[Comparison of 64 MDCT coronary CTA and coronary angiography in the detection of coronary artery stenosis in low risk patients with stable angina and acute coronary syndrome]. / Comparaison du scanner 64-détecteurs et de la coronarographie dans la détection des sténoses coronariennes chez des patients porteurs d'angor stable et de syndrome coronaire aigu à bas risques.

PURPOSE: To determine the accuracy of 64 MDCT coronary CTA (CCTA) compared to coronary angiography in low risk patients with stable angina and acute coronary syndrome and determine the number of significant coronary artery stenoses ( 50%) in these patients. Materials and methods. Fifty-five patients underwent CCTA using a 32 MDCT unit with z flying focus allowing the acquisition of 64 slices of 0.6 mm thickness as well as coronary angiography (gold standard). Nine patients were excluded due to prior coronary artery bypass surgery (n=4), insufficient breath hold (n=3), calcium scoring>1000 (n=1) and delay between both examinations over 4 months (n=1). Forty-six patients: 27 males and 19 females were included. CCTA results were compared to coronary angiography per segment and artery with threshold detection of stenoses 50%. The degree of correlation between both examinations was performed using a regression analysis with a Pearson correlation coefficient<0.05 considered significant. RESULTS: The overall accuracy of CCTA was 90%; limitations related to the presence of calcifications, motion artifacts or insufficient vessel opacification. The correlation for all analyzed segments was 96.4%. Thirty-eight of 50 significant stenoses seen on coronary angiography were correctly detected on CCTA. Sensitivity, specificity, PPVC and NPV for detection of stenoses 50% were 76%, 98.3%, 80.3% and 97.7% respectively. Evaluation per segment had a NPV of 96.8% (interventricular and diagonal segments) to 100% (main trunk). CONCLUSION: Our results for specificity and NPV are similar to reports from the literature. This suggests that CCTA in this clinical setting may replace coronary angiography.

[Hot issues in bifurcation lesions PCI in 2019]. / Angioplastie des lésions coronaires de bifurcation en 2019 : questions brûlantes ?

Coronary bifurcations are involved in 15-20% of all percutaneous coronary interventions (PCI) and remain one of the most challenging lesions in interventional cardiology in terms of procedural success rate as well as long-term cardiac events. The optimal management of bifurcation lesions is still debated but involves careful assessment, planning and a sequential provisional approach. The preferential strategy for PCI of bifurcation lesions remains to use main vessel (MV) stenting with a proximal optimisation technique (POT) and provisional side branch (SB) stenting as a preferred approach. Final kissing balloon inflation is not recommended in all cases. In the minority of lesions where two stents are required, careful deployment and optimal expansion are essential to achieve a long-term result. Intracoronary imaging techniques (IVUS, OCT) and FFR are useful endovascular tools to achieve optimal results.

Severity of periodontal disease correlates to inflammatory systemic status and independently predicts the presence and angiographic extent of stable coronary artery disease.

BACKGROUND: Periodontal disease (PD) has been recognized as a risk factor for systemic diseases, but its involvement in the pathogenesis of coronary artery disease (CAD) remains debated. OBJECTIVES: We sought to evaluate the potential relations between severity of the PD, inflammatory response and angiographic lesions extent in patients with stable CAD. DESIGN: A total of 131 subjects referred to our centre for coronary angiography were evaluated for presence and extension of CAD, then divided into two groups, one with presence of lesions (cases, n = 85) and other one with absence of lesions (controls, n = 46). Mean periodontal pocket depth (PPkD), high sensitivity C reactive protein (hs-CRP), serum amyloid A protein (SAA) and fibrinogen levels were measured in all patients. RESULTS: Cases and controls did not differ according to their baseline characteristics and prevalence of traditional cardiovascular risk factors. PPkD was greater in patients with CAD than in controls (2.24 +/- 1.28 mm vs 1.50 +/- 0.93 mm, P < 0.001 by Student's t-test). Systemic inflammatory response was more pronounced in cases than in controls, with higher values of hs-CRP, SAA and fibrinogen. Furthermore, PPkD values correlated with hs-CRP (r = 0.80, P < 0.001), SAA (r = 0.71, P < 0.001), fibrinogen levels (r = 0.72, P < 0.001) and the American College of Cardiology/American Heart Association angiographic score (r = 0.68, P < 0.001) in cases. Multivariate analysis indicated a persistent independent correlation between PPkD and angiographic score after adjustment for inflammatory markers levels. CONCLUSION: In the present study, PD lesions predicted presence of CAD stenosis in patients with cardiovascular risk factors. PD severity was correlated to angiographic extent of coronary lesions, independent of systemic inflammatory status. Those results suggest that these patients might benefit from an intensive periodontal therapy to prevent CAD progression.

