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Antecedentes: El Shock Cardiogénico (SC) y las Angioplastías de Alto Riesgo (AAR) están asociadas con altas tasas de mortalidad. El uso del dispositivo Impella CP podría reducir el riesgo de muerte en estos escenarios. En Chile no existen reportes evaluando el uso del dispositivo Impella CP. Objetivo: Analizar los desenlaces clínicos en pacientes que fueron sometidos al uso del dispositivo Impella CP por SC o por AAR. Métodos: Se realizó un estudio retrospectivo en 17 pacientes, los cuales representan el total de implantes realizados en el país, entre octubre 2021 y agosto 2023. Se describió las características, demográficas, procedimentales y después del implante. Se estimó la mortalidad general y se identificaron factores asociados. Resultados: La edad de los pacientes fue 69± 3,7 años y 88,2% fueron hombres. El 64,7% recibió el dispositivo por SC y 35,3% por AAR. Dentro de las comorbilidades estudiadas, la hipertensión arterial fue la más frecuente, 94,1%. Un 58,8% de los pacientes fueron revascularizados a través de la arteria radial. El 29,4% recibió el dispositivo previo a la angioplastía y 70,6% lo recibió después. El 47,1% de las angioplastías fue guiada por imágenes. En 11,8% de ellos se realizó litotricia intracoronaria y 5,9% por ablación intracoronaria. Los pacientes estuvieron 13 ±3,4 días con el soporte. La mortalidad global fue de 41,2%. Conclusiones: El uso del dispositivo Impella presentó pocas complicaciones vasculares. La mortalidad asociada con su colocación en Chile fue relativamente similar con la reportada en la literatura.

Background: Cardiogenic shock and high-risk Angioplasty are associated with a high mortality rate. Using the Impella CP device could reduce the risk of death in these scenarios. In Chile, there are no studies evaluating the use of the Impella CP device. Objective: To analyse the clinical outcomes in patients who have undergone placement of the Impella CP device for cardiogenic shock and high-risk angioplasties. Methods: A retrospective study was carried out on 17 patients, which represent the total number of implants performed in the country, between October 2021 and August 2023. The demographic, procedural and post-implant characteristics were described. Overall mortality and associated factors were identified. Results: The age was 69± 3.7 years, where 88.2% were men. 64.7% of patients received the device by SC and 35.3% by AAR. Among the comorbidities studied, arterial hypertension was the most frequent with 94.1%. 58.8% of patients were revascularized through the radial artery. 29.4% of patients received the device before angioplasty and 70.6% received it afterwards. 47.1% of angioplasties were image-guided, 11.8% had intracoronary lithotripsy, and 5.9% had intracoronary ablation. The patients spent 13 ±3.4 days with the support. Overall mortality was 41.2%. Conclusion: use of the Impella device was associated with few vascular complications. Mortality associated with use of the Impella device in Chile was similar to that previously reported in other studies.

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La isquemia miocárdica es un fenómeno secundario a la perfusión insuficiente del músculo cardíaco que en algunos casos puede ocurrir de forma aguda llevando a la necrosis celular y constituyendo el infarto agudo al miocardio (IAM). A pesar de que el diagnóstico de IAM es principalmente clínico, en ciertos casos en que no se sospeche de forma activa por presentar síntomas no típicos de isquemia miocárdica, el diagnóstico puede sugerirse por la Tomografía Computarizada (TC), que puede mostrar hallazgos sugerentes de IAM. A continuación, se comunica una serie de 4 casos clínicos con diagnóstico imagenológico incidental de IAM.

Myocardial ischemia is secondary to myocardial under perfusion. It can develop acutely leading to cell necrosis and myocardial infarction (AMI), or have a chronic course. Though the diagnosis of AMI is mainly clinical, in certain cases the symptoms may be atypical and the diagnosis can be suggested by images such as Computed Tomography (CT). Herein we report a series of 4 clinical cases with diagnosis of AMI following incidental CT imaging. There was an abdominal pain in 3 patients and a cervical pain in the remaining one. CT scan showed a hypodense myocardial image. The final diagnosis was confirmed by the appropriate laboratory and angiographic methods.

