Search

Background Improved prediction of the risk of early major bleeding in pulmonary embolism (PE) is needed to optimize acute management. Research Question Does a simple scoring system predict early major bleeding in acute PE patients, identifying patients with either high or low probability of early major bleeding? Study Design and Methods From a multicenter prospective registry including 2,754 patients, we performed post hoc multivariable logistic regression analysis to build a risk score to predict early (up to hospital discharge) major bleeding events. We validated the endpoint model internally, using bootstrapping in the derivation dataset by sampling with replacement for 500 iterations. Performances of this novel score were compared with that of the VTE-BLEED (Venous Thrombo-Embolism Bleed), RIETE (Registro informatizado de la enfermedad tromboembolica en Espana; Computerized Registry of Patients with Venous Thromboembolism), and BACS (Bleeding, Age, Cancer, and Syncope) models. Results Multivariable regression identified three predictors for the occurrence of 82 major bleeds (3.0%; 95% CI, 2.39%-3.72%): Syncope (+1.5); Anemia, defined as hemoglobin 2.5 points). Observed bleeding rates increased with increasing risk group, from 0.97% (95% CI, 0.53%-1.62%) in the low-risk to 8.93% (95% CI, 6.15%-12.44%) in the high-risk group. C-index was 0.74 (95% CI, 0.73-0.76) and Brier score 0.028 in the derivation cohort. Similar values were calculated from internal bootstrapping. Performance of the PE-SARD score was better than that observed with the VTE-BLEED, RIETE, and BACS scores, leading to a high proportion of bleeding-risk reclassification in patients who bled and those who did not. Interpretation The PE-SARD bleeding risk score is an original, user-friendly score to estimate risk of early major bleeding in patients with acute PE.

We aimed to investigate pacemaker dependency after at least 1 year in patients with early (7 days) implantation, compared to those who received a pacemaker ≥7 days after cardiac surgery. Secondary endpoints were length of hospital stay and in-hospital complications.Retrospective analysis of 108 consecutive patients who received a pacemaker after cardiac surgery between 06/2012 and 06/2018. Characteristics and outcomes were compared between patients with early (7 days) and late (≥7 days) implantation. Patients were followed up with evaluation of pacemaker dependency between April and June 2019. We identified predictors of dependency by logistic regression.In total, 63.9% were men, average age 71.9 ± 11.8 years; 32 (29.6%) had early implantation, and 76 (70.4%) late implantation. After a median 3.2 years [IQR 1.9, 4.5] of follow-up, 30 patients (27.8%) had died, and there was no difference in pacemaker dependency among survivors (66.7% vs. 46.5%, early vs. late respectively, p = .15). Patients in the early group had a shorter length of stay (11.5 [9.0, 14.0] vs. 15.0 [11.5, 20] days, p = .002) and less often had new-onset atrial fibrillation (AF) post-surgery (22.7% vs. 47.8%, p = .05). The only significant predictor of dependency was aortic valve replacement surgery (OR = 4.70, 95% CI [1.36 to 16.24]).Early implantation of a permanent pacemaker (7 days after cardiac surgery) does not impact on the proportion of patients with long-term (12 months) pacemaker dependency, but is associated with shorter length of stay and less frequent new-onset AF. These findings warrant prospective confirmation in randomized trials.

In atrial fibrillation (AF), lower risks of death and bleeding with non-vitamin-K oral anticoagulants (NOACs) were reported in meta-analyses of controlled trials, but whether these findings hold true in real-world practice remains uncertain. Risks of bleeding and death were assessed in 52 032 patients with newly diagnosed AF enrolled in GARFIELD-AF (Global Anticoagulant Registry in the FIELD–Atrial Fibrillation), a worldwide prospective registry. Baseline treatment was vitamin K antagonists (VKAs) with or without antiplatelet (AP) agents (VKA ± AP) (20 151; 39.3%), NOACs ± AP agents (14 103; 27.5%), AP agents only (10 748; 21.0%), or no antithrombotics (6219; 12.1%). One-year follow-up event rates (95% confidence interval [CI]) of minor, clinically relevant nonmajor (CRNM), and major bleedings were 2.29 (2.16-2.43), 1.10 (1.01-1.20), and 1.31 (1.21-1.41) per 100 patient-years, respectively. Bleeding risk was lower with NOACs than VKAs for any bleeding (hazard ratio (HR) [95% CI]), 0.85 [0.73-0.98]) or major bleeding (0.79 [0.60-1.04]). Compared with no bleeding, the risk of death was higher with minor bleeding (adjusted HR [aHR], 1.53 [1.07-2.19]), CRNM bleeding (aHR, 2.59 [1.80-3.73]), and major bleeding (aHR, 8.24 [6.76-10.04]). The all-cause mortality rate was lower with NOACs than with VKAs (aHR, 0.73 [0.62-0.85]). Forty-five percent (114) of all deaths occurred within 30 days, and 40% of these were from intracranial/intraspinal hemorrhage (ICH). The rates of any bleeding and all-cause death were lower with NOACs than with VKAs. Major bleeding was associated with the highest risk of death. CRNM bleeding and minor bleeding were associated with a higher risk of death compared to no bleeding. Death within 30 days after a major bleed was most frequently related to ICH. This trial was registered at www.clinicaltrials.gov as #NCT01090362.