[Circulating endothelial microparticles: a new marker of vascular injury]. / Microparticules endothéliales circulantes: un nouveau marqueur du dysfonctionnement vasculaire.

Cell activation or apoptosis leads to plasma membrane blebbing and microparticles (MPs) release. MPs are submicron membrane vesicles expressing a panel of oxidized phospholipids and proteins specific of the cells they originate from. Exposure of negatively charged phospholipids and tissue factor confers a procoagulant potential to MPs. Increases in plasma MPs levels, particularly those of endothelial origin, reflects cellular injury and appears now as a surrogate marker of vascular dysfunction. MPs are also biologically active and stimulate pro-inflammatory responses in target cells. Thus, MPs can promote a prothrombogenic and pro-inflammatory vicious circle leading to vascular dysfunction. A better understanding of MPs composition, as well as their effects and the mechanisms leading to their clearance will likely open new therapeutic approaches in the treatment and the prognosis of cardiovascular diseases.

[Left atrial appendage occlusion in elderly]. / Fermeture d'auricule gauche percutanée chez le sujet âgé.

Left atrial appendage occlusion (LAAO) is an alternative option to oral anticoagulation therapy in patients with non-valvular atrial fibrillation. According to French regulations, this procedure is currently reserved for patients with formal contraindications to VKA and direct thrombin inhibitors. LAAO procedures reduce ischemic and stroke risks compared to no treatment and also reduce bleeding events compared to VKA therapy in eligible patients. The peri-procedural complications risk has been reported to be limited in the different series published so far. Although elderly patients (>75 years) have either higher ischemic and bleeding risk than younger subjects, they hardly benefit from optimal anticoagulation. Thus, these subjects might greatly benefit from LAAO. Published studies reported excellent feasibility and efficiency of LAAO procedure in elderly patients. Yet there is a trend towards a higher incidence of peri-procedural complications (including tamponade), long-term safety is excellent and comparable to what is observed in patients<75 years. Therefore, interventional percutaneous LAAO is an attractive strategy in elderly patients with atrial fibrillation that should be incorporated in a multidisciplinary management.

Fetal electrocardiotocography in labor and neonatal outcome: an observational study in 1889 patients in the French center of Edouard Herriot, Lyon.

BACKGROUND: The STAN methodology has been shown to reduce both operative delivery for fetal distress and the cord artery metabolic acidosis rate. OBJECTIVE: The objective of this study was to monitor delivery modes and perinatal outcomes following the introduction of the STAN methodology and the evolution of its use at our institution. METHODS: Two periods were characterized: June 2000-June 2002 (period 1) and July 2002-April 2005 (period 2). Parity, mode of labor and delivery, ST events, and neonatal outcome (Apgar score and pH of the umbilical cord artery and vein), cases of metabolic acidosis and operative delivery for fetal distress were studied. RESULTS: One thousand eight hundred and eighty-nine women were included in the study. The rate of use of STAN increased from 13.5% to 16% over these two time periods. The rate of metabolic acidosis was low: 0.28% and 0.45%, respectively. No cases of neonatal encephalopathy or of perinatal death were diagnosed. There was a decrease in the rate of operative delivery for fetal distress (163/701 (22.9%) vs. 228/1111 (20.3%), p = 0.26). CONCLUSIONS: According to the literature, our use of the STAN appears to be very successful; the metabolic acidosis rate was 0.38% and the rate of operative delivery for fetal distress decreased. We improved the accuracy of the interpretation of the fetal heart rate.

[Mitochondrial cardiomyopathy in an adult: a case history]. / Cardiomyopathie mitochondriale de l'adulte: à propos d'un cas.

We report an original case of mitochondrial cardiomyopathy discovered in a young woman during an episode of cardiac decompensation. The diagnosis was suspected from the echocardiographic appearances of granite-like heterogeneous hypertrophic cardiomyopathy. It was confirmed by endomyocardial biopsies. The clinical evolution was favourable with classical treatment. Mitochondrial cardiomyopathy is a rare cause of cardiomyopathy, generally observed in children, with multisystemic localisation. The pathophysiology and genetics are complex. Cardiac involvement is observed in 25% of cases, with the principal manifestation being hypertrophic cardiomyopathy. In the absence of any specific clinical or paraclinical signs, echocardiography and MRI are the techniques of choice for morphological evaluation. Diagnosis relies upon myocardial biopsy, which should be readily advocated in every unexplained case of cardiomyopathy in a young subject. The prognosis is poor and no specific treatment is available.

