Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital anomaly with a large spectrum of anatomical variations. Selective engagement of an AAOCA can present challenges during cardiac catheterization. A comprehensive understanding of the characteristics of major AAOCA can effectively assist operators for selecting and maneuvering catheters. This review outlines the recommended catheter manipulations based on the site of ectopic coronary origin. Identifying the initial course (prepulmonic, subpulmonic, interarterial or retroaortic course) is crucial for classifying each AAOCA. Besides invasive coronary angiography, coronary computed tomography angiography is frequently utilized to enhance the diagnostic assessment. Cardiac catheterization enables the use of intracoronary imaging and physiologic tools for accurately assessing the significance of AAOCA identified as at risk, mainly the anomalies associated with an interarterial course. Intravascular ultrasound is recognized as the gold standard for analyzing AAOCA with interarterial course. Optical tomography coherence imaging can be interesting to evaluate the rare AAOCA with a subpulmonic course, which are associated with ischemic symptoms or myocardial ischemia. Invasive physiological indices using pressure wires can be employed, with the caveat that their threshold values remain uncertain. Decision-making can be challenging for patients with AAOCA. Both non-invasive and invasive imaging tools are essential to support the final choice.

Background The prevalence and location of coronary artery disease (CAD) in anomalous aortic origin of a coronary artery (AAOCA) remain poorly documented in adults. We sought to assess the presence of CAD in proximal (or ectopic) and distal (or nonectopic) segments of AAOCA. We hypothesized that the representation of CAD may differ among the different courses of AAOCA. Methods The presence of CAD was analyzed on coronary angiography and/or coronary computed tomography angiography in 390 patients (median age 64 years; 73% male) with AAOCA included in the anomalous coronary arteries multicentric registry. Results AAOCA mainly involved circumflex artery (54.4%) and right coronary artery (RCA) (31.3%). All circumflex arteries had a retroaortic course; RCA mostly an interarterial course (98.4%). No CAD was found in the proximal segment of interarterial AAOCA, whereas 43.8% of retroaortic AAOCA, 28% of prepulmonic AAOCA and 20.8% subpulmonic AAOCA had CAD in their proximal segments (P < 0.001). CAD was more prevalent in proximal than in distal segments of retroaortic AAOCA (OR: 3.1, 95% CI: 1.8–5.4, P < 0.001). On multivariate analysis, a retroaortic course was associated with an increased prevalence of CAD in the proximal segment (adjusted OR 3.4, 95% CI: 1.3–10.7, P = 0.022). Conclusion Increased prevalence of CAD was found in the proximal segment of retroaortic AAOCA compared to the proximal segments of other AAOCA, whereas no CAD was observed in the proximal segment of interarterial AAOCA. The mechanisms underlying these differences are not yet clearly identified.

Les anomalies de connexion proximale des artères coronaires sont des anomalies congénitales avec de nombreuses formes anatomiques. En raison du risque variable de mort subite, ces anomalies doivent être classées avec précision. Il existe encore des interrogations sur le mécanisme et le risque individuel de la mort subite, l'histoire naturelle de ces anomalies et les bénéfices d'une correction chirurgicale. Des registres observationnels à large échelle pourraient fournir des données plus factuelles aux praticiens en charge des patients concernés. Le registre ANOCOR, le plus important en taille publié à ce jour, a colligé 472 patients (âge moyen de 63 ans) présentant 496 anomalies coronaires. La représentation angiographique (avec la coronarographie invasive ou le scanner coronaire) selon l'artère coronaire et le trajet initial ectopique a pu être précisé avec l'identification de deux phénotypes principaux : l'artère circonflexe (n = 235) avec un trajet rétroaortique dans 97 % des cas et l'artère coronaire droite (n = 165) avec un trajet interartériel dans 89,7 % des cas. Deux formes anatomiques coronaires gauches ont pu être confondues par des cardiologues non experts : celles avec un trajet rétropulmonaire ou interartériel. La mort subite en lien avec l'anomalie coronaire était un mode de présentation très rare (3 patients soit 0,6 % de la cohorte) dans cette population avec très peu de patients jeunes de moins de 35 ans (11 cas soit 2,3 % de la cohorte).

