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Objectives This study sought to assess procedural characteristics, early clinical outcome, and long-term complications after transcatheter closure of atrial septal defect (ASD) in children. Background Transcatheter closure has become the preferred strategy in most cases of isolated secundum ASD. However, reported experience in the pediatric population is limited. Methods A 1998 to 2016 retrospective multicenter study was performed in 9 French tertiary institutions. All children who had an attempt of percutaneous ASD closure with an Amplatzer Septal Occluder were included. Results In 1,326 children (39% males; median age, 9 years [0.7 to 18]; weight, 29 kg [3.6 to 92]), transcatheter ASD closure was performed. Median ASD size was 15 mm (3 to 41); 254 (19.1%) patients had a large ASD (≥20 mm/m2). Procedural success rate was 95.3% (95% confidence interval: 93.9% to 96.3%). No death was observed but periprocedural complications occurred in 24 patients (1.8%). After a median follow-up of 3.5 years (range 6 months to 18 years; 173 patients [13%] followed >10 years), delayed major complications were minimal (n = 12; 1.04%) including no death and/or cardiac erosion. Periprocedural and delayed complications rates were significantly higher in children ≤15 kg (5.2% vs. 1.5%; p = 0.007 and 3.1% vs. 0.7%; p Conclusions Transcatheter ASD closure using Amplatzer Septal Occluder is safe in children with a minimal rate of periprocedural complications and a favorable long-term outcome, especially with no death or cardiac erosion despite a substantial proportion of large defects. Children ≤15 kg and those with large ASDs had a greater risk of complications.

IntroductionIntrathoracic shunt quantification is a major factor for appropriate clinical management of heart and pulmonary diseases. Intracardiac shunts quantified by pulmonary to systemic output ratio (Qp/Qs) are generally assessed by Doppler echocardiography, MRI or catheterisation. Recently, some authors have suggested the concomitant use of thoracic bioimpedance (TB) and inert gas rebreathing (IGR) techniques for shunt quantification. The purpose of this study is to validate the use of this approach under conditions where shunt fraction is directly quantified such as in patients with isolated atrial septal defect (ASD).Methods and analysisThis trial is a prospective, observational single-centre, non-blinded study of adults seen for percutaneous closure of ASD. Qp/Qs ratio will be directly measured by Doppler echocardiography and direct Fick. IGR and TB will be used simultaneously to measure the cardiac output before and after closure: the ratio of outputs measured by IGR and TB reflecting the shunt fraction. The primary outcome will be the comparison of shunt values measured by TB-IGR and Doppler echocardiography.Ethics and disseminationThe study has been approved by an independent Research Ethics Committee (2017-A03149-44 Fr) and registered as an official clinical trial. The results will be published in a peer-reviewed journal.Trial registration numberNCT03437148; Pre-results.

Cardiac fibrosis is associated with heart failure and poor prognosis. Fibrosis biomarkers have been poorly evaluated as a tool to predict cardiac resynchronization therapy (CRT) response generating conflicting results. The present study assessed the predictive value of cardiac fibrosis biomarkers on CRT response. Patients underwent clinical examination, echocardiography and blood fibrosis biomarker evaluation prior to CRT implantation. At six months, a positive response to CRT was defined by a composite endpoint of no death or hospitalization for heart failure, and presence of left ventricular (LV) reverse remodeling (decrease in LV end-systolic volume ≥15%). Sixty patients were included in a multicenter study. At 6 months, 38 were positive responders to CRT and reached the response criteria (63%). Compared to non-responders, CRT responders displayed lower concentration levels of the fibrosis biomarkers procollagen type I C-terminal propeptide [PICP 135[99–166] ng/ml vs. 179[142–226]ng/ml, p = 0.001)] and procollagen type III N-terminal propeptide [PIIINP 5.50[3.66–8.96] ng/ml vs. 8.01[5.01–11.86]ng/ml, p = 0.014)] at baseline. In multivariate analysis, a PICP ≤ 163 ng/ml was associated with a positive CRT response [OR = 7.8(1.3–46.7), p = 0.023] independently of the presence of LBBB, QRS duration, LV lead position or non-ischemic cardiomyopathy. Altogether, the present findings show that a lower degree of cardiac fibrosis is associated with a positive response after CRT implantation. PICP evaluation before CRT implantation could help improve patient selection.

BACKGROUND Transcatheter aortic valve replacement (TAVR) has revolutionized management of high-risk patients with severe aortic stenosis. However, survival and the incidence of severe complications have been assessed in relatively small populations and/or with limited follow-up. OBJECTIVES This report details late clinical outcome and its determinants in the FRANCE-2 (FRench Aortic National CoreValve and Edwards) registry. METHODS The FRANCE-2 registry prospectively included all TAVRs performed in France. Follow-up was scheduled at 30 days, at 6 months, and annually from 1 to 5 years. Standardized VARC (Valve Academic Research Consortium) outcome definitions were used. RESULTS A total of 4,201 patients were enrolled between January 2010 and January 2012 in 34 centers. Approaches were transarterial (transfemoral 73%, transapical 18%, subclavian 6%, and transaortic or transcarotid 3%) or, in 18% of patients, transapical. Median follow-up was 3.8 years. Vital status was available for 97.2% of patients at 3 years. The 3-year all-cause mortality was 42.0% and cardiovascular mortality was 17.5%. In a multivariate model, predictors of 3-year all-cause mortality were male sex (p = 2 of 4 (p < 0.001). Severe events according to VARC criteria occurred mainly during the first month and subsequently in < 2% of patients/year. Mean gradient, valve area, and residual aortic regurgitation were stable during follow-up. CONCLUSIONS The FRANCE-2 registry represents the largest database available on late results of TAVR. Late mortality is largely related to noncardiac causes. Incidence rates of severe events are low after the first month. Valve performance remains stable over time. (J Am Coll Cardiol 2016; 68: 1637-47) (C) 2016 by the American College of Cardiology Foundation.

Erratum : 10.1007/s12350-017-0845-8"As shown in this erratum, the second author’s name needs to be changed from “Merlin Charles” to “Charles Merlin”. His affiliation needs to be changed to “Nuclear Medicine Department, Jean Perrin Cancer Center, Clermont-Ferrand, France”. The original article was corrected."; International audience; BACKGROUND:There are paucity of data comparing measurements of left ventricular systolic performance using cadmium-zinc-telluride (CZT) semiconductor cameras with other imaging modalities. This study compared the new system with echocardiography (echo) and cardiac magnetic resonance (CMR) imaging.METHODS:60 Patients presenting with ST-elevated myocardial infarction (MI) were included. Each patient underwent echo, myocardial perfusion imaging using Spectrum Dynamics D-SPECT(r) (CZT-SPECT), and CMR 6 weeks after MI. The primary endpoint was the agreement between CZT-SPECT and CMR for left ventricular ejection fraction (LVEF) measurement.RESULTS:48 of the 60 patients underwent all 3 studies (echo, CMR, and CZT-SPECT) 40 days after admission. CZT-SPECT and CMR LVEF were well correlated (r = .79, P < .0001), as well as CZT-SPECT vs echo and CMR vs echo (r = .79 and .84, respectively, P < .0001). The segmental LV wall thickening and wall motion also showed good concordance between three techniques.CONCLUSIONS:CZT-SPECT is reliable for LVEF measurement.

