[Bradyarrythmias in acute coronary syndromes]. / Bradyarythmies dans le syndrome coronarien aigu.

In up to 30-40% of the cases acute coronary syndrome (ACS) is complicated by cardiac arrhythmias. The latter can be benign or malignant and mainly occur during the first 24 hours after myocardial infarction. Ischemia time being the key factor, arrythmias decreased dramatically since the implementation of accelerated reperfusion strategies. Bradyarrhythmias are often benign and self-limiting and are less frequent than tachyarrhythmias but can sometimes require specific treatment. The objective of this article is to provide an update on bradycardia and conduction system disorders occurring during ACS and their management.

Le syndrome coronarien aigu (SCA) est compliqué d'arythmies cardiaques jusque dans 30 à 40 % des cas. Celles-ci peuvent être bénignes ou malignes et surviennent principalement durant les premières 24 heures après l'infarctus du myocarde (IDM). Le temps d'ischémie étant le facteur clé, elles sont en baisse depuis la mise en place de stratégies de reperfusion accélérées. Les bradyarythmies, souvent bénignes et spontanément résolutives, sont moins fréquentes que les tachyarythmies mais peuvent parfois nécessiter une prise en charge spécifique. L'objectif de cet article est une mise à jour sur les bradycardies et troubles de la conduction survenant lors d'un SCA ainsi que leurs prises en charge.

Establishing a priori and a posteriori predictive models to assess patients' peak skin dose in interventional cardiology. Part 2: results of the VERIDIC project.

BACKGROUND: Optimizing patient exposure in interventional cardiology is key to avoid skin injuries. PURPOSE: To establish predictive models of peak skin dose (PSD) during percutaneous coronary intervention (PCI), chronic total occlusion percutaneous coronary intervention (CTO), and transcatheter aortic valve implantation (TAVI) procedures. MATERIAL AND METHODS: A total of 534 PCI, 219 CTO, and 209 TAVI were collected from 12 hospitals in eight European countries. Independent associations between PSD and clinical and technical dose determinants were examined for those procedures using multivariate statistical analysis. A priori and a posteriori predictive models were built using stepwise multiple linear regressions. A fourfold cross-validation was performed, and models' performance was evaluated using the root mean square error (RMSE), mean absolute percentage error (MAPE), coefficient of determination (R²), and linear correlation coefficient (r). RESULTS: Multivariate analysis proved technical parameters to overweight clinical complexity indices with PSD mainly affected by fluoroscopy time, tube voltage, tube current, distance to detector, and tube angulation for PCI. For CTO, these were body mass index, tube voltage, and fluoroscopy contribution. For TAVI, these parameters were sex, fluoroscopy time, tube voltage, and cine acquisitions. When benchmarking the predictive models, the correlation coefficients were r = 0.45 for the a priori model and r = 0.89 for the a posteriori model for PCI. These were 0.44 and 0.67, respectively, for the CTO a priori and a posteriori models, and 0.58 and 0.74, respectively, for the TAVI a priori and a posteriori models. CONCLUSION: A priori predictive models can help operators estimate the PSD before performing the intervention while a posteriori models are more accurate estimates and can be useful in the absence of skin dose mapping solutions.

Patient exposure dose in interventional cardiology per clinical and technical complexity levels. Part 1: results of the VERIDIC project.

BACKGROUND: Patients can be exposed to high skin doses during complex interventional cardiology (IC) procedures. PURPOSE: To identify which clinical and technical parameters affect patient exposure and peak skin dose (PSD) and to establish dose reference levels (DRL) per clinical complexity level in IC procedures. MATERIAL AND METHODS: Validation and Estimation of Radiation skin Dose in Interventional Cardiology (VERIDIC) project analyzed prospectively collected patient data from eight European countries and 12 hospitals where percutaneous coronary intervention (PCI), chronic total occlusion PCI (CTO), and transcatheter aortic valve implantation (TAVI) procedures were performed. A total of 62 clinical complexity parameters and 31 technical parameters were collected, univariate regressions were performed to identify those parameters affecting patient exposure and define DRL accordingly. RESULTS: Patient exposure as well as clinical and technical parameters were collected for a total of 534 PCI, 219 CTO, and 209 TAVI. For PCI procedures, body mass index (BMI), number of stents ≥2, and total stent length >28 mm were the most prominent clinical parameters, which increased the PSD value. For CTO, these were total stent length >57 mm, BMI, and previous anterograde or retrograde technique that failed in the same session. For TAVI, these were male sex, BMI, and number of diseased vessels. DRL values for Kerma-area product (PKA), air kerma at patient entrance reference point (Ka,r), fluoroscopy time (FT), and PSD were stratified, respectively, for 14 clinical parameters in PCI, 10 in CTO, and four in TAVI. CONCLUSION: Prior knowledge of the key factors influencing the PSD will help optimize patient radiation protection in IC.

