H. Le Breton

Pacemaker lead infection: echocardiographic features, management, and outcome.

Objective To compare transthoracic and transoesophageal echocardiography (TTE, TOE) in patients with permanent pacemaker lead infection and to evaluate the safety of medical extraction in cases of large vegetations. Methods TTE and TOE were performed in 23 patients with definite pacemaker lead infection. Seventeen patients without previous infection served as a TOE reference for non-infected leads. Results TTE was positive in seven cases (30%) whereas with TOE three different types of vegetations attached to the leads were visualised in 21 of the 23 cases (91%). Of the 20 patients with vegetations and lead culture, 17 (85%) had bacteriologically active infection. Left sided valvar endocarditis was diagnosed in two patients. In the control group, strands were visualised by TOE in five patients, and vegetations in none. Medical extraction of vegetations ⩾u200910 mm was performed in 12 patients and was successful in nine (75%) without clinical pulmonary embolism. After 31.2 (19.1) months of follow up (mean (SD)), all patients except one were cured of infection; three died from other causes. Conclusions Combined with bacteriological data, vegetations seen on TOE strongly suggest pacemaker lead infection. Normal TTE examinations do not exclude this diagnosis because of its poor sensitivity. Medical extraction of even large vegetations appeared to be safe.

Isolated left main coronary artery stenosis: long term follow up in 106 patients after surgery

Objective: To analyse the long term prognosis in patients with isolated stenoses of the left main coronary artery (LMCA) following surgical revascularisation. Patients: 106 patients (71 men and 35 women, mean age 61 years) were operated on between 1982 and 1998. Before surgery, 103 patients presented with angina pectoris and only 10 had a history of myocardial infarction. Their mean left ventricular ejection fraction was 62%. Stenoses were localised on the LMCA ostium in 19 patients, a subgroup characterised by a high proportion of women (68%). Three patients presented with chronic LMCA occlusion. Forty six patients were operated on as an emergency. The mean (SD) number of grafts per patient was 2.0 (0.5), and only one patient had no left anterior descending (LAD) coronary artery bypass. Bypass of the LAD using the internal thoracic artery was performed in 88 cases. Results: Early postoperative mortality was 4.7% and the five year survival was 86.8%. Late mortality occurred in nine cases, and in three of these it was linked to a coronary condition. Of the 92 long term survivors, 81.5% were totally symptom-free and 77% of those of working age were able to resume work. The postoperative outcome of patients with isolated ostial LMCA stenosis did not differ significantly from that of the other patients. Conclusions: The postoperative prognosis of isolated LMCA stenosis appears good in terms of mortality and symptoms.

Randomised comparison of coronary stenting with and without balloon predilatation in selected patients

BACKGROUND The SWIBAP (stent without balloon predilatation) prospective randomised trial was designed to compare direct coronary stenting with stenting preceded by lesion predilatation with an angioplasty balloon. OBJECTIVE To determine the feasibility and safety of direct stenting in non-complex coronary lesions in a prospective study. PATIENTS AND DESIGN All patients <u200976 years of age scheduled to undergo angioplasty of a non-complex, non-calcified lesion in a coronary artery of >u20093.0u2009mm, who granted their informed consent, were randomised into the trial. In group I, the stent was placed without balloon predilatation, while in group II stent implantation was preceded by balloon predilatation. The primary end point was the angiographic result according to procedure assigned by randomisation. An intravascular ultrasound substudy was performed in 60 patients. RESULTS Stent implantation was successful without predilatation in 192 of the 197 group I patients (97.5%), and with predilatation in 197 of the 199 group II patients (99%) (NS). No in-hospital stent thrombosis or death occurred. Overall procedural times, fluoroscopy times, and volumes of contrast agent given (mean (SD)) in group I v group II were 23.50 (13.54) min v 27.96 (15.23) min (pu2009=u20090.002), 6.04 (4.13) min v 6.67 (3.65) min (NS), and 135 (65)u2009ml v 157 (62)u2009ml (pu2009<u20090.001), respectively. No major adverse cardiovascular events had occurred by 30 days. CONCLUSIONS The feasibility and safety of direct stenting of selected and non-complex coronary lesions is confirmed. This technique was as successful as the conventional approach and was associated with a minor reduction in fluoroscopic exposure and procedure time and the administration of less contrast agent.

