Health care in France: recent developments.

Health care in France falls almost exclusively under the responsibility of the Social Security department, which covers almost all the expenditures related to health care, whether hospitalization or medication is concerned. For severe diseases or surgery the coverage is likely to reach as much as 100%. The medical expenditures for several severe diseases, such as cancer, myocardial infarction, or neurodegenerative diseases are 100% covered for a period of time as long as three months. For some procedures, full coverage may be achieved by using a subscription to private health care insurance. Access to cover by the state has recently been opened to anyone living in France, after passage of a special law. There is still a lack of intensive care and hospice beds, given the rapidly increasing number of elderly who cannot be maintained at home. There is a tendency to reduce the number of beds in private and public hospitals due to the great number of such institutions and the general concern that a low volume of procedures, associated with inexperienced health care professionals, is likely to increase morbidity and mortality as well as public health care expenditure. Patients are still free to choose doctors and hospitals (whether private or public), provided that beds are available and that specific procedures can be carried out in the vicinity. So far no waiting list is needed, except for specific procedures performed by a few specialists of high repute. Health care expenses are increasing continuously, which results in a very expensive system in France.

Role of coronary artery lumen enlargement in improving coronary blood flow after balloon angioplasty and stenting: a combined intravascular ultrasound Doppler flow and imaging study.

OBJECTIVES: This study sought to examine the mechanism of increasing coronary flow reserve after balloon angioplasty and stenting. BACKGROUND: Coronary vasodilatory reserve (CVR) does not improve after percutaneous transluminal coronary angioplasty in > or = 50% of patients, postulated to be due to impaired microvascular circulation or inadequate lumen expansion despite adequate angiographic results. METHODS: To demonstrate the role of coronary lumen expansion, serial coronary flow velocity (0.014-in. Doppler guide wire) was measured in 42 patients before and after balloon angioplasty and again after stent placement. A subset (n = 17) also underwent intravascular ultrasound (IVUS) imaging of the target sites after angioplasty and stenting. CVR (velocity) was computed as the ratio of adenosine-induced maximal hyperemic to basal average peak velocity. RESULTS: The percent diameter stenosis decreased from (mean +/- SD) 84 +/- 13% to 37 +/- 18% after angioplasty and to 8 +/- 8% after stenting (both p < 0.05). CVR was minimally changed from 1.70 +/- 0.79 at baseline to 1.89 +/- 0.56 (p = NS) after angioplasty but increased to 2.49 +/- 0.68 after stent placement (p < 0.01 vs. before and after angioplasty). IVUS lumen cross-sectional area was significantly larger after stenting than after angioplasty (8.39 +/- 2.09 vs. 5.10 +/- 2.03 mm2, p < 0.05). Anatomic variables were related to increasing coronary flow velocity reserve (CVR vs. IVUS lumen area: r = 0.47, p < 0.005; CVR vs. quantitative coronary angiographic percent area stenosis: r = 0.58, p < 0.0001). CONCLUSIONS: In most cases, increases in CVR were associated with increases in coronary lumen cross-sectional area. These data suggest that impaired CVR after angioplasty is often related to the degree of residual narrowing, which at times may not be appreciated by angiography. A physiologically complemented approach to balloon angioplasty may improve procedural outcome.

Angioscopy variables predictive of early angiographic outcome after excimer laser-assisted coronary angioplasty.

