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A letter to the editor on coronary thrombosis is presented.

Bioresorbable vascular scaffold (BVS) stents have been proposed recently as an elegant technique for treatment of coronary artery disease. However, perspective that these "dissolvable" stents will replace conventional metallic stents in broad spectrum of clinical conditions and patient categories in the near future has been moderated by non-negligible incidence of stent thrombosis (ST). Mechanical factors, such as strut thickness and malapposition have been implicated in increased risk of BVS ST. Presently described is case of immediate partial BVS ST in a young male related to technical procedural problem, rather than mechanical problem. Glycoprotein IIb/IIIa inhibitors associated with anticoagulation resulted in complete resolution of thrombus and facilitated successful patient outcome.

Background: Transcatheter aortic valve replacement (TAVR) has revolutionized management of high-risk patients with severe aortic stenosis. However, survival and the incidence of severe complications have been assessed in relatively small populations and/or with limited follow-up., Objectives: This report details late clinical outcome and its determinants in the FRANCE-2 (FRench Aortic National CoreValve and Edwards) registry., Methods: The FRANCE-2 registry prospectively included all TAVRs performed in France. Follow-up was scheduled at 30 days, at 6 months, and annually from 1 to 5 years. Standardized VARC (Valve Academic Research Consortium) outcome definitions were used., Results: A total of 4,201 patients were enrolled between January 2010 and January 2012 in 34 centers. Approaches were transarterial (transfemoral 73%, transapical 18%, subclavian 6%, and transaortic or transcarotid 3%) or, in 18% of patients, transapical. Median follow-up was 3.8 years. Vital status was available for 97.2% of patients at 3 years. The 3-year all-cause mortality was 42.0% and cardiovascular mortality was 17.5%. In a multivariate model, predictors of 3-year all-cause mortality were male sex (p < 0.001), low body mass index, (p < 0.001), atrial fibrillation (p < 0.001), dialysis (p < 0.001), New York Heart Association functional class III or IV (p < 0.001), higher logistic EuroSCORE (p < 0.001), transapical or subclavian approach (p < 0.001 for both vs. transfemoral approach), need for permanent pacemaker implantation (p = 0.02), and post-implant periprosthetic aortic regurgitation grade ≥2 of 4 (p < 0.001). Severe events according to VARC criteria occurred mainly during the first month and subsequently in <2% of patients/year. Mean gradient, valve area, and residual aortic regurgitation were stable during follow-up., Conclusions: The FRANCE-2 registry represents the largest database available on late results of TAVR. Late mortality is largely related to noncardiac causes. Incidence rates of severe events are low after the first month. Valve performance remains stable over time., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Biomarkers in acute cardiac care are gaining increasing interest given their clinical benefits. This study is a review of the major conditions in acute cardiac care, with a focus on biomarkers for diagnostic and prognostic assessment. Through a PubMed search, 110 relevant articles were selected. The most commonly used cardiac biomarkers (cardiac troponin, natriuretic peptides, and C-reactive protein) are presented first, followed by a description of variable acute cardiac conditions with their relevant biomarkers. In addition to the conventional use of natriuretic peptides, cardiac troponin, and C-reactive protein, other biomarkers are outlined in variable critical conditions that may be related to acute cardiac illness. These include ST2 and chromogranin A in acute dyspnea and acute heart failure, matrix metalloproteinase in acute chest pain, heart-type fatty acid binding protein in acute coronary syndrome, CD40 ligand and interleukin-6 in acute myocardial infarction, blood ammonia and lactate in cardiac arrest, as well as tumor necrosis factor-alpha in atrial fibrillation. Endothelial dysfunction, oxidative stress and inflammation are involved in the physiopathology of most cardiac diseases, whether acute or chronic. In summary, natriuretic peptides, cardiac troponin, C-reactive protein are currently the most relevant biomarkers in acute cardiac care. Point-of-care testing and multi-markers use are essential for prompt diagnostic approach and tailored strategic management.

