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International audience; Background - Infective endocarditis (IE) is a common and serious complication in patients receiving chronic hemodialysis (HD). Objectives - This study sought to investigate whether there are significant differences in complications, cardiac surgery, relapses, and mortality between IE cases in HD and non-HD patients. Methods - Prospective cohort study (International Collaboration on Endocarditis databases, encompassing 7,715 IE episodes from 2000 to 2006 and from 2008 to 2012). Descriptive analysis of baseline characteristics, epidemiological and etiological features, complications and outcomes, and their comparison between HD and non-HD patients was performed. Risk factors for major embolic events, cardiac surgery, relapses, and in-hospital and 6-month mortality were investigated in HD-patients using multivariable logistic regression. Results - A total of 6,691 patients were included and 553 (8.3%) received HD. North America had a higher HD-IE proportion than the other regions. The predominant microorganism was Staphylococcus aureus (47.8%), followed by enterococci (15.4%). Both in-hospital and 6-month mortality were significantly higher in HD versus non-HD-IE patients (30.4% vs. 17% and 39.8% vs. 20.7%, respectively; p

Background: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce. Methods: A Nationwide French Registry including all patients with tetralogy of Fallot with an ICD was initiated in 2010 by the French Institute of Health and Medical Research. The primary time to event end point was the time from ICD implantation to first appropriate ICD therapy. Secondary outcomes included ICD-related complications, heart transplantation, and death. Clinical events were centrally adjudicated by a blinded committee. Results: A total of 165 patients (mean age, 42.2±13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (interquartile range) follow-up of 6.8 (2.5–11.4) years, 78 (47.3%) patients received at least 1 appropriate ICD therapy. The annual incidence of the primary outcome was 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively; P =0.03). Overall, 71 (43.0%) patients presented with at least 1 ICD complication, including inappropriate shocks in 42 (25.5%) patients and lead dysfunction in 36 (21.8%) patients. Among 61 (37.0%) patients in primary prevention, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with, respectively, 0, 1, 2, or ≥3 guidelines-recommended risk factors. QRS fragmentation was the only independent predictor of appropriate ICD therapies (hazard ratio, 3.47 [95% CI, 1.19–10.11]), and its integration in a model with current criteria increased the 5-year time-dependent area under the curve from 0.68 to 0.81 ( P =0.006). Patients with congestive heart failure or reduced left ventricular ejection fraction had a higher risk of nonarrhythmic death or heart transplantation (hazard ratio, 11.01 [95% CI, 2.96–40.95]). Conclusions: Patients with tetralogy of Fallot and an ICD experience high rates of appropriate therapies, including those implanted in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria including QRS fragmentation might improve risk stratification. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03837574.

International audience; Background: Women with congenital heart disease at high risk for sudden cardiac death have been poorly studied thus far.Objectives: The aim of this study was to assess sex-related differences in patients with tetralogy of Fallot (TOF) and implantable cardioverter-defibrillators (ICDs).Methods: Data were analyzed from the DAI-T4F (French National Registry of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator) cohort study, which has prospectively enrolled all patients with TOF with ICDs in France since 2010. Clinical events were centrally adjudicated by a blinded committee.Results: A total of 165 patients (mean age 42.2 ± 13.3 years) were enrolled from 40 centers, including 49 women (29.7%). Among the 9,692 patients with TOF recorded in the national database, the proportion of women with ICDs was estimated to be 1.1% (95% CI: 0.8%-1.5%) vs 2.2% (95% CI: 1.8%-2.6%) in men (P < 0.001). The clinical profiles of patients at implantation, including the number of risk factors for ventricular arrhythmias, were similar between women and men. During a median follow-up period of 6.8 years (IQR: 2.5-11.4 years), 78 patients (47.3%) received at least 1 appropriate ICD therapy, without significant difference in annual incidences between women (12.1%) and men (9.9%) (HR: 1.22; 95% CI: 0.76-1.97; P = 0.40). The risk for overall ICD-related complications was similar in women and men (HR: 1.33; 95% CI: 0.81-2.19; P = 0.30), with 24 women (49.0%) experiencing at least 1 complication.Conclusions: Our findings suggest that women with TOF at high risk for sudden cardiac death have similar benefit/risk balance from ICD therapy compared with men. Whether ICD therapy is equally offered to at-risk women vs men warrants further evaluation in TOF as well as in other congenital heart disease populations. (French National Registry of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator [DAI-T4F]; NCT03837574)

International audience; Objectives: This study aimed to assess the impact of pulmonary valve replacement (PVR) on ventricular arrhythmias burden in a population of tetralogy of Fallot (TOF) patients with continuous cardiac monitoring by implantable cardioverter-defibrillators (ICDs).Background: Sudden cardiac death is a major cause of death in TOF, and right ventricular overload is commonly considered to be a potential trigger for ventricular arrhythmias.Methods: Data were analyzed from a nationwide French ongoing study (DAI-T4F) including all TOF patients with an ICD since 2000. Survival data with recurrent events were used to compare the burden of appropriate ICD therapies before and after PVR in patients who underwent PVR over the study period.Results: A total of 165 patients (mean age 42.2 ± 13.3 years, 70.1% male) were included from 40 centers. Over a median follow-up period of 6.8 (interquartile range: 2.5 to 11.4) years, 26 patients (15.8%) underwent PVR. Among those patients, 18 (69.2%) experienced at least 1 appropriate ICD therapy. When considering all ICD therapies delivered before (n = 62) and after (n = 16) PVR, the burden of appropriate ICD therapies was significantly lower after PVR (HR: 0.21; 95% confidence interval [CI]: 0.08 to 0.56; p = 0.002). Respective appropriate ICD therapies rates per 100 person-years were 44.0 (95% CI: 35.7 to 52.5) before and 13.2 (95% CI: 7.7 to 20.5) after PVR (p < 0.001). In the overall cohort, PVR before ICD implantation was also independently associated with a lower risk of appropriate ICD therapy in primary prevention patients (HR: 0.29 [95% CI: 0.10 to 0.89]; p = 0.031).Conclusions: In this cohort of high-risk TOF patients implanted with an ICD, the burden of appropriate ICD therapies was significantly reduced after PVR. While optimal indications and timing for PVR are debated, these findings suggest the importance of considering ventricular arrhythmias in the overall decision-making process. (French National Registry of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator [DAI-T4F]; NCT03837574).

