Publications by authors named "Katrien Blanchart"

29 Publications

  • Page 1 of 1

Glycoprotein IIb/IIIa inhibitors use in the setting of primary percutaneous coronary intervention for ST elevation myocardial infarction in patients pre-treated with newer P2Y12 inhibitors.

Clin Cardiol 2021 Jun 11. Epub 2021 Jun 11.

CHU de Caen Normandie, Service de Cardiologie, Caen, France.

Objectives: We sought to investigate the safety and potential benefit of administrating glycoprotein IIb-IIIa inhibitors (GPIs) on top of more potent P2Y12 inhibitors.

Background: A number of clinical trials, performed at a time when pretreatment and potent platelet inhibition was not part of routine clinical practice, have documented clinical benefits of GPI in ST-segment elevation myocardial infarction (STEMI) patients at the cost of a higher risk of bleeding.

Methods: We used the data of a prospective, ongoing registry of patients admitted for STEMI in our center. For the purpose of this study only patients presenting for primary percutaneous coronary intervention and pretreated with new P2Y12 inhibitors (prasugrel or ticagrelor) were included. We compared patients who received GPI with those who did not.

Results: Eight hundred twenty-four STEMI patients were included in our registry; GPIs were used in 338 patients (41%). GPI patients presented more often with cardiogenic shock and Thrombolysis in myocardial infarction (TIMI) flow grade <3. GPI use was not associated with an increase in in-hospital or 3-month mortality. Bleeding endpoints were similar in both groups.

Conclusions: Our study suggests that GPI may be used safely in combination with recent P2Y12 inhibitors in STEMI patients in association with modern primary percutaneous coronary intervention strategies (radial access and anticoagulation with enoxaparin) with similar bleeding and mortality rates at hospital discharge and 3-month follow-up.
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http://dx.doi.org/10.1002/clc.23654DOI Listing
June 2021

Safety and efficacy of very short dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy in older patients undergoing percutaneous coronary intervention: meta-analysis of randomised controlled trials.

Age Ageing 2021 Jun;50(4):1102-1107

CHU de Caen Normandie, Service de Cardiologie, 14000 Caen, France.

Background: older patients undergoing percutaneous coronary intervention (PCI) represent a growing population sharing both a high ischemic and bleeding risk. Dual antiplatelet therapy (DAPT) reduces the incidence of thrombotic events but exposes patients to an increased risk of bleeding and subsequent mortality. Its optimal duration after PCI remains unclear.

Objective: to assess the impact of short-duration DAPT on both bleeding and ischemic events in the specific population of older patients undergoing PCI.

Methods: we performed a meta-analysis of randomised controlled trials comparing the safety and efficacy of standard versus very short duration (≤ 3 months, followed by P2Y12 inhibitor monotherapy) DAPT after PCI with a drug-eluting stent in older patients.

Results: four studies, representing 8,961 older patients, were finally included. Compared with standard duration, short-duration DAPT was associated with similar rates of major bleeding (relative risks, RR 0.70 [0.47; 1.05]) and the composite efficacy endpoint (RR 0.85 [0.63; 1.14]). There was a high level of heterogeneity between the studies (I2 = 68%) regarding major bleeding.

Conclusion: our meta-analysis suggests that short DAPT may be a valid option in older patients after PCI but it also highlights the need for specific studies in such patients on optimal duration of antiplatelet therapy.
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http://dx.doi.org/10.1093/ageing/afab047DOI Listing
June 2021

Comparison of Outcomes and Mortality in Patients Having Left Ventricular Assist Device Implanted Early -vs- Late After Diagnosis of Cardiomyopathy.

Am J Cardiol 2021 05 4;146:82-88. Epub 2021 Feb 4.

Department of Cardiology and Cardiac Surgery, AP-HP CHU Henri Mondor, Créteil, France.

LVAD implantation in patients with a recently diagnosed cardiomyopathy has been poorly investigated. This work aims at describing the characteristics and outcomes of patients receiving a LVAD within 30 days following the diagnosis of cardiomyopathy. Patients from the ASSIST-ICD study was divided into recently and remotely diagnosed cardiomyopathy based on the time from initial diagnosis of cardiomyopathy to LVAD implantation using the cut point of 30 days. The primary end point of the study was all-cause mortality at 30-day and during follow-up. A total of 652 patients were included and followed during a median time of 9.1 (2.5 to 22.1) months. In this population, 117 (17.9%) had a recently diagnosed cardiomyopathy and had LVAD implantation after a median time of 15.0 (9.0 to 24.0) days following the diagnosis. This group of patients was significantly younger, with more ischemic cardiomyopathy, more sudden cardiac arrest (SCA) events at the time of the diagnosis and were more likely to receive temporary mechanical support before LVAD compared with the remotely diagnosed group. Postoperative in-hospital survival was similar in groups, but recently diagnosed patients had a better long-term survival after hospital discharge. SCA before LVAD and any cardiac surgery combined with LVAD implantation were identified as 2 independent predictors of postoperative mortality in recently diagnosed patients. In conclusion, rescue LVAD implantation for recently diagnosed severe cardiomyopathy is common in clinical practice. Such patients experience a relatively low postoperative mortality and have a better long-term survival compared with remotely diagnosed patients.
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http://dx.doi.org/10.1016/j.amjcard.2021.01.027DOI Listing
May 2021

Ticagrelor versus clopidogrel in elective percutaneous coronary intervention (ALPHEUS): a randomised, open-label, phase 3b trial.

Lancet 2020 11 14;396(10264):1737-1744. Epub 2020 Nov 14.

Sorbonne Université, ACTION Study Group, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France. Electronic address:

Background: Percutaneous coronary intervention (PCI)-related myonecrosis is frequent and can affect the long-term prognosis of patients. To our knowledge, ticagrelor has not been evaluated in elective PCI and could reduce periprocedural ischaemic complications compared with clopidogrel, the currently recommended treatment. The aim of the ALPHEUS study was to examine if ticagrelor was superior to clopidogrel in reducing periprocedural myocardial necrosis in stable coronary patients undergoing high-risk elective PCI.