Background: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce. Methods: A Nationwide French Registry including all patients with tetralogy of Fallot with an ICD was initiated in 2010 by the French Institute of Health and Medical Research. The primary time to event end point was the time from ICD implantation to first appropriate ICD therapy. Secondary outcomes included ICD-related complications, heart transplantation, and death. Clinical events were centrally adjudicated by a blinded committee. Results: A total of 165 patients (mean age, 42.2±13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (interquartile range) follow-up of 6.8 (2.5–11.4) years, 78 (47.3%) patients received at least 1 appropriate ICD therapy. The annual incidence of the primary outcome was 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively; P =0.03). Overall, 71 (43.0%) patients presented with at least 1 ICD complication, including inappropriate shocks in 42 (25.5%) patients and lead dysfunction in 36 (21.8%) patients. Among 61 (37.0%) patients in primary prevention, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with, respectively, 0, 1, 2, or ≥3 guidelines-recommended risk factors. QRS fragmentation was the only independent predictor of appropriate ICD therapies (hazard ratio, 3.47 [95% CI, 1.19–10.11]), and its integration in a model with current criteria increased the 5-year time-dependent area under the curve from 0.68 to 0.81 ( P =0.006). Patients with congestive heart failure or reduced left ventricular ejection fraction had a higher risk of nonarrhythmic death or heart transplantation (hazard ratio, 11.01 [95% CI, 2.96–40.95]). Conclusions: Patients with tetralogy of Fallot and an ICD experience high rates of appropriate therapies, including those implanted in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria including QRS fragmentation might improve risk stratification. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03837574.

International audience; Background: Women with congenital heart disease at high risk for sudden cardiac death have been poorly studied thus far.Objectives: The aim of this study was to assess sex-related differences in patients with tetralogy of Fallot (TOF) and implantable cardioverter-defibrillators (ICDs).Methods: Data were analyzed from the DAI-T4F (French National Registry of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator) cohort study, which has prospectively enrolled all patients with TOF with ICDs in France since 2010. Clinical events were centrally adjudicated by a blinded committee.Results: A total of 165 patients (mean age 42.2 ± 13.3 years) were enrolled from 40 centers, including 49 women (29.7%). Among the 9,692 patients with TOF recorded in the national database, the proportion of women with ICDs was estimated to be 1.1% (95% CI: 0.8%-1.5%) vs 2.2% (95% CI: 1.8%-2.6%) in men (P < 0.001). The clinical profiles of patients at implantation, including the number of risk factors for ventricular arrhythmias, were similar between women and men. During a median follow-up period of 6.8 years (IQR: 2.5-11.4 years), 78 patients (47.3%) received at least 1 appropriate ICD therapy, without significant difference in annual incidences between women (12.1%) and men (9.9%) (HR: 1.22; 95% CI: 0.76-1.97; P = 0.40). The risk for overall ICD-related complications was similar in women and men (HR: 1.33; 95% CI: 0.81-2.19; P = 0.30), with 24 women (49.0%) experiencing at least 1 complication.Conclusions: Our findings suggest that women with TOF at high risk for sudden cardiac death have similar benefit/risk balance from ICD therapy compared with men. Whether ICD therapy is equally offered to at-risk women vs men warrants further evaluation in TOF as well as in other congenital heart disease populations. (French National Registry of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator [DAI-T4F]; NCT03837574)

