[Percutaneous closure of left atrial appendage: a new hope for patients with atrial fibrillation?]. / Fermeture percutanée de l'auricule gauche: un nouvel espoir pour le patient en fibrillation auriculaire?

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The risk of thromboembolic events is important, and at that time, there is no definite treatment for AF. Oral anticoagulation also represents a hemorrhagic risk factor. Ninety percent of atrial thrombi are located within the left atrial appendage. The percutaneous closure of this left atrial appendage with a device has been shown to decrease thromboembolic events even after interruption of oral anticoagulation as compared to warfarin in a recent randomized study. Recent data support this innovative technique as a reasonable alternative to long term anticoagulation in patients at high risk of bleeding.

Use of brain natriuretic peptide to detect previously unknown left ventricular dysfunction in patients with acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: Up to 30% of patients with chronic obstructive pulmonary disease (COPD) simultaneously suffer from often-unrecognised chronic heart failure (HF). Their timely identification is challenging as both conditions share similar clinical presentations. OBJECTIVE: To assess the performance of BNP in detecting left ventricular systolic dysfunction in patients with no history of HF admitted for acute exacerbation of COPD in a regional second-care hospital. METHODS: Retrospective medical records analysis of all patients hospitalised between January 2003 and May 2009 with the final diagnosis of acute exacerbation of COPD, and who had undergone BNP dosage at admission followed by an echocardiography. RESULTS: Among the 57 patients included, 13 had left ventricular systolic dysfunction. There was a statistically significant difference of mean BNP values between patients with or without systolic dysfunction (mean 689 pg/ml vs. 340 pg/ml, p = 0.007). For the detection of systolic dysfunction, a BNP level inferior to 100 pg/ml yielded a sensitivity of 92% and a negative predictive value of 91%, whereas BNP higher than 500 yielded a sensitivity of 80% and a positive predictive value of 47%. In a multivariate logistic regression analysis, a BNP value ≥500 (odds ratio 8.5, 95% confidence interval 1.9 to 38.2, p = 0.005) and history of coronary heart disease (odds ratio 5.9, 95% confidence interval 1.01 to 34.7, p = 0.048) remained as independent and mutually adjusted predictors of left ventricular systolic dysfunction. CONCLUSIONS: Our study confirms that BNP can help physicians in identifying heart failure in patients suffering from an acute exacerbation of COPD.

[The role of biomarkers in the evaluation of the patient with dyspnea, chest pain or syncope]. / Utilisation des biomarqueurs chez le patient avec dyspnée, douleur thoracique ou syncope.

This paper reviews the use of 3 biomarkers, BNP (brain natriuretic peptide), troponins and D-dimers, in 3 common clinical situations: the patient presenting with dyspnea, with chest pain or with syncope. The diagnostic utility and the pronostic implications of a positive as well as a negative test are reviewed according the most recent medical literature. Interpretation of false positive and false negative results is also discussed. Familiarity with the use of these tests is increasingly important because practicioners will be soon provided with rapid bed-side multi-markers assays to help them in their differential diagnosis while examining the patient.

[The perioperative period: how drugs should be managed?]. / Médicaments en période périopératoire, que faire?

Medication use during the perioperative period can raise problems in surgical patients. Elderly patients are especially at risk because of polymedication. Risks pertaining to each drug should be carefully evaluated. For example, several drugs can affect coagulation and discontinuation of others can lead to withdrawal symptoms. We suggest here recommendations based on recent publications. It should be kept in mind that, apart from the drug itself, the patient status as well as the surgical procedure also influence the decision to stop or continue a medication. Moreover, it is important to plan to restart any discontinued drug in order to avoid unintended treatment failure after hospital discharge.

Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction.

Recent clinical data show that the risk of coronary thrombosis after antiplatelet drugs withdrawal is much higher than that of surgical bleeding if they are continued. In secondary prevention, aspirin is a lifelong therapy and should never be stopped. Clopidogrel is regarded as mandatory until the coronary stents are fully endothelialized, which takes 3 months for bare metal stents, but up to 1 yr for drug-eluting stents. Therefore, interruption of antiplatelet therapy 10 days before surgery should be revised. After reviewing the data on the use of antiplatelet drugs in cardiology and in surgery, we propose an algorithm for the management of patients, based on the risk of myocardial ischaemia and death compared with that of bleeding, for different types of surgery. Even if large prospective studies with a high degree of evidence are still lacking on different antiplatelet regimens during non-cardiac surgery, we propose that, apart from low coronary risk situations, patients on antiplatelet drugs should continue their treatment throughout surgery, except when bleeding might occur in a closed space. A therapeutic bridge with shorter-acting antiplatelet drugs may be considered.

