Degenerated Transcatheter Aortic Valve Replacement: Investigation and Management Options.

With the expansion of transcatheter aortic valve replacement (TAVR) to younger and lower-surgical-risk patients, many younger and less comorbid patients will be treated with TAVR and are expected to have a life expectancy that will exceed the durability of their transcatheter heart valve. Consequently, the number of patients requiring reintervention will undoubtedly increase in the near future. Redo-TAVR and TAVR explantation followed by surgical aortic valve replacement are the different therapeutic options in the event of bioprosthetic valve failure and the need for reintervention. Patients often anticipate being able to benefit from a redo-TAVR in the event of bioprosthetic valve failure after TAVR, despite the lack of long-term data and the risk of unfavourable anatomy. Our understanding of the feasibility of redo-TAVR is constantly improving thanks to bench test studies and growing worldwide experience. However, much remains unknown. In clinical practice, one of the heart team's objectives is to anticipate the need to reaccess the coronary arteries and implant a second or even a third valve when life expectancy may exceed the durability of the transcatheter heart valve. In this review, we address key definitions in the diagnosis of structural valve deterioration and bioprosthetic valve failure, as well as patient selection and procedural planning for redo-TAVR to reduce periprocedural risk, optimise hemodynamic performance, and maintain coronary access. We describe the bench testing and literature in the redo-TAVR and TAVR explantation fields.

[Aortic stenosis: TAVI for all patients?] / Sténose aortique : TAVI en première intention pour tous les patients ?

Over the last 21 years, the paradigm has shifted from an initial use of TAVI for inoperable aortic stenosis cases to recognition of its benefits for all categories of patients. Since 2021, the European Society of Cardiology has recommended first-line transfemoral TAVI from the age of 75 for all categories of patients with aortic stenosis (high, intermediate, low risk). However, in Switzerland, the Federal Office of Public Health currently places a restriction on the reimbursement of low-risk patients, which is expected to be reassessed in 2023. Surgery remains the best therapeutic option for patients with an unfavorable anatomy and for those whose life expectancy exceeds the potential durability of the valve. In this article we will discuss the evidence supporting TAVI, its current indications and initial complications as well as areas for improvement to potentially further expand its indications.

Au cours des deux dernières décennies, le paradigme est passé d'une utilisation initiale du TAVI pour les cas de sténose aortique inopérables à une reconnaissance de ses bénéfices pour toutes les catégories de patients. Depuis 2021, la Société européenne de cardiologie recommande le TAVI transfémoral en première intention dès 75 ans pour toutes les catégories de patients avec sténose aortique (risque élevé, intermédiaire, bas). En Suisse, l'Office fédéral de la santé publique impose une restriction pour le remboursement des patients à bas risque, avec une réévaluation prévue durant l'année 2023. Cependant, la chirurgie garde une place particulière pour les patients avec une anatomie défavorable et pour ceux dont l'espérance de vie dépasse la durabilité potentielle de la valve. Dans cet article, nous discutons des preuves, des indications actuelles, des complications initiales du TAVI et des points à améliorer pour potentiellement étendre davantage les indications.

[Electrocardiographic abnormalities in the setting of acute central nervous system pathology]. / Anomalies de l'ECG secondaires à une lésion du système nerveux central.

Up to 90% of patients with acute central nervous system lesions, such as stroke, exhibit secondary ECG abnormalities, including ST elevation/depression, T wave inversion, prominent U wave, prolonged QTc interval, sinus bradycardia/pause and atrioventricular block. The pathophysiology involves autonomic nervous system disturbance resulting in altered ventricular repolarization gradients, or even myocardial lesions. Clinical assessment aims at distinguishing asymptomatic neurogenic ECG abnormalities from organic heart conditions such as Takotsubo syndrome, myocardial infarction and chronic coronary syndromes. Serial ECG, cardiac biomarkers and echocardiography should be performed, followed by targeted work-up in selected patients. Prolonged QT, arrhythmias or hemodynamic compromise require continuous monitoring and standard management.

Jusqu'à 90 % des patients souffrant de lésions neurologiques aiguës telles que l'AVC présentent des anomalies ECG neurogènes incluant : sus ou sous-décalage ST, onde T inversée, onde U proéminente, prolongement du QTc, bradycardie/pause sinusale et bloc atrioventriculaire. Leur cause semble être une dérégulation neurovégétative provoquant des gradients de repolarisation ventriculaire, voire des lésions myocardiques. Le bilan doit différencier les nombreux patients avec ECG neurogène asymptomatique de ceux présentant une cardiopathie telle qu'un syndrome de Takotsubo, un infarctus ou une maladie coronarienne stable. Le bilan inclut ECG sérié, biomarqueurs cardiaques et échocardiographie, suivis d'un bilan ciblé chez des patients sélectionnés. Un QT long, des arythmies ou une instabilité hémodynamique imposent un monitoring et les mesures habituelles.

Risks and benefits of urinary catheterisation during inpatient diuretic therapy for acute heart failure: a retrospective, non-inferiority, cohort study.