Background Transposition of great arteries (TGA) defined as the combination of concordant atrioventricular and discordant ventriculo-arterial connections is one of the most common congenital heart defects. Prenatal diagnosis of TGA remains difficult. To determine the impact of antenatal diagnosis we evaluated the sensitivity of antenatal detection and the neonatal mortality of TGA considering two study periods and two major types of TGA. Methods A cross-sectional study was performed. Data were collected from a French population-based birth defect registry. From 1988 to 2012, 94 fetuses with TGA were registered. The study period was subdivided into the 1988 to 1999 period and the 2000 to 2012 period. Two types of TGA were considered: isolated TGA (n = 66) and associated TGA (n = 28). A stratified analysis was performed considering the study periods and the types of TGA. RESULTS Considering the study periods, the sensitivity of prenatal detection of TGA increased significantly (9.8% vs. 51.5%, p = 0.0001). The same trend was found for associated TGA (4.8% vs. 33.3%, p = 0.002) and isolated TGA (21.1% vs. 100%, p

Cardiac neonatal lupus syndrome is due to anti-SSA or SSB antibodies and mainly includes congenital heart block (CHB) and dilated cardiomyopathy (DCM). Its optimal management is still debated. We report a large series of autoimmune high degree CHB.Inclusion criteria in this retrospective study were fetuses or neonates with high-degree CHB associated with maternal anti-SSA/SSB antibodies.214 CHB were included: 202 detected in utero at a median term of 23 weeks' gestation (WG) [range 16 to 39 WG] and 12 neonatal cases diagnosed at a median age of 0 days [range birth to 8 days]. The 214 cases of CHB included 202 (94.4%) third-degree CHB, 8 (3.7%) second-degree CHB, and 4 (1.9%) intermittent CHB. In multivariate analysis, the factors associated with feto-neonatal deaths (15.7%) were hydrops (p0.001; hazard ratio [HR] 12.4 [95% confidence interval (95%CI) 4.7-32.7]) and prematurity (p=0.002; HR 17.1 [95%CI 2.8-103.1]). During a median follow-up of 7 years [birth to 36 years], 148 of 187 children born alive (79.1%) had a pacemaker, 35 (18.8%, one missing data) had DCM, and 22 (11.8%) died. In multivariate analysis, factors associated with child death were in utero DCM (p=0.0157; HR 6.37 [95%CI: 1.25-32.44]), postnatal DCM (p0.0001; HR 227.58[95%CI: 24.33-2128.46]) and pacemaker implantation (p=0.0035; HR 0.11[95%CI: 0.02-0.51]). The use of fluorinated steroids was neither associated with survival nor with regression of 2nd degree CHB.In this second largest series of CHB, we confirm some of the previous results. We were unable to find data supporting the routine use of in utero fluorinated steroids.

Objectives The short-term efficacy and safety of transcatheter closure (TCC) for the management of coronary artery fistulas (CAFs) was investigated in pediatric patients. Background CAFS are rare with potentially severe complications and their management is still a matter of debate. Percutaneous closure appears to be the treatment of choice in anatomically suitable vessels but limited data are available in the pediatric population. Methods This retrospective, observational, multicenter, national study included patients under 16 years of age who underwent TCC of a congenital CAF. Patients with additional congenital heart defect were excluded. Results 61 patients (36 girls, 25 boys) with a median age of 0.6 year [0–15.4] at diagnosis and 3.9 years [0–16] at procedure were included. The CAF was large in 48 patients (79%); it was distal in 23 (38%) and proximal in 22 (36%). Most patients (77%) were asymptomatic at diagnosis. Clinical signs of congestive heart failure were present in seven patients (11%). Perioperative complications included three cases of ST elevation myocardial infarction (exclusively during attempted closure of a distal CAF), three devices migrations, and one case of leg ischemia. One patient died after surgical closure of a large distal CAF that could not be closed by TCC. Follow-up data were collected for 43 patients (70%) for a median of 91 days [0–4,824]. The Kaplan-Meyer estimate for complete occlusion at 2 years was 73 ± 7.6%. Conclusion TCC in the pediatric population appears to be effective and associated with few complications. © 2015 Wiley Periodicals, Inc.

This study sought to assess procedural characteristics, early clinical outcome, and long-term complications after transcatheter closure of atrial septal defect (ASD) in children.Transcatheter closure has become the preferred strategy in most cases of isolated secundum ASD. However, reported experience in the pediatric population is limited.A 1998 to 2016 retrospective multicenter study was performed in 9 French tertiary institutions. All children who had an attempt of percutaneous ASD closure with an Amplatzer Septal Occluder were included.In 1,326 children (39% males; median age, 9 years [0.7 to 18]; weight, 29 kg [3.6 to 92]), transcatheter ASD closure was performed. Median ASD size was 15 mm (3 to 41); 254 (19.1%) patients had a large ASD (≥20 mm/mTranscatheter ASD closure using Amplatzer Septal Occluder is safe in children with a minimal rate of periprocedural complications and a favorable long-term outcome, especially with no death or cardiac erosion despite a substantial proportion of large defects. Children ≤15 kg and those with large ASDs had a greater risk of complications.

cope Curcumin exerts biological activities of interest in cardiovascular prevention. However, its vascular protective effect is still poorly investigated in humans. The present study aims to assess vasculat effect of an acute intake of curcumin and its nutrigenomic impact in circulating immune cells. Methods and results In a randomised, double-blind, crossover design, eighteen healthy smokers consumed a placebo or a 5-gram of curcumin. Before and two hours after the intake, vascular function measurements were performed by using flow-mediated dilation (FMD). In addition, endothelial function in the microcirculation and blood pressure were evaluated. Plasma curcumin concentrations and changes in gene expression in peripheral blood mononuclear cells (PBMC) were analysed. No significant effect of curcumin on FMD was observed when considering the entire study population, mainly due to a high inter-individual variability. A subgroup analysis according to the gender or the cardiovascular-risk score revealed a significant effect of curcumin on FMD in women and in subjects presenting lower cardiovascular risk. No change in gene expression was observed when data were analysed for all volunteers but changes in expression were observed when analyzed according to gender. Conclusions This clinical trial highlights that a substantial variability in efficacy of curcumin exists across individuals. This article is protected by copyright. All rights reserved

