Instituto de Cardiología y Cirugía Cardiovascular

Introduction: Dilated cardiomyopathy (DCM) is a fatal myocardial condition with ventricular structural changes and functional deficits, leading to systolic dysfunction and heart failure (HF). DCM is a frequent complication in oncologic patients receiving Doxorubicin (Dox). Dox is a highly cardiotoxic drug, whereas its damaging spectrum affects most of the organs by multiple pathogenic cascades. Experimentally reproduced DCM/HF through Dox administrations has shed light on the pathogenic drivers of cardiotoxicity. Growth hormone (GH) releasing peptide 6 (GHRP-6) is a GH secretagogue with expanding and promising cardioprotective pharmacological properties. Here we examined whether GHRP-6 administration concomitant to Dox prevented the onset of DCM/HF and multiple organs damages in otherwise healthy rats. Methods: Myocardial changes were sequentially evaluated by transthoracic echocardiography. Autopsy was conducted at the end of the administration period when ventricular dilation was established. Semiquantitative histopathologic study included heart and other internal organs samples. Myocardial tissue fragments were also addressed for electron microscopy study, and characterization of the transcriptional expression ratio between Bcl-2 and Bax. Serum samples were destined for REDOX system balance assessment. Results and discussion: GHRP-6 administration in parallel to Dox prevented myocardial fibers consumption and ventricular dilation, accounting for an effective preservation of the LV systolic function. GHRP-6 also attenuated extracardiac toxicity preserving epithelial organs integrity, inhibiting interstitial fibrosis, and ultimately reducing morbidity and mortality. Mechanistically, GHRP-6 proved to sustain cellular antioxidant defense, upregulate prosurvival gene Bcl-2, and preserve cardiomyocyte mitochondrial integrity. These evidences contribute to pave potential avenues for the clinical use of GHRP-6 in Dox-treated subjects.

Background In this substudy of the Value of Gated-SPECT MPI for Ischemia- Guided PCI of non-culprit vessels in STEMI Patients with Multi vessel Disease after primary PCI trial on the value of myocardial perfusion imaging (MPI) for ischemia-guided percutaneous coronary intervention (PCI) of nonculprit vessels in patients with ST-segment–elevation myocardial infarction (STEMI) and multivessel disease after primary PCI we aim to assess if infarct size affects conventional measures of dyssynchrony at rest. Additionally, we explore if there is an independent correlation of stress-inducible ischemia with dyssynchrony at rest. Methods The 48 patients with imaging at randomization were analyzed. Gated-single-photon emission computed tomography (SPECT) MPI with vasodilator stress and technetium-99m-labeled tracers was performed. The phase histogram bandwidth (HBW), phase SD, and entropy were obtained with the QGS software. Correlation between dyssynchrony at rest and infarct size and inducible ischemia was performed using the Spearman test. Results According to normal database limits dyssynchrony parameters at rest were abnormal for men. In women only HBW was abnormal. Correlation between the summed rest score with dyssynchrony was significant only for entropy ( P = 0.035). No correlation was observed for dyssynchrony and stress-induced ischemia. Conclusion Entropy, as a measure of dyssynchrony, has potential in the assessment of patients with STEMI and multivessel disease after primary PCI. Smaller residual myocardial scars in PCI-reperfused patients with STEMI may contribute to the lack of correlation between dyssynchrony at rest and infarct size and stress-induced ischemia, respectively.

