Stéphane Noble

Clopidogrel 600-Mg Double Loading Dose Achieves Stronger Platelet Inhibition Than Conventional Regimens : Results From the PREPAIR Randomized Study

OBJECTIVES The objective of this study was to compare the level of platelet inhibition achieved by 3 different clopidogrel loading regimens in patients undergoing elective angiography and percutaneous coronary intervention when appropriate. BACKGROUND Optimal platelet inhibition is a key therapeutic goal for patients undergoing percutaneous coronary intervention. Although 600 mg has been described as the maximum absorbed dose when given as a single bolus, the effects of 2 boluses given 24 h apart have not been described. METHODS Patients (n = 148) were randomly assigned to one of 3 regimens: Group A, clopidogrel 300 mg the day before (>or=15 h) + 75 mg the morning of the procedure; Group B, clopidogrel 600 mg the morning of the procedure (>or=2 h); and Group C, clopidogrel 600 mg the day before (>or=15 h) and 600 mg the morning of the procedure (>or=2 h). Blood samples were obtained at baseline and immediately before angiography. Peak and late platelet aggregation were measured in platelet rich plasma, with researchers blinded to treatment allocation. RESULTS There was a consistent difference favoring Group C in all aggregation parameters. Percent inhibition in Groups A, B, and C was 31.4%, 29.0%, and 49.5%, respectively, for peak aggregation (5 micromol/l adenosine diphosphate; p < 0.0001) and 54.1%, 57.7%, and 81.1%, respectively, for late aggregation (p < 0.0001). Similar striking reductions were observed when 20 micromol/l adenosine diphosphate was used. All comparisons between Group C and the other 2 groups were statistically significant, and those between Groups A and B were not. CONCLUSIONS Clopidogrel 600-mg double bolus achieves greater platelet inhibition than conventional single loading doses.

Pulmonary Arterial Hypertension in Patients With Transcatheter Closure of Secundum Atrial Septal Defects A Longitudinal Study

Background—Pulmonary arterial hypertension (PAH) may develop in patients with atrial septal defects (ASD); however, little is known about associated risk factors and its evolution after transcatheter ASD closure. Methods and Results—We conducted a cohort study on 215 adults with attempted transcatheter ASD closure from 1999 to 2006. Patients were classified according to baseline systolic pulmonary artery pressures as having no (I, <40 mm; Hg), mild (II, 40 to 49 mm; Hg), moderate (III, 50 to 59 mm; Hg), or severe (IV, ≥60 mm; Hg) PAH. Independent predictors of moderate or severe PAH were older age (odds ratio [OR], 1.10 per year; P<0.0001), larger ASD (OR, 1.13 per millimeter; P=0.0052), female sex (OR, 3.9; P=0.0313), and at least moderate tricuspid regurgitation (OR, 3.6; P=0.0043). At 15 (interquartile range, 8 to 43) months post–ASD closure, patients with higher baseline pressures were more likely to experience a ≥5-mm; Hg decrease (33.7%, 73.9%, 79.2%, and 100.0% in groups I to IV, P<0.0001), with a larger magnitude of reduction (0, 8, 17, and 22 mm; Hg; P<0.0001). However, normalization of pressures (<40 mm; Hg) occurred less frequently in patients with more advanced PAH (90.2%, 71.7%, 66.7%, and 23.5%, P<0.0001). Among patients with moderate or severe PAH, independent predictors of normalization were lower baseline pressures (OR, 0.91 per mm; Hg; P=0.0418) and no more than mild tricuspid regurgitation (OR, 0.14; P=0.0420). Conclusion—In adults with ASDs, severity of PAH is modulated by age, sex, defect size, and degree of tricuspid regurgitation. Patients with moderate or severe PAH may benefit from substantial reductions in pulmonary artery pressures after transcatheter ASD closure, although the PAH values remain elevated in a sizeable proportion.

High energy excimer laser to treat coronary in-stent restenosis in an underexpanded stent.

Balloon refractory calcific coronary plaques remain a technical challenge. Stent underexpansion is known as a major cause of restenosis and thrombosis. We report a case of in‐stent restenosis 5 months after stent suboptimal implantation in a noncompliant calcific atherosclerotic plaque which could not be disrupted by repeated prolonged high‐pressure balloon inflations. High‐energy excimer laser use altered underlying lesion morphology, allowing full stent apposition. Advances in equipment and technique have allowed more frequent use of high energy excimer laser technology during percutaneous coronary angioplasty with very low rates of complications. Laser technology represents a useful tool to overcome resistant lesions during percutaneous coronary interventions.

Embolization of an amplatzer mVSD occluder device used for percutaneous closure of an ascending aortic pseudoaneurysm: Case report and literature review†

Pseudoaneurysm of the ascending aorta is a rare, but potentially dangerous condition. The high morbidity and mortality rate associated with its surgical management has led to the development of transcatheter approaches. We report a case of percutaneous closure of an ascending aortic pseudoaneurysm using an Amplatzer mVSD occluder device complicated by device embolization at day 27 and we review the literature of Amplatzer devices in this off‐label use.