Localization and quantification of mitral valve prolapse using three-dimensional echocardiography.

AIMS: Mitral valve prolapse is a common source of severe mitral regurgitation in Western countries. Three-dimensional echocardiography can provide views of the entire valve, allowing a complete assessment of the valve leaflets and commissures. It has the potential to precisely locate and quantify mitral valve prolapse. METHODS AND RESULTS: Between January 1997 and December 2000, 91 patients with severe mitral regurgitation due to mitral valve prolapse underwent a transesophageal echocardiography with three-dimensional reconstruction of the mitral valve as part of their pre-operative work-up. The location and extent of the prolapse by echo was compared to the surgical status. The volume of prolapsing leaflet was calculated and compared to the volume of resected tissue whenever a repair was attempted. There was an excellent correspondence between the echographic localization of the prolapse and surgical inspection, and between the volume of prolapsing and surgically resected tissue (r=0.94, p<0.0001). CONCLUSIONS: In patients with severe mitral regurgitation due to mitral valve prolapse, 3D echo allowed a precise localization and an accurate quantification of the prolapsing portion of the leaflets. This technique can provide refinements in the surgical planning of mitral valve repair and in the selection of candidates for this intervention.

Fatal myocardial infarction after lung resection in a patient with prophylactic preoperative coronary stenting.

In this report we present the case of a 77-yr-old man who underwent resection of the upper lobe of the left lung for a carcinoma, six weeks after percutaneous transluminal coronary angioplasty (PTCA) with stenting of the left anterior descending (LAD) and circumflex coronary arteries. Antiplatelet therapy with clopidogrel was interrupted two weeks before surgery to allow for epidural catheter placement and to minimize haemorrhage. The surgical procedure was uneventful. In the immediate postoperative period, however, the patient suffered severe myocardial ischaemia. Emergency coronary angiography showed complete thrombotic occlusion of the LAD stent. In spite of successful recanalization, reinfarction occurred and the patient died in cardiogenic shock. Prophylactic preoperative coronary stenting may put the patient at risk of stent thrombosis if surgery cannot be postponed for three months. In such cases, other strategies such as perioperative beta-blockade for preoperative cardiac management should be considered.

[Patent foramen ovale and stroke]. / Foramen ovale perméable et accident vasculaire cérébral.

About a quarter of the adult population is known to have a patent foramen ovale, rarely accompanied by the presence of an interatrial septal aneurysm. A patent foramen ovale is found in more than 40% of patients younger than 60 years who had a cryptogenic ischemic stroke. Clinical and echocardiographic parameters allow the identification of patients at high risk of recurrence after a first cryptogenic stroke even if treated with Aspirin. A multidisciplinary approach allow the selected patients to benefit of a correction of their cardiac anomaly with promising long term results.

Intrapericardial urokinase irrigation and systemic corticosteroids: an alternative to pericardectomy for persistent fibrino-purulent pericarditis.

A 39-year-old man was admitted for upper abdominal pain and shortness of breath. The chest roentgenogram demonstrated cardiomegaly and left lower lobe atelectasis. Echocardiography showed circumferential pericardial effusion with signs of cardiac tamponade. Pericardial biopsy and fluid analysis were consistent with fibrino-purulent pericarditis. Despite broad-spectrum antibiotics, percutaneous and subsequently surgical drainage, pericardial effusion and tamponade recurred. We report successful treatment of a non-resolving fibrino-purulent pericardial effusion by combined intrapericardial irrigation of fibrinolytics and systemic corticosteroids administration as an alternative to pericardectomy.

Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery.

