Benjamin Marchandot

CT-ADP Point-of-Care Assay Predicts 30-Day Paravalvular Aortic Regurgitation and Bleeding Events following Transcatheter Aortic Valve Replacement

BACKGROUNDnParavalvular aortic regurgitation (PVAR) remains a frequent postprocedural concern following transcatheter aortic valve replacement (TAVR). Persistence of flow turbulence results in the cleavage of high-molecular-weight von Willebrand multimers, primary haemostasis dysfunction and may favour bleedings. Recent data have emphasized the value of a point-of-care measure of von Willebrand factor-dependent platelet function (closure time [CT] adenosine diphosphate [ADP]) in the monitoring of immediate PVAR. This study examined whether CT-ADP could detect PVAR at 30 days and bleeding complications following TAVR.nnnMETHODSnCT-ADP was assessed at baseline and the day after the procedure. At 30 days, significant PVAR was defined as a circumferential extent of regurgitation more than 10% by transthoracic echocardiography. Events at follow-up were assessed according to the Valve Academic Research Consortium-2 consensus classification.nnnRESULTSnSignificant PVAR was diagnosed in 44 out of 219 patients (20.1%). Important reduction of CT-ADP could be found in patients without PVAR, contrasting with the lack of CT-ADP improvement in significant PVAR patients. By multivariate analysis, CT-ADPu2009>u2009180u2009seconds (hazard ratio [HR]: 5.1, 95% confidence interval [CI]: 2.5-10.6; pu2009<u20090.001) and a self-expandable valve were the sole independent predictors of 30-day PVAR. At follow-up, postprocedural CT-ADP >180u2009seconds was identified as an independent predictor of major/life-threatening bleeding (HR: 1.7, 95% CI [1.0-3.1]; pu2009=u20090.049). Major/life-threatening bleedings were at their highest levels in patients with postprocedural CT-ADPu2009>u2009180u2009seconds (35.2 vs. 18.8%; pu2009=u20090.013).nnnCONCLUSIONnPostprocedural CT-ADPu2009>u2009180u2009seconds is an independent predictor of significant PVAR 30 days after TAVR and may independently contribute to major/life-threatening bleedings.

Primary Hemostatic Disorders and Late Major Bleeding After Transcatheter Aortic Valve Replacement

BACKGROUNDnPeriprocedural and late (>30xa0days) bleedings represent major complications after transcatheter aortic valve replacement and have been identified as potential areas for improved patient care.nnnOBJECTIVESnThe authors sought to evaluate the impact of ongoing primary hemostasis disorders on late major/life-threatening bleeding complications (MLBCs).nnnMETHODSnBleedings were assessed according to the VARC-2 (Valve Academic Research Consortium-2) criteria. Closure time of adenosine diphosphate (CT-ADP), a surrogate marker of high molecular weight von Willebrand multimers proteolysis was assessed 24xa0h after the procedure. Ongoing primary hemostasis disorder was defined by a CT-ADP >180 s.nnnRESULTSnAmong 372 patients who survived at 30xa0days, MLBCs occurred in 42 patients (11.3%) at a median follow-up of 383xa0days (interquartile range: 188 to 574xa0days). MLBCs were mainly of gastrointestinal origin (42.8%) and were associated with increased overall mortality (hazard ratio [HR]: 5.66; 95% confidence interval [CI]: 3.10 to 10.31; pxa0< 0.001) and cardiac mortality (HR: 11.62; 95% CI: 4.59 to 29.37; pxa0< 0.001). A 2.5-fold elevation of MLBCs could be evidenced in patients with a CT-ADP > 180xa0s (27.4% vs. 11.5%; pxa0< 0.001). Multivariate regression analysis identified paravalvular leak (PVL) (HR: 6.31; 95% CI: 3.43 to 11.60; pxa0< 0.0001) and CT-ADP > 180xa0s (HR: 3.08; 95% CI: 1.62 to 5.81; pxa0=xa00.0005) as predictor of MLBCs.nnnCONCLUSIONSnMLBCs after transcatheter aortic valve replacement are frequent and associated with an increased morbidity and mortality. PVL and CT-ADP >180xa0s were identified as strong predictors for MLBCs. These findings stronglyxa0suggest that persistent HMW defects contribute to enhanced bleeding risk in patients with residual PVL.

Intramural atrial hematoma complicating transesophageal echocardiography during cardiac arrest

Background: Adequate strategies using either transthoracic (TTE) or transesophageal (TEE) echocardiography in patients receiving cardiopulmonary resuscitation (CPR) is an ongoing area of research. Objectives: As transthoracic point‐of‐care ultrasound (POCUS) during cardiac arrest resuscitation might result in an increased duration of interruptions in the delivery of chest compressions; the use of TEE has been proposed as an alternative. Methods: No technical complications of either TTE nor TEE are so far being reported in the literature. Results: We report the case of a left intramural atrial hematoma complicating TEE procedure during cardiac arrest. This highlights a unique and to our knowledge, first‐in‐man, described complicating TEE procedure during CPR. Conclusions: Further research on the safety of transesophageal echo during CRP is mandatory and the question about any potential harm of particular interest.

