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.

Echocardiographic estimation of pulmonary pressure in patients with severe tricuspid regurgitation.

OBJECTIVES: The estimation of systolic pulmonary artery pressure (sPAP) by transthoracic echocardiography (TTE) is challenging in patients with severe tricuspid regurgitation (TR). The study aimed to determine the reliability of the assessment of sPAP by TTE in this population. METHODS: This study was a single-centre analysis of consecutive patients at the University Hospital of Rennes with right heart catheterisation and TTE, performed with a maximum delay of 48 hours. Lin's concordance coefficient (LCC) and Bland-Altman analysis were used to compare the values. RESULTS: After applying the exclusion criteria, 236 patients were included in the analysis (age 71±11.5 years old; male 56%). The two principal indications were TR (34.3%) and mitral regurgitation (32.2%). The correlation between the two procedures was good in the total population (LCC=0.80; 95% limits of agreement (LOA): 0.74, 0.84), but weaker in the 78 patients (33%) with severe TR (LCC=0.67; 95% LOA: 0.49, 0.80), with a propensity to an underestimation by TTE. An elevated right atrial pressure (RAP) was associated with an underestimation by TTE of about 8 mmHg. The presence of a 'V-wave cut-off' sign on continuous-wave Doppler (OR=3.74; 95% CI 1.48, 9.30; p<0.01), found exclusively in patients with severe TR, was an independent predictor of sPAP misestimation by TTE. CONCLUSION: The reliability of the estimation of sPAP in patients with severe TR could be altered by high RAP which cannot be estimated with current thresholds.

Conductive disturbances in the transcatheter aortic valve implantation setting: An appraisal of current knowledge and unmet needs.

New-onset conduction disturbances, including left bundle branch block and permanent pacemaker implantation, remain a major issue after transcatheter aortic valve implantation. Preprocedural risk assessment in current practice is most often limited to evaluation of the baseline electrocardiogram, whereas it may benefit from a multimodal approach, including ambulatory electrocardiogram monitoring and multidetector computed tomography. Physicians may encounter equivocal situations during the hospital phase, and the management of follow-up is not fully defined, despite the publication of several expert consensuses and the inclusion of recommendations regarding the role of electrophysiology studies and postprocedural monitoring in recent guidelines. This review provides an overview of current knowledge and future perspectives regarding the management of new-onset conduction disturbances in the setting of transcatheter aortic valve implantation, from the preprocedural phase to long-term follow-up.

Clinical outcomes after unprotected left main coronary artery occlusion: A retrospective multicentre cohort analysis.

AIMS: Unprotected left main coronary artery (ULMCA) occlusion is a rare and disastrous condition with scarce data on presentation and outcomes. Herein, we report data on patients presenting with acute coronary syndrome due to ULMCA occlusion at four different institutions. METHODS: This is an international multicentre observational study. Baseline characteristics were retro- and prospectively collected. Clinical follow-up was prospective. The primary outcome was in-hospital death. Patients surviving the index hospitalization were compared with nonsurvivors to find predictors of survival. RESULTS: The study population consisted of 55 patients. Eight patients (15%) died in the cath lab, and 23 (42%) died in hospital. Three (6%) deaths were noncardiac and due to major bleeding. Thirty-two (58%) patients survived the index hospitalization and were discharged. These patients were followed for a median of 17.5 months during which three cardiac deaths occurred. Repeat revascularization was performed in 25% (n = 8). Overall mortality at maximum follow-up was 47% (n = 26). The only significant predictor for hospital survival was left ventricular ejection fraction (odds ratio [OR]: 1.10 (per 1 point increase); 95% confidence interval [CI]: 1.02-1.19; p = 0.02). CONCLUSION: ULMCA occlusion carries a high short-term mortality. Patients who survive index hospitalization have similar mortality rates as compared with other st elevation myocardial infarction patients.

Prevalence of psychoactive drug use in patients hospitalized for acute cardiac events: Rationale and design of the ADDICT-ICCU trial, from the Emergency and Acute Cardiovascular Care Working Group and the National College of Cardiologists in Training of the French Society of Cardiology.

