Mes ennemis, les facteurs de risque My enemies, the risk factors.

We have to distinguish between non-modifiable risk factors such as age, gender, heredity, (we cannot fight against these enemies), and modifiable risk factors (avoidable) such as hypertension, smoking, diabetes, and dyslipidemia. Environmental factors, bad diet, sedentary lifestyle, and smoking are the basis of these risk factors. Cardiovascular disease due to these risk factors is clinically silent during a given period, then symptoms occur which can eventually lead to death. Nine risk factors explain the occurrence of 90 % of myocardial infarctions (MI), their correction avoid 80 % of MI. Despite the presence of several studies proving that secondary prevention reduces coronary mortality, the management of cardiovascular risk factors is not optimal.

[Infectious and inflammatory complications occurring after cardiac surgery in cardiac rehabilitation centres]. / Complications infectieuses et inflammatoires après chirurgie cardiaque survenues dans les services de réadaptations cardiaques.

Patients undergoing cardiac surgery are older, have complex pathologies and several comorbidities, but need to leave the hospital quickly! Therefore, the mission of cardiac rehabilitation centres has substantially changed. Indeed, if 15 to 25% of patients undergoing cardiac surgery will have a postoperative complication requiring a hospital management (infectious, pericardial, rhythmic, neurologic, pulmonary, digestive, etc.), more than 2/3 of these acute events could be managed by cardiac rehabilitation centres for a lower cost. Therefore, the quickest the patient is transferred to a cardiac rehabilitation centre, the easier the cardiac surgery centre could manage his beds. Infectious complications are the most dreadful, particularly mediastinitis.

[Rehabilitation of valvular patient]. / La réadaptation du patient valvulaire.

Valvular disease is the second indication of cardiac rehabilitation (CR) after coronary artery disease. Patients suffering valvular disease are addressed to CR after valvular repair, and are usually old. Valvular replacement are the most frequent, and more and more patients being treated by TAVI are addressed to CR. CR takes place on two phases: From the seventh (day 7) to the fifteenth (day 15) day: management of complications, respiratory physio, and help to autonomy if necessary. From the fifteenth day (day 15): rehabilitation to exercise after an exercise stress test with or without MVO2 measurement. Because the patients are taking anticoagulants and are at risk of endocarditis, therapeutic education takes an important place during the stage. CR of patients suffering valvular disease has demonstrated its usefulness with: An increase of exercise capacity in all kind of valvular disease; A reduction of left ventricular hypertrophy in patients with aortic valve stenosis. No serious complication was observed in all studies regarding CR in patients with valvular disease.

[Cardiac rehabilitation in elderly patient]. / Réadaptation cardiaque du sujet âgé.

According to "OMS" we are old at age 65. Because of the ageing population (life expectancy has increased in Europe) and medical progress, more and more old patients are addressed to cardiac rehabilitation centers. Ageing is a physiological process which varies between individuals, and in the same person organ ageing also differs. Old patient has usually several pathological diseases. Because old patient has restricted functional reserve, acute illness could get him closer to the decompensation area. Complications are more frequent in ageing people, and often need a specific initial treatment which delays rehabilitation. Rehabilitation program of old non-disabled patient is not different from that addressed to youngers. The main objective for dependent people is to restore the ability to perform activities of daily living. Correction of vascular risk factors and therapeutic education are also valuable in elderly. For patients with difficulty to remember or to understand instructions, family help is valuable when possible. The benefit of the rehabilitation in the elderly is demonstrated by several studies.

[Exercise-induced coronary thrombosis]. / Thrombose coronaire à l'effort.

Heavy exertion as a trigger of cardiac events has been known since antiquity as it was already described in 492 BC in the famous Athens Marathon. Myocardial infarction occurring after physical exertion accounts for about 4% of myocardial infarctions. It is more common in men and younger patients. It usually occurs during intense efforts and especially in inactive people with multiple risk factors. It would be more severe with more frequent Q waves of necrosis on the victims' electrocardiograms, with greater troponin release and a more raised GRACE score. Atherosclerotic plaque rupture is at the center of its pathophysiology, this event is responsible of a thrombus formation occluding the coronary artery. The hemodynamic stress imposed on the often-atheromatous coronary arteries during exercise, favor the plaque rupture and the occurrence of myocardial infarctions. To these hemodynamic constraints, are added biochemical and rheological modifications, which favor the formation of an intra-coronary thrombus. The occurrence of acute coronary events during heavy exertion in patients who are often untrained must not make us forget about the benefit of regular exercise on both the life quality and morbimortality levels.

