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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.To evaluate postoperative mortality after surgical rescue post-TAVR, in a population at high surgical risk.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.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.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 centers.

On 26 September 2019, an industrial fire occurred in the Lubrizol factory in Rouen (France), exposing the population to the inhalation of many volatile toxic agents secondary to combustion.To assess the impact of the Lubrizol factory fire on the incidence of coronary artery events.All coronary angiograms performed in Rouen (exposed) and Le Havre (unexposed) from May 2019 to December 2019 were extracted from the prospective France Percutaneous Coronary Intervention (France PCI) registry. To study the impact of the fire on coronary events, an interrupted time series analysis was performed in Rouen, with adjustment on Le Havre in an autoregressive moving average (ARMA)(1,1) model with the precision of 1 week. The primary outcome was the incidence of acute coronary syndrome, and the secondary outcome was the incidence of ST-segment elevation myocardial infarction.The mean number of acute coronary syndromes per week in the exposed zone (Rouen) increased non-significantly from 37.5±9.4 before the fire to 43.2±6.2 after the fire, for an estimated effect of +5.5 (95% confidence interval -0.7 to 11.8; P=0.09) events per week. In municipalities exposed to the plume of smoke (subgroup of Rouen), the mean number of acute coronary syndromes increased non-significantly from 7.3±2.8 before the fire to 8.7±3.6 after the fire, for an estimated effect of +1.0 (95% confidence interval -2.0 to 4.0; P=0.51) events per week. The results were similar when taking into account only ST-segment elevation myocardial infarctions or all coronary events.Our study did not find a significant effect of the Lubrizol factory fire on the incidence of acute coronary syndrome. Further studies are needed to investigate the impact of industrial accidents on air pollution and coronary events.

Sarcopenia in heart failure (HF) is associated with severe outcomes, increased mortality, and high healthcare cost burden. Systematic muscle screening in patients with chronic HF would improve quality and appropriateness of care. Here we tested handgrip strength (HGS) as a screening tool for sarcopenia in patients with chronic HF, using the EWGSOP 2010 and 2019 reference-standard definitions of sarcopenia.HF inpatients, aged 65 years old or above, were prospectively included between November 2014 and September 2018, and relevant sociodemographic, anthropometric and HF characterization data was collected. The accuracy of HGS as a screening test for sarcopenia was assessed by gender using area under the receiver operating characteristic (ROC) curves (AUC).The population consisted of 118 older patients (age: 78.9 yrs; BMI: 26.6 kg/mHGS can be used as a valid tool to screen for sarcopenia in older (≥65 yrs) patients with chronic HF.NCT03153774.

Background There is limited evidence that fractional flow reserve (FFR) is effective in guiding therapeutic strategy in multivessel coronary artery disease (CAD) beyond prespecified percutaneous coronary intervention or coronary graft surgery candidates. Objectives The FUTURE (FUnctional Testing Underlying coronary REvascularization) trial aimed to evaluate whether a treatment strategy based on FFR was superior to a traditional strategy without FFR in the treatment of multivessel CAD. Methods The FUTURE trial is a prospective, randomized, open-label superiority trial. Multivessel CAD candidates were randomly assigned (1:1) to treatment strategy based on FFR in all stenotic (≥50%) coronary arteries or to a traditional strategy without FFR. In the FFR group, revascularization (percutaneous coronary intervention or surgery) was indicated for FFR ≤0.80 lesions. The primary endpoint was a composite of major adverse cardiac or cerebrovascular events at 1 year. Results The trial was stopped prematurely by the data safety and monitoring board after a safety analysis and 927 patients were enrolled. At 1-year follow-up, by intention to treat, there were no significant differences in major adverse cardiac or cerebrovascular events rates between groups (14.6% in the FFR group vs 14.4% in the control group; hazard ratio: 0.97; 95% confidence interval: 0.69-1.36; P = 0.85). The difference in all-cause mortality was nonsignificant, 3.7% in the FFR group versus 1.5% in the control group (hazard ratio: 2.34; 95% confidence interval: 0.97-5.18; P = 0.06), and this was confirmed with a 24 months’ extended follow-up. FFR significantly reduced the proportion of revascularized patients, with more patients referred to exclusively medical treatment (P = 0.02). Conclusions In patients with multivessel CAD, we did not find evidence that an FFR-guided treatment strategy reduced the risk of ischemic cardiovascular events or death at 1-year follow-up. (Functional Testing Underlying Coronary Revascularisation; NCT01881555 )

