Active cancer is associated with an increased risk of atrial fibrillation (AF), which varies depending on the pre-existing substrate (particularly in older patients), the cancer type and stage, and the anticancer therapeutics being taken. To date, studies have not been able to identify the individual contribution of each factor. During anticancer drug therapy, AF may occur with a frequency of ≈ 15–20% according to several factors, including the patient's baseline cardiovascular toxicity risk and the AF-detection strategies used. Many anticancer drugs have been associated with AF or AF reporting, both in terms of incident and recurrent AF, but robust data are lacking. Only bruton tyrosine kinase inhibitor associated AF (mainly ibrutinib) has a high level of evidence, with a ≈ 3–4-fold higher risk of AF. AF in patients with active cancer is associated with a twofold higher risk of systemic thromboembolism or stroke, and the “TBIP” (Thromboembolic risk, Bleeding risk, drug–drug Interactions, Patient preferences) structured approach must be used to evaluate the need for anticoagulation therapy. AF in patients with active cancer is also associated with a sixfold higher risk of heart failure, and optimal symptom control must be targeted, usually with rate-control drugs (beta-blockers), but a rhythm-control strategy may be proposed in patients remaining symptomatic despite optimal rate-control. AF is generally manageable, with the continuation of anticancer drugs (including ibrutinib); interruption of cancer drugs must be avoided whenever possible and weighed against the risk of cancer progression.

Background: Postoperative infections occur in approximately 10% of pediatric cardiac surgeries, involving Staphylococcus species in most cases. Nasal decontamination of Staphylococcus with mupirocin has been reported to reduce postoperative Staphylococcus infections after cardiac surgery in adults, but the effect of preoperative decontamination in children undergoing cardiac surgery has not been sufficiently studied to reach consensus.Methods: We conducted a single-center retrospective study to evaluate the impact of systematic preoperative decolonization with intranasal mupirocin application and skin-washing with chlorhexidine soap on postoperative Staphylococcus infection in children undergoing cardiac surgery. Our population was divided into three groups according to decolonization protocol (group N: no decolonization; group T: targeted decolonization in Staphylococcus aureus [SA] carriers only; and group S: systematic decolonization). Results: A total of 393 children were included between October 2011 and August 2015 (122 in group N, 148 in group T, and 123 in group S). The Staphylococcus infection rate significantly decreased in group S compared to group N (0.8% vs. 7.7%; p < 0.05) and tended to decrease in group S compared to group T (0.8% vs. 4.7%; p = 0.06). Systematic decontamination also significantly reduced the rate of infections starting from the skin (including surgical site infections and bloodstream infections) compared to targeted decolonization or lack of decolonization, but had no effect on the rate of pulmonary infections.Conclusion: The results of our study suggest that systematic preoperative skin and nasal decontamination, regardless of SA carriage status, could reduce the rate of postoperative Staphylococcus infections after cardiac surgery in children.(c) 2022 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

INTRODUCTION:Red blood cell (RBC) transfusion is often required during cardiac surgery in children. However, RBC is a rare product, and its transfusion is associated with adverse events and a worse surgical outcome. Characterization of factors related to RBC transfusion during cardiac surgery in children would provide prevention strategies.METHODS:We conducted a retrospective single-center study, including all children who underwent their first cardiac surgery using bloodless priming cardiopulmonary bypass (CPB).RESULTS:The study included 173 children between 2011 and 2019,; 57 had intraoperative transfusion and 17 postoperative transfusion. Age (OR: 0.76, p<0.001), weight (OR: 0.93, p<0.001), body mass index ([BMI] OR: 0.83, p<0.001), hemoglobin level (OR: 0.68, p<0.05), hematocrit level (OR: 0.88, p<0.05), mean corpuscular volume ([MCV] (OR: 0.86, p<0.001), hemodilution (OR: 100, p<0.01), and CPB duration (OR: 1.01, p<0.05) were associated with an increased risk of intraoperative transfusion in univariate analysis. In multivariate analysis, only CPB duration (OR: 1.02, p<0.001) and MCV (OR: 0.89, p<0.05) were associated with transfusion. Concerning postoperative transfusions, the RACHS surgical difficulty score (OR: 6.83, p<0.01), duration of CPB (OR: 1.01, p<0,001), length of stay in the PICU (OR: 2.37, p<0.001), length of hospitalization (OR: 1.2, p<0.001), and reoperation (OR: 20.59, p<0.001) were significant using univariate analysis, and only the need for a reoperation (OR: 19.16, p<0.01) remained significant in multivariate analysis.CONCLUSION:Low MCV appears to be one of the main risk factors for intraoperative transfusion in RBC. It may reflect iron deficiency that should be checked and supplemented preoperatively in order to reduce the risk of transfusion.

