[Medico-legal implications of infections during interventionnal cardiology procedure]. / Conséquences médico-légales des infections en cardiologie interventionnelle.

Nosocomial infections in interventional cardiology are rare, but their extreme severity is responsible for medico-legal issues. By the will of the legislator, it should be understood that, as soon as the nosocomial nature of an infection has been recognized, the victims will almost systematically obtain compensation. The payer will be determined by the level of seriousness of the infection and the existence or not of a possible fault. To avoid a conviction, the care teams must compel themselves to respect the recommendations of the professional societies, but also to ensure a perfect traceability of the prophylactic measures. Particular attention must be paid to the management of the vascular approach. Finally, it is essential to inform patients and all those involved in the healthcare chain of the need to get in touch with the intervention team if suspicious signs of an infection appear, to allow for specialized cares.

[Medico-legal issues of transcatheter aortic valve implantation (TAVI)]. / Implications médicolégales de l'implantation transcathéter de la valve aortique (TAVI).

Compassionally reserved for inoperable patients in 2002, Transcatheter Aortic Valve Implantation has now a place almost equivalent to surgical valve replacement. The pioneering teams first succeeded in demonstrating a benefit on the mortality of extremely serious patients, while managing a learning curve that seemed unreachable without a strong partnership with cardiac surgeons. This win/win challenge enabled cardiologists to surpass the limits they did not dare to brave (management of large arterial approach, annular rupture and tamponade) and surgeons to appropriate the endovascular's culture. The technological contribution, the maturity of the teams and the expansion to less severe populations have reduced the perioperative mortality of TAVI to less than 3%. At this stage, it seemed interesting to take stock of forensic developments around this technique. After a review of the studies and the healthcare requirements, we reported and analyzed the claims received from one of the leaders of the medical insurance in France. From this feedback, attempts will be made to identify ways of improving the prevention and subsequent treatment of complications, which will undoubtedly limit the risk of subsequent complaints.

[Medico-legal implications of coronary angioplasty among seniors]. / Quels risques médico-légaux en cardiologie interventionnelle chez les personnes âgées ?

It's commonplace to declare that seniors are more fragile, because of a higher rate of comorbidities and complex coronary lesions. However, they take great benefit from angioplasty during acute coronary syndrome, with a higher rate of complications. Based on the study of claims reported to a French medical insurer, it is found that people over 75 years old among victims of interventional cardiology accidents is proportional to the population of seniors in the French population (around 10%). Conversely, the mortality of those seniors was much higher than patients under 75 (83% versus 30%). A strategy, which involves families and anticipates the risks of those fragile patients (fragility of structures, risk of decompensation of comorbidities [kidneys, hemostasis]) can help to prevent the risk of accidents, but may also reduce medico-legal implications of cardiologists.

SMART syndrome: Classic transient symptoms leading to an unusual unfavorable outcome.

BACKGROUND: Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare complication of cerebral radiation therapy that usually presents>10 years after treatment as reversible paroxysmal episodes of neurological dysfunction associated with headaches. CASES: We report here on two cases of SMART syndrome in long-term survivors of high-grade glioma for whom neuropathological data were available. The course of the disease was unfavorable. Although the clinico-radiological picture of SMART syndrome clearly differs from classic cerebral radionecrosis, the gross neuropathological lesions observed in our two patients appeared to be similar to those described in focal radionecrosis. CONCLUSION: SMART syndrome may progress from a benign reversible form to a severe and eventually irreversible form. This severe course may also be confused with tumor progression, and lead to permanent disability and inadequate antitumor treatment. Clinicians should be aware of this latter atypical presentation.

Patterns of relapse in patients with high grade glioma receiving combined treatments including stereotactic re-irradiation for a first relapse.

