Stéphanie Marlière

The 5‐series F2‐isoprostanes possess no vasomotor effects in the rat thoracic aorta, the human internal mammary artery and the human saphenous vein

Among the F2‐isoprostanes, the 15‐ and the 5‐series are currently used as markers of lipid peroxidation in vascular diseases. 15‐F2t‐IsoP (also named iPF2α‐III) exerts a vasoconstriction in most vessels, whereas no data is available concerning 5‐F2t‐IsoP (also named iPF2α‐VI), which is more abundant in plasma. The aim of this study was to determine whether 5‐F2t‐IsoP possess any vascular effects on various vessels including the isolated rat thoracic aorta, the human internal mammary artery and the saphenous vein. In organ baths, 5‐F2t‐IsoP and its 5‐epimer did not affect the basal tone of any vessel, unlike 15‐F2t‐IsoP. These compounds possessed no antagonist effects on 15‐F2t‐IsoP‐induced contractions, No dilator effect was observed in comparison with sodium nitroprusside and acetylcholine on the rat aorta. In conclusion, we show that unlike 15‐F2t‐IsoP, 5‐F2t‐IsoP and its 5‐epimer possess no vasomotor effects and as such are unlikely to be involved in the pathogenesis of vascular diseases. Further studies are required to test whether these mediators may have effects on systems not being measured in the current study.

Vasomotor effects and pathophysiologic relevance of F2-isoprostane formation in vascular diseases

We read with the utmost interest the study by Iuliano et al. [(1)][1]. The investigators showed for the first time that concentrations of 2-F2-isoprostane regioisomers, iPF2α-III (15-F2t-IsoP) and iPF2α-VI (5-F2t-IsoP), were markedly increased in the coronary sinus following percutaneous

Potentially simple score of late gadolinium enhancement cardiac MR in acute myocarditis outcome.

To determine the value of cardiac MRI for the monitoring and the prognosis of patients with acute myocarditis. Cardiac MRI plays an increasingly important role in the diagnosis of acute myocarditis. However, it is less established as a prognostic tool, which requires specific postprocessing of images.

Coronary embolization following electrical cardioversion in a patient treated with dabigatran

A 66-year-old man with a history of atrial fibrillation (AF) was admitted for a ST elevation myocardial infarction (MI). D110 twice daily had been introduced for new-onset atrial fibrillation associated with left ventricular systolic dysfunction (ejection fraction at 40%) twenty five days earlier. Elective electrical cardioversion which had been performed forty eight hours earlier transiently restored a normal sinus rhythm. Signs of congestive heart failure were found on physical examination. EKG showed AF and ST elevation in inferolateral leads associated with a left bundle branch block (Fig. 1). Angiography showed a thrombo-embolic occlusion of an intermediate artery (Fig. 2). The thrombus was successfully removed by a thrombo-aspiration catheter, without coronary stenting, associated with IV aspirin and unfractionated heparin. Admission laboratory data showed highly-sensitive cardiac troponin level at 24 ng/l (N b 14), normal haemoglobin (155 g/L), a platelet count of 150 G/L, normal kidney function (creatinine 86 μmol/L, clearance 85 ml/min according to the Cockroft–Gault formula), prothrombin ratio of 77% and activated partial thromboplastin time at 45 s for a reference time of 32 s. Transthoracic echocardiography showed inferolateral akinesis with a left ventricular ejection fraction of 35% and mild secondary mitral regurgitation. Transesophageal echocardiography showed a residual thrombi in the left atrial appendage. Anticoagulation with warfarin was initiated in addition to aspirin, ramipril, furosemide, spironolactone and bisoprolol. In RE-LY trial [1], D110 and DABIGATRAN 150 mg (D150) were compared to warfarin in patients with non valvular AF. D110 showed similar rates of stroke and systemic embolism but lower rates of major haemorrhage. D150 showed lower rates of stroke and systemic embolism but a similar rate of major haemorrhage. A post hoc analysis of patients who underwent cardioversion in RE-LY [2] showed that the two doses of dabigatran was a safe alternative to warfarin in patients requiring cardioversion. Treatment with vitamin K antagonist for 48 h or more, for patients with AF, or when the duration of AF is unknown, oral anticoagulation therapy (INR 2.0–3.0) is recommended (ESC Class I level of evidence B) for at least 3 weeks prior to and for 4 weeks after electrical or pharmacological cardioversion. Similar treatment duration is recommended for elective cardioversion performed on dabigatran [3]. It is worthy to note that in our patient electrical cardioversionwas performed while receiving D110 for twenty three days. The recommended dose of dabigatran is 150 mg twice daily. In Europe the reduced dose of 110 mg is considered for patients with moderate renal impairment (creatinine clearance between 30 and 50 ml/min in Cockcroft–Gault formula) and a high bleeding risk; or for patients over 80 years; or between 75 and 80 years with a high risk of

