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

Preventing acute decrease in renal function induced by coronary angiography (PRECORD): a prospective randomized trial

SummaryBackgroundInfusion of saline attenuates the decrease in renal function induced by radiographic contrast agents among patients with chronic renal insufficiency.AimThe Preventing Renal alteration in Coronary Disease (PRECORD) trial was a randomized trial to assess the effect on renal function of saline infusion during and after coronary angiography in 201 patients without severe chronic renal insufficiency (serum creatinine<140μmol/L).MethodsAll patients received standard oral hydration: 2000mL of tap water within the 24hours after coronary angiography. Patients were randomized before the procedure to intravenous hydration (1000mL of 0.9% saline infusion) or no additional hydration. The infusion was started in the catheterization laboratory and continued for 24hours. The primary endpoint was the change in calculated creatinine clearance between baseline and 24hours after coronary angiography. The same ionic low osmolar radiographic contrast agent (ioxaglate) was used in all patients.ResultsBoth groups had similar baseline characteristics, including age, serum creatinine, volume of contrast and proportion of patients undergoing ad hoc coronary angioplasty. The overall decrease in serum creatinine clearance 24hours after the procedure was –3.44 (0.68)mL/min. The change in serum creatinine clearance 24hours after the procedure was –2.81 (1.07)mL/min in the infusion group vs –4.09 (0.91)mL/min in the control group (p=0.38).ConclusionRenal function is altered only slightly 24hours after coronary angiography with standard oral hydration alone and is not affected by saline infusion started at the beginning of coronary angiography, even in patients with mild-to-moderate renal dysfunction

Determination of the myocardial area at risk after reperfused acute myocardial infarction with different imaging techniques: cardiac magnetic resonance imaging, multidetector computed tomography and histopathological validation

International audiencen.

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

Continuum of vasodilator stress from rest to contrast medium to adenosine hyperemia for fractional flow reserve assessment

Objectives: This study compared the diagnostic performance with adenosine-derived fractional flow reserve (FFR) ≤0.8 of contrast-based FFR (cFFR), resting distal pressure (Pd)/aortic pressure (Pa), and the instantaneous wave-free ratio (iFR). Background: FFR objectively identifies lesions that benefit from medical therapy versus revascularization. However, FFR requires maximal vasodilation, usually achieved with adenosine. Radiographic contrast injection causes submaximal coronary hyperemia. Therefore, intracoronary contrast could provide an easy and inexpensive tool for predicting FFR. Methods: We recruited patients undergoing routine FFR assessment and made paired, repeated measurements of all physiology metrics (Pd/Pa, iFR, cFFR, and FFR). Contrast medium and dose were per local practice, as was the dose of intracoronary adenosine. Operators were encouraged to perform both intracoronary and intravenous adenosine assessments and a final drift check to assess wire calibration. A central core lab analyzed blinded pressure tracings in a standardized fashion. Results: A total of 763 subjects were enrolled from 12 international centers. Contrast volume was 8 ± 2 ml per measurement, and 8 different contrast media were used. Repeated measurements of each metric showed a bias &lt;0.005, but a lower SD (less variability) for cFFR than resting indexes. Although Pd/Pa and iFR demonstrated equivalent performance against FFR ≤0.8 (78.5% vs. 79.9% accuracy; p = 0.78; area under the receiver-operating characteristic curve: 0.875 vs. 0.881; p = 0.35), cFFR improved both metrics (85.8% accuracy and 0.930 area; p &lt; 0.001 for each) with an optimal binary threshold of 0.83. A hybrid decision-making strategy using cFFR required adenosine less often than when based on either Pd/Pa or iFR. Conclusions: cFFR provides diagnostic performance superior to that of Pd/Pa or iFR for predicting FFR. For clinical scenarios or health care systems in which adenosine is contraindicated or prohibitively expensive, cFFR offers a universal technique to simplify invasive coronary physiological assessments. Yet FFR remains the reference standard for diagnostic certainty as even cFFR reached only ∼85% agreement