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Abstract BackgroundBiomedical data warehouses (BDWs) have become an essential tool to facilitate the reuse of health data for both research and decisional applications. Beyond technical issues, the implementation of BDWs requires strong institutional data governance and operational knowledge of the European and national legal framework for the management of research data access and use. ObjectiveIn this paper, we describe the compound process of implementation and the contents of a regional university hospital BDW. MethodsWe present the actions and challenges regarding organizational changes, technical architecture, and shared governance that took place to develop the Nantes BDW. We describe the process to access clinical contents, give details about patient data protection, and use examples to illustrate merging clinical insights. Implementation (Results)More than 68 million textual documents and 543 million pieces of coded information concerning approximately 1.5 million patients admitted to CHUN between 2002 and 2022 can be queried and transformed to be made available to investigators. Since its creation in 2018, 269 projects have benefited from the Nantes BDW. Access to data is organized according to data use and regulatory requirements. ConclusionsData use is entirely determined by the scientific question posed. It is the vector of legitimacy of data access for secondary use. Enabling access to a BDW is a game changer for research and all operational situations in need of data. Finally, data governance must prevail over technical issues in institution data strategy vis-à-vis care professionals and patients alike.

Structural changes and myocardial fibrosis quantification by cardiac imaging have become increasingly important to predict cardiovascular events in patients with mitral valve prolapse (MVP). In this setting, it is likely that an unsupervised approach using machine learning may improve their risk assessment. This study used machine learning to improve the risk assessment of patients with MVP by identifying echocardiographic phenotypes and their respective association with myocardial fibrosis and prognosis. Clusters were constructed using echocardiographic variables in a bicentric cohort of patients with MVP (n = 429, age 54 ± 15 years) and subsequently investigated for their association with myocardial fibrosis (assessed by cardiac magnetic resonance) and cardiovascular outcomes. Mitral regurgitation (MR) was severe in 195 (45%) patients. Four clusters were identified: cluster 1 comprised no remodeling with mainly mild MR, cluster 2 was a transitional cluster, cluster 3 included significant left ventricular (LV) and left atrial (LA) remodeling with severe MR, and cluster 4 included remodeling with a drop in LV systolic strain. Clusters 3 and 4 featured more myocardial fibrosis than clusters 1 and 2 (P < 0.0001) and were associated with higher rates of cardiovascular events. Cluster analysis significantly improved diagnostic accuracy over conventional analysis. The decision tree identified the severity of MR along with LV systolic strain <21% and indexed LA volume >42 mL/m2 as the 3 most relevant variables to correctly classify participants into 1 of the echocardiographic profiles. Clustering enabled the identification of 4 clusters with distinct echocardiographic LV and LA remodeling profiles associated with myocardial fibrosis and clinical outcomes. Our findings suggest that a simple algorithm based on only 3 key variables (severity of MR, LV systolic strain, and indexed LA volume) may help risk stratification and decision making in patients with MVP. (Genetic and Phenotypic Characteristics of Mitral Valve Prolapse, NCT03884426 ; Myocardial Characterization of Arrhythmogenic Mitral Valve Prolapse [MVP STAMP], NCT02879825) [Display omitted] [ABSTRACT FROM AUTHOR]

• Among patients exhibiting unruptured cerebral aneurysms (UCAs), we compared 45 patients (64 UCAs) exposed to induced arterial hypertension (iHTN) for vasospasm to 73 non-exposed patients (116 UCAs). • There was not a higher rate of rupture or volume growth in the iHTN group. • Volume growth was assessed using semi-automatic image analysis tools going beyond merely considering the aneurysm long axis. • Unruptured unsecured cerebral aneurysms may not be a reason to refrain from iHTN as a treatment for vasospasm. Unruptured cerebral aneurysms (UCAs) often coexist with the ruptured one but are typically left unsecured during the weeks following aneurysmal subarachnoid hemorrhage (aSAH). We compared the rate of UCAs rupture or volume growth (≥5 mm3) between patients exposed to induced arterial hypertension (iHTN) for vasospasm and those not exposed (control group). From 2013 to 2021, we retrospectively included consecutive adult patients with aSAH who had ≥1 UCA. Custom software for digital subtraction angiography (DSA) image analysis characterized UCAs volume, going beyond merely considering UCAs long axis. We analyzed 118 patients (180 UCAs): 45 in the iHTN group (64 UCAs) and 73 in the control group (116 UCAs). Systolic blood pressure in the iHTN group was significantly higher than in the control group for several days after aSAH. During the 107 day-monitoring period [interquartile range(IQR):92;128], no UCA rupture occurred in either group. UCA volume analysis was performed in 44 patients (60 UCAs): none of the UCAs in the iHTN group and 3 out of 42 (7%) in the control group had a >5 mm3 volume growth (p=0.55). Other morphologic parameters did not exhibit any variations that might indicate an increased risk of rupture in the iHTN group compared to the control group. iHTN did not increase the risk of rupture or volume growth of UCAs within several weeks following aSAH. These reassuring results encourage not to refrain, because of the existence of UCAs, from iHTN as an option to prevent cerebral infarction during cerebral vasospasm. [ABSTRACT FROM AUTHOR]