Objectives: The prevalence of chronic heart failure and a reduced ejection fraction (CHF-REF) has increased over the last decade. The cardiopulmonary exercise test (CPET) is an established tool for managing these patients. For patients who are administered beta-blockers, its predictive value is debated. The aim of this study was to assess the prognostic values of several parameters in patients with CHF-REF who were on beta-blockers., Study Design: 390 patients with CHF-REF underwent CPET after cardiac rehabilitation and were followed for two years., Results: The primary endpoints were all-cause mortality, cardiac-related mortality and major cardiovascular events (hospitalization for HF, heart transplantation and acute coronary syndrome or arrhythmia). The mean beta-blockers dosage was 68.9% of the target dose. The two-year mortality rate was 13%, while the mean age of the population was 57.1 years. In addition, most of the patients were men (85.5% vs. 14.5%). The resting LVEF was 35.7 ± 9.4 and the maximal oxygen uptake (peak VO₂) was 19.5 ml/kg/min. The peak VO₂, VE/VCO₂ slope and circulatory power were significant predictors of risk. The prognosis was better when the initial linear VE/VCO₂ slope was lower than 30, and the final steeper VE/VCO₂ slope was lower than 32. There was no difference between the two slopes. The oxygen uptake efficiency slope, oxygen uptake, heart rate recovery, VE/VCO₂/VO₂ index and ventilatory threshold had no prognostic value., Conclusion: The peak VO₂, circulatory power and VE/VCO₂ slope were prognostic indicators for patients with CHF-REF who were on beta-blockers.

Background: Transcatheter aortic valve implantation (TAVI) is a rapidly evolving strategy for therapy of aortic stenosis. We presented the procedural results and analyzed the death causes of 30-day mortality and clinical events in patients who underwent TAVI with Edwards prosthetic valves in University Hospital of Caen, France., Methods: The patients with severe aortic stenosis but at high surgical risk or inoperable were considered as candidates for TAVI. Forty-eight patients undergoing TAVI from July 2010 to September 2011 were enrolled in this registry. The Edwards prosthetic valves were solely used in this clinical trial., Results: Overall 48 patients underwent TAVI, 28 of which accepted TAVI by trans-femoral (TF) approaches, 20 by trans-apical approaches (TA). The aortic valve area (AVA) was (0.70 ± 0.23) cm(2), left ventricular ejection fraction (LVEF) was (57.4 ± 17.6)%, Log EuroSCORE was (19.2 ± 15.8)%, mean gradient was (47.0 ± 16.6) mmHg. There were no significant differences between TF and TA groups in all these baseline parameters. Device success rate was 95.8%, and procedural success rate was 93.7% in total. Procedural mortality was 6.7% (3/48): two deaths in TA group (10%), and one death in TF group (3.6%). Forty-six Edwards valves were implanted: 10 Edwards Sapien and 36 Edwards XT. Procedure-related complications included cardiac tamponade in 2 cases (4.2%), acute myocardial infarction (AMI) in 1 case (2.1%), permanent pacemaker implantation in 1 case (2.1%), life-threatening and major bleeding in 3 cases; access site related major complication in 1 case, AKI stage 3 in 3 cases (6.3%), minor stroke in 1 case (2.1%). Thirty-day survival rate was 89.6%. There were 5 deaths in total (10.4%): 4 in TA group (20%) and 1 in TF group (3.6%)., Conclusion: The procedural success rate and 30-day mortality were acceptable in these high risk patients with Edwards prosthetic valves in the first 48 TAVI.