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Introducción: En nuestro medio, el implante percutáneo de prótesis aórtica (TAVI) se encuentra limitado a pacientes más añosos o de mayor riesgo quirúrgico, en quienes frecuentemente se retarda la intervención hasta que presenten signos avanzados de enfermedad. Objetivo: Evaluar el grado de compromiso miocárdico en pacientes sometidos a TAVI y determinar si la magnitud de este compromiso predice los resultados alejados del procedimiento. Métodos: Registro de pacientes sometidos a TAVI en 2 instituciones de Chile. Según la clasificación propuesta por Genereux el año 2017, se clasificaron desde el punto de vista ecocardiográfico como: 1) compromiso de ventrículo izquierdo; 2) compromiso de aurícula izquierda; 3) hipertensión pulmonar / insuficiencia tricuspídea significativa y 4) disfunción de ventrículo derecho. Resultados: Se incluyeron 209 pacientes. Se logró un procedimiento exitoso en 98,6%, registrándose una mortalidad intrahospitalaria de 2,9%. El compromiso cardíaco se extendió más allá de las cavidades izquierdas en 24,7% de los casos (estadíos 3 y 4). A una mediana de seguimiento de 650 días se registró una mortalidad de 26,8%. El compromiso de cavidades derechas (estadíos 3 y 4) se asoció a una mayor mortalidad (39,6% vs 22,1%, log rank p=0,015). En análisis multivariado, este compromiso fue el único factor que de forma independiente predijo mortalidad (HR 1,87, IC 1,01-3,44, p=0,044). Conclusiones: El compromiso de cavidades derechas se asocia a una mayor mortalidad alejada en pacientes sometidos a TAVI. Estos resultados debiesen estimular una derivación precoz de estos pacientes que, aunque añosos y de alto riesgo, tienen buenos resultados intervenidos precozmente.

Background: Locally, Transcatheter Aortic Valve Implantation (TAVI) is limited to very old or high-risk patients, whose intervention is frequently delayed until they develop signs of advanced disease. Aim: To evaluate the degree of myocardial compromise in patients undergoing TAVI and to determine whether the level of this compromise can predict results during follow-up. Methods: Registry of TAVI patients from 2 institutions in Chile. According to the classification proposed by Genereux in 2017, patients were classified based on the echocardiogram as 1) left ventricular compromise; 2) left atrial compromise; 3) pulmonary hypertension / severe tricuspid regurgitation; 4) right ventricular dysfunction. Results: The study included 209 patients. A successful procedure was achieved in 98.6% of cases, with an in-hospital mortality of 2.9%. Cardiac compromise extended beyond left chambers in 24.7% of cases (stages 3 and 4). During follow-up (median of 650 days) mortality was 26.8%. Right chambers involvement (stages 3 and 4) was associated with increased mortality (39.6% vs 22.1%, log rank p=0.015). In multivariate analysis, this compromise was the only factor that independently predicted mortality (HR 1.87, IC 1.01-3.44, p=0,044). Conclusions: Right chambers involvement was associated to increased mortality during follow-up of patients undergoing TAVI. These results should stimulate earlier referral of these high risk and older patients in order to obtain better results following the intervention.

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La insuficiencia cardíaca (IC) es un problema de salud mundial. En la actualidad existe una clara asociación entre la IC y la diabetes mellitus tipo 2 (DM2), con una prevalencia cada vez mayor de pacientes que presentan concomitantemente ambas patologías. Los inhibidores del cotransportador 2 de sodio-glucosa (ISGLT2) han demostrado disminuir los eventos cardiovasculares, incluida la muerte de origen cardiovascular, por lo que se han instalado como uno de los pilares en su tratamiento. En el presente artículo se describen los principales mecanismos de acción de los ISGLT2 y sus efectos: mejora de condiciones de carga ventricular, metabolismo cardíaco, bioenergética, remodelado ventricular y sus efectos cardioprotectores directos y posiblemente antiarrítmicos.

