Biological and morphological predictive factors of bleeding and ischemic recurrent events in athero-thrombosis

Malgré un traitement optimal, le risque de récurrences ischémiques et hémorragiques dans l’athéro-thrombose reste important et est associé à un mauvais pronostic. L’objectif principal de cette thèse était d’identifier les facteurs prédictifs biologiques et morphologiques associés avec ces récurrences à partir de plusieurs études incluant des patients de profils de risque différents, dans la maladie coronaire stable et instable. Au-delà du taux de LDL-cholestérol et du niveau d’inflammation mesuré par la CRP, la copeptine apparaît comme un biomarqueur utilisable en pratique clinique pour identifier les patients dont le pronostic est le plus défavorable après un syndrome coronarien aigu. D’autre part, la réponse au traitement antithrombotique évaluée par la mesure de la réactivité plaquettaire est un marqueur du risque aussi bien ischémique qu’hémorragique bien qu’une stratégie d’adaptation du traitement en fonction d’une cible de réactivité plaquettaire considérée comme optimale n’est pas associée à une réduction des événements. L’imagerie endocoronaire permet par ailleurs de caractériser les plaques d’athérome présentant des critères de vulnérabilité et à risque de progression. Associer ces critères morphologiques à des marqueurs biologiques permettrait ainsi d’identifier les patients les plus à risque de récurrences. Le risque résiduel après un événement athéro-thrombotique se doit d’être évalué de manière répétée pour optimiser le traitement et rechercher des complications telles que la formation d’un thrombus ventriculaire gauche associé à un taux majeur de récurrences en particulier lié à un traitement anticoagulant fréquemment suboptimal. Il apparaît ainsi nécessaire d’identifier le risque prédominant de chaque patient : inflammatoire, thrombotique, lié au métabolisme du cholestérol ou hémorragique à partir d’une évaluation multimodale.Despite optimal medical treatment, ischemic and bleeding recurrences remain frequent after an atherothrombotic event and are associated with poor prognosis.Based on several studies including patients with different risk profiles, in stable and unstable coronary artery disease setting, the main objective of this work was to identify biological and morphological predictive factors associated with these recurrences. In addition to LDL-cholesterol and systemic inflammation level measured by CRP, copeptine appears as a biomarker that can be used in clinical practice to identify the patients with the highest risk of mortality following an acute coronary syndrome. Moreover, the biological effect to antithrombotic therapy assessed by platelet reactivity monitoring is a marker of both ischemic and bleeding risk, although a strategy of treatment adjustment targeting an optimal platelet reactivity is not associated with a significant reduction of clinical outcomes.In parallel, intracoronary imaging allows the characterization of atheroma plaques to define criteria for plaque vulnerability and risk of plaque progression. Thus, combining these morphological criteria with biological markers would be useful to identify the patients with the higher risk of recurrences.The residual risk after an atherothrombotic event must be continuously evaluated to improve therapeutic management and identify complications such as a left ventricular thrombus which is associated with a major rate of recurrences due to frequent suboptimal anticoagulant treatment.In conclusion, it appears necessary to identify the predominant risk of each patient: inflammatory, thrombotic, related to cholesterol metabolism or bleeding risk with the support of an individualized and multimodal evaluation

Ivabradine: A promising drug in cardiogenic shock to prevent the undesirable sinus tachycardia induced by dobutamine?

International audienc

Coronary Artery Bypass Graft Surgery Guided by FFR

International audienceNo abstract availabl

The false illusion of coronary thrombus device-management

International audienc

Actualités de la revascularisation coronaire après choc cardiogénique secondaire à un infarctus aigu du myocarde

