[REFORCE registry]. / Registre REFORCE.

Severe coronary artery calcification, too often underestimated, increases the complexity of percutaneous coronary interventions. Atherectomy is one of preferred approach for the preparation of calcified lesions before stent placement. Orbital atherectomy is a new method that has proven to be safe and effective in the preparation of calcium plaques (ORBIT I and ORBIT II studies). The recent introduction in France allows to perform a prospective registry named REFORCE. Its main objective is to include 300 patients in order to evaluate security and safety of the device in France during routine use.

[Imaging and radial approach]. / Imagerie et voie radiale.

Radial approach allows in a large majority of cases to perform endovascular imaging. If we can assess anatomical variations with angiography, echography approach begins a mandatory tool to do the puncture safely, but also allows to identify anatomical variations and complications.

[Infection and TAVI]. / Infection et TAVI.

Since trans-catheter valve implantation (TAVI) has emerged for severe symptomatic aortic stenosis treatment, infective endocarditis (IE) appears as a rare but severe complication. Like surgical aortic valve remplacement infective endocarditis (SAVR-IE), TAVI-IE has a noxious impact on morbidity and mortality. Compared to SAVR-IE, TAVI-IE present some similarities as well as differences. Most TAVI-IE occurred during the first year and enterococcus is the more common pathogen. A multimodality imaging approach including echocardiography, multislice computed tomography (CT) and positron emission tomography-CT with blood culture is necessary for the diagnosis. In this high-risk population, the vast majority of TAVI-IE patients are treated with antibiotic therapy alone. Consequently to the expanded indication, the increasing number of TAVI-IE will appear more frequently. If initially only few clinical cases of IE were reported, sparse observational multicenter registries have now been published. Relevant differences were noted on these registries, but some recent publications have provided new informations on IE. The present review reports incidence, symptoms, microbiological profil, risk factors and clinicals outcomes of TAVI-IE. Eventually, we describe the management and the treatment of IE in the context of TAVI.

[Radial artery occlusion ofter coronarography: is it really a problem?] / L'occlusion de l'artère radiale après cathétérisme cardiaque : est-ce réellement un problème ?

The use of transradial access for cardiac procedures has increased worldwide over the past two decades. Despite the many advantages this technique offers, there remains some concern that radial artery occlusion, a potential complication of radial cannulation, might lead to significant ischemic sequelae in the hand. This paper reviews the major causes, its possible consequences and the strategies for its prevention and treatment. It appears however from multiple studies that there is little or no correlation between radial occlusion and symptomatic hand ischemia.

Suspected acute coronary syndrome in a theater of operations: first management, medical evacuation, and final diagnosis: experience of the French Medical Army.

OBJECTIVE: to evaluate the treatment of the acute coronary syndrome (ACS) among soldiers stationed on a theater of operations by structures usually conceived to treat combat-related trauma. METHODS: We performed a retrospective study involving the whole medical evacuations out of a theater of operations to the benefit of the French Armed forces, for a suspected diagnosis of ACS. RESULTS: 35 patients were included in this study with 20 for a diagnosis of persistent ST-Segment Elevation Myocardial Infarction (STEMI). Only an active smoking defined a population at risk in these high medical selective soldiers. The agreement between the initial and the final diagnosis was excellent for STEMI but remains perfectible for NSTEMI. CONCLUSION: the medical structures deployed in a theater of operations were able to provide first treatment in ACS. The use of powerful diagnosis test, like troponine assay, must allow a better selection of the patients justifying a medical evacuation.

[Best conditions to perform TAVI procedures]. / Les bonnes conditions pour réaliser des TAVI.

Well conditions to perform TAVI procedures are guided by ministry regulation and dedicated to centers with both on-site a cath-lab and cardiac surgery. Heart Team decision is mandatory to select patient for TAVI and local anesthesia is recommended. Conditions changes would be discuss according to increased procedures number related to indications evolution.

[Radial approach in the elderly]. / Abord radial chez le sujet âgé.

Due to the steady increase in life expectancy, the number of patients over 80 years of age proposed for coronary angioplasty is increasing significantly. The elderly patient is a patient at high cardiovascular risk and high risk of bleeding; whose severity of prognosis depends of comorbidities. The radial approach presents particularities and technical difficulties that have to be known in this part of the population, but reduce vascular and hemorrhagic complications, as well as mortality. Because of greater safety, the radial approach is therefore the first choice for the elderly.