Intra-coronary thrombus evolution during acute coronary syndrome: regression assessment by serial optical coherence tomography analyses.

AIMS: We investigated the feasibility of thrombus quantification by frequency-domain optical coherence tomography (FD-OCT) methods in patients with highly thrombotic acute coronary syndrome (ACS) treated by deferred stenting strategy. METHODS AND RESULTS: Patients were suitable for inclusion if they presented (i) an ACS that was successfully revascularized by manual thrombo-aspiration and (ii) a large residual thrombus on coronary angiography and initial FD-OCT analysis. These patients underwent a second procedure including FD-OCT analysis after several days of optimal antithrombotic therapy. Serial area measurements within the athero-thrombotic culprit lesion were performed to evaluate the OCT-thrombus score, volume, and length. Sixteen patients (88% men/age = 59.3 ± 4.1 years/94% STEMI) were included in the study. The mean delay between OCT analyses was 3.9 ± 0.3 day. No adverse event was observed during this interval. We observed a reduction of thrombus burden between the two analyses, as assessed by the significant reductions in OCT-thrombus score (22.3 ± 2.6 vs. 10.3 ± 1.3, P < 0.001), OCT-thrombus volume (9.6 ± 2.3 vs. 3.6 ± 0.9 mm(3), P = 0.003), and OCT-thrombus length (11.1 ± 1.4 vs. 7.4 ± 0.8 mm, P = 0.01). The percentages of OCT-thrombus score and volume reduction were highly correlated with the inter-OCT analyses delay (respectively ρ = 0.65 and ρ = 0.84, P < 0.01 for both). CONCLUSION: FD-OCT assessment of thrombus volume in selected ACS patients is feasible, safe, and could allow clot regression monitoring in vivo.

[Efficacy of angioplasty of native coarctations of the aorta of the big infant and of the adult with systematic endoprosthesis implantation]. / Efficacité de l'angioplastie des coarctations natives de l'aorte du grand enfant et de l'adulte avec implantation systématique d'endoprothèse.

The angioplasty of native coarcatations of the aorta remains a controversial treatment due to recurrences and the potential risk of aneurysm or of descending aorta dissection during catheterization. The interest of a systematic implantation of an endoprothesis is poorly documented. We report our experience in a small series of 3 patients aged from 7, 28 to 52 years at the moment of the angioplasty of their native aortic coarctation. In all the three cases it corresponded to a "membranous" type, localized a the level of the isthmus without hypoplasia of the aortic arch. All presented a refractory hypertension. One patient presented an intermittent claudication related to a low perfusion of lower limbs. The angioplasty was performed with BIB balloon, associated at the same time with the implantation of a Palmaz P308 stent in two cases and Genesis PG2910P in the last patient. The efficacy was immediate in all the 3 cases with stopping antihypertensive drugs at the very day of the procedure. The immediate results were complicated by a bilateral hematoma of the scarpa in a context of excessive anticoagulation in one patient requiring blood tranfusion. After a follow-up of one, 12 and 21 months, all the 3 patients are asymptomatic without any significant residual hypertension. The control scan of the infant confirmed the absence of re-coarctation. In conclusion, the angioplasty followed by systematic implantation of an endoprosthesis is a safe and effective technique for treating simple forms of native coarctations of the aortic isthmus. It can be proposed as a first line treatment for big infants and adults affected by localized types.

[Results of the surgery of the truncus arteriosus: present implications]. / Résultats de la chirurgie du tronc artériel commun: implications actuelles.

We report our results of truncus arteriosus surgical reparation in a period of 10 years. From January 1993 to November 2003, 17 patients were operated with a median age and weight of 66 days and 3.5 kg respectively. According to the Van Praagh classification there were 13 cases of type A1, 2 cases of type A2 and 2 cases of A4. The connection between the right ventricle and the pulmonary artery was performed by a homograft (n = 12), a Contegra tube (n = 1) or a Barbero-Marcial intervention (n = 4). In one case, a plasty of the truncus was performed. Patients were classified in two groups: group A for those operated between 1993 and 1997 (n = 8) and group B for those operated after 1997 (n = 9). Five patients died (29%) in the post-operative period, 4 in the group A (50%) and one in group B (11%). The mean duration of intensive care stay was 12.2 (+ 7.4) days. Statistical analysis did not reveal any difference between both groups, especially concerning post-operative treatment or prognosis. In the multivariate analysis, an age below 30 days was a risk factor of post-operative death (OR = 16.5, 95% CI = 1.09 - 250; p = 0.043). After a mean follow-up of 3.9 (+ 3.5) years, 2 patients required a redo intervention for replacement of the pulmonary artery homograft. All 12 suvivors are asymptomatic without any pulmonary hypertension. In conclusion, the results of surgical reparation of the truncus arteriosus seem to improve with experience. According to recent progresses in surgery and intensive care, the intervention can be scheduled beyond the neonatal period without additive risk and with potentially less consecutive redo interventions.