[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.

Should We Be Using Upstream Beta-Blocker Therapy for Acute Myocardial Infarction?

PURPOSE OF REVIEW: Controversy exists whether beta-blockers should be given before primary percutaneous coronary intervention (PCI) or to defer their administration for up to 24 hours. RECENT FINDINGS: Animal studies, most of them conducted in the 1970s and 1980s, showed evidence that early beta-blocker administration may reduce infarct size. Subsequent human studies had mixed results on infarct size and survival. More specifically, in the current primary PCI era, only four studies evaluated the impact of early intravenous beta-blocker administration after acute myocardial infarction, only two of them before PCI. All studies agree that in hemodynamically stable patients, early intravenous beta-blocker administration is safe and protected against malignant arrhythmias. Nevertheless, results on infarct size and mortality are equivocal. Considering the heterogeneity of currently available data, further studies are still needed to assess the benefit of early injection of metoprolol in STEMI patients in a large double-blinded and randomized design versus placebo.

Acute effects of transcatheter aortic valve replacement on the ventricular-aortic interaction.

Transcatheter aortic valve replacement (TAVR) is increasingly used to treat severe aortic stenosis (AS) patients. However, little is known regarding the direct effect of TAVR on the ventricular-aortic interaction. In the present study, we aimed to investigate changes in central hemodynamics after successful TAVR. We retrospectively examined 33 cases of severe AS patients (84 ± 6 yr) who underwent TAVR. Invasive measurements of left ventricular and aortic pressures as well as echocardiographic aortic flow were acquired before and after TAVR (maximum within 5 days). We examined alterations in key features of central pressure and flow waveforms, including the aortic augmentation index (AIx), and performed wave separation analysis. Arterial parameters were determined via parameter-fitting on a two-element Windkessel model. Resolution of AS resulted in direct increase in the aortic systolic pressure and maximal aortic flow (131 ± 22 vs. 157 ± 25 mmHg and 237 ± 49 vs. 302 ± 69 mL/s, P < 0.001 for all), whereas the ejection duration decreased (P < 0.001). We noted a significant decrease in the AIx (from 42 ± 12 to 19 ± 11%, P < 0.001). Of note, the arterial properties remained unchanged. There was a comparable increase in both forward (61 ± 20 vs. 77 ± 20 mmHg, P < 0.001) and backward (35 ± 14 vs. 42 ± 10 mmHg, P = 0.013) pressure wave amplitudes, while their ratio, i.e., the reflection coefficient, was preserved. Our results highlight the impact of TAVR on the ventricular-aortic interaction by affecting the amplitude, shape, and related attributes of the aortic pressure and flow pulse and challenge the interpretation of AIx as a solely vascular measure in AS patients.NEW & NOTEWORTHY Transcatheter aortic valve replacement (TAVR) is linked with an immediate increase in aortic systolic blood pressure and maximal flow, as well as steeper aortic pressure and flow wave upstrokes. After TAVR, the forward wave pumped by the heart is enhanced. Although the arterial properties remain unchanged, the central augmentation index (AIx) is markedly decreased after TAVR. This challenges the interpretation of AIx as a solely vascular measure in patients with aortic valve stenosis.

[Spontaneous coronary artery dissection†: primum nihil nocere]. / Dissection coronaire spontanée†: primum nihil nocere.

Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome, myocardial infarction and sudden cardiac death, among young patient with little/no traditional cardiovascular risk factors. Historically SCAD was considered as a rare pathology, associated primarily with pregnancy and the peripartum period. In recent years, SCAD diagnosis improved thanks to data derived from large registries, thanks to the increased use of diagnostic coronary angiography and the availability of intracoronary imaging. To date there are no randomized trials dedicated to SCAD. However, thanks to global efforts to build national SCAD registries, knowledge of SCAD has tremendously increased during the last years, demonstrating that SCAD is a distinct pathophysiological entity, and presents key differences in management and outcomes compared to ACS of atherosclerotic aetiology.