Introduction Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce. Objective We aimed to describe long-term follow-up of TOF patients implanted with ICD through a nationwide French registry. Methods Nationwide French Registry including all TOF patients with an ICD initiated in 2010 by the French Institute of Health and Medical Research. The primary time to event endpoint was the time from ICD implantation to first appropriate ICD therapy. Clinical events were centrally adjudicated by a blinded committee. Results A total of 165 patients (mean age 42.2 ± 13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (IQR) follow-up of 6.8 (2.5–11.4) years, 78 (47.3%) patients received at least one appropriate ICD therapy. The annual incidence of the primary outcome was 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively, P = 0.03). Overall, 71 (43.0%) patients presented with at least one ICD complication, including inappropriate shocks in 42 (25.5%) patients and lead dysfunction in 36 (21.8%) patients. Among 61 (37.0%) primary prevention patients, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with respectively no, one, two, or ≥ three guideline-recommended risk factors. QRS fragmentation was the only independent predictor of appropriate ICD therapies (HR 3.47, 95% CI 1.19–10.11), and its integration in a model with current criteria increased the 5-year time-dependent area under the curve from 0.68 to 0.81 (P = 0.006) ( Fig. 1 ). Conclusions Patients with TOF and an ICD experience high rates of appropriate therapies, including those implanted in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria including QRS fragmentation might improve risk stratification.

Background Ventricular arrhythmias and sudden death are feared late complications in patients with tetralogy of Fallot. Selection of candidates for primary prevention implantable cardioverter defibrillator (ICD) remains challenging. Purpose To identify patients with tetralogy of Fallot at high-risk of sudden cardiac death in primary prevention. Methods The DAI-T4F study is an ongoing national French registry including all patients with tetralogy of Fallot and ICD ( NCT03837574 ). Information have been collected prospectively since 2010. Cox proportional hazard models were used to identify factors associated with appropriate ICD therapies. Results Among 134 patients enrolled, 47 (35.1%) underwent ICD implantation for primary prevention (median age 49.1 years, 76.6% males). At baseline, 20 (42.6%) patients had NSVT, 17 (36.2%) had altered LVEF ≤ 35%, 16 (34.0%) had positive programmed ventricular stimulation, and 16 (34.0%) had QRS duration ≥ 180ms. During a median (IQR) follow-up duration of 5.3 (2.1–8.0) years, 14 (29.8%) patients had at least one appropriate ICD therapy. The annual incidence of appropriate ICD therapies were 2.8%, 4.6%, 6.3%, and 8.6% in patients with none, one, two, or ≥ three of these factors (P for trend = 0.145). None of predictors, considered isolated, was significantly associated with ICD appropriate therapies. Patients with non-sustained ventricular tachycardia (NSVT) and positive programmed ventricular stimulation had a significant increased risk of ICD appropriate therapies (HR = 3.8, 95% CI: 1.1–14.3, P = 0.035), as well as patients with NSVT and QRSd ≥ 180 ms (HR = 7.2, 95% CI: 1.6–32.7, P = 0.003). No patient with severe altered LVEF without other risk factor had appropriate ICD therapy. Conclusions Our data illustrate that specific risk stratification and primary prevention for sudden cardiac death in patients with tetralogy of Fallot may be improved. The value of a severely altered LVEF appears low in the absence of other risk factors.

International audience; Background: The relationship between pulmonary arterial hypertension-specific drug therapy (PAH-SDT) and mortality in Eisenmenger syndrome (ES) is controversial.Aims: To investigate outcomes in patients with ES, and their relationship with PAH-SDT.Methods: Retrospective, observational, nationwide, multicentre cohort study.Results: We included 340 patients with ES: genetic syndrome (n = 119; 35.3%); pretricuspid defect (n = 75; 22.1%). Overall, 276 (81.2%) patients received PAH-SDT: monotherapy (endothelin receptor antagonist [ERA] or phosphodiesterase 5 inhibitor [PDE5I]) 46.7%; dual therapy (ERA + PDE5I) 40.9%; triple therapy (ERA + PDE5I + prostanoid) 9.1%. Median PAH-SDT duration was 5.5 years [3.0–9.1 years]. Events (death, lung or heart-lung transplantation) occurred in 95 (27.9%) patients at a median age of 40.5 years [29.4–47.6]. The cumulative occurrence of events was 16.7% [95% confidence interval 12.8–21.6%] and 46.4% [95% confidence interval 38.2–55.4%] at age 40 and 60 years, respectively. With age at evaluation or time since PAH diagnosis as time scales, cumulative occurrence of events was lower in patients taking one or two PAH-SDTs (P = 0.0001 and P = 0.004, respectively), with the largest differences in the post-tricuspid defect subgroup (P < 0.001 and P < 0.02, respectively) versus patients without PAH-SDT. By multivariable Cox analysis, with time since PAH diagnosis as time scale, New York Heart Association/World Health Organization functional class III/IV, lower peripheral arterial oxygen saturation and pretricuspid defect were associated with a higher risk of events (P = 0.002, P = 0.01 and P = 0.04, respectively), and one or two PAH-SDTs with a lower risk of events (P = 0.009).Conclusions: Outcomes are poor in ES, but seem better with PAH-SDT. ES with pretricuspid defects has worse outcomes despite the delayed disease onset.; Contexte: L’intérêt du traitement médical spécifique (TMS) de l’hypertension artérielle pulmonaire (HTAP) dans le syndrome d’Eisenmenger (SE) est controversé.Objectifs: Étudier le pronostic à long terme des patients ayant un SE et la relation avec le TMS.Méthodes: Une cohorte observationnelle longitudinale multicentrique rétrospective historique française de 340 SE a été constituée.Résultats: Le shunt était prétricuspide dans 75 cas (22,1 %). Au total, 276 (81,2 %) patients étaient sous TMS (monothérapie 46,7 % ; bi-thérapie 40,9 % ; tri-thérapie 9,1 %). La durée médiane de TMS était de 5,5 ans [3,0–9,1]. Un événement clinique majeur (ECM : décès, transplantation cardiopulmonaire ou bipulmonaire) a été observé dans 95 (27,9 %) cas à un âge médian de 40,5 [29,4–47,6] ans. La survenue cumulée d’un ECM était de 16,7 % [IC 95 % 12,8–21,6 %] et 46,4 % [IC 95 % 38,2–55,4 %] à l’âge de 40 et 60 ans. Avec l’âge ou le délai depuis le premier examen comme échelle temporelle, la survenue cumulée des ECM était moindre chez les patients sous un ou deux TMS (p = 0,0001 et p = 0,004), en particulier chez les patients avec un shunt post-tricuspide (p < 0,001 et p < 0,02) comparée aux patients sans TMS. Une analyse multivariée de Cox avec le délai depuis le diagnostic de l’HTAP comme échelle temporelle a montré qu’une classe fonctionnelle III ou IV de la NYHA/WHO, une saturation périphérique en oxygène basse (en variable continue), un shunt pré-tricuspide et l’absence de TMS étaient associés à un risque augmenté d’ECM (p = 0,002 ; p = 0,01 ; p = 0,04 and p = 0,009, respectivement).Conclusions: Le TMS dans le SE semble associé à un meilleur pronostic. Néanmoins, même avec un traitement médical palliatif, le pronostic du SE reste altéré. Les patients avec un shunt prétricuspide ont un profil clinique et un pronostic plus sombre malgré une survenue plus tardive de l’HTAP.

