In vivo relationship between near-infrared spectroscopy-detected lipid-rich plaques and morphological plaque characteristics by optical coherence tomography and intravascular ultrasound: a multimodality intravascular imaging study.

AIMS: We assessed morphological features of near-infrared spectroscopy (NIRS)-detected lipid-rich plaques (LRPs) by using optical coherence tomography (OCT) and intravascular ultrasound (IVUS). METHODS AND RESULTS: IVUS-NIRS and OCT were performed in the two non-infarct-related arteries (non-IRAs) in patients undergoing percutaneous coronary intervention for treatment of an acute coronary syndrome. A lesion was defined as the 4 mm segment with the maximum amount of lipid core burden index (maxLCBI4mm) of each LRP detected by NIRS. We divided the lesions into three groups based on the maxLCBI4mm value: <250, 250-399, and ≥400. OCT analysis and IVUS analysis were performed blinded for NIRS. We measured fibrous cap thickness (FCT) by using a semi-automated method. A total of 104 patients underwent multimodality imaging of 209 non-IRAs. NIRS detected 299 LRPs. Of those, 41% showed a maxLCBI4mm <250, 39% a maxLCBI4mm 251-399, and 19% a maxLCBI4mm ≥400. LRPs with a maxLCBI4mm ≥400, as compared with LRPs with a maxLCBI4mm 250-399 and <250, were more frequently thin-cap fibroatheroma (TCFA) (42.1% vs. 5.1% and 0.8%; P < 0.001) with a smaller minimum FCT (80 µm vs. 110 µm and 120 µm; P < 0.001); a higher IVUS-derived percent atheroma volume (53% vs. 53% and 44%; P < 0.001) and a higher remodelling index (1.08 vs. 1.02 and 1.01; P < 0.001). MaxLCBI4mm correlated with OCT-derived FCT (r = 0.404; P < 0.001) and was the best predictor for TCFA with an optimal cut-off value of 401 (area under the curve = 0.882; P < 0.001). CONCLUSION: LRPs with increasing maxLCBI4mm exhibit OCT and IVUS features of presumed plaque vulnerability including TCFA morphology, increased plaque burden, and positive remodelling.

Prognostic values of fasting hyperglycaemia in non-diabetic patients with acute coronary syndrome: A prospective cohort study.

BACKGROUND: Controversy remains regarding the prevalence of hyperglycaemia in non-diabetic patients hospitalised with acute coronary syndrome and its prognostic value for long-term outcomes. METHODS AND RESULTS: We evaluated the prevalence of hyperglycaemia (defined as fasting glycaemia ⩾10 mmol/l) among patients with no known diabetes at the time of enrolment in the prospective Special Program University Medicine-Acute Coronary Syndromes cohort, as well as its impact on all-cause death, myocardial infarction, stroke and incidence of diabetes at one year. Among 3858 acute coronary syndrome patients enrolled between December 2009-December 2014, 709 (18.4%) had known diabetes, while 112 (3.6%) of non-diabetic patients had hyperglycaemia at admission. Compared with non-hyperglycaemic patients, hyperglycaemic individuals were more likely to present with ST-elevation myocardial infarction and acute heart failure. At discharge, hyperglycaemic patients were more frequently treated with glucose-lowering agents (8.9% vs 0.66%, p<0.001). At one-year, adjudicated all-cause death was significantly higher in non-diabetic patients presenting with hyperglycaemia compared with patients with no hyperglycaemia (5.4% vs 2.2%, p=0.041) and hyperglycaemia was a significant predictor of one-year mortality (adjusted hazard ratio 2.39, 95% confidence interval 1.03-5.56). Among patients with hyperglycaemia, 9.8% had developed diabetes at one-year, while the corresponding proportion among patients without hyperglycaemia was 1.8% (p<0.001). In multivariate analysis, hyperglycaemia at presentation predicted the onset of treated diabetes at one-year (odds ratio 4.15, 95% confidence interval 1.59-10.86; p=0.004). CONCLUSION: Among non-diabetic patients hospitalised with acute coronary syndrome, a fasting hyperglycaemia of ⩾10 mmol/l predicted one-year mortality and was associated with a four-fold increased risk of developing diabetes at one year.

An unusual thrombus location in a Heartmate 3TM device with fatal outcome.

