[Use and limitations of invasive coronary strategy in nonagerians]. / Intérêts et limites de la stratégie invasive coronaire chez les patients nonagénaires.

BACKGROUND: Nonagenarians are systematically excluded from studies of interventional cardiology. Few data exist on the usefulness, safety, and results of coronary angiography (CA) and percutaneous coronary intervention (PCI) in this population. PURPOSE: To evaluate the benefits and hazards of CA and PCI in nonagenarians. METHODS: Retrospective study conducted from the database (Cardioreport(®)) of the CH de Versailles, from January 2001 to December 2011. RESULTS: From the 15,806 procedures performed in the center during the period, 107 (0.9%) were done in 97 patients aged ≥90years. Half of them underwent PCI. Median age was 92±2years (range: 90 to 100), 56% were women. Main indication was an acute coronary syndrome (77%, acute STEMI in 39%). The first group (n=58) had a single CA leading to strengthen medical treatment, and CABG in one case. The second group (n=49) had a CA followed by immediate (41) or delayed (8) PCI. The primary success rate of PCI was 90%. Radial route was used in 94% in the period 2009-2011 (51% overall). Failure of arterial access (4%) and difficulties of catheterization (13%) were rare. Severe complications occurred in 19%. They were local (11 hematomas, 6 severe, 4 transfusions, and 1 fatal acute ischemia of a lower limb), and general (1 stroke, 1 death by left main rupture during PCI). Twenty percent of the complications (11% of severe ones) were directly related to the procedure. Overall hospital mortality was 10%. CONCLUSIONS: Angiography is feasible in nonagenarians by radial approach without failures and with a reduced rate of complications. PCI was indicated in about half of the cases. PCI may be proposed in nonagerians with a high success rate, and an acceptable risk of local and general complications.

[Accuracy of the door-to-balloon time for assessing the result of the interventional reperfusion strategy in acute ST-segment elevation myocardial infarction]. / Valeur du délai « porte-ballon ¼ pour évaluer l'efficacité de la stratégie interventionnelle de reperfusion à la phase aiguë de l'infarctus du myocarde avec sus-décalage du segment ST.

BACKGROUND: In patients with acute ST-segment elevation myocardial infarction (STEMI), recent clinical guidelines recommend that primary percutaneous coronary intervention (PCI) should be performed within 90min of first medical contact or 45min after admission in cathlab. The Door-to-Balloon time (D2B) is widely used to measure the performance of interventional centres. AIM OF THE STUDY: To analyze the time to reperfusion in a consecutive series of STEMI patients referred for primary PCI, and to evaluate the clinical accuracy of D2B in primary PCI. METHODS: From January 2007 to March 2008, 177 patients were admitted within 12hours of a STEMI in our institution, and 87 were referred for a direct coronary angiography for primary PCI (47 by mobile medical emergency unit, 40 by the emergency department of the institution). RESULTS: The median time from first medical contact to balloon inflation (M2B) was 135min [IQR 112-183]. Recommended times were fulfilled in a minority of patients (M2B<90min: 9%,<120min: 34%). Median cathlab D2B was 51min [IQR 44-65], and was less than 45min in 34% of patients. No differences for times to reperfusion within cathlab were found between in- and off-time hours. M2B and D2B were unavailable in 23 patients (26%), because of a spontaneous TIMI 3 flow reperfusion without indication for immediate PCI in 20 patients, contra-indication for PCI in two (distal occlusion, culprit vessel diameter less than 2mm), and failure in occlusion crossing by the guide-wire in one patient. In contrast, first medical contact- or door-to-reperfusion times, assessed by a TIMI 3 flow without no-reflow in culprit artery, were available in 95% of patients, and were shorter than M2B or D2B, respectively. CONCLUSION: Although it is a feasible and reproducible process performance measure, D2B time is weakly associated with the outcome of the interventional reperfusion strategy in acute STEMI. This measure should be associated with an outcome performance measure, such as the rate of TIMI 3 flow achieved by primary PCI, or replaced by the Door-to-TIMI 3 flow reperfusion time.

[Radiation protection and arterial route in interventional cardiology]. / Radioprotection et voies d'abord en cardiologie interventionnelle.