The interest in revascularization of chronic total occlusions (CTO) of the coronary arteries during the last decade has not waned. It is one of the latest challenges for percutaneous coronary interventions (PCI), requiring a specific organization of the patient pathway, dedicated equipment, and targeted medical expertise, now establishing CTO as a new discipline in interventional cardiology. Despite technical progress, the success rate of CTO-PCI is still lower than that of non-CTO-PCI, mainly due to guidewire failure. What can be the place of IVUS in CTO recanalization? IVUS offers a real-time cross-sectional image of the lumen and the vessel wall and meets all the criteria for assisting guidewire crossing. In addition, and as in any angioplasty of long and calcified complex lesions, IVUS participates in an optimal sizing of the stent and ensures its proper expansion. Optical coherence tomography (OCT) has no place, for multiple reasons, in the management of a CTO procedure but can help on remote control to ensure an optimal result, to validate the interest of a technique. Endocoronary imaging in CTO as in other complex situations is likely to optimize procedural results, to validate strategic options with the ultimate goal of improving clinical results.

The optimal management of patients with ST-segment elevation myocardial infarction (STEMI) presenting late-12 hours following symptom onset-is still under debate.The purpose of this study was to describe characteristics, temporal trends, and impact of revascularization in a large population of latecomer STEMI patients.The authors analyzed the data of 3 nationwide observational studies from the FAST-MI (French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction) program, conducted over a 1-month period in 2005, 2010, and 2015. Patients presenting between 12 and 48 hours after symptom onset were classified as latecomers.A total of 6,273 STEMI patients were included in the 3 cohorts, 1,169 (18.6%) of whom were latecomers. After exclusion of patients treated with fibrinolysis and patients deceased within 2 days after admission, 1,077 patients were analyzed, of whom 729 (67.7%) were revascularized within 48 hours after hospital admission. At 30-day follow-up, all-cause death rate was significantly lower among revascularized latecomers (2.1% vs 7.2%; P 0.001). After a median follow-up of 58 months, the rate of all-cause death was 30.4 (95% CI: 25.7-35.9) per 1,000 patient-years in the revascularized latecomers group vs 78.7 (95% CI: 67.2-92.3) per 1,000 patient-years in the nonrevascularized latecomers group (P 0.001). In multivariate analysis, revascularization of latecomer STEMI patients was independently associated with a significant reduction of mortality occurrence during follow-up (HR: 0.65 [95% CI: 0.50-0.84]; P = 0.001).Coronary revascularization of latecomer STEMI patients is associated with better short and long-term clinical outcomes.

Background Kawasaki disease (KD) is a medium vessel vasculitis occurring in children, as yet of undetermined aetiology. KD can lead to severe complications such as coronary artery aneurysms, thrombosis, and sudden death. Monitoring of coronary anomalies is an important issue in the early phase of the disease, and their follow-up is based on different imaging methods. The interventional treatment of these coronary anomalies, which is often complex, is a therapeutic challenge. Case summary We are reporting the case of a four-year-old child who presented KD which was complicated by coronary aneurysm of the proximal left anterior descending artery and ectasia of the right coronary artery (RCA). These lesions progressively calcified and resulted at the age of 13 in chronic occlusion of the RCA. After confirmation of myocardial viability and myocardial ischaemia, a complex angioplasty guided by intracoronary imaging was performed using rotational atherectomy, a cutting balloon, and a high pressure balloon. The control coronary angiography performed 1 year later revealed two false aneurysm on the RCA at the angioplasty site, which were successfully treated with a covered stent. Discussion This case report describes the challenges of treating coronary artery abnormalities such as calcified coronary lesions in children with KD. The coronary intervention of these lesions remains complex and may lead to coronary rupture. We highlight the advantage of using intracoronary imaging in the management of these calcified lesions for successful revascularization, and to assess the complications of percutaneous coronary intervention.

