Antoine Guedes

Cardiopoietic cell therapy for advanced ischemic heart failure: results at 39 weeks of the prospective, randomized, double blind, sham-controlled CHART-1 clinical trial

Aims Cardiopoietic cells, produced through cardiogenic conditioning of patients’ mesenchymal stem cells, have shown preliminary efficacy. The Congestive Heart Failure Cardiopoietic Regenerative Therapy (CHART-1) trial aimed to validate cardiopoiesis-based biotherapy in a larger heart failure cohort. Methods and results This multinational, randomized, double-blind, sham-controlled study was conducted in 39 hospitals. Patients with symptomatic ischaemic heart failure on guideline-directed therapy (n = 484) were screened; n = 348 underwent bone marrow harvest and mesenchymal stem cell expansion. Those achieving > 24 million mesenchymal stem cells (n = 315) were randomized to cardiopoietic cells delivered endomyocardially with a retention-enhanced catheter (n = 157) or sham procedure (n = 158). Procedures were performed as randomized in 271 patients (n = 120 cardiopoietic cells, n = 151 sham). The primary efficacy endpoint was a Finkelstein–Schoenfeld hierarchical composite (all-cause mortality, worsening heart failure, Minnesota Living with Heart Failure Questionnaire score, 6-min walk distance, left ventricular end-systolic volume, and ejection fraction) at 39 weeks. The primary outcome was neutral (Mann–Whitney estimator 0.54, 95% confidence interval [CI] 0.47–0.61 [value > 0.5 favours cell treatment], P = 0.27). Exploratory analyses suggested a benefit of cell treatment on the primary composite in patients with baseline left ventricular end-diastolic volume 200–370 mL (60% of patients) (Mann–Whitney estimator 0.61, 95% CI 0.52–0.70, P = 0.015). No difference was observed in serious adverse events. One (0.9%) cardiopoietic cell patient and 9 (5.4%) sham patients experienced aborted or sudden cardiac death. Conclusion The primary endpoint was neutral, with safety demonstrated across the cohort. Further evaluation of cardiopoietic cell therapy in patients with elevated end-diastolic volume is warranted.

Transcatheter left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation: results from the Belgian registry.

AIMS This study aimed to assess the safety and efficacy at midterm follow-up of left atrial appendage occlusion (LAAO) using different devices, in real life in Belgium. METHODS AND RESULTS Between June 2009 and November 2016, 457 consecutive patients (63% male, 75±12 yrs, CHA2DS2-VASc 4±0.6, HAS-BLED 3.5±0.7) undergoing LAAO were included. Technical success was 97.1%. There were 19 periprocedural major adverse events (4.1%) including three deaths (0.6%), nine tamponades (1.9%), four major bleedings (0.8%) and two device embolisations (0.4%). Among patients successfully implanted having a complete follow-up (672 patient-years, median follow-up 370 days), the actual annual stroke rate was 1.2%, lower than the expected stroke risk of 4% (70% reduction). The observed bleeding rate was 2%, while the calculated risk was 3.7% (46% reduction). Kaplan-Meier analysis showed a similar overall survival (93±2% and 87±3% versus 91±3% and 87±4%; p=0.35) and event-free survival (92±2% and 84±3% versus 88±3% and 80±5%; p=0.17) at one and two years, for the ACP/Amulet versus the WATCHMAN groups of patients, respectively. CONCLUSIONS The data from the Belgian left atrial appendage occlusion registry suggest that the procedure is effective and relatively safe in a real-world setting, using either the WATCHMAN or the ACP/Amulet device.

RADIAL ARTERY PATENCY AFTER TRANSRADIAL ACCESS: EFFECTIVE AND EASY WAY TO REDUCE THE RADIAL ARTERY OCCLUSION RATE, RESULTS OF THE CRASOC (COMPRESSION OF RADIAL ARTERIES WITHOUT OCCLUSION) STUDY

Methods: From January 2009 to June 2011, we randomized 2107 TRA to low (13cc of air) versus ultra low (10 cc) inflation volume in the TR BandTM compression device. If bleeding occurred, 2 cc were added. After device positioning, type of compression was assessed (“patent hemostasis” or not). Compression was maintained for at least 4 hours. Radial artery patency was evaluated at 24 h by pulse oximetry during ulnar compression. Factors related to patency defined as positive pulse oximetry (PPO) were analyzed.

