BACKGROUND:Cerebral complications in patients with infective endocarditis (IE) are common and worsen prognosis. Determining the optimal timing for cardiac surgery in this context remains challenging. In this study we describe the characteristics and outcomes of IE patients with cerebral complications who were managed either surgically or medically. METHODS:We analyzed all consecutive patients with IE-related cerebral complications enrolled in a prospective cohort study in Aquitaine, France (2013-2021). Patients were classified as operated or nonoperated. The primary outcome was all-cause mortality at 1 month; secondary outcomes included all-cause mortality up to 1 year and the impact of cerebral lesion type and surgical timing. RESULTS:Among 1230 IE patients, 288 had cerebral complications (age 65 ± 14 years, 74% male). Ischemic and hemorrhagic cerebral lesions occurred in 76% and 19% of patients, respectively. Severe valvular damages were present in 43% and cardiac surgery was indicated in 86% of cases. One-month mortality was significantly higher among nonoperated vs operated patients (27% vs 5.9%, P < 0.001). Multivariate analysis identified heart failure, coma, and cardiac surgery (odds ratio 0.24, 95% confidence interval 0.10-0.56, P < 0.001) as independent predictors of mortality. Neither the type of cerebral lesion nor surgical timing appeared to affect prognosis. CONCLUSIONS:When indicated, cardiac surgery should be systematically discussed in IE patients with cerebral complications. Early intervention guided by a multidisciplinary endocarditis team with neurology expertise may improve outcomes.

We report a rare case of a 49-year-old man, who presented an out-of-hospital cardiac arrest (OHCA) due to prolonged coronary artery vasospasm, lasting over 2 hours. Coronary spasm refers to a transient reduction in the calibre of an epicardial coronary artery due to abnormal contraction. This condition is an important cause of acute coronary syndrome and sudden cardiac death. The duration of episodes typically does not exceed 15 minutes. To the best of our knowledge, this case is the first reported of cardiac arrest secondary to such a prolonged coronary vasospasm with thrombolysis in myocardial infarction (TIMI) flow grade 1 upon presentation to the catheterization laboratory.

Background: Myocarditis is commonly diagnosed in the intensive care cardiology unit (ICCU). No current recommendation nor guideline aids exist for aetiological assessments. Methods: From September 2021 to October 2023, 84 patients with acute myocarditis underwent thorough and systematic serum and blood cell panel evaluations to determine the most common causes of myocarditis. Results: Of the 84 patients (median age 34 years, range 22–41 years, 79% male), 16 presented with complicated myocarditis. The systematic aetiological assessment revealed that 36% of patients were positive for lupus anticoagulant, 12% for antinuclear antibodies, 8% for anti-heart antibodies, and 12% for anti-striated muscle antibodies. Viral serology did not yield any significant results. After the aetiological assessment, one patient was diagnosed with an autoimmune inflammatory disorder (Still’s disease). T-cell subset analyses indicated that myocarditis severity tended to increase with the T-cell lymphopenia status. Conclusions: A comprehensive, systematic aetiological assessment was of limited value in terms of predicting the clinical or therapeutic outcomes in myocarditis patients presenting to the ICCU.

This case report discusses progressive cardiogenic shock in a man aged 78 years after catheter ablation for ventricular tachycardia.

Background and Aims This trial sought to assess the safety and efficacy of ShortCut, the first dedicated leaflet modification device, prior to transcatheter aortic valve implantation (TAVI) in patients at risk for coronary artery obstruction. Methods This pivotal prospective study enrolled patients with failed bioprosthetic aortic valves scheduled to undergo TAVI and were at risk for coronary artery obstruction. The primary safety endpoint was procedure-related mortality or stroke at discharge or 7 days, and the primary efficacy endpoint was per-patient leaflet splitting success. Independent angiographic, echocardiographic, and computed tomography core laboratories assessed all images. Safety events were adjudicated by a clinical events committee and data safety monitoring board. Results Sixty eligible patients were treated (77.0 +/- 9.6 years, 70% female, 96.7% failed surgical bioprosthetic valves, 63.3% single splitting and 36.7% dual splitting) at 22 clinical sites. Successful leaflet splitting was achieved in all [100%; 95% confidence interval (CI) 94%-100.0%, P < .001] patients. Procedure time, including imaging confirmation of leaflet splitting, was 30.6 +/- 17.9 min. Freedom from the primary safety endpoint was achieved in 59 [98.3%; 95% CI (91.1%-100%)] patients, with no mortality and one (1.7%) disabling stroke. At 30 days, freedom from coronary obstruction was 95% (95% CI 86.1%-99.0%). Within 90 days, freedom from mortality was 95% [95% CI (86.1%-99.0%)], without any cardiovascular deaths. Conclusions Modification of failed bioprosthetic aortic valve leaflets using ShortCut was safe, achieved successful leaflet splitting in all patients, and was associated with favourable clinical outcomes in patients at risk for coronary obstruction undergoing TAVI.