Since its introduction as a routine arterial route for interventional cardiology, the radial route has been associated with higher X-rays doses, either to the patient and the operator. There is less evidence for this association in recent studies, probably due to the learning curve for this approach, improvement in radiological equipments and in radiation protection techniques. Coronary angiography and percutaneous coronary interventions can be performed by radial route routinely with very low levels of exposure for the patient (<50% of the reference levels). However, for a fixed dose to patient, the operator's exposure remains higher by radial route, compared to femoral route. Optimized individual radiation protection devices for operators are mandatory when procedures are performed by radial approach.

[Secondary prevention after acute coronary syndrome: therapeutic goals achievement in relation with changes in guidelines]. / Prévention secondaire après syndrome coronarien aigu: évolution des recommandations et niveaux d'atteinte des objectifs.

BACKGROUND: Secondary prevention is a key strategy for reducing levels of coronary heart disease, but a gap between guidelines and practice remains. OBJECTIVES: The aim of this double-part survey was to evaluate the improvement in secondary prevention one year after acute coronary syndrome (ACS) in real life, between 1999 and 2005, with respect to the change in guidelines. METHODS: Two surveys of almost similar design were performed in 1999 and 2005-2006. In each survey, unselected consecutive patients suffering from ACS (n=112 hospitalized in 1998, and n=110 in 2004) were evaluated at admission, and one year after hospitalization, for the risk factors, lifestyle, and achievement of therapeutic goals recommended by the most recent guidelines. Follow-up (FU) data were obtained by mail and phone contact with patient, general practitioner and cardiologist, and medical laboratory when appropriate. RESULTS: At 1-year FU (n=192 survivors with FU), smoking cessation (87% in 1999 versus 89% in 2005) and obesity (13% versus 19%, respectively) did not vary significantly. Blood pressure was controlled (< 140/90 mmHg, excepted in diabetics in 2005 with less than 130/80 mmHg) in 65% versus 80% (p<0.03). The rate of patients with no or controlled diabetes mellitus decreased from 1999 to 2005 (90% versus 76%), despite more intensive treatment (insulin in 1% versus 20%).The goals for LDL cholesterol were achieved in 47% of patients in 1999 (< 3.4 mmol/L) and in 76% in 2005 (< 2.6 mmol/L) (p<0.0001). Goals for triglycerides were achieved in 86% in 1999 (< 2g/L), and in 80% in 2005 (< 1.5 g/L) (NS). Besides, 63% of patients received an hypolipemic drug in 1999 (a statin in 59%) and 91% in 2005 (a statin in 88%). Mean number of controlled risk factors was 3.96+/-1.52 in 1999 versus 4.94+/-1.83 in 2005, and prevalence of pts with more than five controlled risk factors at one year FU increased from 15 to 44% (p<0.0001). CONCLUSIONS: These results, drawn from unselected consecutive patients managed in real life, demonstrate an improvement in secondary prevention one year after ACS, between 1999 and 2005, despite strengthened guidelines for blood pressure, triglycerides and LDL cholesterol levels. Control of obesity and diabetes remains unoptimal.

[Variations of radiation dosage delivered to patients undergoing interventional cardiological procedures. A monocentric study 2002-05]. / Variations des doses de rayonnements délivrées au patient en cardiologie interventionnelle. Etude monocentrique 2002-2005.