Intraoperative antithrombotic drug removal by haemoadsorption is a novel strategy to reduce perioperative bleeding in patients on antithrombotic drugs undergoing cardiac surgery. The international STAR registry reports real-world clinical outcomes associated with this application. All patients underwent cardiac surgery before completing the recommended washout period. The haemoadsorption device was incorporated into the cardiopulmonary bypass (CPB) circuit. Patients on P2Y12 inhibitors comprised group 1, and patients on direct-acting oral anticoagulants (DOAC) group 2. Outcome measurements included bleeding events according to standardised definitions and 24-hour chest-tube-drainage (CTD). 165 patients were included from 8 institutions in Austria, Germany, Sweden, and the UK. Group 1 included 114 patients (62.9 ± 11.6years, 81% male) operated at a mean time of 33.2 h from the last P2Y12 inhibitor dose with a mean CPB duration of 117.1 ± 62.0 min. Group 2 included 51 patients (68.4 ± 9.4years, 53% male), operated at a mean time of 44.6 h after the last DOAC dose, with a CPB duration of 128.6 ± 48.4 min. In Group 1, 15 patients experienced a BARC-4 bleeding event (13%), including 3 reoperations (2.6%). The mean 24-hour CTD was 651 ± 407mL. In Group 2, 8 patients experienced a BARC-4 bleeding event (16%) including 4 reoperations (7.8%). The mean CTD was 675 ± 363mL. This initial report of the ongoing STAR registry shows that the intraoperative use of a haemoadsorption device is simple and safe, and may potentially mitigate the expected high bleeding risk of patients on antithrombotic drugs undergoing cardiac surgery before completion of the recommended washout period. Clinical registration number: ClinicalTrials.gov identifier: NCT05077124. Graphical Abstract

Background The COVID-19 pandemic disproportionately impacted Latin America (LATAM), significantly disrupting cardiovascular testing. This study evaluated cardiac procedure recovery in LATAM one year after the outbreak. Methods The International Atomic Energy Agency (IAEA) surveyed 669 centers in 107 countries worldwide, including 135 facilities in 19 LATAM countries, to assess cardiovascular procedure volumes in March 2019, April 2020, and April 2021, and changes in center practices and staffing conditions one year into the COVID-19 pandemic. Findings LATAM centers reported a 21 % decrease in procedure volumes in April 2021 from pre-pandemic-baseline, vs. a 0 % change in the rest of the world (RoW), and greater volume reductions for almost all procedure types. Centers in Central America and Mexico reported the largest procedure reductions (47 % reduction) compared to the Caribbean (15 %), and South America (14 %, p = 0.01), and this LATAM region was a significant predictor of lower procedure recovery in multivariable regression. More LATAM centers reported reduced salaries and increased layoffs of clinical staff compared to RoW, and LATAM respondents estimated that half of physician and non-physician staff experienced excess psychological stress related to the pandemic, compared to 25 % and 30 % in RoW (p < 0.001). Conclusions Cardiovascular testing recovery in LATAM trailed behind RoW for most procedure types, with centers in Central America and Mexico reporting the greatest volume reductions. This study found lasting impacts of COVID-19 on cardiovascular care in LATAM and the need for mental health support for LATAM healthcare workers in current and future pandemics.

This study was designed to evaluate the accuracy of the Hipermax-BF model A7101 automatic oscillometric arm sphygmomanometer (Combiomed, Havana, Cuba) in general population. The research was developed according to the Universal Standard AAMI/ESH/ISO (ISO 81060-2:2018) and the ISO 81060-2:2018/DAM amendment 1 of 2020. The subjects were recruited according to the requirements of age, gender, blood pressure values and arm circumference based on the recommendations. The same arm sequential blood pressure measurement method was used. For measurements with the device under test, the 2-piece cuff was used. 92 subjects were recruited and 85 were analyzed. Mean age was 44.8 ± 14.7 years, mean arm circumference was 32.3 ± 6.2, and 56.5% were female. For Validation Criterion 1, the mean value ± standard deviation of the differences in readings between the device under test and the reference device was 1.2 ± 4.9/0.8 ± 4.9 mmHg (systolic/diastolic). For both pressures, in criterion 1 the standard requires a mean value of the differences ≤ ± 5 mmHg and a standard deviation ≤ ± 8 mmHg. For Validation Criterion 2, the standard deviation of the mean blood pressure differences per subject was 4.2/4.2 mmHg (systolic/diastolic). According to Table 1 of criterion 2 of the standard, for the obtained mean values of 1.23/0.84 mmHg (systolic/diastolic), the maximum allowable standard deviation had to be < 6.84 for PS and < 6.89 for PD. The Combiomed Hipermax-BF A7101 automatic sphygmomanometer meets the requirements of the AAMI/ESH/ISO Universal Standard (ISO 81060-2:2018) in the general population.