This study attempted to determine whether anatomic findings at angioscopy were associated with adverse early angiographic outcomes following excimer laser-assisted coronary angioplasty. Predictive factors of either coronary abrupt vessel closure or early (< or =24 hours) restenosis after percutaneous coronary angioplasty, including clinical and angiographic variables, have been widely evaluated. The role of angioscopic findings may contribute to identification of patients at risk for early poor outcome. Thirty-seven patients with severe lesions, including 23 total occlusions which underwent successful percutaneous transluminal coronary angioplasty (PTCA) with laser irradiation and adjunctive balloon dilatation (n = 35), or stand alone laser (n = 2), had concomitant angioscopic imaging of the target vessel. All patients had a 24-hour angiographic follow up. Early unfavorable outcome (n = 15) was defined as abrupt vessel closure or restenosis (> or = 50% stenosis) at 24 hours. By multivariate logistic regression analysis, immediate post-PTCA residual percent stenosis was associated with a poor outcome (restenosis: 33 +/- 22% vs no restenosis: 21 +/- 14%, p = 0.05). Angioscopic red thrombus aspect was the most significant correlate for early closure or restenosis (7 of 15 patients with unfavorable outcome vs 2 of 22 patients with favorable outcome, odds ratio, 22.9; p < 0.01) and was associated with a significantly higher early minimal lumen diameter loss (1 +/- 0.8 mm in the presence of a red thrombus vs 0.3 +/- 0.5 mm without thrombus, p < 0.005). Red thrombus appearance is associated with an unfavorable early angiographic outcome in patients who undergo laser-assisted coronary angioplasty.

Coronary laser angioplasty.

Balloon angioplasty was introduced among the armament of therapy for coronary heart disease in 1977 by Gruentzig in Zurich. Since the first case was successful, this method of treatment spread out rapidly so that at the present time, more than 400,000 procedures are being performed per year in the U.S. The reasons for such on explosive success includes the relative safety of the procedure, the reduction in cost as compared to surgical bypass procedures, the short in-hospital stay, and short recovery time.

[Coronary disease: should images be treated?]. / Maladie coronaire: faut-il traiter des images?

Precise digitized images of the coronary arteries displaying the dimensions of high risk stenoses and giving objective measurements of their contours and density can be provided by coronarography. On-line angioscopic images of tissue flaps floating in the lumen, recent or structured thrombi, artery wall dissections, plaque ruptures, deep fissurations and sub-intimal haemorrhages demonstrate, in live colour, the pathophysiological mechanisms of coronary artery stenosis. Histological sections of the artery wall, without biopsy, can be visualized with endocoronary echography offering a global view of the wall and differentiating all the physiological layers including the intima and the internal elastic lamina, the blood-wall interface, the media and the adventitia. Our technical imaging capacity is impressive, but is anatomic imaging synonymous with coronary circulation? Certainly not. Sophisticated imaging techniques have led us to associate the severity of the stenosis with its effect on myocardial irrigation, but today therapeutic decisions require not only considering coronary anatomy but also downstream consequences which can be evaluated by measuring coronary artery flow on both sides of the stenosis. Carried on the tip of the angioplasty guide, a piezo-electric crystal emits and receives a Doppler signal. The data is processed in real time giving a complete pattern of blood flow velocity and describing diastolic and systolic flow, differences between upstream and downstream flow, and the effect of pharmacological or physiological tests such as maximal dilatation to measure coronary vascular reserve. Transstenosic pressure measurements complete the diagnostic armentorium. Thus therapeutic decisions can now be made not only on the basis of precise anatomic imaging, but also on functional imaging, giving a complete view of the pathophysiology of the coronary arteries and the effect of disease on myocardial blood supply. It is now up to us to optimize these imaging techniques and to propose treatments which provide patients with coronary artery disease with the best benefit-risk-cost ratio.

In vitro study of a radiofrequency guidewire aimed at recanalization of totally occluded peripheral arteries.

