios clínicos y anatómicos. Se usó PSP-1 y PSP-3 para calificar la calidad de la predilatación, el dimensionamiento de los armazones y la posdilatación. El objetivo primario fue la variable compuesta orientada al dispositivo (muerte cardiaca, infarto de miocardio del vaso diana y revascularización de la lesión diana) a 1 año. También se evaluó la trombosis definitiva o probable del armazón según los criterios del Academic Research Consortium. Resultados: Se trató a 303 (18,2%) pacientes con una PSP-1 óptima y a 182 (8,2%) con una PSP-3 óptima. La validación externa mostró que la escala PSP tiene un valor predictivo negativo muy alto para el objetivo primario compuesto orientado al dispositivo y la trombosis del armazón (91,8 y 89,1% para PSP-1; 98,4 y 97,3% para PSP-3, respectivamente). En pacientes con PSP-3 óptimo, el objetivo primario compuesto orientado al dispositivo y la trombosis del armazón fueron numéricamente inferiores en comparación con los pacientes sin PSP-3 óptimo (0,5 frente a 2,9%; p = 0,085; y 0,5 frente a 1,8%; p = 0,248, respectivamente). En la base de datos combinada, los beneficios de la escala PSP se observaron en diversos escenarios, excepto en el de infarto de miocardio con elevación del segmento ST, en el que se observó una tendencia hacia laausencia de beneficios de una técnica de PSP óptima (pinteracción = 0,100). Conclusiones: Una técnica de PSP óptima no se asoció con una tasa más baja del objetivo primario compuesto orientado al dispositivo. Se necesitan nuevos estudios para evaluar el impacto de la técnica de PSP con un seguimiento más prolongado.

The use of intravascular ultrasound (IVUS) seems to improve the prognosis of patients undergoing PCI of the left main coronary artery (LM) with drug-eluting stents (DES), but there are not well-established criteria for application in the procedural optimization. In our institution, since January

CH5+ is a prototype of an extremely flexible molecule for which the quantum states have eluded an analytical description so far. Therefore, the reconstruction of its quantum states relies on methods as e.g. the search for accumulations of combination differences of rovibrational transitions. Using the available high resolution data of the Cologne laboratories [1], this reconstruction has been improved by using the properties of kernel density estimators as well as new combinatorial approaches to evaluate the found accumulations. Two new symmetry sets have been discovered, and the known ones extended, with 1063 of the 2897 measured lines assigned, which is a significant improvement over the 65 assignments of the previous work. This allowed us not only to reconstruct more parts of the ground state levels, but also of the vibrationally excited states of CH5+.

Objectives: We investigated the safety and efficacy of the bioabsorbable polymer-coated, everolimus-eluting coronary stent (SYNERGY) stent in a real-world study population with acute coronary syndromes (ACS). Background: A number of clinical trials support the overall efficacy and safety of the SYNERGY stent. However, a recent trial (TIDES-ACS) in the context of ACS reported worrying figures of infarction and definite/probable stent thrombosis in the SYNERGY control arm. Methods: This is a multicenter registry (10 centers) including consecutive patients with ACS (unstable angina, non-ST elevated myocardial infarction, ST elevated myocardial infarction) who underwent percutaneous revascularization with the implantation of SYNERGY stent. The primary endpoint was the composite of cardiac death, myocardial infarction and target lesion revascularization at 12 months. Results: A total of 1008 patients were included with age 65.4 +/- 14.8 years, 23.8% females and a 24.5% diabetics. Regarding presentation, a 15.2% with unstable angina, 43% with non-ST elevated myocardial infarction and 41.8% with ST elevated myocardial infarction. Primary outcome was met in 3% (7% in SYNERGY TIDES-ACS arm, P superiority <0.01 and 63% in OPTIMAX TIDES-ACS arm, P superiority <0.01). Cardiac death was 1.3% (1.6%, p = 0.8 and 0.5%, P superiority =0.1 respectively). Myocardial infarction was 1.6% (4.6%, p < 0.01 and 1.8%, P superiority = 0.9 respectively). Target lesion revascularization was 1% (3.4%, p < 0.01 and 5.4%, P superiority <0.01 respectively). Definite or probable thrombosis was 0.9% (2.8%, p <= 0.01 and 1.1%, P superiority = 0.8 respectively). Conclusions: The results of this registry show a very good safety and efficacy profile at 12 months for the SYNERGY stent in patients with ACS. Summary: A recent trial (TIDES-ACS) in the context of acute coronary syndromes (ACS) reported worrying figures of infarction and definite/probable stent thrombosis in the SYNERGY stent control arm. We investigated the safety of SYNERGY stent in a real-world study population with ACS applying the same inclusion/exclusion criteria as used in the TIDES-ACS trial. Primary endpoint was the composite of cardiac death, myocardial infarction and TLR at 12 months. A total of 1008 patients have been included. Primary outcome was met in 3% (7% in SYNERGY TIDES-ACS arm, P superiority <0.01 and 6.3% in OPTIMAX TIDES-ACS arm, P superiority <0.01). (C) 2018 Elsevier Inc. All rights reserved.

