[Screening for familial hypercholesterolemia from low-density lipoprotein cholesterol levels at admission in the coronary care unit]. / Dépistage de l'hypercholestérolémie familiale à partir du LDL cholestérol à l'admission en unité de soins intensifs cardiologiques.

BACKGROUND: Familial hypercholesterolemia (FH) is a frequent genetic disorder that leads to premature atherosclerosis and coronary artery disease. However, knowledge of FH by cardiologists is weak, and FH remains underdiagnosed in France. FH should be suspected when low-density lipoprotein cholesterol (LDLc) levels exceed 1.9g/L (4.9mmol/L) without lipid lowering therapy. PURPOSE: This multicenter retro- and prospective observational study aimed at estimating the prevalence of high LDLc levels in patients admitted in coronary care units, and the impact for the personal and familial follow-up for lipid status. METHODS: Retrospective analysis of all plasma lipid measurements performed at admission in coronary care unit of 4 hospitals in 2017. Retrospective analyses of demographic, clinical, and coronary data of consecutive patients with LDLc levels≥1.9g/L. Prospective 1 year follow-up focused on lipid levels, treatments, and personal and familial screening for FH. RESULTS: Lipid measurement has been performed in 2172 consecutive patients, and 108 (5%) had LDLc level≥1.9g/L (mean age 64±14 years, men 51%). The primary cause of the hospitalisation was acute coronary syndrome (78%), and 22% of patients were free off coronary artery disease. Lipid lowering therapy was present in 9% of patients at admission, and 84% at discharge, with high statins regimen. At 1-year follow-up, control of LDLc level was not performed in 20% of patients, and statin dose was decreased (36%) or withdrawn (7%) in 43%. Lipid measurement has been performed in at least one first degree relative in 37% of patients, and genetic exploration has been done for 3 patients. CONCLUSIONS: Screening of FH in CCU should be routinely performed using the Dutch Score when LDLc is above 1.9g/L. Individual and familial management of patients at high risk for FH screened in CCU should be optimized, both for diagnosis and therapeutic purposes.

Reduction of radiation exposure associated with renewal of the radiologic systems in coronary interventions.

PURPOSE: Interventional coronary procedures are an important source of radiation. This study sought to evaluate the effect of the renewal of the radiologic system on patient exposure during diagnostic coronary angiography (DCA) and percutaneous coronary interventions (PCIs). METHODS: DCA and PCIs were obtained from three centres, which renewed their radiologic systems during their participation in the multicentre prospective observational RAY'ACT-2 study. Data were analysed from the months before and after the radiologic system was changed. The primary outcomes were the dose reduction estimated by the kerma.area product (KAP in Gy·cm2) and the ratio of the KAP to fluoroscopy time (Gy·cm2·min-1). RESULTS: A total of 2148 patients underwent DCA (1575 before and 573 after the system change), and 1563 underwent PCI (1196 before and 367 after). A change in the radiologic system was associated with a KAP reduction of 43% for DCA (median [interquartile range]: 18.1Gy·cm2 [10.2-34.0] versus 31.5 [19.0-49.0], P<0.0001), and 38% for PCI (42.2Gy·cm2 [23.8-81.7] versus 70.1 [42.0-109.0], P<0.0001). Fluoroscopy time did not vary significantly, and the ratio KAP to fluoroscopy time significantly decreased by 54%. The dose reduction was homogeneous between the three centres and between different manufacturer's systems. CONCLUSIONS: In this multicentre study, the renewal of the radiologic system was associated with a highly significant 40%-50% reduction in radiation dose, irrespective of the manufacturer. A close interaction between manufacturers and operators is needed to optimise the use of new equipment and the effectiveness of radiation reduction tools and techniques.

[Measurement of fractional flow reserve in patients with severe aortic stenosis: A valid test?] / Sténose aortique et lésions coronaires : la fractional flow reserve (FFR) est-elle valide ?