Anomalous aortic origin of the coronary arteries are congenital anomalies with many anatomical forms. Due to the varying risk of sudden death, these abnormalities must be classified accurately. There are still questions about the mechanism and individual risk of sudden death, the natural history of these abnormalities and the benefits of a surgical correction. Large-scale observational registries may provide more evidence-based data to practitioners caring for the patients concerned. The ANOCOR registry, the largest in size published to date, enrolled 472 patients (mean age 63 years) with 496 coronary abnormalities. The angiographic representation (with invasive coronary angiography or coronary CT angiography) according to the coronary artery and initial ectopic course could be specified with the identification of two main phenotypes: the circumflex artery (n = 235) with a retroaortic course in 97% of cases and the right coronary artery (n = 165) with an interarterial course in 89.7% of cases. Two left coronary anatomical forms have been confused by non-expert cardiologists: those with a retropulmonary or interarterial course. Sudden death related to coronary anomaly was a very rare mode of presentation (3 patients or 0.6% of the cohort) in this population with very few young patients < 35 years (11 cases or 2.3% of the cohort).

Background Patients with high-gradient (HG) severe aortic stenosis (AS) and left ventricular (LV) dysfunction are at high risk of death. The optimal timing for aortic valve replacement (AVR) is not defined by guidelines. The objective was to define the optimal timing to perform isolated AVR in patients with HG-AS and severe LV dysfunction. Methods We retrospectively included 233 consecutive patients admitted for severe HG-AS (aortic valve area <1cm(2) and mean gradient >= 40mmHg). Severe LV dysfunction was defined by LV ejection fraction <= 35% (LVEF). All-cause mortality while waiting for AVR and after the intervention (30 days) was compared in patients with (n = 28) and without (n = 205) LVEF <= 35%. Results Patients with HG-AS and severe LV dysfunction had a higher risk profile than those with LVEF >35%. AVR was performed in 93% (218/233) of patients, 41% by surgery (SAVR) and 53% by transcatheter (TAVR). TAVR was the preferred method to treat HG-AS patients with LVEF <= 35%. All-cause mortality while waiting for AVR was higher in patients with severe LV dysfunction (22% vs. 2.0%, p < 0.001) and occurred within a shorter time (12 [8-26] days vs. 63 [58-152] days, p = 0.010) compared to those with LVEF >35%. All death in HG-AS patients with a severe LV dysfunction occurred within the first month. Postoperative mortality was low (1.3%), irrespective of LVEF. Conclusions AVR should be performed promptly after Heart Team decision in patients with HG severe AS and LVEF <= 35% because of a very high and premature risk of death while waiting for intervention.

L’émergence du virus SARS-CoV-2 responsable de la maladie à COVID-19 a fait apparaître une nouvelle maladie dont les contours restent encore imparfaitement connus. Alors que les premières données suggéraient une infection purement respiratoire, les publications les plus récentes mettent en évidence un grand pléomorphisme de la maladie, responsable d’atteintes polyviscérales, au premier rang desquelles l’atteinte cardiaque. Cette atteinte cardiaque peut prendre la forme de myocardite aiguë. L’objectif de cette revue est de discuter le rationnel physiopathologique justifiant l’existence de myocardites à SARS-CoV-2 et d’analyser les données de la littérature concernant le diagnostic et le traitement de cette entité particulière.

Randomized studies showed that Dobutamine and Levosimendan have similar impact on outcome but their combination has never been assessed in acute decompensated heart failure (ADHF) with low cardiac output. This is a retrospective, single-center study that included 89 patients (61 ± 15 years) admitted for ADHF requiring inotropic support. The first group consisted of patients treated with dobutamine alone (n = 42). In the second group, levosimendan was administered on top of dobutamine, when the superior vena cava oxygen saturation (ScVO2) remained <60% after 3 days of dobutamine treatment (n = 47). The primary outcome was the occurrence of major cardiovascular events (MACE) at 6 months, defined as all cause death, heart transplantation or need for mechanical circulatory support. Baseline clinical characteristics were similar in both groups. At day-3, the ScVO2 target (>60%) was reached in 36% and 32% of patients in the dobutamine and dobutamine-levosimendan group, respectively. After adding levosimendan, 72% of the dobutamine-levosimendan-group reached the ScVO2 target value at dobutamine weaning. At six months, 42 (47%) patients experienced MACE (n = 29 for death). MACE was less frequent in the dobutamine-levosimendan (32%) than in the dobutamine-group (64%, p = 0.003). Independent variables associated with outcome were admission systolic blood pressure and dobutamine-levosimendan strategy (OR = 0.44 (0.23–0.84), p = 0.01). In conclusion, levosimendan added to dobutamine may improve the outcome of ADHF refractory to dobutamine alone.

