Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 128
Filtrar
1.
EuroIntervention ; 2020 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-33319763

RESUMO

AIMS: Obtain European data on SCAD, determine the prevalence of FMD and enable genetic analyses in this population. METHODS AND RESULTS: Data from a national French registry of SCAD cases, were analysed prospectively and retrospectively. Clinical and angiographic data and management strategy were collected. Major adverse cardiovascular events (MACE) were analysed after one-year follow-up. Subjects were screened for fibromuscular dysplasia (FMD) and blood was collected for DNA extraction. From June 2016 to August 2018, 373 SCAD cases were confirmed by the core lab. Mean age was 51.5 years. Patients were mostly women (90.6%) and 54.7% of cases had less than two cardiovascular risk factors. At 1 year, 295 patients (79.1%) were treated conservatively and the MACE rate was 12.3%, and no case of mortality. Recurrence rate of SCAD was 3.3%. FMD was found at ³ 1 arterial site in 45.0% of cases. We also confirmed the genetic association between the PHACTR1 locus and SCAD (odds ratio=1.66, P=7.08×10 -8 ). CONCLUSIONS: Here we describe the largest European SCAD cohort where FMD was found in 45% of cases and the genetic association with PHACTR1 was confirmed. This nationwide cohort is a valuable resource for future clinical and genetic investigation to understand SCAD aetiology.

2.
Cardiovasc Diagn Ther ; 10(5): 1415-1428, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33224765

RESUMO

Optical coherence tomography (OCT) imaging provides high resolution assessment of coronary parietal and endoluminal abnormalities. Clinical evidence and intuitive utilization make this tool relevant for use in daily practice in the catheterization laboratory. In the present review, we summarize the benefits of OCT for the optimization of percutaneous coronary intervention (PCI) in daily practice. First, we focus on the characterization of lesion type with a view to anticipating challenges during PCI. Then, we describe the utility of OCT to identify culprit lesions and ambiguous angiographic findings. Finally, we outline targets for optimization after PCI and the mechanisms underlying stent failure.

3.
EuroIntervention ; 2020 Nov 24.
Artigo em Inglês | MEDLINE | ID: mdl-33226003

RESUMO

AIMS: IVUS is currently recommended by international guidelines to guide left main stem (LMS) PCI. Although OCT resolution outmatches IVUS, this tool is not yet recommended in LMS angioplasty due to the absence of data. This pilot study aimed to analyze the feasibility, safety and impact of OCT-guided LMS PCI. METHODS AND RESULTS: This prospective, multicenter trial investigated whether patients might benefit from OCT-guided PCI for mid/distal LMS according to a pre-specified protocol. The primary endpoint was procedural success defined as follows: residual angiographic stenosis <50% + TIMI 3 flow in all branches + adequate OCT stent expansion (LEMON criteria). Seventy patients were included in the final analysis (median age: 72 (64-81) y, 73% male). The OCT pre-specified protocol was applied in all patients. The primary endpoint was achieved in 86 % of subjects. Adequate stent expansion was observed in 86%, significant edge dissection in 30% and residual significant struts malapposition in 24% of the cases. OCT guidance modified operators' strategy in 26% of the patients. The one-year survival free from major clinical adverse events was 98.6 (97.2-100) %. CONCLUSIONS: This study is the first to report the feasibility and performance of OCT-guided LMS PCI according to a pre-specified protocol.

4.
Thromb Res ; 196: 476-482, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33091699

RESUMO

OBJECTIVES: The safety and efficacy of direct oral anticoagulants (DOACs) in intermediate-high risk pulmonary embolism (PE) are unknown. The aims of the present study were to describe outcomes of patients receiving early apixaban or rivaroxaban prescription rather than the recommended delayed prescription strategy. METHODS: Retrospective post-hoc analysis based on prospectively collected data from a multicenter cohort including all consecutive PE patients stratified as intermediate-high risk. Group definitions were: early group with DOAC prescription <72 h after admission; delayed group with DOAC prescription between 72 h and discharge. The 30-day primary efficacy outcome was a clinical composite of all-cause death and hemodynamic decompensation. The 30-day primary safety outcome was major bleeding. RESULTS: Among 2411 patients admitted with PE, 302 were treated with a DOAC for an intermediate-high risk PE: 34.2% in the early group and 65.9% in the delayed group. The primary outcome occurred in 4.8% (including 1 death and 4 hemodynamic decompensations) in the early DOAC group and in 9.0% in the delayed DOAC group (OR, 0.44, 95% CI 0.15-1.30). The rate of major bleeding did not differ between groups (OR, 0.99; 95% CI 0.45-2.18). The length of stay was numerically shorter in the early group whereas the other outcomes did not differ significantly. CONCLUSION: The rate of 30-day outcomes was low in patients receiving a DOAC earlier after admission. Patients in the early DOAC group had a numerically shorter length of stay, with similarly low rates of death and bleeding, and similar RV function recovery compared to the delayed strategy.