X-ray exposure of patient during coronary angiography (CA) and percutaneous transluminal coronary angioplasty (PTCA) may have some deleterious effects. The dose area product (DAP), related to the effective dose, is a measure of stochastic risk and a potential quality indicator. The aim of our study was to assess radiation exposure of patients in a large series of "real life" interventional cardiac procedures. We evaluated DAP and Fluoroscopy time (t) during CA and/or PTCA in 3600 consecutive patients from 2002 to 2005. Procedures were performed by five experienced physicians, using successively femoral and radial techniques. DAP and t significantly correlated (r = 0.73; p < 0.0001). Median [25th-75th percentiles] values for DAP and for t were 63 [40-101] Gy.cm2 and 6.3 [4-10] min for CA, 100 [62-178] Gy.cm2 and 14.0 [9-22] min for elective PTCA, and 141 [90-219] Gy.cm2 and 15.7 [11-23] min for CA immediately followed by ad hoc PTCA, respectively. Differences between operators ranged from 50% (CA) to 70% (PTCA) for both DAP and t (p < 0.001). Moving from the femoral to the radial approach resulted in a 1.5 to 2-fold increase in DAP in 2002 (p < 0.001). DAP and t then decreased toward the european DIMOND reference values (in 2005: 53.4 Gy.cm2 and 5.5 min for CA, 104.64 Gy.cm2 and 13.1 min for elective PTCA, 128.4 Gy.cm2 and 13.6 min for ad hoc PTCA). In conclusion, radiation exposure to patients and staff are strongly dependent on operators, time course, and the arterial access, due in part to the learning curve for radial approach. The enhanced knowledge of radiation dose is the first step of a radiation dose-reduction program, likely to minimize patient and operator radiation hazards in interventional cardiology. Definition of national reference values for DAP and fluoroscopy time would be helpful for appropriate comparisons.

[Medium-term follow-up after percutaneous aortic valvuloplasty in the elderly. Clinical study apropos of 102 cases]. / Suivi à moyen terme après valvuloplastie aortique percutanée du sujet âgé. Etude clinique à propos de 102 procédures.

Percutaneous transluminal balloon aortic valvuloplasty was introduced in 1985 and, owing to its sometimes dramatic short-term results, it has rapidly become a useful procedure in the management of aortic stenosis in elderly subjects. The purpose of this study was to determine its clinical results at medium-term and to identify possible prognostic factors in order to improve the selection of patients suitable for this technique. Between January 1986 and December 1987, 78 patients (30 men, 48 women, aged from 60 to 93 years, mean 80 +/- 6.7 years) totalling 85 procedures were selected among 102 dilatations on the basis of a primary success without complications. Dilatation was performed by a technique similar to that described by Cribier et al. The follow-up period was 10 +/- 5.7 months (range: 1 to 27 months). The aortic valve area increased from 0.47 +/- 0.15 cm2 to 0.77 +/- 0.23 cm2, i.e. from 0.29 +/- 0.09 cm2/m2 to 0.48 +/- 0.13 cm2/m2 as regards the indexed area. The hospital mortality rate was 3.3 p. 100. At the end of the follow-up period 55 p. 100 of the patients were in NYHA class I or II; 29 p. 100 had died, 10 p. 100 had undergone a second dilatation and 13 p. 100 had had aortic valve replacement. This distribution into functional classes and major cardiac events was not significantly different in the subgroup of patients with an aortic valve area greater than 0.9 cm2 or in the subgroup of primary failure. The patients who died for cardiac reasons were older (p less than 0.01), had a lower cardiac output before and after dilatation (p less than 0.001) and a lower ejection fraction after dilatation (p less than 0.05) or even before in case of early death (p less than 0.05). Mortality and morbidity therefore were high at medium-term and unrelated to the haemodynamic effect of dilatation. On the other hand, the left ventricular systolic function was determinant, mainly because it could improve or remain stable when initially altered. These results suggest that only patients for whom aortic valve replacement is truly contra-indicated and who have a limited alteration of left ventricular function should be selected for aortic valvuloplasty.

[Hemodynamic effects of intravenous injections of amiodarone chlorhydrate in normal subjects and coronary patients]. / Effets hémodynamiques de l'injection intra-veineuse de chlorhydrate d'amiodarone chez le sujet normal et le coronarien

A study has been made of the haemodynamic affects of a single intravenous injection of amiodarone chorhydrate (5 mg/kg); the injection was given at rest to six normal subjects and six patients with coronary insufficiency due to atherosclerosis. The effects of the drug are most marked at the fifteenth minute after injection, and are: slowing of the heart rate; lessened cardiac output and left ventricular effort; a significant increase in mean pulmonary arterial pressure and diastolic pressure; slight variations in flow in the coronary sinus, with an increase in the ratio of coronary sinus flow to cardiac output. Amiodarone chlorhydrate appears to exert a favourable action upon the heart because, while it maintains myocardial perfusion, it tends to diminish the myocardial oxygen requirement by decreasing the rate of contraction and the contractility of the myocardium.