[How to solve difficult side branch access: case report and literature review]. / Je n'arrive pas à passer mon guide dans la branche fille ; cas clinique et revue de la littérature.

We present the case of a 53-year-old patient with history of hypertension and dyslipidemia, admitted for effort-induced angina. Coronary angiography revealed two-vessel disease with severe stenosis of the LAD- Diagonal bifurcation (MEDINA 1-1-1). This lesion was considered complex regarding the severe stenosis of the bifurcation core, the angulation <45°, and the severity and length of the diagonal lesion. The procedure was planned according to a TAP technique. The flow in the diagonal was however lost after stenting the main vessel causing an ST elevation with chest pain. It was subsequently recovered using the rescue jailed balloon technique before re-crossing the stent struts of the LAD using a Gaia First® (Asahi) guidewire. The aim of this case report is to illustrate some pitfalls that can be encountered in bifurcation percutaneous interventions and to present technical solutions to solve difficult side branch access issues through a literature review.

[How to deal with elevated gradient following TAVR?] / Le gradient reste élevé après mon TAVI, que faire?

Over the past two decades, transcatheter aortic valve implantation (TAVI) has become a safe and effective therapeutic option for symptomatic and severe aortic stenosis, regardless of the surgical risk spectrum. With the expansion of TAVI indications to low-risk and younger patients, it is crucial to ensure satisfactory and durable hemodynamic outcomes to guarantee transcatheter heart valve (THV) longevity. However, secondary THV dysfunction may occur, often manifested by an increased transvalvular gradient. According to VARC-3 criteria, these dysfunctions can be attributed to four main mechanisms: 1) structural valve deterioration; 2) non-structural valve dysfunction; 3) thrombosis; 4) and endocarditis. Each mechanism leads to specific abnormalities, requiring a systematic diagnostic approach and appropriate treatment. This article illustrates, through two clinical cases, the diagnosis and management of secondary transvalvular gradient elevation after TAVI.

[Percutaneous closure of a coronary-pulmonary fistula : a case report]. / Fermeture percutanée d'une fistule coronaro-pulmonaire : à propos d'un cas.

BACKGROUND: A coronary artery fistula is an abnormal connection between one or more coronary arteries and a cardiac chamber or great vessel, often discovered incidentally through cardiac imaging. Although coronary artery fistulas are typically asymptomatic during the first two decades of life, particularly when small, they can become clinically significant over time. CASE PRESENTATION: We present the case of a 71-year-old female patient with a history of exertional dyspnea. Diagnostic coronary angiography revealed a significant coronary artery fistula originating from the proximal right coronary artery and draining into the pulmonary artery trunk. Given the patient's symptoms and the anatomical features of the fistula, she was successfully treated with transcutaneous closure using a liquid embolic agent (Onyx). CONCLUSION: Although surgical intervention has historically been the primary treatment for CAF, minimally invasive techniques such as transcutaneous closure are proving to be effective alternatives.

[Coronary sinus reducer : Technical aspects, prevention and management of potential complications]. / Réducteur de sinus coronaire : aspects techniques, prévention et gestion des complications.

Coronary sinus reducer implantation is a percutaneous technique creating a narrowing in the coronary sinus through the implantation of an hourglass-shaped endoprosthesis. It is proposed to reduce symptoms in patients suffering from refractory angina pectoris. This innovative treatment is experiencing a major craze among interventional cardiologists. It is associated with very high procedural success rates. Complications are rare and include coronary sinus dissection or perforation and migration of the device. This review exposes the device implantation technique, the potential anatomical difficulties, the tips and tricks to overcome challenging situations. It also focuses on the prevention and management of potential complications.

How to manage an entrapped undeflatable coronary balloon.

An entrapped undeflatable coronary balloon is a rare complication during percutaneous coronary intervention. It is a complication that can be stressful for the operator, with potentially catastrophic implications for the patient. A fully inflated balloon in the coronaries impedes the blood flow to the distal myocardium and hence causes ischemia, that could jeopardize the hemodynamics of the patients and potentially lead to life-threatening complications. In this article, we go over the bail-out techniques that have been tried while highlighting the pros and cons of each technique.

[La « technique du buddy stent ¼ pour pallier un mauvais support lors de l'implantation d'un stent couvert dans le traitement d'une perforation coronaire]. / The "buddy stent technique" to overcome poor support for cover stent implantation to treat coronary perforation.