PURPOSE: Bevacizumab and stereotactic treatment are efficient combined or alone in relapse glioma. However, patterns of relapse after this kind of salvage treatment have never been studied. The purpose of this unicentric retrospective analysis was to assess and understand the patterns of relapse of high grade glioma treated with stereotactic radiation, with or without bevacizumab. PATIENTS AND METHODS: Twenty patients with high grade glioma relapse received a stereotactic radiation; among them two patients received temozolomide and eight patients received bevacizumab; among the latter, four received also irinotecan. We matched the stereotactic radiation treatment planning scan with the images of the first treatment and of the second relapse in order to determine the patterns of failure and associate dosimetric profile. RESULTS: For the total population, median follow-up from the first diagnosis and relapse were 46.1 and 17.6 months, respectively. Among the 13 patients who relapsed, ten did not receive chemotherapy and three received it (P<0.05), two received temozolomide and one bevacizumab. Patients who received bevacizumab had no "out-of-field" recurrences. Among the 32 irradiated relapses, 15 were "in-field" recurrences; among them two were treated with bevacizumab and 13 were not (P<0.05). For the 32 lesions, a favourable prognostic factor of control was the association of a high-dose of irradiation and the use of bevacizumab. CONCLUSION: For patients with relapsed high grade glioma, local control was higher with combined bevacizumab and high-dose stereotactic radiation.

Successful Treatment of Mitochondrial Toxicity in an HIV-Positive Patient After Liver Transplantation.

Liver transplantation in patients infected with the human immunodeficiency virus (HIV) has been increasingly performed with reasonable outcomes; however, medical management of both immunosuppression and antiretroviral therapy can be challenging owing to drug toxicities and interactions. Nucleoside reverse transcriptase inhibitors (NRTIs), a common backbone of highly active antiretroviral therapy (HAART), were the first class of effective antiretroviral drugs developed. NRTIs are commonly used for posttransplant HAART therapy and have a rare but fatal complication of mitochondrial toxicity, manifesting as severe lactic acidosis, hepatic steatosis, and lipoatrophy. Herein, we have reported on the first known successful treatment of severe mitochondrial toxicity secondary to NRTIs in an HIV-infected transplant recipient.

[Infections associated with percutaneous arterial closure devices: medico-legal issues]. / Les implications médico-légales des infections sur les systèmes de fermeture percutanée artérielle.

Percutaneous suture closure devices have reduced the time needed for manual compression and hospital stays, but several meta-analysis emphasized a higher risk of vascular damages compared to manual compression. Two cases of infections on percutaneous suture closure devices were analyzed; which had medico-legal issues. Beyond the medical point of view, the patient's complaints, the way lawyers and medical experts have examined the cases were analyzed and resulted in physicians and hospitals being sentenced. Rather than stigmatizing those devices, we just want to invite cardiologists not to underestimate this serious risk. Before using those devices, physicians should balance the risk-benefit ratio, follow prevention guidelines, and most of all, be aware of any single signs of emerging infection to detect and treat them early, and thus reduce the severity of infections thanks to a targeted antibiotic treatment adapted to the antibiogram and an active role of vascular surgeons.

Heart transplantation for Chagas cardiomyopathy in the United States.

Since an initial case in 2006, we noted multiple patients undergoing heart transplantation (HTx) for Chagas cardiomyopathy (CC) at our transplant program. The clinical characteristics, laboratory results and outcomes of patients with CC undergoing HTx in the United States have not been reported previously. In 2010, we implemented a systematic screening and management program for patients undergoing HTx for CC. Before HTx, all patients with idiopathic dilated cardiomyopathy who were born in a Chagas disease endemic country were screened for Trypanosoma cruzi (TC) infection with serology. After HTx, monitoring for TC reactivation was performed using clinical visits, echocardiography, endomyocardial biopsy and serial whole blood polymerase chain reaction (PCR) testing. Between June 2006 and January 2012, 11 patients underwent HTx for CC. One patient was empirically treated due to the presence of TC amastigotes in explanted cardiac tissue. Two patients experienced allograft dysfunction due to TC reactivation and three patients experienced subclinical reactivation (positive PCR results), which were treated. Chagas disease is a common cause of dilated cardiomyopathy in patients from endemic countries undergoing HTx at a transplant program in the United States. Reactivation is common after transplantation and can cause adverse outcomes.

