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Long-term results of transcatheter mitral valve replacement (TMVR) using balloon-expandable valves remain uncertain. This study aims to evaluate the long-term outcomes and durability of bioprosthetic heart valves after TMVR in patients undergoing valve in valve (ViV), valve in ring (ViR) and valve in mitral annular calcification (ViMAC) procedures. All patients undergoing TMVR for bioprosthesis or ring failure or severe annular calcifications in our center were included. A ballon expandable transcatheter aortic valve (SAPIEN XT or SAPIEN 3) was used in all cases. Patients were followed at 3 months, 1 year and yearly thereafter by means of clinical visits or phone contacts. The primary outcome was a combined criteria of death and mitral re-intervention (mitral valve replacement, heart transplantation, TMVR in TMVR). A total of 200 patients underwent TMVR between may 2010 and august 2023, with 121 (60,5%) ViV, 45 (22,5%) ViR and 34 (17%) ViMAC procedures. The median age of the population was 70 years. Over a median follow-up period of 2.6 years [IQR: 0.7–6.7], the composite outcome of death or mitral reintervention occurred in 102 patients: 84 (82%) patients had died, 12 (12%) required mitral surgical replacement, 2 (2%) underwent heart transplantation and 4 (4%) required TMVR in TMVR. This outcome occurred more frequently in the ViR and ViMAC group than in the ViV group (Fig. 1) (P < 0.0001). Regarding echocardiographic findings, there was a significant reduction in mean transmitral valve gradient after the procedure with a median of 6.0 versus 10.3 mmHg before. The mean gradient remained initially stable with a slight increase during the longer follow up period (Fig. 2a). The median gradient was of 7 mmHg at 1.3 and 5 years 8 mmHg at 7 years and 9 mmHg at 9 years. A similar trend was observed with the assessment of the mitral valve area showing a slight decrease over the years. Reoccurrence of higher-grade (3–4+) mitral regurgitation was infrequent at last follow-up (Fig. 2b). This study suggests acceptable long term clinical outcomes and an excellent durability of TMVR using balloon expandable valves. [ABSTRACT FROM AUTHOR]

Smoking is a well-identified risk factor for recurrent, CV events in patients with stable CAD. However, smoking status is not binary, and there is a wide diversity of smoking habits trajectories within this population, with different consequences on residual CV risk. To better understand how smoking status evolves in patients with CAD, and how it is associated with subsequent CV events. We analysed the CLARIFY registry, which included 32,378 patients with CAD. We defined groups according to smoking status at inclusion in the registry: never, former and active smokers. For former smokers, we assessed the timing of definitive smoking discontinuation and its relationship with subsequent CV events. For active smokers, we investigated the association between smoking reduction or discontinuation in active smokers with outcomes. The primary endpoint was the occurrence of MACE defined by CV death or MI during the 5-year follow-up period adjusted on known predictors for MACE in CAD patients. At inclusion, 13,366 (41.3%) patients never smoked, 14,973 (46.2%) were former smokers, and 4,039 (12.5%) were current smokers. In active smokers at time of CAD diagnosis, definite smoking cessation occurred within the year of CAD diagnosis for half of them. Each additional year of active smoking after CAD diagnosis increased the risk of MACE (aHR 1.08, 95% CI 1.04–1.12 per year). However, regardless of the duration of smoking cessation, former smokers did not return to the cardiovascular risk levels observed in individuals who never smoked (figure). In active smokers at inclusion, smoking cessation was associated with improved CV outcomes, irrespective of the timing of cessation during follow-up (aHR 0.56, 95% CI 0.42–0.76, P < 0.001). Among active smokers, 25.7% reduced their quantity smoked within the first year of follow-up without quitting, but this did not significantly reduce the rate of CV death and MI (aHR 0.96, 95% CI 0.74–1.26, P = 0.78) compared to other active smokers. In active smokers diagnosed with CAD, the majority of definite quitters cease smoking within the first year of CAD diagnosis. Each subsequent year of active smoking adversely affects CV outcomes. Smoking cessation at any time significantly reduces the risk of CV death or recurrent MI compared to persistent active smokers, although CV risk of former smokers does not decrease to the levels observed in never-smokers. [ABSTRACT FROM AUTHOR]