The aim of this study was to assess the safety and efficacy of the TightRail™ sheath for pacemaker/defibrillator transvenous lead extraction (TLE).Multicenter observational study including patients who underwent a TLE with the TightRail™ sheath in five French university hospitals from September 2014 to January 2020.Two hundred and twenty-five patients (76% males, 71 ± 12 years) underwent a TLE procedure with the TightRail™. A total of 438 leads were extracted using the TightRail™, and the mean age of the extracted leads was 128 ± 85 months; of these, 344 (79%) were pacing leads and 94 (21%) were implantable cardioverter defibrillator leads. The overall clinical success of the extraction procedures was 93%. Overall, 410 of the 438 leads (95%) were extracted (complete or incomplete removal). After multilevel mixed-effects logistic regression model, we found that lead age (odds ratio [OR], 95% confidence interval [CI] for a 1 year increase: 1.11 [1.07-1.15], p .001) and number of leads extracted (OR, 95% CI: 2.09 [1.50-2.96], p .001) were the two independent factors associated with complete lead removal failure. Finally, there were 7 (3%) cases of major complications but no per-procedural death.This is the first large-scale survey assessing the efficacy and safety profile of the Tightrail™ mechanical sheath. The clinical success rate was 93%, and the lead removal failure was dependent on the age and number of leads. We show a satisfactory safety profile in this cohort of patients from primarily low-volume centers with older leads.

Background Bleeding prediction scores may help to guide acute management of patients with pulmonary embolism (PE). However, existing scoring systems have not been validated for in-hospital assessment. We aimed to compare 6 available bleeding scores, in a real-life cohort for the prediction of major in-hospital bleeding. Methods We recorded in-hospital characteristics of 2,754 PE patients included in a prospective observational multicenter cohort study contributing 18,028 person-days of follow-up. We assessed the VTE-BLEED, RIETE, ORBIT, HEMORRA2HAGES, ATRIA, and HAS-BLED scores at baseline. ISTH-defined bleeding events were independently adjudicated. The accuracy of the scores for the prediction of in-hospital bleeding was evaluated and compared. Results We observed 82 first in-hospital major bleeding events (3.0% (95% CI, 2.4–3.7)). Overall, the predictive power of bleeding scores was poor, with a C index ranging from 0.57 to 0.69 (Figure 1). The RIETE score had the numerically highest model fit and best discriminatory capacity, but without reaching statistical significance versus the ORBIT, HEMORR2HAGES, and ATRIA scores. The VTE-BLEED and HAS-BLED scores had significantly lower C indices, integrated discrimination improvement, and net reclassification improvement compared to the four others. Conclusion Currently available scoring systems have insufficient accuracy for the prediction of in-hospital major bleeding in patients with acute PE. The development of acute-PE-specific risk scores is needed to optimally target patients that warrant bleeding-prevention strategies. Funding Acknowledgement Type of funding sources: None. Figure 1

Background We assessed the impact of preprocedural plasma levels of MRproANP (midregional N‐terminal pro–atrial natriuretic peptide) and sST2 (soluble suppression of tumorigenicity 2) on recurrence of atrial fibrillation (AF) at 1 year after catheter ablation of AF. Methods and Results This was a prospective, multicenter, observational study including patients undergoing catheter ablation of AF. MRproANP and sST2 were measured in a peripheral venous blood preprocedure, and MRproANP was assessed in the right and left atrial blood during ablation. The primary end point was recurrent AF between 3 and 12 months postablation, defined as a documented (>30 seconds) episode of AF, flutter, or atrial tachycardia. We included 106 patients from December 2017 to March 2019; 105 had complete follow‐up, and the mean age was 63 years with 74.2% males. Overall, 34 patients (32.1%) had recurrent AF. In peripheral venous blood, MRproANP was significantly higher in patients with recurrent AF (median, 192.2; [quartile 1–quartile 3, 155.9–263.9] versus 97.1 [60.9–150.7] pmol/L; P P =0.0033). In the atria, MRproANP was significantly higher than in peripheral blood and was higher during AF than during sinus rhythm. Receiver operating characteristic curve analysis identified a threshold of MRproANP>107.9 pmol/L to predict AF recurrence at 1 year and a threshold of >26.7 ng/mL for sST2. By multivariate analysis, MRproANP>107.9 pmol/L was the only independent predictor of recurrent AF (OR, 24.27; 95% CI, 4.23–139.18). MRproANP95%). Conclusions Elevated MRproANP level independently predicts recurrent AF, whereas sST2 levels do not appear to have any prognostic value in assessing the risk of recurrence of AF up to 1 year after catheter ablation. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03351816.