[Short-term exercise-based cardiac rehabilitation induced changes in cardiorespiratory, mechanical and neuromuscular responses to progressive exercise testing]. / Dissociation des réponses cardiorespiratoires et neuromusculaires à l'exercice à la suite de 4 semaines de réentraînement à l'effort chez des patients cardiaques.

Previous studies showed that changes in peak of oxygen uptake value (VO2peak) with training were poorly related to changes in Maximal Tolerated Power output (MTP) among patients with cardiovascular disease. This result could be due to a difference between cardiopulmonary adaptation to training and the skeletal muscle conditioning. OBJECTIVE: The aim of the study was to compare the responses to exercise training of electromyographic activities of vastus lateralis (rms-EMG) and respiratory parameters. METHODS: Nine cardiac patients (64.0±3.1y, 172.9±4.8cm, 83.4±16.3kg, BMI: 27.8±4.5) performed an incremental cycling exercise test to determine MTP, VO2peak and peak values of heart rate, before and after an aerobic training. Ventilatory thresholds were respectively determined as the breakpoint in the curve of carbon dioxide output against oxygen uptake plot (VT1) and the point at which the ratio of minute ventilation to carbon dioxide output starts to increase (VT2). EMGth1 and EMGth2 were defined as the first and the second breakpoints in the rms-EMG - power output relationship. RESULTS: Short-term exercise training (23.7±8.8 days) induced a significant increase in VO2peak (P=0.004), MTP (P=0.015), VT1 (P=0.001) and VT2 (P=0.001). Changes in VO2peak only attained the survival criteria (3.5±2.9mLmin-1kg-1). No significant differences (P>0.05) existed between mean power values of VT1 and EMGth1 (60.5±4.1 vs. 59.2±9.6% of MTP, respectively), or between VT2 and EMGth2 (78.3±5.7 vs. 80.2±5.2% of MTP). After training, EMGth1 occurred significantly before VT1 (60.5±6.2 vs. 64.8±4.8% of MTP, P=0.049). CONCLUSION: This might be taken into account for prescribing exercise rehabilitation according initial clinical limitations of patients.

Exercise-based Cardiac Rehabilitation in Coronary Disease: Training Impulse or Modalities?

To compare the effects of 2 short programs with similar training load (TL), based on combined aerobic - resistance training (CT) or aerobic training (AT) on cardiorespiratory responses, 32 patients with coronary heart disease (CHD: 63.8±8.0y, 1.73±0.06 m, 84.8±15.9 kg, Left Ventricular Ejection Fraction: 0.53±0.8) performed 4 weeks of exercise rehabilitation based on CT (n=16) or AT (n=16). Maximal tolerated power (MTP), peak values of oxygen uptake (VO2peak) and heart rate (HRpeak), anaerobic threshold (VT1) were determined during an incremental cycling exercise test before and after training periods. TL, quantified using the session rating of perceived exertion, did not differ between both modalities (CT: 4 438±572 vs. AT: 4 346±592 AU, p=0.300). Improvements in VO2peak were larger after CT (+36.4±24.7% of pre-training VO2peak, i. e., +4.4±2.3 mL.min-1.kg-1, n=14) than observed after AT (+20.1±9.1% of pre-training VO2peak, i. e., +2.6±1.0 mL.min-1.kg-1, n=12) (p=0.014). Additionally, CT significantly improved power (54.6±23.8 vs. 75.1±21.2 watts, p=0.001) and VO2 associated at VT1 (VO2: 9.8±2.5 vs. 12.6±2.9 mL.min-1.kg-1, p=0.001). This might be taken into account when prescribing exercise rehabilitation for CHD patients with different initial clinical limitations.

[Cardiac rehabilitation in women]. / La réadaptation cardiaque chez la femme coronarienne.