A rare primary cardiac tumour : cavernous hemangioma of the tricuspid valve.

Tricuspid valve cavernous hemangioma is a rare and also an unusual primary benign tumour developed from endocardium, as cardiac valves are predominantly avascular structures; the incidence is <3% of all detected primary heart tumours. We describe a 52-year-old woman who presented with palpitations and atypical left chest pain. On admission, physical examination revealed normal heart sounds and no abnormal murmurs. Exercise test and 24-h Holter monitoring were non-concluding. Transthoracic echocardiography, including …

Early prognosis and predictor analysis for positive coronary angiography after out-of-hospital cardiac arrest (OHCA).

Abstract Background: Key predictors of survival after OHCA have been described in the literature. Current guidelines recommend emergency angiography in patients without an obvious extra-cardiac cause of arrest. However, the value of this strategy is debated. Moreover, diagnosis of acute coronary ischaemia after OHCA remains challenging, especially in patients without ST-segment elevation. Objectives: The primary objective was to identify qualitative variables associated with an increased chance of 30-d survival after OHCA. The secondary objective was to identify predictors of 30-d survival among patients with ischaemic cardiomyopathy and patients without ST-segment elevation. Afterwards, we sought to identify parameters associated with acute coronary ischaemia and positive coronary angiography in patients without ST-segment elevation. Methods: Retrospective single-centre study including 123 patients resuscitated from OHCA. Baseline characteristics, resuscitation settings and angiographic findings were analysed. Results: The predictors of 30-d survival after OHCA included witnessed cardiac arrest, haemodynamic instability and coronary angiography. Convertible cardiac rhythm, history of coronary disease and presence of at least two cardiovascular risk factors were associated with acute coronary ischaemia. Predictors for a positive angiography in patients without ST-segment elevation included history of coronary disease, gender, diabetes, dyslipidaemia and presence of at least two cardiovascular risk factors (all p < .05). Conclusions: We identified qualitative predictors of 30-day survival after OHCA. Our findings suggest that the recognition of acute coronary ischaemia after OHCA might be improved. The identification of risk criteria may help to select the best candidates for emergency angiography.

Early prognosis and predictor analysis for positive coronary angiography after out-of-hospital cardiac arrest (OHCA)

Background Cardiac arrest occurring out of hospital carries a poor likelihood of overall survival. Key predictors of survival have been described in the literature. Current guidelines recommend emergency coronary angiography in patients without an obvious extra-cardiac cause of arrest. However, the prognostic value of this strategy is debated. Moreover, diagnosis of acute coronary ischemia after OHCA remains challenging, especially in patients without ST-segment elevation. Objectives Our aim was to identify qualitative variables associated with 30-day survival after OHCA. Afterwards, we sought to determine if coronary angiography was associated with better outcome and to identify predictors for a positive angiography in patients without ST-segment elevation. Methods This is a retrospective single-center study that investigated data from a consecutive series of 123 patients admitted to our emergency department (ED) with resuscitated OHCA (2012–2014). Baseline characteristics, resuscitation settings and angiographic findings were analyzed. Results Convertible cardiac rhythm, witnessed status, acute coronary syndrome (ACS), ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI) and coronary angiography were associated with an increased chance of 30-day survival. Among patients without ST-segment elevation, predictors for a positive angiography included history of coronary disease, age, gender, diabetes, dyslipidemia and presence of at least two cardiovascular risk factors ( Table 1 , Fig. 1 ). Conclusions We identified qualitative predictors for 30-day survival after OHCA. Diagnosis of ACS and coronary angiography were associated with a better outcome. Among patients without ST-segment elevation, the identification of risk factors may help to select the best candidates for emergency angiography. These findings suggest that the recognition of acute coronary ischemia after OHCA might be improved. Parameters associated with coronary artery disease in patients with cardiac etiology and absence of ST-segment elevation.