Background The benefit–risk balance and optimal timing of surgery for severe infective endocarditis (IE) with ischemic or hemorrhagic strokes is unknown. The study aim was to compare the neurological outcome between patients receiving surgery or not. Methods In a prospective register-based multicenter ICU study, patients were included if they met the following criteria: (i) left-sided IE with an indication for heart surgery; (ii) with cerebral complications documented by cerebral imaging before cardiac surgery; (iii) with Sequential Organ Failure Assessment score ≥ 3. Exclusion criteria were isolated right-sided IE, in-hospital acquired IE and patients with cerebral complications only after cardiac surgery. In the primary analysis, the prognostic value of surgery in term of disability at 6 month was assessed by using a propensity score-adjusted logistic regression. Results 192 patients were included including ischemic stroke (74.5%) and hemorrhagic lesion (15.6%): 67 (35%) had medical treatment and 125 (65%) cardiac surgery. In the propensity score-adjusted logistic regression, a favorable 6-month neurological outcome was associated with surgery (odds ratio 13.8 (95% CI 6.2–33.7). The 1-year mortality was strongly reduced with surgery in the fixed-effect propensity-adjusted Cox model (hazard ratio 0.18; 95% CI 0.11–0.27; p < 0.001). These effects remained whether the patients received delayed surgery ( n = 62/125) or not and whether they were deeply comatose (Glasgow Coma Scale ≤ 10) or not. Conclusions In critically ill IE patients with an indication for surgery and previous cerebral events, a better propensity-adjusted neurological outcome was associated with surgery compared with medical treatment.

OBJECTIVES: The aim of this study was to investigate the impact of Valve Academic Research Consortium 3 minor access site vascular complications (VCs) in patients who underwent percutaneous transfemoral (TF) transcatheter aortic valve implantation (TAVI). METHODS: This single-centre retrospective study included consecutive patients who underwent percutaneous TF-TAVI from 2009 to 2021. A propensity score-matched analysis was performed to compare early and long-term clinical results between patients with VC and without VC (nVC). RESULTS: A total of 2161 patients were included, of whom 284 (13.1%) experienced access site VC. Propensity score analysis allowed to match 270 patients from the VC group with 727 patients from the nVC group. In the matched cohorts, the VC group showed longer operative times (63.5 vs 50.0 min, P < 0.001), higher operative and in-hospital mortality (2.6% vs 0.7%, P = 0.022; and 6.3% vs 3.2%, P = 0.040, respectively), longer hospital length of stay (8 vs 7 days, P = 0.001) and higher rates of blood transfusion (20.4% vs 4.3%, P < 0.001) and infectious complications (8.9% vs 3.8%, P = 0.003). Overall survival during follow-up was significantly lower in the VC group (hazard ratio 1.37, 95% CI 1.03-1.82, P = 0.031) with 5-year survival rates being 58.0% (95% CI 49.5-68.0%) and 70.7% (95% CI 66.2-75.5%) for the VC and nVC groups, respectively. CONCLUSIONS: This retrospective study observed that minor access site VCs during percutaneous TF-TAVI can be serious events affecting early and long-term outcomes.

(1) Background: Hyperglycaemia and hypoglycaemia are both emerging risk factors for cardiovascular disease. Nevertheless, the potential effect of glycaemic variability (GV) on mid-term major cardiovascular events (MACE) in diabetic patients presenting with acute heart failure (AHF) remains unclear. This study investigates the prognostic value of GV in diabetic patients presenting with acute heart failure (AHF). (2) Methods: this was an observational study including consecutive patients with diabetes and AHF between January 2015 and November 2016. GV was calculated using standard deviation of glycaemia values during initial hospitalisation in the intensive cardiac care unit. MACE, including recurrent AHF, new-onset myocardial infarction, ischaemic stroke and cardiac death, were recorded. The predictive effects of GV on patient outcomes were analysed with respect to baseline characteristics and cardiac status. (3) Results: In total, 392 patients with diabetes and AHF were enrolled. During follow-up (median (interquartile range) 29 (6–51) months), MACE occurred in 227 patients (57.9%). In total, 92 patients died of cardiac causes (23.5%), 107 were hospitalised for heart failure (27.3%), 19 had new-onset myocardial infarction (4.8%) and 9 (2.3%) had an ischaemic stroke. Multivariable logistic regression analysis showed that GV > 50 mg/dL (2.70 mmol/L), age > 75 years, reduced left ventricular ejection fraction (LVEF < 30%) and female gender were independent predictors of MACE: hazard ratios (HR) of 3.16 (2.25–4.43; p < 0.001), 1.54 (1.14–2.08; p = 0.005), 1.47 (1.06–2.07; p = 0.02) and 1.43 (1.05–1.94; p = 0.03), respectively. (4) Conclusions: among other well-known factors of HF, a GV cut-off value of >50 mg/dL was the strongest independent predictive factor for mid-term MACE in patients with diabetes and AHF.

