Are there good and bad responders to prehospital thrombolysis in the acute phase of myocardial infarction? OPTIMAL study rationale.

The effectiveness of thrombolytics has been clearly demonstrated in more than half the cases in the large cohorts of patients selected for trials during the acute phase of myocardial infarction. At individual level, thrombolysis will clinically either succeed or fail so, for the medical team managing the patient, choice of treatment may be likened to a gamble which in the best of cases (most often) leads to an uncomplicated success and, in the worst of cases, failure worsened by a severe complication. OPTIMAL is a multidisciplinary and multicentre, prospective cohort study associating mobile medical teams and interventional cardiology units to test the hypothesis that the outcome of prehospital thrombolysis does not depend on chance alone but also varies according to demographic, etiological, clinical and logistic factors involved in the occurrence and management of myocardial infarction. The primary objective of this French study, conducted over one year on more than 800 subjects, is to identify the predictors of the results of prehospital thrombolysis from a very early angiographic evaluation. The results for this cohort may be useful for setting up appropriate management strategies for acute myocardial infarction, from the prehospital phase (thrombolysis or not) up to in-hospital orientation of the patients (angiography room or Intensive Care Unit) and to determine the most judicious time for coronary angiography. OPTIMAL is to date the largest prospective serie of prehospital thrombolysis evaluated by an early angiographic control.

A randomized study comparing two guidewire strategies for angioplasty of chronic total coronary occlusion.

Chronic total coronary occlusions were more frequently crossed using the Crosswire as a primary guidewire strategy than with the conventional strategy. This strategy resulted in a lower number of guidewires being used, a trend toward shorter procedural and fluoroscopy times, and decreased use of contrast media.

Stenting small coronary arteries.

Stenting of small coronary arteries was long contra-indicated because of a high rate of subacute occlusion. We report a single-center registry including 190 patients stented with 2.5 mm balloons. Procedural success was 98% and subacute occlusion rate was 2.6%. Clinical follow-up showed a 24.5% repeat intervention rate. These results seemed acceptable, warranting stent implantation in small arteries in the case of acute or threatened closure. New stent designs and coatings may contribute to the improvement of outcomes and to the decrease in subacute occlusion and restenosis rates.

Tortuous internal mammary artery angioplasty: accordion effect with limitation of flow.

Mechanical straightening of a tortuous vessel during angioplasty has been well described. It can be mistaken for thrombus, dissection or spasm. This report presents a case in which straightening of vessel due to stiff guide wire results in accordion effect and flow limitation.

Coronary angiography using 4 or 6 French diagnostic catheters: a prospective, randomized study.

Diagnostic catheter size has been progressively decreased in order to reduce complications (particularly access-site complications) and permit early ambulation after coronary angiography. However, excessive down-sizing can result in poor catheter conformation and poor imaging quality of coronary angiograms (CA). This study randomly compared the accuracy and angiographic quality (QUAL) of CA performed with 4 French (Fr) vs. 6 Fr diagnostic catheters. Injections were done manually using a low-viscosity, non-heated, low-osmolality contrast media (Iomeprol). CAs were performed via the femoral approach using Judkins catheters. Handling, torque, selectively and stability were graded from 1 (excellent) to 4 (unacceptable) by the operator. QUAL was also graded from 1 (unacceptable) to 10 (excellent) by the operator in all patients and by an independent Core laboratory in 50 patients matched for gender and weight. Between January and April 1997, a total of 405 consecutive patients were randomized. Mean age was 63.4 +/- 11.1 years and 79% were male. Clinical characteristics of patients, quality of left coronary catheter and cross-over rates (1.5% with 6 Fr vs. 3.9% with 4 Fr catheters) were similar in both groups. Using the right coronary catheters, the only difference was handling, which was found to be easier with 6 Fr catheters (1.16 +/- 0.55 vs. 1.34 +/- 0.77, respectively; p = 0.007). Similarly, handling difficulty using the pigtail catheter was the only significant difference between the two groups (1.16 +/- 0.50 vs. 1.33 +/- 0.77, respectively; p = 0.009), but no cross-over was necessary in either group. The QUAL of CA was slightly but significantly better with 6 Fr than with 4 Fr catheters but considered non-diagnostic (< 7/10) in 1.4% vs. 6.8% of left CAs (p = NS). Procedural time (21.0 +/- 7.2 minutes vs. 19.0 +/- 8.1 minutes; p = 0.007) was shorter with 4 Fr catheters, but x-ray exposure, compression times and amount of contrast media used were similar. Ambulation was obtained at 2 hours in 15.1% vs. 34.0% of patients (p < 0.001) and at 4 hours in 43.8% vs. 52.4% (p < 0.05), respectively. The incidence of the worst access-site complication (moderate hematoma) was similar (1%) in both groups. CA can be performed using 4 Fr catheters and manual injections of low-viscosity contrast media with acceptable angiographic results in the majority of cases. This is associated with a shorter procedural time and earlier ambulation, and a decreased but acceptable angiographic quality.