BACKGROUND AND OBJECTIVES:Patients older than 75 years with ST-segment elevation myocardial infarction undergoing primary angioplasty in cardiogenic shock have high mortality. Identification of preprocedural predictors of short- and long-term mortality could be useful to guide decision-making and further interventions. METHODS:We analyzed a nationwide registry of primary angioplasty in the elderly (ESTROFA MI+75) comprising 3576 patients. The characteristics and outcomes of the subgroup of patients in cardiogenic shock were analyzed to identify associated factors and prognostic predictors in order to derive a baseline risk prediction score for 1-year mortality. The score was validated in an independent cohort. RESULTS:A total of 332 patients were included. Baseline independent predictors of mortality were anterior myocardial infarction (HR 2.8, 95%CI, 1.4-6.0 P=.005), ejection fraction<40% (HR 2.3, 95%CI, 1.14-4.50 P=.018), and time from symptom onset to angioplasty >6hours (HR 3.2, 95%CI, 1.6-7.5; P=.001). A score was designed that included these predictive factors (score "6-ANT-40"). Survival at 1 year was 54.5% for patients with score 0, 32.3% for score 1, 27.4% for score 2 and 17% for score 3 (P=.004, c-statistic 0.70). The score was validated in an independent cohort of 124 patients, showing 1-year survival rates of 64.5%, 40.0%, 28.9%, and 22.2%, respectively (P=.008, c-statistic 0.68). CONCLUSIONS:A preprocedural score based on 3 simple clinical variables (anterior location, ejection fraction<40%, and delay time >6 hours) may be used to estimate survival after primary angioplasty in elderly patients with cardiogenic shock and to guide preinterventional decision-making.

HomeCirculation: Cardiovascular ImagingVol. 11, No. 12Percutaneous Closure of a Large Iatrogenic Atrial Septal Laceration Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPercutaneous Closure of a Large Iatrogenic Atrial Septal Laceration Cesar Jiménez-Méndez, MD, Alberto Cecconi, MD, PhD, Teresa Alvarado, MD, Lourdes Domínguez, MD, Guillermo Diego, MD, Pablo Díez-Villanueva, MD, PhD, Fernando Rivero, MD, Felipe Hernández-Hernández, MD, Luis Jesus Jiménez-Borreguero, MD and Fernando Alfonso, MD, PhD Cesar Jiménez-MéndezCesar Jiménez-Méndez Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain (C.J.-M., A.C., T.A., L.D., G.D., P.D.-V., F.R.). , Alberto CecconiAlberto Cecconi Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain (C.J.-M., A.C., T.A., L.D., G.D., P.D.-V., F.R.). , Teresa AlvaradoTeresa Alvarado Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain (C.J.-M., A.C., T.A., L.D., G.D., P.D.-V., F.R.). , Lourdes DomínguezLourdes Domínguez Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain (C.J.-M., A.C., T.A., L.D., G.D., P.D.-V., F.R.). , Guillermo DiegoGuillermo Diego Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain (C.J.-M., A.C., T.A., L.D., G.D., P.D.-V., F.R.). , Pablo Díez-VillanuevaPablo Díez-Villanueva Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain (C.J.-M., A.C., T.A., L.D., G.D., P.D.-V., F.R.). , Fernando RiveroFernando Rivero Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain (C.J.-M., A.C., T.A., L.D., G.D., P.D.-V., F.R.). , Felipe Hernández-HernándezFelipe Hernández-Hernández Department of Cardiology, Clínica Universidad de Navarra, Madrid, Spain (F.H.-H.). , Luis Jesus Jiménez-BorregueroLuis Jesus Jiménez-Borreguero Luis Jesús Jiménez-Borreguero, MD, Department of Cardiology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Hospital de la Princesa, Calle Diego de León 62, 28006 Madrid, Spain. Email E-mail Address: [email protected] and Fernando AlfonsoFernando Alfonso Originally published17 Dec 2018https://doi.org/10.1161/CIRCIMAGING.118.008409Circulation: Cardiovascular Imaging. 