Position paper of French Interventional Group (GACI) for TAVI in France in 2018

Aortic stenosis is a frequent disease in the elderly. Its prevalence is 0.4% with a sharp increase after the age of 65, and its outcome is very poor when the patient becomes symptomatic. The interventional procedure known as TAVI (trans-catheter aortic valve implantation), which was developed in France and carried out for the first time in Rouen by Prof. Alain Cribier and his team in 2002, has proven to be a valid alternative to surgical aortic valve replacement. At first, this technique was shown to be efficient in patients with contra-indications to surgical treatment or deemed to be at high surgical risk. Given the very promising outcomes achieved as a result of close heart team collaboration, appropriate patient selection, simplified procedures and reduced complication rates, transfemoral (TF) TAVI is now preferred in symptomatic intermediate risk patients>75 years old according to the latest ESC guidelines. In 2017, in France, TAVI is currently performed in 50 centers with on-site cardiac surgery. The 2016 TAVI outcomes recorded in the French national TAVI registry (France TAVI) are very encouraging and show that for 7133 patients treated (age 83.4±7 years, logistic Euroscore 14%), 87% of whom via the TF approach, cross-over to surgery was very low (0.5%) with a 3.0% in-hospital mortality rate. The substantial increase in TAVI indications and the improvement of its outcomes may in the near future call for a reconsideration of the number of high volume centers authorized to carry out this technique.

Prognostic implications of pulmonary hypertension in patients with severe aortic stenosis undergoing transcatheter aortic-valve implantation: study from the FRANCE 2 registry

Aims: Pulmonary hypertension (PH) is associated with poor prognosis in patients with severe aortic stenosis (AS). The aim of this multicentre study was to describe clinical outcome after transcatheter aortic-valve implantation (TAVI).nnMethods: The FRANCE 2 registry included all patients undergoing TAVI in France in 2010 and 2011. Patients were divided into 3 groups depending on pre-TAVI systolic pulmonary artery pressure (sPAP) estimated in transthoracic echocardiography: group I, sPAP 60 mmHg (severe PH). Patients were followed up for 1 year.nnResults: 2,435 patients whose pre-TAVI sPAP was reported were included. 845 were in group I (34.7%), 1,112 in group II (45.7%) and 478 in group III (19.6%). Procedural success, early complications and 30-day mortality were statistically similar across sPAP groups. 1-year mortality was higher in groups II and III (group I, 21.6%; group II, 27.8%; group III, 28.4%; p=0.032). Mild-to-moderate and severe PH was identified as an independent factor of all-cause mortality. The major adverse cardiovascular event rates did not differ according to sPAP. NYHA functional class improved significantly in all groups.nnView this table:nnTable 1. Events at 1 yearnnnnnnConclusion: PH (sPAP > 40 mmHg) in AS patients undergoing TAVI was associated with increased 1-year mortality especially when severe (sPAP > 60 mmHg) but not with increased 30-day mortality, and functional status was significantly improved.

Opacification d'une veine coronaire lors d'une angiographie ventriculaire gauche avec myographie accidentelle chez une femme de 78 ans porteuse d'un rétrécissement aortique serré

Resume Dans le cadre du bilan dune dyspnee deffort NYHA II, un retrecissement aortique calcifie et serre est decouvert chez une patiente de 78xa0ans. La surface valvulaire aortique fonctionnelle est evaluee a 0,75xa0cm2 a lechocardiographie et il est par ailleurs note dimportantes calcifications mitrales non stenosantes ainsi quune forte hypertrophie ventriculaire gauche. Lors du bilan angiocoronarographique la valve aortique est franchie assez difficilement a laide dun guide droit sur lequel est descendue une sonde pig-tail. Lors de langiographie ventriculaire gauche, un aspect de myographie est observe avec opacification de la veine coronaire interventriculaire posterieure se drainant dans le sinus coronaire. La patiente est restee strictement asymptomatique pendant tout lexamen et les suites ont ete tres simples, sans epanchement pericardique ni nouvelle anomalie parietale du ventricule gauche. La patiente beneficiera quelques semaines plus tard dun remplacement valvulaire aortique sans complication.

Large fistula between right coronary artery and right atrium in a 50 year old asymptomatic woman

A 50 year old asymptomatic woman without prior medical history was found to have a continuous murmur, which was loudest in the lower right parasternal region. Her physical examination and standard ECG were normal. Transthoracic echocardiography revealed mild right ventricular dilatation, with …