Jean-François Piéchaud

A randomized comparison of direct stenting with conventional stent implantation in selected patients with acute myocardial infarction

OBJECTIVESnWe sought to determine whether direct stenting might prevent the adverse events associated with stent implantation during primary angioplasty and to compare it with conventional stent implantation in patients with acute myocardial infarction (AMI).nnnBACKGROUNDnNo trial has demonstrated that stents favorably influence mortality rate. Recent studies have even suggested a negative impact of stents on coronary blood flow and clinical outcome.nnnMETHODSnOf 409 patients treated by primary angioplasty with stent implantation in our center, 206 (50%) were enrolled in this randomized, single-center trial and allocated to direct stent implantation (n = 102) or stent implantation after balloon pre-dilation (n = 104). The study end points included angiographic results (final corrected Thrombolysis In Myocardial Infarction [TIMI] frame count and a composite end point of slow and no-reflow or distal embolization), an electrocardiogram marker of myocardial reperfusion assessment (ST-segment resolution) and in-hospital clinical outcome (death and recurrent infarction).nnnRESULTSnDirect stent implantation failed in eight patients but succeeded after pre-dilation in all. A non-significant increase in TIMI flow grade 3 was achieved after direct stenting (95.1% vs. 93.3%, p = 0.74) without significant difference in the corrected TIMI frame count (31.5 +/- 17 and 35.2 +/- 20 frames after direct and conventional stent, respectively, p = 0.42). The composite angiographic end point was significantly reduced by direct stent implantation (11.7% vs. 26.9%, p = 0.01). ST-segment resolution was also significantly improved after direct stent (no ST-segment resolution in 20.2% vs. 38.1% after direct and conventional stent, respectively, p = 0.01). Death and/or recurrent infarction occurred in six patients after conventional stent implantation and in two patients after direct stenting (p = 0.28).nnnCONCLUSIONSnIn selected patients with AMI, direct stenting can be applied safely and effectively. This strategy may result in a significant reduction of microvascular injury, as suggested by improved ST-segment resolution after reperfusion with major potential clinical consequences.

Coronary Artery Obstruction After the Arterial Switch Operation for Transposition of the Great Arteries in Newborns

OBJECTIVESnWe sought to describe a large series of coronary artery obstructions after the arterial switch operation for transposition of the great arteries and to discuss their clinical implications.nnnBACKGROUNDnAortic root angiography and myocardial perfusion imaging yield ambiguous results regarding the fate of the coronary artery anastomoses after the arterial switch operation. Late death related to coronary artery obstruction and growth of the translocated coronary arteries are of major concern in these patients.nnnMETHODSnSelective coronary artery angiography was performed prospectively in a total of 165 children.nnnRESULTSnA total of 12 coronary occlusions, 8 major stenoses, 6 minor stenoses of the left ostium and 4 stretchings of one coronary artery were identified. Obstructions were more frequent in types D and E (p < 0.001) of the Yacoub and Radley-Smith classification. Coronary obstruction was documented in all patients with electrocardiographic and ultrasound evidence of myocardial ischemia at time of study. Early postoperative ischemia did not predict coronary artery lesion if the patient had fully recovered. Persistent or delayed myocardial ischemia was highly predictive of coronary artery lesions. The incidence of coronary artery obstruction was very high (11 of 35) in patients operated on by a rapidly abandoned technique of single-orifice reimplantation of both coronary artery ostia.nnnCONCLUSIONSnSelective coronary angiography is the most accurate means to assess coronary artery obstruction after the arterial switch operation. Precise diagnosis of coronary artery lesions after this operation will help to elucidate the pathogenesis, develop adequate therapeutic strategies and might indicate how to prevent coronary complications after operation.

