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Laila Cheddadi,1 Olivier Lairez,1–4 Thibault Lhermusier,1,5 Francisco Campelo-Parada,1 Michel Galinier,1,3,4 Didier Carrié,1,3,5 Nicolas Boudou1 1Department of Cardiology, University Hospital of Rangueil, 2Department of Nuclear Medicine, 3Cardiac Imaging Center, Toulouse University Hospital, 4Medical School of Rangueil, 5Medical School of Purpan, University Paul Sabatier, Toulouse, France Background: The performance of alcohol septal ablation (ASA) in elderly symptomatic patients with drug-refractory obstructive hypertrophic cardiomyopathy is still to be confirmed. The objective of this study was to compare the efficacy and safety of ASA in patients under and over 65 years old.Methods and results: Fifty-one consecutive patients with obstructive hypertrophic cardiomyopathy who underwent ASA were retrospectively included and reviewed for in-hospital major acute cardiac events and follow-up. Twenty-eight patients were over 65 years old. Left ventricular outflow tract obstruction at rest, use of diuretic and average dose of diuretic were higher in patients over 65 years old. There was no difference in hospital stay between patients under and over 65 years old. Among patients over 65 years old, 2 (7%) died before being discharged. Major acute cardiac events were more frequent in patients over 65 years old in comparison with younger patients (43% versus 9%, respectively, P=0.007). The average follow-up duration was 16±15 months. There was no difference between patients under and over 65 years old regarding the efficacy of the procedure with a decrease of the New York Heart Association class of 1.3±0.6 and 1.4±0.7 (P=0.510) and the maximum left ventricular outflow tract gradient of 86±57 and 81±36 mmHg (P=0.733), respectively.Conclusion: Elderly patients have the same benefits as younger patients after ASA but have more complications including mortality events. Keywords: alcohol septal ablation, hypertrophic cardiomyopathy, elderly

Paravalvular leak (PVL), conduction disturbances and vascular complications remain the most common post-TAVR complications. To address these adverse outcomes, the 3rd generation of transcatheter heart valves has been developed. Last generation prosthesis provides an outer pericardial wrap for enhanced sealing and PVL prevention. The aim of this study was to compare incidence and severity of PVL, and 1-year survival after TAVR with SAPIEN 3 versus EVOLUT PRO. An observational retrospective analysis was conducted on 1481 patients who underwent TAVR for symptomatic severe aortic stenosis in six different European centres. The primary endpoint was to assess the frequency and severity of PVL at 30-days post-TAVR. The secondary endpoint was to compare 1-year survival between EVOLUT PRO and SAPIEN 3. SAPIEN 3 transcatheter heart valve was implanted in 78.3% (n = 1160) of study participants while EVOLUT PRO in 21.7% (n = 321). PVL is more commonly observed in the EVOLUT PRO at pre-hospital discharge (55.1% vs. 37.3%), 1-month (51% vs. 41.4%) and 1-year (51.3% vs. 39.3%) follow-up. This difference mainly concerns low grade (mild/trace) PVL. The frequency of high degree (moderate/severe) PVL was almost similar in both groups throughout the study period (5.3% vs. 5.8% pre-hospital discharge, 4% vs. 3.1% at 1-month and 3.2% vs. 4.9% at 1-year). No significant difference in survival over 1-year has been observed [HR = 0.73 (0.33–1.63), P = 0.442]. The detection rate of PVL post-TAVR with 3rd heart valves generation remains high. There are no major differences between both devices regarding the frequency of significant (moderate/severe) PVL and survival. [ABSTRACT FROM AUTHOR]

