Publications by authors named "Luis Paiva"

75 Publications

Iatrogenic atrial septal defect after percutaneous left atrial appendage closure: a single-center study.

Int J Cardiovasc Imaging 2021 Mar 14. Epub 2021 Mar 14.

Cardiology Department, Centro Hospitalar e universitário de Coimbra - Hospital Geral, Quinta dos Vales - São Martinho do Bispo, 3043-853, Coimbra, Portugal.

There is conflicting evidence regarding the significance of iatrogenic atrial septal defects (iASDs) after transseptal puncture during percutaneous cardiac interventions. To study the clinical outcome of iASD after percutaneous left atrial appendage occlusion (LAAo). Single-center, retrospective study of 70 consecutive patients who underwent percutaneous LAAo between May 2010 and August 2017, and subsequent transesophageal echocardiography (TEE) at 1 month. The sample population was divided into two groups: A (with iASD, 22 (37%) patients) and B (no iASD, 44 (63%) patients). Procedures were guided either by TEE (36 patients (54%)) or intracardiac echocardiography (ICE) from the left atrium (30 patients (46%)). The primary end point was presence of iASD at 1 month, and secondary end points included mortality, hospital admission due to heart failure (HF), and right atrium (RA) size during follow-up. 70 patients were included in this study and the prevalence of iASD at 1 month was 37%. The use of ICE was associated with iASD (adjusted odds ratio, 3.79; 95% CI 1.27-11.34). The presence of iASD was not associated with adverse events (mortality, 15.4% vs 20.5%; P = 0.60; HF hospitalizations, 7.7% vs 13.6%, P = 0.45; and RA area, 24.8 ± 7.0 cm vs 22.2 ± 6.8 cm, P = 0.192). At 1-month follow-up after LAAo, iASD was present in one third of patients, but was not associated with clinical outcomes. The use of ICE was associated with a higher risk of short-term iASD.
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http://dx.doi.org/10.1007/s10554-021-02212-4DOI Listing
March 2021

Distribution of GnRH and Kisspeptin Immunoreactivity in the Female Llama Hypothalamus.

Front Vet Sci 2020 2;7:597921. Epub 2021 Feb 2.

Instituto de Ciencia Animal, Facultad de Ciencias Veterinarias, Universidad Austral de Chile, Valdivia, Chile.

Llamas are induced non-reflex ovulators, which ovulate in response to the hormonal stimulus of the male protein beta-nerve growth factor (β-NGF) that is present in the seminal plasma; this response is dependent on the preovulatory gonadotrophin-releasing hormone (GnRH) release from the hypothalamus. GnRH neurones are vital for reproduction, as these provide the input that controls the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary gland. However, in spontaneous ovulators, the activity of GnRH cells is regulated by kisspeptin neurones that relay the oestrogen signal arising from the periphery. Here, we investigated the organisation of GnRH and kisspeptin systems in the hypothalamus of receptive adult female llamas. We found that GnRH cells exhibiting different shapes were distributed throughout the ventral forebrain and some of these were located in proximity to blood vessels; sections of the mediobasal hypothalamus (MBH) displayed the highest number of cells. GnRH fibres were observed in both the organum vasculosum laminae terminalis (OVLT) and median eminence (ME). We also detected abundant kisspeptin fibres in the MBH and ME; kisspeptin cells were found in the arcuate nucleus (ARC), but not in rostral areas of the hypothalamus. Quantitative analysis of GnRH and kisspeptin fibres in the ME revealed a higher innervation density of kisspeptin than of GnRH fibres. The physiological significance of the anatomical findings reported here for the ovulatory mechanism in llamas is still to be determined.
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http://dx.doi.org/10.3389/fvets.2020.597921DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884347PMC
February 2021

β-NGF Stimulates Steroidogenic Enzyme and Gene Expression, and Progesterone Secretion via ERK 1/2 Pathway in Primary Culture of Llama Granulosa Cells.

Front Vet Sci 2020 23;7:586265. Epub 2020 Oct 23.

Institute of Animal Science, Faculty of Veterinary Sciences, Universidad Austral de Chile, Valdivia, Chile.

