Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke

BACKGROUND Trials of patent foramen ovale (PFO) closure to prevent recurrent stroke have been inconclusive. We investigated whether patients with cryptogenic stroke and echocardiographic features representing risk of stroke would benefit from PFO closure or anticoagulation, as compared with antiplatelet therapy. METHODS In a multicenter, randomized, open-label trial, we assigned, in a 1:1:1 ratio, patients 16 to 60 years of age who had had a recent stroke attributed to PFO, with an associated atrial septal aneurysm or large interatrial shunt, to transcatheter PFO closure plus long-term antiplatelet therapy (PFO closure group), antiplatelet therapy alone (antiplatelet-only group), or oral anticoagulation (anticoagulation group) (randomization group 1). Patients with contraindications to anticoagulants or to PFO closure were randomly assigned to the alternative noncontraindicated treatment or to antiplatelet therapy (randomization groups 2 and 3). The primary outcome was occurrence of stroke. The comparison of PFO closure plus antiplatelet therapy with antiplatelet therapy alone was performed with combined data from randomization groups 1 and 2, and the comparison of oral anticoagulation with antiplatelet therapy alone was performed with combined data from randomization groups 1 and 3. RESULTS A total of 663 patients underwent randomization and were followed for a mean (+/- SD) of 5.3 +/- 2.0 years. In the analysis of randomization groups 1 and 2, no stroke occurred among the 238 patients in the PFO closure group, whereas stroke occurred in 14 of the 235 patients in the antiplatelet-only group (hazard ratio, 0.03; 95% confidence interval, 0 to 0.26; P<0.001). Procedural complications from PFO closure occurred in 14 patients (5.9%). The rate of atrial fibrillation was higher in the PFO closure group than in the antiplatelet-only group (4.6% vs. 0.9%, P = 0.02). The number of serious adverse events did not differ significantly between the treatment groups (P = 0.56). In the analysis of randomization groups 1 and 3, stroke occurred in 3 of 187 patients assigned to oral anticoagulants and in 7 of 174 patients assigned to antiplatelet therapy alone. CONCLUSIONS Among patients who had had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. PFO closure was associated with an increased risk of atrial fibrillation

Diagnostic Value of (18)F-Fluorodeoxyglucose Positron Emission Tomography Computed Tomography in Prosthetic Pulmonary Valve Infective Endocarditis

OBJECTIVES: The aim of this study was to assess the diagnostic performances of (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET)/computed tomography (CT) in congenital heart disease (CHD) patients with pulmonary prosthetic valve or conduit endocarditis (PPVE) suspicion. BACKGROUND: PPVE is a major issue in the growing CHD population. Diagnosis is challenging, and usual imaging tools are not always efficient or validated in this specific population. Particularly, the diagnostic yield of (18)F-FDG PET/CT remains poorly studied in PPVE. METHODS: A retrospective multicenter study was conducted in 8 French tertiary centers. Children and adult CHD patients who underwent (18)F-FDG PET/CT in the setting of PPVE suspicion between January 2010 and May 2020 were included. The cases were initially classified as definite, possible, or rejected PPVE regarding the modified Duke criteria and finally by the Endocarditis Team consensus. The result of (18)F-FDG PET/CT had been compared with final diagnosis consensus used as gold-standard in our study. RESULTS: A total of 66 cases of PPVE suspicion involving 59 patients (median age 23 years, 73% men) were included. Sensitivity, specificity, positive predictive value, and negative predictive value of (18)F-FDG PET/CT in PPVE suspicion were respectively: 79.1% (95% CI: 68.4%-91.4%), 72.7% (95% CI: 60.4%-85.0%), 91.9% (95% CI: 79.6%-100.0%), and 47.1% (95% CI: 34.8%-59.4%). (18)F-FDG PET/CT findings would help to correctly reclassify 57% (4 of 7) of possible PPVE to definite PPVE. CONCLUSIONS: Using (18)F-FDG PET/CT improves the diagnostic accuracy of the Duke criteria in CHD patients with suspected PPVE. Its high positive predictive value could be helpful in routine to shorten diagnosis and treatment delays and improve clinical outcomes.L'Institut de Rythmologie et modélisation Cardiaqu

Sustainable livelihoods to adaptive capabilities: a global learning journey in a small state, Zanzibar

