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OBJECTIVES The interference of a transtricuspid cardiac implantable electronic device (CIED) lead with tricuspid valve function may contribute to the mechanism of tricuspid regurgitation (TR) and poses specific therapeutic challenges during transcatheter tricuspid valve intervention (TTVI). Feasibility and efficacy of TTVI in presence of a CIED is unclear. BACKGROUND Feasibility of TTVI in presence of a CIED lead has never been proven on a large basis. METHODS The study population consisted of 470 patients with severe symptomatic TR from the TriValve (Transcatheter Tricuspid Valve Therapies) registry who underwent TTVI at 21 centers between 2015 and 2018. The association of CIED and outcomes were assessed. RESULTS Pre-procedural CIED was present in 121 of 470 (25.7%) patients. The most frequent location of the CIED lead was the posteroseptal commissure (44.0%). As compared with patients without a transvalvular lead (no-CIED group), patients having a tricuspid lead (CIED group) were more symptomatic (New York Heart Association functional class III to IV in 95.9% vs. 92.3%; p = 0.02) and more frequently had previous episodes of right heart failure (87.8% vs. 69.0%; p = 0.002). No-CIED patients had more severe TR (effective regurgitant orifice area 0.7 ± 0.6 cm2 vs. 0.6 ± 0.3 cm2; p = 0.02), but significantly better right ventricular function (tricuspid annular plane systolic excursion = 16.7 ± 5.0 mm vs. 15.9 ± 4.0 mm; p = 0.04). Overall, 373 patients (79%) were treated with the MitraClip (Abbott Vascular, Santa Clara, California) (106 [87.0%] in the CIED group). Among them, 154 (33%) patients had concomitant transcatheter mitral repair (55 [46.0%] in the CIED group, all MitraClip). Procedural success was achieved in 80.0% of no-CIED patients and in 78.6% of CIED patients (p = 0.74), with an in-hospital mortality of 2.9% and 3.7%, respectively (p = 0.70). At 30 days, residual TR ≤2+ was observed in 70.8% of no-CIED and in 73.7% of CIED patients (p = 0.6). Symptomatic improvement was observed in both groups (NYHA functional class I to II at 30 days: 66.0% vs. 65.0%; p = 0.30). Survival at 12 months was 80.7 ± 3.0% in the no-CIED patients and 73.6 ± 5.0% in the CIED patients (p = 0.30). CONCLUSIONS TTVI is feasible in selected patients with CIED leads and acute procedural success and short-term clinical outcomes are comparable to those observed in patients without a transtricuspid lead.

Background Aspecific scoring systems are used to predict the risk of death postsurgery in patients with infective endocarditis ( IE ). The purpose of the present study was both to analyze the risk factors for in‐hospital death, which complicates surgery for IE , and to create a mortality risk score based on the results of this analysis. Methods and Results Outcomes of 361 consecutive patients (mean age, 59.1±15.4 years) who had undergone surgery for IE in 8 European centers of cardiac surgery were recorded prospectively, and a risk factor analysis (multivariable logistic regression) for in‐hospital death was performed. The discriminatory power of a new predictive scoring system was assessed with the receiver operating characteristic curve analysis. Score validation procedures were carried out. Fifty‐six (15.5%) patients died postsurgery. BMI >27 kg/m 2 (odds ratio [ OR ], 1.79; P =0.049), estimated glomerular filtration rate OR , 3.52; P IV ( OR , 2.11; P =0.024), systolic pulmonary artery pressure >55 mm Hg ( OR , 1.78; P =0.032), and critical state ( OR , 2.37; P =0.017) were independent predictors of in‐hospital death. A scoring system was devised to predict in‐hospital death postsurgery for IE (area under the receiver operating characteristic curve, 0.780; 95% CI, 0.734–0.822). The score performed better than 5 of 6 scoring systems for in‐hospital death after cardiac surgery that were considered. Conclusions A simple scoring system based on risk factors for in‐hospital death was specifically created to predict mortality risk postsurgery in patients with IE .

Transcatheter therapies for the treatment of valve heart diseases have expanded dramatically over the last years. The new developments and improvements in devices and techniques, along with the increasing expertise of operators, have turned the catheter-based approaches for valvular disease into an established treatment option. Various imaging techniques are used during these procedures, but echocardiography plays an essential role during patient selection, intra-procedural monitoring, and post-procedure follow-up. The echocardiographic assessment of patients undergoing transcatheter interventions places demands on echocardiographers that differ from those of the routine evaluation of patients with valve disease, and there is a need for specific expertise for those working in the cath lab. In the context of the current rapid developments and growing use of transcatheter valve therapies, this document intends to update the previous recommendations and address new advancements in imaging, particularly for those involved in any stage of the treatment of patients with valvular heart diseases.