The increasing number of patients with coronary artery disease undergoing major non-cardiac surgery justifies guidelines concerning preoperative evaluation, stress testing, coronary angiography, and revascularization. A review of the recent literature shows that stress testing should be limited to patients with suspicion of a myocardium at risk of ischaemia, and coronary angiography to situations where revascularization can improve long-term survival. Recent data have shown that any event in the coronary circulation, be it new ischaemia, infarction, or revascularization, induces a high-risk period of 6 weeks, and an intermediate-risk period of 3 months. A 3-month minimum delay is therefore indicated before performing non-cardiac surgery after myocardial infarction or revascularization. However, this delay may be too long if an urgent surgical procedure is requested, as for instance with rapidly spreading tumours, impending aneurysm rupture, infections requiring drainage, or bone fractures. It is then appropriate to use perioperative beta-block, which reduces the cardiac complication rate in patients with, or at risk of, coronary artery disease. The objective of this review is to offer a comprehensive algorithm to help clinicians in the preoperative assessment of patients undergoing non-cardiac surgery.

[Out of hours coronary angiography: changing indications]. / Coronarographies en dehors des heures ouvrables: évolution des indications.

The authors have recently demonstrated that 13% of indications for cardiac catheterisation performed "after hours" (week ends, holidays or from 6 pm to 7 am) are Class III of the AHA/ACC recommendations (i.e. indications not based on recognised medical evidence). In order to limit procedures performed for these unrecognised indications, a consensus of experts has defined a number of local recommendations. The aim of this paper was to study the impact of these recommendations on the indications of "out of hours" cardiac catheterisation. Two patient populations were identified and compared with respect to these recommendations. The first group comprised 157 consecutive patients treated between 1993 and 1994 (average age 58 +/- 13 years; 35% females) and the second one of 148 consecutive patients treated from 1998 to 1999 (average age 57 +/- 13 years; 25% females). The local recommendations were respected in 61% of cases and not applied in 39% of cases. This was a satisfactory result in view of the fact that the local recommendations are more restrictive than international guidelines as they cover emergency indications. In the second group of patients, there were no AHA/ACC Class III indications (30% Class I, 6% Class IIa and 3% Class IIb). There was a significant increase in the number of primary angioplasties for acute myocardial infarction (27 vs 2%; p < 0.001) and an expected reduction in salvage angioplasties (17 vs 7%; p < 0.01). There was no significant change in the indications in patients with unstable angina, the European and American guidelines having been published at the end of data collection. Therefore, the introduction of recommendations for out of hours cardiac catheterisation has limited the number performed for unrecognised indications in favour of evidence based procedures.

Left atrial radiofrequency compartmentalization for chronic atrial fibrillation during heart surgery.

BACKGROUND: The excellent results of the Maze III operation have demonstrated that a surgical cure of atrial fibrillation (AF) is possible. A simplified Maze procedure with radiofrequency (RF)ablation of the atrial tissue added to open heart surgery may help to cure chronic AF with low risk. METHODS: From May 1998 to March 2001, an RF left atrial compartmentalization concomitant to a cardiac surgical intervention was performed on 40 of 1,258 patients (3.2 %). Thirty-seven patients had mitral valve disease, two had aortic valve disease and one had coronary artery disease. All patients presented with chronic refractory AF for a mean time of 40.4 months ranging from 4 months to 18 years. RESULTS: Mitral valve replacement (MVR) was performed in 19 patients, mitral valve repair in 12, combined aortic and mitral valve procedures were performed in 6, aortic valve replacement(AVR) in 2 and CABG in 1 patient. Cardiopulmonary bypass time for the complete procedure was 138 +/- 32 minutes with an ablation time of 19 +/- 5 minutes. No complication related to RF application was noted. Sinus rhythm was present in 68% after 12.5 +/- 8.5 months. CONCLUSIONS: RF left atrial compartmentalization combined with cardiac surgical interventions proved to be easy and safe to perform. The long-term results still have to be confirmed with further regular patient follow-up examinations.

[Open heart radio frequency left atrial compartmentation during mitral valve surgery: an alternative to the labyrinth procedure?]. / Compartimentation auriculaire gauche par radiofréquence à ciel ouvert lors de chirurgie mitrale: une alternative possible à l'opération du labyrinthe?