Effective management of low-density lipoprotein cholesterol (LDL-C) is crucial for preventing recurrent cardiovascular (CV) events in patients with chronic coronary syndrome (CCS). Sex may impact the LDL-C management. We examined sex-specific LDL-C management in CCS patients, assessing target achievement rates and their implications for CV outcomes. In the international CLARIFY registry, we included 22,134 CCS patients with baseline LDL-C measurements. LDL-C levels were monitored annually over the 5-year follow-up period. Target LDL-C was set at 100 mg/dL, in line with prevailing recommendations at that time. Sex-specific differences in LDL-C were adjusted forage, geographical region and indication for lipid lowering drugs (stroke, MI, PAD). The primary endpoint was the incidence of MACE, defined as CV death or MI during the 5-year follow-up, evaluated using multivariable analysis adjusted for known predictors of recurrent CV events in CCS patients. Of 22,134 patients, 21.6% were women. Upon inclusion (6.5 ± 6.3 years after CCS diagnosis), women were more likely than men to have LDL-C levels above the recommended threshold (45.6% vs. 37.4%; aOR 1.47, 95%CI 1.38–1.58, P < 0.001, Fig. 1) and less likely to receive statin treatment (82.7% vs. 85.4%, P < 0.001). The discrepancies endured over the 5-year observation period, with women consistently showing lower likelihood of achieving LDL-C targets at 1, 2, 3, 4, and5 years post-inclusion (P < 0.001 for all time points). Overall, women were less likely than men to have all available LDL-C concentrations within the target range (37.8% vs. 44.6%; aOR 0.70, 95% CI 0.64–0.76, P < 0.001) and more likely to never reach the target LDL-C goal during follow-up (22.6% vs. 17.5%; aOR 1.43, 95% CI 1.32–1.55, P < 0.001). Failing to achieve at least one LDL-C concentration below100 mg/dL was associated with an increased risk of subsequent MACE (adjusted HR 1.57, 95%CI 1.38–1.77, P < 0.001), with similar associations observed in both men (aHR 1.66, 95% CI 1.44–1.91, P < 0.001) and women (aHR 1.31, 95% CI 1.01–1.70, P = 0.05). In patients with CCS, women consistently showed lower likelihood of reaching LDL-C targets throughout follow-up compared to men. Women were more likely to have no LDL-C concentration within recommended range during follow-up, which is particularly concerning given its association with an increased risk of CV events. [ABSTRACT FROM AUTHOR]

In addition, no significant difference in renal-event-free Kaplan-Meier survival curves was found according to tertiles of GRS in patients with T2D and T1D (log-rank=0.88, P=0.64 and log-rank=3.8, P=0.15, respectively; Figs. On pooling both T2D and T1D patients, every 10% increase in GRS was associated with an NS effect on eGFR trajectory (P=0.43). In conclusion, a GRS-based on 18 GWAS-derived SNPs does not allow clinically relevant prediction of the risk of chronic renal failure in patients with either T2D or T1D. [Extracted from the article]

Whether the use of ticagrelor in chronic coronary syndrome patients undergoing complex percutaneous coronary intervention (PCI) can prevent type 4 myocardial infarction (MI) or myocardial injury as compared to clopidogrel is unknown. To evaluate outcomes of complex PCI in stable coronary patients and the efficacy of ticagrelor versus clopidogrel in these patients randomized in the ALPHEUS trial. All PCI procedures were blindly reviewed by two core laboratory readers and classified as complex if they had at least one of the following criteria: stent length ≥ 60 mm, two-stent bifurcation, use of atherectomy, left main, bypass graft, chronic total occlusion, use of guide catheter extensions, multiwire technique, multiple stents. The primary endpoint was a composite of type 4a or b MI and major myocardial injury, defined by the 3rd and 4th universal definition of MI, during the 48 h after PCI. Angiographic complications and the composite of death, MI, stroke at 48 hours and at 30 days were also evaluated. We compared the event rates in the randomized groups according to the presence or not of complex PCI criteria and evaluated interaction with ticagrelor or clopidogrel. Among the 1866 patients randomized, 910 (48.3%) PCI were classified as complex PCI. Multiple criteria of complex PCI were found in 14.4% (2 criteria) and 9.1% (≥ 3 criteria) of the patients. The primary endpoint was more frequent in complex PCI (45.6% vs 26.6%; p < 0.001) driven by higher rates of type 4MI and angiographic complications (12.2% vs 4.8%; p < 0.001 and 19.3% vs 8.6%; p < 0.05, respectively). The composite of death, MI, stroke at 48 hours (12.7% vs 5.1%; p < 0.05) and at 30 days (13.4% vs 5.3%; p < 0.05) were also more frequent in complex PCI. No interaction was found between the complexity of PCI and the randomized treatment for the primary endpoint (p for interaction = 0.35) nor the secondary endpoints (Figure 1). Complex PCI patients have higher rates of periprocedural and cardiovascular events which are not reduced by ticagrelor as compared with clopidogrel. [ABSTRACT FROM AUTHOR]