Cardiogenic shock due to unprotected left main coronary artery thrombosis in the era of mechanical circulatory support

of mechanical circulatory support Gilles Barone-Rochette ⁎, Gérald Vanzetto , Arnaud Fluttaz , Stéphanie Marlière , Hélène Bouvaist , Michel Durand , Olivier Chavanon , Dominique Blin , Jacques Machecourt a a Department of Cardiology, CHU A Michallon, Grenoble, France b Department of Anesthesia and Intensive Care, CHU A Michallon, Grenoble, France c Department of Cardiac Surgery, CHU A Michallon, Grenoble, France

Influence of gender on delays and early mortality in ST-segment elevation myocardial infarction: Insight from the first French Metaregistry, 2005–2012 patient-level pooled analysis

BACKGROUND Women show greater mortality after acute myocardial infarction. We decided to investigate whether gender affects delays and impacts in-hospital mortality in a large population. METHODS AND RESULTS We performed a patient-level analysis of 7 French MI registries from different regions from January 2005 to December 2012. All patients with acute STEMI were included within 12 h from symptom onset and a first medical contact with a mobile intensive care unit an emergency department of a hospital with percutaneous coronary intervention facility. Primary study outcomes were STEMI, patient and system, delays. Secondary outcome was in-hospital mortality. 16,733 patients were included with 4021 females (24%). Women were significantly older (mean age 70.6 vs 60.6), with higher diabetes (19.6% vs 15.4%) and hypertension rates (58.7% vs 38.8%). Patient delay was longer in women with adjusted mean difference of 14.4 min (p < 0.001); system delay did not differ. In-hospital death occurred 3 times more in women. This disadvantage persisted strongly adjusting for age, therapeutic strategy and delay with a 1.85 (1.32-2.61) adjusted hazard ratio. CONCLUSIONS This overview of 16,733 real-life consecutive STEMI patients in prospective registries over an extensive period strongly indicates gender-related discrepancies, highlighting clinically relevant delays in seeking medical attention. However, higher in-hospital mortality was not totally explained by clinical characteristics or delays. Dedicated studies of specific mechanisms underlying this female disadvantage are mandatory to reduce this gender gap.

Pulmonary Capillary Wedge Pressure Measurement: A Challenge for Diagnosis of Pulmonary Arterial Hypertension

Background: International registries report an aging population suffering from PAH (Pulmonary Artery Hypertension) engendering diagnosis difficulties linked with growing cases of group 2 related to left heart failure with preserved Ejection Fraction (PH-HFpE). Pulmonary Capillary Wedge Pressure (PCWP) measurement by right heart catheterization remains a technical challenge for patient classification; many centers still use digital PCWP given by cath lab software. Here, we have tried to demonstrate misclassification impact of this approximation. Methods: We investigated the PCWP-Left Ventricular End Diastolic Pressure (LVEDP) relationship in a prospective series of 31 patients undergoing heart catherization for suspicion of PAH. Digital and end expiration PCWP were measured in right and left pulmonary arteries for comparison with end expiration LVEDP. Results: We explored 31 patients, 65.4 ± 11 years old, 67.7% were female, with LVEF 60.6 ± 5.2%, Diagnosis of HFpEF was found in 62% of cases and PAH in 10% when using end expiration LVEDP. Right end expiration PCWP, left end expiration PCWP, right digital PCWP, left digital PCWP and end expiration LVEDP were respectively 16.2 ± 6.7mmHg, 16,6 ± 6.4mmHg, 12.2 ± 6.1mmHg (p<0.001), 12.7 ± 6.1mmHg, and 15.8 +/- 4.8mmHg, with a significant difference (p<0.001) between the right and left digital PCWP and end expiration LVEDP. Conclusion: Using digital PCWP instead of end expiration PCWP measurement during RHC, results in a significant underestimation of the LVEDP, this translated to 22% of patients with Pulmonary Hypertension (PH) being misclassified as having group1 rather than group2 PH. Misclassified patients are at risk of receiving inadequate therapy and biased therapeutic studies. When in doubt left heart catheterization should be performed for PAH diagnosis.

312: Out-of-hospital cardiac arrest: use of automated external defibrillators and in-hospital death

