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Balloon pulmonary angioplasty (BPA) to treat chronic thromboembolic pulmonary hypertension (CTEPH) is generally reserved for distal obstruction precluding pulmonary endarterectomy (PEA) but can be used in patients with proximal disease who are at high surgical risk or refuse surgery. This single-center retrospective study compared BPA efficacy in patients with proximal versus distal CTEPH. Of the 478 patients, 36 had proximal disease, follow-up was 11.6 months and mean number of BPA 6. After BPA, PVR, and mean pulmonary artery pressure decreased significantly in the proximal and distal groups (from 6.5 to 4.0 WU and 39 to 31 mmHg and from 7.6 to 3.8 WU and 44 to 31 mmHg, respectively, p  < 0.001 for all comparisons). NYHA class also improved significantly in both groups, from 3 to 2, whereas the 6-min walk distance, cardiac output, and serum NT pro-BNP showed significant improvements only in the distal group. Thus, when PEA for CTEPH is technically feasible but not performed due to severe comorbidities or patient refusal, BPA can produce significant hemodynamic improvements, albeit less marked than in patients with distal disease. Better patient selection to BPA might improve outcomes in patients with proximal disease who are ineligible for PEA., Competing Interests: The authors declare no conflict of interest., (© 2024 The Author(s). Pulmonary Circulation published by John Wiley & Sons Ltd on behalf of Pulmonary Vascular Research Institute.)

Background: Data regarding the safety and long-term effectiveness of percutaneous closure of paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI) are scarce., Aims: This study aims to present a large multicentre international experience of percutaneous post-TAVI PVL closure., Methods: All patients who underwent percutaneous post-TAVI PVL closure in 14 hospitals across Europe and North America between January 2018 and October 2022 were included., Results: Overall, 45 patients (64% male) were enrolled. The median age was 80 years (75-84). Among them, 67% and 33% had self-expanding and balloon-expandable valve implantations, respectively. Baseline post-TAVI PVL was severe in 67% of cases and moderate in the rest. The time from index TAVI to PVL closure procedure was 16.1 (8.7-34.8) months. Most patients were in NYHA Class III and IV (73%) before the procedure, and 40% had referred hospitalisations for heart failure between TAVI and the PVL closure procedure. Successful PVL closure was achieved in 94%, reducing regurgitation to ≤mild in 91% and moderate in the rest. The Amplatzer Valvular Plug III was the most frequently used device (27 cases), followed by the Amplatzer Valvular Plug 4. The incidence of severe adverse events was 11%. None of the patients died during the index hospitalisation. During long-term follow-up (21.7±16.2 months), the all-cause mortality rate was 14%, and patients presented improvement in functional status and a significant reduction in the rate of hospitalisation for heart failure (from 40% to 6%)., Conclusions: Percutaneous PVL closure is a feasible and safe option for treating post-TAVI leaks. Successful PVL reduction to mild or less could be associated with acute and long-lasting improvements in clinical outcomes.

Prosthetic paravalvular leaks (PVLs) are associated with congestive heart failure and hemolysis. Surgical PVL closure carries high risks. Transcatheter implantation of occluding devices in PVL is a lower risk but challenging procedure. Of the available devices, only two have been specifically approved in Europe for transcatheter PVL closure (tPVLc): the Occlutech ® Paravalvular Leak Device (PLD) and Amplatzer™ ParaValvular Plug 3 (AVP 3). Here, we review the various tools and devices used for tPVLc, based on three observational registries including 748 tPVLc procedures performed in 2005-2021 at 33 centres in 11 countries. In this case, 12 registry investigators with over 20 tPVLc procedures each described their practical tips and tricks regarding imaging, approaches, delivery systems, and devices. They considered three-dimensional echocardiography to be the cornerstone of PVL assessment and procedure guidance. Anterograde trans-septal mitral valve and retrograde aortic approaches were used in most centres, although some investigators preferred the transapical approach. Hydrophilic-coated low-profile sheaths were used most often for device deployment. The AVP 3 and PLD devices were chosen for 89.0% of procedures. Further advances in design and materials are awaited. These complex procedures require considerable expertise, and experience accumulated over a decade has no doubt contributed to improve practices.