[Multicentric experience with the use of Sheathless 6.5 French-size catheter in coronary angioplasty for bifurcation lesions: feasibility and safety]. / Expérience multicentrique de l'utilisation du Sheathless 6.5 French dans l'angioplastie coronaire des lésions de bifurcation : faisabilité et sécurité

BACKGROUND: Transradial intervention of coronary lesion is increasing in frequency and is associated with lower major vascular access site complications. However, the small size of the radial artery is a major limitation of this technique, especially for bifurcation lesions, because 6-French guiding catheters are necessary to optimize the technique. A Sheathless guiding catheter has recently been introduced, optimizing a large lumen with a small size. OBJECTIVES: The aim of this study is to report our preliminary experience performing bifurcated transradial interventions using a 6.5 French Sheathless guide catheter. PATIENTS AND METHODS: From March 2009 to February 2012 in three hospitals, 46 consecutive patients were enrolled in this study who underwent transradial approach (TRA) for percutaneous bifurcation coronary interventions using the 6.5 French Sheathless Eaucath guiding catheter system because of small radial artery caliber. RESULTS: In this study, 46 patients were enrolled with mean age of 72.13 ± 16.41 years. The majority of patients were females with sex-ratio 0.53. Procedural success using the 6.5 French Sheathless guide catheter system was 100 % with no cases requiring conversion to a conventional guide and catheter system. During procedures, adjunctive devices used in this cohort included IVUS (2 patients), 35 bifurcated lesions were treated with a kissing-balloon technique in the group of 46 patients undergoing bifurcation PCIs, one patient required rotational atherectomy, thrombus-aspiration catheters had used in four patients, FFR-guided angiography in four patients. We report one case of chronic total occlusion bifurcated lesion successfully treated using this hydrophilic catheter. There were no radial artery site complications. CONCLUSION: The treatment of coronary bifurcation lesions with 6.5 French Sheathless guiding catheter by transradial approach is feasible and appears safe in this multicenter study.

[SMART syndrome: case report of a rare complication after cerebral radiation therapy]. / SMART Syndrome : à propos d'un cas d'une complication rare après radiothérapie cérébrale et revue de la littérature.

The authors report a 71-year-old woman case who developed, 7 years after a cerebral radiation therapy for a parietooccipital glioblastoma, a stroke-like migraine attacks after radiotherapy syndrome (SMART syndrome), a rare complication characterized by reversible neurologic deficits with migraine described after cerebral irradiation. Transient gyriform reversible enhancement is found on MRI during crises. This case report allows discussing the clinical, iconographic presentation and the clinical outcome of this syndrome at the light of the literature publication.

Neural control of breathing: insights from genetic mouse models.

Recent studies described the in vivo ventilatory phenotype of mutant newborn mice with targeted deletions of genes involved in the organization and development of the respiratory-neuron network. Whole body flow barometric plethysmography is the noninvasive method of choice for studying unrestrained newborn mice. Breathing-pattern abnormalities with apneas occur in mutant newborn mice that lack genes involved in the development and modulation of rhythmogenesis. Studies of deficits in ventilatory responses to hypercapnia and/or hypoxia helped to identify genes involved in chemosensitivity to oxygen and carbon dioxide. Combined studies in mutant newborn mice and in humans have shed light on the pathogenesis of genetically determined respiratory-control abnormalities such as congenital central hypoventilation syndrome, Rett syndrome, and Prader-Willi syndrome. The development of mouse models has opened up the field of research into new treatments for respiratory-control disorders in humans.

[Coronary artery disease and coronary angioplasty in chronic hemodialysis patients]. / Coronaropathie et angioplastie coronaire dans l'insuffisance rénale dialysée.