Atrial fibrillation is associated with a risk of cerebral embolism, the only proven effective prevention of which is anticoagulant therapy. There is no known alternative in cases with contra-indications to this treatment. Percutaneous exclusion of the left atrial appendage by the implantation of a prosthesis (PLAATO System, ev3 Inc., Plymouth, Minnesota) is a new approach to the prevention of these complications. The authors report the results observed in a series of 11 consecutive patients (7 men, mean age 72 +/- 9 years) in whom this procedure was proposed. All patients had atrial fibrillation for over 3 months, were at high risk and had contra-indications to oral anticoagulants. The implantation of the prosthesis was performed after treatment with aspirin and clopidogrel, under general anaesthesia radioscopy and transoesophageal echocardiographic guidance with success in 9 cases (1 implantation refused in the catheter laboratory and 1 failure). The only complication observed was transient ST elevation treated by emergency angioplasty. The echographic and angiographic criteria of success of left atrial appendage exclusion were fulfilled in all implanted patients. The hospital course was uncomplicated. One recurrence of stroke was observed at the second month: transoesophageal echocardiography confirmed the absence of thrombosis, of migration of the prosthesis and its impermeability in all the patients. After 7 +/- 5 months' follow-up, no other adverse event was observed. This new procedure is technically feasible. Despite encouraging results, its long-term efficacy in the prevention of thromboembolic complications of atrial fibrillation remains to be demonstrated.

New French recommendations on infective endocarditis (IE) prevention were recently published and mark a turning point in the history of antibiotic prophylaxis. Endocarditis is an evolving disease, and its clinical and microbiological profile dramatically changes over time. The French surveys that were conducted in 1991 and 1999 showed variations in underlying heart disease with a decrease in native valvular disease and an increase of IE in patients without previously known heart disease. Moreover, the distribution of responsible microorganisms dramatically changed over time, with a marked decrease of oral streptococci. In addition, some dogmas are now challenged. First of all, the part of responsibility of dental procedures is debated, as dental bacteraemia possibly responsible of endocarditis are more likely due to daily manoeuvres such as tooth brushing or chewing gum than to occasional dental procedures. Moreover, as suggested by case-control studies, efficacy--or lack of efficacy--of antibiotic prophylaxis is far from being clinically proved. For all these reasons, the proportion of theoretically avoidable endocarditis seems very low, and the benefit of largely and systematically applied antibiotic prophylaxis may be discussed, not only in terms of financial cost but also in terms of microbiological threat of emergence of antibiotic resistant bacteria. So, the general idea of those new recommendations was to maintain the principle and the modalities of antibiotic prophylaxis, but to limit its indications to situations at high benefit to risk ratio, i.e. procedures at high risk in patients at high risk. Depending on the situation, antibiotic prophylaxis may be either recommended or become optional and decision-making factors are defined. Furthermore, the importance of general prophylaxis was emphasised, concerning more specifically oral and cutaneous hygiene, and patients and practitioners' education, such as, for example, recommendations on blood cultures to be performed before any antibiotic treatment in case on fever occurring in a patient at risk during the 3 months following a procedure at risk.

Coronary flow reserve is the ability of coronary flow to increase above its basal value when the coronary vascular bed is maximally dilated. It is a global parameter of coronary flow, which is early altered in the presence of epicardial coronary artery stenosis or a coronary microcirculation disorder. Until now, clinical use of coronary flow reserve has been hampered by the lack of an easy, reliable and non-invasive method. Recently developed high-frequency transthoracic Doppler echocardiography now allows non-invasive assessment of coronary flow reserve. After an initial learning curve, it is possible to study coronary flow, essentially in the left anterior descending artery. Coronary flow reserve is expressed as the ratio of maximal hyperaemic to basal mean coronary velocity. Maximal hyperaemic flow is obtained with adenosine. Clinical applications of coronary flow reserve are numerous. Coronary flow reserve enables the assessment of hemodynamic relevance of a moderate coronary stenosis. Detection of coronary restenosis is also possible by repeated non-invasive measurement of coronary flow reserve. Moreover, evaluation of the microcirculation is of crucial importance in order to appreciate myocardial reperfusion following successful recanalisation on the infarct-related artery. Transthoracic Doppler echocardiography could allow identification of "no-reflow" by analysis of coronary flow pattern and coronary flow reserve. Furthermore, transthoracic Doppler echocardiography constitutes one of the only available and simple means to evaluate microcirculatory disorders (hypertension, diabetes,...). Finally, the possibility of non-invasive follow-up of arterial bypasses constitutes a major advantage of this technique.