Coronary artery disease (CAD) occurs later in life in women when compared to men (10 years later). The FAST-MI study has shown that the profile of women with CAD has changed in the past 15 years, they are younger, more obese, and usually smokers. Whatever the age at which CAD occurs in women, the prognosis tends to be worse than in men, despite a higher frequency of acute coronary syndrome (ACS) with angiographically normal coronary arteries in women. In women without significant lesion at coronary angiography, the WISE study has shown abnormalities of the coronary vasomotricy. Despite its beneficial effect on morbidity and mortality, cardiac rehabilitation is underused particularly in women. Indeed, several factors do not encourage a woman to follow a cardiac rehabilitation program, even after an ACS. These factors may be cultural, domestic, familial, orthopedic, or even the fear of exercising. Therefore, physicians have to be particularly convincing in women, in order to have them participating in rehabilitation programs. Physical capacity is lower in women when compared to men. However, the weaker the physical capacity, the better the benefit of cardiac rehabilitation. Physical endurance training continuously or in interval, associated to muscle strengthening can improve the physical capacity in women. Vascular risk factors correction is also an important step for the management of women with CAD. Therapeutic education and several available workshops help women to better understand their disease and to improve their self-management when they return home. Anxiety, depression, and sexual dysfunction frequently deteriorate the quality of life of our patients. Therefore, psychological management is also essential in our departments.

[Is there a disassociation of ventilatory and electromyographic thresholds in patients with heart disease during a graded cycling exercise?] / Concordance et dissociation des seuils de fatigue électromyographiques et des seuils ventilatoires chez le patient en réadaptation cardiaque.

Exercise prescription was generally based on the determination of ventilatory thresholds (VT1, VT2) during cardiopulmonary exercise testing (CPX). Changes in surface electromyographic activity (EMGth1, EMGth2) were also related to VT1 and VT2 in healthy subjects. OBJECTIVE: To observe the occurrence of EMGth1 and EMGth2 and whether these events accompany VT1 and VT2 during CPX in cardiac patients (CP). METHOD: Thirty-four CP (62.1±7.3years, 172.1±6.3cm, 81.3±15.3kg, BMI: 27.3±4.1) performed a cycle CPX at a 60-rpm cadence. VT1 was determined as the breakpoint in the curve of carbon dioxide output against oxygen uptake plot (V-slope method). VT2 was defined as the point at which the ratio of minute ventilation to carbon dioxide output starts to increase. The root mean square of electromyogram (rms-EMG) was on-line calculated from the real time bipolar surface electromyographic signals recorded from the vastus lateralis. EMGth1 and EMGth2 were defined as the first and the second breakpoints in the rms-EMG-power output relationship. RESULTS: Peak values of oxygen uptake (16.3±4.6mL·min-1·kg-1) and heart rate (106.7±13.8bpm) were reached at 112.9±38.5w (PMT). VT1 and VT2 occurred at 71.1±25.9w (62.5±5.5% PMT) and 87.9±28.6w (78.0±5.1% PMT). All subjects presented two breakpoints in the rms-EMG curve, EMGth1 at 68.0±24.7w and EMGth2 at 88.5±30.1w, i.e. 60.0±7.6 and 78.6±5.0% of PMT. EMGth1 occurred significantly before VT1 (P=0.004, small effect size). No significant difference was observed between EMGth2 and VT2 (P=0.13, small effect size). CONCLUSION: The EMGth1 occurrence before VT1 suggested a role of skeletal muscle conditioning on ventilatory responses, which should be taken into account in cardiac rehabilitation program prescription.

[Cardiac rehabilitation after myocardial infarction]. / La réadaptation cardiaque en postinfarctus du myocarde.

Although the proofs of the benefits of cardiac rehabilitation accumulate, many patients are not sent to rehabilitation units, especially younger and very elderly patients. As the length of stay in acute care units decreases, rehabilitation offers more time to fully assess the patients' conditions and needs. Meta-analyses of randomised trials suggest that mortality can be improved by as much as 20-30%. In addition, rehabilitation helps managing risk factors, including hyperlipidemia, diabetes, smoking and sedentary behaviours. Physical training also helps improving exercise capacity. Because of all of these effects, cardiac rehabilitation for post-myocardial infarction patients has been given a class IA recommendation in current guidelines.

[Muscle retraining or aerobic endurance training? What will improve the aerobic capacity of patients with coronary disease in the only 4 weeks?]. / Modalités ou charge de réentraînement: quelle modalité choisir pour améliorer l'aptitude aérobie du patient coronarien en seulement 4 semaines?

