Aims Although some scores based on traditional statistical methods are available for risk stratification in patients hospitalized in cardiac intensive care units (CICUs), the interest of machine learning (ML) methods for risk stratification in this field is not well established. We aimed to build an ML model to predict in-hospital major adverse events (MAE) in patients hospitalized in CICU. Methods and results In April 2021, a French national prospective multicentre study involving 39 centres included all consecutive patients admitted to CICU. The primary outcome was in-hospital MAE, including death, resuscitated cardiac arrest, or cardiogenic shock. Using 31 randomly assigned centres as an index cohort (divided into training and testing sets), several ML models were evaluated to predict in-hospital MAE. The eight remaining centres were used as an external validation cohort. Among 1499 consecutive patients included (aged 64 +/- 15 years, 70% male), 67 had in-hospital MAE (4.3%). Out of 28 clinical, biological, ECG, and echocardiographic variables, seven were selected to predict MAE in the training set (n = 844). Boosted cost-sensitive C5.0 technique showed the best performance compared with other ML methods [receiver operating characteristic area under the curve (AUROC) = 0.90, precision-recall AUC = 0.57, F1 score = 0.5]. Our ML score showed a better performance than existing scores (AUROC: ML score = 0.90 vs. Thrombolysis In Myocardial Infarction (TIMI) score: 0.56, Global Registry of Acute Coronary Events (GRACE) score: 0.52, Acute Heart Failure (ACUTE-HF) score: 0.65; all P < 0.05). Machine learning score also showed excellent performance in the external cohort (AUROC = 0.88). Conclusion This new ML score is the first to demonstrate improved performance in predicting in-hospital outcomes over existing scores in patients admitted to the intensive care unit based on seven simple and rapid clinical and echocardiographic variables. Trial Registration ClinicalTrials.gov Identifier: NCT05063097.

Introduction: The risk stratification at admission to the intensive cardiac care unit (ICCU) is crucial and remains challenging. Objectives: We aimed to investigate the accuracy of a machine learning (ML)-model based on initial transthoracic echocardiography (TTE) to predict in-hospital major adverse events (MAEs) in a broad spectrum of patients admitted to ICCU. Methods: All consecutive patients hospitalized in ICCUs with a complete TTE performed within the first 24 hours of admission were included in this prospective multicenter study (39 centers). Sixteen TTE parameters were evaluated. The ML model involved automated feature selection by random survival forest and model building with an extreme gradient boosting (XGBoost) algorithm. The primary outcome was in-hospital MAEs defined as all-cause death, resuscitated cardiac arrest, or cardiogenic shock. Results: Of 1,499 consecutive patients (63 6 15 years, 70% male), MAEs occurred in 67 patients (4.5%). The 5 TTE parameters selected in the model were left ventricular outflow tract velocity-time integral, E/e' ratio, systolic pulmonary artery pressure, tricuspid annular plane systolic excursion, and left ventricular ejection fraction. Using the XGBoost, the ML model exhibited a higher area under the receiver operating curve compared with any existing scores (ML model, 0.83 vs logistic regression, 0.76, ACUTE-HF score:,0.66; thrombolysis in myocardial infarction score, 0.60; Global Registry of Acute Coronary Events score, 0.58, all P < .001). The ML model had an incremental prognostic value for predicting MAE over a traditional model including clinical and biological data (C index 0.80 vs 0.73, P = .012; chi-square 59.7 vs 32.4; P < .001). Conclusion: The ML model based on initial TTE exhibited a higher prognostic value to predict in-hospital MAEs compared with existing scores or clinical and biological data in the ICCU.