Although the association of atrial fibrillation (AF) and coronary artery disease is a growing public health concern, data in patients with chronic coronary syndrome (CCS) is scarce. We aimed to describe the incidence rate and predictors of new-onset AF in CCS outpatients as well as its association with major adverse cardiovascular events (MACE) using a large-scale registry. The international ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease (CLARIFY), provides real-world data from 32,703 outpatients with CCS from 45 countries. Our analysis included 29,001 patients without prior AF at baseline. Over the median 5-year follow-up, 1453 (5%) had a new-onset AF diagnosed with an annual incidence rate of around 1%. Independent predictors of AF were increased age, treated hypertension, history of peripheral artery disease and an alcohol intake ≥ 1 drink per week. Left ventricular ejection fraction value and a high triglyceride level were independent predictors of lower new-onset AF rate. As rhythmic status was a variable that changed during follow-up, incident AF was included as a time-varying covariate in the Cox regression model. Compared to CCS patients without AF, those with new-onset AF had a higher rate of MACE, including the composite endpoint of cardiovascular death, non-fatal myocardial infarction or non-fatal stroke, hazard ratio (HR) 2.52 (95% CI 2.11-3.01); cardiovascular death, HR 3.22 (2.63-3.94); stroke, HR 2.80 (2.01-3.91); all cause death, HR 2.64 (2.23-3.11); hospitalization for heart failure, HR 9.38 (8.02-10.97); major bleeding, HR 4.33 (2.94-6.39), P < 0.001 for each and myocardial infarction, HR 1.55 (1.08-2.22), P < 0.016 (Table 1, Fig. 1). New-onset AF is strongly associated with the risk of MACE and should be considered as a prognostic turning point in CCS patients. Many predictors have been identified which presence should lead to broader screening for arrhythmias in CCS patients. [ABSTRACT FROM AUTHOR]

Context: International guidelines recommend an early invasive strategy for patients with high-risk acute coronary syndromes without ST-segment elevation, but the optimal timing of intervention is uncertain.Objective: To determine whether immediate intervention on admission can result in a reduction of myocardial infarction compared with a delayed intervention.Design, Setting, and Patients: The Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention (ABOARD) study, a randomized clinical trial that assigned, from August 2006 through September 2008 at 13 centers in France, 352 patients with acute coronary syndromes without ST-segment elevation and a Thrombolysis in Myocardial Infarction (TIMI) score of 3 or more to receive intervention either immediately or on the next working day (between 8 and 60 hours after enrollment).Main Outcome Measures: The primary end point was the peak troponin value during hospitalization; the key secondary end point was the composite of death, myocardial infarction, or urgent revascularization at 1-month follow-up.Results: Time from randomization to sheath insertion was 70 minutes with immediate intervention vs 21 hours with delayed intervention. The primary end point did not differ between the 2 strategies (median [interquartile range] troponin I value, 2.1 [0.3-7.1] ng/mL vs 1.7 [0.3-7.2] ng/mL in the immediate and delayed intervention groups, respectively; P = .70). The key secondary end point was observed in 13.7% (95% confidence interval, 8.6%-18.8%) of the group assigned to receive immediate intervention and 10.2% (95% confidence interval, 5.7%-14.6%) of the group assigned to receive delayed intervention (P = .31). The other end points, as well as major bleeding, did not differ between the 2 strategies.Conclusion: In patients with acute coronary syndromes without ST-segment elevation, a strategy of immediate intervention compared with a strategy of intervention deferred to the next working day (mean, 21 hours) did not result in a difference in myocardial infarction as defined by peak troponin level.Trial Registration: clinicaltrials.gov Identifier: NCT00442949. [ABSTRACT FROM AUTHOR]

Transcatheter mitral valve implantation (TMVI) is a new treatment option for high-risk surgical patients with degenerated bioprosthesis (ViV), failed annuloplasty rings (ViR) and severe mitral annular calcification (ViMAC). However, limited data exist on transcatheter heart valve (THV) thrombosis. To report the incidence, clinical impact and treatment outcomes of THV thrombosis in patients undergoing TMVI. All consecutive patients underwent TMVI in our center between July 2010 and September 2019 were included. A transoesophageal echocardiography (TOE) and a computed tomography (CT) were performed at discharge and each follow-up clinical visit (3 months, 1 year and then annually). THV thrombosis was defined as the presence of at least one thickened leaflet with restricted motion confirmed by TOE and/or contrast CT, and was classified according to the timing of diagnosis as immediate (at discharge), early (at the 3-month clinical visit), or late (at the 1-year clinical visit and thereafter) (Table 1). A total of 132 patients underwent TMVI. At a median follow-up of 1.4 years, THV thrombosis was observed in 16 (12.1%) patients: 7 (43.8%) in the ViV TMVI group, 5 (31.2%) in the ViR group and 4 (25%) in the ViMAC group (P = 0.93). In 13 (81.2%) patients, THV thrombosis occured within the first 3 months. Neither stroke nor other thromboembolic event occurred. Rates of early and late THV thrombosis were higher in patients without anticoagulation than in those treated with anticoagulation (respectively 25% vs.3.2%, p = 0.018 and 13.6% vs.0%, P = 0.023). After optimization of antithrombotic treatment, THV thrombosis resolved in all but one asymptomatic patient (Fig. 1). THV thrombosis is frequent after TMVI, occurs mainly within the first 3 months, is mostly subclinical and resolves after optimization of antithrombotic treatment. An anticoagulation therapy for at least 3 months after the procedure is mandatory. [ABSTRACT FROM AUTHOR]

