Impact of intracoronary optical coherence tomography in routine clinical practice: A contemporary cohort study.

BACKGROUND/PURPOSE Guidelines recommend intracoronary optical coherence tomography (OCT) to assess stent failure and guide percutaneous coronary intervention (PCI) but OCT may be useful for other indications in routine clinical practice. METHODS/MATERIALS We conducted an international registry of OCT cases at two large tertiary care centers to assess clinical indications and the potential impact on decision making of OCT in clinical routine. Clinical indications, OCT findings, and their impact on interventional or medical treatment strategy were retrospectively assessed. RESULTS OCT was performed in 810 coronary angiography cases (1928 OCT-pullbacks). OCT was used for diagnostic purposes in 67% (N = 542) and OCT-guided percutaneous coronary intervention in 50% (N = 404, 136 cases with prior diagnostic indication). Most frequent indications for diagnostic OCT were culprit lesion identification in suspected ACS (29%) and stent failure assessment (28%). OCT findings in the diagnostic setting influenced patient management in 74%. OCT-guided PCIs concerned ACS patients in 45%. Among the 55% with chronic coronary syndrome, long lesions >28 mm (19%), left main PCI (16%), and bifurcation PCI with side-branch-stenting (5%) were the leading indications for PCI-guidance. Post-procedural OCT findings led to corrective measures in 52% (26% malapposition, 14% underexpansion, 6% edge dissection, 3% intrastent mass, 3% geographic plaque miss). CONCLUSIONS OCT was most frequently performed to identify culprit lesions in suspected ACS, for stent failure assessment, and PCI-guidance. OCT may impact subsequent treatment strategies in two out of three patients

Intérêt des tests d'inhibition plaquettaire dans la prédiction des saignements graves chez les patients traités par prasugrel dans les syndromes coronariens aigus (protocole PRACTICE P2Y12)

L'objectif principal réside dans la détermination de la valeur diagnostique intrinsèque de 3 tests de quantification de l'inhibition plaquettaire (VASP®, VERIFY NOW® et INNOVANCE®) pour la prédiction des saignements graves dans une cohorte de 46 patients traités par prasugrel dans le cadre d'un syndrome coronarien aigu. Les objectifs secondaires étaient d'une part d'évaluer l'observance au traitement par prasugrel et si possoble de la corréler à la survenue d'évenements hémorragiques, d'autre part de corréler les résultats des tests biologiques entre eux afin de savoir si ils sont comparables dans l'évaluation de l'inhibition plaquettaire sous prasugrel, et enfin d'identifier d'autres facteurs susceptibles d'aider à prédire les saignements graves. 46 patients ont bénéficié de la réalisation des tests biologiques ainsi que d'un suivi téléphonique à 1 mois et à 6 mois. La recherche de la valeur diagnostique intrinsèque pour chaque test ainsi que pour la détermination des autres facteurs prédictifs de saignement s'est faite grâce aux courbes ROC, à 'indice de Youden et au test de Fisher. L'évaluation de la corrélation des résultats des test biologiques s'est faite grâce au test de Spearman. L'incidence des saignements graves a été de 10.86% au cours du suivi sur 6 mois. Les patients ayant présenté des saignements graves ayant une inhibition plaquettaire plus puissante que les autres sujets. (VASP p = 0.19 et VERIFY NOW® p = 0.35). Une indice de réactivité plaquettaire en VASP> 28% a une VPN du saignement grave de 100% à 6 mois (p=0.067). L'observance du traitement a été de 100% même chez les patients ayant présenté un saignement grave. L'indice de réactivité plaquettaire et l'inhibition plaquettaire mesurée par le VERIFY NOW® sont relativement bien corrélés avec un coefficient de corrélation linéaire de Spearman à 0.556. En ce qui concerne les facteurs prédictifs autres, tous les patients ayant présentés un saignement grave étaient des hommes et on dénombre 80% de SCA ST +. De plus, une FEVG moyenne en phase aigue 28% et FEVG moyenne > 60% a une valeur prédictive négative de saignement à 6 mois de 100% (p=0.001). Le VASP est un examen fiable pour l'évaluation de l'inhibition plaquettaire sous prasugrel, ses résultats sont corrélés à ceux du VERIFY NOW®. La fraction d'éjection est un autre facteur pouvant aider à prédire le risque hémorragique des patients sous prasugrel. Un IRP < 28% associé à une FEVG < 60% sont prédictifs des saignements graves à 6 mois. L'INNOVANCE® n'est pas pertinent dans l'évaluation de l'inhibition plaquettaire sous prasugrel.CLERMONT FD-BCIU-Santé (631132104) / SudocSudocFranceF