Background Host factors and complications have been associated with higher mortality in infective endocarditis ( IE ). We sought to develop and validate a model of clinical characteristics to predict 6‐month mortality in IE . Methods and Results Using a large multinational prospective registry of definite IE (International Collaboration on Endocarditis [ ICE ]–Prospective Cohort Study [ PCS ], 2000–2006, n=4049), a model to predict 6‐month survival was developed by Cox proportional hazards modeling with inverse probability weighting for surgery treatment and was internally validated by the bootstrapping method. This model was externally validated in an independent prospective registry ( ICE ‐ PLUS , 2008–2012, n=1197). The 6‐month mortality was 971 of 4049 (24.0%) in the ICE ‐ PCS cohort and 342 of 1197 (28.6%) in the ICE ‐ PLUS cohort. Surgery during the index hospitalization was performed in 48.1% and 54.0% of the cohorts, respectively. In the derivation model, variables related to host factors (age, dialysis), IE characteristics (prosthetic or nosocomial IE , causative organism, left‐sided valve vegetation), and IE complications (severe heart failure, stroke, paravalvular complication, and persistent bacteremia) were independently associated with 6‐month mortality, and surgery was associated with a lower risk of mortality (Harrell's C statistic 0.715). In the validation model, these variables had similar hazard ratios (Harrell's C statistic 0.682), with a similar, independent benefit of surgery (hazard ratio 0.74, 95% CI 0.62–0.89). A simplified risk model was developed by weight adjustment of these variables. Conclusions Six‐month mortality after IE is ≈25% and is predicted by host factors, IE characteristics, and IE complications. Surgery during the index hospitalization is associated with lower mortality but is performed less frequently in the highest risk patients. A simplified risk model may be used to identify specific risk subgroups in IE .

Background We evaluated prognostic value at 6 months of residual pulmonary vascular obstruction (RPVO) measured before discharge in patients with intermediate- or high-risk pulmonary embolism (PE). Methods and results Prospective registry including 416 consecutive patients with intermediate- or high-risk PE who survived the acute phase. Patients with previous cardiopulmonary disease were excluded. Perfusion lung scans were performed within 6–8 days after the onset of treatment. Residual pulmonary vascular obstruction was graded as the proportion of the lung not perfused. Primary objective was a combined endpoint at 6 months, including death, recurrent PE, and appearance of signs of heart failure. At 6 months, 32 patients (7.7%) had at least one adverse event: 12 deaths (2.9%), 12 recurrent PE (2.9%), and 14 (3.4%) heart failure. Independent predictors of combined endpoint were: cancer [odds ratio (OR) 3.07 (1.22–7.85)]; renal insufficiency at admission [OR: 2.53 (1.17–5.8)]; persistent signs of right ventricular dysfunction at 48 h echography [OR: 3.99 (1.36–11.3)]. The severity of RPVO at discharge was significantly associated with an unfavourable outcome [OR: 2.66 (1.58–3.93)]. The incremental prognostic value of RPVO information was confirmed by significantly improved goodness-of-fit. Threshold RPVO for predicting adverse events was estimated at 35% [area under the curve = 0.76 (0.73–0.82)]. Patients with RPVO greater than threshold at discharge had a significantly higher risk of death at 6 months ( P = 0.01). Conclusions Residual pulmonary vascular obstruction evaluated before hospital discharge in patients with intermediate- to high-risk PE is a powerful prognostic factor for a 6-month outcome. RPVO ≥35% is associated with an increased risk of adverse events at 6 months.

Platypnea-orthodeoxia is a rare syndrome characterised by dyspnea and hypoxemia worsened on upright posture. We report the case of a 76-year-old man treated for lung adenocarcinoma who had developed severe hypoxemia due to right-to-left shunt through a patent foramen ovale (PFO). Diagnosis was suspected by systemic uptake of isotope during lung scintigraphy performed to eliminate pulmonary embolism. Arterial blood gas analysis in supine and upright positions demonstrated orthodeoxia. Contrast-enhanced trans-oesophageal echocardiography revealed a slightly redundant atrial septum and large right-to-left shunt through a PFO despite normal pulmonary pressure. Chest computed tomography and echocardiography showed a 59-mm aneurysm of the thoracic aorta. The opening of the PFO seemed to be the result of mechanical deformation of the atrial septum by aortic root dilatation and possibly by lung carcinoma. Transcatheter closure of the atrial defect has provided excellent results, including a rapid increase in systemic saturation and improvement of symptoms without any complications.

An increase in albuminuria occurs in the early days after acute myocardial infarction. The aim of this study was to assess the relation between albuminuria and 30-day mortality, as well as its incremental predictive value, on top of established prognostic parameters.Demographic, clinical, and biological characteristics at admission, as well as in-hospital treatments and 1-month survival, were recorded in 1,211 consecutive patients admitted for acute myocardial infarction. Albuminuria was assessed from an 8-hour overnight urine collection within the first 2 days using immunonephelemetry. The population was categorized into 3 groups according to albuminuria levels (20, 20-200, and200 microg/min). Among survivors on day 2, 52% (625/1,211) of patients had an albuminuria level20 microg/min, 39% (477) between 20 and 200 microg/min, and 9% (109)200 microg/min. High levels of albuminuria were associated with older age, peripheral vessel disease, systolic blood pressure, glucose, creatinine, troponin, B-type natriuretic peptide, and high-sensitivity C reactive protein levels, as well as use of angiography, angiotensin-converting enzyme inhibitors, and beta blockers. At 1 month, there was a significantly higher mortality rate in groups with higher albuminuria. After adjustment for baseline characteristics, patients with albuminuria level of20 microg/min had a 2.7-fold higher 30-day mortality, and those with200 microg/min had an almost 4-fold higher 30-day mortality compared to those with albuminuria level of20 microg/min. The addition of albuminuria information improved the discrimination capacity of the model and the global risk prediction.Albuminuria level, taken as a quantitative or categorical variable, is an independent and powerful predictor of mortality after acute myocardial infarction.

To describe characteristics of infective endocarditis (IE) in pacemaker (PM) recipients, including the annual incidence and exact localization of IE on PM leads, cardiac valves, or both, we prospectively analyzed 45 PM recipients from a group of 559 patients with definite IE who responded to a population-based survey conducted in France in 1999. Thirty-three patients had definite PM-lead IE (group I), and 12 had valvular IE without evidence of PM involvement (group II). The valvular structure was involved in almost two-thirds of IE cases among PM recipients. Of the 28 patients (62%) with valvular IE, 10 group I patients had tricuspid involvement, and 6 group I patients had left heart-valve involvement. The most frequent causative organisms in groups I and II were staphylococci (82%) and streptococci (50%), respectively. The incidence of age- and sex-standardized IE was 550 cases/million PM recipients per year. The incidence of IE with PM involvement is between that of valvular IE in the general population and prosthetic valve IE.

