AIMS:Timely reperfusion is a key quality-of-care target in ST-segment elevation myocardial infarction (STEMI). When primary percutaneous coronary intervention (PPCI) cannot be delivered within 120 min from first medical contact (FMC), guidelines recommend fibrinolysis as early as possible within 12 h of symptom onset in eligible patients. We quantified missed opportunities for fibrinolysis in a nationwide STEMI network. METHODS AND RESULTS:We analysed consecutive STEMI patients enrolled ≤24 h from symptom onset in the France-PCI registry (2014-22). First medical contact was approximated by the first diagnostic electrocardiogram (ECG). Initial reperfusion was classified as timely PPCI (FMC-to-device ≤120 min), delayed PPCI (>120 min), or fibrinolysis. Among delayed PPCI, eligibility for fibrinolysis required no oral anticoagulant, no prior stroke, and no documented contraindication. We evaluated temporal trends, regional variation, and outcomes. Among 19 472 patients, 12 633 (64.9%) underwent timely PPCI, 5895 (30.3%) delayed PPCI, and 944 (4.8%) fibrinolysis. Timely PPCI increased over time, whereas fibrinolysis declined. Among delayed PPCI, 3279/5895 (55.6%) presented within the prespecified early-presenter window (symptom-to-ECG ≤3 h) and met our strict fibrinolysis-eligibility criteria, yet underwent delayed PPCI; this proportion remained stable across years, with marked regional heterogeneity. Fibrinolysis use was favoured by mobile intensive care units, helicopter transport, and longer distance to PPCI centres, whereas older age was associated with delayed PPCI without fibrinolysis. CONCLUSION:In this national STEMI network, more than half of delayed PPCI in eligible early presenters represented a persistent missed-fibrinolysis gap. Routine audit of delayed PCI and missed fibrinolysis as system-level quality metrics should guide time-based pre-hospital triage and align reperfusion with guideline-recommended targets.

BACKGROUND:The link to mortality and respective weight of ischemic events, hemorrhagic events or both after percutaneous coronary interventions (PCI) remain unclear, especially in regards of the time of occurrence. OBJECTIVES:To compare the association between ischemic and bleeding complications and mortality according to the timing of their occurrence after PCI. METHODS:All patients included in the FRANCE PCI registry between 2014 and 2020 were categorized, according to the occurrence of an ischemic complication (stent thrombosis, myocardial infarction, stroke or unplanned revascularization), a major bleeding (BARC type≥3), both or none of these complications. The analysis was also performed according to the timing of the complication (in-hospital or within one year of PCI). The primary outcome was all-cause mortality, analyzed 1/ during the index hospitalization for PCI by multivariable logistic regression, and 2/ over different periods of time after discharge from the index hospitalization, with a piecewise Cox multivariable model using ischemic and hemorrhagic complications as time-dependent variables. RESULTS:A total of 54,599 patients were included (75% male, median age 69 years), with an acute PCI in 52.9% of the cases. During hospitalization, ischemic complications (aOR 8.4, 95% CI 6.4-10.9), bleeding complications (aOR 10.3, 95% CI 8.1-13.2), and their combination (aOR 13.2, 95% CI 7.0-24.7) were all associated with increased mortality. After discharge, both ischemic and bleeding complications remained significantly associated with all-cause mortality although the strength of these associations decreased over time. Late (beyond 24 weeks) bleeding complications were more strongly associated with mortality (aHR 6.0 95%CI:5.0-7.3) than late ischemic complications (aHR 2.5 95%CI:2.0-3.1). CONCLUSIONS:After PCI there is an incremental risk of death with ischemic, bleeding and the combination of ischemic and bleeding complications occurring during hospitalization. Bleeding complications late after discharge seem to bear a higher risk of death than ischemic complications.

BACKGROUND:Dual antiplatelet therapy reduces ischaemic complications after percutaneous coronary intervention, but increases bleeding risk, especially in patients who are already at high bleeding risk. Current guidelines therefore recommend abbreviated dual antiplatelet therapy in this population. AIM:To evaluate the real-world use of abbreviated dual antiplatelet therapy (≤3 months) after percutaneous coronary intervention according to bleeding risk, using data from the nationwide FRANCE-PCI registry. METHODS:All consecutive patients undergoing percutaneous coronary intervention for either acute or chronic coronary syndrome between 2014 and 2023 across 56 hospitals, who were alive at 1 year, and in whom dual antiplatelet therapy duration was known, were included. High bleeding risk was defined as the presence of at least one of the following: age≥75 years; chronic oral anticoagulant therapy; previous stroke; or chronic kidney disease. RESULTS:Among 115,992 patients included, 41.4% met the criteria for high bleeding risk. Abbreviated dual antiplatelet therapy was prescribed in 23.1% of patients with a high bleeding risk versus 3.6% of patients without a high bleeding risk. Among patients with a high bleeding risk, factors independently associated with prolonged (>3 months) dual antiplatelet therapy use were: increasing age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.02-1.03); female sex (OR 1.18, 95% CI 1.11-1.25); diabetes mellitus (OR 1.15, 95% CI 1.08-1.22); previous stroke (OR 1.54, 95% CI 1.39-1.69); chronic kidney disease (OR 1.24, 95% CI 1.15-1.34); acute coronary syndrome (OR 1.52, 95% CI 1.44-1.61); and stent length≥60mm (OR 1.18, 95% CI 1.09-1.28). CONCLUSIONS:In real-word practice, less than one third of patients with a high bleeding risk received abbreviated dual antiplatelet therapy after percutaneous coronary intervention. The use of prolonged dual antiplatelet therapy remained driven by ischaemic risk markers, highlighting persistent uncertainty in bleeding risk/ischaemic risk trade-offs.

