[Isolated right ventricular acute myocardial infarction mimicking anterior infarction]. / Infarctus isolé du ventricule droit mimant un infarctus antérieur.

Isolated right ventricular acute myocardial infarction is rare and its presentation can sometimes mimic an anterior ST-segment elevation myocardial infarction. We reported two cases of isolated right ventricular acute myocardial infarction presenting with a ST-elevation in anterior leads. The first case was admitted for an out-of-hospital cardiac arrest due to ventricular fibrillation. The patient died from neurologic consequences of the cardiac arrest, despite a successful prehospital thrombolysis, followed by a percutaneous angioplasty of the right coronary artery. The second case occurred after a complex percutaneous angioplasty of the right coronary artery, complicated by a total occlusion of a right marginal branch. These two cases illustrate the limits of the ECG for the diagnosis of isolated right ventricular acute infarction, and the difficulties of the differential diagnosis with anterior infarction, which may determine the treatment and the prognosis.

[Coronary artery spasm revealed by an out-of-hospital cardiac arrest associated with a moyamoya disease. A case report of multimodality imaging]. / Arrêt cardiaque par spasme coronaire associé à une maladie de Moyamoya. Apport de l'imagerie cardiaque multimodale.

Moyamoya disease is a rare angiopathy characterized by a progressive distal occlusion of the internal carotid arteries and their branches. Extracerebral involvement, including coronary arteries, has been described. We report the case of a patient with moyamoya disease who suffered an out-of-hospital cardiac arrest associated with coronary spasm. We discussed the possible links between coronary spasm and moyamoya, as well as the contribution of multimodal cardiac imaging, combining conventional and intracoronary imaging, cardiac MRI, provocative tests for spasm, in the exploration of out-of-hospital cardiac arrest without obvious electrocardiographic and angiographic cause.

Immediate coronary angiography in survivors of out-of-hospital cardiac arrest without obvious extracardiac cause: Who benefits?

BACKGROUND: Immediate coronary angiography (iCA) and primary percutaneous coronary angioplasty (pPCI) in patients successfully resuscitated after out-of-hospital cardiac arrest (OHCA) of suspected cardiac cause is controversial. Our aims were to assess the results of iCA, the prognostic impact of pPCI after OHCA, and to identify subgroups most likely to benefit from this strategy. METHODS: In this single-centre retrospective study, patients aged ≥18 years with sustained return of spontaneous circulation after OHCA and no evidence of a non-cardiac cause underwent routine iCA at admission, with pPCI if indicated. Results of iCA, and factors associated with in-hospital survival were analysed. RESULTS: Between 2006 and 2013, 160 survivors from OHCA presumed of cardiac origin were included (median age, 60 years; 85% males). iCA showed significant coronary-artery lesions in 75% of patients, and acute occlusion or unstable lesion in only 41%. pPCI was performed in 34% of patients and was not associated with survival by univariate or multivariate analysis (P=0.67). ST-segment elevation predicted acute coronary occlusion in 40%. An initial shockable rhythm was associated with higher in-hospital survival (52% vs. 19%; P<0.001). After initial defibrillation, the first rhythm recorded by 12-lead electrocardiography was highly associated with prognosis: secondary asystole had a very low survival rate (5%, 1/21) despite PCI in 43% of patients, compared to sustained ventricular tachycardia/fibrillation (42%, 15/36) and supraventricular rhythm (71%, 50/70) (P<0.001). CONCLUSIONS: In our experience, the prevalence of acute coronary occlusion or unstable lesion immediately after OHCA of likely cardiac cause is only 41%. Immediate CA in OHCA survivors, with pPCI if indicated, should be restricted to highly selected patients.

[Intracoronary administration of antithrombotic agents via a perfusion balloon catheter in patients with ST-segment elevation myocardial infarction presenting with massive intraluminal thrombus and failed aspiration]. / Apport de l'administration intracoronaire d'antithrombotiques par cathéter à ballon de perfusion en phase aiguë d'infarctus du myocarde avec thrombus massif et échec de la thromboaspiration.

