Publications by authors named "Romain Didier"

54 Publications

Detection of Myocardial Infarction by Cardiac Magnetic Resonance in Embolic Stroke Related to First Diagnosed Atrial Fibrillation.

J Stroke Cerebrovasc Dis 2021 Jun 10;30(6):105753. Epub 2021 Apr 10.

Department of Cardiology, Dijon University Hospital, 21000 Dijon, France. Electronic address:

Introduction: Elevated troponin levels are found in a significant number of patients who are diagnosed with acute embolic stroke (AES) after first diagnosed atrial fibrillation (AF). These myocardial injuries, which are known as cardiocerebral infarction (CCI), are potentially caused by coronary embolism and correspond to simultaneous cardiac and cerebral embolisms. However, this severe condition remains poorly understood. In this prospective study, we aimed to investigate the prevalence and the cardiac magnetic resonance (CMR) characteristics of CCI.

Materials And Methods: Consecutive patients with first diagnosed AF hospitalized for AES in a neurovascular intensive care unit from 2019 to 2020 were included. Troponin Ic kinetic were measured <72 h, MRI and coronary angiography or CT scan were performed <7 days after admission. Patients with significant coronary lesions were excluded.

Results: During the study period, 1150 patients with strokes were hospitalized in the neurovascular intensive care unit (ICU). Of these patients, 955 had an ischemic stroke and 97 had a transient ischemic attack. Among the 44 patients with AES and with first diagnosed AF, 34 patients underwent CMR and CMR analysis identified 12 MI. A significant rise in troponin (>0.10 µg/L) was observed in 35% of the total population (12/34 patients). More specifically, a rise was seen in 23% of the AES without MI group, 58% of the AES with MI. In addition, coronary embolism was identified in 3 patients who underwent coronary angiography (3/12) and MI was often (30%) localized in infero-latero-medial and infero-apical segments. Most AES were localized in the superficial sylvian territory.

Conclusion: We found a high prevalence of CMR-confirmed double embolization sites in the acute phase of an embolic stroke. Further studies are required to better characterize the pathophysiology, clinical course and prognostic value of CCI. Moreover, optimal management strategies, including antiplatelet therapy, remain to be determined.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105753DOI Listing
June 2021

Stent Size Optimization in the Femoral Bifurcation Using a Fractal Model: A Morphological Analysis.

Ann Vasc Surg 2021 Apr 24;72:57-65. Epub 2020 Dec 24.

Department of Vascular Surgery, Vascular Center, Groupe Hospitalier Paris St Joseph, Paris, France.

Objectives: Stenting of common femoral artery (CFA) bifurcation lesions is complex due to harmonious asymmetric geometry between the CFA and deep or superficial femoral artery. In order to ensure an optimal flow, the stents must be implanted according to the diameter of the CFA and the diameter of the daughter vessels. The aim of this study was to validate a mathematical formula for the CFA bifurcation in order to optimize the implantation of stents in this bifurcation with a fast and efficient method.

Materials/methods: We retrospectively included all patients who underwent transcatheter aortic valve implantation and who had a healthy CFA bifurcation on the CT-scan. Diameters of the mother vessel (D), daughter vessels (D: larger vessel; D: smaller vessel), and the ratio between the two were calculated. According to the latter, the following linear model was proposed: [D = (D/D + D) × (D + D)] and was compared to the four existing models (Murray, HK, Flow, Finet). Finally, we calculated the relative error between the prediction of the four models and the measurements.

Results: Overall, 110 CFA bifurcations were included. Mean CFA diameter was 7.75 ± 1.67 mm. Mean D diameter was 5.79 ± 1.21 mm and mean D diameter was 5.23 ± 1.09 mm. A reduction of 25 % was seen between the CFA and the larger daughter-vessel. The mean ratio between the CFA and the daughter vessels was 0.71. Our model [D = 0.71× (D + D)] and the flow law were the most accurate (relative difference of 1.59 ± 11.97% and 1.01 ± 11.94%, respectively). However, Murray's law had a statistically significant deviation from the real mother-vessel diameter (P < 0.001).

Conclusions: We developed a simple fractal ratio between CFA and daughter vessels, which could be easily used in daily practice during CFA percutaneous reconstruction to identify the optimal diameters of the diseased vessels.
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http://dx.doi.org/10.1016/j.avsg.2020.12.002DOI Listing
April 2021

Myocardial Infarction after Kidney Transplantation: A Risk and Specific Profile Analysis from a Nationwide French Medical Information Database.

J Clin Med 2020 Oct 19;9(10). Epub 2020 Oct 19.

Department of Cardiology, University Teaching Hospital Burgundy, 21000 Dijon, France.

Introduction: Renal transplant recipients have a high peri-operative risk for cardiovascular events. The post-transplantation period also carries a risk of myocardial infarction (MI). Coronary artery disease (CAD) is a leading cause of death in these patients. We aimed to assess the risk of MI, the specific morbidity profile of MI after transplantation as well as the long-term prognosis after MI in renal transplantation (RT) patients regarding cardiovascular (CV) death and all-cause death.

Methods: From a French national medical information database, all of the patients seen in French hospitals in 2013 with at least 5-years follow-up were retrospectively identified and patients without transplantation but with previous dialysis at baseline were excluded. There were 17,526 patients with RT and 3,288,857 with no RT.

Results: Among these patients, 1020 in the RT group (5.8%), and 93,320 in the non-RT group (2.8%) suffered acute MI during a median follow-up of 5.4 years. After multivariable adjustment, risk of MI was higher in RT patients than in non-RT patients (HR 1.45, IC 95% 1.35-1.55). The mean age was 59.5 years for transplant patients with MI, and 70.6 years for the reference population with MI ( < 0.0001). MI patients with RT (vs. non RT patients) were more likely to have hypertension, diabetes dyslipidemia, and peripheral artery disease (76.0% vs. 48.1%, 38.7% vs. 25.2%, 33.2% vs. 23.2%, and 31.2% vs. 17.3%, respectively, < 0.0001). Incidence of non ST-elevation MI (NSTEMI) was higher in RT patients while incidence of ST-elevation MI (STEMI) was higher in patients without RT. In unadjusted analysis, risk of all-cause death and CV death within the first month after MI were higher in patients without RT (18% vs. 11.1% < 0.0001 and 12.3% vs. 7.8%, < 0.0001, respectively). However, multivariable analysis indicated that risk of all-cause death was higher in patients with RT than in those with no RT (adjusted HR 1.15 IC 95% 1.03-1.28).