BACKGROUND:The optimal timing for initiating P2Y12 inhibitor therapy in patients undergoing percutaneous coronary intervention (PCI) remains controversial. In this study we analyzed the impact of dual antiplatelet therapy (DAPT) pretreatment on premature stent thrombosis in patients with chronic coronary syndrome and non-ST-elevation myocardial infarction treated by PCI. METHODS:We analyzed data from 53,898 PCI procedures (44,412 patients) in the "France PCI" registry between 2014 and 2020. Patients were divided into P2Y12 inhibitor pretreatment (83.2%) and no-pretreatment (16.8%) groups. The primary endpoint was incidence of in-hospital definite stent thrombosis. RESULTS:Pretreatment was associated with a significantly lower incidence of in-hospital stent thrombosis (0.1% vs 0.4%; odds ratio [OR] 0.35, 95% confidence interval [CI] 0.22-0.57). At 1 year, the pretreatment group showed lower rates of major adverse cardiovascular events (6.6% vs 7.8%; OR 0.83, 95% CI 0.74-0.92) and all-cause mortality (4.6% vs 6.0%; OR 0.71, 95% CI 0.63-0.80). Notably, there was no significant increase in major bleeding events in the pretreatment group. CONCLUSIONS:In this large, real-world cohort, P2Y12 inhibitor pretreatment was associated with a significant reduction in in-hospital stent thrombosis and improved 1-year clinical outcomes without increased major bleeding risk. Our findings suggest that selective use of antiplatelet pretreatment may still play a crucial role in improving ischemic outcomes for patients undergoing PCI.

Introduction:Acute ST-elevation myocardial infarction (STEMI) is a frequent and serious presentation of acute coronary syndrome. The STOP-SCA+ study aimed to (i) describe 1-year compliance to secondary prevention cardiac tri-therapy and (ii) identify factors associated with negative outcomes 1 year after STEMI, particularly the impact of compliance and rehabilitation care. Methods:Patients who were >18 years old and hospitalized for STEMI in five interventional cardiac centers with the same cardiac registry in one French region (2.5 million inhabitants), between 2014 and 2018, were included. After a probabilistic matching with the National Health Insurance database [Système National des Données de Santé (SNDS), 96% matching], compliance for cardiac tri-therapy was studied: aspirin, P2Y12 inhibitor, and statin. Factors associated with poor outcomes (ischemic complications, death) were analyzed using Cox modeling and those for compliance by logistic regression. Results:A total of 3,768 patients were included, of whom 84% underwent primary percutaneous coronary intervention. At 1 year, 3,362 had at least one tri-therapy delivery (89.2%), of whom 53% were compliant, and 2,478 patients went to cardiac rehabilitation (65.8%). Death occurred in 130 patients and/or ischemic complications in 194 (total of poor outcomes 8.0%). Compliance was not associated with complications over the year [HR 1.16 (0.86-1.57)], while the absence of cardiac rehabilitation [2.31 (1.73-3.08)] was associated, as well as female sex 1.54 (1.08-2.19), renal impairment [2.87 (1.49-5.53)], initial STEMI clinical presentation [pejorative Killip 2.04 (1.19-3.50)], and LVEF <40% at discharge [2.22 (1.65-2.99)]. Additionally, cardiac rehabilitation was associated with compliance [OR 1.55 (1.34-1.79)]. Discussion:Pejorative outcomes 1 year after a STEMI represented 8% of cases, mainly related to patient features, the initial clinical presentation, and the absence of access to rehabilitation. Compliance part in patient health outcomes will need further modeling to accurately study its impact. Matching clinical and medico-administrative databases proved to be relevant for assessing outcomes at a large scale.

[This corrects the article DOI: 10.3389/fcvm.2025.1484401.].