La dissection coronaire spontanée est une cause importante de syndrome coronarien aigu, d'infarctus du myocarde et de mort subite, chez des patients jeunes, présentant peu ou pas de facteurs de risque cardiovasculaire traditionnels. Historiquement elle était considérée comme une pathologie rare, survenant essentiellement en association avec la grossesse et le peripartum. Il n'existe à l'heure actuelle pas d'études randomisées concernant la dissection coronaire spontanée. Toutefois, grâce à un effort international visant à établir de larges registres nationaux répertoriant les patients atteints de dissection coronaire spontanée, les connaissances concernant cette pathologie ont largement évolué au cours des dernières années, permettant de mettre en évidence que la dissection coronaire spontanée constitue une entité physiopathologique distincte, et que son traitement et son évolution clinique sont distincts du syndrome coronarien aigu d'origine athérosclérotique.

3D-printed heart model to guide LAA closure: useful in clinical practice?

OBJECTIVES: Correct device sizing for left atrial appendage (LAA) closure remains challenging due to complex LAA shapes. The aim of our study was to investigative the utility of personalized 3D-printed models (P3DPM) of the LAA to guide device size selection. METHODS: Fifteen patients (75.4 ±8.5years) scheduled for LAA closure using an Amulet device underwent cardiac computed tomography (CT). The LAA was segmented by semiautomatic algorithms using Vitrea® software. A 1.5-mm LAA thick shell was exported in stereolithography format and printed using TangoPlus flexible material. Different Amulet device sizes on the P3DPM were tested. New P3DPM-CT with the device was acquired in order to appreciate the proximal disc sealing the LAA ostium and the compression of the distal lobe within the LAA. We predicted the device size with P3DPM and compared this with the device sizes predicted by transesophageal echocardiography (TEE) and CT as well as the device size implanted in patients. RESULTS: The device size predicted by 3D-TEE and CT corresponded to the implanted device size in 8/15 (53%) and 10/15 (67%), respectively. The predicted device size from the P3DPM was accurate in all patients, obtaining perfect contact with the LAA wall, without device instability or excessive compression. P3DPM-CT with the deployed device showed device deformation and positioning of the disk in relation to the pulmonary veins, allowing us to determine the best device size in all 15 cases. CONCLUSION: P3DPM allowed us to simulate the LAA closure procedure and thus helped to identify the best Amulet size and position within the LAA. KEY POINTS: • A 3D-printed heart model allows to simulate the LAA closure procedure. • A 3D-printed heart model allowed to identify the optimal Amulet size and position. • 3D-printed heart models may contribute to reduce the Amulet implantation learning curve.

Percutaneous Coronary Intervention of Chronic Total Occlusions in Patients with Diabetes Mellitus: a Treatment-Risk Paradox.

PURPOSE OF REVIEW: Diabetes mellitus (DM) is highly prevalent among patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). This review aims to summarize the available evidence on CTO recanalization in patients with DM. RECENT FINDINGS: Coronary artery bypass grafting (CABG) surgery is the recommended revascularization modality for patients with DM and multivessel coronary artery disease (CAD). However, the optimal management strategy in diabetic patients with CTO and single-vessel disease or prior CABG remains a clinical dilemma. Contemporary, large-scale, observational registries support the notion that CTO PCI, if performed at high-volume CTO PCI centers by highly experienced operators, conveys similar high procedural success and low complication rates in patients with and without DM. Although DM patients have more frequently CTOs and may derive greater benefit from complete revascularization, they are less frequently exposed to CTO PCI than non-DM patients (treatment-risk paradox). CTO PCI performed by highly experienced operators constitutes a safe and effective treatment option for selected diabetic CTO patients who are not candidates for CABG. Randomized studies are warranted to compare long-term outcomes of CTO PCI and medical therapy in this high-risk subset.

[Mitral clipping in the treatment of secondary mitral regurgitation]. / Clip mitral dans l'insuffisance mitrale secondaire.

Secondary mitral regurgitation is a frequent valvulopathy due to left ventricle remodeling. Although, its poor prognostic has been established, surgical interventions have shown no substantial benefits in terms of mortality benefit. MitraClip represents a transcatheter alternative. Two randomized trials - MITRA-FR and COAPT comparing the clipping versus optimal medical therapy- have confirmed the feasibility of this intervention in patients with secondary mitral regurgitation. MITRA-FR did not show any significant benefit for the MitraClip group with respect to the composite endpoint (all-cause mortality and rehospitalization for heart failure) at 12 months. On the other hand, COAPT showed a clear superiority of MitraClip in terms of mortality and rehospitalization rates, compared to the conservative treatment alone at 24 months.