BACKGROUND: Massive intracoronary thrombus is associated with adverse procedural results including failed aspiration and unfavourable reperfusion. We aim to evaluate the effect of the intracoronary administration of antithrombotic agents via a perfusion catheter in patients with ST-segment elevation myocardial infarction (STEMI) presenting with a large thrombus burden and failed aspiration. METHODS: We retrospectively analyzed the thrombus burden, the TIMI grade flow, and the myocardial Blush in 25 consecutive STEMI patients with a large thrombus burden and failed manual aspiration, who received intracoronary infusion of glycoprotein IIb/IIIa inhibitors (N=17) or bivalirudine (N=8) via a 6F-infusion catheter (ClearWay™ RX) RESULTS: Mean age was 67±14 years, 16 patients (64 %) presented with anterior STEMI, and 7 (28 %) with cardiogenic shock. Immediately after intracoronary infusion, the TIMI flow grade improved of 2 grades in 7 patients (28 %), and 1 grade in 14 (56 %), a complete resolution of the thrombus was observed in 9 patients, and a >50 % resolution in 12. Blush was improved of 3 grades in 15 patients (60 %), of 2 grades in 7 (28 %), and Blush grade 0 remained in 3. At the end of procedure, we observed normal TIMI 3flow in most patients (92 %), a complete resolution of thrombus in 80 %, and a Blush grade 3 in 68 %. CONCLUSIONS: In STEMI patients presenting with a large thrombus burden and failed aspiration, intracoronary administration of glycoprotein IIb/IIIa inhibitors or bivalirudin via the perfusion catheter ClearWay™ RX significantly reduced the thrombus burden and improved the TIMI flow and the Blush grade, without bleeding.

[Evolution of the interventional reperfusion strategy and reperfusion times in acute ST-segment elevation myocardial infarction]. / Évolution de la prise en charge interventionnelle et des délais de reperfusion à la phase aiguë de l'infarctus du myocarde avec sus-décalage du segment ST.

BACKGROUND: In patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), the recommended times (first medical contact-to-balloon (M2B) <120 or <90min, and door-to-balloon (D2B) <45min) are reached in less than 50% of patients. PURPOSE: To compare the interventional reperfusion strategy and reperfusion times between two series of consecutive STEMI patients referred for pPCI within 12hours of symptom onset, in 2007 and 2012. METHODS: Retrospective study of 182 patients, 87 admitted from January 2007 to March 2008 (period 1), and 95 admitted from January to December 2012 (period 2). The procedural characteristics and the different times between onset of pain and mechanical reperfusion were gathered and compared by non-parametric tests. RESULTS: Radial access, thromboaspiration, and drug eluting stents were more frequent, and cardiogenic shock was less common during period 2, compared with the period 1. The median time from first medical contact to balloon (M2B) decreased by 26% (135min, [quartiles: 113-183] in 2007 versus 100 [76-137] in 2012, P<0.001), in relation to the reduction in both prehospital times and time in the catheterization laboratory (D2B: 51 [44-65] and 44min [37-55], respectively, P<0.01). CONCLUSIONS: The D2B and M2B times significantly decreased in our centre between 2007 and 2012, and reached the recommended values in >60% of the cases. This may be explained by better coordination between emergency medical units and interventional cardiologists, and by the presence of two paramedics in the catheterization laboratory for 24/24 7/7 pPCI since 2010 in France, in accordance with recent national regulation.

[Use and limitations of invasive coronary strategy in nonagerians]. / Intérêts et limites de la stratégie invasive coronaire chez les patients nonagénaires.