Background From a registry of 249 confirmed pulmonary embolism (PE) patients submitted to thrombolytic therapy (TT), we analysed predictors of in-hospital course and long-term mortality. Methods and results The combined clinical end point of in-hospital course associated death, recurrent PE, repeat thrombolysis, surgical embolectomy or bleeding complications. The long-term follow-up included analysis of survival, and occurrence of PE-related events, defined as recurrent deep vein thrombosis, recurrent PE, occurrence of congestive heart failure or change of New York Heart Association functional class to class III or IV in patients who survived the acute phase. In-hospital clinical course was uneventful in 165 (66.3%) patients. Initial right ventricular (RV) dysfunction was reversible in 80% within 48h following TT. Initial pulmonary vascular obstruction >70% (RR=5.3 [2.1; 13.6]); haemodynamic instability at presentation (RR=2.6 [1.1; 6]); persistence of septal paradoxical motion after TT (RR=5.9 [1.4; 25.9]); and insertion of intracaval filter (RR=3.7 [1.4; 9.4]) were independent predictors of poor in-hospital course. Mean follow-up was 5.3±2.6 years. Of the 227 patients alive after the hospital stay, the probability of survival was 92% at 1 year, 79% at 3 years and 56% at 10 years. Multivariate predictors of long-term mortality were age >75 years (RR=2.73 [2.18; 3.21]; P =0.0002), persistence of vascular pulmonary obstruction >30% after thrombolytic treatment (RR=2.22 [1.69; 2.74]; P =0.003), and cancer (RR=2.03 [1.40; 2.65]; P =0.04). Conclusion The recovery of RV function should be considered as a marker of thrombolysis efficacy, while residual pulmonary vascular obstruction and cancer are independent predictors of long-term mortality. These results advocate the identification of high-risk patients by means of systematic lung-scan and echocardiography pre- and post-thrombolysis, and raise the question of the need for thromboendarterectomy in patients with residual pulmonary vascular obstruction.

International audience; Background - The impact of early valve surgery (EVS) on the outcome of Staphylococcus aureus (SA) prosthetic valve infective endocarditis (PVIE) is unresolved. The objective of this study was to evaluate the association between EVS, performed within the first 60 days of hospitalization, and outcome of SA PVIE within the International Collaboration on Endocarditis-Prospective Cohort Study. Methods - Participants were enrolled between June 2000 and December 2006. Cox proportional hazards modeling that included surgery as a time-dependent covariate and propensity adjustment for likelihood to receive cardiac surgery was used to evaluate the impact of EVS and 1-year all-cause mortality on patients with definite left-sided S. aureus PVIE and no history of injection drug use. Results - EVS was performed in 74 of the 168 (44.3%) patients. One-year mortality was significantly higher among patients with S. aureus PVIE than in patients with non-S. aureus PVIE (48.2% vs 32.9%; P = .003). Staphylococcus aureus PVIE patients who underwent EVS had a significantly lower 1-year mortality rate (33.8% vs 59.1%; P = .001). In multivariate, propensity-adjusted models, EVS was not associated with 1-year mortality (risk ratio, 0.67 [95% confidence interval, .39-1.15]; P = .15). Conclusions - In this prospective, multinational cohort of patients with S. aureus PVIE, EVS was not associated with reduced 1-year mortality. The decision to pursue EVS should be individualized for each patient, based upon infection-specific characteristics rather than solely upon the microbiology of the infection causing PVIE.

Percutaneous mitral valvuloplasty with the Inoue balloon is conventionally performed with double vascular access: arterial and venous. However, in patients with a good echogenic window it may be performed with venous access only and the procedure monitored by 2D-echocardiography and colour flow mapping. This should result in early ambulation and hospital discharge with reduced arterial complications.To compare retrospectively the immediate results of percutaneous mitral valvuloplasty with the Inoue balloon in two groups of patients: Group I: venous access only (no arterial access, n = 102) and Group II: conventional double vascular access (arterial and venous access, n = 275).The baseline characteristics of the two groups were comparable for age, sex, clinical, echocardiographic, radiological and haemodynamic variables. The mitral valve area (Group I: 1.1 +/- 0.3 to 1.85 +/- 0.5 cm2 vs Group II: 1.05 +/- 0.2 to 1.85 +/- 0.5 cm2, P = ns) and transmitral gradient (Group I: 11 +/- 4 to 4.7 +/- 2 mmHg vs Group II: 12 +/- 4 to 4.8 +/- 2 mmHg, P = ns) before and after mitral valvuloplasty were not statistically different. A good immediate result, defined as mitral valve area1.5 cm2 and mean mitral gradient5 mmHg with mitral regurgitationor = 2+ at the end of the procedure, was observed in 77% of the cases in the venous-only group and 79% in the double access group (P = ns). The incidence of severe mitral regurgitation (Grade III or IV) was not statistically significant. Procedural duration (71 +/- 24 min vs 109 +/- 26 min, P0.01), fluoroscopic time (12.5 +/- 5.5 min vs 18.5 +/- 6 min, P0.01) and hospital stay (2.8 +/- 1.5 days vs 4.8 +/- 2.6 days, P0.001) were significantly shorter in the venous-only group than in the conventional Inoue series.Single venous access balloon mitral valvuloplasty is as equally safe and effective as double vascular access. The additional advantages of single venous access are shorter procedural duration, fluoroscopic time and hospital stay. We recommend that it be performed by an experienced operator (minimum of 100 trans-septal punctures) in patients without major thoracic deformity and a good echogenic window.

Background Right ventricular (RV) function is a major prognostic factor in patients (pts) with operated tetralogy of Fallot (TOF). We compared the results of RV speckle tracking (two-dimensional [2D] strain) with those of magnetic resonance imaging (MRI) in this setting. Methods At transthoracic echocardiogram (echo), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), velocity of S-wave at tricuspid annulus with tissue Doppler, and 2D strain (longitudinal maximal systolic strain) were recorded. Their results were compared to RV indexed end-diastolic volume (EDV), indexed end-systolic volume (ESV), and RV ejection fraction (EF) at MRI. Results Twenty-two pts (16 M) aged 11–62 years (mean 23.2 ± 10.8) were included. Parameters of RV systolic function were as follows: RVFAC = 40 ± 10%, TAPSE = 18 ± 4 mm, S-wave = 10 ± 0.2 cm/sec, and RV EF at MRI = 43 ± 11%. Global RV systolic strain was −15.5 ± 4.2%, free wall strain was −15.1 ± 6.3%, and septal strain was −15.8 ± 3.8% on average for the whole group. Echo indexed RV end-diastolic area correlated with EDV at MRI (r = 0.73), as well as echo indexed RV end-systolic area and ESV at MRI (r = 0.71). Global RV 2D strain correlated well with RV EF at MRI: r = 0.68; P

