Publications by authors named "Guillaume Leurent"

63 Publications

Successful heart transplantation for COVID-19-associated post-infectious fulminant myocarditis.

ESC Heart Fail 2021 May 2. Epub 2021 May 2.

Department of Anesthesia and Critical Care, University Hospital of Rennes, Rennes, F-35000, France.

Various clinical presentations of the 2019 coronavirus disease (COVID-19) have been described, including post-infectious acute and fulminant myocarditis. Here, we describe the case of a young patient admitted for COVID-19-associated post-infectious fulminant myocarditis. Despite optimal pharmacologic management, haemodynamic status worsened requiring support by veno-arterial extracorporeal membrane oxygenation. Emergent heart transplantation was required at Day 11 given the absence of cardiac function improvement. The diagnosis of post-infectious COVID-19-associated myocarditis was made from both pathologic examination of the explanted heart and positive SARS-CoV-2 serology.
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http://dx.doi.org/10.1002/ehf2.13326DOI Listing
May 2021

Electrophysiological Study-Guided Permanent Pacemaker Implantation in Patients With Conduction Disturbances Following Transcatheter Aortic Valve Implantation.

Am J Cardiol 2021 Mar 20. Epub 2021 Mar 20.

Univ Rennes, CHU Rennes, Inserm, LTSI - UMR1099, F 35000 Rennes, France. Electronic address:

Conduction disturbances remain common following transcatheter aortic valve implantation (TAVI). Aside from high-degree atrioventricular block (HAVB), their optimal management remains elusive. Invasive electrophysiological studies (EPS) may help stratify patients at low or high risk of HAVB allowing for an early discharge or permanent pacemaker (PPM) implantation among patients with conduction disturbances. We evaluated the safety and diagnostic performances of an EPS-guided PPM implantation strategy among TAVI recipients with conduction disturbances not representing absolute indications for PPM. All patients who underwent TAVI at a single expert center from June 2017 to July 2020 who underwent an EPS during the index hospitalization were included in the present study. False negative outcomes were defined as patients discharged without PPM implantation who required PPM for HAVB within 6 months of the initial EPS. False positive outcomes were defined as patients discharged with a PPM with a ventricular pacing percentage <1% at follow-up. A total of 78 patients were included (median age 83.5, 39% female), among whom 35 patients (45%) received a PPM following EPS. The sensitivity, specificity, positive and negative predictive values of the EPS-guided PPM implantation strategy were 100%, 89.6%, 81.5%, and 100%, respectively. Six patients suffered a mechanical HAVB during EPS and received a PPM. These 6 patients showed PPM dependency at follow-up. In conclusion, an EPS-guided PPM implantation strategy for managing post-TAVI conduction disturbances appears effective to identify patients who can be safely discharged without PPM implantation.
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http://dx.doi.org/10.1016/j.amjcard.2021.03.014DOI Listing
March 2021

Are We Right to Believe in the Value of Transcatheter Treatment of Secondary Tricuspid Regurgitation?

J Am Coll Cardiol 2021 Jan;77(3):240-242

Cardiology Department, Bichat Hospital, AP-HP, Université de Paris, Paris, France.

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http://dx.doi.org/10.1016/j.jacc.2020.11.037DOI Listing
January 2021

Oral Anticoagulation Continuation Throughout TAVR: High Risk-High Reward or Marginal Gains?

JACC Cardiovasc Interv 2021 01 23;14(2):145-148. Epub 2020 Dec 23.

Université de Rennes 1, CHU Rennes Service de Cardiologie, Inserm LTSI U1099, France.

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http://dx.doi.org/10.1016/j.jcin.2020.10.026DOI Listing
January 2021

Percutaneous Treatment of Mitral Regurgitation With the PASCAL Device: A Full Grasp of the Pathology?

JACC Cardiovasc Interv 2020 12;13(23):2779-2781

Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France; CHU Rennes, Service de Cardiologie, Rennes, France.

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http://dx.doi.org/10.1016/j.jcin.2020.09.057DOI Listing
December 2020

Determinants and Impact of Heart Failure Readmission Following Transcatheter Aortic Valve Replacement.

Circ Cardiovasc Interv 2020 07;13(7):e008959

Université de Rennes 1, CHU Rennes Service de Cardiologie, Inserm LTSI U1099, F 35000 Rennes, France (V.A., A.B., G.L., M.B., E.D., E.G., A.L., S.S., M.L.G., D.B., H.L.B.).

Background: Heart failure (HF) readmission is common post-transcatheter aortic valve replacement (TAVR). Nonetheless, limited data are available regarding its predictors and clinical impact. This study evaluated the incidence, predictors, and impact of HF readmission within 1-year post-TAVR, and assessed the effects of the prescription of HF therapies at discharge on the risk of HF readmission and death.

Methods: Patients included in the TAVR registry of a single expert center from 2009 to 2017 were analyzed. Competing-risk and Cox regressions were performed to identify predictors of HF readmission and death.