Heart failure (HF) is a global health problem. Currently there is a clear association between HF and type 2 diabetes mellitus (DM2), with an increasing prevalence of patients presenting with both pathologies concomitantly. Sodium-glucose cotransporter 2 inhibitors (ISGLT2) have shown to significantly reduce cardiovascular events, including cardiovascular death. These results have placed ISGLT2 as one of the main pillars in the treatment of HF. This article will focus on the mechanisms of action, and their effects: improved ventricular loading conditions, cardiac metabolism, bioenergetics, ventricular remodeling, direct cardioprotective and possibly antiarrhythmic effects.

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Heart failure (HF) is a global health problem. There is a strong association h between HF and type 2 diabetes mellitus (DM2), with an increasing prevalence of patients having both conditions concomitantly. Sodium-glucose cotransporter 2 inhibitors (ISGLT2) significantly reduce cardiovascular events, including cardiovascular death. In this article we will focus on the current evidence about the effectiveness of these medications in adults with heart failure with reduced or preserved ejection fraction.

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COVID-19 pandemic generated multiple challenges for the health system. Cardiovascular disease is associated with a worse prognosis of infections. Moreover, most hospital resources and operative rooms were destined to patients with COVID-19 infection, deferring the treatment of most valvular patients requiring surgery. We report seven patients with symptomatic severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI) with conscious sedation and early discharge. No patient required intensive care unit admission or mechanical ventilation. After a 90-day follow-up, there were no complications or unplanned readmissions.

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BACKGROUND: Transcatheter Aortic Valve Implantation (TAVI) is beneficial in patients with symptomatic severe Aortic Stenosis (AS). There is no consensus about the best anticoagulation strategy for patients with a recent TAVI and with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) are effective to prevent embolic events with a significant lower incidence of bleeding. There is scarce evidence about the use of these drugs in patients undergoing TAVI. AIM: To assess the management of anticoagulation at the moment of discharge of patients with AF and TAVI. Material and Methods: A four question survey was sent to cardiologists involved in TAVI programs in different international centers. Results: The survey was answered by 72 interventional cardiologists. Even with the lack of randomized evidence, in most of the scenarios DOACs are prescribed at discharge in patients with indication for anticoagulation. Also, in patients with high bleeding risk, most cardiologists would perform a left atrial appendage closure. In patients with concomitant coronary artery disease, if a stent was recently implanted, prescription of the combination of a DOAC and one antiplatelet drug was the most common answer. In patients with a former coronary angioplasty, DOAC or Warfarin was the therapy of choice. CONCLUSIONS: In the absence of randomized data, interventional cardiologists prescribe DOACs at discharge to patients with AF and TAVI, without following current guidelines in most cases.

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COVID-19 pandemic generated multiple challenges for the health system. Cardiovascular disease is associated with a worse prognosis of infections. Moreover, most hospital resources and operative rooms were destined to patients with COVID-19 infection, deferring the treatment of most valvular patients requiring surgery. We report seven patients with symptomatic severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI) with conscious sedation and early discharge. No patient required intensive care unit admission or mechanical ventilation. After a 90-day follow-up, there were no complications or unplanned readmissions.

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BACKGROUND: Transcatheter Aortic Valve Implantation (TAVI) is beneficial in patients with symptomatic severe Aortic Stenosis (AS). There is no consensus about the best anticoagulation strategy for patients with a recent TAVI and with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) are effective to prevent embolic events with a significant lower incidence of bleeding. There is scarce evidence about the use of these drugs in patients undergoing TAVI. AIM: To assess the management of anticoagulation at the moment of discharge of patients with AF and TAVI. MATERIAL AND METHODS: A four question survey was sent to cardiologists involved in TAVI programs in different international centers. RESULTS: The survey was answered by 72 interventional cardiologists. Even with the lack of randomized evidence, in most of the scenarios DOACs are prescribed at discharge in patients with indication for anticoagulation. Also, in patients with high bleeding risk, most cardiologists would perform a left atrial appendage closure. In patients with concomitant coronary artery disease, if a stent was recently implanted, prescription of the combination of a DOAC and one antiplatelet drug was the most common answer. In patients with a former coronary angioplasty, DOAC or Warfarin was the therapy of choice. CONCLUSIONS: In the absence of randomized data, interventional cardiologists prescribe DOACs at discharge to patients with AF and TAVI, without following current guidelines in most cases.