Aim Aortic stenosis increases left atrial (LA) pressure and may lead to its remodeling. This can cause supraventricular arrhythmia. The aim of this study was to determine if the size of the LA and the presence of atrial fibrillation are related to the prognosis of patients with aortic stenosis. Material and methods Clinical evaluation and standard transthoracic echocardiographic studies were performed in 397 patients with moderate to severe aortic stenosis. Results In all patients, LA dimension above the median (≥43 mm) was associated with a significantly higher risk of death [HR 1.79 (CL 1.06-3.03)] and a LA volume above the median of 80 ml was associated with a significantly higher risk of death [HR 2.44 (CI 1.12-5.33)]. The presence of atrial fibrillation was significantly associated with a higher risk of death (p <0.0001). The presence of atrial fibrillation [HR 1.69 (CI 1.02-2.86)], lower left ventricular ejection fraction [HR 1.23 (CI 1.04-1.45)], higher NYHA heart failure class [HR 4.15 (CI 1.40-13.20)] and renal failure [HR 2.10 (CI 1.31-3.56)] were independent risk factors of death in patients in aortic stenosis. Conclusion The size and volume of the LA and the occurrence of atrial fibrillation are important risk factors for death in patients with aortic stenosis. The presence of renal dysfunction, low left ventricular ejection fraction, high NYHA functional class and atrial fibrillation are independent risk factors of poor prognosis in patients with aortic stenosis.

Cardiac electrical activity is mainly determined by a set of voltage-dependent channels that control depolarizing currents carried by Na+ and Ca2+ cations and repolarizing currents carried by K+ and Cl− ions. Arrhythmia often results from a disorder in these currents or from the occurrence of additional inward currents such as those generated by the transient receptor potential (TRP) channels. In mammals, the TRP family comprises six major subfamilies; TRPC (canonical), TRPV (vanilloid), TRPA (ankyrin), TRPM (melastatin), TRPP (polycystin), and TRPML (mucolipin). In the heart, TRP channels are known to be involved in various diseases, including hypertrophy, heart failure, and arrhythmia. A large part of this chapter focuses on the potential contribution of TRP channels, namely TRPCs and TRPM4, that could carry an inward current at the resting potential to modulate cardiac rhythm, as well as on their potential arrhythmic effects. Specific attention is given to the proarrhythmic effects of ATP as a purinergic agonist. Under ischemia, a burst of ATP is released that stimulates P2Y2 receptors, which through phospholipase C activates heterotetrameric TRPC3/TRPC7 channels and, as well, releases Ca2+ from the sarcoplasmic reticulum to activate TRPM4. The subsequent inward currents could depolarize the cell and trigger anomalous activity. Furthermore, several other neurotransmitters that all induce through G protein or tyrosine kinase, the formation of DAG could, as well, modulate cardiac rhythm and trigger arrhythmia.

Pregnant women with mitral stenosis have a high cardiovascular risk, and their outcomes vary greatly. The management of these patients should be individualized and carried out by a multidisciplinary team. This case series presents 3 cases of pregnant women with severe mitral stenosis, describing their progression and therapeutic strategies.

Introducción: La intervención quirúrgica cardiaca es compleja, pero con resultados satisfactorios para el paciente, pues incrementa su supervivencia y calidad de vida. El síndrome de bajo gasto cardiaco en el periodo posoperatorio es una de las entidades que ensombrece el pronóstico y eleva los índices de morbilidad y mortalidad en dichos pacientes. Objetivo: Estimar la supervivencia de los pacientes con síndrome de bajo gasto cardiaco en el periodo posoperatorio según variables clínicas y ecocardiográficas. Métodos: Se realizó una investigación de cohorte de supervivencia en 56 pacientes operados del corazón, diagnosticados con síndrome de bajo gasto cardiaco posoperatorio, quienes fueron atendidos en el Centro de Cardiología y Cirugía Cardiovascular de Santiago de Cuba, desde enero del 2019 hasta noviembre del 2021. Resultados: Predominaron el grupo etario de 65 o más años (60,7 %), la diabetes mellitus (44,6 %) como antecedente patológico personal y los pacientes con fracción de eyección de 45 % o más, quienes presentaron mayor cantidad de decesos (29,8 %). La función del ventrículo derecho afectada se halló en 52,6 % de los fallecidos. El tiempo de circulación extracorpórea de 90 minutos o más primó en 67,9 % de los afectados, de los cuales 42,1 % murieron. Conclusiones: Se observó que la diabetes mellitus, el tiempo de circulación extracorpórea y el sangrado perioperatorio prolongados, así como la función sistólica biventricular se relacionaron con el pronóstico del síndrome de bajo gasto cardiaco en el periodo posoperatorio.