Chronic renal insufficiency leads to many cardiovascular complications and provide worst prognosis, especially when patients need hemodialysis. The atherosclerosis of chronic hemodialysis patients is qualified as "accelerated" by some authors, because of a very fast and large progression. To improve prognosis, it seems to be very important to detect and treat the frequent and serious underlying cardiovascular disease. Because of the high rate of diabetes mellitus, silent ischemia is a very frequent clinical situation. In the other hand, coronary artery disease in chronic hemodialysis patients is frequently complex, with a large coronary extension and high rate of coronary calcifications. Consequently, this disease needs a specific therapeutic approach. Even though, percutaneous coronary interventions (PCI) are more complex in this population, it provides good results, and improves patient's prognosis. However, the rate of complications of the vascular approach and the rate of restenosis is high. New devices, such as Drug Eluting Stents (DES) can critically decrease restenosis rate, and closure devices for trans-femoral approach, provides very encouraging results in this high risk population. Despite, good results of PCI with DES use, the mortality is still high in this population. To improve our efficiency, we have to progress in our therapeutic strategies and optimize medical approach to treat the important biological perturbations.

[Medical liability and coronary artery diseases]. / Responsabilité médicale et pathologie coronaire.

Until recently, for many people dying from a myocardial infarction was an inevitable fate. Myocardial infarction mortality rates have decreased drastically. At the same time, stents have clearly secured coronary angioplasties, removing the problems linked to coronary dissections such as abrupt closure or emergency coronary bypass. The iatrogenic risks have increased on account of the use of sophisticated techniques, powerful medications or the treatment of older patients. On the one hand, the media have informed people about the tremendous improvements in cardiology, however, on the other hand they have also given them over-optimistic expectations leading to an increase in the number of physicians sued. Now, physicians have to master ever more complex parameters such as new examination techniques prescriptions and interpretation (CT-scanner, MRI) and new medications. In order to prevent lawsuits, physicians should educate and inform their patients. To increase their chances in case of a lawsuit, physicians should improve the traceability of the treatment prescribed and information given to patients, but also make patients assume their responsibilities when they are reluctant to follow medical advices or treatments.

Inhibitory effects of repeated hyperoxia on breathing in newborn mice.

Brief oxygen therapy is commonly used for resuscitation at birth or prevention of hypoxaemia before procedures during the neonatal period. However, O(2) may severely depress breathing, especially when administered repeatedly. The aim of the present study was to test the effects of repeated hyperoxia on breathing control in newborn mice. A total of 97 Swiss mouse pups were assigned to O(2) or air on post-natal day 0, 1 or 2. Each pup in the O(2) group was subjected to four hyperoxic tests (100% O(2) for 3 min followed by 12 min normoxia), whereas pups in the air group were maintained in normoxia. Breathing variables were measured using flow-through barometric plethysmography. O(2) significantly decreased minute ventilation as seen in a decrease in respiratory rate. This decrease became significantly larger with repeated exposure and ranged -17- -26% for all ages combined. Furthermore, hyperoxia increased total apnoea duration, as compared with the baseline value. In newborn mice, repeated hyperoxia increasingly depressed breathing. This finding further supports a need for stringent control of oxygen therapy, most notably repeated oxygen administration in the neonatal period for premature newborn infants and those carried to term.

Ventilatory response to hyperoxia in newborn mice heterozygous for the transcription factor Phox2b.

Heterozygous mutations of the transcription factor PHOX2B have been found in most patients with central congenital hypoventilation syndrome, a rare disease characterized by sleep-related hypoventilation and impaired chemosensitivity to sustained hypercapnia and sustained hypoxia. PHOX2B is a master regulator of autonomic reflex pathways, including peripheral chemosensitive pathways. In the present study, we used hyperoxic tests to assess the strength of the peripheral chemoreceptor tonic drive in Phox2b+/-newborn mice. We exposed 69 wild-type and 67 mutant mice to two hyperoxic tests (12-min air followed by 3-min 100% O2) 2 days after birth. Breathing variables were measured noninvasively using whole body flow plethysmography. The initial minute ventilation decrease was larger in mutant pups than in wild-type pups: -37% (SD 13) and -25% (SD 18), respectively, P<0.0001. Furthermore, minute ventilation remained depressed throughout O2 exposure in mutants, possibly because of their previously reported impaired CO2 chemosensitivity, whereas it returned rapidly to the normoxic level in wild-type pups. Hyperoxia considerably increased total apnea duration in mutant compared with wild-type pups (P=0.0001). A complementary experiment established that body temperature was not influenced by hyperoxia in either genotype group and, therefore, did not account for genotype-related differences in the hyperoxic ventilatory response. Thus partial loss of Phox2b function by heterozygosity did not diminish the tonic drive from peripheral chemoreceptors.