The prevalence, and prognostic implication of left bundle branch block (LBBB) patients with stable coronary artery disease (CAD) is unknown. To describe the prevalence, incidence and prognostic implications of LBBB in patients with stable CAD. CLARIFY is an international registry of more than 30.000 patients with stable CAD. LBBB was defined as a QRS complex > 120 milliseconds. Patients with previous pacemaker implantation or defibrillator were excluded. The primary outcome was a composite of cardiovascular (CV) Death, MI or stroke, and secondary outcomes included hospitalization for heart failure (HF) or the need for pacemaker implantation. From the 23.457 patients with available data, 1.041 (4.4%) had LBBB at baseline and 1.237 (5.3%) during 5-year follow-up. Only 21 patients with newly diagnosed LBBB overtime, had a documented MI the same year. Compared to patients without LBBB, patients with LBBB had a higher risk profile regarding age (67.2 ± 10.1 versus 63.6 ± 10.4 years, P < 0.0001), history of coronary artery bypass grafting (29.2% vs. 23.7%, P < 0.0001), diabetes (35.1% vs. 28.4%, P < 0.0001), and HF (25.2% vs. 16.8%, P < 0.0001). In multivariate analysis there was no difference in the rate of primary outcome between LBBB or no-LBBB patients (adjusted HR 1.04, 95% CI 0.85–1.29). Patients with LBBB had a higher rate of pacemaker implantation (adjusted HR 2.21, 95% CI 1.55–3.15, P < 0.0001) and hospitalization for HF (adjusted HR 1.53, 95% CI 1.25–1.88, P < 0.0001) (Table 1 , Fig. 1). The prevalence of LBBB in patients with stable CAD was 4.4% and 5.3% with 5-year follow-up. The majority of newly diagnosed LBBB were not contemporary of myocardial infarction. LBBB was not associated with a higher rate of major adverse cardiovascular events, but with a higher risk of pacemaker implantation and hospitalization for heart failure. This is the first study reporting such results in a broad population of stable CAD patients. [ABSTRACT FROM AUTHOR]

Introduction Percutaneous mitral commissurotomy (PMC) was the first available percutaneous treatment of valvular diseases and experience has led to extend its indications to patients with less favourable anatomy. Objectives To analyze:. –the temporal trends of PMC in a single center with a large experience of this technique; –the predictive factors of poor immediate results (PIR) of PMC. Methods From mid-1986 to 2016, 1 year for each decade was chosen to analyze the temporal trends over 30 years: 1987, 1996, 2006 and 2016. All patients who underwent a PMC in our center during these 4 years were included in the study. PIR of PMC were defined as a final mitral valve area (MVA) < 1.5 cm2 or the presence of mitral regurgitation (MR) grade > 2. Results A total of 603 patients were included: 111, 202, 205 and 85 for the 4 years, respectively. Mean patient age increased > 10 years between 1987 and 2016 (P < 0.0001). Consistently, the presence of calcification increased from 25% of patients at the beginning of PMC to > 40% during the last decade (P < 0.0001) (Fig. 1). The severity of mitral stenosis did not significantly differ during the 30 years. Over the 3 decades, 84 patients experienced PIR of PMC (13.9%) and the percentage of PIR increased significantly in 2016 (24% versus 11 to 14% in previous decades, P < 0.05). We found in multivariate analysis 3 factors to be independently associated with PIR: a smaller baseline MVA (P < 0.0001), a higher pre-PMC grade of MR (P < 0.01) and the presence of calcification as assessed by a Cormier score of 3 (P < 0.001). Conclusion Changes in patient presentation with an older age and an increased occurrence of calcification over the years are consistent with the epidemiology of rheumatic fever and account for the increase in the rate of PIR. Despite more patients with severe mitral calcification, good immediate results of PMC were still achieved in > 3/4 patients in recent years, thus allowing to postpone surgery. [ABSTRACT FROM AUTHOR]