Transradial approach for percutaneous interventions has emerged as an alternative to transfemoral access which is known to be more associated with vascular local complications. However, lack of guiding-catheter support via the radial access is one of the problems encountering the operators. Many solutions have been proposed to overcome this problem. We report on a 62-year-old man with tight stenosis of the distal part of the right coronary artery. He underwent coronary angiography and then percutaneous angioplasty via the right radial artery. During the procedure, attempts to advance a stent beyond a tortuosity at the level of the second segment failed due to lack of support of the 6-Fr Judkins right 4 guiding catheter, even with the buddy wire technique. Then, switching to a 5-Fr Judkins right 4 guiding catheter allowed safe deep engagement and resulted in successful advancement and deployment of the stent.

Aim: The clinical outcome of patients with severe renal dysfunction undergoing percutaneous coronary intervention (PCI) is poor. However little is known concerning the impact of mild renal insufficiency on long-term clinical outcomes after successful coronary stenting. The present prospective observational study was designed to evaluate long-term clinical outcomes in relation to renal insufficiency after successful coronary stenting., Methods and Results: A consecutive series of 1454 patients were enrolled between January 4th 1997 and January 4th 1999 Demographic and clinical characteristics and long term clinical outcome were compared for patients with normal creatinine clearance (>60 ml/mn), mild renal dysfunction (creatinine clearance rates 30-60 ml/mn) and severe renal dysfunction (creatinine clearance rates <30 ml/mn). Patients with moderate or severe renal dysfunction were older and with more severe coronary artery disease. Beyond conventional risk factors like age (RR = 1.72 [1.10-2.68] 95% CI ; p<0.018), or low left ventricular ejection fraction (RR = 2.60 [1.72-3.94] 95% CI ; p<0.001), severe (creatinine clearance rates < 30 ml/min) and mild (creatinine clearance 30-60 ml/min) renal dysfunction were also identified as strong independent predictors of death after successful coronary stenting (RR = 4.91 [2.63-9.15] 95% CI, p<0.001 and RR = 1.57 [1.03-2.40] 95% CI, p<0.034, respectively)., Conclusions: In patients with successful coronary stenting, preprocedural creatinine clearance remains an important independent predictor of long term death. These data reinforce the importance of widespread application of prevention strategies especially in patients with coronary artery disease complicated by renal dysfunction.

Background: The A1166C polymorphism of the angiotensin II type 1 receptor (AT1R) gene, which appears to be the main receptor mediating the pleitropic vascular effects of angiotensin II in human beings, has been associated with the risk of myocardial infarction (MI), the severity of coronary vasoconstriction and the occurrence of sudden death. The question therefore arises whether the A1166C polymorphism constitutes a hereditary risk factor of survival after an acute myocardial infarction., Methods and Results: In a large prospective study of 970 consecutive patients with a recent myocardial infarction the A1166C polymorphism was detected using a PCR based protocol. During the follow-up period (median, 2.5 years), 75 patients died and 62 from cardiovascular causes. The prespecified primary and secondary end points considered were total mortality and cardiovascular mortality. No differences between AA, AC, and CC groups were observed with respect to baseline clinical characteristics. Beyond conventional risk factors like age (RR=2.8 [1.6-5.0] 95% CI; p<0.001), hypercholesterolemia (RR=2.1 [1.2-3.7] 95% CI; p<0.014) or low left ventricular ejection fraction (RR=2.7 [1.5-4.8] 95% CI; p<0.002), the AT1R CC genotype was also identified as a strong independent predictor of death after myocardial infarction (RR=3.2 [1.5-7.0] 95% CI ; p<0.004). After adjustment for mortality causes, the AT1R CC genotype was confirmed to be an independent predictor of cardiovascular death after myocardial infarction (RR=2.8 [1.2-6.5] 95% CI; p<0.021)., Conclusions: The AT1R CC genotype after adjustment is a strong predictor of death in post MI patients. This new finding may help to identify high risk post MI patients who may benefit from new therapeutic strategies.