Background and Aims The length of stay (LOS) after transcatheter aortic valve implantation (TAVI) remains extremely variable whereas early discharge has been shown to be feasible and safe. The study objective was to evaluate the efficacy and safety of an intervention aimed at reducing LOS after transfemoral TAVI. Methods FAST-TAVI II is a prospective, multicentre, cluster, randomized, controlled study including patients with severe symptomatic aortic stenosis, who had transfemoral TAVI. The intervention consisted in a dedicated training programme to implement 10 quality of care measures to reduce LOS with an implementation phase of eight weeks. The primary endpoint was the proportion of patients discharged early within 3 days. Secondary endpoints included: LOS, 30-day mortality and 30-day incidence of readmission for cardiovascular events. Results During the study period, 969 patients were enrolled in the intervention group and 860 patients in the control group. Mean age was 81.9 +/- 6.6 years and mean EuroSCORE II was 4.4 +/- 4.5%. Early discharge was achieved in 563 (58.1%) patients in the intervention group vs. 364 (42.3%) patients in the control group (P < .0001). Median LOS was significantly reduced in the intervention group compared to the control group [3 (IQR: 3) vs. 4 days (IQR: 3), P < .0001]. Thirty-day mortality was low and similar in the two groups (0.5% vs. 0.9%, P = .30), as were 30-day readmissions (4.6% vs. 2.8%, P = .28). Conclusions The intervention was simple and fast to implement, and was effective and safe to reduce LOS and increase the proportion of patients discharged early after TAVI (NCT04503655).

Background: Despite the evolution of stent technology, there is a non-negligible risk of in-stent restenosis (ISR) after Percutaneous coronary intervention (PCI). Large-scale registry data on the prevalence and clinical manage-ment of ISR is lacking.Methods: The aim was to describe the epidemiology and management of patients with & GE;1 ISR lesions treated with PCI (ISR PCI). Data on characteristics, management and clinical outcomes were analyzed for patients undergoing ISR PCI in the France-PCI all-comers registry.Results: Between January 2014 and December 2018, 31,892 lesions were treated in 22,592 patients, 7.3 % of whom underwent ISR PCI. Patients undergoing ISR PCI were older (68.5 vs 67.8; p < 0.001), and more likely to have diabetes (32.7 % vs 25.4 %, p < 0.001), chronic coronary syndrome or multivessel disease. ISR PCI concerned drug eluting stents (DES) ISR in 48.8 % of cases. Patients with ISR lesions were more frequently treated with DES than drug eluting balloon or balloon angioplasty (74.2 %, 11.6 % and 12.9 %, respectively). Intravascular imaging was rarely used. At 1 year, patients with ISR had higher target lesion revascularization rates (4.3 % vs. 1.6 %; HR 2.24 [1.64-3.06]; p < 0.001).Conclusions: In a large all-comers registry, ISR PCI was not infrequent and associated with worse prognosis than non-ISR PCI. Further studies and technical improvements are warranted to improve the outcomes of ISR PCI.& COPY; 2023 Elsevier Inc. All rights reserved.

Introduction In 2020, the coronavirus disease 2019 (COVID-19) pandemic disrupted the health system and a drop in percutaneous coronary interventions (PCI) was observed. Objective The objective of this study was to evaluate the impact of the COVID-19 pandemic on a full year of elective and urgent PCIs, from the national France-PCI registry. Method The primary endpoint was to compare the number of PCIs performed in 2019 (before the pandemic), and 2020 (during the pandemic). Results Between January 1, 2019 and December 31, 2020, in the 20 participating centers, 22,807 consecutive PCIs were included. The total number of PCIs was reduced by −11.5% between 2019 and 2020 (12,102 versus 10,705; P<0.001), mainly due to a reduction in elective interventions (−21.9%; P<0.001). There was a significant decrease in PCIs for stable angina (P<0.001) and silent ischemia (P<0.001). For urgent PCIs, the decrease was less, mainly driven by a non-ST+ acute coronary syndromes (ACS) reduction (−5.7%; P=0.01), as well as a decrease of early ST-Elevation myocardial infarctions (STEMIs)<24 Hours (−7.1%; P=0.02). There was also a significant increase in the number of late STEMIs>24H (+23.4%; P=0.002). Following the decrease in ACS during the first lockdown from March to May 2020, there was an unexpected significant increase in urgent interventions (“rebound effect”) out of step with the rest of the year (P=0.002) (Fig. 1A). Nevertheless, there was no increase in elective PCIs after the first lockdown in comparison with the rest of the year 2020 (P=0.67) (Fig. 1B). In 2020, patients were significantly younger (P=0.001), with less prior history of coronary artery disease (P=0.001), and prasugrel was more often prescribed after PCIs (P=0.001). In 2020, the radial approach was more often performed (P=0.001), as well as an “Ad-hoc” PCI (P=0.01), and the median fluoroscopy time was lengthened (P<0.001). For STEMIs<24H, there was more frequently anterior localizations (P=0.03), and ground medical transport was the majority (P=0.03). The time from onset of symptoms to first medical contact was significantly lengthened (P=0.01), and a non-significant increase in total ischemic time (P=0.08) was found. Finally, there was no significant increase in intra-hospital cardiovascular events during the pandemic in 2020. Conclusion We show an extraordinary reduction in elective and urgent PCIs, as well as a never described paradoxical increase in urgent PCIs after the first lockdown, during the COVID-19 pandemic.

