Characteristics and prognosis of patients with angiographic stent thrombosis: comparison between drug-eluting and bare-metal stents.

INTRODUCTION: Conflicting data exist on the risk of stent thrombosis with drug-eluting stents (DES) versus bare-metal stents (BMS). Little is known about the potential different characteristics and outcomes of DES versus BMS thrombosis. OBJECTIVE: To compare the characteristics, timing and outcomes of patients with angiographic stent thrombosis according to type of stent implanted. METHODS: The population comprised consecutive patients who underwent BMS or DES implantation (January 2003-April 2007) at Pitié-Salpêtrière Hospital. Data from patients with and without a stent thrombosis were compared to identify predictors of thrombosis. Timing of thrombosis (acute,<24 hours; subacute,<30 days; late,>30 days; very late,>1 year), clinical, angiographic and procedural characteristics, and outcomes were compared between patients with a BMS or DES thrombosis. RESULTS: A total of 3579 patients received a BMS (2815 lesions, 2318 patients) or a DES (1536 lesions, 1261 patients). Documented angiographic stent thrombosis occurred in 52 (1.4%) patients, 16 (1.3%) with a DES and 36 (1.6%) with a BMS. Rates of acute (0.1% versus 0.2%), subacute (1% versus 0.7%), late (both 0.2%) and very late (both 0.2%) thrombosis were similar in patients with BMS and DES thrombosis. Factors predictive of stent thrombosis were similar, including left ventricular failure (P<0.0001), initial percutaneous coronary intervention (PCI) for acute myocardial infarction (P<0.0001), multivessel PCI (P<0.0001), and balloon dilatation before stenting (P<0.04). Eleven (21%) cases of BMS (n=8, 22%) or DES (n=3, 19%) thrombosis arose soon after stopping antiplatelet therapy. Thirteen of 52 (25%) patients died a few hours after the event. Twenty-seven (52%) major adverse cardiac events occurred at 18 months, 7 in patients with a DES and 20 in those with a BMS (44% versus 55%, P=NS). These included 16 deaths (31%), 7 repeat PCIs and 4 myocardial infarctions. There were no independent predictive factors of death after stent thrombosis. CONCLUSIONS: BMS and DES thrombosis are similar in terms of timing of thrombosis, characteristics and outcomes, and share the same risk of late thrombosis after interruption of antiplatelet therapy.

[Absence of nephro-protective effect of acetylcysteine in patients with chronic renal failure investigated by coronary angiography]. / Absence d'effet néphroprotecteur de l'acetylcystéine chez les patients avec insuffisance rénale chronique explorés par coronarographie.

Recent studies have suggested that an oral dose of acetylcysteine could play a prophylactic role in the prevention of nephrotoxicity from iodine contrast media in patients affected by chronic renal failure. Between June 2001 and September 2002 we selected 120 patients with a basal plasma creatinine level greater than 1.36 mg/dl investigated by coronary angiography. The treatment group included 60 patients who received 600 mg of acetylcysteine in the morning and evening before the day of the examination together with intravenous saline hydration. The control group patients received hydration alone. The clinical characteristics of the groups were comparable as well as the basal plasma creatinine level: 2.01+/-1.1 mg/dl in the acetylcysteine group and 1.81+/-0.69 in the control group. The plasma creatinine level was measured 24 and 48 hours after coronary angiography. The respective changes in plasma creatinine level at 24 and 48 hours were 0.12+/-0.29 and 0.02+/-0.29 mg/dl in the acetylcysteine group and 0.06+/-0.29 and 0.07+/-0.43 mg/dl in the control group (NS). Acute renal failure caused by the contrast medium, defined by an increase of 25% in the plasma creatinine level compared to the basal value, occurred in 3 patients from the acetylcysteine group and 2 patients from the control group. The only predictive factor for acute renal failure was the quantity of contrast medium (316+/-141 vs 173+/-115 ml, p<0.05). In conclusion, acute renal failure caused by contrast medium is rare in sufficiently hydrated patients with moderate chronic renal failure when a low dose of contrast medium is used. Our study does not confirm a prophylactic effect of acetylcysteine in the prevention of nephrotoxicity from contrast media following coronary angiography in patients with moderate chronic renal failure.

[Value of combined coronary angioplasty and coronary angiography]. / Intérêt de l'angioplastie coronaire dans le même temps que la coronarographie.