Background Bleeding is associated with higher risk of adverse outcomes in pulmonary embolism (PE). The “Bleeding Academic Research Consortium” (BARC) developed a classification of events combining laboratory & clinical parameters, but based on acute coronary syndrome patients. We investigated whether this classification is applicable in the context of PE, where no standard bleeding definition exists. Methods Prospective, single-center registry of patients with confirmed PE. We excluded BARC types 1 or 4 bleeding, considered not to be applicable to the context of PE. BARC type 2 bleeds were defined as any overt bleeding requiring non-surgical or medical care, or leading to hospitalisation. Type 3 bleeds were defined as drop of >3 g/dL in haemoglobin, any transfusion, tamponnade, intra-cranial hemorrhage, or bleeding requiring surgical intervention. Type 5 bleeds were defined as any fatal bleed. Results From 2007 to 2011, 666 patients with confirmed PE were included; average age 66±18 years; 52% women; 25% low-risk, 61% intermediate-risk and 14% high-risk PE. Treatment was: unfractionated heparin in 93 (14%), enoxaparin in 200 (30%), fondaparinux in 373 (56%). Thrombolysis was given in 167 (25%). Sixty patients (9%) experienced bleeding (n=13, 43, 4 for BARC types 2, 3, 5 respectively). Main in-hospital events are shown in table 1. By multivariate analysis, independent predictors of in-hospital death were: cardiogenic shock (OR 12.6 [4.8-20.8]); chronic obstructive pulmonary disease (OR 5.27 [2.25-8.43]); acute right ventricular dysfunction (OR 2.98 [1.25-6.96]) and any bleeding (BARC 2,3,5) (OR 3.15 [1.34-7.37]). Conclusion Our data suggest that the BARC classification can be applied to acute PE and that bleeding is associated with unfavourable in-hospital outcome. We suggest use of the BARC as the standard for classification of bleeding events in PE. Table . Results BARC type 2 (A) BARC type 3/5 (B) No bleed (n=606) C) p (A) vs (C) p (B) vs (C) Death 2 (15.4%) 7 (15%) 19 (3.1%) 0.034 0.0014 Recurrent PE 0 4 (8.5%) 5 (0.9%) 0.67 Treatment escalation 1 (7.7%) 2 (4.2%) 4 (0.7%) 0.017 0.028

Heparin-induced thrombocytopenia is a rare but severe complication of heparin therapy that can result in severe venous or arterial thromboembolic events and whose treatment remains partially unanswered. Recombinant hirudin is potentially effective as an antithrombotic treatment in the management of heparin-induced thrombocytopenia, given its potent antithrombin effects without known interaction with platelets. We report the results obtained with intravenous recombinant hirudin (HBW 023) administered on a compassionate basis to patients suffering from heparin-induced thrombocytopenia. Six patients suffering from heparin-induced thrombocytopenia were submitted to intravenous recombinant hirudin (HBW 023) administered at a dose of 0.05 mg/kg/hr after an initial bolus injection of 0.07 mg/kg in the case of a venous thromboembolic event, and at a dose of 0.15 mg/kg/hr with the same initial bolus injection in the case of an arterial thromboembolic event. Whenever possible, oral anticoagulation with acenocoumarol was introduced at the same time as recombinant hirudin, which was interrupted as soon as the international normalized ratio reached 3. Clinical events, particularly thromboembolism and bleeding, were noted; activated partial thromboplastin time (aPTT), and platelet count were assessed throughout the administration of recombinant hirudin. Heparins responsible for heparin-induced thrombocytopenia were porcine sodium or calcium heparinate in four cases, nadroparin in one case, and enoxaparin in one case. Thrombocytopenia was discovered on routine systematic platelet count in two patients and after the occurrence of arterial and venous thromboembolism in two patients, respectively. After discontinuation of heparin and the onset of recombinant hirudin, clinical evolution was uneventful in all patients, with no recurrence of thromboembolism, limb amputation, or hemorrhagic complication. The aPTT ratio varied from 1.8 to 3.5 (median 2.4) throughout administration of recombinant hirudin. Platelet count rose from nadir (median value 60 x 10(9), 15 to 90) to above 100 x 10(9)/L in every patient within 3-6 days (median 5), after discontinuation of heparin. Intravenous administration of recombinant hirudin ensured safe anticoagulation in patients with heparin-induced thrombocytopenia and made it possible to wait for oral anticoagulation to become efficient and platelet count to return to normal values without occurrence or recurrence of thromboembolism.

Aim: Right ventricular (RV) dysfunction is key for risk stratification in pulmonary embolism (PE). The goal of this study was to compare RV strain values between low and intermediate-to-high risk PE patients assessed by two-dimensional (2D) strain imaging. Methods: The inclusion criterion was a diagnosis of PE confirmed by thoracic computed tomography scan with contrast medium, or by scintigraphy perfusion lung scan. Risk stratification of PE was defined as high when there was hemodynamic instability; intermediate when there were signs of RV dysfunction on echocardiography; and/or elevated troponin I and/or brain natriuretic peptide and low when none of these criteria were present. All patients underwent echocardiography at admission. Apical four-chamber images were analyzed off line using both conventional and 2D strain imaging. Results: Sixty-two patients (mean age 66 years) were prospectively recruited: 33 with low risk PE, 29 with intermediate-to-high risk PE. Global 2D RV strain differed significantly between groups (−13.1% vs. −18.7%, P

Multivalvular endocarditis accounts for 15% of all endocarditis. The mechanisms of spread of the infection differs whether endocarditis is only left-sided (involving both the mitral and aortic valves) or bilateral. In left-sided bivalvular endocarditis, it is often a secondary mitral lesion following a primary aortic endocarditis. Multivalvular endocarditis often results in severe and extensive cardiac lesions, well described at echocardiography and frequently responsible for severe heart failure. Patients often need surgery, which consists of radical debridement of all the infected tissue with reconstruction using different types of prostheses; therefore, the surgery may be very complex. The goal should be an early diagnosis of endocarditis to avoid spread of the infection to more than one valve, to improve the prognosis for those patients.

Objectives . The aim of the study was to prospectively estimate the safety of thrombolytic therapy in elderly patients with massive pulmonary embolism in comparison with that in nonelderly patients. Background . In massive pulmonary embolism, lysis of thrombi can be achieved faster with thrombolytic therapy than with conventional heparin therapy, but it is administered with great caution in elderly patients because the risk of bleeding is thought to be higher than in nonelderly patients. Yet, thrombolytic therapy might be of value in elderly patients also, in allowing potentially more rapid improvement than is achieved with conventional heparin therapy. Methods . Eighty-nine patients with massive pulmonary embolism defined as Miller score ≥ 17/34 underwent thrombolytic therapy without consideration of age if they had no contraindication for such treatment. Fifty-three patients were ≤ 70 years old (mean age ± SD 54 ± 15 years; range 18 to 70), and 36 patients were ≥ 71 years old (78 ± 5 years; range 71 to 88). Except for mean age, there were no significant differences between the two treatment groups, particularly in terms of clinical presentation, average Miller score and pulmonary artery pressure regimen. Thrombolytic therapy was administered in the form of streptokinase at a dose of 100,000 IU/h over 12 h, with an initial injection of 250,000 IU over 15 min. Heparin was introduced 12 h after initiation of thrombolytic therapy. Urokinase or tissue-type plasminogen activator was used only in case of contraindication to streptokinase. Results . The frequency of uncomplicated clinical course was the same in both treatment groups. Surgical embolectomy was necessary in three nonelderly patients (5.6%) and one elderly patient (2.7%). Changes in pulmonary pressure regimen and Miller score were identical in both groups. Three patients died during the in-hospital course: two nonelderly patients (3.7%) and one elderly patient (2.7%). Minor bleeding occurred in five nonelderly (9.4%) and five elderly (13.8%) patients (p = 0.74). Major bleeding was observed in three nonelderly (5.6%) and five elderly (13.8%) patients (p = 0.29). Bleeding subsequent to early invasive procedure accounted for six (75%) of eight patients with major bleeding: two nonelderly patients (one of whom died) and four elderly patients. No intracranial hemorrhage was observed. No predisposing factor for bleeding was identified, except the need for early vascular access for pulmonary angiography through the femoral approach or for percutaneous insertion of an intracaval device for partial interruption of the inferior vena cava. Conclusions . Thrombolytic therapy administered for massive pulmonary embolism in patients free of contraindication yields similar results and carries a similar risk for bleeding complications in elderly compared with nonelderly patients. Limiting early invasive procedures may result in less frequent major bleeding complications.