OBJECTIVE: The aim of this study was to compare the effects of 4 weeks of CT and AT, which training impulse (total external workload and perceived exertion), are similar on power associated at VO2 peak (pVO2 peak) and cardiorespiratory responses of patient with CAD. METHOD: Eighteen male with CAD (62 ± 7 years, 175 ± 2 cm, 84 ± 16 kg, fraction of ejection = 0.49 ± 0.16) performed 4 weeks of CT (n = 9) or AT (n = 9). pVO2 peak, maximal and first ventilatory threshold values of oxygen uptake (VO2 peak, VO2-vt) and heart rate (HRmax, HR-vt) were measured before and after training session. Total training impulse (exercise rehabilitation and other paramedical actions) were evaluated and harmonized between AT and CT according to Foster et al. formula (1996) RESULTS: No significant difference were found in training impulse between AT and CT (3650 ± 220 vs 3497 ± 190 U, P = NS). VO2 pic increased after AT (16.9 ± 4.4 vs 18.9 ± 4.9 mL O2/min/kg, P < 0.05) and remained unchanged after CT (17.7 ± 7.8 vs 17.8 ± 7.2, P = NS). Four weeks of training induced significant increase in pVO2 peak, VO2-vt and FC-vt, expressed in absolute or relative value (P < 0,05), without any difference between AT and CT modalities (P = NS). CONCLUSIONS: Improving pVO2 pic following an exercise training does not necessarily preclude an improvement in coronary VO2 pic. pVO2 peak was not improved with the same cardiorespiratory adaptations between AT and CT. Thus, there seems important to measure gas exchanges of subject with CAD during the incremental test and identify the respective part of muscular and cardiorespiratory functions in exercise exhaustion.

[Cannabis and acute coronary syndrome with ST segment elevation]. / Cannabis et syndromes coronariens aigus avec sus-décalage de ST.

Cannabis is the most common substance of drug abuse in the world and has euphoric and hallucinogenic effects. Its cardiovascular effects are well-known. However, there is limited information concerning cannabis-induced acute coronary syndrome and the exact contribution of cannabis smoking to coronary artery disease. We report and discuss a case of ST-Elevation acute coronary syndrome occurring in a young patient aged 24 years, who was a heavy cannabis smoker.

[Non-invasive coronary flow reserve is an independent predictor of exercise capacity after acute anterior myocardial infarction]. / La réserve coronaire non invasive est un prédicteur indépendant de la capacité d'exercice après infarctus antérieur aigu.

BACKGROUND: After acute myocardial infarction (MI) coronary microvascular impairment and reduced exercise capacity are both determinant of prognosis. OBJECTIVE: We tested whether non-invasive coronary flow reserve (CFR) performed after MI predicts post-MI exercise capacity (EC). METHODS: Fifty consecutive patients (pts) (mean age 56.5±11years, 30% women) with a first reperfused ST-elevation anterior MI, and sustained TIMI 3 flow after mechanical reperfusion, underwent prospectively non-invasive CFR in the distal part of the left anterior descending artery (LAD), using intravenous adenosine infusion (0.14mg/kg per minute, within 2min), within 24h after successful primary coronary angioplasty (CFR 1), and 4±1.6months later after a period of convalescence and a cardiac rehabilitation program (CFR 2). CFR was defined as peak hyperaemic LAD flow velocity divided by baseline flow velocity. All pts also underwent semi-supine exercise stress echocardiography (ESE) the same day of CFR 2. ESE was performed at an initial workload of 25-30watts with a 20watts increase at 2-minute intervals. Beta-blockers were withheld 24h before ESE. RESULTS: The mean CFR 2 increased significantly when compared to CFR 1 (2.9±0.65 versus 1.9±0.4, P<0.01). During ESE, percentage of maximal predict heart rate achieved was 82±12%, maximal workload 95±30watts, exercise duration 486±155s, the ratio of double product 3.1±0.8, and EC 5.8±1.1 metabolic equivalents. No ischemia was induced during ESE in all pts, and the degree of mitral regurgitation did not differ significantly between rest and exercise. CFR 2 was significantly correlated to all indices related to EC (all, P<0.01), whereas CFR 1 was correlated to LV systolic function at follow-up (P<0.05) but not to EC. In multivariate analysis including age, sex, and body mass index, CFR 2 remained an independent predictor of EC (P<0.01). CONCLUSION: Contrarily to acute CFR, CFR at follow-up is an independent predictor of EC after reperfused anterior MI. This suggests that the improvement of the coronary microcirculation is closely linked to the physical aptitude after MI.