Even if the HeartMate 3TM left ventricular assist device is associated with excellent outcomes, complications, such as pump thrombosis continue to affect patients on hemodynamic support. We report the history of a 68-year-old man who underwent implantation of an HeartMate 3TM as a bridge to transplantation. Nineteen months later, he developed signs of heart failure leading to cardiogenic shock. Neither clinical examination nor parameters from the device allowed a clear-cut diagnosis. Only surgical exploration revealed the presence of clots between the polyethylene terephthalate (Dacron®) and polytetrafluoroethylene tubes. This constitutes a weakness of this device for which we propose to the manufacturer for minimal modifications to overcome the problem.

Five-Year Outcomes in Patients With Diabetes Mellitus Treated With Biodegradable Polymer Sirolimus-Eluting Stents Versus Durable Polymer Everolimus-Eluting Stents.

Background The choice of optimal drug-eluting stent therapy for patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention remains uncertain. We aimed to assess the long-term clinical outcomes after percutaneous coronary intervention with biodegradable polymer sirolimus-eluting stents (BP-SES) versus durable polymer everolimus-eluting stents (DP-EES) in patients with DM. Methods and Results In a prespecified subgroup analysis of the BIOSCIENCE (Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Stent Versus Durable Polymer Everolimus-Eluting Stent for Percutaneous Coronary Revascularization) trial (NCT01443104), patients randomly assigned to ultrathin-strut BP-SES or thin-strut DP-EES were stratified according to diabetic status. The primary end point was target lesion failure, a composite of cardiac death, target vessel myocardial infarction, and clinically indicated target lesion revascularization, at 5 years. Among 2119 patients, 486 (22.9%) presented with DM. Compared with individuals without DM, patients with DM were older and had a greater baseline cardiac risk profile. In patients with DM, target lesion failure at 5 years occurred in 74 patients (cumulative incidence, 31.0%) treated with BP-SES and 57 patients (25.8%) treated with DP-EES (risk ratio, 1.23; 95% CI, 0.87-1.73 [P=0.24]). In individuals without DM, target lesion failure at 5 years occurred in 124 patients (16.8%) treated with BP-SES and 132 patients (16.8%) treated with DP-EES (risk ratio, 0.98; 95% CI, 0.77-1.26 [P=0.90; P for interaction=0.31]). Cumulative 5-year incidence rates of cardiac death, target vessel myocardial infarction, clinically indicated target lesion revascularization, and definite stent thrombosis were similar among patients with DM treated with BP-SES or DP-EES. There was no interaction between diabetic status and treatment effect of BP-SES versus DP-EES. Conclusions In a prespecified subgroup analysis of the BIOSCIENCE trial, we found no difference in clinical outcomes throughout 5 years between patients with DM treated with ultrathin-strut BP-SES or thin-strut DP-EES. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01443104.

Exclusion of a coronary aneurysm with a polyurethane-covered stent.

A coronary artery aneurysm is a challenging cli-nical situation due to the lack of sufficient evidence from randomized controlled studies and the lack of consensus on a management strategy. The present case is a description of the exclusion of a middle segment aneurysm of the left circumflex coronary artery using a PK Papyrus covered stent (Biotronik, AG, Bulach, Switzerland). The final images were favorable.

[Mitral clipping in the treatment of secondary mitral regurgitation]. / Clip mitral dans l'insuffisance mitrale secondaire.

Secondary mitral regurgitation is a frequent valvulopathy due to left ventricle remodeling. Although, its poor prognostic has been established, surgical interventions have shown no substantial benefits in terms of mortality benefit. MitraClip represents a transcatheter alternative. Two randomized trials - MITRA-FR and COAPT comparing the clipping versus optimal medical therapy- have confirmed the feasibility of this intervention in patients with secondary mitral regurgitation. MITRA-FR did not show any significant benefit for the MitraClip group with respect to the composite endpoint (all-cause mortality and rehospitalization for heart failure) at 12 months. On the other hand, COAPT showed a clear superiority of MitraClip in terms of mortality and rehospitalization rates, compared to the conservative treatment alone at 24 months.

L'insuffisance mitrale secondaire est une pathologie fréquente dont la prise en charge médicale est primordiale. L'approche chirurgicale n'a pas montré de bénéfice significatif en termes de réduction de la mortalité. Récemment, les procédures d'implantation de clips mitraux ont été analysées au cours de deux études randomisées (MITRA-FR et COAPT) qui comparent le clip à un traitement médicamenteux optimal. MITRA-FR n'a pas montré de bénéfice du clip par rapport au traitement médicamenteux pour le critère de jugement primaire (mortalité de toute cause et réhospitalisation pour insuffisance cardiaque) à 12 mois. A l'opposé, l'étude COAPT a montré un clair bénéfice du MitraClip par rapport au traitement conservateur en termes de mortalité globale et réhospitalisation pour insuffisance cardiaque à 24 mois.

