Archives of Cardiovascular Diseases最新文献

Background: Coronary chronic total occlusions (CTO) are frequent, and coronary angioplasty has been increasingly used in recent years for lesion revascularisation. However, to date, no dedicated multicentric prospective study is available in France.

Aim: To describe the characteristics of CTO patients and to assess current treatment strategies in French catheterisation laboratory practice.

Methods: Patients presenting with CTOs were included from 16/09/2021 to 13/12/2021 over two consecutive prospective phases. In phase I (one month), data were collected to include all patients presenting CTO at diagnostic angiography. In phase II (two months), data were collected focusing on patients who underwent CTO-PCI.

Results: A total of 1303 patients (1460 CTOs) were included in 68 French centres. The mean age was 67.7±10.7 years and 84.3% of the patients were men. The prevalence of prior PCI (44.6%), and diabetes mellitus (35.6%) was high. In phase I, multivessel coronary artery disease was detected in two-thirds of cases, and most of them (88.5%) had a single CTO. The mean J-CTO score was 1.9±1.2, with a proportion of difficult and very difficult CTO (J CTO score ≥2) of 61.1%. The selected treatment was medical therapy in 57% of cases, coronary angioplasty in 30% and bypass surgery in 13%. In phase II, 528 patients were included with a mean J-CTO score of 1.8±1.2. Successful guidewire crossing through CTO lesion was obtained with an antegrade access in 89% of patients. Procedural success rate of CTO-PCI was 80%, with a rate of major in-hospital complications of 1% (death: 0.4%, MI: 0.2%, stroke: 0.2%, emergency CABG: 0.2%).

Conclusion: This prospective study provides a snapshot of CTOs prevalence and CTO treatment strategies in France in 2021.

Background: Few studies have assessed coronary physiology in the setting of coronary artery disease (CAD) with severe aortic stenosis (AS). Fractional flow reserve (FFR) to guide revascularization in such patients is not validated.

Aims: We describe changes in coronary physiology in this population before and after transcatheter aortic valve implantation (TAVI).

Methods: Patients with stable CAD and severe AS treated with TAVI were prospectively included during 2020-2023. Coronary physiology was assessed before and immediately after TAVI, and at follow-up (median 5.4 months).

Results: Twenty-nine patients (mean age 81.3 years) were included. Median (95% confidence interval) FFR decreased numerically, from 0.83 (0.79-0.84) pre-TAVI to 0.81 (0.78-0.83) post-TAVI. During hyperaemia, the transit mean time reduced numerically, from 0.27 (0.19-0.35) to 0.20 (0.18-0.27) seconds, reflecting increased coronary flow. Basal microvascular resistance increased numerically, from 24 (21-35) to 32 (23-45), while resistive reserve ratio increased significantly, from 1.8 (1.5-2.3) to 2.6 (2.2-3.1) (P=0.002). Consequently, coronary flow reserve (CFR) improved significantly, from 1.5 (1.2-1.7) to 1.9 (1.5-2.4) (P=0.006). Among 21 patients with follow-up, no significant change in FFR was observed and the significance of the increase in CFR was lost. Only three patients had an index of microvascular resistance>25, indicating microvascular impairment during hyperaemia.

Conclusions: In stable CAD patients treated with TAVI for severe AS, valve replacement provides an immediate improvement in CFR. FFR shows a minimal decrease after valve implantation, supporting its reproducibility to guide revascularization in such patients.

Clinical trial registration: .NCT04663334.

Background: Same-day discharge (SDD) has been adopted for interventional cardiology procedures, however, data on patient experience are scarce.

Aims: To investigate patient-reported experience after various SDD electrophysiology procedures.

Methods: Consecutive patients undergoing electrophysiology procedures, who fulfilled pre-defined eligibility criteria for SDD, completed the questionnaire before discharge. Procedures suitable for SDD included non/minimally-invasive (e.g. electric cardioversions, tilt tests) and invasive procedures (e.g. cardiac device replacements, catheter ablations). The questionnaire assessed patient experience before and during the procedure, satisfaction with the provided information and understanding of the discharge instructions.

