Outcomes and Safety of Transcaval Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-analysis.

BACKGROUND: The transcaval (TCv) vascular approach is increasingly utilized in transcatheter aortic valve replacement (TAVR), in patients unsuitable for the gold-standard transfemoral approach. We aimed to evaluate the efficacy, safety, and clinical outcomes associated with TCv-TAVR. METHODS: A systematic review and meta-analysis was conducted by searching PubMed/MEDLINE, EMBASE and the Cochrane Library for all articles assessing the TCv approach published until December 2023. Outcomes included 30-day and 1-year all-cause mortality (ACM), 30-day rehospitalization, peri-operative and post-operative complications at 30 days. The meta-analysis was registered on the PROSPERO database with the identifier CRD42024501921. RESULTS: A total of eight studies with 467 patients were included. TCv-TAVR procedures achieved a success rate of 98.5%. TCv-TAVR was associated with a 30-day ACM rate of 6.4% (95% confidence interval [CI]: 3.9-8.2%), a one-year ACM rate of 14.4% (95% CI: 2.3- 27.6%) and a 30-day rehospitalization rate at of 4.4% (95% CI: 2.2-10.6%). Postoperative stroke or transient ischemic attack, major vascular complications and major or life-threatening bleeding occurred in 3.9%, 8.5% and 10.1% of cases, respectively. Cumulative meta-analyses showed a trend of decreasing rates of vascular complications. CONCLUSIONS: The TCv approach in TAVR demonstrated a reassuring efficacy and safety profile, with mortality and post-operative complication rates comparable to those reported for supra-aortic alternative TAVR access routes. The temporal decrease in vascular complications suggests potential improvements in procedural techniques and device technology. These findings further support the TCv approach as a viable option in patients ineligible for the transfemoral access.

[Cardiac CT in 2024]. / CT cardiaque en 2024.

Coronary Computed Tomography Angiography (CCTA) has now become an established tool in the diagnostic process for patients suspected of coronary artery disease. In light of rapid technological development, CCTA has evolved into an imaging modality providing both anatomical and functional information to guide patient management. In this article, we describe the role of cardiac CT in assessing atherosclerotic plaque, chest pain evaluation, cardiovascular risk stratification, planning and guiding coronary intervention, as well as structural heart diseases.

Le scanner coronarien est actuellement un outil reconnu dans le processus diagnostique des patients chez qui on suspecte une maladie coronarienne. Bénéficiant d'un développement technologique rapide et procurant des informations tant morphologiques que fonctionnelles, le CT cardiaque devient une modalité d'imagerie incontournable pour orienter la prise en charge des patients. Dans cet article, nous décrivons le rôle du CT cardiaque dans l'évaluation de la plaque d'athérosclérose, des douleurs thoraciques, de la stratification du risque cardiovasculaire, de la planification et du guidage de l'intervention coronarienne, ainsi que des maladies cardiaques structurelles.

A study of ChatGPT in facilitating Heart Team decisions on severe aortic stenosis.

BACKGROUND: Multidisciplinary Heart Teams (HTs) play a central role in the management of valvular heart diseases. However, the comprehensive evaluation of patients' data can be hindered by logistical challenges, which in turn may affect the care they receive. AIMS: This study aimed to explore the ability of artificial intelligence (AI), particularly large language models (LLMs), to improve clinical decision-making and enhance the efficiency of HTs. METHODS: Data from patients with severe aortic stenosis presented at HT meetings were retrospectively analysed. A standardised multiple-choice questionnaire, with 14 key variables, was processed by the OpenAI Chat Generative Pre-trained Transformer (GPT)-4. AI-generated decisions were then compared to those made by the HT. RESULTS: This study included 150 patients, with ChatGPT agreeing with the HT's decisions 77% of the time. The agreement rate varied depending on treatment modality: 90% for transcatheter valve implantation, 65% for surgical valve replacement, and 65% for medical treatment. CONCLUSIONS: The use of LLMs offers promising opportunities to improve the HT decision-making process. This study showed that ChatGPT's decisions were consistent with those of the HT in a large proportion of cases. This technology could serve as a failsafe, highlighting potential areas of discrepancy when its decisions diverge from those of the HT. Further research is necessary to solidify our understanding of how AI can be integrated to enhance the decision-making processes of HTs.

Transcarotid vascular access for transcatheter aortic valve implantation: is choosing the left side always right?