Background: The evolution of patients hospitalized with coronavirus disease 2019 (COVID-19) is still hard to predict, even after several months of dealing with the pandemic.Aims: To develop and validate a score to predict outcomes in patients hospitalized with COVID-19.Methods: All consecutive adults hospitalized for COVID-19 from February to April 2020 were included in a nationwide observational study. Primary composite outcome was transfer to an intensive care unit from an emergency department or conventional ward, or in-hospital death. A score that estimates the risk of experiencing the primary outcome was constructed from a derivation cohort using stacked LASSO (Least Absolute Shrinkage and Selection Operator), and was tested in a validation cohort.Results: Among 2873 patients analysed (57.9% men; 66.6 +/- 17.0 years), the primary outcome occurred in 838 (29.2%) patients: 551 (19.2%) were transferred to an intensive care unit; and 287 (10.0%) died in-hospital without transfer to an intensive care unit. Using stacked LASSO, we identified 11 variables independently associated with the primary outcome in multivariable analysis in the derivation cohort (n = 2313), including demographics (sex), triage vitals (body temperature, dyspnoea, respiratory rate, fraction of inspired oxygen, blood oxygen saturation) and biological variables (pH, platelets, C-reactive protein, aspartate aminotransferase, estimated glomerular filtration rate). The Critical COVID-19 France (CCF) risk score was then developed, and displayed accurate calibration and discrimination in the deriva-tion cohort, with C-statistics of 0.78 (95% confidence interval 0.75-0.80). The CCF risk score performed significantly better (i.e. higher C-statistics) than the usual critical care risk scores.Conclusions: The CCF risk score was built using data collected routinely at hospital admission to predict outcomes in patients with COVID-19. This score holds promise to improve early triage of patients and allocation of healthcare resources.(c) 2022 Published by Elsevier Masson SAS.

Background. & mdash; The coronavirus disease 2019 (COVID-19) pandemic has led to a public health crisis. Only limited data are available on the characteristics and outcomes of patients hospitalized for COVID-19 in France. Aims. & mdash; To investigate the characteristics, cardiovascular complications and outcomes of patients hospitalized for COVID-19 in France. Methods. & mdash; The Critical COVID-19 France (CCF) study is a French nationwide study including all consecutive adults with a diagnosis of severe acute respiratory syndrome coronavirus 2 (SARSCov-2) infection hospitalized in 24 centres between 26 February and 20 April 2020. Patients admitted directly to intensive care were excluded. Clinical, biological and imaging parameters were systematically collected at hospital admission. The primary outcome was in-hospital death. Results. & mdash; Of 2878 patients included (mean +/- SD age 66.6 +/- 17.0 years, 57.8% men), 360 (12.5%) died in the hospital setting, of which 7 (20.7%) were transferred to intensive care before death. The majority of patients had at least one (72.6%) or two (41.6%) cardiovascular risk factors, mostly hypertension (50.8%), obesity (30.3%), dyslipidaemia (28.0%) and diabetes (23.7%). In multivariable analysis, older age (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.03 & minus; 1.06; P < 0.001), male sex (HR 1.69, 95% CI 1.11 & minus; 2.57; P = 0.01), diabetes (HR 1.72, 95% CI 1.12 & minus; 2.63; P = 0.01), chronic kidney failure (HR 1.57, 95% CI 1.02 & minus; 2.41; P = 0.04), elevated troponin (HR 1.66, 95% CI 1.11 & minus; 2.49; P = 0.01), elevated B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptide (HR 1.69, 95% CI 1.0004 & minus; 2.86; P = 0.049) and quick Sequential Organ Failure Assessment score >= 2 (HR 1.71, 95% CI 1.12 & minus; 2.60; P = 0.01) were independently associated with in-hospital death. Conclusions. & mdash; In this large nationwide cohort of patients hospitalized for COVID-19 in France, cardiovascular comorbidities and risk factors were associated with a substantial morbi-mortality burden. (c) 2021 Published by Elsevier Masson SAS.