5.
Arch Cardiovasc Dis ; 113(11): 749-759, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32978090

RESUMO

Acute pulmonary embolism is a frequent cardiovascular emergency with an increasing incidence. The prognosis of patients with high-risk and intermediate-high-risk pulmonary embolism has not improved over the last decade. The current treatment strategies are mainly based on anticoagulation to prevent recurrence and reduce pulmonary vasculature obstruction. However, the slow rate of thrombus lysis under anticoagulation is unable to acutely decrease right ventricle overload and pulmonary vasculature resistance in patients with severe obstruction and right ventricle dysfunction. Therefore, patients with high-risk and intermediate-high-risk pulmonary embolism remain a therapeutic challenge. Reperfusion therapies may be discussed for these patients, and include systemic thrombolysis, catheter-directed therapies and surgical thrombectomy. High-risk patients require systemic thrombolysis, but may have contraindications as a result of the high risk of bleeding. In addition, intermediate-high-risk patients should not receive systemic thrombolysis, despite its high efficacy, because of prohibitive bleeding complications. Recently, percutaneous reperfusion techniques have been developed to acutely decrease pulmonary vascular obstruction with lower-dose or no thrombolytic agents and, thus, potentially higher safety than systemic thrombolysis. Some of these techniques improve key haemodynamic variables. Cardiac surgical techniques and venoarterial extracorporeal membrane oxygenation as temporary circulatory support may be useful in selected cases. The development of pulmonary embolism centres with multidisciplinary pulmonary embolism teams is mandatory to enable adequate use of reperfusion and improve outcomes. We aim to present the state of the art regarding reperfusion therapies in pulmonary embolism, but also to provide guidance on their indications and patient selection.

6.
Eur Respir J ; 56(4)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32907890

RESUMO

BACKGROUND: Coronavirus disease 2019 (COVID-19) may predispose to venous thromboembolism. We determined factors independently associated with computed tomography pulmonary angiography (CTPA)-confirmed pulmonary embolism (PE) in hospitalised severe COVID-19 patients. METHODS: Among all (n=349) patients hospitalised for COVID-19 in a university hospital in a French region with a high rate of COVID-19, we analysed patients who underwent CTPA for clinical signs of severe disease (oxygen saturation measured by pulse oximetry ≤93% or breathing rate ≥30 breaths·min-1) or rapid clinical worsening. Multivariable analysis was performed using Firth penalised maximum likelihood estimates. RESULTS: 162 (46.4%) patients underwent CTPA (mean±sd age 65.6±13.0 years; 67.3% male (95% CI 59.5-75.5%). PE was diagnosed in 44 (27.2%) patients. Most PEs were segmental and the rate of PE-related right ventricular dysfunction was 15.9%. By multivariable analysis, the only two significant predictors of CTPA-confirmed PE were D-dimer level and the lack of any anticoagulant therapy (OR 4.0 (95% CI 2.4-6.7) per additional quartile and OR 4.5 (95% CI 1.1-7.4), respectively). Receiver operating characteristic curve analysis identified a D-dimer cut-off value of 2590 ng·mL-1 to best predict occurrence of PE (area under the curve 0.88, p<0.001, sensitivity 83.3%, specificity 83.8%). D-dimer level >2590 ng·mL-1 was associated with a 17-fold increase in the adjusted risk of PE. CONCLUSION: Elevated D-dimers (>2590 ng·mL-1) and absence of anticoagulant therapy predict PE in hospitalised COVID-19 patients with clinical signs of severity. These data strengthen the evidence base in favour of systematic anticoagulation, and suggest wider use of D-dimer guided CTPA to screen for PE in acutely ill hospitalised patients with COVID-19.