PURPOSE:International guidelines recommend invasive coronary angiography (ICA) or coronary computed tomography angiography (CCTA) before surgery for infective endocarditis (IE). Given the low level of evidence for this recommendation, we aimed to assess the impact of coronary evaluation in this context. METHODS:This multicenter retrospective study included adult patients diagnosed with IE who underwent cardiac surgery, and whose coronary status was considered unknown at the time of IE diagnosis. Patients were divided in two groups: those who underwent a coronary evaluation (C group) and those who did not (NC group). The primary endpoint was to determine the prevalence of coronary evaluation during the preoperative workup for IE. Secondary endpoints included the safety of coronary evaluation, the prevalence of coronary revascularization, and the one-year post-operative prognosis. RESULTS:323 patients were included, with 43% in the NC group and 57% in the C group (ICA for 149 patients, CCTA for 35 patients). Coronary evaluation found no lesion, non-significant coronary artery disease (CAD), and significant CAD in 51.1%, 28.8%, and 20.1% of cases, respectively. Thirteen patients underwent coronary artery bypass graft during the IE surgery. Tolerability of ICA was excellent: no embolic events and no additional renal toxicity. CONCLUSION:While coronary evaluation was recommended for almost all patients, it was only performed in just over half of the cases. Preoperative coronary assessment remains useful and safe, but should probably not delay urgent valvular surgery.

OBJECTIVES:The estimation of systolic pulmonary artery pressure (sPAP) by transthoracic echocardiography (TTE) is challenging in patients with severe tricuspid regurgitation (TR). The study aimed to determine the reliability of the assessment of sPAP by TTE in this population. METHODS:This study was a single-centre analysis of consecutive patients at the University Hospital of Rennes with right heart catheterisation and TTE, performed with a maximum delay of 48 hours. Lin's concordance coefficient (LCC) and Bland-Altman analysis were used to compare the values. RESULTS:After applying the exclusion criteria, 236 patients were included in the analysis (age 71±11.5 years old; male 56%). The two principal indications were TR (34.3%) and mitral regurgitation (32.2%). The correlation between the two procedures was good in the total population (LCC=0.80; 95% limits of agreement (LOA): 0.74, 0.84), but weaker in the 78 patients (33%) with severe TR (LCC=0.67; 95% LOA: 0.49, 0.80), with a propensity to an underestimation by TTE. An elevated right atrial pressure (RAP) was associated with an underestimation by TTE of about 8 mmHg. The presence of a 'V-wave cut-off' sign on continuous-wave Doppler (OR=3.74; 95% CI 1.48, 9.30; p<0.01), found exclusively in patients with severe TR, was an independent predictor of sPAP misestimation by TTE. CONCLUSION:The reliability of the estimation of sPAP in patients with severe TR could be altered by high RAP which cannot be estimated with current thresholds.

Background: The influence of permanent pacemaker implantation upon outcomes after transcatheter aortic valve implantation (TAVI) remains controversial. Aims: To evaluate the impact of permanent pacemaker implantation after TAVI on short- and long-term mortality, and on the risk of hospitalization for heart failure. Methods: Data from the large FRANCE-TAVI registry, linked to the French national health single -payer claims database, were analysed to compare 30 -day and long-term mortality rates and hospitalization for heart failure rates among patients with versus without permanent pacemaker implantation after TAVI. Multivariable regressions were performed to adjust for confounders. Results: A total of 36,549 patients (mean age 82.6 years; 51.6% female) who underwent TAVI from 2013 to 2019 were included in the present analysis. Among them, 6999 (19.1%) received permanent pacemaker implantation during the index hospitalization, whereas 232 (0.6%) underwent permanent pacemaker implantation between hospital discharge and 30 days after TAVI, at a median of 11 (interquartile range: 7-18) days. In -hospital permanent pacemaker implantation was not associated with an increased risk of death between discharge and 30 days (adjusted odds ratio: 0.91, 95% confidence interval: 0.64-1.29). At 5 years, the incidence of all -cause death was higher among patients with versus without permanent pacemaker implantation within 30 days of the procedure (adjusted hazard ratio: 1.13, 95% confidence interval: 1.07-1.19). Permanent pacemaker implantation within 30 days of TAVI was also associated with a higher 5 -year rate of hospitalization for heart failure (adjusted subhazard ratio: 1.17, 95% confidence interval: 1.11-1.23). Conclusions: Permanent pacemaker implantation after TAVI is associated with an increased risk of longterm hospitalization for heart failure and all -cause mortality. Further research to mitigate the risk of postprocedural permanent pacemaker implantation is needed as TAVI indications expand to lower -risk patients. (c) 2024 Elsevier Masson SAS. All rights reserved.