A novel radiofrequency ablative system (40 msec-train pulses with twenty 200 msec pulses at the carrier frequency of 750 KHz and 1 Hz repetition rate) aimed at recanalizing totally occluded peripheral arteries was investigated by means of in vitro tissue ablation from human postmortem arterial wall samples. The samples were submitted to irradiation with a guidewire 150 cm long, maximum diameter of ceramic tip 0.033 inch positioned perpendicular to the tissue surface in saline, contrast medium or blood using varying generator power. Ablation efficacy was determined as the depth of vaporization per pulse delivered. Electrical current for the train duration was measured as voltage at the 1 ohm-resistor. In saline, the ablation efficacy increased from 8 to 65 microns/pulse with generator power increasing from 11 W to 27.5 W. There was no significant difference in the ablation efficacy between saline and blood. In contrast medium, the ablation efficacy was significantly lower. For the same generator power, the electrical current varied during the ablation procedure from 1.3 +/- 0.2 A at the beginning of the procedure to 1.1 +/- 0.2 A after the first pulses and to 2.0 A before artery wall perforation occurred. Neither tissue ablation nor current variations were observed when radiofrequency energy was emitted on calcified tissue. The diameter of craters was 0.89 +/- 0.1 mm (range: 0.85-0.96 mm). No major thermal injury such as carbonization or charring was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous angioscopy in patients with restenosis after excimer laser coronary angioplasty.

Coronary angioscopy was performed in two patients with restenosis after excimer laser coronary angioplasty to improve our knowledge of restenosis after excimer laser angioplasty. The characteristics of the angioscopic findings in restenosis after excimer laser angioplasty consisted of smooth white plaques, which were distinctly different from the yellow plaques commonly observed in primary lesions. These findings indicate that restenosis in these patients after excimer laser angioplasty may be associated with smooth muscle cell proliferation and fibrosis.

Acute complications of excimer laser coronary angioplasty: a detailed analysis of multicenter results. Coinvestigators of the U.S. and European Percutaneous Excimer Laser Coronary Angioplasty (PELCA) Registries.

OBJECTIVES: The aim of this study was to document and analyze the incidence and consequences of complications of excimer laser coronary angioplasty. BACKGROUND: Excimer laser coronary angioplasty has been reported to be a safe and feasible alternative or adjunct to conventional balloon angioplasty, but serious and unique complications have been observed. METHODS: Data on 1,595 interventions of excimer laser coronary angioplasty in 1,521 patients were analyzed, using a merged data base from the U.S. and European Percutaneous Excimer Laser Coronary Angioplasty (PELCA) registries. RESULTS: Procedural success was achieved in 89.3% of interventions. Stand-alone laser angioplasty was performed in 17.8% of interventions. Complications included dissection (22.0%), vasospasm (6.1%), filling defects (4.8%), abrupt reclosure (6.1%), embolization (2.3%), perforation (2.4%), arrhythmia (0.7%) and aneurysm formation (0.3%). Major complications were non-Q wave myocardial infarction (2.3%), Q wave myocardial infarction (1.0%), coronary artery bypass grafting (3.1%) and death (0.7%). Logistic regression analysis revealed correlation between dissections and the use of larger catheter size (p = 0.0005), high energy per pulse levels (p = 0.0001 for native vessels), lesion length > 10 mm (p = 0.001) and presence of a side branch (p = 0.01). The incidence of perforations was higher in women (p = 0.004), in treatment of total occlusions (p = 0.02) and in the presence of a side branch (p = 0.03). Fatal complications were correlated with patients with multivessel disease (p < 0.0001), patients with acute myocardial infarction (p = 0.0009) and older patients (> 70 years old, p = 0.004). The incidence of major complications decreased after performance of 50 laser angioplasty procedures at one institution (p = 0.02). CONCLUSIONS: This analysis defines both the learning curve and the profile of complications for excimer laser angioplasty and provides insight into the selection of appropriate patients and proper performance of the procedure.

Angioscopy after laser and balloon coronary angioplasty.

