Publications by authors named "Batric Popovic"

41 Publications

Prevalence, Incidence and Prognostic Implications of Left Bundle Branch Block in Patients with Chronic Coronary Syndromes (From the CLARIFY Registry).

Am J Cardiol 2021 07 16;150:40-46. Epub 2021 May 16.

Université de Paris, Assistance Publique - Hôpitaux de Paris; FACT, French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Paris, France; INSERM U-1148, Laboratory for Vascular Translationnal Science; National Heart and Lung Institute, Royal Brompton Hospital, Imperial College, London, United Kingdom.

Left Bundle Branch Block (LBBB) is a frequently encountered electrical abnormality in patients with chronic (more than 3 months after myocardial infarction, or evidence of coronary artery disease with ischemia) coronary syndromes (CCS), but its prognostic significance remains unclear. We aimed to describe the prevalence, incidence and five-year outcomes of LBBB in outpatients with CCS using the CLARIFY registry. Main outcome was a composite of CV death, MI or stroke. Secondary outcomes included all cause death, hospitalization for heart failure (HF) and permanent pacemaker implantation. Among 23.544 patients with available information regarding LBBB status at baseline, 1.041 (4.4%) had LBBB at baseline and 1.015 (4.5%) patients developed a new LBBB during 5-year follow-up. In multivariate analysis, LBBB at baseline was not associated with the composite outcome of CV death, MI or stroke (HR 1.06, 95% CI [0.86 - 1.31], p = 0.67) or the risk of all-cause death (HR 1.07, 95% CI [0.87 - 1.32], p = 0.52) but was significantly associated with a higher risk of hospitalization for HF (HR 1.50, 95% CI [1.21 - 1.88], p < 0.001) and permanent pacemaker implantation (HR 2.11, 95% CI [1.45 - 3.07], p < 0.001). The main factors associated with new-onset LBBB were male sex (HR 0.8 [0.66-0.98], p = 0.028) history of atrial fibrillation (HR 1.29, 95% CI [1.01 - 1.64], p = 0.04), CABG (HR 1.27, [1.08 - 1.51], p = 0.004) and MI (HR 1.19, 95% CI [1.01 - 1.40], p = 0.034). In conclusion, in a contemporary registry of outpatients with CCS, the prevalence of LBBB was 4.4% and the additional 5-years incidence 6.2%. LBBB, in itself, was not associated with a higher risk of major adverse cardiovascular events or all cause mortality. It was however an independent predictor of risk of hospitalization for heart failure and permanent pacemaker implantation.
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http://dx.doi.org/10.1016/j.amjcard.2021.03.047DOI Listing
July 2021

Outcomes in non-ST-segment elevation myocardial infarction patients according to heart failure at admission: Insights from a large trial with systematic early invasive strategy.

Eur Heart J Acute Cardiovasc Care 2020 Oct 20. Epub 2020 Oct 20.

Université de Paris, puis APHP, Hotel Dieu, Centre de diagnostic et de Thérapeutique; French Alliance for Cardiovascular Trials (FACT); INSERM LVTS-U1148.

Background: Previous studies published before the era of systematic early invasive strategy have reported a higher mortality in non-ST-segment elevation myocardial infarction patients with heart failure. The aim of our study was to compare the clinical characteristics, outcomes and causes of death of patients according to their heart failure status at admission in a large non-ST-segment elevation myocardial infarction population with planned early invasive management.

Methods: We performed a post-hoc analysis of the Treatment of Acute Coronary Syndrome with Otamixaban randomised trial which included non-ST-segment elevation myocardial infarction patients with systematic coronary angiography within 72 h. Patients were categorised according to presence or absence of heart failure (Killip grade ≥2) at admission.

Results: A total of 13,172 patients were enrolled, of whom 944 (7.2%) had heart failure. At day 30, death occurred in 213 patients (1.6%) and cardiovascular death was the dominant cause of death in both groups ((with vs without heart failure) 78.8% vs 78.4%, p = 0.94). At six months, death occurred in 90/944 (9.5%) patients with heart failure and 258/12228 patients without heart failure (2.1%) (p < 0.001). After adjustment on Global Registry of Acute Coronary Events risk score, heart failure was an independent predictor of all-cause mortality at day 30 (odds ratio: 1.58; 95% confidence interval, 1.06-2.36, p = 0.02) and at day 180 (odds ratio: 1.77; 95% confidence interval, 1.3-2.42, p < 0.001) as well as of ischaemic complications (cardiovascular death, myocardial infarction, stent thrombosis or stroke at day 30 (odds ratio: 1.28; 95% confidence interval, 1.01-1.62, p = 0.04).

Conclusion: Non-ST-segment elevation myocardial infarction patients with heart failure at admission still have worse outcomes than those without heart failure, even with systematic early invasive strategy. Further efforts are needed to improve the prognosis of these high risk patients.
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http://dx.doi.org/10.1177/2048872619896205DOI Listing
October 2020

Prevalence, clinical determinants and prognostic implications of coronary procedural complications of percutaneous coronary intervention in non-ST-segment elevation myocardial infarction: Insights from the contemporary multinational TAO trial.

Arch Cardiovasc Dis 2021 Mar 29;114(3):187-196. Epub 2021 Jan 29.

FACT (an F-CRIN network), DHU-FIRE, Hôpital Bichat, AP-HP, 75018 Paris, France; Université Paris-Diderot, Sorbonne Paris Cité, 75013 Paris, France; Inserm U1148, 75877 Paris, France; NLHI, ICMS, Royal Brompton Hospital, Imperial College, SW3 6LY London, UK.

Background: Few data are available on procedural complications of percutaneous coronary intervention (PCI) in the setting of acute coronary syndrome in the contemporary era.

Aim: We sought to describe the prevalence of procedural complications of PCI in a non-ST-segment elevation acute coronary syndrome (NSTE ACS) cohort, and to identify their clinical characteristics and association with clinical outcomes.

Methods: Patients randomized in TAO (Treatment of Acute coronary syndrome with Otamixaban), an international randomized controlled trial (ClinicalTrials.gov Identifier: NCT01076764) that compared otamixaban with unfractionated heparin plus eptifibatide in patients with NSTE ACS who underwent PCI, were included in the analysis. Procedural complications were collected prospectively, categorized and adjudicated by a blinded Clinical Events Committee, with review of angiograms. A multivariable model was constructed to identify independent clinical characteristics associated with procedural complications.

Results: A total of 8656 patients with NSTE ACS who were enrolled in the TAO trial underwent PCI, and 451 (5.2%) experienced at least one complication. The most frequent complications were no/slow reflow (1.5%) and dissection with decreased flow (1.2%). Procedural complications were associated with the 7-day ischaemic outcome of death, myocardial infarction or stroke (24.2% vs. 6.0%, odds ratio 5.01, 95% confidence interval 3.96-6.33; P<0.0001) and with Thrombolysis In Myocardial Infarction major and minor bleeding (6.2% vs. 2.3%, odds ratio 2.79, 95% confidence interval 1.86-4.2; P<0.0001). Except for previous coronary artery bypass grafting, multivariable analysis did not identify preprocedural clinical predictors of complications.