Background: Percutaneous closure of paravalvular leak (PVL) has emerged as an alternative to surgical management in selected cases. Achieving complete PVL occlusion, while respecting prosthesis function remains challenging. A multimodal imaging analysis of PVL morphology before and during the procedure is mandatory to select an appropriate device. We aim to explore the additional value of 3D printing in predicting device related adverse events including mechanical valve leaflet blockade, risk of device embolization and residual shunting., Methods: From the FFPP registries (NCT05089136 and NCT05117359), we included 11 transcatheter PVL closure procedures from three centers for which 3D printed models were produced. Cardiac CT was used for segmentation for 3D printed models (3D-heartmodeling, Caissargues, France). Technology used a laser to fuse very fine powders (TPU Thermoplastic polyurethane) into a final part-laser sintering technology (SLS) with an adapted elasticity. A simulation on 3D printed model was performed using a set of occluders., Results: PVLs were located around aortic prostheses in six cases, mitral prostheses in four cases and tricuspid ring in one case. The device chosen during the simulation on the 3D printed model matched the one implanted in eight cases. In the three other cases, a similar device type was chosen during the procedures but with a different size. A risk of prosthesis leaflet blockade was identified on 3D printed models in four cases. During the procedure, the occluder was removed before release in one case. In another case the device was successfully repositioned and released. In two patients, leaflet impingement was observed post-operatively and surgical device removal had to be performed., Conclusion: In a case-series of complex transcatheter PVL closure procedures, hands-on simulation testing on 3D printed models proved its usefulness to plan and facilitate these challenging procedures., Competing Interests: The authors declare no conflict of interest.

Aims: Limited data exist regarding the incidence and aetiology of life-threatening events such as major cardiac events or exertional heat stroke during long-distance races. We aimed to provide an updated incidence, etiology and prognosis of life-threatening events during long-distance races., Methods: The prospective RACE PARIS registry recorded all life-threatening events/fatal events occurring during 46 marathons, half-marathons and other long-distance races in the Paris area between 2006 and 2016, comprising 1,073,722 runners. Event characteristics were determined by review of medical records and interviews with survivors., Results: The incidence of life-threatening events, exertional heat stroke and major cardiac events was 3.35 per 100,000, 1.02 per 100,000 and 2.33 per 100,000, respectively, including 18 sudden cardiac arrests (1.67 per 100,000). The main aetiology of sudden cardiac arrest was myocardial ischaemia (11/18), due to acute coronary thrombosis (6/11), stable atherosclerotic coronary artery disease (2/11), coronary dissection (1/11), anomalous connection (1/11) or myocardial bridging (1/11). A third of participants with ischaemia-related major cardiac events presented with pre-race clinical symptoms. Major cardiac events were more frequent in the case of a high pollution index (6.78 per 100,000 vs. 2.07 per 100,000, odds ratio 3.27, 95% confidence interval 1.12-9.54). Case fatality was low (0.19 per 100,000). Similarly, we report in a meta-analysis of eight long-distance race registries comprising 16,223,866 runners a low incidence of long-distance race-related sudden cardiac arrest (0.82 per 100,000) and fatality (0.39 per 100,000). Death following sudden cardiac arrest was strongly associated with initial asystole or pulseless rhythm., Conclusion: Long-distance race-related life-threatening events remain rare although serious events. Better information for runners on the risk of pre-race clinical symptoms, outside air pollution and temperature may reduce their incidence., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: To evaluate safety and efficacy of balloon pulmonary angioplasty (BPA) in a large cohort of patients with chronic thromboembolic pulmonary hypertension (CTEPH)., Methods: From 2014 to 2017, 184 inoperable CTEPH patients underwent 1006 BPA sessions. Safety and efficacy during the first 21 months (initial period) were compared with those of the last 21 months (recent period). A total of 154 patients had a full evaluation after a median duration of 6.1 months., Results: Overall, there was a significant improvement in New York Heart Association functional class, 6-min walk distance (mean change +45 m), and a significant decrease in mean pulmonary artery pressure (PAP) and in pulmonary vascular resistance (PVR) by 26% and 43%, respectively. The percentage decreases of mean PAP and PVR were 22% and 37% in the initial period versus 30% and 49% in the recent period, respectively (p<0.05). The main complications included lung injury, which occurred in 9.1% of 1006 sessions (13.3% in the initial period versus 5.9% in the recent period; p<0.001). Per-patient multivariate analysis revealed that baseline mean PAP and the period during which BPA procedure was performed (recent versus initial period) were the strongest factors related to the occurrence of lung injury. 3-year survival was 95.1%., Conclusion: This study confirms that a refined BPA strategy improves short-term symptoms, exercise capacity and haemodynamics in inoperable CTEPH patients with an acceptable risk-benefit ratio. Safety and efficacy improve over time, underscoring the unavoidable learning curve for this procedure., Competing Interests: Conflict of interest: P. Brenot has nothing to disclose. Conflict of interest: X. Jaïs reports grants and personal fees from Actelion, GSK, Bayer and MSD, outside the submitted work. Conflict of interest: Y. Taniguchi has nothing to disclose. Conflict of interest: C. Garcia Alonso has nothing to disclose. Conflict of interest: B. Gerardin has nothing to disclose. Conflict of interest: S. Mussot has nothing to disclose. Conflict of interest: O. Mercier has nothing to disclose. Conflict of interest: D. Fabre has nothing to disclose. Conflict of interest: F. Parent has nothing to disclose. Conflict of interest: M. Jevnikar has nothing to disclose. Conflict of interest: D. Montani reports grants and personal fees from Actelion and Bayer, personal fees from GSK, Pfizer, BMS and MSD, outside the submitted work. Conflict of interest: L. Savale reports grants, personal fees and non-financial support from Actelion and GSK, personal fees and non-financial support from MSD, outside the submitted work. Conflict of interest: O. Sitbon reports grants, personal fees and non-financial support from Actelion Pharmaceuticals and GlaxoSmithKline, grants and personal fees from Bayer HealthCare, grants and non-financial support from Merck, personal fees from Arena Pharmaceuticals, outside the submitted work. Conflict of interest: E. Fadel has nothing to disclose. Conflict of interest: M. Humbert reports grants and personal fees from Actelion, Bayer, GSK and from MSD, personal fees from Johnson & Johnson and United Therapeutics, outside the submitted work. Conflict of interest: G. Simonneau reports grants, personal fees and non-financial support from Actelion Pharmaceuticals, Bayer Healthcare, Merck and GlaxoSmithKline, outside the submitted work., (Copyright ©ERS 2019.)