Results: Among 750 patients, 102 (13.6%) were readmitted for HF within 1-year post-TAVR. Overall, 53 patients (7.1%) experienced late readmissions (>30 days post-TAVR), and 17 (2.3%) had multiple readmissions. In ≈30% of readmissions, no trigger could be identified. Predominant causes of readmissions were changes in medication/nonadherence and supraventricular arrhythmia. Independent predictors of HF readmission included diabetes mellitus, chronic lung disease, previous acute HF, grade III or IV aortic regurgitation, and pulmonary hypertension both at discharge from the index hospitalization but not HF therapies. Overall, HF readmission did not significantly impact all-cause mortality (hazard ratio [HR], 1.36 [95% CI, 0.99-1.85]). However, late (HR, 1.90 [95% CI, 1.30-2.78]) and multiple HF readmissions (HR, 2.10 [95% CI,1.17-3.76]) were significantly associated with all-cause mortality. Prescription of renin-angiotensin system inhibitors at discharge was associated with a lower rate of all-cause mortality, especially among patients receiving doses of 25% to <50% (HR, 0.67 [95% CI, 0.48-0.94]) and 75% to 100% (HR, 0.61 [95% CI, 0.37-0.98]) of the optimal daily dose.

Conclusions: HF readmission is common within 1-year of TAVR. Late and multiple HF readmissions associate with an increased risk of long-term all-cause mortality. Baseline comorbidities (diabetes, chronic lung disease, previous acute HF) and echocardiographic findings at discharge (grade III or IV aortic regurgitation, pulmonary hypertension) identified patients at high risk of HF readmission.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.120.008959DOI Listing
July 2020

The 50-year-old pulmonary artery catheter: the tale of a foretold death?

ESC Heart Fail 2020 06 20;7(3):783-785. Epub 2020 Apr 20.

PhyMedExp, Université de Montpellier, INSERM, CNRS, Cardiology Department, CHU de Montpellier, France.

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http://dx.doi.org/10.1002/ehf2.12702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261538PMC
June 2020

Conduction disturbances following trancatheter aortic valve implantation: increasing the 'pace' towards prospective evidence.

Eur Heart J 2020 08;41(29):2782-2784

Université de Rennes 1, Service de Cardiologie CHU Rennes, INSERM LTSI U1099, Rennes, France.

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http://dx.doi.org/10.1093/eurheartj/ehz957DOI Listing
August 2020

Percutaneous closure of paravalvular leak after transcatheter valve implantation in mitral annular calcification.

EuroIntervention 2020 Apr;15(17):1518-1519

Department of Cardiology, Univ. Rennes 1, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France.

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http://dx.doi.org/10.4244/EIJ-D-19-00744DOI Listing
April 2020

The Tricuspid Valve: No Longer the Forgotten Valve!

JACC Cardiovasc Interv 2019 12;12(24):2496-2498

ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Asissitance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France. Electronic address:

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http://dx.doi.org/10.1016/j.jcin.2019.10.052DOI Listing
December 2019

EDUCATIONAL SERIES ON THE SPECIALIST VALVE CLINIC: The central role of the cardiac imager in heart valve disease

Echo Res Pract 2019 Dec 1;6(4):T15-T21. Epub 2019 Dec 1.

University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France.

In this review, we discuss the central role of the imager in the heart team in the successful application of current guidelines for heart valve diseases to daily practice, and for improving patient care through new approaches, new techniques and new strategies for dealing with increasingly complex cases. This is an opportunity to emphasize the importance of having good imagers and the value of continuous learning in a modern heart team. It is essential to employ technological improvements and to appropriately adapt guidelines to the patients we see day to day.
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http://dx.doi.org/10.1530/ERP-19-0046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6865361PMC
December 2019

Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction in Patients ≥70 Years of Age.

Am J Cardiol 2020 01 11;125(1):1-10. Epub 2019 Oct 11.

Department of Cardiology and Vascular Diseases, Pontchaillou University Hospital, University of Rennes 1, Rennes, France; Center for Clinical Investigation 804, Signal and Image Treatment laboratory (LTSI), National Institute of Health and Medical Research U1099, Rennes, France.

The benefit-risk ratio of a pharmacoinvasive strategy (PI) in patients ≥70 years of age with ST-segment elevation myocardial infarction (STEMI) remains uncertain resulting in its limited use in this population. This study compared efficacy and safety of PI with primary percutaneous coronary intervention (pPCI). Data from 2,841 patients (mean age: 78.1 ± 5.6 years, female: 36.1%) included in a prospective multicenter registry, and who underwent either PI (n = 269) or pPCI (n = 2,572), were analyzed. The primary end point was in-hospital major adverse cardiovascular events (MACE) defined as the composite of all-cause mortality, nonfatal MI, stroke, and definite stent thrombosis. Secondary end points included all-cause death, major bleeding, net adverse clinical events, and the development of in-hospital Killip class III or IV heart failure. Propensity-score matching and conditional logistic regression were used to adjust for confounders. Within the matched cohort, rates of MACE was not statistically different between the PI (n = 247) and pPCI (n = 958) groups, (11.3% vs 9.0%, respectively, odds ratio 1.25, 95% confidence interval 0.81 to 1.94; p = 0.31). Secondary end points were comparable between groups at the exception of a lower rate of development of Killip class III or IV heart failure after PI. The rate of intracranial hemorrhage was significantly higher in the PI group (2.3% vs 0.0%, p = 0.03). In conclusion, the present study demonstrated no difference regarding in-hospital MACE following PI or pPCI in STEMI patients ≥70 years of age. An adequately-powered randomized trial is needed to precisely define the role of PI in this high-risk subgroup.
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http://dx.doi.org/10.1016/j.amjcard.2019.09.044DOI Listing
January 2020

Left ventricular function after correction of mitral regurgitation: Impact of the clipping approach.