International audience; Background & aims: Sarcopenia is a multifactorial syndrome resulting in a decrease in both muscle mass and function. Little is known about the prevalence and prognostic impact of sarcopenia in patients with acutely decompensated chronic heart failure (ADHF). We aimed to evaluate the prevalence (main endpoint) and impact of sarcopenia on ADHF patients.Methods: 140 ADHF patients were enrolled between November 2014 and September 2018 in a multi-center prospective longitudinal study. A similar, independent multi-departmental cross-sectional study in 165 ADHF patients was used for external validation of prevalence data. All subjects were assessed on the European Working Group on Sarcopenia criteria.Results: Ninety-one patients (65%) had sarcopenia (vs. 53.6% in the external replication regional cohort). Patients with sarcopenia were older and more likely to have eGFR

Background Spontaneous coronary artery dissection (SCAD) is still an underdiagnosed condition that requires a detailed assessment of angiographic signs. It also shares similar clinical presentations with Takotsubo syndrome (TTS). The concomitant presentation of SCAD with TTS is a possible occurrence, making it difficult for clinicians to treat and manage. Case summary This study included a 49-year-old woman with retrosternal chest pain who was admitted to the emergency department. Coronary angiography indicated Type 2A SCAD involving the middle part of the left anterior descending artery, while the left ventriculography indicated a typical left ventricular apical ballooning compatible with TTS. A conservative approach to the management of SCAD was observed. After a 3-month follow-up, the control coronary angiography showed a complete angiographic resolution. The results of the transthoracic echocardiogram (TTE) and cardiac magnetic resonance revealed a complete normalization of the pathological features. The patient remained asymptomatic and showed no recurrence of chest pain. Discussion Although TTS and SCAD are commonly observed in patients who share certain characteristics (women, without atheromatous terrain, stress-related factors), it is difficult to establish a pathophysiological link between them. This observation confirms the non-random association of two rare entities of myocardial infarction with no obstructive coronary arteries. Although TTS can be easily diagnosed via non-invasive imaging, the diagnosis of SCAD is more difficult. The findings of this study suggest a concomitant presentation between SCAD and TTS. Although the treatment approach to SCAD is usually conservative, severe forms of this disease require early diagnosis and appropriate treatment.

OBJECTIVES To evaluate the effectiveness of anticoagulant therapies in patients with clinical transcatheter heart valve (THV) thrombosis, to describe complications, and to assess their risk profile was the objectives. BACKGROUND Little research has been conducted on clinical THV thrombosis. METHODS Patients with clinical THV thrombosis were identified based on greater than 50% increased transvalvular gradient on transthoracic echocardiogram confirmed by 4-dimensional computed tomography, transesophageal echocardiogram, or regression with anticoagulant therapy. A cohort free from thrombosis for more than 1,100 days postprocedure was used for comparison. RESULTS Fifty-four patients with clinical THV thrombosis were identified. Most subjects (98.1%) received anticoagulant therapy which was effective (≥50% reduction in transvalvular gradient or return to postprocedure value) in 96%. The rate of serious hemodynamic or embolic complications in the thrombosis population was 31.5%. A multivariate analysis of subjects with and without thrombosis indicated a significantly increased risk of thrombosis from preexisting thrombocytopenia (odds ratio [OR] 9.96), absence of predilatation (OR = 5.67), renal insufficiency (OR = 4.84), and >10 mmHg mean transvalvular gradient postprocedure (OR = 3.36). No recurrence of thrombosis was identified during on average 685 days follow-up. CONCLUSIONS These data, from one of the largest cohorts with clinical THV thrombosis confirm anticoagulants appear effective. The rate of serious associated complications was high. The findings underline the importance of recognizing risk factors for thrombosis.

International audience; BackgroundST‐elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) are associated with a worse prognosis. However, few comparisons are available according to coronary status in the era of modern reperfusion and optimized secondary prevention.HypothesisWe hypothesized that the difference in prognosis according to number of vessel disease in STEMI patients has reduced.MethodsAll consecutive STEMI patients undergoing primary percutaneous coronary intervention (PCI) within 24 h of symptoms onset between January 1, 2014 and June 30, 2016 enrolled in the CRAC (Club Régional des Angioplasticiens de la région Centre) France PCI registry were analyzed. Baseline characteristics, management, and outcomes at 1‐year were analyzed according to coronary status (one‐, two‐, and three‐VD).ResultsA total of 1886 patients (mean age 62.2 ± 14.0 year; 74% of male) were included. Patients with MVD (two or three‐VD) represented 53.7%. They were older with higher cardiovascular risk factor profile. At 1 year, the rate of major adverse cardiovascular events (MACE, defined as all‐cause death, stroke or re‐MI) was 10%, 12%, and 12% in one‐, two, and three‐VD respectively (p = .28). In multivariable adjusted Cox proportional hazard regression model, two‐ and three‐VD were not associated with higher rate of MACE compared to patients with single VD (HR, 1.09; 95%CI 0.76–1.56 for two‐VD; HR, 0.74; 95%CI 0.48–1.14 for three‐VD).ConclusionsMVD still represents an important proportion of STEMI patients but their prognoses were not associated with worse clinical outcomes at 1‐year compared with one‐VD patients in a modern reperfusion area and secondary medication prevention.

