[Pre-hospitalization treatment with Abciximab in the preparation of patients for primary angioplasty in the acute phase of myocardial infarct. Immediate and long-term (one month) results]. / Traitement préhospitalier par abciximab des patients candidats à une angioplastie primaire en phase aiguë d'infarctus du myocarde. Résultats immédiats et à l mois.

Percutaneous transluminal coronary angioplasty (PTCA) is an alternative to fibrinolysis in the treatment of acute myocardial infarction (AMI). However, after balloon PTCA, the rate of early re-occlusion, of re-infarctus and of restenosis remains high. Stent implantation with antiplatelet drug regimen (aspirin, ticlid) limits these risks. Abciximab (new GPIIb/IIIa receptors inhibitor) reduces PTCA complications rate in the acute coronary syndromes. Intravenous administration of abciximab can restore a normal flow in the infarcted related coronary artery (IRA) after few minutes. A monocentric, non randomized, prospective pilot study was iniated to assess the feasibility of pre-hospital treatment with abciximab in preparation to primary PTCA stenting in AMI (primary endpoint) and to appreciate potential benefits in initial IRA patency as well as prevention of PTCA thrombotic complications (secondary endpoint). Between April 1997 and January 1998, 38 AMI were treated with abciximab in pre-hospital phase (group A). Mobil Intensive Care Unit (MICU) team implemented the treatment and guaranteed immediate transport to the cathlab (abciximab bolus-coronary angiography time = 37 +/- 17 min). Immediate results were compared to those of 198 paired patients who were treated for AMI during the same period (Group T). Initial IRA flow TIMI grade 3 was significantly higher in group A, 24%, than in group T, 9% (p < 0.017). The rates of per-procedural complications (no flow, distal embolism), of local complications, of transfusions were not significantly different. During 1 month follow-up, there was no significant difference between group A and group T concerning death, re-MI, stent thrombosis and new revascularization. To conclude, the pre-hospital treatment with abciximab in AMI is feasible by MICU medical team without any delay of the cathlab admission. It is associated with no increased hemorrhagic complications rate. The abciximab pre-hospital treatment improves the initial IRA patency. These encouraging preliminary results expect to be confirmed by larger, multicentric, randomized and prospective studies.

Long-term follow-up of a sponge breast implant and review of the literature.

A case of a woman who underwent removal of a breast implant consistent with a polyvinyl sponge contained within a polyethylene bag is described. The use of the polyvinyl alcohol sponge as a breast implant virtually ceased in the mid 1960s with the introduction of silicone gel breast prostheses. However, it is still possible that the plastic surgeon may encounter a patient with one of these sponge implants in place. Thus, it is important for the plastic surgeon to be aware of their existence, natural history, and potential late complications. In addition, since the removal of silicone from general use for augmentation mammaplasty, there have been intense efforts to identify new filler materials for use in breast implants. Polyvinyl alcohol has been considered a possible material. There is a paucity of information in the recent literature pertaining to the characteristics and use of polyvinyl alcohol sponge implants. Therefore, this report describes a patient treated 38 years following placement of this type of implant and reviews the literature.

A retrospective study of changes in physical symptoms and body image after reduction mammaplasty.

Reduction mammaplasty is performed typically to alleviate the painful physical symptoms of macromastia. Women who suffer from macromastia also frequently present to the plastic surgeon with heightened body image dissatisfaction and maladaptive behavioral changes in response to their breast size. Numerous investigations have demonstrated improvement in physical symptoms after breast reduction surgery. Studies have also suggested that psychological improvement occurs postoperatively; however, they have not used well-validated, standardized psychological measures. The present study is a retrospective analysis of the physical and psychological status of women who underwent reduction mammaplasty. One hundred ten patients who underwent a reduction mammaplasty between 1982 and 1996 were mailed a packet of questionnaires designed to assess current physical symptoms and body image. Sixty-one of the 110 patients (55 percent) responded. The vast majority reported substantial improvement or elimination of neck, back, shoulder, and breast pain, grooving from bra straps, poor posture, skin irritation, and social embarrassment. In addition, they reported significantly less dissatisfaction with their breasts as compared with a sample of breast reduction patients assessed preoperatively. Symptom relief and improved body image occurred independently of preoperative body weight, as we found few significant differences between obese and non-obese women concerning the resolution of physical symptoms or improvement in body image. Results provide further evidence of the efficacy of reduction mammaplasty not only for relief of physical symptoms but also for alleviation of body image dissatisfaction.