Conclusions: MI is not an uncommon complication after RT (incidence of around 5.8% after 5 years). RT is independently associated with a 45% higher risk of MI than in patients without RT, with a predominance of NSTEMI. MI in patients with RT is independently associated with a 15% higher risk of all-cause death than that in patients with MI and no RT.
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http://dx.doi.org/10.3390/jcm9103356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7589663PMC
October 2020

Successful linkage of French large-scale national registry populations to national reimbursement data: Improved data completeness and minimized loss to follow-up.

Arch Cardiovasc Dis 2020 Aug - Sep;113(8-9):534-541. Epub 2020 Jul 22.

Department of Cardiology, CHRU Brest, 29200 Brest, France; RHU STOP-AS, 76000 Rouen, France. Electronic address:

Background: Registries, a cornerstone of contemporary medicine, frequently suffer from incomplete documentation and losses to follow-up. By linking data to a single-payer national claims database, national registries may be enriched and the quality enhanced.

Aims: To explore the value of data from the French Système National des Données de Santé (SNDS) as a resource to enhance the quality of registries when combined with data from electronic case report forms, and to assess the power to minimize data gaps and losses to follow-up.

Methods: A probabilistic algorithm was developed to link and match records in the SNDS with patient data from the electronic case report forms of two registries on transcatheter aortic valve implantation: FRANCE-2 and FRANCE-TAVI. The algorithm created patient profiles from transcatheter aortic valve implantation procedures in the SNDS, matching them as closely as possible to the profiles in the registry databases. The objective was to achieve 90% linkage of the populations. The linked database was analysed for completeness and loss to follow-up. For validation, mortality curves for the linked registry cohorts were compared with those for the original populations.

Results: A total of 34,397 unique registries entries were identified, and 89.9% of patients in the SNDS could be linked. Rates of losses to follow-up over 2 years were 1.0% in the linked FRANCE-TAVI population compared with 40.3% based on electronic case report form documentation. For FRANCE-2, 3-year rates of losses to follow-up were 1.7% and 6.1%, respectively. Mortality curves for populations based on SNDS and electronic case report form data were practically superimposable.

Conclusions: Linking data from a single-payer national claims database to national registries using a probabilistic approach is feasible and can close data gaps and practically abolish losses to follow-up in the registry population.
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http://dx.doi.org/10.1016/j.acvd.2020.04.006DOI Listing
September 2020

Late discovery of left atrial appendage occluder device embolization: a case report.

BMC Cardiovasc Disord 2020 06 22;20(1):305. Epub 2020 Jun 22.

Department of Cardiology, University Hospital of Brest, Brest, Cedex, 29609, France.

Background: Left atrial appendage (LAA) closure has been well evaluated in the prevention of stroke in patients with atrial fibrillation. Device embolization remains one of the most common complications. To the best of our knowledge, there have been no reports of late discovery of LAA occluder device embolization at 1.5 years after implantation.

Case Presentation: We describe the case of a 77-year-old man who underwent uneventful LAA closure. Echocardiography performed the next day showed the device in place. The patient was discharged but was then lost to follow-up. 1.5 years later, he was admitted for ischemic stroke. Transesophageal echocardiography showed the absence of the occluder device in the LAA. Computed tomography scan of the abdomen showed the device in the abdominal aorta. Due to the high cardiovascular risk, the device was kept in place and the patient was treated medically.

Conclusions: Per-procedural and late device embolization are not uncommon. Review of the literature however showed no report of late discovery of device embolization at 1.5 years. Follow-up echocardiography is mandatory for the detection of endothelialization or embolization.
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http://dx.doi.org/10.1186/s12872-020-01589-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7310060PMC
June 2020

Evaluation of length of stay after transfemoral transcatheter aortic valve implantation with SAPIEN 3 prosthesis: A French multicentre prospective observational trial.

Arch Cardiovasc Dis 2020 Jun - Jul;113(6-7):391-400. Epub 2020 May 14.

Normandie University, UNIROUEN, INSERM U1096, Department of Cardiology, Rouen University Hospital, FHU REMOD-VHF, 76000 Rouen, France.

Background: Complications decrease after transfemoral transcatheter aortic valve implantation (TAVI), and early discharge is feasible and safe in selected populations.

Aims: To evaluate length of stay (LOS) and reasons for prolonged hospitalisation after transfemoral TAVI in unselected patients.

Methods: Patients with severe aortic stenosis, who had transfemoral TAVI with the SAPIEN 3 prosthesis using exclusively local anaesthesia, were prospectively and consecutively included at five French high-volume centres. LOS was calculated from TAVI procedure to discharge. Reasons for prolonged hospitalisation (i.e.>3 days) were evaluated.

Results: Between 2017 and 2018, 293 patients were included, with a mean age of 82.4±6.5 years and a mean logistic EuroSCORE of 13.7±9.0%. The in-hospital mortality rate was 1.4%. The median LOS was 5 (3-7) days, and varied considerably between centres (from 2 to 7 days). Sixty-four (21.8%) patients were discharged within 3 days after transfemoral TAVI. Reported reasons for prolonged hospitalisation were complications in 62.2%, loss of autonomy in 3.1%, discharge refusal in 2.2% and logistical reasons in 0.9%. In 31.6% of cases, the investigators reported no apparent reasons.

Conclusions: The results of our study suggest that LOS after transfemoral TAVI, using the SAPIEN 3 prosthesis and a minimalist approach, varies considerably between centres. In almost a third of cases, hospitalisation was prolonged without any apparent reason. Efforts should be made to educate centres to reduce LOS.
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http://dx.doi.org/10.1016/j.acvd.2019.11.010DOI Listing
September 2020

Giant sinus of Valsalva aneurysm mimicking severe pulmonary hypertension.

Int J Cardiovasc Imaging 2020 Sep 9;36(9):1695-1696. Epub 2020 May 9.

Brest University Hospital, Brest, France.

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http://dx.doi.org/10.1007/s10554-020-01875-9DOI Listing
September 2020

Analysis of weather exposure 7 days before occurrence of ST-segment elevation myocardial infarction.

