OBJECTIVESUsing French transcatheter aortic valve replacement (TAVR) registries linked with the nationwide administrative databases, the study compared the rates of long-term mortality, bleeding, and ...ischemic events after TAVR in patients requiring oral anticoagulation with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). BACKGROUNDThe choice of optimal drug for anticoagulation after TAVR remains debated. METHODSData from the France-TAVI and FRANCE-2 registries were linked to the French national health single-payer claims database, from 2010 to 2017. Propensity score matching was used to reduce treatment-selection bias. Two primary endpoints were death from any cause (efficacy) and major bleeding (safety). RESULTSA total of 24,581 patients who underwent TAVR were included and 8,962 (36.4%) were treated with OAC. Among anticoagulated patients, 2,180 (24.3%) were on DOACs. After propensity matching, at 3 years, mortality (hazard ratio HR: 1.37; 95% confidence interval CI: 1.12-1.67; P < 0.005) and major bleeding including hemorrhagic stroke (HR: 1.64; 95% CI: 1.17-2.29; P < 0.005) were lower in patients on DOACs compared with those on VKAs. The rates of ischemic stroke (HR: 1.32; 95% CI: 0.81-2.15; P = 0.27) and acute coronary syndrome (HR: 1.17; 95% CI: 0.68-1.99; P = 0.57) did not differ among groups. CONCLUSIONSIn these large multicenter French TAVR registries with an exhaustive clinical follow-up, the long-term mortality and major bleeding were lower with DOACs than VKAs at discharge. The present study supports preferential use of DOACs rather than VKAs in patients requiring oral anticoagulation therapy after TAVR.
Objective
To evaluate the incidence and risk factors for ICE during a PV.
Materials and methods
Single-center retrospective analysis of 1512 consecutive patients who underwent 1854 PV procedures for ...osteoporotic (34 %), malignant (39.9 %) or other cause (26.1 %) of vertebral compression fractures (VCFs)/spine tumor lesions. Only thoracic or lumbar PVs were included. PVs were performed with polymethylmethacrylate (PMMA) low-viscosity bone cement under fluoroscopic guidance. Chest imaging (X-ray or CT) was performed the same day after PV in patients with high clinical suspicion of ICE. All post-procedural chest-imaging examinations were reviewed, and all ICEs were agreed upon in consensus by two radiologists.
Results
ICEs were detected in 72 patients (92 cement embolisms). In 86.1 % of the cases, concomitant pulmonary artery cement leakage was detected. Symptomatic ICEs were observed in six cases (8.3% of all ICEs; 0.32% of all PV procedures). No ICE led to death or permanent sequelae. Multiple levels treated during the same PV session were associated with a higher ICE rate OR: 3.59, 95% CI: (1.98-6.51);
p
< 0.001; the use of flat panel technology with a lower ICE occurrence OR: 0.51, 95% CI: (0.32-0.83);
p
= 0.007.
Conclusion
Intracardiac cement embolism after PV has a low incidence (3.9 % in our study). Symptomatic complications related to ICE are rare (0.3%); none was responsible for clinical sequelae in our series.
Key Points
• The incidence of intracardiac cement embolism (ICE) during PVP is low (3.9%).
•
Having a high number of treated vertebrae during the same session is a significant risk factor for ICE.
•
Symptomatic intracardiac cement embolisms have a low incidence (8.3% of patients with ICE).
In this trial, bedside platelet-function monitoring to adjust antiplatelet therapy after coronary stent implantation did not reduce the rate of subsequent cardiovascular events, a finding that calls ...into question the clinical value of this type of testing.
Clopidogrel and aspirin play a central role in the treatment of patients undergoing percutaneous coronary intervention.
1
Up to one third of patients have inadequate platelet inhibition, with an increased risk of events.
2
–
5
Platelet-function testing can determine the degree of platelet reactivity during treatment at the bedside and potentially identify patients in whom adjustment of antiplatelet therapy is warranted to minimize the risks of both ischemic and bleeding complications.
6
Cohort studies and meta-analyses have largely shown the prognostic value of high platelet reactivity during antiplatelet therapy in patients undergoing coronary stenting.
7
,
8
Randomized clinical trials have also shown that stronger . . .
Composition of Coronary Thrombus in Acute Myocardial Infarction Silvain, Johanne, MD, PhD; Collet, Jean-Philippe, MD, PhD; Nagaswami, Chandrasekaran, MD ...