Objectives The aim of this study was to compare a delayed and a very early invasive strategy in patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) without pre-treatment. Background The optimal delay of the invasive strategy in patients with NSTE-ACS remains debated and has never been investigated in patients not pre-treated with P2Y12–adenosine diphosphate receptor antagonists. Methods A prospective, open-label, randomized controlled trial was conducted. Altogether, 741 patients presenting with intermediate- or high-risk NSTE-ACS intended for an invasive strategy were included. The modified intention-to-treat analysis was composed of 709 patients after 32 withdrew consent. Patients were randomized 1:1 to the delayed invasive group (DG) (n = 363) with coronary angiography (CA) performed 12 to 72 h after randomization or the very early invasive group (EG) (n = 346) with CA within 2 h. No pre-treatment with a loading dose of a P2Y12–adenosine diphosphate receptor antagonist was allowed before CA. The primary endpoint was the composite of cardiovascular death and recurrent ischemic events at 1 month, as determined by a blinded adjudication committee. Results Most patients had high-risk NSTE-ACS in both groups (93% in the EG vs. 92.5% in the DG). The median time between randomization and CA was 0 h (interquartile range [IQR]: 0 to 1 h) in the EG group and 18 h (IQR: 11 to 23 h) in the DG. The primary endpoint rate was significantly lower in the EG (4.4% vs. 21.3% in the DG; hazard ratio: 0.20; 95% confidence interval: 0.11 to 0.34; p Conclusions Without pre-treatment, a very early invasive strategy was associated with a significant reduction in ischemic events at the time of percutaneous coronary intervention in patients with intermediate- and high-risk NSTE-ACS. (Early or Delayed Revascularization for Intermediate and High-Risk Non ST-Elevation Acute Coronary Syndromes; NCT02750579)

Transcatheter aortic valve implantation (TAVI) has become the major approach to manage the severe aortic stenosis in inoperable patients that frequently present a coronary artery disease. To date, the available data related to the impact of these coronary lesions on survival is conflicting. When indicated, coronary revascularization could be beneficial for proximal lesions when performed before or during TAVI. The per-procedure coronary artery occlusion is rare, but with a bad prognosis. The coronary occlusion is more frequent with short distance of the coronary implantation and the small aortic sinuses, mostly occurring in the left main coronary. The scan analysis to identify high-risk cases is therefore important before the procedure in order to anticipate and prevent complications by specific techniques. Recently, late occlusion cases have been described and linked to thrombus or fibrosis mechanisms. The rate of success of percutaneous coronary intervention (PCI) after TAVI approach is weak, because of the difficulties of selective catheterization due to the stent of prosthesis. The different techniques of PCI have been outlined according to the type of the prosthesis.

BackgroundFirst medical contact (FMC)-to-balloon time is associated with outcome of ST-elevation myocardial infarction (STEMI). We assessed the impact on mortality and the determinants of indirect vs. direct transfer to the cardiac catheterization laboratory (CCL).MethodsWe analyzed data from 2,206 STEMI patients consecutively included in a prospective multiregional percutaneous coronary intervention (PCI) registry. The primary endpoint was 1-year mortality. The impact of indirect admission to CCL on mortality was assessed using Cox models adjusted on FMC-to-balloon time and covariables unequally distributed between groups. A multivariable logistic regression model assessed determinants of indirect transfer.ResultsA total of 359 (16.3%) and 1847 (83.7%) were indirectly and directly admitted for PCI. Indirect admission was associated with higher risk features, different FMCs and suboptimal pre-PCI antithrombotic therapy.At 1-year follow-up, 51 (14.6%) and 137 (7.7%) were dead in the indirect and direct admission groups, respectively (adjusted-HR 1.73; 95% CI 1.22–2.45). The association of indirect admission with mortality was independent of pre-FMC and FMC characteristics. Older age, paramedics- and private physician-FMCs were independent determinants of indirect admission (adjusted-HRs 1.02 per year, 95% CI 1.003–1.03; 5.94, 95% CI 5.94 3.89–9.01; 3.41; 95% CI 1.86–6.2, respectively).ConclusionsOur study showed that, indirect admission to PCI for STEMI is associated with 1-year mortality independent of FMC to balloon time and should be considered as an indicator of quality of care. Indirect admission is associated with higher-risk features and suboptimal antithrombotic therapy. Older age, paramedics-FMC and self-presentation to a private physician were independently associated with indirect admission. Our study, supports population education especially targeting elderly, more adequately dispatched FMC and improved pre-CCL management.