Arch Cardiovasc Dis 2020 Jan 18;113(1):22-30. Epub 2019 Dec 18.

Service de cardiologie, hôpital Cavale Blanche, CHRU Brest, 29200 Brest, France. Electronic address:

Background: Several studies have highlighted the relationship between weather patterns and the occurrence of ST-elevation myocardial infarction (STEMI).

Aim: To evaluate the statistical association between the occurrence of STEMI and meteorological variables over the preceding 7 days.

Methods: This was a retrospective study, using prespecified data from the ORBI (Breton Regional Observatory on Myocardial Infarction) registry, which includes all consecutive patients hospitalized for STEMI in the geographical area of Brest, France. Over a 7-year period, we compared the number of STEMIs per week with the mean values of meteorological variables over the preceding 7 days.

Results: Overall, 7517 patients with STEMI were recorded in the ORBI registry between January 2009 and January 2016. After exclusion of patients not living in the geographical area of interest, 742 patients were included. The weekly incidence of STEMI ranged from 0 to 7 (median 2, interquartile range 1-3). In the univariate analysis, air temperature (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.005-1.01 per 1°C decrease; P=0.03) and atmospheric pressure (OR 1.03, 95% CI 1.01-1.06 per 1 hPa increase; P=0.008) were associated with the weekly incidence of STEMI. In the multivariable analysis, air temperature (OR 1.06, 95% CI 1.01-1.10 per 1°C decrease; P=0.01), atmospheric pressure (OR 1.05, 95% CI 1.02-1.08 per 1 hPa increase; P<0.001) and duration of humidity>80% (OR 1.09, 95% CI 1.02-1.15 per 1hour increase; P=0.007) in the previous 7 days were associated with the occurrence of STEMI.

Conclusions: In this specific geographical area, occurrence of STEMI was statistically associated with a decrease in air temperature, an increase in atmospheric pressure and an increase in humidity over the preceding 7-day period.
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http://dx.doi.org/10.1016/j.acvd.2019.09.012DOI Listing
January 2020

Impact of Baseline Left Ventricular Diastolic Dysfunction in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation.

Am J Cardiol 2020 01 30;125(2):258-263. Epub 2019 Oct 30.

Section of Cardiology, MedStar Heart and Vascular Institute at MedStar Washington Hospital Center, Washington, District of Columbia. Electronic address:

We sought to assess the impact of diastolic dysfunction (DD) grade, as per the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines, on survival of patients with severe aortic stenosis (AS) who underwent transcatheter aortic valve implantation (TAVI). We included consecutive patients with severe AS who underwent TAVI in our institution. DD grading was determined retrospectively according to the 2016 ASE DD guidelines and categorized to grade I-III and indeterminate grade I-II DD. Comparison of 1-year survival according to DD grade was performed by Kaplan-Meier analysis, and evaluation of DD at 1 year was performed in a subset of patients. Among 606 TAVI patients, 394 (65%) had sufficient data for DD grading. Seventy-seven (20%) had grade I DD, 191 (48%) had grade II, 60 (15%) had grade III, and 66 (17%) had an indeterminate grade between I and II. Baseline characteristics indicate higher rates of atrial fibrillation, brain natriuretic peptide level, pulmonary artery systolic pressure, and indexed left ventricular mass as DD grade increases (all p ≤0.01). In conclusion, comparison of 1-year survival revealed a higher rate of mortality in patients with grade III DD that remained statistically significant following adjustment in a multivariate Cox proportional hazard model. DD grade after TAVI improved in patients with grades II and III. Severe AS patients with grade III DD have higher risk for 1-year mortality after TAVI compared with milder degrees of DD. Further research is warranted to explore a potential benefit for aortic valve therapy at an earlier stage of the disease process.
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http://dx.doi.org/10.1016/j.amjcard.2019.10.016DOI Listing
January 2020

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

Patent Foramen Ovale and Ischemic Stroke in Patients With Pulmonary Embolism: A Prospective Cohort Study.

Ann Intern Med 2019 06 7;170(11):756-763. Epub 2019 May 7.

Brest University Hospital, Western Brittany University, Brest, France (E.L., S.T., D.B., R.D., Y.J., R.L., C.H., A.D., G.L., K.L., C.L., D.M., F.C.).

Background: Pulmonary embolism (PE) is associated with increased risk for ischemic stroke, but the underlying mechanism remains unclear. The authors hypothesized that paradoxical embolism through patent foramen ovale (PFO) should be the main mechanism.

Objective: To determine the frequency of recent ischemic stroke in patients with symptomatic PE according to whether PFO was detected.

Design: Prospective cohort study with masked assessment of stroke outcomes. (ClinicalTrials.gov: NCT01216423).

Setting: 4 French hospital centers.

Participants: 361 consecutive patients with symptomatic acute PE from 13 November 2009 through 21 December 2015.

Intervention: Systematic contrast transthoracic echocardiography (TTE) and cerebral magnetic resonance imaging (MRI) within 7 days after enrollment.

Measurements: Recent symptomatic or silent ischemic stroke was diagnosed on the basis of clinical examination and cerebral MRI showing a hypersignal on the trace diffusion-weighted image with reduction or pseudonormalization of apparent diffusion coefficient.

Results: Contrast TTE was conclusive in 324 of 361 patients and showed PFO in 43 patients (13%). The median age was 66 years (interquartile range, 54 to 77 years). In total, 51% of patients (145/284) had associated deep venous thrombosis, 91% (279/306) had cardiovascular risk factors, and 10% (16/151) presented with arrhythmia (no difference between PFO and non-PFO groups). Cerebral MRI was conclusive in 315 patients. Recent ischemic stroke was more frequent in the PFO group than in the non-PFO group (9 of 42 patients [21.4%] vs. 15 of 273 patients [5.5%]; difference in proportions, 15.9 percentage points [95% CI, 4.7 to 30.7 percentage points]).

Limitation: Because of inconclusive contrast TTE or MRI, 46 patients were excluded from analysis.

Conclusion: Frequency of recent ischemic stroke in patients with symptomatic PE was higher in patients with PFO than in those without PFO. This finding supports the hypothesis that paradoxical embolism is an important mechanism of ischemic stroke in patients with PFO.

Primary Funding Source: French Ministry of Health.
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http://dx.doi.org/10.7326/M18-3485DOI Listing
June 2019

Transcatheter aortic valve implantation in patients with severe aortic stenosis: Does lower-risk profile mean a young patient?