Methods: The ALPHEUS study, a phase 3b, randomised, open-label trial, was done at 49 hospitals in France and Czech Republic. Patients with stable coronary artery disease were eligible for the study if they had an indication for PCI and at least one high-risk characteristic. Eligible patients were randomly assigned (1:1) to either ticagrelor (180 mg loading dose, 90 mg twice daily thereafter for 30 days) or clopidogrel (300-600 mg loading dose, 75 mg daily thereafter for 30 days) by use of an interactive web response system, and stratified by centre. The primary outcome was a composite of PCI-related type 4 (a or b) myocardial infarction or major myocardial injury and the primary safety outcome was major bleeding, both of which were evaluated within 48 h of PCI (or at hospital discharge if earlier). The primary analysis was based on all events that occurred in the intention-to-treat population. The trial was registered with ClinicalTrials.gov, NCT02617290.

Findings: Between Jan 9, 2017, and May 28, 2020, 1910 patients were randomly assigned at 49 sites, 956 to the ticagrelor group and 954 to the clopidogrel group. 15 patients were excluded from the ticagrelor group and 12 from the clopidogrel group. At 48 h, the primary outcome was observed in 334 (35%) of 941 patients in the ticagrelor group and 341 (36%) of 942 patients in the clopidogrel group (odds ratio [OR] 0·97, 95% CI 0·80-1·17; p=0·75). The primary safety outcome did not differ between the two groups, but minor bleeding events were more frequently observed with ticagrelor than clopidogrel at 30 days (105 [11%] of 941 patients in the ticagrelor group vs 71 [8%] of 942 patients in the clopidogrel group; OR 1·54, 95% CI 1·12-2·11; p=0·0070).

Interpretation: Ticagrelor was not superior to clopidogrel in reducing periprocedural myocardial necrosis after elective PCI and did not cause an increase in major bleeding, but did increase the rate of minor bleeding at 30 days. These results support the use of clopidogrel as the standard of care for elective PCI.

Funding: ACTION Study Group and AstraZeneca.
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http://dx.doi.org/10.1016/S0140-6736(20)32236-4DOI Listing
November 2020

Relation of Body Mass Index to Outcomes in Patients With Heart Failure Implanted With Left Ventricular Assist Devices.

Am J Cardiol 2020 10 6;133:81-88. Epub 2020 Aug 6.

Department of Cardiology and cardiac surgery, University Hospital, Dijon, France.

We aimed at characterizing the impact of low and high body mass index (BMI) on outcomes after left-ventricular assist device (LVAD) surgery and define the predictors of mortality in patients with abnormal BMI (low/high). This study was conducted in 19 centers from 2006 to 2016. Patients were divided based on their baseline BMI into 3 groups of BMI: low (BMI ≤18.5 kg/m²); normal (BMI = 18.5 to 24.99 kg/m²) and high (BMI ≥25 kg/m²) (including overweight (BMI = 25 to 29.99 kg/m²), and obesity (BMI ≥30 Kg/m²)). Among 652 patients, 29 (4.4%), 279 (42.8%) and 344 (52.8%) had a low-, normal-, and high BMI, respectively. Patients with high BMI were significantly more likely men, with more co-morbidities and more history of ventricular/supra-ventricular arrhythmias before LVAD implantation. Patients with abnormal BMI had significantly lower survival than those with normal BMI. Notably, those with low BMI experienced the worst survival whereas overweight or obese patients had similar survival. Four predictors of mortality for LVAD candidates with abnormal BMI were defined: total bilirubin ≥16 µmol/L before LVAD, hypertension, destination therapy, and cardiac surgery with LVAD. Depending on the number of predictor per patients, those with abnormal BMI may be divided in 3 groups of 1-year mortality risk, i.e., low (0 to 1 predictor: 29% and 31%), intermediate (2 to 3 predictors, 51% and 52%, respectively), and high (4 predictors: 83%). In conclusion, LVAD recipients with abnormal BMI experience lower survival, especially underweight patients. Four predictors of mortality have been identified for LVAD population with abnormal BMI, differentiating those a low-, intermediate-, and high risks of death.
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http://dx.doi.org/10.1016/j.amjcard.2020.07.045DOI Listing
October 2020

Implantable cardiac defibrillator leads dysfunction after LVAD implantation.

Pacing Clin Electrophysiol 2020 11 24;43(11):1309-1317. Epub 2020 Jul 24.

Department of Cardiology and Cardiac Surgery, AP-HP CHU Henri Mondor, Créteil, France.

Background: Implantable cardioverter-defibrillator (ICD) lead dysfunction has been reported after left ventricular assist device (LVAD) implantation in limited single-center studies. We aimed at describing and characterizing the incidence of ICD lead parameters dysfunction after LVAD implantation.

Methods: Among the 652 patients enrolled in the ASSIST-ICD study, only patients with an ICD prior to LVAD were included (n = 401). ICD lead parameters dysfunction following LVAD implantation is defined as follows: (a) >50% decrease in sensing threshold, (b) pacing lead impedance increase/decrease by >100Ω, and (c) >50% increase in pacing threshold.

Results: One hundred twenty-two patients with an ICD prior to LVAD had available ICD interrogation reports prior and after LVAD. A total of 67 (55%) patients exhibited at least one significant lead dysfunction: 17 (15%) exhibited >50% decrease in right ventricular (RV) sensing, 51 (42%) had >100 Ω increase/decrease in RV pacing impedance, and 24 (20%) experienced >50% increase in RV pacing threshold. A total of 52 patients experienced ventricular arrhythmia during follow-up and all were successfully detected and treated by the device. All lead dysfunction could be managed conservatively.

Conclusion: More than 50% of LVAD-recipients may experience >1 significant change in lead parameters but none had severe clinical consequences.
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http://dx.doi.org/10.1111/pace.14004DOI Listing
November 2020

Evaluation of Left Main Coronary Artery Using Optical Frequency Domain Imaging and Its Pitfalls.

J Interv Cardiol 2020 12;2020:4817239. Epub 2020 Jun 12.

CHU de Caen Normandie, Service de Cardiologie, Caen 14000, France.

Objectives: We aimed to assess the quality of optical frequency domain imaging (OFDI) of the left main (LM) arterial wall and describe and analyse potential artefacts in this setting.

Background: OFDI is increasingly used to assess ambiguous lesions and optimize LM percutaneous coronary intervention. However, its ability to provide artefact-free high-quality images of coronary ostia and large segments such as the LM remains uncertain.

Methods: We included 42 consecutive patients who underwent OFDI, including LM imaging. Each OFDI frame was subdivided into four quadrants and analysed. The number of quadrants with artifacts was calculated within the proximal, mid, and distal LM and the first 5 mm of the left anterior descending artery (LAD) and/or left circumflex artery (LCX).

