032: Thirty months outcomes after PCI of unprotected left main coronary artery according to the SYNTAX score

AimsTo assess middle term outcomes according to SYNTAX score and rates of delayed surgical/bleeding events after unprotected left main (LM) coronary artery (ULMCA) PCI in an unselected patients population.MethodsConsecutive patients treated by PCI for ULMCA were included among a single center 3508 PCI database within 36 months. Syntax scores were calculated, post discharge extracardiac surgery or hemorrhage were recorded during follow-up as clinical outcomes (Death, TVR, MACCE=cardiovascular death+MI+stroke+TLR).Results102 (3.6%) patients underwent PCI of the LM, including 21 protected LM. Among the 81 patients with PCI of ULMCA, mean age was 65±13, 27% had urgent PCI for AMI or cardiogenic shock, 61% had DES.SYNTAX score was 28±14 in mean and ≤22 in 30 (37%), 23 to 32 in 22 (27%) and ≥33 in 29 (36%) patients.At 30±11 months follow up (98% of the patients), death occurred in 24 patients (30%), TVR in 16 (20%) and MACCE in 35 (43%). Clinical events according to the SYNTAX score are shown in figure. No cardiovascular death occurred in patients with syntax ≤22. MACCE rates were significantly lower when DES were used (24% vs. 64%, p<0.05) and in case of non-urgent PCI (36% vs. 71%, p<0.05).During follow-up, 20 (25%) and 12 (15%) patients underwent unplanned extracardiac surgery and/or hemorrhage, leading to antiplatelet withdrawal in 31% of the cases.ConclusionsIn unselected patients treated by PCI of ULMCA with Syntax score ≤22, outcomes were found to be excellent with no cardiovascular death observed at 30 months. DES and non-urgent PCI were associated with a better prognosis. One patient out of three underwent unplanned extracardiac surgery or hemorrhage during follow up.Figure: 30-months outcomes according to SYNTAX scor

Intérêt de l’échocardiographie trans-œsophagienne tridimensionnelle pour évaluer le débit cardiaque chez les patients admis en réanimation : étude pilote

International audienceBackgroundThree-dimensional transoesophageal echocardiography (3D-TOE) is a new noninvasive tool for quantitative assessment of left ventricular (LV) volumes and ejection fraction.AimThe objective of this pilot study was to evaluate the feasibility and accuracy of 3D-TOE for the estimation of cardiac output (CO), using transpulmonary thermodilution with the Pulse index Contour Continuous Cardiac Output (PiCCO) system as the reference method, in intensive care unit (ICU) patients.MethodsFifteen ICU patients on mechanical ventilation prospectively underwent PiCCO catheter implantation and 3D-TOE. 3D-TOE LV end-diastolic and end-systolic volumes were determined using semi-automated software. CO was calculated as the product of LV stroke volume (end-diastolic volume − end-systolic volume) multiplied by heart rate. CO was also determined invasively by transpulmonary thermodilution as the reference method.ResultsAmong 30 haemodynamic evaluations, 29 (97%) LV 3D-TOE datasets were suitable for CO calculation. The mean 3D-TOE image acquisition and post-processing times were 46 and 155 seconds, respectively. There was a correlation (r = 0.78; P < 0.0001) between PiCCO and 3D-TOE CO. Compared with PiCCO, the 3D-TOE CO mean bias was 0.38 L/min, with limits of agreement of −1.97 to 2.74 L/min.ConclusionsNoninvasive estimation of CO by 3D-TOE is feasible in ICU patients. This new semi-automated modality is an additional promising tool for noninvasive haemodynamic assessment of ICU patients. However, the wide limits of agreement with thermodilution observed in this pilot study require further investigation in larger cohorts of patients.ContexteL’échocardiographie trans-œsophagienne tridimensionelle (ETO-3D) est une nouvelle modalité non invasive d’évaluation des volumes et de la fraction d’éjection du ventricule gauche (VG).ObjectifÉvaluer la faisabilité et la performance de l’ETO-3D comparativement à la thermodilution transpulmonaire par méthode PiCCO pour la mesure du débit cardiaque (DC).MéthodesDans cette étude pilote, 15 patients sous ventilation mécanique admis en réanimation et bénéficiant d’un monitorage hémodynamique invasif par le système PiCCO ont été prospectivement évalués par ETO-3D. Les volumes télé-diastolique et télé-systolique du VG ont été mesurés en utilisant un logiciel semi-automatique spécifique. Le DC a ensuite été calculé en multipliant le volume d’éjection systolique du VG (volume télé-diastolique − volume télé-systolique) par la fréquence cardiaque. Le DC a également été mesuré de façon invasive par thermodilution transpulmonaire.RésultatsParmi les 30 évaluations hémodynamiques effectuées, 29 (97 %) acquisitions ETO-3D étaient exploitables. Les temps moyens nécessaires pour l’acquisition et l’analyse des données ETO-3D étaient respectivement de 46 et 155 secondes. Les mesures de DC effectuées par ETO-3D et par méthode invasive étaient corrélées (r = 0,78 ; p < 0,0001). Le biais moyen entre les 2 méthodes de mesure était de 0,38 L/min, les limites d’agrément étaient de −1,97 à 2,74 L/min.ConclusionsL’évaluation non invasive du DC par ETO-3D est faisable. Cette nouvelle modalité ultrasonore est un outil prometteur pour l’évaluation hémodynamique des patients admis en réanimation. Les limites d’agrément relativement larges observées dans cette étude pilote comparativement à la theromdilution nécessitent toutefois d’être évaluer sur de plus larges populations de patients