Antiplatelet Therapy in ACS Patients: Comparing Appropriate P2Y12 Inhibition by Clopidogrel to the Use of New P2Y12 Inhibitors

Aim: In percutaneous coronary intervention (PCI)-treated acute coronary syndrome (ACS) patients on clopidogrel therapy, high on-treatment platelet adenosine diphosphate (ADP) reactivity was observed in numerous studies, with significant increases in non-fatal myocardial infarction, definite/probable stent thrombosis, or cardiovascular mortality. Compared to clopidogrel, prasugrel and ticagrelor provide more potent platelet inhibition. Whether new P2Y12 inhibitors reduce thrombotic events in a similar manner compared to the rate observed with appropriate P2Y12 inhibition by clopidogrel must still be determined. This study sought to compare longterm outcomes between clopidogrel responders (platelet reactivity index [PRI] vasodilator-stimulated phosphoprotein [VASP] < 61%) and patients under prasugrel or ticagrelor therapy following PCI-treated ACS. Methods: 730 ACS patients undergoing urgent PCI were prospectively enrolled into two groups: clopidogrel responders (n = 448) and those under ticagrelor or prasugrel therapy (n = 282). The primary endpoint was a composite of cardiovascular death, myocardial infarction, stent thrombosis, and stroke; the secondary endpoint comprised major hemorrhagic events. Results: The median follow-up was 260 ± 186 days. Clopidogrel patients were older and more likely to present non-ST segment elevation myocardial infarction, cardiovascular risk factors, atrial fibrillation, or prior vascular disease. After propensity score matching, the primary endpoint was met in 7.1% of the clopidogrel group and 4.1% of the prasugrel/ticagrelor group (p = 0.43). Minor bleeding events were significantly reduced in the clopidogrel group (1.1% vs. 3%; p = 0.03). In a multivariate analysis, the antiplatelet treatment strategy was not an independent primary endpoint predictor. Conclusion: In PCI-treated ACS patients, clopidogrel therapy and PRI VASP < 61% were not associated with increased risks of thrombotic events compared to prasugrel or ticagrelor therapy.

Ventricular arrhythmias and sudden cardiac arrest in Takotsubo cardiomyopathy: Incidence, predictive factors, and clinical implications

BACKGROUNDnTakotsubo cardiomyopathy (TTC) is a stress-related transient cardiomyopathy. Life-threatening arrhythmias (LTA) can occur and worsen prognosis.nnnOBJECTIVEnThe purpose of this study was to assess the incidence and outcome of LTA in TTC, as well as its predictive factors and clinical implications.nnnMETHODSnWe studied 214 consecutive cases of TTC over 8 years. The study cohort was divided into 2 groups: those with LTA (LTA group) and those without (non-LTA group). LTA was defined as ventricular tachycardia, ventricular fibrillation, or cardiac arrest.nnnRESULTSnLTA occurred in 23 (10.7%) of patients mainly in the first 24 hours of hospitalization: ventricular tachycardia (n = 2), ventricular fibrillation (n = 11), cardiac arrest (n = 10: 5 asystole, 3 complete heart block, and 2 sinoatrial block). LTAs were associated with lower left ventricular ejection fraction (LVEF) and a high rate of conduction disturbances. In-hospital (39.1% vs 8.9%; Pxa0<xa0.001) and 1-year mortality (47.8% vs 14.1%; P < .001) rates were significantly increased in the LTA group. LVEF and QRS duration >105 ms were independent predictors of LTA. In cases where a device was implanted, conduction disturbances persisted after the index event despite complete recovery of LVEF. There was no ventricular arrhythmia recurrence during follow-up.nnnCONCLUSIONnLTAs occur early in patients presenting with TTC and are associated with significantly worse short- and long-term prognosis. Left ventricular impairment and QRS duration >105 ms are independent predictors of LTA. Ventricular arrhythmias occurred in the acute phase without further recurrence recorded in hospital survivors, whereas severe conduction disorders persisted during long-term follow-up. These findings may have implications on the choice of device therapy for this specific patient subgroup.