Summary Background Takotsubo cardiomyopathy (TTC) continues to be under-diagnosed, due to its varying presentation, with potentially serious consequences if treatment is delayed. Aims To demonstrate the consistent involvement of catecholaminergic stress in TTC, regardless of the trigger. Methods Between 01 July 2009 and 31 August 2013, patients managed in our centre for thoracic pain syndrome, with or without troponin release, were followed up prospectively. TTC was diagnosed from the apical ballooning seen on left ventricular imaging (angiography or transthoracic echocardiography) in the absence of a significant coronary artery lesion. Triggers (emotional trauma, surgical stress and β2-mimetic intoxication) were recorded; catecholamine-secreting tumours were screened for with a urinary methoxylate-derivative assay. Results TTC was diagnosed in 40 out of 2754 (1.5%) patients with thoracic pain syndrome, with or without troponin release. Triggers were emotional trauma ( n = 29, 72.5%), surgical stress ( n = 5, 12.5%), adrenergic intoxication ( n = 3, 7.5%) and catecholaminergic tumour ( n = 3, 7.5%). Mean left ventricular ejection fraction at admission was 38.0 ± 15.7%. Eight (20%) patients initially showed cardiogenic shock. In-hospital mortality was 7.5%, with no deaths from cardiogenic causes. Thirty-five (94.6%) of the survivors had recovered a normal left ventricular ejection fraction (> 55%) by discharge. Conclusion Whatever the trigger, the common denominator in TTC is catecholaminergic stress. Classically suggested after emotional trauma, TTC may also be induced by surgical stress or endogenous or iatrogenic β2-mimetic intoxication. The various contexts all have a similarly excellent cardiovascular prognosis if treated early.

Background A persistent anastomosis between the pulmonary veins that connect with the left atrium and the systemic vein that drains into the right atrium has occasionally been reported. We report characteristics and transcatheter therapy in partially abnormal pulmonary venous return with additional drainage to the left atrium. Methods We retrospectively studied such patients in 5 institutions. Results Ten patients (6 girls) presented at a median age of 8 (0.1 to 54) years with 2 anatomic types: 8 vertical vein types with drainage of the left upper lobe to the innominate vein via a large vertical vein (left superior cardinal vein) and to the left atrium via the left upper pulmonary vein; and 2 scimitar vein (SV) types with drainage of the right middle and lower pulmonary veins into the inferior vena cava and to the left atrium via an anomalous connecting vein. Associated malformations were aortic coarctation (n = 2) and secundum atrial septal defects (n = 3). Two patients of the vertical vein type were operated. Transcatheter occlusion of the abnormal pulmonary venous return was performed in 7 cases, associated with occlusion of systemic arterial supply (n = 2), secundum atrial septal closure (n = 2), left upper pulmonary vein stenosis stenting (n = 1), and coarctation stenting (n = 1). Including previously published cases, 18 patients (13 vertical veins and 5 scimitar veins) underwent transcatheter repair. Patients over 40 years of age tend to be symptomatic at presentation (p = 0.056). Conclusion In partially abnormal pulmonary venous return with dual drainage, transcatheter therapy can be offered in the majority of patients. © 2013 Elsevier Ireland Ltd.

Nowadays transcatheter aortic valve implantation (TAVI) is an accepted alternative to surgical aortic valve replacement for high-risk patients (pts). Successful TAVI procedures for failed aortic surgical bioprosthesis (TAV-in-SAV) have already been reported. In the presented two cases of TAV-in-SAV implantation a strut distortion of the stent was revealed on angiographic imaging and confirmed on control CT scan. In both procedures, a dislocation of the medtronic core valve (MCV) prosthesis during implantation led to valve retrieval, with a necessity of reloading it in the 18F introducer before subsequent implantation of the same valve in correct position.

International audience; Background. - Multicentre registries of myocardial infarction management show a steady improvement in prognosis and greater access to myocardial revascularization in a more timely manner. While French registries are the standard references, the question arises: are data stemming solely from the activity of French cardiac intensive care units (ICUs) a true reflection of the entire French population with ST-segment elevation myocardial infarction (STEMI)? Aim. - To compare data on patients hospitalized for STEMI from two French registries: the French registry of acute ST-elevation or non-ST-elevation myocardial infarction (FAST-MI) and the Echantillon generaliste des beneficiaires (EGB) database. Methods. - We compared patients treated for STEMI listed in the FAST-MI 2010 registry (n=1716) with those listed in the EGB database, which comprises a sample of 1/97th of the French population, also from 2010 (n=403). Results. - Compared with the FAST-MI 2010 registry, the EGB database population were older (67.2 +/- 15.3 vs 63.3 +/- 14.5 years; P < 0.001), had a higher percentage of women (36.0% vs 24.7%; P < 0.001), were less likely to undergo emergency coronary angiography (75.2% vs 96.3%; P < 0.001) and were less often treated in university hospitals (27.1% vs 37.0%; P = 0.001). There were no significant differences between the two registries in terms of cardiovascular risk factors, comorbidities and drug treatment at admission. Thirty-day mortality was higher in the EGB database (10.2% vs 4.4%; P < 0.001). Conclusions. - Registries such as FAST-MI are indispensable, not only for assessing epidemiological changes over time, but also for evaluating the prognostic effect of modern STEMI management. Meanwhile, exploitation of data from general databases, such as EGB, provides additional relevant information, as they include a broader population not routinely admitted to cardiac ICUs.

Outcomes of septal alcoholization in hypertrophic obstructive cardiomyopathy are not enough studied in all centers. The purpose of this study was to determine the outcomes of septal alcoholization in hypertrophic obstructive cardiomyopathy in our hospital. A retrospective and prospective descriptive study focused on all patients aged at least 18 years treated by alcohol septal ablation between July 2005 and June 2010 in the cardiology unit of Clermont-Ferrand teaching Hospital. The inclusion criteria were, hypertrophic obstructive cardiomyopathy with left ventricular outflow tract obstruction ≥ 50 mmHg, symptomatic despite optimal medical therapy. The clinical, paraclinical data and the results of alcohol ablation were collected from medical records of patients and a telephone conversation with the patients or their physicians. These data were analyzed by EPI info 6.04. Eleven patients with average age of 56.27 ± 15, 83 were included of which 81.8% of men. The main indications of alcohol septal were dyspnea stage NYHA II-IV (45.5%), lipothymia (18.2%) and invalidating angina (18.2%). Main electrocardiographic abnormalities were left ventricular hypertrophy and disorders of repolarization with 72.7% each. Minor conductive disorders were found in 45.5% of the cases. The left ventricular outflow tract obstruction was 98.18 ± 25.93 mmHg before alcohol septal ablation and 18.91 ± 31.97 mmHg after a follow-up of 25.64 ± 21.97 months. The success rate was 81.8%. Conductive disorders (45.5%) required the establishment of a definitive pacemaker in 36.4% of the patients. A cardiac defibrillator was implanted at 27.3%. Septal alcoholization was succesful.Keywords: Hypertrophic obstructive cardiomyopathy, therapy, septal alcohol ablation