BACKGROUND: Psychoactive drugs, including illicit drugs, are associated with an increased rate of cardiovascular events. The prevalence and outcome of patients using these drugs at the time of admission to an intensive cardiac care unit is unknown. AIM: To assess the prevalence of psychoactive drugs detected in consecutive patients hospitalized in an intensive cardiac care unit for an acute cardiovascular event. METHODS: This is a nationwide prospective multicentre study, involving 39 centres throughout France, including all consecutive patients hospitalized in an intensive cardiac care unit within 2weeks. Psychoactive drug use will be assessed systematically by urine drug assay within 2hours of intensive cardiac care unit admission, to detect illicit (cannabinoids, cocaine, amphetamines, ecstasy, heroin and other opioids) and non-illicit (barbiturates, benzodiazepines, tricyclic antidepressants, methadone and buprenorphine) psychoactive drugs. Smoking will be investigated systematically by exhaled carbon monoxide measurement, and alcohol consumption using a standardized questionnaire. In-hospital major adverse events, including death, resuscitated cardiac arrest and cardiogenic shock, will be recorded. After discharge, all-cause death and major adverse cardiovascular events will be recorded systematically and adjudicated at 12months of follow-up. RESULTS: The primary outcome will be the prevalence of psychoactive drugs detected by systematic screening among all patients hospitalized in an intensive cardiac care unit. The in-hospital major adverse events will be analysed according to the presence or absence of detected psychoactive drugs. Subgroup analysis stratified by initial clinical presentation and type of psychoactive drug will be performed. CONCLUSIONS: This is the first prospective multicentre study to assess the prevalence of psychoactive drugs detected by systematic screening in consecutive patients hospitalized for acute cardiovascular events.

Prognostic impact of permanent pacemaker implantation after transcatheter aortic valve replacement.

BACKGROUND: Conduction disturbances requiring permanent pacemaker implantation (PPI) remain a common complication of transcatheter aortic valve replacement (TAVR). OBJECTIVE: The purpose of this study was to determine the prognostic impact of PPI after TAVR according to the timing of implantation relative to TAVR. METHODS: A total of 1199 patients (median age 83 years; interquartile range 78-86 years; 549 [45.8%] female) were included in the analysis, of whom 894 (70.8%) had not undergone PPI, 130 (10.8%) had undergone previous PPI, 116 (9.7%) had undergone in-hospital PPI, and 59 (4.9%) had undergone PPI during follow-up. Median follow-up was 2.94 years (1.42-4.32 years). The primary outcome was the composite of all-cause mortality and hospitalization for heart failure. RESULTS: PPI during follow-up was associated with a higher occurrence of the primary outcome (hazard ratio [HR] 2.11; 95% confidence interval [CI] 1.39-3.20) whereas previous PPI and in-hospital PPI were not (HR 0.96; 95% CI 0.71-1.29 and HR 1.26; 95% CI 0.88-1.81, respectively). PPI during follow-up was associated with a higher risk of hospitalization for heart failure (sub-HR 3.21; 95% CI 2.02-5.11), while this relationship was only borderline significant for previous PPI (sub-HR 1.51; 95% CI 0.99-2.29). In contrast, there was no relationship between in-hospital PPI and the subsequent risk of hospitalization for heart failure. CONCLUSION: Previous PPI and in-hospital PPI had no long-term prognostic impact on the risk of all-cause mortality and hospitalization for heart failure, whereas PPI during follow-up was associated with a higher risk of hospitalization for heart failure. The present study questions the deleterious influence of periprocedural post-TAVR PPI, which has previously been suggested by certain studies.

Validation of a Whole Heart Segmentation from Computed Tomography Imaging Using a Deep-Learning Approach.

The aim of this study is to develop an automated deep-learning-based whole heart segmentation of ECG-gated computed tomography data. After 21 exclusions, CT acquired before transcatheter aortic valve implantation in 71 patients were reviewed and randomly split in a training (n = 55 patients), validation (n = 8 patients), and a test set (n = 8 patients). A fully automatic deep-learning method combining two convolutional neural networks performed segmentation of 10 cardiovascular structures, which was compared with the manually segmented reference by the Dice index. Correlations and agreement between myocardial volumes and mass were assessed. The algorithm demonstrated high accuracy (Dice score = 0.920; interquartile range: 0.906-0.925) and a low computing time (13.4 s, range 11.9-14.9). Correlations and agreement of volumes and mass were satisfactory for most structures. Six of ten structures were well segmented. Deep-learning-based method allowed automated WHS from ECG-gated CT data with a high accuracy. Challenges remain to improve right-sided structures segmentation and achieve daily clinical application.

Early and late ventricular arrhythmias complicating ST-segment elevation myocardial infarction.