Echocardiography 2019 11 4;36(11):2010-2018. Epub 2019 Nov 4.

CHU Rennes, Inserm, LTSI - UMR 1099, University of Rennes, Rennes, France.

Aims: Functional mitral regurgitation (FMR) is associated with poor outcome in systolic heart failure (HF) patients. Percutaneous edge-to-edge mitral valve repair (PMVR) in Mitra-Fr study failed to prove any beneficial effect over optimal medical treatment (OMT) but win in COAPT study. Nevertheless, little is known about the effect of PMVR on LV performance and mechanics in HF patients with severe secondary MR.

Method And Results: Thirty-seven patients with severe FMR undergoing PMVR were included and compared (according to indices of LV myocardial function and the relationship between LV-size and the degree of regurgitation) to nineteen patients with FMR treated by OMT. Both groups were clinically comparable. At 6-month follow-up, cardiac index such as LV global constructive work (GCW) improved significantly in both groups (1.86 vs 2.13 L/min/m , P = .02, 1.73 vs 2.28 L/min/m P = .002 and 977 vs 1101 mm Hg.%, P = .003, 967 vs 1110 mm Hg.%, P = .002 for PMVR and OMT groups, respectively) whereas left ventricular (LV) end-systolic volume index, LV ejection fraction, and global longitudinal strain were not different. Receiver operating characteristics in PMVR with LVEF ≤ 35% subgroup analysis demonstrated that global work index (GWI) had the best ability to identify patients with worse evolution (AUC = 0.882; P = .009), confirmed by univariable logistic regression, particularly for patients with GWI < 482 mm Hg.%.

Conclusion: Echocardiographic characteristics at 6-month follow-up are not different when compare PMVR and OMT for HF patients with severe FMR. A low global work index might be a tool for discouraging the implantation of clips for this indication.
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http://dx.doi.org/10.1111/echo.14523DOI Listing
November 2019

Percutaneous repair or medical treatment for secondary mitral regurgitation: outcomes at 2 years.

Eur J Heart Fail 2019 12 18;21(12):1619-1627. Epub 2019 Nov 18.

Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS, UMR5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Service de Biostatistique - Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Villeurbanne, France.

Aims: The MITRA-FR trial showed that among symptomatic patients with severe secondary mitral regurgitation, percutaneous repair did not reduce the risk of death or hospitalization for heart failure at 12 months compared with guideline-directed medical treatment alone. We report the 24-month outcome from this trial.

Methods And Results: At 37 centres, we randomly assigned 304 symptomatic heart failure patients with severe secondary mitral regurgitation (effective regurgitant orifice area >20 mm or regurgitant volume >30 mL), and left ventricular ejection fraction between 15% and 40% to undergo percutaneous valve repair plus medical treatment (intervention group, n = 152) or medical treatment alone (control group, n = 152). The primary efficacy outcome was the composite of all-cause death and unplanned hospitalization for heart failure at 12 months. At 24 months, all-cause death and unplanned hospitalization for heart failure occurred in 63.8% of patients (97/152) in the intervention group and 67.1% (102/152) in the control group [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.77-1.34]. All-cause mortality occurred in 34.9% of patients (53/152) in the intervention group and 34.2% (52/152) in the control group (HR 1.02, 95% CI 0.70-1.50). Unplanned hospitalization for heart failure occurred in 55.9% of patients (85/152) in the intervention group and 61.8% (94/152) in the control group (HR 0.97, 95% CI 0.72-1.30).

Conclusions: In patients with severe secondary mitral regurgitation, percutaneous repair added to medical treatment did not significantly reduce the risk of death or hospitalization for heart failure at 2 years compared with medical treatment alone.
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http://dx.doi.org/10.1002/ejhf.1616DOI Listing
December 2019

Is there still a role for the intra-aortic balloon pump in the management of cardiogenic shock following acute coronary syndrome?

Arch Cardiovasc Dis 2019 Dec 24;112(12):792-798. Epub 2019 Jun 24.

Aix-Marseille Université, AP-HM, Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Centre for CardioVascular and Nutrition research (C2VN), Inserm 1263, INRA 1260, Cardiology Department, Hôpital Nord, 13000 Marseille, France.