Conclusions: In a contemporary NSTE ACS population, procedural complications with PCI remain frequent, are difficult to predict based on clinical characteristics, and are associated with worse ischaemic and haemorrhagic outcomes.
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http://dx.doi.org/10.1016/j.acvd.2020.09.005DOI Listing
March 2021

Simulation-based training in cardiology: State-of-the-art review from the French Commission of Simulation Teaching (Commission d'enseignement par simulation-COMSI) of the French Society of Cardiology.

Arch Cardiovasc Dis 2021 Jan 5;114(1):73-84. Epub 2021 Jan 5.

French Commission of Simulation Teaching (Commission d'enseignement par simulation-COMSI) of the French Society of Cardiology, 75012 Paris, France; Tours University, 37000 Tours, France; Cardiology Department, Tours University Hospital, 37000 Tours, France. Electronic address:

In our healthcare system, mindful of patient safety and the reduction of medical errors, simulation-based training has emerged as the cornerstone of medical education, allowing quality training in complete safety for patients. Initiated by anaesthesiologists, this teaching mode effectively allows a gradual transfer of learning, and has become an essential tool in cardiology teaching. Cardiologists are embracing simulation to master complex techniques in interventional cardiology, to manage crisis situations and unusual complications and to develop medical teamwork. Simulation methods in cardiology include high-fidelity simulators, clinical scenarios, serious games, hybrid simulation and virtual reality. Simulation involves all fields of cardiology: transoesophageal echocardiography, cardiac catheterization, coronary angioplasty and electrophysiology. Beyond purely technical issues, simulation can also enhance communication skills, by using standardized patients, and can improve the management of situations related to the announcement of serious diseases. In this review of recent literature, we present existing simulation modalities, their applications in different fields of cardiology and their advantages and limitations. Finally, we detail the growing role for simulation in the teaching of medical students following the recent legal obligation to use simulation to evaluate medical students in France.
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http://dx.doi.org/10.1016/j.acvd.2020.10.004DOI Listing
January 2021

Outcomes in non-ST-segment elevation myocardial infarction patients according to heart failure at admission: Insights from a large trial with systematic early invasive strategy.

Eur Heart J Acute Cardiovasc Care 2020 Oct 20:2048872619896205. Epub 2020 Oct 20.

Université de Paris, puis APHP, Hotel Dieu, Centre de diagnostic et de Thérapeutique; French Alliance for Cardiovascular Trials (FACT); INSERM LVTS-U1148.

Background: Previous studies published before the era of systematic early invasive strategy have reported a higher mortality in non-ST-segment elevation myocardial infarction patients with heart failure. The aim of our study was to compare the clinical characteristics, outcomes and causes of death of patients according to their heart failure status at admission in a large non-ST-segment elevation myocardial infarction population with planned early invasive management.

Methods: We performed a post-hoc analysis of the Treatment of Acute Coronary Syndrome with Otamixaban randomised trial which included non-ST-segment elevation myocardial infarction patients with systematic coronary angiography within 72 h. Patients were categorised according to presence or absence of heart failure (Killip grade ≥2) at admission.

Results: A total of 13,172 patients were enrolled, of whom 944 (7.2%) had heart failure. At day 30, death occurred in 213 patients (1.6%) and cardiovascular death was the dominant cause of death in both groups ((with vs without heart failure) 78.8% vs 78.4%,  = 0.94). At six months, death occurred in 90/944 (9.5%) patients with heart failure and 258/12228 patients without heart failure (2.1%) ( < 0.001). After adjustment on Global Registry of Acute Coronary Events risk score, heart failure was an independent predictor of all-cause mortality at day 30 (odds ratio: 1.58; 95% confidence interval, 1.06-2.36,  = 0.02) and at day 180 (odds ratio: 1.77; 95% confidence interval, 1.3-2.42,  < 0.001) as well as of ischaemic complications (cardiovascular death, myocardial infarction, stent thrombosis or stroke at day 30 (odds ratio: 1.28; 95% confidence interval, 1.01-1.62,  = 0.04).

Conclusion: Non-ST-segment elevation myocardial infarction patients with heart failure at admission still have worse outcomes than those without heart failure, even with systematic early invasive strategy. Further efforts are needed to improve the prognosis of these high risk patients.
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http://dx.doi.org/10.1177/2048872619896205DOI Listing
October 2020

Reduced Rivaroxaban Dose Versus Dual Antiplatelet Therapy After Left Atrial Appendage Closure: ADRIFT a Randomized Pilot Study.

Circ Cardiovasc Interv 2020 07 17;13(7):e008481. Epub 2020 Jul 17.

Sorbonne Université, ACTION Study Group (Allies in Cardiovascular Trials, Initiatives and Organized Networks), INSERM UMRS1166, ICAN, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (G.D., J.S., N.B., A.C., N.H., D.B., G.M.).

Background: Percutaneous left atrial appendage closure (LAAC) exposes to the risk of device thrombosis in patients with atrial fibrillation who frequently have a contraindication to full anticoagulation. Thereby, dual antiplatelet therapy (DAPT) is usually preferred. No randomized study has evaluated nonvitamin K antagonist oral anticoagulant after LAAC, and we decided to evaluate the efficacy and safety of reduced doses of rivaroxaban after LAAC.

Methods: ADRIFT (Assessment of Dual Antiplatelet Therapy Versus Rivaroxaban in Atrial Fibrillation Patients Treated With Left Atrial Appendage Closure) is a multicenter, phase IIb study, which randomized 105 patients after successful LAAC to either rivaroxaban 10 mg (R, n=37), rivaroxaban 15 mg (R, n=35), or DAPT with aspirin 75 mg and clopidogrel 75 mg (n=33). The primary end point was thrombin generation (prothrombin fragments 1+2) measured 2 to 4 hours after drug intake, 10 days after treatment initiation. Thrombin-antithrombin complex, D-dimers, rivaroxaban concentrations were also measured at 10 days and 3 months. Clinical end points were evaluated at 3-month follow-up.

Results: The primary end point was reduced with R (179 pmol/L [interquartile range (IQR), 129-273], <0.0001) and R (163 pmol/L [IQR, 112-231], <0.0001) as compared with DAPT (322 pmol/L [IQR, 218-528]). We observed no significant reduction of the primary end point between R and R while rivaroxaban concentrations increased significantly from 184 ng/mL (IQR, 127-290) with R to 274 ng/mL (IQR, 192-377) with R, <0.0001. Thrombin-antithrombin complex and D-dimers were numerically lower with both rivaroxaban doses than with DAPT. These findings were all confirmed at 3 months. The clinical end points were not different between groups. A device thrombosis was noted in 2 patients assigned to DAPT.