BACKGROUND: Nonagenarians are systematically excluded from studies of interventional cardiology. Few data exist on the usefulness, safety, and results of coronary angiography (CA) and percutaneous coronary intervention (PCI) in this population. PURPOSE: To evaluate the benefits and hazards of CA and PCI in nonagenarians. METHODS: Retrospective study conducted from the database (Cardioreport(®)) of the CH de Versailles, from January 2001 to December 2011. RESULTS: From the 15,806 procedures performed in the center during the period, 107 (0.9%) were done in 97 patients aged ≥90years. Half of them underwent PCI. Median age was 92±2years (range: 90 to 100), 56% were women. Main indication was an acute coronary syndrome (77%, acute STEMI in 39%). The first group (n=58) had a single CA leading to strengthen medical treatment, and CABG in one case. The second group (n=49) had a CA followed by immediate (41) or delayed (8) PCI. The primary success rate of PCI was 90%. Radial route was used in 94% in the period 2009-2011 (51% overall). Failure of arterial access (4%) and difficulties of catheterization (13%) were rare. Severe complications occurred in 19%. They were local (11 hematomas, 6 severe, 4 transfusions, and 1 fatal acute ischemia of a lower limb), and general (1 stroke, 1 death by left main rupture during PCI). Twenty percent of the complications (11% of severe ones) were directly related to the procedure. Overall hospital mortality was 10%. CONCLUSIONS: Angiography is feasible in nonagenarians by radial approach without failures and with a reduced rate of complications. PCI was indicated in about half of the cases. PCI may be proposed in nonagerians with a high success rate, and an acceptable risk of local and general complications.

[Low dose cardiac computed tomography: how to obtain it?]. / Scanner cardiaque basse dose: comment l'obtenir?

Since the introduction of Multi-slice computed tomography (CT), cardiac CT has been the increasingly used as a noninvasive modality for the diagnosis of coronary disease. Despite its potential benefits and promising clinical results, it has suffered from high doses of radiation associated with a risk of radiation-induced cancers. This has raised serious concerns in clinical practice. A number of strategies were then implemented to reduce the radiation dose associated with cardiac CT. The aim of this review is not to compare doses of different CT systems available on the market but to present an overview of different approaches to dose reduction and future directions.

[Accuracy of the door-to-balloon time for assessing the result of the interventional reperfusion strategy in acute ST-segment elevation myocardial infarction]. / Valeur du délai « porte-ballon ¼ pour évaluer l'efficacité de la stratégie interventionnelle de reperfusion à la phase aiguë de l'infarctus du myocarde avec sus-décalage du segment ST.

BACKGROUND: In patients with acute ST-segment elevation myocardial infarction (STEMI), recent clinical guidelines recommend that primary percutaneous coronary intervention (PCI) should be performed within 90min of first medical contact or 45min after admission in cathlab. The Door-to-Balloon time (D2B) is widely used to measure the performance of interventional centres. AIM OF THE STUDY: To analyze the time to reperfusion in a consecutive series of STEMI patients referred for primary PCI, and to evaluate the clinical accuracy of D2B in primary PCI. METHODS: From January 2007 to March 2008, 177 patients were admitted within 12hours of a STEMI in our institution, and 87 were referred for a direct coronary angiography for primary PCI (47 by mobile medical emergency unit, 40 by the emergency department of the institution). RESULTS: The median time from first medical contact to balloon inflation (M2B) was 135min [IQR 112-183]. Recommended times were fulfilled in a minority of patients (M2B<90min: 9%,<120min: 34%). Median cathlab D2B was 51min [IQR 44-65], and was less than 45min in 34% of patients. No differences for times to reperfusion within cathlab were found between in- and off-time hours. M2B and D2B were unavailable in 23 patients (26%), because of a spontaneous TIMI 3 flow reperfusion without indication for immediate PCI in 20 patients, contra-indication for PCI in two (distal occlusion, culprit vessel diameter less than 2mm), and failure in occlusion crossing by the guide-wire in one patient. In contrast, first medical contact- or door-to-reperfusion times, assessed by a TIMI 3 flow without no-reflow in culprit artery, were available in 95% of patients, and were shorter than M2B or D2B, respectively. CONCLUSION: Although it is a feasible and reproducible process performance measure, D2B time is weakly associated with the outcome of the interventional reperfusion strategy in acute STEMI. This measure should be associated with an outcome performance measure, such as the rate of TIMI 3 flow achieved by primary PCI, or replaced by the Door-to-TIMI 3 flow reperfusion time.