The beta-nerve growth factor (β-NGF) from llama seminal plasma exerts ovulatory and luteotrophic effects following intramuscular or intrauterine infusion in llamas and alpacas. In this study, we investigate the effect of llama β-NGF on the expression of genes involved in angiogenesis and progesterone synthesis as well as progesterone release in preovulatory llama granulosa cells; we also determine whether these changes are mediated via the ERK1/2 signaling pathway. From adult female llamas, we collected granulosa cells from preovulatory follicles by transvaginal ultrasound-guided follicle aspiration; these cells were pooled and incubated. After 80% confluence, the cultured granulosa cells were treated with β-NGF, β-NGF plus the MAPK inhibitor U0126, or luteinizing hormone, and the abundance of angiogenic and steroidogenic enzyme mRNA transcripts were quantified after 10 and 20 h by RT-qPCR. We also quantified the progesterone concentration in the media after 48 h by radioimmunoassay. We found that application of β-NGF increases the abundance of mRNA transcripts of the vascular endothelial growth factor () and the steroidogenic enzymes cytochrome P450 side-chain cleavage (P450scc/), steroidogenic acute regulatory protein (), and 3β-hydroxysteroid dehydrogenase () at 10 and 20 h of treatment. Application of the MAPK inhibitor U0126 resulted in downregulation of the genes encoding these enzymes. β-NGF also enhanced progesterone synthesis, which was prevented by the prior application of the MAPK inhibitor U0126. Finally, western blot analysis confirmed that β-NGF activates the ERK1/2 signaling pathway. In conclusion, our results indicate that β-NGF exerts direct luteotropic effects on llama ovarian tissue via the ERK 1/2 pathway.
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http://dx.doi.org/10.3389/fvets.2020.586265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645075PMC
October 2020

Determinants and prognostic implication of periprocedural myocardial injury after successful recanalization of coronary chronic total occlusion.

Cardiovasc Interv Ther 2020 Nov 1. Epub 2020 Nov 1.

Department of Cardiology, Coimbra University Hospital Centre, Coimbra, Portugal.

Periprocedural myocardial injury (PMI) has been generally associated with major adverse cardiac events (MACE), however, limited studies addressed its clinical implications following chronic total occlusion (CTO) percutaneous coronary intervention (PCI). To evaluate the determinants and prognostic implication of PMI following CTO-PCI. Retrospective single-centre study of 125 consecutive patients undergoing CTO-PCI was attempted between December 2013 and December 2017. Angiographic success was achieved in 115 patients (92.0%) and cTn-I values were obtained 12-24 h following PCI. PMI was defined as an elevation of cTn-I above 5 times the 99th-percentile upper reference limit. Baseline demographic, clinical, angiographic and procedural characteristics were compared. Multivariate analysis was performed to determine the predictors of PMI and the correlates of PMI and 1-year MACE, a composite of all-cause death, non-fatal myocardial infarction, and target lesion revascularization. Overall, mean age was 67 ± 17 years; 25 patients (21.7%) were female; and PMI occurred in 41 patients (35.7%). Multivessel coronary artery disease (MVD) (odds ratio [OR], 3.41; 95% confidence interval [CI], 1.09-10.67; p = 0.04) and procedural complications (a composite of iatrogenic coronary artery dissection/haematoma or perforation) (OR, 19.08; 95% CI, 3.77-96.65; p < 0.01) predicted PMI. Significant collateralization (Rentrop 3) (hazard ratio, [HR], 0.19; 95% CI, 0.06-0.64; p < 0.01) and procedural complications (HR, 8.86; 95% CI, 2.66-29.46; p < 0.01) were independently associated with 1-year MACE, while PMI was not (p = 0.26). In this contemporary cohort, PMI following successful CTO-PCI was a common finding and was predicted by MVD and procedural complications. PMI was not independently associated with 1-year MACE.
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http://dx.doi.org/10.1007/s12928-020-00727-6DOI Listing
November 2020

Fusion imaging in interventional cardiology.

Rev Port Cardiol 2020 08 28;39(8):463-473. Epub 2020 Jul 28.

Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal; Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

The number and complexity of percutaneous interventions for the treatment of structural heart disease has increased in clinical practice in parallel with the development of new imaging technologies, in order to render these interventions safer and more accurate. Complementary imaging modalities are commonly used, but they require additional mental reconstruction and effort by the interventional team. The concept of fusion imaging, where two different modalities are fused in real time and on a single monitor, aims to solve these limitations. This is an important tool to guide percutaneous interventions, enabling a good visualization of catheters, guidewires and devices employed, with enhanced spatial resolution and anatomical definition. It also allows the marking of anatomical reference points of interest for the procedure. Some studies show decreased procedural time and total radiation dose with fusion imaging; however, there is a need to obtain data with more robust scientific methodology to assess the impact of this technology in clinical practice. The aim of this review is to describe the concept and basic principles of fusion imaging, its main clinical applications and some considerations about the promising future of this imaging technology.
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http://dx.doi.org/10.1016/j.repc.2020.03.014DOI Listing
August 2020

Peripheral insulin administration enhances the electrical activity of oxytocin and vasopressin neurones in vivo.

J Neuroendocrinol 2020 04 16;32(4):e12841. Epub 2020 Mar 16.

Centre for Discovery Brain Sciences, The University of Edinburgh, Edinburgh, UK.