Background: The survival of patients after prolonged cardiac arrest is still inadequate. Extracorporeal life support (ECLS) represents an alternative therapeutic method for patients who do not respond to conventional cardiopulmonary cerebral resuscitation. This technology is used to support the circulation of a patient with severe cardiac failure., Methods: Between June 1997 and January 2003, 40 ECLS procedures were performed in patients who presented with refractory cardiac arrest. During external cardiac massage, the patient was connected to an extracorporeal circuit by the insertion of an arterial and venous cannula through the femoral vessels. The extracorporeal circuit included a centrifugal pump and an oxygenator. Mean age was 42 +/- 15 years; the average time of external cardiac massage was 105 +/- 44 minutes., Results: Once the circulation was restored, 22 patients were disconnected from the extracorporeal circulation because of brain death or multiorgan failure; after 24 hours, among the 18 survivors, 6 were weaned off the pump, 9 were bridged to a ventricular assist device, and 2 patients were directly bridged to cardiac transplantation. Eight patients are alive and without any sequelae at 18 month's follow-up., Conclusions: In prolonged cardiac arrest with failing conventional measures, rescue by extracorporeal support provides an ultimate therapeutic option with a good outcome in survivors. Our results encourage the wider application of ECLS for refractory cardiocirculatory arrest in selected patients. The high rate of neurologic death needs further improvements in the early phase of resuscitation maneuvers.

The primary objective of the present study was to assess the feasibility and the safety of the Seaquence stent (CathNet-Science) deployment for the treatment of coronary artery disease and the event-free survival of patients treated with this coronary stent. The study was conducted as a multicenter, prospective, observational registry. Patients with stable or unstable angina pectoris who were candidates for percutaneous coronary intervention with elective stenting of one single de novo lesion in a native coronary artery > or =3 mm in diameter were included in the study. Clinical follow-up was performed at 1 month and 9 months. Major adverse coronary events (MACE), that is, cardiac death, myocardial infarction, and target vessel revascularization (re-PTCA or CABG), were recorded over a period of 9 months. Using this stent, a 99% in-hospital success rate was achieved. A total of 17 patients presented MACE (8.7%) during the whole follow-up period and target lesion revascularization was needed for 14 (7.1%) patients. Using multivariate analysis only some clinical parameters (patients treated for unstable angina, with a history of CABG or of female gender) were found as independent predictors of MACE after coronary stenting. Procedural related factors, angiographic characteristics, or reference diameter were not found to influence clinical outcome. Because the study was performed in patients with a high proportion of complex lesions (relative high-risk nonselected population with nearly one third calcified lesions, many long and type B2 and C lesions) we can conclude that the coronary Seaquence stent can be considered as a stent of reference in routine practice.

Objectives: Recently, direct stenting has been shown in retrospective and randomized studies to be feasible and safe in highly selected patients, with a potential interest to reduce the cost of the procedure and the rate of no-reflow. This randomized pilot study was designed to compare the incidence of no-reflow after direct stenting or conventional stenting after balloon predilation in acute coronary syndrome-related lesions., Methods and Results: Between December 1998 and October 1999, 130 patients in our center with acute coronary syndromes were included in this study and randomized in 2 groups. In group A (n = 65), direct stent implantation was performed without balloon predilation. In group B (n = 65), conventional balloon predilation was carried out before stent implantation. Baseline clinical and angiographic characteristics before the procedure were similar in the 2 groups of patients. No-reflow was observed in 7.7% after direct stenting and in 6.1% after conventional stent implantation (P = not significant). The immediate clinical success rate was similar in the 2 groups. Among the procedural data, only duration of the procedure (shorter in the direct stenting group), the number of balloons used, and the quantity of contrast agent (lower in the direct stenting group) were significantly different between the 2 groups (P <.05). The 6-month clinical outcome was similar in the 2 groups., Conclusion: This randomized study confirms the promising results of previous studies that show the feasibility and the safety of direct coronary stenting in highly selected acute coronary syndrome-related lesions. The major impact of this strategy is the improvement of the cost-benefit ratio, with no major influence on the acute complications and especially on the occurrence of no-reflow in this high-risk population.