L'insuffisance mitrale secondaire est une pathologie fréquente dont la prise en charge médicale est primordiale. L'approche chirurgicale n'a pas montré de bénéfice significatif en termes de réduction de la mortalité. Récemment, les procédures d'implantation de clips mitraux ont été analysées au cours de deux études randomisées (MITRA-FR et COAPT) qui comparent le clip à un traitement médicamenteux optimal. MITRA-FR n'a pas montré de bénéfice du clip par rapport au traitement médicamenteux pour le critère de jugement primaire (mortalité de toute cause et réhospitalisation pour insuffisance cardiaque) à 12 mois. A l'opposé, l'étude COAPT a montré un clair bénéfice du MitraClip par rapport au traitement conservateur en termes de mortalité globale et réhospitalisation pour insuffisance cardiaque à 24 mois.

[Patent foramen ovale closure : update]. / Fermeture du foramen ovale perméable : où en sommes-nous en 2018 ?

The question of whether to perform percutaneous PFO closure to reduce the risk of recurrent ischemic stroke has been a dilemma for many years. Recent randomized trials have shown the superiority of percutaneous closure compared to medical therapy for large shunts. The indication of PFO closure is based on a multidisciplinary decision involving neurologists, cardiologists and hemostasis specialists. Important points are: PFO anatomy, brain imaging, history of venous thromboembolism and potential thrombophilia. In addition, atrial fibrillation (AF) should systematically be excluded. The intervention is performed under fluoroscopic guidance alone or with additional echocardiographic guidance. The procedural complication rate is low. There is an increased incidence of AF after percutaneous closure compared with medical therapy.

De récentes données randomisées démontrent une supériorité de la fermeture percutanée du foramen ovale perméable (FOP) comparée au traitement médicamenteux lors de shunt de grande taille. La fermeture du FOP repose sur une décision multidisciplinaire lors d'un colloque entre neurologues, cardiologues et spécialistes de l'hémostase. Les points à considérer sont : l'anatomie du FOP, l'imagerie cérébrale, les antécédents de maladie thromboembolique veineuse et la recherche d'une thrombophilie. De plus, il faut systématiquement exclure la fibrillation auriculaire (FA). L'intervention se fait par un accès veineux fémoral sous guidance fluoroscopique seul ou avec également une guidance échocardiographique. Le taux de complications lors de la procédure est faible mais il existe une augmentation de l'incidence de FA après fermeture percutanée.

[Post-myocardial infarction ventricular septal defect]. / Communication interventriculaire postinfarctus du myocarde : mise au point.

Post-myocardial infarction ventricular septal defect corresponds to the rupture of the ventricular septum between the healthy and infarcted parts. It is a rare complication still associated with a high mortality rate. Its diagnostic should be evoked in case of pathologic cardiac auscultation and confirmed by emergent transthoracic echocardiography. Hemodynamic stabilisation, mainly with the insertion of an intra-aortic balloon pump is the first step in the management. The subsequent modality of closure, either surgical or transcatheter, as well as the ideal timing should be discussed in the Heart team. Successful closure decreases the 30-day mortality rate to 30-40 %.

La communication interventriculaire postinfarctus du myocarde correspond à la rupture du septum interventriculaire au niveau de la transition entre les tissus sain et infarci. C'est une complication rare mais mortelle après un infarctus du myocarde. Le diagnostic est avant tout clinique et doit être évoqué en cas d'auscultation cardiaque pathologique et confirmé par une échocardiographie transthoracique réalisée en urgence. La stabilisation hémodynamique, dans la majorité des cas à l'aide d'un ballon de contre-pulsion intra-aortique, est la première étape de la prise en charge. Ensuite, la décision d'une fermeture chirurgicale ou percutanée et son timing doivent être évalués au sein du Heart team. La fermeture chirurgicale ou percutanée permet de diminuer la mortalité à 30-40 % à 30 jours.

[The place of balloon pulmonary angioplasty in the management of chronic thromboembolic pulmonary hypertension]. / Place de l'angioplastie percutanée dans le traitement de l'hypertension pulmonaire postembolique.