OBJECTIVES: Percutaneous intracoronary angioscopy was used to study the morphologic changes occurring in coronary arteries after balloon or laser angioplasty. BACKGROUND: Angioscopy is thought to provide details of the coronary vessel lumen and the inner wall. METHODS: Coronary lesions were studied in 44 patients with a 4.5F Imagecath angioscope before and after each interventional procedure. Balloon and laser angioplasty were performed in 21 (group I) and 23 patients (group II), respectively. There was no difference in age, gender or angiographic lesion appearance before the procedure between the two groups. RESULTS: Circumferential visualization of the target lesion was successfully completed in 17 group I and 19 group II patients. A larger lumen than that observed at baseline was seen in all 17 group I and in 13 of the 19 group II patients. Tissue remnants were observed in all group I and II patients. Laser irradiation resulted in characteristic sharp-edged craters. Dissection was identified in 2 of 19 patients before versus 9 of 19 patients after balloon angioplasty (p < 0.05) and in 0 of 23 patients before versus 4 of 23 patients after laser angioplasty (p = NS). Subintimal hemorrhage was observed in 3 of 19 patients before versus 11 of 19 patients after balloon angioplasty (p < 0.05) and in 2 of 23 patients before versus 4 of 23 patients after laser angioplasty (p = NS). The frequency of hemorrhage was higher in group I than in group II (11 of 19 vs. 4 of 23, respectively, p < 0.02). CONCLUSIONS: Angioscopy provides valuable information on lesion morphology after coronary interventions. Balloon dilation results in a high rate of dissection and subintimal hemorrhage. Laser angioplasty is able to ablate obstructing tissue and results in a lower rate of subintimal hemorrhage than balloon dilation.

[Implantation of Strecker's endocoronary prosthesis. Apropos of 21 cases]. / Implantation de prothèses endocoronaires de Strecker. A propos de 21 cas.

The aim of this study was to assess the safety and efficacy of implantation of Strecker coronary stents. The implantation was performed in 21 patients during elective angioplasty (N = 18) or in emergency situations (N = 3). The indications were acute occlusion after angioplasty (N = 3), restenosis (N = 12), incomplete balloon angioplasty results (N = 4) and implantation of first intent (N = 2). The site of implantation was a venous bypass graft in 9 cases, the left anterior descending artery in 5 cases, the right coronary artery in 4 cases and the left circumflex in 3 cases. The average length of the lesions was 8.4 +/- 4.1 mm, including 15 short (< 10 mm) and 6 long (> 10 mm) lesions. Four lesions were located at an acute angle (> 45 degrees) and 4 at the site of origin of a side branch. The diameter of the normal segment of the treated artery was < 3 mm in 12 cases and > 3 mm in 9 cases. Seven 3 mm, five 3.5 mm, six 4 mm and three 4.5 mm diameter stents were implanted. There were no failures to position or implant the stents. After the implantation, the minimal lernen diameter of the artery at the angioplasty site was greater than that obtained with balloon (2.87 +/- 0.67 mm versus 1.83 +/- 1.11 mm, p < 0.001). There was no early restenosis at control angiography at 24 hours (2.78 +/- 0.20 mm versus 2.87 +/- 0.67 mm NS).(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of coronary vasomotricity by intracoronary ultrasonography]. / Evaluation de la vasomotricité coronarienne par échographie endocoronaire.

Coronary vasomotion dependent on the endothelium and on the smooth muscle has been intensively studied by quantitative angiography and intracoronary Doppler. Intracoronary ultrasound is a new imaging technique which allows precise measurement of the section of the coronary artery. This study was undertaken to assess the value of intracoronary ultrasound in the investigation of epicardial coronary artery vasomotion. Twenty hypercholesterolaemic patients with irregularity of the arterial lumen on angiography and 6 normo-cholesterolaemic subjects with normal coronary angiogram (control group) were included. An intracoronary ultrasonic catheter with a rotating mirror (4.3 French, CVIS) emitting at 30 MHz was positioned in the proximal segment of a coronary artery. Endothelial function was studied during sympathetic stimulation by a cold pressor test and during increased coronary flow by local injection of papaverine. The intima of the coronary arteries of the patient group was significantly thicker than that of the control group. The cold test induced significant paradoxical vasoconstriction of the atheromatous coronary arteries and a significant vasodilatation of the coronary arteries of the control group. The increased coronary flow tended to constrict the ateromatous arteries but significantly dilated the normal arteries. Administration of Linsidomine (SIN-1) induced vasodilatation by direct relaxation of the smooth muscle in both groups. No correlation was observed between the thickness of the intima measured by intracoronary ultrasound and the abnormal vasomotor response to the vasomotion different stimuli. The results of this study concord with those of studies of coronary by quantitative angiography. Intracoronary ultrasound provides an accurate method of studying coronary endothelial function and the vasomotor tone of the epicardial coronary arteries.

