AIMSThe radiation exposure resulting from cardiovascular procedures may increase the risk of cancer, and/or cause skin injury. Whether the novel cardiovascular automated radiation reduction X-ray system (CARS) can help reduce the patient radiation dose in daily clinical practice remains unknown. The aim of this study was to evaluate the reduction in patient radiation dose with the use of CARS in the cardiac catheterisation laboratory (CCL).METHODS AND RESULTSThis study retrospectively analysed 1,403 consecutives patients who underwent a cardiac catheterisation with coronary angiography (CA) and/or a percutaneous coronary intervention (PCI) in the Brest University Hospital over the course of one year. Patient radiation doses (dose area product and air kerma) were collected and compared between the CCL with (new CCL) and without (control CCL) CARS. Additionally, the patient radiation doses according to femoral versus radial access, procedural complexity and body mass index were compared. The radiation lesion position on the skin was assessed by automatically optimising the X-ray source to image distance (SID) and subsequently generating a radiation Dose-Map for those procedures exceeding 3 Gray of exposure. Overall, 447 patients underwent procedures in the control CCL and 956 in the new CCL. Baseline patient and procedural characteristics were similar between the two groups, with the exception of male gender and primary PCI, which were more prevalent in the new CCL group. Compared to the control CCL, the utilisation of the CARS in the new CCL resulted in a reduction of dose area product by 46% for CA, 56% for PCI alone and 54% for CA and PCI during the same procedure. Of note, radial access generated a higher radiation dose than femoral access (p<0.001). In this study, seven patients had an air kerma exceeding 3 Gray; however, only one patient had a skin dose greater than 3 Gray.CONCLUSIONSThe utilisation of the CARS resulted in a significant reduction in patient radiation doses compared to the control equipment. A real-time Dose-Map may help the operator change the projection during complex procedures to reduce the patient skin dose.

Previous coronary artery bypass grafting (CABG) increases operative risk in conventional valve replacement. Transcatheter aortic valve implantation (TAVI) has been shown to be successful in high-risk patient subgroups. The present study compared outcome and overall survival in patients who underwent TAVI with and without history of CABG. From January 2010 to December 2011, 683 of the 3,761 patients selected for TAVI in 34 French centers (18%) had a history of CABG. Outcomes (mortality and complications) were collected prospectively according to the Valve Academic Research Consortium (VARC) criteria. Patients with previous CABG were younger, with higher rates of diabetes and vascular disease and higher logistic European System for Cardiac Operative Risk Evaluation (29.8 +/- 16.4 vs 20.1 +/- 13.0, p <0.001) but lower rates of pulmonary disease. Two types of valve (Edwards SAPIEN and Medtronic CoreValve) were implanted in equal proportions in the 2 groups. The 30-day and 1-year mortality rates from all causes on Kaplan-Meier analysis (9.2% vs 9.7%, p = 0.71; and 19.0% vs 20.2%, p = 0.49, respectively) did not differ according to the history of CABG. There were no significant differences in the Valve Academic Research Consortium complications (myocardial infarction, stroke or vascular, and bleeding complications). On multivariate analysis, CABG was not associated with greater 1-year post-TAVI mortality. In conclusion, previous CABG did not adversely affect outcome in patients who underwent TAVI, which may be an alternative to surgery in high-risk patients with severe aortic stenosis and history of CABG. (C) 2015 Elsevier Inc. All rights reserved.

Aim: The aim of this study was to observe the effects of an early and low-dose atorvastatin treatment on the development of atherosclerotic plaques. The WHHL (Watanabe Heritable Hyperlipidemic) rabbit, an animal model spontaneously developing atherosclerotic plaques was used. The evolution of atherosclerosis was followed thanks to optical coherence tomography (OCT).

