Nicolas Combaret

Invasive management without stents in selected acute coronary syndrome patients with a large thrombus burden: a prospective study of optical coherence tomography guided treatment decisions

AIMS To assess whether a strategy of invasive management without stents in selected acute coronary syndrome (ACS) patients with a large thrombus burden (LTB) might be feasible and safe. METHODS AND RESULTS We performed a prospective non-randomised observational cohort study of invasive treatment decisions guided by optical coherence tomography (OCT) in selected ACS patients with LTB. Among 852 ACS patients who had undergone invasive coronary angiography, 101 (11.8%) patients with large thrombus burden on initial angiography underwent thrombectomy to restore TIMI 3 flow without stenting. All of these patients then had repeat angiography with OCT (days 0-2 [Group 1], days 3-6 [Group 2] or days 7-30 [Group 3]). No adverse events occurred between the initial and second angiograms. Residual thrombus was detected in 68% of patients with OCT (respectively, 94%, 79% and 32% in Group 1, Group 2 and Group 3), and 20% of cases with angiography. Plaque rupture was detected by OCT in 65% of cases. Minimal lumen area was 2.81 mm2, 3.40 mm2 and 4.89 mm2 in Group 1, Group 2 and Group 3, respectively. Sixty-two percent of patients were stented (respectively, 76%, 61% and 50%). During a minimum follow-up period of 12 months in all patients, one non-fatal MI occurred and one PCI was performed for angina. CONCLUSIONS Medical management without stents is safe and feasible in selected ACS patients with LTB. OCT revealed culprit lesion characteristics that were not disclosed by angiography and facilitated treatment decisions.

Very late stent thrombosis related to incomplete neointimal coverage or neoatherosclerotic plaque rupture identified by optical coherence tomography imaging

AIMS Recent data have reported that neoatherosclerosis could develop long after stent implantation and lead to subsequent rupture and acute coronary syndrome (ACS). We sought to identify the presence of in-stent neoatheroma (ISNA) in patients with very late stent thrombosis (VLST) using optical coherence tomography (OCT). METHODS AND RESULTS All patients from two catheterization centres who presented with ACS related to VLST underwent a standard coronary angiography and intra-coronary OCT. ISNA was defined as the combination of diffuse neointimal proliferation, lipid-laden intima with plaque organization, and fibrous cap rupture with no evidence of an uncovered strut. Out of 2139 ACS patients, 20 presented with definite VLST, including 10 with evidence of ISNA lesions, detected using OCT. The mean delay between initial percutaneous coronary intervention and VLST was longer in the ISNA patients compared with non-ISNA patients (10.5 ± 1.6 vs. 4.0 ± 0.6 years, P = 0.003). The mean LDL-cholesterol tended to be higher in ISNA patients compared with non-ISNA patients. OCT analysis revealed significantly thicker neointimal coverage as well as a lower number of uncovered struts in ISNA lesions compared with the other patients. LDL-cholesterol levels were correlated with the average neointima thickness (Spearmans rho = 0.46, P = 0.04). All the ISNA lesions were treated through initial thrombectomy followed by redo stenting in nine patients. CONCLUSION Our data show that ISNA is frequent in patients with VLST. These results suggest that OCT imaging is helpful in identifying the underlying mechanisms of VLST and, therefore, in the clinical decision-making process.

Coronary Artery Fenestration Guided by Optical Coherence Tomograhy Before Stenting New Interventional Option in Rescue Management of Compressive Spontaneous Intramural Hematoma

A 46-year-old woman, with a medical history of 7 hormonal stimulation attempts for in vitro fertilization in the past 2 years and moderate smoking, presented at the emergency department during the first hour of chest pain. ECG showed ST-segment–elevation myocardial infarction in anterior derivations. Emergency coronary angiography did not show atheroma but suggested a long intramural hematoma on left anterior descending coronary artery from the first septal branch, with Thrombolysis In Myocardial Infarction myocardial perfusion grade 1 flow (Figure [A]). Endocoronary optical coherence tomographic imaging confirmed intramural hematoma compressing true lumen without intimal rupture or thrombus (Figure [A′]). Delayed …

Diagnostic accuracy of copeptin sensitivity and specificity in patients with suspected non-ST-elevation myocardial infarction with troponin I below the 99th centile at presentation.