Results: The quadrants analysis showed an overall artifact rate of 8.9%, mostly out-of-field (45.1%) or residual blood (44.7%) artefacts. Most artifacts were located in the proximal LM (18.6%) with a stepwise reduction of artifact rates towards distal segments (mid LM 5.8%; distal LM 3.6%, ostial LAD 2.6%, and ostial LCX 0%; < 0.001). While 20 (48.8%) patients had angiographically visible plaques, OFDI showed plaques in 32 patients (76.2%; =0.007).

Conclusion: OFDI can accurately evaluate the LM and detect and assess angiographically unvisualized atherosclerotic plaques providing accurate assessment of >90% of the quadrants of the LM and the ostia of its bifurcation branches. However, artifacts mainly located in the proximal LM and decreasing distally in a stepwise fashion should be considered in the interpretation of OFDI in this setting.
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http://dx.doi.org/10.1155/2020/4817239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7306070PMC
November 2020

Usefulness of a personalized algorithm-based discharge checklist in patients hospitalized for acute heart failure.

ESC Heart Fail 2020 06 22;7(3):1217-1223. Epub 2020 Apr 22.

Department of Cardiology, Normandie University, UNICAEN, CHU de Caen Normandie, EA4650 Signalisation, Electrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique (SEILIRM), FHU REMOD-VHF, Caen, France.

Aims: The aim of this study is to evaluate the usefulness of a personalized discharge checklist (PCL) based on simple baseline characteristics on mortality, readmission for heart failure (HF), and quality of care in patients hospitalized for acute HF.

Methods And Results: We designed an algorithm to generate PCL, based on 2016 HF European Society of Cardiology Guidelines and the screening of common comorbidities in elderly HF patients. We prospectively included 139 patients hospitalized for HF from May 2018 to October 2018. A PCL was fulfilled for each patient at admission and 24 to 48 hours before the planned discharge. A control cohort of 182 consecutive patients was retrospectively included from May 2017 to October 2017. The primary composite endpoint was mortality or readmission for HF at 6 months. The secondary endpoints were mortality, readmission for HF, and quality of care (evidence-based medications, management of HF comorbidities, and planned care plan). There was no difference among baseline characteristics between PCL and control cohorts; mean age was 78.1 ± 12.2 vs. 79.0 ± 12.5 years old (P = 0.46) and 61 patients (43.9%) vs. 63 (34.6%) had HF with left ventricular ejection fraction (LVEF) <40% (P = 0.24). During the 6 month follow-up period, 59 patients (42.4%) reached the primary endpoint in the PCL cohort vs. 92 patients (50.5%) in the control cohort [hazard ratio (HR): 0.79, 95% confidence interval (CI) (0.57-1.09), P = 0.15]. Subgroup analysis including only patients with either altered (<40%) or mid-range or preserved (≥40%) LVEF showed no significant difference among groups. There was a non-significant trend toward a reduction in HF readmission rate in the PCL group [38 patients (27.3%) vs. 64 patients (35.2%), HR: 0.73, 95%CI (0.49-1.09), P = 0.13]. There was no difference regarding survival or the use of evidence-based medications. A higher proportion of patients were screened and treated for iron and vitamin D deficiencies (53.2% vs. 35.7%, P < 0.01 and 73.4% vs. 29.7%, P < 0.01, respectively), as well as malnutrition supplemented in the PCL group. There was a higher referral to HF follow-up programme in the PCL group but not to telemedicine or cardiac rehabilitation programs.

Conclusions: In this preliminary study, the use of a PCL did not improve outcomes at 6 months in patients hospitalized for acute HF. There was a non-significant trend towards a reduction in HF readmission rate in the PCL group. In addition, the management of HF comorbidities was significantly improved by PCL with a better referral to follow-up programme. A multicentre study is warranted to assess the usefulness of a simple costless personalized checklist in a large HF patients' population.
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http://dx.doi.org/10.1002/ehf2.12604DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261525PMC
June 2020

Residual platelet reactivity, thrombus burden and myocardial reperfusion in patients treated by PCI after successful pre-hospital fibrinolysis compared to primary PCI.

J Thromb Thrombolysis 2020 Nov;50(4):858-866

CHU de Caen Normandie, Service de Cardiologie, Caen, 14000, France.

We compared residual platelet reactivity and post PCI atherothrombotic burden using OFDI in patients successfully treated by primary PCI versus pharmacoinvasive approach (PI) defined as PCI after successful pre-hospital fibrinolysis. Despite pre-hospital P2Y12-inhibitor loading dose, high rates of high on-treatment platelet reactivity were found at the time of PCI in both groups. Primary PCI patients had higher post stenting thrombus burden and lower rates of final normal myocardial blush grade compared to PI. These findings support the use of a pharmacoinvasive reperfusion strategy especially when primary PCI cannot be timely performed.
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http://dx.doi.org/10.1007/s11239-020-02113-8DOI Listing
November 2020

Outcomes of Left Ventricular Assist Device Implantation in Patients With Uncommon Etiology Cardiomyopathy.

Am J Cardiol 2020 05 8;125(9):1421-1428. Epub 2020 Feb 8.

Department of Cardiology and cardiac surgery, University Hospital, Dijon, France.

The impact of uncommon etiology cardiomyopathies on Left-ventricular assist device (LVAD)-recipient outcomes is not very well known. This study aimed to characterize patients with uncommon cardiomyopathy etiologies and examine the outcomes between uncommon and ischemic/idiopathic dilated cardiomyopathy. This observational study was conducted in 19 centers between 2006 and 2016. Baseline characteristics and outcomes of patients with uncommon etiology were compared to patients with idiopathic dilated/ischemic cardiomyopathies. Among 652 LVAD-recipients included, a total of 590 (90.5%) patients were classified as ischemic/idiopathic and 62 (9.5%) patients were classified in the "uncommon etiologies" group. Main uncommon etiologies were: hypertrophic (n = 12(19%)); cancer therapeutics-related cardiac dysfunction (CTRCD) (n = 12(19%)); myocarditis (n = 11(18%)); valvulopathy (n = 9(15%)) and others (n = 18(29%)). Patients with uncommon etiologies were significantly younger with more female and presented less co-morbidities. Additionally, patients with uncommon cardiomyopathies were less implanted as destination therapy compared with ischemic/idiopathic group (29% vs 38.8%). During a follow-up period of 9.1 months, both groups experienced similar survival. However, subgroup of hypertrophic/valvular cardiomyopathies and CTRCD had significantly higher mortality compared to the ischemic/idiopathic or myocarditis/others cardiomyopathies. Conversely, patients with myocarditis/others etiologies experienced a better survival. Indeed, the 12-months survival in the myocarditis/others; ischemic/idiopathic and hypertrophic/CTRCD/valvulopathy group were 77%; 65%, and 46% respectively. In conclusion, LVAD-recipients with hypertrophic cardiomyopathy, valvular heart disease and CTRCD experienced the higher mortality rate.
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http://dx.doi.org/10.1016/j.amjcard.2020.01.042DOI Listing
May 2020

Systematic review and meta-analysis of the prognostic impact of cancer among patients with acute coronary syndrome and/or percutaneous coronary intervention.