AIMS:Unprotected left main coronary artery (ULMCA) occlusion is a rare and disastrous condition with scarce data on presentation and outcomes. Herein, we report data on patients presenting with acute coronary syndrome due to ULMCA occlusion at four different institutions.METHODS:This is an international multicentre observational study. Baseline characteristics were retro- and prospectively collected. Clinical follow-up was prospective. The primary outcome was in-hospital death. Patients surviving the index hospitalization were compared with nonsurvivors to find predictors of survival.RESULTS:The study population consisted of 55 patients. Eight patients (15%) died in the cath lab, and 23 (42%) died in hospital. Three (6%) deaths were noncardiac and due to major bleeding. Thirty-two (58%) patients survived the index hospitalization and were discharged. These patients were followed for a median of 17.5 months during which three cardiac deaths occurred. Repeat revascularization was performed in 25% (n = 8). Overall mortality at maximum follow-up was 47% (n = 26). The only significant predictor for hospital survival was left ventricular ejection fraction (odds ratio [OR]: 1.10 (per 1 point increase); 95% confidence interval [CI]: 1.02-1.19; p = 0.02).CONCLUSION:ULMCA occlusion carries a high short-term mortality. Patients who survive index hospitalization have similar mortality rates as compared with other st elevation myocardial infarction patients.

New-onset conduction disturbances, including left bundle branch block and permanent pacemaker implantation, remain a major issue after transcatheter aortic valve implantation. Preprocedural risk assessment in current practice is most often limited to evaluation of the baseline electrocardiogram, whereas it may benefit from a multimodal approach, including ambulatory electrocardiogram monitoring and multidetector computed tomography. Physicians may encounter equivocal situations during the hospital phase, and the management of follow-up is not fully defined, despite the publication of several expert consensuses and the inclusion of recommendations regarding the role of electrophysiology studies and postprocedural monitoring in recent guidelines. This review provides an overview of current knowledge and future perspectives regarding the management of new-onset conduction disturbances in the setting of transcatheter aortic valve implantation, from the preprocedural phase to long-term follow-up.

Background: Psychoactive drugs, including illicit drugs, are associated with an increased rate of cardio-vascular events. The prevalence and outcome of patients using these drugs at the time of admission to an intensive cardiac care unit is unknown.Aim: To assess the prevalence of psychoactive drugs detected in consecutive patients hospitalized in an intensive cardiac care unit for an acute cardiovascular event.Methods: This is a nationwide prospective multicentre study, involving 39 centres throughout France, including all consecutive patients hospitalized in an intensive cardiac care unit within 2 weeks. Psychoac-tive drug use will be assessed systematically by urine drug assay within 2 hours of intensive cardiac care unit admission, to detect illicit (cannabinoids, cocaine, amphetamines, ecstasy, heroin and other opioids) and non-illicit (barbiturates, benzodiazepines, tricyclic antidepressants, methadone and buprenorphine) psychoactive drugs. Smoking will be investigated systematically by exhaled carbon monoxide measure-ment, and alcohol consumption using a standardized questionnaire. In-hospital major adverse events, including death, resuscitated cardiac arrest and cardiogenic shock, will be recorded. After discharge, all-cause death and major adverse cardiovascular events will be recorded systematically and adjudicated at 12 months of follow-up.Results: The primary outcome will be the prevalence of psychoactive drugs detected by systematic screen -ing among all patients hospitalized in an intensive cardiac care unit. The in-hospital major adverse events will be analysed according to the presence or absence of detected psychoactive drugs. Subgroup analysis stratified by initial clinical presentation and type of psychoactive drug will be performed.Conclusions: This is the first prospective multicentre study to assess the prevalence of psychoactive drugs detected by systematic screening in consecutive patients hospitalized for acute cardiovascular events.(c) 2022 Published by Elsevier Masson SAS.