Objectives and Background. To assess the long-term results of percutaneous aortic valvuloplasty and aortic valve replacement in elderly persons, two similar nonrandomized series of patients ≥ 75 years old treated by one or the other method between January 1986 and March 1989 in the same institution were compared. Methods. Forty-six patients, 23 men and 23 women, with a mean age of 79.7 ± 3.6 years (range 75 to 90) underwent percutaneous aortic valvuloplasty with use of the Cribier method (group 1). Twenty-three additional patients, 14 men and 9 women with a mean age of 78.4 ± 2.4 years (range 75 to 86) underwent aortic valve replacement with a bioprosthesis (group 2). All of them suffered from severe calcified aortic stenosis. Clinical and hemodynamic status were similar in both groups. The mean follow-up period was 21.5 months (5 days to 60 months) in group 1 and 27.5 months (7 days to 61 months) in group 2. Results. Three patients (6.5%) in group 1 died within 5 days after percutaneous aortic valvuloplasty; 24 patients (52%) died during the follow-up period, 16 of whom died of recurrent cardiac failure. Of 16 patients (35%) subsequently operated on at an average of 15.8 months after percutaneous aortic valvuloplasty, 2 died at operation. Only three group 1 patients (6.5%) are still alive without subsequent aortic valve replacement. In group 2, two patients (8.7%) died postoperatively and three (13%) died during the follow-up period. All other patients (78%) are still alive and In New York Heart Association functional class I or II. The overall survival rate in group 1 was 75% at 1 year, 47% at 2 years and 33% at 5 years. In group 2, the Survival rate was 83% at 1 and 2 years and 75% at 3 and 4 years. Conclusions. The results of percutaneous aortic valvuloplasty do not compare favorably with those of surgery in elderly people, and this treatment should not be recommended.

From 1987 to 1990, 215 patients aged 53 +/- 13 years underwent percutaneous mitral valvulotomy in our institution. Mean gradient dropped on average from 13 +/- 4 to 5 +/- 2 mmHg and mitral valve area increased from 1.0 +/- 0.26 to 1.97 +/- 0.5 cm2 at the end of the procedure. Good results, defined as mitral valve area greater than or equal to 1.5 cm2 and mitral regurgitation less than or equal to 2+ at the end of the procedure, were obtained in 78% of the cases. In 41 patients with a poor anatomical form of mitral stenosis, mean gradient decreased from 12 +/- 3 to 6 +/- 6 mmHg and mitral valve area increased from 1.0 +/- 0.3 to 1.7 +/- 0.5 cm2. Good results were obtained in only 50% of the patients. One third of the 3+ mitral regurgitation occurred in this subgroup of patients. In patients with prior surgical commissurotomy, in elderly people and in patients with associated valvulopathy or prosthetic aortic valve, the success rate was similarly low. A significant inverse relationship was found between X-ray and echo scores on the one hand and mitral valve area at the end of the procedure on the other, thus confirming that the results of percutaneous mitral valvulotomy are related to the anatomical form of mitral stenosis. However, patients with poor anatomical forms can undergo the procedure with an acceptable risk compared to benefit ratio.

No data are available on the efficacy and safety of a combination of fondaparinux and thrombolysis in the setting of high to intermediate risk pulmonary embolism (PE). Patients submitted to thrombolysis and fondaparinux, presenting withor =1 of the following criteria were included: (1) cardiogenic shock, (2) syncope, (3)or =1 proximal thrombo-embolus at CT scan, (4) positive troponin test, (5) echocardiographic findings indicating right ventricular (RV) dysfunction. In-hospital results included death, recurrent PE, persistent RV dysfunction at 48 h echocardiography, bleeding complications. Twenty seven patients were included; 22 received a 2 h infusion of rt-PA and 5 received a 2 h infusion of streptokinase. Ten patients presented with cardiogenic shock (37%), 8 with syncope (30%), all had RV dysfunction. 82% of patients had an uneventful in-hospital course. One patient died during hospital stay from refractory shock. Thrombolysis failed in 2 patients (7%), requiring successful rescue surgical embolectomy. Bleeding events occurred in 2 patients (7%), of whom 1 required blood transfusion. Despite the small sample size, our data suggest that fondaparinux procures adequate tolerability compared to standard current therapy in combination with thrombolysis in high to intermediate risk PE.

The aortic valve area was serially evaluated in 45 patients, mean age 78 years, suffering from severe aortic stenosis who underwent percutaneous aortic valvuloplasty. The aortic valve area was calculated from haemodynamic data prior to and immediately after the procedure using the mean gradient. Serial determinations of the aortic valve area were also obtained 1 day before, 1 day after and 2 months after valvuloplasty from the thermodilution cardiac output and Doppler echocardiography mean left ventricle-to-aorta gradient. The mean gradient significantly decreased from 75±24 to 42±16mmHg (P>0.01) when measured from haemodynamic data and from 63±20 to 41±13 mmHg (P>001) when estimated from Doppler-derived data. It rose to 48±15 mmHg at 2 months (NS). The aortic valve area increased significantly from 0–48±0–13 to 0–67±0–29 cm2 (P>0.01) when calculated from haemodynamic data, and from 0–53±0–18 to 0–74±0–23 cm2 (P 0.01) but poorly afterwards (r=0.57, P>0.01). The aortic valve area was not influenced by valvuloplasty in eight patients. At 2 months, restenosis was apparent in eight patients out of 32 that were re-evaluated. Three patients died within 5 days of the procedure. After an average 12 months 'follow-up, eight more patients died. Symptoms were not influenced or recurred in 17 patients, while 17 others remained improved by at least one NYHA functional class. Seven patients were operated on, and there was one operative death. The calculated aortic valve area was significantly greater at the end of the procedure in the patients with persistent improvement compared with those with a poor result (0–83±0–29 cm2 vs 065±0–14 cm2, P < 0–05). In conclusion, in this study one third of the patients submitted to percutaneous aortic valvuloplasty had no objective improvement in calculated valve area or early restenosis after 2 months. Functional improvement was observed in one third of the patients. Immediate re-estimation of the aortic valve area from haemodynamic data at the end of the procedure may not reflect the actual effect of valvuloplasty on the aortic orifice