Background and purpose: Asymptomatic intracranial hemorrhage (aICH) is a common occurrence after endovascular treatment (EVT) for acute ischemic stroke (AIS). The aims of this study were to address its impact on 3‐month functional outcome and to identify risk factors for aICH after EVT. Methods: Patients with AIS attributable to anterior circulation large vessel occlusion who underwent EVT were enrolled in a multicenter prospective registry. Based on imaging performed 22–36 h post‐EVT, we included patients with no intracranial hemorrhage (ICH) or aICH. Poor outcome defined as a 3‐month modified Rankin Scale (mRS) score 4–6 and overall 3‐month mRS score distribution were compared according to presence/absence of aICH, and aICH subtype using logistic regression. We assessed the risk factors of aICH using a multivariate logistic regression model. Results: Of the 1526 patients included in the study, 653 (42.7%) had aICH. Patients with aICH had a higher rate of poor outcome: odds ratio (OR) 1.88 (95% confidence interval [CI] 1.44–2.44). Shift analysis of mRS score found a fully adjusted OR of 1.79 (95% CI 1.47–2.18). Hemorrhagic infarction (OR 1.63 [95% CI 1.22–2.18]) and parenchymal hematoma (OR 2.99 [95% CI 1.77–5.02]) were associated with higher risk of poor outcome. Male sex, diabetes, coronary artery disease, baseline National Institutes of Health Stroke Scale score and Alberta Stroke Program Early Computed Tomography Score, number of passes and onset to groin puncture time were independently associated with aICH. Conclusions: Patients with aICH, irrespective of the radiological pattern, have a worse functional outcome at 3 months compared with those without ICH after EVT for AIS. The number of EVT passes and the time from onset to groin puncture are factors that could be modified to reduce deleterious ICH. [ABSTRACT FROM AUTHOR]

Left ventricular (LV) replacement myocardial fibrosis has been described in MVP. We aimed at assessing the prevalence, pathophysiological and prognostic significance of LV replacement myocardial fibrosis through late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) in MVP Four hundred patients (53 ± 15 years, 55% male) with MVP underwent echocardiography and CMR. Correlates of replacement myocardial fibrosis (LGE +), influence of MR degree, and ventricular arrhythmia were assessed. The primary outcome was a composite of cardiovascular events. LGE+ was observed in 110 patients (28%; 91 myocardial wall including 71 basal inferolateral wall, 29 papillary muscle). LGE+ prevalence was 13% in trace-mild MR, 28% in moderate and 37% in severe MR, and was associated with specific features of mitral valve apparatus, more dilated LV and more frequent ventricular arrhythmias (45 vs. 26%, P < 0.0001). In trace-mild MR, despite the absence of significant volume overload, abnormal LV dilatation was observed in 16% of patients and ventricular arrhythmia in 25%. Correlates of LGE+ in multivariable analysis were LV mass [OR 1.01, 95% CI (1.002–1.017), P = 0.009] and moderate-severe MR [OR: 2.28, 95% CI (1.21–4.31), P = 0.011]. LGE+ was associated with worse 4-year cardiovascular event-free survival (49.6 ± 11.7 in LGE+ vs. 73.3 ± 6.5% in LGE-, P < 0.0001). In a stepwise multivariable Cox model, MR volume and LGE+ [HR: 2.6 (1.4–4.9), P = 0.002] were associated with poor outcome (Fig. 1). LV replacement myocardial fibrosis is frequent in patients with MVP, is associated with mitral valve apparatus alteration, more dilated LV, MR grade, ventricular arrhythmia, and is independently associated with cardiovascular events. These findings suggest a MVP-related myocardial disease. Finally, CMR provides additional information to echocardiography in MVP. [ABSTRACT FROM AUTHOR]