The intra-aortic balloon pump has been widely used in the management of cardiogenic shock. Reducing cardiac afterload and myocardial oxygen consumption, and improving coronary blood flow, this safe and simple mechanical circulatory support has been considered the cornerstone of cardiogenic shock management for decades. However, because it failed to provide any clinical benefit in recent randomized trials, the latest guidelines discourage its routine use in this clinical setting. Moreover, new percutaneous circulatory supports providing greater haemodynamic improvement have recently been developed. Thus, intra-aortic balloon pump use has declined considerably in this clinical setting. However, the device does retain a minor role in cardiogenic shock management - mainly in the setting of mechanical complication of acute coronary syndrome, and for left ventricular unloading in patients treated with extracorporeal life support.
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http://dx.doi.org/10.1016/j.acvd.2019.04.009DOI Listing
December 2019

Clip therapy for secondary mitral regurgitation: the beginning of a long story?

Acta Cardiol 2020 06 12;75(3):186-188. Epub 2019 Jun 12.

Department of Cardiology, CHU Rennes, Inserm, Univ Rennes, Rennes, France.

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http://dx.doi.org/10.1080/00015385.2019.1569314DOI Listing
June 2020

Early outcomes of transcarotid access for transcatheter aortic valve implantation.

EuroIntervention 2020 Feb 7;15(15):e1332-e1334. Epub 2020 Feb 7.

Division of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France.

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http://dx.doi.org/10.4244/EIJ-D-18-01192DOI Listing
February 2020

Doppler sonography of cerebral blood flow for early prognostication after out-of-hospital cardiac arrest: DOTAC study.

Resuscitation 2019 08 27;141:188-194. Epub 2019 May 27.

Service des Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, CHU Rennes, 2 rue Henri Le Guilloux, 35033 Rennes Cedex, France. Electronic address:

Aim: To assess the neurological prognosis of comatose survivors of cardiac arrest by early transcranial Doppler sonography (TCD).

Methods: This was a prospective study performed between May 2016 and October 2017 in a medical intensive care unit (ICU) and a cardiac ICU of a university teaching hospital. All patients older than 18 years who were successfully resuscitated from an out-of-hospital cardiac arrest (OHCA) with persistent coma after the return of spontaneous circulation (ROSC) were eligible. We excluded patients for whom OHCA was associated with traumatic brain injury, no possibility of TCD measurements, or who were dead before establishing the neurological prognosis. We measured the pulsatility index (PI) and diastolic flow velocity (DFV) of the right and left middle cerebral arteries within 12 h after ICU admission. The lowest DFV and highest PI values were used for the statistical analysis. The neurological outcome at hospital discharge was evaluated by the cerebral performance category.

Results: Forty-two patients were included in the final analysis: 15 had good and 27 poor neurological outcomes. The PI was higher in the poor outcome (1.49 vs. 1.12, p = 0.01) than good outcome group and the DFV was lower in the poor outcome group (17.3 cm svs. 26.0 cm s; p = 0.01).

Conclusion: Data provided by early TCD after ROSC are associated with neurological outcome. The use of TCD could help guide interventions to improve cerebral perfusion after ROSC in patients resuscitated from OHCA.
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http://dx.doi.org/10.1016/j.resuscitation.2019.05.024DOI Listing
August 2019

Simultaneous transapical aortic and mitral valve implantation in a patient with porcelain aorta.

Eur J Cardiothorac Surg 2019 Dec;56(6):1202-1203

Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France.

Left-sided double valve disease in the setting of extensive mitral annular calcifications and porcelain aorta raises multiple surgical challenges when considering an open surgical repair. We herein present the case of a 67-year-old patient with severe symptomatic aortic and mitral stenosis associated with extensive mitral annular calcifications and porcelain aorta, successfully treated by simultaneous transapical transcatheter aortic and mitral valve implantation.
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http://dx.doi.org/10.1093/ejcts/ezz148DOI Listing
December 2019

Design and preliminary results of FRENSHOCK 2016: A prospective nationwide multicentre registry on cardiogenic shock.

Arch Cardiovasc Dis 2019 May 11;112(5):343-353. Epub 2019 Apr 11.

Inserm, CNRS, PhyMedExp, cardiology department, université de Montpellier, CHU de Montpellier, 34295 Montpellier, France.

Background: Most data on the epidemiology of cardiogenic shock (CS) have come from patients with acute myocardial infarction admitted to intensive cardiac care units (ICCUs). However, CS can have other aetiologies, and could be managed in intensive care units (ICUs), especially the most severe forms of CS.

Aim: To gather data on the characteristics, management and outcomes of patients hospitalized in ICCUs and ICUs for CS, whatever the aetiology, in France in 2016.

Methods: We included all adult patients with CS between April and October 2016 in metropolitan France. CS was defined (at admission or during hospitalization) by: low cardiac output, defined by systolic blood pressure<90mmHg and/or the need for amines to maintain systolic blood pressure>90mmHg and/or cardiac index<2.2L/min/m; elevation of the left and/or right heart pressures, defined by clinical, radiological, biological, echocardiographic or invasive haemodynamic overload signs; and clinical and/or biological signs of malperfusion (lactate>2mmol/L, hepatic insufficiency, renal failure).

Results: Over a 6-month period, 772 patients were included in the survey (mean age 65.7±14.9 years; 71.5% men) from 49 participating centres (91.8% were public, and 77.8% of these were university hospitals). Ischaemic trigger was the most common cause (36.3%).