Assuntos
Anticoagulantes/administração & dosagem , Infecções por Coronavirus/complicações , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Pneumonia Viral/complicações , Embolia Pulmonar/etiologia , Embolia Pulmonar/prevenção & controle , Idoso , Betacoronavirus , Angiografia por Tomografia Computadorizada , Infecções por Coronavirus/epidemiologia , Feminino , França/epidemiologia , Humanos , Masculino , Oximetria , Pandemias , Pneumonia Viral/epidemiologia , Valor Preditivo dos Testes , Embolia Pulmonar/diagnóstico por imagem , Estudos Retrospectivos , Sensibilidade e Especificidade
7.
Biomed Opt Express ; 11(6): 3374-3394, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-32637261

RESUMO

Intravascular optical coherence tomography (IVOCT) can accurately assess stent apposition and expansion, thus enabling the optimisation of a stenting procedure to minimize the risk of device failure. This paper presents a deep convolutional based model for automatic detection and segmentation of stent struts. The input of pseudo-3D images aggregated the information from adjacent frames to refine the probability of strut detection. In addition, multi-scale shortcut connections were implemented to minimize the loss of spatial resolution and refine the segmentation of strut contours. After training, the model was independently tested in 21,363 cross-sectional images from 170 IVOCT image pullbacks. The proposed model obtained excellent segmentation (0.907 Dice and 0.838 Jaccard) and detection metrics (0.943 precision, 0.940 recall and 0.936 F1-score), significantly better than conventional features-based algorithms. This performance was robust and homogenous among IVOCT pullbacks with different sources of acquisition (clinical centres, imaging operators, type of stent, time of acquisition and challenging scenarios). In addition, excellent agreement between the model and a commercialized software was observed in the quantification of clinically relevant parameters. In conclusion, the deep-convolutional model can accurately detect stent struts in IVOCT images, thus enabling the fully-automatic quantification of stent parameters in an extremely short time. It might facilitate the application of quantitative IVOCT analysis in real-world clinical scenarios.

8.
Eur Heart J Acute Cardiovasc Care ; 9(8): 879-887, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32363879

RESUMO

AIMS: To improve attainment of LDL-cholesterol (LDL-c) targets, an expert group proposed an algorithm for lipid-lowering therapy during hospitalization for acute coronary syndrome and during follow-up. We aimed to assess adherence to this algorithm, and evaluate its impact on LDL-c levels and on attainment of therapeutic LDL-c targets in a population of post-acute coronary syndrome patients. METHODS AND RESULTS: Prospective, observational study including patients admitted for acute coronary syndrome between February 2017 and September 2018. Patients admitted without statins or ezetimibe were considered 'naïve'. Baseline LDL-c was admission LDL-c in naïve patients, and for those taking lipid-lowering therapy at admission, baseline LDL-c was back-calculated. In line with the most recent guidelines, the target was a >50% reduction in naïve LDL-c and <55 mg/dL. In total, 270 patients were analysed, mean age 67 ± 12 years, 78% men, 26% diabetic. At admission, 175 (65%) were naïve, 95 (35%) had previous lipid-lowering therapy, of which 13 (5%) statin+ezetimibe. Average LDL-c at admission was 120 ± 47 mg/dL (136 ± 44 mg/dL in naïve, 91 ± 39 mg/dL in pretreated patients). Discharge prescription was in compliance with the algorithm in 204 (76%) patients. Average LDL-c at two months was 57 ± 28 mg/dL; it was <55 mg/dL in 135 (50%), and 178 (66%) achieved a >50% reduction. Overall, 125/270 (46%) achieved the LDL-c goal. The reduction in LDL-c observed at two months persisted at five months. CONCLUSION: Prescription of high-intensity statins, associated with ezetimibe where applicable, achieves LDL-c levels <55 mg/dL in 50% of patients at two months, and attains therapeutic goals defined by the European Society of Cardiology in 46% of cases.