An 86-year-old woman was managed for a non-ST-segment elevation myocardial infarction. Coronary angiography revealed significant stenoses at the left anterior descending, left ostial circumflex (LCX), obtuse first marginal, and a Medina 1.0.1 bifurcation lesion at the middle LCX/ second obtuse marginal (OM2). During percutaneous coronary intervention, the rupture of the pre-dilatation balloon was complicated by a type III coronary perforation at the level of the LCX/OM2 bifurcation, leading to cardiac tamponade. Hemodynamics were stabilized by percutaneous pericardial drainage. The placement of a covered stent (BeGraft, Bentley InnoMed), to seal the coronary perforation, was not possible due to its great rigidity and the angulation towards the OM2, even with the use of a guiding catheter extension (Guidezilla, Boston Scientific). To further increase support, we decided to use the flexibility of a regular drug-eluting stent which we implanted from the LCX to the OM2, thereby creating a rail-like path in which the covered stent could then be positioned and deployed successfully, allowing the perforation to be sealed with a good final result. This is what we called the "buddy stent technique".

3D Stent Reconstruction Using CMCT: A Novel Method to Assess Stent Expansion.

Stent underexpansion in calcified coronary stenosis is an important predictor of major short- and long-term adverse cardiovascular events. In this case, we describe a novel method for assessing stent expansion using 3-dimensional stent reconstruction with C-arm motion compensated computed tomography.

Clinical effects of permanent pacemaker implantation after transcatheter aortic valve implantation: Insights from the nationwide FRANCE-TAVI registry.

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

Evolution of REperfusion Strategies and impact on mortality in Old and Very OLD STEMI patients. The RESOVOLD-e-MUST study.

BACKGROUND: The use of myocardial reperfusion-mainly via angioplasty-has increased in our region to over 95%. We wondered whether old and very old patients have benefited from this development. METHODS: Setting: Greater Paris Area (Ile-de-France). DATA: Regional registry, prospective, including since 2003, data from 39 mobile intensive care units performing prehospital treatment of patients with ST segment elevation myocardial infarction (STEMI) (<24 h). PARAMETERS: Demographic, decision to perform reperfusion and outcome (in-hospital mortality). PRIMARY ENDPOINT: Reperfusion decision rate by decade over age 70. SECONDARY ENDPOINT: Outcome. RESULTS: We analysed the prehospital management of 27,294 patients. There were 21,311 (78%) men and 5,919 (22%) women with a median age of 61 (52-73 years). Among these patients, 8,138 (30%) were > 70 years, 3,784 (14%) > 80 years and 672 (2%) > 90 years.The reperfusion decision rate was 94%. It decreased significantly with age: 93, 90 and 76% in patients in their seventh, eighth and ninth decade, respectively. The reperfusion decision rate increased significantly over time. It increased in all age groups, especially the higher ones. Mortality was 6%. It increased significantly with age: 8, 16 and 25% in patients in their seventh, eighth and ninth decade, respectively. It significantly decreased over time in all age groups. The odds ratio of the impact of reperfusion decision on mortality reached 0.42 (0.26-0.68) in patients over 90 years. CONCLUSION: the increase in the reperfusion decision rate was the greatest in the oldest patients. It reduced mortality even in patients over 90 years of age.

Intervención de lesiones en bifurcación relacionadas con oclusión coronaria crónica total: incidencia, tratamiento y resultados hospitalarios / Interventions in chronic total occlusions with bifurcation lesions: incidence, treatment, and in-hospital outcome

Introducción y objetivos: Las oclusiones coronarias crónicas totales (OCT) que afectan a lesiones en bifurcación representan un subconjunto de lesiones difíciles de tratar y poco estudiadas en la literatura. Este estudio analiza la incidencia, la estrategia de tratamiento, los resultados hospitalarios y las complicaciones de la intervención coronaria percutánea (ICP) de las OCT en bifurcación (OCT-BIF). Métodos: Se evaluaron los datos de 607 pacientes consecutivos con OCT tratados en el Institut Cardiovasculaire Paris Sud (ICPS), Massy, Francia, entre enero de 2015 y febrero de 2020. Se compararon 2 subgrupos de pacientes (OCT-BIF, n=245; OCT-no BIF, n=362) en cuanto a estrategia de procedimiento, resultado hospitalario y tasa de complicaciones. Resultados: La media de edad de los pacientes fue 63,2±10,6 años; el 79,6% eran varones. Las lesiones en bifurcación estuvieron implicadas en el 40,4% de los procedimientos. La complejidad general de la lesión fue alta (valores medios de las puntuaciones J-CTO, 2,30 ± 1,16, y PROGRESS CTO, 1,37±0,94). El stent condicional fue la estrategia preferida para el tratamiento de las lesiones en bifurcación (93,5%). Los pacientes OCT-BIF presentaban una mayor complejidad de la lesión según la puntuación J-CTO (2,42±1,02 frente a 2,21±1,23 de los pacientes OCT-no BIF; p=0,025) y la puntuación PROGRESS CTO (1,60±0,95 frente a 1,22±0,90 de los pacientes OCT-no BIF; p<0,001). El éxito de la intervención fue del 78,9% y no se vio afectado por la presencia de bifurcación (el 80,4% en el grupo de OCT-BIF y el 77,8% en el grupo de OCT-no BIF; p=0,447) ni por el lugar de la bifurcación (OCT-BIF en segmento proximal, el 76,9%; OCT-no BIF en segmento medio, el 83,8%; OCT-BIF en segmento distal, el 85%; p=0,204). Las tasas de complicaciones fueron similares en ambos grupos...(AU)