Results: The questionnaire was completed by 501 patients (57.5% men). Invasive procedures accounted for 56.7% of SDD procedures. Most patients (88.9%) described SDD as a good or quite good experience, while 95.3% would not hesitate to undergo a second SDD procedure if necessary. A direct interview with a healthcare team member was the preferred method of obtaining information. At discharge, a considerable number of patients were unsure about the provided instructions, including those related to anticoagulation. Patient-reported satisfaction did not differ between invasive and non/minimally-invasive procedures (P=0.06). However, after an invasive procedure, patients had a better understanding of discharge instructions (59.5% vs 41.9%; P<0.001). Most patients who underwent a procedure under general anaesthesia reported a good or quite good experience (87.7% vs 84.2% of sedation patients; P=0.16).

Conclusion: SDD was generally a positive experience for patients undergoing invasive or non/minimally-invasive procedures. However, discharge instructions and patient understanding require improvement.

Background: Immune checkpoint inhibitor (ICI)-induced myocarditis is a life-threatening adverse drug reaction. Abatacept (a CTLA-4-immunoglobulin fusion protein) has been proposed as a compassionate-use treatment for ICI myocarditis (in combination with corticosteroids and ruxolitinib) but no clinical trial has yet been performed. The abatacept dose can be adjusted using real-time assessment of its target, the CD86 receptor occupancy on circulating monocytes (CD86RO).

Methods: The ACHLYS trial is an ongoing dose-finding, Phase II, randomized, double-blind trial in which three different abatacept doses are being tested, aiming to reach CD86RO≥80% after the first dose and sustainably during the first 3 weeks of ICI myocarditis treatment (primary outcome). Adult patients with cancer presenting severe or corticosteroid-resistant ICI myocarditis have been included. ICI are withheld after inclusion and for the study duration. Abatacept is administered by intravenous injection on Days 1, 5±2 and 14±2 at 10, 20 or 25mg/kg depending on the randomization arm (n=7 per arm) with concomitant ruxolitinib and corticosteroids. After evaluation of the primary outcome on Day 21, complementary injections of abatacept (for≤3 months) and a ruxolitinib/corticosteroids weaning strategy are standardized depending on criteria evaluating resolution of ICI myocarditis severity (troponin T level and clinical assessment). Secondary objectives compare immunological, myocardial and muscular proxies of treatment response between randomization arms, and cancer progression-free and overall survivals up to 1 year.

Conclusion: The ACHLYS trial will define the most appropriate starting dose of abatacept to treat life-threatening ICI myocarditis, in combination with ruxolitinib and corticosteroids.

Clinicaltrials: GOV: NCT05195645.

Background: Catheter ablation for atrial fibrillation in patients with heart failure with reduced ejection fraction is associated with a significant reduction in morbimortality. The convergent procedure is a valid ablation option for the treatment of long-standing persistent atrial fibrillation.

Aim: To describe the outcomes of patients with heart failure with reduced ejection fraction and long-standing persistent atrial fibrillation who underwent the convergent procedure.

Methods: We studied consecutive patients included in two French centres between 2009 and 2020. Primary endpoint was freedom from any atrial arrhythmia assessed on 24-hour Holter electrocardiogram at 3, 6 and 12 months after the procedure. Left ventricular ejection fraction was assessed on transthoracic echocardiography before and 1 year after the procedure. All patients had at least 12 months of follow-up.

Results: Forty-three patients were included (86% were men). Baseline left ventricular ejection fraction was 38±10.5% and indexed left atrial volume was 50±27mL/m². Among the study population, 34 patients (79%) were free from atrial fibrillation/tachycardia at the end of follow-up. No periprocedural death occurred. We observed two groin haematomas and four mild pericardial effusions. At 12-month follow-up, 21 patients (49%) were still on antiarrhythmic drug therapy, and a reduction in antiarrhythmic drug dosage was achieved in 10 patients (23%). The absolute median improvement in left ventricular ejection fraction was 8% at 12 months (P=0.003).

Conclusions: The convergent procedure has been shown to be effective and safe for patients with patients with heart failure with reduced ejection fraction and long-standing persistent atrial fibrillation, with significant left ventricular function improvement.

Background: Recommended treatment after acute coronary syndrome (ACS) involves high-intensity statin therapy to achieve the low-density lipoprotein (LDL-C) target of<1.4mmol/L (European guidelines), but many patients discontinue statins because of real or perceived side-effects. Whether body mass index (BMI) influences statin intolerance remains unclear.

Aim: To assess statin tolerance 3months after initiation, and to identify factors determining tolerance and persistence.