BMC Cardiovasc Disord 2020 01 30;20(1):38. Epub 2020 Jan 30.

CHU de Caen Normandie, Service de Cardiologie, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.

Background: Patients with cancer admitted for an acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI) represent a growing and high-risk population. The influence of co-existing cancer on mortality remains unclear in such patients. We aimed to assess the impact of cancer on early and late, all-cause and cardiac mortality in the setting of ACS and/or PCI.

Methods: We performed a systematic review and meta-analysis of studies comparing outcomes of patients with and without a history of cancer admitted for ACS and/or PCI.

Results: Six studies including 294,528 ACS patients and three studies including 39,973 PCI patients were selected for our meta-analysis. Patients with cancer had increased rates of in-hospital all-cause death (RR 1.74 [1.22; 2.47]), cardiac death (RR 2.44 [1.73; 3.44]) and bleeding (RR 1.64 [1.35; 1.98]) as well as one-year all-cause death (RR 2.62 [1.2; 5.73]) and cardiac death (RR 1.89 [1.25; 2.86]) in ACS studies. Rates of long term all-cause (RR 1.96 [1.52; 2.53]) but not cardiac death were higher in cancer patients admitted for PCI.

Conclusion: Cancer patients represent a high-risk population both in the acute phase and at long-term after an ACS or PCI. The magnitude of the risk of mortality should however be tempered by the heterogeneity among studies. Early and long term optimal management of such patients should be promoted in clinical practice.
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http://dx.doi.org/10.1186/s12872-020-01352-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993442PMC
January 2020

Residual atherothrombotic burden after primary percutaneous coronary intervention and myocardial reperfusion-An optical frequency domain imaging study.

Catheter Cardiovasc Interv 2020 07 13;96(1):91-97. Epub 2019 Aug 13.

CHU de Caen Normandie, Service de Cardiologie, Caen, France.

Objectives: We aimed to assess the relationship between residual in-stent atherothrombotic burden (ATB) after primary percutaneous coronary intervention (PCI) measured by optical frequency domain imaging (OFDI) using different measurement methods and myocardial blush grade (MBG).

Background: The impact of residual ATB after primary PCI on myocardial reperfusion remains unclear.

Methods: We prospectively included 60 ST-elevation myocardial infarction patients pretreated with aspirin and ticagrelor. OFDI volumetric quantification using planimetry (with intervals every frame or every millimeter) and semiquantitative score were used to determine ATB. Patients were divided into two groups according to final MBG 3 or <3.

Results: The mean ATB was 10.08 ± 5.21%. ATB was lower in patients with final MBG 3 compared to those with impaired MBG, regardless of the measurement method (8.15 ± 5.58 vs. 11.77 ± 4.28%; p = .007 for quantification per frame; 7.8 ± 5.19 vs. 11.07 ± 4.07%; p = .009 for quantification per mm and 11.21 ± 11.75 vs. 22.91 ± 17.35; p = .003 for the semiquantitative thrombus score, respectively).

Conclusion: Residual post-stenting ATB remains substantial after primary PCI in STEMI patients, even when pretreated with ticagrelor and aspirin. ATB appears as a significant correlate of suboptimal myocardial reperfusion, a known surrogate of clinical outcome.
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http://dx.doi.org/10.1002/ccd.28429DOI Listing
July 2020

Residual platelet reactivity after pre-treatment with ticagrelor prior to primary percutaneous coronary intervention is associated with suboptimal myocardial reperfusion.

Eur Heart J Acute Cardiovasc Care 2019 Aug 12:2048872619860214. Epub 2019 Aug 12.

1 Department of Cardiology, Caen University Hospital, France.

Background: The evidence of a clinical benefit of P2Y12 inhibitor pre-treatment in primary percutaneous coronary intervention (PCI) and the relation between the level of platelet inhibition and myocardial reperfusion with newer potent P2Y12 inhibitors remain unclear. We aimed to assess the relationship between platelet reactivity at the time of primary PCI after pre-treatment with aspirin and ticagrelor and the post-PCI myocardial blush grade (MBG).

Methods: We prospectively included 61 patients. Platelet reaction units for ticagrelor (PRU) and aspirin reaction units (ARU) were measured using the point-of-care test VerifyNow before PCI. The high on-ticagrelor (PRU >208) and on-aspirin (ARU ⩾ 550) platelet reactivity (HPR and HaPR) were assessed. Patients were divided into two groups according to MBG 3 or <3.

Results: MBG 3 was identified in 28 (46%) patients. Mean PRU was lower in such patients as compared with those with MBG <3 (155.82 ± 90.91 . 227.42 ± 65.18; =0.001) while mean ARU was similar between groups. HPR and HaPR were observed in 30 (49.2%) and 11 patients (18%), respectively. HPR but not HaPR was more frequent in the group with impaired MBG (66.7 . 28.6%; =0.003 and 21.2 14.3%; =0.48 respectively).

Conclusion: Our study shows that higher PRU and the subsequent HPR at the time of primary PCI, after pretreatment with ticagrelor, are the only correlates of post PCI MBG. These findings support the earliest possible loading with ticagrelor prior to primary PCI.
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http://dx.doi.org/10.1177/2048872619860214DOI Listing
August 2019

A head-to-head comparison of three coronary fractional flow reserve measurement technologies: The fractional flow reserve-device study.

Catheter Cardiovasc Interv 2020 05 12;95(6):1094-1101. Epub 2019 Aug 12.

Caen University Hospital, Caen, France.