Arch Cardiovasc Dis 2019 May 18;112(5):293-295. Epub 2019 Apr 18.

University hospital of Brest, Department of cardiology, 29200 Brest, France. Electronic address:

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http://dx.doi.org/10.1016/j.acvd.2019.03.003DOI Listing
May 2019

Assessment of Long-Term Structural Deterioration of Transcatheter Aortic Bioprosthetic Valves Using the New European Definition.

Circ Cardiovasc Interv 2019 04;12(4):e007597

Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital, Department of Cardiology, FHU REMOD-VHF, France (E.D., A.S., C.T., P.Y.L., G.A., A.C., H.E.).

Background: The durability of transcatheter aortic bioprosthetic valves is a crucial issue, but data are scarce, especially beyond 5 years of follow-up. We aimed to assess long-term (7 years) structural valve deterioration (SVD) and bioprosthetic valve failure of transcatheter aortic bioprosthetic valves.

Methods And Results: Consecutive patients with at least 5-year follow-up available undergoing transcatheter aortic valve implantation from April 2002 to December 2011 in 5 French centers were included. Incidence of SVD and bioprosthetic valve failure were defined according to newly standardized criteria of the European Association of Percutaneous Cardiovascular Interventions/European Society of Cardiology/European Association for Cardio-Thoracic Surgery and reported as cumulative incidence function to account for the competing risk of death. One thousand four hundred three consecutive patients were included with a mean age of 82.6±7.5 years and with a mean logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) of 21.3±7.5%. A balloon-expandable valve was used in 83.7% of cases. Survival rates were 83.5% (95% CI, 81.4%-85.5%) and 18.6% (95% CI, 15.3%-21.8%) at 1 and 7 years, respectively. Median duration of follow-up was 3.9 years. Bioprosthetic valve failure occurred in 19 patients with a 7-year cumulative incidence of 1.9% (95% CI, 1.4%-2.4%). SVD occurred in 49 patients (moderate, n=32; severe, n=17) with a 7-year cumulative incidence of moderate and severe SVD of 7.0% (95% CI, 5.6%-8.4%) and 4.2% (95% CI, 2.9%-5.5%), respectively. Five patients had aortic valve reintervention (1.0%; 95% CI, 0.4%-1.6%) including 1 case of surgical aortic valve replacement and 4 redo-transcatheter aortic valve implantation. The incidences of SVD and bioprosthetic valve failure were not significantly different between balloon and self-expandable prostheses.

Conclusions: The long-term assessment of transcatheter aortic bioprosthetic valves durability is limited by the poor survival of our population beyond 5 years. Further studies are warranted, particularly in younger and lower-risk patients.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.118.007597DOI Listing
April 2019

In vivo validation of Dosemap software use in interventional cardiology with dosimetrics indicators and peak skin dose evaluation.

Catheter Cardiovasc Interv 2019 Aug 4;94(2):216-222. Epub 2019 Feb 4.

Department of Cardiology, Brest University Hospital, Brest, France.

Objectives: The aim of this study was to determine the accuracy of DoseMap™ software as compared to gafchromic film in real clinical practices.

Background: The radiation exposure from cardiovascular procedures could expose patients to potential risk of cancer and/or skin injury. New tools like Dosemap software were developed to estimate the patient skin dose in the cardiac catheterization laboratory. However, little data are available to validate this estimation of patient radiation skin dose.

Methods: This is a prospective cross-sectional study comparing the peak skin dose (PSD) measured by gafchromic film used as reference with an estimated PSD given by Dosemap software, in patients with BMI > 30 kg/m undergoing elective diagnostic and/or therapeutic interventional cardiology procedures, from April 2016 to December 2016, at the Brest University Hospital Centre, France.

Results: After four exclusions of patients for poor quality of gafchromic films, 90 patients were included, with 58 angiography (67.4%), 14 percutaneous interventions (16.3%), and 14 both (16.3%). The median PSD and PSD were similar with 157 mGy [IQR: 99; 273] versus 158 mGy [IQR: 101; 295] (P = 0.65), respectively, with an excellent correlation (r = 0.95). The comparison between cumulative air kerma and PSD was different 366 mGy [IQR: 246; 575] versus 158 mGy [IQR: 101; 295] (P < 0.01) with moderate correlation (r = 0.79). No correlation was found between the dose area product and PSD (r = 0.51).

Conclusion: DoseMap is an effective and valid method as compared to gafchromic films to estimate PSDs during interventional cardiologic procedures.
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http://dx.doi.org/10.1002/ccd.28097DOI Listing
August 2019

Safeguarding continuing cardiovascular research excellence and quality publications in France: A working document from the French Society of Cardiology.

Arch Cardiovasc Dis 2019 Apr 10;112(4):234-240. Epub 2019 Jan 10.

Department of Cardiology, CHU de la Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest cedex, France. Electronic address:

Background: France has a long history of successful cardiovascular research and scientific innovations, but its continued success cannot be taken for granted.

Aims: To identify current obstacles to cardiovascular research in France and to crystallize the analysis into recommendations for maintained and enhanced research excellence in the future.

Methods: The French Society of Cardiology set up seven Working Groups, each comprising four to eight cardiologists, covering a spectrum of research institutes, hospitals, specialties, ages and research experience. The Working Groups met regularly in person or by conference call to analyse experiences, refine situation assessments and formulate recommendations for improvements. Results and suggestions were presented to a Core Team, which worked to synthesize, prioritize and organize the findings into a consolidated situation assessment and generate a set of action-orientated recommendations.

Results: Four key areas of action were identified: stronger focus on the generation of high-quality data; facilitation of future cardiovascular research; greater promotion and support for research among young cardiologists; and increased focus and support for communications. Most recommendations targeted structural shortcomings and may be implemented at low additional financial cost.

Conclusions: It is possible to maintain, and even increase, the quality of cardiovascular research in France and to boost the conversion of successful projects into high-impact publications, without major increases in funding. Intense collaboration between specialties and organizations is necessary to achieve sustainable results.
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http://dx.doi.org/10.1016/j.acvd.2018.11.002DOI Listing
April 2019

Five-Year Clinical Outcome and Valve Durability After Transcatheter Aortic Valve Replacement in High-Risk Patients.