BACKGROUND:Conduction disturbances requiring permanent pacemaker implantation (PPI) remain a common complication of transcatheter aortic valve replacement (TAVR).OBJECTIVE:The purpose of this study was to determine the prognostic impact of PPI after TAVR according to the timing of implantation relative to TAVR.METHODS:A total of 1199 patients (median age 83 years; interquartile range 78-86 years; 549 [45.8%] female) were included in the analysis, of whom 894 (70.8%) had not undergone PPI, 130 (10.8%) had undergone previous PPI, 116 (9.7%) had undergone in-hospital PPI, and 59 (4.9%) had undergone PPI during follow-up. Median follow-up was 2.94 years (1.42-4.32 years). The primary outcome was the composite of all-cause mortality and hospitalization for heart failure.RESULTS:PPI during follow-up was associated with a higher occurrence of the primary outcome (hazard ratio [HR] 2.11; 95% confidence interval [CI] 1.39-3.20) whereas previous PPI and in-hospital PPI were not (HR 0.96; 95% CI 0.71-1.29 and HR 1.26; 95% CI 0.88-1.81, respectively). PPI during follow-up was associated with a higher risk of hospitalization for heart failure (sub-HR 3.21; 95% CI 2.02-5.11), while this relationship was only borderline significant for previous PPI (sub-HR 1.51; 95% CI 0.99-2.29). In contrast, there was no relationship between in-hospital PPI and the subsequent risk of hospitalization for heart failure.CONCLUSION:Previous PPI and in-hospital PPI had no long-term prognostic impact on the risk of all-cause mortality and hospitalization for heart failure, whereas PPI during follow-up was associated with a higher risk of hospitalization for heart failure. The present study questions the deleterious influence of periprocedural post-TAVR PPI, which has previously been suggested by certain studies.

Guerin, Annea; Peschanski, Nicolasb; Bedossa, Marca; Leurent, Guillaumea; Martins, Raphaël P.a Author Information

The aim of this study is to develop an automated deep-learning-based whole heart segmentation of ECG-gated computed tomography data. After 21 exclusions, CT acquired before transcatheter aortic valve implantation in 71 patients were reviewed and randomly split in a training (n = 55 patients), validation (n = 8 patients), and a test set (n = 8 patients). A fully automatic deep-learning method combining two convolutional neural networks performed segmentation of 10 cardiovascular structures, which was compared with the manually segmented reference by the Dice index. Correlations and agreement between myocardial volumes and mass were assessed. The algorithm demonstrated high accuracy (Dice score = 0.920; interquartile range: 0.906–0.925) and a low computing time (13.4 s, range 11.9–14.9). Correlations and agreement of volumes and mass were satisfactory for most structures. Six of ten structures were well segmented. Deep-learning-based method allowed automated WHS from ECG-gated CT data with a high accuracy. Challenges remain to improve right-sided structures segmentation and achieve daily clinical application.