Oxytocin neurones are involved in the regulation of energy balance through diverse central and peripheral actions and, in rats, they are potently activated by gavage of sweet substances. Here, we test the hypothesis that this activation is mediated by the central actions of insulin. We show that, in urethane-anaesthetised rats, oxytocin cells in the supraoptic nucleus show prolonged activation after i.v. injections of insulin, and that this response is greater in fasted rats than in non-fasted rats. Vasopressin cells are also activated, although less consistently. We also show that this activation of oxytocin cells is independent of changes in plasma glucose concentration, and is completely blocked by central (i.c.v.) administration of an insulin receptor antagonist. Finally, we replicate the previously published finding that oxytocin cells are activated by gavage of sweetened condensed milk, and show that this response too is completely blocked by central administration of an insulin receptor antagonist. We conclude that the response of oxytocin cells to gavage of sweetened condensed milk is mediated by the central actions of insulin.
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http://dx.doi.org/10.1111/jne.12841DOI Listing
April 2020

Ovulation mechanism in South American Camelids: The active role of β-NGF as the chemical signal eliciting ovulation in llamas and alpacas.

Theriogenology 2020 Jul 30;150:280-287. Epub 2020 Jan 30.

Faculty of Veterinary Sciences, Universidad Austral de Chile, Valdivia, Chile. Electronic address:

The ovulation-inducing effect of seminal plasma was first suggested in Bactrian camels over 30 years ago, initiating a long search to identify the 'ovulation-inducing factor' (OIF) present in camelids semen. During the last decade, primarily in llamas and alpacas, this molecule has been intensively studied characterizing its biological and chemical properties and ultimately identifying it as β-Nerve Growth Factor (β-NGF). The high concentration of OIF/β-NGF in seminal plasma of llamas and alpacas, and the striking effects of seminal fluid on ovarian function strongly support the notion of an endocrine mode of action. Also, have challenged the dogma of mating induced ovulation in camelid species, questioning the classical definition of reflex ovulators, which at the light of new evidence should be revised and updated. On the other hand, the presence of OIF/β-NGF and its ovulatory effect in camelids confirm the notion that seminal plasma is not only a transport and survival medium for sperm but also, a signaling agent targeting female tissues after insemination, generating relevant physiological and reproductive consequences. The presence of this molecule, conserved among induced as well as spontaneous ovulating species, clearly suggests that the potential impacts of this reproductive feature extend beyond the camelid species and may have broad implications in mammalian fertility. The aim of the present review is to provide a brief summary of all research efforts undertaken to isolate and identify the ovulation inducing factor present in the seminal plasma of camelids. Also to give an update of the current understanding of the mechanism of action of seminal β-NGF, at central and ovarian level; finally suggesting possible brain targets for this molecule.
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http://dx.doi.org/10.1016/j.theriogenology.2020.01.078DOI Listing
July 2020

Spontaneous coronary artery dissection: "To stent or not to stent, that is the question".

Rev Port Cardiol 2019 08 4;38(8):609.e1-609.e7. Epub 2019 Nov 4.

Centro Hospitalar Universitário Coimbra, Hospital Geral, Coimbra, Portugal.

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome that typically occurs in relatively young patients without classical cardiovascular risk factors for coronary artery disease. The etiology appears to be multifactorial and optimal management is not clearly established, so the treatment strategy is often selected based on clinical presentation and coronary anatomy. We present two cases of spontaneous coronary artery dissection with different initial approaches, highlighting the importance of a case-by-case assessment.
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http://dx.doi.org/10.1016/j.repc.2017.06.027DOI Listing
August 2019

Percutaneous Occlusion of Paravalvular Aortic Leaks: A Single-Center Experience Focused on Intracardiac Echocardiography.

J Invasive Cardiol 2019 Nov;31(11):346-351

Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra - Pólo Hospital Geral, Quinta dos Vales, 3041-801, Coimbra, Portugal.

Objectives: To describe our initial experience with an intracardiac echocardiography (ICE) for guidance of aortic percutaneous paravalvular leak occlusion (PPVLO) and to assess the outcomes after aortic PPVLO.

Background: PPVLO has emerged as an alternative to cardiac surgery for patients with symptomatic PVLs. ICE is an appealing alternative to transesophageal echocardiography (TEE) for guidance of percutaneous structural interventions, but experience with ICE for PPVLO guidance is limited.

Methods: We performed a retrospective analysis of all aortic PPVLOs performed in our center. The primary endpoints were technical and procedural success. Secondary endpoints included procedure-related complications, mortality, hospital admission due to heart failure, and improvement in New York Heart Association (NYHA) functional class.