Circulation 2018 12;138(23):2597-2607

Department of Cardiology, Parly 2 Hospital, Le Chesnay, France (X.F.).

Background: The FRANCE-2 registry (French Aortic National Corevalve and Edwards) previously reported good early- and medium-term clinical and echocardiographic efficacy for transcatheter aortic valve replacement. We here report 5-year follow-up results from the registry.

Methods: The registry includes all consecutive patients undergoing transcatheter aortic valve replacement for severe aortic stenosis in France. Follow-up is scheduled at 30 days, 6 months, then annually from 1 to 5 years. Clinical events were defined according to the Valve Academic Research Consortium criteria, and hemodynamic structural valve deterioration (SVD) was defined according to the consensus statement by the European Association of Percutaneous Cardiovascular Interventions.

Results: Between January 2010 and January 2012, 4201 patients were enrolled in 34 centers. Five-year vital status was available for 95.5% of patients; 88.1% had clinical evaluation or died. Overall, at 5 years, all-cause mortality was 60.8% (n=2478; 95% CI, 59.3% to 62.3%). The majority of cardiovascular events occurred in the first month after valve implantation, and incidence remained low thereafter, at <2% per year up to 5 years, except for heart failure. The rate of heart failure was 14.3% at 1 year, then decreased over time to <5% per year. In cumulative incidence function, the rates of severe SVD and moderate/severe SVD at 5 years were 2.5% and 13.3%, respectively. Mortality did not differ between patients with or without severe SVD (hazard ratio, 0.71; 95% CI, 0.47-1.07; P=0.1). Finally, in the population of patients with severe SVD, 1 patient (1.7%) experienced a stroke, and 8 patients presented ≥1 heart failure event (13.3%).

Conclusions: The 5-year follow-up results of the FRANCE-2 registry represent the largest long-term data set available in a high-risk population. In surviving patients, the low rate of clinical events and the low level of SVD after 1 year support the long-term efficacy of transcatheter aortic valve replacement in both types of transcatheter prosthesis featuring in the registry.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.118.036866DOI Listing
December 2018

Long-term atorvastatin treatment decreases heart maximal oxygen consumption and its vulnerability to in vitro oxidative stress in Watanabe heritable hyperlipidemic rabbit.

Can J Physiol Pharmacol 2018 Nov 16;96(11):1112-1118. Epub 2018 Jul 16.

a EA 4324 ORPHY, Université de Bretagne Occidentale, IBSAM, Brest, France.

Statins are currently used in prevention of cardiovascular diseases in high-risk populations, and could be considered in primary prevention. However, few studies are available on the long-term effects of low doses of statins, especially on mitochondrial function and reactive oxygen species (ROS) metabolism at cardiac level. This study aimed to determine potential effects of a long-term atorvastatin treatment, at low-dose concentration, on the myocardium mitochondrial respiration. Thirty-four Watanabe rabbits were treated or not with atorvastatin (2.5 mg·kg·day) from the age of 3 to 12 months. Every 3 months, proton leak, basal (V), and maximal (V) mitochondrial respiration on cardiac permeabilized fibers were measured. Additionally, the vulnerability to ROS, cardiac enzymatic antioxidant defenses, and oxidative damage (lipoperoxidation) were analyzed. Proton leak increased over the duration of the experiment (up to 60% from V at 12 months). Moreover, the statin treatment induced a decrease of V and a decrease of ROS susceptibility of cardiac mitochondria. However, the lipoperoxidation and the antioxidant defenses were not dependent on the presence of statin treatment, or on its duration. This is the first study showing a protective effect of long-term statins treatment against the ROS susceptibility in the cardiac muscle.
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http://dx.doi.org/10.1139/cjpp-2018-0085DOI Listing
November 2018

Non-vitamin K antagonist oral anticoagulants in atrial fibrillation patients with bioprosthetic valves.

Expert Rev Cardiovasc Ther 2018 May 23:1-6. Epub 2018 May 23.

f Department of Medicine and The Thrombosis and Atherosclerosis Research Institute , McMaster University , Hamilton , Canada.

Introduction: The non-vitamin K antagonist oral anticoagulants (NOACs), which include dabigatran, apixaban, edoxaban and rivaroxaban, are preferred over vitamin K antagonists for stoke prevention in most patients with non-valvular atrial fibrillation. The NOACs are contraindicated in atrial fibrillation patients with rheumatic mitral stenosis or mechanical heart valves. There is evidence that bioprosthetic heart valves are less thrombogenic than mechanical heart valves, but it is unknown whether the risk of thromboembolism in atrial fibrillation patients with bioprosthetic valves differs from that in patients without such valves. Areas covered: The authors present a review of the efficacy and safety evidence surrounding the use of NOACs for stroke prevention in atrial fibrillation patients with bioprosthetic heart valves. Expert commentary: While the data is limited, there is no significant difference in thromboembolic, and bleeding outcomes in patients with AF and bioprosthetic heart valves treated with NOAC therapy. Future studies are required before definitive conclusions can be drawn regarding the safety and efficacy of NOAC therapy in AF patients bioprosthetic heart valves.
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http://dx.doi.org/10.1080/14779072.2018.1475229DOI Listing
May 2018

Comparison of four methods to assess high-on platelet reactivity under P2Y12 receptor inhibitor.

Platelets 2018 May 26;29(3):257-264. Epub 2018 Mar 26.

a Service d'hématologie Biologique, CHRU de Brest , Brest , France.