This thesis takes global learning out of the formal setting of a Northern classroom to a rural community setting in the Global South as a social learning process. It begins with a critical reflection of a large EU project to develop a global learning programme as a Global North South initiative. The focus narrows to Zanzibar, a small island state, to critically reflect on the delivery of the programme. And then further to focus on the global social learning and change that occurred in a rural community setting in the north of the island. Through participatory action research, I investigate the relevance of global learning as a social learning process, how norms and rules are shaped within a community setting and how these enable social change towards sustainable livelihoods. The thesis splices the intersection between critical and social theories of learning and engagement, to include critical social theories of Habermas (1984) and Wals (2007); critical race theories of Giroux (1997) and Said (1994) and distributive justice and entitlements theories of Sen (1997) and Moser (1998). It demonstrates the importance of dissonance and a safe space for deliberative dialogue, to be able to consider the global pressures and forces on local realities as the precursor to social change towards sustainability. I conclude by relating the learning from this small island state to the wider world and the current discourse on quality of education in a community development context

Congenital and childhood atrioventricular blocks: pathophysiology and contemporary management

Atrioventricular block is classified as congeni- tal if diagnosed in utero, at birth, or within the first month of life. The pathophysiological process is believed to be due to immune-mediated injury of the conduction system, which occurs as a result of transplacental pas- sage of maternal anti-SSA/Ro-SSB/La antibodies. Childhood atrioventricular block is therefore diagnosed between the first month and the 18th year of life. Genetic variants in multiple genes have been described to date in the pathogenesis of inherited progressive car- diac conduction disorders. Indications and techniques of cardiac pacing have also evolved to allow safe perma- nent cardiac pacing in almost all patients, including those with structural heart abnormalities

300: Perioperative assessment of patients with repaired tetralogy of Fallot undergoing pulmonary valve replacement?

PurposePulmonary valve replacement (PVR) is commonly performed in aduts with repaired TOF to avoid late complications related to severe pulmonary regurgitation. However, few data are available concerning perioperative complications. The aim of this study was to evaluate the perioperative complications and to determine predictive factors of the Low Cardiac Output Syndrome (LCOS) in patients undergoing PVR.Methods and Results30 patients with TOF who underwent PVR between 2008 and 2009 were retrospectivelly enrolled. Mean age at valve surgery was 29.5 (range: 6.5–56.5). PVR was conducted with beating heart using a normothermic CPB (77+/−25min) in 16 pts. 14 pts underwent additional surgery requiring aortic cross clamp (CPB mean time was 113+/−21min). Survival rate was 97% at 90 days. Post operative complications were uncommon (VT in 6%, Mechanical Ventilation> 24 hours in 6%, renal dysfunction in 10%) except for the LCOS (46%). Prolonged CPB duration> 80min (p<0.01) and aortic cross-clamp (p=0.03) increased LCOS (OR33 and 6). Age, RV or LV volumes and function, and preoperative additionnal lesion were not significatively predictive of perioperative complications.ConclusionThese data underline the major role of myocardial protection during PVR in TOF patients. Short beating heart normothermic CPB leads to a decrease LCOS

0344: Why levosimendan should be considered for the treatment of viral myocarditis in children

BackgroundAnimal studies showed that levosimendan protects cardiomyocytes against apoptotic cell death in acute viral myocarditis. In addition to its inotropic properties, levosimendan seems to prevent the detrimental effects of oxidative stress and to limit cardiomyocyte loss.AimTo analyze the outcome of children who received levosimendan for acute or fulminant viral myocarditis.Patients and methodsRetrospective single center study covering the period 2007- 2013. All children (<18 years) with viral myocarditis were treated, in association with epinephrine and/or milrinone, with a 24-hours infusion of levosimendan. Clinical, biological and echocardiographic evolutions were analyzed.ResultsBetween 2007 and 2013, 18 successive children were treated, 9 for acute myocarditis and 9 for fulminant myocarditis (according to the international clinicopathological classification). Median age was 4 years (1.1-11) and median weight was 15kg (10-40). BNP level significantly decreased 48 hours after the beginning of the infusion (4599ng/L [2698-9266] vs 1928ng/L [848-4557], p=0.05). No dialysis was necessary. Among the fulminant myocarditis group, 1 patient (11%) required early mechanical circulatory support with a limitation of care due to severe neurologic complications. 13 patients (72%) recovered a LVEF >55% (100% for the acute myocarditis group). 1 patient had heart transplantation 18 months later.ConlusionIn our experience, levosimendan was efficient for the inotropic support of acute and fulminant viral myocarditis. We believe that its cardioprotective effect enabled us to limit the use of mechanical assistance (only 11% of the fulminant forms) and allowed a recovering of the cardiac function for the majority of the patients. Although further clinical studies are needed to confirm these data, levosimendan should be systematically considered for the treatment of these critical patients