Objectives: To compare three FFR technologies: the electric-sensor Pressurewire® (P), the optic-sensor Comet® (C) guidewire, and the optic-sensor Navvus® (N) microcatheter.

Background: Different technologies are used to measure fractional flow reserve (FFR) for the functional assessment of coronary lesions with potential discrepancies.

Methods: Sixty-six FFR measurements performed on 32 lesions using each technology were used for a paired comparison of FFR on simultaneous measurements and in clinically relevant conditions (guidewires alone, N on a guidewire).

Results: Simultaneous measurements of FFR were significantly (p < .0001) correlated between systems (ρ = 0.88, 0.81 and 0.86 for P and N, P and C and, C and N, respectively). The presence of the N microcatheter, led to reduced values of FFR measured by P or C guidewires (p < .0001). The concomitant presence of P and C guidewires led to significantly lower FFR values (p < .0001) measured by P but not by C. In clinically relevant conditions, values of FFR measured by the optic-sensor C guidewire and N catheter were similar and lower than those measured by the P guidewire (p < .0001). The agreement between the three technologies (FFR ≤ 0.80) was 94%.

Conclusions: FFR values simultaneously measured by three different technologies, are strongly correlated, and provide strongly concordant results. However, significant differences are found between values of FFR. The presence of N, but also C lead to a decrease of FFR measured by P. In clinically relevant conditions, the two optic-sensor technologies provide similar FFR measurements, lower than those measured by the piezo-electric technology suggesting a sensor-technology-related measurement variability.

Clinical Trial Registration: NCT#03052803.
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http://dx.doi.org/10.1002/ccd.28433DOI Listing
May 2020

Residual platelet reactivity after pre-treatment with ticagrelor prior to primary percutaneous coronary intervention is associated with suboptimal myocardial reperfusion.

Eur Heart J Acute Cardiovasc Care 2019 Aug 12. Epub 2019 Aug 12.

Department of Cardiology, Caen University Hospital, France.

Background: The evidence of a clinical benefit of P2Y12 inhibitor pre-treatment in primary percutaneous coronary intervention (PCI) and the relation between the level of platelet inhibition and myocardial reperfusion with newer potent P2Y12 inhibitors remain unclear. We aimed to assess the relationship between platelet reactivity at the time of primary PCI after pre-treatment with aspirin and ticagrelor and the post-PCI myocardial blush grade (MBG).

Methods: We prospectively included 61 patients. Platelet reaction units for ticagrelor (PRU) and aspirin reaction units (ARU) were measured using the point-of-care test VerifyNow before PCI. The high on-ticagrelor (PRU >208) and on-aspirin (ARU ⩾ 550) platelet reactivity (HPR and HaPR) were assessed. Patients were divided into two groups according to MBG 3 or <3.

Results: MBG 3 was identified in 28 (46%) patients. Mean PRU was lower in such patients as compared with those with MBG <3 (155.82 ± 90.91 vs. 227.42 ± 65.18; p=0.001) while mean ARU was similar between groups. HPR and HaPR were observed in 30 (49.2%) and 11 patients (18%), respectively. HPR but not HaPR was more frequent in the group with impaired MBG (66.7 vs. 28.6%; p=0.003 and 21.2 vs. 14.3%; p=0.48 respectively).

Conclusion: Our study shows that higher PRU and the subsequent HPR at the time of primary PCI, after pretreatment with ticagrelor, are the only correlates of post PCI MBG. These findings support the earliest possible loading with ticagrelor prior to primary PCI.
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http://dx.doi.org/10.1177/2048872619860214DOI Listing
August 2019

Improving quality of care in patients with decompensated acute heart failure using a discharge checklist.

Arch Cardiovasc Dis 2019 Aug - Sep;112(8-9):494-501. Epub 2019 Jul 25.

Normandie Université, UNICAEN, CHU de Caen Normandie, Department of Cardiology, 14000 Caen, France.

Background: The use of a discharge checklist may decrease heart failure readmission rate.

Aims: We aimed to evaluate the usefulness of a checklist in patients hospitalized for heart failure, in terms of mortality, cardiovascular mortality and readmission rates, and quality of care, including therapeutic optimization and careplan planning.

Methods: We prospectively used a discharge checklist in 103 patients hospitalized for heart failure between July 2015 and January 2016. Quality of care and outcomes were compared with a retrospective cohort of 137 patients with same inclusion criteria, hospitalized between June 2014 and December 2014. The primary endpoints were total and cardiovascular mortality and readmissions for heart failure at 6months. The secondary endpoint was quality of care rendered, measured by evidence-based medications, appropriate medication uptitration and planned discharge care.

Results: At 6months, there were no differences between the checklist and control cohorts in the rates of all-cause mortality (10.7% vs. 13.1%; P=0.57), cardiovascular mortality (8.7% vs. 10.9%; P=0.58) and readmission (29.1% vs. 32.1%; P=0.62). Follow-up after discharge was better planned in the checklist group. The use of the checklist yielded therapeutic optimization with a higher dose of beta-blockers and renin-angiotensin-aldosterone system blockers, especially in patients with a reduced left ventricular ejection fraction (<50%) (P=0.03 and P=0.02, respectively).

Conclusions: The use of a simple discharge checklist in patients with acute heart failure showed no benefit in terms of readmission and mortality rates; however, it yielded better quality of care, including therapeutic optimization and careplan planning.
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http://dx.doi.org/10.1016/j.acvd.2019.05.003DOI Listing
November 2019

Vitamin K antagonist vs direct oral anticoagulants with antiplatelet therapy in dual or triple therapy after percutaneous coronary intervention or acute coronary syndrome in atrial fibrillation: Meta-analysis of randomized controlled trials.

Clin Cardiol 2019 Jul 9. Epub 2019 Jul 9.

CHU de Caen Normandie, Service de Cardiologie, Caen, France.

Background: The combination of vitamin K antagonists (VKA) for atrial fibrillation (AF) and antiplatelet agents following percutaneous coronary intervention (PCI) is associated with an increased bleeding risk.

Hypothesis: Direct oral anticoagulants (DOAC) are associated with a greater safety profile but the optimal antithrombotic treatment strategy, especially when considering ischemic events, is unclear.

