There is great heterogeneity in lengths of stay in interventional cardiology but the number of outpatient procedures is increasing. The expected benefits of an outpatient procedure are numerous and non-inferiority of this strategy has been demonstrated. Proper selection of patients eligible for this treatment is essential to minimize the risks of unplanned hospitalization and early complications. It is based on clinical, medico-social and organizational criteria. Perfect management of the care pathway based on an organizational unit and a geographical unit is essential.

Il existe une grande hétérogénéité dans les durées de séjour en cardiologie interventionnelle mais le nombre de procédures ambulatoires augmentent. Les bénéfices attendus à une procédure ambulatoire sont nombreux et la non infériorité de cette stratégie a été démontrée. La bonne sélection des patients éligibles à cette prise en charge est indispensable pour minimiser les risques d'hospitalisation non prévue et de complications précoces. Elle s'appuie sur des critères cliniques, médico-sociaux et organisationnels. Une parfaite gestion du parcours de soins s'appuyant sur une cellule d'organisation et une unité géographique est indispensable.

Context Despite 20 years of improvement in acute coronary syndromes care, patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) remains a major clinical challenge with a stable incidence and mortality. While intra-aortic balloon pump (IABP) did not meet its expectations, percutaneous mechanical circulatory supports (pMCS) with higher hemodynamic support, large availability and quick implementation may improve AMICS prognosis by enabling early hemodynamic stabilization and unloading. Both interventional and observational studies suggested a clinical benefit in selected patients of the IMPELLA((R)) CP device within in a well-defined therapeutic strategy. While promising, these preliminary results are challenged by others suggesting a higher rate of complications and possible poorer outcome. Given these conflicting data and its high cost, a randomized clinical trial is warranted to delineate the benefits and risks of this new therapeutic strategy. Design The ULYSS trial is a prospective randomized open label, 2 parallel multicenter clinical trial that plans to enroll patients with AMICS for whom an emergent percutaneous coronar y inter vention (PCI) is intended. Patients will be randomized to an experimental therapeutic strategy with pre-PCI implantation of an IMPELLA((R)) CP device on top of standard medical therapy or to a control group undergoing PCI and standard medical therapy. The primary objective of this study is to compare the efficacy of this experimental strategy by a composite end point of death, need to escalate to ECMO, long-term left ventricular assist device or heart transplantation at 1 month. Among secondary objectives 1-year efficacy, safety and cost effectiveness will be assessed.

La coagulation intravasculaire disséminée est un syndrome caractérisé par un excès de génération de thrombine et de fibrine dans la circulation qui est associé à un mauvais pronostic. La survenue de thrombus intracardiaques dans ce contexte est rare et aggrave le pronostic.

Disseminated intravascular coagulation is a syndrome characterized by thrombin and fibrin generation which is associated with organ failure and death. Intracardiac thrombus may occur and further deteriorate prognosis. We report the case of a patient with massive intraventricular thrombus revealed by an acute ischemia of the upper left limb in a context of pulmonary adenocarcinoma complicated by a disseminated intravascular coagulation. We describe the diagnostic modalities and the fatal evolution.

L'anévrisme du sinus de Valsalva est une anomalie cardiaque rare qui peut être congénitale ou acquise dont la complication la plus fréquente est la rupture dans le ventricule droit ou l'oreillette droite et rarement vers les cavités gauches ou le péricarde. La rupture de l'anévrisme du sinus de Valsalva peut être symptomatique et bien tolérée mais parfois peut entraîner une instabilité hémodynamique grave, telle qu'une insuffisance cardiaque aiguë voire une mort subite.

Aneurysm of the sinus of Valsalva is a rare cardiac condition, which could be either acquired or congenital. The most frequent complication is a rupture into right cavities or more rarely into left cavities or pericardium. Rupture could be either asymptomatic or poorly tolerated with hemodynamic instability, acute heart failure or sudden death. We report the case of a 24-year-old patient with no past medical history presenting with a partially ruptured sinus of Valsalva into the pericardium and in whom the initial diagnosis was idiopathic pericardial effusion; we describe diagnostic modalities and management.

Impending paradoxical embolism is a biatrial thrombus in transit across a patent foramen ovale. It constitutes a rare clinical condition, possibly associated with multiple embolization and high mortality. We report the exceptional case of a 71-year-old-man presenting a giant impending paradoxical thrombus, complicated with pulmonary, cerebral, and coronary embolization. The patient underwent urgent surgery and was finally discharged without complications.