Patients with chronic coronary syndrome (CCS) currently have overall a relatively low rate of long-term ischaemic events but some high risk subsets of patient still experience a worse prognosis such as polyarterial disease patients. Cigarette smoking and diabetes mellitus are strongly associated with polyarterial disease and may be associated with an additional increase in ischaemic outcomes. We aimed to determine the 5-year ischaemic risk of CCS outpatients according to arterial disease phenotype as well as diabetic and smoking status. We analyzed data from 32,703 consecutive CCS outpatients enrolled in the prospective observational CLARIFY registry. Subsets of patients were compared according to their vascular phenotypes: Coronary artery disease (CAD) alone, CAD with peripheral artery disease (PAD) or cerebrovascular disease (CVD) (CAD + 1), CAD with CVD and PAD (CAD + 2) and according to their diabetic and smoking status. The primary outcome was a composite of cardiovascular death, myocardial infarction or stroke, adjusted by age, sex and geographic origin at 5 years. The 5-year primary outcome event rate was 9.5% overall (95% confidence interval (CI) 9.3–9.7) increasing according to the number of diseased arterial beds: from 8.4% (95% CI 8.1–8.7) in patients with CAD alone to 17.4% (95% CI 16.9–17.8) for CAD + 2 patients (P < 0.001). Subgroup analyzes according to diabetes and smoking status revealed an even greater variation of the primary outcome event rate ranging from 7% (95% CI 6.5–7.6) in non-diabetic, non-smoking CAD alone patients to 20.3% (95% CI 19.1–21.4) in diabetics and smokers CAD + 2 patients (Fig. 1). CCS patients with polyarterial disease are a heterogeneous group of patients, in which the ischaemic risk varies not only according to the number of arterial beds involvement, but also according to smoking and diabetes status. These findings highlighted a very vulnerable population of CCS patients. [ABSTRACT FROM AUTHOR]

The COMPASS trial compared 3 antithrombotic strategies in patients with stable CAD or PAD: Aspirin alone or a combination of Aspirin and different dose of Rivaroxaban. This trial has been stopped prematurely, due to overwhelming efficacy. These could potentially change the management of stable CAD and PAD patients. To describe the proportion of COMPASS-eligible patients in the REACH registry. To describe the reasons for ineligibility, and to compare the clinical characteristics, management and outcomes of COMPASS-eligible vs ineligible patients. REACH is an international prospective registry of patients with established stable CAD or PAD. The COMPASS inclusion and exclusion criteria were applied to the REACH population. The primary outcome was a composite of cardiovascular (CV) death, myocardial infarction (MI) and stroke. From the 65,351 patients in the overall REACH population, 24,677 were excluded because they did not have CAD or PAD, 15,885 were excluded because of missing information. The 24,969 remaining patients constituted the evaluable population. Among these, 10,983 patients were excluded because of exclusion criteria. The COMPASS-eligible population included 13,986 patients (56% of COMPASS-evaluable). Patients were excluded because: 4902 (19.6%) had a high bleeding risk (REACH score > 10), 3707 (14.9%) required AC, 5324 (21.3%) had HF, 1597 (6.4%) required DAPT due to ACS/PCI in the prior 12 months. The COMPASS-eligible population had a lower 4-year rate of CV death, non-fatal MI, or non-fatal stroke (14% [13.26–14.73] vs. 23.6% [22.54–24.64]); all-cause mortality (10.9% [10.2–11.5] vs. 22.5% [21.5–23.6]); or hospitalization for atherothrombotic events (26.7% [25.8–27.6] vs. 32.9% [31.8–34.0]), P < 0.001 ( Table 1 , Fig. 1 ). COMPASS-eligible patients represent approximately half of the spectrum of CAD/PAD patients in the real world REACH registry. COMPASS-eligible patients have a lower risk profile, and lower event rates compared to COMPASS-ineligible patients. [ABSTRACT FROM AUTHOR]