Syndrome coronarien aigu avec sus décalage persistant du segment ST ("délais et modalités de prise en charge en Auvergne)

Le but de notre étude était de caractériser quels étaient les délais de revascularisation et les acteurs de la prise en charge des syndromes coronariens aigus avec sus décalage persistant du segment ST dans notre région afin de voir si nos pratiques étaient conformes aux recommandations de la société française de cardiologie. Notre travail a porté sur 300 patients admis consécutivement pour syndrome coronarien sus ST entre janvier 2005 et mai 2007. Tous les patients retenus ont bénéficié d'une procédure de revascularisation dans les 24 premières heures. Nous dénombrons 54% de procédure d'angioplastie primaire. Le taux de revascularisation à la 3ème heure est de 53%. La SFC recommande un délai entre la prise en charge du patient et l'angioplastie inférieur à 90 minutes. Ce dernier a pu être respecté pour 41% des patients ayant bénéficié d'une angioplastie primaire. Un délai de prise en charge - arrivée en salle de coronarographie - inférieur à 45 minutes n'est possible que pour les patients distants de moins de 40 km du centre de cardiologie interventionnelle. Dans le groupe fibrinolyse, 62% des patients sont fibrinolysés dans les 30 minutes suivant la prise en charge. Les délais de revascularisation sont supérieurs aux recommandations et donc perfectibles. Néanmoins ces délais sont superposables à ceux déjà publiés. Tous les délais sont optimisés par l'intervention du SAMU. Cette filière de prise en charge doit être privilégiée.CLERMONT FD-BCIU-Santé (631132104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Perméabilité du foramen ovale après accident vasculaire cérébral ischémique (comparaison de l'échocardiographie trans-thoracique en seconde harmonique, du doppler transcrânien et de l'échocardiographie trans-oesophagienne)

CLERMONT FD-BCIU-Santé (631132104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Apport de la tomographie par cohérence optique dans la prise en charge de la resténose intrastent

International audienc

153: Comparison of primary pacemaker implantations in the following transcatheter aortic valve implantation (TAVI) in the University Hospital of Clermont Ferrand, according to two types of valve

IntroductionAortic valve replacement is the definitive therapy for severe aortic stenosis (valve area<0.6cm2/m2). Elderly and the associated comorbidity represent an operative risk (estimated with the EuroSCORE). TAVI is an alternative to surgery or balloon valvuloplasty. Two valves were marketed: Edwards and CoreValve. The complications of TAVI are well known and similar for the both. Only the primary pacemaker implantations (PPI) are greater with CoreValves. The objectives are to compare the PPI after a TAVI in the CHU of Clermont Ferrand depending on the type of valve, then to explain this difference.MethodWe used the register FRANCE II to a retrospective analysis of all patients with a TAVI in the CHU of Clermont Ferrand. We only excluded patients who died within 24 hours post procedure and patients who were already a pacemaker. The search for a PPI, age, type of valve, diameter of the valve, surgical approach, presence of bundle branch block (BB), operator dependence and learning curve were analyzed.ResultsFrom January 2010 to March 2012, 78 were included in this study (66% of CoreValve and 34% of Edwards). Of the 22 PPI (22.9%), 100% complicated a Corevalve (p=0.00034). Age, operator, learning curve, surgical approach and diameter of the valve are not risk factors for PPI, in contrast to the presence of BB (p=0.025).ConclusionThis study confirms that CoreValves are more complicated PPI than Edwards. The presence of BB is a risk factor for primary implantation. The lack of power of this study does not reveal other risk factors such as the diameter of the valve or the learning curve effect

Role for Vascular Factors in Long-Term Outcomes After Transcatheter Aortic Valve Implantation