BACKGROUND: The transcarotid (TC) vascular access for transcatheter aortic valve implantation (TAVI) has emerged as the first-choice alternative to the transfemoral access, in patients unsuitable for the latter. The use of both the left and right common carotid arteries (CCAs) for TC-TAVI has been described, but the optimal side is subject to debate. We conducted this pilot study to compare the level of vessel tortuosity and plaque burden from either the left CCA to the aortic annulus, or the right CCA to the aortic annulus, considering them as surrogates for technical and procedural complexity. METHODS: Consecutive patients who underwent TC-TAVI between 2018 and 2021 in our institution were included. Using three-dimensional reconstruction, pre-TAVI neck and chest computed tomography angiography exams were reviewed to assess the tortuosity index (TI), sum of angles metric, as well as plaque burden, between each CCA and the aortic annulus. RESULTS: We included 46 patients who underwent TC-TAVI. No significant difference regarding the mean TIs between the left and right sides (respectively 1.20 and 1.19, p = 0.82), the mean sum of angles (left side: 396°, right side: 384°, p = 0.27), and arterial plaque burden (arterial plaque found in 30% of left CCAs and 45% of right CCAs, p = 0.19) was found. CONCLUSIONS: We found no convincing data favoring the use of one particular access side over the other one. The choice of the CCA side in TC-TAVI should to be made on a case-by-case basis, in a multidisciplinary fashion, and may also depend on the operators' experience.

Prevention of esophageal lesions during atrial fibrillation catheter ablation using esophageal temperature monitoring: A systematic review and meta-analysis.

INTRODUCTION: The use of esophageal temperature monitoring (ETM) for the prevention of esophageal injury during atrial fibrillation (AF) ablation is often advocated. However, evidence supporting its use is scarce and controversial. We therefore aimed to review the evidence assessing the efficacy of ETM for the prevention of esophageal injury. METHODS: We performed a meta-analysis and systematic review of the available literature from inception to December 31, 2022. All studies comparing the use of ETM, versus no ETM, during radiofrequency (RF) AF ablation and which reported the incidence of endoscopically detected esophageal lesions (EDELs) were included. RESULTS: Eleven studies with a total of 1112 patients undergoing RF AF ablation were identified. Of those patients, 627 were assigned to ETM (56%). The overall incidence of EDELs was 9.8%. The use of ETM during AF ablation was associated with a non significant increase in the incidence of EDELs (12.3% with ETM, vs. 6.6 % without ETM, odds ratio, 1.44, 95%CI, 0.49, 4.22, p = .51, I2 = 72%). The use of ETM was associated with a significant increase in the energy delivered specifically on the posterior wall compared to patients without ETM (mean power difference: 5.13 Watts, 95% CI, 1.52, 8.74, p = .005). CONCLUSIONS: The use of ETM does not reduce the incidence of EDELs during RF AF ablation. The higher energy delivered on the posterior wall is likely attributable to a false sense of safety that may explain the lack of benefit of ETM. Further randomized controlled trials are needed to provide conclusive results.

[Cardiology: what's new in 2023]. / Cardiologie: ce qui a changé en 2023.

The year 2023 has been extremely rich in new publications in the various subfields of cardiology. Furthermore, the European Society of Cardiology (ESC) has issued revised guidelines focused on the management of acute coronary syndrome (ACS) and endocarditis, as well as an update on the recommendations for the management of heart failure and cardiovascular prevention. The most significant updates according to the Cardiology Department of CHUV are summarized in this review article.

L'année 2023 a été extrêmement riche en nouvelles publications dans les différents sous-domaines de la cardiologie. De plus, la Société européenne de cardiologie (ESC) a formulé des directives révisées axées sur le management du syndrome coronarien aigu (SCA) et de l'endocardite ainsi qu'une mise à jour des recommandations sur la prise en charge de l'insuffisance cardiaque et la prévention cardiovasculaire. Les nouveautés les plus importantes selon l'équipe du Service de cardiologie du CHUV sont résumées dans cet article de synthèse.

Eosinophilic myocarditis during treatment of acute myeloid leukaemia: cardiac magnetic resonance in the very early phase mimicking triple-vessel coronary artery disease: a case report.