Position paper of French Interventional Group (GACI) for TAVI in France in 2018.

Aortic stenosis is a frequent disease in the elderly. Its prevalence is 0.4% with a sharp increase after the age of 65, and its outcome is very poor when the patient becomes symptomatic. The interventional procedure known as TAVI (trans-catheter aortic valve implantation), which was developed in France and carried out for the first time in Rouen by Prof. Alain Cribier and his team in 2002, has proven to be a valid alternative to surgical aortic valve replacement. At first, this technique was shown to be efficient in patients with contra-indications to surgical treatment or deemed to be at high surgical risk. Given the very promising outcomes achieved as a result of close heart team collaboration, appropriate patient selection, simplified procedures and reduced complication rates, transfemoral (TF) TAVI is now preferred in symptomatic intermediate risk patients>75 years old according to the latest ESC guidelines. In 2017, in France, TAVI is currently performed in 50 centers with on-site cardiac surgery. The 2016 TAVI outcomes recorded in the French national TAVI registry (France TAVI) are very encouraging and show that for 7133 patients treated (age 83.4±7 years, logistic Euroscore 14%), 87% of whom via the TF approach, cross-over to surgery was very low (0.5%) with a 3.0% in-hospital mortality rate. The substantial increase in TAVI indications and the improvement of its outcomes may in the near future call for a reconsideration of the number of high volume centers authorized to carry out this technique.

[Cardiac toxicity of catecholamines. Report of two cases]. / Toxicité myocardique des catécholamines: à propos de deux observations.

INTRODUCTION: The role of catecholamines in the cardiac expression of pheochromocytoma is well-known. The physiopathology of the syndrome of Tako-tsubo remains more unclear. EXEGESIS: We describe 2 clinical cases of acute coronary syndrome with left ventricular dysfunction and no coronary artery stenosis. The first, a syndrome of Tako-tsubo, also known as transient left ventricular apical ballooning syndrome, is characterized by transient wall-motion in the absence of obstructive epicardial coronary disease. The second is a pheochromocytoma with myocardial suffering during hypertension crisis. Through the similarities of these 2 observations, we discuss the physiopathological assumptions to explain the syndrome of Tako-tsubo by underlining the essential place of the catecholamine hypersecretion. CONCLUSION: Syndrome of Tako-tsubo and pheochromocytoma are 2 distinct clinical entities. The link between these 2 affections is probably the pathogenic role in cardiac toxicity with the catecholamines.

[Vascular approaches and closure devices for percutaneous coronary intervention]. / Les voies d'abord et systèmes de fermeture dans l'angioplastie coronaire.

The choice of a transradial or transfemoral approach remains a pivotal decision in percutaneous coronary angioplasty. We discuss here the varying criteria leading to a rational choice in the arterial access choice. Since the emergent transradial approach in France has led to a dramatic reduction in local vascular complications, we also discuss the remaining place of femoral approach and the usefulness of femoral percutaneous closure devices.

[Increased secretion of Nt-proBNP immediately after percutaneous coronary intervention: about 90 cases]. / Elévation de la sécrétion du Nt-proBNP dans les 24 heures suivant une angioplastie coronaire: à propos de 90 cas.

Nt-proBNP have emerged as useful biomarker for the diagnosis and prognostic of heart failure but also recently in acute coronary syndrome. Myocardial ischemia is probably an important stimulus for Nt-proBNP release. Transient myocardial ischemia is inducing by balloon inflation during percutaneous coronary intervention (PCI). The authors propose to determine the Nt-proBNP secretion after uncomplicated coronary intervention in patients with preserved cardiac function. Ninety patients were enrolled in this study. Plasma Nt-proBNP was increased significantly from 135.5 to 157.8 pg/ml and 202.5 pg/ml at 8 and 24 hours following PCI, respectively. History of myocardial infarction and complex lesions were the most powerful predictors of higher Nt-proBNP peak concentration. Prognostic value must be evaluated in larger studies.

[Management of high-risk pulmonary embolism with pulmonary artery trunk mobile thrombus]. / Gestion d'une embolie pulmonaire à haut risque avec thrombus mobile du tronc artériel pulmonaire.