Balloon valvotomy for critical stenosis or atresia of pulmonary valve in newborns

OBJECTIVESnPercutaneous balloon valvotomy was studied retrospectively in newborns with critical pulmonary valve stenosis or atresia to assess its potential role as an alternative therapy to operation.nnnBACKGROUNDnSevere right ventricular outflow tract obstructions are life-threatening conditions requiring prostaglandin infusion immediately after birth and then relief of the valvular obstruction. To avoid surgical hazards at this age, it would be useful to extend to newborns the balloon valvotomy so effective in older patients.nnnMETHODSnNinety-seven newborns (82 with critical pulmonary valve stenosis, 15 with atresia) underwent balloon valvotomy, provided that they had a well developed right ventricle, including an infundibulum close to the pulmonary artery. In patients with atresia, the outflow tract membrane had to be perforated with a wire needle or a radiofrequency probe.nnnRESULTSnBalloon valvotomy could be performed in 81 patients and was effective in 77. It caused 3 fatal and 16 nonfatal complications. Ten patients with persistent poor right ventricular compliance despite an effective valvotomy required a surgical shunt. Among the 81 patients in whom the procedure could be performed, right ventricular surgery was avoided in 5 (55%) of the 9 patients with atresia (95% confidence interval [CI] 28% to 80%) and 55 (76%) of the 72 patients with stenosis (95% CI 66% to 86%) at the end of the follow-up period (9.7 years).nnnCONCLUSIONSnBalloon pulmonary valvotomy is not always feasible in newborns, but it is relatively safe and effective and should be considered a valid alternative to operation.

Percutaneous balloon valvuloplasty in neonates with critical aortic stenosis

Percutaneous balloon valvuloplasty was attempted in 10 newborn infants with critical aortic valve stenosis and severe congestive heart failure. Three had a very small left ventricle and aortic anulus. In one infant, the aortic valve could not be passed, and in another infant, a technical error resulted in severe valvular damage, aortic insufficiency and death. Among the eight patients who had effective dilation, the stenosis was relieved in seven as assessed by a significant decrease in transvalvular pressure gradient, improvement of left ventricular contraction and eventual inversion of the ductal shunting. The procedure failed in the only patient whose dilation was performed with an undersized balloon. Aortic insufficiency occurred in three infants and was severe (perforated cusp) in one, moderate in one whose valve was dilated with an excessively large balloon and mild and transient in one. None of the three infants with a very small left ventricle recovered (two died and one underwent cardiac transplantation). Among the seven infants with a left ventricle of acceptable size, three underwent subsequent aortic valvotomy; one of these died and two bad good results. The remaining four are doing well 16 +/- 5 months later (mean +/- SD) with mild to moderate residual aortic stenosis and normal left ventricular function. In conclusion, percutaneous balloon valvuloplasty is an acceptable alternative to surgery in neonates with critical aortic valve stenosis. Incidence of complications and good relief of the obstruction depend on a careful technique. Immediate results are similar to those of surgery. Late prognosis depends on the quality of the left heart structures.

Endomyocardial biopsies for early detection of mitochondrial disorders in hypertrophic cardiomyopathies

Considering the high proportion of unexplained hypertrophic cardiomyopathies on the one hand and the occurrence of cardiomyopathies in several mitochondrial disorders on the other, we hypothesized that isolated hypertrophic cardiomyopathies in infancy could occasionally be the result of defects of oxidative phosphorylation. By means of a scaled-down technique, we were able to investigate oxidative phosphorylation on minute amounts of endomyocardial tissue (1 mg) in three patients with concentric hypertrophic cardiomyopathy (shortening fraction in diameter, 18% to 27%; normal mean +/- 1 SD, 33 +/- 3%) and in control subjects. Although the absolute respiratory chain enzyme activities in the endomyocardial biopsy specimens of the patients were within the low normal range, the determination of the activity ratios allowed us to ascribe hypertrophic cardiomyopathies to respiratory chain enzyme abnormalities in all three cases (complex I, two cases; multiple enzyme deficiency, one case). The respiratory chain enzyme activity ratios, which are normally constant irrespective of the tissue tested, were markedly abnormal in all three patients (cytochrome c oxidase/reduced nicotinamide-adenine dinucleotide cytochrome c reductase, 4.6 to 10.4; normal mean +/- 1 SD, 2.9 +/- 0.5). We conclude that mitochondrial disorders should be regarded as potential causes of hypertrophic cardiomyopathy in early infancy. Because cardiac catheterization is routinely performed for hemodynamic investigation of cardiomyopathies, we suggest that endomyocardial biopsies be considered as a tool for early detection of mitochondrial cardiomyopathies, especially in hypertrophic forms of the disease.