Placement of coronary stents in bifurcation lesions by the "culotte" technique.

Coronary angioplasty of bifurcation lesions remains a technical challenge. Balloon angioplasty induces recoil and the "snow-plow" effect with a risk of side branch occlusion. The late result is associated with a high rate of reintervention. Randomized studies in nonbifurcated lesions have demonstrated better short- and midterm results after stent placement. We propose the "culotte" technique as a new technique to place intracoronary stents in bifurcation lesions: implantation of 2 similar stents in 2 steps in the main branch and in the side branch with overlapping of the 2 stents in the main branch before bifurcation. We performed this technique in 50 patients (in the left anterior diagonal branch in 33, in the left circumflex obtuse marginal branch in 12, in the right coronary artery in 4, and in the left main coronary artery in 1). The clinical success rate was 94% with 3 non-Q-wave myocardial infarctions. Late results indicated a 24% target lesion revascularization rate, which improved when a true kissing balloon inflation was used to achieve final deployment of both stents. This culotte technique is highly feasible and provides excellent short-term results. Assessment of its midterm benefit requires further study.

Influence of Contrast Media on the Results of Percutaneous Transluminal Coronary Angioplasty with Provisional Stenting: A Comparative Study.

Contradictory data concerning the use of non-ionic contrast media during percutaneous coronary angioplasty (PTCA) have been published. Many clinical studies have suggested that a higher rate of PTCA complications (using balloon angioplasty) was observed using non-ionic versus ionic contrast media. In order to verify these results in the era of coronary stenting, we compared the in-hospital outcome of 384 patients (pts) dilated using ionic contrast media (ioxaglate) and 387 pts dilated with non ionic contrast media (iopamidol). From October 15th 1993 to July 15th 1994, 773 consecutive pts were included in this study. At the beginning of the procedure, the pts received a first bolus of heparin (7500 IU for pts who had not been pretreated with heparin and 5000 IU for pts already treated with heparin). After the first bolus the activated clotting time (ACT) was measured and the pts received an additional bolus of 2500 IU when the ACT was below 300 sec. When the procedure exceeded one hour an additional bolus of 5000 IU was injected. The main characteristics of the 2 groups (Ioxaglate vs Iopamidol) were comparable (demographic data, indication of PTCA, procedural data, first dose of heparin, total dose of heparin). The final ACT was higher in the ioxaglate group (634 +/- 111 vs. 474 +/- 310, p < 0.001). During the hospital course, blood transfusion or vascular surgery was necessary in 1.6 vs. 1.0% (NS), acute closure occurred in 2.1 vs. 4.9% (p = 0.03), acute Q-wave myocardial infarction in 0.5 vs. 0.75% (p = NS), emergency bypass surgery in 0 vs. 0.5% (NS), death in 0.8 vs. 0.3% (NS) and major cardiac event (death, myocardial infarction, coronary artery bypass surgery) in 0.8 vs. 1.6% (NS). Stents were less frequently used in the Ioxaglate group (21.5 vs. 28.5%, p = 0.03) especially in the subset of bailout stenting (2.0 vs. 4.9%, p = 0.04). CONCLUSION: This study suggests that PTCA with provisional stenting can be performed safely using ionic or non-ionic contrast media. However, the ACT obtained with the same dosage of heparin is significantly higher with the ionic contrast media whereas the risk of acute closure and the rate of bail-out coronary stenting is lower.

[Coronary artery stenting without antivitamin K. Results after a month]. / Implantation de prothèses endocoronaires sans antivitamine K. Résultats à un mois.