Background In contrast to SPECT-myocardial perfusion scintigraphy (MPS), positron emission tomography (PET)-MPS can be acquired during pharmacological stress and provides absolute quantification of stress myocardial blood flow (MBF). PET-MPS is therefore well suited for the more accurate detection of balanced myocardial ischemia in patients with three-vessel coronary artery disease (3V-CAD) Purpose The aim of this study was to compare the diagnostic performances of 99m Technetium (Tc)-MIBI-SPECT MPS and 82 Rubidium (Rb)-PET MPS for the detection of 3V-CAD. Methods Two hundred and ninety-two patients underwent gated MPS with Tc-MIBI-SPECT in association to the best stress test feasible (exercise and combined tests were prioritized) and gated MPS with Rb-PET and pharmacological stress using dipyridamole. Patients with at least one MPS considered as positive were referred for coronary angiography (CA). Patients were classified as positive for myocardial ischemia in case of significant stenosis (≥ 70%, or ≥ 50% and FFR ≤ 0.8) on CA or, in absence of CA, occurrence of cardiovascular event during the following year. Results Rb-PET-MPS offered better diagnostic performances than Tc-SPECT-MPS for the identification of stress LV dysfunction in patients with 3V-CAD (sensitivity: 75% vs. 56%, respectively; P = 0.18; specificity: 83% vs. 71%, respectively; P < 0.05). Quantification of MBF with Rb-PET-MPS provided high sensitivity for the detection of 3V-CAD (94% for global stress MBF < 1.8 ml/mn/g) but poor specificity (60%). By combining the diagnostic criteria for LV dysfunction and low stress MBF, the specificity of Rb-PET-MPS for the detection of patients with 3V-CAD increased to 92% for global stress MBF < 1.8 ml/mn/g, whilst maintaining a sensitivity of 75%. Conclusions Rb-PET-MPS offers to identify moderate stress LV dysfunction and decreased stress global MBF resulting into higher diagnostic performances for the detection of patients with 3V-CAD in comparison to Tc-SPECT-MPS. [ABSTRACT FROM AUTHOR]

Transcatheter mitral valve implantation (TMVI) is emerging as an alternative to surgical mitral valve replacement (SMVR) in selected high-risk patients. It may avoid redo-biological SMVR and delay definitive mechanical SMVR in young women wishing for pregnancy and suffering from failure of mitral bioprosthesis or annuloplasty. To evaluate the feasibility, safety and outcomes of TMVI in this specific population. From 2013 to 2018, 12 young women with degenerated mitral bioprostheses (n = 6) and annuloplasties (n = 6), pregnant (n = 1) or wishing for pregnancy (n = 11), were treated with transseptal valve-in-valve or valve-in-ring TMVI, using the Edwards SAPIEN XT/3 valves, and were prospectively followed at 1 month, 6 months, 1 year and yearly thereafter. Mean age was 29 ± 5 years and EuroSCORE II 3.2 ± 0.8%. The mode of failure was stenosis in 9 cases and regurgitation in 3. Systolic pulmonary artery pressure was 56 ± 26 mmHg. One TMVI was performed in emergency, in the setting of severe bioprosthesis failure complicated by cardiogenic shock and multiorgan failure. One per-procedure prosthesis atrial embolization occurred and required a conversion to standard surgery. One intra-ventricular obstruction was secondarily observed and lead to an elective SMVR. Median follow-up was 36 (4–51) months. At 6 months/1 year, 83% of the patients were in NYHA classes I/II. Mitral regurgitation was ≤ 1+ in all the cases and mean gradient was 8 ± 2 mmHg. Three patients could achieve 4 uneventful pregnancies. At last follow-up, there was no death and 3 patients underwent definitive mechanical SMVR. Valve-in-valve and valve-in-ring TMVIs avoid redo biological SMVR and allow young women carrying through uneventful pregnancies. This strategy delays definitive mechanical SMVR and the drawbacks of anticoagulation and may appear as a promising option in young women contemplating pregnancy. [ABSTRACT FROM AUTHOR]

Previous experience in infants has shown that percutaneous insertion of a cannula into the left atrium incorporated into the extracorporeal membrane oxygenation (ECMO) circuit decreases left cardiac pressures and improves pulmonary edema (PE). However, data on adults is scarce. This study aimed to evaluate the feasibility and safety of percutaneous decompression of the left atrium (PDLA) in patients supported by ECMO with refractory PE. A total of 23 consecutive patients were included between January 2015 and September 2018. A venous cannula incorporated to the ECMO circuit was inserted into the left atrium via transvenous transseptal catheterization. Data were retrospectively collected. Patients were classified as responders if the blood partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio increased at least by 20% or their respiratory failure improved to a less severe stage, or they were extubated during the first 48 hours. A successful procedure was defined as an adequate placement of the cannula in a patient who left the catheterization room alive. PDLA was successfully performed in all patients. One patient (4.3%) had a cardiac tamponade and one (4.3%) a hemothorax. No other procedural complications occurred. At day 2, PaO2/FiO2 ratio increased by 79 ± 143 (P = 0.161). Twelve patients (52.2%) were weaned from ECMO, 13 patients (56.5%) underwent heart transplantation and 10 patients (43.7%) were discharged alive from hospital. At a mean follow-up of 251 ± 288 days, 9 (39.1%) were alive. A total of 11 patients were classified as responders: they were more likely to be weaned from ECMO (54.5% vs. 44.4%, P = 0,391) and mechanical ventilatory support (54.5% vs. 22.2%, P = 0,142) and had a tendency to greater in-hospital survival (54.5% vs. 33.3%, P = 0,343). PDLA was feasible, safe and allowed an improvement in oxygenation-status of patients with refractory PE during ECMO support. [ABSTRACT FROM AUTHOR]