Given that life expectancy has been improved, nonagenarians become a significant proportion of world population. As aortic stenosis is primarily a disease of the elderly, the need for invasive cardiac approaches is expected to increase in people of extreme age We compare the in-hospital adverse clinical outcomes and mortality after TAVI procedures in nonagenarians to < 90 years patients. A retrospective study was conducted on 1336 patients who underwent TAVI at Toulouse University hospital, Rangueil, France. Post-TAVI adverse clinical outcomes were defined according to Valve Academic Research Consortium-2 Criteria. The studied population was divided into 2 groups according to age. Out of 1336 patients, 250 (18.7%) were nonagenarians with a mean age of 91.8 ± 1.9 years.While comorbidities were less common in nonagenarians, the calculated scores to predict mortality were significantly higher. Pacemaker implantation (12.4% vs. 12.1%, P = 0.08), stroke (2% vs. 1.8%, P = 0.86) and major vascular complications (9.2% vs. 6.7%, P = 0.17) were more common in nonagenarians while acute kidney injury (1.2% vs. 2.7%, P = 0.15) and major bleeding events (3.2%vs3.4%, P = 0.87) were more common in < 90 year group. The rate of procedures success in nonagenarians and < 90 year group was 93.2% and 96.9%, respectively. Adjusted multivariate analysis showed that Nonagenarians are more likely to develop major vascular complications [OR = 1.76 95%CI (1.04;3)]. Survival analysis showed a significant difference in mortality during hospitalization period only (P = 0.004) The prevalence of TAVI success is remarkably high in nonagenarians and comparable to that of younger age. The nonagenarians are significantly at higher risk for in-hospital death after TAVI and they are more likely to develop major vascular complications. The difference in mortality rate during hospitalization period was two times more but it becomes no longer significant after hospital discharge. [ABSTRACT FROM AUTHOR]

Management of mitral regurgitation (MR) recurrence after failed surgical mitral annuloplasty with ring implantation (SMARI) is controversial. Transcatheter edge-to-edge mitral valve repair (TEER) is one option, but rings increase the procedural' difficulty. To evaluate the results of TEER in patients with SMARI. The Clip-in-Ring registry is a multicenter registry conducted in 11 centers in France, approved by local institutional review boards, of consecutive TEER following SMARI. Outcomes were the Mitral Valve Academic Research Consortium (MVARC) technical, modified 30-days device and procedural successes (where 10 mmHg is considered as a cut-off for significant mitral stenosis) and MVARC-complications. Twenty three patients were studied: age: 69 ± 10; male: 74%; STS score: 3.0 [2.0–5.8], EuroScore II: 12.0 [6.4–18.5]; left ventricle ejection fraction: 53 ± 12%; complete rings: 60%; MR grade 3+/4+: 17/78%; NYHA class III/IV: 47/22%; median surgery-TEER delay: 23 [6–94] months. Technical success of the TEER was 100%. At discharge, residual MR grade was ≤ 2+ in 87% and median trans-mitral gradient was 4 [3–5] mmHg. Thirty days modified MVARC-device success device and procedural success were 82%: 4 patients (17%) had residual MR grade > 2+, including 2 patients who needed a complementary surgery. No patient had a 30-days trans-mitral gradient > 7 mmHg. No patient died or suffered a stroke or any life-threatening complications. One patient presented vascular access complication requiring transfusion. No other MVARC-2 adverse event was reported (Fig. 1). TEER in patients with failed mitral ring is feasible, and safe. Larger registries should delineate its exact role in the therapeutic armamentarium for this medical issue. [ABSTRACT FROM AUTHOR]

Targeted therapy is certainly considered the future of cancer treatment. Several new molecules targeting critical intracellular signaling actors, particularly kinases, are arriving in clinics and many other are under development. However, proteins targeted by these drugs are common to many cell types and are particularly implicated in the highly dynamic processes of platelet activation. Therefore, the effects of targeted drugs, including kinase inhibitors, on platelet activation have to be considered in clinical practice. Moreover, their analysis also represents an opportunity to increase our knowledge in platelet biology and physiology and to develop novel antiplatelet strategies. In this review we briefly describe the major platelet signaling pathways that may be affected by these new drugs and discuss some clinical implications of their use. [ABSTRACT FROM AUTHOR]

The prevalence of coronary artery disease (CAD) detected in preoperative work-up for transcatheter aortic valve implantation (TAVI) is high. Instead, the management of a concomitant CAD and its effect on procedural outcomes remain unclear. We evaluate the impact of CAD revealed during preoperative workup and percutaneous coronary intervention (PCI) on TAVI procedures. A retrospective study was conducted on 1336 consecutive patients who underwent TAVI in Toulouse University Hospital, Rangueil, France. The studied population was divided into 2 groups: CAD-TAVI group and No CAD-TAVI group. Then, the CAD-TAVI group was segregated into 2 subgroups: PCI-TAVI group and No PCI-TAVI group. In-hospital adverse clinical outcomes were assessed in each group. Pre-TAVI work-up revealed significant CAD in 36% of 1030 patients eligible for inclusion in the study. The overall prevalence of in-hospital death, stroke, major or life threatening bleeding, minor bleeding, major vascular complications, minor vascular complications, pacemaker implantation, and acute kidney injury was 2.7%, 2.4%, 2.8%, 3.6%, 3.9%, 7.5%, 12.5%, and 2.7%, respectively. Among the studied population, 55% were admitted to the cardiac care unit. No statistical significant difference was observed between groups. Patients with CAD diagnosed in pre-TAVI work-up were not more likely to develop in-hospital adverse clinical outcomes post-TAVI procedure. Also, no significant difference in mortality was observed. In parallel, performing PCI did not increase the risk of in-hospital death and complications. The difference in terms of the distribution of antithrombotic regimen may explain the higher non significant prevalence of bleeding events in the PCI-TAVI group. [ABSTRACT FROM AUTHOR]