Methods: We performed a meta-analysis of randomized controlled trials comparing outcomes in AF patients following PCI and/or acute coronary syndrome (ACS) when treated with DOAC vs VKA, both in combination with one (dual) or two (triple) antiplatelet regimens. A systematic review was performed by searches of electronic databases MEDLINE (source PubMed) and the Cochrane Controlled Clinical Trials Register Database as well as Cardiology annual meetings. Three studies were finally included.

Results: Compared to VKA triple therapy, the use of DOAC was associated with a decreased risk of any bleeding (relative risk [RR] 0.68 [0.62; 0.74]), major bleeding (RR 0.61 [0.51; 0.75]) and intracranial bleeding (RR 0.33 [0.17; 0.66]) and similar rates of the composite efficacy endpoint (RR 1.0 [0.87; 1.14]) and its components. Similar and consistent results were observed with both dual and triple therapy including a DOAC compared to VKA.

Conclusion: Our meta-analysis supports the use of dual therapy combining a DOAC and clopidogrel as the default regimen in most AF patients after PCI and/or ACS.
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http://dx.doi.org/10.1002/clc.23224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6727878PMC
July 2019

Bedside mental status and outcome in elderly patients admitted for acute coronary syndromes.

Heart 2019 11 29;105(21):1635-1641. Epub 2019 May 29.

EA4650, Normandie Université, Caen, France.

Objective: We investigated whether mental status assessed by simple bedside tests in elderly patients admitted for acute coronary syndromes (ACS) was associated with higher risk of mortality.

Methods: We used the data from a prospective, open, ongoing cohort of patients≥75 years old admitted for ACS to a tertiary centre. Cognitive impairment (CogI) was defined by delirium detected by the Confusion Assessment Method or an abnormal Mini Mental State Examination score. A Cox model adjusted on predefined correlates of mortality was used to assess the relationship between CogI and 1-year mortality.

Results: Six-hundred consecutive patients with mental status assessment within 48 hours after admission were included. CogI was identified in 172 (29%) patients among whom 153 (25.5%) had an abnormal Mini Mental State Evaluation and 19 (3.2%) delirium. Death occurred in 49 (28.6%) patients with and 43 (10.5%) patients without CogI at 1 year. There was a significant association between CogI and 1-year mortality (adjusted-HR 2.4, 95% CI 1.53 to 3.62), p<0.001) independent of other covariables. CogI was also independently associated with higher rates of in-hospital bleeding and mortality as well as 3-month rates of all-cause, cardiovascular-related and heart failure-related rehospitalisation.

Conclusions: CogI detected by simple bedside tests in patients≥75 admitted for ACS is associated with an increased risk of 1-year mortality and 3 month rehospitalisation independent of other correlates of poor outcome.
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http://dx.doi.org/10.1136/heartjnl-2019-314978DOI Listing
November 2019

Plaque erosion versus rupture characterization by optical frequency domain imaging before and after coronary stenting following successful fibrinolysis for ST-segment elevation myocardial infarction.

Heart Vessels 2019 Mar 6;34(3):401-409. Epub 2018 Sep 6.

Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.

Intracoronary thrombus burden affects the quality of myocardial reperfusion in the setting of ST-elevation myocardial infarction (STEMI). We aimed to study the characteristics of the plaque and thrombus assessed by intracoronary optical frequency domain imaging (OFDI) according to the presence of plaque rupture or erosion in STEMI patients treated with successful fibrinolysis. Pre-stenting thrombus and post-stenting atherothrombotic burden were compared between plaque rupture and erosion. Twenty-seven consecutive patients were included: 17 (63%) had OFDI-plaque rupture and 10 (37%) had OFDI-erosion. Thrombus volume and burden were significantly higher in case of rupture compared to erosion at baseline (13.4 ± 18.4 vs 2.8 ± 2.3 mm; p = 0.03 and 33.8 ± 17.5 vs 17.5 ± 9.9%; p = 0.007, respectively). In the rupture group, the core of the thrombus consisted dominantly of red thrombus evenly distributed along the entire culprit plaque. In the erosion group, it consisted dominantly of white thrombus with a focal distribution near the minimal lumen area zone. After stenting, the atherothrombotic volume, burden and its distribution, as well as angiographic estimators of myocardial reperfusion were similar between groups. Our study showed that pre-PCI thrombus amount, typesetting and distribution are mainly linked to the underlying mechanism of STEMI. After stenting, the atherothrombotic burden and its distribution were similar between the groups.
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http://dx.doi.org/10.1007/s00380-018-1258-6DOI Listing
March 2019

Point of Care Tests VerifyNow P2Y12 and INNOVANCE PFA P2Y Compared to Light Transmittance Aggregometry After Fibrinolysis.

Clin Appl Thromb Hemost 2018 Oct 2;24(7):1109-1116. Epub 2018 May 2.

1 Department of Cardiology, Caen University Hospital, Caen, France.

Detection of high on-treatment platelet reactivity (HPR) by point-of-care tests has not been validated after successful fibrinolysis for ST-elevation myocardial infarction. We assessed the validity of the point-of-care VerifyNow P2Y12 (VN) and INNOVANCE PFA P2Y (PFA) tests on HPR compared to light transmittance aggregometry (LTA) in these patients. The HPR was identified in 10 (34.5%) patients, 15 (51.7%) patients, and 14 (50%) patients using LTA, VN, and PFA, respectively. Discrepancies were observed between the tests despite significant correlations between platelet reactivity measures by LTA and VN ( r = 0.74; P < .0001) and LTA and PFA ( r = .75; P < .0001). Compared to LTA, VN and PFA were associated with a 92% and 53% and 92% and 64% positive predictive value (PPV) and negative predictive value (NPV), respectively, in detecting HPR. When combined, VN and PFA results yielded 90% and 100% PPV and NPV values if discrepancies between the 2 tests were considered as non-HPR. The VN or PFA identify patients without HPR correctly but overestimate the proportion of HPR patients. The association of the 2 tests, in case of HPR, improves the accuracy of the detection of HPR.
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http://dx.doi.org/10.1177/1076029618772354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714754PMC
October 2018

Antithrombotic Therapy for ACS in Elderly Patients.

Cardiovasc Drugs Ther 2017 Dec;31(5-6):609-618

Department of Cardiology, CHU de Caen, F-14033, Caen, France.

Background: Patients over 75 account for more than one third of those presenting with myocardial infarction and more than 50% of intrahospital mortality. There are no specific guidelines for the management of acute coronary syndromes (ACS) in the elderly.