9.
EuroIntervention ; 2020 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-32392171

RESUMO

AIMS: To analyse the relationship between stent expansion criteria using optical coherence tomography (OCT) analysis and the final PCI functional result. METHODS AND RESULTS: This post-hoc analysis of the DOCTORS study included non-ST elevation segment ACS patients undergoing OCT-guided PCI. The procedure functional result was assessed by the measurement of fractional flow reserve (FFR). Stent expansion was assessed on OCT runs according to the DOCTORS criteria and ILUMIEN-III criteria. The study included N=116 patients (Age: 60.8±11.5 years/ male gender:71%). The final expansion was considered optimal in 10%, acceptable in 9% and unacceptable in 81% of the stents according to ILUMIEN-III criteria, although being successful in 70% of the patients according to the DOCTORS criteria. Hypertension and larger proximal reference segment dimension were independent predictors of inadequate device ILUMIEN-III expansion. FFR values were respectively 0.93[0.91-0.95] vs. 0.95[0.92-0.97] in patients with optimal+ acceptable vs. unacceptable ILUMIEN-III expansion (p=0.22), 0.94[0.91-0.97] vs. 0.95 [0.93-0.97] in patients with optimal vs. non-optimal DOCTORS expansion (p=0.23) and 0.95[0.92-0.97] vs. 0.92[0.90-0.95]in patients with minimal stent area ³4.5 mm2 vs. <4.5 mm2 (p=0.03). CONCLUSIONS: In this selected population, no relationship was observed between optimal stent expansion according to ILUMIEN-III or DOCTORS OCT criteria and final post-PCI FFR values.

10.
BMC Cardiovasc Disord ; 20(1): 157, 2020 04 05.
Artigo em Inglês | MEDLINE | ID: mdl-32248819

RESUMO

BACKGROUND: We studied the course of plasma concentrations of 4 cardiovascular biomarkers: natriuretic peptides (BNP, NT-proBNP; mid-regional (MR) pro-atrial NP); and soluble endothelial CD146 (sCD146), in patients with severe mitral valve stenosis undergoing percutaneous mitral commissurotomy (PMC) to identify potential markers of procedural success. METHODS: Biomarkers were tested in 40 patients the day before and the day after PMC. Success was defined as mitral valve area ≥ 1.5 cm2; or an increase of ≥0.5 cm2 in mitral valve area associated with echocardiographic mitral regurgitation

Assuntos
Fator Natriurético Atrial/sangue , Procedimentos Cirúrgicos Cardíacos , Estenose da Valva Mitral/cirurgia , Idoso , Biomarcadores/sangue , Antígeno CD146/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estenose da Valva Mitral/sangue , Estenose da Valva Mitral/diagnóstico por imagem , Estenose da Valva Mitral/fisiopatologia , Peptídeo Natriurético Encefálico/sangue , Paris , Fragmentos de Peptídeos/sangue , Valor Preditivo dos Testes , Estudos Prospectivos , Recuperação de Função Fisiológica , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
11.
Aging Clin Exp Res ; 32(1): 133-140, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30903598

RESUMO

BACKGROUND: Clinical research is an essential step in the successful translation of knowledge from basic research into concrete clinical applications, yet many people are reluctant to provide consent when actually approached to actively participate in clinical trials. AIMS: We investigated the factors that influence older patient's (≥ 65 years) decisions to accept or refuse to participate in a prospective randomized clinical trial in secondary prevention after acute coronary syndrome. METHODS: Qualitative approach based on individual semi-structured interviews with patients who were approached for consent to participate in a currently ongoing clinical trial was adopted. Patients were interviewed after the consent process (8 accepted; 8 refused the trial). Interviews were analysed using grounded theory methodology. RESULTS: Sixteen patients aged ≥ 65 years participated. The main concept to emerge from these interviews is that the actual trial itself does not appear to be the primary determinant in the decision to participate in clinical research. Rather, patients' decisions to participate (or not) in clinical research appear to be primarily determined by their capacity to deal with the current health event that has disrupted their life, and by their available mental and physical resources. DISCUSSION AND CONCLUSION: Older patients display varying levels of engagement in their own health, ranging from low engagement with high trust in the medical profession, to high engagement mirrored by distrust of the medical profession. Structural conditions, such as personal benefit from trial participation, or logistic barriers to participation, seem to affect both accepters and refusers in the same manner.