OBJECTIVES: Patients with acute congestive heart failure (HF) regularly undergo urinary catheterisation (UC) at hospital admission. We hypothesised that UC has no clinical benefits with regard to weight loss during inpatient diuretic therapy for acute congestive HF and increases the risk of urinary tract infection (UTI). DESIGN: Retrospective, non-inferiority study. SETTING: Geneva University Hospitals' Department of Medicine, a tertiary centre. PARTICIPANTS: In a cohort of HF patients, those catheterised within 24 hours of diuretic therapy (n=113) were compared with non-catheterised patients (n=346). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary endpoint was weight loss 48 hours after starting diuretic therapy. Secondary endpoints were time needed to reach target weight, discontinuation of intravenous diuretics and resolution of respiratory failure. Complications included the time to a first UTI, first hospital readmission and death. RESULTS: A total of 48-hour weight loss was not statistically different between groups and the adjusted difference was below the non-inferiority boundary of 1 kg (0.43 kg (95% CI: -0.03 to 0.88) in favour of UC, p<0.01 for non-inferiority). UC was not associated with time to reaching target weight (adjusted HR 1.0; 95% CI: 0.7 to 1.5), discontinuation of intravenous diuretics (aHR 0.9; 95% CI: 0.7 to 1.2) or resolution of respiratory failure (aHR 1.1; 95% CI: 0.5 to 2.4). UC increased the risk of UTI (aHR 2.5; 95% CI: 1.5 to 4.2) but was not associated with hospital readmission (aHR 1.1; 95% CI: 0.8 to 1.4) or 1-year mortality (aHR 1.4; 95% CI: 1.0 to 2.1). CONCLUSION: In this retrospective study, with no obvious hourly diuresis-based diuretic adjustment strategy, weight loss without UC was not inferior to weight loss after UC within 24 hours of initiating diuretic treatment. UC had no impact on clinical improvement and increased the risk of UTI. This evidence, therefore, argues against the systematic use of UC during a diuretic therapy for HF.

Chronic isolated radial head dislocation in adults: Technical note and literature review.

Isolated traumatic radial head dislocation is exceedingly rare in adults, usually diagnosed on an emergency basis, and reduced by external manoeuvres. If the diagnosis is not made immediately, external reduction is no longer feasible. Various options have been described for treating these chronic forms, including therapeutic abstention, radial head resection and annular ligamentoplasty combined, if appropriate, with osteotomy of the ulna. In patients with incapacitating symptoms, proposing a surgical option makes sense. Here, we describe the technique developed by PM Grammont, which combines ligamentoplasty and an oblique flat osteotomy of the ulna. We used this technique in a 31-year-old male with isolated anterior dislocation of the radial head of 3 months' duration. One year after surgery, he had fully recovered range of motion in all planes. He returned to work 5 months after surgery. The promising clinical and radiological outcomes in our patient support the use of this technique in adults with chronic isolated radial head dislocation. LEVEL OF EVIDENCE: IV.

[Epidemiology and strategy to prevent urinary catheters related complications]. / Epidémiologie et stratégies de prévention des complications liées au sondage urinaire.

Indwelling urinary catheter (IUC) is encountered in every four admitted in-patients. The risk of bacteriuria increases by 3­7 % every day and is almost universal at 30 days. Of these, 10 % will develop symptomatic infection, bacteremia, septic choc or death. Traumatic complications of IUC are seldom studied, but are at least as frequent as the infectious complications of IUC, with similar impact on LOS or morbidity. Prevention should focus on finding alternatives to IUC (for example, use of condom for men, assess the non-hourly diuresis), a strict compliance on known indication for IUC and hygiene, as well as to ask every day the possibility to withdraw the catheter.

Une sonde urinaire (SU) est posée à un quart des patients hospitalisés. La bactériurie est inéluctable, augmentant de 3 à 7 % par jour et affectant virtuellement tous les patients à un mois. De ces patients, 10 % vont devenir symptomatiques, avec à l'extrémité du spectre, la bactériémie, le choc septique et le décès. Les complications non infectieuses des SU sont moins étudiées mais tout aussi fréquentes, avec un impact similaire sur la durée de séjour et la morbidité. La prévention des complications des SU passe par la recherche d'autres possibilités (par exemple, étuis péniens, contrôle de la diurèse non horaire), un respect strict des indications aux SU et des règles d'hygiène lors de la manipulation du système, ainsi que par un souci quotidien d'effectuer le retrait des SU dont l'indication n'est plus justifiée.

Röttinger approach with dual-mobility cup to improve functional recovery in hip osteoarthritis patients: biomechanical and clinical follow-up.

PURPOSE: We assumed that the combination of dual-mobility total hip arthroplasty (THA) using the minimally-invasive Röttinger anterolateral approach could guarantee hip stability with faster functional recovery. We objectively analyzed functional improvement after dual-mobility THA by quantitative gait analysis. METHODS: We compared the results achieved following two different surgical approaches: Röttinger's versus Moore's approach (posterolateral approach). We included 70 patients in an open prospective single-centre study: 38 by Rottinger's approach (age = 67yo) and 32 by Moores's approach (age = 68yo). Clinical and biomechanical analysis (kinematic and kinetic parameters of the hip) were conducted at the pre-operative period and at six months post-op RESULTS: We found a significant improvement in all clinical scores and all biomechanical parameters but no difference was found between the two approaches. However, the study showed marked clinical, biomechanical and functional improvements for patients treated with dual-mobility THA for osteoarthritis without complete hip recovery compared with a control group. CONCLUSIONS: The combination of the Röttinger approach with a dual-mobility cup remains a valid choice for primary THA without functional advantage at midterm.