The presence of a right intraventricular thrombus is a marker of severity of pulmonary embolism (PE), and is associated with high mortality. We report the case of a young patient with a PE postoperative of patellar tendon surgery. The cardiac echocardiography at its admission revealed a voluminous mobile thrombus of 1.7cm diameter located on the pulmonary trunk. Systemic thrombolysis was performed because of respiratory deterioration allowing a rapid disappearance of the thrombus and recovery. Our case emphasizes the value of a complete ultrasound analysis centered on the pulmonary trunk in the case of intermediate-risk PE. No recommendation exists on the management of these right ventricular thrombi, thrombolysis appearing to be the first-line treatment.

[Contribution of intracoronary imaging in acute coronary syndrome]. / Apport de l'imagerie endocoronaire dans le syndrome coronarien aigu.

Acute coronary syndrome (ACS) remains a major cause of mortality and morbidity in the world, although it has considerably decreased through technical and pharmacological advances. The physiopathological approach of the ACS has progressed considerably in recent years thanks to the anatomopathological work and the data of the endocoronary imaging, in particular of the endovascular ultrasound (IVUS). Plaque rupture is the most common cause of ACS, however OCT (optical coherence tomography) studies have shown that surface plaque erosion was more common than thought. The use of OCT in the ACS may prove to be a valuable diagnostic aid: study of the culpable lesion, spontaneous coronary dissection or intramural spontaneous hematoma, stent thrombosis; from a therapeutic point of view: reduction of the risk of stent malapposition, additional technique, delayed stenting, implantation of a bioresorbable stent, medical treatment of ACS without stenting. Endocoronary imaging, especially OCT, will of course never be systematic as treatment of ACS, but providing excellent value for both diagnosis and treatment, it must be an integral part of the therapeutic arsenal available in cathlab.

[Radial approach in women]. / La voie d'abord radiale chez la femme.

Since the first series of coronary angiographies through the radial approach reported by Campeau in 1989, the radial route has become a major approach, used in up to 95 % of PCIs in some centers. As documented by this clinical case, and although registries show that the radial approach is underused in women compared to men, women benefit from the radial approach mainly by reducing the bleeding risk. Indeed, despite more frequent difficulties encountered by using this approach in women, the radial approach has to be preferred because it reduces haemorrhagic complications and death in comparison to the femoral route.

[Purulent pericarditis in a patient with diabetes mellitus treated by percutaneous pericardiocentesis]. / Péricardite purulente chez un patient diabétique traitée par drainage péricardique percutané.

Purulent pericarditis seldom occurs in Western countries, yet its mortality rate remains high between 20 and 35 % despite early treatment. We report the case of a 43-year-old patient admitted in the intensive cardiologic care unit with a pre-tamponade, requiring an immediate percutaneous pericardiocentesis allowing the drainage of a purulent effusion. Evolution with antibiotic therapy adapted according to the bacteriological findings was favorable and 3-months follow-up shows a near complete regression of the effusion. This case recalls us this rare diagnosis entity and illustrates the possibility of a mere percutaneous pericardial drainage with the condition of a strict medical surveillance.

[Management of chest pain by the Emergency Ambulance Service: the DOLORES register]. / Prise en charge de la douleur thoracique par le SAMU: le registre DOLORES.

Pre-hospital management of chest pain is a difficult problem. The emergency doctor has to take triage decisions based on instantaneous data whereas the decisional rationale of the many pathologies concerned, including acute coronary syndromes, is often based on observation over several hours. There have been few studies of the efficacy of pre-hospital management of chest pain by an emergency ambulance service. Therefore, the DOLORES register was set up to assess this problem over a 6 month period by the emergency ambulance service of Necker Hospital in Paris. Between January and June 2004, the Necker emergency ambulance service was called out on 205 occasions for chest pain. Forty-three patients had acute coronary syndromes (ACS) with ST elevation. Of the remaining 162 patients, 32 stayed at home, 2 were admitted the following day by cardiologists for coronary angiography, 52 were admitted for observation to the emergency unit and 76 were admitted to the coronary care unit. In the latter two groups, the final diagnosis of ACS without ST elevation was retained in 11/52 and 57/76 patients respectively. Finally, 2 patients were admitted directly to the catheter laboratory. The clinical and paraclinical data noted by the emergency ambulance service and at hospital admission was concordant in all cases. Pre-hospital triage by the emergency ambulance service seems to be effective. These results require confirmation with a large scale study.