BACKGROUND:In this study, we aimed to report clinical characteristics and outcomes of patients with and without SARS-CoV-2 infection who were referred for acute coronary syndrome (ACS) during the peak of the pandemic in France.METHODS:We included all consecutive patients referred for ST-elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) during the first 3 weeks of April 2020 in 5 university hospitals (Paris, south, and north of France), all performing primary percutaneous coronary intervention.RESULTS:The study included 237 patients (67 ± 14 years old; 69% male), 116 (49%) with STEMI and 121 (51%) with NSTEMI. The prevalence of SARS-CoV-2-associated ACS was 11% (n = 26) and 11 patients had severe hypoxemia on presentation (mechanical ventilation or nasal oxygen > 6 L/min). Patients were comparable regarding medical history and risk factors, except a higher prevalence of diabetes mellitus in SARS-CoV-2 patients (53.8% vs 25.6%; P = 0.003). In SARS-CoV-2 patients, cardiac arrest on admission was more frequent (26.9% vs 6.6%; P < 0.001). The presence of significant coronary artery disease and culprit artery occlusion in SARS-CoV-2 patients respectively, was 92% and 69.4% for those with STEMI, and 50% and 15.5% for those with NSTEMI. Percutaneous coronary intervention was performed in the same percentage of STEMI (84.6%) and NSTEMI (84.8%) patients, regardless of SARS-CoV-2 infection, but no-reflow (19.2% vs 3.3%; P < 0.001) was greater in SARS-CoV-2 patients. In-hospital death occurred in 7 SARS-CoV-2 patients (5 from cardiac cause) and was higher compared with noninfected patients (26.9% vs 6.2%; P < 0.001).CONCLUSIONS:In this registry, ACS in SARS-CoV-2 patients presented with high a percentage of cardiac arrest on admission, high incidence of no-reflow, and high in-hospital mortality.

The outbreak of the SARS-CoV-2 virus responsible for the COVID-19 disease has given rise to a new disease whose boundaries are still to be discovered. While the first data suggested a purely respiratory infection, the most recent publications highlight a large pleomorphism of the disease, responsible for multiple organ damage, of which cardiac injury seems to be the most represented. This cardiac injury can present as acute myocarditis. Our aim was to discuss the pathophysiological rationale underlying the existence of SARS-CoV-2 myocarditis and to analyze the literature data regarding the diagnosis and treatment of this particular entity.

Accumulating evidence supports the interaction among vascular aging, inflammation and atherosclerosis. Therefore, exploring underlying pathophysiology may highlight key linking pathways that could be targeted for intervention. Cathepsin B (CTSB), a proteolytic enzyme mainly located in lysosomes and endosomes, can be activated and released by ageing-associated cell acidification. CTSB may also be involved in arterial degeneration, calcification and arterial stiffening by augmenting inflammatory load and by degradation of the elastin-containing arterial extracellular matrix. CTSB is also highly expressed in human carotid plaques and correlates with plaque severity and symptomatic events. Thus, experimental evidence supports a central role of CTSB in ageing processes, atherogenesis and its consequences. However, its clinical role in atherosclerotic cardiovascular disease (ASCVD) has not been sufficiently explored, while its association with vascular aging is unknown. CTSB expression in peripheral blood mononuclear cells (PBMCs) was measured in 224 consecutive subjects (148 without clinically overt coronary artery disease (CAD) (control group), 46 with stable CAD and 30 with acute myocardial infarction (AMI)) using quantitative SYBR Green real-time polymerase chain reaction. Participants underwent peripheral vascular assessment by measurement of aortic stiffness using pulse wave velocity (PWV) (Complior, Artech Medical Saint Quentin Fallavier, France) and by documentation of carotid and femoral atherosclerotic plaques using high-resolution B-mode ultrasound imaging (14.0-MHz multifrequency linear-array probe, Vivid 7 Pro, General Electric Boston, United States). All subjects provided written consent for participation in the study. CTSB in the highest tertile was associated with older age, higher prevalence of arterial hypertension, hyperlipidaemia and with lower estimated glomerular filtration rate (p< 0.05 for all). Overall, CAD patients presented higher CTSB expression than controls (p1⁄4 0.006) (Figure 1). Comparisons by subgroups of CAD showed that AMI patients had increased CTSB expression compared to control subjects (p1⁄4 0.007), while stable CAD and AMI patients did not differ (p1⁄4 0.154). In addition, in control subjects but not in CAD patients, CTSB in the highest tertile presented fourfold increased odds for higher PWV after adjustment for traditional CAD risk factors (TRFs) and renal function (Table 1, Figure 1). CTSB levels were also independently associated with the number of CAD arteries after adjustment for TRFs and renal