The authors report their experience of radiofrequency left atrial compartimentation during open heart mitral valve surgery on 37 patients with a 42 +/- 12 months history of atrial fibrillation. The preoperative left ventricular ejection fraction was 62 +/- 8%; the left atrial diameter was 59 +/- 11 mm. The mean operative time was 245 +/- 60 minutes, which included 19 +/- 5 minutes for the ablation procedure. There were 2 early postoperative deaths and 2 deaths from non-cardiac causes at 3 and 6 months. The left ventricular ejection fraction and left atrial dimension were significantly decreased at the time of hospital discharge (54 +/- 12% and 51 +/- 7 mm respectively) (p < 0.01). After an average follow-up of 1 year, 81% of patients were free of atrial fibrillation: 6 patients had undergone DC cardioversion and 1 had a dual-chamber pacemaker. Patients in sinus rhythm after the ablation were associated with shorter periods of atrial fibrillation and smaller left atrial dimensions postoperatively than those who remained in fibrillation. The authors conclude that radiofrequency compartimentation of the left atrium associated with antiarrhythmic therapy can interrupt atrial fibrillation in 81% of patients at 1 year: the ablation procedure takes only 8% of the operation time. Predictive factors of success of ablation should be defined to determine which patients benefit most from this technique.

Bulls-eye display and quantitation of myocardial perfusion defects using three-dimensional contrast echocardiography.

Three-dimensional (3-D) myocardial contrast echocardiography (MCE) is able to derive parallel cutting planes of the left ventricle (LV). However, assessment of the site and extent of myocardial perfusion abnormalities has to rely on the reader's 3-D mental reconstruction from the tomograms, and a manual approach has to be employed for quantitative analysis. The objective of this study was to explore the display and quantitative capability of a bulls-eye format from contrast 3-D MCE in the assessment of perfusion abnormalities derived from a canine model of acute myocardial infarction (MI). Three-dimensional MCE data were acquired sequentially in a rotational scanning format during triggered harmonic imaging with an intravenous contrast agent. Reconstructed short-axis views of the LV were aligned in a bulls-eye format with the apex as the inner most ring. The total LV was divided into 120 sectors. The number of sectors with lack of contrast enhancement was used to derive the percent of the LV (%LV) with perfusion defect and was compared with the extent of MI calculated from postmortem triphenyl tetrazolium chloride (TTC) staining. The perfusion defect regions shown on bulls-eye images corresponded correctly with the territories of the occluded coronary arteries. Three-dimensional MCE perfusion defect mass (19.2 +/- 6.0 %LV) correlated well with anatomic MI mass (19.3 +/- 5.6 %LV; r = 0.92, SEE = 2.3%, mean differential = 0.1 +/- 2.4%). We conclude that bulls-eye display of contrast 3-D MCE demonstrates the site and extent of perfusion abnormalities in an easily appreciable manner. It also allows fast and accurate assessment of endangered myocardium.

Beating heart coronary artery surgery: is sternotomy a suitable alternative to minimal invasive technique?

OBJECTIVES: To evidence the respective advantages and drawbacks of minimal invasive-thoracotomy (MIDCAB) and off-pump sternotomy (OPCAB) coronary bypass techniques. METHODS: The perioperative and mid-term (3 months) results of the first 31 MIDCABs and 39 OPCABs performed by a single experienced coronary surgeon (F.S.) were compared. Differences were assessed by two-tailed chi-square or unpaired t-test, and significance assumed for P-values < or =0.05. RESULTS: Groups were widely comparable. There were no in-hospital deaths nor permanent neurologic events. OPCAB patients received more anastomoses (mean 1.09/patient vs. 1.89/patient, P<0.001) during a shorter coronary occlusion period (26.1+/-8 vs. 16.6+/-4.5min, P<0.001), whilst immediate extubation prevailed in MIDCABs (22/31 vs. 17/39, P<0.05). Significant complications occurred in seven MIDCABs vs. none in OPCABs (P<0.01). Other in-hospital parameters were similar. Controls at 3 months evidenced more residual discomfort among MIDCAB patients (14/30 vs. 7/39, P<0.05). CONCLUSIONS: Differences in early complication rates may be due to a learning effect. However, OPCAB allows us to implant more grafts and is more comfortable for both patient and surgeon. These advantages may well counterbalance the cosmetic benefits of MIDCAB procedures.

[Coronary artery bypass by mini-thoracotomy: noticeable benefits with clinical experience of the treatment team]. / Pontages coronariens par mini-thoracotomie: bénéfices visibles avec l'expérience croissante de l'équipe traitante.