Background. - Ventricular arrhythmias can be life-threatening complications of ST-segment elevation myocardial infarction (STEMI). Aims. - To describe the incidence, predictors and in-hospital impact of early ventricular arrhythmia (EVA, occurring < day 2 after STEMI) and late ventricular arrhythmia (LVA, occurring > day 2 after STEMI) in patients with STEMI. Methods. - Data from 13,523 patients enrolled in a prospective registry were analysed. Logistic and Cox regressions were performed to identify predictors of EVA, LVA and in-hospital all-cause mortality. Predictors of LVA were used to build a risk score. Results. - EVA occurred in 678 patients (5%), whereas 120 patients (0.9%) experienced LVA, at a median timing of 3 days after STEMI. EVA was associated with a significantly higher risk of all cause mortality (hazard ratio: 1.44, 95% confidence interval: 1.17-1.76; P = 0.001), whereas no association was observed with LVA (hazard ratio 0.86, 95% confidence interval 0.57-1.28; P = 0.45). Multivariable predictors of LVA were: age > 65 years; serum creatinine > 85 mu mol/L on admission; pulse pressure < 45 mmHg on admission; presence of a Q wave on admission electrocardiogram; Thrombolysis In Myocardial Infarction flow grade < 3 after percutaneous coronary intervention; and left ventricular ejection fraction < 45%. The score derived from these variables allowed the classification of patients into four risk categories: low (0-21); low to-intermediate (22-34); intermediate-to-high (35-44); and high (> 45). Observed LVA rates were 0.2%, 0.3%, 0.9% and 2.5%, across the four risk categories, respectively. The model demonstrated good discrimination (20-fold cross-validated c-statistic of 0.76) and adequate calibration (Hosmer-Lemeshow P = 0.23). Conclusions. - EVA is 5-fold more common than LVA in the setting of STEMI, and portends a higher risk of in-hospital all-cause mortality. LVA is mainly associated with the patient's baseline risk profile and surrogate markers of larger infarct size. We developed and internally validated a risk score identifying patients at high risk of LVA for whom early intensive care unit discharge may not be suitable. (c) 2021 Elsevier Masson SAS. All rights reserved.

Conduction disturbances remain common following transcatheter aortic valve implantation (TAVI). Aside from high-degree atrioventricular block (HAVB), their optimal management remains elusive. Invasive electrophysiological studies (EPS) may help stratify patients at low or high risk of HAVB allowing for an early discharge or permanent pacemaker (PPM) implantation among patients with conduction disturbances. We evaluated the safety and diagnostic performances of an EPS-guided PPM implantation strategy among TAVI recipients with conduction disturbances not representing absolute indications for PPM. All patients who underwent TAVI at a single expert center from June 2017 to July 2020 who underwent an EPS during the index hospitalization were included in the present study. False negative outcomes were defined as patients discharged without PPM implantation who required PPM for HAVB within 6 months of the initial EPS. False positive outcomes were defined as patients discharged with a PPM with a ventricular pacing percentage <1% at follow-up. A total of 78 patients were included (median age 83.5, 39% female), among whom 35 patients (45%) received a PPM following EPS. The sensitivity, specificity, positive and negative predictive values of the EPS-guided PPM implantation strategy were 100%, 89.6%, 81.5%, and 100%, respectively. Six patients suffered a mechanical HAVB during EPS and received a PPM. These 6 patients showed PPM dependency at follow-up. In conclusion, an EPS-guided PPM implantation strategy for managing post-TAVI conduction disturbances appears effective to identify patients who can be safely discharged without PPM implantation. (C) 2021 Elsevier Inc. All rights reserved.