Introduction and objectives: Coronary chronic total occlusions (CTO) involving bifurcation lesions are a challenging lesion subset that is understudied in the literature. This study analyzed the incidence, procedural strategy, in-hospital outcomes and complications of percutaneous coronary interventions (PCI) for bifurcation-CTO (BIF-CTO). Methods: We assessed data from 607 consecutive CTO patients treated at the Institut Cardiovasculaire Paris Sud (ICPS), Massy, France between January 2015 and February 2020. Procedural strategy, in-hospital outcomes and complication rates were compared between 2 patient subgroups: BIF-CTO (n=245=and non–BIF-CTO (n=362). Results: The mean patient age was 63.2±10.6 years; 79.6% were men. Bifurcation lesions were involved in 40.4% of the procedures. Overall lesion complexity was high (mean J-CTO score 2.30±1.16, mean PROGRESS-CTO score 1.37±0.94). The preferred bifurcation treatment strategy was a provisional approach (93.5%). BIF-CTO patients presented with higher lesion complexity, as assessed by J-CTO score (2.42±1.02 vs 2.21±1.23 in the non–BIF-CTO patients, P=.025) and PROGRESS-CTO score (1.60±0.95 vs 1.22±0.90 in the non–BIF-CTO patients, P<.001). Procedural success was 78.9% and was not affected by the presence of bifurcation lesions (80.4% in the BIF-CTO group, 77.8% in the non–BIF-CTO-CTO group, P=.447) or the bifurcation site (proximal BIF-CTO 76.9%, mid–BIF-CTO 83.8%, distal BIF-CTO 85%, P=.204). Complication rates were similar in BIF-CTO and non–BIF-CTO. Conclusions: The incidence of bifurcation lesions is high in contemporary CTO PCI. Patients with BIF-CTO present with higher lesion complexity, with no impact on procedural success or complication rates when the predominant strategy is provisional stenting.(AU)

[Registry CARDIO-ARSIF - Database on coronary angiography and percutaneous coronary invasive performed in Île-de-France]. / Registre CARDIO-ARSIF - Base de données sur les coronarographies et angioplasties coronaires réalisées en Île-de-France.

The CARDIO-ARSIF registry has been continuously collecting comprehensive data on coronary angiography and percutaneous coronary interventions (PCI) performed in the 36 catheterization laboratories across the Île-de-France region since 2000. Over the period from 2003 to 2022, this registry has recorded information from more than 330,000 patients, encompassing more than one million procedures. Among these procedures, 58% consisted of coronary angiography, 13% were percutaneous coronary interventions (PCI), and the remaining 28% were PCI performed on an ad-hoc basis. This extensive dataset serves as a valuable resource for both qualitative and quantitative assessments of practices and the relevance of procedures in the field of coronary invasive cardiology. The results of these analyses undergo annual validation by a dedicated scientific committee and are shared with the teams of investigators. The exploitation of this data has led to scientific publications, with one notable finding being a consistent reduction in the radiation doses received by patients, regardless of the type of procedure.

The France PCI registry: Design, methodology and key findings.

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) procedures 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.

Pharmacological coronary spasm provocative testing in clinical practice: A French Coronary Atheroma and Interventional Cardiology Group (GACI) position paper.

Vasospastic angina, also described as Prinzmetal angina, was first described as a variant form of angina at rest with transient ST-segment elevation; it is common and present in many clinical scenarios, including chronic and acute coronary syndromes, sudden cardiac death, arrhythmia and syncope. However, vasospastic angina remains underdiagnosed, and provocative tests are rarely performed. The gold-standard diagnostic approach uses invasive coronary angiography to induce coronary spasm using ergonovine, methylergonovine or acetylcholine as provocative stimuli. The lack of uniform protocol decreases the use and performance of these tests, accounting for vasospastic angina underestimation. This position paper from the French Coronary Atheroma and Interventional Cardiology Group (GACI) aims to review the indications for provocative tests, the testing conditions, drug protocols and positivity criteria.