Results: Ten aortic PPVLOs were included. ICE was used to guide 40% of the aortic PPVLOs. Median follow-up was 22 months (interquartile range, 3-33 months). Mortality was 22% and hospital admission due to heart failure was 33%. Technical and procedural success rates were 90% and 80%, respectively. Median NYHA class improved significantly after the procedure (P<.01). Success was achieved in all ICE cases without any procedure-related complications.

Conclusion: In our initial experience with an ICE-guided approach for aortic PPVLO, technical and procedural success were achieved and there were no procedure-related complications.
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November 2019

Left atrial appendage occlusion for stroke despite oral anticoagulation (resistant stroke). Results from the Amplatzer Cardiac Plug registry.

Rev Esp Cardiol (Engl Ed) 2020 Jan 27;73(1):28-34. Epub 2019 Apr 27.

Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece.

Introduction And Objectives: Despite the efficacy of oral anticoagulant (OAC) therapy, some patients continue to have a high residual risk and develop a stroke on OAC therapy (resistant stroke [RS]), and there is a lack of evidence on the management of these patients. The aim of this study was to analyze the safety and efficacy of left atrial appendage occlusion (LAAO) as secondary prevention in patients with nonvalvular atrial fibrillation who have experienced a stroke/transient ischemic attack despite OAC treatment.

Methods: We analyzed data from the Amplatzer Cardiac Plug multicenter registry on 1047 consecutive patients with nonvalvular atrial fibrillation undergoing LAAO. Patientes with previous stroke on OAC therapy as indication for LAAO were identified and compared with patients with other indications.

Results: A total of 115 patients (11%) with RS were identified. The CHADS-VASc and the HAS-BLED score were significantly higher in the RS group (respectively 5.5±1.5 vs 4.3±1.6; P <.001; 3.9±1.3 vs 3.1±1.2; P <.001). No significant differences were observed in periprocedural major safety events (7.8 vs 4.5%; P=.1). With a mean clinical follow-up of 16.2±12.2 months, the observed annual stroke/transient ischemic attack rate for the RS group was 2.6% (65% risk reduction) and the observed annual major bleeding rate was 0% (100% risk reduction).

Conclusions: Patients with RS undergoing LAAO showed similar safety outcomes to patients without RS, with a significant reduction in stroke/transient ischemic attack and major bleeding events during follow-up. Adequately powered controlled trials are needed to further investigate the use of LAAO in RS patients.
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http://dx.doi.org/10.1016/j.rec.2019.02.013DOI Listing
January 2020

Intracardiac echography for left atrial appendage closure: A step-by-step tutorial.

Catheter Cardiovasc Interv 2019 04 30;93(5):E302-E310. Epub 2018 Sep 30.

Hospital Geral, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

Objectives: We sought to provide a practical educational tool for the utilization of intracardiac echography (ICE) in the left atrium for the percutaneous closure of the left atrial appendage (LAA).

Background: Although transesophageal echocardiography (TEE) is the gold-standard imaging technique for LAA closure, ICE is stepping in to support noncoronary cardiology interventions by improving workflow and case turnover and may be more adequate for frail patients with significant and multiple comorbidities.

Methods: This article discusses the utility of ICE for LAA closure, its advantages compared to TEE, contraindications to TEE use and offers an extensive illustration of the main steps of the procedure.

Conclusions: The use of ICE in the left atrium allows a feasible guidance of all steps of the percutaneous closure of LAA.
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http://dx.doi.org/10.1002/ccd.27898DOI Listing
April 2019

Registry of left atrial appendage closure and initial experience with intracardiac echocardiography.

Rev Port Cardiol 2018 09 13;37(9):763-772. Epub 2018 Sep 13.

Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Coimbra, Portugal; Serviço de Cardiologia, Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal.

Introduction: Percutaneous closure of the left atrial appendage (LAA) is a promising therapy in patients with atrial fibrillation with high risk for stroke and contraindication for oral anticoagulation (OAC). Intracardiac echocardiography (ICE) may make this percutaneous procedure feasible in patients in whom transesophageal echocardiography (TEE) is inadvisable. Our aim was to assess the efficacy and safety of LAA closure and the feasibility of ICE compared to TEE to guide the procedure.

Methods: In this cohort study of patients who underwent LAA closure between May 2010 and January 2017, clinical and imaging assessment was performed before and after the procedure.

Results: In 82 patients (mean age 74±8 years, 64.4% male) the contraindications for OAC were severe bleeding or anemia (65%), high bleeding risk (14%), labile INR (16%), or recurrent embolic events (5%). The procedural success rate was 96.3%. The procedure was guided by TEE or ICE, and no statistically significant differences were observed between the two techniques. During follow-up, one patient had an ischemic stroke at 12 months, two had bleeding complications at six months, and there were four non-cardiovascular deaths. Embolic and bleeding events were less frequent than expected from the observed CHADSVASc (0.6% vs. 6.3%; p<0.001) and HAS-BLED (1.2% vs. 4.1%; p<0.001) risk scores.