Conclusions: To date, FRENSHOCK is the largest CS survey; it will provide a detailed and comprehensive global description of the spectrum and management of patients with CS in a high-income country.
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http://dx.doi.org/10.1016/j.acvd.2019.02.001DOI Listing
May 2019

Endocarditis after percutaneous edge-to-edge in a heart transplant recipient: management through the HeartPort technique.

Interact Cardiovasc Thorac Surg 2019 Mar 15. Epub 2019 Mar 15.

Division of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France.

In the case illustrated in this study, a heart transplant recipient received percutaneous mitral edge-to-edge for secondary mitral regurgitation on the basis of increased reoperative risk. After development of mitral endocarditis, reoperation and mitral valve replacement were successfully performed through the HeartPort technique. We discuss the technical aspects, including the positioning of the Intraclude® device and the access to the mitral valve in this context. We address the decision-making issues (role of minimally invasive surgery to reduce operative risk in patients with one or more previous sternotomies).
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http://dx.doi.org/10.1093/icvts/ivz052DOI Listing
March 2019

Comparison of the Transarterial and Transthoracic Approaches in Nontransfemoral Transcatheter Aortic Valve Implantation.

Am J Cardiol 2019 05 8;123(9):1501-1509. Epub 2019 Feb 8.

University of Rennes 1, Cardiac, Thoracic, and Vascular Surgery Department, Pontchaillou University Hospital, Signal and Image Treatment laboratory (LTSI), National Institute of Health and Medical Research U1099, Rennes, France.

Transfemoral approach stands as the reference access-route for transcatheter aortic valve implantation (TAVI). Nonetheless, alternatives approaches are still needed in a significant proportion of patients. This study aimed at comparing outcomes between transthoracic-approach (transapical or transaortic) and transarterial-approach (transcarotid or subclavian) TAVI. Data from 191 consecutive patients who underwent surgical-approach TAVI from May 2009 to September 2017 were analyzed. Patients were allocated in 2 groups according to the approach. The primary end point was the 30-day composite of death of any cause, need for open surgery, tamponade, stroke, major or life-threatening bleeding, stage 2 or 3 acute kidney injury, coronary obstruction, or major vascular complications. During the study period, 104 patients underwent transthoracic TAVI (transapical: 60.6%, transaortic: 39.4%) whereas 87 patients underwent transarterial TAVI (subclavian: 83.9%, transcarotid: 16.1%). Logistic EuroSCORE I tended to be higher in transthoracic-TAVI recipients. In-hospital and 30-day composite end point rates were 25.0% and 11.5% (p = 0.025), and 26.0% and 14.9% (p = 0.075) for the transthoracic and transarterial cohorts, respectively. Propensity score-adjusted logistic regression demonstrated no significant detrimental association between the 30-day composite end point and transthoracic access (odds ratio 2.12 95% confidence interval 0.70 to 6.42; p = 0.18). Transarterial TAVI was associated with a shorter length of stay (median: 6 vs 7 days, p <0.001). TAVI approach was not an independent predictor of midterm mortality. In conclusion, nontransfemoral transarterial-approach TAVI is safe, feasible, and associated with comparable rates of major perioperative complications, and midterm mortality compared with transthoracic-approach TAVI.
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http://dx.doi.org/10.1016/j.amjcard.2019.01.040DOI Listing
May 2019

Admissions to intensive cardiac care units in France in 2014: A cross-sectional, nationwide population-based study.

Medicine (Baltimore) 2018 Oct;97(40):e12677

Cardiology Department, University Hospital of Montpellier, Montpellier.

Geographic variation in admission to the intensive cardiac care unit (ICCU) might question about the efficiency and the equity of the healthcare system. The aim was to explain geographic variation in the rate of admission to ICCU for coronary artery disease (CAD) or heart failure (HF) in France.We conducted a retrospective study based on the French national hospital discharge database. All inpatient stays for CAD or HF with an admission to an ICCU in 2014 were included. We estimated population-based age and sex-standardized ICCU admission rates at the department level. We separately modeled the department-level admission rates for HF and CAD using generalized linear models.In all, 61,010 stays for CAD and 27,828 stays for HF had at least 1 ICCU admission. The ICCU admission rates were explained by the admission rate for CAD, by the diabetes prevalence, by the proportion of the population >75 years, and by the drive time to the ICCU.This work sheds light on the finding of substantial geographic variation in the ICCU admission rates for CAD and HF in France. This variation is explained by both the age and the health status of the population and also by the drive time to the closest ICCU for HF. Moreover, ICCU admission for HF might be more prone to unwarranted variations due to medical practice patterns.
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http://dx.doi.org/10.1097/MD.0000000000012677DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200530PMC
October 2018

Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation.

N Engl J Med 2018 12 27;379(24):2297-2306. Epub 2018 Aug 27.