Introduction La néphropathie diabétique est une pathologie complexe comprenant l'interaction des facteurs environnementaux et génétiques. L'hypothèse selon laquelle l'information génétique permettrait une prédiction du risque d'insuffisance rénale chronique chez les patients diabétiques de type 2 n'a pas été testée. Matériels et Méthodes Nous avons sélectionné 18 polymorphismes mononucléotidiques (SNPs) identifiés par le CKD consortium comme associés avec la fonction rénale ou l'insuffisance rénale terminale et construit un score de risque génétique compris entre 0 et 100 %. Nous avons déterminé ce score de risque génétique chez les patients diabétiques de type 2 d'origine Caucasienne issus de la cohorte SUR-DIAGENE. Le critère de jugement principal était la survenue d'événements rénaux, définis par le doublement de la créatinine soutenue plus d'un mois et/ou l'insuffisance rénale terminale. Les critères secondaires étaient les évolutions du débit de filtration glomérulaire, et le risque de mort toute cause. Résultats Dans notre population d'étude ( n = 1 316), le score de risque génétique médian était de 50,0 % (mi n = 27,8 %, max = 72,2 %). À l'inclusion, le score de risque génétique n'était pas différent selon le stade d'insuffisance rénale ( p = 0,296). Au cours du suivi (médiane 67 mois), 80 événements rénaux sont survenus, soit une incidence de 1,1 % personne.années (IC 95 % : 0,8 %-1,3 %). Il n'y avait pas de différence significative entre les scores de risque génétique des 80 patients ayant un événement rénal au cours du suivi et les autres patients : HR = 1,08 (IC 95 % : 0,82-1,44) ; p = 0,578. Le score de risque génétique n'était pas lié à la trajectoire des DFG ( p = 0,491). Au cours du suivi, 383 patients sont décédés. Il n'y avait pas de différence entre les scores des patients décédés pendant le suivi et les autres : HR = 1,06 (IC 95 % : 0,84-1,09) ; p = 0,526. Conclusions Dans notre cohorte de patients diabétiques de type 2, le score de risque génétique basé sur 18 SNPs identifiés par le CKD consortium n'a pas de valeur pronostique pour l'insuffisance rénale ou la vitesse de déclin de fonction rénale. [ABSTRACT FROM AUTHOR]

Introduction: L’anomalie de la fonction rénale est un facteur de risque important pour la mort toutes causes chez les sujets présentant un diabète de type 2 (DT2). Il a été récemment suggéré que le taux circulant de TNFR1 pouvait être un biomarqueur de l’insuffisance rénale terminale chez des sujets DT2. Sa pertinence pour ce qui concerne la mort toutes causes, n’a cependant pas été établie de manière concluante. Matériels et méthodes: Nous avons cherché à évaluer la valeur pronostique des concentrations sériques de TNFR1 vis-à-vis du risque de décès toutes causes chez des sujets DT2 atteints de maladie rénale chronique et suivis dans la cohorte SURDIAGENE. Résultats: Un total de 522 sujets atteint de DT2 compliqué d’une atteinte rénale (débit de filtration glomérulaire estimé, DFGe < 60ml/min et/ou ratio Albumine/Créatinine urinaire, uACR > 30mg/mmol) ont été analysés. Pendant le suivi (durée médiane de 48 mois), 196 décès ont été enregistrés dont 129 d’origine cardiovasculaire. La mortalité toutes causes (IC 95 %) augmentait en fonction des quartiles de concentrations de TNFR1 (1er quartile : 4,7 % patientannée (3,0 %–6,3 %) ; 2e quartile : 7,7 % (5,4 %–10,0 %) ; 3e quartile : 9,3 % (6,7 %–11,9 %) et 4e quartile : 15,9 % (12,2 %–19,5 %), Dans une analyse multivariée prenant en considération l’âge, la durée du diabète, l’HbA1c, l’uACR et le DFGe, les sujets du 4e quartile avaient un risque ajusté de décès toutes causes multiplié par 2,98 (IC 95 % : 1,70–5,23) comparativement à ceux du 1er quartile, L’index d’amélioration de la discrimination intégrée était statistiquement significatif lorsque l’on ajoutait les concentrations de TNFR1 dans l’équation de risque dérivée de l’UKPDS (p=0,031). Conclusion: TNFR1 est un solide facteur de risque pour la mort toutes causes chez les sujets DT2 avec anomalie de la fonction rénale. Son utilité clinique peut être proposée en complément des facteurs de risque établis pour le décès toutes causes. [Copyright &y& Elsevier]