Conclusions: In this population percutaneous LAA closure was shown to be safe and effective given the lower frequency of events than estimated by the CHADSVASc and HAS-BLED scores. The clinical and imaging results of procedures guided by ICE in the left atrium were not inferior to those guided by TEE.
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http://dx.doi.org/10.1016/j.repc.2018.03.009DOI Listing
September 2018

Thrombus in left atrial appendage - Overcoming percutaneous closure limitations.

Rev Port Cardiol 2018 Mar 30;37(3):269-270. Epub 2018 Mar 30.

Centro Hospitalar Universitário Coimbra, Hospital Geral, Coimbra, Portugal.

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http://dx.doi.org/10.1016/j.repc.2017.04.006DOI Listing
March 2018

A poor outcome after surgical aortic replacement.

Rev Port Cardiol 2017 Dec 7;36(12):965-966. Epub 2017 Dec 7.

Hospital Geral, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Universidade de Coimbra, Coimbra, Portugal.

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http://dx.doi.org/10.1016/j.repc.2016.10.014DOI Listing
December 2017

[Secondary Arterial Hypertension: Uncertainties in Diagnosis].

Acta Med Port 2017 Jun 30;30(6):493-496. Epub 2017 Jun 30.

Serviço de Cardiologia. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal.

Arterial hypertension is regarded today as a global public health problem, and the prevalence rate in Portugal is 26.9%. According to the etiology, is classified into primary or secondary arterial hypertension. In about 90% of cases it is not possible to establish a cause, so is called primary arterial hypertension. In the remaining 5 to 10%, it can be identified secondary causes, which are potentially treatable. For secondary arterial hypertension study to be cost-effective, it is essential to understand which patients investigate, and evaluate the best strategy to adopt. The main causes identified as responsible for secondary arterial hypertension are: kidney disease; endocrine and vascular diseases and obstructive sleep apnea. Among these some are consensual, and others more controversial in the literature. In this regard we present two cases of arterial hypertension, which are potentially secondary in etiology, but still focus of debate.
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http://dx.doi.org/10.20344/amp.8007DOI Listing
June 2017

Risk stratification in acute coronary syndromes: Graced by a new score?

Rev Port Cardiol 2017 09 31;36(9):677-679. Epub 2017 Aug 31.

Hospital Geral, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Universidade de Coimbra, Coimbra, Portugal.

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http://dx.doi.org/10.1016/j.repc.2017.03.007DOI Listing
September 2017

Characterization of Cerebrovascular Events After Left Atrial Appendage Occlusion.

Am J Cardiol 2016 Dec 15;118(12):1836-1841. Epub 2016 Sep 15.

Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece.

Cardioembolic strokes are generally more lethal and disabling than other source of strokes. Data from PROTECT AF (Watchman Left Atrial Appendage Closure Technology for Embolic Protection in Patients With Atrial Fibrillation) suggest that strokes after left atrial appendage occlusion (LAAO) with the Watchman device are less disabling than those in the warfarin group. No data assessing the severity of strokes after LAAO with the AMPLATZER Cardiac Plug (ACP) are available. The objective of the study was to evaluate the severity of cerebrovascular events after LAAO with the ACP in a population mostly characterized by an absolute or relative contraindication to oral anticoagulation. Data from the ACP multicenter registry were analyzed. Disabling strokes were defined as those with a modified Rankin score of 3 to 6 at 90 days after the event. A total of 1,047 subjects were included. The mean age and CHADS score were 75 ± 8 years and 2.8 ± 1.3, respectively. Procedural success was achieved in 97.3% and 4.9% of the patients presented procedural major adverse events. Clinical follow-up was complete in 98.2% of patients with a median of 13 months. There were 9 strokes (0.9%), 9 transient ischemic attacks (0.9%), and no intracranial hemorrhages (0%) at follow-up. After excluding 2 patients with pre-LAAO disability, functional assessment showed disabling events in 3 (19%) of the remaining 16 patients. The median time of presentation was 420 days (interquartile range 234 to 671) after LAAO, and 17 patients (94%) were on single-antiplatelet therapy when the event occurred. According to our results, cerebrovascular events after LAAO with the ACP system were infrequent and mostly nondisabling.
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http://dx.doi.org/10.1016/j.amjcard.2016.08.075DOI Listing
December 2016

Satisfaction and gains perceived by nursing students with medium and high-fidelity simulation: A randomized controlled trial.

Nurse Educ Today 2016 Nov 30;46:127-132. Epub 2016 Aug 30.