Martine Gilard,* Hélène Eltchaninoff,† Bernard Iung,‡ Patrick Donzeau-Gouge,§ Karine Chevreul,|| Jean Fajadet,¶ Pascal Leprince,# Alain Leguerrier,** Michel Lievre,†† Alain Prat,‡‡ Emmanuel Teiger,|| Thierry Lefevre,§ Dominique Himbert,‡ Didier Tchetche,¶ Didier Carrié,§§ Bernard Albat,|||| Alain Cribier,† Gilles Rioufol,## Arnaud Sudre,‡‡ Didier Blanchard,*** Frederic Collet,††† Pierre Dos Santos,‡‡‡ Nicolas Meneveau,§§§ Ashok Tirouvanziam,|||||| Christophe Caussin,¶¶¶ Philippe Guyon,### Jacques Boschat,* Herve Le Breton,** Frederic Collart,**** Remi Houel,†††† Stephane Delpine,‡‡‡‡ Geraud Souteyrand,§§§§ Xavier Favereau,|||||||| Patrick Ohlmann,¶¶¶¶ Vincent Doisy,#### Gilles Grollier,***** Antoine Gommeaux,††††† Jean-Philippe Claudel,‡‡‡‡‡ Francois Bourlon,§§§§§ Bernard Bertrand,|||||||||| Eric Van Belle,‡‡ Marc Laskar,¶¶¶¶¶ and for the France 2 (French Aortic National Corevalve and Edwards) Investigators

La maladie valvulaire aortique dégénérative constitue une pathologie dont l’incidence et la prévalence ne cessent de croître. Elle touche électivement une population âgée présentant souvent des antécédents lourds, notamment vasculaires, respiratoires, rénaux…Elle implique une prise en charge chirurgicale dont les résultats sont directement corrélés aux comorbidités du patient qui bénéficie du remplacement valvulaire aortique. Le remplacement valvulaire aortique transcathéter (TAVI) permet de proposer à ces malades à haut risque ou contre-indiqués à la chirurgie une alternative thérapeutique. Plus de 50 000 valves ont été implantées depuis la première implantation chez l’homme en 2002.

Background Preclinical studies and pilot clinical trials have shown that high-dose erythropoietin (EPO) reduces infarct size in acute myocardial infarction. We investigated whether a single high-dose of EPO administered immediately after reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) would limit infarct size.Methods A total of 110 patients undergoing successful primary coronary intervention for a first STEMI was randomized to receive standard care either alone (n = 57) or combined with intravenous administration of 1,000 U/kg of epoetin beta immediately after reperfusion (n = 53). The primary end point was infarct size assessed by gadolinium-enhanced cardiac magnetic resonance after 3 months. Secondary end points included left ventricular (LV) volume and function at 5-day and 3-month follow-up, incidence of microvascular obstruction (MVO), and safety.Results Erythropoietin significantly decreased the incidence of MVO (43.4% vs 65.3% in the control group, P = .03) and reduced LV volume, mass, and function impairment at 5-day follow-up (all P < .05). After 3 months, median infarct size (interquartile range) was 17.5 g (7.6-26.1 g) in the EPO group and 16.0 g (9.4-28.2 g) in the control group (P = .64); LV mass, volume, and function were not significantly different between the 2 groups. The same number of major adverse cardiac events occurred in both groups.Conclusions Single high-dose EPO administered immediately after successful reperfusion in patients with STEMI did not reduce infarct size at 3-month follow-up. However, this regimen decreased the incidence of MVO and was associated with transient favorable effects on LV volume and function. (Am Heart J 2012;163:200-207.e1.)

BACKGROUND:Transcatheter aortic-valve implantation (TAVI) is an emerging intervention for the treatment of high-risk patients with severe aortic stenosis and coexisting illnesses. We report the results of a prospective multicenter study of the French national transcatheter aortic-valve implantation registry, FRANCE 2.METHODS:All TAVIs performed in France, as listed in the FRANCE 2 registry, were prospectively included in the study. The primary end point was death from any cause.RESULTS:A total of 3195 patients were enrolled between January 2010 and October 2011 at 34 centers. The mean (±SD) age was 82.7±7.2 years; 49% of the patients were women. All patients were highly symptomatic and were at high surgical risk for aortic-valve replacement. Edwards SAPIEN and Medtronic CoreValve devices were implanted in 66.9% and 33.1% of patients, respectively. Approaches were either transarterial (transfemoral, 74.6%; subclavian, 5.8%; and other, 1.8%) or transapical (17.8%). The procedural success rate was 96.9%. Rates of death at 30 days and 1 year were 9.7% and 24.0%, respectively. At 1 year, the incidence of stroke was 4.1%, and the incidence of periprosthetic aortic regurgitation was 64.5%. In a multivariate model, a higher logistic risk score on the European System for Cardiac Operative Risk Evaluation (EuroSCORE), New York Heart Association functional class III or IV symptoms, the use of a transapical TAVI approach, and a higher amount of periprosthetic regurgitation were significantly associated with reduced survival.CONCLUSIONS:This prospective registry study reflected real-life TAVI experience in high-risk elderly patients with aortic stenosis, in whom TAVI appeared to be a reasonable option. (Funded by Edwards Lifesciences and Medtronic.).

