Background : Since the onset of the COVID-19 pandemic, several cardiovascular manifestations have been described. Among them, venous thromboembolism (VTE) seems to be one of the most frequent, particularly in intensive care unit patients. We report two cases of COVID-19 patients developing acute pulmonary embolism (PE) after discharge from a first hospitalization for pneumonia of moderate severity. Case summary : Two patients with positive RT-PCR test were initially hospitalized for non-severe COVID-19. Both received standard thromboprophylaxis during the index hospitalization and had no strong predisposing risk factors for VTE. Few days after discharge, they were both readmitted for worsening dyspnoea due to PE. One patient was positive for lupus anticoagulant. Discussion : Worsening respiratory status in COVID-19 patients must encourage physicians to search for PE since SARS-CoV-2 infection may act as a precipitant risk factor for VTE. Patients may thus require more aggressive and longer thromboprophylaxis after COVID-19 related hospitalization.

Background: Residual coronary artery disease (CAD) has been associated with worsened prognosis in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS). The residual SYNTAX Score (rSS) aims to assess residual CAD after PCI. The association between kidney function and rSS has not been investigated in ACS patients. In this study, we sought to determine whether chronic kidney disease (CKD) patients exhibit more incomplete revascularization following stage revascularization procedures by PCI. We evaluated the impact of incomplete revascularization on the occurrence of major cardiovascular events (MACE) at one-year follow-up. Methods: A total of 831 ACS patients undergoing PCI were divided into 3 subgroups according to their estimated Glomerular Filtration Rate (eGFR): 695 with eGFR ≥ 60 mL/min/1.73 m², 108 with eGFR 60–30 mL/min/1.73 m², 28 with eGFR < 30 mL/min/1.73 m². Initial SYNTAX score (SS) and rSS were calculated for all patients. Incomplete revascularization was defined by rSS > 8. The primary endpoint was the occurrence of MACE (all-cause mortality, myocardial infarction (MI), repeated revascularization except from planned revascularization, stroke and definite or probable recurrent stent thrombosis) one year after the index procedure. Results: Severe CKD patients had significantly higher MACE (12.0% vs. 25.9% vs. 35.7%; p < 0.001), all-cause mortality, cardiovascular mortality and heart failure events. Patients with rSS > 8 had higher MACE, all-cause and cardiovascular mortality. CKD was an independent predictive factor of rSS > 8 (HR: 1.65, 95% CI: 1.01 to 2.71; p = 0.048). Multivariate analysis identified rSS > 8, but not CKD, as an independent predictor of cardiac death and MACE. Conclusion: In ACS, CKD is predictive of incomplete revascularization, which stands out as a strong predictor of adverse cardiovascular outcomes including cardiac death and MACE.

With respect to the transfemoral approach, transradial procedures enable a drastic reduction of bleeding events and are associated with a reduction of mortality. Radial artery spasm (RAS) is one of the most common complications and may lead to patient discomfort and procedural failure. Currently, there is no consensus on the optimal sedation protocol to avoid RAS. The aim of this study was to investigate the respective impact of opioids analgesia and inhalation sedation with a 50% nitrous oxide/oxygen premix (Kalinox) on pain and occurrence of RAS during transradial coronary procedures. Consecutive patients undergoing transradial coronary angiography were prospectively enrolled in one, single center observational study (Nouvel Hôpital Civil, Strasbourg, France). Patients received opioids analgesia or inhalation sedation with Kalinox. The primary endpoints of the study were the incidence of a pain scale ≥5/10 and the occurrence of RAS. The secondary endpoints were the incidence of side effects. A total of 325 patients were enrolled (185 in the opioids analgesia group, 140 in the Kalinox group). RAS and pain scale ≥5 rates were not significantly different in the opioids analgesia and Kalinox groups (respectively 13.5% vs. 10.0% and 16.2% vs. 11.4%). Headache was more frequently observed in the Kalinox group (6.4% vs. 0.0%; p = 0.002). By multivariate analysis, female gender, BMI <25 kg/m², puncture difficulty, the use of plastic needle and 6F sheath were identified as independent predictors of RAS. Procedural inhalation sedation by Kalinox is as safe as opioids analgesia during transradial coronary angiography.

Background : The presence of a dilated coronary sinus (CS) assessed by transthoracic echocardiography (TTE) is highly suggestive of inferior or superior vena cava (SVC) anomalies, in the absence of a shunt. The most frequent finding is the persistence of a left superior vena cava (LSVC): well-known feature to electrophysiologists. Abnormal inferior vena cava (IVC) drainage is another cause of CS dilatation. Case summary : An 83-year-old woman presented with heart failure symptoms, atrial fibrillation with rapid ventricular rate, and a dilated CS assessed by TTE. Atrioventricular (AV) node ablation was considered given the poor efficacy of a rate control strategy. Cardiac computed tomography (CT) revealed a double SVC with an LSVC draining directly into the dilated CS. Single-lead pacemaker implantation was performed using a right-sided vascular access with no technical difficulties. An aborted AV node ablation procedure was due to the impossibility of getting to the right atrium. Fluoroscopy and CT imaging at second look analysis confirmed the diagnosis of an abnormal IVC with an agenesia of its supra-hepatic segment directly drained into the CS. Discussion : Our clinical case illustrates an unusual and rare double venous abnormality: both LSVC and IVC directly drained into the CS and were responsible for its massive dilatation.

Left atrial (LA) dilation is implicated in atrial fibrillation (AF) recurrence after catheter ablation (CA),^1,2 but there are limited data considering LA volume (LAV) in relation to low-voltage zones (LVZs). Some studies on AF ablation have noted an interesting association between large LA size and the presence of LVZs on LA voltage maps.^3–5 However, in the cohort of Bergonti et al.,⁵ 30% of paroxysmal and persistent AF patients showed significantly increased LA volume index (LAVI) without any LVZs. We assessed LA bipolar voltage and the outcome of pulmonary vein isolation (PVI) alone in a cohort of persistent AF patients with normal voltage map in relation to LAVI. Additionally, we also evaluated the predictors of LA enlargement in the same population. This single-centre retrospective study included 214 consecutive persistent AF patients who underwent a PVI alone in our institution between January 2019 and February 2023 (Ethics Committee approval no. CE-2024-26). Patients enrolled in the study had a normal LA voltage map without LVZ and no underlying structural heart disease. The cohort was divided into two groups of LAVI: <48 mL/m² (n = 36) and ≥48 mL/m² (n = 178). We chose this threshold based on ultrasound data. Normal LAVI was considered <34 mL/m² while a severe LA dilation is ≥48 mL/m² in transthoracic echography.⁶ High-density LA voltage maps were obtained with a multipolar mapping catheter PentaRay® (Biosense Webster, Diamond Bar, CA, USA) using 3D mapping system in sinus rhythm. Low-voltage zone was defined as 30 s. Antiarrhythmic drugs (AADs) were gradually discontinued between 3 and 6 months post-ablation in the absence of recurrence at physician’s discretion.