Background: Obstructive coronary artery disease is the main cause of death worldwide. By tracking events and gaining feedback on patient management, the most relevant information is provided to public health services to further improve prognosis.Aims: To create an inclusive and accurate registry of all percutaneous coronary intervention (PCI) proce-dures performed in France, to assess and improve the quality of care and create research incentives. Also, to describe the methodology of this French national registry of interventional cardiology, and present early key findings. Methods: The France PCI registry is a multicentre observational registry that includes consecutive patients undergoing coronary angiography and/or PCI. The registry was set up to provide online data analysis and structured reports of PCI activity, including process of care measures and assessment of risk-adjusted outcomes in all French PCI centres that are willing to participate. More than 150 baseline data items, describing demographic status, PCI indications and techniques, and in-hospital and 1-year outcomes, are captured into local reporting software by medical doctors and local research technicians, with subsequent encryption and internet transfer to central data servers. Annual activity reports and scoring tools available on the France PCI website enable users to benchmark and improve clinical practices. External validation and consistency assessments are performed, with feedback of data completeness to centres.Results: Between 01 January 2014 and 31 December 2022, participating centres increased from six to 47, and collected 364,770 invasive coronary angiograms and 176,030 PCIs, including 54,049 non-ST -segment elevation myocardial infarction cases and 31,631 ST-segment elevation myocardial infarction cases. Fifteen studies stemming from the France PCI registry have already been published. Conclusions: This fully electronic, daily updated, high-quality, low-cost, national registry is sustainable, and is now expanding. Merging with medicoeconomic databases and nested randomized scientific studies are ongoing steps to expand its scientific potential. (c) 2023 Elsevier Masson SAS. All rights reserved.

Background: Fractional Flow Reserve (FFR) has become the invasive gold standard to quantify myocardial ischemia generated by a coronary stenosis in patients with chronic coronary syndrome, but in clinical practice it is still underutilised to guide percutaneous coronary intervention (PCI) compared to angiography (angio).Methods: We sought to compare, in a national French registry (France PCI), the clinical impact of FFR-guided PCI compared with angio-guided PCI at one year. We extracted from the France PCI database all chronic coronary syndrome patients treated with PCI for coronary stenosis <90% between 2014 and 2019. Our composite clinical endpoint was the rate of major adverse clinical events (MACE) defined as the composite of the following endpoints: rates of death, myocardial infarction, stent thrombosis, revascularisation, stroke, and bleeding with a BARC score ≥ 3. Findings: 14384 patients with one-year clinical follow-up were included. Among them, 13125 had angio-guided PCI (91%) and 1259 (9%) had FFR-guided PCI. We observed a significantly higher rate of MACE in the angio-guided group versus the FFR-guided group: 1478 (11·3%) versus 100 (7·9%) (p<0·0001), respectively, with Hazard Ratio (HR) of 1·440, 95% confidence Interval (CI) [1·211-1·713] (p=0·0004). This result was driven by the higher occurrence of death in the angio-guided group versus the FFR-guided-group: 506 (3·9%) versus 17 (1·4%) (p<0·0001), respectively, with HR of 2·845, 95% CI [2·099-3·856] (p<0·0001). After adjustment for potential confounding factors, HRs were 1·287, 95% CI [1·028-1·613] (p=0·028) for MACE and 2·527, 95% CI [1·452-4·399] (p=0·001) for death. No significant differences between angio-guided PCI and FFR-guided PCI were observed for other clinical endpoints.Interpretation: Our study showed that FFR was the most important predictor of death after adjustment for confounding factors. PCI guided with FFR improves outcome at one year compared to angio-guided PCI with a reduction of 64M of death at one year.Funding: NoneDeclaration of Interest: The authors do not have any conflict of interest to report related to this manuscript.Ethical Approval: The French Persons Protection Committee (IRB00003888) approved the study protocol (no. 15-231). Data file collection and storage were approved by the French National Commission for Data Protection and Liberties (no. 2014-073).

BACKGROUND:In patients with ST-segment elevation myocardial infarction (STEMI) who have multivessel disease, the FLOWER-MI trial found no significant clinical benefit to fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) compared to angiography-guided PCI.AIMS:Our aim was to estimate the cost-effectiveness and cost-utility of FFR-guided PCI, the secondary endpoint of the FLOWER-MI trial.METHODS:Costs, major adverse cardiovascular events (composite of all-cause death, non-fatal myocardial infarction [MI], and unplanned hospitalisation leading to urgent revascularisation), and quality-adjusted life years were calculated in both groups. The incremental cost-effectiveness and cost-utility ratios were estimated. Uncertainty was explored by probabilistic bootstrapping. The analysis was conducted from the perspective of the health care provider with a time horizon of one year.RESULTS:At one year, the average cost per patient was 7,560€ (±2,218) in the FFR-guided group and 7,089€ (±1,991) in the angiography-guided group (p-value<0.01). The point estimates for the incremental cost-effectiveness and cost-utility ratios found that the angiography-guided strategy was cost saving and improved outcomes, with a probabilistic sensitivity analysis confirming dominance.CONCLUSIONS:The FFR-guided strategy at one year is unlikely to be cost effective compared to the angiography-guided strategy on both clinical and quality of life outcomes.