A 54-year-old woman was hospitalized for an acute pulmonary oedema revealing a severe aortic stenosis (AS) associated with an aortic aneurysm and a left ventricular hypertrophy (LVH). The coronary angiography found an equivocal left main lesion. Fractional flow reserve (FFR) showed hemodynamic significance (FFR=0.78) and optical coherence tomography confirmed this result with a minimal lumen area of 4.9mm2. FFR-guided percutaneous intervention is reported to improve outcome in patients with stable coronary disease. However, only few data are available in cases of AS. In this condition, secondary LVH is associated with microcirculatory dysfunction, which interferes with optimal hyperemia. An elevated right atrial pressure could also modify FFR measurement. This risk of underestimation of a coronary lesion in patients with severe AS has to be taken into consideration in clinical practice.

[Fast track chest pain pathway in emergency department]. / La prise en charge rapide des douleurs thoraciques aux urgences.

Acute chest pain is a common reason of consultation in the emergency department. The difficulty lies in discriminating patients with acute coronary syndrome or other life-threatening conditions from those non-cardiovascular, non-life-threatening chest pain. Only 15 to 25 % of patients with acute chest pain actually have acute coronary syndrome. Algorithms using high sensitivity troponin at admission and a second assessment 1 or 3hours later are validated to "rule in" or "rule out" the diagnosis of non ST-elevation myocardial infarction. This may reduce the delay for the diagnosis translating into shorter stay in the emergency department. Those algorithms must be interpreted in the context of clinical and ECG criteria.

[Troponin elevation in the absence of acute coronary syndrome]. / L'élévation de la troponine en dehors des syndromes coronariens aigus.

Cardiac troponins are the most sensitive and specific markers of myocardial injury. Cardiac troponin elevation are common in many diseases and do not necessarily indicate the presence of a thrombotic acute coronary syndrome. In clinical practice, interpretation of dynamic changes of troponin may be challenging. Troponin evaluation should be performed only if clinically indicated and must be interpreted in the context of clinical presentation, ECG changes, troponin level and kinetic. In the absence of thrombotic acute coronary syndrom, troponin retains a prognostic value. Its practical interest as a risk criteria is limited to a few situations like pulmonary embolism, pericarditis an myocarditis.

[Free floating thrombus in right cardiac chambers and thrombolysis]. / Thrombus flottant dans les cavités droites.

Free-floating thrombi in the right heart chambers is a rare phenomenon. Nearly 99% of detected cases are associated with the presence of proven pulmonary embolism. Its presence is associated with a poor outcome with a mortality between 27 to 44% according to studies. Despite the emergency of treatment, optimal management of free floating right heart thrombus remains controversial with no clear consensus. We present the case of a 84-year-old man hospitalised for acute decompensated heart failure. After an initial favourable evolution, a degradation of respiratory occurred with dyspnea and desaturation. A bedside transthoracic echocardiography showed a mobile serpiginous thrombus, 7cm size, moving to and across the tricuspid valve. A computed tomography of the chest demonstrated massive bilateral pulmonary embolism. After persistence of the thrombus and seven days of heparinotherapy, thrombolysis therapy was initiated. The thrombus disappeared 24h after thrombolysis. Without contra-indication, thrombolysis is a faster, readily available treatment for the management of floating thrombus in the right heart chambers associated with pulmonary embolism.

[Extensive iatrogenic coronary dissection during coronary angioplasty: a series of 19 consecutive patients]. / Dissection coronaire extensive compliquant une angioplastie: à propos d'une série de 19 cas consécutifs.

PURPOSE OF THE STUDY: Extensive coronary dissection is a rare complication of intraluminal angioplasty. We report a retrospective study of 19 patients who consulted in a general hospital without cardiac surgery. PATIENTS AND METHODS: After consulting our coronarography and angioplasty database, we included the extensive coronary dissections (type D, E and F) in our study. The medical files of the selected patients were analysed. RESULTS: Between January 2003 and March 2010, 19 coronary angioplasty (total: 2542) were complicated with extensive dissections (incidence 0,75%). For 62,3% of the patients, the dissection was related to the guiding catheter. Eleven patients had type A and B1 lesions. The dissections affected the right coronary artery for 16 patients, the left anterior descending coronary artery for two patients and the left main coronary artery for one patient. After angioplasty, a final TIMI flow 3 was obtained for only 11 patients. In nine cases, we observed a limited extension to the aorta that did not need a chirurgical intervention and had no influence on the prognosis. The complications were common, such as death (n=1), coronary bypass (n=2), myocardial infarction (n=8), cardiogenic shock (n=2) and circulatory assistance (n=2). CONCLUSION: Extensive coronary dissection is a rare complication of angioplasty. The right coronary is the most frequent vessel concerned and an extension to aorta is usual. The treatment is usually based on sealing the entry with a coronary stent. The complications are common and serious and we did not find any predicting factors to extensive coronary dissections that are unpredictable.