Chronic thromboembolic pulmonary hypertension (CTEPH) is uncommon. Its diagnosis should not be delayed as its prognosis is poor if not treated. In most cases, an acute pulmonary embolism is found in the medical history of the patient. Once suspected, a specific work-up should be performed in a pulmonary hypertension (PH) center. The ventilation/perfusion scan has a central role in this workup but the emergence of non invasive imaging technologies provides morphological and functional information which take part in the therapeutic decision making, such as operability. Surgical endarterectomy remains the only curative treatment. In some specific patients, percutaneous transluminal pulmonary angioplasty (AAP) is performed. This developing technique is a safe and efficient treatment on a clinical and hemodynamic standpoint. The main complication after AAP is lung reperfusion edema.

L'hypertension pulmonaire postembolique (CTEPH) est une maladie rare. Son diagnostic ne doit pas être retardé, compte tenu de son mauvais pronostic en l'absence de prise en charge adaptée. Dans la plupart des cas, un épisode d'embolie pulmonaire est retrouvé dans l'histoire médicale du patient. Une fois suspectée, la CTEPH nécessite une approche multidisciplinaire tant pour la stratégie diagnostique que thérapeutique. Les nouvelles techniques d'imagerie permettent de définir précisément le traitement de choix, tenant compte des comorbidités et de la topographie des lésions. Le seul traitement curatif reste l'endartérectomie pulmonaire. L'angioplastie percutanée des artères pulmonaires, effectuée dans des centres experts, se profile comme une alternative en cours de validation et doit se discuter au cas par cas. Cette technique permet de traiter non seulement des patients jugés inopérables mais également les patients avec une hypertension pulmonaire résiduelle postendartérectomie. La complication la plus fréquente est l'œdème de reperfusion.

Extra-cardiac stimulators: what do cardiologists need to know?

For several decades, treating patients with pacemakers has been the privilege of cardiologists. However, in the last 30 years, researchers have found new targets for electrical stimulation in different clinical subspecialities, such as deep brain stimulation (for the treatment of Parkinson's disease, essential tremor, dystonia, and some psychiatric illnesses); spinal cord stimulation (for refractory angina, chronic pain, and peripheral artery disease); and sacral (for diverse urologic and proctologic conditions), vagal (for epilepsy), and phrenic nerve stimulation (for sleep apnoea). The purpose of this article is to familiarize cardiologists with these 'extra-cardiac pacemakers' and to discuss potential issues that must be addressed when these patients undergo cardiac procedures.

Effect of high-intensity statin therapy on atherosclerosis in non-infarct-related coronary arteries (IBIS-4): a serial intravascular ultrasonography study.

AIM: The effect of long-term high-intensity statin therapy on coronary atherosclerosis among patients with acute ST-segment elevation myocardial infarction (STEMI) is unknown. The aim of this study was to quantify the impact of high-intensity statin therapy on plaque burden, composition, and phenotype in non-infarct-related arteries of STEMI patients undergoing primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: Between September 2009 and January 2011, 103 STEMI patients underwent intravascular ultrasonography (IVUS) and radiofrequency ultrasonography (RF-IVUS) of the two non-infarct-related epicardial coronary arteries (non-IRA) after successful primary PCI. Patients were treated with high-intensity rosuvastatin (40 mg/day) throughout 13 months and serial intracoronary imaging with the analysis of matched segments was available for 82 patients with 146 non-IRA. The primary IVUS end-point was the change in per cent atheroma volume (PAV). After 13 months, low-density lipoprotein cholesterol (LDL-C) had decreased from a median of 3.29 to 1.89 mmol/L (P < 0.001), and high-density lipoprotein cholesterol (HDL-C) levels had increased from 1.10 to 1.20 mmol/L (P < 0.001). PAV of the non-IRA decreased by -0.9% (95% CI: -1.56 to -0.25, P = 0.007). Patients with regression in at least one non-IRA were more common (74%) than those without (26%). Per cent necrotic core remained unchanged (-0.05%, 95% CI: -1.05 to 0.96%, P = 0.93) as did the number of RF-IVUS defined thin cap fibroatheromas (124 vs. 116, P = 0.15). CONCLUSION: High-intensity rosuvastatin therapy over 13 months is associated with regression of coronary atherosclerosis in non-infarct-related arteries without changes in RF-IVUS defined necrotic core or plaque phenotype among STEMI patients.