Introduction The availability of automated external defibrillators (AEDs) has spread throughout urban areas, for use by the general population in an effort to improve the outcomes of patients with out-of-hospital cardiac arrest (CA). The efficacy and safety of this approach are not well known. We sought to assess the in-hospital outcomes of patients treated with such AEDs for out-of-hospital CA. Methods Between 2004 and 2010, 12,144 consecutive patients with out-of-hospital CA were enrolled in the RENAU-RESURCOR permanent registry, which is being conducted in the French Alps. Since 2008, 190 AEDs have been placed in cities in this region, mainly in public areas. We report in-hospital survival rates in patients treated or not treated with these AEDs. Results Data were analysed from 3249 consecutive patients with CA occurring before the arrival of emergency non-medical care services and with cardiopulmonary resuscitation attempted by prehospital emergency medical staff. The cause of CA was cardiac in 2135 patients (572 were in ventricular fibrillation) and non-cardiac in 1114 (eg, drowning, respiratory failure, asphyxia, trauma, haemorrhage, poisoning). Twenty-four patients were treated with AEDs: these patients were younger, more often male and the median time from collapse to electric shock was shorter (Table). Over time the rate of patients treated with an AED increased: 1/1606 (0.1%) in 2008; 8/1688 (0.5%) in 2009; 15/1638 (0.9%) in 2010. In-hospital survival was 25% for patients treated with AED vs 3.4% for those not treated with AED (P Conclusion The rate of in-hospital survival in patients with out-of-hospital CA could be improved with the use of AEDs available in the community. These preliminary data need to be evaluated and confirmed in larger studies with analysis taking account of confounding factors. Table. Patient characteristics and in-hospital survival rates according to use or lack of use of out-of-hospital automated external defibrillator (AED). Treated with AED (n=24) Not treated with AED (n=3225) Age, median (interquartile range), yrs 60 (45–70) 65 (45-70) Men, n (%) 16 (67) 2294 (71) Time from collapse to shock, median (interquartile range), min 6 (2–12) 14 (10–18) Overall survival, n (%) 6 (25) 110 (3.4) Survival (cardiac cause of CA), n (%) 6/20 (30) 84/2115 (4.0) Survival (non-cardiac cause of CA), n (%) 0/4 (0) 26/1110 (2.3) Survival (CA and ventricular fibrillation), n (%) 5/12 (42) 1/560 (0.2)

041 Percutaneous coronary intervention of unprotected left main coronary artery for cardiogenic shock

Primary coronary angioplasty (PCA) of unprotected left main coronary artery (LM) in patients (pts) with cardiogenic shock (CS) is a high-risk procedure, carrying a high morbi-mortality. Accordingly we aimed to assess the prevalence, clinical presentation, therapeutic workout and in-hospital and long-term prognosis of pts presenting with CS due to TIMI flow 0-1 LM thrombosis. Over a 6-years period, and out of a prospective cath-lab database of 6062 files, 17 cases of CS secondary to LM thrombosis were identified and confirmed by reanalysis of angiograms. Therapeutic management and in-hospital outcome were obtained from medical files and prospective follow-up was obtained. The study population consisted in 13 men (76%) with a mean age of 64±16 years, corresponding to a prevalence of 0.28% of pts proposed for coronary procedure. Clinical presentation was an ACS with and without persistent ST-elevation in 11 (65%) and 6 cases (35%) respectively. Five patients (29%) received pre-hospital thromboysis, which failed to achieved reperfusion in all cases. Twelve patients (71%) undergone mechanical support (intra-aortic balloon pumping alone in 55%, extracorporeal life support alone in 5%, and both in 45%). The majority of PCA were performed with bare metal stent (n=14, 82%), under GPIIbIIIa antagonists in 8 cases, and instrumental thrombectomy in 3 cases. In-hospital death occurred in 5 pts (29%). At mean follow-up of 23 months (100% completed) survival rate was 53% for entire cohort and 75% among discharged pts. Most patients were in NYHA class I (7/9), with averaged left ventricular ejection fraction of 50+17%. One pts was implanted with a Thoratec device and is awaiting heart transplantation, and one is in terminal heart failure. LM occlusion with CS has a very high mortality rate. However, PCA in such setting with use of aggressive mechanical life support carries an acceptable level of major adverse coronary event at medium and long-term prognosis.

337 Extra Corporeal Life Support: A hope in refractory cardiac cardiac arrest?

Background Extracorporeal life support (ECLS) using the percutaneous femoral approach has been proposed as a resuscitative tool in patients (pts) with refractory cardiac arrest (CA) or refractory cardiogenic shock. Little is known however about medium term outcome in this setting. Purpose Accordingly, we aimed to analyse the feasibility, complications, short- and medium-term outcome of emergency ECLS implanted during or after CA. Method Retrospective analysis of in-hospital data and prospective follow-up of 50 consecutive patients (pts) successfully implanted with ECLS between 2005-2007. Results CA was secondary to ST+ acute coronary syndrome, non ischemic heart disease, poisoning, and pulmonary embolism in 27 (54%), 17 (34%), 4 (8%), and 2 pts (4%) respectively (33 males, mean age 47±14 years). Mean delay between CA and ECLS was 48±50 min. Percutaneous femoral implantation of ECLS was attempted in 56 pts, and was successful in 50 (feasibility 89%): In- and out of- hospital CA occurred in 43 and 7 pts respectively. 40 pts had recovered spontaneous circulation at the time of ECLS implantation but had persistent cardiogenic shock, while 10 pts were still under cardiopulmonary resuscitation. Mean duration of ECLS was 38±48 hours. 38 patients died in ICU, mainly from multiple organ failure or brain death. Twelve patients (24%) were explanted and 10 patients (20%) were discharge from hospital after a median stay of 29 days. All discharged patients were alive at a median follow-up of 16.8 months. None had neurological disability, one underwent heart transplantation, and all were in NYHA class I or II. Conlusion In our initial experience, 20% of the treated patients were discharged, and were alive at 16 months with a good quality of life. Results of the following patients who have benefited from ECLS after these 50 initial patients will be also presented. ECLS should therefore be considered in selected pts with persistent hemodynamics failure after CA.