Complete recovery of string sign of the internal mammary artery graft 11 years after coronary artery bypass surgery associated with disparition of competitive flow

In 2005, a 66-year-old patient was diagnosed ischaemic cardiomyopathy with angiographic three vessels coronary artery disease (fractional flow reserve was not performed at this time). He underwent coronary artery bypass surgery: right internal mammary artery (RIMA) on left anterior descending artery (LAD), left internal mammary artery on second left marginal and saphenous venous graft on posterior interventricular artery. Three years after surgery, cineangiogram was performed because of an adenosine MIBI stress test suggestive of ischaemia in the apex and mid-inferolateral segments. Angiogram showed a string sign of the RIMA with a dominant antegrade coronary flow through the native LAD. Fractional flow reserve measured in the distal LAD through the left main was 0.83. In 2017, the exam was redone because of heart failure with new severe systolic dysfunction. At that time, LAD stenosis had progressed to subtotal occlusion. The RIMA was then fully patent, with an antegrade flow perfusing the whole distal LAD territory Figure 1. It is well known that internal mammary arteries have flow adaptation capabilities, allowing vasoactive [1] and anatomical [2] increase in lumen diameter in response to higher flow demand after grafting on a large coronary territory. Conversely, a balanced or native-dominant flow frequently occurs when graft is implanted beyond a moderate or haemodynamically non-significant coronary stenosis. This could lead to severe diffuse narrowing of the graft (string sign) and graft occlusion [3]. It is still not known whether and how often reopening of the graft lumen in the case of a string sign happens in case of progression of native stenosis [4]. Although such functional recovery is alluded to in several reports, reopening of a non-functional graft has never been convincingly illustrated. Consequently, string sign is generally considered as graft deterioration at the same level as graft occlusion [3]. To the best of our knowledge, this is the first case in the literature showing a full recovery of string sign internal mammary artery graft, late after surgery, associated with severe progression of native vessel stenosis which was initially proven haemodynamically nonsignificant.

Double guide double wrist 5F left coronary artery transradial percutaneous coronary intervention and the X-Kiss technique.

ABSTRACT Percutaneous coronary intervention for bifurcated anatomy, particularly at the proximal left coronary artery site, requires guide catheters (GC) of at least 6 french and preferably larger in diameter. We describe a new trans-radial approach more suitable for small artery size: the simultaneous use of both radial arteries for double cannulation of the LMCA with 5F GC: each GC will target either the LM/LAD or the LM/CX artery (or LM-LAD/LM-LAD-1st diagonal branch) stenoses. The technique successfully was applied to 5 cases. When the technique was used for distal left main coronary artery stenoses (3 cases), a special crogss-like configuration obtained when guide catheters, coronary wires and balloons kissed was observed.

Elevation of biomarkers and long-term outcome after percutaneous coronary intervention

The impact of an elevation of cardiac biomarkers occurring after percutaneous coronary intervention (PCI) on long‐term outcome remains controversial. Most available data are based on observational registries using multivariable analysis. In this study, a case–control approach was used to assess separately the impact of post‐PCI elevation of CK‐MB on the short‐term in‐hospital outcome and on the long‐term outcome after hospital discharge.

Distal ‘buddy-in-jail’ technique: a complementary ‘Jail with stent’ method for stent delivery

Abstract Delivery of coronary stents can be challenging, but the use of a second or ‘buddy’ wire helps the progression of equipment through tortuous and rigid vessels. We successfully positioned a coronary stent in a distal lesion, intentionally jailing the buddy wire during stent delivery. The jailed wire was then used to proceed further with proximal coronary stenting. We report 10 cases using either the jailed or the non-jailed wire for this modified ‘buddy-in-jail’ technique.