Background About 80% of cardiovascular diseases (including heart failure [HF]) occur in low‐income and developing countries. However, most clinical trials are conducted in developed countries. Hypothesis The American Registry of Ambulatory or Acutely Decompensated Heart Failure (AMERICCAASS) aims to describe the sociodemographic characteristics of HF, comorbidities, clinical presentation, and pharmacological management of patients with ambulatory or acutely decompensated HF in America. Methodology Descriptive, observational, prospective, and multicenter registry, which includes patients >18 years with HF in an outpatient or hospital setting. Collected information is stored in the REDCap electronic platform. Quantitative variables are defined according to the normality of the variable using the Shapiro–Wilk test. Results This analysis includes data from the first 1000 patients recruited. 63.5% were men, the median age of 66 years (interquartile range 56.7–75.4), and 77.6% of the patients were older than 55 years old. The percentage of use of the four pharmacological pillars at the time of recruitment was 70.7% for beta‐blockers (BB), 77.4% for angiotensin‐converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB II)/angiotensin receptor‐neprilysin inhibitor (ARNI), 56.8% for mineralocorticoid receptor antagonists (MRA), and 30.7% for sodium–glucose cotransporter type‐2 inhibitors (SGLT2i). The main cause of decompensation in hospitalized patients was HF progression (64.4%), and the predominant hemodynamic profile was wet‐warm (68.3%). Conclusions AMERICCAASS is the first continental registry to include hospitalized or outpatient patients with HF. Regarding optimal medical therapy, approximately a quarter of the patients still need to receive BB and ACEI/ARB/ARNI, less than half do not receive MRA, and more than two‐thirds do not receive SGLT2i.

Resumen La insuficiencia cardíaca (IC) es una patología que afecta al 1% de la población y se encuentra acompañada de deficiencia de hierro como comorbilidad en el 50% de los casos. La anemia, por su parte, está presente en el 22-37% de los casos de IC. Este es un documento de consenso que busca sintetizar la información disponible sobre la anemia y la deficiencia de hierro, y su comportamiento en pacientes con IC, que se divide en fisiopatología, clasificación, escenarios clínicos y algoritmos (rutas de manejo), tratamiento y seguimiento. Este artículo integra las recomendaciones internacionales basadas en la evidencia y se presenta una síntesis de las estrategias de manejo.

Objectives Coronary computed tomography angiography (CCTA) has higher diagnostic accuracy than coronary artery calcium (CAC) score for detecting obstructive coronary artery disease (CAD) in patients with stable chest pain, while the added diagnostic value of combining CCTA with CAC is unknown. We investigated whether combining coronary CCTA with CAC score can improve the diagnosis of obstructive CAD compared with CCTA alone. Methods A total of 2315 patients (858 women, 37%) aged 61.1 ± 10.2 from 29 original studies were included to build two CAD prediction models based on either CCTA alone or CCTA combined with the CAC score. CAD was defined as at least 50% coronary diameter stenosis on invasive coronary angiography. Models were built by using generalized linear mixed-effects models with a random intercept set for the original study. The two CAD prediction models were compared by the likelihood ratio test, while their diagnostic performance was compared using the area under the receiver-operating-characteristic curve (AUC). Net benefit (benefit of true positive versus harm of false positive) was assessed by decision curve analysis. Results CAD prevalence was 43.5% (1007/2315). Combining CCTA with CAC improved CAD diagnosis compared with CCTA alone (AUC: 87% [95% CI: 86 to 89%] vs. 80% [95% CI: 78 to 82%]; p < 0.001), likelihood ratio test 236.3, df: 1, p < 0.001, showing a higher net benefit across almost all threshold probabilities. Conclusion Adding the CAC score to CCTA findings in patients with stable chest pain improves the diagnostic performance in detecting CAD and the net benefit compared with CCTA alone. Clinical relevance statement CAC scoring CT performed before coronary CTA and included in the diagnostic model can improve obstructive CAD diagnosis, especially when CCTA is non-diagnostic. Key Points • The combination of coronary artery calcium with coronary computed tomography angiography showed significantly higher AUC (87%, 95% confidence interval [CI]: 86 to 89%) for diagnosis of coronary artery disease compared to coronary computed tomography angiography alone (80%, 95% CI: 78 to 82%, p < 0.001). • Diagnostic improvement was mostly seen in patients with non-diagnostic C. • The improvement in diagnostic performance and the net benefit was consistent across age groups, chest pain types, and genders.