[Methacholine challenge in young children: measurement of resistance by interruption]. / Test a la métacholine chez le jeune enfant: Mesure de la résistance par interruption.

The aims of this study were 1. To evaluate the measurement of resistance by interruption (Rint) of bronchoconstriction induced by inhalation of methacholine and 2. To determine a threshold of increase of resistance in young children to differentiate responders from non-responders. Forty-six children (mean age 5 [4.3-6.1] years) referred for methacholine challenge were tested by measurement of Rint and transcutaneous oxygen tension. A fall of 20% or more in oxygen tension from the baseline was used to define the responders. The children studied had a baseline Rint significantly higher than normal (0.84 [0.68-1.01] vs. 0.76 [0.60-0.90] kPa L(-1)s; p < 0.03). Forty-one children were responders and had an increase in Rint significantly different from the non-responders (p < 0/04). An increase in Rint of 35% distinguished responders from non-responders in young children with chronic cough. Interrupter resistance increases significantly during bronchial provocation in responding young children and may be used to measure the degree of bronchoconstriction.

Automatic classification of activity and apneas using whole body plethysmography in newborn mice.

An increasing number of studies in newborn mice are being performed to determine the mechanisms of sleep apnea, which is the hallmark of early breathing disorders. Whole body plethysmography is the method of choice, as it does not require immobilization, which affects behavioral states and breathing. However, activity inside the plethysmograph may disturb the respiratory signal. Visual classification of the respiratory signal into ventilatory activity, activity-related disturbances, or apneas is so time-consuming as to considerably hamper the phenotyping of large pup samples. We propose an automatic classification of activity based on respiratory disturbances and of apneas based on spectral analysis. This method was validated in newborn mice on the day of birth and on postnatal days 2, 5, and 10, under normoxic and hypoxic (5% O(2)) conditions. For both activity and apneas, visual and automatic scores showed high Pearson's correlation coefficients (0.92 and 0.98, respectively) and high intraclass correlation coefficients (0.96-0.99), supporting strong agreement between the two methods. The present results suggest that breathing disturbances may provide a valid indirect index of activity in freely moving newborn mice and that automatic apnea classification based on spectral analysis may be efficient in terms of precision and of time saved.

Control of breathing in newborn mice lacking the beta-2 nAChR subunit.

AIM: To study the ventilatory and arousal/defence responses to hypoxia in newborn mutant mice lacking the beta2 subunit of the nicotinic acetylcholine receptors. METHODS: Breathing variables were measured non-invasively in mutant (n = 31) and wild-type age-matched mice (n = 57) at 2 and 8 days of age using flow barometric whole-body plethysmography. The arousal/defence response to hypoxia was determined using behavioural criteria. RESULTS: On day 2, mutant pups had significantly greater baseline ventilation (16%) than wild-type pups (P < 0.02). Mutant pups had a decreased hypoxic ventilatory declines. Arousal latency was significantly shorter in mutant than in wild-type pups (133 +/- 40 vs. 146 +/- 20 s, respectively, P < 0.026). However, the duration of movement elicited by hypoxia was shorter in mutant than in wild-type pups (14.7 +/- 5.9 vs. 23.0 +/- 10.7 s, respectively, P < 0.0005). Most differences disappeared on P8, suggesting a high degree of functional plasticity. CONCLUSION: The blunted hypoxic ventilatory decline and the shorter arousal latency on day 2 suggested that disruption of the beta2 nicotinic acetylcholine receptors impaired inhibitory processes affecting both the ventilatory and the arousal response to hypoxia during postnatal development.