This paper reports experience with a new antithrombotic agent prescribed to reduce the incidence of subacute occlusions during the first month after coronary stenting. Therefore, a powerful association of platelet antiaggregant agents was tested. From December 1992 to October 1994, coronary stenting was successfully achieved in 1,294 patients (1,118 men, average age 60.5 +/- 10 years) who were then treated with the association of ticlopidine 0.25 g/day and aspirin 0.10 g/day for one month. This was covered with anticoagulation with a low molecular weight heparin for a variable period (one month, two weeks, then one week), according to the different phases of the study protocol. In all, 1487 stents were successfully implanted (1,330 Palmaz Schatz; 63 Cook; 80 Wictor; 13 AVE and 1 Strecker) in 1,326 vessels (520 left anterior descending, 208 left circumflex, 475 right coronary, 16 left main coronary arteries and 107 venous grafts) using balloon catheters of 2.5 mm to 5 mm diameter for average 3.45 +/- 0.4 mm). Major complications in the first month included 9 deaths (0.7%), 22 occlusions (1.7%): 14 myocardial infarcts (1%) and 11 aorto-coronary bypass procedures (0.85%). There were 136 local haematomas or false aneurysms (10.5%), 42 of which (3.25%) required blood transfusion or surgical repair. This multicenter trial of a protocol associating platelet antiaggregant agents and low molecular weight heparin for one month showed a low incidence of subocclusion after coronary stenting (1.7 +/= 2.5%) and should enable interventional cardiologists to widen the indications for coronary stenting.

Intracoronary stenting without coumadin: one month results of a French multicenter study.

In order to simplify post-coronary stenting treatment and to obtain a lower rate of complications, especially in bailout situations, seven French institutions treated 246 stented patients with 0.25 g/day of ticlopidine, 0.1 g/day of IV aspirin, and 2 days of heparin followed by low-molecular-weight heparin for 1 month. Fifty percent of patients had a planned stenting procedure, and 50% had an unplanned procedure, including 29 (11.8%) in bailout situations. Subacute occlusion occurred in three (1.2%) patients (one death, two non-Q-wave infarctions). During the 1 month follow-up period, another death was reported (non-stent-related), two elective coronary artery bypass grafts were performed, and three additional patients presented with non-Q-wave myocardial infarctions. Nine (3.7%) patients had a groin complication that required blood transfusion or surgical repair. These results suggest that while waiting for the technological advancements of stents, postprocedural treatment that includes a low dosage of ticlopidine, aspirin, and low-molecular-weight heparin is a very effective alternative to conventional poststenting therapy.

[Contribution of new technologies to the management of acute complications of coronary angioplasty]. / Apport des nouvelles technologies à la prise en charge des complications aiguës de l'angioplastie coronaire.

This retrospective study of 4,000 coronary angioplasty procedures performed between 1/1/87 and 31/1/92 was undertaken to assess the benefits of new therapeutic options (perfusion balloon catheter, temporary and permanent stenting, laser balloon angioplasty, cardiopulmonary bypass) in the management of major complications of angioplasty and to evaluate the results of emergency coronary bypass surgery. Angioplasty was performed before (1,000 angioplasties: Group 1) and after (3,000 angioplasties: Group 2) the introduction of these new techniques at the Centre cardiologique du Nord. Despite the increasing complexity of the clinical and angiographic features of the patients, the global results show a significant decrease in the rates of emergency bypass surgery (2.1% in Group 1 versus 0.7% in Group 2; p < 0.0015) and of periprocedural acute myocardial infarctions (1.8% in Group 1 versus 0.7% in Group 2; p < 0.015). The use of these new techniques in cases of acute complications of coronary angioplasty decreases the signs of ischaemia before surgery (61.9% in Group 1 versus 68.1% in Group 2; p < 0.05). Coronary bypass surgery was performed under haemodynamically stable conditions in all patients requiring the procedure in Group 2, enabling the surgeon to perform more complete revascularisation with implantation of the mammary artery in 50% of cases (9.5% of cases in Group 1; p < 0.001). The interval to emergency bypass surgery depends mainly on the rapidity of the operative decision in cases of failure of these new techniques.

Multiple subtypes of excitatory amino acid receptors coupled to the hydrolysis of phosphoinositides in rat brain.