Restoration of coronary blood flow in severely narrowed and chronically occluded coronary arteries before and after angioplasty: implications regarding restenosis.

The restenosis rate after recanalization of chronic totally occluded coronary arteries is high. This may be due to a competitive flow or a low coronary flow velocity. This study was designed to assess differences in coronary blood flow velocity between severely narrowed and occluded arteries before and after successful percutaneous transluminal coronary angioplasty. Thirty-five patients were studied including 12 with an occluded vessel (group 1) and 23 with a stenosis (group 2). Rest and peak hyperemic (papaverine) coronary blood flow velocities were measured. Before successful percutaneous transluminal coronary angioplasty, velocity was lower in occlusions than in stenoses (3.8 +/- 2.1 vs 7.9 +/- 4.8 cm/sec; p < 0.02), whereas resistance was higher (31.7 +/- 20.8 vs 13.7 +/- 7.0 mm hg/cm/sec, respectively; p = 0.0009). There was no significant difference in vasodilator reserve between the two groups. After successful percutaneous transluminal coronary angioplasty, the velocity increased in both groups and the resistance index decreased. Velocity and resistance were similar in the two groups. The vasodilator reserve did not change after the procedure. It was concluded that the coronary flow velocity achieved after successful recanalization of chronic totally occluded arteries is similar to that observed after dilation of stenoses. These results do not support the hypothesis that the high rate of restenosis in recanalized chronically occluded vessels is due to differences in post-percutaneous transluminal coronary angioplasty blood flow velocity.

Clinical results of coronary excimer laser angioplasty: report from the European Coronary Excimer Laser Angioplasty Registry.

From January 1991 to January 1993 the clinical and angiographic data of 470 patients were included in the European Coronary Excimer Laser Angioplasty Registry. Symptoms were CCS class 3 in 23% and CCS class 4 in 14.7%; unstable angina was present in 14.7% and 6.6% of patients had acute myocardial infarction. Of 477 treated lesions, 60% were type B2, and 19% type C. The lesion was located in the LAD in 61%, in the LCX in 16%, in the RCA in 20%, in a protected left main stem in 1.3% and in a saphenous vein graft in 2.5%, respectively. Failure of laser angioplasty occurred in 56 (12%) interventions. By multivariate analysis failure was associated with the intention to treat long segmental lesions (risk ratio (RR) 3.6, confidence interval (CI) 2.9 to 4.4; P = 0.0005), segments with severe prestenotic tortuosity (RR 3.5, CI 2.4 to 4.6; P = 0.02) and total occlusions (RR 2.1; CI 1.4 to 2.8; P = 0.05). Complications included vasospasm (13.4%), dissection (14.7%), flow limiting dissection (4%), reclosure (7.8%), and perforation (1.9%). Myocardial infarction occurred in 2.1%, CABG was requested in 1.9%, and the mortality was 1.5%. Procedural success was achieved in 89%. Individual morphological criteria for a reduced procedural success were the presence of a thrombus (RR 6.4; CI 5.0 to 7.7; P = 0.007) and vessel calcification (RR 2.6; CI 1.9 to 3.2; P = 0.005). Procedural success was slightly lower in type C lesions (86%) than in type B2 (88%) type B1 (95%), and type A lesions (92%), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)