Conclusions: Thrombin generation measured after LAAC was lower in patients treated by reduced rivaroxaban doses than DAPT, supporting an alternative to the antithrombotic regimens currently used after LAAC and deserves further evaluation in larger studies. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03273322.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.008481DOI Listing
July 2020

Changes in characteristics and management among patients with ST-elevation myocardial infarction due to COVID-19 infection.

Catheter Cardiovasc Interv 2021 Feb 15;97(3):E319-E326. Epub 2020 Jul 15.

Département de Cardiologie, CHU Nancy, Nancy, France.

Objectives: To assess changes in characteristics and management among ST-elevation myocardial infarction (STEMI) patients with coronavirus disease (COVID-19) who underwent primary percutaneous coronary intervention.

Methods: Our prospective, monocentric study enrolled all STEMI patients who underwent PPCI during the COVID-19 outbreak (n = 83). This cohort was first compared with a previous cohort of STEMI patients (2008-2017, n = 1,552 patients) and was then dichotomized into a non-COVID-19 group (n = 72) and COVID-19 group (n = 11).

Results: In comparison with the pre-outbreak period, patients during the outbreak period were older (59.6 ± 12.9 vs. 62.6 ± 12.2, p = .03) with a delayed seek to care (mean delay first symptoms-balloon 3.8 ± 3 vs. .7.4 ± 7.7, p < .001) resulting in a two-fold higher in-hospital mortality (non COVID-19 4.3% vs. COVID-19 8.4%, p = .07). Among the 83 STEMI patients admitted during the outbreak period, 11 patients were infected by COVID-19. Higher biological markers of inflammation (C-reactive protein: 28 ± 39 vs. 98 ± 97 mg/L, p = .04), of fibrinolysis (D-dimer: 804 ± 1,500 vs. 3,128 ± 2,458 μg/L, p = .02), and antiphospholipid antibodies in four cases were observed in the COVID-19 group. In this group, angiographic data also differed: a thrombotic myocardial infarction nonatherosclerotic coronary occlusion (MINOCA) was observed in 11 cases (1.4% vs. 54.5%, p < .001) and associated with higher post-procedure distal embolization (30.6% vs. 72.7%, p = .007). The in hospital mortality was significantly higher in the COVID-19 group (5.6% vs. 27.3%, p = .016).

Conclusion: The COVID-19 outbreak implies deep changes in the etiopathogenesis and therapeutic management of STEMI patients with COVID-19. The impact on early and long-term outcomes of systemic inflammation and hypercoagulability in this specific population is warranted.
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http://dx.doi.org/10.1002/ccd.29114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405489PMC
February 2021

Plasma Galectin-3 predicts deleterious vascular dysfunction affecting post-myocardial infarction patients: An explanatory study.

PLoS One 2020 11;15(5):e0232572. Epub 2020 May 11.

Université de Lorraine, INSERM, UMR-1116, Nancy, France.

Objectives: In a previous analysis of a post-myocardial infarction (MI) cohort, abnormally high systemic vascular resistances (SVR) were shown to be frequently revealed by MRI during the healing period, independently of MI severity, giving evidence of vascular dysfunction and limiting further recovery of cardiac function. The present ancillary and exploratory analysis of the same cohort was aimed at characterizing those patients suffering from high SVR remotely from MI with a large a panel of cardiovascular MRI parameters and blood biomarkers.

Methods: MRI and blood sampling were performed 2-4 days after a reperfused MI and 6 months thereafter in 121 patients. SVR were monitored with a phase-contrast MRI sequence and patients with abnormally high SVR at 6-months were characterized through MRI parameters and blood biomarkers, including Galectin-3, an indicator of cardiovascular inflammation and fibrosis after MI. SVR were normal at 6-months in 90 patients (SVR-) and abnormally high in 31 among whom 21 already had high SVR at the acute phase (SVR++) while 10 did not (SVR+).

Results: When compared with SVR-, both SVR+ and SVR++ exhibited lower recovery in cardiac function from baseline to 6-months, while baseline levels of Galectin-3 were significantly different in both SVR+ (median: 14.4 (interquartile range: 12.3-16.7) ng.mL-1) and SVR++ (13.0 (11.7-19.4) ng.mL-1) compared to SVR- (11.7 (9.8-13.5) ng.mL-1, both p < 0.05). Plasma Galectin-3 was an independent baseline predictor of high SVR at 6-months (p = 0.002), together with the baseline levels of SVR and left ventricular end-diastolic volume, whereas indices of MI severity and left ventricular function were not. In conclusion, plasma Galectin-3 predicts a deleterious vascular dysfunction affecting post-MI patients, an observation that could lead to consider new therapeutic targets if confirmed through dedicated prospective studies.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0232572PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213735PMC
July 2020

Prognostic influence of acute decompensated heart failure in patients planned for transcatheter aortic valve implantation.

Catheter Cardiovasc Interv 2020 11 26;96(5):E542-E551. Epub 2020 Feb 26.

Department of Cardiology, CHU, Nancy, France.

Objective: The aim of our study was to evaluate the outcome of patients with severe aortic stenosis presenting with acute decompensated heart failure (ADHF) and planned for transcatheter aortic valve implantation (TAVI) and to study the variables influencing their prognosis.

Methods: Our retrospective study included 801 patients planned for TAVI in our center. Seven hundred and fifty-six underwent TAVI and were categorized according to ADHF as the initial clinical presentation into two groups: ADHF group (n = 261) and no-ADHF group (n = 495). Pre as well as periprocedural outcomes and 1 year mortality were analyzed.

Results: Among the patients planned for the TAVI procedure, 45 patients remained untreated: 35 patients died while waiting to undergo TAVI which represented 20% of all deaths in our study, ADHF was observed in 23 of 45 (51%) these untreated patients. The 1-year all-cause mortality rate was significantly higher in the ADHF group versus the no-ADHF group (27% vs. 15%, p < .0001). In multivariate analysis, male gender (odds ratio [OR] =2.5, 95% confidence interval [CI]: 1.37-4.57, p = .03), body mass index <25 kg/m (OR = 2.76, 95% CI: 1.51-5.04, p = .0009), and logistic EuroSCORE II ≥20% (OR = 3.04, 95% CI: 1.56-5.94, p = .001) were associated with a higher 1-year mortality in the ADHF group.

Conclusion: The patients eligible for TAVI presenting with ADHF were associated with a higher mortality for both: while on the waiting list for TAVI as well as at 1-year follow-up and thus asking for clearer criteria to prioritize action in this high-risk TAVI patients.
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http://dx.doi.org/10.1002/ccd.28813DOI Listing
November 2020

Five-year outcomes following timely primary percutaneous intervention, late primary percutaneous intervention, or a pharmaco-invasive strategy in ST-segment elevation myocardial infarction: the FAST-MI programme.