From Hopital Cardiovasculaire Louis Pradel, Chirurgie Cardio-Vasculaire et Transplantation Cardiaque (J.-F.O.), Pharmacy Department and Laboratoire Mateis (X.A.), and Hopital Cardiovasculaire Louis Pradel, Clinical Investigation Center and Heart Failure Department, INSERM 1407 (C.B., G.S., N. Mewton), Hospices Civils de Lyon and Claude Bernard University, Lyon, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Bichat (D.M.-Z., B.I., A.V.), and APHP, Hôpital Européen Georges Pompidou (N.K.), Paris, Centre Hospitalier Universitaire (CHU) Rennes, Hôpital Pontchaillou, Rennes (G.L., E.D.), Assistance Publique-Hôpitaux de Marseille (APHM), Hôpital de la Timone (G.B.), and Hôpital Saint Joseph (N. Michel), Marseille, CHU Nantes, Hôpital Guillaume et René Laennec, Nantes (N.P., J.-N.T., P.G.), Institut Jacques Cartier, Massy (T.L., B.C.), Clinique du Millénaire (C.P.) and CHU Montpellier, Hôpital Arnaud-de-Villeneuve (F.L.), Montpellier, CHU Angers, Angers (F.R.), CHU Toulouse, Hôpital Rangueil, Toulouse (D.C.), Centre Cardiologique du Nord, Saint-Denis (M.N.), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg (P.O.), Centre Hospitalier Régional Universitaire (CHRU) de Tours, Hôpital Trousseau, Tours (C.S.E.), APHP, Hôpital Henri Mondor, Créteil (E.T.), CHU Bordeaux, Hôpital Haut-Lévêque, Pessac (L.L.), CHRU Brest, Hôpital de La Cavale Blanche, Brest (M.G.), and Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Centre National de la Recherche Scientifique (CNRS), and Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne (F.B., D.M.-B.) - all in France; and the University of Ottawa Heart Institute, Division of Cardiology, Ottawa, Canada (D.M.-Z.).

Background: In patients who have chronic heart failure with reduced left ventricular ejection fraction, severe secondary mitral-valve regurgitation is associated with a poor prognosis. Whether percutaneous mitral-valve repair improves clinical outcomes in this patient population is unknown.

Methods: We randomly assigned patients who had severe secondary mitral regurgitation (defined as an effective regurgitant orifice area of >20 mm or a regurgitant volume of >30 ml per beat), a left ventricular ejection fraction between 15 and 40%, and symptomatic heart failure, in a 1:1 ratio, to undergo percutaneous mitral-valve repair in addition to receiving medical therapy (intervention group; 152 patients) or to receive medical therapy alone (control group; 152 patients). The primary efficacy outcome was a composite of death from any cause or unplanned hospitalization for heart failure at 12 months.

Results: At 12 months, the rate of the primary outcome was 54.6% (83 of 152 patients) in the intervention group and 51.3% (78 of 152 patients) in the control group (odds ratio, 1.16; 95% confidence interval [CI], 0.73 to 1.84; P=0.53). The rate of death from any cause was 24.3% (37 of 152 patients) in the intervention group and 22.4% (34 of 152 patients) in the control group (hazard ratio, 1.11; 95% CI, 0.69 to 1.77). The rate of unplanned hospitalization for heart failure was 48.7% (74 of 152 patients) in the intervention group and 47.4% (72 of 152 patients) in the control group (hazard ratio, 1.13; 95% CI, 0.81 to 1.56).

Conclusions: Among patients with severe secondary mitral regurgitation, the rate of death or unplanned hospitalization for heart failure at 1 year did not differ significantly between patients who underwent percutaneous mitral-valve repair in addition to receiving medical therapy and those who received medical therapy alone. (Funded by the French Ministry of Health and Research National Program and Abbott Vascular; MITRA-FR ClinicalTrials.gov number, NCT01920698 .).
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http://dx.doi.org/10.1056/NEJMoa1805374DOI Listing
December 2018

Multimodality imaging guidance for percutaneous paravalvular leak closure: Insights from the multi-centre FFPP register.

Arch Cardiovasc Dis 2018 Jun - Jul;111(6-7):421-431. Epub 2018 Jun 22.

Faculté de médecine Paris-Sud, hôpital Marie-Lannelongue, université Paris-Sud, Paris-Saclay, 92350 Le Plessis-Robinson, France.

Background: Percutaneous paravalvular leak (PVL) closure has emerged as a palliative alternative to surgical management in selected high-risk patients. Percutaneous procedures are challenging, especially for mitral PVL. Accurate imaging of the morphologies of the defects is mandatory, together with precise guidance in the catheterization laboratory to enhance success rates.

Aims: To describe imaging modalities used in clinical practice to guide percutaneous PVL closure and assess the potential of new imaging tools.

Methods: Data from the 'Fermeture de Fuite paraprothétique' (FFPP) register were used. The FFPP register is an international multi-institutional collaborative register started in 2017 with a retrospective and a prospective part. A descriptive analysis of multimodality imaging used to guide PVL closure in clinical practice was performed.

Results: Data from 173 procedures performed in 19 centres from three countries (France, Belgium and Poland) were collected, which included eight cases of PVL following transcatheter valve replacement. Transoesophageal echocardiography was used in 167 cases (96.5%) and 3D echocardiography in 87.4% of cases. In one case, 3D-echocardiography was fused with fluoroscopy images in real time using echonavigator software. Details about multimodality imaging were available from a sample of 31 patients. Cardiac computed tomography (CT) was performed before 10 of the procedures. In one case, fusion between preprocedural cardiac CT angiography data and fluoroscopy data was used. In two cases, a 3D model of the valve with PVL was printed.