Chain pain following cardiac surgery in a 35-year-old man

Clinical introduction A 35-year-old man with multiple cardiovascular risk factors presented with a recent history of fever and acute heart failure. His initial echocardiogram showed evidence of severe aortic regurgitation due to ongoing infective endocarditis. Preoperative coronary angiography revealed no coronary abnormalities. Urgent aortic valve replacement was performed and a 29u2009mm St Jude mechanical valve was implanted. While blood and resected valvular tissue cultures were negative for bacteria, a PCR-based analysis revealed the presence of penicillin-sensitive Streptococcus pneumoniae. Echocardiographic follow-up study at day 3 showed excellent mechanical valve function with no persistent signs of endocarditis. Eight days after surgery, our patient presented with severe chest pain. The ECG is shown in figure 1A and coronary angiography was performed for diagnostic confirmation (figure 1B–D and online supplementary video 1). 10.1136/heartjnl-2018-313577.supp1 Supplementary file 1 Figure 1 (A) 12-lead ECG. (B, C) Selective angiogram of the left main, left anterior descending artery and circumflex artery. (D) Aortic root angiography. Question Which of the following is most likely the diagnostic? Occlusion of the left anterior descending coronary artery Dissection of the left anterior descending coronary artery Valsalva aneurysm presenting as an acute coronary syndrome Left anterior descending coronary artery spasm Left main coronary aneurysm

Giant ventricular pseudoaneurysm following inferior myocardial infarction: insights from multimodal imaging approach

An 85-year-old woman was referred to our institution because of inferior ST-segment elevation myocardial infarction (STEMI) with a moderate troponin peak of 10.88 lg/L (N < 0.04 lg/L). Angiographic data showed a two-vessel coronary artery disease with a proximal occlusion of the right coronary artery (RCA) and a complex highly calcified bifurcation stenosis involving the left anterior descending artery (LAD segment 2) and the ostium of the second diagonal branch. The patient underwent angioplasty of the infarct-related RCA. Decision was made to refer the patient within a month to our cath lab for secondary treatment of the LAD bifurcation lesion. The discharge TTE disclosed inferior wall akinesia, small basal inferior aneurysm, and normal left ventricular ejection fraction (LVEF). The patient was readmitted 17 days after discharge due to recurrent acute anterior STEMI and cardiogenic shock (severe left ventricular (LV) dysfunction with LVEF of 25% at the time of admission in the cath lab). Urgent coronary angiography was performed 4 h after symptoms onset and showed a complete occlusion of the proximal LAD, well above the bifurcation lesion. Percutaneous coronary intervention with stenting of the culprit lesion was performed, but revascularization of the bifurcation lesion was considered too high risk. Transthoracic echocardiography disclosed a large defect (8.5 mm) of the basal inferior wall (Figure 1A), with extension in to a pseudoaneurysm. A colour Doppler analysis (Figure 1B) showed shunt flows passing from the LV to the aneurysmal pouch. 2D and 3D maximum intensity projection (MIP) multiphasic cardiac CT images provided a non-invasive modality for the evaluation of the pseudoaneurysm. It helped to define the anatomy, size, course, relationship of the pseudoaneurysm and determine further therapeutic strategies. Cardiac CT revealed a giant pseudoaneurysm (31 47 mm) running the length of the right ventricle (Figure 2). The final diagnosis was cardiogenic shock related to recurrent anterior STEMI and the fast growing development of an inferior pseudoaneurysm.

Atrial arrhythmias in Takotsubo cardiomyopathy: incidence, predictive factors, and prognosis

AimsnTakotsubo cardiomyopathy (TTC) is a stress-related transient cardiomyopathy. It is unclear whether TTC is associated with poorer prognosis when atrial arrhythmia (AA), atrial fibrillation or flutter, occurs. The purpose of this study was to assess the incidence of AA in patients with TTC, predictive factors of AA, and its association with mortality.nnnMethods and resultsnWe studied 214 consecutive cases of TTC over 8u2009years. The study cohort was divided into two groups-those with newly diagnosed AA (AA-group) and those without (non-AA group). AA occurred in 24.8% of the patients. The AA group presented with lower left ventricular ejection fraction (LVEF) on admission and higher cardiac arrest rate. Admission and peak levels of troponin, B-type natriuretic peptide (BNP), C-reactive protein (CRP), and leucocytes were higher in the AA group. In-hospital, 30-day, cardiovascular, and all-cause mortality were significantly higher in the AA group. Independent predictors of newly diagnosed AA were troponin peak [odds ratio (OR) 1.03 (1.003-1.06); Pu2009=u20090.029], CRP peak [OR 1.006 (1.001-1.01); Pu2009=u20090.026], and LVEF on admission [OR 0.96 (0.93-0.99); Pu2009=u20090.01]. Newly diagnosed AA was not predictive of mortality. The BNP peak [OR 1.00 (1.000-1.001); Pu2009=u20090.022] and leucocytes peak [OR 1.095 (1.034-1.16); Pu2009=u20090.002] were predictive factors of in-hospital mortality. LVEF upon discharge [OR 0.935 (0.899-0.972); Pu2009=u20090.001] and leucocytes peak [OR 1.068 (1.000-1.139); Pu2009=u20090.049] were predictive of cardiovascular death.nnnConclusionnNewly diagnosed AA is frequently observed in patients presenting with TTC and is associated with poorer short- and long-term prognosis. Inflammation, myocardial damage, and LVEF are predictors of AA onset and cardiovascular mortality.