BACKGROUND:Although cardiovascular comorbidities seem to be strongly associated with worse outcomes in patients with coronavirus disease 2019 (COVID-19), data regarding patients with preexisting heart failure are limited. AIMS:To investigate the incidence, characteristics and clinical outcomes of patients with COVID-19 with a history of heart failure with preserved or reduced ejection fraction. METHODS:We performed an observational multicentre study including all patients hospitalized for COVID-19 across 24 centres in France from 26 February to 20 April 2020. The primary endpoint was a composite of in-hospital death or need for orotracheal intubation. RESULTS:Overall, 2809 patients (mean age 66.4±16.9years) were included. Three hundred and seventeen patients (11.2%) had a history of heart failure; among them, 49.2% had heart failure with reduced ejection fraction and 50.8% had heart failure with preserved ejection fraction. COVID-19 severity at admission, defined by a quick sequential organ failure assessment score>1, was similar in patients with versus without a history of heart failure. Before and after adjustment for age, male sex, cardiovascular comorbidities and quick sequential organ failure assessment score, history of heart failure was associated with the primary endpoint (hazard ratio [HR]: 1.41, 95% confidence interval [CI]: 1.06-1.90; P=0.02). This result seemed to be mainly driven by a history of heart failure with preserved ejection fraction (HR: 1.61, 95% CI: 1.13-2.27; P=0.01) rather than heart failure with reduced ejection fraction (HR: 1.19, 95% CI: 0.79-1.81; P=0.41). CONCLUSIONS:History of heart failure in patients with COVID-19 was associated with a higher risk of in-hospital death or orotracheal intubation. These findings suggest that patients with a history of heart failure, particularly heart failure with preserved ejection fraction, should be considered at high risk of clinical deterioration.

Importance:Prescription drug spending in the US requires policy intervention to control costs and improve the value obtained from pharmaceutical spending. One such intervention is to apply cost-effectiveness evidence to decisions regarding drug coverage and pricing, but this intervention depends on the existence of such evidence to guide decisions.Objective:To characterize the availability and quality of cost-effectiveness studies for prescription drugs with the greatest Medicare Part D spending.Design, Setting, and Participants:In this national cross-sectional analysis, publicly available 2016 Medicare drug spending records were merged with 2016 US Food & Drug Administration Orange Book data and the Tufts Medical Center Cost-Effectiveness Analysis (CEA) Registry. All studies published through 2015 that evaluated the cost-effectiveness of the 250 drugs for which Medicare Part D spending was the greatest in US-based adult patient populations were included. Data were analyzed from September 2018 to June 2020.Main Outcomes and Measures:The presence and quality of published cost-effectiveness analyses for the 250 drugs for which Medicare Part D spending was greatest in 2016 were assessed based on the inclusion of key cost-effectiveness analysis elements and global ratings by independent reviewers for the Tufts CEA Registry.Results:Medicare Part D spending on the 250 drugs in the sample totaled $122.8 billion in 2016 (84.1% of total spending). Of these 250 drugs, 91 (36.4%) had a generic equivalent and 159 (63.6%) retained some patent exclusivity. There were 280 unique cost-effectiveness analyses for these drugs, representing data on 135 (54.0%) of the 250 drugs included and 67.0% of Part D spending on the top 250 drugs. The 115 drugs (46.0%) without cost-effectiveness studies accounted for 33.0% of Part D spending on the top 250 drugs. Of the 280 available studies, 128 (45.7%) were industry sponsored. A large proportion of the studies (250 [89.3%]) did not meet the minimum quality requirements.Conclusions and Relevance:In this cross-sectional study, a substantial proportion of 2016 Medicare Part D spending was for drugs with absent or low-quality cost-effectiveness analyses. The lack of quality analyses may present a challenge in efforts to develop policies addressing drug spending in terms of value.

BACKGROUND:Generic medications cost less than brand-name medications and are similarly effective, but brand-name medications are still prescribed. We evaluated patterns in generic cardiovascular medication fills and estimated the potential cost savings with increased substitution of generic for brand-name medications.METHODS:This was a cross-sectional study of cardiovascular therapies using the Medicare Part D database of prescription medications in 2017. We evaluated drug fill patterns for therapies with available brand-name and generic options. We determined the generic substitution ratio and estimated the potential savings with increased generic substitution at the national, state, and clinician level. We compared states with laws related to mandatory pharmacist generic substitution and patient consent for substitution.RESULTS:Of ≈$22.9 billion spent on cardiovascular drugs in Medicare Part D prescription programs in 2017, ≈$11.0 billion was spent on medications with both brand-name and generic options. Although only 2.4% of medication fills were for the brand-name choice, they made up 21.2% of total spending. Accounting for estimated brand-name rebates, generic substitution for these medications would save $641 million, including $135 million in costs shouldered by patients. Furthermore, the minority of clinicians with the lowest generic utilization was responsible for a large proportion of the potential cost savings.CONCLUSIONS:There are substantial potential cost savings from substituting brand-name medications with generic medications. These savings would be primarily driven by lower use of brand-name therapies by the minority of clinicians who prescribe them at increased rates.

