Nicolas Durel

Effect of thrombus aspiration on infarct size and left ventricular function in high-risk patients with acute myocardial infarction treated by percutaneous coronary intervention. Results of a prospective controlled pilot study

BACKGROUND Thrombus aspiration devices have been shown to improve reperfusion criteria and to reduce distal embolization in patients treated by percutaneous coronary interventions (PCI) in the acute phase of ST-elevation myocardial infarction (STEMI). There are, however, little data about their efficacy in the reduction of infarct size. METHODS We sought to assess in a prospective randomized trial the impact of thrombus aspiration on infarct size and severity and on left ventricular function in high-risk patients with a first STEMI. The primary end point was scintigraphic infarct size, and secondary end points were infarct severity and regional and global left ventricular function. Forty-four patients with completely occluded (Thrombolysis in Myocardial Infarction flow 0-1) proximal segments of infarct-related artery were randomly assigned to thrombus aspiration group with the Export catheter (n = 20) (Medtronic, Inc, Minneapolis, MN) or PCI-only group. A rest Tc-99-mibi gated single-photon emission computed tomographic and contrast-enhanced magnetic resonance imaging were performed 6 +/- 2 days later. RESULTS Infarct size was comparable in patients in the thrombus aspiration group and PCI-only group (30.6% +/- 15.8% vs 28.5% +/- 17.9% of the left ventricle, P = .7) as was infarct severity in infarct-related artery territory (55% +/- 12% vs 55% +/- 14%, P = .9). Transmurality score as assessed by magnetic resonance imaging was similar in both groups (2.03 +/- 1.05 vs 2.16 +/- 1.21, P = .7). There was no impact of thrombus aspiration on other secondary end points. CONCLUSION In our study, thrombus aspiration with the Export catheter performed as adjunctive therapy in high-risk patients with total occlusion of the proximal part of major coronary arteries does not decrease infarct size or severity and has no effect on left ventricular regional and global function.

Effectiveness of anticoagulant therapy in the treatment of post-TAVI bioprosthetic thrombosis

Bioprosthetic thromboses are rarely reported in post-transcatheter aortic valve implantation (TAVI). We describe herein the case of bioprosthetic valve thrombosis in an 82-year-old patient which resolved completely after anticoagulant therapy.

Distortion of the CoreValve during transcatheter aortic valve-in-valve implantation due to valve dislocation

Nowadays transcatheter aortic valve implantation (TAVI) is an accepted alternative to surgical aortic valve replacement for high-risk patients (pts). Successful TAVI procedures for failed aortic surgical bioprosthesis (TAV-in-SAV) have already been reported. In the presented two cases of TAV-in-SAV implantation a strut distortion of the stent was revealed on angiographic imaging and confirmed on control CT scan. In both procedures, a dislocation of the medtronic core valve (MCV) prosthesis during implantation led to valve retrieval, with a necessity of reloading it in the 18F introducer before subsequent implantation of the same valve in correct position.

Different patterns of left ventricular enlargement and long-term prognosis after reperfused acute myocardial infarction.

BACKGROUND Dilation of end-systolic and end-diastolic volumes (ESV, EDV) has been used to define left ventricular remodelling after acute myocardial infarction (MI), but the prognostic significance of different enlargement patterns has not been evaluated fully. AIM To analyse the evolution of left ventricular volumes and parameters of global and regional contractility and their correlations with long-term prognosis in patients treated by angioplasty in the acute phase of MI. METHODS Seventy-four patients (mean age 56+/-13 years; 77% men), treated successfully by angioplasty in the acute phase of MI, were included prospectively. Significant enlargement of left ventricular volumes was defined as a greater than 20% increase between acute phase and 6-month control, assessed by contrast ventriculography. Clinical follow-up was obtained for all patients at 82+/-19 months. RESULTS Four groups were identified based on volume evolution: Group I (n=29, 39%; no volume enlargement); Group II (n=8, 11%; isolated EDV enlargement); Group III (n=10, 14%; isolated ESV enlargement); Group IV (n=27, 36%; ESV plus EDV enlargement). Global left ventricular ejection fraction increased in Groups I (p=0.001) and II (p=0.037), but decreased in Groups III (p=0.0002) and IV (p=0.019). The 6-year event-free survival rate was significantly (p=0.0039) better in Groups I and II (100%) than in Groups III and IV (80 and 78%, respectively). CONCLUSION ESV enlargement in patients with reperfused acute MI impacts negatively on long-term prognosis, while isolated EDV enlargement does not.

Very late active stent thrombosis: Contribution of optical coherence tomography

MOTS CLÉS Thrombose de stent ; Tomographie par cohérence optique ; Thromboaspiration A 42-year-old man was explored by angiography after non-ST-segment elevation myocardial infarction. A monolesion was treated by direct stenting (paclitaxel-eluting stent, 3.5 × 20 mm) on the proximal left anterior descending coronary artery (LAD) and a final kissing balloon on the LAD diagonal, with an excellent result. Clinical follow-up was good (under treatment with aspirin and clopidogrel) until the patient decided to stop all antiplatelet treatment 2 years after successful stent implantation. Ten days later he was admitted for acute anterior ST-segment elevation myocardial infarction complicated by cardiogenic shock 2 hours after onset of chest pain. Angiography showed late stent occlusion of the proximal LAD (Fig. 1A). Thromboaspiration on the LAD (Fig. 1B), followed by the first diagonal (Fig. 1C), restored thrombolysis in myocardial infarction (TIMI) flow grade 3. The patient presented reperfusion syndrome. It was decided to optimize medical treatment with glycoprotein IIb/IIIa inhibitor perfusion. A control angiography was performed on D2: flow was TIMI-3 without angiographic visualization of a thrombus (Fig. 1D). Optical coherence tomography (OCT) showed a residual endoluminal image on a short segment immediately upstream of the bifurca-

153: Comparison of primary pacemaker implantations in the following transcatheter aortic valve implantation (TAVI) in the University Hospital of Clermont Ferrand, according to two types of valve

Introduction Aortic valve replacement is the definitive therapy for severe aortic stenosis (valve area Method We used the register FRANCE II to a retrospective analysis of all patients with a TAVI in the CHU of Clermont Ferrand. We only excluded patients who died within 24 hours post procedure and patients who were already a pacemaker. The search for a PPI, age, type of valve, diameter of the valve, surgical approach, presence of bundle branch block (BB), operator dependence and learning curve were analyzed. Results From January 2010 to March 2012, 78 were included in this study (66% of CoreValve and 34% of Edwards). Of the 22 PPI (22.9%), 100% complicated a Corevalve (p=0.00034). Age, operator, learning curve, surgical approach and diameter of the valve are not risk factors for PPI, in contrast to the presence of BB (p=0.025). Conclusion This study confirms that CoreValves are more complicated PPI than Edwards. The presence of BB is a risk factor for primary implantation. The lack of power of this study does not reveal other risk factors such as the diameter of the valve or the learning curve effect.