We developed a detailed imaging phenotype of the cerebral complications in critically ill patients with infective endocarditis (IE) and determine whether any specific imaging pattern could impact prognostic information. One hundred ninety-two patients admitted to the intensive care units of seven tertiary centers with severe, definite left IE and neurological complications were included. All underwent cerebral imaging few days after admission to define the types of lesions, their volumes, and their locations using voxel-based lesion-symptom mapping (VLSM). We employed uni- and multi-variate logistic regression analyses to explore the associations among imaging features and other prognostic variables and the 6-month modified Rankin Scale (mRS) score. Ischemic lesions were the most common lesions (75%; mean volume, 15.3 ± 33 mL) followed by microbleeds (50%; mean number, 4 ± 7.5), subarachnoidal hemorrhages (20%), hemorrhagic strokes (16%; mean volume, 14.6 ± 21 mL), and hemorrhagic transformations (10%; mean volume, 5.6 ± 11 mL). The volume of hemorrhagic transformations, the severity of leukopathy, and the compromises of certain locations on the motor pathway from the VLSM were associated with a poor 6-month mRS score on univariate analyses. However, upon multivariate analyses, no such specific imaging pattern independently predicted the mRS; this was instead influenced principally by age (OR = 1.03 [1.004–1.06]) and cardiac surgery status (OR = 0.06 [0.02–0.16]) in the entire cohort, and by age (OR = 1.04 [1.01–1.08]) and Staphylococcus aureus status (OR = 2.86 [1.19–6.89]) in operated patients. In a cohort of severely ill IE patients with neurological complications, no specific imaging pattern could be highlighted as a reliable predictor of prognosis.

Background: Acute glucose fluctuations are associated with hypoglycaemia and are emerging risk factors for cardiovascular outcomes. However, the relationship between glycaemic variability (GV) and the occurrence of mid-term major cardiovascular events (MACE) in diabetic patients remains unclear. This study investigates the prognostic value of GV in diabetic patients with acute heart failure (AHF). Methods: This was an observational study including consecutive patients with diabetes and AHF between January 2015 and November 2016. GV was assessed using standard deviation of glycaemia values during initial hospitalization in intensive cardiac care unit. MACE, including recurrent AHF, new-onset myocardial infarction, ischemic stroke and cardiac death, were recorded. The predictive effects of GV on patient outcomes were analysed with respect to baseline characteristics and cardiac status. Results: A total of 392 patients with diabetes and AHF were enrolled. During follow-up median [(interquartile range) 29 (6-51) months], MACE occurred in 227 patients (57.9%). 92 patients died (23.5%) of cardiac causes, 107 were hospitalized for heart failure (27.3%), 19 had new-onset myocardial infarction (4.8%), and 9 (2.3%) had an ischemic stroke. Multivariable logistic regression analysis showed that GV >50 mg/dL (2.70 mmol/L), Age >75 years, reduced left ventricular ejection fraction (LVEF <30%) and female gender were independent predictors of MACE: Hazard Ratios (HR) of 3.16 [2.25-4.43; p<0.001], 1.54 [1.14-2.08; p=0.005], 1.47 [1.06-2.07; p=0.02] and 1.43 [1.05-1.94; p=0.03], respectively. Conclusions: Among other well-known factors of HF, a GV cut-off value of >50 mg/dL was the strongest independent predictive factor for mid-term MACE in patients with diabetes and AHF.