International audience; Reintroduction of amiodarone in patients with a history of amiodarone-induced thyrotoxicosis (AIT) is rarely used. To date, the risk of AIT recurrence after amiodarone reintroduction is unpredicted. The aim of the study was to evaluate the risk of AIT recurrence. Retrospectively, from 2000 to 2011, all euthyroid patients with a history of AIT with amiodarone reintroduction were included. Type and severity of the first AIT, amiodarone chronology, and thyroid function evolution after reintroduction of amiodarone were investigated: 46 of 172 patients with AIT history needed amiodarone reintroduction. At first AIT episode, the mean age was 62.2 ± 16 years with male gender predominance; 65% of patients were classified as type 1 AIT. AIT recurred in 14 patients (30%), 12 patients developed hypothyroidism (26%), and 20 patients remained euthyroid (44%). Characteristics of type 1 AIT during the first episode, namely briefer exposure period to amiodarone and longer duration of treatment to normalize thyroid hormones, were predictive of AIT recurrence; 73% of patients (8 of 11) with previous episode of type 1 AIT, who did not receive a preventive thioamide treatment, developed a second episode of AIT. Thioamide preventive treatment could be useful to prevent type 1 AIT recurrence. In conclusion, AIT recurrence after amiodarone reintroduction is 4 times more frequent in patients with type 1 AIT history. Thyroid ablation before amiodarone reintroduction in patients with a history of type 1 AIT is preferred. Preventive thioamide treatment could be suggested in patients with type 1 AIT history pending for surgery.

Objective. The excess cardiac risk, found in RA has been attributed to biological inflammation. Effective control of inflammation may be of benefit in reducing cardiovascular risk in RA patients. The aim of this study is to investigate the effects of 24 and 52 weeks of rituximab treatment on arterial stiffness and cardiovascular risk factors. Methods. Arterial stiffness was measured by augmentation index (AIx) and pulse wave velocity (PWV), and other cardiovascular risk factors (lipid profile, blood pressure) were collected in active RA patients. Results. Thirty-three patients, of whom 29 were females, with a mean age of 60.9 (12.0) years were included. Thirty patients had positive RFs, 27 had positive anti-CCP antibody and 93.9% (n = 31) were erosive. Nineteen patients were non-responders to anti-TNF-a treatments. After rituximab treatment, no change was observed in arterial stiffness, neither after 6 nor after 12 months [PWV 8.1 (3.1) m/s at baseline, 8.1 (2.8) at 6 months, 8.0 (2.7) at 1 year, P = 0.924; and AIx 30.4 (8.2)% at baseline, 28.6 (7.6) at 6 months, 29.4 (6.7) at 1 year, P = 0.216]. Total and low-density lipoprotein cholesterol levels increased significantly but high-density lipoprotein (HDL) and triglyceride levels were unchanged. The atherogenic index (total cholesterol/HDL cholesterol) was increased, but not to a level of significance. No change was found in other cardiovascular risk factors. DAS-28 according to levels of ESR and CRP and biologic inflammation were significantly improved. Conclusion. Arterial stiffness did not improve after 6 and 12 months of rituximab therapy. The treatment had a beneficial effect on biologic inflammation and disease activity, but caused a pro-atherogenic lipid profile.

Summary Background Optical coherence tomography is a high-resolution imaging technology that allows in vivo assessment of neointimal hyperplasia and strut coverage after coronary stenting. Aim Assessment of spatial distribution of healing, 6 months after zotarolimus-eluting stent implantation. Methods Forty-two zotarolimus-eluting stents were monitored by optical coherence tomography 6 months after implantation. Mean neointimal strut coverage thickness and percentage of neointimal hyperplasia were measured every millimetre. Non-covered strut ratios were assessed on each slice. In addition, the spatial distribution of neointimal hyperplasia and strut coverage were analysed longitudinally on five stent segments and axially on each slice. Results There were no clinical events at 6 months under dual antiplatelet therapy. The optical coherence tomography analysis showed a mean neointimal hyperplasia thickness of 333 ± 147 μm and neointimal hyperplasia obstruction of 36.1 ± 12.3%. The percentage of covered struts at 6 months was very high (98.9%). Only 6/745 slices analysed (0.8%) had non-covered strut ratios exceeding 30%. There was no significant heterogeneity in either longitudinal or axial neointimal hyperplasia distribution. No thrombi were observed. Conclusion This optical coherence tomography study found relatively constant neointimal hyperplasia thickness, regardless of the zotarolimus-eluting stent length or diameter. This spatially homogeneous neointimal hyperplasia was associated with near-total coverage of all struts, 6 months after implantation.

Kawasaki disease (KD) is an acute multisystemic vasculitis occurring predominantly in children and rarely in adults. Diagnosis is made clinically using diagnostic guidelines; no specific test is available. "Incomplete" KD is a more recent concept, which refers to patients with fever lasting > or =5 days and 2 or 3 clinical criteria (rash, conjunctivitis, oral mucosal changes, changes of extremities, adenopathy), without reasonable explanation for the illness. To describe the clinical and laboratory features of classical (or "complete") KD, and incomplete KD in adults, we report 10 cases of adult KD, including 6 patients who fulfilled the criteria for incomplete KD, diagnosed either at presentation (n = 4) or retrospectively (n = 2). At the time of clinical presentation, complete KD was diagnosed in 4 patients, while 4 patients fulfilled the criteria for incomplete KD. For 3 of the 4 patients with incomplete KD, presence of severe inflammation, laboratory findings (hypoalbuminemia, anemia, elevation of alanine aminotransferase, thrombocytosis after 7 days, white blood cell count > or =15,000/mm, and urine > or =10 white blood cell/high power field), or echocardiogram findings were consistent with the diagnosis. In 2 patients, the diagnosis of KD was made retrospectively in the presence of myocardial infarction due to coronary aneurysms, after an undiagnosed medical history evocative of incomplete KD. Seven patients received intravenous immunoglobulins (IVIG), after a mean delay of 12.5 days, which appeared to shorten the course of the disease. This relatively large series of adult KD highlights the existence of incomplete KD in adults and suggests that the algorithm proposed by a multidisciplinary committee of experts to diagnose incomplete KD in children could be useful in adults. Further studies are needed to determinate whether prompt IVIG may avoid artery sequelae in adult patients with complete or incomplete KD.