Melody® transcatheter pulmonary valve implantation: Results from a French registry

BACKGROUNDnPercutaneous implantation of pulmonary valves has recently been introduced into clinical practice.nnnAIMnTo analyse data of patients treated in France between April 2008 and December 2010.nnnMETHODSnProspective, observational, multi-centric survey by means of a database registry of the Filiale de cardiologie pédiatrique et congénitale.nnnRESULTSnSixty-four patients were included, with a median (range) age of 21.4 (10.5-77.3) years. The majority (60.9%) of the patients were New York Heart Association (NYHA) class II. The most common congenital heart disease was tetralogy of Fallot with or without pulmonary atresia (50%). Indication for valve implantation was stenosis in 21.9%, regurgitation in 10.9% and association of stenosis and regurgitation in 67.2%. Implantation was successful in all patients. Pre-stenting was performed in 96.9% of cases. Median (range) procedure time was 92.5 (25-250) minutes. No significant regurgitation was recorded after the procedure, and the trans-pulmonary gradient was significantly reduced. Early minor complications occurred in five cases (7.8%). Three patients died during a median follow-up of 4.6 (0.2-5.2) years, two from infectious endocarditis and one from end-stage cardiac failure. Surgical reintervention was required in three patients. Follow-up with magnetic resonance imaging demonstrated significant improvements in right ventricular volumes and pulmonary regurgitation in mixed and regurgitant lesions.nnnCONCLUSIONSnTranscatheter pulmonary valve implantation is highly feasible and mid-term follow-up demonstrates sustained improvement of right ventricular function. Late endocarditis is of concern, therefore longer follow-up in more patients is urgently needed to better assess long-term outcome.nnnCLINICAL TRIAL REGISTRATIONnNCT01250327.

Significant persistent ductus arteriosus in infants less or equal to 6 kg: percutaneous closure or surgery?

BACKGROUNDnPercutaneous closure of large persistent ductus arteriosus using the Amplatzer duct occluder is an alternative to surgery. However, this device is not recommended in infants weighing less than 6 kg.nnnAIMnTo evaluate the safety and effectiveness of this procedure in low-body-weight infants.nnnMETHODSnWe reviewed retrospectively data for infants weighing less or equal to 6 kg who underwent percutaneous closure of significant persistent ductus arteriosus using the Amplatzer duct occluder in France between 1998 and 2007.nnnRESULTSnData for 58 patients (mean weight: 5 kg, range: 3.4-6; mean age: 5.5 months, range: 2.1-15.3) were reviewed. Mean angiographic persistent ductus arteriosus minimal diameter was 3.7 mm (range: 1-7.5). Implantation of the Amplatzer duct occluder was successful in 89.7% of cases. In six (10.3%) patients, the device was not implanted because it would have led to significant aortic obstruction. One procedure-related death occurred in a 4 kg infant (1.7%). Major and minor complications occurred in 6.9 and 31.0% of patients, respectively. Persistent ductus arteriosus diameter greater than 3.7 mm, type C (tubular shape) and diameter/patient weight ratio greater than 0.91 were significantly associated with an unsuccessful procedure and/or major complications. During a median 10-month follow-up, no late device embolization occurred.nnnCONCLUSIONSnAlthough percutaneous closure of significant persistent ductus arteriosus with the Amplatzer duct occluder is effective in low-body-weight infants, the level and severity of complications indicate surgery as first-line treatment, at least until further studies are done to assess the safety and effectiveness of the new Amplatzer duct occluder II in low-body-weight infants.

Assessment of left ventricular ejection fraction using the wall motion score index in cardiac magnetic resonance imaging.