2018;11:e008409A 69-year-old man with a medical history of hypertension, atrial fibrillation, and 2 previous cardiac surgeries (mitral valve replacement with a mechanic prosthesis in 2006 because of severe mitral stenosis and mitral prosthesis replacement with a biologic valve after a prosthesis thrombosis in 2007) was admitted in other hospital for heart failure. Echocardiography documented moderate left ventricular dysfunction (LVEF, 39%), mitral prosthetic valve dysfunction, moderate aortic regurgitation, severe tricuspid regurgitation, and pulmonary hypertension. Based on these findings, a third cardiac surgery was recommended. Mitral, aortic, and tricuspid valve replacement were performed without intraoperative complications, and the patient was successfully discharged 1 month later.The patient presented 4 days later to our emergency department for acute heart failure. Transthoracic echocardiography evidenced an atrial septal defect with a severe left-to-right shunt (Qp/Qs ratio of 2.2). For a better anatomic assessment, a transesophageal echocardiography was performed. Although the initial 2-dimensional echo imaging was suggestive of a large ostium secundum atrial septal defect (Figure [A] and [B]), 3-dimensional echo imaging clearly demonstrated an elliptical shaped orifice of 15×55 mm following the surgical incision line used for access to left atrium in the recent mitral valve surgery (Figure [C] and [D]). These findings were consistent with a large iatrogenic septal atrial laceration as complication of mitral valve surgery. The case was discussed by the Heart Team, and considering the high surgical risk (EuroSCORE II, 18%), a percutaneous approach was recommended.Download figureDownload PowerPointFigure. Echocardiographic assessment of the defect.A, Two- dimensional (2D) transoesophageal echocardiography (TOE), short-axis view. Findings consistent with ostium secundum atrial septal defect (arrow). B, 2D-TOE color Doppler, short-axis view. Left-to-right shunt is present. C and D, Three-dimensional (3D) TOE, view from right atrium (RA) and left atrium (LA), respectively. Large atrial septal laceration after surgical septostomy incision line is observed. E, 3D-TOE, LA view. Two percutaneous devices placed simultaneously. F, 3D-TOE, RA view, device implantation during percutaneous closure intervention. G, 3D-TOE, LA view after device implantation. A small residual atrial septal defect is documented. Arrow indicates atrial septal defect. H, 3D-TOE color Doppler view, 2 small residual left to right shunts are observed. MV indicates mitral prosthetic valve; SCV, superior cava vein; and TV, tricuspid prosthetic valve.Initially, we opted for aligning 2 Amplatzer septal occluder devices, but the procedure was unsuccessful because they were displacing each other (Figure [E]). Eventually, percutaneous closure was successfully performed implanting a 34-mm waist Amplatzer Septal Occluder device with a small residual atrial defect (final Qp/Qs, 1.3; Figure [F] through [H]).Atrial septal defect is an uncommon complication after cardiac surgery, and it is associated to septostomy procedure for mitral replacement interventions. This complication is traditionally managed with a surgical approach. However, should not we consider percutaneous approaches in high surgical risk patients?Percutaneous closure of ostium secundum atrial septal defects is an accepted alternative to surgical repair for smaller defects (diameter, <38 mm) with acceptable rims (>5 mm).1,2 In our case, a maximal diameter of 55 mm could be considered anatomically prohibitive for percutaneous closure considering that the largest device has a waist diameter of 40 mm. However, it is widely accepted that a single dimension measurement of atrial septal defect is inaccurate because shape may vary from round to elliptical, especially in iatrogenic ones. In these cases, 3-dimensional echocardiography provides a much more accurate anatomic characterization.3 On the contrary, echocardiography sizing previous to the procedure does not consider that the implantation of a round device produces a deformation of the oval atrial septal defects decreasing the maximal diameter and increasing the minimal diameter. For these reasons, in oval atrial septal defects, balloon sizing is almost mandatory because it allows to test the viability of the procedure assessing the