Assuntos
Atitude Frente a Saúde , Tomada de Decisões , Consentimento Livre e Esclarecido , Seleção de Pacientes , Idoso , Cardiologia/métodos , Feminino , Humanos , Masculino , Estudos Prospectivos , Pesquisa Qualitativa , Ensaios Clínicos Controlados Aleatórios como Assunto
12.
Arch Cardiovasc Dis ; 113(1): 31-39, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31690519

RESUMO

BACKGROUND: Evidence-based clinical practice guidelines define initial management of acute pulmonary embolism (PE) according to risk stratification for early death. AIMS: The aims of the present study were to investigate patterns of non-compliance with guidelines for the acute PE treatment, and the associated risk of adverse events. METHODS: We performed an observational, multicentre, cohort study of acute PE. Inclusion criteria were all patients with pulmonary embolism admitted to the participating centres between January 2011 and April 2017. The measure of 100% compliance was used to allocate patients in the compliant or non-compliant groups. The primary outcome was all-cause death at 6 months. Secondary outcomes included recurrent venous thromboembolism and major bleeding. RESULTS: In total, 1285 patients were included. Treatment was not in compliance with the guidelines in 172 patients (13.4%). Four factors were identified to be related to non-compliance with the guidelines: shock or hypotension (relative risk [RR] 5.23, 95% confidence interval [CI] 2.64-10.30; P<0.001), renal insufficiency (RR 1.80, 95% CI 1.41-2.28; P<0.001), active cancer (RR 1.35, 95% CI 1.24-1.48; P<0.001) and right ventricular dysfunction at admission (RR 1.06, 95% CI 1.01-1.11; P=0.01). The primary endpoint of all-cause death at 6 months occurred in 62 of 172 patients (36.0%) in the non-compliant group and in 131 of 1113 patients (11.8%) in the compliant group (hazard ratio 2.02, 95% CI 1.45-2.81; P<0.001). The rates of recurrent venous thromboembolism (8.7% vs 1.1%; P<0.001) and major bleeding (13.4% vs 4.9%, P=0.04) from admission to 6-month follow-up were higher in the non-compliant group. CONCLUSION: Non-compliance with guidelines was independently associated with worse outcomes, including death, recurrent venous thromboembolism and bleeding.


Assuntos
Fidelidade a Diretrizes/tendências , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/tendências , Embolia Pulmonar/terapia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Comorbidade , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidade , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
13.
Circulation ; 141(4): 243-259, 2020 01 28.
Artigo em Inglês | MEDLINE | ID: mdl-31736356

RESUMO

BACKGROUND: No randomized study powered to compare balloon expandable (BE) with self expanding (SE) transcatheter heart valves (THVs) on individual end points after transcatheter aortic valve replacement has been conducted to date. METHODS: From January 2013 to December 2015, the FRANCE-TAVI nationwide registry (Registry of Aortic Valve Bioprostheses Established by Catheter) included 12 141 patients undergoing BE-THV (Edwards, n=8038) or SE-THV (Medtronic, n=4103) for treatment of native aortic stenosis. Long term mortality status was available in all patients (median 20 months; interquartile range, 14 to 30). Patients treated with BE-THV (n=3910) were successfully matched 1:1 with 3910 patients treated with SE-THV by using propensity score (25 clinical, anatomical, and procedural variables) and by date of the procedure (within 3 months). The first coprimary outcome was ≥ moderate occurrence of paravalvular regurgitation or in-hospital mortality, or both. The second coprimary outcome was 2-year all-cause mortality. RESULTS: In propensity-matched analyses, the incidence of the first coprimary outcome was higher with SE-THV (19.8%) compared with BE-THV (11.9%; relative risk, 1.68 [95% CI, 1.46-1.91]; P<0.0001). Each component of the outcome was also higher in patients receiving SE-THV: ≥ moderate paravalvular regurgitation (15.5% versus 8.3%; relative risk, 1.90 [95% CI, 1.63-2.22]; P<0.0001) and in hospital mortality (5.6% versus 4.2%; relative risk, 1.34 [95% CI, 1.07-1.66]; P=0.01). During follow up, all cause mortality occurred in 899 patients treated with SE-THV (2-year mortality, 29.8%) and in 801 patients treated with BE-THV (2-year mortality, 26.6%; hazard ratio, 1.17 [95% CI, 1.06-1.29]; P=0.003). Similar results were found using inverse probability of treatment weighting using propensity score analysis. CONCLUSION: The present study suggests that use of SE-THV was associated with a higher risk of paravalvular regurgitation and higher in-hospital and 2-year mortality compared with use of BE-THV. These data strongly support the need for a randomized trial sufficiently powered to compare the latest generation of SE-THV and BE-THV. CLINICAL TRIAL REGISTRATION: https://www.clinicaltrials.gov. Unique identifier: NCT01777828.


