Renal infarction (RI) is a rare disease with poor prognosis. Appropriate secondary prevention treatment is essential and requires an exhaustive etiological assessment. We aimed to determine whether ...invasive endovascular explorations may improve the diagnostic process and change the secondary prevention treatment strategy in RI patients.
We report a retrospective observational study of 25 RI patients referred to Tours University Hospital between 2011 and 2018 for etiological investigation including renal arteriography and intravascular ultrasonography (IVUS). We sought for antithrombotic treatment regimen, vital status, bleeding and ischemic outcomes during the median follow-up of 59 months.
Invasive explorations showed local arterial disease in 14 patients (56%). This led to a diagnosis or change in diagnosis in 9 patients (36%) and to a change in antithrombotic strategy in 56% of cases, with an increased prescription of antiplatelet therapy. No patient died, only two patients (8%) had persistent mild renal insufficiency. One IVUS complication was reported and treated without any significant long-term consequences.
Invasive endovascular investigations of RI may modify the secondary prevention treatment through a better assessment of the aetiology of RI. Multicentric randomized studies are necessary to advocate the hypothesis that invasive exploration of renal artery can improve long-term prognosis.
Risk-benefit assessment for transcatheter aortic valve implantation (TAVI) is still a matter of debate. We aimed to identify patients with a bad outcome within 1 year after TAVI, and to develop a ...Futile TAVI Simple score (FTS). Based on the administrative hospital-discharge database, all consecutive patients treated with percutaneous TAVI in France between 2010 and 2018 were included. A prediction model was derived and validated for 1-year all-cause death after TAVI (considered as futility) by using split-sample validation: 20,443 patients were included in the analysis (mean age 83 ± 7 years). 7,039 deaths were recorded (yearly incidence rate 15.5%), among which 3,702 (53%) occurred in first year after TAVI procedure. In the derivation cohort (n = 10,221), the final logistic regression model included male sex, history of hospital stay with heart failure, history of pulmonary oedema, atrial fibrillation, previous stroke, vascular disease, renal disease, liver disease, pulmonary disease, anaemia, history of cancer, metastasis, depression and denutrition. The area under the curve (AUC) for the FTS was 0.674 (95%CI 0.660 to 0.687) in the derivation cohort and 0.651 (95%CI 0.637 to 0.665) in the validation cohort (n = 10,222). The Hosmer–Lemeshow test had a p-value of 0.87 suggesting an accurate calibration. The FTS score outperformed EuroSCORE II, Charlson comorbidity index and frailty index for identifying futility. Based on FTS score, 7% of these patients were categorized at high risk with a 1-year mortality at 43%. In conclusion, the FTS score, established from a large nationwide cohort of patients treated with TAVI, may provide a relevant tool for optimizing healthcare decision.
A systematic review and meta-analysis was performed to evaluate the safety and efficacy of drug-eluting stents (DES) vs bare-metal stents (BMS) in atrial fibrillation (AF) patients.
We systematically ...searched 5 engines until May 2019 for cohort studies and randomized controlled trials (RCTs). Primary outcomes were major bleeding and major adverse cardiac events (MACE) including cardiac death, myocardial infarction, target vessel revascularization (TVR) or stent thrombosis. Effects of inverse variance random meta-analyses were described with relative risks (RR) and their 95% confidence intervals (CI). We also stratified analyses by type (triple TAT vs dual DAT) and duration (short-vs long-term) of antithrombotic therapy.
Ten studies (3 RCTs; 7 cohorts) including 10,353 patients (DES: 59.6%) were identified. DES did not show higher risk of major bleeding than BMS (5.6% vs 6.9%, RR 1.07; 95%CI, 0.89–1.28, p = 0.47; I2 = 0%) or MACE (12% vs 13.6%; RR 0.96; 95%CI 0.81–1.13, p = 0.60; I2 = 44%). Although, DES almost decreased TVR risk (6.4% vs 8.4%, RR 0.78; 95%CI, 0.61–1.01, p = 0.06; I2 = 15%). Stratified analyses by type and duration of antithrombotic therapy showed no differences in major bleeding or MACE between both types of stents. In DES, long-term TAT showed higher major bleeding risk than long-term DAT (7.7% vs 4.7%, RR 1.48, 95%CI 1.08–2.03, p = 0.01; I2 = 12%). For both types of stents, MACE risk was similar between TAT and DAT.
In patients with AF undergoing PCI, DES had similar rate of major bleeding and MACE than BMS. DAT seems to be a safer antithrombotic therapy compared with TAT.
•In patients with AF undergoing PCI, DES showed similar rate of major bleeding and MACE than BMS.•DES showed a trend of a lower risk of TVR and a similar risk of stent thrombosis in comparison to BMS.•DAT seems to be a safer antithrombotic therapy compared with TAT.
The objective of the study was to identify and quantify the potential improvement of left ventricular contractility after percutaneous transluminal coronary angioplasty (PTCA) using 4-dimensional ...(4D) speckle tracking echocardiography (4D STE). We investigated 41 patients with coronary disease by 4D STE pre- and 24 hours postcoronarography with (n = 18) or without (n = 23) PTCA. The 4D STE visualizes in real time the myocardium strain on 2- and 4-chamber apical views and on 3 transverse views of the left ventricle. Average and total strain of the left ventricle were measured. Of the 18 PTCA patients, 15 showed significant increase in left ventricle mean (+15 ± 6) and total strain (240 ± 100), which corresponded to an increase of 93% ± 55% from precoronarography, whereas the remainder showed no change. The total strain corresponded to 33% ± 10% (before PTCA) and 59% ± 11% (post PTCA) of the estimated normal strain for each patient. Strain improved in 70% of the segment downstream from the stent, and there was a negative correlation between the amplitude of the mean and total strain improvements after 24 hours and the mean and total strain values before PTCA. In the non-PTCA group, 21 of the 23 patients showed no changes in strain, whereas 2 showed improvement. The 4D STE showed significant improvements in left ventricular contractility in more than 70% of the areas downstream from the PTCA segment. This corresponded to an increase in the initial contractility by approximately 93% ± 55%; however, the myocardium contractility remained approximately 59% of normal level. No changes were seen in patients without PTCA.