International audienceCardiogenic shock complicating acute myocardial infarction is challenging, and continues to be associated with high rates of in-hospital and long-term mortality. Coronary revascularization is critical for improving prognosis in CS. Thus, a systematic protocol-driven approach to cardiogenic shock, the development of specialized cardiac care centres, technical advances in interventional cardiology enabling treatment of more complex and severe lesions, the availability of recent antithrombotic therapies and the evolution of new haemodynamic support devices are important considerations in current management of cardiogenic shock complicating acute ischaemic heart disease. Despite these potentially meaningful developments, several substantial gaps in knowledge still exist regarding optimal coronary revascularization of patients with cardiogenic shock. This review will describe current principles in the revascularization of these patients, with a focus on: the time to transfer and revascularize; the choice of vascular access site; the need for complete revascularization or only a culprit lesion strategy; the optimal antithrombotic therapy; the type, place and timing of haemodynamic support; and the medical care system network.La survenue d’un choc cardiogénique après un infarctus du myocarde aigu reste une situation clinique fréquente et grave dont le pronostic est associé à une morbi-mortalité élevée. La revascularisation coronaire peut en théorie permettre d’améliorer le devenir de ces patients mais la rapidité du transfert, la précocité du geste, les modalités ainsi que le choix et le moment d’une éventuelle assistance restent des points essentiels. En conséquence, il paraît indispensable de construire une organisation en réseau avec des protocoles de prise en charge des patients présentant un choc cardiogénique constitué ou un infarctus du myocarde avec risque évolutif rapide vers le choc. L’organisation de soins doit tendre vers le développement de centres spécialisés comportant un environnement optimal de réanimation cardiologique, de support hémodynamique, pharmacologique et chirurgical. Dans cette revue de la littérature récente, nous discuterons des principes actuels de la revascularisation, en insistant particulièrement sur: (1) les délais de mise en œuvre; (2) la voie d’abord vasculaire; (3) le caractère ciblé de la revascularisation; (4) l’environnement anti-thrombotique; (5) la place de l’assistance et notamment le type d’assistance, le moment idéal du support hémodynamique; et (6) l’organisation du réseau de soins critique

What if the worst consequences of COVID-19 concerned non-COVID patients?

We highlight in this short article the side-effects of COVID-19 pandemic on the management of non-COVID patients, with potential detrimental and irreversible complications. We thus propose adjusted strategies to deal with both COVID and non-COVID patients

A rare cause of acute coronary syndrome in a handyman

International audienc

Recanalized Coronary Thrombus Role of OCT in Identifying a Slow-Evolving and Underestimated Coronary Lesion

Pathological studies have revealed spontaneous recanalized coronary thrombi as a frequent evolution of coronary occlusions; however, they are poorly recognized on coronary angiography, and the optimal therapeutic strategy for clinical evolution is unknown. We report the role of optical coherence tomography in identifying a recanalized coronary thrombus causing myocardial ischemia after 11 years of follow-up. (Level of Difficulty: Intermediate.

New Insights in Research About Acute Ischemic Myocardial Injury and Inflammation

International audienceRecognition that inflammation may contribute to the pathogenesis of various cardiac diseases has naturally led to the evaluation of the therapeutic potential of a range of anti-inflammatory approaches. Unfortunately, results in most settings have been disappointing. The majority of novel approaches fail despite promising preclinical data, partly attributable to off-target effects. The purpose of this review, focused on inflammation following acute myocardial ischemia, is to give a brief overview of the new insights regarding research on pro-inflammatory signaling cascades that could be targeted for cardioprotective therapeutic developments

Collagen plug-based vascular closure devices do not decrease vascular and bleeding complications occurring after balloon aortic valvuloplasty

International audienceBACKGROUND:The benefits of vascular closure devices (VCDs) in the prevention of vascular complications after femoral intervention remain controversial.AIM:To evaluate the efficiency of collagen plug-based VCDs in the prevention of femoral access complications after balloon aortic valvuloplasty.METHODS:We conducted a prospective analysis of consecutive patients who underwent balloon aortic valvuloplasty by femoral retrograde technique in our centre between 2009 and 2012. Group 1 included 75 patients in whom femoral puncture haemostasis was obtained with the use of an 8F collagen plug-based VCD (Angio-Seal™; Saint-Jude Medical, Inc.); group 2 included 105 patients who had manual or mechanical groin compression (FemoStop™; RADI Medical Systems, Inc.). We did not use heparin during the procedure. We collected data on major in-hospital adverse events, major bleeding (Bleeding Academic Research Consortium classification≥3) and vascular access complications.RESULTS:We included 180 patients with severe and symptomatic aortic stenosis. Indications for valvuloplasty were mainly bridge to transcatheter aortic valve implantation or palliative therapy (72%). The groups were similar in terms of median age, lower limb artery disease and body mass index. Vascular and bleeding complications occurred in 11.1% of patients and were not decreased with the use of VCDs (relative risk 2.60, 95% confidence interval 1.10-3.09; P=0.05). These findings were consistent across all prespecified subgroups. Duration of hospital stay was not reduced by VCDs.CONCLUSIONS:Based on the results of this study, performed with small-size sheaths and without heparin, collagen plug-based VCDs increase femoral access complications following aortic valvuloplasty. Systematic use of VCDs in elderly patients, with probable advanced limb atherosclerosis, is questionable