Improved prediction of the risk of early major bleeding in pulmonary embolism (PE) is needed to optimize acute management.Does a simple scoring system predict early major bleeding in acute PE patients, identifying patients with either high or low probability of early major bleeding?From a multicenter prospective registry including 2,754 patients, we performed post hoc multivariable logistic regression analysis to build a risk score to predict early (up to hospital discharge) major bleeding events. We validated the endpoint model internally, using bootstrapping in the derivation dataset by sampling with replacement for 500 iterations. Performances of this novel score were compared with that of the VTE-BLEED (Venous Thrombo-Embolism Bleed), RIETE (Registro informatizado de la enfermedad tromboembólica en España; Computerized Registry of Patients with Venous Thromboembolism), and BACS (Bleeding, Age, Cancer, and Syncope) models.Multivariable regression identified three predictors for the occurrence of 82 major bleeds (3.0%; 95% CI, 2.39%-3.72%): Syncope (+1.5); Anemia, defined as hemoglobin 12 g/dL (+2.5); and Renal Dysfunction, defined as glomerular filtration rate 60 mL/min (+1 point) (SARD). The PE-SARD bleeding score was calculated by summing all the components. Overall, 52.2% (95% CI, 50.29%-54.11%) of patients were classified as low bleeding-risk (score, 0 point), 35.2% (95% CI, 33.39%-37.04%) intermediate-risk (score, 1-2.5 points), and 12.6% (95% CI, 9.30%-16.56%) high-risk (score2.5 points). Observed bleeding rates increased with increasing risk group, from 0.97% (95% CI, 0.53%-1.62%) in the low-risk to 8.93% (95% CI, 6.15%-12.44%) in the high-risk group. C-index was 0.74 (95% CI, 0.73-0.76) and Brier score 0.028 in the derivation cohort. Similar values were calculated from internal bootstrapping. Performance of the PE-SARD score was better than that observed with the VTE-BLEED, RIETE, and BACS scores, leading to a high proportion of bleeding-risk reclassification in patients who bled and those who did not.The PE-SARD bleeding risk score is an original, user-friendly score to estimate risk of early major bleeding in patients with acute PE.

The safety and efficacy of direct oral anticoagulants (DOACs) in intermediate-high risk pulmonary embolism (PE) are unknown. The aims of the present study were to describe outcomes of patients receiving early apixaban or rivaroxaban prescription rather than the recommended delayed prescription strategy.Retrospective post-hoc analysis based on prospectively collected data from a multicenter cohort including all consecutive PE patients stratified as intermediate-high risk. Group definitions were: early group with DOAC prescription72 h after admission; delayed group with DOAC prescription between 72 h and discharge. The 30-day primary efficacy outcome was a clinical composite of all-cause death and hemodynamic decompensation. The 30-day primary safety outcome was major bleeding.Among 2411 patients admitted with PE, 302 were treated with a DOAC for an intermediate-high risk PE: 34.2% in the early group and 65.9% in the delayed group. The primary outcome occurred in 4.8% (including 1 death and 4 hemodynamic decompensations) in the early DOAC group and in 9.0% in the delayed DOAC group (OR, 0.44, 95% CI 0.15-1.30). The rate of major bleeding did not differ between groups (OR, 0.99; 95% CI 0.45-2.18). The length of stay was numerically shorter in the early group whereas the other outcomes did not differ significantly.The rate of 30-day outcomes was low in patients receiving a DOAC earlier after admission. Patients in the early DOAC group had a numerically shorter length of stay, with similarly low rates of death and bleeding, and similar RV function recovery compared to the delayed strategy.

© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology. This is an open access article under the terms of the Creative Commons Attribution-Non Commercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes., Aims: Changes in echocardiographic parameters and biomarkers of cardiac and venous pressures or estimated plasma volume during hospitalization associated with decongestive treatments in acute heart failure (AHF) patients with either preserved left ventricular ejection fraction (LVEF) (HFPEF) or reduced LVEF (HFREF) are poorly assessed. Methods and results: From the metabolic road to diastolic heart failure: diastolic heart failure (MEDIA‐DHF) study, 111 patients were included in this substudy: 77 AHF (43 HFPEF and 34 HFREF) and 34 non‐cardiac dyspnea patients. Echocardiographic measurements and blood samples were obtained within 4 h of presentation at the emergency department and before hospital discharge. In AHF patients, echocardiographic indices of cardiac and venous pressures, including inferior vena cava diameter [from 22 (16–24) mm to 13 (11–18) mm, P = 0.009], its respiratory variability [from 32 (8–44) % to 43 (29–70) %, P = 0.04], medial E/e' [from 21.1 (15.8–29.6) to 16.6 (11.7–24.3), P = 0.004], and E wave deceleration time [from 129 (105–156) ms to 166 (128–203) ms, P = 0.003], improved during hospitalization, similarly in HFPEF and HFREF patients. By contrast, no changes were seen in non‐cardiac dyspnea patients. In AHF patients, all plasma biomarkers of cardiac and venous pressures, namely B‐type natriuretic peptide [from 935 (514–2037) pg/mL to 308 (183–609) pg/mL, P < 0.001], mid‐regional pro‐atrial natriuretic peptide [from 449 (274–653) pmol/L to 366 (242–549) pmol/L, P < 0.001], and soluble CD‐146 levels [from 528 (406–654) ng/mL to 450 (374–529) ng/mL, P = 0.003], significantly decreased during hospitalization, similarly in HFPEF and HFREF patients. Echocardiographic parameters of cardiac chamber dimensions [left ventricular end‐diastolic volume: from 120 (76–140) mL to 118 (95–176) mL, P = 0.23] and cardiac index [from 2.1 (1.6–2.6) mL/min/m2 to 1.9 (1.4–2.4) mL/min/m2, P = 0.55] were unchanged in AHF patients, except tricuspid annular plane systolic excursion (TAPSE) that improved during hospitalization [from 16 (15–19) mm to 19 (17–21) mm, P = 0.04]. Estimated plasma volume increased in both AHF [from 4.8 (4.2–5.6) to 5.1 (4.4–5.8), P = 0.03] and non‐cardiac dyspnea patients (P = 0.01). Serum creatinine [from 1.18 (0.90–1.53) to 1.19 (0.86–1.70) mg/dL, P = 0.89] and creatinine‐based estimated glomerular filtration rate [from 59 (40–75) mL/min/1.73m2 to 56 (38–73) mL/min/1.73m2, P = 0.09] were similar, while plasma cystatin C [from 1.50 (1.20–2.27) mg/L to 1.78 (1.33–2.59) mg/L, P < 0.001] and neutrophil gelatinase associated lipocalin (NGAL) [from 127 (95–260) ng/mL to 167 (104–263) ng/mL, P = 0.004] increased during hospitalization in AHF. Conclusions: Echocardiographic parameters and plasma biomarkers of cardiac and venous pressures improved during AHF hospitalization in both acute HFPEF and HFREF patients, while cardiac chamber dimensions, cardiac output, and estimated plasma volume showed minimal changes., This study was supported by a grant from the European Union funded by the Seventh Framework Programme for Health in 2010 (FP7-HEALTH-2010-MEDIA; Luxembourg) (F.Z., P.R., A. M) and research fellowship from Japan Heart Foundation (E. A.). P.R., N.G., T.C., and F.Z. are supported by a public grant overseen by the French National Research Agency (ANR) as part of the second “Investissements d’Avenir” programmes Fighting Heart Failure (reference: ANR-15-RHU-0004), GEENAGE Impact Lorraine Université d’Excellence and by the Contrat de Plan Etat Lorraine IT2MP and FEDER Lorraine. LNLVA is supported by a training grant from the European Society of Cardiology (2015) and a travelling award from the International Society for Heart and Lung Transplantation (August 2015 and 2016). LNLVA gratefully acknowledges the financial support from the Fund for Cardiac Surgery through the Jacqueline Bernheim prize 2015.