[Sirolimus-eluting stent displaced fracture: case report and review of the literature]. / Fracture déplacée d'un stent actif au sirolimus : à propos d'un cas et revue de la littérature.

Drug-eluting stents have greatly reduced the risk of in-stent restenosis compared to bare metal stents by inhibiting neointimal growth. However, they may carry some long-term risks, especially the risk of late stent thrombosis. Recently, several cases of drug-eluting stent fracture have been also reported. The mechanisms, the diagnosis, the clinical implications and the management of this new complication are not well-known. We report the observation of a new case of displaced, sirolimus drug-eluting stent fracture. To our knowledge, this is the first reported case in France.

[Cardiac rehabilitation after acute myocardial infarction]. / La réadaptation cardiaque en post-infarctus du myocarde.

At the time of evidence-based medicine, while the proofs of the benefits of cardiac rehabilitation to the coronary multiply, a large number of patients are still managed without any form of rehabilitation. In particular, younger patients with myocardial infarction treated by early reperfusion and older subjects. The objective of in-hospital or ambulatory cardiac rehabilitation is a global coverage of the patient and his/her risk factors, that the short duration of hospitalization in the acute phase does not allow. Several randomized studies, metaanalyses, and registers show a decrease from 20 to 30% of the mortality after cardiac rehabilitation. The benefits of physical training on risk factors modification are demonstrated by numerous works: improvement of lipid parameters and arterial pressure, prevention of diabetes, increased smoking cessation, loss of weight, better overall well-being; besides the management of risk factors, physical training improves exercise capacity, a recognised prognostic factor. The efficiency of cardiac rehabilitation may be comparable with that of the key treatments of coronary artery disease, such as beta-blockers or coronary angioplasty. All these proofs give to the cardiac rehabilitation in post-myocardial infarction a high-level recommendation, grade IA.

[Legionella myopericarditis]. / Myopéricardite à Legionella.

Cardiac involvement in legionella infection is rare but it is the most common extra-pulmonary complication. It usually takes the form of pericarditis, but a case of legionella myoparicarditis with global left ventricular hypokinesia on echocardiography has been described. The authors report a case of myopericarditis with massive pulmonary oedema and respiratory distress which regressed clinically and on echocardiography with reduction in chamber dilatation and complete recovery of left ventricular function. Legionellosis was confirmed on serology. The infection was probably contracted during a previous hospital admission, therefore, probably a nosocomial infection. Following the description of this case, a review of the literature is proposed.

[Repolarization anomalies in postoperative ECG after aorto-coronary bypass]. / Anomalies de repolarisation de l'ECG post-opératoire des pontages aorto-coronaires.

The authors studied 164 patients admitted in 1994 to their rehabilitation centre less than 5 weeks after a coronary artery bypass graft. They performed an ECG on admission and noted the presence and localization of repolarization abnormalities such as a flat or negative T wave as well as the presence of QRS abnormalities, such as conduction disorders or sequelae of necrosis. The abnormalities were compared with the presence and severity of the pericardial reaction on ultrasonography and in the revascularized territories. Two-thirds of patients presented repolarization abnormalities in the anteroseptoapical (ASA) territory, regardless of the intensity of the pericardial reaction. 88% of patients with no QRS abnormalities (75 patients), had an ASA repolarization abnormality. 80% of patients presenting sequelae of isolated inferior necrosis had normal ASA repolarization. The intensity of the pericardial reaction does not determine the presence of postoperative repolarization abnormalities, but rather "myocardial" abnormalities and especially sequelae of inferior necrosis which "normalize" ASA repolarization in 80% of cases, which raises a doubt about the mechanism of these repolarization abnormalities.

[Isolated congenital diverticulum of the left ventricle disclosed by ventricular tachycardia in a 72-year-old woman]. / Diverticule congénital isolé du ventricule gauche découvert par une tachycardie ventriculaire chez une femme de 72 ans.