BackgroundFirst medical contact (FMC)-to-balloon time is associated with outcome of ST-elevation myocardial infarction (STEMI). We assessed the impact on mortality and the determinants of indirect vs. direct transfer to the cardiac catheterization laboratory (CCL).MethodsWe analyzed data from 2,206 STEMI patients consecutively included in a prospective multiregional percutaneous coronary intervention (PCI) registry. The primary endpoint was 1-year mortality. The impact of indirect admission to CCL on mortality was assessed using Cox models adjusted on FMC-to-balloon time and covariables unequally distributed between groups. A multivariable logistic regression model assessed determinants of indirect transfer.ResultsA total of 359 (16.3%) and 1847 (83.7%) were indirectly and directly admitted for PCI. Indirect admission was associated with higher risk features, different FMCs and suboptimal pre-PCI antithrombotic therapy.At 1-year follow-up, 51 (14.6%) and 137 (7.7%) were dead in the indirect and direct admission groups, respectively (adjusted-HR 1.73; 95% CI 1.22–2.45). The association of indirect admission with mortality was independent of pre-FMC and FMC characteristics. Older age, paramedics- and private physician-FMCs were independent determinants of indirect admission (adjusted-HRs 1.02 per year, 95% CI 1.003–1.03; 5.94, 95% CI 5.94 3.89–9.01; 3.41; 95% CI 1.86–6.2, respectively).ConclusionsOur study showed that, indirect admission to PCI for STEMI is associated with 1-year mortality independent of FMC to balloon time and should be considered as an indicator of quality of care. Indirect admission is associated with higher-risk features and suboptimal antithrombotic therapy. Older age, paramedics-FMC and self-presentation to a private physician were independently associated with indirect admission. Our study, supports population education especially targeting elderly, more adequately dispatched FMC and improved pre-CCL management.

Developed in the late 1980s, rotational atherectomy has raised a lot of hope for its innovative principle of selective ablation, allowing volume reduction (instead of redistribution) of atherosclerotic plaque, while sparing healthy tissue. Long shunned for its disappointing results on restenosis, the Rotablator finally reasserted itself in the 2000s; era of drug eluting stents and coronary angioplasty boom, thus generating emergence of complex lesions. Indeed, the Rotablator has demonstrated an undeniable benefit in complex (type C) and calcified lesions preparation (before stenting), with a procedural success rate of 95%. Although these lesions only represent a small amount (2-3%) of percutaneous coronary interventions (PCI), they remain a technical impasse for plain-old balloon angioplasty strategy, making the Rotablator more suitable for these resistant lesions' treatment. Registry data attest the safety of this therapy, with a rate of peri-procedural complications and in-hospital mortality comparable to conventional angioplasty (France PCI register). However, certain specific, rare but serious complications (burr entrapment, broken Rotawire, coronary perforation) justify trained teams, perfect knowledge of the equipment, and strict compliance with good practice guidelines. In 2018, the rise of a new method of atherectomy by intra-vascular lithotripsy (Shockwave) has coincided with Rotablator decreasing activity (this finding being biased by a general decrease in PCI activity due to Covid pandemic). This therapeutic range's enhancement revolutionizes calcified lesions treatment, tending towards precise targeting of each indication, depending in particular on calcium distribution's anatomy in the plaque.

BACKGROUND:ST-elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) are associated with a worse prognosis. However, few comparisons are available according to coronary status in the era of modern reperfusion and optimized secondary prevention.HYPOTHESIS:We hypothesized that the difference in prognosis according to number of vessel disease in STEMI patients has reduced.METHODS:All consecutive STEMI patients undergoing primary percutaneous coronary intervention (PCI) within 24 h of symptoms onset between January 1, 2014 and June 30, 2016 enrolled in the CRAC (Club Régional des Angioplasticiens de la région Centre) France PCI registry were analyzed. Baseline characteristics, management, and outcomes at 1-year were analyzed according to coronary status (one-, two-, and three-VD).RESULTS:A total of 1886 patients (mean age 62.2 ± 14.0 year; 74% of male) were included. Patients with MVD (two or three-VD) represented 53.7%. They were older with higher cardiovascular risk factor profile. At 1 year, the rate of major adverse cardiovascular events (MACE, defined as all-cause death, stroke or re-MI) was 10%, 12%, and 12% in one-, two, and three-VD respectively (p = .28). In multivariable adjusted Cox proportional hazard regression model, two- and three-VD were not associated with higher rate of MACE compared to patients with single VD (HR, 1.09; 95%CI 0.76-1.56 for two-VD; HR, 0.74; 95%CI 0.48-1.14 for three-VD).CONCLUSIONS:MVD still represents an important proportion of STEMI patients but their prognoses were not associated with worse clinical outcomes at 1-year compared with one-VD patients in a modern reperfusion area and secondary medication prevention.