[Fissuration of thoracic aneurysm in Horton disease, favourable course after surgery]. / Fissuration d'un anévrysme thoracique au cours d'une maladie de Horton, évolution favorable après chirurgie.

The authors report another case of rupture of the thoracic aorta in Giant Cell arteritis. The progressive nature of the rupture enabled life-saving aortic replacement with a vascular prosthesis. Only one previous report of this type of operation was found in a search of the literature. The prevalence of aortitis in Giant Cell arteritis would appear to be underestimated after autopsy studies. It affects the thoracic aorta mainly in the ascending segment but sometimes involves the whole aorta. It may remain asymptomatic or be complicated by arterial occlusion, aortic regurgitation, aneurysm, dissection or rupture. Effective steroid therapy could prevent these complications.

[Mobile thrombi of the right heart in pulmonary embolism]. / Thrombus mobiles des cavités droites dans l'embolie pulmonaire.

Systematic transthoracic echocardiography in all cases of pulmonary embolism may demonstrate right heart thrombi. The results of this monocentric series of 28 consecutive cases observed between 1987 and 1996 were analysed. Twenty-four patients were in NYHA Class IV: thirteen were in cardiogenic shock. Echocardiographic signs of acute cor pulmonale were usually observed: 96.3% of patients had right ventricular dilatation, 85.2% paradoxical interventricular septal motion, 88.9% pulmonary hypertension. The thrombus was typical serpentine (27/28 cases) arising from the lower limb veins. Passage into the left heart chambers through a patent foramen ovale was observed in 3 cases. Pulmonary embolism was confirmed in all cases. This is an extreme therapeutic emergency and 13 patients (46.4%) died despite treatment: surgery (7/16), thrombolysis (2/5), heparin (3/4) or interventional radiology (1/3). After the acute phase, the prognosis was generally good, as demonstrated by the 100% survival rate at 28.6 +/- 25 months. This study confirms the gravity of mobile right heart thrombi in pulmonary embolism. The diagnosis is echocardiographic. No significant difference in mortality was observed between the different therapeutic approaches used in this series. The echocardiographic finding of these thrombi is a traditional indication for emergency surgical embolectomy. Thrombolysis is rapid and readily available and seems to provide promising results alone or before surgery. In patients with contraindications to thrombolysis, interventional radiology or simple heparin therapy may be proposed.

[Immediate revascularization by angioplasty and coronary stents in patients over age 80 with myocardial infarction]. / Revascularisation immédiate par angioplastie et implantation d'une endoprothèse coronaire chez l'octogénaire victime d'un infarctus du myocarde.

The aim of this study was to assess the results of revascularisation by angioplasty and stenting in octogenarians in the acute phase of myocardial infarction. One hundred and four patients over 80 years of age were identified between January 1995 and April 1995 out of 906 patients admitted within 24 hours of the onset of myocardial infarction. The average age was 85 +/- 4 years with a female predominance (63.4%) and a high incidence of cardiogenic shock (28.8%). Ninety eight patients underwent angioplasty with coronary stenting in 81 patients (82.6%) within 39 +/- 35 min of hospital admission. A primary success was obtained in 96% of cases with restitution of TIMI 3 flow in 83.6% of cases. Hospital mortality was 26.5%, highly influenced by the presence of cardiogenic shock (60.7% versus 12.8% without shock). Univariate analysis showed cardiogenic shock (p < 0.0001) and ejection fraction (p = 0.009) to be predictive of mortality, and a tendency in favour of TIMI 3 flow (p = 0.07) and stent implantation (p = 0.09). Complications were rare: 1% of minor cerebrovascular accidents and 4% of vascular complications. There were no cases of emergency bypass surgery and only one patient had a recurrence of ischaemia at 30 days. The authors conclude that the results at 1 month in a high risk group of octogenarians seem to be in favour of an invasive management with coronary stenting in the acute phase of myocardial infarction.

[Current status of treatment of chronic cardiac insufficiency]. / Actualités sur le traitement de l'insuffisance cardiaque chronique.