BACKGROUNDnLeft ventricular ejection fraction (LVEF) is an important indicator of left ventricular function and of the severity and prognosis of ischaemic heart disease. Assessment of regional function using the wall motion score index (WMSI) is an alternative means of evaluating left ventricular function.nnnAIMnWe attempted to evaluate LVEF by a method using the WMSI with cardiac magnetic resonance imaging (MRI).nnnMETHODSnOne hundred and twenty-two patients referred for evaluation of heart disease had rest WMSI evaluation by cardiac MRI. The WMSI was evaluated using the 16-segment model and score proposed by the American Society of Echocardiography. In our first group of 80 patients, a correlation between WMSI and cardiac MRI LVEF was established and a regression equation was derived. This regression equation was then used in 42 consecutive patients to compare WMSI LVEF with the gold standard MRI LVEF.nnnRESULTSnIn the first 80 patients, MRI LVEF and WMSI correlated very well (r=0.93). Similarly, in the second group of 42 patients, WMSI LVEF derived from the regression equation correlated very well with MRI LVEF (r=0.94).nnnCONCLUSIONnAn objective evaluation of LVEF can be easily made using the WMSI with cardiac MRI, which correlates very well with standard MRI planimetric methods.

Stenting in paediatric and adult congenital heart diseases: A French multicentre study in the current era

BACKGROUNDnMany stents are used off-label during the management of congenital heart diseases (CHD).nnnAIMSnTo describe indications for, results of, and adverse events associated with stenting in CHD in current practice.nnnMETHODSnParticipation in this study was proposed to all catheterization laboratories that specialize in CHD in France (M3C network). All paediatric and adult CHD cases with stent implantation in 2013 were included retrospectively.nnnRESULTSnOverall, 207 stents were implanted in 151 patients across 11 centres. Median age was 13.7 years (range, 5 days to 70.1 years). Main procedure indications were branch pulmonary artery angioplasty (n=46, 29.1%), aortic (re)coarctation stenting (n=43, 27.2%), percutaneous pulmonary valve implantation (n=32, 20.2%) and ductus arteriosus stenting (n=14, 8.9%). The main stents implanted were the CP Stent™ (n=61, 29.5%), the Max™ LD stent (n=43, 20.8%), the Valeo(®) stent (n=28, 13.5%) and valved stents (n=30, 14.5%). Procedures were considered successful in 96.8% of cases (95% confidence interval [CI] 92.8-99.0%). Adverse events were observed in 23 procedures (14.7%, 95% CI 9.5-21.0%). Ductus arteriosus stenting (odds ratio 12.4, 95% CI 2.0-77.5; P<0.01) and pulmonary revalvulation (odds ratio 5.9, 95% CI 1.1-32.3; P=0.04) were risk markers for stent-related adverse events.nnnCONCLUSIONSnStents are used in various CHD catheterization procedures, from infancy to adult age. The adverse events rate is significant and is related to the type of procedure.

Sinus of Valsalva Rupture: Percutaneous Closure With Real-Time 3-Dimensional Echocardiography

rom the Institut ardiovasculaire Paris Sud, ôpital Jacques Cartier, assy, France. anuscript received ecember 10, 2009; revised anuscript received anuary 12, 2010, accepted anuary 12, 2010. An asymptomatic 23-year-old man was noted to have a harsh pansystolic murmur on examination. Transthoracic echocardiography revealed a ruptured sinus of Valsalva (SOV), which was confirmed on transesophageal echocardiography (TEE) (A, Online Video 1). The relation between the rupture, right atrium (RA), and aortic valve (Ao) can be clearly seen (B, Online Videos 2 and 3). Using fluoroscopic and real-time 3-dimensional TEE guidance, the defect was closed with an Amplatzer septal closure device (C and D, arrows, Online Videos 4, 5, 6, 7, 8, and 9). This case demonstrates the utility of real-time 3-dimensional TEE in assisting the diagnosis and percutaneous treatment of cardiac defects. Sinus of Valsalva rupture is rare (1). Untreated, it carries a risk of development of right ventricular (RV) overload and pulmonary hypertension. Aneurysms arising from the right coronary sinus are the most common, and usually extend and rupture into the right-side heart chambers (1). LA left atrium. ublished by Elsevier Inc. doi:10.1016/j.jacc.2010.01.074