Although indispensable, radiation exposure during cardiac catheterization procedures can cause specific radiation-induced diseases. These affect the patient but also the interventional cardiologist. Exposure to high or repeated radiation doses causes deterministic effects. Moreover, even low-dose exposure, especially when repeated, produces a risk of stochastic effets. In that respect, it is crucial to improve the radiation safety of cardiac angiography and interventions, to promote radiation protection and to maintain this exposure « As Low As Reasonably Achievable ». Thus, there is a necessity to spread knowledge about safety standards and recommandations to reduces the dose among interventionalists. Data collection and comparaison of practices are precious to this quality improvement process. For the year 2020, France-PCI registry had collected dosimetric datas related to 55 783 coronary angiographic and interventional procedures from 30 centers in France. Mean fluoroscopy time was 4,4 minutes for diagnostic procedures. Mean PDS was 1 767cGy.Cm2 and mean Air Kerma de 257Gy. Coronary percutaneous angioplasty procedures were related to approximately two to three times higher mean exposures. Mean exposure related to chronic coronary total occlusion treatment procedures was also two times higher than exposure related to non-CTO interventions. These data also highlighted wide disparities between centers.

Developed in the late 1980s, rotational atherectomy has raised a lot of hope for its innovative principle of selective ablation, allowing volume reduction (instead of redistribution) of atherosclerotic plaque, while sparing healthy tissue. Long shunned for its disappointing results on restenosis, the Rotablator finally reasserted itself in the 2000s; era of drug eluting stents and coronary angioplasty boom, thus generating emergence of complex lesions. Indeed, the Rotablator has demonstrated an undeniable benefit in complex (type C) and calcified lesions preparation (before stenting), with a procedural success rate of 95%. Although these lesions only represent a small amount (2-3%) of percutaneous coronary interventions (PCI), they remain a technical impasse for plain-old balloon angioplasty strategy, making the Rotablator more suitable for these resistant lesions' treatment. Registry data attest the safety of this therapy, with a rate of peri-procedural complications and in-hospital mortality comparable to conventional angioplasty (France PCI register). However, certain specific, rare but serious complications (burr entrapment, broken Rotawire, coronary perforation) justify trained teams, perfect knowledge of the equipment, and strict compliance with good practice guidelines. In 2018, the rise of a new method of atherectomy by intra-vascular lithotripsy (Shockwave) has coincided with Rotablator decreasing activity (this finding being biased by a general decrease in PCI activity due to Covid pandemic). This therapeutic range's enhancement revolutionizes calcified lesions treatment, tending towards precise targeting of each indication, depending in particular on calcium distribution's anatomy in the plaque.

Early mortality post-ST-segment elevation myocardial infarction (STEMI) in France remains high. The multicentre France Percutaneous Coronary Intervention Registry includes every patient undergoing coronary angiography in France. We analyzed the prevalence and impact of unmodifiable and modifiable risk factors on 30-day survival in patients experiencing STEMI. Patients admitted for STEMI between 01/2014 and 12/2016 were included in the analysis. Patients with nonobstructive coronary artery disease, with cardiogenic shock or cardiac arrest without STEMI, were excluded. Prehospital, clinical and procedural data were collected prospectively by the cardiologist in the cath lab using medical reporting software. Information on outcomes, including mortality, was obtained by a dedicated research technician by phone calls or from medical records. Marginal Cox proportional hazards regression was used to test the predictive value for survival at 30 days in a multivariable analysis. Included were 2590 patients (74% men) aged 63 ± 14 years. During the first month, 174 patients (6.7%) died. After adjustment, unmodifiable variables significantly associated with reduced 30-day survival were: age80 years (prevalence 15%; hazard ratio [HR] 2.7; 95% confidence interval [CI] 1.5-4.7), chronic kidney disease (2%; HR 5.3; 95% CI 2.6-11.1), diabetes mellitus (14%; HR 1.6; 95% CI 1.0-2.5), anterior or circumferential electrical localization (39%; HR 2.0; 95% CI 1.4-2.9), and Killip class 2, 3, or 4 (7%; HR 3.4; 95% CI 1.9-5.9; 2%; HR 10.1; 95% CI 5.3-19.4; 4%; HR 18; 95% CI 10.8-29.8, respectively). Among modifiable variables, total ischemic time3 hours (68%; HR 1.8; 95% CI 1.1-3.0), lack of appropriate premedication (18%; HR 2.2; 95% CI 1.5-3.3), and post-PCI TIMI3 (6%; HR 4.9; 95% CI 3.2-7.6) were significantly associated with reduced 30-day survival. Most predictors of 30-day survival post-STEMI are unmodifiable, but outcomes might be improved by optimizing modifiable factors, most importantly ischemic time and appropriate premedication.