Growing use of fractional flow reserve (FFR) and intracoronary imaging techniques by optical coherence tomography or intravascular ultrasound has raised concerns about additional exposure during coronary angiography and percutaneous coronary interventions (PCIs). Using data from the prospective CRAC-France PCI Prospective Multicentre registry, we sought to evaluate the effect of these new techniques on the radiation dose to patients undergoing coronary procedures. Data on Kerma Area Product (P-KA), total air kerma (KA(r)) and fluoroscopy time from 42 182 coronary procedures were retrospectively compared, using multivariable linear regression, according to whether they included FFR and intracoronary imaging. In coronary angiography, FFR was associated with longer fluoroscopy time and higher P-K(A) (21.0 vs. 18.9 Gy.cm(2)) and KA(r) (372 vs. 299 mGy) (all p < 0.001). Intracoronary imaging was associated with longer fluoroscopy time, higher contrast volume (both p < 0.001), lower P-KA (18.3 vs. 19.0 Gy.cm(2), p = 0.02) and similar KA(r). In PCI, FFR was associated with a moderate increase in KA(r) (682 vs. 626 mGy, p < 0.01) but not P-KA (35.9 vs. 33.7 Gy.cm(2), p = 0.34). For intracoronary imaging, there were no differences between groups, except for contrast volume. Increased patient exposure associated with FFR and intracoronary imaging is moderate in diagnostic coronary angiography and minimal or none in PCI, provided optimization techniques are used. It should not be a limitation on the use of these techniques given the important additional information they provide.

Bien que le pronostic de l’infarctus du myocarde s’améliore depuis 20 ans, sa mortalité reste élevée malgré des thérapeutiques efficaces et des parcours optimisés. Le but était d’identifier les facteurs patient et parcours associés à la mortalité d’un syndrome coronarien aigu avec sus-décalage du segment ST (SCA ST + ) pris en charge dans cinq des six centres de cardiologie interventionnelle en région Centre-Val-de-Loire (cohorte CRAC). Les patients ayant eu un SCA ST+ entre 2014 et 2016 ont été inclus dans l’étude. Le parcours intra-hospitalier a été décrit. Les facteurs associés à la mortalité intra-hospitalière et à un an des patients ayant eu une angioplastie primaire ont été analysés par modèle de Cox. Ont été inclus 2512 patients, dont 92 % de revascularisation (n = 2311) et 82 % d’angioplastie primaire (n = 2049), et 4 % de perdus de vue (n = 111). La mortalité à un an était de 9,5 % (n = 228), dont près des 2/3 décédés durant l’hospitalisation initiale (n = 145 soit 5,8 %, dont 38 le jour d’arrivée). Parmi les 1966 patients avec angioplastie primaire, 9,8 % étaient décédés à un an (n = 192, 2/3 en hospitalisation initiale) et les principaux facteurs associés étaient : âge ≥ 65 ans (HR : 2,5 - IC95 % [1,6–3,8]), sexe féminin (1,5 [1,0–2,1]), insuffisance rénale (5,7 [3,1–10,3]), échec initial de l’angioplastie (4,6 [3,0–7,0]), score de gravité (Killip) élevé (9,6 [6,7–13,7]) et présence de complications cardiovasculaires initiales (3,5 [2,3–5,5]). Un délai de revascularisation > 2 h significativement associé au décès durant l’hospitalisation (1,8 [1,2–2,7]), ne l’était plus à 1 an. Les traitements antiagrégants prescrits et leur durée n’ont pu être pris en compte car seulement connus pour les survivants à un an. La cohorte CRAC a permis d’estimer le poids de facteurs patient et délai sur la mortalité à un an post-SCA ST+. Les prescriptions, leur durée comme les réhospitalisations seront analysées via le Système national des données de santé (SNDS).

The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2020.05.042] on http://www.annalsthoracicsurgery.org. The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2020.05.042] on http://www.annalsthoracicsurgery.org. A 62-year-old asymptomatic woman with a history of arterial hypertension was referred for computed tomographic angiography to explore rapidly increasing dilation of the ascending aorta that was noted on echocardiography. Physical examination and laboratory findings were unremarkable, with no signs of infectious or inflammatory disease. Computed tomographic angiography (Figure 1A) confirmed a 55-mm homogeneous aortic aneurysm of the tubular aorta, with no aortic dissection. Findings on precontrast and postcontrast computed tomographic angiography (Figure 1B) were compatible with type A aortic intramural hematoma secondary to circumferential thickening of the tubular aorta wall, with hyperdense attenuation and no late enhancement. Operation revealed an unexpected, voluminous, and inflammatory aneurysm of the ascending aorta (Figure 1C, Video). Successful replacement of the tubular aorta by a prosthetic tube was achieved through median sternotomy, with extracorporeal circulation. Histologic examination (Figure 1D) revealed the diagnosis of giant cell aortitis in response to severe inflammation of the aortic wall, with true giant cells. In conclusion, the diagnosis was quiescent and chronic giant cell aortitis complicated by a large, inflammatory aneurysm. This case is interesting because it shows that giant cell aortitis (especially in its chronic form) and chronic type A aortic intramural hematoma can have similar initial presentations and thus must be included in their respective differential diagnoses. This case also confirms that multimodal imaging (including nuclear and magnetic resonance imaging) could be useful to differentiate these 2 entities, which may have different treatments and prognoses. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjYTM2NDY3NTkwYmYyM2RjZDY3ZDlhODI2MjFjNDAyNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4OTQ2MjY5fQ.iPCYM3hBQ8Hi9-qNzSLF6RWAdQRwyxnrnjLiBzG3Vzo5g2klEH1sgUVAeSiA24JOpkNJD3SadcRW9KTHZNDrjZqk1RkZ8lulIp-VeakdCTJhIqo-IieVGM5AIm4wMZjKrQz33psaWRRYslVSJX6fHPv9DtlF6hBKPx1uplxySFrX3HWdS0vanidIve0JE41141QyxI-A6ejcmDhUpfef4t-XNwQBYmaV0g9SVuZMmqXZTn22dhR3zaQIcsEczeEc7hINZifn2MrFA4pWLPCO9GkGI7VhHloHfA2iPfS0X3BASN5mAoHtbRzQ66KzMuf5phYDD7tmzkr9j0OFavQjtA Download .mp4 (3.94 MB) Help with .mp4 files Video 1