Conclusion: Echocardiography, particularly the 3D mode, is the cornerstone of PVL imaging. Other imaging modalities, such as cardiac CT and cardiac magnetic resonance imaging, may be of complementary interest. New techniques such as imaging fusion and printing may further facilitate the percutaneous approach of PVLs.
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http://dx.doi.org/10.1016/j.acvd.2018.05.001DOI Listing
October 2018

Current indications for the intra-aortic balloon pump: The CP-GARO registry.

Arch Cardiovasc Dis 2018 Dec 13;111(12):739-748. Epub 2018 Jun 13.

Université Rennes, Department of cardiology, CHU Rennes, Inserm, LTSI-UMR 1099, 35000 Rennes, France; EA4324, département de cardiologie, optimisation des régulations physiologiques (ORPhy), UFR sciences et techniques, CHU de Brest, 29200 Brest, France; L'institut du Thorax, CHU Nantes, service de cardiologie, 44093 Nantes, France. Electronic address:

Background: Intra-aortic balloon pumps (IABPs) have been used routinely since the 1970s. Recently, large randomized trials failed to show that IABP therapy has meaningful benefit, and international recommendations downgraded its place, particularly in cardiogenic shock.

Aims: The aim of this registry was to describe the contemporary use of IABP therapy, in light of these new data.

Methods: This prospective multicentre registry included 172 patients implanted with an IABP in 19 French cardiac centres in 2015. Baseline characteristics, aetiologies leading to IABP use, and IABP-related and disease-related complications were assessed. In-hospital and 1-year mortality rates were studied.

Results: A total of 172 patients were included (mean age 65.5±12.0 years; 118 men [68.6%]). The reasons for IABP implantation were mainly haemodynamic (n=107; 62.2%), followed by bridge to revascularization (n=34; 19.8%) and four other "rare" aetiologies (n=29 patients; 16.8%). In-hospital and 1-year mortality rates were 40.7% and 45.8%, respectively. Fourteen patients (8.1%) experienced ischaemic or haemorrhagic complications, which were directly related to the IABP in seven patients (4.1%).

Conclusions: Despite current international guidelines regarding the place of IABPs in ischaemic cardiogenic shock without mechanical complications, this aetiology remains the leading cause for its utilization in the contemporary era.
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http://dx.doi.org/10.1016/j.acvd.2018.03.011DOI Listing
December 2018

Mechanical circulatory support in patients with cardiogenic shock in intensive care units: A position paper of the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology, endorsed by the "Groupe Athérome et Cardiologie Interventionnelle" of the French Society of Cardiology.

Arch Cardiovasc Dis 2018 Oct 11;111(10):601-612. Epub 2018 Jun 11.

Department of Cardiology, Paris-Diderot University, Lariboisiere Hospital, AP-HP, 75010 Paris, France.

Cardiogenic shock (CS) is a major challenge in contemporary cardiology. Despite a better understanding of the pathophysiology of CS, its management has only improved slightly. The prevalence of CS has remained stable over the past decade, but its outcome has seen few improvements, with the 1-month mortality rate still in the range of 40-60%. Inotropes and vasopressors are the first-line therapies for CS, but they are associated with significant hazards, and have well-known deleterious effects. Furthermore, a significant number of patients develop refractory CS with haemodynamic instability, causing critical organ hypoperfusion and/or pulmonary congestion, despite increasing doses of catecholamines. A major change has resulted from the recent advent and availability of potent mechanical circulatory support (MCS) devices. These devices, which ensure sustained blood flow, provide a great and long-awaited opportunity to improve the prognosis of CS. Several efficient MCS devices are now available, including left ventricle-to-aorta circulatory support devices and full pulmonary and circulatory support with venoarterial extracorporeal membrane oxygenation. However, evidence to support their indications, the timing of implantation and the selection of patients and devices is scarce. Because these devices are gaining momentum and are becoming readily available, the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology aims to propose practical algorithms for the use of these devices, to help intensive care unit and cardiac care unit physicians in this complex area, where evidence is limited.
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http://dx.doi.org/10.1016/j.acvd.2018.03.008DOI Listing
October 2018

Predicting the development of in-hospital cardiogenic shock in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention: the ORBI risk score.

Eur Heart J 2018 06;39(22):2090-2102

Department of Cardiology and Vascular Diseases, Pontchaillou University Hospital, Center for Clinical Investigation 804, University of Rennes 1, Signal and Image Treatment laboratory (LTSI), National Institute of Health and Medical Research U1099, Rennes, France.

Aims: To derive and validate a readily useable risk score to identify patients at high-risk of in-hospital ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS).

