166 Balloon aortic valvuloplasty in unstable and critically ill patients: analysis of three strategies

AimThanks to improved technology and the advent of transcatheter aortic valve implantation (TAVI), balloon aortic valvuloplasty (BAV) has reappared in the management of high risk patients with severe aortic stenosis in a critical clinical state in three different therapeutic strategies: 1) palliative care [A] 2) bridge to surgery [B] 3) bridge to TAVI [C]. Our main objective was to assess the safety, the effiency and the pertinence of BAV.MethodsThirty six patients with severe aortic stenosis and prohibitive surgical risk (logistic Euroscore>15% or severe commorbidities) underwent 39 BAV: 8 in strategy A, 20 in strategy B, 11 in strategy C. 3 patients underwent a second BAV due to early restenosis.ResultsThere was a significant improvement of the hemodynamic parameters after BAV: the peak to peak transaortic gradient was reduced by 56% (47mmHg vs 30mmHg; p<0.001) and index valve area was increased by 48% (0.35 vs 0.52cm2/m2; p<0.001). There was no severe procedural complication (no death due to procedure, no massive aortic insuffisiency, no tamponade). Two patients (5.1%) needed a pacemaker implantation for postprocedure atrioventricular block and 6 patients (15.4%) had moderate bleeding of the femoral artery site. The mortality and follow up for the three strategies are summarized in the table.ConclusionBAV is a safe and efficient transient therapeutic strategy for patients with severe aortic stenosis with prohibitive surgical risk. BAV appears to be more pertinent in bridge to surgery or brige to TAVI than in palliative care. For patients in critical clinical state, BAV stabilizes the hemodynamic status and allows the assessment of anatomical selection criteria for TAVIStratégy A(n=8)Stratégy B(n=20)Stratégy C(n=11)Age (mean, min-max)80 (61–94)73 (44–85)81 (60–87)Mean logistic Euroscore (%)4822.644.2Death n (%)6 (75)8 (40)5 (45)Cardiovascular death n (%)4 (50)3 (15)2 (18)Time of occurrence (days, min-max)12 (0–47)66 (0–130)155 (10–316)Aortic valve replacement n (%)-14 (70)-TAVI n (%)--2 (18

Thrombus burden management during primary coronary bifurcation intervention: a new experimental bench model

Background: Management of thrombus burden during primary percutaneous coronary intervention (pPCI) is a key-point, given the high risk of stent malapposition and/or thrombus embolization. These issues are especially important if pPCI involves a coronary bifurcation. Herein, a new experimental bifurcation bench model to analyze thrombus burden behavior was developed. Methods: On a fractal left main bifurcation bench model, we generated standardized thrombus with human blood and tissue factor. Three provisional pPCI strategies were compared (n = 10/group): 1) balloon-expandable stent (BES), 2) BES completed by proximal optimizing technique (POT), and 3) nitinol self-apposing stent (SAS). The embolized distal thrombus after stent implantation was weighed. Stent apposition and thrombus trapped by the stent were quantified on 2D-OCT. To analyze final stent apposition, a new OCT acquisition was performed after pharmacological thrombolysis. Results: Trapped thrombus was significantly greater with isolated BES than SAS or BES+POT (18.8 ± 5.8% vs. 10.3 ± 3.3% and 6.2 ± 2.1%, respectively; p &lt; 0.05), and greater with SAS than BES+POT (p &lt; 0.05). Isolated BES and SAS tended show less embolized thrombus than BES+POT (5.93 ± 4.32 mg and 5.05 ± 4.56 mg vs. 7.01 ± 4.32 mg, respectively; p = NS). Conversely, SAS and BES+POT ensured perfect final global apposition (0.4 ± 0.6% and 1.3 ± 1.3%, respectively, p = NS) compared to isolated BES (74.0 ± 7.6%, p &lt; 0.05). Conclusions: This first experimental bench model of pPCI in a bifurcation quantified thrombus trapping and embolization. BES provided the best thrombus trapping, while SAS and BES+POT achieved better final stent apposition. These factors should be taken into account in selecting revascularization strategy

Primary PCI with or without Thrombectomy

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PREVENTION PRIMAIRE DE LA RESTENOSE INTRASTENT (ETUDE EXPERIMENTALE SUR ARTERES ILIATIQUES DE LAPIN D'UN STENT RECOUVERT DE CARBURE DE SILICIUM)

LYON1-BU Santé (693882101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Final kissing balloon inflation: the whole story

International audienceFinal kissing balloon inflation (KBI) after provisional bifurcation stenting has failed to provide clear clinical benefit except for a decrease in side branch stenosis, while a significant reduction of major adverse cardiac events has been documented in two-stent deployment. The optimisation of KBI in terms of proximal optimisation technique, appropriate guidewire re-crossing, minimal balloon overlapping, and balloon size selection may overcome the drawbacks of conventional KBI by: 1) correcting the proximal malapposition expected from fractal geometry; 2) optimising side branch ostium strut opening while conserving a bifurcation area free of malapposition at both the carina and the side branch ostium; and 3) optimising the geometry, velocity fields and shear rate

Percutaneous Management of Mitral Perforation During Transcatheter Aortic Valve Replacement

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Very late neoatherosclerotic plaque rupture in drug-eluting stent restenosis

International audienceA 71-year-old man presented in emergency department for non-ST-elevation myocardial infarction. At admission, 12-lead ECG was in sinus rhythm without sign of myocardial ischemia, and troponin slightly increased. The only notable feature of the patient's medical history was single-vessel coronary artery disease revealed 10 years previously, treated by stenting of the second segment of the right coronary artery with a 3.0 x 25 mm bare metal stent. Three months later, intrastent restenosis was managed by implantation of a 3.0 x 28 mm paclitaxel-eluting stent. Two years before the present admission, following a non contributive stress test for atypical chest pain, coronary angiogram had found a 60% diffuse intrastent restenosis. The present coronary angiogram performed via a right transradial approach demonstrated a focal intrastent restenosis (85%) with irregular contours. Optical coherence tomography (OCT) showed an atherosclerotic intrastent neolesion with intimal tear. OCT demonstrated more precisely a minimal luminal area of 1.02 mm (77.9% area stenosis), two wide cavities (length 1.1 and 1.4 mm) separated by a plaque rupture of 6.8 mm. Myocardial ischemia was evenly demonstrated on this artery with a fractional flow reserve under 0.50 after 150 mg intracoronary adenosine bolus. The culprit lesion was treated by a 3.0 x 38 mm everolimus-eluting stent, with good angiographic results, confirmed on OCT

Modeling geometric artefacts in intravascular ultrasound imaging

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Numerical model and experimental test bench for hemodynamic : study of coronary artery: bifurcation, stent…

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