Infective endocarditis is a serious disease associated with high mortality despite recent advances in diagnosis and treatment. Aggregatibacter aphrophilus is a fastidious Gram-negative member of the HACEK organisms (Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae). A. aphrophilus is associated with dental infections but has also been implicated in cases of infective endocarditis. We highlight the importance of a high index of suspicion in symptomatic patients with an initial negative blood culture, particularly in high-risk groups such as patients with congenital valve disease and prosthetic valve. The knowledge of this rare entity may lead to early diagnosis and appropriate management. We review the main characteristics of Aggregatibacter aphrophilus endocarditis reported in the medical literature.

Background: Data about performance measures (PM) in patients with ST segment Elevation Myocardial Infarction (STEMI) in low- and middle-income countries is really scarce. One of the reasons is the lack of appropriate measures for these scenarios where coronary intervention is not the standard treatment. Objective: This study aimed to develop a set of PM and quality markers for patients with STEMI in these countries. Methods: Two investigators systematically reviewed existing guidelines and scientific literature to identify potential PM by referring to documents searched through PubMed from 2010 through 2019, using terms "Myocardial Infarction", "STEMI", "quality indicator", and "performance measure". A modified Delphi technique, involving multidisciplinary panel interview, was used. A 15-member multidisciplinary expert panel individually rated each potential indicator on a scale of 1 (lowest) to 5 (highest) during three rounds. All indicators that received a median score ≥4.5, in final round without significant disagreement were included as PM. Results: Through the consensus-building process, 84 potential indicators were found, of which 10 were proposed as performance measures and 2 as quality metrics, as follows: Pre-Hospital Electrocardiogram; Patients with reperfusion therapy; Pre-hospital Reperfusion; Ischemic time less than 120 minutes; System delay time less than 90 minutes; In-hospital Mortality; Complete in-hospital Treatment; Complete in-hospital Treatment in patients with Heart Failure; 30 day-Re-admissions; 30 day-mortality; Patients with in-hospital stress test performed; and, Patients included in rehabilitation programs. Conclusion: This document provides the official set of PM of attention in ST segment Elevation Myocardial Infarction of the Cuban Society of Cardiology and Cuban National Group of Cardiology.

Cardiac diseases are the main cause of death for both sexes worldwide. Treatment varies widely according to the sex of a patient, as there are differences in physiopathology, epidemiology, clinical presentation and management. However, women have been largely excluded from research studies in this field. At present, differences are starting to be recognized and more attention is being paid to the identification of female-specific (or emergent) atherosclerotic risk factors. Diagnostic testing also merits attention because cardiac imaging offers important information to help diagnosis and guide cardiac disease management. In this sense, multimodal imaging should be used with the most cost-effective approach, integrating this information into the clinical sphere according to the pretest probability of the disease. In this review, we address sex-specific features of ischemic heart disease that should be considered in the clinical assessment of women, as well as the value of different imaging techniques (including technical and clinical aspects) for management of women with ischemic heart disease, and identify future areas of action concerning ischemic heart disease in women.

Para que una alteración física sea considerada una enfermedad, debe cumplir con los criterios definidos por la OMS. El miocardio no compacto (MNC) es una hipertrabeculación ventricular no bien definida, de la que se duda si es una miocardiopatíaen sí misma, o solo una variación de la normalidad. Nosotros analizamos 161 resonancias magnéticas cardíacas realizadasa 140 pacientes con MNC y sus relaciones con otras patologías, exponiéndolos a los criterios de “enfermedad” definidos porla OMS. Tras un análisis crítico, consideramos que no debería ser considerada una miocardiopatía en sí misma, sino unaadaptación miocárdica ante condiciones adversas.