[Non invasive methylergometrine test should be carried out after cardiac arrest due to coronary spasm?]. / Faut-il faire un test au méthergin non invasif après un arrêt cardiaque par spasme coronaire?

A 59-year-old man was admitted after cardiac arrest with successful reanimation. There was no significant coronary lesion. We conclude to the diagnosis of coronary spasm after the occurrence of a chest pain with anterior ST elevation reversible with intravenous nitrates. One month later, non-invasive methylergometrine test was carried out and complicated by a cardiac arrest due to complete heart block and asystole treated by chest compression, molsidomine and epinephrine. No cardiac event occurred within the following six months. Technique (invasive versus not invasive) and indication of methylergometrine test for the follow-up of severe manifestations of coronary spasm should be better specified in international guidelines.

[Acute non protected main left coronary artery occlusion: a report of six cases treated by angioplasty]. / Infarctus par occlusion aiguë du tronc commun non protégé : à propos de six cas traités par angioplastie.

AIM: Acute main left coronary artery occlusion is rarely observed during primary angioplasty in myocardial infarction. This retrospective study reports the results of six patients treated by angioplasty in a hospital without cardiac surgery department. PATIENTS AND METHODS: From 2002 to 2009, 746 patients were treated by primary angioplasty for acute coronary syndromes with ST elevation. Among those patients, six (0,7%) had acute non protected main left coronary occlusion. We report clinical, angiographical data and follow-up. RESULTS: The population was composed of six patients (five males) with an average age of 64+/-7 years. Five patients were admitted with cardiogenic shock and four were mechanically ventilated. Distal occlusion of main left coronary artery and dominant right coronary artery were noted in all cases. Sub-occluded lesion of right coronary artery was noted in one case. Successful procedure with bare metal stent was achieved in five cases. Mortality rate was 66% (n=4): three patients died in hospital and another 1 or 2 months later of congestive heart failure. Coronary artery bypass grafting was performed at 4 and 12 months later for two patients. They are alive after 12 and 72 months of follow-up. CONCLUSION: We demonstrate the feasibility of percutaneous coronary intervention of acute main left coronary occlusion. Inspite successful procedure, intrahospital mortality rate is still high and prognosis is related to cardiogenic shock.

[Pulmonary hypertension and heart failure: the role of pulmonary vasculature]. / Hypertension pulmonaire et insuffisance cardiaque : le rôle de la vascularisation pulmonaire.

Left heart disease is the most common cause of pulmonary hypertension. Increased left-sided filling pressure leads to passive postcapillary venous hypertension. In some patients, pulmonary vasoconstriction and vascular remodeling may lead to a further increase in pulmonary pressure. When precapillary hypertension component is associated to left heart failure, the elevation of pulmonary pressure is out of proportion with left atrial pressure: transpulmonary gradient greater than 12 mmHg (mean pulmonary pressure -- mean capillary pressure) and pulmonary vascular resistance greater than three Wood units. Precapillary pulmonary hypertension is common in severe systolic heart failure. Before cardiac transplantation, increased pulmonary vascular resistance greater than 3,5 Wood units are reported in 19 to 35% of patients. In those patients vasoreactivity tests are performed with inotropic and/or systemic and/or pulmonary agents to determine the risk of right heart failure after transplantation. There is no pulmonary vascular resistance level above which transplantation is contraindicated. Cardiac assistance may be used before and after transplantation when pulmonary hypertension is severe and not reversible with conventional treatment and/or pulmonary vasodilators. The contribution of precapillary PH in diastolic heart failure is not known but can be significant and lead to disproportionate PH particularly in elderly. The precapillary component of pulmonary hypertension could be a therapeutic target for specific pulmonary vasodilators. Until now pharmacological trials has been disappointing and those medications can be dangerous because of increasing blood flow to the pulmonary capillaries with a risk of pulmonary edema when left sided pressure are still elevated.

[Multidetector computed tomography coronarography: from studies to everyday life]. / Le scanner coronaire : des études à la pratique courante.