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Heart failure (HF) is a global health problem. There is a strong association h between HF and type 2 diabetes mellitus (DM2), with an increasing prevalence of patients having both conditions concomitantly. Sodium-glucose cotransporter 2 inhibitors (ISGLT2) significantly reduce cardiovascular events, including cardiovascular death. In this article we will focus on the current evidence about the effectiveness of these medications in adults with heart failure with reduced or preserved ejection fraction.

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We report a 55-year-old woman with a history of hypothyroidism and type 2 diabetes mellitus who consulted at the emergency room because of intermittent oppressive chest discomfort. At admission, electrocardiogram showed a complete atrioventricular block. A transthoracic echocardiogram disclosed severe left ventricular dysfunction. The patient developed cardiogenic shock that required the installation of the Impella system. An emergency coronary angiography showed an ostial occlusion of the anterior descending artery. Despite successful primary angioplasty, she persisted with refractory shock and progressive hypoxemia. A concomitant connection to the extracorporeal membrane oxygenation system (ECMO) was decided. The support of both devices allowed the stabilization of the patient and the improvement of perfusion parameters.

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Recently, intravascular lithoplasty (IVL) has been introduced as a novel technique for treating calcified intracoronary artery lesions. There are no reports of this intervention in Latin America. We report 2 cases in which IVL was successfully used to treat this type of coronary artery lesions.

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Transcatheter aortic valve implantation (TAVI) has a lower perioperative risk than traditional surgery mostly when the transfemoral access is used. Some patients have anatomical conditions that contraindicate the use of this route. Lithoplasty is a novel technique that fractures calcium in coronary and peripheral arteries using pulsatile waves transmitted through an angioplasty balloon. We report an 83 year-old male with an aortic stenosis requiring TAVI, with severe calcification of his femoral and aortic arteries. A balloon lithoplasty of the right iliac-femoral tract was carried out, which allowed the use of the transfemoral route to install the aortic prosthesis. The patient had a good subsequent evolution.

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We report a 55-year-old woman with a history of hypothyroidism and type 2 diabetes mellitus who consulted at the emergency room because of intermittent oppressive chest discomfort. At admission, electrocardiogram showed a complete atrioventricular block. A transthoracic echocardiogram disclosed severe left ventricular dysfunction. The patient developed cardiogenic shock that required the installation of the Impella system. An emergency coronary angiography showed an ostial occlusion of the anterior descending artery. Despite successful primary angioplasty, she persisted with refractory shock and progressive hypoxemia. A concomitant connection to the extracorporeal membrane oxygenation system (ECMO) was decided. The support of both devices allowed the stabilization of the patient and the improvement of perfusion parameters.

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RESUMEN INTRODUCCIÓN: En pacientes con estenosis Aórtica (EA) severa sintomática, el implante de válvula aórtica percutánea transcatéter (TAVI) por vía transfemoral constituye el estándar de tratamiento en aquellos de riesgo quirúrgico intermedio o alto. El uso de un abordaje minimalista ha demostrado ser seguro y efectivo, si bien no existen reportes sobre la realidad nacional Métodos: Estudio descriptivo sobre la experiencia con pacientes sometidos al implante de TAVI bajo un protocolo minimalista en Unidad de Cardiología Intervencional y Hemodinamia del Hospital Sótero del Río desde Enero de 2018. Se analizaron las variables clínicas de los pacientes y del procedimiento así como desenlaces clínicos intrahospitalarios y seguimiento alejado. Resultados: Entre Enero 2018 hasta Abril 2019, un total de 10 pacientes fueron sometidos al implante de TAVI por vía transfemoral. El score STS-PROM promedio fue de 7,1. Se logró un implante exitoso en el 100% de los casos con un gradiente medio residual de 8 mmHg y sin leak moderado a severo en ningún paciente. No hubo eventos cerebrovasculares isquémicos perioperatorios ni muerte en este grupo. Se requirió implante de marcapasos definitivo en 3 pacientes y un paciente presentó hematoma femoral perioperatorio que requirió transfusión de glóbulos rojos. La mediana de la estadía hospitalaria fue de 2 días. Conclusiones: El uso de una estrategia minimalista para el implante de TAVI en nuestra realidad nacional es seguro y aplicable. Los resultados perioperatorios y a 30 días fueron comparables a los descritos en experiencias internacionales.