Setting: Although antithrombotic therapy seems to be effective and safe in such patients, it requires specific precautions and treatment adjustments because of the higher bleeding risk due to comorbidities such as renal function impairment and malnutrition.

Results: Scientific evidence concerning elderly patients is scarce as they are either excluded or underrepresented in most randomized trials. Overall, the antithrombotic therapy needs to be adapted to avoid complications, mainly bleeding complications, without compromising the effectiveness of the treatment in this high-risk population.

Conclusion: In the present paper, we review the current treatment strategies in ACS while focusing on data concerning the elderly, according to available data in pivotal trials and in both AHA/ACC and ESC guidelines.
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http://dx.doi.org/10.1007/s10557-017-6761-yDOI Listing
December 2017

Recurrent unexpected myocardial infarction in a young woman: Insights on spontaneous coronary artery dissection and multimodality imaging.

Cardiovasc Revasc Med 2018 Jan - Feb;19(1 Pt B):123-125. Epub 2017 Jul 19.

Department of Cardiology, Caen University Hospital, 14000 Caen, France.

A 45-year-old female was admitted for a transient anterior ST-segment elevation myocardial infarction (STEMI). Coronary angiogram showed a diffuse severe stenosis of the distal left anterior descending (LAD) coronary artery, which was managed medically. Three years later, a recurrent transient anterior STEMI led to a second coronary angiography showing a tubular stenosis of the mid-LAD with normal distal coronary bed. An optical coherence tomography (OCT) revealed a spontaneous coronary artery dissection (SCAD) with an extensive compressive mural hematoma without any intimal tear. Conservative treatment was continued. A repeat systematic angiogram 3months later suggested spontaneous healing but the OCT revealed several focal residual hematomas. This case illustrates the different possible angiographic appearances of SCAD and the contribution of the OCT in doubtful situations.
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http://dx.doi.org/10.1016/j.carrev.2017.07.011DOI Listing
March 2019

Argon Exposure Induces Postconditioning in Myocardial Ischemia-Reperfusion.

J Cardiovasc Pharmacol Ther 2017 Nov 5;22(6):564-573. Epub 2017 Apr 5.

1 Signalisation, Electrophysiologie et Imagerie des lésions d'ischémie-reperfusion myocardique, Normandie Univ, UNICAEN, Caen, France.

Background And Purpose: Cardioprotection against ischemia-reperfusion (I/R) damages remains a major concern during prehospital management of acute myocardial infarction. Noble gases have shown beneficial effects in preconditioning studies. Because emergency proceedings in the context of myocardial infarction require postconditioning strategies, we evaluated the effects of argon in such protocols on mammalian cardiac tissue.

Experimental Approaches: In rat, cardiac I/R was induced in vivo by transient coronary artery ligature and cardiac functions were evaluated by magnetic resonance imaging. Hypoxia-reoxygenation (H/R)-induced arrhythmias were evaluated in vitro using intracellular microelectrodes on both rat-isolated ventricle and a model of border zone in guinea pig ventricle. Hypoxia-reoxygenation loss of contractile force was assessed in human atrial appendages. In those models, postconditioning was induced by 5 minutes application of argon at the time of reperfusion.

Key Results: In the in vivo model, I/R produced left ventricular ejection fraction decrease (24%) and wall motion score increase (36%) which was prevented when argon was applied in postconditioning. In vitro, argon postconditioning abolished H/R-induced arrhythmias such as early after depolarizations, conduction blocks, and reentries. Recovery of contractile force in human atrial appendages after H/R was enhanced in the argon group, increasing from 51% ± 2% in the nonconditioned group to 83% ± 7% in the argon-treated group ( P < .001). This effect of argon was abolished in the presence of wortmannin and PD98059 which inhibit prosurvival phosphatidylinositol-3-kinase (PI3K)/protein kinase B (Akt) and MEK/extracellular receptor kinase 1/2 (ERK 1/2), respectively, or in the presence of the mitochondrial permeability transition pore opener atractyloside, suggesting the involvement of the reperfusion injury salvage kinase pathway.

Conclusion And Implications: Argon has strong cardioprotective properties when applied in conditions of postconditioning and thus appears as a potential therapeutic tool in I/R situations.
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http://dx.doi.org/10.1177/1074248417702891DOI Listing
November 2017

Prehospital fibrinolysis versus primary percutaneous coronary intervention in ST-elevation myocardial infarction: a systematic review and meta-analysis of randomized controlled trials.

Crit Care 2016 Nov 5;20(1):359. Epub 2016 Nov 5.

Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.

Background: Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy in patients with ST-elevation myocardial infarction (STEMI), but its benefit over prehospital fibrinolysis (FL) is not clear.

Methods: We performed a systematic review and meta-analysis of randomized controlled trials in which outcomes of patients with STEMI managed with FL early in the prehospital setting versus PPCI were compared.

Results: Compared with PPCI, FL was consistently associated with similar rates of short-term (30-90 days) death (relative risk [RR] 0.94, 95 % CI 0.67-1.31) and cardiovascular death (RR 0.95, 95 % CI 0.64-1.4), a decreased risk of cardiogenic shock (RR 0.67, 95 % CI 0.48-0.95), and an increased risk of any stroke (RR 3.57, 95 % CI 1.39-9.17) and hemorrhagic stroke (RR 4.37, 95 % CI 1.25-15.26). FL was also associated with similar rates of 1-year mortality (RR 1.01, 95 % CI 0.75-1.34) and major bleeding (RR 1.31, 95 % CI 0.96-1.78) in comparison with PPCI, but with a notable level (I index 30.5 % and 59.8 %) of heterogeneity among studies.

Conclusions: Our study suggests that, compared with PPCI, FL performed in the early prehospital setting is associated with similar mortality rates, lower rates of cardiogenic shock, and higher rates of stroke in patients with STEMI. Although the number of studies comparing the two strategies is relatively low, our results support prehospital FL and transfer to hub percutaneous coronary intervention (PCI) centers as a valid alternative to PPCI, allowing potential limitation of resources allocated to developing proximity 24/7 PCI facilities.
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http://dx.doi.org/10.1186/s13054-016-1530-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5097407PMC
November 2016

Preoperative plasma aldosterone and the risk of atrial fibrillation after coronary artery bypass surgery: a prospective cohort study.