Improving access to transcatheter aortic valve implantation across Europe by restructuring cardiovascular services: An expert council consensus statement.

Transcatheter aortic valve implantation (TAVI) is recommended for a growing range of patients with severe aortic stenosis in the European Society of Cardiology and European Association for Cardio-Thoracic Surgery (ESC/EACTS) 2021 Guidelines update. However, guideline implementation programs are needed to ensure the application of clinical recommendations which will favorably influence disease outcomes. An Expert Council was convened to identify whether cardiology services across Europe are set up to address the growing needs of patients with severe aortic stenosis for increased access to TAVI by identifying the key challenges faced in growing TAVI programs and mapping associated solutions. Wide variation exists across Europe in terms of TAVI availability and capacity to deliver the increased demand for TAVI in different countries. The recommendations of this Expert Council focus on the short-to-medium-term aspects where the most immediate, actionable impact can be achieved. The focus on improving procedural efficiency and optimizing the patient pathway via clinical practice and patient management demonstrates how to mitigate the current major issues of shortfall in catheterization laboratory, workforce, and bed capacity. Procedural efficiencies may be achieved through steps including streamlined patient assessment, the benchmarking of standards for minimalist procedures, standardized approaches around patient monitoring and conduction issues, and the implementation of nurse specialists and dedicated TAVI coordinators to manage organization, logistics, and early mobilization. Increased collaboration with wider stakeholders within institutions will support successful TAVI uptake and improve patient and economic outcomes. Further, increased education, collaboration, and partnership between cardiology centers will facilitate sharing of expertise and best clinical practice.

Interventions in chronic total occlusions with bifurcation lesions: incidence, treatment, and in-hospital outcome.

INTRODUCTION AND OBJECTIVES: Coronary chronic total occlusions (CTO) involving bifurcation lesions are a challenging lesion subset that is understudied in the literature. This study analyzed the incidence, procedural strategy, in-hospital outcomes and complications of percutaneous coronary interventions (PCI) for bifurcation-CTO (BIF-CTO). METHODS: We assessed data from 607 consecutive CTO patients treated at the Institut Cardiovasculaire Paris Sud (ICPS), Massy, France between January 2015 and February 2020. Procedural strategy, in-hospital outcomes and complication rates were compared between 2 patient subgroups: BIF-CTO (n=245=and non-BIF-CTO (n=362). RESULTS: The mean patient age was 63.2±10.6 years; 79.6% were men. Bifurcation lesions were involved in 40.4% of the procedures. Overall lesion complexity was high (mean J-CTO score 2.30±1.16, mean PROGRESS-CTO score 1.37±0.94). The preferred bifurcation treatment strategy was a provisional approach (93.5%). BIF-CTO patients presented with higher lesion complexity, as assessed by J-CTO score (2.42±1.02 vs 2.21±1.23 in the non-BIF-CTO patients, P=.025) and PROGRESS-CTO score (1.60±0.95 vs 1.22±0.90 in the non-BIF-CTO patients, P<.001). Procedural success was 78.9% and was not affected by the presence of bifurcation lesions (80.4% in the BIF-CTO group, 77.8% in the non-BIF-CTO-CTO group, P=.447) or the bifurcation site (proximal BIF-CTO 76.9%, mid-BIF-CTO 83.8%, distal BIF-CTO 85%, P=.204). Complication rates were similar in BIF-CTO and non-BIF-CTO. CONCLUSIONS: The incidence of bifurcation lesions is high in contemporary CTO PCI. Patients with BIF-CTO present with higher lesion complexity, with no impact on procedural success or complication rates when the predominant strategy is provisional stenting.

Prevalence, Management and Outcomes of Percutaneous Coronary Intervention for Coronary In-Stent Restenosis: Insights From the France PCI Registry.

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 management of ISR is lacking. METHODS: The aim was to describe the epidemiology and management of patients with ≥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.

Computed Tomography/Fluoroscopy Fusion and 3D Transesophageal Echocardiography-Guided Percutaneous Paravalvular Leak Closure.

Percutaneous paravalvular leak closure seems a safe alternative to surgery in frail patients. However, it is a challenging procedure that should be tailored to each patient with optimal imaging guidance. Transesophageal echocardiography during the procedure and computed tomography scan/fluoroscopy fusion provide guidance for critical steps, such as PVL localization and crossing. (Level of Difficulty: Advanced.).