Competing Interests: The authors declare no conflict of interest.

Background: Percutaneous paravalvular leak (PVL) closure has emerged as a palliative alternative to surgical management in selected high-risk patients. Percutaneous procedures are challenging, especially for mitral PVL. Accurate imaging of the morphologies of the defects is mandatory, together with precise guidance in the catheterization laboratory to enhance success rates., Aims: To describe imaging modalities used in clinical practice to guide percutaneous PVL closure and assess the potential of new imaging tools., Methods: Data from the 'Fermeture de Fuite paraprothétique' (FFPP) register were used. The FFPP register is an international multi-institutional collaborative register started in 2017 with a retrospective and a prospective part. A descriptive analysis of multimodality imaging used to guide PVL closure in clinical practice was performed., Results: Data from 173 procedures performed in 19 centres from three countries (France, Belgium and Poland) were collected, which included eight cases of PVL following transcatheter valve replacement. Transoesophageal echocardiography was used in 167 cases (96.5%) and 3D echocardiography in 87.4% of cases. In one case, 3D-echocardiography was fused with fluoroscopy images in real time using echonavigator software. Details about multimodality imaging were available from a sample of 31 patients. Cardiac computed tomography (CT) was performed before 10 of the procedures. In one case, fusion between preprocedural cardiac CT angiography data and fluoroscopy data was used. In two cases, a 3D model of the valve with PVL was printed., Conclusion: Echocardiography, particularly the 3D mode, is the cornerstone of PVL imaging. Other imaging modalities, such as cardiac CT and cardiac magnetic resonance imaging, may be of complementary interest. New techniques such as imaging fusion and printing may further facilitate the percutaneous approach of PVLs., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Emergency bedside veno-arterious ECMO implantation can be the only saving gesture in the suspicion of acute massive pulmonary embolism leading to haemodynamic failure, even before CT-scan imaging. Once the massive pulmonary embolism is confirmed it is possible to undergo surgical or percutaneous pulmonary thrombectomy, when thrombolytic therapy is contraindicated., (Copyright © 2017. Published by Elsevier SAS.)