Mitral valve prolapse (MVP) is a frequent disease that can be complicated by mitral regurgitation (MR), heart failure, arterial embolism, rhythm disorders and death. Left ventricular (LV) myocardial replacement fibrosis, a marker of maladaptive remodelling in numerous pathological conditions, has been evidenced in mitral valve prolapse (MVP) patients. To evaluate the prevalence, determinants, and prognostic significance of LV myocardial fibrosis assessed through late gadolinium enhancement (LGE+) by cardiac magnetic resonance (CMR) imaging in MVP patients. We included 426 patients from 2 centres (55 ± 16 years, 56% male) with MVP (trace to severe MR) who underwent a comprehensive echocardiography and CMR imaging. Gadolinium was injected in 411 (96%) patients. The primary outcome endpoint was a composite of cardiovascular events. Of 411 patients, myocardial fibrosis (LGE+) was observed in 118 (29%; 100 myocardial wall including 66 basal inferolateral wall, 30 papillary muscle). LGE+ prevalence was 14% in trace-mild MR, 28% in moderate and 39% in severe MR, and was associated with worse heart chambers remodelling, larger mitral annulus, longer MV leaflets and presence of flail leaflet. Determinants of LGE+ in multivariable analysis were mainly LV mass (OR 1.01, P = 0.008) associated to the magnitude of MR and coronary artery disease. Four years cardiovascular events-free survival was decreased in patients with LGE+ (49.7 ± 11.9 vs. 76.2 ± 6.2%, P < 0.0001). In a stepwise multivariable Cox model, MR volume, LA volume index and LGE+ (HR: 2.69 [1.38–5.25], P = 0.004) were associated with impaired outcome (Fig. 1). LV myocardial replacement fibrosis is frequent in MVP patients, related to both mitral valve apparatus alteration and MR grade (trace-mild 14%, moderate 28%, severe 39%), and emerges as a predictor of cardiovascular events. CMR imaging provides additional information to echocardiography in MVP. [ABSTRACT FROM AUTHOR]

Background: Mechanical thrombectomy (MT) is an effective treatment for acute ischemic stroke from large vessel occlusion (LVO). While embolization to a new territory (ENT) after MT is well-documented, data on embolization in the same distal territory (EDT) are limited. Achieving modified Treatment In Cerebral Infarction (mTICI) 3 reperfusion presents significant clinical benefits over mTICI 2b/2c, necessitating strategies to reduce both ENT and EDT. Previous studies suggest higher rates of EDTs with contact aspiration compared with stentrievers. However, comprehensive comparison studies in clinical practice are scarce. This study compares the rates of overall clot emboli (OCE) between these MT strategies., Methods: A retrospective, multicenter observational study was conducted at four university hospitals in France from January 2015 to November 2019. Adult patients (≥18 years) with acute ischemic stroke due to LVO, treated with either contact aspiration (ADAPT, A Direct Aspiration First Pass Technique) or stentrievers, specifically using the Embotrap device to maintain sample homogeneity, were included. Digital subtraction angiography was used for imaging, with two independent, blinded reviewers assessing OCE post-first MT pass. Propensity score full matching and independent sample testing were employed to evaluate OCE after the first MT pass., Results: A significant difference in OCE rates was observed between contact aspiration and stentriever techniques, with the stentriever technique resulting in fewer embolic events compared with ADAPT, based on a propensity score analysis that accounts for key confounding factors., Conclusion: A statistically significant reduction in embolic events was observed with the stentriever technique compared with contact aspiration. These results suggest that the stentriever method may offer a safer profile in terms of embolic risk for LVO interventions, and should be considered over contact aspiration when embolic risk is a primary concern, while also considering individual patient factors., Competing Interests: Competing interests: K Janot reports consulting fees for Balt. N-A Sourour reports conflict of interest with Medtronic, Balt (consulting fee or honorarium, non-related to the study). F Clarençon reports conflict of interest with Medtronic, Balt Extrusion (consultant; non-related to the study), ClinSearch (core lab; non-related to the study), Penumbra, Stryker (payment for reading; non-related) and Artedrone (Board; non-related to the study). The other authors did not report any conflict related to this study., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Biomedical data warehouses (BDWs) have become an essential tool to facilitate the reuse of health data for both research and decisional applications. Beyond technical issues, the implementation of BDWs requires strong institutional data governance and operational knowledge of the European and national legal framework for the management of research data access and use., Objective: In this paper, we describe the compound process of implementation and the contents of a regional university hospital BDW., Methods: We present the actions and challenges regarding organizational changes, technical architecture, and shared governance that took place to develop the Nantes BDW. We describe the process to access clinical contents, give details about patient data protection, and use examples to illustrate merging clinical insights., Unlabelled: More than 68 million textual documents and 543 million pieces of coded information concerning approximately 1.5 million patients admitted to CHUN between 2002 and 2022 can be queried and transformed to be made available to investigators. Since its creation in 2018, 269 projects have benefited from the Nantes BDW. Access to data is organized according to data use and regulatory requirements., Conclusions: Data use is entirely determined by the scientific question posed. It is the vector of legitimacy of data access for secondary use. Enabling access to a BDW is a game changer for research and all operational situations in need of data. Finally, data governance must prevail over technical issues in institution data strategy vis-à-vis care professionals and patients alike., (© Matilde Karakachoff, Thomas Goronflot, Sandrine Coudol, Delphine Toublant, Adrien Bazoge, Pacôme Constant Dit Beaufils, Emilie Varey, Christophe Leux, Nicolas Mauduit, Matthieu Wargny, Pierre-Antoine Gourraud. Originally published in JMIR Medical Informatics (https://medinform.jmir.org).)

