Immediate coronary angiography in survivors of out-of-hospital cardiac arrest without obvious extracardiac cause: Who benefits?

BACKGROUND: Immediate coronary angiography (iCA) and primary percutaneous coronary angioplasty (pPCI) in patients successfully resuscitated after out-of-hospital cardiac arrest (OHCA) of suspected cardiac cause is controversial. Our aims were to assess the results of iCA, the prognostic impact of pPCI after OHCA, and to identify subgroups most likely to benefit from this strategy. METHODS: In this single-centre retrospective study, patients aged ≥18 years with sustained return of spontaneous circulation after OHCA and no evidence of a non-cardiac cause underwent routine iCA at admission, with pPCI if indicated. Results of iCA, and factors associated with in-hospital survival were analysed. RESULTS: Between 2006 and 2013, 160 survivors from OHCA presumed of cardiac origin were included (median age, 60 years; 85% males). iCA showed significant coronary-artery lesions in 75% of patients, and acute occlusion or unstable lesion in only 41%. pPCI was performed in 34% of patients and was not associated with survival by univariate or multivariate analysis (P=0.67). ST-segment elevation predicted acute coronary occlusion in 40%. An initial shockable rhythm was associated with higher in-hospital survival (52% vs. 19%; P<0.001). After initial defibrillation, the first rhythm recorded by 12-lead electrocardiography was highly associated with prognosis: secondary asystole had a very low survival rate (5%, 1/21) despite PCI in 43% of patients, compared to sustained ventricular tachycardia/fibrillation (42%, 15/36) and supraventricular rhythm (71%, 50/70) (P<0.001). CONCLUSIONS: In our experience, the prevalence of acute coronary occlusion or unstable lesion immediately after OHCA of likely cardiac cause is only 41%. Immediate CA in OHCA survivors, with pPCI if indicated, should be restricted to highly selected patients.

[Complicated transcatheter aortic-valve endocarditis with abscess and pseudoaneurysm: Value of the ECG-gated multidetector computed tomography angiography]. / Endocardite infectieuse sur TAVI compliqué d'abcès et pseudo-anévrysme : apport du scanner cardiaque synchronisé à l'ECG.

A 80-year-old man was admitted to catheterization room for an acute infero-lateral ST-elevation myocardial infarction (STEMI). Coronary angiography showed a thrombotic occlusion of the second left marginal branch, and normal other coronary arteries. The thrombo-embolic mechanism of the STEMI, and the infectious context in this patient who had had a transcatheter aortic valve implantation (TAVI) two months earlier, led us to suspect a bioprosthesis endocarditis. It was confirmed by transthoracic and transoesophageal echocardiography, which showed an aortic-mitral curtain abscess and aortic bioprosthesis vegetations, associated to Enterococcus faecalis bacteriemia. In order to specify the diagnosis, an ECG-gated multidetector CT angiography (MDCTA) had been performed. Additionally to echocardiographic findings, MDCTA showed a pseudo-aneurysm, sized 20 to 22mm, beginning from the outflow tract of the left ventricle to end on the antero-lateral face of the aorta. The patient was referred for emergency aortic bioprosthesis removal and replacement. Through this case, MDCTA showed its importance for the diagnosis and the prognostic evaluation of cardiac prosthesis endocarditis. MDCTA provided additional informations that echocardiography could not detect, because of artifacts caused by the prosthetic material and calcifications, frequent in elderly patients with comorbidities.

Assessment of global longitudinal strain at low-dose anthracycline-based chemotherapy for the prediction of subsequent cardiotoxicity.