International audience; Background: Percutaneous coronary intervention (PCI)-related myonecrosis is frequent and can affect the long-term prognosis of patients. To our knowledge, ticagrelor has not been evaluated in elective PCI and could reduce periprocedural ischaemic complications compared with clopidogrel, the currently recommended treatment. The aim of the ALPHEUS study was to examine if ticagrelor was superior to clopidogrel in reducing periprocedural myocardial necrosis in stable coronary patients undergoing high-risk elective PCI.Methods: The ALPHEUS study, a phase 3b, randomised, open-label trial, was done at 49 hospitals in France and Czech Republic. Patients with stable coronary artery disease were eligible for the study if they had an indication for PCI and at least one high-risk characteristic. Eligible patients were randomly assigned (1:1) to either ticagrelor (180 mg loading dose, 90 mg twice daily thereafter for 30 days) or clopidogrel (300-600 mg loading dose, 75 mg daily thereafter for 30 days) by use of an interactive web response system, and stratified by centre. The primary outcome was a composite of PCI-related type 4 (a or b) myocardial infarction or major myocardial injury and the primary safety outcome was major bleeding, both of which were evaluated within 48 h of PCI (or at hospital discharge if earlier). The primary analysis was based on all events that occurred in the intention-to-treat population. The trial was registered with ClinicalTrials.gov, NCT02617290.Findings: Between Jan 9, 2017, and May 28, 2020, 1910 patients were randomly assigned at 49 sites, 956 to the ticagrelor group and 954 to the clopidogrel group. 15 patients were excluded from the ticagrelor group and 12 from the clopidogrel group. At 48 h, the primary outcome was observed in 334 (35%) of 941 patients in the ticagrelor group and 341 (36%) of 942 patients in the clopidogrel group (odds ratio [OR] 0·97, 95% CI 0·80-1·17; p=0·75). The primary safety outcome did not differ between the two groups, but minor bleeding events were more frequently observed with ticagrelor than clopidogrel at 30 days (105 [11%] of 941 patients in the ticagrelor group vs 71 [8%] of 942 patients in the clopidogrel group; OR 1·54, 95% CI 1·12-2·11; p=0·0070).Interpretation: Ticagrelor was not superior to clopidogrel in reducing periprocedural myocardial necrosis after elective PCI and did not cause an increase in major bleeding, but did increase the rate of minor bleeding at 30 days. These results support the use of clopidogrel as the standard of care for elective PCI.Funding: ACTION Study Group and AstraZeneca.

In recent years, transcatheter aortic valve implantation (TAVI) without predilation (direct TAVI) has become the preferred method for implanting TAVI prostheses. Appropriate patient selection is important to avoid suboptimal outcomes and associated complications.To evaluate whether aortic valve calcification measured with computed tomography predicts suboptimal results from direct TAVI with a self-expanding prosthesis.Single-centre retrospective analysis of patients who received a CoreValve™ prosthesis (Medtronic, Minneapolis, MN, USA) in a direct TAVI procedure between January 2018 and March 2019. Aortic valve calcification assessment (aortic valve calcium score, calcium volume and calcium mass) was calculated from the computed tomography scan before TAVI. Procedural characteristics, need for postdilation and complications were analysed.Of 168 included patients, 18 were postdilated. Aortic valve calcium score (4259 vs. 2578; P0.001), calcium volume (1184 vs. 647mmA high aortic valvular calcium score, assessed by computed tomography scan, is an independent predictor of suboptimal prosthesis implantation outcomes in direct TAVI.