[Elevated troponin without a myocardial infarction]. / Troponine élevée sans infarctus du myocarde.

The interpretation of troponin elevation whitout a typical myocardial infarction symptomatology is a daily challenge in the acute care setting. Using current investigative techniques, doctors navigate between the five types of myocardial infarction established by the Fourth Universal Definition. However, due to the development of ultrasensitive troponin assays, the myocardial injury without ischemia, acute or chronic, is became a more common entity. The purpose of this article is to describe the situations without typical symptoms of myocardial ischemia and their mechanisms to better differentiate them.

L'interprétation d'une élévation de la troponine sans une clinique d'infarctus du myocarde représente un défi au quotidien dans les services de soins aigus. A l'aide des techniques actuelles d'investigation, le médecin doit s'orienter entre les cinq types d'infarctus du myocarde établis par la Quatrième définition universelle. Cependant, en raison du développement des techniques ultrasensibles de dosage de la troponine, la lésion myocardique sans ischémie, aiguë ou chronique, est devenue une entité de plus en plus reconnue. Le but de cet article est de décrire les situations d'élévation de la troponine sans ischémie myocardique et leurs mécanismes afin de pouvoir mieux les différencier.

Prognostic value of elevated lipoprotein(a) in patients with acute coronary syndromes.

BACKGROUND: Minimal lipoprotein(a) [Lp(a)] target values are advocated for high-risk cardiovascular patients. We investigated the prognostic value of Lp(a) in the acute setting of patients with acute coronary syndromes (ACS). MATERIALS AND METHODS: Plasma levels of Lp(a) were collected at time of angiography from 1711 patients hospitalized for ACS in a multicentre Swiss prospective cohort. Associations between elevated Lp(a) ≥30 mg/dL (cut-off corresponding to the 75th percentile of the assay) or Lp(a) tertiles at baseline, and major adverse cardiovascular events (MACE) at 1 year, defined as a composite of cardiac death, myocardial infarction or stroke, were assessed using hazard ratios (HR) and 95% confidence intervals (CI) adjusting for traditional cardiovascular risk factors (age, sex, smoking, diabetes, hypertension, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C] and triglycerides. RESULTS: Lp(a) levels range between 2.5 and 132 mg/dL with a median value of 6 mg/dL and a mean value of 14.2 mg/dL. A total of 276 patients (23.0%) had Lp(a) plasma levels ≥30 mg/dL. Patients with elevated Lp(a) were more likely to be of female gender and to have higher levels of total cholesterol, LDL-C, HDL-C and triglycerides. Higher Lp(a) was associated with failure to reach the LDL-C target <1.8 mmol/L at 1 year (HR 1.71, 95% CI 1.13-2.58, P = 0.01). No association was found between elevated Lp(a) and MACE at 1 year (HR 1.05, 95% CI 0.64-1.73), nor for Lp(a) tertiles (HR 0.82, 95% CI 0.52-1.28, P > 0.20) or standardized continuous variables (0.98, 95% CI 0.82-1.19 for each increase of standard deviation). CONCLUSIONS: Our real-world data suggest high Lp(a) levels at time of angiography are not predictive for cardiovascular outcomes in patients otherwise medically well controlled, but might be useful to identify patients who would not be on LDL-C targets 1 year after ACS.

Percutaneous Coronary Intervention of Chronic Total Occlusions in Patients with Diabetes Mellitus: a Treatment-Risk Paradox.

PURPOSE OF REVIEW: Diabetes mellitus (DM) is highly prevalent among patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). This review aims to summarize the available evidence on CTO recanalization in patients with DM. RECENT FINDINGS: Coronary artery bypass grafting (CABG) surgery is the recommended revascularization modality for patients with DM and multivessel coronary artery disease (CAD). However, the optimal management strategy in diabetic patients with CTO and single-vessel disease or prior CABG remains a clinical dilemma. Contemporary, large-scale, observational registries support the notion that CTO PCI, if performed at high-volume CTO PCI centers by highly experienced operators, conveys similar high procedural success and low complication rates in patients with and without DM. Although DM patients have more frequently CTOs and may derive greater benefit from complete revascularization, they are less frequently exposed to CTO PCI than non-DM patients (treatment-risk paradox). CTO PCI performed by highly experienced operators constitutes a safe and effective treatment option for selected diabetic CTO patients who are not candidates for CABG. Randomized studies are warranted to compare long-term outcomes of CTO PCI and medical therapy in this high-risk subset.