Congenital heart disease (CHD) can lead to under vascularization of placenta, which can affect fetal development and subsequent neurological outcome. No data are currently available regarding neurodevelopmental outcome of children born to mothers with CHD. Characteristics of pregnancy, birth and neonatal period, items of neurodevelopment during infancy recorded in health book, need for speech therapist, physiotherapist, school helper and grade repetition were retrospectively collected in children under 10 years old born to CHD mothers followed up in 5 French congenital heart disease centres, and compared to a control population (children and brotherhood from mother consulting in 2 paediatric traumatology emergency rooms). Children under 7 years old of both groups were prospectively screened for neurodevelopmental trouble using the neurodevelopmental test developed by the “Haute Autorité de Santé” (HAS). One hundred and nineteen children from 83 CHD mothers and 122 children from 118 control mothers were included. Children from CHD mothers were born earlier (37.9 ± 2.6 vs. 39.3 ± 1.5 WA) and with a higher rate of prematurity (17.6 vs. 4.9%). They displayed lower birth weights (2910 ± 650 vs. 3370 ± 500 g), lower APGAR scores at 1 minute (8.6 ± 2.3 vs. 9.3 ± 1.5) and a smaller head circumference at 9 months (44.7 ± 1.4 vs. 45.3 ± 1.4 cm). There was no difference in the age of walking and head circumference at 24 months, as well as grade repetitions and need for speech therapist, physiotherapist, or school helper. The HAS neurodevelopmental test suspected trouble in 5.9% of children from CHD mothers and 11.5% of control children (NS). Despite increased prematurity and worse APGAR score, children from mothers with CHD appear not to show symptoms of neurodevelopment impairment in our study.

Background. - Branch pulmonary artery stenosis complicates the management of congenital heart diseases. Surgical branch pulmonary artery angioplasty is associated with a high reintervention rate. As an alternative, percutaneous or intraoperative branch pulmonary artery stents have been implanted to improve efficiency, but long-term evaluations are limited. Aim. - To describe the long-term evolution of branch pulmonary artery stents. Methods. - We conducted a retrospective cohort study at Tours University Hospital. All stents implanted by surgery or catheterization in branch pulmonary arteries with a minimum follow-up of 12 months and at least one catheterization control were included. The primary endpoint combined cardiovascular mortality, surgical or percutaneous reintervention for stent complication or new stent implantation. Results. - Between 2007 and 2017, 76 stents in 51 patients were included (62 stents implanted by surgery, 14 by catheterization). At implantation, the patients' mean age and weight were 4.7 years (interquartile range 4.2 years) and 17.3 kg (interquartile range 11.0 kg), respectively. Mean branch pulmonary artery minimum diameter was 4.1 +/- 2.1 mm (mean Z-score-4.9 +/- 2.9), and mean initial stent diameter was 9.1 +/- 3.1 mm. During a follow-up of 5.3 years (range 0-11.2 years), freedom from primary endpoint was 86.8% (95% confidence interval 79.6-94.8%) at 1 year, 71.5% (95% confidence interval 61.9-82.7%) at 5 years and 69.6% (95% confidence interval 59.6-81.2%) at 10 years. We did not identify any factors associated with major adverse cardiovascular events. Among stents without major adverse cardiovascular events, the mean branch pulmonary artery diameter Z-score at last evaluation had increased by +4.8 +/- 3.2 compared with the initial diameter (P < 0.001). After stent implantation, a median of 2 re-expansions were performed for each stent (range 0-7). Conclusions. - Stent implantation should offer a good long-term solution for branch pulmonary artery stenosis, although iterative re-expansions are required. (C) 2020 Elsevier Masson SAS. All rights reserved.