International audience; Background: Intravascular ultrasound (IVUS)-guided PCI improves the prognosis of left main stem (LMS) PCI and is currently recommended by international guidelines. Although OCT resolution is greater than that of IVUS, this tool is not yet recommended in LMS angioplasty due to the absence of data.Aims: This pilot study aimed to analyse the feasibility, safety and impact of OCT-guided LMS PCI.Methods: This prospective, multicentre trial investigated whether patients might benefit from OCT-guided PCI for mid/distal LMS according to a pre-specified protocol. The primary endpoint was procedural success defined as follows: residual angiographic stenosis

In patients with ST-elevation myocardial infarction (STEMI) who have multivessel disease, percutaneous coronary intervention (PCI) for nonculprit lesions (complete revascularization) is superior to treatment of the culprit lesion alone. However, whether complete revascularization that is guided by fractional flow reserve (FFR) is superior to an angiography-guided procedure is unclear.In this multicenter trial, we randomly assigned patients with STEMI and multivessel disease who had undergone successful PCI of the infarct-related artery to receive complete revascularization guided by either FFR or angiography. The primary outcome was a composite of death from any cause, nonfatal myocardial infarction, or unplanned hospitalization leading to urgent revascularization at 1 year.The mean (±SD) number of stents that were placed per patient for nonculprit lesions was 1.01±0.99 in the FFR-guided group and 1.50±0.86 in the angiography-guided group. During follow-up, a primary outcome event occurred in 32 of 586 patients (5.5%) in the FFR-guided group and in 24 of 577 patients (4.2%) in the angiography-guided group (hazard ratio, 1.32; 95% confidence interval, 0.78 to 2.23; P = 0.31). Death occurred in 9 patients (1.5%) in the FFR-guided group and in 10 (1.7%) in the angiography-guided group; nonfatal myocardial infarction in 18 (3.1%) and 10 (1.7%), respectively; and unplanned hospitalization leading to urgent revascularization in 15 (2.6%) and 11 (1.9%), respectively.In patients with STEMI undergoing complete revascularization, an FFR-guided strategy did not have a significant benefit over an angiography-guided strategy with respect to the risk of death, myocardial infarction, or urgent revascularization at 1 year. However, given the wide confidence intervals for the estimate of effect, the findings do not allow for a conclusive interpretation. (Funded by the French Ministry of Health and Abbott; FLOWER-MI ClinicalTrials.gov number, NCT02943954.).

We describe what could be a bailout strategy in the event of (1) failure to reach the distal true lumen, (2) slight improvement in the distal flow, but allowing clinical resolution of STEMI, or (3) a situation not suited to surgery. The "prick-and-wait" technique presented in this case led to a complete recovery.

Regular physical exercice has undeniable cardiovascular benefits and improves life expectancy. This benefice seems limited to moderate intensity exercises. Intense and chronic physical exercice would lead to heart structural changes. For a long time, knowledge of these cardiac effects seemed limited to the left ventricle. Since more authors have shown that right ventricle is vulnerability to the effects of intense chronic training. We report a Gallavardin-type ventricular stress tachycardia in a young with healthy hearted; in whom a right infundibular arrhythmogenic focus has been found in the absence of structural alteration of the right ventricle. Intense athletic activity may reveal a latent arrhythmogenic focus through sympathetic activation. Ablation was the preferred therapeutic strategy, preferred to drug therapy and derived from an analysis of risk-benefit ratios.

Background: \ud Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndromes (ACS) afflicting predominantly younger to middle-aged women. Observational studies have reported a high prevalence of extracoronary vascular anomalies, especially fibromuscular dysplasia (FMD) and a low prevalence of coincidental cases of atherosclerosis. PHACTR1/EDN1 is a genetic risk locus for several vascular diseases, including FMD and coronary artery disease, with the putative causal noncoding variant at the rs9349379 locus acting as a potential enhancer for the endothelin-1 (EDN1) gene.\ud \ud Objectives: \ud This study sought to test the association between the rs9349379 genotype and SCAD.\ud \ud Methods: \ud Results from case control studies from France, United Kingdom, United States, and Australia were analyzed to test the association with SCAD risk, including age at first event, pregnancy-associated SCAD (P-SCAD), and recurrent SCAD.\ud \ud Results: \ud The previously reported risk allele for FMD (rs9349379-A) was associated with a higher risk of SCAD in all studies. In a meta-analysis of 1,055 SCAD patients and 7,190 controls, the odds ratio (OR) was 1.67 (95% confidence interval [CI]: 1.50 to 1.86) per copy of rs9349379-A. In a subset of 491 SCAD patients, the OR estimate was found to be higher for the association with SCAD in patients without FMD (OR: 1.89; 95% CI: 1.53 to 2.33) than in SCAD cases with FMD (OR: 1.60; 95% CI: 1.28 to 1.99). There was no effect of genotype on age at first event, P-SCAD, or recurrence.\ud \ud Conclusions: \ud The first genetic risk factor for SCAD was identified in the largest study conducted to date for this condition. This genetic link may contribute to the clinical overlap between SCAD and FMD.