INTRODUCTION: Multidetector computed tomography coronarography is a promising tool, offering a non-invasive anatomic evaluation of coronary arteries. The great majority of studies conducted upon it are single-center studies, and have reported results based upon a highly selected patient population. Our aim was to determine its diagnostic accuracy among an unselected population in multicenter studies. METHODS: Fifty-two patients were included in a non-randomised, retrospective study. Patients underwent multidetector computed tomography coronarography (16, 40 and 64 slices), in ten different centers (community hospitals or private centres), for clinical suspicion of coronary stenoses. The diagnostic accuracy for detecting significant coronary stenoses (> or =50%) was determined in comparison with conventional coronarography. RESULTS: The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were 91.4%, 17.7%, 69.6%, 50.0%, and 67.3%, respectively, in a patient-based analysis, and 55.3%, 85.6%, 30.3%, 94.4% and 82.5% in a segment-based analysis. CONCLUSION: The results of this study indicate that routine implementation of multidetector computed tomography coronarography is limited by a high false-positive rate, when performed among an unselected population of patients with a high pretest probability of having coronary stenoses, in centres with variable expertises. Its place within the range of diagnostic tools has yet to be determined by large multicenter studies, before being subject to precise recommendations framing its routine clinical application.

[Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome]. / Le syndrome de takotsubo ou ballonisation apicale transitoire du ventricule gauche.

Takotsubo is a reversible cardiomyopathy, often triggered by a stressful event. It combines clinical features mimicking a myocardial infarction, transient apical ballooning of the left ventricle, normal coronary arteries and a small rise in troponin level. There is a striking female predominance with mean age ranging from 65 to 76 years among series. Preceding stressful event is documented in 50 to 100% of patients. The most common clinical presentation is an angor-like chest pain with ST-segment elevation on the electrocardiogram (70%). The prognosis is excellent even if serious complications may occur: pulmonary oedema, cardiogenic shock, transient dynamic intraventricular gradient, life-threatening arrhythmias. In-hospital mortality is in the range of 0 to 10%. The recurrence rate is low. The precise physiopathology of the syndrome remains unknown but catecholamine mediated myocardial stunning is the most favored explanation.

[Transient left ventricular apical ballooning syndrome or Takotsubo cardiomyopathy. About 11 cases]. / Ballonisation apicale transitoire du ventricule gauche ou syndrome de tako-tsubo. a propos de 11 cas et revue de la littérature.

Takotsubo cardiomyopathy is a clinical entity mimicking an ST elevation myocardial infarction recently identified. Are associated a chest pain, electrocardiographics abnormalities, minor elevation of enzyme biomarkers in patients who don't have any significant angiographic stenosis on the coronary angiography and where left ventricle angiography shows apical regional wallmotion abnormalities with a characteristic apical ballooning aspect. Between march 2003 and march 2005, we included 11 patients for whom this syndrom was suspected. Mean age was 70, 3 years old. Electrocardiogram was abnormal in all cases. Biological markers show for all patients an elevation of troponin I. All patients had a coronary angiography and coronary arteries were normal. Left ventricle angiography showed in all cases wall-motion abnormalities in the apex with a ballooning aspect. A psychological or physical inducing factor has been found for 8 patients. The evolution was simple for all patients with no complications noted and no recurrence with a mean follow up of 15 months. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrom have a good long-term prognosis even if serious complications sometimes deathly can be seen. The cause of this syndrom is unknown but it must be considered as a possible diagnosis of ST elevation myocardial infarction with normal coronary arteries.

[Indications of drug eluting stents]. / Indication des stents actifs.

The publication in 2001 of the first in-man results showing zero restenosis after sirolimus eluting stent implantation produced enormous excitement in the cardiological community. Today, both sirolimus and paclitaxel eluting stents have been shown in randomized trials to reduce restenosis as compared with conventional metallic stents. However, since drug eluting stents become available in Europe very little has changed in the every life of almost all interventional laboratories in Europe. The limitation currently impeding more widespread use of the new technology is nontechnical, nonmedical but economic. The high price of drug eluting stents relative to bare stents has been an obstacle to more widespread utilization of drug eluting stents.

[Isolated carcinoid tumor of the ovary disclosed by tricuspid insufficiency]. / Une tumeur carcinoïde isolée de l'ovaire révélée par une insuffisance tricuspide.