Eur Heart J 2020 02;41(7):858-866

Deparment of Clinical Pharmacology and Clinical Research Platform of East of Paris (URCEST-CRCEST-CRB), rue de Chaligny, 75012 Paris, France.

Aims: ST-segment elevation myocardial infarction (STEMI) guidelines recommend primary percutaneous coronary intervention (pPCI) as the default reperfusion strategy when feasible ≤120 min of diagnostic ECG, and a pharmaco-invasive strategy otherwise. There is, however, a lack of direct evidence to support the guidelines, and in real-world situations, pPCI is often performed beyond recommended timelines. To assess 5-year outcomes according to timing of pPCI (timely vs. late) compared with a pharmaco-invasive strategy (fibrinolysis with referral to PCI centre).

Methods And Results: The French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) programme consists of nationwide observational surveys consecutively recruiting patients admitted for acute myocardial infarction every 5 years. Among the 4250 STEMI patients in the 2005 and 2010 cohorts, those with reperfusion therapy and onset-to-first call time <12 h (n = 2942) were included. Outcomes at 5 years were compared according to type of reperfusion strategy and timing of pPCI, using Cox multivariable analyses and propensity score matching. Among those, 1288 (54%) patients had timely pPCI (≤120 min from ECG), 830 (28%) late pPCI (>120 min), and 824 (28%) intravenous fibrinolysis. Five-year survival was higher with a pharmaco-invasive strategy (89.8%) compared with late pPCI [79.5%; adjusted hazard ratio (HR) 1.51; 1.13-2.02] and similar to timely pPCI (88.2%, adjusted HR 1.02; 0.75-1.38). Concordant results were observed in propensity score-matched cohorts and for event-free survival.

Conclusion: A substantial proportion of patients have pPCI beyond recommended timelines. As foreseen by the guidelines, these patients have poorer 5-year outcomes, compared with a pharmaco-invasive strategy.
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http://dx.doi.org/10.1093/eurheartj/ehz665DOI Listing
February 2020

Association of Multiple Enrichment Criteria With Ischemic and Bleeding Risks Among COMPASS-Eligible Patients.

J Am Coll Cardiol 2019 07;73(25):3281-3291

FACT, French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France; Hôpital Avicenne, Assistance Publique-hôpitaux de Paris, Bobigny, France; Imperial College, Royal Brompton Hospital, London, United Kingdom. Electronic address:

Background: The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial found clinical benefit of low-dose rivaroxaban plus aspirin, but at the expense of increased bleeding risk in patients with stable vascular disease.

Objectives: This study evaluated the balance of ischemic and bleeding risks according to the presence of ≥1 enrichment criteria in "COMPASS-eligible" patients.

Methods: Key COMPASS selection criteria were applied to identify a COMPASS-eligible population (n = 16,875) from the REACH (REduction of Atherothrombosis for Continued Health) Registry of stable atherothrombotic patients. Ischemic outcome was the composite of cardiovascular death, myocardial infarction, or stroke. Bleeding outcome was serious bleeding (hemorrhagic stroke, hospitalization for bleeding, transfusion).

Results: Patients were categorized according to the enrichment criteria: age >65 years (81.5%), diabetes (41.0%), moderate renal failure (40.2%), peripheral artery disease (33.7%), current smoker (13.8%), heart failure (13.3%), ischemic stroke (11.1%), and asymptomatic carotid stenosis (8.7%). Each criterion was associated with a consistent increase in ischemic and bleeding events, but no individual subgroup derived a more favorable trade-off. Patients with multiple criteria had a dramatic increase in ischemic risk (7.0% [95% confidence interval (CI): 5.6% to 8.7%], 12.5% [95% CI: 11.1% to 14.1%], 16.6% [95% CI: 14.7% to 18.6%], and 21.8% [95% CI: 19.9% to 23.9%] with 1, 2, 3, and ≥4 enrichment criteria, respectively), but a more modest absolute increase in bleeding risk (1.5% [95% CI: 0.9% to 2.1%], 1.8% [95% CI: 1.3% to 2.2%], 2.0% [95% CI: 1.5% to 2.6%], 3.2% [95% CI: 2.6% to 3.9%]).

Conclusions: In a population of stable vascular patients at high risk of atherothrombotic events, the subset with multiple enrichment criteria had a greater absolute increase in ischemic than in bleeding risk and may be good candidates for low-dose rivaroxaban in addition to aspirin.
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http://dx.doi.org/10.1016/j.jacc.2019.04.046DOI Listing
July 2019

Twenty-year trends in profile, management and outcomes of patients with ST-segment elevation myocardial infarction according to use of reperfusion therapy: Data from the FAST-MI program 1995-2015.

Am Heart J 2019 08 16;214:97-106. Epub 2019 May 16.

Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Department of Cardiology, 75015 Paris; Université Paris-Descartes, 75006 Paris, France.

The increased use of reperfusion therapy in ST-segment-elevation myocardial infarction (STEMI) patients in the past decades is generally considered the main determinant of improved outcomes. The aim was to assess 20-year trends in profile, management, and one-year outcomes in STEMI patients in relation with use or non-use of reperfusion therapy (primary percutaneous coronary intervention (pPCI) or fibrinolysis).

Methods: We used data from 5 one-month French nationwide registries, conducted 5 years apart from 2005 to 2015, including 8579 STEMI patients (67% with and 33% without reperfusion therapy) admitted to cardiac intensive care units in France.

Results: Use of reperfusion therapy increased from 49% in 1995 to 82% in 2015, with a shift from fibrinolysis (37.5% to 6%) to pPCI (12% to 76%). Early use of evidence-based medications gradually increased over the period in both patients with and without reperfusion therapy, although it remained lower at all times in those without reperfusion therapy. One-year mortality decreased in patients with reperfusion therapy (from 11.9% in 1995 to 5.9% in 2010 and 2015, hazard ratio [HR] adjusted on baseline profile 0.40; 95% CI: 0.29-0.54, P < .001) and in those without reperfusion therapy (from 25.0% to 18.2% in 2010 and 8.1% in 2015, HR: 0.33; 95% CI: 0.24-0.47, P < .001).

Conclusions: In STEMI patients, one-year mortality continues to decline, both related to increased use of reperfusion therapy and progress in overall patient management. In patients with reperfusion therapy, mortality has remained stable since 2010, while it has continued to decline in patients without reperfusion therapy.
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http://dx.doi.org/10.1016/j.ahj.2019.05.007DOI Listing
August 2019

Primary percutaneous coronary intervention in ST-elevation myocardial infarction with an ectatic infarct-related artery.

Coron Artery Dis 2019 06;30(4):277-284

CHU Nancy, Département de Cardiologie.

Objective: The aim of this study was to describe the procedural characteristics, myocardial perfusion, and long-term outcomes in ST-elevation myocardial infarction patients with an ectatic infarct-related artery (IRA).