Several reports suggest that illicit drug use may be a major cause of acute myocardial infarction (AMI) independently of smoking habits, and associated with a poorer prognosis. We sought to determine the frequency of history of illicit drug use in an AMI population and its impact on short- and mid-term prognosis. Based on the administrative hospital-discharge database, we collected information for all patients treated with AMI between 2010 and 2018 in France. We identified patients with history of illicit drug use and the adverse outcomes were investigated during follow-up. Among 797,212 patients with ST-segment elevation myocardial infarction (STEMI) or non-STEMI (mean age 69 years, 66% male), 3827 patients (0.5%) had a known history of illicit drug use (cannabis, cocaine or opioid). Patients with illicit drug use were younger and had less comorbidities. They presented more frequently with STEMI and anterior localization compared to those with no history of illicit drug use. In univariate analysis, patients with illicit drug use had lower short-term mortality rates compared to those without history of illicit drug use: 4.9% vs 10.1% at one month (p<0.0001), respectively. However, this might be attributed to a younger age at the time of presentation. Using logistic multivariable analysis with adjustment on age, gender, other cardiovascular and non-cardiovascular comorbidities, type and localisation of MI and procedures of revascularization, history of illicit drug use was associated with a non-significant higher risk of death at one year (adjusted odds ratio OR 1.12 95% CI 0.98–1.29). This trend was supported by a significantly higher risk of death at one year in patients with a history of opioid use (OR 1.27 95% CI 1.04–1.29, p=0.01). In a large and systematic nationwide analysis of patients with AMI, history of illicit drug use was associated with a non-significant higher overall odds of mortality, which was significant among those with opioid use. Type of funding source: None

Abstract Background PCSK9 antibodies are novel potent and expansive lipid lowering agents that demonstrated clinical benefit in high risk patients. We hypothesized that optimization of dose and administration schedule, ideally adapted to the target population, could reduce costs while maintaining the clinical benefit. Objective To explore the relationship between LDL-Cholesterol (LDL-C) decrease by anti-PCSK9 monoclonal antibodies and several covariates such as drug dose, administration schedule, baseline LDL-C, population and statins. Methods We performed systematic review, meta-analysis and meta-regression of randomized controlled trials that compared alirocumab or evolocumab to placebo or no treatment and reported LDL-C decrease, with a minimum follow-up of 12 weeks and with a sample size of 30 patients or more. Electronic searches of MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov from inception to March 2019. We evaluated the quality of included studies and extracted aggregate data. We used random effect models and multivariate multilevel meta-regression to explore factors influencing LDL-C decrease. All analyses were performed with R. Results From 1479 references identified and screened on title/abstract, the full texts of 72 articles were screened. We included 32 studies (31 references.) Anti-PCSK9 mAbs decreased LDL-C by 53%, 95% CI (−56% to −50%), with no significant difference between the two drugs (p=0.07). In univariate meta-regressions, higher baseline LDL-C level, monthly administration, higher percentage of patients with high-dose statins were associated with a lower LDL-C decrease (p<0.0001, p=0.02 and p=0.006 respectively). Drug dose and population did not influence LDL-C decrease in univariate analysis, but with a significant statistical interaction between drug dose and administration schedule (p=0.03). In multivariate meta-regression, LDL-C decrease remained significantly and negatively influenced by baseline LDL-C level (p<0.0001) and the percentage of patients with high-dose statins (p=0.0009), and was significantly and positively influenced by drug dose (p<0.0001). Conclusion Alirocumab and evolocumab showed substantial LDL-C reductions in clinical trials, without significant differences in their biological efficacies. A higher baseline LDL-C, higher intensity of statin co-treatment and a lower dose seemed to negatively influence LDL-C decrease. Funding Acknowledgement Type of funding source: None