AIM OF THE STUDY: Minimally invasive coronary artery bypass surgery is fundamentally different as compared to open sternal approach under cardiopulmonary bypass. Modifications of the surgical, anesthesiologic and post-operative techniques are necessary before evaluation of its real benefit. We analyze the potential effect of a learning period on the short term results of this technique. METHODS: From July 1997 to February 1999, 20 patients were operated using this method. We compare the results of the first 10 patients (group 1: 8M/2F, 59.6 +/- 13.8 years) to those of the last 10 patients (group 2: 8M/2F; age = 63.2 +/- 6.1 years). DISCUSSION: Progress between the two groups is striking. Left anterior descending coronary clamping time could be reduced from 28.5 +/- 2.4 min. in group 1 to 22.2 +/- 1.8 min. in group 2 (p < 0.05), and operative time was reduced from 125 +/- 4 min. to 97 +/- 5 min. (p < 0.005). The post-operative atrial fibrillation rate diminished from 4/10 in group 1 to 1/10 in group 2.3/10 patients in group 1 suffered a post-operative pneumonia whereas none in group 2 had pulmonary complication. The stay in the intensive care unit could be reduced from 2.3 +/- 0.3 days to 1.4 +/- 0.2 days (p < 0.05) and the total post-operative stay diminished from 8.5 +/- 0.9 days to 4.7 +/- 0.5 days (p < 0.005). CONCLUSION: There are evidence for a learning period in minimally invasive cardiac surgery. Short term benefits of this technique are then evident as demonstrated by a reduction in the ICU stay and the hospital stay.

Blunt trauma of the heart: CT pattern of atrial appendage ruptures.

Blunt trauma patients with myocardial ruptures rarely survive long enough to reach a trauma center; however, for the survivors, prompt diagnosis and surgery are mandatory and save up to 80% of patients. Preoperative diagnosis of myocardial ruptures is assessed by echocardiography or, more rarely, by angiocardiography. We report two cases of blunt trauma patients with an atrial appendage rupture which could be retrospectively identified on admission CT survey.

Flow convergence flow rates from 3-dimensional reconstruction of color Doppler flow maps for computing transvalvular regurgitant flows without geometric assumptions: An in vitro quantitative flow study.

OBJECTIVE: This study was designed to develop and test a 3-dimensional method for direct measurement of flow convergence (FC) region surface area and for quantitating regurgitant flows with an in vitro flow system. BACKGROUND: Quantitative methods for characterizing regurgitant flow events such as flow convergence with 2-dimensional color flow Doppler imaging systems have yielded variable results and may not be accurate enough to characterize those more complex spatial events. METHOD: Four differently shaped regurgitant orifices were studied: 3 flat orifices (circular, rectangular, triangular) and a nonflat one mimicking mitral valve prolapse (all 4 orifice areas = 0.24 cm(2)) in a pulsatile flow model at 8 to 9 different regurgitant flow rates (10 to 50 mL/beat). An ultrasonic flow probe and meter were connected to the flow model to provide reference flow data. Video composite data from the color Doppler flow images of the FC were reconstructed after computer-controlled 180 degrees rotational acquisition was performed. FC surface area (S cm(2)) was calculated directly without any geometric assumptions by measuring parallel sliced flow convergence arc lengths through the FC volume and multiplying each by the slice thickness (2.5 to 3.2 mm) over 5 to 8 slices and then adding them together. Peak regurgitant flow rate (milliliters per second) was calculated as the product of 3-dimensional determined S (cm(2)) multiplied by the aliasing velocity (centimeters per second) used for color Doppler imaging. RESULTS: For all of the 4 shaped orifices, there was an excellent relationship between actual peak flow rates and 3-dimensional FC-calculated flow rates with the direct measurement of the surface area of FC (r = 0.99, mean difference = -7.2 to -0.81 mL/s, % difference = -5% to 0%), whereas a hemielliptic method implemented with 3 axial measurements of the flow convergence zone from 2-dimensional planes underestimated actual flow rate by mean difference = -39.8 to -18.2 mL/s, % difference = -32% to -17% for any given orifice. CONCLUSIONS: Three-dimensional reconstruction of flow based on 2-dimensional color Doppler may add quantitative spatial information, especially for complex flow events. Direct measurement of 3-dimensional flow convergence surface areas may improve accuracy for estimation of the severity of valvular regurgitation.