Patients And Methods: The retrospective analysis included 1270 consecutive ST-elevation myocardial infarction patients treated by primary percutaneous coronary intervention who were categorized according to the coronary anatomy of the IRA as follows: ectatic group (n=91) and control group (n=1179).

Results: Compared with the control group, patients in the ectatic group experienced lower Thombolysis in myocardial infarction grade 3 flow rate after percutaneous coronary intervention (64.8 vs. 88.2%: ectatic group vs. nonectatic group, P<0.001) and more frequent distal embolization (44.4 vs. 11.1%, P<0.001). ECG ST resolution was significantly lower in the ectatic group (P<0.001). Paradoxically, the left ventricular ejection fraction values at discharge were significantly higher in the ectatic group (P=0.032) and the infarct size assessed within 6-12 months after discharge tended to be smaller (P=0.06). The 30-day mortality rate was not significantly different between the two groups (3.3 vs. 5.0%, P=0.378) as well as Kaplan-Meier analysis for long-term overall survival in both groups (P=0.8).

Conclusion: Patients with ectatic IRA were characterized by discrepancies between high angiographic thrombus burden in a larger vessel and impact on left ventricular function that may influence their long-term survival.
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http://dx.doi.org/10.1097/MCA.0000000000000720DOI Listing
June 2019

The Simulation Training in Coronary Angiography and Its Impact on Real Life Conduct in the Catheterization Laboratory.

Am J Cardiol 2019 04 24;123(8):1208-1213. Epub 2019 Jan 24.

Université de Lorraine, 54000, Nancy, France; Département de Cardiologie, Centre Hospitalier Universitaire Brabois, Nancy, France.

Our study aimed to evaluate the effectiveness of mentored simulation training (ST) in coronary angiography and to assess the transferability of acquired skills from virtual reality to the real world. Twenty cardiology residents were randomized to ST or control before performing real-life cases in the catheterization laboratory. The control group underwent secondary ST and reperformed real-life cases in the catheterization laboratory. Skill metrics were compared between the ST and the control group, and within the control group between before and after ST. In real-life cases, the procedure time was shorter (p = 0.002), the radiation dose lower (p = 0.001), and the global procedure skill score was higher (p = 0.0001) in the ST group as compared with the control (before ST) group. During virtual ST procedural time (p <0.001), fluoroscopic time (p <0.001), training contrast amount (p <0.001), and global training score (p <0.001) significantly decreased. In the control group, all monitoring procedure parameters were significantly improved after ST, as well as, the global procedure flow score (p <0.0001). In conclusion, simulator-based training in coronary angiography improved operator skills compared with traditional in catheterization laboratory mentor-based training. ST should be incorporated in the curriculum of the interventionalist to improve learning in coronary angiography.
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http://dx.doi.org/10.1016/j.amjcard.2019.01.032DOI Listing
April 2019

Are all drug-eluting stents created equal?

Lancet 2018 10 22;392(10154):1172-1174. Epub 2018 Sep 22.

Institut Lorrain du Coeur et des Vaisseaux, CHU de Nancy, Université de Lorraine, F-54500 Vandoeuvre -lès-Nancy, France.

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http://dx.doi.org/10.1016/S0140-6736(18)32334-1DOI Listing
October 2018

Correction to: Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients.

Intensive Care Med 2018 11;44(11):2022-2023

Department of Anesthesiology and Critical Care, APHP - Saint Louis Lariboisière University Hospitals, University Paris Diderot and INSERM UMR-S 942, Paris, France.

Because of a technical error, the code corresponding to the outcome for the Basir et al. cohort was mis-implemented in the original version of our article. Characteristics of the cohort are in fact the followings.
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http://dx.doi.org/10.1007/s00134-018-5372-9DOI Listing
November 2018

Endothelial-driven increase in plasma thrombin generation characterising a new hypercoagulable phenotype in acute heart failure.

Int J Cardiol 2019 Jan 25;274:195-201. Epub 2018 Jul 25.

Université de Lorraine, INSERM, DCAC, F-54000 Nancy, France. Electronic address:

Background: Subjects with heart failure (HF) are at higher risk of developing thrombosis. We investigated whether endothelium activation and inflammation induce a prothrombotic biological profile in patients with acute decompensated HF (ADHF) and sinus rhythm.

Methods: Our prospective study included 34 ADHF patients, 30 patients with stable chronic HF (CHF) and 30 control inpatients without HF. In vitro thrombin generation and its downregulation by activated protein C (APC) was monitored by calibrated automated thrombography at hospital admission, at the day of discharge and after discharge, following at least six weeks of clinical stability. Circulating endothelium-derived extracellular vesicles (eEVs) were quantified by flow cytometry and nucleosomes by ELISA.

Results: Thrombin generation is increased and APC sensitivity is decreased independently of platelets in ADHF at admission compared to controls (p < 0.01). Thrombin generation was also increased in CHF but only in the presence of platelets. Plasma markers of endothelium activation (von Willebrand factor, factor VIII, procoagulant eEVs and circulating nucleosomes) and the ability of plasmas to induce neutrophil extracellular trap formation in control neutrophils are elevated in ADHF at admission compared to controls (p < 0.001). In-hospital prothrombotic changes in ADHF improved significantly at the post-discharge time-point. Circulating nucleosomes were positively correlated with APC sensitivity (p = 0.013) and annexin-V-positive eEVs (p = 0.004).

Conclusions: This proof-of-concept study identified an endothelial-driven hypercoagulable phenotype at the acute phase of decompensated HF contrasting with the platelet-dependent prothrombotic state in CHF. These results highlighted a cross-talk between circulating eEVs and nucleosomes, procoagulant factors and impairment of the APC anticoagulant activity in ADHF.
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http://dx.doi.org/10.1016/j.ijcard.2018.07.130DOI Listing
January 2019

Heart failure with preserved ejection fraction: A systemic disease linked to multiple comorbidities, targeting new therapeutic options.

Arch Cardiovasc Dis 2018 Dec 28;111(12):766-781. Epub 2018 Jun 28.

Cardiology Department, Institut Lorrain-du-Cœur-et-des-Vaisseaux, CHU Nancy-Brabois, allée du Morvan, 54500 Vandoeuvre-les-Nancy, France.

Heart failure is a pathology associated with severe morbidity and mortality. In this large field, heart failure with preserved ejection fraction (HFpEF) appears to be an increasing global health problem; it should be considered as a progressive syndrome, characterized by complex mechanisms of systemic and cardiac adaptation that vary over time, particularly with ageing. Multiple biological phenotypes contribute to the heterogeneous clinical syndrome. HFpEF emerges as a model with proinflammatory cardiovascular and non-cardiovascular coexisting comorbidities, leading to systemic inflammation and subsequent fibrosis and to diverse clinical HFpEF phenotypes. All of these aspects are often present in the elderly population, bordering on the emergence of a true geriatric syndrome. The therapeutic approach cannot be uniform, and must involve management of the different comorbidities according to a phenotype treatment strategy, respecting the pharmacological approaches to the biological pathways involved in the proinflammatory comorbidity-related status. Future studies should consider these multiple distinct HFpEF phenotypes in the development of large morbimortality trials adapted to comorbidities or specific risk factors.
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http://dx.doi.org/10.1016/j.acvd.2018.04.007DOI Listing
December 2018

Emergency Coronary Angiography After Out-of-Hospital Cardiac Arrest: Is It Essential or Futile?