P2Y12 receptor inhibitors are antiplatelet agents commonly prescribed in the treatment of coronary artery disease. Their efficacy can be limited by high on-treatment platelet reactivity (HPR), which can be evaluated by different biological assays. Most commonly, HPR is evaluated by flow cytometric vasodilator-stimulated phosphoprotein-phosphorylation (VASP-P) assay, which can be time consuming. To evaluate the potential interest of novel technologies, we compared four different assays. Ninety patients receiving P2Y12 inhibitors were included. Four technologies were evaluated: the current standard test measuring VASP-P by flow cytometry, the historical reference test based on light transmittance aggregation (LTA), and two relatively novel techniques: whole blood multiple electrode aggregometry (MEA) and platelet function analyzer (PFA), which are less time consuming. The three latter tests were compared with the VASP-P assay as a reference using receiver operating characteristics (ROC) analysis: LTA has an excellent comparability with the VASP test (ROC AUC > 0.9); the other two tests (multiplate and PFA) have only satisfactory comparability (ROC AUC around 0.7) and therefore may not replace the VASP "gold standard" test, if importance is attached to a quantitative assessment of the substitution parameter of VASP. Nevertheless, if a binary approach of the anti-aggregation result is sought, then one can conclude that the three tests are equivalent since Cohen's kappa coefficients are very close for the three tests (k = 0.548 for LTA; k = 0.554 for MEA; k = 0.570 for PFA/P2Y), and a similar proportion of patients are misclassified (15% for LTA, 14% for MEA, and 13.6% for PFA). Discriminant factor analysis using all the parameters provided by each test did not improve the diagnostic performance of MEA or PFA. In conclusion, only LTA shows a good comparability to the VASP assay using ROC curve analysis, probably because misclassified patients have results close to the cutoff values. All three tests have moderate agreement regarding the classification of patients as responders to P2Y12 inhibition.
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http://dx.doi.org/10.1080/09537104.2018.1453058DOI Listing
May 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

Impact of coronary artery disease in patients undergoing transcatheter aortic valve replacement: Insights from the FRANCE-2 registry.

Clin Cardiol 2017 Dec 16;40(12):1316-1322. Epub 2017 Dec 16.

Department of Cardiology, European Hospital of Georges Pompidou, Public Assistance Hospitals of Paris, Paris Descartes University, Paris, France.

Background: Coronary artery disease (CAD) is common in patients undergoing transcatheter aortic valve replacement (TAVR). However, the impact of CAD distribution before TAVR on short- and long-term prognosis remains unclear.

Hypothesis: We hypothesized that the long-term clinical impact differs according to CAD distribution in patients undergoing TAVR using the FRench Aortic National CoreValve and Edwards (FRANCE-2) registry.

Methods: FRANCE-2 is a national French registry including all consecutive TAVR performed between 2010 and 2012 in 34 centers. Three-year mortality was assessed in relation to CAD status. CAD was defined as at least 1 coronary stenosis >50%.

Results: A total of 4201 patients were enrolled in the registry. For the present analysis, we excluded patients with a history of coronary artery bypass. CAD was reported in 1252 patients (30%). Half of the patients presented with coronary multivessel disease. CAD extent was associated with an increase in cardiovascular risk profile and in logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) (from 19.3% ± 12.8% to 21.9% ± 13.5%, P < 0.001). Mortality at 30 days and 3 years was 9% and 44%, respectively, in the overall population. In multivariate analyses, neither the presence nor the extent of CAD was associated with mortality at 3 years (presence of CAD, hazard ratio [HR]: 0.90; 95% confidence interval [CI]: 0.78-1.07). A significant lesion of the left anterior descending (LAD) was associated with higher 3-year mortality (HR: 1.42; 95% CI: 1.10-1.87).

Conclusions: CAD is not associated with decreased short- and long-term survival in patients undergoing TAVR. The potential deleterious effect of LAD disease on long-term survival and the need for revascularization before or at the time of TAVR should be validated in a randomized control trial.
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http://dx.doi.org/10.1002/clc.22830DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6490315PMC
December 2017

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

Intraprocedural invasive hemodynamic parameters as predictors of short- and long-term outcomes in patients undergoing transcatheter aortic valve replacement.

Cardiovasc Revasc Med 2018 04 22;19(3 Pt A):257-262. Epub 2017 Sep 22.

Section of Interventional Cardiology, MedStar Washington Hospital Center, Georgetown University Hospital, Washington, D.C., USA. Electronic address:

Objective: Evaluation of invasive hemodynamic parameters as prognostic markers of mortality in patients undergoing TAVR.

Background: The value of invasive intraprocedural hemodynamic evaluation of patients undergoing transcatheter aortic valve replacement is unclear.

Methods: Consecutive patients who underwent transfemoral TAVR and had complete prospectively collected intraprocedural invasive hemodynamic parameters were retrospectively analyzed. Patients with alternative access, planned general anesthesia, or baseline ≥moderate Tricuspid Regurgitation were excluded. Pre- and post-valve implant parameters included heart rate, systolic and diastolic blood pressures, cardiac output and index, pulmonary arterial systolic and diastolic pressures, transaortic pressure gradient and right atrial pressure. The primary end points were the association of the intraprocedural hemodynamic changes with all-cause mortality at 30days and 1year. Extensive Receiver Operating Characteristic analyses yielded dichotomized threshold of hemodynamic values in association with the binary outcome of mortality.

Results: A total of 312 patients (52% male, mean age 83years) were evaluated. A significant association with 30-day and 1-year mortality was found between intraprocedural post-valve implant cardiac index <1.9 vs. ≥1.9L/min/m (Log-ranked p=0.0286 and p=0.0432, respectively). Four subgroups with pre- and post-valve implant CI changes (L/min/m) were compared: [1] pre<1.9, stable_post<1.9; [2] pre<1.9, improved_post≥1.9; [3] pre≥1.9, stable_post≥1.9; and [4] pre≥1.9, worsened_post<1.9. Group 1 (lower CI with no post-valve improvement) had the worst survival, and Group 3 (higher CI and stable post-valve) had the best survival at 1-year follow-up (Log-ranked p=0.0089).

Conclusions: In patients with severe aortic stenosis undergoing TAVR, invasive monitoring can assess for hemodynamic prognostic markers of survival.
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http://dx.doi.org/10.1016/j.carrev.2017.09.011DOI Listing
April 2018

Management and Outcome of Residual Aortic Regurgitation After Transcatheter Aortic Valve Implantation.

Am J Cardiol 2017 Aug 31;120(4):632-639. Epub 2017 May 31.

Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC. Electronic address:

We aimed to evaluate the success rates of balloon valvuloplasty post-dilation (BVPD) and a second-valve deployment in reducing residual aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) and its impact on outcome. Residual AR immediately post-TAVI in patients with aortic stenosis is a common condition that adversely affects outcome. Patients who underwent TAVI who had more-than-mild residual AR were managed either with medical therapy, re-intervention with BVPD, or a second valve. The clinical impact of these strategies was evaluated, and the anatomical features of patients with successful and unsuccessful intervention were compared. Among 572 patients with TAVI, 110 (19%) had significant residual AR after initial device deployment. Sixty patients were treated by BVPD (n = 49) or second-device deployment (n = 11), whereas 50 patients were treated medically. Successful reduction in residual AR to mild and below was achieved in 56% of the intervention group. Eccentric and calcified annuli were present in patients in whom residual AR remained despite re-intervention (p = 0.004). Interventions to reduce residual AR were independently associated with improved survival compared with conservative medical therapy (hazard ratio 0.45, 95% confidence interval 0.94 to 0.21, p = 0.03). BVPD or a second valve were safe and were not associated with increased rate of periprocedural complications. In conclusion, both BVPD and a second-valve deployment to reduce residual AR post-TAVI are effective and safe. The success rates are inversely correlated with the annulus eccentricity and calcification. These measures should be encouraged to reduce acute residual AR as they are associated with improved long-term survival.
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http://dx.doi.org/10.1016/j.amjcard.2017.05.033DOI Listing
August 2017

6- Versus 24-Month Dual Antiplatelet Therapy After Implantation of Drug-Eluting Stents in Patients Nonresistant to Aspirin: Final Results of the ITALIC Trial (Is There a Life for DES After Discontinuation of Clopidogrel).

JACC Cardiovasc Interv 2017 06;10(12):1202-1210

Poly de St. Laurent, Rennes, France.

Objectives: The aim of this study was to test the hypothesis that 6-month dual antiplatelet therapy (DAPT) is noninferior to 24-month DAPT in aspirin-sensitive patients.

Background: The ITALIC (Is There a Life for DES After Discontinuation of Clopidogrel) trial showed that rates of bleeding and thrombotic events at 1 year were much the same with 6 versus 12 months of DAPT after percutaneous coronary intervention with second-generation drug-eluting stents. In this report, 2-year follow-up is presented.

Methods: In a multicenter randomized study, patients with confirmed nonresistance to aspirin undergoing drug-eluting stent implantation were allocated to 6 or 24 months of DAPT. The primary endpoint was a composite of death, myocardial infarction, urgent target vessel revascularization, stroke, and major bleeding at 12 months post-percutaneous coronary intervention. The secondary endpoints comprised the same composite endpoint at 24 months and each individual component.

Results: Overall, 2,031 patients from 70 centers were screened; 926 were randomized to 6-month and 924 to 24-month DAPT. Noninferiority was demonstrated for 6- versus 12-month DAPT, with an absolute risk difference of 0.11% (95% confidence interval: -1.04% to 1.26%; p = 0.0002). At 2 years, the composite endpoint was unchanged, at 3.5% for 6 months and 3.7% for 24 months (p = 0.79), and rates of myocardial infarction (1.3% vs. 1.0%; p = 0.51), stroke (0.6% vs. 0.8%; p = 0.77), and target vessel revascularization (1.0% vs. 0.3%; p = 0.09) were likewise similar. There was a trend toward higher mortality with longer DAPT (2.2% vs. 1.2%; p = 0.11). Four patients (0.4%) in the 24-month group and none in the 6-month group had major bleeding.

Conclusions: Two-year outcomes in the ITALIC trial confirmed the 1-year results and showed that patients receiving 6-month DAPT after percutaneous coronary intervention with second-generation drug-eluting stent have similar outcomes to those receiving 24-month DAPT.
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http://dx.doi.org/10.1016/j.jcin.2017.03.049DOI Listing
June 2017

Outcome of implantation of a second self-expanding valve for the treatment of residual significant aortic regurgitation.

Catheter Cardiovasc Interv 2017 Oct 15;90(4):673-679. Epub 2017 Mar 15.

Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.

Background: Residual aortic regurgitation (AR) following transcatheter aortic valve replacement (TAVR) is associated with adverse outcome. We sought to evaluate the efficacy and safety of second CoreValve (CV) implantation to treat residual AR following the initial CV deployment.

Methods And Results: TAVR patients treated with a second CV due to moderate and above residual AR were compared to single device implantation. Valvular function parameters were compared at baseline, post procedure, and 30 days. Among 172 CV TAVR patients, 11 required a second device (6%) due to significant residual AR. The main differences between the groups were higher rates of low ejection fraction in patients with 2 CV implanted and higher annular diameter (27 [29-25] vs. 25 [26-24] mm, P = 0.03), requiring a larger device. Although two patients in the two CV group had high initial implantation, low implantation was similar between the groups. A second CV achieved adequate reduction in residual AR in six patients (55%), while an additional four patients had moderate residual AR. Only one remained with moderate to severe AR after 30 days follow-up. There were no cases of peri-procedural stroke or mortality.

Conclusions: Second implantation of self-expanding valve can successfully reduce residual significant AR following initial CV implantation and should be considered as therapeutic option for this population. © 2017 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ccd.26960DOI Listing
October 2017

Comparison of Baseline Characteristics and Inhospital Outcomes of Patients and Use of Bare Metal Versus Drug-Eluting Stents During Percutaneous Coronary Intervention 2005 to 2015 at a Single Tertiary Hospital.

Am J Cardiol 2017 May 9;119(9):1324-1330. Epub 2017 Feb 9.

Division of Cardiology, MedStar Washington Hospital Center, Washington, DC. Electronic address:

With steady growth in the use of drug-eluting stents (DES), the indications for bare metal stents (BMS) have significantly changed over the last decade. This study aims to describe trends in the use of BMS and the evolution of the population receiving them over the past 10 years and determine patient characteristics associated with using BMS. Consecutive patients who underwent percutaneous coronary intervention (PCI) at the Washington Hospital Center from January 2005 through March 2015 were included. Baseline characteristics and inhospital outcomes of patients who underwent PCI with BMS versus DES were compared during 2 different time periods: from 2005 to 2010 and from 2011 to 2015. Multivariable analyses were performed for each period of time to determine independent variables associated with the choice of BMS rather than DES; 20,321 patients who underwent PCI were included in the present study. The mean age was 65.0 ± 12.5 years, 65.2% were men, and 30.4% were black. BMS use peaked in 2007 (47%) but has fallen steadily since; BMS accounted for only 10% of stents used in 2015. Presentation with acute coronary syndrome or cardiogenic shock was more common in patients receiving a BMS; this was reflected in higher rates of inhospital mortality and major bleeding among patients receiving BMS versus DES. Covariables independently associated with receiving a BMS common to both time periods included black race, Hispanic ethnicity, cardiogenic shock or acute coronary syndrome, oral anticoagulation, current smoking, increasing age, lower hematocrit, and history of chronic renal insufficiency. In conclusion, there has been a precipitous decline in the use of BMS over the last decade. Newer stent technology that promises shorter duration of dual antiplatelet therapy is likely to lead to the extinction of BMS over the next decade.
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http://dx.doi.org/10.1016/j.amjcard.2017.01.016DOI Listing
May 2017

Impact of right ventricular function on outcome of severe aortic stenosis patients undergoing transcatheter aortic valve replacement.