The detection of coronary disease before valve surgery remains difficult in the absence of coronary arteriography. The contribution of myocardial scintigraphy with dipyridamole (MS-DP) was studied in 34 consecutive patients with valve disease (11 mitral and 23 aortic) with a mean age of 63 +/- 11 years having undergone coronary arteriography before valve surgery. Coronary arteriography was performed because of angina (21 cases) or age (women greater than 50, men greater than 40). Positive criteria of coronary disease were the presence of at least one frank and clearly visible fault of myocardial perfusion (MS-DP positive) and at least one stenosis of greater than 70 per cent by coronary arteriography. Coronary disease existed in 13 patients (38 per cent). Ten patients (29 per cent) had a positive MS-DP. The sensitivity and specificity of MS-DP in detecting coronary disease were 69 per cent and 95 per cent respectively. Its positive predictive value was 90 per cent. MS-DP was negative in all asymptomatic patients (19 per cent of them having coronary disease) and in 11 symptomatic patients (18 per cent of them having coronary disease). The low positive predictive value of angina (52 per cent) increased to 90 per cent when combined with a positive MS-DP. Because of relatively low sensitivity, basing indications for coronary arteriography before valve surgery on the results of MS-DP cannot be advised.

Correlations between left ventricular segmental kinetics and collateral circulation patterns were studied in 292 patients with coronary disease (182 women, 274 men: mean age 54 years). Left ventricular segmental kinetics were analyzed qualitatively by angiography (10 segments were individualized on RAO and LAO projections) and rated as normal, hypokinetic, akinetic or aneurysmal. The type of collateral circulation observed (contralateral, homocoronary and homolateral) and the number of collateral vessels were recorded. Collateral circulation was present in 49 p. 100 of the patients and in 29 p. 100 of the 587 pathological arteries (i.e. more than 50 p. 100 stenosis) identified. 89 p. 100 of the occluded arteries were revascularized by collateral circulation, the latter being effected by 213 collateral vessels (mean: 1.41 +/- 0.36 vessel per occluded artery). Collateral circulation through 1, 2 or 3 collateral vessels was noted in 62 p. 100, 35 p. 100 and 3 p. 100 respectively of the cases. Collateral circulation was contralateral in 51 p. 100, homocoronary in 33 p. 100 and homolateral in 16 p. 100 of the cases. Normal or hypokinetic segments in the territory of an occluded artery were more frequent in the presence (43 p. 100) than in the absence (31 p. 100) of collateral circulation, but the difference was not significant. They were also more frequent in three-vessel patients (59 p. 100) than in one-vessel (21 p. 100; p less than 0.01) or two-vessel (37 p. 100; p less than 0.05) patients in the presence of collateral circulation.(ABSTRACT TRUNCATED AT 250 WORDS)

A new case of late fracture of an outlet strut in a convexo-concave Björk-Shiley valve is reported. The fracture occurred 6 years after aortic implantation of the valve and was responsible for aorto-iliac embolization by the prosthetic disc and death of the patient from cardiogenic shock. This not uncommon complication of the Björk-Shiley valve prosthesis is usually ascribed to the relative fragility of its outlet strut welded to the metallic ring and subjected to strong pressures. Although most cases were observed within the first two years of prosthetic valve insertion, and mainly with valves manufactured in 1981 and 1982, our case and a few others demonstrate the possibility of late rupture. Cardiologists must be aware of this possible complication, since in some favourable cases it can be diagnosed at an early stage and the patient's life can be saved by an emergency operation.

Voluntary sequential ambulatory recording is a diagnostic method of recording per-critical electrocardiographs in symptomatic patients with the aid of a portable solid-state technology recorder. In order to assess the value of this technique in the detection of arrhythmias, a multicenter study was performed in 1,287 symptomatic patients suspected of having paroxysmal arrhythmias (palpitations in 86.5% of cases). The quality of the sequential ambulatory recording was judged to be good in 54.9% and mediocre in 40.2% of cases: only 4.9% of recordings were uninterpretable. This technique allowed identification of a cardiac arrhythmia related to symptoms in 42.5% of the 1,091 cases which were analysed; sustained supraventricular tachycardia (11.7%), ventricular extrasystoles (14.9%) and simple sinus tachycardia (9.5%) were the principal abnormalities. The per-critical recording was negative in 57.5% of patients, suggesting a purely functional origin of symptoms in these cases. Atrial fibrillation was more common in hypertensive patients (11.3% vs 5.5% in normotensives, p less than 0.01) as were ventricular extrasystoles (23.1% vs 13% in normotensives, p less than 0.001). Voluntary sequential ambulatory recording seems to be a technique well adapted to the detection of symptomatic arrhythmias and a useful complement to Holter recording.