A man, living in France, complained about dyspnea and weakness for the last year. At admission, the electrocardiogram showed atrial fibrillation. Transthoracic echocardiographyandcardiacmagnetic resonance imaging revealed a rare case of massively calcified left ventricular endomyocardial fibrosis (EMF), resulting in an obliteration of the apex (Fig. 1A and B). Despite the severity of the calcification intruding the fibrosis, h

Objective: The cardiotoxicity of anthracyclines remains a key problem in patients with aggressive non-Hodgkin’s lymphoma (NHL). With regard to the actual long-term prognosis of aggressive NHL, the development of cardioprotective strategies is mandatory for these patients. A cost-effectiveness analysis was carried out to determine the potential economic profile of dexrazoxane or liposome-encapsulated doxorubicin in patients with aggressive NHL treated with a CHOP regimen (cyclophosphamide, doxorubicin, vincristine, prednisone) as first-line therapy. Methods: A decision-analysis model described clinical events and economic consequences for theoretical patients who were to receive eight consecutive cycles of a CHOP regimen containing 50 mg/m2 of doxorubicin as first-line chemotherapy. The timeframe of the model was the patient’s lifetime. The probabilities were related to the cumulative dose of doxorubicin and age. The study was carried out from the perspective of the French healthcare system. Patients entered the model at ‘choose’ node: no cardioprotection versus cardioprotection with dexrazoxane or liposome-encapsulated doxorubicin. The model was based on a retrospective epidemiological study and on published data. The clinical end-point was life expectancy. Direct medical costs related to the cardioprotection and the treatment of congestive heart failure were considered. Monetary values for French prices in the year 2002 were used. Several univariate sensitivity analyses were carried out with varying clinical and economic parameters. Results: Per 100 patients, the two cardioprotective strategies provided similar benefits that were estimated as 24.5 and 13.4 life-years in 60- and 40-year-old patients, respectively. The cost per life-year saved with dexrazoxane was estimated as €6931 and €15 599 in 60- and 40-year-old patients, respectively, and €22 940 and €44 982, respectively, with liposome-encapsulated doxorubicin. Several sensitivity analyses showed the robustness of the model. Conclusion: The results suggest the potential clinical and economic usefulness of cardioprotective therapies in patients with aggressive NHL. Prospective studies are needed to confirm these findings.

Background The management of patients with acute massive pulmonary embolism (PE) who do not respond to fibrinolytic therapy remains unclear. We aimed to compare rescue surgical embolectomy and repeat thrombolysis in patients who did not respond to thrombolysis. Methods We conducted a prospective single-center registry of PE patients who underwent thrombolytic therapy. Lack of response to thrombolysis within the first 36 h was prospectively defined as both persistent clinical instability and residual echocardiographic right ventricular dysfunction. Patients underwent surgical embolectomy or repeat thrombolysis, at the discretion of the attending physician. The clinical end point was a combined end point including recurrent PE, bleeding complications, or PE-related death, which was defined as death from recurrent PE or cardiogenic shock. Long-term adverse outcomes included death, recurrent thromboembolic events, and congestive heart failure. Results From January 1995 to January 2005, 488 PE patients underwent thrombolysis, of whom 40 (8.2%) did not respond to thrombolysis. Fourteen patients were treated by rescue surgical embolectomy, and 26 were treated by repeat thrombolysis. There was no significant difference in baseline characteristics between the two groups. The in-hospital course was uneventful in 11 of the surgically treated patients (79%) and in 8 patients (31%) treated by repeat thrombolysis (p = 0.004). There was a trend for higher mortality in the medical group than in the surgical group (10 vs 1 deaths, respectively; p = 0.07). There were significantly more recurrent PEs (fatal and nonfatal) in the repeat-thrombolysis group (35% vs 0%, respectively; p = 0.015). While no significant difference was observed in number of major bleeding events, all bleeding events in the repeat-thrombolysis group were fatal. The rate of uneventful long-term evolution was the same in the two groups. Conclusion Rescue surgical embolectomy led to a better in-hospital course when compared with repeat thrombolysis in patients with massive PE who have not responded to thrombolysis. The transfer of patients who have not responded to thrombolysis to tertiary cardiac surgery centers could be considered as an alternative option.

Background Troponin elevation in the setting of acute pulmonary embolism (PE) is of small magnitude and short duration and can go unnoticed in pts referred late after symptom onset. Methods Prospective, single-center registry of pts with confirmed intermediate-risk PE, defined as at least 1 echocardiographic finding of right ventricular (RV) dysfunction (endo-diastolic (EDRV)/left ventricular (EDLV) end-diastolic diameter ratio >=1 in the 4-chamber view, paradoxical septal systolic motion or pulmonary hypertension defined as RV/atrial gradient >30mmHg), or positive troponin test. Combined in-hospital endpoint was defined as death, non-fatal recurrent PE, or residual pulmonary vascular obstruction (RPVO) ≥35%. Results 282 pts were included, age 66±14 years, 59% women, 174 (62%) referred ≤5 days after symptom onset, 108 (38%) after >5 days. Troponin elevation was observed in 126 (72%) treated within ≤5 days, in 60 (56%) treated after >5 days (p=0.004). A significant interaction was observed between time since symptom onset and both troponin elevation and persistence of EDRV/EDLV diameter ratio>1 at 48h. The negative predictive value of troponin elevation was 85% in patients treated within 5 days of symptoms, but fell to 70% in those admitted >5 days after symptom onset (p=0.002). Positive troponin was an independent predictor of adverse outcome (OR=1.43 [1.08-5.56]). ROC curves show that prognostic value of positive troponin test was higher in pts referred ≤5 days than in pts referred >5 days after symptom onset (p=0.01). Conclusion There is a significant relation between troponin elevation and time since symptom onset in patients with intermediate-risk PE. Negative predictive value of troponin elevation is adequate in pts treated early (≤5 days) but is suboptimal in pts treated >5 days after symptom onset. Table . Results >5 days since symptom onset p Sensitivity 72% (61.3-82.7) 51% (42.4-59.6) 0.005 Specificity 42% (44.5-49.5) 47% (39.1-54.9) 0.33 PPV 26% (18.4-33.6) 30% (22.2-37.8) 0.81 NPV 85% (78.4-91.6) 70% (63-77) 0.002