Combined coronary angioplasty and coronary angiography is performed in most catheter laboratories and has become a routine procedure. The aim of this study was to assess its clinical results and economic value. This was a retrospective monocenter study performed over an 11 year period (1990-2000) which included 2,727 patients requiring coronary angioplasty after coronary angiography. The angioplasty procedure was performed at the same time as angiography (combined, n = 1,809) or after angiography (deferred, n = 631). Patients admitted for acute coronary syndromes not stabilised by pharmacological interventions were excluded from the study. The comparison of these two modes of angioplasty was based on primary success rates, complications, duration of hospital stay and hospital costs. The combined procedure was used progressively more frequently over the study period, increasing from 54% to 88% in 2000. The hospital clinical results (Success and complication rates) were comparable in the two groups. The predictive factors of failure were the year of the angioplasty procedure and occlusive lesions on multivariate analysis. The combined procedure was associated with a shorter hospital stay than deferred angioplasty (8.2 +/- 6.1 days versus 15.0 +/- 8.0 days, p = 0.0001) and with lower costs. The authors conclude that combined coronary angiography-angioplasty is as effective and as safe as deferred angioplasty. It is associated with a shorter hospital stay and lower hospital costs.

[New techniques of interventional cardiology]. / Nouvelles techniques de cardiologie interventionnelle.

Balloon coronary angioplasty for coronary stenosis has a success rate of over 90%, but secondary restenosis occurs in 30 to 40% of the patients. In addition, long calcified, ulcerated and distal lesions cannot be treated with the balloon technique. New techniques are thus needed and are currently under clinical evaluation. Stents are metallic meshes designed as vascular prostheses to maintain the arterial lumen open. Currently, stents are indicated in case of acute coronary occlusion during the angioplasty procedure and more rarely in case of elastic recoil after dilatation. First intention stents can reduce the rate of restenosis by about one-fourth, although use is limited due to the risk of thrombosis. The rotablator has a fine elliptoid tip which rotates at 180,000 rpm. When inserted into the area of stenosis, the rotablator attacks preferentially hard resistant material and is thus indicated for calcified lesions. It should not be used in large arteries or if a thrombus is visible on the angiography. Primary success rate is 95% and recoil does not exceed 5%. But this method still is not the final solution since the rate of restenosis is 44%, and even 54% for calcified lesions. In directional arthrectomy the tip of the catheter carries a metal cylinder with a lateral window which can be positioned on the lesion. Atheromatous material is then cut off with a rotating knife and trapped in the catheter's reservoir. This new system gives results which are currently similar to those for conventional angioplasty. The potential role of transluminal laser atherectomy, an effective but costly technique, is yet to be established. These new devices offer great potential, but their impact will depend to a great extent on the experience of the cardiology team and must be evaluated in comparison with the results of the classical balloon angioplasty.

[Coronary angioplasty, a privileged method of myocardial revascularization of the elderly]. / L'angioplastie coronaire, méthode privilégiée de revascularisation myocardique du sujet âgé.

Coronary angioplasty is a myocardial revascularisation technique of choice in the elderly, avoiding the need for general anesthesia as well as the complications of thoracotomy and extracorporeal circulation. Used in a continuous series of 62 patients, it provided a 79% primary success rate in this situation, where reaching the coronary artery and penetrating the stenosis may be difficult. Femoral complications (hematoma, false aneurysm) are commoner in this age group, but appear to be beneficially influenced by the replacement of heparin by ticlopidine peri-operatively. With 24 months follow-up, the proportion of patients free of any major cardiac event and NYHA classes I and II is 66%, actuarial survival rate without infarction is 76%. These results would tend to restrict the indications for bypass after the age of 75 to cases of stenosis of the left main coronary artery, failure of angioplasty or multi-vessel atheroma with a "culprit lesion" inaccessible to dilatation.

[Third angioplasty, and after that?]. / La troisième angioplastie, et après?