Extracranial internal carotid artery stenosis is a risk factor for perioperative stroke in patients undergoing coronary artery bypass (CAB) surgery. Although both selective and nonselective methods of preoperative carotid screening have been advocated, it remains unclear if this screening is clinically relevant. Files of patients consecutively undergoing CAB were reviewed. Patients were retrospectively stratified into high- or low-risk groups according to risk factors for significant carotid stenosis and perioperative stroke identified in the literature: presence of peripheral vascular disease, carotid bruit, diabetes mellitus, age over 70 years and/or previous history of cerebrovascular disease. Prevalence of carotid stenosis detected by ultrasonography, surgical management, and perioperative stroke rates were determined in each group. 205 consecutive patients underwent preoperative carotid screening. The prevalence of significant carotid stenosis detected by ultrasonography was 5.8%. Univariate analysis confirmed that peripheral vascular disease (p = 0.005), carotid bruit (p = 0.003) and diabetes mellitus (p = 0.05) were significant risk factors for stenosis. Carotid stenosis was a risk factor for stroke (p = 0.03). Prevalence of carotid stenosis was higher in high-risk group than in low-risk group (9.1% vs 1.2%; p<0.05). All concomitant or staged carotid endarterectomies/CAB (5/205) and all patients who suffered perioperative strokes (5/205) were in the high-risk group (p = 0.01). In our cohort, selective screening of patients with either an age over 70, a carotid bruit, a history of cerebrovascular disease, a diabete mellitus or a peripheral vascular disease would have reduced the screening load by 40% with trivial impact on surgical management or neurologic outcomes.

La maladie coronaire athéromateuse se manifeste par une atteinte diffuse des vaisseaux coronaires avec des lésions plus ou moins sténosantes responsables de tableaux cliniques variés. Il est alors indispensable d’identifier et de quantifier ces lésions sur l’ensemble du réseau épicardique. Ce bilan nécessite, en raison du petit diamètre et de la mobilité de ces artères sinueuses, une bonne résolution temporelle et spatiale que possède la coronarographie conventionnelle. De plus, elle peut être suivie d’un geste thérapeutique d’angioplastie. Cependant, plus d’un tiers des coronarographies sont normales ou non suivi d’un geste d’angioplastie, ce qui ouvre une place pour un examen non invasif à la résolution spatiale et temporelle suffisante.

Background. - Extracranial internal carotid artery stenosis is a risk factor for perioperative stroke in patients undergoing coronary artery bypass surgery (CAB). Although selective and nonselective methods of preoperative carotid screening have been advocated, it remains unclear if this screening is clinically relevant.Aim. - To test whether selective carotid screening is as effective as non-selective screening in detecting significant carotid disease.Methods. - The case records of patients consecutively undergoing CAB were reviewed. Patients were stratified retrospectively into high- or low-risk groups according to risk factors for significant carotid stenosis and perioperative stroke: peripheral vascular disease (PVD), carotid bruit, diabetes mellitus, age >70 years and/or history of cerebrovascular disease. Prevalence of carotid stenosis detected by ultrasonography, surgical management and perioperative stroke rates were determined in each group.Results. - Overall, 205 consecutive patients underwent preoperative carotid screening. The prevalence of significant carotid stenosis was 5.8%. Univariate analysis confirmed that PVD (P=0.005), carotid bruit (P=0.003) and diabetes mellitus (P=0.05) were significant risk factors for stenosis. Carotid stenosis was a risk factor for stroke (P=0.03). Prevalence of carotid stenosis was higher in the high-risk group (9.1%) than the low-risk group (1.2%) (P<0.05). All concomitant or staged carotid endarterectomies/CAB (5/205) and all patients who had perioperative strokes (5/205) were in the high-risk group (P=0.01).Conclusion. - In our cohort, selective screening of patients aged >70 years, with carotid bruit, a history of cerebrovascular disease, diabetes mellitus or PVD would have reduced the screening load by 40%, with trivial impact on surgical management or neurological outcomes. (C) 2010 Published by Elsevier Masson SAS.