Chronic kidney disease (CKD) is associated with an increased risk of acute coronary syndrome (ACS) and cardiovascular death. CKD patients suffering from ACS are exposed to an increased risk of thrombotic recurrences and a higher bleeding rate than patients with normal renal function. However, CKD patients are excluded or underrepresented in clinical trials. Therefore, determining the optimal antiplatelet strategy in this population is of utmost importance. We designed the TicagRelor Or Clopidogrel in severe or terminal chronic kidney patients Undergoing PERcutaneous coronary intervention for acute coronary syndrome (TROUPER) trial: a prospective, controlled, multicenter, randomized trial to investigate the optimal P2Y12 antagonist in CKD patients with ACS. Patients with stage ≥3b CKD are eligible if the diagnosis of ACS is made and invasive strategy scheduled. Patients are randomized 1:1 between a control group with a 600-mg loading dose of clopidogrel followed by a 75-mg/d maintenance dose for 1 year and an experimental group with a 180-mg loading dose of ticagrelor followed by a 90-mg twice daily maintenance dose for the same duration. The primary end point is defined by the rate of major adverse cardiovascular events, including death, myocardial infarction, urgent revascularization, and stroke at 1 year. Safety will be evaluated by the bleeding rate (Bleeding Academic Research Consortium). To demonstrate the superiority of ticagrelor on major adverse cardiovascular events, we calculated that 508 patients are required. The aim of the TROUPER trial is to compare the efficacy of ticagrelor and clopidogrel in stage >3b CKD patients presenting with ACS and scheduled for an invasive strategy. RCT# NCT03357874.

OBJECTIVES:The aim of this study was to compare a delayed and a very early invasive strategy in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) without pre-treatment.BACKGROUND:The optimal delay of the invasive strategy in patients with NSTE-ACS remains debated and has never been investigated in patients not pre-treated with P2Y12-adenosine diphosphate receptor antagonists.METHODS:A prospective, open-label, randomized controlled trial was conducted. Altogether, 741 patients presenting with intermediate- or high-risk NSTE-ACS intended for an invasive strategy were included. The modified intention-to-treat analysis was composed of 709 patients after 32 withdrew consent. Patients were randomized 1:1 to the delayed invasive group (DG) (n = 363) with coronary angiography (CA) performed 12 to 72 h after randomization or the very early invasive group (EG) (n = 346) with CA within 2 h. No pre-treatment with a loading dose of a P2Y12-adenosine diphosphate receptor antagonist was allowed before CA. The primary endpoint was the composite of cardiovascular death and recurrent ischemic events at 1 month, as determined by a blinded adjudication committee.RESULTS:Most patients had high-risk NSTE-ACS in both groups (93% in the EG vs. 92.5% in the DG). The median time between randomization and CA was 0 h (interquartile range [IQR]: 0 to 1 h) in the EG group and 18 h (IQR: 11 to 23 h) in the DG. The primary endpoint rate was significantly lower in the EG (4.4% vs. 21.3% in the DG; hazard ratio: 0.20; 95% confidence interval: 0.11 to 0.34; p < 0.001), driven by a reduction in recurrent ischemic events (19.8% vs. 2.9%; p < 0.001). No difference was observed for cardiovascular death.CONCLUSIONS:Without pre-treatment, a very early invasive strategy was associated with a significant reduction in ischemic events at the time of percutaneous coronary intervention in patients with intermediate- and high-risk NSTE-ACS. (Early or Delayed Revascularization for Intermediate and High-Risk Non ST-Elevation Acute Coronary Syndromes; NCT02750579).

