Value of CMR in quantification of paravalvular aortic regurgitation after TAVI.

AIMS: To assess the value of cardiac magnetic resonance (CMR) using phase-contrast velocity mapping for paravalvular aortic regurgitation (PAR) quantification. METHODS AND RESULTS: All patients undergoing transcatheter aortic valve implantation (TAVI) in our centre between November 2012 and August 2013, without CMR-contraindication were included. PAR severity was assessed 5 days after TAVI using: transthoracic echocardiography (TTE) and CMR [regurgitant volume (RV), regurgitant fraction (RF)]. Aortic regurgitation (AR) index was obtained during TAVI. Thirty of 51 patients who underwent TAVI were included (COREVALVE, n = 10; or EDWARDS SAPIEN XT, n = 20). At TTE, PAR was mild in 22, moderate in 3, and severe in 5 patients. Reliable phase-contrast images were acquired at the sino-tubular junction for SAPIEN and at the tubular portion of the ascending aorta for COREVALVE. The reproducibility of CMR was high (coefficient of correlation = 0.99 for intra- and inter-operator variability). At CMR, RV, and RF were significantly (P < 0.0005) correlated with AR severity at TTE, with mean RF values at 9.2 ± 7.6% in mild, 20.3 ± 4.2% in moderate, and 46.8 ± 10.8% in severe PAR. A cut-off value of RF < 14% at CMR accurately discriminated mild from moderate/severe (sensitivity: 100%, specificity: 82%). The mean AR index was 29.4 ± 6 for mild and 13.8 ± 5 for moderate/severe PAR. Three patients had a RF > 14% and a low AR index <25 despite a mild PAR at TTE, suggesting an underestimation at TTE. CONCLUSION: CMR is a reproducible, accurate, and reliable method to assess PAR severity. CMR may allow correcting an underestimation at TTE when AR index is doubtful.

[Characteristics and management of ST-elevation myocardial infarction in France: Regional variations in 2010]. / Prise en charge du syndrome coronaire aigu avec sus-décalage de ST en France : variations régionales en 2010.

Data on regional variations in the characteristics, management and early outcome of patients admitted with ST-elevation myocardial infarction (STEMI) in France are limited. We used data from the FAST-MI 2010 registry to determine whether regional specificities existed, dividing the French territory into 6 larger geographical regions. Variations in the patients' characteristics were found, partly related to regional variations in demography. Acute reperfusion strategy showed more use of primary percutaneous coronary intervention in the greater Paris area, compared to other regions, which would be expected owing to geography and local availability of catheterization laboratories. Overall, however, in-hospital management showed more similarities than differences across regions. Complications, and in particular in-hospital mortality, did not differ significantly among regions.

Safety and effectiveness of the association ezetimibe-statin (E-S) versus high dose rosuvastatin after acute coronary syndrome: the SAFE-ES study.

BACKGROUND: Statin therapy is a cornerstone therapy for secondary prevention after acute coronary syndrome (ACS). However, the use of these drugs can be limited by side effects, mainly muscular pain. Ezetimibe is a newer lipid-lowering agent, with fewer side effects. AIMS: The present study was designed to compare a commercially available association of ezetimibe and simvastatin (E-S) to high dose Rosuvastatin on cholesterol and muscular enzyme levels and occurrence of muscular pain. METHODS: All consecutive ACS statin-naïve patients with LDL cholesterol (LDL-C)>100mg/dL randomly received either high dose statin (Rosuvastatin 20mg) or E-S 10/40-mg. All patients had one-month follow-up with biological testing and clinical examination. We compared the two groups on the biological efficiency and incidence of muscular pain. RESULTS: One hundred and twenty-eight patients were randomized; 64 received E-S and 64 Rosuvastatin. In the two groups, the lowering of LDL-C level (Δ=51%) at one month was significant (P<0.01) without any difference in the rate of lowering on LDL-C or HDL-C suggesting that E-S is as effective as high dose Rosuvastatin (P=0.77 and P=0.99). The rate of patients reaching the objective of LDL-C<100mg/dL (45%) and LDL-C<70mg/dL (51%) was not different in the two clusters (P=0.65). Incidence of muscular pain was 15% higher in patients treated with Rosuvastatin (P=0.01) without any difference on CPK level (P=0.6). CONCLUSION: Using an association of E-S in an effective alternative strategy to high dose Rosuvastatin with a lower incidence of muscular pain, which might impact adherence to medication after ACS.