BACKGROUND: Ventricular arrhythmias can be life-threatening complications of ST-segment elevation myocardial infarction (STEMI). AIMS: To describe the incidence, predictors and in-hospital impact of early ventricular arrhythmia (EVA, occurring

Electrophysiological Study-Guided Permanent Pacemaker Implantation in Patients With Conduction Disturbances Following Transcatheter Aortic Valve Implantation.

Conduction disturbances remain common following transcatheter aortic valve implantation (TAVI). Aside from high-degree atrioventricular block (HAVB), their optimal management remains elusive. Invasive electrophysiological studies (EPS) may help stratify patients at low or high risk of HAVB allowing for an early discharge or permanent pacemaker (PPM) implantation among patients with conduction disturbances. We evaluated the safety and diagnostic performances of an EPS-guided PPM implantation strategy among TAVI recipients with conduction disturbances not representing absolute indications for PPM. All patients who underwent TAVI at a single expert center from June 2017 to July 2020 who underwent an EPS during the index hospitalization were included in the present study. False negative outcomes were defined as patients discharged without PPM implantation who required PPM for HAVB within 6 months of the initial EPS. False positive outcomes were defined as patients discharged with a PPM with a ventricular pacing percentage <1% at follow-up. A total of 78 patients were included (median age 83.5, 39% female), among whom 35 patients (45%) received a PPM following EPS. The sensitivity, specificity, positive and negative predictive values of the EPS-guided PPM implantation strategy were 100%, 89.6%, 81.5%, and 100%, respectively. Six patients suffered a mechanical HAVB during EPS and received a PPM. These 6 patients showed PPM dependency at follow-up. In conclusion, an EPS-guided PPM implantation strategy for managing post-TAVI conduction disturbances appears effective to identify patients who can be safely discharged without PPM implantation.

Determinants and Impact of Heart Failure Readmission Following Transcatheter Aortic Valve Replacement.

BACKGROUND: Heart failure (HF) readmission is common post-transcatheter aortic valve replacement (TAVR). Nonetheless, limited data are available regarding its predictors and clinical impact. This study evaluated the incidence, predictors, and impact of HF readmission within 1-year post-TAVR, and assessed the effects of the prescription of HF therapies at discharge on the risk of HF readmission and death. METHODS: Patients included in the TAVR registry of a single expert center from 2009 to 2017 were analyzed. Competing-risk and Cox regressions were performed to identify predictors of HF readmission and death. RESULTS: Among 750 patients, 102 (13.6%) were readmitted for HF within 1-year post-TAVR. Overall, 53 patients (7.1%) experienced late readmissions (>30 days post-TAVR), and 17 (2.3%) had multiple readmissions. In ≈30% of readmissions, no trigger could be identified. Predominant causes of readmissions were changes in medication/nonadherence and supraventricular arrhythmia. Independent predictors of HF readmission included diabetes mellitus, chronic lung disease, previous acute HF, grade III or IV aortic regurgitation, and pulmonary hypertension both at discharge from the index hospitalization but not HF therapies. Overall, HF readmission did not significantly impact all-cause mortality (hazard ratio [HR], 1.36 [95% CI, 0.99-1.85]). However, late (HR, 1.90 [95% CI, 1.30-2.78]) and multiple HF readmissions (HR, 2.10 [95% CI,1.17-3.76]) were significantly associated with all-cause mortality. Prescription of renin-angiotensin system inhibitors at discharge was associated with a lower rate of all-cause mortality, especially among patients receiving doses of 25% to <50% (HR, 0.67 [95% CI, 0.48-0.94]) and 75% to 100% (HR, 0.61 [95% CI, 0.37-0.98]) of the optimal daily dose. CONCLUSIONS: HF readmission is common within 1-year of TAVR. Late and multiple HF readmissions associate with an increased risk of long-term all-cause mortality. Baseline comorbidities (diabetes, chronic lung disease, previous acute HF) and echocardiographic findings at discharge (grade III or IV aortic regurgitation, pulmonary hypertension) identified patients at high risk of HF readmission.

Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction in Patients ≥70 Years of Age.

The benefit-risk ratio of a pharmacoinvasive strategy (PI) in patients ≥70 years of age with ST-segment elevation myocardial infarction (STEMI) remains uncertain resulting in its limited use in this population. This study compared efficacy and safety of PI with primary percutaneous coronary intervention (pPCI). Data from 2,841 patients (mean age: 78.1 ± 5.6 years, female: 36.1%) included in a prospective multicenter registry, and who underwent either PI (n = 269) or pPCI (n = 2,572), were analyzed. The primary end point was in-hospital major adverse cardiovascular events (MACE) defined as the composite of all-cause mortality, nonfatal MI, stroke, and definite stent thrombosis. Secondary end points included all-cause death, major bleeding, net adverse clinical events, and the development of in-hospital Killip class III or IV heart failure. Propensity-score matching and conditional logistic regression were used to adjust for confounders. Within the matched cohort, rates of MACE was not statistically different between the PI (n = 247) and pPCI (n = 958) groups, (11.3% vs 9.0%, respectively, odds ratio 1.25, 95% confidence interval 0.81 to 1.94; p = 0.31). Secondary end points were comparable between groups at the exception of a lower rate of development of Killip class III or IV heart failure after PI. The rate of intracranial hemorrhage was significantly higher in the PI group (2.3% vs 0.0%, p = 0.03). In conclusion, the present study demonstrated no difference regarding in-hospital MACE following PI or pPCI in STEMI patients ≥70 years of age. An adequately-powered randomized trial is needed to precisely define the role of PI in this high-risk subgroup.

Doppler sonography of cerebral blood flow for early prognostication after out-of-hospital cardiac arrest: DOTAC study.

AIM: To assess the neurological prognosis of comatose survivors of cardiac arrest by early transcranial Doppler sonography (TCD). METHODS: This was a prospective study performed between May 2016 and October 2017 in a medical intensive care unit (ICU) and a cardiac ICU of a university teaching hospital. All patients older than 18 years who were successfully resuscitated from an out-of-hospital cardiac arrest (OHCA) with persistent coma after the return of spontaneous circulation (ROSC) were eligible. We excluded patients for whom OHCA was associated with traumatic brain injury, no possibility of TCD measurements, or who were dead before establishing the neurological prognosis. We measured the pulsatility index (PI) and diastolic flow velocity (DFV) of the right and left middle cerebral arteries within 12 h after ICU admission. The lowest DFV and highest PI values were used for the statistical analysis. The neurological outcome at hospital discharge was evaluated by the cerebral performance category. RESULTS: Forty-two patients were included in the final analysis: 15 had good and 27 poor neurological outcomes. The PI was higher in the poor outcome (1.49 vs. 1.12, p = 0.01) than good outcome group and the DFV was lower in the poor outcome group (17.3 cm s-1vs. 26.0 cm s-1; p = 0.01). CONCLUSION: Data provided by early TCD after ROSC are associated with neurological outcome. The use of TCD could help guide interventions to improve cerebral perfusion after ROSC in patients resuscitated from OHCA.

Comparison of the Transarterial and Transthoracic Approaches in Nontransfemoral Transcatheter Aortic Valve Implantation.

Transfemoral approach stands as the reference access-route for transcatheter aortic valve implantation (TAVI). Nonetheless, alternatives approaches are still needed in a significant proportion of patients. This study aimed at comparing outcomes between transthoracic-approach (transapical or transaortic) and transarterial-approach (transcarotid or subclavian) TAVI. Data from 191 consecutive patients who underwent surgical-approach TAVI from May 2009 to September 2017 were analyzed. Patients were allocated in 2 groups according to the approach. The primary end point was the 30-day composite of death of any cause, need for open surgery, tamponade, stroke, major or life-threatening bleeding, stage 2 or 3 acute kidney injury, coronary obstruction, or major vascular complications. During the study period, 104 patients underwent transthoracic TAVI (transapical: 60.6%, transaortic: 39.4%) whereas 87 patients underwent transarterial TAVI (subclavian: 83.9%, transcarotid: 16.1%). Logistic EuroSCORE I tended to be higher in transthoracic-TAVI recipients. In-hospital and 30-day composite end point rates were 25.0% and 11.5% (p = 0.025), and 26.0% and 14.9% (p = 0.075) for the transthoracic and transarterial cohorts, respectively. Propensity score-adjusted logistic regression demonstrated no significant detrimental association between the 30-day composite end point and transthoracic access (odds ratio 2.12 95% confidence interval 0.70 to 6.42; p = 0.18). Transarterial TAVI was associated with a shorter length of stay (median: 6 vs 7 days, p <0.001). TAVI approach was not an independent predictor of midterm mortality. In conclusion, nontransfemoral transarterial-approach TAVI is safe, feasible, and associated with comparable rates of major perioperative complications, and midterm mortality compared with transthoracic-approach TAVI.

Safety and effectiveness of the transsubclavian approach for transcatheter aortic valve implantation with the 14-F CoreValve Evolut R device.

