Laurent Schmutz

Prognostic Impact of Calcium Score after Transcatheter Aortic Valve Implantation Performed With New Generation Prosthesis

Calcium score (CS) is a well-known prognostic factor after transcatheter aortic valve implantation (TAVI) performed with first generation prosthesis but few data are available concerning new generation valves. The aim of this study was to evaluate if CS remains a prognostic factor after Sapien 3 and Evolut R valves implantation. Agatston CS was evaluated on multislice computed tomography before TAVI in 346 patients implanted with Sapien XT (n = 61), CoreValve (n = 57) devices, (group 1, n = 118), and with new generation Sapien 3 (n = 147), Evolut R (n = 81) prosthesis, (group 2, n = 228). Major adverse cardiovascular events and aortic regurgitation (AR) were evaluated at 1 month. The 2 groups were similar at baseline except for logistic Euroscore (20.1% in group 1 vs 15.0 % in group 2; p = 0.001), chronic renal failure (44.1% vs 37.2% respectively, p = 0.007) and preprocedural CS (4,092 ± 2,176 vs 3,682 ± 2,109 respectively, p = 0.022). In group 1, 28 patients (23.7%) had adverse clinical events vs 21 (9.2%) in group 2 (p <0.01). In multivariate analysis, a higher CS was predictive of adverse events in group 1 (5,785 ± 3,285 vs 3,565 ± 1,331 p <0.0001) but not in group 2 (p = 0.28). A higher CS was associated with AR in group 1 (6,234 ± 2711 vs 3,429 ± 1,505; p <0.001) and in patients implanted with an Evolut R device from group 2 (4,085 ± 3,645 vs 2,551 ± 1,356; p = 0.01). In conclusion, CS appears as an important prognostic factor of major events after TAVI with first generation valves but not with new generation devices. CS remains associated with AR only with new generation self-expandable Evolut R devices.

0022 : Transcatheter aortic valve implantation without intensive care unit admission

Objectives The aim of the study was to evaluate feasibility and safety of transcatheter aortic valve implantation (TAVI) performed without subsequent intensive care unit (ICU) admission using simple clinical, ECG and echocardiographic criteria. Methods We included prospectively 177 consecutive patients who underwent TAVI in our center. Low-risk patients, admitted to conventional cardiology unit, had stable clinical state, LVEF > 40%, transfemoral access, no right bundle branch block (RBBB), permanent pacing with self-expandable valve and no complication during the procedure. High-risk group included other patients who were transferred to ICU. The primary endpoint concerned in-hospital events (VARC-2 criteria). Results Mean age of patients was 83.5±6.5 years and mean logistic Euroscore was 14.6±9.7%. The balloon expandable SAPIENS 3 valve was mainly used (n=148; 83.6%), mostly with transfemoral access (n=167; 94,4%). Among the 61 patients (34.5%) included in the low-risk group, only 1 (1.6%) had a minor complication (NPV: 98.4%; 95% CI: 0.91-0.99). Conversely, 47 patients (40.5%) from the high-risk group had clinical events (PPV: 40.5%; 95% CI: 0.31-0.50), mainly conductive disorders requiring pacemaker (n=26; 22.4%). In multivariate analysis, RBBB (OR: 14.1; 95% CI: 3.5-56.3), use of self-expandable valve without pacemaker (OR: 5.5; 95% CI: 2-16.3), vitamin K antagonist treatment (OR: 3.8; 95% CI: 1.1-12.6) and female gender (OR: 2.6; 95% CI 1.003-6.9) were pre-procedural predictive factors of in-hospital adverse events. Conclusions Our results suggested that TAVI can be performed safely without ICU admission in selected patients. This strategy may optimize efficiency and cost-effectiveness of the procedure. The author hereby declares no conflict of interest Table . In hospital major adverse events in the two groups of patients. Post TAVI adverse events Low risk group (n=61; 34.5%) High risk group (n=116: 65.5%) Death (n=1; 0.6%) 0 1 (0.9%) Acute pulmonary oedema (n=1; 0.6%) 0 1 (0.9%) New high conductive disorder (n=36; 20.2%) 0 36 (31%) Permanent pacing requiring (n=26; 14.7%) 0 26 (22.4%) Major vascular complication (n=1; 0.6%) 0 1 (0.9%) Pericardial effusion requiring medical intervention (n=2; 1.2%) 0 2 (1.8%) Acute kidney injury (Akin 2 or 3) (n=3; 1.8%) 0 3 (2.7%) Secondary transfer to ICU (n=1) (pericardial effusion) 1 (1.6%) Total of patient with at least one complication (n=48; 27.1%) 1 (1.6%) 47 (40.5%)

Optical Coherence Tomography Evidence of Spontaneous Healing of an Intramural Coronary Hematoma

A 57-year-old woman with no cardiovascular risk factors was admitted to our institution for noneST-elevation myocardial infarction. An admission electrocardiogram showed inverted negative T waves and a significant elevation of ultrasensitive troponin. A transthoracic echocardiogram showed severe apical hypokinesia with a 45% left ventricular ejection fraction. A coronary angiogram revealed a nonsignificant lesion of the mideleft anterior descending artery (Fig. 1A) without other lesions. Optical coherence tomography (OCT) confirmed an extensive left anterior descending hematoma without intimal tear (Fig. 1, B and C). No angioplasty was proposed given its location and extension. Angiographic (Fig. 1D) and OCT controls (Fig. 1, E and F) were obtained at 1 year and showed the complete healing of coronary hematoma. Intramural coronary hematoma has been reported to be a very rare cause of acute coronary syndrome and is often