Summary Background Optical coherence tomography is an imaging method that enables cardiologists to study atheromatous plaques, and to check the implantation and evolution of coronary stents. It is an invasive technique, providing high-resolution (10 μm) in vivo images, but with limitations and artefacts that need to be understood before the field of application can be extended. Aim To determine the feasibility and limitations of optical coherence tomography coronary imaging from a single-centre experience. Methods We analysed the first 301 optical coherence tomography (version M2, LightLab Imaging) sequences obtained in our department from examination of 73 patients. Results Results showed that 92% of sequences for selected lesions were usable, with a mean examination time of 17 min. Only one complication occurred (ventricular fibrillation, reduced by external electroshock). In our registry, sequence quality depended on operator experience (improving after 20 examinations), and was impaired by artefacts, especially in right coronary analysis and in arteries of greater than 3.5 mm calibre. Conclusions Proximal coronary occlusion and the distal flush quality currently required for quality imaging should no longer be indispensable with the new generation of optical coherence tomography systems.

Le stenting coronaire a permis d’elargir les indications de revascularisation endoluminale, de securiser les procedures et de diminuer le taux de restenose. La thrombose de stent est une complication rare, de mauvais pronostic et multifactorielle. Si l’impact de la nature du stent (nu ou actif) sur la survenue de thrombose reste controverse, certains defauts de procedures non deceles par l’angiographie peuvent en etre responsables. L’imagerie endocoronaire fournie par l’echographie (IVUS) ou par une nouvelle methode de haute resolution qu’est la tomographie par coherence optique (OCT) permet d’apprecier le resultat optimal d’un stenting, de confirmer l’absence de complications immediates et, a terme, d’observer la couverture neo-intimale de l’endoprothese. Nous rapportons l’experience monocentrique des differentes anomalies observees en OCT apres stenting. La diffusion de cette technique devrait contribuer a l’optimisation des resultats de procedures complexes et a une meilleure comprehension des facteurs impliques dans la thrombose.

SummaryBackgroundIntrastent thrombosis, while rare, has a poor prognosis. Strut non-coverage is one causal factor, especially in cases of resistance to or premature discontinuation of dual antiplatelet therapy.AimTo compare neointimal coverage with paclitaxel and zotarolimus drug-eluting stents, using optical coherence tomography (OCT).MethodsTwenty-two drug-eluting stents (11 paclitaxel-eluting stents and 11 zotarolimus-eluting stents) were examined by OCT, 6 months after implantation. Mean neointimal strut-coverage thickness and percentage neointimal hyperplasia were measured every millimetre. On each OCT image, struts were classified into one of four categories: well-apposed to vessel wall with apparent neointimal coverage; well-apposed to vessel wall without neointimal coverage; malapposed to the vessel wall; or located on a major side branch.ResultsOCT analysis showed a lower percentage of neointimal hyperplasia with paclitaxel-eluting stents than with zotarolimus-eluting stents (17% vs 38% and mean thickness 154μm vs 333μm, respectively; p

Summary Background Percutaneous closure of large persistent ductus arteriosus using the Amplatzer ® duct occluder is an alternative to surgery. However, this device is not recommended in infants weighing less than 6 kg. Aim To evaluate the safety and effectiveness of this procedure in low-body-weight infants. Methods We reviewed retrospectively data for infants weighing less or equal to 6 kg who underwent percutaneous closure of significant persistent ductus arteriosus using the Amplatzer ® duct occluder in France between 1998 and 2007. Results Data for 58 patients (mean weight: 5 kg, range: 3.4–6; mean age: 5.5 months, range: 2.1–15.3) were reviewed. Mean angiographic persistent ductus arteriosus minimal diameter was 3.7 mm (range: 1–7.5). Implantation of the Amplatzer ® duct occluder was successful in 89.7% of cases. In six (10.3%) patients, the device was not implanted because it would have led to significant aortic obstruction. One procedure-related death occurred in a 4 kg infant (1.7%). Major and minor complications occurred in 6.9 and 31.0% of patients, respectively. Persistent ductus arteriosus diameter greater than 3.7 mm, type C (tubular shape) and diameter/patient weight ratio greater than 0.91 were significantly associated with an unsuccessful procedure and/or major complications. During a median 10-month follow-up, no late device embolization occurred. Conclusions Although percutaneous closure of significant persistent ductus arteriosus with the Amplatzer ® duct occluder is effective in low-body-weight infants, the level and severity of complications indicate surgery as first-line treatment, at least until further studies are done to assess the safety and effectiveness of the new Amplatzer ® duct occluder II in low-body-weight infants.

We present an unusual fortuitously discovered case of atresia of the left inferior pulmonary vein with drainage via anastomosis to the left upper pulmonary vein and the left atrium. Atresia of the pulmonary veins is a very rare anomaly that results from defective incorporation of the pulmonary venous system into the left atrium. The initial diagnosis, drawn from plain radiographs, was confirmed by cardiac catheterization and pulmonary angiography. The appearance of clinical signs, prognosis, and the need for treatment depend on how well substitute drainage is performed.

Summary Introduction Thromboembolic accidents and haemorrhage are the main complications observed during long-term follow-up of mechanical heart valve patients. Several suggestions for improving anticoagulation quality have been made, including international normalised ratio (INR) self-monitoring. Objectives We report the preliminary results of a single-centre, open, randomised study (scheduled population of 200 patients), which compares monthly laboratory monitoring (group A) versus weekly self-monitoring of INR (group B). The primary aim is INR stability improvement within the target range, and the secondary aim is adverse events reduction. Patients and methods Between May 2004 and June 2005, 67 patients with an average age of 56.6 years (± 9.6), were enrolled in the study (group A: 34 patients, group B: 33 patients). The mean follow-up was 47 weeks (± 11.5). The two groups differed only in the sex ratio (44.1 and 21.2% of women in groups A and B respectively, p = 0.0459). Mechanical heart valves were aortic in 73% of patients, mitral in 13.5%, and multiple in 13.5%. Sixty-five patients (97%) were treated with fluindione, the others with acenocoumarol. The intraclass correlation coefficient between the self- and laboratory-monitored INR was 0.75. Results The time spent in the INR target range (group A: 53 ± 19%, group B: 57 ± −19%, p = 0.45) and the time spent in the INR therapeutic range, between 2 and 4.5, (group A: 86 ± 14%, group B: 91 ± 7%, p = 0.07) are longer in group B, but not significantly so. For patients outside the range, the absolute mean deviation of INR from the target or therapeutic range (range standardized between 0 and 100) is lower for the self-monitoring group (41.1 ± 39.3 and 11.27 ± 11.2) than for the control group (62.4 ± 72.6 and 39.2 ± 52.8). This difference is significant ( p = 0.0004 and p = 0.0005). Eighteen adverse events were reported: 17 haemorrhages, 13 in group A (9 mild, 4 serious) and four in group B (all mild), and one sudden death in group B, two days after the patient's discharge. No thromboembolic events were reported. Six patients (8.8 %), 3 in each group, dropped out of the study. Conclusion This first study evaluating INR self-monitoring in France shows that this method leads to better stability of the INR within the target range. On the basis of these preliminary data, this appears to be related to a decrease in serious haemorrhages (11.8% serious haemorrhage cases in group A versus 0% in group B, p = 0.06, NS).