Background. Conventional coronary angiography (CA) is still recommended before valvular surgery. Preliminary studies suggest that multislice spiral computed tomography coronary angiography (MSCT-CA) can be used to rule out coronary artery disease (CAD).Aim. To assess prospectively the safety of ruling out CAD before surgery solely on the basis of normal MSCT-CA in patients with severe aortic valve disease.Methods. We included all consecutive patients scheduled for aortic valve surgery. We first estimated the calcium score (Agatston score equivalent [ASE]). Patients underwent injected MSCT if the ASE was < 1000. CA was cancelled when MSCT-CA quality was sufficient and showed no significant CAD. Our primary endpoint was the occurrence of perioperative myocardial infarction in patients who underwent surgery with no prior CA.Results. Between 1st July 2005 and 30th June 2008, we included 199 patients with severe aortic valve disease: 118 men (59%); mean age 69 +/- 12 years; 63 patients (32%) underwent CA directly because. the ASE was >= 1000. Of 136 patients who underwent MSCT-CA, 106 (78%) had a normal MSCT-CA and underwent aortic valve surgery without prior CA; CA was performed in 30 patients because of abnormal (n=18) or bad quality (n=12) MSCT-CA. One patient of the 106 (0.94%, 95% confidence interval 0.17-5.15) had a perioperative myocardial infarction.Conclusions. When the ASE is <1000, MSCT is safe and may be recommended instead of CA as a first-line means of ruling out CAD in patients with severe aortic valve disease. (C) 2010 Elsevier Masson SAS. All rights reserved.

Cardiovascular magnetic resonance imaging (MRI) has evolved over the last few years into a valuable tool for the diagnosis and management of cardiovascular diseases. Late gadolinium-enhanced MRI and stress myocardial perfusion MRI have been shown to be useful in detecting infarct tissue and in predicting myocardial viability and patient prognosis. The strengths of MRI lie in its ability to comprehensively image cardiac anatomy, function, perfusion, viability and physiology in ‘one-stop testing’ and to provide high-quality diagnostic information without the need for radiation. This article summarises the current clinical applications of MRI in interventional cardiology.

We evaluated the safety and efficacy of dual antiplatelet therapy, in association with oral anticoagulant (OAC) therapy, in patients undergoing percutaneous coronary intervention (PCI). The use of this triple therapy increases the rate of adverse outcomes, as shown by retrospective studies. In this first prospective multicenter registry STENTIng and oral antiCOagulation (STENTICO), all patients with OAC therapy undergoing PCI were included and followed up at 2 and 12 months. A total of 359 patients were included from 40 French centers. In 234 (65.2%; group 1) of these 359 patients, OAC therapy was discontinued (22 +/- 31 days). In 125 patients (34.8%; group 2), triple therapy was continued. The baseline characteristics were similar in the 2 groups. In group 2, a radial approach was more often used (65.6% vs 43.8%, p = 0.003), fewer drug-eluting stents were implanted (33.3% vs 24.8%, p = 0.06), and fewer anti-glycoprotein IIb/IIIa antagonists were prescribed (5.6% vs 8.5%, p = 0.02). The stroke rate did not differ significantly, at 3.0% (95% confidence interval 0.8% to 5.2%) for group 1 versus 0.8% (95% confidence interval -0.8% to 2.4%) in group 2. Severe and moderate bleeding, according to the Global Use of Strategies to Open Coronary Arteries (GUSTO) criteria, occurred in 2.1% and 6.4% of groups 1 and 2, respectively (p = 0.04). A significant difference in bleeding risk was found between the femoral and radial approaches (10.3% vs 3.8%, respectively; p = 0.01). In conclusion, adding dual antiplatelet therapy to pre-existing OAC therapy increases the post-PCI bleeding risk. Temporary discontinuation decreased this bleeding risk but tended to increase the risk of stroke. A radial approach for PCI could be a good alternative to the conventional femoral route to avoid bleeding.