Bivalirudin during percutaneous coronary intervention in acute coronary syndromes

International audienceIntroduction: Anticoagulant therapy is critical to prevent ischemic recurrences and complications in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Unfractionated heparin (UFH), an injectable anticoagulant has several limitations: lack of predictability of its biological efficacy, platelets activation, heparin-induced thrombopenia and bleedings. Bivalirudin, a synthetic direct thrombin inhibitor has biological properties that promised better clinical outcome in ACS patients undergoing PCI. Areas covered: The present review aimed to summarize two decades of randomized clinical trials that compared bivalirudin to UFH in ACS patients treated with PCI. Early trials highlighted a reduction of bleedings with bivalirudin compared to UFH in combination with glycoprotein inhibitors (GPI). Recent studies questioned this reduction given that GPI are less and less used during PCI. Further, trials raised concerns about the risk of stent thrombosis in patients treated with bivalirudin. In light of this data, bivalirudin has been downgraded in international guidelines and appears as a second line anticoagulant agent after UFH. Expert opinion: The highly questioned reduction of bleedings under bivalirudin and the potential risk of stent thrombosis are unwarranted. Based on clinical trials, UFH has no equivalent in terms of anticoagulation in ACS patients undergoing PCI

Wearable cardioverter defibrillator: Bridge or alternative to implantation?

International audienceThe implantable cardioverter-defibrillator (ICD) is effective to prevent sudden cardiac death (SCD) in selected patients with heart disease known to be at high risk for ventricular arrhythmia. Nevertheless, this invasive and definitive therapy is not indicated in patients with potentially transient or reversible causes of sudden death, or in patients with temporary contra-indication for ICD placement. The wearable cardioverter defibrillator (WCD) is increasingly used for SCD prevention both in patients awaiting ICD implantation or with an estimated high risk of ventricular arrhythmia though to be transient. We conducted a review of current clinical uses and benefits of the WCD, and described its technical aspects, limitations and perspectives

Seasonal variations in cardiac implantable electronic device infections

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Intensified immunosuppressive therapy in patients with immune checkpoint inhibitor-induced myocarditis

International audienceBackgroundMyocarditis is a rare but life-threatening adverse event of cancer treatments with immune checkpoint inhibitors (ICIs). Recent guidelines recommend the use of high doses of corticosteroids as a first-line treatment, followed by intensified immunosuppressive therapy (IIST) in the case of unfavorable evolution. However, this strategy is empirical, and no studies have specifically addressed this issue. Therefore, we aimed to investigate and compare the clinical course, management and outcome of ICI-induced myocarditis patients requiring or not requiring IIST.MethodsThis case–control study included all patients consecutively admitted to The Mediterranean University Center of Cardio-Oncology (Aix-Marseille University, France) for the diagnosis of ICI-induced myocarditis according to Bonaca’s criteria and treated with or without IIST. In addition, we searched PubMed and included patients from previously published case reports treated with IIST in the analysis. The clinical, biological, imaging, treatment, all-cause death and cardiovascular death data of patients who required IIST were compared with those of patients who did not.ResultsA total of 60 patients (69±12 years) were included (36 were treated with IIST and 24 were not). Patients requiring IIST were more likely to have received a combination of ICIs (39% vs 8%, p=0.01), and developed the first symptoms/signs of myocarditis earlier after the onset of ICI therapy (median, 18 days vs 60 days, p=0.002). They had a significantly higher prevalence of sustained ventricular arrhythmia, complete atrioventricular block, cardiogenic shock and troponin elevation. Moreover, they were more likely to have other immune-related adverse events simultaneously (p<0.0001), especially myositis (p=0.0002) and myasthenia gravis (p=0.009). Patients who required IIST were more likely to die from any cause (50% vs 21%, p=0.02). Among them, patients who received infliximab were more likely to die from cardiovascular causes (OR, 12.0; 95% CI 2.1 to 67.1; p=0.005).ConclusionThe need for IIST was more common in patients who developed myocarditis very early after the start of ICI therapy, as well as when hemodynamic/electrical instability or neuromuscular adverse events occurred. Treatment with infliximab might be associated with an increased risk of cardiovascular death

