Is the duration of dual antiplatelet therapy (DAPT) excessive in post-angioplasty in chronic coronary syndrome? Data from the France-PCI registry (2014-2019).

Background: while the duration of dual antiplatelet therapy (DAPT) following coronary angioplasty for chronic coronary syndrome (CCS) recommended by the European Society of Cardiology has decreased over the last decade, little is known about the adherence to those guidelines in clinical practice in France. Aim: To analyze the real duration of DAPT post coronary angioplasty in CCS, as well as the factors affecting this duration. Methods: Between 2014 and 2019, 8.836 percutaneous coronary interventions for CCS from the France-PCI registry were evaluated, with 1 year follow up, after exclusion of patients receiving oral anticoagulants, procedures performed within one year of an acute coronary syndrome, and repeat angioplasty. Results: Post-percutaneous coronary intervention (PCI) DAPT duration was > 12 months for 53.1% of patients treated for CCS; 30.5% had a DAPT between 7 and 12 months, and 16.4% a DAPT ≤ 6 months. Patients with L-DAPT (>12 months) were at higher ischemic risk [25.0% of DAPT score ≥2 vs. 18.8% DAPT score ≥2 in S&I-DAPT group (≤12 months)]. The most commonly used P2Y12 inhibitor was clopidogrel (82.2%). The prescription of ticagrelor increased over the period. Conclusions: post-PCI DAPT duration in CCS was higher than international recommendations in the France PCI registry between 2014 and 2019. More than half of the angioplasty performed for CCS are followed by a DAPT > 12 months. Ischemic risk assessment influences the duration of DAPT. This risk is probably overestimated nowadays, leading to a prolongation of DAPT beyond the recommended durations, thus increasing the bleeding risk.

[stent thrombosis : A won battle ? (data from the France PCI registry)]. / Thrombose de stent : une bataille gagnée ? (Données du registre France PCI).

GOAL: The aim of the study is to assess the incidence, risk factors and prognosis of definite stent thrombosis (ST) at 1 year in the France PCI multicenter prospective registry. PATIENTS AND METHODS: Only patients who underwent coronary angioplasty with at least one stent implantation between 1st January 2014 and 31 December 2019 were included. The population was separated into 2 groups: the "ST" group with stent thrombosis and the "control" group without stent thrombosis. RESULTS: 35,435 patients were included. 256 patients (0.72%) presented a ST at 1 year. The rate of ST decreased significantly in acute coronary syndrome (1.5% in 2014 vs. 0.73% in 2019; p = 0.05) but not in chronic coronary syndrome (0.46% in 2014 vs 0.40%; p = 0.98). The risk factors are young age (65.8 years vs 68.2; p = 0.002), clinical context (35.27% vs 16.68%; p = 0.0001), diabetes (35.2 % vs 26.4%; p = 0.002), renal failure (11.7% vs 8%; p = 0.009) and history of coronary angioplasty (28.63% vs 21.86%; p = 0.009) and peripheral arterial disease (14.5% vs 10.1%; p = 0.021), LV dysfunction (37% vs 27.5%; p = 0.003), mean length (39.6 mm vs 31, 7mm; p <0.0001) and the mean number of stents per procedure (1.9 vs 1.6; p <0.0001), a TIMI flow ≤1 pre procedure (21.5% vs 12.4%; p <0.0001) and an intrastent restenosis (11% vs 6%; p <0.0001). The 1-year mortality of the ST group was significantly higher than that of the control group (19.14% vs 5.82%; p <0.0001). CONCLUSION: Since 2014, the incidence of ST at 1 year has been decreasing but remains stuck at a floor level of 0.54% in 2019. The battle for ST seems to have been partly won and its risk factors well identified, but its mortality is still high.

[TAVI and coronary revascularization]. / TAVI et revascularisation coronaire.

Transcatheter aortic valve implantation (TAVI) has become the major approach to manage the severe aortic stenosis in inoperable patients that frequently present a coronary artery disease. To date, the available data related to the impact of these coronary lesions on survival is conflicting. When indicated, coronary revascularization could be beneficial for proximal lesions when performed before or during TAVI. The per-procedure coronary artery occlusion is rare, but with a bad prognosis. The coronary occlusion is more frequent with short distance of the coronary implantation and the small aortic sinuses, mostly occurring in the left main coronary. The scan analysis to identify high-risk cases is therefore important before the procedure in order to anticipate and prevent complications by specific techniques. Recently, late occlusion cases have been described and linked to thrombus or fibrosis mechanisms. The rate of success of percutaneous coronary intervention (PCI) after TAVI approach is weak, because of the difficulties of selective catheterization due to the stent of prosthesis. The different techniques of PCI have been outlined according to the type of the prosthesis.