Assuntos
Próteses Valvulares Cardíacas , Sistema de Registros , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Intervalo Livre de Doença , Feminino , Seguimentos , França/epidemiologia , Humanos , Masculino , Taxa de Sobrevida
14.
Catheter Cardiovasc Interv ; 96(6): 1145-1153, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31763775

RESUMO

OBJECTIVE: We sought to evaluate the correlations of pre-PCI QFR analysis with virtual PCI called residual QFR and post-PCI QFR compared to post-PCI FFR. BACKGROUND: Quantitative flow ratio (QFR) is a computation of fractional flow reserve (FFR) based on angiography without use of a pressure wire. The ability to evaluate post-PCI FFR using pre-PCI QFR analysis with a virtual PCI and the correlation between post-PCI QFR compared to post-PCI FFR remains unknown. METHODS: From the DOCTORS (Does Optical Coherence Tomography Optimize Results of Stenting) study population, we blindly analyzed residual QFR and post-PCI QFR from angiographies and compared them to post-PCI FFR. RESULTS: Ninety-three post-PCI QFR measurements and 84 pre-PCI residual QFR measurements were compared to post-PCI FFR measurements. No significant difference were observed between mean post-PCI FFR value (0.92 ± 0.05) compared to mean residual (0.93 ± 0.05) QFR and between mean post-PCI FFR value compared to mean post-PCI QFR values were (0.93 ± 0.05) (p > .05 for both). The correlation coefficient of residual QFR with post-PCI FFR was 0.68 (95% CI: 0.53-0.78) and the correlation coefficient of post-PCI-QFR with post-PCI FFR was 0.79 (95% CI: 0.70-0.86). CONCLUSIONS: Residual QFR corresponding to pre-PCI QFR analysis with virtual PCI, and post-PCI QFR analysis, correlated well with post-PCI FFR. Further studies are needed to prospectively validate a QFR-guided PCI strategy.

16.
Rev Neurol (Paris) ; 176(1-2): 53-61, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31787326

RESUMO

BACKGROUND: Unlike previous randomized clinical trials (RCTs), recent trials and meta-analyses have shown that transcatheter closure of patent foramen ovale (PFO) reduces stroke recurrence risk in young and middle-aged adults with an otherwise unexplained PFO-associated ischaemic stroke. AIM: To produce an expert consensus on the role of transcatheter PFO closure and antithrombotic drugs for secondary stroke prevention in patients with PFO-associated ischaemic stroke. METHODS: Five neurologists and five cardiologists with extensive experience in the relevant field were nominated by the French Neurovascular Society and the French Society of Cardiology to make recommendations based on evidence from RCTs and meta-analyses. RESULTS: The experts recommend that any decision concerning treatment of patients with PFO-associated ischaemic stroke should be taken after neurological and cardiological evaluation, bringing together the necessary neurovascular, echocardiography and interventional cardiology expertise. Transcatheter PFO closure is recommended in patients fulfilling all the following criteria: age 16-60 years; recent (≤6 months) ischaemic stroke; PFO associated with atrial septal aneurysm (>10mm) or with a right-to-left shunt>20 microbubbles or with a diameter≥2mm; PFO felt to be the most likely cause of stroke after thorough aetiological evaluation by a stroke specialist. Long-term oral anticoagulation may be considered in the event of contraindication to or patient refusal of PFO closure, in the absence of a high bleeding risk. After PFO closure, dual anti-platelet therapy with aspirin (75mg/day) and clopidogrel (75mg/day) is recommended for 3 months, followed by monotherapy with aspirin or clopidogrel for≥5 years. CONCLUSIONS: Although a big step forward that will benefit many patients has been taken with recent trials, many questions remain unanswered. Pending results from further studies, decision-making regarding management of patients with PFO-associated ischaemic stroke should be based on a close coordination between neurologists/stroke specialists and cardiologists.