Am Heart J 2017 02 29;184:141-147. Epub 2016 Oct 29.

Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC. Electronic address:

Background: Right ventricular (RV) dysfunction was shown to be associated with adverse outcomes in a variety of cardiac patients and is considered a risk factor for adverse outcome according to the updated Valve Academic Research Consortium criteria.

Objective: Our goal was to assess the impact of RV function at baseline on 1-year mortality among patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).

Methods: All patients with severe AS treated with TAVR from May 2007 to March 2015 at our center were included in the present study, and baseline and procedural characteristics were recorded for each patient. The patients were categorized according to RV function at baseline as assessed by current guidelines, and a comparison of mortality rates up to 1 year was performed.

Results: Among 650 patients, 606 had adequate echocardiogram quality and 146 (24%) had RV dysfunction. There were significant differences between the 2 groups, as patients with RV dysfunction were younger (81±9 vs 84±7 years, P=.01) and were more likely to be male (65% vs 42%, P<.001). In addition, patients with RV dysfunction had higher rates of prior myocardial infarction (26% vs 16%, P=.02) and atrial fibrillation (51% vs 39%, P=.02). Echocardiographic parameters demonstrated higher rates of left ventricular ejection fraction <40% (40% vs 18%, P<.001), tricuspid regurgitation above moderate (16% vs 9%, P=.04), and higher pulmonary artery systolic pressure (50±17 vs 44±16 mm Hg, P<.001) among patients with severe AS and RV dysfunction compared with patients with normal RV function. Despite the unfavorable cardiac function, patients with severe AS undergoing TAVR have similar functional class (P=.22) and mortality rates at 1year (27% vs 23%, log-rank P=.45).

Conclusions: Patients with severe AS and RV dysfunction have similar 1-year mortality and functional class after TAVR to patients with normal RV function. The presence of RV dysfunction does not correlate with outcome in patients with severe AS.
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http://dx.doi.org/10.1016/j.ahj.2016.09.018DOI Listing
February 2017

Anatomical Variations of the Venous Drainage from the Left Adrenal Gland: An Anatomical Study.

World J Surg 2017 Apr;41(4):991-996

Laboratoire d'Anatomie Des Alpes Françaises (LADAF), Faculty of Medicine, Grenoble Alpes University, Grenoble, France.

Background: For radiologists, the venous drainage of adrenal glands is a key to the technique of selective adrenal venous sampling. For endocrine surgeons, it is key to adrenalectomy for carcinoma and pheochromocytoma. This study aims to demonstrate direct anastomosis between the left adrenal vein, the diaphragmatic circulation and the azygos system. Anatomical textbooks only offer very little information concerning the left adrenal vein (LAV) and its potential anastomosis with the reno-lumbo-azygo trunk (RLAT) and the diaphragmatic circulation.

Methods: Between November 2014 and October 2015 in the LADAF (French Alps Anatomy Laboratory), we dissected 44 formalin-fixed adult cadavers.

Results: We found no direct anastomosis between the left adrenal vein and the reno-azygo-lumbar trunk and two anastomoses (4.5%) between the adrenal capsular vein and azygos system. A lumbo-azygo trunk has been found 38 times (86.3%), drained 35 times (79.5%) into the left renal vein and 3 times (6.8%) into the left genital vein. An inferior phrenic vein ending into an adrenal vein was highlighted in all cases, 6 times (13.7%) in a double adrenal vein and 38 times (86.3%) in a single one.

Conclusions: No connections have been found between left adrenal vein and the RLAT, and frequency of the IPV is discordant with the literature. However, our findings concerning the capsular vessels' anastomosis with the azygos system, inferior diaphragmatic flow and double adrenal vein could have two clinical applications: Firstly, the ligation of the adrenal vein solely is not enough to entirely interrupt the adrenal vein drainage, and secondly, sampling of hormones in the LAV could be underestimated because of the risk of dilution.
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http://dx.doi.org/10.1007/s00268-016-3817-2DOI Listing
April 2017

What should a fellow-in-training expect at national cardiovascular conferences? The interventional cardiology fellows' perspective.

Cardiovasc Revasc Med 2016 Oct - Nov;17(7):438-440. Epub 2016 Sep 6.

Section of Interventional Cardiology, Division of Cardiology, MedStar Washington Hospital Center, Georgetown University Hospital, Washington, D.C.

Background: It has become challenging for cardiovascular fellows-in-training (FIT) to determine which national cardiovascular conference (NCC) to attend given the broad range of meetings and the breadth of information offered. The aim of this study was to report our own experiences of the utility and individual strengths of the NCCs and to further understand the interventional cardiology (IC) FITs' viewpoint regarding the benefits of the individual NCCs.

Methods: A survey was formulated with questions and scenarios regarding topics deemed to be of highest importance for an IC-FIT. The survey emphasized experiences regarding the utility and benefits of the NCCs, time management, optimization of acquired education, and specific interests in clinical and research topics. The completely anonymous survey was sent via an email format to a total of 234, majority of IC (fourth and fifth years) and a minority of general (third year), FITs.

Results: A completed survey response was received from 131 of the fellows (56%). The results demonstrated that the IC-FITs endorsed that the small, focused sub-specialty interventional meetings vs. the large society general meetings were more beneficial in regard to the didactic education offered. In addition, the IC-FITs indicated that pre-planning for the meetings is the most beneficial approach in optimizing one's education and that the caliber of expert faculty, case-based and live-case presentations are among the most important aspects of the meetings.

Conclusions: Interventional cardiology FITs prefer the small sub-specialty interventional meetings over the large society general NCCs in regard to the benefits of didactic learning.
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http://dx.doi.org/10.1016/j.carrev.2016.08.009DOI Listing
February 2017