Objectives. Increased incidence of cardiovascular disease (CVD) has been observed in AS. The reasons of this increase are not fully understood (greater prevalence of traditional cardiovascular risks, consequences of treatment (NSAID) or biological inflammation). The objectives of this study are to assess intima–media thickness (IMT) and arterial stiffness (i.e augmentation index AIx), markers of sub-clinical atherosclerosis in AS patients and to examine the effects of TNF-� inhibitors on arterial stiffness in active AS patients. Methods. Sixty AS patients were enrolled with 60 healthy controls. Their BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and BASFI (Bath Ankylosing Spondylitis Functional Index) scores, ESR and CRP levels were recorded. Subclinical atherosclerosis was assessed by measurement of AIx by pulse wave analysis and IMT by carotid echography. Results. We found significantly increased IMT in the AS group compared with healthy controls. After adjustment for confounding factors, an underlying trend towards increased IMT was still present (P ¼ 0.06). No difference was found in arterial stiffness between the two groups. AS patients, treated or not with anti-TNF-� at baseline, had significantly increased IMT and AIx or a trend towards increase. IMT was positively correlated with tobacco use, WHR and blood pressure but not correlated with CRP level. Despite improvement in markers of disease activity, arterial stiffness was unchanged after 14 weeks of treatment with TNF antagonists. Conclusion. This study shows a trend towards increased subclinical atherosclerosis in AS patients. TNF-� blockade does not seem to improve arterial stiffness in AS patients, but our results lack statistical power.

International audience; The etiology of congenital heart defect (CHD) combines environmental and genetic factors. So far, there were studies reporting on the screening of a single gene on unselected CHD or on familial cases selected for specific CHD types. Our goal was to systematically screen a proband of familial cases of CHD on a set of genetic tests to evaluate the prevalence of disease-causing variant identification. A systematic screening of GATA4, NKX2-5, ZIC3 and Multiplex ligation-dependent probe amplification (MLPA) P311 Kit was setup on the proband of 154 families with at least two cases of non-syndromic CHD. Additionally, ELN screening was performed on families with supravalvular arterial stenosis. Twenty-two variants were found, but segregation analysis confirmed unambiguously the causality of 16 variants: GATA4 (1 x), NKX2-5 (6 x), ZIC3 (3 x), MLPA (2 x) and ELN (4 x). Therefore, this approach was able to identify the causal variant in 10.4% of familial CHD cases. This study demonstrated the existence of a de novo variant even in familial CHD cases and the impact of CHD variants on adult cardiac condition even in the absence of CHD. This study showed that the systematic screening of genetic factors is useful in familial CHD cases with up to 10.4% elucidated cases. When successful, it drastically improved genetic counseling by discovering unaffected variant carriers who are at risk of transmitting their variant and are also exposed to develop cardiac complications during adulthood thus prompting long-term cardiac follow-up. This study provides an important baseline at dawning of the next-generation sequencing era.

Iatrogenic coronary dissection is a rare but potentially serious complication of coronary angiography and angioplasty. Treatment with angioplasty guided only by angiography is often difficult. Optical coherence tomography imaging seems to be an interesting technique to lead the management of iatrogenic coronary dissection. Diagnosis can be made by optical coherence tomography; it can also eliminate differential diagnosis. Furthermore, this technique can guide safely the endovascular treatment.

Pheochromocytoma and paraganglioma (PPG) are rare and late-diagnosed catecholamine secreting tumors, which may be associated with unrecognized and/or severe cardiomyopathies. We performed a computer-assisted systematic search of the electronic Medline databases using the MESH terms “myocarditis,” “myocardial infarction,” “Takotsubo,” “stress cardiomyopathy,” “cardiogenic shock”, or “dilated cardiomyopathy,” and “pheochromocytoma” or “paraganglioma” from 1961 to August 2012. All detailed case reports of cardiomyopathy due to a PPG, without coronary stenosis, and revealed by acute symptoms were included and analyzed. A total of 145 cases reports were collected (49 Takotsubo Cardiomyopathies [TTC] and 96 other Catecholamine Cardiomyopathies [CC]). At initial presentation, prevalence of high blood pressure (87.7%), chest pain (49.0%), headaches (47.6%), palpitations (46.9%), sweating (39.3%), and shock (51.0%) were comparable between CC and TTC. Acute pulmonary edema (58.3% vs 38.8%, P = 0.03) was more frequent in CC. There was no difference in proportion of patients with severe left ventricular systolic dysfunction (LV Ejection Fraction [LVEF]

Summary Background The prevalence and incidence of heart failure (HF) in elderly patients are increasing worldwide. Management of HF with reduced ejection fraction (HF-REF) in patients aged 80 years or more follows international guidelines, despite the lack of a dedicated study in this frail population. Aims To determine whether optimized management of HF-REF in patients aged 80 years or more can improve quality of life at 6 months. Methods Patients aged 80 years or more hospitalized for acute HF-REF were randomized prospectively into an optimized group or a control group (usual care). All patients benefitted from the same in-hospital management. Optimized group patients were also managed at 3, 6 and 9 weeks, and 3, 6, 9 and 12 months after initial hospitalization, to optimize HF-REF treatment. The primary endpoint was quality of life at 6 months. Results The trial was stopped prematurely, according to prespecified rules and an independent data monitoring board, after 34 patients were included ( n = 17 in each group). There was no difference in quality of life at baseline and at 6 months between the two groups ( P = 0.14 and 0.64, respectively), although a significant improvement was observed between baseline and 6 months in the optimized group compared with the control group: −20.2 ± 25.2 ( P = 0.01) versus −9.9 ± 19.0 ( P = 0.19). Mortality at 12 months was lower in the optimized group (17.7% vs 47.1%; P = 0.03). There was no increase in acute renal failure, hyperkalaemia or falls in the optimized group ( P = 0.49, 1 and 1, respectively). Conclusions Optimizing the management of HF-REF in patients aged 80 years or more, according to the modalities of the HF80 study, seems to be both effective and safe.