OBJECTIVES: The aim of this study was to assess whether global longitudinal strain (GLS) measured early during treatment with anthracycline (at a cumulative dose of 150mg/m2) can predict subsequent alterations in left ventricular ejection fraction (LVEF). METHODS AND RESULTS: Eighty-six patients suffering from Hodgkin's disease, non-Hodgkin's lymphoma or acute leukemia and receiving anthracyclines were prospectively included. They underwent complete echocardiography on four separate occasions: baseline (V1); after reaching a cumulative dose of 150mg/m2 (V2); end of treatment (V3); one year follow-up (V4). Six patients developed cardiotoxicity defined by a decrease in LVEF by more than 10 percentage points to a value of at least less than 53% at V4. Both GLS measured at V1 and at V2 were significantly lower in the cardiotoxicity group compared with the control group (P=0.042 and P=0.01, respectively). Compared to GLS at V1, GLS obtained at V2 provided implemental predictive information and appeared to be the strongest predictor of cardiotoxicity (area under the receiver operating characteristic curve, 0.823). At a threshold of -17.45% for GLS measured at V2, the sensitivity and specificity of detecting cardiotoxicity were 67% (95%CI: [33-100%]) and 97% (95%CI: [94-100%]) respectively. CONCLUSION: GLS>-17.45%, obtained after 150mg/m2 of anthracycline therapy, is a significant predictor of future anthracycline-induced cardiotoxicity. This study should encourage physicians to perform echocardiography earlier during treatment with anthracyclines.

[Intracoronary administration of antithrombotic agents via a perfusion balloon catheter in patients with ST-segment elevation myocardial infarction presenting with massive intraluminal thrombus and failed aspiration]. / Apport de l'administration intracoronaire d'antithrombotiques par cathéter à ballon de perfusion en phase aiguë d'infarctus du myocarde avec thrombus massif et échec de la thromboaspiration.

BACKGROUND: Massive intracoronary thrombus is associated with adverse procedural results including failed aspiration and unfavourable reperfusion. We aim to evaluate the effect of the intracoronary administration of antithrombotic agents via a perfusion catheter in patients with ST-segment elevation myocardial infarction (STEMI) presenting with a large thrombus burden and failed aspiration. METHODS: We retrospectively analyzed the thrombus burden, the TIMI grade flow, and the myocardial Blush in 25 consecutive STEMI patients with a large thrombus burden and failed manual aspiration, who received intracoronary infusion of glycoprotein IIb/IIIa inhibitors (N=17) or bivalirudine (N=8) via a 6F-infusion catheter (ClearWay™ RX) RESULTS: Mean age was 67±14 years, 16 patients (64 %) presented with anterior STEMI, and 7 (28 %) with cardiogenic shock. Immediately after intracoronary infusion, the TIMI flow grade improved of 2 grades in 7 patients (28 %), and 1 grade in 14 (56 %), a complete resolution of the thrombus was observed in 9 patients, and a >50 % resolution in 12. Blush was improved of 3 grades in 15 patients (60 %), of 2 grades in 7 (28 %), and Blush grade 0 remained in 3. At the end of procedure, we observed normal TIMI 3flow in most patients (92 %), a complete resolution of thrombus in 80 %, and a Blush grade 3 in 68 %. CONCLUSIONS: In STEMI patients presenting with a large thrombus burden and failed aspiration, intracoronary administration of glycoprotein IIb/IIIa inhibitors or bivalirudin via the perfusion catheter ClearWay™ RX significantly reduced the thrombus burden and improved the TIMI flow and the Blush grade, without bleeding.

[Coronary stent evaluation with cardiac CT: Literature review]. / Évaluation des stents coronaires en scanner cardiaque: revue de la littérature.

Since the introduction of the 64-generation scanners, the accuracy and robustness of the diagnosis of coronary artery disease has progressed. The main advantage of cardiac CT is the exclusion of coronary artery disease by its excellent negative predictive value. Currently, cardiac CT applications extend thanks to innovations both in terms of technological development systems scanner or stents implanted. This is a literature review of stent evaluation with cardiac CT.

Establishment of diagnostic reference levels in cardiac CT in France: a need for patient dose optimisation.

The objective of this study was to propose diagnostic reference levels (DRLs) for coronary computed tomography angiography (CCTA), in the context of a large variability in patient radiation dose, and the lack of European recommendations. Volume Computed Tomography Dose Index (CTDIvol) and dose-length product (DLP) were collected from 460 CCTAs performed over a 3-month period at eight French hospitals. CCTAs (∼50 per centre) were performed using the routine protocols of the centres, and 64- to 320-detector CT scanners. ECG gating was prospective (n = 199) or retrospective (n = 261). The large gap in dose between these two modes required to propose specific DRLs: 26 and 44 mGy for CTDIvol, and 370 and 970 mGy cm for DLP, respectively. This study confirms the large variability in patient doses during CCTA and underlines the need for the optimisation of cardiac acquisition protocols. Availability of national DRLs should be mandatory in this setting.