Serum levels of osteopontin predict major adverse cardiovascular events in patients with severe carotid artery stenosis.

BACKGROUND: Inflammatory mediators in the blood stream and within plaques are key determinants in atherogenesis. Here, we investigated serum osteopontin (OPN) as a potential predictor of poor outcome in patients with severe carotid atherosclerosis. METHODS: Carotid plaques and serum were collected from patients asymptomatic (n=185) or symptomatic (n=40) for ischemic stroke. Plaques were stained for lipids, smooth muscle cells, neutrophils, M1 and M2 macrophage subsets and matrix metallopropteinase-9 (MMP-9). Serum levels of OPN and interleukin-6 (IL-6) were determined by colorimetric enzyme-linked immunosorbent assays. RESULTS: Symptomatic patients showed a two-fold increase in serum OPN levels. In both symptomatic and asymptomatic patients, OPN levels positively correlated with intraplaque count of neutrophils, total macrophages, and MMP-9 content. In asymptomatic patients, OPN levels also positively correlated with lipids and M1 macrophage subsets. Receiver operating characteristic curve analysis identified serum OPN concentration of 70ng/ml as the best cut-off value to predict major adverse cardiovascular events (MACEs). Patients with high OPN levels had more vulnerable plaque phenotype and reduced levels of HDL-cholesterol and IL-6 as compared to low OPN levels. Kaplan-Meier curve confirmed that patients with OPN levels >70ng/ml had more MACEs at a 24-month follow-up. In the multivariate survival analysis, OPN levels >70ng/ml predicted MACEs, independently of age, gender, and symptomatic status. CONCLUSION: High circulating OPN levels were strongly correlated with vulnerability parameters within plaques and predict MACEs in patients with severe carotid artery stenosis. Although confirmation is needed from larger trials, OPN could be a promising clinical tool to assess atherosclerotic outcomes.

Serum lipoprotein (a) predicts acute coronary syndromes in patients with severe carotid stenosis.

BACKGROUND: Different cut-off values of serum lipoprotein (a) [Lp (a)] were recently identified to better stratify cardiovascular risk categories. Both pathophysiological and prognostic values of Lp (a) remain unclear. MATERIALS AND METHODS: Here, the prognostic value of Lp (a) and its correlation with intraplaque features were assessed in patients with severe carotid artery stenosis undergoing endarterectomy (n = 180). The cut-off value of 10 mg/dL for serum Lp (a) was selected to predict 24-month follow-up acute coronary syndrome (ACS). In addition, the association between serum Lp (a) and intraplaque lipids, collagen, inflammatory and vascular cells was assessed. Serum Lp (a) levels were measured by nephelometric assay. RESULTS: Patients with high Lp (a) had similar comorbidities, medications and laboratory parameters as compared to low Lp (a) levels. At 24-month follow-up, patients with high Lp (a) had more ACS as compared to low levels. Histological parameters within plaques were comparable in the study groups. No significant correlation between Lp (a) serum levels and intraplaque parameters was found, except for a weak positive association with smooth muscle cells in upstream plaque portions. When adjusted for gender, the presence of dyslipidaemia and chronic coronary artery disease, Lp (a) ≥10 mg/dL remained predictive for ACS. CONCLUSIONS: Lp (a) determination could be a useful tool to predict ACS in patients with severe carotid stenosis.

Tratamiento conservador en pacientes con síndrome coronario agudo sin elevación del ST: una entidad mal definida / Medically-managed patients with nonst-segment elevation acute coronary syndromes: an ill-defined entity

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Chemotherapy-induced Takotsubo cardiomyopathy, a case report and review of the literature.

BACKGROUND: Several chemotherapy molecules, monoclonal antibodies and tyrosine kinase inhibitors, have been linked to Takotsubo cardiomyopathy (TC). CASE PRESENTATION: In this article, we describe the case of a 45-year-old woman who developed TC after receiving an intra-arterial and intra-venous polychemotherapy for locally advanced epidermoid carcinoma of the anal canal. This is the first described case of TC associated with intra-arterial chemotherapy. CONCLUSIONS: A review of the literature points to 5-fluorouracil as the most common molecule associated with TC and highlights the potential risk associated with rechallenging patient with the same drug.