Aim: Long distance running races are associated with a low risk of life-threatening events much often attributed to hypertrophic cardiomyopathy. However, retrospective analyses of aetiology lack consistency., Methods and Results: Incidence and aetiology of life-threatening/fatal events were assessed in long distance races in the prospective Registre des Accidents Cardiaques lors des courses d'Endurance (RACE Paris Registry) from October 2006 to September 2012. Characteristics of life-threatening/fatal events were analysed by interviewing survivors and reviewing medical records including post-mortem data of each case. Seventeen life-threatening events were identified of 511 880 runners of which two were fatal. The vast majority were cardiovascular events (13/17) occurring in experienced male runners [mean (±SD) age 43 ± 10 years], with infrequent cardiovascular risk factors, atypical warning symptoms prior to the race or negative treadmill test when performed. Acute myocardial ischaemia was the predominant aetiology (8 of 13) and led to immediate myocardial revascularization. All cases with initial shockable rhythm survived. There was no difference in event rate according to marathons vs. half-marathons and events were clustered at the end of the race. A meta-analysis of all available studies including the RACE Paris registry (n = 6) demonstrated a low prevalence of life-threatening events (0.75/100 000) and that presentation with non-shockable rhythm [OR = 29.9; 95% CI (4.0-222.5), P = 0.001] or non-ischaemic aetiology [OR = 6.4; 95% CI (1.4-28.8), P = 0.015] were associated with case-fatality., Conclusion: Life-threatening/fatal events during long distance races are rare, most often unpredictable and mainly due to acute myocardial ischaemia. Presentation with non-shockable rhythm and non-ischaemic aetiology are the major determinant of case fatality., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Background: Whereas the coronary artery disease death rate has declined in high-income countries, the incidence of acute coronary syndromes (ACS) is increasing in sub-Saharan Africa, where their management remains a challenge., Aim: To propose a consensus statement to optimize management of ACS in sub-Saharan Africa on the basis of realistic considerations., Methods: The AFRICARDIO-2 conference (Yamoussoukro, May 2015) reviewed the ongoing features of ACS in 10 sub-Saharan countries (Benin, Burkina-Faso, Congo-Brazzaville, Guinea, Ivory Coast, Mali, Mauritania, Niger, Senegal, Togo), and analysed whether improvements in strategies and policies may be expected using readily available healthcare facilities., Results: The outcome of patients with ACS is affected by clearly identified factors, including: delay to reaching first medical contact, achieving effective hospital transportation, increased time from symptom onset to reperfusion therapy, limited primary emergency facilities (especially in rural areas) and emergency medical service (EMS) prehospital management, and hence limited numbers of patients eligible for myocardial reperfusion (thrombolytic therapy and/or percutaneous coronary intervention [PCI]). With only five catheterization laboratories in the 10 participating countries, PCI rates are very low. However, in recent years, catheterization laboratories have been built in referral cardiology departments in large African towns (Abidjan and Dakar). Improvements in patient care and outcomes should target limited but selected objectives: increasing awareness and recognition of ACS symptoms; education of rural-based healthcare professionals; and developing and managing a network between first-line healthcare facilities in rural areas or small cities, emergency rooms in larger towns, the EMS, hospital-based cardiology departments and catheterization laboratories., Conclusion: Faced with the increasing prevalence of ACS in sub-Saharan Africa, healthcare policies should be developed to overcome the multiple shortcomings blunting optimal management. European and/or North American management guidelines should be adapted to African specificities. Our consensus statement aims to optimize patient management on the basis of realistic considerations, given the healthcare facilities, organizations and few cardiology teams that are available., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Background: Coronary stents have evolved over time, from bare-metal stents to drug-eluting stents, and now to bioactive stents., Aims: We sought to explore the immediate outcome of the titanium-nitride-oxide-coated bioactive stent, Titan2(®), in real-world practice, and the incidence of major cardiac events at follow-up., Methods: Consecutive patients admitted for percutaneous intervention for at least one significant (≥50%) lesion in a native coronary artery were treated with Titan2(®) stent implantation. The primary endpoint was total major adverse cardiac events at 12-month follow-up. Secondary endpoints included target lesion revascularization at 12-month follow-up and the duration of dual antiplatelet therapy., Results: Among 356 patients (mean age 67.4 ± 12.1 years), 77.2% were male and 39.3% were treated for myocardial infarction (MI). A total of 546 Titan2(®) stents were implanted in 420 lesions. Angiographic and clinical procedural success was achieved in all cases. No cases of in-hospital major adverse cardiac events or acute stent thrombosis were reported. Of 335 patients (94.1%) with 12-month clinical follow-up, four (1.2%) died, MI occurred in five (1.5%), target lesion revascularization was performed in 17 (5.1%) and major adverse cardiac events occurred in 24 (7.2%). One patient (0.3%) suffered late stent thrombosis during follow-up, but no cases of acute or subacute stent thrombosis occurred. Dual antiplatelet therapy continued beyond 6 months in 64.5% of patients., Conclusions: In real-world practice, Titan2(®) stent implantation achieves an excellent immediate outcome, with a low incidence of major adverse cardiac events at 12-month follow-up., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