Coimbra Nursing School, Portugal. Electronic address:

Background: The use of simulation to reproduce the experience of health care settings and its use as a strategy in the teaching of nurses has grown at an unprecedented rate. There is little scientific evidence to examine the differences in satisfaction and gains perceived by the students with the use of medium and high fidelity.

Objectives: To analyse and benchmark gains and satisfaction perceived by nursing students, according to their participation in medium- and high-fidelity simulated practice.

Design: Randomized control trial post-test only design with control group.

Setting And Participants: Students of the 4th year of the Bachelor's Degree in Nursing who performed medium and high-fidelity simulated practice in a Simulation Centre environment.

Methods: A satisfaction scale and a scale of perceived gains from the simulation were applied to the students who underwent simulated practice in a medium-fidelity environment (control group) and high-fidelity environment (experimental group). Statistical analysis was performed and a significance level of p<0.05 was established.

Results: Of the 85 students who participated in the study, the majority were female (92.94%), with an average age of 21.89years (SD=2.81years). Satisfaction is statistically significant in the realism dimension and overall satisfaction. In the gains perceived with the simulation there is a statistically significant difference in the dimension recognition/decision.

Conclusion: Students are very satisfied with the realism of high-fidelity simulated practice and consider that this helps them more with recognition and decision compared with the medium-fidelity simulation.
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http://dx.doi.org/10.1016/j.nedt.2016.08.027DOI Listing
November 2016

Diagnostic approach to cardiac amyloidosis: A case report.

Rev Port Cardiol 2016 May 23;35(5):305.e1-7. Epub 2016 Apr 23.

Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Coimbra, Portugal.

The authors present a case of systemic amyloidosis with cardiac involvement. We discuss the need for a high level of suspicion to establish a diagnosis, diagnostic techniques and treatment options. Our patient was a 78-year-old man with chronic renal disease and atrial fibrillation admitted with acute decompensated heart failure of unknown cause. The transthoracic echocardiogram revealed severely impaired left ventricular function with phenotypic overlap between hypertrophic and restrictive cardiomyopathy. After an extensive diagnostic workup, which included an abdominal fat pad biopsy, the final diagnosis was amyloidosis.
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http://dx.doi.org/10.1016/j.repc.2016.01.004DOI Listing
May 2016

Additional value of associating aortic valve calcification to coronary calcium as a gatekeeper for coronary tomography angiography.

BMC Cardiovasc Disord 2015 Jul 1;15:61. Epub 2015 Jul 1.

Cardiology Department, Coimbra's Hospital and University Centre - General Hospital, 3041-801 S. Martinho do Bispo, Coimbra, Portugal.

Background: Aortic valve calcification shares risk factors with coronary artery disease. Coronary calcium has been used has a gatekeeper to performing coronary tomography angiography. The aim of this study was to evaluate aortic valve calcification as a predictor of obstructive coronary artery disease by computed tomography, and its possible usefulness, alongside with coronary calcium, to improve the decision of whether or not to proceed with computed tomography angiography.

Methods: Transversal case-control study including 154 consecutive patients (62 ± 12 years, 57.6 % female, without known coronary or valve disease) undergoing calcium scoring and angiography through computed tomography (Phillips Brilliance, 16-slice). Predictors of aortic valve calcification and obstructive coronary artery disease were identified. Usefulness of aortic valve calcification when added to calcium score for prediction of obstructive coronary artery disease was assessed by binary logistic regression and net reclassification index.

Results: Aortic valve calcification was associated with higher coronary calcium, extent and prevalence of obstructive coronary disease, which was identified in 22.1 % of patients and was discriminated by aortic valve calcium with an area under curve 0.749 (p < 0.001, Youden index: 61). A higher discriminative power was achieved with a model based on coronary and aortic valve calcification (AUC 0.900, p < 0.001). Compared with calcium score >400 as a gatekeeper to angiography, the association of aortic calcium >61 allowed a net reclassification index of +7.7 % of patients.

Conclusions: Aortic valve calcification is associated with the prevalence and extent of obstructive coronary artery disease by computed tomography angiography and is an easy, fast and useful method to improve the selection of patients for angiography.
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http://dx.doi.org/10.1186/s12872-015-0058-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4486129PMC
July 2015

Authors' reply.

Europace 2015 Sep 2;17(9):1456. Epub 2015 Apr 2.

Cardiology Department, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB23 3RE, UK.

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http://dx.doi.org/10.1093/europace/euv023DOI Listing
September 2015

Universal definition of myocardial infarction: clinical insights.

Cardiology 2015 27;131(1):13-21. Epub 2015 Mar 27.

Coimbra's Hospital and University Centre, Coimbra, Portugal.

Aims: The universal definition of myocardial infarction (MI) classifies acute ischaemia into different classes according to lesion mechanism. Our aim was to perform a detailed comparison between these different types of MI in terms of baseline characteristics, management and prognosis.

