[Show abstract][Hide abstract] ABSTRACT: T1 mapping is now a clinically feasible method, providing pixel-wise quantification of the cardiac structure's T1 values. Beyond focal lesions, well depicted by late gadolinium enhancement sequences, it has become possible to discriminate diffuse myocardial alterations, previously not assessable by noninvasive means. The strength of this method includes the high reproducibility and immediate clinical applicability, even without the use of contrast media injection (native or pre-contrast T1). The two most important determinants of native T1 augmentation are (1) edema related to tissue water increase (recent infarction or inflammation) and (2) interstitial space increase related to fibrosis (infarction scar, cardiomyopathy) or to amyloidosis. Conversely, lipid (Anderson-Fabry) or iron overload diseases are responsible for T1 reduction. In this pictorial review, the main features provided by native T1 mapping are discussed and illustrated, with a special focus on the awaited clinical purpose of this unique, promising new method.
Full-text · Article · Dec 2014 · Clinical Medicine Insights: Cardiology
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND The currently recommended duration of dual antiplatelet therapy (DAPT) in drug-eluting stent (DES) recipients is 12 months to reduce the risk of late stent thrombosis, particularly in those with acute coronary syndrome (ACS). OBJECTIVES This study hypothesized that antiplatelet treatment with DAPT for 6 months may be noninferior to 24-month DAPT in aspirin-sensitive patients. METHODS A multicenter, randomized study assigned patients undergoing implantation of everolimus-eluting stents with confirmed nonresistance to aspirin to receive 6- or 24-month DAPT. The primary endpoint was a composite of death, myocardial infarction, urgent target vessel revascularization, stroke, and major bleeding at 12 months post-stenting. RESULTS A total of 2,031 patients were enrolled in 70 European and Middle Eastern centers. The trial was prematurely terminated due to recruitment problems, leaving 941 patients randomized to 24-month DAPT and 953 to 6- month DAPT. The 2 treatment groups had similar baseline and procedural characteristics. There was no significant difference in the primary endpoint (24-month: 1.5% vs. 6- month: 1.6%; p = 0.85). Noninferiority was demonstrated for 6- versus 24-month DAPT, with an absolute risk difference of 0.11% (95% confidence interval: = 1.04% to 1.26%; p for noninferiority = 0.0002). There were no significant differences in stent thrombosis or bleeding complications. In the 792 (44%) high-risk patients with ACS, primary and secondary endpoints did not significantly differ (hazard ratio: 1.7 [95% confidence interval: 0.519 to 6.057; p = 0.361]). CONCLUSIONS Rates of bleeding and thrombotic events were not significantly different according to 6-versus 24-month DAPT after PCI with new-generation DES in good aspirin responders. (Is There A LIfe for DES After Discontinuation of Clopidogrel [ITALICplus]; NCT01476020) (C) 2015 by the American College of Cardiology Foundation.
No preview · Article · Nov 2014 · Journal of the American College of Cardiology
[Show abstract][Hide abstract] ABSTRACT: Background
Optimum duration of dual antiplatelet treatment (DAPT) after coronary stenting remains uncertain, with an unknown efficacy to safety ratio of extended treatment leading to discrepancies between international guidelines and clinical practice. We assessed whether DAPT continuation beyond 1 year after coronary stenting is beneficial.
This analysis was a planned extension of the previously published ARCTIC-Monitoring trial, in which we randomly allocated 2440 patients to a strategy of platelet function testing with antiplatelet treatment adjustment or a conventional strategy after coronary stenting with drug-eluting stent (DES). We recruited patients (aged 18 years or older) scheduled for planned DES implantation at 38 centres in France. After 1 year of follow-up, patients without contraindication to interruption of DAPT were eligible for a second randomisation to this second phase of the study (ARCTIC-Interruption). Using a computer-generated randomisation sequence (1:1; stratified by centre), we allocated patients to a strategy of interruption of DAPT where the thienopyridine was interrupted and single aspirin antiplatelet treatment was maintained (interruption group) or a strategy of DAPT continuation for 6–18 months (continuation group). The primary endpoint was the composite of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularisation, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00827411.
Between Jan 4, 2011, and March 3, 2012, 1259 eligible patients were randomly allocated to treatment in ARCTIC-Interruption: 624 to the interruption group and 635 to the continuation group. After a median follow-up of 17 months (IQR 15–18), the primary endpoint occurred in 27 (4%) patients in the interruption group and 24 (4%) patients in the continuation group (hazard ratio [HR] 1·17 [95% CI 0·68–2·03]; p=0·58). STEEPLE major bleeding events occurred more often in the continuation group (seven [1%] patients) compared with the interruption group (one [<0·5%] patient; HR 0·15 [0·02–1·20]; p=0·073). Major or minor bleedings were also more common in the continuation group compared with the interruption group (12 [2%] patients vs three [1%] patients; HR 0·26 [0·07–0·91]; p=0·04).
Our finding suggests no apparent benefit but instead harm with extension of DAPT beyond 1 year after stenting with DES when no event has occurred within the first year after stenting. No conclusion can be drawn for high-risk patients who could not be randomised. The consistency between findings from all trials of such interruption suggests the need for a reappraisal of guidelines for DAPT after coronary stenting towards shorter duration of treatment.
Allies in Cardiovascular Trials Initiatives and Organized Networks (ACTION Study Group), Fondation de France, Sanofi-Aventis, Cordis, Medtronic, Boston Scientific, Fondation SGAM.