Myocardial infarction with non obstructive coronary arteries (MINOCA) is a complex working diagnosis including coronary and non-coronary causes, like spontaneous coronary dissection, coronary thrombosis or embolism, myocarditis and cardiomyopathy. The prevalence of MINOCA is increasing, but the underlying etiology remains undetermined in more than 10% of cases. Hypotheses on the potential contributing role of myocardial bridge (MB) in takotsubo cardiomyopathy and coronary artery spasm (CAS) have been raised. We aim to investigate the relationship between MB and MINOCA. An observational retrospective study was conducted on 15,036 patients who had been referred for coronary angiography and who fulfilled the Definition of Myocardial Infarction. The study population was divided into STEMI and Non-STEMI patients, from which we defined two main groups: the MINOCA group and the coronary artery disease (CAD) group. The prevalence of MB was calculated in each group (Fig. 1). The distribution of angiographic MB among the groups was significantly greater in the MINOCA group (2.9% vs. 0.8%, P < 0.001). MINOCA accounted for 14.5% of spontaneous myocardial infarctions, and the clinical presentation was frequently NSTEMI rather than STEMI (84.3% vs. 15.7%, P < 0.001). Adjusted multivariate analyses showed a positive association between MB and MINOCA [OR = 3.28, 95% CI (2.34; 4.61) P < 0.001]. Cardiovascular risk factors were less common in the MINOCA population, which was younger and more often female. The main finding of the present study was that MB is an independent predictor for MINOCA, increasing the corresponding risk by threefold. Because MB prevalence differed significantly between the controls (CAD group) and in the MINOCA group, which was positively correlated to MB, it seems likely that MB would be a potential cause of MINOCA. Future prospective studies are necessary to highlight the physiologic significance of MB in some MINOCA patients. [ABSTRACT FROM AUTHOR]

Background: The appropriate duration of treatment with beta-blocker drugs after a myocardial infarction is unknown. Data are needed on the safety and efficacy of the interruption of long-term beta-blocker treatment to reduce side effects and improve quality of life in patients with a history of uncomplicated myocardial infarction. Methods: In a multicenter, open label, randomized, noninferiority trial conducted at 49 sites in France, we randomly assigned patients with a history of myocardial infarction, in a 1:1 ratio, to interruption or continuation of beta-blocker treatment. All the patients had a left ventricular ejection fraction of at least 40% while receiving long-term beta-blocker treatment and had no history of a cardiovascular event in the previous 6 months. The primary end point was a composite of death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for cardiovascular reasons at the longest follow-up (minimum, 1 year), according to an analysis of noninferiority (defined as a between-group difference of <3 percentage points for the upper boundary of the two-sided 95% confidence interval). The main secondary end point was the change in quality of life as measured by the European Quality of Life-5 Dimensions questionnaire. Results: A total of 3698 patients underwent randomization: 1846 to the interruption group and 1852 to the continuation group. The median time between the last myocardial infarction and randomization was 2.9 years (interquartile range, 1.2 to 6.4), and the median follow-up was 3.0 years (interquartile range, 2.0 to 4.0). A primary-outcome event occurred in 432 of 1812 patients (23.8%) in the interruption group and in 384 of 1821 patients (21.1%) in the continuation group (risk difference, 2.8 percentage points; 95% confidence interval [CI], <0.1 to 5.5), for a hazard ratio of 1.16 (95% CI, 1.01 to 1.33; P = 0.44 for noninferiority). Beta-blocker interruption did not seem to improve the patients' quality of life. Conclusions: In patients with a history of myocardial infarction, interruption of long-term beta-blocker treatment was not found to be noninferior to a strategy of beta-blocker continuation. (Funded by the French Ministry of Health and ACTION Study Group; ABYSS ClinicalTrials.gov number, NCT03498066; EudraCT number, 2017-003903-23.). [ABSTRACT FROM AUTHOR]