Assuntos
Isquemia Encefálica/cirurgia , Cateterismo Cardíaco/normas , Procedimentos Endovasculares/normas , Forame Oval Patente/cirurgia , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle , Adolescente , Adulto , Isquemia Encefálica/complicações , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/métodos , Cardiologia/organização & administração , Cardiologia/normas , Consenso , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Prova Pericial , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Neurologia/organização & administração , Neurologia/normas , Recidiva , Prevenção Secundária/métodos , Prevenção Secundária/normas , Sociedades Médicas/normas , Dispositivos de Acesso Vascular/normas , Técnicas de Fechamento de Ferimentos/instrumentação , Técnicas de Fechamento de Ferimentos/normas , Adulto Jovem
18.
Eur Heart J Suppl ; 21(Suppl I): I23-I30, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31777454

RESUMO

Systemic thrombolysis for acute pulmonary embolism (PE) reduces the risk of death and cardiovascular collapse but is associated with an increased rate of bleeding. The desire to minimize the risk of bleeding events has driven the development of catheter-based strategies for pulmonary reperfusion in PE. These catheter-based strategies utilize lower-dose fibrinolytic regimens or purely mechanical techniques to expedite removal of the embolus. Several devices providing mechanical or suction embolectomy and catheter-directed thrombolysis, with or without facilitation by ultrasound, have been tested. Data are inconsistent regarding the efficacy and safety of mechanical and suction embolectomy. The most comprehensive data on catheter-based techniques stem from trials of ultrasound-facilitated catheter fibrinolysis. Ultrasound-facilitated catheter fibrinolysis relieves right ventricular pressure overload with a lower risk of major bleeding and intracranial haemorrhage than historical rates with systemic fibrinolysis. However, further research is required to determine the optimal application of ultrasound-facilitated catheter fibrinolysis and other catheter-based therapies in patients with acute PE.

19.
Int J Cardiol ; 297: 22-29, 2019 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-31630816

RESUMO

AIMS: The impact of diabetes mellitus (DM) on clinical outcomes after transcatheter aortic valve replacement (TAVR) remains unclear. The aim of this study was to investigate the impact of DM on short-term clinical outcomes after TAVR in a large randomized trial population. METHODS AND RESULTS: BRAVO-3 trial randomized 802 patients undergoing trans-femoral TAVR to procedural anticoagulation with bivalirudin or unfractionated heparin. The study population was divided according to the presence of DM, and further stratified according to the use of insulin. Net adverse cardiovascular outcomes (NACE - death, myocardial infarction (MI), stroke or major bleeding by Bleeding Academic Research Consortium (BARC) type 3b or above) was the primary outcome in-hospital and at 30-days. Of the total 802 randomized patients, 239 (30%) had DM at baseline, with 87 (36%) being treated with insulin. At 30-days, DM patients experienced numerically higher rates of net adverse cardiovascular events (16.3% vs. 14.4%, p=0.48) and acute kidney injury (19.7% vs. 15.1%, p=0.11), while non-DM (NDM) patients had numerically higher rates of cerebrovascular accidents (3.6% vs. 1.7%, p=0.22). After multivariable adjustment, DM patients had higher odds of vascular complications at 30-days (OR 1.57, p=0.03) and life-threatening bleeding both in-hospital (OR 1.50, p=0.046) and at 30-days (OR 1.50, p=0.03) with the excess overall risk primarily attributed to the higher rates observed among non-insulin dependent DM patients. CONCLUSIONS: Patients with DM had higher adjusted odds of vascular and bleeding complications up to 30-days post-TAVR. Overall, there was no significant association between DM and early mortality following TAVR.


Assuntos
Estenose da Valva Aórtica/cirurgia , Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 2/complicações , Complicações Pós-Operatórias/epidemiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Feminino , Humanos , Masculino , Fatores de Risco , Fatores de Tempo
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA