Impact of the 2018 French two-score allocation scheme on the profile of heart transplantation candidates and recipients: Insights from a high-volume centre.

BACKGROUND: In 2018, a new cardiac allograft allocation scheme, based on an individual scoring system, considering the risk of death both on the waiting list and after heart transplantation, was implemented in France. AIM: To assess the impact of this new scheme on the profile of transplantation candidates and recipients. METHODS: In this single-centre retrospective study, we included consecutive patients listed and/or transplanted between 01 January 2012 and 30 September 2021 at La Pitié-Salpêtrière Hospital. Baseline characteristics of patients were retrieved from the national CRISTAL registry and were compared according to the type of allocation scheme (before or after 2018). RESULTS: A total of 1098 newly listed transplantation candidates and 855 transplant recipients were included. One-year mortality rates after listing and after transplantation were 12.4% and 20%, respectively. At listing, the proportion of candidates on inotropes significantly declined following the scheme update (26.3 versus 20.9%; P=0.038), reflecting a change in medical practice. At transplantation, recipients had worse kidney function (estimated glomerular filtration rate<60mL/min/1.73 m2: old scheme, 29.7%; new scheme, 46.4%; P<0.001) and were more likely to be on extracorporeal membrane oxygenation support (33.5% versus 28.1%; P=0.080) under the new scheme, reflecting the prioritization of more severe patients. Outcomes after transplantation were not significantly influenced by the allocation system. CONCLUSIONS: The implementation of the 2018 French allocation scheme had a limited impact on the profile of transplantation candidates, but selected more severe patients for transplantation without significant impact on outcomes after transplantation.

Management of High-Risk Pulmonary Embolism: What Is the Place of Extracorporeal Membrane Oxygenation?

Pulmonary embolism (PE) is a common disease with an annual incidence rate ranging from 39-115 per 100,000 inhabitants. It is one of the leading causes of cardiovascular mortality in the USA and Europe. While the clinical presentation and severity may vary, it is a life-threatening condition in its most severe form, defined as high-risk or massive PE. Therapeutic options in high-risk PE are limited. Current guidelines recommend the use of systemic thrombolytic therapy as first-line therapy (Level Ib). However, this treatment has important drawbacks including bleeding complications, limited efficacy in patients with recurrent PE or cardiac arrest, and formal contraindications. In this context, the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the management of high-risk PE has increased worldwide in the last decade. Strategies, including VA-ECMO as a stand-alone therapy or as a bridge to alternative reperfusion therapies, are associated with acceptable outcomes, especially if implemented before cardiac arrest. Nonetheless, the level of evidence supporting ECMO and alternative reperfusion therapies is low. The optimal management of high-risk PE patients will remain controversial until the realization of a prospective randomized trial comparing those cited strategies to systemic thrombolysis.

Epidemiology, thrombolytic management, and outcomes of acute stroke among patients with chronic kidney disease: a systematic review and meta-analysis.

BACKGROUND: The relative frequency of ischaemic versus haemorrhagic stroke among patients with chronic kidney disease (CKD) has not been clearly described. Moreover, no recent meta-analysis has investigated the outcomes of patients with CKD treated with thrombolysis for acute ischaemic stroke. We conducted a systematic review and meta-analysis to estimate the proportion of stroke subtypes and the outcomes of thrombolysis in CKD. METHODS: A PubMed, EMBASE and Cochrane literature research was conducted. The primary outcome was the proportion and incidence of ischaemic versus haemorrhagic strokes among patients with CKD. In addition, we assessed the impact of CKD on disability, mortality and bleeding among patients with acute ischaemic stroke treated with thrombolysis. The pooled proportion and the risk ratio were estimated using a random-effects model. RESULTS: Thirty-nine observational studies were included: 22 on the epidemiology of stroke types and 17 on the outcomes of thrombolysis in this population. In the main analysis (>99 281 patients), ischaemic stroke was more frequent than haemorrhagic among patients with CKD [78.3%, 95% confidence interval (CI) 73.3-82.5%]. However, among patients with kidney failure, the proportion of ischaemic stroke decreased and was closer to that of haemorrhagic stroke (59.8%, 95% CI 49.4-69.4%). CKD was associated with worse clinical outcomes in patients with acute ischaemic stroke compared with patients with preserved kidney function. CONCLUSIONS: The relative frequency of haemorrhagic stroke seems to increase as kidney function declines. Among patients with acute ischaemic stroke treated with thrombolysis, presence of CKD is associated with higher disability, mortality and bleeding, compared with patients with preserved kidney function.

[Psychological health and cardiovascular disease : interdependency and therapeutic opportunities]. / Corpus sanum in mente sana : stratégies de promotion de la santé psychique en cas de pathologie cardiovas.

Despite progress in primary and secondary prevention, pharmacological and device-based therapies, cardiovascular disease remains a leading cause of morbidity and mortality worldwide. The specifics of cardiac disorders being in the spotlight, less attention has been given to psychological health and its interdependent relation to cardiovascular disease. Psychological health issues can contribute to increase cardiovascular disease risk, and cardiovascular disease itself can promote development of mental health issues. Psychological health in patients with cardiovascular disease represents an underexplored opportunity for intervention, an endeavour that could be designed as behavioural cardiology, which would be synergistic with efforts aimed at primary and secondary prevention.

Malgré les progrès réalisés en prévention primaire et secondaire ainsi qu'en termes de traitements pharmacologiques et de dispositifs médicaux, les pathologies cardiovasculaires restent la cause principale de morbidité et de mortalité à travers le monde. L'attention médicale portant particulièrement sur les pathologies cardiaques elles-mêmes, la santé mentale du patient peut être l'objet d'une attention insuffisante. Les souffrances psychiques contribuent à une augmentation du risque de pathologie cardiovasculaire et, réciproquement, une pathologie cardiovasculaire rend vulnérable et peut favoriser l'apparition d'un trouble psychique. La prise en charge globale du sujet cardiopathe, en particulier de son vécu intrapsychique, représente une opportunité d'intervention largement sous-exploitée. Cette discipline, nommons-la cardiologie comportementale, pourrait être menée en parallèle des mesures de prévention primaire et secondaire.