Controlled sedation with midazolam and analgesia with nalbuphine to alleviate pain in patients undergoing subcutaneous implantable cardioverter defibrillator implantation

International audienceSubcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to transvenous ICD to prevent sudden cardiac death. Subcutaneous ICD implantation frequently requires general anesthesia because of procedure nociceptive steps during creation of a large device pocket and lead tunneling. This study aims to determine if a strategy of operator-guided controlled sedation with midazolam and analgesia with nalbuphine is effective in alleviating pain during S-ICD implantation. This prospective study included consecutive patients undergoing S-ICD implantation under controlled sedation with midazolam and combined analgesia with nalbuphine. The Critical-Care Pain Observation Tool (CPOT), a behavioral pain scale, was used for pain assessment during S-ICD placement and the Numeric Rate Scale (NRS) was used for evaluation of pain recollection after patient recovery. CPOT score of 3 or above and NRS score of 4 or above are considered to be associated with significant pain. Sixteen patients were included in this study: Ten men (62.5%) and six women with a mean age of 54 +/- 11 years. Indication for S-ICD implantation was primary prevention in 11 patients (68.8%). Mean dose of administrated midazolam and nalbuphine was 0.11 +/- 0.03 and 0.27 +/- 0.05 mg/kg, respectively. Mean CPOT during the whole procedure was 1.4 +/- 1.6. No patient presented procedural pain recollection as all 16 patients had NRS score less than 4. No serious adverse event related to sedation occurred during S-ICD implantation. This study suggests that operator-guided controlled sedation with midazolam and analgesia with nalbuphine is effective to alleviate procedural pain in patients undergoing S-ICD implantation and may constitute an alternative to general anesthesia

Prevalence and characteristics of coronary artery disease in heart failure with preserved and mid-range ejection fractions: A systematic angiography approach

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Identification of two thaumatin-like proteins (TLPs) in the pollination drop of hybrid yew that may play a role in pathogen defence during pollen collection.

We describe the proteomic identification of two pathogenesis-related group 5 (PR-5) proteins, an acidic thaumatin-like protein (TLP) and a basic TLP isolated from the pollination drop of hybrid yew (Taxus x media Rehder). The basic TLP (TxmTLPb) was the most abundant protein in the yew pollination drop based on protein spot size after two-dimensional electrophoresis. The acidic TLP (TxmTLPa) is also a major protein component of the yew ovular secretion and appears to be encoded by a number of mRNAs transcribed from a TLP gene family that has undergone limited sequence divergence. We have sequenced five acidic TLP-encoding cDNAs (TxmTLPa-1,2,3,4 and 5) isolated from the yew ovule that vary from each other by no more than five out of 233 amino acid residues in their predicted protein sequences. All of the cDNA variants encode TLPs possessing the 16 conserved cysteine residues and five charged amino acid side chains associated with antifungal activity. Amplification of genomic DNA with TxmTLPa primers indicated that at least 11 acidic TLPs with highly similar amino acid sequences may be expressed in yew tissues. Antibodies against TLPs confirmed the identity of TxmTLPa and TxmTLPb in the yew pollination drop and detected TLPs in the ovular secretions of four other species from three other conifer families. Our results suggest that TLPs are a conserved component of conifer ovular secretions and are involved in broad spectrum pathogen defence of ovules.Peer reviewed: YesNRC publication: Ye