Three-dimensional transesophageal echocardiography for descending aortic atheroma: a preliminary study

International audienceTransesophageal echocardiography (TEE) is an efficient method for characterization of aortic atherosclerotic plaques (AAP). The aim of our study was to evaluate the feasibility and the additional contribution of three-dimensional (3D) TEE in the evaluation of AAPs in descending thoracic aorta. We studied 82 patients referred for TEE regardless of the indication. All patients underwent two-dimensional (2D) conventional acquisitions. A 3D TEE study was performed for all AAPs localized in the descending thoracic aorta. Thickness, degree of calcification, the presence of ulceration or mobile debris were compared for 2D and 3D modes. From 3D data, three types of AAPs were defined according to their morphological characteristics (surface and contours). Among 192 AAPs found on 2D acquisition, 189 (98.4 %) were also identified by 3D TEE. For AAP characterization, agreement was good between 2D TEE and 2D extracted from 3D with the multiplanar reconstruction mode: 83.6 % (k = 0.69) for thickness and 82.5 % (k = 0.72) for degree of calcification. All AAPs ulcerations (n = 13) and mobile debris (n = 3) seen in 2D were identified in 3D. 2D characteristics of the 3D AAPs' morphological types were different: type I plaques were thin and rarely calcified; type III plaques were thicker and often calcified; and type II presented intermediate characteristics. There was overlap among groups and the 3D morphology could not be predicted from 2D data. 3D TEE is a feasible method for the analysis of AAPs. In addition to conventional characterization, 3D TEE provides a new morphological approach to AAPs

Impact of negative inotropic drugs on accuracy of diastolic stress echocardiography for evaluation of left ventricular filling pressure

Abstract The ratio of early diastolic trans-mitral flow velocity to tissue-Doppler mitral annular early diastolic velocity (E/e′), and left ventricular end-diastolic pressure(LVEDP) have been shown to be correlated at rest, provided that patients are not on positive inotropic drugs. Data concerning the latter correlation during exercise stress are conflicting. Therefore, we investigated if use of negative inotropic drugs (NID), impacts the accuracy of E/e′ as a surrogate for LVEDP during low-level exercise. An exercise(50 watts) during cardiac invasive hemodynamic monitoring and an exercise echocardiography were performed prospectively within 24 hours in 54 patients (81%male, 62 ± 9years) with preserved LV Ejection-Fraction. Before exercise, the patients had scattered LVEDP (13.8 ± 5.8 mmHg) and septal E/e′ (8.7 ± 2.7). Half of them were on NID, mainly betablockers(n = 26). The correlation between septal-E/e′ and LVEDP was low for examinations performed at rest (r = 0.35,p = 0.01) with no significant impact of NID. For measurements performed at 50 Watts, NID had a significant impact on the association between septal-E/e′50 watts and LVEDP50 watts (β = −0.28,p = 0.03). Correlation between septal-E/e′50 watts and LVEDP50 watts persisted in patients on NID (r = 0.61,p = 0.001) while it disappeared in the group of patients with no NID (r = 0.15,p = 0.47). NID use is an important confounding factor to take into consideration when assessing exercise LVFP using stress E/e′ in patients with preserved LVEF

Low level exercise echocardiography helps diagnose early stage heart failure with preserved ejection fraction: a study of echocardiography versus catheterization

International audienceBackgroundIncreased left ventricular end-diastolic pressure (LVEDP) with exercise is an early sign of heart failure with preserved left ventricular ejection fraction (LVEF). The abnormal exercise increase in LVEDP is nonlinear, with most change occurring at low-level exercise. Data on non-invasive approach of this condition are scarce. Our objective was assessing E/e′ to estimate low level exercise LVEDP using a direct invasive measurement as the reference method.Methods and resultsSixty patients with LVEF >50 % prospectively underwent both exercise cardiac catheterization and echocardiography. E/e′ was measured at rest and during low-level exercise. Abnormal LVEDP was defined as >16 mmHg. Patients with a history of coronary artery disease and/or abnormal LV morphology were classified as having apparent cardiac disease (CD). Thirty-four (57 %) patients had elevated LVEDP only during exercise. Most of the change in LVEDP occurred since the first exercise level (25 W). There was a correlation between LVEDP and septal E/e′ at rest and during exercise. Lateral E/e′ and E/average e′ ratio had worse correlations with LVEDP. In the whole population, exercise septal E/e′ at 25 W had the best accuracy for abnormal exercise LVEDP, area under curve (AUC) = 0.79. However, while low-level exercise septal E/e′ had a high accuracy in CD patients (n = 26, AUC = 0.96), E/e′ was not linked to LVEDP in patients without CD (n = 34).ConclusionLow-level exercise septal E/e′ is valuable for predicting abnormal exercise LVEDP in patients with preserved LVEF and apparent CD. However, this new diagnosis approach appears not reliable in patients with normal LV morphology and without coronary artery disease