Toxicity assessment of the herbicides sulcotrione and mesotrione toward two reference environmental microorganisms: Tetrahymena pyriformis and Vibrio fischeri.

The potential toxicity of sulcotrione (2-[2-chloro-4-(methylsulfonyl)benzoyl]-1,3-cyclohexanedione) and mesotrione (2-[4-(methylsulfonyl)-2-nitrobenzoyl]-1,3-cyclohexanedione), two selective triketonic herbicides, was assessed using representative environmental microorganisms frequently used in ecotoxicology: the eukaryote Tetrahymena pyriformis and the prokaryote Vibrio fischeri. The aims were also to evaluate the toxicity of different known degradation products, to compare the toxicity of these herbicides with that of atrazine, and to assess the toxicity of the commercial herbicidal products Mikado and Callisto. Toxicity assays involved the Microtox test, the T. pyriformis population growth impairment test, and the T. pyriformis nonspecific esterase activity test. For each compound, we report original data (IC(50) values) on nontarget cells frequently used in ecotoxicology. Analytical standards sulcotrione and mesotrione showed no toxic effect on T. pyriformis population growth but a toxic influence was observed on nonspecific esterase activities of this microorganism and on metabolism of V. fischeri. Most of the degradation products studied and the two commercial formulations showed a greater toxicity than the parent molecules. Compared with the effect of atrazine, the toxicity of these triketonic herbicides was less than in T. pyriformis and greater than or the same as in V. fischeri. Additional work is needed to obtain a more accurate picture of the environmental impact of these herbicides. It will be necessary in future experiments to study the ecosystemic levels (aquatic and soil compartments) and to assess the potential toxicity of the newly discovered degradation products and of the additives accompanying the active ingredient in the commercial herbicidal formulations.

Cardiac rupture or pericardial effusion?

After cardiogenic shock, myocardial rupture is the leading cause of in-hospital death from acute myocardial infarction (AMI). When possible, rapid diagnosis must lead to an emergency surgical repair to prevent sudden death. However, in some cases, despite new imaging techniques, the diagnosis may be difficult to obtain and the decision whether or not to operate, difficult. In the present report we describe the challenging case of a patient presenting a sub-acute cardiac rupture three days after anterior AMI.

Involvement of Tetrahymena pyriformis and selected fungi in the elimination of anthracene, and toxicity assessment of the biotransformation products.

Anthracene (AC) is a non-mutagenic and non-carcinogenic, low-molecular-weight polycyclic aromatic hydrocarbon present in the environment. Its toxicity can be dramatically increased after solar-light exposure. Biotransformation capacities of AC by Tetrahymena pyriformis and a selection of eight micromycetes were studied, and the ability of these microorganisms to detoxify the polluted ecosystems was assessed. We showed that T. pyriformis was able to accumulate high amounts of AC without any transformation. In contrast, the fungi Cunninghamella elegans, Absidia fusca, Absidia cylindrospora, Rhodotorula glutinis, and Aspergillus terreus were able to transform AC with a high efficiency. Cytotoxicity assays conducted on HeLa cells and T. pyriformis showed that crude extract from A. fusca culture medium obtained after AC biotransformation was not toxic. For A. fusca and A. cylindrospora, 1-4 dihydroxyanthraquinone was shown to be the major product during the biotransformation process. This compound seemed to be a dead-end metabolite at least for the Absidia strains. The cytotoxicity of 1-4 dihydroxyanthraquinone was higher than that of AC to T. pyriformis but lower to HeLa cells. On the whole our results showed that the microorganisms studied were all able to decontaminate an AC-polluted ecosystem, either by accumulating or transforming the compound. A possible detoxification process resulting from AC biotransformation can be considered only using the human cell model.