Outcome of acute fulminant myocarditis in children.

OBJECTIVES: To highlight clinical features and outcome of acute fulminant myocarditis (AFM) in children. METHODS: Diagnostic criteria were (1) the presence of severe and acute heart failure; (2) left ventricular dysfunction on echocardiography; (3) recent history of viral illness; and (4) no history of cardiomyopathy. RESULTS: Eleven children were included between 1998 and 2003, at a median age of 1 (0 to 9) year. Their mean left ventricular ejection fraction (LVEF) was 22 (SD 9)% at presentation. A virus was identified in five patients: human parvovirus B19 (n = 2), Epstein-Barr (n = 1), varicella zoster (n = 1), and coxsackie (n = 1). The median intensive care unit course was 13 (2-34) days. Intravenous inotropic support was required by nine patients and eight were mechanically ventilated. All patients received corticosteroid, associated with intravenous immunoglobulin in seven. Five patients experienced cardiocirculatory arrest that was successfully resuscitated in four. At a median follow up of 58.7 (33.8-83.1) months, the 10 survivors are asymptomatic with normalised LVEF. CONCLUSION: Despite a severe presentation, the outcome of AFM is favourable. Aggressive symptomatic management is warranted and heart transplantation should be considered only when maximal supportive therapy does not lead to improvement.

In vivo and in vitro characterization of skeletal muscle metabolism in patients with statin-induced adverse effects.

OBJECTIVE: Statins (3-hydroxymethylglutaryl-coenzyme A reductase inhibitor) are widely used to treat hypercholesterolemia. They are generally well tolerated, but myotoxic effects have been reported and the corresponding mechanisms are still a matter of debate. The aim of the present study was to determine whether impairment of calcium homeostasis and/or mitochondrial impairment could account for the adverse effects of statins in skeletal muscle. METHODS: Eleven patients with increased creatine kinase levels and myalgias after statin treatment were evaluated using in vitro contracture tests (IVCTs), histology, and 31P magnetic resonance spectroscopy (31P-MRS). RESULTS: IVCT results were abnormal in 7 of the 9 patients, indicating an impaired calcium homeostasis. The 31P-MRS investigation disclosed no anomaly at rest, and the aerobic function assessed during the postexercise recovery period was normal. On the contrary, the pH recovery kinetics was significantly slowed down as indicated by a reduced proton efflux, which could be ultimately linked to a failure of calcium homeostasis. Overall, our observations indicate a normal mitochondrial function and raise the possibility that statins may unmask a latent pathology involving an impairment of calcium homeostasis such as malignant hyperthermia (MH). CONCLUSION: In case of susceptibility to MH, statins treatment must be administered with caution, and signs of adverse effects should be checked.

Hypoplastic coronary artery disease: report of one case.

Hypoplastic coronary artery disease (HCAD) is a rare abnormality with a high rate of sudden death and poor outcome. HCAD was revealed by myocardial infarction in a teenager with objective evidence of silent ischaemia on myocardial scintigraphy. After four years of follow up, he suddenly collapsed during exercise and subsequently died. Although HCAD is very uncommon, it should be actively excluded in children and young adults who experience sudden cardiac death. Aggressive treatment such as implantable cardioverter-defibrillator or heart transplantation may be indicated for this rare coronary abnormality.

Lipid-altering efficacy of switching from atorvastatin 10 mg/day to ezetimibe/simvastatin 10/20 mg/day compared to doubling the dose of atorvastatin in hypercholesterolaemic patients with atherosclerosis or coronary heart disease.

This randomised, double-blind study evaluated the efficacy and safety of ezetimibe/simvastatin (EZE/SIMVA) 10/20 mg tablet compared to doubling the atorvastatin (ATV) dose in hypercholesterolaemic patients with atherosclerotic or coronary heart disease (CHD). The study group included 435 male and female CHD patients (aged >or=18 years) who had not achieved their low-density lipoprotein cholesterol (LDL-C) goal of <2.50 mmol/l while on a stable dose of ATV 10 mg for >or=6 weeks. After a 1-week diet/stabilisation period, patients with LDL-C >or=2.50 mmol/l and