Background: Chemotherapy of acute myeloid leukaemia (AML) can cause a broad spectrum of cardiotoxic effects. Cardiac magnetic resonance (CMR) is key for the diagnosis of eosinophilic myocarditis (EM) defined by the presence of sub-endocardial necrosis and fibrosis. This case report describes the picture of severe triple-vessel ischaemia due to infiltration of eosinophilia without atherosclerotic coronary artery disease (CAD). Case summary: A 57-year-old woman was diagnosed with AML requiring chemotherapy. Three days after initiation of chemotherapy, the patient presented with chest pain and new left ventricular (LV) dysfunction and hyper-eosinophilia. A CMR examination initially was compatible with severe triple-vessel ischaemia. Tissue characterization by CMR was not done due to severe dyspnoea promoting the differential diagnosis of triple-vessel CAD or chemotherapy-induced triple-vessel coronary spasm. However, invasive coronary angiography excluded obstructive CAD. Severe LV dysfunction and troponin elevation persisted arguing against coronary vasospasm. Chemotherapy induced a massive increase in blood eosinophils, and EM was considered as most likely diagnosis. Immunosuppressive treatment improved the patient's status and a CMR later on confirmed the diagnosis of EM. Discussion: Chemotherapy-induced massive eosinophilia can cause widespread coronary micro-vascular infiltration mimicking severe triple-vessel CAD. Early CMR did not evaluate tissue composition, and EM was not considered which delayed adequate treatment. A complete CMR assessment is key to establish the correct diagnosis.

Intracoronary Brachytherapy for Restenosis: 20 Years of Follow-Up.

BACKGROUND/PURPOSE: Intracoronary brachytherapy (ICB) has mainly been used to treat in-stent restenosis following percutaneous coronary intervention and was virtually abandoned about 20 years ago. However, patients treated with this strategy are still alive and some teams continue to perform this therapy. We aimed to investigate the very long-term clinical outcome of patients treated with ICB. METHODS/MATERIALS: A total of 173 consecutive patients who had been treated with ICB at a large tertiary referral centre between 1998 and 2003 were included. The primary endpoint of the study was all-cause mortality. The secondary endpoints were as follows: occurrence of major adverse cardiac events (MACE, defined as all-cause death, non-fatal myocardial infarction, or target vessel revascularization), cardiac death, and presence of angina at the end of follow-up. RESULTS: Patients' mean age at the time of ICB was 64 ± 10 years and 77 % were male. Restenosis (bare metal stent vs. balloon angioplasty) was the only indication for ICB. Unstable angina was present in 34 % of the patients. Follow-up was available for 166 patients. After a mean follow-up of 20 ± 1.3 years, 66 % of the patients had died (including 74 patients (67 %) with cardiac death). Cumulative MACE rate at 20 years was 96 %. CONCLUSIONS: Very long-term follow-up of patients with in-stent restenosis treated with ICB confirmed a high all-cause mortality rate mainly due to cardiac causes and MACEs.

[An update on some atypical electrocardiographic forms of acute coronary syndrome The "STEMI equivalents"]. / Mise au point sur certaines formes électrocardiographiques atypiques du syndrome coronarien aigu - « Équivalents STEMI ¼.

The diagnosis of acute coronary syndrome with ST segment elevation (STEMI) is based on clinical symptoms suggestive of acute myocardial ischemia and precise ECG criteria. STEMI is due to an acute occlusion or subocclusion of a coronary artery, generating a transmural ischaemia, requiring coronary angiography with urgent coronary revascularization. However, some authors consider the current STEMI ECG criteria to be too restrictive: up to 30 % of patients who do not meet these criteria present with critical coronary artery stenosis or acute coronary occlusion. Atypical electrocardiographic patterns, known as "STEMI equivalents", can be found in some cases and justify a rapid cardiological evaluation. We present a pragmatic review of five STEMI equivalents.

Le diagnostic de syndrome coronarien aigu avec sus-décalage du segment ST (ST-Elevation Myocardial Infarction (STEMI)) est basé sur une clinique évocatrice d'une ischémie myocardique et des critères ECG précis. Le STEMI est le reflet d'une (sub)occlusion aiguë d'une artère coronaire engendrant une ischémie transmurale, nécessitant une coronarographie avec un geste de revascularisation en urgence. Certains auteurs considèrent les critères ECG actuels du STEMI comme étant trop restrictifs : jusqu'à 30 % des patients ne remplissant pas ces critères présenteraient une sténose coronarienne critique ou une occlusion coronarienne aiguë. Des aspects électrocardiographiques atypiques, dits « équivalents STEMI ¼, peuvent être mis en évidence dans certains cas et justifient une prise en charge cardiologique rapide. Nous présentons une revue pragmatique de cinq équivalents STEMI.