Background We studied the course of plasma concentrations of 4 cardiovascular biomarkers: natriuretic peptides (BNP, NT-proBNP; mid-regional (MR) pro-atrial NP); and soluble endothelial CD146 (sCD146), in patients with severe mitral valve stenosis undergoing percutaneous mitral commissurotomy (PMC) to identify potential markers of procedural success. Methods Biomarkers were tested in 40 patients the day before and the day after PMC. Success was defined as mitral valve area ≥ 1.5 cm2; or an increase of ≥0.5 cm2 in mitral valve area associated with echocardiographic mitral regurgitation Results Average age was 63.5 ± 12.7 years; 32(80%) were female. Before PMC, mean valve area was 1.1 ± 0.2 cm2, mean gradient 9.1 ± 3.5 mmHg. PMC was successful in 30 (75%) and unsuccessful in 10 (25%). PMC yielded a significant reduction in MR-proANP and sCD146, driven by a significant reduction in these biomarkers in patients with successful procedure, whereas no reduction was observed in patients with unsuccessful procedure. A significant correlation was found between changes in plasma sCD146 and the relative change in mitral valve area. Elevated pre-procedural sPAP correlated with high sCD146, and accordingly, a significant correlation between the decrease in sPAP and sCD146 after PMC was shown. Conclusions MR-proANP and plasma sCD146 decreased significantly immediately after successful PMC. They appear to be markers of immediate success of PMC and of the hemodynamic improvement achieved by this procedure in patients with MS. Trial registration This study is part of the cohorts registered with ClinicalTrials.gov on June 16, 2011 under the number NCT01374880.

Acute myocarditis is associated with cardiac arrhythmia in 25% of cases, a third of these arrhythmias are ventricular tachycardia (VT) or ventricular fibrillation (VF). The implantation of a cardiac defibrillator (ICD) following sustained ventricular arrhythmia remains controversial in these patients. We sought to assess the risk of major arrhythmic ventricular events (MAEs) over time in patients implanted with an ICD following sustained VT/VF in the acute phase of myocarditis compared to those implanted for VT/VF occurring on myocarditis sequelae. Our retrospective observational study included patients implanted with an ICD following VT/VF during acute myocarditis or VT/VF on myocarditis sequelae, from 2007 to 2017, in 15 French university hospitals. Over a median follow-up period of 3 years, MAE occurred in 11 (39%) patients of the acute myocarditis group and 24 (60%) patients of the myocarditis sequelae group. Kaplan&ndash, Meier MAE rate estimates at one and three years of follow-up were 19% and 45% in the acute group, and 43% and 64% in the sequelae group. Patients who experienced sustained ventricular arrhythmias during acute myocarditis had a very high risk of VT/VF recurrence during follow-up. These results show that the risk of MAE recurrence remains high after resolution of the acute episode.

Aims Congestion is a central feature of acute heart failure (HF) and its assessment is important for clinical decisions (e.g. tailoring decongestive treatments). It remains uncertain whether patients with acute HF with preserved ejection fraction (HFpEF) are comparably congested as in acute HF with reduced EF (HFrEF). This study assessed congestion, right ventricular (RV) and renal dysfunction in acute HFpEF, HFrEF and non-cardiac dyspnoea. Methods and results We compared echocardiographic and circulating biomarkers of congestion in 146 patients from the MEDIA-DHF study: 101 with acute HF (38 HFpEF, 41 HFrEF, 22 HF with mid-range ejection fraction) and 45 with non-cardiac dyspnoea. Compared with non-cardiac dyspnoea, patients with acute HF had larger left and right atria, higher E/e', pulmonary artery systolic pressure and inferior vena cava (IVC) diameter at rest, and lower IVC variability (all P 0.05) compared with HFrEF. Conclusion In acute conditions, HFpEF and HFrEF presented in a comparable state of venous congestion, with similarly altered RV and kidney function, despite higher BNP in HFrEF.

Monoclonal antibodies targeted against the immune checkpoint molecules CTLA-4 and PD-1 have recently obtained approval for the treatment of metastatic melanoma and advanced/refractory non small-cell lung cancers and metastatic renal cancer. Besides their efficacy profile, these immune targeted agents also generate immune-related adverse events that may be life threatening if not anticipated and managed appropriately. This new family of dysimmune toxicities remains largely unknown to the broad oncology community. We propose here some practical guidelines for the oncologist to help in the clinical care of patients under immune checkpoint molecules.