The present interest in myocardial contrast echocardiography is related to the development of new contrast agents which can be used intravenously and the perfection of new echocardiographic technologies. Amongst the potential applications of this technique, the study of myocardial perfusion in the acute phase of myocardial infarction is one of the most promising as shown by the experience acquired over several years with intracoronary contrast echocardiography. It allows assessment of the extent of the zones at risk before recanalisation, the presence of collateral vessels and, above all, the quality of myocardial reperfusion. The demonstration of the absence of effective reperfusion of the myocardial microcirculation, or the phenomenon of no-reflow, is one of the main advantages of contrast echocardiography and has been identified as an important independent prognostic factor. This technique could therefore become essential in the evaluation of methods for reducing the extent of microvascular damage. Although many questions remain unanswered about the ideal methods of performing and analysing intravenous contrast echocardiography, the preliminary results confirm the potential of the technique in non-invasive evaluation of myocardial reperfusion in the acute phase of myocardial infarction.

Vascular damage during intervertebral disc surgery is uncommon. It sometimes leads to the formation of an arteriovenous fistula and about one hundred cases have been reported in the literature. The diagnosis is often early, with signs of venous hypertension predominating. The authors report a case of arteriovenous fistula presenting late as apparently primary congestive cardiac failure. The mechanisms of this condition were demonstrated during preoperative instrumental manoeuvres. Surgical correction is the only treatment alternative. Repair must be arterial and venous, most often using prosthetic material. This generally enables total and permanent recovery, but overall mortality in pathology of this type is not nil.

The authors report the case of a right ventricular metastasis presenting with ventricular tachycardia and underline the usual diagnostic problems of secondary cardiac tumours, the symptoms of which are often unspecific and late. The appearance of a cardiac arrhythmia in the absence of known cardiac disease should raise the possibility of a cardiac metastasis in patients with malignant disease. The reported case also illustrates the diagnostic value of non-invasive cardiac imaging techniques (echocardiography and ultra-fast computerised tomography) in this context.

201TI reverse redistribution is a common finding early after reperfusion therapy for myocardial infarction. Its mechanism and clinical implications remain unclear. The aim of this study was to clarify the relationships between reverse redistribution, microvascular perfusion, and myocardial viability.Resting, 10-min-postinjection, and redistribution 201TI data obtained for 33 patients 8 and 42 d after the onset of acute myocardial infarction were compared with echocardiographic wall motion measured acutely and on day 42. Microvascular perfusion was assessed by myocardial contrast echocardiography performed 10 min after restoration of complete patency of the infarct artery.Marked significant reverse redistribution was found on day 8 (absolute change, 7.5%+/-7.9% of the 10-min-postinjection defect size; P5x0.000001) and significantly decreased on day 42 (2.7%+/-6.8%; P = 0.004 between days 8 and 42). The 10-min-postinjection defect size best predicted the final infarct size on day 42 and was closely related to microvascular perfusion. Patients with adequate reperfusion had a smaller postinjection defect on day 8 (21.1%+/-14.6%) and a larger reverse redistribution (10.2%+/-6.1%) than did patients with no reflow (35.3%+/-13% and 3.2%+/-9.2%, respectively; P0.04 for both).Reverse redistribution was marked early after myocardial infarction in patients with complete patency of the infarct artery and decreased in subsequent weeks. Reverse redistribution was associated with restoration of adequate microvascular reperfusion and with myocardial salvage and viability. The early postinjection scans on day 8 were the relevant images for assessing myocardial salvage and predicting wall motion recovery.

Complete coronary reperfusion after thrombolysis or primary angioplasty is associated with limitation of infarct size and conservation of left ventricular function. The area of viable myocardium recovers its function secondarily, the amount of recovery being related to the precocity of reperfusion. Patients with a patent artery in the acute stage do not all recover segmental contraction to the same extent. There are considerable discrepancies between coronary patency and myocardial perfusion. Myocardial perfusion, measured in the acute phase by myocardial contrast echocardiography is the best predictor of preservation of function. This suggests that microvascular lesions are a sign of the extent and irreversibility of myocardial damage. Modern treatment of infarction should not only restore coronary patency but also ensure effective myocardial reperfusion. The factors which determine recovery of ventricular function after reperfusion during the acute phase, are, in addition to early and complete coronary recanalisation and effective myocardial reperfusion: short duration of ischaemia, small size of the area at risk, collateral circulation, ability of the myocardium to withstand ischaemia, limitation of reperfusion injury. Other factors (smoking, pre-infarction angina, the occluded artery or method of reperfusion) may play a role but the role of confounding factors is always difficult to exclude.