[Hereditary haemorrhagic telangiectasia: importance of a multidisciplinary approach]. / Maladie de Rendu-Osler-Weber: importance d'une prise en charge multidisciplinaire.

The Rendu-Osler-Weber disease, also known as hereditary haemorrhagic telangiectasia, is an autosomal dominant inherited disease. Its main manifestations are nosebleeds and digestive tract bleeding due to angiodysplasia. The presence of arteriovenous malformations in organs such as lung, liver, brain, etc. can cause serious complications (haemorrhage, stroke, brain abscess, hypoxemia, increased cardiac output, pulmonary arterial hypertension). Diagnosis is based on clinical criteria and can be confirmed by genetic analysis. The prevalence of this rare disease is 1/5,000 to 1/10,000 and its expression varies widely, even in the same family. The management must be multidisciplinary and based on prevention and treatment of bleeding complications as well as screening and treatment of arteriovenous malformations.

Ultrathin strut biodegradable polymer sirolimus-eluting stent versus durable polymer everolimus-eluting stent for percutaneous coronary revascularisation (BIOSCIENCE): a randomised, single-blind, non-inferiority trial.

BACKGROUND: Refinements in stent design affecting strut thickness, surface polymer, and drug release have improved clinical outcomes of drug-eluting stents. We aimed to compare the safety and efficacy of a novel, ultrathin strut cobalt-chromium stent releasing sirolimus from a biodegradable polymer with a thin strut durable polymer everolimus-eluting stent. METHODS: We did a randomised, single-blind, non-inferiority trial with minimum exclusion criteria at nine hospitals in Switzerland. We randomly assigned (1:1) patients aged 18 years or older with chronic stable coronary artery disease or acute coronary syndromes undergoing percutaneous coronary intervention to treatment with biodegradable polymer sirolimus-eluting stents or durable polymer everolimus-eluting stents. Randomisation was via a central web-based system and stratified by centre and presence of ST segment elevation myocardial infarction. Patients and outcome assessors were masked to treatment allocation, but treating physicians were not. The primary endpoint, target lesion failure, was a composite of cardiac death, target vessel myocardial infarction, and clinically-indicated target lesion revascularisation at 12 months. A margin of 3·5% was defined for non-inferiority of the biodegradable polymer sirolimus-eluting stent compared with the durable polymer everolimus-eluting stent. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT01443104. FINDINGS: Between Feb 24, 2012, and May 22, 2013, we randomly assigned 2119 patients with 3139 lesions to treatment with sirolimus-eluting stents (1063 patients, 1594 lesions) or everolimus-eluting stents (1056 patients, 1545 lesions). 407 (19%) patients presented with ST-segment elevation myocardial infarction. Target lesion failure with biodegradable polymer sirolimus-eluting stents (69 cases; 6·5%) was non-inferior to durable polymer everolimus-eluting stents (70 cases; 6·6%) at 12 months (absolute risk difference -0·14%, upper limit of one-sided 95% CI 1·97%, p for non-inferiority <0·0004). No significant differences were noted in rates of definite stent thrombosis (9 [0·9%] vs 4 [0·4%], rate ratio [RR] 2·26, 95% CI 0·70-7·33, p=0·16). In pre-specified stratified analyses of the primary endpoint, biodegradable polymer sirolimus-eluting stents were associated with improved outcome compared with durable polymer everolimus-eluting stents in the subgroup of patients with ST-segment elevation myocardial infarction (7 [3·3%] vs 17 [8·7%], RR 0·38, 95% CI 0·16-0·91, p=0·024, p for interaction=0·014). INTERPRETATION: In a patient population with minimum exclusion criteria and high adherence to dual antiplatelet therapy, biodegradable polymer sirolimus-eluting stents were non-inferior to durable polymer everolimus-eluting stents for the combined safety and efficacy outcome target lesion failure at 12 months. The noted benefit in the subgroup of patients with ST-segment elevation myocardial infarction needs further study. FUNDING: Clinical Trials Unit, University of Bern, and Biotronik, Bülach, Switzerland.

Retrograde aortic valve crossing of the CoreValve prosthesis using the buddy balloon technique.

In rare cases, retrograde aortic valve crossing during transcatheter aortic valve implantation may be challenging despite improvements in delivery catheter profile, size, and steerability compared with the first generation devices. Herein, we report a case of challenging transfemoral Medtronic CoreValve placement that was possible, thanks to the buddy balloon technique, using a peripheral 6-F compatible balloon.