Circ Cardiovasc Interv 2018 06;11(6):e006804

CHRU Nancy, Département de Cardiologie, F-54000 Nancy, France (B.P.).

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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.118.006804DOI Listing
June 2018

Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients.

Intensive Care Med 2018 06 1;44(6):847-856. Epub 2018 Jun 1.

Department of Anesthesiology and Critical Care, APHP - Saint Louis Lariboisière University Hospitals, University Paris Diderot and INSERM UMR-S 942, Paris, France.

Objective: Catecholamines have been the mainstay of pharmacological treatment of cardiogenic shock (CS). Recently, use of epinephrine has been associated with detrimental outcomes. In the present study we aimed to evaluate the association between epinephrine use and short-term mortality in all-cause CS patients.

Design: We performed a meta-analysis of individual data with prespecified inclusion criteria: (1) patients in non-surgical CS treated with inotropes and/or vasopressors and (2) at least 15% of patients treated with epinephrine administrated alone or in association with other inotropes/vasopressors. The primary outcome was short-term mortality.

Measurements And Results: Fourteen published cohorts and two unpublished data sets were included. We studied 2583 patients. Across all cohorts of patients, the incidence of epinephrine use was 37% (17-76%) and short-term mortality rate was 49% (21-69%). A positive correlation was found between percentages of epinephrine use and short-term mortality in the CS cohort. The risk of death was higher in epinephrine-treated CS patients (OR [CI] = 3.3 [2.8-3.9]) compared to patients treated with other drug regimens. Adjusted mortality risk remained striking in epinephrine-treated patients (n = 1227) (adjusted OR = 4.7 [3.4-6.4]). After propensity score matching, two sets of 338 matched patients were identified and epinephrine use remained associated with a strong detrimental impact on short-term mortality (OR = 4.2 [3.0-6.0]).

Conclusions: In this very large cohort, epinephrine use for hemodynamic management of CS patients is associated with a threefold increase of risk of death.
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http://dx.doi.org/10.1007/s00134-018-5222-9DOI Listing
June 2018

Myocardial reperfusion for acute myocardial infarction under an optimized antithrombotic medication: What can you expect in daily practice?

Cardiovasc Revasc Med 2018 Oct - Nov;19(7 Pt B):820-825. Epub 2018 Feb 27.

CHU Nancy, Département de Cardiologie, Nancy F-54000, France. Electronic address:

Aims: To assess both epicardiac macrovascular as well as microvascular and tissue reperfusion following different intravenous preadmission antithrombotic strategies prior primary PCI in STEMI patients.

Methods And Results: Consecutive STEMI patients (n = 488) undergoing pPCI received prehospitally either bivalirudin (n = 179), bivalirudin and periprocedural GPIIb/IIIa inhibitors (GPI) (n = 109), heparin (n = 99) or heparin and periprocedural GPI (n = 101). Epicardial perfusion and microvascular perfusion were assessed by angiography (TIMI flow rate and corrected TIMI frame count [cTFC]) and by ECG (ST resolution [STR]). TIMI 3 flow was restored at the end of the procedure in 85.2% of the cases; cTFC of ≤23 was obtained in 37.2% of cases and STR >70% in 42.5% of the cases. The rates of STR >70% and cTFC ≤23 were not different between the three groups. Multivariate analysis did not identify a predictive antithrombotic treatment to obtain either post-procedural TIMI 3 flow rate or a STR rate >70%. TIMI 3 flow before procedure and delay first symptoms-balloon <6 h represented a positive predictive value of STR rate >70% and the LAD as infarct related artery a negative predictive value of STR rate of >70%.

Conclusion: The process of myocardial reperfusion by pPCI continues to be improved with earlier reperfusion but an optimal tissular reperfusion was present in only half of the cases.
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http://dx.doi.org/10.1016/j.carrev.2018.02.015DOI Listing
August 2019

Coronary Embolism Among ST-Segment-Elevation Myocardial Infarction Patients: Mechanisms and Management.

Circ Cardiovasc Interv 2018 01;11(1):e005587

From the Département de Cardiologie (B.P., N.B., S.P., C.H.M., P.A.M., C.S.S., Y.J., E.C.) and Epidémiologie et Evaluation Cliniques (N.A.), CHU Nancy, France.

Background: Coronary artery embolism (CE) is recognized as an important nonatherosclerotic cause of ST-segment-elevation myocardial infarction. The objective was to describe clinical characteristics and long-term outcomes and to identify risks factors of CE in a large consecutive series of ST-segment-elevation myocardial infarction patients.

Methods And Results: We studied 1232 consecutive patients who presented with de novo ST-segment-elevation myocardial infarction. CE was diagnosed based on criteria encompassing clinical, angiographic, and diagnostic imaging findings. A total of 53 patients were identified in the CE group including 12 (22.6%) patients with multisites CE and 9 patients with other extracoronary localization. Compared with the non-CE group, age and coronary risks factors were not significantly different in the CE group except for smoking (=0.03) and body mass index (<0.001). Interventional coronary procedures were characterized by a higher use of glycoprotein IIb/IIIa inhibitors (<0.001) and lower use of angioplasty (<0.001) in the CE group. The most frequent underlying cardiac diseases were atrial fibrillation (n=15, 28.3%) followed by dilated cardiomyopathy (n=5), endocarditis (n=4), and intracardiac tumor (n=3), whereas among systemic diseases, malignancy (n=8) and systemic autoimmune disease or antiphospholipid syndrome (n=4) were present. No etiopathological mechanisms could be identified in 14 patients (26.4%). Coronary embolism was associated with a higher risk of death (crude hazard ratio, 4.87; 95% confidence interval, 2.52-9.39; <0.0001).

Conclusions: Etiopathogenesis of ST-segment-elevation myocardial infarction secondary to CE is diverse ranging from cardiac to systemic disease, and patient long-term survival is worse than expected according to the baseline cardiovascular risk.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.117.005587DOI Listing
January 2018

Acute Myocardial Infarction: Changes in Patient Characteristics, Management, and 6-Month Outcomes Over a Period of 20 Years in the FAST-MI Program (French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction) 1995 to 2015.

Circulation 2017 Nov 27;136(20):1908-1919. Epub 2017 Aug 27.

Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Department of Cardiology; Université Paris-Descartes, Paris, France; INSERM U-970, France (E.P., N.A., N.D.).

Background: ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI) management has evolved considerably over the past 2 decades. Little information on mortality trends in the most recent years is available. We assessed trends in characteristics, treatments, and outcomes for acute myocardial infarction in France between 1995 and 2015.