A 68-year old woman was hospitalised because of isolated right heart failure. Doppler echocardiography revealed severe tricuspid regurgitation with thickened, shortened, hypomobile leaflets. Pulmonary valve was thickened with mild pulmonary regurgitation. Mitral and aortic valves were normal. The patient was finally diagnosed with carcinoid heart disease from an isolated ovarian carcinoid cancer without hepatic metastases. Ovarectomy was performed and the patient was considered cured of her cancer. Because of refractory right heart failure, she underwent tricuspid valve replacement with a bioprosthesis. Such cardiovascular manifestations are rarely the presenting symptoms of carcinoid disease. Carcinoid heart disease from ovarian primary cancer is exceptional. In this circumstance, carcinoid cardiac lesions may develop in the absence of hepatic metastases because the venous blood from the ovaries drains into the inferior vena cava without hepatic first past effect. Surgical resection of primary ovarian carcinoid tumor is often curative and the prognosis depends mainly on the cardiac condition. The diagnosis of carcinoid syndrome should be discussed in patients with organic tricuspid regurgitation without left valvular disease.

Immediate results of percutaneous mitral commissurotomy. A predictive model on a series of 1514 patients.

BACKGROUND: The wide use of percutaneous mitral commissurotomy (PMC) underlines the need to identify the predictive factors of the results. Using a large series allowed us to develop a multivariate model that can be applied to improve patient selection. METHODS AND RESULTS: Between 1986 and 1995. PMC was undertaken in 1514 patients. Mean age was 45 +/- 15 years. Echocardiography showed that 245 patients (16%) had pliable valves and mild chordal thickening (group 1), 886 (59%) had extensive subvalvular disease (group 2), and 383 (25%) had calcified valves (group 3). PMC failed in 22 patients; it was performed with a single balloon in 30 patients, a double balloon in 586, and the Inoue balloon in 876. Good immediate results were defined as a valve area > or = 1.5 cm2 with mitral regurgitation Sellers' grade < or = 2 and were obtained in 1348 patients (89%). A logistic model developed from the first 1088 cases identified the following predictors of immediate results: age (P = .004), echocardiographic group (P < .0001), valve area (P < .0001), and effective balloon dilating area (EBDA) (P = .03). Two interactions were significant: age at previous commissurotomy (P = .013) and EBDA by initial mitral regurgitation (P = .034). The type of balloon was of borderline significance (P = .09). The model was validated on an independent sample comprising the subsequent 426 procedures. For a threshold of probability of good results of .75, sensitivity was 92%, specificity 25%, and predictive accuracy 87%. CONCLUSIONS: Prediction of the immediate results of PMC is multifactorial. The predictive model developed and validated can be contributive in decision making for individual patients.

Specifics of technique in percutaneous mitral commissurotomy in a case of dextrocardia and situs inversus with mitral stenosis.

Percutaneous mitral commissurotomy (PMC) was successfully performed in a 48-year-old woman with dextrocardia and situs inversus and a severe mitral stenosis. After PMC, the valve area increased from 0.97 to 1.89 cm2, and no complication occurred. This case shows that PMC is practicable in a case of dextrocardia with situs inversus. The procedure appears to be safer and easier when carried out with the inoue balloon, image inversion on the screen, and under transesophageal echocardiographic monitoring.

[Pure epicarditis after surgical repair of atrial septal defect: a rare form of constrictive pericarditis. Apropos of a case]. / Epicardite pure après correction chirurgicale d'une communication interauriculaire: une forme rare de péricardite constrictive. A propos d'un cas.

The authors report a case of constrictive pericarditis occurring two years after surgical repair of an atrial septal defect in a 37 year-old-man. The diagnosis was made by right heart catheterisation and magnetic resonance imaging. The special feature of this clinical case was the exclusive localisation of the fibrosis on the visceral pericardium or epicarditis. The outcome was favourable after resection of the visceral pericardium respecting the parietal pericardium. Magnetic resonance imaging and right heart catheterisation performed 6 months after surgery were normal. Constrictive pericarditis is a classical complication of cardiac surgery but relatively rare after repair of an atrial septal defect. Isolated involvement of the visceral pericardium is rare and allows surgical correction by exclusive epicardectomy respecting the parietal pericardium.