Background Repaired aortic coarctation (CoA) is associated with high long-term mortality and morbidity. Despite optimal early correction, patients with CoA remain at high risk of hypertension and death. We evaluated outcomes and follow-up of all patients who underwent CoA surgery, and alive at 30 days, between 1978 and 2012. Methods Retrospective cohort study in a single university teaching hospital. All data were obtained from medical records. Vital status, medical history and results of imaging were analyzed Results A total of 85 patients (63 men) were included. Median age (range) at surgery was 69 (2-13356) days; 19 (2-54) years at examination. Mean follow up was 15.8 years (1343 person-years). No deaths were observed. Reintervention was common (31%) and most often due to ReCoA (13 patients, 16%). In case of ReCoA, 8 patients had thoracic surgery, and 5 percutaneous angioplasty with stenting. Half (53%) had a bicuspid aortic valve, associated with aortic valve regurgitation (21 cases). Aneurysm of the ascending aorta was diagnosed in 8 patients, without surgical indication. Prevalence of hypertension was high (18 pts, 21%); no related complications were noted; 17 patients were being treated. All patients had normal LV ejection fraction, but half (56%) had increased LV mass. In total, 28 MRI were performed. MRI showed 22 Romanesque aortic arches, 2 Crenel arches and 1 Gothic arch. Regarding follow-up, 66% were followed as recommended by ESC guidelines. Only 4 patients were lost to follow up. There were 15 pregnancies (8 patients); no complications were noted. Conclusions Primary repair of CoA was performed with low rates of mortality and morbidity. However, prevalence of hypertension, aortic valve abnormalities and ascending aorta aneurysms remain high, confirming CoA as an overall vascular disease. Furthermore, many patients required further reoperation. These findings emphasize that patients with CoA need lifelong follow-up.

Aortic dissection (AD) is a disease with a high-risk of mortality. Late deaths are often related to complications in nonoperated aortic segments. Between 1984 and 1996, we retrospectively analyzed the data of 109 patients with acute AD (81 men and 28 women; average age 61 ± 14 years). All imaging examinations were reviewed, and a magnetic resonance imaging examination was performed at the time of the study. Aortic diameters were measured on each aortic segment. Predictive factors of mortality were determined by Cox’s proportional hazard model, in univariate and multivariate analyses, using BMDP statistical software. Follow-up was an average of 44 ± 46 months (range 24 to 164). Actuarial survival rates were 52%, 46%, and 37% at 1, 5, and 10 years, respectively, for type A AD versus 76%, 72%, and 46% for type B AD. Predictors of late mortality were age >70 years and postoperative false lumen patency of the thoracic descending aorta (RR 3.4, 95% confidence intervals 1.20 to 9.8). Descending aorta diameter was larger when false lumen was patent (31 vs 44 mm; p = 0.02) in type A AD. Furthermore, patency was less frequent in operated type A AD when surgery had been extended to the aortic arch. Thus, patency of descending aorta false lumen is responsible for progressive aortic dilation. In type A AD, open distal repair makes it possible to check the aortic arch and replace it when necessary, decreases the false lumen patency rate, and improves late survival.

Objective To assess the agreement between left ventricular (LV) volumes and ejection fraction (EF) determined by two-dimensional echocardiography (2-D echo) and by cineangiography in postinfarction patients. Design LV end-diastolic and end-systolic volumes indexed (EDVI and ESVI) to body surface area as well as EF were determined by both methods in all patients. Setting Multicenter trial conducted in five university hospitals. Patients 63 patients, 61 male, two female, mean age 55.5 +/- 10.4 years, suffering from a recent myocardial infarction. Eighty-one pairs of measurements were available. Methods The results of biplane 2-D echo measures, using apical four-chamber (4C) and two-chamber (2C) views were compared to those of a 30 degrees right anterior oblique cineangiography projection, using either the apical method of discs or the area-length 2-D echo method. Moreover, eyeball EF was estimated at 2-D echo and cineangiography, and was compared to the conventional methods. The agreement between results was assessed by the Bland and Altman method. Results The agreement between 2-D echo and cineangiography results was poor. Mean differences (MD) were -21.8 (EDVI, ml/m(2)), -9.5 (ESVI, ml/m(2)), and -0.9 (EF, %), respectively for 2-D echo method of discs versus cineangiography, and -23.2, -9.3, and -5.7 for area-length 2-D echo versus cineangiography. For EF (%), MD was -3.6 for eyeball cineangiography versus cineangiography, -1.3 for eyeball 2-D echo versus method of discs, and +0.30 for eyeball 2-D echo versus area-length 2-D echo, respectively. Two-dimensional echo is likely to underestimate LV volumes compared to cineangiography, especially for largest volumes. Even for EF, discrepancies are large, with a lack of agreement of 21%-25% between conventional methods, but agreement is better between eyeball EF and usual methods. Conclusions Even with modern echocardiographic devices, agreement between 2-D echo and cineangiography-derived LV volumes and EF remains moderate, and both methods must not be considered interchangeable in clinical practice.

Study Aim: To investigate whether the BARC classification of bleeding events is applicable in the context of PE, where no standard definition exists Anticoagulant and thrombolytic agents form the cornerstone of PE management, but their use is associated with an increased risk of bleeding. Bleeding complications are associated with an increased risk of subsequent adverse outcomes in pulmonary embolism (PE). The “Bleeding Academic Research Consortium” (BARC) developed a classification of bleeding events combining laboratory and clinical parameters, but this classification was developed in ACS patients, and its applicability to other settings remains unknown.

Mean pulmonary artery pressure (MPA), cardiac output (CO), and right ventricular ejection fraction (RVEF) were serially assessed with use of a 5-way, rapid response rate, Swan-Ganz catheter in 45 Pts submitted to thrombolytic therapy (TI) for massive pulmonary embolism (PE) defined as Miller score l 17/34, and mean pulmonary artery pressure g20 mmHg. Total pulmonary resistance (TPR) was determined from MPA and CO and expressed in dynes/sec/cm-5. Pulmonary angiography was performed before and 24 after TT. Streptokinase (STK) was used in 22 Pts, and tissue plasminogen activator (t-PA) in 23. T 0 T 1 h T2 h T 12 h TPR-STK 701 ± 261 591 ± 203 583 ± 211 380 ± 155 TPR-t-PA 735 ± 390 508 ± 330 405 ± 210 * 338 ± 142 RVEF-STK 0.18 ± 0.02 0.20 ± 0.07 020 ± 0.09 026 ± 0.10 RVEF-t-PA 0.18 ± 0.08 024 ± 0.09 0.27 ± 0.09 * 029 ± 0.09 * p l 0.05 between STK and t-PA A significant decrease in TPR inversely correlated to a significant increase in RVEF occurred in both treatment groups, but significantly more rapidly in the t-PA group than in the STK group. The difference was significant 2 hand 4 h after onset of TT, but had vanished at 12 h. Miller score, similar in both groups before TT, was identical in both groups at 24 h. Conclusion t-PA induced a significantly faster hemodynamic improvement than STK in massive PE, but with a catch-up phenomenon apparent 12 h after onset of therapy.

BackgroundGuidelines recommend low molecular weight heparin (LMWH) and fondaparinux (fonda) over unfractionated heparin (UFH) for initial treatment of acute pulmonary embolism (PE), except in patients (pts) at high risk of bleeding & with severe renal dysfunction. No trial has assessed the comparative efficacy of enoxaparin (enox) and fonda in this setting.MethodsProspective, multicenter registry. Pts with proven recent PE (symptom onset