Methods And Results: An observational retrospective single-centre cohort study was performed, including 1,000 consecutive patients admitted for type 1 (76.4%) or type 2 MI (23.6%). Type 2 MI patients were older, had a higher prevalence of comorbidities and worse medical status at admission. In-hospital mortality did not differ significantly between the MI groups (8.8 vs. 9.7%, p = 0.602). However, mortality during follow-up was almost 3 times higher in type 2 MIs (HR 2.75, p < 0.001). Type 2 MI was an independent all-cause mortality risk marker, adding discriminatory power to the GRACE model. Finally, important differences in traditional risk score performances (GRACE, CRUSADE) were found between both MI types.

Conclusions: Several important baseline differences were found between these MI types. Regarding prognosis, long-term survival is significantly compromised in type 2 MIs, potentially translating patients' higher medical complexity and frailty. Distinction between type 1 and type 2 MI seems to have important implications in clinical practice and likely also in the results of clinical trials.
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http://dx.doi.org/10.1159/000371739DOI Listing
July 2015

Percutaneous patent foramen ovale closure: the Paradoxical Cerebral Embolism Prevention Registry.

Rev Port Cardiol 2015 Mar 27;34(3):151-7. Epub 2015 Feb 27.

Serviço de Cardiologia, Hospital Geral, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

Introduction: The natural history and therapeutic interventions for secondary prevention after a cerebrovascular event in patients with patent foramen ovale (PFO) are not yet established. This study aims to assess the safety and efficacy of percutaneous PFO closure in a population of patients with ischemic cerebrovascular disease of unknown etiology.

Methods: This prospective observational study included patients with a history of cryptogenic transient ischemic attack (TIA) or stroke who underwent percutaneous PFO closure. The effectiveness of the device for the secondary prevention of TIA or stroke was assessed by comparing observed events in the sample with expected events for this clinical setting.

Results: The sample included 193 cases of percutaneous PFO closure (age 46.4 ± 13.1 years, 62.2% female) with a mean follow-up of 4.3 ± 2.2 years, corresponding to a total exposure to ischemic events of 542 patient-years. The high-risk characteristics of the PFO were assessed prior to device implantation. There were seven primary endpoint events during follow-up (1.3 per 100 patient-years), corresponding to a relative risk reduction of 68.2% in recurrent TIA or stroke compared to medical therapy alone. The procedure was associated with a low rate of device- or intervention-related complications (1.5%).

Conclusions: In this long-term registry, percutaneous PFO closure was shown to be a safe and effective therapy for the secondary prevention of cryptogenic stroke or TIA.
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http://dx.doi.org/10.1016/j.repc.2014.08.009DOI Listing
March 2015

Implantable cardioverter-defibrillators in the elderly: rationale and specific age-related considerations.

Europace 2015 Feb 5;17(2):174-86. Epub 2014 Dec 5.

Cardiology Department, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB23 3RE, UK.

Despite the increasingly high rate of implantation of cardioverter-defibrillators (ICD) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We comprehensively reviewed the state-of-the-art data regarding the applicability, safety, clinical- and cost-effectiveness of the ICD in elderly patients, and analysed which patients in this age stratum are more likely to get a survival benefit from this therapy. Although peri-procedural risk may be slightly higher in the elderly, this procedure is still relatively safe in this age group. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is comparable in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantage of the device on arrhythmic death may be largely attenuated by a higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in highly selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD intervention among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live >5-7 years after implantation. Biological age rather than chronological age per se should be the decisive factor in making a decision on ICD selection for survival benefit.
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http://dx.doi.org/10.1093/europace/euu296DOI Listing
February 2015

Improving risk stratification in non-ST-segment elevation myocardial infarction with combined assessment of GRACE and CRUSADE risk scores.

Arch Cardiovasc Dis 2014 Dec 11;107(12):681-9. Epub 2014 Sep 11.

Coimbra's Hospital and University Centre, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal.

Background: Risk assessment is fundamental in the management of acute coronary syndromes (ACS), enabling estimation of prognosis.

Aims: To evaluate whether the combined use of GRACE and CRUSADE risk stratification schemes in patients with myocardial infarction outperforms each of the scores individually in terms of mortality and haemorrhagic risk prediction.

Methods: Observational retrospective single-centre cohort study including 566 consecutive patients admitted for non-ST-segment elevation myocardial infarction. The CRUSADE model increased GRACE discriminatory performance in predicting all-cause mortality, ascertained by Cox regression, demonstrating CRUSADE independent and additive predictive value, which was sustained throughout follow-up. The cohort was divided into four different subgroups: G1 (GRACE<141; CRUSADE<41); G2 (GRACE<141; CRUSADE≥41); G3 (GRACE≥141; CRUSADE<41); G4 (GRACE≥141; CRUSADE≥41).