When there is no correctable cause, cardiac failure continues to progress and outcome is poor. However several controlled clinical trials have shown that several therapeutic agents relieve symptoms, improve exercise tolerance and, for some, reduce mortality. Patients in NYHA functional class II, III and IV, whose systolic function is impaired should be treated by digitalis, diuretics and angiotensin-converting-enzyme inhibitors. These therapeutic agents are complementary and each of them are required. Moreover a study has shown that the impairment of patients in NYHA functional class I (who are still asymptomatic but with a ventricular ejection fraction < 35%) could be slowed by angiotensin-converting-enzyme inhibitors. In each case, it is of paramount importance to exclude treatable causes of heart failure because the best the symptomatic treatment can do is slow the inevitable worsening of the disease.

[Painful left bundle-branch block during exertion]. / Le bloc de branche gauche douloureux d'effort.

Two new cases of exercise related left-bundle branch block are reported in this study. They should be added to the twenty established and published cases. Comparison opens the way to discussion of the mechanism of onset. Ischemia is often accused, although no exploration has been able to demonstrate its responsibility in the origin of the problem. These two cases have novel features, particularly in describing the first case of painful exercise related bundle branch block in a subject twenty-three years of age. Ischemia linked to epicardial coronary lesions cannot be held responsible, but the possibility of micro-circulatory ischemia is suggested.

[Paroxysmal supraventricular tachycardia induced by deglutition]. / Tachycardie supra-ventriculaire paroxystique induite par la déglutition.

The authors report the case of a 43-year-old man with runs of tachycardia, sometimes atrial and sometimes by reentry, induced by atrial extrasystoles provoked by ewallowing. This rare condition, 21 descriptions of which are referred to, raises the problem of the inducing mechanism, with discussion of the role of mechanical stimulus played by the alimentary bolus or of a reflex of ortho- or parasympathetic origin. The discussion includes a detailed review of this condition and its treatment. The prognosis is always excellent but symptomatic discomfort may be considerable. Spontaneous recovery is possible, as in the case described here.

[Doppler echocardiography in the evaluation of left ventricular diastolic function]. / Apport de l'échocardiographie-Doppler à l'évaluation de la fonction diastolique ventriculaire gauche.

It is now well recognized that a disorder of left ventricular filling can be sufficient to account for congestive heart failure. Furthermore, evaluation of heart disease would not be complete if it did not include assessment of left ventricular filling, improvement of which probably ensures better control of the heart disease. An efficient and reliable tool for the study of diastolic function is therefore essential. The authors review the current state of knowledge and the more recent developments in Doppler echocardiography in the evaluation of left ventricular diastolic function. After revising the pathophysiology, the methods of studying ventricular filling are described. The recording technique is described, taking into account recent developments in transthoracic and transoesophageal approaches. This investigation provides parameters allowing semiquantitative estimation of filling pressures (mean left atrial pressure, end-diastolic pressure) and reliable evaluation of overall diastolic performance.

[Doppler echocardiography of tricuspid insufficiency. Methods of quantification]. / Echocardiographie-Doppler de l'insuffisance tricuspidienne. Méthodes de quantification.

Evaluation of tricuspid incompetence has benefitted considerably from the development of Doppler ultrasound. In addition to direct analysis of the valves, which provides information about the mechanism involved, this method is able to provide an accurate evaluation, mainly through use of the Doppler mode. In addition to new criteria being evaluated (mainly the convergence zone of the regurgitant jet), some indices are recognised as good quantitative parameters: extension of the regurgitant jet into the right atrium, anterograde tricuspid flow, laminar nature of the regurgitant flow, analysis of the flow in the supra-hepatic veins, this is only semi-quantitative, since the calculation of the regurgitation fraction from the pulsed Doppler does not seem to be reliable; This accurate semi-quantitative evaluation is made possible by careful and consistent use of all the criteria available. The authors set out to discuss the value of the various evaluation criteria mentioned in the literature and try to define a practical approach.

[Preventive treatment of systemic embolic complications of atrial fibrillation]. / Le traitement prophylactique des complications emboliques systémiques de la fibrillation auriculaire.

Non-valvular atrial fibrillation multiplies the risk of presumed embolic events by a factor of four. The hemorrhagic risk of anticoagulant treatment varies considerably and its prophylactic efficacy was not tested in any randomised trial before the end of 1989. The recommendations of experts at that time recognised that data were inadequate. The publication since of four randomised trials involving 3,049 patients has provided a more objective base for management decisions, highly in favour of the anticoagulation of cases of non-isolated atrial fibrillation in the absence of contraindications.