BACKGROUND Femoral access is the gold standard for transcatheter aortic valve replacement (TAVR). Guidelines recommend reconsidering surgery when this access is not feasible. However, alternative peripheral accesses exist, although they have not been accurately compared with femoral access. OBJECTIVES This study compared nonfemoral peripheral (n-FP) TAVR with femoral TAVR. METHODS Using the data from the national prospective French registry (FRANCE TAVI [French Transcatheter Aortic Valve Implantation]), this study compared the characteristics and outcomes of TAVR procedures according to whether they were performed through a femoral or a n-FP access, using a pre-specified propensity score-based matching between groups. Subanalysis during 2 study periods (2013 to 2015 and 2016 to 2017) and among low/intermediate-low and intermediate-high/high volume centers were performed. RESULTS Among 21,611 patients, 19,995 (92.5%) underwent femoral TAVR and 1,616 (7.5%) underwent n-FP TAVR (transcarotid, n = 914 or trans-subclavian, n = 702). Patients in the n-FP access group had more severe disease (mean logistic EuroSCORE 19.95 vs. 16.95; p < 0.001), with a higher rate of peripheral vascular disease, known coronary artery disease, chronic pulmonary disease, and renal failure. After matching, there was no difference in the rate of post-procedural death and complications according to access site, except for a 2-fold lower rate of major vascular complications (odds ratio: 0.45; 95% confidence interval: 0.21 to 0.93; p = 0.032) and unplanned vascular repairs (odds ratio: 0.41; 95% confidence interval: 0.29 to 0.59; p < 0.001) in those who underwent n-FP access. The comparison of outcomes provided similar results during the second study period and in intermediate-high/high volume centers. CONCLUSIONS n-FP TAVR is associated with similar outcomes compared with femoral peripheral TAVR, except for a 2-fold lower rate of major vascular complications and unplanned vascular repairs. n-FP TAVR may be favored over surgery in patients who are deemed ineligible for femoral TAVR and may be a safe alternative when femoral access risk is considered too high. (C) 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.

According to recent literature, pretreatment with a P2Y12 ADP receptor antagonist before coronary angiography appears no longer suitable in non–ST‐segment elevation acute coronary syndrome (NSTE‐ACS) due to an unfavorable risk–benefit ratio. Optimal delay of the invasive strategy in this specific context is unknown. We hypothesize that without P2Y12 ADP receptor antagonist pretreatment, a very early invasive strategy may be beneficial. The EARLY trial (Early or Delayed Revascularization for Intermediate‐ and High‐Risk Non–ST‐Segment Elevation Acute Coronary Syndromes?) is a prospective, multicenter, randomized, controlled, open‐label, 2‐parallel‐group study that plans to enroll 740 patients. Patients are eligible if the diagnosis of intermediate‐ or high‐risk NSTE‐ACS is made and an invasive strategy intended. Patients are randomized in a 1:1 ratio. In the control group, a delayed strategy is adopted, with the coronary angiography taking place between 12 and 72 hours after randomization. In the experimental group, a very early invasive strategy is performed within 2 hours. A loading dose of a P2Y12 ADP receptor antagonist is given at the time of intervention in both groups. Recruitment began in September 2016 (n = 558 patients as of October 2017). The primary endpoint is the composite of cardiovascular death and recurrent ischemic events at 1 month. The EARLY trial aims to demonstrate the superiority of a very early invasive strategy compared with a delayed strategy in intermediate‐ and high‐risk NSTE‐ACS patients managed without P2Y12 ADP receptor antagonist pretreatment.

According to PARTNER 2 (2016), Transcatheter Aortic Valve Replacement (TAVR) is non inferior to surgery in intermediate risk patient. Furthermore, TAVR through a transfemoral access might be superior to surgery (second cohort, not designed for superiority) while TAVR through other access sites,

Femoral access is currently the preferred approach for TAVI procedures. However, it is not feasible in all cases and alternative access sites, peripheral and transthoracic have emerged. To compare femoral to non-femoral peripheral vascular access site in propensity matched group. Using data from the national prospective French registry in France – the France TAVI registry – we compared the characteristics and outcomes of TAVI procedures according to whether they were performed through a femoral or a non-femoral peripheral (transcarotid or transaxillary), with a propensity score-based matching of patients with femoral and non-femoral peripheral interventions. Among 13.157 patients included in the France TAVI registry, 83.9% underwent a femoral TAVI, 6.7% a non-femoral peripheral vascular TAVI, and 9.4% transthoracic TAVI. Patients in non-femoral peripheral access were more severe (mean logistic Euroscore 17.3 vs. 19.7, P < 0.001), with a higher rate of peripheral vascular disease, known coronary artery disease, chronic pulmonary disease and renal failure. After matching, there was no difference in the rate of complications according to access site, except for a twice-lower rate of vascular-access related complications in the non-femoral peripheral vascular approach (OR 0.56 (0.32–0.96), P = 0.03 after adjustment to the prosthesis type). There was no difference in short or long term mortality rates. Compared to femoral approach, non-femoral peripheral TAVI is associated with a similar outcome except for a twice-lower rate to access site-related complications. It should be considered more routinely as an alternative to femoral approach.