Chest pain in patients with undiagnosed Behçet's disease.

Behçet's disease (BD) is a systemic inflammatory disease having a chronic and prolonged course with 4 major symptoms: oral and genital ulcerations, eye disease and cutaneous manifestations, as well as other multisystem involvements. Arterial involvement is a comparatively rare complication in BD and coronary lesions are extremely rare. We report here two cases of BD presenting as myocardial infarction (MI) with coronary artery aneurysm (CAA), with good improvement after immunosuppressive therapy.

[High-risk left main coronary stenting supported by percutaneous Impella Recover LP 2.5 assist device]. / Assistance ventriculaire gauche percutanée avec le système Impella Recover LP 2,5 au cours d'une angioplastie à haut risque du tronc commun coronaire gauche.

Percutaneous coronary interventions (PCI) of complex coronary lesions in patients with severely depressed left ventricular (LV) function may increasingly constitute an alternative to surgical revascularization. The availability of hemodynamic support devices offers a promising option to reduce PCI-related complications in such high-risk procedures. We report the case of a successful distal left main coronary artery T-stenting supported by the Impella Recover LP 2.5 assist device in a patient with severe LV dysfunction.

[Clinical and angiographic outcomes after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique]. / Résultats immédiats et à long terme après angioplastie coronaire avec stents actifs de lésions de bifurcation par la technique du << crush stenting >>

The most common approach in the treatment of bifurcation lesions is stenting only the main branch (MB) with provisional T-stenting of the side branch (SB). However, some bifurcation lesions may have extensive disease within a large SB requiring stenting of this vessel. The "crush" technique, which has been proposed as an alternative approach to other strategies to treat complex bifurcations, is a relatively simple technique that ensures complete coverage of the SB ostium. Previous series have reported its safety and feasibility, but limited data are available about the long-term outcomes. We report our experience on 21 consecutive patients (pts) treated with the "crush" technique with drug-eluting stents (DES) between November 2005 and March 2007. Clinical follow-up was 18+/-7 months for 19 pts (90%), and angiographic follow-up was completed in 66% of pts (N=14), at a mean time of 8.5+/-4 months. Mean pt age was 70+/-11 years; 33% (N=7) had diabetes mellitus, and mean preoperative logistic EUROSCORE predicted 11% mortality rate. The left anterior descending artery/diagonal and the distal left main were the most frequent bifurcation locations (52 and 43% of cases respectively), with a type 1,1,1 of the Medina classification of bifurcation lesions in 62% of pts, and an angulation MB-SB below 50 degrees in 66% of cases. Final kissing balloon dilation was performed in 90% of pts (N=20). Stent diameter and length were similar between MB and SB. The procedure was successfull in 100% of cases in the MB and 95% of cases in the SB. Procedure-related CK elevation above 2 ULN was seen in two pts (9.5%), without ECG modification. One pt had subacute stent thrombosis 5 days after his procedure. At the end of follow-up, target vessel revascularization (TVR) was required in four pts (19%), and target lesion revascularisation (TLR) in three pts (14%) whom had focal restenosis in the SB ostium (one pt) and in the MB and SB ostia (one pt). Sudden death occurred in one pt 14 months after his procedure. In conclusion, when an effective strategy for stenting both branches is planned, the "crush" technique with final kissing balloon can be safely used by experienced operators to treat complex bifurcation lesions with DES. The safety profile and TLR rate in our small series of "crush" stenting were similar to that of other studies reported thus far.

Risk factors of arterial hypertension after renal transplantation.

Arterial hypertension often present after kidney transplantation is of multifactorial origin. The aim of this study was to determine the role of donor and recipient factors in the development of hypertension after renal transplantation. We retrospectively analyzed the data of 280 patients transplanted between 1985 and 2005, who still had functioning grafts at 1 year after transplantation. We recorded donor and recipient parameters. One hundred eighty-seven patients (66.8%) were hypertensive. Upon multivariate analysis of recipient factors, pretransplant hypertension (odds ratio) [OR]: 8.5, 95% confidence interval [CI]: 4.5 to 16.1); serum creatinine level > 130 micromol/L at 6 months (OR: 2.5, 95% CI: 1.3 to 4,7), male gender (OR: 2.02, 95% CI: 1.2 to 3.4), and chronic rejection (OR: 2.4, 95% CI: 1.2 to 4.7) were independent predisposing factors. Among donor factors, age was significantly associated with arterial hypertension upon univariate analysis. In conclusion, recipient factors, especially pretransplant hypertension, contribute to the disorder in renal transplant patients.

[Intracoronary thrombectomy with the Export Aspiration Catheter before angioplasty in patients with ST-segment elevation myocardial infarction]. / Thromboaspiration par le cathéter Export avant angioplastie dans les syndromes coronariens aigus avec sus-décalage du ST.