[Effect of sub-inhibitory concentrations of cefixime on the morphology, hemagglutination and adhesiveness of urinary strains of Escherichia coli]. / Action de concentrations sub-inhibitrices de céfixime sur la morphologie, le pouvoir hémagglutinant et d'adhésion de souches urinaires d'Escherichia coli.

The treatment of urinary tract infections is one of the indications of cefixime, a new oral cephem. The aim of the present work was to study the in vitro effect of cefixime sub- and infra-MICs on the morphology, haemagglutination and adhesiveness to epithelial cells of three uropathogenic Escherichia coli strains pretreated with sub-MICs (1/2 to 1/64 the MIC) of cefixime during growth phase (37 degrees C for 18 h). This treatment led to morphological alterations of the bacteria with filament formation. The E. coli strains showed different haemagglutination profiles (MS; MS-MR; MR). In the presence of cefixime sub-MICs (1/2 to 1/32 the MIC), MR E. coli showed a markedly altered capacity for haemagglutination (using guinea pig, human P1 and p erythrocytes). Adhesiveness was studied with human buccal cells for MS adhesins and human urothelial cells for MR adhesins. A significant decrease of adherence (70-90 per cent) was observed after pretreatment of E. coli strains with cefixime (up to 1/32 the MIC). Compared with other antibiotics active against E. coli, such as nalidixic acid, norfloxacin and ampicillin, the effect of 1/8 the MIC of cefixime on adhesiveness, was more pronounced. These results demonstrate that sub-MICs of cefixime induce a marked reduction in adhesiveness of E. coli. This property might potentiate the effectiveness of cefixime in the treatment of urinary tract infections due to E. coli.

Influence of sub-inhibitory concentrations of antibacterials on the surface properties and adhesion of Escherichia coli.

The effect of sub-inhibitory concentrations of antibacterials, including quinolones, on the surface properties of a uropathogenic strain of Escherichia coli was examined. The effect on the charge and hydrophobicity of the cell surface was assessed by means of partition between two aqueous phases, polyethylene glycol and dextran. Antibiotics at 1/8 x MIC inhibited adhesion to uroepithelial cells, and induced an increase in bacterial charge and hydrophobicity. Inhibition of adhesion correlated with increased charge, but not with hydrophobicity. The influence of magnesium on the inhibition of adhesion by sub-MICs of pefloxacin was also investigated. Loss of the anti-adhesive property of pefloxacin was observed with increasing magnesium concentrations, suggesting that quinolones should be free from magnesium to induce an inhibition of adhesion. Examination by electron microscopy showed a disappearance of fimbriae following treatment of E. coli cells with 1/8 x MIC of pefloxacin.

Effect of pefloxacin on microorganism: host cell interaction.

Recent evidence indicates that certain antibiotics affect bacterial adherence and phagocyte-micro-organism interactions. These interactions are important in the early stages of bacterial pathogenesis, that is, attachment to mucosal surfaces and invasion. Among the antibiotics of interest in this field are the fluoroquinolones. Sub-MICs of pefloxacin can alter the ability of Gram-positive cocci (Staphylococcus aureus, Enterococcus faecalis) and Gram-negative bacilli (Escherichia coli) to adhere to different eukaryotic cells (uroepithelial and buccal cells) and to fibrin-platelet matrices. The mechanism by which pefloxacin reduces adhesion is not completely understood. However in the case of Esch. coli, the inhibition of haemagglutination and adherence corresponds to: (1) a decrease in production of fimbriae; (2) changes in the composition of outer membrane proteins; and (3) an effect on partition coefficient (carried out with the PEG/dextran system) which can be attributed to changes in electric and/or hydrophobic properties of the Esch. coli surface. The first step of phagocytosis is represented by adherence of opsonized bacteria to the membrane receptors of phagocytes. Consequently, the action of pefloxacin on phagocytosis is also of importance. Pretreatment of bacteria (Staph. aureus, Ent. faecalis, Esch. coli and Legionella pneumophila) with 1/4 the MIC of pefloxacin leads to an increase in uptake of the different strains by phagocytes (polymorphonuclear leucocytes and macrophages). Exposure of the phagocytes to 10 mg/l of pefloxacin enhances phagocytosis of strains that have not been pretreated. Finally, entry of antibiotics into phagocytic cells is a prerequisite for activity against intracellular organisms. The concentration of pefloxacin by polymorphs and macrophages is high (intracellular concentration/extracellular concentration = 5-10). Such findings correlate well with the intracellular activity of pefloxacin, demonstrated with guinea pig macrophages and different bacteria (Staph. aureus, L. pneumophila).

