Thierry Lefèvre

Sex‐based differences in outcomes with bivalirudin or unfractionated heparin for transcatheter aortic valve replacement: Results from the BRAVO‐3 randomized trial

Women comprise almost 50% of patients undergoing transcatheter aortic valve replacement (TAVR) and previous studies have indicated higher rates of procedural complications and bleeding in women compared to men. It is unknown whether men and women demonstrate a differential response to bivalirudin versus unfractionated heparin (UFH) in TAVR. We sought to evaluate outcomes by sex and type of anticoagulant from the Bivalirudin Versus Heparin Anticoagulation in Transcatheter Aortic Valve Replacement (BRAVO‐3) trial of transfemoral TAVR.

Treatment of Coronary Bifurcation Lesions

The optimal treatment for coronary bifurcation lesions is still the subject of debate. Balloon angioplasty for this type of lesion used to be associated with significant risk of acute complications compounded by a high risk of recurrent stenosis. With the advent of bare-metal stents, the first controversies arose as to whether one or several stents should be used to treat these lesions. The outcome of various nonrandomized studies demonstrated the benefit of implementing a single-stent strategy, whereby a stent is implanted in the main branch across the side branch. Drug-eluting stents allowed considerable reduction in the risk of restenosis and repeat interventions while encouraging the development of numerous complex techniques permitting complete bifurcation coverage. However, the results of large randomized studies, for which 5-year data is now available, confirmed the absence of benefits for complex strategies compared with provisional side-branch stenting, when both approaches are possible. Today, the provisional side branch stenting approach is considered the gold standard. This chapter explains when and how to perform this technique and how to resolve common difficulties. It also describes when and how to use a two-stent approach.

Position paper of French Interventional Group (GACI) for TAVI in France in 2018

Aortic stenosis is a frequent disease in the elderly. Its prevalence is 0.4% with a sharp increase after the age of 65, and its outcome is very poor when the patient becomes symptomatic. The interventional procedure known as TAVI (trans-catheter aortic valve implantation), which was developed in France and carried out for the first time in Rouen by Prof. Alain Cribier and his team in 2002, has proven to be a valid alternative to surgical aortic valve replacement. At first, this technique was shown to be efficient in patients with contra-indications to surgical treatment or deemed to be at high surgical risk. Given the very promising outcomes achieved as a result of close heart team collaboration, appropriate patient selection, simplified procedures and reduced complication rates, transfemoral (TF) TAVI is now preferred in symptomatic intermediate risk patients>75 years old according to the latest ESC guidelines. In 2017, in France, TAVI is currently performed in 50 centers with on-site cardiac surgery. The 2016 TAVI outcomes recorded in the French national TAVI registry (France TAVI) are very encouraging and show that for 7133 patients treated (age 83.4±7 years, logistic Euroscore 14%), 87% of whom via the TF approach, cross-over to surgery was very low (0.5%) with a 3.0% in-hospital mortality rate. The substantial increase in TAVI indications and the improvement of its outcomes may in the near future call for a reconsideration of the number of high volume centers authorized to carry out this technique.

The Transradial Approach for Bifurcation Lesions

The history of transradial approach for cardiac catheterism begins before the one of transfemoral approach. The technique is adapted in 1992 for PCI by Kiemeneij. Since that time this approach is proved to be superior to femoral approach regarding the risk of vascular complications, more comfortable for the patient, perfectly adapted to outpatient diagnosis and coronary intervention. A reduction of procedural related mortality has been found speciallyin acute coronary syndroms situations. The transradial approach has been adapted to most clinical, angiographical and technical subsets for PCI. Transradial approach for coronary diagnosis and intervention are related to anatomy, like some anatomical variations and small size of the vessel. For the treatment of coronary bifurcation lesions the only one specific limitation is the necessity of 6F guiding catheter (it can be a sheathless one), and for only one technique a 7F (the Simultaneous Kissing Stent). Acornary bifurcation is an anatomic and physiologic entity dedicated to flow flow distribution, with 3 segments, Proximal Main, Distal Main and Side Branch, and 3 different diameter.In non left main bifurcation the provisional side branch stenting strategy is the most frequently used after multiple randomized comparison with techniques begining with side branch stenting (inverted Culotte, DK Crush Transradial approach can be used also to treat distal left main stenosis using the same techniques, without any randomized comparative trial published.