[Post-myocardial infarction ventricular septal defect]. / Communication interventriculaire postinfarctus du myocarde : mise au point.

Post-myocardial infarction ventricular septal defect corresponds to the rupture of the ventricular septum between the healthy and infarcted parts. It is a rare complication still associated with a high mortality rate. Its diagnostic should be evoked in case of pathologic cardiac auscultation and confirmed by emergent transthoracic echocardiography. Hemodynamic stabilisation, mainly with the insertion of an intra-aortic balloon pump is the first step in the management. The subsequent modality of closure, either surgical or transcatheter, as well as the ideal timing should be discussed in the Heart team. Successful closure decreases the 30-day mortality rate to 30-40 %.

La communication interventriculaire postinfarctus du myocarde correspond à la rupture du septum interventriculaire au niveau de la transition entre les tissus sain et infarci. C'est une complication rare mais mortelle après un infarctus du myocarde. Le diagnostic est avant tout clinique et doit être évoqué en cas d'auscultation cardiaque pathologique et confirmé par une échocardiographie transthoracique réalisée en urgence. La stabilisation hémodynamique, dans la majorité des cas à l'aide d'un ballon de contre-pulsion intra-aortique, est la première étape de la prise en charge. Ensuite, la décision d'une fermeture chirurgicale ou percutanée et son timing doivent être évalués au sein du Heart team. La fermeture chirurgicale ou percutanée permet de diminuer la mortalité à 30-40 % à 30 jours.

Switzerland: coronary and structural heart interventions from 2010 to 2015.

In 2015, Switzerland had a population of 8.3 million inhabitants. Since the first coronary angioplasty performed by Andreas Grüntzig in Zurich in 1977, the number of percutaneous procedures has steadily increased. The aim of this report is to summarise the current state of catheter-based cardiac interventions in adults in the country and to detail trends between 2010 and 2015. Since 1987, the Working Group for Interventional Cardiology of the Swiss Society of Cardiology has collected annually aggregate data from all facilities with cardiac catheterisation laboratories in the country. In 2015, a total of 37 institutions covered 17 of the 26 Swiss cantons. Over the six-year period, there was a continuous increase in the number of coronary angiography and percutaneous coronary interventions (PCI) (median increase rate of 3.2%/year for coronary angiography and of 2.6%/year for PCI). Notable was the adoption of the transradial approach for PCI, going from a median rate of 17% in 2012 to 51.9% in 2015. With respect to structural heart interventions, the number of patent foramen ovale as well as atrial septal defect closures has remained stable, while the number of transcatheter aortic valve implantations and transcatheter mitral valve repairs has shown a fourfold increase.

Percutaneous PFO closure for cryptogenic stroke in the setting of a systematic cardiac and neurological screening and a standardised follow-up protocol.

BACKGROUND: There are no uniform workup and follow-up (FU) protocols for patients presenting with cryptogenic embolism (CE) who undergo percutaneous closure of a patent foramen ovale (PFO). METHODS: We prospectively performed a systematic cardiac and neurological FU protocol in all patients who underwent percutaneous PFO closure in order to assess the incidence of subsequent cardiac and neurological adverse events. All patients received dual antiplatelet therapy for 6 months and were systematically included in a 12-month standardised FU protocol including: clinical evaluation-transthoracic and transoesophageal echocardiography, 24-hour Holter monitoring and/or 1-week R-test, and transcranial Doppler. Late FU (>12 months) was performed by reviewing medical records. RESULTS: Over a 10-year period, 221 consecutive patients underwent PFO closure for CE and 217 of them (98%) completed the 12-month FU. Ischaemic event recurrence at 12-month and late FU (mean time 69±35 months, median time 65 months, Q1:38 months, Q3:98 months) was observed in 6 (2.8%) and 3 patients (1.4%), respectively. The initial diagnosis of CE was reconsidered in 17 cases (7.8%), as the clinical and paraclinical FU exams showed possible alternative aetiologies for the initial event: 13 patients (6.0%) presented at least 1 episode of atrial fibrillation, while in 4 cases (1.8%) a non-ischaemic origin of the initial symptoms was identified. CONCLUSIONS: Alternative diagnoses explaining the initial symptoms are rarely detected with an in-depth screening for alternative diagnoses before PFO closure. Despite extensive screening, atrial fibrillation is the most frequently observed alternative aetiology for cryptogenic stroke.