Journal of the American College of Cardiology,
03/2011, Letnik:
57, Številka:
12
Journal Article
Recenzirano
Odprti dostop
Objectives We sought to analyze the composition of coronary thrombus in vivo in ST-segment elevation myocardial infarction (STEMI) patients. Background The dynamic process of intracoronary thrombus ...formation in STEMI patients is poorly understood. Methods Intracoronary thrombi (n = 45) were obtained by thromboaspiration in 288 consecutive STEMI patients presenting for primary percutaneous intervention, and analyzed using high-definition pictures taken with a scanning electron microscope. Plasma biomarkers (TnI, CRPus, IL-6, PAI-1, sCD40 ligand, and TNF-α) and plasma fibrin clot viscoelastic properties were measured simultaneously on peripheral blood. Results Thrombi were mainly composed of fibrin (55.9 ± 18%) with platelets (16.8 ± 18%), erythrocytes (11.5 ± 9%), cholesterol crystals (5.2 ± 8.4%), and leukocytes (1.3 ± 2.0%). The median ischemic time was 175 min (interquartile range: 140 to 297). Ischemic time impacted thrombi composition, resulting in a positive correlation with intracoronary thrombus fibrin content, r = 0.38, p = 0.01, and a negative correlation with platelet content, r = −0.34, p = 0.02. Thus, fibrin content increased with ischemic time, ranging from 48.4 ± 21% (<3 h) up to 66.9 ± 9% (>6 h) (p = 0.02), whereas platelet content decreased from 24.9 ± 23% (<3 h) to 9.1 ± 6% (>6 h) (p = 0.07). Soluble CD40 ligand was positively correlated to platelet content in the thrombus (r = 0.40, p = 0.02) and negatively correlated with fibrin content (r = −0.36; p = 0.04). Multivariate analysis indicated that ischemic time was the only predictor of thrombus composition, with a 2-fold increase of fibrin content per ischemic hour (adjusted odds ratio: 2.00 95% confidence interval: 1.03 to 3.7; p = 0.01). Conclusions In acute STEMI, platelet and fibrin contents of the occlusive thrombus are highly dependent on ischemia time, which may have a direct impact on the efficacy of drugs or devices used for coronary reperfusion.
Summary Background Clopidogrel and low-dose aspirin have become the mainstay oral antiplatelet regimen to prevent recurrent ischaemic events after acute coronary syndromes or stent placement. The ...frequent genetic functional variant 681 G>A (*2) of cytochrome P450 2C19 ( CYP2C19 ) is an important contributor to the wide variability between individuals of the antiplatelet effect of clopidogrel. We assessed whether the CYP2C19*2 polymorphism affected long-term prognosis of patients who were chronically treated with clopidogrel. Methods Between April 1, 1996, and April 1, 2008, 259 young patients (aged <45 years) who survived a first myocardial infarction and were exposed to clopidogrel treatment for at least a month, were enrolled in a multicentre registry and underwent CYP2C19*2 determination. The primary endpoint was a composite of death, myocardial infarction, and urgent coronary revascularisation occurring during exposure to clopidogrel. Follow-up was every 6 months. The key secondary endpoint was stent thrombosis proven by angiography. Findings Median clopidogrel exposure time was 1·07 years (IQR 0·28–3·0). Baseline characteristics were balanced between carriers (heterozygous *1/*2, n=64; homozygous *2/*2, n=9) and non-carriers (n=186) of CYP2C19*2 variant. The primary endpoint occurred more frequently in carriers than in non-carriers (15 vs 11 events; hazard ratio HR 3·69 95% CI 1·69–8·05, p=0·0005), as did stent thrombosis (eight vs four events; HR 6·02 1·81–20·04, p=0·0009). The detrimental effect of the CYP2C19*2 genetic variant persisted from 6 months after clopidogrel initiation up to the end of follow-up (HR 3·00 1·27–7·10, p=0·009). After multivariable analysis, the CYP2C19*2 genetic variant was the only independent predictor of cardiovascular events (HR 4·04 1·81–9·02, p=0·0006). Interpretation The CYP2C19*2 genetic variant is a major determinant of prognosis in young patients who are receiving clopidogrel treatment after myocardial infarction. Funding Délégation à la Recherche Clinique, Assistance Publique-Hôpitaux de Paris.
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