Abstract Aims To evaluate the incidence, predictors, and impact of heart failure (HF) readmission within 1-year post-transcatheter aortic valve replacement (TAVR), and assess the effects of the prescription of guidelines-recommended therapies (i.e. renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists) at discharge on the risk of HF readmission and death. Methods and results Patients included in the TAVR registry of a single expert centre from 2009 to 2017 were analysed. Competing-risk and Cox regressions were performed to identify predictors of HF readmission and death. Among 750 patients, 102 (13.6%) were readmitted for HF within 1-year post-TAVR. The 30-day incidence of HF readmission was 6.6%, 53 patients (7.1%) experienced late readmissions (>30 days post-TAVR), and 17 (2.3%) had multiple readmissions. Independent predictors of HF readmission included diabetes mellitus, chronic lung disease, previous acute HF, grade III or IV aortic regurgitation, and pulmonary hypertension both at discharge from the index hospitalisation but not guidelines-recommended therapies. Overall, HF readmission did not significantly impact all-cause mortality (HR: 1.36, 95% CI: 0.99–1.85). However, late (HR: 1.90, 95% CI: 1.30–2.78) and multiple HF readmissions (HR: 2.10, 95% CI: 1.17–3.76) were significantly associated with all-cause mortality. Prescription of RAS inhibitors at discharge was associated with a lower rate of all-cause mortality, especially among patients receiving doses of 25–<50% (HR: 0.67, 95% CI: 0.48–0.94), and 75–100% (HR: 0.61, 95% CI: 0.37–0.98) of the optimal daily dose. Conclusion HF readmission is common within 1-year of TAVR. Late and multiple HF readmissions associate with an increased risk of long-term all-cause mortality. Baseline comorbidities (diabetes, chronic lung disease, previous acute HF) and echocardiographic findings at discharge (grade III or IV aortic regurgitation, pulmonary hypertension) identified patients at high-risk of HF readmission. Guidelines-recommended therapies did not significantly affect the 1-year risk of HF readmission. Funding Acknowledgement Type of funding source: None

Abstract Aims To describe the incidence, predictors, and in-hospital impact of early SVA (eSVA, occurring < day 2 post-STEMI) and late SVA (lSVA, occurring ≥ day 2 post-STEMI) in STEMI patients. To derive and internally validate a risk score to identify patients at high-risk of lSVA. Methods Data of 13523 patients enrolled in the ORBI registry were analysed. Logistic regression was performed to identify predictors of eSVA, lSVA, and in-hospital all-cause mortality. Predictors of lSVA were used to build a risk score. Results eSVA occurred in 678 patients (5%) whereas 120 patients (0.9%) experienced lSVA at a median timing of 3 days post-STEMI. eSVA associated with a significantly higher risk of all-cause mortality (adjusted OR:1.90, 95% CI: 1.39–2.61, p<0.001) whereas only a trend was observed with lSVA (adjusted OR: 1.69, 95% CI:0.91–3.13, p=0.09). Multivariable predictors of eSVA are listed in Table 1. Multivariable predictors of lSVA are listed in the Figure. The score derived from these variables allowed the classification of patients into four risk categories: low (0–21), low-to- intermediate (22–34), intermediate-to-high (35–44), and high (≥45). Observed lSVA rates were 0.2%, 0.4%, 0.8%, and 2.5%, across the four risk categories, respectively. The model demonstrated good discrimination (20-fold cross-validated c-statistic of 0.76) and adequate calibration (Hosmer-Lemeshow p=0.40). Conclusion eSVA are 5-fold more common than lSVA in the setting of STEMI, mainly associate with other early complications, and portends a 2-fold higher risk of in-hospital mortality. Moreover, we developed a risk score identifying patients at high risk of lSVA for whom early ICU discharge may not be suitable. Funding Acknowledgement Type of funding source: None

Background: Heart failure (HF) readmission is common post–transcatheter aortic valve replacement (TAVR). Nonetheless, limited data are available regarding its predictors and clinical impact. This study evaluated the incidence, predictors, and impact of HF readmission within 1-year post-TAVR, and assessed the effects of the prescription of HF therapies at discharge on the risk of HF readmission and death. Methods: Patients included in the TAVR registry of a single expert center from 2009 to 2017 were analyzed. Competing-risk and Cox regressions were performed to identify predictors of HF readmission and death. Results: Among 750 patients, 102 (13.6%) were readmitted for HF within 1-year post-TAVR. Overall, 53 patients (7.1%) experienced late readmissions (>30 days post-TAVR), and 17 (2.3%) had multiple readmissions. In ≈30% of readmissions, no trigger could be identified. Predominant causes of readmissions were changes in medication/nonadherence and supraventricular arrhythmia. Independent predictors of HF readmission included diabetes mellitus, chronic lung disease, previous acute HF, grade III or IV aortic regurgitation, and pulmonary hypertension both at discharge from the index hospitalization but not HF therapies. Overall, HF readmission did not significantly impact all-cause mortality (hazard ratio [HR], 1.36 [95% CI, 0.99–1.85]). However, late (HR, 1.90 [95% CI, 1.30–2.78]) and multiple HF readmissions (HR, 2.10 [95% CI,1.17–3.76]) were significantly associated with all-cause mortality. Prescription of renin-angiotensin system inhibitors at discharge was associated with a lower rate of all-cause mortality, especially among patients receiving doses of 25% to <50% (HR, 0.67 [95% CI, 0.48–0.94]) and 75% to 100% (HR, 0.61 [95% CI, 0.37–0.98]) of the optimal daily dose. Conclusions: HF readmission is common within 1-year of TAVR. Late and multiple HF readmissions associate with an increased risk of long-term all-cause mortality. Baseline comorbidities (diabetes, chronic lung disease, previous acute HF) and echocardiographic findings at discharge (grade III or IV aortic regurgitation, pulmonary hypertension) identified patients at high risk of HF readmission.