Methods: STATIC was a single-centre cohort study (November 2021 to April 2023) of patients admitted to cardiac intensive care units for ACS. The study had three stages: T0 (admission); W6 (6 weeks after ACS: statin efficiency); and M3 (3months after ACS: statin tolerance and persistence). SAMS score was used to evaluate imputability in patients reporting muscular side-effects. Multivariable analysis identified factors influencing tolerance; statin persistence was assessed using pharmacy dispensing data.

Results: Overall, 289 patients were included (77.9% men; mean age 64.2years; 22.7% with BMI≥30kg/m²). At T0, 38.1% had hypertension, 28.5% dyslipidaemia and 15.9% diabetes. At discharge, 269 patients received statins: 97.0% had a high-intensity statin; 43.5% had a statin/ezetimibe combination. At W6, mean LDL-C was 1.58mmol/L, with 45.5% at the LDL-C target. At M3, 6.0% reported side-effects (3.6% muscular, 1.2% liver, 1.2% gastrointestinal). Mean SAMS score was 5.67. No significant differences in muscular or hepatic side-effects were found between patients with BMI≥30 versus<30 kg/m². Persistence was 98.4% at M3 follow-up. The proportion of patients on a high-intensity statin or a statin/ezetimibe did not change from discharge to M3 (P=0.45 and P=1.00, respectively).

Conclusions: Statins are effective, but not always enough to reach LDL-C target. Tolerance and persistence were good, with muscular side-effects as expected, but without any guarantee of statin imputability. BMI did not influence statin tolerance in this study.

Background: Percutaneous extracorporeal membrane oxygenation (ECMO) has been developed thanks to the progress in the field of cannulation, but still justifies the presence of an on-site cardiac resuscitation department. Corsica is a French island without an on-site cardiac surgery department.

Aim: To evaluate the percutaneous ECMO programme in Corsica.

Methods: All patients who received ECMO at the Bastia Hospital Centre between 01 January 2016 and 30 April 2022 were included.

Results: ECMO was implanted in 39 patients. The mean age was 52.7years, with male predominance (84.6%). The majority of veno-arterial ECMOs were placed in the coronary angiography laboratory, whereas venovenous ECMOs were preferentially placed in the medical intensive care unit. Twenty patients (51.3%) were medically transferred to other referral centres after canulation. Percutaneous vascular cannulation was performed with ultrasound guidance in all cases (100%), and was successfully performed without immediate complications in all patients except two (who presented an immediate complication during cannulation), which is similar to large trials, despite the absence of on-site cardiac surgery. The use of ultrasound guidance (and sometimes fluoroscopy guidance) during cannulation and the experience of the medical team facilitated control over correct positioning of the cannulas and decreased implantation failure, without the need for a surgical approach.

Conclusions: Percutaneous ECMO by trained interventional cardiologists without a surgical approach appears to be safe. Widespread use of percutaneous cannulation without cardiac surgery would increase survival for some patients who are far from these centres.

Background: Heart failure (HF) prevalence may increase because of population ageing and has become a major public health issue in European countries.

Aim: To update the epidemiology of HF in France in 2022.

Methods: Adults hospitalized for HF in 2022 were identified in the National Health Data System (SNDS) and followed up for 1year. The first stay of the year was taken as the index hospitalization. The prevalence of HF was estimated by combining hospitalization data and patients with 100% coverage for a long-term disease associated with HF. Patients and their hospital stays were described on the basis of the sociodemographic and medical information in the SNDS.

Results: In 2022, 181,178 adults were hospitalized for HF in France, which equates to a crude rate of 339.3 per 100,000 inhabitants, and 1,376,692 prevalent cases of HF were recorded, which is an estimated prevalence of 2.6% in the adult population. For people living in the most socioeconomically deprived municipalities, the rate of hospitalization was 1.6 times higher than for those living in the least deprived municipalities. The departments of Haut-de-France and Réunion Island, and some departments in Normandy and the Grand-Est had much higher rates than others. The fatality rate was 10.2% in hospital, and 34.0% at 1year. Only 20.1% of patients were admitted to a rehabilitation unit within 6months, and 47.9% of patients alive at 1year were being treated with a combination of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and beta-blockers.

Conclusions: The large number of people hospitalized for HF, and the fact that rates vary across the different French departments, means that more ambitious general cardiovascular prevention measures are needed, and that healthcare provision needs significant adaptation. Short-term patient outcomes could be improved by following recommendations more closely and taking into account patients' social circumstances.