J Hypertens 2016 12;34(12):2449-2457

aDepartment of Pharmacology, CHU de Caen bNormandie Univ, UNICAEN, CHU Caen, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique cDepartment of Cardiology, CHU de Caen dDepartment of Biochemistry ePôle Réanimations Anesthésie SAMU/SMUR fDepartment of Cardiac Surgery, CHU de Caen, Caen gDepartment of Pharmacology, GH Pitié-Salpétrière, Paris, France hDepartment of Cardiovascular Sciences, Sapienza University, Rome, Italy iDepartment of Nuclear Medicine jDepartment of Biostatistics and Clinical Research, CHU de Caen, Caen, France.

Objective: Postoperative atrial fibrillation (POAF) is associated with poor outcomes after coronary artery bypass graft (CABG) surgery. We aimed to assess the additional value of preoperative plasma aldosterone levels, a biomarker promoting proarrhythmic and profibrotic pathways, for predicting POAF after CABG.

Methods: We conducted a prospective cohort study involving consecutive patients with left ventricular ejection fraction (LVEF) more than 50% requiring elective CABG in our university hospital. Plasma aldosterone levels, two-dimensional echocardiography including left atrial strain analysis and galectin-3 (Gal-3) examination were assessed before cardiac surgery. The primary endpoint was the occurrence of POAF within 30 days after surgery.

Results: POAF occurred in 34 (24.8%) out of the 137 included patients. Compared with controls, patients experiencing POAF were significantly older (73 years old ± 8 vs 65 ± 11, P < 0.001) and had higher preoperative plasma aldosterone levels [183 pmol/l (interquartile range 138-300) vs 143 pmol/l (interquartile range 96.5-216.5), P < 0.01]. Age [odds ratio (OR), 1.088; 95% confidence interval (CI) (1.038-1.140); P = 0.0004] and plasma aldosterone levels [OR, 1.007; 95% CI (1.003-1.012); P = 0.0013] were independently associated with POAF in multivariate analysis and could therefore be combined to predict the occurrence of POAF ['Aldoscore', OR, 2.7; 95% CI (1.7-4.3); P < 0.0001]. Reverse transcriptase PCR analysis performed on right atrial appendage and plasma examination revealed that Gal-3 was activated in POAF patients.

Conclusion: We developed the preoperative 'Aldoscore' for POAF risk stratification among patients with preserved LVEF requiring elective CABG. This new tool may be helpful to identify good responders to interventions targeting the proarrhythmic and profibrotic pathways of aldosterone.
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http://dx.doi.org/10.1097/HJH.0000000000001105DOI Listing
December 2016

Safety and efficacy of IIb/IIIa inhibitors in combination with highly active oral antiplatelet regimens in acute coronary syndromes: A meta-analysis of pivotal trials.

Platelets 2017 Mar 22;28(2):174-181. Epub 2016 Sep 22.

a Department of Cardiology , Caen University Hospital , Caen , France.

The risk and benefit of GP-IIb/IIIa Inhibition (GPI) in combination with recent antiplatelet regimens in acute coronary syndromes (ACS) remain unassessed. The advent of fast-acting highly active oral P2Y inhibitors questions the additional value and risk of their association with GPI. We studied the effect of GPI in combination with prasugrel and ticagrelor, compared to clopidogrel on major bleeding in pivotal randomized controlled trials in the setting of ACS, using a meta-analytic approach. A similar analysis, further including the comparison of a double versus standard dose clopidogrel regimen, was performed for the risk of the primary efficacy endpoint. The combination of GPI and recent P2Y inhibitors was associated with a similar risk of bleeding as compared with GPI and the standard clopidogrel regimen (RR 0.92 [0.74; 1.13]). The benefit of recent regimens, including double dose clopidogrel, in reducing the primary ischemic endpoint (RR 0.86 [0.78; 0.94]) persisted in those treated with GPI. Although GPI use was associated with a consistent increase in the risk of bleeding in both recent (RR 1.27 [1.05-1.55]) and standard regimens (RR 2.01 [1.64-2.47]), the relative magnitude of such an increase was lower in association with prasugrel or ticagrelor as compared with clopidogrel. The risk of bleeding using a combination of GPI and oral antiplatelet regimens is mainly related to the use of GPI and not the oral antiplatelet regimen. Considering the absence of increased risk of bleeding and the persistence of the benefit of recent P2Y regimens in combination with GPI as compared with the standard clopidogrel regimen, the use of such a combination within the guidelines is supported by our findings.
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http://dx.doi.org/10.1080/09537104.2016.1218453DOI Listing
March 2017

Restrictive Physiology of Right Ventricle after Ross Procedure.

Echocardiography 2016 Jan 20;33(1):162-3. Epub 2015 Sep 20.

Department of Cardiology, CHU de Caen, Caen, France.

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http://dx.doi.org/10.1111/echo.13078DOI Listing
January 2016

Iatrogenic bidirectional dissection of the right coronary artery and the ascending aorta: the worst nightmare for an interventional cardiologist.

Korean Circ J 2012 Jul 26;42(7):504-6. Epub 2012 Jul 26.

Department of Cardiology, CHU de Caen, Caen, France.

Although rare, iatrogenic aortocoronary dissection is one of the complications most dreaded by the interventional cardiologist. If not managed promptly, it can have redoubted and serious consequences. Herein, we present the case of a 70 year-old woman who was treated by stenting of the second segment of the right coronary artery (RCA) for recurrent angina but, unfortunately, the procedure was complicated by anterograde dissection of the RCA with a simultaneous retrograde propagation to the proximal part of the ascending aorta. Successful stenting of the entry point was able to recuperate the RCA and to limit the retrograde propagation to the ascending aorta, but there was an extension of the dissection to the aortic valve leaflets resulting in a massive aortic insufficiency. Therefore, surgical aortic valve replacement with prosthetic tube graft was performed [corrected].
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http://dx.doi.org/10.4070/kcj.2012.42.7.504DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3409402PMC
July 2012

A rare combination of coronary anomalies: what is the culprit?

J Cardiovasc Med (Hagerstown) 2011 Dec;12(12):883-4

Department of Cardiology, University Hospital of Caen, Avenue Côte de Nacre, Caen, France.

The case of a woman with anomalous origin of the circumflex coronary artery that communicates with the left ventricle via a fistula, revealed by typical angina, is described and the several pathomechanisms involved are discussed.
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http://dx.doi.org/10.2459/JCM.0b013e32834cadc4DOI Listing
December 2011
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