AIMS: In addition to the transfemoral route, common approaches for transcatheter aortic valve implantation (TAVI) are the transapical and transaortic ones. Yet, these are associated with morbidity. The transsubclavian approach (TSA) is an alternative to minimize invasiveness. METHODS: Fifteen consecutive patients underwent TAVI via TSA using the CoreValve Evolut R. The 14F delivery system without sheath was directly introduced into the artery. RESULTS: Success was 100%; contrast volume was 99.4 ±â€Š29.58 ml. Patients were extubated after 1.66 ±â€Š0.89 h. Hemoglobin drop was 0.64 ±â€Š0.28 g/dl. There were no complications. Hospital stay was 4.53 ±â€Š1.24 days: 11 patients were discharged home, the remainder to rehabilitation. CONCLUSION: TSA is associated with limited morbidity, early patient mobilization, short hospitalization.

Evolution of Length of Stay After Surgical and Transcatheter Aortic Valve Implantation Over 8 Years in 1,849 Patients >75 Years of Age and Comparison Between Transfemoral and Transsubclavian Transcatheter Aortic Valve Implantation.

Minimized length of hospitalization (LoS) and lower risk of hospitalization-related complications are key requirements in the treatment of aortic valve disease, mainly in the elderly candidates. Our objective was to evaluate evolution of LoS after surgical (SAVR) or transcatheter aortic valve implantation (TAVI) and its predictors. We enrolled 1,849 elderly (aged >75) patients receiving SAVR or TAVI from 2009 to 2016. In the surgical cohort (n = 1,006) the mean LoS slightly decreased from 13.81 ± 9.27 days (2009) to 10.96 ± 3.77 (2016); in the TAVI cohort (n = 843), LoS passed from 13.33 ± 9.17 (2009) to 6.21 ± 4.30 days (2016). All-cause mortality at 1 month was 3.77 % (SAVR) versus 4.7% (TAVI) (p >0.05). Among Transfemoral TAVI (TF, n = 681), and Transsubclavian TAVI (TS, n = 62), average LoS was comparable (7.38 days ± 7.11 vs 7.31 ± 4.32; median 6.0 and 6.0 days, p = 0.07). Procedural success was reached in 93% (TF) and in 85.4% (TS) (p = 0.20). There were no meaningful differences among TF and TS in terms of VARC-2 postprocedural morbidity, except for the rate of vascular access-related complications; these occurred in 8.8% of cases in the TF group versus 1.6% in the TS group (p = 0.05). In conclusion the present analysis showed a faster improvement in terms of LoS for TAVI compared with SAVR over 8 years of activity. The 2 strategies presented comparable all-causes mortality at 30 days. LoS, rates of procedural success and complications were comparable among TF and TS TAVI; nonetheless, vascular access-related complications were more frequent in the TF cohort. This suggests the validity of the TS route as an alternative to the TF approach.

Current indications for the intra-aortic balloon pump: The CP-GARO registry.

BACKGROUND: Intra-aortic balloon pumps (IABPs) have been used routinely since the 1970s. Recently, large randomized trials failed to show that IABP therapy has meaningful benefit, and international recommendations downgraded its place, particularly in cardiogenic shock. AIMS: The aim of this registry was to describe the contemporary use of IABP therapy, in light of these new data. METHODS: This prospective multicentre registry included 172 patients implanted with an IABP in 19 French cardiac centres in 2015. Baseline characteristics, aetiologies leading to IABP use, and IABP-related and disease-related complications were assessed. In-hospital and 1-year mortality rates were studied. RESULTS: A total of 172 patients were included (mean age 65.5±12.0 years; 118 men [68.6%]). The reasons for IABP implantation were mainly haemodynamic (n=107; 62.2%), followed by bridge to revascularization (n=34; 19.8%) and four other "rare" aetiologies (n=29 patients; 16.8%). In-hospital and 1-year mortality rates were 40.7% and 45.8%, respectively. Fourteen patients (8.1%) experienced ischaemic or haemorrhagic complications, which were directly related to the IABP in seven patients (4.1%). CONCLUSIONS: Despite current international guidelines regarding the place of IABPs in ischaemic cardiogenic shock without mechanical complications, this aetiology remains the leading cause for its utilization in the contemporary era.

Predicting the development of in-hospital cardiogenic shock in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention: the ORBI risk score.