Methods And Results: In all, 6838 patients without CS on admission and treated by primary percutaneous coronary intervention (pPCI), included in the Observatoire Régional Breton sur l'Infarctus (ORBI), served as a derivation cohort, and 2208 patients included in the obseRvatoire des Infarctus de Côte-d'Or (RICO) constituted the external validation cohort. Stepwise multivariable logistic regression was used to build the score. Eleven variables were independently associated with the development of in-hospital CS: age >70 years, prior stroke/transient ischaemic attack, cardiac arrest upon admission, anterior STEMI, first medical contact-to-pPCI delay >90 min, Killip class, heart rate >90/min, a combination of systolic blood pressure <125 mmHg and pulse pressure <45 mmHg, glycaemia >10 mmol/L, culprit lesion of the left main coronary artery, and post-pPCI thrombolysis in myocardial infarction flow grade <3. The score derived from these variables allowed the classification of patients into four risk categories: low (0-7), low-to-intermediate (8-10), intermediate-to-high (11-12), and high (≥13). Observed in-hospital CS rates were 1.3%, 6.6%, 11.7%, and 31.8%, across the four risk categories, respectively. Validation in the RICO cohort demonstrated in-hospital CS rates of 3.1% (score 0-7), 10.6% (score 8-10), 18.1% (score 11-12), and 34.1% (score ≥13). The score demonstrated high discrimination (c-statistic of 0.84 in the derivation cohort, 0.80 in the validation cohort) and adequate calibration in both cohorts.

Conclusion: The ORBI risk score provides a readily useable and efficient tool to identify patients at high-risk of developing CS during hospitalization following STEMI, which may aid in further risk-stratification and thus potentially facilitate pre-emptive clinical decision making.
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http://dx.doi.org/10.1093/eurheartj/ehy127DOI Listing
June 2018

Myocardial infarction and thrombophilia: Do not miss the right diagnosis!

Rev Port Cardiol 2018 Jan 15;37(1):89.e1-89.e4. Epub 2017 Dec 15.

Centre Hospitalier Universitaire (CHU) de Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, France; Université de Rennes 1, Laboratoire Traitement du Signal et de l'Image (LTSI), Rennes, France; Institut National de la Santé et de la Recherche Médicale (Inserm), Rennes, France.

Protein C deficiency is a coagulation cascade disorder often resulting in venous thromboembolic events but is also a possible contributor to arterial thrombosis. To date, approximately ten cases of myocardial infarction (MI) due to protein C deficiency have been reported in the literature. However, affirming this mechanism requires ruling out the most common causes of MI, i.e. the rupture or erosion of an atherosclerotic plaque. Intravascular imaging of coronary arteries can be of help to identify angiographically undetected atherosclerosis. We report a case of an ST-segment elevation myocardial infarction (STEMI) in a young man with apparent evidence of arterial thrombosis resulting from protein C deficiency and heterozygous factor Leiden mutation which was contradicted by intravascular imaging demonstrating atherosclerosis.
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http://dx.doi.org/10.1016/j.repc.2016.12.018DOI Listing
January 2018

Immediate complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease treated by primary percutaneous coronary intervention: Insights from the ORBI registry.

Arch Cardiovasc Dis 2018 Nov 8;111(11):656-665. Epub 2017 Dec 8.

CIC-IT 804, service de cardiologie et maladies vasculaires, CHU Pontchaillou, 35000 Rennes, France; Inserm U1099, laboratoire de traitement du signal et de l'image, université de Rennes 1, 35000 Rennes, France.

Background: Recent studies demonstrated the superiority of complete revascularization (CR) in patients treated by primary percutaneous coronary intervention (pPCI) in ST-elevation myocardial infarction (STEMI).

Aim: To evaluate whether immediate CR improves in-hospital outcomes in patients with STEMI with multivessel disease.

Methods: Data from a prospective multicentre registry including 9365 patients with STEMI were analysed. Patients with multivessel disease and treated with pPCI (n=3412) were included and separated into two groups according to whether immediate CR was performed during the index procedure. The primary endpoint was in-hospital major adverse cardiovascular events (MACE), defined as a composite of all-cause death, non-fatal myocardial infarction, stroke and definite stent thrombosis. Secondary endpoints were individual components of MACE and major bleeding. Multivariable Cox regression and propensity-score adjustment were performed to account for confounders.

Results: Immediate CR was performed in 98 patients (2.9%), whereas 3314 patients (97.1%) were incompletely revascularized. The prevalence of severe heart failure (Killip class III or IV) and significant lesions of the left main coronary artery were higher in the immediate CR group (21.6% vs. 13.5% and 24.5% vs. 6.7%, respectively; P<0.001 for both). After adjustment, immediate CR was not associated with reduced rates of MACE (hazard ratio [HR] 0.64, 95% confidence interval [CI]: 0.31-1.35; P=0.24) or all-cause death (HR: 0.52, 95% CI: 0.23-1.16; P=0.11), but with increased risks of definite stent thrombosis (HR: 3.93, 95% CI: 1.12-13.75; P=0.03) and major bleeding (HR: 17.46, 95% CI: 2.29-133.17; P=0.006).

Conclusion: Immediate CR did not improve in-hospital outcomes of patients with STEMI with multivessel disease in this analysis. Randomized studies are warranted to elucidate the optimal timing of CR in patients with STEMI.
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http://dx.doi.org/10.1016/j.acvd.2017.08.005DOI Listing
November 2018