Background and Purpose: The ever-growing availability of imaging led to increasing incidentally discovered unruptured intracranial aneurysms (UIAs). We leveraged machine-learning techniques and advanced statistical methods to provide new insights into rupture intracranial aneurysm (RIA) risks., Methods: We analysed the characteristics of 2505 patients with intracranial aneurysms (IA) discovered between 2016 and 2019. Baseline characteristics, familial history of IA, tobacco and alcohol consumption, pharmacological treatments before the IA diagnosis, cardiovascular risk factors and comorbidities, headaches, allergy and atopy, IA location, absolute IA size and adjusted size ratio (aSR) were analysed with a multivariable logistic regression (MLR) model. A random forest (RF) method globally assessed the risk factors and evaluated the predictive capacity of a multivariate model., Results: Among 994 patients with RIA (39.7%) and 1511 patients with UIA (60.3 %), the MLR showed that IA location appeared to be the most significant factor associated with RIA (OR, 95% CI: internal carotid artery, reference; middle cerebral artery, 2.72, 2.02-3.58; anterior cerebral artery, 4.99, 3.61-6.92; posterior circulation arteries, 6.05, 4.41-8.33). Size and aSR were not significant factors associated with RIA in the MLR model and antiplatelet-treatment intake patients were less likely to have RIA (OR: 0.74; 95% CI: 0.55-0.98). IA location, age, following by aSR were the best predictors of RIA using the RF model., Conclusions: The location of IA is the most consistent parameter associated with RIA. The use of 'artificial intelligence' RF helps to re-evaluate the contribution and selection of each risk factor in the multivariate model., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease characterized by the triad of nose bleeding, telangiectasia and familial heredity., Case Report: We report the case of a patient who had idiopathic venous cerebral thrombosis complicated by a cerebral infarction treated with warfarin. In the context of a psoas hematoma by warfarine overdose and immobilization, the patient had deep vein thrombosis of the left lower limb with pulmonary embolism revealing a pulmonary arteriovenous malformation. After a reexamination, the patient clinical phenotype of HHT was confirmed genetically. The patient was treated with rivaroxaban allowing clinical improvement and partial recanalization of all thrombosis after six months. Thrombotic overisk has already been studied in HHT patients but the use of anticoagulants is at higher risk in these patients. However this patient experienced no adverse event with rivaroxaban., Conclusion: This is the first case described of cerebral venous thrombosis treated with rivaroxaban revealing an HHT., (Copyright © 2020. Published by Elsevier Masson SAS.)