[Acute stent thrombosis due to resistance to clopidogrel ? A case report]. / Implication de la résistance au clopidogrel dans la thrombose aiguë de stent ? A propos d'un cas.

The authors report the case of a 65 year old man who presented with an acute coronary syndrome without ST elevation due to acute stent thrombosis 12 hours after implantation. Recent reports in the literature suggest the role of resistance to antiplatelet drugs in acute, subacute or late stent thrombosis. This patient was included in a protocol studying the response to antiplatelet drugs in patients undergoing coronary stenting and fulfilled the criteria of resistance to clopidogrel. This clinical case illustrates the possible role of "resistance" to antiplatelet drugs in stent thromboses.

Assessment of the potential toxicity of herbicides and their degradation products to nontarget cells using two microorganisms, the bacteria Vibrio fischeri and the ciliate Tetrahymena pyriformis.

The potential toxicity of several herbicides-alachlor, diuron and its photo and biotransformation products, glyphosate and its metabolite aminomethyl phosphonic acid (AMPA)-to nontarget cells was assessed using two microorganisms frequently used in ecotoxicology, Vibrio fischeri and Tetrahymena pyriformis. Toxicity assays involved the Microtox test, the T. pyriformis population growth impairment test employing three different processes (flasks, tubes, microplates), and the T. pyriformis nonspecific esterase activities test. Several IC(50) or EC(50) values are reported for each molecule. Alachlor exerted a toxic effect on the two nontarget cells used. The results for diuron and its photo and biotransformation products indicated that most of the metabolites presented nontarget toxicity higher than that of diuron. Glyphosate and AMPA had a less negative effect on T. pyriformis than on V. fischeri. Nevertheless, in all cases, glyphosate was found to be more toxic than AMPA. Comparison analysis of the sensitivity of the different tests showed that, in general, tests using the eukaryotic cell (T. pyriformis) were more sensitive than test using the prokaryotic cell (V. fischeri), and that a population growth criterion is more sensitive than an enzymatic criterion. The three different processes that could be used to evaluate effects on population growth rate were equally sensitive for the herbicides tested. A significant correlation between toxicity data and the hydrophobicity of the chemicals could only be established with the growth population test. This study demonstrates that it is essential to assess the toxicity of the metabolites formed to complete a more comprehensive study of the environmental impact of a polluting agent.

Diagnosis of Coxiella burnetii pericarditis using a systematic prescription kit in case of pericardial effusion.

Coxiella burnetii, regarded as a potential agent of pericarditis, wa found to be responsible for almost 5% of the cases of idiopathic pericardial effusion reported in this series. Diagnosis was aided by use of a systematic kit described in this paper.

[Beneficial effect of a loading dose of 600 mg of clopidogrel on platelet parameters in patients admitted for acute coronary syndrome]. / Bénéfice d'une dose de charge de 600 mg de clopidogrel sur les paramètres plaquettaires chez les patients admis pour syndrome coronaire aigu.

INTRODUCTION: Despite the beneficial effect of an aspirin-clopidogrel combination in acute coronary syndrome, the incidence of ischaemic recurrences remains significant and very probably implicates a variability in the response to anti-platelet agents. OBJECTIVE: We sought to demonstrate the evidence for a beneficial effect, in terms of anti-platelet effect, of a higher loading dose of 600 mg of clopidogrel compared to the usual 300 mg in patients admitted to our centre with acute coronary syndrome. MATERIALS AND METHODS: Platelet reactivity was evaluated with the ADP 10_mol test and the degree of platelet activation by the expression of P-selectin. 178 consecutive patients admitted for acute coronary syndrome received 250 mg of intravenous aspirin together with either a loading dose of 300 mg of clopidogrel (n = 104) or 600 mg (n = 74) administered 12 to 24 hours prior to coronary angiography. RESULTS: The patients who received 600 mg of clopidogrel had an average aggregation intensity to ADP and a rate of platelet high reactivity post treatment that was significantly lower [48+20 vs 58+18, p = 0.0011 and 11 patients (15%) vs 26 patients (25%), p = 0.0003 respectively]. The degree of platelet activation evaluated with P-selectin was significantly lower in patients receiving 600mg [0.33 + 0.17 vs 0.50+0.29, p < 0.001]. CONCLUSION: Our study provides evidence for a beneficial effect of a loading dose of 600mg of clopidogrel compared to the usual 300 mg in terms of platelet reactivity and platelet activation post treatment.