[Recent insights on spontaneous coronary artery dissection (SCAD): From diagnosis suspicion to long-term outcomes]. / Hématome et dissection coronaire spontanés, enseignements récents : de la suspicion diagnostique au devenir après traitement.

Spontaneous coronary artery dissection (SCAD) is a poorly understood and under-diagnosed entity of acute coronary syndrome, affecting predominantly young women. Relatively large series have been published in the past five years highlighting this condition, once believed to be rare. Indeed, the pathophysiology, natural history, clinical presentation, patient profile, diagnostic modalities, management and outcomes of SCAD are becoming better understood. The aim of our review is to provide a brief "state of the art" of SCAD in 2016 to help the clinician in the management of this challenging condition.

[Overview of medical practices in wet AMD in France]. / Vue d'ensemble des pratiques médicales dans la DMLA exsudative en France.

BACKGROUND AND OBJECTIVES: Wet AMD is characterized by the formation of choroidal neovascularization, mediated by vascular endothelial growth factor (VEGF) and responsible for a decrease in visual acuity and metamorphopsia of sudden onset. Intravitreal anti-VEGF can stabilize or even improve visual acuity. Although there is a consensus among ophthalmologists about the induction phase injection of anti-VEGF, there appear to be differences in practice regarding therapeutic treatment modalities. The goal of this work was to explore this hypothesis and to better understand real life practices. METHOD: The Ipsos institute conducted a qualitative survey of 16 retinal specialists and 9 general ophthalmologists in September and October 2013, using a questionnaire developed by a scientific committee of experts. Fifteen telephone interviews and 4 face-to-face meetings with a retina specialist and an ophthalmologist were conducted. This qualitative study allowed the development of a quantitative survey of 200 retina specialists and general ophthalmologists, conducted between November 2013 and January 2014, to describe practices in diagnosis, treatment and follow-up of wet AMD. RESULTS: A distribution of roles between the ophthalmologist making the initial diagnosis and the retinal specialists responsible for treatment and follow-up was noted. Treatment was initiated within 10 days of diagnosis as recommended by the HAS in only one third of patients. After the induction phase of treatment, i.e. three monthly injections of anti-VEGF, treatment and monitoring practices were heterogeneous with 74% of physicians using a PRN treatment protocol, 22% a bimonthly protocol (with monthly monitoring in 19.4% of cases) and 4% a "treat and extend" protocol. There was little change in the protocol chosen in the case of recurrence. CONCLUSION: Three quarters of ophthalmologists report using a PRN protocol, and over 90% report seeing their patients monthly, either for injection or for a check-up. This apparent uniformity is in reality more complex: for the large majority, they prefer to closely follow the patient so as to treat the slightest recurrence, but with great variability in practices with regard to individualization of treatment.

[Impact of transcatheter aortic valve implantation in the treatment of aortic valve disease after previous coronary artery bypass]. / Impact des techniques interventionnelles dans le traitement de la valvulopathie aortique après revascularisation myocardique chirurgicale préalable.

INTRODUCTION: Patients with a history of coronary artery bypass and aortic valve disease constitute a high-risk group for conventional redo surgery. The transcatheter aortic valve implantation (TAVI) may be an alternative for high-risk patients. The purpose of this study is to evaluate the impact of TAVI in the treatment of aortic valve disease after previous surgical coronary artery revascularization. PATIENTS AND METHODS: This is a single-center retrospective, observational study, including 87 patients undergoing surgery for surgical heart valve replacement or TAVI from January 2007 to December 2013. RESULTS: The introduction of transcatheter aortic valve implantation techniques has doubled the number of redo patients treated for aortic valve disease. From 2010 to 2013, the patients treated by conventional surgery diminished by 30%, with improved postoperative outcomes. This study allowed us to notice differences in patient's in terms of operative risk factors. For the same reasons no comparison was possible between 2 subgroup of patients. Hospital mortality was 6.4% for conventional aortic surgery and 20% for transcatheter aortic valve treatment. CONCLUSION: Surgery remains the standard treatment for aortic valve disease even in redo patients, but TAVI becomes a very interesting tool as it may represent a tailored approach for our patients.

Intra-coronary thrombus evolution during acute coronary syndrome: regression assessment by serial optical coherence tomography analyses.