The goal of this study was to evaluate the safety and performance of the Multi-Link Frontier coronary bifurcation stent system (Guidant Corp., Santa Clara, California), a novel dedicated device ...designed for permanent side branch (SB) access, stent delivery by simultaneous kissing balloon inflation, and optimal main branch (MB) and SB ostium scaffolding.
The treatment of coronary bifurcation lesions remains challenging, and various approaches using stents have been proposed.
The primary end point was the 180-day incidence of major adverse cardiac events (MACE) per intent-to-treat analysis. Secondary end points included device success, 30-day MACE, angiographic restenosis, and target lesion revascularization (TLR) rates at 180 days.
After a learning phase of two cases per center, 105 patients were prospectively included in 11 centers. The left anterior descending coronary artery/diagonal bifurcation was the target in 80% of cases. The Frontier stent was successfully implanted in 96 patients (91%), and procedural success was obtained in 93%. Two patients suffered in-hospital myocardial infarction (MI) secondary to SB occlusion, and one patient underwent elective coronary artery bypass grafting. At 30 days and 6 months, the MACE rates were 2.9% and 17.1% (no death, no subacute stent thrombosis, Q-wave MI 1.0% and 1.9%, non-Q-wave MI 1.0% and 1.9%, TLR 1.0% and 13.3%). The MB in-stent restenosis was 25.3%, in-segment 29.9%. The SB restenosis was 29.1%. The overall restenosis rate for any branch was 44.8%.
The results of this Frontier registry demonstrate the safety and performance of this dedicated stent system for the treatment of bifurcation lesions. The device can be successfully implanted in more than 90% of all cases, with a high procedural success rate and low 30-day and 6-month MACE rates.
Percutaneous coronary intervention (PCI) is the cornerstone of revascularization in acute coronary syndromes (ACS). The radial artery catheterization (RAC) is associated with less bleeding ...complications. However it is not clear whether the benefit on bleedings associated with RAC could be translated into a reduction of long term major adverse cardiovascular events (MACE). In patients with ST elevation myocardial infarction (STEMI), we have to determine if the use of RAC allows the recanalization of the coronary artery in a timely fashion. We aimed to confirm that RAC reduces haemorrhagic complications and determine if this advantage on bleedings could be translated into a 6 months MACE reduction. We also checked if RAC did not lengthen the time puncture to balloon (TPB) in the subgroup of STEMI patents.
All patients hospitalized for an ACS and treated with PCI between 01/2008 and 12/2008 were considered for this study. Predictors of in hospital minor and major bleedings and 6 months MACE were sought by uni and multivariate analysis.
Altogether, 626 patients were included. 509 treated with RAC and 117 with a femoral artery catheterization (FAC). As compared to FAC, RAC decreased in hospital minor and major bleedings, respectively by 80%(OR=0.2, CI=0.06-0.6, p=0,004) and 74% (OR=0.26, CI=0.1-0.7, p=0,007). In patients with STEMI, there was no difference in TPB whatever the arterial access used (13 min vs 14 min, p=0.7). At 6 months, RAC was found as an independent predictor for less MACE (OR=0.4, CI=0.1-1.1, p=0.05).
Patients treated by PCI derive benefit from the use of RAC on in-hospital bleedings but also on the reduction of 6 months ischemic events. In STEMI patients it does not extend the TPB. Use of RAC should have a widespread diffusion.
Abstract Background In the elderly patients, the optimal reperfusion strategy of acute ST-segment elevation myocardial infarction (STEMI) remains a topic of debate. Moreover, there is a lack of data ...regarding the effect of time to treatment (TT) on prognosis of STEMI in elderly patients. Purpose The goal of our work was to analyze, in real life, the link between TT and 1-year mortality in patients with STEMI (≥75 years) who were treated with thrombolysis (THL) or primary percutaneous coronary intervention (PCI). Methods and materials Data were extracted from our university hospital prospective registry. Between 1995 and 2005, all patients who met the criteria (≥75 years old, has had an acute STEMI <12 h, has been admitted directly into our cardiologic care unit, and has had a revascularization procedure) were included in the analysis. Using logistic regression, we studied the relation between TT and 1-year mortality for each strategy of reperfusion in patients with STEMI who were ≥75 years old. Results One hundred fifty-nine consecutive patients with STEMI <12 h were analyzed; 35 were treated with THL and 124 were treated with primary PCI. Mean age (±S.D.) was 80±4 years, and 56% of patients were men. In logistic regression analysis, TT was not associated to death after THL ( P =.81), while it was positively correlated after PCI ( P =.03). All-cause 1-year mortality was markedly higher in the THL group than in the PCI group (51.4% vs. 15.3%; P <.001). Conclusion Our work suggests that the extrapolation of algorithm of revascularization used in younger patients is not appropriate for elderly patients. Specific algorithm of revascularization and recommendations are needed in elderly patients.
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