OBJECTIVES: We aimed to assess the safety and feasibility of thrombectomy with the Export Aspiration Catheter (EAC) before angioplasty, and its ability to improve angiographic results in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Distal embolization of atherothrombotic material often occurs during angioplasty in STEMI, compromising optimal myocardial reperfusion. METHODS: We performed a thrombus-aspiration with EAC prior to angioplasty in 64 consecutive patients with STEMI. Successful thrombectomy was defined as an improvement of TIMI flow grade > or =1. RESULTS: Successful thrombectomy (increase of TIMI flow > or =1) was achieved in 40 patients (62.5%). Mean TIMI flow grade increased from 0.7 +/- 1 to 1.9 +/- 1.2 (P < 0.0001) after thrombectomy. TIMI flow grade 3 was observed more frequently after EAC compared with guidewire alone (51.5 vs. 9%, P = 0.0062). Direct stenting was performed in most of patients (N=41, 64%). Distal embolization and noreflow/slowflow phenomenon occurred in 8 patients (12.5%). No vessel injury after EAC thrombectomy was reported. After treatment with balloon angioplasty and/or stenting, final TIMI flow grade 3 was achieved in 54 patients (84.5%). By multivariate analysis, ischemic time <6 h was a significant independent predictor of successful thrombectomy (P = 0.0437). CONCLUSIONS: Our series suggests that EAC thrombectomy prior to angioplasty in the setting of STEMI is safe and feasible. It might reduce the culprit coronary lesion's thrombus burden, leading to improved flow restoration and myocardial reperfusion. Further large randomized studies are warranted to confirm these preliminary results and to assess the impact of thrombus-aspiration on infarct size as well as on clinical outcomes.

[Assessment of pure isolated mitral valve insufficiency by Doppler echocardiography]. / Quantification des insuffisances mitrales pures isolees par l'echodoppler cardiaque.

Taking 33 patients having pure MI as a material, the authors find a correlation between regurgitation fraction obtained by calculation of outputs estimated by Touch's method and angiographic values. There is a statistically significant differences (P < 0.001) between regurgitation fraction of grade I to II and grade II to III MI. The ratio mitral integral time velocity (ITV) to Aortic (ITV) is an important semi-quantitative assessment of pure MI. In fact, a ratio > 1.3 identify important degree of MI with 82% sensitivity and 93% specificity. The authors estimate that there is a correlation between the ratio of regurgitant jet surface to left atrial surface found in TEE and their degree of MI in angiography with a significant difference (P < 0.001) between the ratio of grade I to II and grade II to III MI in angiography. A ratio higher than 40% allow to identify grade III MI at minimum.

[Mitral stenosis secondary to Hurler's syndrome]. / Rétrécissement mitral secondaire à un syndrome de Hurler.

Valvular disease in mucopolysaccharidosis type I-Hurler (MPS/1H) is relatively common, but mitral stenosis is very rare in this genetic abnormality. The authors describe the case of a 16-year old girl with Hurler's syndrome diagnosed at 4 years of age. The morphological features were characteristic: bridged nose, thickened lips, macroglassia, short neck (gargoylism, short, thick fingers and limitation of brachial and fore-arm flexion. She presented with stage II dyspnoea and paroxysmal nocturnal dyspnoea. Radiological and echocardiographic studies revealed severe mitral stenosis with haemodynamic complications requiring mitral valve replacement. Anatomopathological analysis of the mitral valve confirmed mucopolysaccharide deposits as the cause of this particular case of mitral stenosis.

[Place of definitive cardiac stimulation in cardiomyopathies and atrial arrhythmia]. / Place de la stimulation cardiaque definitive au cours des cardiomyopathies et des arythmies atriales.

Definitive cardiac stimulation ralatually used for brady cardia are going to be in the third millennium the specific therapy of arrhythmia and cardiomyopathy. In the last 10 years, may progress occur in the use of cardiac stimulation as hemodynamic therapy of obstructions hypertrophic and dilated cardiomyopathies resistant to conventional medical treatment. Moreover auricular stimulation present antiarrhythmic effects in some atrial arrhythmias as auricular fibrillations auricular diseases and atypical flutters. It confirmed by prospective multicentric randomized trials cardiac stimulation may represent in the future a good physiopathologic and efficient treatment free from the side effects of drugs that remain partially active. These perspectives needs to be modulated by the known and acceptable risks of a definitive cardiac stimulation.

[Infectious enterococcal endocarditis associated with Laubry and Pezzi syndrome]. / Endocardite infectieuse a enterocoque sur syndrome de Laubry et Pezzi.

Laubry and Pezzi syndrome is a rare but serious complication of ventricular septal defect that increase the infectious endocarditis risk. Authors report a case of an 18 years old young girl presenting an enterococcus infectious endocarditis associated to Laubry and Pezzi syndrome. Initial course is not favourable requiring a surgical treatment in the acute stage. Bacterial endocarditis combined with Laubry and Pezzi syndrome have a poor prognosis needing observation and strict preventive precautions when a favoring factor is present.