HomeCirculation: Cardiovascular ImagingVol. 13, No. 10Rare Case of an Intrapericardial Ectopic Thyroid (Struma Cordis) on the Ascending Aorta Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessCase ReportPDF/EPUBRare Case of an Intrapericardial Ectopic Thyroid (Struma Cordis) on the Ascending Aorta Hicham Mesrar, MD Didier Chatel, MD Christophe Barbey, MD Jean-Paul Biny, MD Marc-Antoine Arnould, MD Guillaume Gouffran, MD Olivier Bar, MD Stéphan ChassaingMD Hicham MesrarHicham Mesrar Hicham Mesrar, MD, Department of Interventional Cardiology and Cardiac Imaging, Institut du Cœur St-Gatien, Nouvelle Clinique Tours Plus, Tours, France. Email E-mail Address: [email protected] https://orcid.org/0000-0001-5707-6995 Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Didier ChatelDidier Chatel Department of Cardiac Surgery (D.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Christophe BarbeyChristophe Barbey Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Jean-Paul BinyJean-Paul Biny Laboratory of Pathology Origet, Pôle Equa Santé, Tours, France (J.-P.B.). , Marc-Antoine ArnouldMarc-Antoine Arnould Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Guillaume GouffranGuillaume Gouffran Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Olivier BarOlivier Bar Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. , Stéphan ChassaingStéphan Chassaing Department of Interventional Cardiology and Cardiac Imaging (H.M., C.B., M.-A.A., G.G., O.B., S.C.), Institut du Cœur Saint-Gatien, Nouvelle Clinique Tours Plus, France. Originally published23 Sep 2020https://doi.org/10.1161/CIRCIMAGING.120.010508Circulation: Cardiovascular Imaging. 2020;13:e010508Cardiac ectopic thyroid gland, also called Struma cordis (SC), is a rare finding. Ectopic thyroid tissue occurs because of embryological malformation, and its prevalence is ≈1 in 300 000 to 400 000 individuals. In 1941, Dotsch discovered SC during routine chest autopsy.1 We report about an unexpected asymptomatic cardiac mass detected using multimodal imaging. Surgical resection and histological analysis revealed ectopic thyroid tissue on the ascending aorta (AA).A right cardiac mass was discovered by chance in a 67-year-old White male during chest computed tomography (CT) for recurrent infectious pneumonitis. He had a history of ischemic heart disease related to many cardiovascular risk factors, including smoking. He was clinically asymptomatic; physical examination was normal, as were chest X-ray, ECG, and biological examinations. Preoperative thyrotropin-releasing hormone and free thyroxine (FT4) levels were normal at 0.76 mIU/L and 12.9 pmol/L, respectively.Two-dimensional transthoracic echocardiography revealed preserved heart function with no pericardial effusion evident; however, the cardiac mass was not visible. Gated cardiac CT (Figure 1) confirmed an ovoid mass with moderate contrast enhancement, measuring 45×35×28 mm, in close contact with the anterolateral AA wall, anterior pericardium, right auricle, and superior vena cava. However, clearly determining whether the mass was intracavitary (within the right auricle) or extracavitary (in the pericardium) using CT was difficult. Cardiac CT after 3 months confirmed the mass had not evolved. Additional imaging with ECG-gated cardiac magnetic resonance imaging at 1.5 T demonstrated a regular and heterogeneous noninfiltrating tissue mass, with moderate gadolinium enhancement (Figure 2, Movies I and II in the Data Supplement). The immobile mass appeared close to the anterolateral AA wall, was nonpediculated, and did not invade the pericardium. Cine-cardiac magnetic resonance sequences finally confirmed the mass was located in the pericardium. The signal intensity of the mass was isointense on T1-weighted images (with and without fat-saturation) and high on T2-weighted images. 18-fluorodeoxyglucose positron emission tomography-CT was performed to examine possible hypermetabolic activity of the cardiac mass that was comparable with neoplasia; however, results were negative. Similarly, thoraco-abdominopelvic CT scanning did not reveal any secondary neoplasms. Without confirmed diagnosis, surgical exploration was performed.Download figureDownload PowerPointFigure 1. Cardiac computed tomography. Axial (A) and coronal (B) planes showing the right juxta-aortic ovoid mass.Download figureDownload PowerPointFigure 2. Cardiac magnetic resonance imaging. Axial (A), sagittal (B), and coronal (C) cine-cardiac magnetic resonance sequences demonstrating the intrapericardial location of the cardiac mass arising from the ascending aorta.Complete excision of the intrapericardial mass appended to the aorta was achieved by median sternotomy without the need for extracorporeal circulation (Figure 3, Movie III in the Data