A 72-year-old woman presented with poorly tolerated ventricular tachycardia reduced by intravenous amiodarone. The possibility of an ischaemic aetiology led us to perform coronary angiography. The coronary arteries were pathological. Left ventricular angiography revealed limited anterior hypokinesia and a large contractile apical pouch appended to the left ventricle by a long narrow neck. Despite the appearance suggestive of congenital left ventricular diverticulum (contractility, narrow neck) and because of the coexistence of ischaemic heart disease, we preferred to confirm the muscular nature of the diverticulum by myocardial thallium scintigraphy, which showed reversible decreased uptake in the anterior zone related to coronary artery disease, and confirmed the muscular nature of the diverticulum which showed normal thallium uptake. MRI clearly visualized the ventricular ectasia attached by a narrow neck to the rest the left ventricle. This long narrow neck indicated that this muscular diverticulum constituted a congenital diverticulum. The contribution of ultrasonography was limited by a poorly defined point during the examination. This congenital diverticulum, discover during adulthood, and previously asymptomatic, is a rare lesion, in the light of a review of the literature.

AREVA: multicenter randomized comparison of low-dose versus standard-dose anticoagulation in patients with mechanical prosthetic heart valves.

BACKGROUND: Moderate anticoagulation may be proposed to reduce the risk of hemorrhage for certain patients with a mechanical prosthesis, but the consequences for risk of thromboembolism are debated. METHODS AND RESULTS: The purpose of the AREVA trial was to compare moderate oral anticoagulation (international normalized ratio [INR] of 2.0 to 3.0) with the usual regimen (INR of 3.0 to 4.5) after a single-valve replacement with a mechanical prosthesis, either Omnicarbon or St Jude. Patients included were between 18 and 75 years old, in sinus rhythm, and with a left atrial diameter < or = 50 mm on the time-motion echocardiogram. Patients were randomized for INR after surgery. From 1991 to 1994, 433 patients underwent valve replacement (aortic, 414; mitral, 19) with 353 St Jude and 80 Omnicarbon prostheses; 380 patients were randomized for INR: 188 for INR 2.0 to 3.0 and 192 for INR 3.0 to 4.5. Mean follow-up was 2.2 years (1 to 4 years). Analysis of 18001 INR samples showed that the mean of the median of INR was 2.74 +/- 0.35 in the 2.0 to 3.0 group and 3.21 +/- 0.33 in the 3.0 to 4.5 group (P < .0001). Thromboembolic events, as assessed from clinical data and CT brain scans, occurred in 10 patients in the 2.0 to 3.0 INR group and 9 patients in the 3.0 to 4.5 INR group (P = .78). Hemorrhagic events occurred in 34 patients in the 2.0 to 3.0 INR group and 56 patients in the 3.0 to 4.5 INR group (P < .01), with 13 and 19 major hemorrhagic events, respectively (P = .29). CONCLUSIONS: In selected patients with mechanical prostheses, moderate anticoagulation prevents thromboembolic events as effectively as conventional anticoagulation and reduces the incidence of hemorrhagic events.

[Restenosis on coronary endoprosthesis: treatment by implantation of a new endoprosthesis. Apropos of a case]. / Resténose sur endoprothèse coronaire: traitement par implantation d'une nouvelle endoprothèse. A propos d'un cas.

A 60-year-old man was admitted to hospital with threatened anterior myocardial infarction due to double tight stenosis in the 1st and 2nd segments of the left anterior descending artery. This double stenosis was successfully treated, without any complications, by two Palmatz-Schatz 15.4 mm (PS 154 A) coronary stents. He was readmitted to hospital six months later for another episode of threatened anterior infarction, due to restenosis involving the 2 coronary stents. Balloon angioplasty of this restenosis was attempted, but the poor result led us to insert 2 contiguous articulated Palmatz-Schatz 154 mm stents (PS 154 A) inside the previous two stents. The result was excellent with no complications apart from distal dissection induced by the guide, requiring insertion of an AVE Stent, 8 mm long and 3 mm in diameter. An exercising myocardial scintigraphy performed one month after the procedure was normal. The patient is still asymptomatic with a follow-up of 6 months. The feasibility and low risk of complication of balloon angioplasty in the case of restenosis, after insertion of an intracoronary stent have been demonstrated by several studies. To our knowledge, no case of restenosis of an intracoronary stent, treated by insertion of a new stent, have been reported. We report a case of restenosis on two Palmatz-Schatz stents successfully treated by insertion of two contiguous PS 154 A stents.