Systematic use of transradial approach or suture of the femoral artery after angioplasty: attempt at achieving zero access site complications.

Access site complications occur in 5-15% of cases according to the various series. The predictive factors most often reported in the literature are the size of the puncture site and the intensity of the antiplatelet or anticoagulant treatment associated with the angioplasty procedure. Six senior cardiologists in a high volume Cardiology center (>1,500 procedures a year) with an individual experience >500 procedures in either the radial approach or the percutaneous suture of the femoral artery with the Techstar/Prostar system, conducted a prospective study from January 1 to December 31, 1999. The aim of this study was to eliminate the occurrence of access site complications by using either one of two techniques that were at the operator's discretion, i.e., systematic radial approach, or percutaneous suture of the femoral artery. A total of 956 patients were included over the study period; 60.7% of these patients had percutaneous arterial closure of the femoral artery and the remaining 39.3% were treated via the radial approach; 88.7% were stented. The patients were administered a mean 9,000 IU of heparin during the procedure; 1.9% had been fibrinolyzed and Reopro was used in 5.9%. No complications were documented in the radial group. Of the 580 patients in the femoral suture group, 96.9% had femoral suture, immediately effective in 508 cases (90.4%). Only 3 patients required additional prolonged compression. One significant hematoma (0.2%) necessitating blood transfusion was reported in the femoral group. Infection at the puncture site with subsequent antibiotic treatment was reported in 2 patients (0.3%). No further access site complications were observed at one-month follow-up. After completion of the learning curve, the two techniques (radial approach and percutaneous arterial suture) permit the almost total elimination of access site complications.

Stenting in acute myocardial infarction.

The limitations (recurrent ischaemia, restenosis, reocclusion) of percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction (MI) can be addressed by stenting. The preliminary results of stenting are favourable (Stent PAMI, STENTIM, ZWOLLE trials). We report the results of the ICPS registry including 519 patients directly treated with angioplasty and stenting at the acute phase of myocardial infarction, with a repeat MI rate of 1% and a mortality of 3.7% in the non-shock group.

Stenting of bifurcation lesions: a rational approach.

The occurrence of stenosis in or next to coronary bifurcations is relatively frequent and generally underestimated. In our experience, such lesions account for 15%-18% of all percutaneous coronary intervention > (PCI). The main reasons for this are (1) the coronary arteries are like the branches of a tree with many ramifications and (2) because of axial plaque redistribution, especially after stent implantation, PCI of lesions located next to a coronary bifurcation almost inevitably cause plaque shifting in the side branches. PCI treatment of coronary bifurcation lesions remains challenging. Balloon dilatation treatment used to be associated with less than satisfactory immediate results, a high complication rate, and an unacceptable restenosis rate. The kissing balloon technique resulted in improved, though suboptimal, outcomes. Several approaches were then suggested, like rotative or directional atherectomy, but these techniques did not translate into significantly enhanced results. With the advent of second generation stents, in 1996, the authors decided to set up an observational study on coronary bifurcation stenting combined with a bench test of the various stents available. Over the last 5 years, techniques, strategies, and stent design have improved. As a result, the authors have been able to define a rational approach to coronary bifurcation stenting. This bench study analyzed the behavior of stents and allowed stents to be discarded that are not compatible with the treatment of coronary bifurcations. Most importantly, this study revealed that stent deformation due to the opening of a strut is a constant phenomenon that must be corrected by kissing balloon inflation. Moreover, it was observed that the opening of a stent strut into a side branch could permit the stenting, at least partly, of the side branch ostium. This resulted in the provocative concept of "stenting both branches with a single stent." Therefore, a simple approach is currently implemented in the majority of cases: stenting of the main branch with provisional stenting of the side branch. The technique consists of inserting a guidewire in each coronary branch. A stent is then positioned in the main branch with a wire being "jailed" in the side branch. The wires are then exchanged, starting with the main branch wire that is passed through the stent struts into the side branch. After opening the stent struts in the side branch, kissing balloon inflation is performed. A second stent is deployed in the side branch in the presence of suboptimal results only. Over the last 2 years, this technique has been associated with a 98% angiographic success rate in both branches. Two stents are used in 30%-35% of cases and final kissing balloon inflation is performed in > 95% of cases. The in-hospital major adverse cardiac events (MACE) rate is around 5% and 7-month target vessel revascularization (TVR) is 13%. Several stents specifically designed for coronary bifurcation lesions are currently being investigated. The objective is to simplify the approach for all users. In the near future, the use of drug-eluting stents should reduce the risk of restenosis.