A 52-year-old male was referred for an acute anterior ST-segment elevation myocardial infarction (STEMI). Coronary angiography revealed an acute left anterior descending artery occlusion. The patient was treated with a drug-eluting stent (DES). Despite long and repeated high-pressure inflations (>20 atm) of non-compliant balloons, OPN NCⓇ high-pressure balloon (SIS Medical AG; Frauenfeld, Switzerland), rotational atherectomy, and cutting balloon, there was a severe hourglass stent underexpansion caused by coronary calcification. Thus, intravascular lithotripsy (IVL) (Shockwave Medical, Fremont, CA, USA) was attempted to re-dilate this calcified lesion. Underexpansion was successfully treated after delivering 70 shockwaves to the narrowest segment. IVL delivers localized pulsatile sonic pressure waves inducing circumferential calcium modification and multiple fractures. Our observation illustrates the additional value of coronary lithotripsy as a bail-out procedure to tackle severely calcified, de novo coronary lesions causing stent underexpansion in the context of STEMI, when all other available techniques failed.

OBJECTIVES Among all patients presenting with myocardial infarction with nonobstructive coronary arteries (MINOCA), epicardial causes may be suspected when there is a correlation between electrocardiogram (ECG) changes and regional wall motion abnormalities (WMAs). We evaluated the diagnostic yield of intravascular optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) in this specific setting. BACKGROUND OCT is able to identify different morphologic features of coronary plaques that are well known causes of MINOCA. Furthermore, CMR has become the gold standard for detection of myocardial infarction in the setting of MINOCA. METHODS In a prospective 2-center study, consecutive patients with MINOCA including ECG features of ischemia associated with corresponding WMAs underwent OCT and CMR. RESULTS Forty patients (mean age: 50 +/- 11 years, 62.5% male, 32.5% with ST-segment elevation) were enrolled. Coronary arteries were normal on coronary angiography in 10 patients (25%); 18 patients (45%) presented minimal lumen irregularities, whereas the remaining 12 patients (30%) showed mild to moderate ($30% but <50%) coronary lesions. Plaque rupture, eruptive calcific nodule, plaque erosion, lone thrombus, and spontaneous coronary artery dissection were found in 14 (35%), 1 (2.5%), 12 (30%), 3 (7.5%), and 2 (5%) patients, respectively. Acute myocardial infarction was evident at CMR in 31 of 40 patients (77.5%). Twenty-three patients (57.5%) had a substrate and/or diagnosis supported by both techniques with an evident relationship between the findings obtained by the 2 techniques. By coupling OCT with CMR, a substrate and/or diagnosis was found in 100% of cases. CONCLUSIONS OCT coupled with CMR can provide a clear substrate and/or diagnosis in the vast majority of patients presenting with MINOCA including ECG features of ischemia associated with corresponding WMAs. (C) 2020 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.

Intensive Cardiology Care Unit — Interventional Cardiology, Hôpital Cardiologique du Haut Lévêque, Bordeaux University Hospital, Pessac, France Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA Medico-Surgical Department (Valvulopathies, Cardiac Surgery, Adult Structural Interventional Cardiology), Hôpital Cardiologique du Haut-Lévêque, Bordeaux University Hospital, Pessac, France

Impella for cardiogenic shock Monocentric cohort of 112 patients supported with an Impella device (2011-2017) At implantation, patients were : INTERMACS I 68, INTERMACS II 42 ,INTERMACS III 8 32 patients had ECMO first Mean support: 6,7 days (max 22) ![Figure][1] ![Figure][1] ![

Percutaneous edge-to-edge repair using MitraClip (R) (Abbott Laboratories, Abbott Park, IL, USA) can be used to treat mitral regurgitation. However, real-time echocardiographic guidance is vital; and use of 3D transoesophageal echocardiography to guide the procedure has improved reproducibility, reliability and safety. This review describes the MitraClip (R) device - which is composed of a steerable guide catheter (SGC) and a Clip Delivery System (CDS) - and the MitraClip (R) procedure. The procedure consists of six steps: (1) transseptal approach and puncture; (2) introduction of the SGC into the left atrium; (3) navigation with the CDS into the left atrium to place the MitraClip (R) above the mitral valve; (4) crossing the valve and advancing the CDS into the left ventricle; (5) grasping the leaflets and assessment of the quality of the grasping; and (6) final mitral regurgitation assessment. This review also describes which imaging techniques are applicable to each stage of the procedure; and contains examples of the various images obtained during these steps. (C) 2018 Published by Elsevier Masson SAS.

Gouffran et al. previously showed that the incidence of stent thrombosis (ST) in out-hospital cardiac arrest (OHCA) patients treated by primary percutaneous coronary intervention is high and associated with poor clinical outcome, even in patients receiving new oral P2Y12 inhibitors, such as ticagrelor or prasugrel [1]. Alterations in platelet reactivity and pharmacokinetics of antiplatelet agents may predispose to ST in such patients [2]. Indeed, this effect might be partially explainable by the impaired or delayed absorption of those drugs induced by gastroparesis [3].