La myocardite aiguë (MA) peut révéler certaines maladies auto-immunes ou inflammatoires (MAII). Le traitement spécifique de la MAII permet d'améliorer le pronostic. Son diagnostic précoce est donc un enjeu majeur. L'objectif de cette étude était de décrire les caractéristiques cliniques et l'évolution des patients admis pour MA révélant une MAII. Tous les patients adultes hospitalisés pour une myocardite aiguë dans un département hospitalo-universitaire de cardiologie sur une période de 8 ans, de janvier 2011 à janvier 2019, ont été inclus et analysés de manière rétrospective. Le diagnostic de myocardite aiguë était basé sur l'association de critères cliniques, d'un taux élevé de Troponine T, et d'anomalies myocardiques évocatrices en IRM en l'absence de coronaropathie. Les différentes MAII ont été diagnostiquées selon les critères internationaux actuels. Deux cent dix-huit (35.3 [26.4-47.1] ans, 75.2 % d'hommes) patients ont été analysés. Au total, 15 (6,9 %) patients avaient une myocardite aiguë révélant une MAII jusque-là non connue. Les MAII diagnostiquées étaient un lupus érythémateux systémique (n = 3), une maladie de Still (n = 3), une sarcoïdose systémique (n = 2) un syndrome des antiphospholipides (n = 1), un syndrome des antisynthétases anti-Jo1 (n = 1), une granulomatose éosinophile avec polyangéite (n = 1), une connectivite mixte (n = 1), une arthrite réactionnelle (n = 1), une maladie de Basedow (n = 1) et une maladie de Crohn (n = 1). Au diagnostic de MA, la fonction ventriculaire gauche était inférieure à 30 % chez 5 (33.3 %) patients avec MAII. Tous les patients avec MAII, exceptés deux, ont été traités avec des corticoïdes en association avec un traitement immunosuppressif ou immunomodulateur. À la fin du suivi médian de 16.6 [3.4-37.8] mois, l'ensemble des patients avait récupéré une fonction ventriculaire gauche normale. En comparant en analyses multivariées les patients avec (n = 15) ou sans (n = 203) MAII, l'absence de douleur thoracique, la présence d'un épanchement péricardique et un taux sérique élevé de CRP au diagnostic de MA étaient associés à la présence d'une MAII. Les myocardites aiguës inaugurales de MAII sont sévères au diagnostic mais d'évolution favorable sous traitement spécifique. Au diagnostic de MA, la présence d'un épanchement péricardique et un taux sérique élevé de CRP augmentent la probabilité d'avoir à une MAII. [ABSTRACT FROM AUTHOR]

BACKGROUND: The use of intensive lipid-lowering therapy by means of statin medications is recommended after transient ischemic attack (TIA) and ischemic stroke of atherosclerotic origin. The target level for low-density lipoprotein (LDL) cholesterol to reduce cardiovascular events after stroke has not been well studied. METHODS: In this parallel-group trial conducted in France and South Korea, we randomly assigned patients with ischemic stroke in the previous 3 months or a TIA within the previous 15 days to a target LDL cholesterol level of less than 70 mg per deciliter (1.8 mmol per liter) (lower-target group) or to a target range of 90 mg to 110 mg per deciliter (2.3 to 2.8 mmol per liter) (higher-target group). All the patients had evidence of cerebrovascular or coronary-artery atherosclerosis and received a statin, ezetimibe, or both. The composite primary end point of major cardiovascular events included ischemic stroke, myocardial infarction, new symptoms leading to urgent coronary or carotid revascularization, or death from cardiovascular causes. RESULTS: A total of 2860 patients were enrolled and followed for a median of 3.5 years; 1430 were assigned to each LDL cholesterol target group. The mean LDL cholesterol level at baseline was 135 mg per deciliter (3.5 mmol per liter), and the mean achieved LDL cholesterol level was 65 mg per deciliter (1.7 mmol per liter) in the lower-target group and 96 mg per deciliter (2.5 mmol per liter) in the higher-target group. The trial was stopped for administrative reasons after 277 of an anticipated 385 end-point events had occurred. The composite primary end point occurred in 121 patients (8.5%) in the lower-target group and in 156 (10.9%) in the highertarget group (adjusted hazard ratio, 0.78; 95% confidence interval, 0.61 to 0.98; P=0.04). The incidence of intracranial hemorrhage and newly diagnosed diabetes did not differ significantly between the two groups. CONCLUSIONS: After an ischemic stroke or TIA with evidence of atherosclerosis, patients who had a target LDL cholesterol level of less than 70 mg per deciliter had a lower risk of subsequent cardiovascular events than those who had a target range of 90 mg to 110 mg per deciliter. (Funded by the French Ministry of Health and others; Treat Stroke to Target ClinicalTrials.gov number, NCT01252875.). [ABSTRACT FROM AUTHOR]