Only few studies reported the outcomes of thrombolysis among elderly patients with ST-segment elevation myocardial infarction (STEMI), which results in a controversial benefit-risk ratio and a lower usage rate of thrombolysis in this population. The aim of the present study was to compare efficacy and safety of thrombolysis therapy with primary percutaneous coronary intervention (p-PCI) in patients aged ≥ 70 years old. Data from 2841 patients (mean age: 78.1 ± 5.6 years, female: 36.1%) included in a prospective multicenter registry, and who underwent either thrombolysis therapy (N = 269) or p-PCI (N = 2572), were analyzed. The primary endpoint was in-hospital major adverse cardio-vascular events (MACE) defined as the composite of all-cause mortality, non-fatal MI, stroke and definite stent thrombosis (ST). Secondary endpoints included all-cause death, BARC 3 or 5 major bleeding, net adverse clinical events (NACE) and the development of in-hospital Killip class III or IV heart failure. Propensity-score matching and conditional logistic regression were used to adjust for confounders. Within the matched cohort, rates of MACE was not statistically different between the thrombolysis (N = 247) and pPCI (N = 958) groups, (11.3% vs. 9.0% respectively, OR: 1.25, 95% CI: 0.81–1.94; P = 0.31). Secondary endpoints were comparable between groups at the exception of a significant difference for the development of Killip class III or IV heart failure in favor of the thrombolysis group (3.3% vs. 9.3%, OR: 0.38, 95% CI: 0.18–0.79; P = 0.01) (Fig 1). Thrombolysis may be a safe and effective strategy in selected elderly patients, which may reduce the development of severe heart failure without a higher major bleeding rate.

Aim: To assess the neurological prognosis of comatose survivors of cardiac arrest by early transcranial Doppler sonography (TCD). Methods: This was a prospective study performed between May 2016 and October 2017 in a medical intensive care unit (ICU) and a cardiac ICU of a university teaching hospital. All patients older than 18 years who were successfully resuscitated from an out-of-hospital cardiac arrest (OHCA) with persistent coma after the return of spontaneous circulation (ROSC) were eligible. We excluded patients for whom OHCA was associated with traumatic brain injury, no possibility of TCD measurements, or who were dead before establishing the neurological prognosis. We measured the pulsatility index (PI) and diastolic flow velocity (DFV) of the right and left middle cerebral arteries within 12 h after ICU admission. The lowest DFV and highest PI values were used for the statistical analysis. The neurological outcome at hospital discharge was evaluated by the cerebral performance category. Results: Forty-two patients were included in the final analysis: 15 had good and 27 poor neurological outcomes. The PI was higher in the poor outcome (1.49 vs. 1.12, p = 0.01) than good outcome group and the DFV was lower in the poor outcome group (17.3 cm s(-1) vs. 26.0 cm s(-1); p = 0.01). Conclusion: Data provided by early TCD after ROSC are associated with neurological outcome. The use of TCD could help guide interventions to improve cerebral perfusion after ROSC in patients resuscitated from OHCA.