[Dilated cardiomyopathy secondary to acromegaly]. / Cardiomyopathie dilatée secondaire à une acromégalie.

In acromegaly, dilated cardiomyopathy is rare. Indeed, arterial hypertension, coronary artery disease and hypertrophic cardiomyopathy are more common. The authors report a case of a 42-years-old man with dyspnea (class III NYHA) and palpitations. The cardiac echography showed a dilated cardiomyopathy. The investigations revealed an acromegaly as an etiology. Diagnosis was based on patient morphotype, a high level of growth hormone (GH) and a pituitary adenoma detected by magnetic resonance imagery. This case is characterized by the absence of arterial hypertension and hypertrophic cardiomyopathy. The coronary angiography was normal. Consequently, in this particular case, dilated cardiomyopathy seems specific to acromegaly.

Progesterone and synthetic steroids produce insulin resistance at the post-receptor level in adipocytes of female rats.

The effects of progesterone, its agonists (progestin RU-5020, glucocorticoid RU-26988) and antagonist (antiprogesterone, anti-glucocorticoid RU-486) were tested on isolated fat cells in vitro. When added to the incubation medium, all four steroids decreased basal glucose oxidation. The inhibitory effect of the steroids appeared early (20 min incubation) and was sustained during a 2-h incubation. The early inhibitory effect was less marked for progesterone agonist RU-5020 than for the other three steroids. When incubation was prolonged for 2 h, the lowest inhibitory effect was observed with progesterone antagonist RU-486. Insulin-stimulated glucose oxidation was inhibited by progesterone, its antagonist RU-486, one of its agonists RU-26988, but not by the other agonist RU-5020. Analysis of the dose response curves showed that progesterone, RU-26988, and RU-486 decreased fat cells' responsiveness and, only for RU-486, sensitivity to insulin. Adipocytes isolated from ovariectomized, progesterone-treated rats showed a decreased maximal response to insulin and decreased insulin sensitivity in opposition to cells incubated directly with the steroid. No inhibition of 125I-labeled insulin binding was seen as an acute or chronic effect of progesterone. It is concluded that progesterone and the studied related steroids decrease glucose oxidation by mechanism(s) distal to insulin binding to its specific receptors.

Insulin binding and action in adipocytes of pregnant rats: evidence that insulin resistance is caused by post-receptor binding defects.

Insulin resistance was investigated in the adipose cell of rats which were at days 16 and 20 of pregnancy. Data are presented to relate insulin binding and biological effect, which was evaluated by the ability of insulin to stimulate [1-14C]glucose oxidation. Adipocytes from pregnant rats bound more insulin than fat cells from control (non-pregnant) animals and the number of insulin receptors per adipocyte increased during pregnancy. Basal glucose oxidation rate was decreased at 16 and 20 days of pregnancy: however, the dose-response curve for insulin-stimulated glucose oxidation was significantly depressed only after 20 days of pregnancy. The concentration at which insulin increased glucose oxidation by 50% increased with the duration of pregnancy. We conclude that during pregnancy in the rat the adipocyte response to insulin was decreased, despite an increase in insulin binding. This result suggests that a major determinant of insulin resistance in rat adipocytes during pregnancy is present after the initial insulin-receptor interaction. Consequently, a post-receptor defect may be largely responsible for the insulin resistance.

Glucose metabolism in the female rat adipocyte: lipid synthesis from glucose during pregnancy and progesterone treatment.

Pregnancy and progesterone treatment of ovariectomized rats decrease glucose metabolism through the pentose-phosphate pathway in isolated female rat adipocytes. As demonstrated in previous studies, progesterone directly decreases [1-14C]glucose oxidation through the pentose-phosphate pathway and lipogenesis from [6-14C]glucose, the present study therefore compared glucose-induced lipid synthesis during pregnancy (10, 16 and 20 days of pregnancy) with the effect of progesterone treatment (5 mg/rat per day for 14 days) to shed more light on the role of this steroid in glucose metabolism during pregnancy. The inhibition of [6-14C]glucose incorporation into triacylglycerols in the progesterone-treated rats was comparable to that which occurs during late (20 days) and mid-pregnancy (16 days) but not during early pregnancy (10 days). The inhibition of fatty acid synthesis was more important as pregnancy advanced and was different from the decrease in fatty acid synthesis induced by progesterone treatment. The sensitivity to insulin was comparable in virgin, ovariectomized and progesterone-treated ovariectomized rats but not in pregnant rats. This implies that progesterone and insulin affect glucose-induced lipid synthesis by distinct processes and that the impaired glucose metabolism is characterized by a reduction in basal glucose utilization rather than by an impaired insulin response.