A patient with severe, symptomatic functional mitral regurgitation was initially considered not suitable for MitraClip (Abbott Vascular, Abbott Park, Illinois) implantation because of non-coapting mitral leaflets. Repeated levosimendan infusions in combination with intensive diuresis induced sufficient valve coaptation, thus allowing MitraClip implantation to be performed. (Level of Difficulty: Intermediate.)

The management of ST-segment elevation myocardial infarction (STEMI) has evolved significantly over the last decades. STEMI treatment includes reperfusion therapy, ideally by primary percutaneous coronary intervention (pPCI), modern antithrombotic therapy and secondary prevention measures. Even though many areas in the management of STEMI are well studied and analyzed in the guidelines, there are still challenges and unanswered questions on how to improve outcomes. This review aims to offer an insight in areas that need to be explored.

Background and aims: One of the objectives of the ESC-EORP EUROASPIRE V survey is to determine how well European guidelines on the management of dyslipidaemias are implemented in coronary patients. Methods: Standardized methods were used by trained technicians to collect information on 7824 patients from 130 centers in 27 countries, from the medical records and at a visit at least 6 months after hospitalization for a coronary event. All lipid measurements were performed in one central laboratory. Patients were divided into three groups: on high-intensity LDL-C-lowering-drug therapy (LLT), on low or moderate-intensity LLT and on no LLT. Results: At the time of the visit, almost half of the patients were on a high-intensity LLT. Between hospital discharge and the visit, LLT had been reduced in intensity or interrupted in 20.8% of the patients and had been started or increased in intensity in 11.7%. In those who had interrupted LLT or had reduced the intensity, intolerance to LLT and the advice of their physician were reported as the reason why in 15.8 and 36.8% of the cases, respectively. LDL-C control was better in those on a high-intensity LLT compared to those on low or moderate intensity LLT. LDL-C control was better in men than women and in patients with self-reported diabetes. Conclusions: The results of the EUROASPIRE V survey show that most coronary patients have a less than optimal management of LDL-C. More professional strategies are needed, aiming at lifestyle changes and LLT adapted to the need of the individual patient.

We studied the observer variability in the description and classification of anomalous connections of the coronary arteries (ANOCOR) between a non-expert group of physicians (ANOCOR investigators) and a group of expert physicians, using the ANOCOR cohort. The diagnosis of ANOCOR requires an appropriate identification for the management of the patients involved. A misdiagnosis may have serious repercussions for the management to come. For example a subpulmonic course is sometimes interpreted as an interarterial course (Fig. 1). Consecutive patients identified by 71 referring cardiologists (ANOCOR investigators) were included in the ANOCOR cohort. ANOCOR was diagnosed by invasive and/or computed tomography (CT) coronary angiography. Angiographic images were reviewed by an angiographic committee with experience in the ANOCOR field. Both ANOCOR investigators and angiographic committee filled out a questionnaire to classify each ANOCOR with the type of coronary artery involved, the site of anomalous connection, and the initial course. Observer variability between ANOCOR investigators and angiographic committee was assessed by κ statistics. ANOCOR with an interarterial course were defined as at-risk. In total, 496 ANOCOR were identified among 472 patients of the ANOCOR cohort and an interarterial course was present in 31% of the abnormalities. The agreement for the type of artery was excellent (κ = 0.92, 95% CI: 0.86–0.98, P < 0.05), while the agreement for the site of anomalous connection was moderate (κ = 0.50, 95% CI: 0.42–0.58, P < 0.05), and the agreement for the initial course was only fair (κ = 0.32, 95% CI: 0.28–0.37, P < 0.05). Observer agreement for the identification of at-risk forms was moderate (κ = 0.497, 95% CI: 0.40–0.59, P < 0.05) (Table 1). Observer variability in the assessment of ANOCOR between non-experienced and experienced physicians can be significant. We found that expert physicians provide a more robust classification of ANOCOR in comparison with non-expert physicians. Therefore, referral to physicians with a relevant experience should be considered, especially if an ANOCOR at-risk is suspected.