We assessed the long-term (>10 years) clinical course of patients with documented coronary lesions deemed nonsignificant according to fractional flow reserve (FFR) assessment and investigated whether the initial FFR value impacted on prognosis. From January 2000 to October 2003, all patients submitted to coronary angiography with FFR measurement were included in a single-center, prospective registry. Patients with an FFR value >0.80 were treated medically without revascularization. Major adverse cardiac events (MACE) (death, acute coronary syndrome (ACS), or coronary revascularization) were compared according to initial FFR value (absolute value and by category, ≤0.90 vs >0.90). Analyses were performed using a multivariable Cox model and propensity score matching. Among 257 patients (332 lesions) treated medically initially, 131 (51%, 143 lesions) had FFR ≤0.90 and 126 (49%, 189 lesions) >0.90. During follow-up (median duration, 11.6 years), 82 (31.9%) had a MACE, 38 (14.8%) died, 17 (6.6%) had ACS, 93 (36.2%) had repeat coronary angiography, and 27 (10.5%) had revascularization. There was no clinical, biologic or angiographic difference between patients with initial FFR value ≤0.90 versus >0.90. Adjusted Cox model showed no difference in relative risk of MACE, death, ACS, or revascularization. Coronary angiographies were numerically more frequent in patients with FFR ≤0.90, versus FFR >0.90. These findings were confirmed by propensity score–matched comparison. In patients with coronary narrowings left unrevascularized based on FFR, an FFR value between 0.80 and 0.90 has no impact on long-term outcome compared with those with FFR >0.90. In conclusion, patients with high FFR values should not be considered as having a lower risk of coronary event.

Puumala orthohantavirus (PUUV) is the most prevalent of the four species of zoonotic hantaviruses found in Europe, causing nephropathia epidemica, a mild form of hemorrhagic fever with acute kidney injury that presents with elevated serum creatinine level, proteinuria and hematuria. The febrile phase of the infection begins with flu-like syndrome and visual disturbance. Laboratory results can show thrombocytopenia. The oliguric phase with elevated serum creatinine level then occurs. Cardiac involvement is sometimes observed, especially ECG abnormality: transient T-waves inversion, generally in the lateral or inferior leads. Marked bradycardia has been exceptionally described. We report the case of a 36-year-old woman with acute PUUV infection. Two days after admission, the patient presented a sinus bradycardia at 25/min. The bradycardia was asymptomatic, persisted one week and resolved spontaneously. Cardiac involvement in Puumala virus infection seems not to be associated with a bad prognosis. Bradycardia in the course of an influenza-like illness in endemic areas should suggest several pathogens such as legionella, Q fever or PUUV virus infection. Keywords: Hantaviruses, Bradycardia, Hemorrhagic fever with renal syndrome, Puumala virus, France

We assessed incidence, predictors, and impact on 6-month mortality of contrast-induced acute kidney injury (CI-AKI) after coronary angiography with or without percutaneous coronary intervention in patients with acute coronary syndrome (ACS), according to 3 different CI-AKI definitions. Serum creatinine (sCr) was assessed at baseline and 48 to 72 hours after procedure to classify patients into 3 CI-AKI groups: Group 1: increase in sCR ≥25% over baseline but absolute increase 25% in the remaining 844 (84.2%). CI-AKI was significantly associated with 6-month all-cause mortality using the definitions for Group 2 (hazard ratio 3.1, 95% confidence interval [CI] 1.5 to 6.6, p = 0.002) and Group 3 (hazard ratio 2.03, 95% CI 1.03 to 4.0, p = 0.04), but not Group 1. In conclusion, based on the definition used for CI-AKI, CI-AKI is observed in 6% to 15.7% of patients. An increase of 25% over baseline sCr does not identify high-risk patients. CI-AKI defined as an increase in sCr >0.3 mg/dl identifies 15.7% of the population at 2-fold higher risk of mortality.

Background Mitral stenosis (MS) may cause progressive dyspnea on exertion, pulmonary hypertension (PH), atrial fibrillation and right ventricular (RV) failure. Patients with MS presenting with change in dyspnea severity often require a complete cardiologic assessment, but the use of biomarkers may be an alternative for the initial assessment of MS and its complications. The aim of this study was to evaluate the role of several cardiovascular biomarkers for this purpose. Methods Clinically stable patients with moderate or severe MS were included in this prospective multicenter observational study. ECG, transthoracic echocardiography and biomarker measurement (BNP, MR-proANP and sCD146) were performed at inclusion. One cohort of patients with pre-capillary PH (PAH) was included for comparison of biomarker levels in different etiologies of PH. Results A total of 117 MS (70% severe, 30% moderate stenosis) were included. Plasma levels of all three biomarkers were higher in severe MS compared to moderate MS. PH was associated with higher levels of BNP and MR-proANP. The presence of atrial fibrillation increased plasma levels of BNP and sCD146, whereas MR-proANP was not affected by atrial fibrillation. PAH patients had higher levels of sCD146 compared to MS patients with PH. RV dysfunction was associated with higher levels of sCD146. Conclusion MS and its complications affect plasma levels of cardiovascular biomarkers. The use of MR-proANP may be helpful for the assessment of severe stenosis and the presence of PH in the early phase. sCD146 might help identifying patients with more advanced PH and RV-dysfunction.