Background: Early identification of patients at risk for severe coronavirus disease 2019 (COVID-19) is a major issue to help clinicians optimise patient-flow management and allocation of healthcare resources. Methods: This retrospective, observational, multicentre study included all consecutive patients admitted to hospital with COVID-19 across 24 centres in France between February 26 and April 20, 2020. Comprehensive data, including clinical, biological, and imaging variables, were recorded at admission. The primary outcome was a composite of transfer to intensive care unit (ICU) or in-hospital death without transfer to ICU. Findings: Among 2878 patients (57·9% men, 67±17 years), the primary outcome occurred in 838 (29·3%) patients: 19·1% were transferred to ICU and 10·0% died in-hospital without transfer to ICU. Based on the derivation cohort (n=2105), 12 variables were independently associated with the primary outcome in the final model: demographics (age, sex), triage vitals (body temperature, Glasgow coma scale, dyspnoea, respiratory frequency, fraction of inspired oxygen), biological (platelets, C-reactive protein, aspartate aminotransferase, glomerular filtration rate), and imaging (degree of scanographic lesions) data. A risk-stratification score was developed that displayed accurate calibration and discrimination, with C-statistics of 0·80 (95% confidence interval 0·78 to 0·82) in the derivation cohort and 0·79 (95% confidence interval 0·75 to 0·83) in validation cohort. Interpretation: Using data from a multicentre series of patients with COVID-19, we identified independent predictors of severe COVID-19 in hospitalised patients, including clinical, biological, and imaging variables at admission. An accurate integrative risk score was developed and externally validated to optimise early triage of patients.Trial Registration: NCT04344327Funding Statement: None.Declaration of Interests: None.Ethics Approval Statement: The CCF study was declared to and authorised by the French data protection committee (Commission Nationale Informatique et Liberté, CNIL, authorisation n°2207326v0), and was conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Background and objective Chronic total occlusion (CTO) guidewire have been recently reported as an alternative to radiofrequency for perforating atretic pulmonary valve. Since procedure failures or perforation of the right ventricle still occurred with CTO, we tried to enhance the stability, steering, and pushability of the wire using a microcatheter in order to improve the safety and efficacy of the procedure. Methods We performed pulmonary valve perforation with CTO guidewire and microcatheter in five consecutive newborns with pulmonary atresia with intact ventricular septum (PA-IVS) under fluoroscopic and echocardiographic control. Results The valve was easily perforated at the first attempt for all patients. After perforation, the microcatheter positioned in the main pulmonary artery allowed the exchange of the CTO guidewire for a more flexible wire, avoiding lesion and facilitating manipulation in the distal pulmonary branch arteries. The pulmonary valve was then dilated with balloons of increasing size as usually performed. We did not experience any procedural or early complications. Blalock-Taussig shunt was performed in 2 children because of a persistent cyanosis, 4 and 10 days after perforation. Conclusions The combined use of a CTO guide and a microcatheter appears to be a safe and reliable technique for perforating the pulmonary valve of newborns with PA-IVS. Further procedures with this approach are needed to confirm this first experience.

Primary or secondary branch pulmonary artery (BPA) stenosis complicates the management of congenital heart diseases. Surgical pulmonary plasty is the gold standard treatment, but is associated with a low freedom from reintervention rate of 46% at 10 years [1]. As an alternative, percutaneous or intraoperative stents have been implanted to improve efficiency, but limited data are available concerning longterm outcome [2], [3], [4], [5]. We hypothesized that prognosis of intraoperative or percutaneous stent implantation in BPA stenosis is good with further re-expansion and limited complications. We conducted a retrospective cohort study at CHU de Tours. All stents implanted by surgery or catheterization in BPA with a minimum follow-up of 12 months and at least 1 catheterization control have been included. The primary endpoint was composite, combining cardiovascular mortality, surgical stent removing or percutaneous implantation of a new homolateral stent. Between February 2007 and December 2017, 76 stents in 51 patients were included (62 stents implanted by surgery, 14 by catheterization). At the time of implantation, patients had mean age and weight of 56.3 months (IQR 65.4) and 17.4 kgs (IQR 11.0) respectively. There was 68.4% of secondary stenosis. Mean BPA minimum size was 4.1 mm (mean Z-score of − 5.0), and mean initial stent diameter was 9.1 mm. During a mean follow-up of 5.3 years (range 0–11,2 years), freedom from primary endpoint was 86.8% (CI 79.6–94.8%) at 1 year, 78.9% (CI 70.2–88.6%) at 2 years, 71.5% (CI 61.9–82.7%) at 5 years and 69.6% (CI 59.6–81.2%) at 10 years (Fig. 1). Among surviving stents, mean BPA size Z-score at last evaluation was increase of +4.69 compared to initial size (P < 0.001) (Fig. 2). A lower BPA size at implantation seemed to be associated with a worse outcome of the stent (P < 0.05). Our results suggest that percutaneous or intraoperative stent implantation could constitute a good alternative to BPA plasty alone.

Immune thrombocytopenia (ITP) is a disease caused by autoimmune platelet destruction that can occur as a primary or secondary process. ITP is a diagnosis of exclusion with no confirmatory diagnostic test. Diagnostic bone marrow biopsy should be pursued in select cases, such as abnormalities on peripheral smear, abnormalwhite blood cell count or hemoglobin, or treatment- refractory ITP. Treatment for ITP should be initiated in patients with fewer than 30,000 platelets per microliter or significant bleeding. First- line treatment for primary ITP is high- dose dexamethasone, intravenous immunoglobulin, or anti- D immunoglobulin. Splenectomy should be deferred for at least six months in favor of treatments with lower morbidity.