Supplement). The operation was deemed successful, and postoperative echocardiogram was normal. Pathological examination confirmed a diagnosis of cardiac ectopic thyroid tissue growing from the AA adventitia without histological malignancy (Figure 4). In the first weeks after surgery, the patient showed no clinical signs of secondary hypothyroidism, thyroid hormone levels were normal (postoperative thyrotropin-releasing hormone and FT4 were 0.81 mIU/L and 13.5 pmol/L, respectively), and thyroid ultrasonography showed a pretracheal thyroid with no morphological abnormality.Download figureDownload PowerPointFigure 3. Intraoperative macroscopic view. Revealing the intrapericardial mass appended to the ascending aorta wall.Download figureDownload PowerPointFigure 4. Histological examination. Highlighting thyroid tissue comprising thyroid vesicles of variable sizes with colloid content, free of cytonuclear atypia. Hematoxylin eosin saffron, magnification ×4.SC is a rare entity that affects mostly middle-aged women (90% cases). Cardiac SC may result from aberrant craniocaudal migration of the primitive heart and thyroid during embryogenesis.1 The most common cardiac locations for SC are intracavitary, mainly in the interventricular groove and the right ventricular outflow tract. Intrapericardial ectopic thyroid arising from the AA, as described here, is extremely rare, and to our knowledge, only 5 similar cases have been previously reported.2 Initial presentation is often an incidental finding during imaging in asymptomatic patients; however, in some cases, the mass can lead to dyspnea, atypical chest pain, syncope, pulmonary embolism, ventricular arrhythmia, or sudden death owing to possible cavitary compression or obstruction in the heart.The main differential diagnoses of SC are cardiac tumors, which largely affect the right side of the heart, and cardiac thrombi.3 These diagnoses should be excluded before considering exceptional alternative diagnoses, including cardiac ectopic thyroid, intrapericardial hematoma, teratoma, pleuropericardial or hydatid cysts, and paraganglioma. Secondary tumors (metastases) from the lung, breast, thyroid, esophagus, lymphoma, melanoma, and leukemia are the most common cardiac masses detected. Primary tumors are predominately benign (myxoma, lipoma, fibroma, rhabdomyoma, fibroelastoma, hemangioma) but are sometimes malignant, including sarcoma, lymphoma, or mesothelioma.Multimodal imaging using echocardiography, cardiac magnetic resonance, and CT is essential to completely characterize heart masses. Cardiac CT and cardiac magnetic resonance can define anatomic relationships between the mass, myocardium, and pericardium owing to their significant spatial and temporal resolution.In SC cases, thyroid hormone levels are often normal and usually do not contribute to diagnosis. A normal thyroid position is also typically observed. Treatment can be surgical for symptomatic patients or if diagnosis is uncertain. Prognosis is generally favorable, similar to benign cardiac tumors, and no SC recurrence case has ever been described.4This case is interesting because it highlights the importance of performing multimodal imaging to confirm the rare diagnosis of cardiac ectopic thyroid tissue.Sources of FundingNone.DisclosuresNone.FootnotesThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.120.010508.Hicham Mesrar, MD, Department of Interventional Cardiology and Cardiac Imaging, Institut du Cœur St-Gatien, Nouvelle Clinique Tours Plus, Tours, France. Email hicham.[email protected]comReferences1. Gackowski A, Pietrucha A, Miszalski-Jamka T, Rostoff P, Sadowski J, Nessler J. Intrapericardial ectopic thyroid gland mimicking cardiac tumor.Int J Cardiol2012; 158:e55–e56. doi: 10.1016/j.ijcard.2011.10.109CrossrefMedlineGoogle Scholar2. Williams RJ, Lindop G, Butler J. Ectopic thyroid tissue on the ascending aorta: an operative finding.Ann Thorac Surg2002; 73:1642–1643. doi: 10.1016/s0003-4975(01)03439-7CrossrefMedlineGoogle Scholar3. Ozpolat B, Dogan OV, Gökaslan G, Erekul S, Yücel E. Ectopic thyroid gland on the ascending aorta with a partial pericardial defect: report of a case.Surg Today2007; 37:486–488. doi: 10.1007/s00595-006-3439-7CrossrefMedlineGoogle Scholar4. Taylor MA, Bray M, Roberts WC. Aberrant thyroid gland attached to ascending aorta.Am J Cardiol1986; 57:708. doi: 10.1016/0002-9149(86)90871-4CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails October 2020Vol 13, Issue 10Article InformationMetrics Download: 39 © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.120.010508PMID: 32967443 Originally publishedSeptember 23, 2020 Keywordsmagnetic resonance imagingthyroid glandcardiac tumorPDF download SubjectsComputerized Tomography (CT)Magnetic Resonance Imaging (MRI)