Results: Outcomes and variables estimating clinical severity, such as admission Killip-Kimbal class and left ventricular systolic dysfunction, deteriorated progressively throughout the subgroups (G1 to G4). Survival analysis differentiated three risk strata (G1, lowest risk; G2 and G3, intermediate risk; G4, highest risk). The GRACE+CRUSADE model revealed higher prognostic performance (area under the curve [AUC] 0.76) than GRACE alone (AUC 0.70) for mortality prediction, further confirmed by the integrated discrimination improvement index. Moreover, GRACE+CRUSADE combined risk assessment seemed to be valuable in delineating bleeding risk in this setting, identifying G4 as a very high-risk subgroup (hazard ratio 3.5; P<0.001).

Conclusions: Combined risk stratification with GRACE and CRUSADE scores can improve the individual discriminatory power of GRACE and CRUSADE models in the prediction of all-cause mortality and bleeding. This combined assessment is a practical approach that is potentially advantageous in treatment decision-making.
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http://dx.doi.org/10.1016/j.acvd.2014.06.008DOI Listing
December 2014

Which method of left atrium size quantification is the most accurate to recognize thromboembolic risk in patients with non-valvular atrial fibrillation?

Cardiovasc Ultrasound 2014 Jul 22;12:28. Epub 2014 Jul 22.

Cardiology Department, Coimbra's Hospital and University Centre - General Hospital, Coimbra, Portugal.

Background: Left atrial (LA) size is a predictor of cardiovascular outcomes in patients in sinus rhythm, whereas conflicting results have been found in atrial fibrillation (AF). This study aims to: (1) Evaluate the accuracy of LA size to identify surrogate markers of an increased thromboembolic risk in patients with AF; (2) Assess the best method to evaluate LA size in this setting.

Methods: Cross-sectional study enrolling 500 consecutive patients undergoing transthoracic and transesophageal echocardiography evaluation during a non-valvular AF episode. LA size was measured on transthoracic echocardiography using several methods: anteroposterior diameter, area in four-chamber view, and volumes by the ellipsoid, single- and biplane area-length formulas. Surrogate markers of stroke were evaluated by transesophageal echocardiography: LA appendage (LAA) thrombus, LAA low flow velocities, dense spontaneous echocardiographic contrast and LA abnormality.

Results: Except for non-indexed anteroposterior diameter, increased LA size quantified by all the other methods showed a moderate to high discriminatory power to identify all the surrogate markers of stroke. A higher accuracy was observed for indexed LA area in four-chamber view (LAA thrombus: AUC = 0.708, CI95% 0.644- 0.772, p<0.001; LAA low flow velocities: AUC = 0.733, CI95% 0.674- 0.793, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.693, CI95% 0.638- 0.748, p<0.001; LA abnormality: AUC = 0.705, CI95% 0.654-0.755, p<0.001), indexed single-plane area-length volume (LAA thrombus: AUC = 0.701, CI95% 0.633-0.770, p<0.001; LAA low flow velocities: AUC = 0.726, CI95% 0.660-0.792, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.673, CI95% 0.611-0.736, p<0.001; LA abnormality: AUC = 0.687, CI95% 0.629-0.744, p<0.001), and indexed biplane area-length volume (LAA thrombus: AUC = 0.707, CI95% 0.626-0.788, p<0.001; LAA low flow velocities: AUC = 0.737, CI95% 0.664-0.810, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.651, CI95% 0.578-0.724, p<0.001; LA abnormality: AUC = 0.683, CI95% 0.617-0.749, p<0.001), without significant difference between them. Indexed LA area in four-chamber view and indexed area-length volumes also were independent predictors of surrogate markers of stroke.

Conclusions: Left atrium enlargement is associated with an increased prevalence of surrogate markers of stroke in patients with non-valvular AF. Indexed LA area in four-chamber view and indexed area-length volumes displayed the strongest association.
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http://dx.doi.org/10.1186/1476-7120-12-28DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4121510PMC
July 2014

Cardiac involvement in antiphospholipid syndrome associated with Sneddon syndrome: a challenging diagnosis.

Rev Port Cardiol 2014 Feb 7;33(2):115.e1-7. Epub 2014 Feb 7.

Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Hospital Geral, Coimbra, Portugal.

Sneddon syndrome is a rare clinical entity characterized by the association of ischemic cerebrovascular disease and livedo reticularis. The authors report a case of stroke and myocardial infarction in a 39-year-old man with Sneddon syndrome and antiphospholipid syndrome who subsequently met some criteria for systemic lupus erythematosus, highlighting the complexity of cardiovascular involvement in systemic diseases.
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http://dx.doi.org/10.1016/j.repc.2013.09.006DOI Listing
February 2014