Methods: We used data from 5 one-month registries, conducted 5 years apart, from 1995 to 2015, including 14 423 patients with acute myocardial infarction (59% STEMI) admitted to cardiac intensive care units in metropolitan France.

Results: From 1995 to 2015, mean age decreased from 66±14 to 63±14 years in patients with STEMI; it remained stable (68±14 years) in patients with NSTEMI, whereas diabetes mellitus, obesity, and hypertension increased. At the acute stage, intended primary percutaneous coronary intervention increased from 12% (1995) to 76% (2015) in patients with STEMI. In patients with NSTEMI, percutaneous coronary intervention ≤72 hours from admission increased from 9% (1995) to 60% (2015). Six-month mortality consistently decreased in patients with STEMI from 17.2% in 1995 to 6.9% in 2010 and 5.3% in 2015; it decreased from 17.2% to 6.9% in 2010 and 6.3% in 2015 in patients with NSTEMI. Mortality still decreased after 2010 in patients with STEMI without reperfusion therapy, whereas no further mortality gain was found in patients with STEMI with reperfusion therapy or in patients with NSTEMI, whether or not they were treated with percutaneous coronary intervention.

Conclusions: Over the past 20 years, 6-month mortality after acute myocardial infarction has decreased considerably for patients with STEMI and NSTEMI. Mortality figures continued to decline in patients with STEMI until 2015, whereas mortality in patients with NSTEMI appears stable since 2010.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.117.030798DOI Listing
November 2017

Triggering Receptor Expressed on Myeloid cells-1: a new player in platelet aggregation.

Thromb Haemost 2017 08 27;117(9):1772-1781. Epub 2017 Jul 27.

Prof. Sébastien Gibot, Service de Réanimation Médicale, Hôpital Central, 29 avenue de Lattre de Tassigny, 54035 Nancy Cedex, France, Tel.: +33 383852970, Fax: +33 383858511, E-mail:

Triggering Receptor Expressed on Myeloid cells-1 (TREM-1) is an immunoreceptor initially known to be expressed on neutrophils and monocytes/macrophages. TREM-1 acts as an amplifier of the inflammatory response during both infectious and aseptic inflammatory diseases. Another member of the TREM family, The Triggering receptor expressed on myeloid cells Like Transcript-1 (TLT-1) is exclusively expressed in platelets and promotes platelet aggregation. As the gene that encodes for TLT-1 is located in the TREM-1 gene cluster, this prompted us to investigate the expression of TREM-1 on platelets. Here we show that TREM-1 is constitutively expressed in α-granules and mobilised at the membrane upon platelet activation. Pharmacologic inhibition of TREM-1 reduces platelet activation as well as platelet aggregation induced by collagen, ADP, and thrombin in human platelets. Aggregation is similarly impaired in platelets from Trem-1 mice. In vivo, TREM-1 inhibition decreases thrombus formation in a carotid artery model of thrombosis and protects mice during pulmonary embolism without excessive bleeding. These findings suggest that TREM-1 inhibition could be useful adducts in antiplatelet therapies.
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http://dx.doi.org/10.1160/TH17-03-0156DOI Listing
August 2017

A Fractional Flow Reserve Guidewire Causing Longitudinal Stent Compression and Successful Recovery.

Heart Views 2017 Apr-Jun;18(2):58-61

Cardiovasculaire Institute, Cardiology, Nancy University, Vandoeuvre-les-Nancy, France.

Longitudinal stent deformation (LSD) is a rare complication but can occur during coronary intervention. We report a case with LSD of the distal edge, documented by an optical coherence tomography investigation and successfully recovered.
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http://dx.doi.org/10.4103/1995-705X.208674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5501031PMC
July 2017

Incidence, indications and predicting factors of permanent pacemaker implantation after transcatheter aortic valve implantation: A retrospective study.

Arch Cardiovasc Dis 2017 Oct 21;110(10):508-516. Epub 2017 Jun 21.

Département de cardiologie, CHU de Nancy, 54511 Vandœuvre-lès-Nancy, France; Université de Lorraine, 54000 Nancy, France. Electronic address:

Background: As the number of transcatheter aortic valve implantation (TAVI) procedures is constantly increasing, it is important to consider common complications, such as pacemaker (PM) implantation, and their specific risk factors.

Aims: Echocardiographic, computed tomography and electrocardiographic data were analysed to determine the predicting factors, if any, associated with PM implantation.

Methods: This retrospective study included patients referred to Nancy University Hospital for a TAVI procedure from January 2013 to December 2015. Both Medtronic CoreValve and Edwards SAPIEN valves were implanted. Patients with preprocedurally implanted PMs and/or referred from another institution were excluded.

Results: Of 208 TAVI patients, 23 had a pre-existing PM and were excluded. A new PM was required in 38 patients (20.5%). Pre-existing right bundle branch block (RBBB), the use of the Medtronic CoreValve and large prostheses were identified as predictors of PM implantation (P=0.0361, P=0.0004 and P=0.0019, respectively). Using logistic regression, predictors of PM implantation included first-degree atrioventricular block (odds ratio 3.7, 95% confidence interval 1.5-9.1; P=0.0054) and large aortic annulus diameter in echocardiography (odds ratio 1.2, 95% confidence interval 1-1.4; P=0.0447), with a threshold of 24.1mm. For the combination of preTAVI PR duration >220ms and QRS duration >120ms, the positive predictive value for PM implantation reached 80%.

Conclusion: Use of the Medtronic CoreValve, RBBB and first-degree atrioventricular block are major risk factors for post-TAVI PM implantation. In addition, large aortic annulus and large valvular prosthesis are independent risk factors for PM implantation. The combination of preTAVI prolonged PR interval and increased QRS duration could be used as a marker for periprocedural PM implantation.
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http://dx.doi.org/10.1016/j.acvd.2017.03.004DOI Listing
October 2017

Bilateral unilateral internal mammary revascularization in patients with left ventricular dysfunction.

World J Cardiol 2017 Apr;9(4):339-346

Batric Popovic, Yves Juilliere, Damien Voilliot, Département de Cardiologie, CHU Nancy, F-54000 Nancy, France.

Aim: To investigate the survival benefit of bilateral internal mammary artery (BIMA) grafts in patients with left ventricular dysfunction.

Methods: Between 1996 and 2009, we performed elective, isolated, primary, multiple cardiac arterial bypass grafting in 430 consecutive patients with left ventricular ejection fraction ≤ 40%. The early and long-term results were compared between 167 patients undergoing BIMA grafting and 263 patients using left internal mammary artery (LIMA)-saphenous venous grafting (SVG).