The excitatory amino acid (EAA) analogues quisqualate, ibotenate, and trans-(+/-)-1-amino-1,3-cyclopentanedicarboxylate (trans-ACPD) activate the metabotropic EAA receptors that are coupled to the hydrolysis of phosphoinositides (PI). Previous studies of hippocampal cross sections demonstrated that PI hydrolysis stimulated by these agonists can be inhibited by either L-aspartate-beta-hydroxamate (L-A beta HA) or DL-2-amino-3-phosphonopropionate (DL-AP3). The goal of the present studies was to determine if all metabotropic EAA receptors are sensitive to L-A beta HA and DL-AP3. Two approaches were used. In the first, using cerebellar cross sections, the effects of these agonists and inhibitors were examined. The EC50 values (the concentrations required to evoke half-maximal stimulation) of quisqualate, ibotenate, and trans-ACPD in cerebellum were similar to the EC50 values that we observed previously in hippocampus, but neither L-A beta HA nor DL-AP3 blocked PI hydrolysis. The EC50 values were 0.65 +/- 0.17 microM for quisqualate, 12.8 +/- 2.5 microM for ibotenate, and 18.1 +/- 3.1 microM for trans-ACPD. All data were best fit to theoretical curves that had Hill slopes of 1. In the second approach, another EAA analogue, D-aspartate, was identified as an agonist that stimulates PI hydrolysis. The EC50 for PI hydrolysis stimulated by D-aspartate was 470 +/- 90 microM in hippocampus. Neither L-A beta HA nor DL-AP3 blocked PI hydrolysis stimulated by D-aspartate in hippocampus.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value and limits of balloon laser-assisted angioplasty in the treatment of acute obstruction during percutaneous transluminal coronary angioplasty]. / Intérêt et limites de l'angioplastie par le ballon laser dans le traitement des occlusions aiguës au cours des angioplasties coronaires transluminales percutanées.

One of the problems of percutaneous transluminal coronary angioplasty is acute occlusion during the procedure, the main cause of serious complications and emergency coronary bypass surgery. Acute occlusion is generally related to severe intimal dissection and/or thrombosis. In animal experiments, it is possible to treat intimal dissection and dessicate thrombi by balloon laser angioplasty. Using this method, a programmed laser energy may be delivered to the arterial wall via a fiber optic system linked to a Nd:Yag laser during classical balloon inflation. This has been proposed for the treatment of acute coronary occlusion. Between September 1989 and August 1990, 923 patients underwent coronary angioplasty at the Centre Cardiologique du Nord. Peroperative acute occlusions occurred 52 times (3.9%) in 52 patients. Sixteen patients who were "candidates" for emergency coronary bypass surgery (residual stenosis > or = 75%; delayed flow; myocardial ischaemia) were treated by laser balloon angioplasty, 14 with success (87%). Two patients had to be operated as an emergency. There were no hospital deaths. The average follow-up was 4.7 months for the 14 non-operated patients. Systematic control coronary angiography was refused by 2 asymptomatic patients. In the other 12 patients investigated 1 to 17 months after the procedure, there were 10 restenoses (76%), 6 of which were treated by repeat angioplasty and 3 by coronary bypass surgery. These results show that balloon laser angioplasty is very effective in the treatment of peroperative acute occlusions, enabling emergency coronary bypass surgery to be avoided in 87% of cases, but it is associated with a very high restenosis rate which is difficult to accept.

[Coronary angioplasty under extracorporeal circulation. Technique and experience of the Centre cardiologique du Nord]. / Angioplastie coronaire sous circulation extracorporelle. Technique et expérience du Centre cardiologique du Nord.

Between May 1989 and April 1990, 21 patients, candidates for coronary angioplasty but with major left ventricular dysfunction, underwent the procedure using percutaneous cardiopulmonary support (CPS). All patients had one or more previous infarcts, severe angina, and 19 out of 21 had one or more episodes of cardiac failure. Angioplasty was carried out by the usual method, after establishing a percutaneous femoro-femoral CPS. Twenty-three procedures were performed and 22 successes were recorded without any complications (success = 95% per patient). There were no deaths, infarcts or emergency surgical referrals. Two patients required transfusion. The canulae were removed by compression. The only local complication was one case of deep vein thrombosis. The results of this short series suggest that myocardial revascularisation is possible with an acceptable risk in selected coronary patients with severe left ventricular dysfunction by coronary angioplasty with percutaneous cardiopulmonary support.

[A new procedure for the study and treatment of myocardial infarction in the acute phase: percutaneous coronary angioscopy]. / Nouveau procédé d'investigation et de traitement de l'infarctus du myocarde à la phase aiguë: angioscopie coronarienne percutanée.

The recent development of small diameter optical fibers, which are also very flexible allows us to realise percutaneous coronary angioscopy. First of all we visualized normal dog's arteries, bifurcations, origin of small branches; then we created and visualized intimal tears, dissections and experimental thrombi. The second part of this work consisted in applying this new technic in three patients who had an evolving myocardial infarction and an occluded right coronary artery. In all three cases a clot has been visualized, occluding the lumen of the artery. This small experiment shows that percutaneous angioscopy is a feasible, quick and save procedure. Its developments will be very important according to the development of percutaneous interventional therapies.