AIMS: We investigated the feasibility of thrombus quantification by frequency-domain optical coherence tomography (FD-OCT) methods in patients with highly thrombotic acute coronary syndrome (ACS) treated by deferred stenting strategy. METHODS AND RESULTS: Patients were suitable for inclusion if they presented (i) an ACS that was successfully revascularized by manual thrombo-aspiration and (ii) a large residual thrombus on coronary angiography and initial FD-OCT analysis. These patients underwent a second procedure including FD-OCT analysis after several days of optimal antithrombotic therapy. Serial area measurements within the athero-thrombotic culprit lesion were performed to evaluate the OCT-thrombus score, volume, and length. Sixteen patients (88% men/age = 59.3 ± 4.1 years/94% STEMI) were included in the study. The mean delay between OCT analyses was 3.9 ± 0.3 day. No adverse event was observed during this interval. We observed a reduction of thrombus burden between the two analyses, as assessed by the significant reductions in OCT-thrombus score (22.3 ± 2.6 vs. 10.3 ± 1.3, P < 0.001), OCT-thrombus volume (9.6 ± 2.3 vs. 3.6 ± 0.9 mm(3), P = 0.003), and OCT-thrombus length (11.1 ± 1.4 vs. 7.4 ± 0.8 mm, P = 0.01). The percentages of OCT-thrombus score and volume reduction were highly correlated with the inter-OCT analyses delay (respectively ρ = 0.65 and ρ = 0.84, P < 0.01 for both). CONCLUSION: FD-OCT assessment of thrombus volume in selected ACS patients is feasible, safe, and could allow clot regression monitoring in vivo.

[Cardiovascular adverse effects due to phenylephrine eye drops in ophtalmic surgery]. / Effets indésirables cardiovasculaires des collyres à la phényléphrine en chirurgie ophtalmologique.

Adverse systemic reactions such as cardiovascular effects may occur following topical ocular application of phenylephrine. We report the case of a 49-year-old woman who, following topical application of phenylephrine eyedrops, experienced hypertension with electrocardiographic modifications and a rise in cardiac troponin Ic.

[Therapeutic use of amniotic membranes and their derivate cells]. / Utilisations thérapeutiques des membranes fœtales et de leurs cellules dérivées.

During all the pregnancy, the foetal membranes play several functions (mechanic, anti-infectious, hormonal, regulation of the amniotic fluid homeostasis...) fundamental for an optimal development and maternal-foetal physiology. After delivery, these amniotic membranes have regained for a few years, a new interest and a second "ex-utero" life due to their therapeutic use. This use was firstly initiated experimentally in ophthalmological pathologies, around 1950. The recent understanding of molecular and cellular mechanisms enables to explain scientifically these first empiric uses. They are an interesting solution in ocular aggressions like viral attacks, chemical or temperature burns. They also represent an attractive alternative in case of corneal grafts and a biological matrix for limb cells cultures used to regenerate the corneal lesions. An industrial engineering is now in place to boost the performances of these human membranes. The isolation and identification of stem cells (mesenchymal origin) in these amniotic membranes are promising in the field of cell therapy. Recently, the first results have been published demonstrating the clinical efficiency of the stems cell during pancreatic, cardiac, lung neuronal lesions.

Management of spontaneous coronary artery dissection: review of the literature and discussion based on a series of 12 young women with acute coronary syndrome.

Spontaneous coronary artery dissection (SCAD) is a rare pathology, principally affecting young women free of atheroma risk factors. Its physiopathology remains little understood, and the prognosis for such acute coronary syndromes is poor, as they occur suddenly. Management is often difficult, and no guidelines exist. The present single-center retrospective study concerns 12 cases of SCAD occurring between 2001 and 2008 in female patients under the age of 60. Eleven patients survived, with a favorable long-term evolution. Only 2 had conservative medical therapy, the other 10 undergoing percutaneous coronary intervention (2 procedures involving a coronary artery bypass graft). On the basis of this series and data from the literature, we suggest a strategy to improve the often dire prognosis of SCAD. Emergency angiography to confirm diagnosis is essential. Treatment should be guided by the extent of the lesions, the myocardial ischemia and the hemodynamic status. Conservative medical therapy is a reasonable approach in the case of distal dissection or conserved coronary flow. Percutaneous coronary intervention is feasible in the acute phase to restore coronary perfusion and hemodynamic stability. Surgery - emergency bypass or assisted circulation - should be restricted to cases where percutaneous coronary intervention has failed or is impossible.