Objective To determine whether copeptin-us can rule out diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) without prolonged monitoring and serial blood sampling in patients with high-sensitive cardiac troponin I (hs-cTnT) below the 99th centile at presentation to the emergency department (ED). Design Prospective, non-randomised, individual blinded diagnostic accuracy study. Setting Two EDs of a rural region of France. Participants Patients with chest pain suspected of NSTEMI with onset within the last 12 h were considered for enrolment. Interventions Serial clinical, electrographical and biochemical investigations were performed at admission and after 2, 4, 6 and 12 h. Hs-cTnT was measured using an assay with Dimension VISTA, Siemens. Copeptin was measured by the BRAHMS copeptin-us assay on the KRYPTOR Compact Plus system. The follow-up period was 90 days. Primary and secondary outcome measures Copeptin, troponin, myoglobin and creatine kinase values. Clinical and paraclinical events. The final diagnosis was adjudicated blinded to copeptin result. Results During 12 months, 102 patients were analysed. Final diagnosis was NSTEMI for 7.8% (n=8), unstable angina for 3.9% (n=4), cardiac but non-coronary artery disease for 8.8% (n=9), non-cardiac chest pain for 52% (n=53) and unknown for 27.5% (n=28). There was no statistical difference for copeptin values between patients with NSTEMI and others (respectively 5.5 pmol/L IQR (3.1–7.9) and 6.5 pmol/L IQR (3.9–12.1), p=0.49). Only one patient with NSTEMI had a copeptin value above the cut-off of 95th centile at admission. Conclusions In this study, copeptin does not add a diagnostic value at admission to ED for patients with suspected acute coronary syndrome without ST-segment elevation and with hs-cTnT below the 99th centile. Trial registration number Clinicaltrials.gov identifier: NCT01334645.

Contribution of guidance by optical coherence tomography (OCT) in rescue management of spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a rare pathology with a poor prognosis, affecting young patients, often peripartum women, without cardiovascular risk factors.1 The SCAD management remains controversial. In the case of haemodynamic instability with coronary occlusion, rescue percutaneous intervention may be required but still challenging.2 A 43-year-old nurse was admitted for acute myocardial infarction complicated by cardiogenic shock. Emergent angiography revealed a total occlusion …

Mechanical abnormalities associated with first- and second-generation drug-eluting stent thrombosis analyzed by optical coherence tomography in the national PESTO French registry

BACKGROUND AND OBJECTIVES DES thrombosis may be triggered by different mechanisms that are difficult to identify by angiography alone. This work aimed to investigate and compare the characteristics of stent thrombosis (ST) between 1st- and 2nd-generation drug-eluting stents (DES) among a large cohort of patients explored by optical coherence tomography (OCT). METHODS AND RESULTS The PESTO study was a prospective national registry involving 29 French catheterization facilities. Patients with acute coronary syndromes were prospectively screened for presence of definite ST and analyzed by OCT after culprit lesion deocclusion. The analysis involved 71 subjects including 34 patients with 1st-generation DES (DES1G) and 35 patients with 2nd-generation DES (DES2G). Most patients (80%) presented with very late stent thrombosis. The median time between initial PCI and ST was longer in DES1G than DES2G patients (3.8 [2.6-6.5] years vs. 1.1 [0.04-2.3] years, p<0.0001). OCT identified an underlying morphological abnormality in 96% of the cases. Significant malapposition was the main abnormality observed either in DES1G (26%) or DES2G patients (35%). Ruptured neoatherosclerotic lesions were more frequently observed with DES1G than with DES2G (26% vs. 3%, p=0.008). There was no significant difference in percentage of malapposed struts and uncovered struts between groups. CONCLUSIONS In this registry, DES thrombosis mainly occurred ≥1year after initial PCI. OCT identified a mechanical abnormality in the vast majority of the cases. Similar causes were observed between DES1G and DES2G, but neoatherosclerotic lesions were more common in DES1G.

Contour segmentation of the intima, media, and adventitia layers in intracoronary OCT images application to fully automatic detection of healthy wall regions

PurposeQuantitative and automatic analysis of intracoronary optical coherence tomography images is useful and time-saving to assess cardiovascular risk in the clinical arena.MethodsFirst, the interfaces of the intima, media, and adventitia layers are segmented, by means of an original front propagation scheme, running in a 4D multi-parametric space, to simultaneously extract three non-crossing contours in the initial cross-sectional image. Second, information resulting from the tentative contours is exploited by a machine learning approach to identify healthy and diseased regions of the arterial wall. The framework is fully automatic.ResultsThe method was applied to 40 patients from two different medical centers. The framework was trained on 140 images and validated on 260 other images. For the contour segmentation method, the average segmentation errors were

Contribution of optical coherence tomography imaging in management of iatrogenic coronary dissection

29 \pm 46~\upmu \text {m}