[Usefulness of transesophageal echocardiography to optimize treatment after ischemic stroke]. / Intérêt de l'échocardiographie trans-œsophagienne dans l'optimisation de la stratégie thérapeutique après un accident vasculaire cérébral ischémique.

AIM OF THE STUDY: In the setting of ischemic stroke, the place of transesophageal echocardiography (TEE) is still matter of debate. The aim of the study is to evaluate the therapeutic impact provided by TEE and to characterize patients in whom TEE is warranted. PATIENTS AND METHOD: Three hundred and fifty-nine consecutive patients were included in the study. "Decisive TEE" (DTEE) was defined by echographic findings resulting in a change of treatment, whereas "informative TEE" (ITEE) was defined by TEE revealing a potential cardiac or aortic source of embolism. RESULTS: Three hundred and forty-one patients underwent TEE. Twenty-eight patients (8.2%) had DTEE and 184 (53.9%) had ITEE. DTEE were as follows: thrombus in the left atrial appendage in 6 patients, complex aortic plaques in 10 patients, patent foramen ovale (PFO) associated with atrial septal aneurism (ASA) and an important right to left shunt (3 patients), FOP associated with ASA and lower limb phlebitis (1 patient), 4 cases of endocarditis and 4 patients with intense spontaneous echo contrast in the left atrium. In most cases of DTEE (67.8%), the patient was given anticoagulation drugs. Left atrial dilatation (P=0.005) and multivessel territory stroke (P=0.018) were statistically predictive of DTEE. CONCLUSIONS: In the setting of ischemic stroke, TEE provides important additional informations, but modifies therapeutic strategy in less than 10% of cases. Multivessel territory stroke, and left atrial dilatation were predictive of DTEE.

[Undifferentiated sarcoma: usefulness of multimodality cardiac imaging in characterizing a rare intracardiac mass]. / Sarcome cardiaque indifférencié : intérêt de l'imagerie multimodale dans la caractérisation d'une masse intracardiaque.

We report the case of a man presenting with a Pierre Marie-Bamberger syndrome. This paraneoplastic syndrome revealed an undifferentiated intracardiac sarcoma. This case emphasizes the need for multimodality imaging to characterize intracardiac tumor.

[Evaluation of a selective strategy for glycoprotein IIb/IIIa inhibitors administration in non-ST segment elevation acute coronary syndromes]. / Évaluation d'une stratégie sélective de prescription des antagonistes de la glycoprotéine IIb/IIIa dans les syndromes coronariens aigus sans sus-décalage du segment ST.

AIMS: We evaluated the impact of a selective strategy for glycoprotein IIb/IIIa inhibitors administration in non ST-segment elevation acute coronary syndrome. PATIENTS AND METHOD: Between February 1st, 2007, and February 1st, 2009, 331 consecutive patients were prospectively included in the study. Criteria for upstream glycoprotein IIb/IIIa inhibitors administration were as follows: transient ST elevation greater than 1mm, ST-segment depression greater than 2mm, ischemic recurrence, TIMI risk score greater than 5. Global mortality and cardiovascular outcomes were assessed at Day 7 and Day 30. RESULTS: The overall use of glycoprotein IIb/IIIa inhibitors was 16%. The procedure was successfully applied in 98%. Compared with non eligible patients (group 1, n = 254), eligible patients (group 2, n = 77) had a higher risk profile, median age: 73 versus 66, p < 0.01, TIMI risk score: 4 versus 3, p < 0.001. Eligible patients (66%) actually received the treatment. Among the 26 eligible but untreated patients, 19% had major bleeding risk, 34% had an unfavourable risk-benefit ratio and 34% were not suitable for an invasive strategy. Cardiovascular events occurred in 5.1% at Day 7 (Group 1, 1.6%), and 6.0% at Day 30 (group 1, 2.4%). Overall mortality at Day 30 was 1.2% (0.4% in Group 1). CONCLUSION: A strategy for glycoprotein IIb/IIIa inhibitors administration in non ST-segment elevation acute coronary syndrome restricted to 4 very high risk situations may be considered, without evidence for a loss of chance in intermediate risk patients, untreated although eligible for treatment according to the current guidelines.