The authors studied retrospectively a series of 39 patients with a documented second restenosis after coronary angioplasty between January 1987 and November 1992, 33 of whom (31 men, 2 women) underwent a third procedure. The artery dilated was the left anterior descending (n = 17 including 9 proximal stenoses), the right coronary (n = 10), the left circumflex or its branches (n = 5) and the left main stem (n = 1). The lesions were confirmed to one vessel in 25 cases (75%) and affected two vessels in 8 cases (25%). The third angioplasty procedure was performed on a single artery in all cases. The average left ventricular ejection fraction was 60% (43%-75%). The diameter of the dilated artery was over 3.25 mm in 24% of cases (8/33). The primary success rate was 100% without any complications. The average period between the first and second angioplasties was 16 +/- 10 weeks, and between the second and third angioplasties 19 +/- 12 weeks. Angioplastic controls of the 3rd angioplasty were performed in 25 cases (75%). A third restenosis (n = 7) was treated by surgical bypass (n = 1), repeat angioplasty (n = 4), endocoronary stenting (n = 1) or medically (n = 1), with a global follow-up of 22 months (2-56 months), 2 patients underwent coronary bypass grafting, 2 have residual angina (contralateral lesion which could not be dilated), 1 had an infarct in the territory of an undilated artery, and 28 (85%) were asymptomatic. The restenosis rate after the third angioplasty procedure was 28% (7/25).(ABSTRACT TRUNCATED AT 250 WORDS)

[Dysfunction of aortocoronary bypass. Prognosis]. / Dysfonction des pontages aorto-coronaires. Etude pronostique.

From 1978 to 1988, 108 patients with at least one occluded or stenosed aorto-coronary bypass graft (over 75% stenosis) underwent coronary angiography on average 31 months after the initial coronary bypass surgery. The occluded or stenosed coronary graft was either a saphenous vein (n = 126 including 9 sequentials) or internal mammary artery (n = 5). The bypassed artery was the left anterior descending (n = 66), right coronary (n = 40), left marginal (n = 25) or diagonal (n = 9). The number of occluded or stenosed grafts by patient was 1.2. The left ventricular ejection fraction was 55% (range 25 to 77%). During a mean follow-up period of 60 months after coronary angiography, there were 14 cardiac deaths and 15 non-lethal myocardial infarctions. Treatment comprised 12 angioplasties, 26 new bypass grafts and 3 cardiac transplantations. The 8 year actuarial survival was 84%. The survival without infarction at 8 years was 69%. Survival was significantly decreased to 72% when the occluded or stenosed graft was located on the left anterior descending artery. The survival without infarction at 8 years was 52% in the patients with dysfunction of left anterior descending artery grafts and 89% when the diseased graft was located on another artery (right coronary, left marginal, diagonal). Therefore, the data of this retrospective study show that coronary graft dysfunction on the right coronary, left marginal or diagonal arteries do not greatly influence life expectancy in the medium term after coronary bypass surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Congenital mitral and tricuspid double stenosis]. / Double sténose tricuspide et mitrale congénitale.

The authors report the case of a child followed up from the age of 4 months to the age of 15 for asymptomatic congenital heart disease. Initial clinical examination showed the presence of a systolic murmur and a diastolic rumble in the xiphoid area with signs of right atrial dilatation-hypertrophy. During follow-up, an apical diastolic rumble was detected with left atrial dilatation from the age of 3. Doppler echocardiography carried out recently showed double mitral and tricuspid valve stenosis with two-dimensional appearances of doming of both valves and moderate transvalvular pressure gradients with slight elevation of pulmonary artery pressures on the Doppler study. The very early detection of the malformation and the continuous follow-up of this patient indicate the congenital and not rheumatic origin of this double valve stenosis.

[Dental pain and cardiac pain]. / Douleurs dentaires et douleurs cardiaques.

Some aching troubles encountered in heart disease can affect the jaw and patients can visit a dentist for this reason. The severity of this affection needs a quick diagnostic for preserving the patient's life.

[Pericarditis and pulmonary embolism. A difficult differential diagnosis and a confusing association]. / Péricardite et embolie pulmonaire. Un diagnostic différentiel difficile, une association déroutante.

The association of pericarditis and pulmonary embolism may be the source of diagnostic error and delay in the administration of anticoagulant therapy. Two cases are reported. Pericarditis occurred late in patients with severe, chronic pulmonary embolism with electrocardiographic changes of acute cor pulmonale. Two physiopathological mechanisms for this association have been proposed. The first, haemodynamic, suggests friction between the pericardium and distended right ventricle and pulmonary artery. The second, an immunological hypothesis, compares the association of pericarditis and pulmonary embolism to that of the Dressler syndrome after myocardial infarction. This assimilation would imply the constitution of an anatomical pulmonary infarction. It is not justifiable to accept this pathogenesis on the evidence of transient pulmonary opacities resulting from intra-alveolar haemorrhage or of linear opacities of pulmonary atelectasis secondary to hypocapnic pneumoconstriction which are radiological signs of anatomo-physiological stages of pre-infarction.