[OCT-3 documentation of spontaneous resolution of blunt macular hole injury: a case study]. / Documentation par OCT-3 de la résolution spontanée d'un trou maculaire post-traumatique.

OBJECTIVE: To report a case of a spontaneous resolution of a macular hole resulting from injury. OBSERVATION: A 17-year-old man experienced a blunt injury: fundus examination found a full-thickness macular hole. It was studied with a clinical exam and optical coherence tomography images. After two weeks, the macular hole spontaneously disappeared. DISCUSSION: Blunt injury is the most frequent ocular injury. The consequences can be very serious because of possible lesions in the macular area: the visual function prognosis can therefore be disastrous. Macular holes can have a good prognosis, and spontaneous closure is sometimes observed. This report attempts to explain the mechanisms. CONCLUSION: Disappearance of a macular hole resulting from injury can occur spontaneously, especially in young patients. OCT is today indispensable, making it possible to follow up the injury and its consequences objectively, reliably and with very good reproducibility.

[Kawasaki disease is also a disease of adults: report of six cases]. / La maladie de Kawasaki est aussi une maladie de l'adulte: a propos de six observations.

Kawasaki disease is an inflammatory arterial disease of unknown cause usually affecting young children, the principal complication of which is coronary artery aneurysm. Early treatment with immunoglobulins and aspirin prevents this complication. The diagnosis requires expert clinical criteria and, in atypical forms, a more recent decisional diagnostic tree has to be used. The authors report 6 cases of adult Kawasaki disease. As in the other sixty or so cases in the literature, hepatic forms were the commonest (5/6). Only three of the six cases met the classical clinical criteria and the diagnosis was made by the decisional tree or after coronary complications in the oldest subject. The five treated patients progressed favourably after a course of immunoglobulins. Echocardiography detected 100% of children with coronary disease but it was more difficult in adults in whom new non-invasive methods of coronary imaging (fast CT and MRI) and stress testing should complete the investigations. The association of prolonged pyrexia, clinical criteria and a biological inflammatory syndrome should, after exclusion of the differential diagnoses, suggest a diagnosis of Kawasaki disease in the adult as in the child. The possibility of coronary disease, even though extremely rare, should be recognised by the cardiologist and lead to diagnostic and therapeutic managements as aggressive as in children.

[Implantation of mechanical pulmonary and tricuspid valve prostheses at a distance from complete repair of Tetralogy of Fallot]. / Implantation de deux prothèses mécaniques, pulmonaire et tricuspide, à distance d'une réparation complète de tétralogie de Fallot.

The authors report the case of a 39 years old woman operated for tetralogy of Fallot at the age of 6. Multiple complications due to postoperative atrioventricular block and a poor surgical result on the pulmonary outflow tract led to several reoperations. Right ventricular dysfunction with pulmonary regurgitation and mitral tricuspid valve disease in a context of endocarditis on the pacing catheter led to double pulmonary and tricuspid valve replacement with mechanical prostheses. The outcome at follow-up at 3 years is good. To the authors' knowledge, this is the first reported case of double mechanical valve replacement of the right heart after complete repair of tetralogy of Fallot.

[The place of telemedicine in rhythmology and cardiac pacing]. / Place de la télémédecine en rythmologie et stimulation cardiaque.

Rapid advancement in telecommunication technology has made possible automatic periodic transmission of pacemaker and implantable defibrillator data to the attending physician (home monitoring). Furthermore, technology using remote control software allows, through device programmers, interrogation of the device memory, permitting remote monitoring by physicians or technical support of the manufacturer. Potential applications of these two capabilities include a close watch over the functioning of the devices, ability to obtain an earlier diagnosis (and management) of arrhythmic events, and assistance at the time of implant procedure and routine follow up. Finally these new tools raise several questions concerning safety aspects (including reliability of transmission, encrypted transfer, restricted access of the central database), economic aspects, and physician and manufacturer's liability.

[Streptococcus pyogenes endocarditis following varicella: a case report]. / Varicelle compliquée d'une endocardite à streptocoque A: à propos d'une observation.

Although varicella is most often a benign and self-limited disease of childhood, it can be associated with a variety of serious and potential lethal complications. Especially, the incidence of severe infectious complications caused by group A streptococci has been increasing over the last years. We report the case of a previously healthy young boy with an aortic bicuspidy who developed a varicella complicated by endocarditis due to group A streptococcus, and a haemophagocytic syndrome. A favorable outcome was obtained after an early valvular replacement and 6 weeks of intravenous antibiotics.