Results: The mean age of the overall population was 60.1 ± 15 years. In-hospital mortality was not different between the two groups (7.8% 10.3%, = 0.49). Early postoperative morbidity included myocardial infarction (4.2% 3.8%, = 0.80), stroke (1.2% 3.8%, = 0.14), and mediastinitis (5.3% 2.3%, = 0.11). At 8-year follow-up, Kaplan-Meier-estimated survival (74.2% 58.9%, = 0.02) and Kaplan-Meier-estimated event-free survival (all cause deaths, myocardial infarction, stroke, target vessel revascularization, heart failure) (61.7% and 41.1%, < 0.01) were significantly higher in the BIMA group compared with the LIMA-SVG group in univariate analysis. The propensity score matching analysis confirmed that BIMA grafting is a safe revascularization procedure but there was no long term survival ( = 0.40) and event-free survival ( = 0.13) in comparison with LIMA-SVG use.

Conclusion: Our longitudinal analysis suggests that BIMA grafting can be performed with acceptable perioperative mortality in patients with left ventricular dysfunction.
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http://dx.doi.org/10.4330/wjc.v9.i4.339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5411968PMC
April 2017

Ventricular Dysfunction in Patients with Acute Coronary Syndrome Undergoing Coronary Surgical Revascularization: Prognostic Impact on Long-Term Outcomes.

PLoS One 2016 22;11(12):e0168634. Epub 2016 Dec 22.

CHU Nancy, Service de chirurgie des maladies cardiovasculaires et transplantations, Nancy, France.

Background: Patients with non-ST elevation acute coronary syndrome complicated by left ventricular dysfunction (LVEF) are a poor prognosis group. The aim of our study was to assess the short and long term LEVF prognostic value in a cohort of NSTE-ACS patients undergoing surgical revascularization.

Methods: We performed elective and isolated CABG on a cohort of 206 consecutive patients with LVEF≤0.40 complicating acute coronary syndrome. The case cohort was compared with a cohort of controls (LVEF>0.40) randomly selected (2:1) among patients who underwent the procedure during this period.

Results: The Kaplan-Meier 5-year estimated survival rates for patients in the low and normal LVEF groups were 70.8% (95% confidence interval CI: 64.2-77.4) and 81.7% (95%CI: 77.8-85.6), respectively. A low LVEF was associated with both a higher all-cause (HR [95%CI] = 1.84[1.18-2.86]) and a higher cardiovascular mortality (HR = 2.07 [1.27-3.38]) during the first 12 months of follow-up. After adjustment for potential confounders, a low LVEF remained associated with a higher cardiovascular mortality only (1.87[1.03-3.38]) during the first 12 months of follow-up. After 12 months of follow-up, a low LVEF was no more associated with all-cause, nor cardiovascular mortality.

Conclusion: Patients with low LVEF might require more intensive care than patients with normal LVEF during the year after the surgical procedure, but once the first postoperative year over, the initial low LVEF was no more associated with long term mortality.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0168634PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5179064PMC
July 2017

Prognostic Value of the Thrombolysis in Myocardial Infarction Risk Score in ST-Elevation Myocardial Infarction Patients With Left Ventricular Dysfunction (from the EPHESUS Trial).

Am J Cardiol 2016 Nov 22;118(10):1442-1447. Epub 2016 Aug 22.

CHU Nancy, Département de Cardiologie, Nancy, France; INSERM, Centre d'Investigation Clinique CIC-P 9501, Nancy, France.

The Thrombolysis in Myocardial Infarction (TIMI) risk score remains a robust prediction tool for short-term and midterm outcome in the patients with ST-elevation myocardial infarction (STEMI). However, the validity of this risk score in patients with STEMI with reduced left ventricular ejection fraction (LVEF) remains unclear. A total of 2,854 patients with STEMI with early coronary revascularization participating in the randomized EPHESUS (Epleronone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study) trial were analyzed. TIMI risk score was calculated at baseline, and its predictive value was evaluated using C-indexes from Cox models. The increase in reclassification of other variables in addition to TIMI score was assessed using the net reclassification index. TIMI risk score had a poor predictive accuracy for all-cause mortality (C-index values at 30 days and 1 year ≤0.67) and recurrent myocardial infarction (MI; C-index values ≤0.60). Among TIMI score items, diabetes/hypertension/angina, heart rate >100 beats/min, and systolic blood pressure <100 mm Hg were inconsistently associated with survival, whereas none of the TIMI score items, aside from age, were significantly associated with MI recurrence. Using a constructed predictive model, lower LVEF, lower estimated glomerular filtration rate (eGFR), and previous MI were significantly associated with all-cause mortality. The predictive accuracy of this model, which included LVEF and eGFR, was fair for both 30-day and 1-year all-cause mortality (C-index values ranging from 0.71 to 0.75). In conclusion, TIMI risk score demonstrates poor discrimination in predicting mortality or recurrent MI in patients with STEMI with reduced LVEF. LVEF and eGFR are major factors that should not be ignored by predictive risk scores in this population.
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http://dx.doi.org/10.1016/j.amjcard.2016.08.004DOI Listing
November 2016

Fifteen-year trends in the management of cardiogenic shock and associated 1-year mortality in elderly patients with acute myocardial infarction: the FAST-MI programme.

Eur J Heart Fail 2016 09;18(9):1144-52

AP-HP, Hôpital Européen Georges Pompidou, Paris, France, and Université Paris-Descartes, Paris, France.

Aims: Alhough cardiogenic shock (CS) after acute myocardial infarction (AMI) is more common in elderly patients, information on the epidemiology of these patients is scarce. This study aimed to assess the trends in prevalence, characteristics, management, and outcomes of elderly patients admitted with CS complicating AMI between 1995 and 2010, using data from the FAST-MI programme.

Methods And Results: We analysed the incidence and 1-year mortality of CS in four nationwide French surveys carried out 5 years apart from 1995 to 2010, including consecutive AMI patients over 1-month periods. Among the 10 610 patients, 3389 were aged ≥75 years, of whom 9.9% developed CS. The prevalence of CS decreased in elderly patients from 11.6% in 1995 to 6.7% in 2010 (P = 0.02). Over the 15-year period, the characteristics of elderly patients with CS changed, with more diabetes, hypertension, and hypercholesterolaemia. The use of PCI increased markedly in elderly patients with and without CS, reaching 51% and 59%, respectively, in 2010. In addition, medical therapy also evolved, with more patients receiving antithrombotic agents, beta-blockers, and statins. Over time, 1-year mortality decreased by 32% among elderly patients with CS but remained high (59% in 2010). ST-segmet elevation myocardial infarction and previous AMI were independent correlates of increased 1-year death, while study period was associated with decreased mortality (2010 vs, 1995: hazard ratio 0.40, 95% confidence interval 0.27-0.61, P < 0.001), along with early use of PCI.

Conclusion: Cardiogenic shock in elderly patients with AMI remains a major clinical concern. However, 1-year mortality declined in these patients, a decrease potentially mediated by broader use of PCI and the improvement of global patient management.
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http://dx.doi.org/10.1002/ejhf.585DOI Listing
September 2016