[Platelet function after a high dose bolus of tirofiban immediately after coronary angioplasty]. / Etude de la fonction plaquettaire après bolus de tirofiban a haute dose au décours immédiat de I'angioplastie coronaire.

In the TARGET trial, the lower incidence of cardiac events at one month with abciximab compared with tirofiban was attributed to a lack of efficacy in the first hour because of suboptimal dosage. The object of this study was to confirm that high dose tirofibal is associated with over 90% platelet inhibition during the first hour and to analyse the effect of this new dosage on platelet activation. Thirty-three patients treated with clopidogrel and aspirin for an acute coronary syndrome without ST elevation were given before angioplasty a bolus of 25 microg/Kg of tirofiban injected in 3 minutes, followed by an infusion of 0.15 microg/kg/min. Blood samples were taken before the treatment (TO) and at the 45th minute (T1) to measure platelet aggregation induced by ADP, the expression of P-selection, the quantification of circulating monocyte-platelet aggregates and the phospholyration of VASP protein. The results showed that all patients had over 90% (100%) inhibition of platelet aggregation at T1. The expression of P-selection was significantly reduced (T0: 0.195 +/- 0.057 MFI; T1: 0.186 +/- 0.055 MFI, p = 0.03). There was no significant difference in the number of monocyte-platelet aggregates or in the phosphorylation of VASP. In conclusion, a bolus of 25 microg/Kg/3 min of tirofiban provides over 90% inhibition of platelet aggregation in the first hour. The initial platelet proactivator effect at this dosage was shown to have disappeared with an inhibition of platelet activation.

[Myocardial infarction during post-abortion DIC]. / Infarctus du myocarde au cours d'une CIVD du post-abortum.

We report the case of a 40 year old woman admitted for dilatation and curettage at 12 weeks of amenorrhoea with post-abortion partial placental retention. Clinically she had developed disseminated intravascular coagulation (DIC) complicated by an acute coronary syndrome with persistent ST elevation in the inferior leads. Management of her myocardial ischaemia was symptomatic, due to the underlying complex coagulation disorder making coronary reperfusion techniques impossible. After treatment for the cause of DIC, coronary angiography revealed no detectable angiographic lesion or spasm. In this context, the most likely aetiological hypothesis is a thrombus related to the DIC in an otherwise healthy heart, which was spontaneously lysed.

[Endomyocardial fibrosis: a rare case of restrictive cardiomyopathy in a Caucasian female]. / Fibrose endomyocardique: une cause rare de cardiomyopathie restrictive chez une patiente caucasienne.

The authors report the case of endomyocardial fibrosis diagnosed in a young Caucasian female presenting with progressive congestive cardiac failure. The diagnosis was suspected on the echocardiographic, magnetic resonance imaging and cardiac catheterisation findings in association with the clinical presentation. After a short course of symptomatic medical therapy, the patient underwent the only curative treatment of this pathology, surgical endocardectomy and combined valvular surgery. The confirmation of the diagnosis was obtained a posteriori by histopathological examination of the operative findings which showed appearances of endomyocardial fibrosis similar to those observed in tropical regions. The patient was discharged on the eighth postoperative day, much improved clinically, and follow-up at one year was very satisfactory.