Dynamic iron status after acute heart failure

International audienceBackground Iron deficiency (ID) is common in heart failure (HF), and is associated with unfavourable clinical outcomes. Although it is recommended to screen for ID in HF, there is no clear consensus on the optimal timing of its assessment. Aim To analyse changes in iron status during a short-term follow-up in patients admitted for acute HF. Methods Iron status (serum ferritin concentration and transferrin saturation) was determined in 110 consecutive patients (median age: 81 years) admitted to a referral centre for acute HF, at three timepoints (admission, discharge and 1 month after discharge). ID was defined according to the guidelines. Results The prevalence rates of ID at admission, discharge and 1 month were, respectively, 75% (95% confidence interval [CI] 67–83%), 61% (95% CI: 52–70%), and 70% (95% CI: 61–79%) (P = 0.008). Changes in prevalence were significant between admission and discharge (P = 0.0018). Despite a similar ID prevalence at admission and 1 month (P = 0.34), iron status changed in 25% of patients. Between admission and discharge, variation in C-reactive protein correlated significantly with that of ferritin (ρ = 0.30; P = 0.001). Advanced age, anaemia, low ferritin concentration and low creatinine clearance were associated with the persistence of ID from admission to 1 month. Conclusions Iron status is dynamic in patients admitted for acute HF. Although ID was as frequent at admission as at 1 month after discharge, iron status varied in 25% of patients.Contexte La carence martiale (CM) est fréquente dans l’insuffisance cardiaque (IC) et associée à un pronostic défavorable. Bien qu’il soit recommandé de la dépister au cours de l’IC, il n’existe pas de consensus quant au moment optimal de réalisation du bilan martial. Nous avons analysé l’évolution du bilan martial au cours du suivi à court terme de patients hospitalisés pour IC aiguë. Méthodes Un bilan martial (taux sérique de ferritine et coefficient de saturation de la transferrine) a été effectué chez 110 patients consécutifs (âge médian : 81 ans) admis pour IC aiguë dans un centre de référence à trois moments différents (admission, sortie et 1 mois après la sortie). La carence martiale était définie conformément aux guidelines. Résultats Les taux de prévalence de la CM à l’admission, à la sortie et à 1 mois étaient respectivement de 75 % (intervalle de confiance [IC] 95 %, 67 % 83 %), 61 % (IC : 95 %, 52 % 70 %) et 70 % (IC : 95 %, 61 % 79 %) (p = 0,008). Ces changements de prévalence étaient significatifs entre l’admission et la sortie (p = 0,0018). Malgré une prévalence de la CM similaire entre l’admission et 1 mois (p = 0,34), le bilan martial avait changé chez 25 % des patients. Entre l’admission et la sortie, la variation de la protéine C-réactive était significativement corrélée à celle de la ferritine (ρ = 0,30; p = 0,001). L’âge avancé, l’anémie, un faible taux de ferritine et la faible clairance de la créatinine étaient associés à la persistance de la CM entre l’admission et 1 mois. Conclusions Le bilan martial est dynamique chez les patients admis pour une IC aiguë. Bien que la CM soit aussi fréquente à l’admission qu’à 1 mois après la sortie, le bilan martial varie chez 25 % des patients

OCT Analysis of Very Early Strut Coverage of the Synergy Stent in Non-ST Segment Elevation Acute Coronary Syndrome Patients.

International audienceOBJECTIVES:Early endothelialization of drug-eluting stent (DES) is a major challenge to reduce the risk of stent thrombosis and the duration of dual-antiplatelet therapy (DAPT) in high bleeding-risk patients. The aim of the present study is to evaluate very early strut coverage with optical coherence tomography (OCT) of the Synergy stent (Boston Scientific) at 1 month in non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients.METHODS:This substudy of the EARLY trial prospectively included NSTE-ACS patients treated with the Synergy DES. OCT analysis of the Synergy stent was performed during a staged PCI of additional lesions at 1 month. The primary endpoint was the percentage of covered struts assessed with OCT at 1 month.RESULTS:Twenty-four patients were included, with a mean stent length of 35.9 ± 10.1 mm per patient. The rate of covered struts was 78.5% out of 3839 struts analyzed. Nineteen patients (79.2%) had at least 70% of their struts covered. The average neointimal thickness was 0.0508 ± 0.016 mm.CONCLUSIONS:In NSTE-ACS patients undergoing culprit percutaneous coronary intervention with the Synergy stent, the rate of covered struts at 1 month was 78.5%. This rapid coverage is in line with the results of clinical trials demonstrating the safety of short-duration DAPT in selected patients who are at high bleeding risk and treated with new-generation DES options

Ventricular Arrhythmia Occurrence and Compliance in Patients Treated With the Wearable Cardioverter Defibrillator Following Percutaneous Coronary Intervention

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