We report here the long term follow-up of the first french case, at our knowledge, of alcohol septal transcoronary ablation in March 1998 in Clinique Ambroise Paré in an 76 year-old woman. This patient was in NYHA III-IV functional class and at control outflow gradient was 100 mmHg. She was prior treated with high dosis of beta-blockers then DDD-pacemaker with no effects on symptoms. The technique used was the one described by Sigwart and al., with injection of 3 cm3 of ethyl alcohol in the first septal branch, after checking decrease of gradient during occlusion of septal branche with balloon angioplasty. After alcohol ablation, the gradient decreased immediately to 15 mmHg and disappeared at long-term follow up. Three years and half after the procedure, no complication occurred, the patient remains asymptomatic and the control echocardiography shows interventricular septal reduction of thickness from 22 to 12 mm.

The authors report the case of a 74-year-old hypertensive man hospitalised with chest pain accompanied by shock and hemo-mediastinum. The diagnosis of spontaneous rupture of the thoracic aorta, suspected by aortic arteriography, was confirmed by thoracic CT scan with injection of contrast medium. Emergency surgery revealed a 4 cm longitudinal linear tear of the horizontal aorta, with neither dissection nor aneurysm. Simple suture during extra-corporeal circulation with normothermia and the heart beating, was successful after prolonged postoperative intensive care. This case of complete and spontaneous acute rupture of the horizontal thoracic aorta appears to be the first to have been successfully treated surgically.

Between April 4, 1984, and December 31, 1987, 156 consecutive neonates with simple transposition of the great arteries underwent an arterial switch operation (ASO) at our institution. Surgery was performed before the age of 15 days in 96%, and patient weight was less than 3 kg in 28%. Seventeen patients (10.9%) died after surgery. One patient was lost to follow-up. Of the 138 survivors, two died of myocardial infarction 35 and 40 days, respectively, after surgery. They were the only late deaths, and actuarial survival rates were 87% (70% confidence level [CL], 83-89%) at 45 days and 87% (70% CL, 68-95%) at 52 months. Another patient had a myocardial infarction 50 days after surgery and is well 50 months later. Pulmonary stenosis was observed in 14 patients (10.3%) during the first year after surgery; two patients were reoperated on 10 and 12 months, respectively, after ASO. Aortic regurgitation was observed in 17 patients: two had grades II and III, respectively, aortic regurgitation on aortography; in 15 patients, it was detected only by Doppler examination. At the last follow-up (2-52 months after ASO; mean, 27.3 +/- 11.3 months), all patients were asymptomatic and taking no medication. On bidimensional echocardiography, left ventricular fractional shortening was normal at rest in all survivors but one. One patient had junctional rhythm, and one had Wenckebach periods; the remainder were in sinus rhythm. For as long as 5 years after ASO, late death and reintervention were rare; 99% of the survivors were asymptomatic and had sinus rhythm and good systemic ventricular function.(ABSTRACT TRUNCATED AT 250 WORDS)