ABSTRACT BACKGROUND: In patients with symptomatic severe aortic stenosis, transcatheter percutaneous aortic valve implant (TAVI) is the standard treatment in those with intermediate or high surgical risk. The use of a minimalist approach has proven to be safe and effective, although there are no reports on the national reality Methods: Descriptive study on the experience with patients undergoing TAVI implantation under a minimalist protocol at the Interventional Cardiology and Hemodynamics Unit of the Hospital Sótero del Río since January 2018. Clinical characteristics of the patients and the procedure were analyzed as well as intrahospital outcomes and at 30-days follow up. Results: Between January 2018 and April 2019, a total of 10 patients underwent TAVI implantation by transfemoral approach in our institution. The average STS-PROM score was 7.1. A successful implant was achieved in 100% of cases with an average residual gradient of 8 mmHg and no moderate to severe leak in any patient. There were no perioperative ischemic cerebrovascular events nor death in this group. A definitive pacemaker implant was required in 3 patients and one patient developed femoral hematoma that required red blood cell transfusion. The median hospital stay was 2 days. Conclusions: The use of a minimalist strategy for TAVI implantation in our national reality is safe and applicable. Immediate results and at 30-days follow up were comparable to those described in international experiences.

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RESUMEN:TAVI transfemoral en una paciente con obesidad extrema y estenosis aórtica severa. Una mujer extremadamente obesa (IMC 62.5 Kg/M2) con estenosis aórtica severa fue descartada para cirugía bariátrica y reemplazo valvular aórtico. Se efectuó una TAVI por vía transfemoral, sin anestesia general. Se describen cuidadosas técnicas para efectuar la punción femoral y su sellado posterior. La paciente se recuperó sin incidentes, la gradiente transvalvular aórtica se redujo significativamente y hubo mínima insuficiencia valvular.

ABSTRACT: An extremely obese woman (BMI 62.5 Kg/M2) with severe symptomatic aortic stenosis was discarded for bariatric surgery or aortic valve replacement. A transfemoral TAVI was performed, without general anesthesia. Careful techniques to perform and seal the transfemoral puncture are described. The patient recovered uneventfully with a significant decrease in aortic valve gradient and minimal aortic insufficiency.

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We report a 65-years old woman with a history of permanent atrial fibrillation with high risk for ischemic and bleeding events. She developed a heart failure with severely impaired left ventricular ejection fraction and severe secondary mitral regurgitation. Given her high surgical risk, using transesophageal echocardiography guidance, a concomitant deployment of two MitraClip devices using a high-posterior septal puncture and a left atrial appendage closure with an Amplatzer Amulet occluder were performed through the same access.

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We report a 65-years old woman with a history of permanent atrial fibrillation with high risk for ischemic and bleeding events. She developed a heart failure with severely impaired left ventricular ejection fraction and severe secondary mitral regurgitation. Given her high surgical risk, using transesophageal echocardiography guidance, a concomitant deployment of two MitraClip devices using a high-posterior septal puncture and a left atrial appendage closure with an Amplatzer Amulet occluder were performed through the same access.