0098: One year incidence and clinical impact of bleeding outcomes in STEMI patients treated by prasugrel or clopidogrel in real life: the BLEED-MI study

Purposes The aim of this study was to evaluate one-year incidence of bleeding events and their impact on compliance in patients admitted for ST Elevation Myocardial Infarction (STEMI) and treated by prasugrel or clopidogrel in « real-world ». Methods Patients admitted for a STEMI were treated by either clopidogrel or prasugrel according to the physician with respect of guidelines. The primary endpoint was the first occurrence of bleeding events within 12 months assessed by the Bleeding Academic Research Consortium (BARC) classification using a dedicated questionnaire focused on bleeding events. Topography bleedings, causes of premature cessation and ischemic events were also compared. Results 390 patients were enrolled, 211 in prasugrel group and 179 in clopidogrel group. Patients in the prasugrel group were younger, with higher body weight and were more frequently men. At 12 months, a bleeding complication occurred in 40% of patients regardless of its severity or treatment prescribed. Major bleedings (BARC 3) were significantly lower with prasugrel than clopidogrel (1% versus 6%, p=0.001). Minimal bleedings (BARC 1) were more frequent in clopidogrel group than prasugrel group (respectively 27% and 18%; p=0.05). However BARC 2 bleedings occurred more often in prasugrel group (14% versus 6%, p=0.01) (figure). Subcutaneous and gastrointestinal haemorraghes were the most frequent. Over one-year, the rate of cessation was 18% in the prasugrel group and only 10% in the clopidogrel group (p=0.04). Respectively for prasugrel and clopidogrel, rates of recommend discontinuation were 10% and 4% (p=0.02) and of disruption were 8% and 5% (p=0.3). Despite more frequent discontinuation, mortality remains very low in the prasugrel group (0.5% versus 7%, p=0.0003). Conclusion In real-world, in a low bleeding risk population, the rate of major bleedings with prasugrel at 12 months was low but nuisance bleedings were frequent with significant impact on premature cessation Download : Download full-size image Abstract 0098 – Figure: 12 months bleedings classification

Évolution des stents pharmacoactifs

L’intervention coronarienne percutanee (ICP) a ete introduite dans les annees 1970 et le premier stent metallique nu (Bare-Metal Stent, BMS) a ete implante par le Pr Jacques Puel en 1986. Les stents a elution de medicaments ( drug-eluting stent, DES) ont ete developpes pour lutter contre la restenose rencontree avec les stents nus. L’arrivee des stents actifs a permis une importante reduction de la restenose intrastent mais, de maniere parallele, une augmentation des thromboses de stent tres tardives a ete observee avec la premiere generation de stents actifs. L’arrivee des stents actifs « nouvelle generation » avec amelioration des plateformes mais aussi des polymeres (biocompatibles ou resorbables) a permis une amelioration des resultats cliniques notamment une reduction des thromboses de stent tres tardives permettant d’envisager une reduction de la duree de la bitherapie antiplaquettaire a 6 mois pour l’angioplastie elective. Dans le meme temps, les stents integralement bioresorbables sont maintenant disponibles, mais ne peuvent pas etre proposes dans toutes les situations cliniques.

075 - Identification of patients at risk for premature discontinuation of oral antiplatelet therapy after elective percutaneous coronary intervention

Background Premature discontinuation of antiplatelet therapy is a major risk factor of stent thrombosis after drug-eluting stent placement leading to an increased risk of death. Objectives We sought to determine by a simple questionnaire the prevalence of patients at risk for premature discontinuation of oral antiplatelet therapy in elective percutaneous coronary intervention (PCI). Methods Patients scheduled for elective PCI underwent a routine interview (RI) and a specific questionnaire (SQ) by two independent physicians the day before the intervention. The SQ was designed to identify bleeding disorders, suspected cancer, planned invasive procedures and self evaluation of compliance. The final decision of drug eluting stent (DES) implantation was made by a third independent physician who performed the planned PCI and who had full access to the patient record. Results At least one contraindication to DES implantation was found in one third of the study population (82/302, 27%) after the RI. All these patients were also identified by the SQ. At total of 31 additional patients were identified by the SQ as non eligible for DES implantation. Active bleeding (n = 14) and scheduled biopsies (n = 4) were the two main contraindications to DES implantation isolated by the SQ. Patients characteristics and angiographic findings identified 59.9% patients (n = 181/302) eligible for a DES implantation. Finally the physician performing the PCI excluded 66.3% of the patients (n = 79/302) who could receive a DES and implanted a bare metal stent (BMS) instead. This decision was based on the findings of the dedicated questionnaire on top of the interview in 30 patients (38%) and in 49 patients (62%) for other reasons. Conclusions In elective PCI, a simple questionnaire used before DES implantation can improve identification of patients at high risk for premature discontinuation of antiplatelet therapy.