Lung diseases are associated with higher mortality on patients undergoing on Tanscatheter aortic-valve implantation (TAVI). Impact of lung diseases are poorly investigated on alternative access. His study aim to compare 30-day and 1-year mortality after transaortic (TA) or transfemoral (TF) TAVI on patients with chronic lung diseases. All patients with symptomatic aortic stenosis were consecutively included between January 2012 and January 2016. Spirometry was performed and interpreted by a pneumologyst. Pulmonary diseases were defined according based on spirometric results. The allocation strategy for SAVR or TAVI, the way, the valve selection, was at the discretion of our local multidisciplinary Heart Team. Clinical follow-up was performed by clinical visit or phone consultation. The primary end point was the death from any cause after TAVI. A total of 164 patients were analysed. Comparing 82 TA to 82 TF patients mortality was similar at 30 day (RR = 1.24 (0.52–2.92) P = 0.692). Mortality rates after 1 year was also similar (RR = 1.35 (0.76–2.42), P = 0.308). There was no impact in lenght of hospitalisation (TF: n = 7.2 ± 2 days, TA n = 8 ± 3.3 days P = 0.108) (Fig. 1). In patients undergoing on TAVI, these results suggest that compared with the TF in TA approach lung diseases do not impact mortality. Access selection should not be impact by a lung dieases. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) after Transcatheter aortic-valve implantation (TAVI) is rare but severe complication. The primary aim of this study was to evaluate incidence, micro-organisms, clinical characteristics, outcomes and management of IE after TAVI. In a single-center, 996 patients were follow-up after TAVI between 2008 and 2018. By appling modified Duke criteria we perform diagnosis of IE. We identified 11 cases with « definite diagnosis » representing 1,1% of incidence. Patients characterised by a mean age of 79,6 years. Chronic kidney (5 patients) and diabet (4 patients) was frequent. IE appared after a median of 23,8 months after implantation. Reasons for initial diagnosis was fever (7 patients), heart failure (4 patients), poor condition (4 patients) and septic choc (1 patient). The most frequent causal micro-organisms were Staphylococcus aureus (3 patients) and coagulase-negative staphyloccoci (3 patients). Only one blood culture was negative. Vegetations were demonstrated in 8 cases. Only one patient developed a severe aortic regurgitation. There were no cases of embolism. Five patients had an indication for valve intervention according to the guidelines. After multidisciplinary assessment, medical treatment was the only way in this frailty population. Two patients had a persitent infection. At one year follow-up 7 patients were alive. IE is rare but severe complication. In our popultation rate was 1,1% of patients. Staphylococcus aureus and coagulase-negative staphyloccoci were the most represented micro-organisms. Even if valve intervention was necessary, antibiotic treatment was only performed. [ABSTRACT FROM AUTHOR]

Background Elderly patients represent a large proportion of patients admitted for Acute Coronary Syndrome (ACS). Whether frailty, defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors, may impact the clinical outcomes in this population remains unclear. Objective To determine the prevalence of frailty and its impact on all-cause mortality in patients aged ≥ 80 years admitted for ACS. Methods This prospective observational study was conducted among patients aged 80 or older admitted in a tertiary hospital for ACS. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). Population was divided into 3 classes: [0–3] EFS-score, [4–6] EFS-score, and [≥ 7] EFS-score. Results Two hundred and thirty-six patients were included with a mean follow-up duration of 470 days. The mean age was 85.9 years. Seventy-five patients died during follow-up period. Hundred and nineteen subjects (50.4%) had a [0–3] EFS-score, 68 patients (28.8%) had a [4–6] EFS-score and 49 patients (20.8%) had a [≥ 7] EFS-score. All-cause mortality rate was 17.7% in the [0–3] EFS-score group, 35.3% in the [4–6] EFS-score group and 61.2% in the [≥ 7] EFS-score group ( P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: HR was 1.59 (95% CI [0.78–3.26]) within the [4–6] EFS-score group, and HR was 4.03 (95% CI [2.02–8.04]) within the [≥ 7] EFS-score group ( Table 1 , Fig. 1 ). Conclusion Frailty is a strong and independent prognosis factor of midterm all-cause mortality in elderly patients presenting with ACS. [ABSTRACT FROM AUTHOR]