[A case, a review: We have to promote radial approach for acute coronary syndrome]. / Un cas, une revue : la voie d'abord radiale doit être privilégiée dans les SCA ST.

This overweight woman's case, who underwent a primary coronary intervention for STEMI, reminds us how much the trans-radial angioplasty is interesting in this particular case leaning on the recent literature, randomized trials and registries, in terms of major adverse events reduction including mortality. We are going to debate about hesitation of using radial approach whose only everyday's practising could make this approach a STEMI one.

One-week and six-month angiographic controls of stent implantation after occlusive and nonocclusive dissection during primary balloon angioplasty for acute myocardial infarction.

We prospectively assessed in 124 consecutive patients by means of 1-week and 6-month follow-up angiograms the rate of reocclusion and restenosis of coronary stenting with Palmaz-Schatz stents after occlusive and nonocclusive dissection during primary balloon angioplasty for acute myocardial infarction (AMI). Patients were further evaluated clinically at 1 year. Stenting was performed on large (>3.2 mm) coronary arteries for suboptimal results (47%), occlusive (8%), or nonocclusive dissections (45%) after balloon angioplasty. Stents were delivered using the bare stent technique and high pressure inflations (>12 atm). All patients received ticlopidine 250 mg (500 mg if weight was >80 kg) and aspirin 100 mg for 1 month. No patient received warfarin. At 1 week, 6 patients died of cardiogenic shock and 2 of right ventricular infarction. One subacute occlusion occurred at day 14. At 6 months, in 95 patients, the angiographic restenosis rate (>50% diameter stenosis) was 19%. One-year clinical follow-up, available in 55 patients, indicated cardiac death in 5, and repeat revascularization in 3. Thus, coronary stenting on large (>3.2 mm) coronary arteries after occlusive and nonocclusive dissection during primary balloon angioplasty for AMI using bare Palmaz-Schatz stents, high pressures, ticlopidine, and aspirin is safe. Our reocclusion and restenosis rates are similar to those of trials on elective stenting in stable patients.

[Coronary angioplasty using 5 or 6 F guide catheters. Results of a comparative, monocentric, prospective randomized study]. / Angioplasties coronaires par cathéters guides 5 ou 6 F. Résultats d'une étude comparative, monocentrique, prospective, randomisée.

Improvement of balloon and stent profile allows to use smaller-diameter catheters to avoid vascular complications by reduce the size of puncture site. First studies using 5 F guiding catheters showed good results in term of safety and feasibility. The authors performed a prospective, randomised study to define exactly the place of such small catheter compared to 6 F approach. One hundred forty eight patients were randomised, 77 in the 5 F group. The success rate per lesions was not significantly different but was less in the 5 F group (91.1 vs 96.5%). The crossover to 6 F allows good results in mainly cases. Limitations are unstable back up, worse opacification, and inability to use covered stent and to treat bifurcation lesions. There are no advantages in term of vascular complications. So, these catheters seem to be limited to treat simple lesion, allowing using the same sheath immediately after coronarography, but these results must be confirmed in a large, multicentric study.

[Left ventricular filling and left bundle branch block: an echocardiographic and radionuclide study]. / Remplissage ventriculaire gauche et bloc de branche gauche: étude échocardiographique et isotopique.

Left bundle branch block changes the activation and haemodynamics of the left ventricle. In order to evaluate its consequences on left ventricular filling, the duration of the isovolumic relaxation period, the velocities and the integrals of the rapid and slow filling waves were recorded by Doppler echocardiography and the ejection fraction, the peak filling rate and its time of apparition were measured by gamma angiocardiography in 18 patients aged 55 +/- 9 years and 18 control subjects aged 53 +/- 9 years. Left bundle branch block was associated with a prolonged isovolumic relaxation period (104 +/- 14 vs 88 +/- 11 ms) a delayed and reduced peak filling rate and an increased atrial filling velocity at a heart rate comparable to that of control subjects (69 +/- 9 vs 72 +/- 8 beats/mn). Despite these changes in left ventricular relaxation and filling and a reduced ejection fraction (55 +/- 7 vs 61 +/- 6%, p < 0.01) cardiac output was not significantly decreased in left bundle branch block (4.9 +/- 1 vs 5.2 +/- 0.9 l/mn). Therefore, left bundle branch block interferes with left ventricular filling and ejection fraction without decreasing the resting enddiastolic volume.