Introducción: Aunque la incidencia general de infarto agudo de miocardio ha disminuido en muchos países desarrollados en las últimas décadas, aún genera números elevados de morbilidad y mortalidad en los de bajos ingresos; mostrando cifras mayores en tiempos de la pandemia por coronavirus. Objetivo: Caracterizar a pacientes con diagnóstico de infarto agudo de miocardio según variables clinicoepidemiológicas, ecocardiográficas y terapéuticas. Métodos: Se realizó una investigación descriptiva y retrospectiva, desde enero de 2018 hasta noviembre de 2022, de 263 pacientes con diagnóstico de infarto agudo de miocardio, atendidos en el Centro de Cardiología y Cirugía Cardiovascular de Santiago de Cuba. Entre las variables analizadas figuraron la edad, el sexo, la topografía del infarto, las complicaciones, las alteraciones ecocardiográficas y el tratamiento trombolítico. Resultados: En la serie predominaron el sexo masculino y el grupo etario menor o igual de 65 años. Se observó una mayor frecuencia del infarto en la topografía inferior (177, para 67,3 %); de estos afectados, 52,1 % tuvo complicaciones. Asimismo, la complicación de mayor frecuencia fue la fibrilación auricular paroxística, seguida del infarto de ventrículo derecho; mientras que la fracción de eyección menor de 45 %, el volumen de la aurícula izquierda y la motilidad parietal presentaron significación estadística. Conclusiones: Las características clinicoepidemiológicas, ecocardiográficas y terapéuticas de los pacientes con infarto agudo de miocardio en la provincia de Santiago de Cuba no difieren del contexto epidemiológico mundial.

Background: The aim of this study is to whether higher transcatheter aortic valve implantation (TAVI) with self-expandable valves using the right and left cusp overlap strategy (Cusp Overlap, COVL) is associated with a lower incidence of moderate or severe paravalvular regurgitation (PVR), compared with the conventional strategy (CON). Methods: A total of 206 consecutive patients undergoing TAVI with self-expandable valves between August 2019 and May2022 were analyzed. The CON technique was used in the first 101 patients (49%) and COVL was used in 105 (51%). The primary endpoint (PEP) was the presence of moderate or severe paravalvular regurgitation at 30 days. Results: There were no clinical differences between the groups in terms of mean age, sex or comorbidities, except for a trend towards more patients with diabetes and previous percutaneous coronary intervention in the COVL group. The STS score was greater in the COVL group (6.9 ± 2.2 vs. 5.8 ± 2.4 in the CON group; p = 0.01). There was no difference in the PEP at 30 days with 2% incidence of moderate PVR in the CON group and 0.9% in the COVL group, and none of them presented severe PVR. There were no differences in mortality, myocardial infarction, coronary artery obstruction, stroke, major bleeding or vascular complications. The need for permanent pacemaker was lower with the COVL strategy (6.7% vs. 17.8%, p = 0.01) and a new left bundle branch block occurred in 5.7% vs. 12.9% (p = 0.07). Conclusions: In this single-center series, the strategy of high transcatheter aortic valve implantation using the COVL strategy showed no difference in the presence of moderate or severe regurgitation compared with the conventional strategy, with no differ ences in complications, and was associated with a lower need for definitive pacemaker and with a trend towards lower incidence of left bundle branch block at 30 days.

Cancer and cardiovascular disease are the two main causes of death worldwide in both men and women. In the past decades, survival rate in cancer patients has substantially improved due to new treatments and developments in radiation therapy (RT). In women, breast cancer (BC) is the leading cause of cancer death and thoracic RT is a main component of the treatment in many cases. Nevertheless, despite new techniques that limit the area receiving RT, cardiac damage is still an important concern in BC patients. In this review, the following aspects will be addressed: pathophysiology of postradiotherapy heart damage in women with BC; mechanisms, diagnosis and prevention/management of heart damage; and future areas of potential research for radiotherapy injury in women.