The pathogenic mechanism of unstable angina, a clinical expression of coronary heart disease, is similar to that of myocardial infarction. The main event is the instability of the atheromatous plaque adhering to the coronary intima leading to thrombosis and occlusion. Clinical manifestations can be severe since fatal or non-fatal myocardial infarction occurs in 3.9% and 5.4% of the case respectively. Adapted medical treatment can stabilize the situation in most patients, justifying early preventive treatment. Moreover, it has been estimated that a premonitory phase of angina had gone unnoticed or undiagnosed in one-half of all myocardial infarcts. In nearly all patients with unstable angina, coronarography is of major importance for rapidly defining an adapted therapeutic strategy. Myocardial revascularization (especially by angioplasty) is often needed to limit the risk of major cardiac events occurring within a short or moderate delay. Unfortunately, these procedures carry a supplementary risk of thrombosis. Thus the emphasis placed on measures capable of improving the anti-thrombotic risk in unstable angina by using new antiplatelet agents, or for certain patients at high risk of a major cardiac event, antithrombosis agents. Finally, the search for compounds capable of stabilizing the previously formed atheromatous plaque (and thus avoiding rupture) is a prime objective for an overall management strategy for patients with coronary heart disease.

The authors report a case of acute thioridazine (Melleril) poisoning with manifestations of polymorphous ventricular rhythm disturbances in the form of torsades de pointes, with an impaired conscious level. The opportunity is taken to review the electrocardiographic changes and cardiac complications linked to the quinidine-like effect of Melleril.

Digital stress echocardiography (DSE) with dobutamine infusion has recently emerged as an attractive alternative to exercise stress testing for evaluating coronary artery disease. DSE seems particularly useful in the diagnosis or the assessment of ischemia in patients unable to exercise or when the test is difficult to interpret. DSE has also proved to be useful in patients undergoing preoperative evaluation of cardiac risk. The assessment of residual myocardial viability in patients with previous myocardial infarction is another promising development. After a description of the methodology of dobutamine stress echocardiography, this article reviews the experience obtained to date with this technique in the diagnosis and the evaluation of coronary artery disease.

BACKGROUND Tricuspid regurgitation is associated with increased rates of heart failure (HF) and mortality. Transcatheter tricuspid valve interventions (TTVI) are promising, but the clinical benefit is unknown. OBJECTIVES The purpose of this study was to investigate the potential benefit of TTVI over medical therapy in a propensity score matched population. METHODS The TriValve (Transcatheter Tricuspid Valve Therapies) registry collected 472 patients from 22 European and North American centers who underwent TTVI from 2016 to 2018. A control cohort formed by 2 large retrospective registries enrolling medically managed patients with >= moderate tricuspid regurgitation in Europe and North America (n = 1,179) were propensity score 1:1 matched (distance +/- 0.2 SD) using age, EuroSCORE II, and systolic pulmonary artery pressure. Survival was tested with Cox regression analysis. Primary endpoint was 1-year mortality or HF rehospitalization or the composite. RESULTS After matching, 268 adequately matched pairs of patients were identified. Compared with control subjects, TTVI patients had lower 1-year mortality (23 +/- 3% vs. 36 +/- 3%; p = 0.001), rehospitalization (26 +/- 3% vs. 47 +/- 3%; p < 0.0001), and composite endpoint (32 +/- 4% vs. 49 +/- 3%; p = 0.0003). TTVI was associated with greater survival and freedom from HF rehospitalization (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.46 to 0.79; p = 0.003 unadjusted), which remained significant after adjusting for sex, New York Heart Association functional class, right ventricular dysfunction, and atrial fibrillation (HR: 0.39; 95% CI: 0.26 to 0.59; p < 0.0001) and after further adjustment for mitral regurgitation and pacemaker/defibrillator (HR: 0.35; 95% CI: 0.23 to 0.54; p < 0.0001). CONCLUSIONS In this propensity-matched case-control study, TTVI is associated with greater survival and reduced HF rehospitalization compared with medical therapy alone. Randomized trials should be performed to confirm these results. (C) 2019 by the American College of Cardiology Foundation.