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Introducción: El cierre percutáneo de orejuela izquierda con dispositivos percutáneos (CPOI) ha demostrado ser útil en la prevención de embolia arterial como alternativa al tratamiento anticoagulante (TACO) en pacientes con fibrilación auricular no valvular (FANV). Sin embargo, en las primeras semanas post implante, existe el riesgo de formación de trombos sobre el dispositivo. Objetivos: Describir e Identificar los factores de riesgo para la formación de trombos sobre el dispositivo posterior al cierre de orejuela izquierda. Métodos: Se incluyeron 15 pacientes con FANV y alto riesgo hemorrágico, sometidos a CPOI con dispositivo Ultrasept (Cardia Inc., Eagan, MN), en el Hospital Clínico de la Universidad Católica, entre Abril 2013 y Junio 2014. A todos se les realizó eco-cardiograma transesofágico (ETE) al primer, tercer y sexto mes post implante. Todos los pacientes recibieron aspirina en forma permanente y TACO por 45 días el que se reemplazó por clopidogrel hasta el sexto mes post implante. Se analizaron parámetros clínicos y ecocardiográficos en forma retrospectiva para identificar los factores de riesgo asociados a la formación de trombos sobre el dispositivo. Resultados: La edad promedio de los pacientes fue 77± 8 años, 73% de sexo masculino. El 80% tenía FA permanente y 20% FA paroxística. EL Score de CHA2DS2VASc promedio fue de 5 (mínimo 3, máximo 8 puntos). En 4 pacientes (26.6%), encontramos trombos en el dispositivo en el seguimiento con ETE (1 paciente al primer mes y 3 al tercer mes), sin consecuencias clínicas. Al comparar los pacientes que formaron trombos con el resto, no hubo diferencias en las variables clínicas (edad, sexo, Hipertensión arterial (HTA), Diabetes Mellitus (DM), Dislipidemia, Tabaquismo, Insuficiencia Renal, AVE previos), ni en las variables ecocardiográficas estudiadas, como el área de la aurícula izquierda (AI), contraste espontáneo en la AI, insuficiencia mitral ni cierre incompleto de orejuela (medida por la existencia de flujo peridispositivo). Sin embargo, los pacientes con trombos presentaron CHA2DS2VASc score más alto (7.1 vs 4.7; p= 0.001) y fracción de eyección (FE) más baja (43% vs 55%; p= 0.001). En la curva ROC de CHA2DS2VASc para predecir una mayor probabilidad de formación de trombos, un valor > 6 obtiene una sensibilidad de un 100% y una especificidad de un 80%. En nuestro seguimiento clínico de 2 años ± 5.7 meses posterior al implante, 1 paciente tuvo un AVE isquémico identificando como fuente enfermedad carotidea (no tenía trombos en el dispositivo). El resto de los pacientes se mantienen asintomáticos. Conclusiones: En nuestra experiencia, el CHA2DS-2VASc score (> 6) y la fracción de eyección baja, fueron factores de riesgo para la formación de trombos sobre el dispositivo de cierre de orejuela. Este hallazgo debería confirmarse en series más grandes dado que podría cambiar la estrategia de anticoagulación post implante.

Background: Percutaneous closure of the left atrial appendage (LAA) has been shown to be useful in the prevention of arterial embolism as an alternative to oral anticoagulants in patients with non valvular atrial fibrillation. However, thrombus formation may develop in the first weeks following device implantation/ Aim: to identify risk factors for thrombus development on devices used for LAA closure. Methods: 15 patients with non valvular AF and high risk for anticoagulant treatment were included. Patients received an Ultrasept (Cardia Inc., Eagan, MN) between April 2013 and June 2014. Transesophageal echocardiography was performed in all patients 1, 3 and 6 months post implant. All patients received aspirin permanently and acenocumarol for 45 days, followed by clopidogrel until 6 months post implant. Results: Mean age was 77 years old (SD 8). 73% were males. AF was permanent in 80% and paroxysmal in 20%. Mean CHA2DS2VASC was 8 (range 3 to 8). Thrombus were revealed by TEE in 4 patients (26.6%), at 1 month (1 patient) and at 3 months post implant (3 patients). No complications occurred in these patients. Clinical variables (age, sex, hyper-tension, diabetes, dyslipidemia, smoking habit, renal failure and prior strokes) were no different in patients with or without thrombus. The same was true for left atrial size, mitral insufficiency or incomplete closure of LAA. In contrast, patients with thrombus formation had a higher CHA2DS2VASc score (7.1 vs 4.7, p=0.001 and a lower LV ejection fraction (43% vs 55%, p=0.001). A CHA2DS2VASc score > 6 was 100% sensible and 80% specific for thrombus formation (ROC curve). After a follow-up of 24 ± 5 months only 1 patients had and ischemic cerebro-vascular event which was attributed to carotid artery disease (the patient had no evidence of device thrombus). All other patients remain asymptomatic. Conclusion: A CHA2DS2VASc score > 6 and a low ejection fraction were risk factors for thrombus formation on LAA closing device. Confirmation of these findings in a larger series of patients could lead to a change in anticoagulant strategy following the implantation of devices to close the LAA.

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