Transfemoral approach stands as the reference access-route for transcatheter aortic valve implantation (TAVI). Nonetheless, alternatives approaches are still needed in a significant proportion of patients. This study aimed at comparing outcomes between transthoracic-approach (transapical or transaortic) and transarterial-approach (transcarotid or subclavian) TAVI. Data from 191 consecutive patients who underwent surgical-approach TAVI from May 2009 to September 2017 were analyzed. Patients were allocated in 2 groups according to the approach. The primary end point was the 30-day composite of death of any cause, need for open surgery, tamponade, stroke, major or life-threatening bleeding, stage 2 or 3 acute kidney injury, coronary obstruction, or major vascular complications. During the study period, 104 patients underwent transthoracic TAVI (transapical: 60.6%, transaortic: 39.4%) whereas 87 patients underwent transarterial TAVI (subclavian: 83.9%, transcarotid: 16.1%). Logistic EuroSCORE I tended to be higher in transthoracic-TAVI recipients. In-hospital and 30-day composite end point rates were 25.0% and 11.5% (p = 0.025), and 26.0% and 14.9% (p = 0.075) for the transthoracic and transarterial cohorts, respectively. Propensity score-adjusted logistic regression demonstrated no significant detrimental association between the 30-day composite end point and transthoracic access (odds ratio 2.12 95% confidence interval 0.70 to 6.42; p = 0.18). Transarterial TAVI was associated with a shorter length of stay (median: 6 vs 7 days, p <0.001). TAVI approach was not an independent predictor of midterm mortality. In conclusion, nontransfemoral transarterial-approach TAVI is safe, feasible, and associated with comparable rates of major perioperative complications, and midterm mortality compared with transthoracic-approach TAVI. (C) 2019 Elsevier Inc. All rights reserved.

Epidemiologic data about cardiogenic shock (CS) are still poor and focused on ischemic CS, forgetting all part of the CS encountered in clinical practice. FRENSHOCK registry (NCT02703038) was a large prospective multicenter registry of non-selected CS patients admitted in critical care units realized between April and October 2016 in France. Patients were included if they met the following three criteria: – low cardiac output defined by SBP < 90 mmHg and/or the need of amines, or a low cardiac output defined by CI < 2.2L/min/m2 (TTE or Swan–Ganz); – elevation of left and/or right heart pressures defined by clinic/radiology/biology/echocardiography/Swan-Ganz; – clinical and/or biological hypoperfusion. In total, 772 patients were included in 48 centers (male 72%, mean age of 66y). Comorbidities associated previous coronary revascularization 26%, peripheral arterial disease 15%, renal failure 21%, COPD 6%, diabetes 28%, tobacco 28%, dyslipidemia 35% and hypertension 47%. 56% were known for previous cardiomyopathy (30% ischemic, 10% idiopathic, 8% valvular). CS etiology often associated several triggers: ischemic was retained for 36% (type 1 infarction 17%). Non-ischemic trigger factors were predominant (64%): supra-ventricular (13%) and ventricular arrythmia (13%), infection (12%), iatrogenic (6%), conductive disorders (2%), non-observance (4%), and others (14%). At admission median SBP was 101.2 mmHg. Right heart failure signs were present in 49% and left signs in 72% (Killip IV 49%). Biological analysis found high lactate (3.0 mmol/L), renal (eGFR 49.6 ml/min) and hepatic alteration (ASAT 90.0 UI/ml; PT 57.1%). Median LVEF was 26.3% and TAPSE 13.4 mm. When realized (52%) coronarography was pathological in 81% (monotroncular 31%, bitroncular 35% and tritroncular 34%). A culprit lesion (79%) concern LVA 48%, RCA 23% and left main 15%. CS presentation and etiology are heterogeneous with a predominance of non-ischemic CS in practice.