International audienceDespite major technological advances, 1-year morbi-mortality after transcatheter aortic valve implantation (TAVI) is still high. Further outcome improvements may be obtained provided proper identification of prognostic factors. A change of prognostic value over time should be the hallmark of an outcome-implicated factor. In 1,425 patients treated by TAVI, the examined prognostic factors were: demographic factors and co-morbidities (age, male gender, glomerular filtration rate, and chronic obstructive pulmonary disease), cardiac function (left ventricular ejection fraction, pulmonary pressure, aortic gradient, dyspnea, and mitral regurgitation), and vascular factors (coronary artery disease, peripheral vascular disease (PVD), previous stroke, and thoracic aortic calcium-TAC-as assessed by CT scan). Cox models were used to analyze cardiovascular and all-cause mortalities over 3 years of follow-up. The time-dependent effects of the factors were analyzed using the distribution of Schoenfeld residuals. During the study period, 375 (26.3%) deaths occurred of whom 248 (17.4%) from cardiovascular causes. Only 2 factors associated with cardiovascular or all-cause mortality showed significant changes over time: dyspnea and PVD. The effect of dyspnea on cardiovascular mortality decreased over time (first- and third-year hazard ratios [95% confidence intervals]: 1.47 [1.10; 1.96] and 0.94 [0.55; 1.63], respectively), whereas the effect of PVD increased (first- and third-year hazard ratios: 0.87 [0.56; 1.35] and 2.58 [1.25; 5.33], respectively). TAC had a stable effect. In conclusion, the detrimental effects of vascular factors remained stable (TAC) or increased (PVD) over time. These factors should be targeted by specific measures to improve post-TAVI outcomes

Emergency bailout surgery saves lives in high‐risk patients with complications after TAVR

International audienceIntroduction: With the expansion of the indication for transcatheter aortic valve implantation (TAVR), the value of access to on-site emergency heart surgery at performing centers needs to be assessed.Aims: To evaluate postoperative mortality after surgical rescue post-TAVR, in a population at high surgical risk.Methods: Retrospective analysis of a cohort of patients included in the France-TAVI registry who had undergone TAVR with the latest generation valves between January 2017 and February 2020.Results:Among the 968 patients undergoing TAVR, 6 patients (0.62%) were identified as candidates for surgery: 3 in the peri-operative context and 3 during hospitalization. Four subjects were managed in a salvage situation, two due to tamponade, one due to aortic dissection, and one due to aortic annulus rupture. One patient died of a delayed aortic annulus rupture and one patient presented a right coronary occlusion which was medically treated. All patients who underwent emergency surgery were discharged alive from the hospital.Conclusions: In TAVR patients initially contraindicated for surgery, emergency bailout surgery could be performed successfully with all patients discharged alive. Access to on-site heart surgery represents a life-saving resource for TAVR center

Post-Dilatation of New-Generation Self-Expandable Transcatheter Aortic Valves Does Not Increase Atrioventricular Conduction Abnormalities

The impact that post-dilatation has on the risk of experiencing conduction disorders after post-transcatheter aortic valve replacement with self-expanding valves (SE-TAVR) is unclear. We compared the rate of developing an atrioventricular (AV) high-grade conduction disorder and permanent pacemaker implantation (PPI) in post-TAVR patients undergoing post-dilatation. We enrolled patients with severe symptomatic calcified aortic stenosis (CAS) who were undergoing SE-TAVR between 1 January 2016, and 19 April 2019 at a single French center. Of the 532 patients treated with SE-TAVR, 417 subjects (78.4%) received Corevalve Evolute R and 115 subjects (21.6%) received the latest-generation Corevalve Evolute Pro valve. In total, 104/532 patients (19.5%; 21.6% with Evolute R vs. 12.2% with Evolute Pro, p = 0.024) required post-dilatation. Evolut R was associated with an increased risk of post-dilatation (odds ratio 2.1 (1.01–4.33, p = 0.046)). We did not observe any post-dilatation increases in AV or in intra- and interventricular conduction disorders. In total, 26.1% of participants needed PPI within the first 30 post-procedure days (p = 0.449). Post-dilatation was not associated with a higher PPI risk (subdistribution hazard ratio 1.033 (0.726–1.471); p = 0.857). No significant differences existed between the groups in terms of one-year mortality (10.3%; p = 0.507). Post-dilatation in SE-TAVR did not increase the rate of electrical conduction disorders and PPI in the early implantation phase. The latest generation of SE-TAVR valves was associated with less need for post-dilatation