Impact of bifurcation lesions on angiographic characteristics and procedural success in primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

BACKGROUND Bifurcation lesions (BFLs) remain a challenging lesion subset, often associated with lower success rates than less complex lesions. There are few data regarding the impact of BFLs in the setting of ST-segment elevation myocardial infarction (STEMI). AIMS To assess the impact of BFLs on angiographic characteristics and procedural success in primary percutaneous coronary interventions (PCIs). METHODS Out of 1070 primary PCIs performed between November 2006 and December 2008, 114 patients (10.7%) with a BFL (side branch ≥2.0mm) were identified and matched with 114 patients without a BFL, according to age, sex and infarct-related artery. RESULTS Baseline characteristics were similar in both groups. Using the Medina classification, true BFLs ([1,1,1]; [1,0,1]; [0,1,1]) were found in 46.5% of cases. Mean contrast volume (265±91 and 207±68mL), procedural time (51.0±26.6 vs 35.3±11.5min) and fluoroscopy time (16.2±11.2 vs 9.8±5.1min) were significantly higher in the BFL group than the non-BFL group (p<0.0001). However, time to reperfusion and angiographic success rates (residual stenosis ≤ 30% and Thrombolysis in Myocardial Infarction flow grade 3 in main branch) were similar in BFL and non-BFL patients (13.7±7.9 vs 12.1±5.7min, respectively, p=0.087; 96.5 vs 99.1%, respectively, p=0.18), with no periprocedural events (in-hospital death, emergent coronary artery bypass graft or repeat PCI<24h). CONCLUSION Despite being challenging lesions, BFLs in STEMI were associated with similar time to reperfusion and procedural success but led to significantly greater contrast use and prolonged procedural time compared with non-BFLs.

Estudio con diferentes técnicas de imagen de un aneurisma gigante trombosado en la arteria coronaria derecha

La informacion sobre las relaciones genotipo-fenotipo y el pronostico de las diferentes mutaciones en el gen de la troponina T es escasa y en ocasiones contradictoria. Se realizo estudio del gen TNNT2 en 127 pacientes con miocardiopatia hipertrofica (MCH), identificandose 3 mutaciones en 4 familias (3,1%): Phe87Leu, no descrita, Arg 278Cys (2 familias) y Asp271Ile. Se identificaron 7 portadores de Phe87Leu (29 a 52 anos) con hipertrofia leve (grosor

Remodeling is a more important determinant of lumen size than atheroma burden in left main coronary artery disease

BACKGROUND Left main coronary artery (LMCA) disease influences survival; however, the predictors of LMCA changes over time are incompletely understood. METHODS Paired intravascular ultrasound (IVUS) and core laboratory analyses were performed in a standardized fashion in 207 subjects (mean +/- SD age 58 +/- 10 years, 80% men). The average follow-up duration was 18 months (range 12-24 months). The IVUS measurements were first obtained at the smallest lumen area and the largest plaque area at follow-up and the corresponding positions in the LMCA were then measured at baseline. RESULTS The LMCA percentage of atheroma area at baseline was 38.2% +/- 11.8%, and 133 patients (64%) experienced an increase in percentage of atheroma area. Change in lumen area correlated positively with change in total vessel area (R = 0.85, P < .0001) and negatively with change in percentage of atheroma area (R = -0.58, P < .0001). Change in plaque area correlated well with change in total vessel area (R = 0.64, P < .0001) but only weakly with change in lumen area (r = 0.14, P = .039). Although LMCA length correlated negatively with baseline lumen area and total vessel area, it did not correlate with their changes over time. On multivariable analyses, current smoking predicted an increase in percentage of atheroma area (P = .0013) and plaque area (P = .0041). Height negatively predicted change in percentage of atheroma area (P = .001). CONCLUSIONS The LMCA lumen dimensions are more tightly linked with remodeling than with atheroma progression/regression.

Transcatheter membranous ventricular septal defect closure through a mechanical aortic prosthesis using the Amplatzer membranous ventricular septal defect occluder

An iatrogenic ventricular septal defect (VSD) after aortic valve replacement is rare, but represents a significant complication. Repeat surgery to repair such a defect carries a high surgical risk. The transcatheter approach (either transvascular or transapical) could be considered as an alternative to open chest surgery. We describe the successful transcatheter closure of an iatrogenic VSD with an Amplatzer Membranous VSD Occluder in a patient with previous combined mitral and aortic mechanical valve replacements. The device was implanted through a CarboMedics mechanical valve in the aortic position.

Alcohol Septal Ablation for Obstructive Hypertrophic Cardiomyopathy: The Perfect Septal Branch May Originate From an Atypical Location

Due to anatomical variability in the distribution and size of septal perforator arteries, not all patients are ideal candidates for alcohol septal ablation. Myocardial contrast echocardiography is essential in selecting the appropriate septal branch. We report a case where the target septal artery did not originate from the left anterior descending artery, but from the first diagonal branch.

Transcatheter embolization of anomalous systemic arterial supply with Amplatzer Vascular Plugs II in Scimitar syndrome.

A 57‐year‐old woman suffering from recurrent pneumonia and considered to be high risk for surgical correction of an atrial septal defect (ASD) associated with a right lung sequestration vascularized by arteries coming from the abdominal aorta and an abnormal venous drainage into the inferior vena cava (Scimitar syndrome). Therefore stepwise transcatheter approach was offered as an alternative treatment. We performed ASD closure and embolization of the anomalous systemic arterial supply using Amplatzer Vascular Plugs II. The abnormal venous drainage was conservatively treated (Qp/Qs: 1.1/1 after ASD closure and anomalous arterial supply embolization). At 24‐month follow‐up, no recurrent pneumonia was reported, functional class improved and right cardiac cavities normalized.