BackgroundContrast induced nephrotoxicity (CIN) after coronary angiography or angioplasty (CA) has been shown to be related to mortality. The rate and predictors of CIN when preventive measures are applied are poorly documented.MethodsAll consecutive patients submitted to non-urgent CA in 2014 with low-osmolar contrast medium were stratified for CIN risk: patients with renal dysfunction (defined as eGFR44mmol/L in SCr. CIN rate was related to quartiles of eGFR before CA: 20% when eGFR87ml/min. The amount of contrast medium was not a predictor of CIN. In patients without renal dysfunction, a lower SCr was a predictor of CIN. Conversely, in patients with renal dysfunction, older age and diabetes were associated with CIN (figure).ConclusionsIn contemporary routine practice, CIN occurs in 20%, driven by a relative 25% increase in SCr, and irrespective of the amount of contrast medium. In patients with renal dysfunction, older age and diabetes were associated with CIN.

Data on the use of direct oral anticoagulants (DOAC) in patients(pts) with intermediate-high risk pulmonary embolism (PE) are lacking. We conducted a prospective multicentre multidisciplinary registry study (1) to describe the antithrombotic strategy in real-life practice at the acute phase of

Initial management of Pulmonary Embolism (PE) has been the subject of guidelines issued by the European Society of Cardiology (ESC). The aims of this study were to describe non-compliance with guidelines and identify predictive factors of non-compliance; to evaluate the impact of non-compliance on

Background: Catheter ablation is the treatment of choice for the management of atrial fibrillation (AF). The main limitation of this technique is the success rate, which is in the range of 70 to 80%. It is therefore critical to identify patients likely to benefit from this procedure, and who will

Little is known about the clinical implications of residual pulmonary vascular obstruction(RPVO) on long-term outcomes and about the optimal timing of V-Q scan control during patient follow-up. We aimed to investigate the prognostic value on 5-year adverse events of RPVO, measured by two ventilation

Rationale and aim Introduced in early 2000, Fractional Flow Reserve (FFR) was initially validated for deferring percutaneous coronary intervention (PCI) when >0.80. After September 2012, FAME2 suggested performing PCI when FFR Methods Rate and indications of FFR use and decision for PCI was assessed monthly between April 1999 and Sept 2014 in a single center. We calculated monthly the rates of FFR, coronary angiography (CA) and PCI. Cumulative curves for CA, PCI and FFR we determined the according to time elapsed since 1999. Results In a single center, 26629 CA, 12270 PCI and 2454 FFR were performed between 1999 and 2014. Monthly rates were 182 CA, 77 PCI and 14 FFR. The cumulative curves showed that the rates of CA and PCI were stable, with a near-perfect linear correlation for each time interval. Conversely, there was a change in the rate of FFR, the best spline point for the FFR use was found in September 2012. From 1999 to Sept 2012, the rate of FFR was 14/month and increased to 21/month after Sept 2012. There was no significant difference in the patient characteristics, indications for CA or center team or equipment between the 2 periods, but the rate of FFR/CA increased from 7.3 to 12%. Conclusion Physicians performed more FFR after Sept 2012. This increase in routine use of FFR was only explained by the additional indication for FFR resulting from the publication of the FAME2 study. Download : Download high-res image (170KB) Download : Download full-size image Abstract 0301 – Figure

BackgroundWe investigated the course of residual pulmonary vascular obstruction (RPVO) from discharge up to 3 – 6 months after pulmonary embolism (PE).MethodsProspective registry including 202 consecutive patients with PE who survived the acute phase (high risk PE: 12.4%, intermediate-risk: 65.8%, and low- risk: 21.8%). Patients with a prior history of chronic pulmonary disease were excluded. Ventilation-perfusion (V/Q) lung scan was performed in all patients before discharge, and again at follow-up (between 3 and 6 months after discharge). Treatment was in accordance with current guidelines. Evolution of RPVO was determined as the relative change in lung perfusion (in %) between discharge and follow-up V/Q scans.ResultsBetween both lung scans, RPVO decreased from 29.1±15% to 10.9±11.4%, with an average relative change of 61.7±33.4%. Overall, 49 patients (24.2%) presented a full resolution of lung perfusion. Relative change in RPVO was