Objectives The aim of this study was to develop a new scoring system based on thoracic aortic calcification (TAC) to predict 1-year cardiovascular and all-cause mortality. Background A calcified aorta is often associated with poor prognosis after transcatheter aortic valve replacement (TAVR). A risk score encompassing aortic calcification may be valuable in identifying poor TAVR responders. Methods The C4CAPRI (4 Cities for Assessing CAlcification PRognostic Impact) multicenter study included a training cohort (1,425 patients treated using TAVR between 2010 and 2014) and a contemporary test cohort (311 patients treated in 2015). TAC was measured by computed tomography pre-TAVR. CAPRI risk scores were based on the linear predictors of Cox models including TAC in addition to comorbidities and demographic, atherosclerotic disease and cardiac function factors. CAPRI scores were constructed and tested in 2 independent cohorts. Results Cardiovascular and all-cause mortality at 1 year was 13.0% and 17.9%, respectively, in the training cohort and 8.2% and 11.8% in the test cohort. The inclusion of TAC in the model improved prediction: 1-cm3 increase in TAC was associated with a 6% increase in cardiovascular mortality and a 4% increase in all-cause mortality. The predicted and observed survival probabilities were highly correlated (slopes >0.9 for both cardiovascular and all-cause mortality). The model’s predictive power was fair (AUC 68% [95% confidence interval [CI]: 64% to 72%]) for both cardiovascular and all-cause mortality. The model performed similarly in the training and test cohorts. Conclusions The CAPRI score, which combines the TAC variable with classical prognostic factors, is predictive of 1-year cardiovascular and all-cause mortality. Its predictive performance was confirmed in an independent contemporary cohort. CAPRI scores are highly relevant to current practice and strengthen the evidence base for decision making in valvular interventions. Its routine use may help prevent futile procedures.

OBJECTIVES This study sought to compare outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) in a catheterization laboratory (cath lab) to those undergoing TAVR in a hybrid operating room (OR). BACKGROUND TAVR can be performed in a cath lab or in a hybrid OR. Comparisons between these locations are scarce. METHODS All TAVRs performed in 48 centers across France between January 2013 and December 2015 were prospectively included in the FRANCE TAVI (French Transcatheter Aortic Valve Implantation) registry. The primary endpoint of this study was all-cause mortality at 1 year. Secondary endpoints consisted of 30-day complications and 3-year mortality. All analyses were adjusted for baseline and procedural characteristics. RESULTS A total of 12,121 patients were included in this study, 62% of which underwent TAVR in a cath lab versus 38% in a hybrid OR. Mean age was 82.9 +/- 7.2 years, 48.9% of patients were men, and mean Logistic EuroScore was 17.9% +/- 12.3%. Both procedure locations showed similar, below 2% rates of intraprocedural complications. After adjusting for baseline and procedural characteristics, major bleeding and infections were significantly higher in the hybrid OR group (bleeding, 6.3% vs. 4.8%; infection, 6.1% vs. 3.5%; p < 0.05). Adjusted mortality rates at 1 and 3 years did not differ significantly between groups (for cath lab vs. hybrid OR, respectively 1 year 16.2% vs. 15.8%; p = 0.91; 3 years 38.4% vs. 36.4%; p = 0.49). CONCLUSIONS Midterm mortality after TAVR was similar between the cath lab and the hybrid OR. These findings support the performance of TAVR in either location, which has important implications on health care organization and costs. (c) 2018 Published by Elsevier on behalf of the American College of Cardiology Foundation.

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.

Aims: The aim of this study was to analyse delays in emergency medical system transfer of ST-segment elevation myocardial infarction (STEMI) patients to percutaneous coronary intervention (PCI) centres according to transport modality in a rural French region. Methods and results: Data from the prospective multicentre CRAC / France PCI registry were analysed for 1911 STEMI patients: 410 transferred by helicopter and 1501 by ground transport. The primary endpoint was the percentage of transfers with first medical contact to primary percutaneous coronary intervention within the 90 minutes recommended in guidelines. The secondary endpoint was time of first medical contact to primary percutaneous coronary intervention. With helicopter transport, time of first medical contact to primary percutaneous coronary intervention in under 90 minutes was less frequently achieved than with ground transport (9.8% vs. 37.2%; odds ratio 5.49; 95% confidence interval 3.90; 7.73; P Conclusions: Helicopter transport of STEMI patients was five times less effective than ground transport in maintaining the 90-minute first medical contact to primary percutaneous coronary intervention time recommended in guidelines, particularly for transfer distances less than 50 km.