[Show abstract][Hide abstract] ABSTRACT: Background
Aortic valve stenosis (AVS) can be complicated by bleeding associated with acquired type 2A von Willebrand syndrome. The association of AVS and gastrointestinal bleeding from angiodysplasia is defined as Heyde's syndrome. We sought to evaluate the impact of TAVI on primary hemostasis disorders and to assess its effectiveness to treat Heyde's syndrome.
We prospectively enrolled 49 consecutive patients with severe AVS addressed for TAVI in our institution. Biological primary hemostasis parameters were assessed at baseline and one week after the procedure.
We identified 1 (2%) patient with Heyde's syndrome, and 11 patients (22.4%) with a ratio vWF:CB/vWF:Ag under 0.7, compatible with type 2A vWF syndrome. At baseline, a significant link between vWF abnormalities and the severity of AVS was evidenced: mean aortic transvalvular gradient was negatively correlated with the levels of vWF antigen (vWF:Ag) (r= -0.29, p< 0.05), vWF ristocetin cofactor activity (vWF:RCo) (r=-0.402, p=0.006) and vWF collagen-binding activity (vWF:CB) (r=-0.441, p=0.005). One week after the procedure, a significant increase of vWF:Ag, vWF:RCo, and vWF:CB was evidenced in the whole cohort (respectively 3.32 vs 2.29 IU/mL, p< 0.001 ; 2.98 vs 1.86 IU/mL, p< 0.001 ; 3.16 vs 2.16 IU/mL, p< 0.001). Patients with pre-TAVI vWF abnormalities consistent with a type 2A vWF syndrome preferentially improved their vWF function with respect to patients with a normal ratio (relative increase of vWF:CB of 63.8% vs 3.5%).
Primary hemostasis parameters involving vWF are improved after TAVI, especially in patients with preexisting abnormalities consistent with acquired type 2A von Willebrand syndrome. Moreover, our observations, although limited to a small single-center study, suggest that Heyde's syndrome can be cured by TAVI.
No preview · Article · Sep 2014 · Journal of the American College of Cardiology
[Show abstract][Hide abstract] ABSTRACT: Background:
In STEMI patients treated by primary PCI, damage of the microvascular circulation caused by distal embolization of thrombotic material affects the quality of myocardial reperfusion. Important controversies remain concerning the usefulness of the manual thrombectomy to improve myocardial perfusion. The aim of this study is to evaluate the impact of manual thrombectomy on ST resolution as a surrogate of reperfusion extent.
Two hundred and thirty-nine consecutive STEMI patients with an <12 hours onset of symptoms, were enrolled in an observational registry. Patients were divided into two cohorts according to the reperfusion strategy: manual thrombectomy before primary PCI (n=102) or conventional-PCI (n=137). The primary endpoint was the post procedural frequency of complete (>70%) resolution of ST segment elevation.
A complete resolution of ST segment elevation occurred in 51.4% of patients in the thrombectomy group and in 35,6% of those in the conventional-PCI group (P=0.018). Thrombectomy strategy was associated with a lower use of stents. Multivariate analysis identified manual thrombectomy (HR=2.08 IC 95% (1.01-4.26); P=0.046), inferior location and short ischemic delay (<180 min) as independent predictors of ST resolution. The cumulative Kaplan-Meier estimate of MACE was not significantly different between the two groups at one, three years follow-up.
In STEMI patients, manual thrombectomy improves myocardial reperfusion as assessed by the percentage of ST segment resolution and a lower use of stents. However, in this cohort of limited size, this strategy did not translate into an improved cardiovascular outcome at one year follow-up.
No preview · Article · Sep 2014 · Archives of Cardiovascular Diseases
[Show abstract][Hide abstract] ABSTRACT: Background
To date, no randomized study has investigated the value of optical coherence tomography (OCT) in optimizing the results of coronary angioplasty for non-ST elevation acute coronary syndromes (NSTE-ACS).
DOCTORS is a randomized, prospective, multicentre, open-label clinical trial to evaluate the utility of OCT to optimize results of angioplasty of a lesion responsible for NSTE-ACS. Patients (n = 250) will be randomized to undergo OCT-guided angioplasty (use of OCT to optimise procedural result, including change to strategy with the possibility of additional interventions); or angioplasty under fluoroscopy alone.
The primary endpoint is the functional result of the angioplasty procedure as assessed by fractional flow reserve (FFR) measured at the end of the procedure. Secondary endpoints include safety of OCT in the context of angioplasty for ACS; percentage of patients in whom OCT reveals sub-optimal result of stenting; percentage of patients in whom a change in procedural strategy is decided based on OCT data; correlation between quantitative measures by OCT and FFR; determination of a threshold for quantitative OCT measure that best predicts FFR ≥0.90; identification of OCT variables that predict post-procedure FFR. Adverse cardiac events (death, recurrent myocardial infarction, stent thrombosis, repeat target lesion revascularisation) at 6 months will be recorded.
The DOCTORS randomized trial (ClinicalTrials.govNCT01743274) is designed to investigate whether use of OCT yields useful additional information beyond that obtained by angiography alone, and if so, whether this information changes physician strategy and impacts on the functional result of angioplasty as assessed by FFR.
No preview · Article · Aug 2014 · American Heart Journal
[Show abstract][Hide abstract] ABSTRACT: We report a very rare case of a 43-year-old patient with fatal left ventricular subepicardial aneurysm rupture complicating embolic myocardial infarction due to mitral valve infective endocarditis.
No preview · Article · Jan 2014 · Echocardiography