grade of deformation and the residual shunts. Nevertheless in atrial lacerations, balloon sizing is a high-risk procedure because it may expand the maximum diameter after the previous surgical incision.4 Therefore, we discharged this strategy and finally opted for a direct device implantation.Deformation of the septal defect by the round device cannot explain alone the success of the procedure; the features of the device should be also considered. The right and left atrial disks (44 and 50 mm, respectively, in our case) extend radially from the connecting waist to provide anchorage, and the resultant coverage area could improve the closure area offered by the waist itself.In conclusion, our case demonstrates the feasibility of percutaneous closure for large atrial septal laceration after mitral valve surgery. In addition, we consider 3-dimensional echocardiography mandatory to assess the anatomy and plan the closure strategy.DisclosuresNone.Footnotes*Drs Jiménez-Méndez and Cecconi contributed equally to this work.Luis Jesús Jiménez-Borreguero, MD, Department of Cardiology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Hospital de la Princesa, Calle Diego de León 62, 28006 Madrid, Spain. Email [email protected]comReferences1. Suárez de Lezo J, Medina A, Pan M, Romero M, Segura J. Transcatheter occlusion of complex atrial septal defects.Cathet Cardiovasc Intervent. 2000; 51:33–41.CrossrefMedlineGoogle Scholar2. Fraisse A, Trivedi KR. Transcatheter closure of atrial septal defects: how large is too large?Cardiovasc Diagn Ther. 2014; 4:213–214. doi: 10.3978/j.issn.2223-3652.2014.04.02MedlineGoogle Scholar3. Sharma VK, Radhakrishnan S, Shrivastava S. Three-dimensional trans-esophageal echocardiographic evaluation of atrial septal defects: a pictorial essay.Images Paediatr Cardiol. 2011; 13:1–18.MedlineGoogle Scholar4. Gupta SK, Sivasankaran S, Bijulal S, Tharakan JM, Harikrishnan S, Ajit K. Trans-catheter closure of atrial septal defect: balloon sizing or no balloon sizing – single centre experience.Ann Pediatr Cardiol. 2011; 4:28–33. doi: 10.4103/0974-2069.79619CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails December 2018Vol 11, Issue 12 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.118.008409PMID: 30562111 Originally publishedDecember 17, 2018 Keywordsthoracic surgeryheart failureheart septal defects, atrialatrial fibrillationhypertensionPDF download Advertisement SubjectsCongenital Heart DiseaseEchocardiographyImaging

Aims: To analyse systematic isolated post-dilatation of the side branch as a part of provisional stent technique. Methods: 1960 angioplasties performed in two centres were prospectively registered, of which 382 were coronary bifurcations with a side branch > 2 mm. In centre A, isolated post-dilatation of the side branch was performed regardless its impairment after main vessel stenting. In centre B, side branch post-dilatation was performed only if it was severely affected after stent implantation. Results: There was no difference between the two centres in the rale of side branch affection after stent implantation (A: 44.6 vs B: 49.3%, p = 0.48) nor in the procedural success rate (A: 98.6% vs B: 96.7%, p = 0.45). After one-year follow-up, a reduction of cardiovascular events was observed in centre A (A: 4.4% vs B: 10.4%, p = 0.043) with a trend towards lower cardiac mortality (A: 2.2% vs B: 6.5%, p = 0.093) and stent thrombosis (A: 0% vs B: 2.6%, p 0.077). There were no differences in the rate of myocardial infarction related to the treated artery (A: 1.4% vs B: 3.9%, p = 029), or target lesion revascularization (A: 1.4% vs. B: 32%, p = 0.45). Conclusions: Systematic isolated post-dilatation of the side branch in the provisional stent technique was associated with a high angiographic success rate, and a low rate of cardiovascular events during follow-up. Although the study design does not allow definitive conclusions, this strategy could be considered a valid option in some cases or even as part of the provisional stent technique. (C) 2017 Elsevier Inc. All rights reserved.