Transposition of great arteries (TGA) defined as the combination of concordant atrioventricular and discordant ventriculo-arterial connections is one of the most common congenital heart defects. Prenatal diagnosis of TGA remains difficult. To determine the impact of antenatal diagnosis we evaluated the sensitivity of antenatal detection and the neonatal mortality of TGA considering two study periods and two major types of TGA.A cross-sectional study was performed. Data were collected from a French population-based birth defect registry. From 1988 to 2012, 94 fetuses with TGA were registered. The study period was subdivided into the 1988 to 1999 period and the 2000 to 2012 period. Two types of TGA were considered: isolated TGA (n = 66) and associated TGA (n = 28). A stratified analysis was performed considering the study periods and the types of TGA.Considering the study periods, the sensitivity of prenatal detection of TGA increased significantly (9.8% vs. 51.5%, p = 0.0001). The same trend was found for associated TGA (4.8% vs. 33.3%, p = 0.002) and isolated TGA (21.1% vs. 100%, p 0.001). A late diagnosis of TGA (7 days after birth) was observed in 13.2% of cases. Neonatal mortality decreased significantly over time for isolated TGA (25.0% vs. 0 p = 0.01). Prenatal diagnosis of both types of TGA did not improve survival.We demonstrated that prenatal diagnosis and neonatal mortality of TGA varied greatly according to the malformation type and the study period. This could be explained by an improvement in terms of medical management.

Bioprosthetic thromboses are rarely reported in post-transcatheter aortic valve implantation (TAVI). We describe herein the case of bioprosthetic valve thrombosis in an 82-year-old patient which resolved completely after anticoagulant therapy.

Background The out-of-hospital cardiac arrest represent the leading cause of death worldwide. Several therapeutic elements such as early reperfusion developed in recent years to reduce the high morbidity and mortality observed in this situation. The objective of this study was to evaluate the influence of emergency coronary angiography (CAG) and primary percutaneous coronary intervention (PCI) on the outcome of patients survivors after out-of-hospital cardiac arrest. Methods Between January 2012 and June 2013, a total of 54 consecutive patients survivors of out-of-hospital cardiac arrest underwent systematic emergency coronary angiography. Results Thirty five of the 54 patients had clinically significant coronary disease on angiography, 23 of whom had coronary-artery occlusion (43%). Angioplasty was attempted in 20 patients and was technically successful in 18. The in-hospital survival rate was 48%. Multivariate logistic-regression analysis revealed that angioplasty was an independent predictor of survival (95 percent confidence interval, 3.1 to 750.1; P =0.006). Conclusions Acute coronary-artery occlusion is frequent in survivors of out-of-hospital cardiac arrest. Accurate diagnosis by immediate coronary angiography can be followed in suitable candidates by coronary angioplasty, which seems to improve survival.

Background Rognosis of heart failure with reduced ejection fraction (HFREF) is improved by tailored drugs optimization but poor is known concerning such optimization in HFREF patients implanted by implantable cardiac defibrillator (ICD) or cardiac resynchronization therapy (CRT). We conduct an evaluation of European guidelines implement before device implantation. Methods Between January 2009 and December 2014, data were extracted from the echantillon generaliste des beneficiaires (EGB) database, a representative 1/97 random sample of the population covered by the French national health insurance system. We included HFREF patients implanted by ICD or CRT. Survival and treatments were analyzed at baseline, 3 months and until January 2016. Results We included a sample of 378 patients (135 CRT, 243 ICD) with a mean age of 68 ± 13 years old. Mean follow-up was 23 months (11–42). At baseline, 36% of patients had only one or no HF drug among beta-blocker (BB), angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blockers (ARB) and mineralocorticoid receptor antagonist (MRA). Twenty-six percent had an optimal treatment (all the 3 classes). At 3 months, prescription rate was higher compared to baseline but not at the end of follow-up. HF hospitalization rate was higher in non-optimized patient group 28% vs. 14% (P = 0.001). HFrEF optimal treatment was associated with a better survival (HR = 0.27 [0.15–0.46], P Fig. 1 ). Conclusion HFREF drugs are under prescribed before CRT and ICD implantations despite we demonstrated that treatment optimization reduced HF hospitalization.

Heart failure (HF) is a major public health issue. This study conducted a real-life analysis of the impact of clinical characteristics and medical management of HF on its prognosis. Analysis was based on the EGB (“Echantillon Generaliste des Beneficiaires”) database. A cohort comprising 1825 adult patients with a first admission for HF between 2009 and 2011 was created and followed until June 2013 (median 22.3 [7.7–34.5] months) for survival analysis. Mean age was 77.3 ± 13.2 years (53 % ≥80 years). The overall incidence of HF admission was 117 [112–122] per 100,000 population with a marked increase in patients >80 years (1297 [1217–1348]). At discharge, only 8 % of patients received recommended combination of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), beta-blockers (BB) and mineralocorticoid receptor antagonists (MRA). Only prescription levels of BB and vitamin K antagonists, at discharge, increased during the study period. In-hospital mortality was 9 % and survival was 71.6 %[69.5–73.6] and 52.0 %[49.4–54.6] at 12 and 36 months, respectively. In multivariate analysis, female gender [HR:0.78 (0.67–0.91), p = 0.001], ACEi/ARB + BB + MRA [0.41 (0.28–0.60), p

Aims: To assess whether a strategy of invasive management without stents in selected acute coronary syndrome (ACS) patients with a large thrombus burden (LTB) might be feasible and safe.\ud \ud Methods and results: We performed a prospective non-randomised observational cohort study of invasive treatment decisions guided by optical coherence tomography (OCT) in selected ACS patients with LTB. Among 852 ACS patients who had undergone invasive coronary angiography, 101 (11.8%) patients with large thrombus burden on initial angiography underwent thrombectomy to restore TIMI 3 flow without stenting. All of these patients then had repeat angiography with OCT (days 0-2 [Group 1], days 3-6 [Group 2] or days 7-30 [Group 3]). No adverse events occurred between the initial and second angiograms. Residual thrombus was detected in 68% of patients with OCT (respectively, 94%, 79% and 32% in Group 1, Group 2 and Group 3), and 20% of cases with angiography. Plaque rupture was detected by OCT in 65% of cases. Minimal lumen area was 2.81 mm2, 3.40 mm2 and 4.89 mm2 in Group 1, Group 2 and Group 3, respectively. Sixty-two percent of patients were stented (respectively, 76%, 61% and 50%). During a minimum follow-up period of 12 months in all patients, one non-fatal MI occurred and one PCI was performed for angina.\ud \ud Conclusions: Medical management without stents is safe and feasible in selected ACS patients with LTB. OCT revealed culprit lesion characteristics that were not disclosed by angiography and facilitated treatment decisions.