Treatment of Coronary Artery Bifurcation Lesions

The treatment of coronary bifurcation lesions is still a very controversial subject. The objectives of the present review are to describe the tools which have been developed with a view to providing an objective analysis of these lesions (basic data, de fi nitions, classi fi cations, quanti fi cation, imaging techniques), to summarize the results of randomized studies, large registries, and metaanalyses, and to describe the most currently used techniques. Treatment of unprotected left main lesions is only brie fl y discussed as the differences with other coronary bifurcations are merely of quantitative nature.

Consensus du GACI (Groupe athérome et cardiologie interventionnelle) sur la prise en charge interventionnelle des syndromes coronaires aigus avec sus-décalage persistant du segment ST en France

Le syndrome coronaire aigu avec sus-décalage persistant du segment ST (SCA ST+) met en jeu le pronostic vital immédiat et impose une prise en charge urgente afin d’obtenir une reperfusion myocardique la plus rapide possible. Les patients doivent être pris en charge dans une structure de cardiologie interventionnelle adaptée et autorisée par les schémas régionaux d’organisation sanitaires (SROS), afin de ré-ouvrir l’artère coronaire responsable de l’infarctus dans les plus brefs délais, l’angioplastie primaire étant considérée comme le traitement de référence [1]. Lorsque l’angioplastie n’est pas réalisable dans les délais recommandés, la thrombolyse doit être utilisée en dehors des contre-indications et le patient admis dans un centre pouvant réaliser une angioplastie coronaire. La prise en charge idéale du SCA ST+ débute par un appel le plus précoce possible au Samu-centre 15, puis une prise en charge pré-hospitalière médicalisée déclenchée dans tous les cas pouvant évoquer un SCA ; en particulier, en cas de douleur thoracique n’ayant pas une autre cause évidente, ce qui inclut le doute dans les indications d’engagement des moyens médicaux pré-hospitaliers. Ceci nécessite donc une bonne information du public, une collaboration étroite entre les médecins de l’urgence (SAMU, SMUR) et les cardiologues interventionnels et la mise en place de réseaux de soins et de protocoles thérapeutiques. Si les derniers registres français (USIK, USIC, Fast MI et stent for life) ont permis de documenter des progrès considérables depuis 1995 (augmentation des appels au 15, réduction des délais d’appel, réduction des délais de prise en charge médicalisée et augmentation du taux de reperfusion par angioplastie), encore trop de patients ne bénéficient pas d’une reperfusion en phase aiguë ou bénéficient d’une reperfusion trop tardive. Il existe en France une grande disparité régionale dans la prise en charge des SCA ST+ : différences inter régionales (urbaines ou rurales), différences entre structures d’accueil de cardiologie interventionnelle (centres hospitalo-universitaires, centres hospitaliers généraux ou centres privés), mais aussi existence d’une grande disparité dans l’organisation des réseaux, plus ou moins formalisés entre les SAMU (service daide médicale urgente), les hôpitaux publics et les centres privés. Les dernières recommandations de l’European society of cardiology (ESC) [1] insistent sur l’importance d’établir des référentiels au sein d’un réseau régional de prise en charge de l’infarctus du myocarde. Le bureau du GACI (Groupe athérome et cardiologie interventionnelle de la Société française de cardiologie), représentant les cardiologues interventionnels des secteurs publics et privés, acteurs majeurs dans cette filière, a jugé utile de rédiger un consensus afin d’optimiser la prise en charge interventionnelle des SCA ST+ en France.