Aims: To derive and validate a readily useable risk score to identify patients at high-risk of in-hospital ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS). Methods and results: In all, 6838 patients without CS on admission and treated by primary percutaneous coronary intervention (pPCI), included in the Observatoire Régional Breton sur l'Infarctus (ORBI), served as a derivation cohort, and 2208 patients included in the obseRvatoire des Infarctus de Côte-d'Or (RICO) constituted the external validation cohort. Stepwise multivariable logistic regression was used to build the score. Eleven variables were independently associated with the development of in-hospital CS: age >70 years, prior stroke/transient ischaemic attack, cardiac arrest upon admission, anterior STEMI, first medical contact-to-pPCI delay >90 min, Killip class, heart rate >90/min, a combination of systolic blood pressure <125 mmHg and pulse pressure <45 mmHg, glycaemia >10 mmol/L, culprit lesion of the left main coronary artery, and post-pPCI thrombolysis in myocardial infarction flow grade <3. The score derived from these variables allowed the classification of patients into four risk categories: low (0-7), low-to-intermediate (8-10), intermediate-to-high (11-12), and high (≥13). Observed in-hospital CS rates were 1.3%, 6.6%, 11.7%, and 31.8%, across the four risk categories, respectively. Validation in the RICO cohort demonstrated in-hospital CS rates of 3.1% (score 0-7), 10.6% (score 8-10), 18.1% (score 11-12), and 34.1% (score ≥13). The score demonstrated high discrimination (c-statistic of 0.84 in the derivation cohort, 0.80 in the validation cohort) and adequate calibration in both cohorts. Conclusion: The ORBI risk score provides a readily useable and efficient tool to identify patients at high-risk of developing CS during hospitalization following STEMI, which may aid in further risk-stratification and thus potentially facilitate pre-emptive clinical decision making.

Myocardial infarction and thrombophilia: Do not miss the right diagnosis!

Protein C deficiency is a coagulation cascade disorder often resulting in venous thromboembolic events but is also a possible contributor to arterial thrombosis. To date, approximately ten cases of myocardial infarction (MI) due to protein C deficiency have been reported in the literature. However, affirming this mechanism requires ruling out the most common causes of MI, i.e. the rupture or erosion of an atherosclerotic plaque. Intravascular imaging of coronary arteries can be of help to identify angiographically undetected atherosclerosis. We report a case of an ST-segment elevation myocardial infarction (STEMI) in a young man with apparent evidence of arterial thrombosis resulting from protein C deficiency and heterozygous factor Leiden mutation which was contradicted by intravascular imaging demonstrating atherosclerosis.

Immediate complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease treated by primary percutaneous coronary intervention: Insights from the ORBI registry.

BACKGROUND: Recent studies demonstrated the superiority of complete revascularization (CR) in patients treated by primary percutaneous coronary intervention (pPCI) in ST-elevation myocardial infarction (STEMI). AIM: To evaluate whether immediate CR improves in-hospital outcomes in patients with STEMI with multivessel disease. METHODS: Data from a prospective multicentre registry including 9365 patients with STEMI were analysed. Patients with multivessel disease and treated with pPCI (n=3412) were included and separated into two groups according to whether immediate CR was performed during the index procedure. The primary endpoint was in-hospital major adverse cardiovascular events (MACE), defined as a composite of all-cause death, non-fatal myocardial infarction, stroke and definite stent thrombosis. Secondary endpoints were individual components of MACE and major bleeding. Multivariable Cox regression and propensity-score adjustment were performed to account for confounders. RESULTS: Immediate CR was performed in 98 patients (2.9%), whereas 3314 patients (97.1%) were incompletely revascularized. The prevalence of severe heart failure (Killip class III or IV) and significant lesions of the left main coronary artery were higher in the immediate CR group (21.6% vs. 13.5% and 24.5% vs. 6.7%, respectively; P<0.001 for both). After adjustment, immediate CR was not associated with reduced rates of MACE (hazard ratio [HR] 0.64, 95% confidence interval [CI]: 0.31-1.35; P=0.24) or all-cause death (HR: 0.52, 95% CI: 0.23-1.16; P=0.11), but with increased risks of definite stent thrombosis (HR: 3.93, 95% CI: 1.12-13.75; P=0.03) and major bleeding (HR: 17.46, 95% CI: 2.29-133.17; P=0.006). CONCLUSION: Immediate CR did not improve in-hospital outcomes of patients with STEMI with multivessel disease in this analysis. Randomized studies are warranted to elucidate the optimal timing of CR in patients with STEMI.