Aim Iatrogenic coronary artery dissection is rare but severe complication of coronary angiography and angioplasty. It might lead to a definitive vessel occlusion with its short (myocardial infarction and arrhythmias) and long-term (heart failure) consequences. We hypothesized that OCT imaging could be helpful to manage this complication. Method we made an exhaustive analysis of iatrogenic coronary dissection appeared between January 2012 and December 2013 in Clermont-Ferrand University Hospital and leading to the modification of the initial procedure. Medical records were retrospectively reviewed with angiographic and endocoronary examination. We compared OCT and non-OCT management. Results 49 cases were recorded with 8 using OCT imaging. Most frequent causes were the stent (35%) and the approach catheter (35%). Most of the dissections were classified D. Every patient treated with OCT imaging had a severe dissection (D, E or F type) and in particular when the operator had not the certitude of positioning the guide wire in the true lumen. Stent implantation was the most used therapy (72%). All patients treated with OCT benefited of a successful stent implantation, without lesion aggravation after highpressured contrast injection. Results are similar in both groups despite more severe dissections and more complex procedures in OCT group. Conclusion OCT imaging seems to be a secure and reliable technique for endovascular treatment when it comes to management of iatrogenic dissections.

We describe a case of recurrent Kawasaki disease (KD) in a non-Asian 6-year-old boy who had been diagnosed with typical KD without cardiac involvement at age 3 years. He was admitted to the PICU 3 years later for heart failure, hypotension, and deterioration of his general condition. Ultrasonography revealed left ventricular dysfunction with a 44% ejection fraction and grade I mitral valve failure without coronary artery involvement. Subsequent observation of hyperemic conjunctiva, bilateral cervical adenopathies with erythematous skin (normal neck ultrasound and computed axial tomography findings), peeling of the fingertips at day 8 of the illness, and occurrence of an inflammatory syndrome led to a diagnosis of incomplete recurrent KD with a clinical picture of Kawasaki shock syndrome (KSS). Clinical improvement was rapidly obtained after intravenous immunoglobulin and intravenous corticosteroid therapy (30 mg/kg per day for 3 subsequent days). Left ventricular function gradually improved, with ultrasound returning to normal after 3 months. Diagnosis was difficult to establish because of the recurrence of the disease and the incomplete clinical picture, with clinical features of KSS. Physicians need to be aware of these pitfalls in the management of patients with clinical signs of KD.

The short-term efficacy and safety of transcatheter closure (TCC) for the management of coronary artery fistulas (CAFs) was investigated in pediatric patients.CAFS are rare with potentially severe complications and their management is still a matter of debate. Percutaneous closure appears to be the treatment of choice in anatomically suitable vessels but limited data are available in the pediatric population.This retrospective, observational, multicenter, national study included patients under 16 years of age who underwent TCC of a congenital CAF. Patients with additional congenital heart defect were excluded.61 patients (36 girls, 25 boys) with a median age of 0.6 year [0-15.4] at diagnosis and 3.9 years [0-16] at procedure were included. The CAF was large in 48 patients (79%); it was distal in 23 (38%) and proximal in 22 (36%). Most patients (77%) were asymptomatic at diagnosis. Clinical signs of congestive heart failure were present in seven patients (11%). Perioperative complications included three cases of ST elevation myocardial infarction (exclusively during attempted closure of a distal CAF), three devices migrations, and one case of leg ischemia. One patient died after surgical closure of a large distal CAF that could not be closed by TCC. Follow-up data were collected for 43 patients (70%) for a median of 91 days [0-4,824]. The Kaplan-Meyer estimate for complete occlusion at 2 years was 73 ± 7.6%.TCC in the pediatric population appears to be effective and associated with few complications.

In this prospective study we evaluated the efficacy of a battery of noninvasive tests including clinical evaluation (CE), exercise testing (ET), and dobutamine stress echocardiography (DSE) for assessment of cardiac risk in 90 patients indicated for aortic reconstruction. As the gold-standard reference technique, coronary arteriography was performed in each patient after non-invasive evaluation. The sensitivity of CE was low (61%). ET proved to be more sensitive (71.4%) and highly specific (95.8%) but feasibility (77%) and diagnostic accuracy (42%) were low. DSE demonstrated acceptable sensitivity (78%) and specificity (75.5%) with high feasibility (94.5%) and diagnostic accuracy (100%). None of the four patients with false negative ET results and only one of seven with false-negative DSE required coronary bypass. On the basis of these findings we conclude that a combination of CE and ET with DES, if necessary, can reliably assess cardiac risk before aortic reconstruction. Noninvasive assessment is a reliable alternative to routine coronary arteriography.

We report a case with very early antenatal diagnosis of aortico-left ventricular tunnel (ALVT) at 22 weeks of pregnancy. Early recognition of ALVT by antenatal ultrasound allows prompt neonatal management and avoidance of harmful aortic valve regurgitation. The present case is unique because of the conjunction of very early antenatal diagnosis, prompt postnatal management, early surgical repair on the sixth day of life, direct closure from the aorta of the aortic orifice only, and optimal postoperative course with excellent mid-term result.

Background Experimental studies suggest that the antiproliferative effect of heparin after arterial injury is maximized by pretreatment. No previous studies of restenosis have used a pretreatment strategy. We designed this study to determine whether treatment with nadroparin, a low-molecular-weight heparin, started 3 days before the procedure and continued for 3 months, affected angiographic restenosis or clinical outcome after coronary angioplasty. Methods and Results In a prospective multicenter, double-blind, randomized trial, elective coronary angioplasty was performed on 354 patients who were treated with daily subcutaneous nadroparin (0.6 mL of 10 250 anti-Xa IU/mL) or placebo injections started 3 days before angioplasty and continued for 3 months. Angiography was performed just before and immediately after angioplasty and at follow-up. The primary study end point was angiographic restenosis, assessed by quantitative coronary angiography 3 months after balloon angioplasty. Clinical follow-up was continued up to 6 months. Clinical and procedural variables and the occurrence of periprocedural complications did not differ between groups. At angiographic follow-up, the mean minimal lumen diameter and the mean residual stenosis in the nadroparin group (1.37±0.66 mm, 51.9±21.0%) did not differ from the corresponding values in the control group (1.48±0.59 mm, 48.8±18.9%). Combined major cardiac-related clinical events (death, myocardial infarction, target lesion revascularization) did not differ between groups (30.3% versus 29.6%). Conclusions Pretreatment with the low-molecular-weight heparin nadroparin continued for 3 months after balloon angioplasty had no beneficial effect on angiographic restenosis or on adverse clinical outcomes.