[Current indications for cardiac CT]. / Les indications actuelles du scanner cardiaque.

There is a need to define the current indications for coronary CT angiography (CCTA) even as technology continuously evolves. CCTA using 64 MDCT units has shown to be highly accurate for diagnosis of stenoses >or=50% on selected populations. It is currently used for its negative predictive value (96-98%). Stenosis quantification remains inferior to conventional coronary angiography with tendency to overestimate stenoses <70%. For diagnosis of coronary artery disease, CCTA is considered based on clinical findings (pre-test probability of coronary artery disease) and presence of myocardial ischemia on other functional studies. The main appropriate indications include: In the setting of acute coronary syndrome, CCTA excludes coronary artery disease with excellent NPV and good negative likelihood ratio (0.05) when ECG is non-contributory, 2 consecutive troponin levels at 6 hours are negative in a patient with low risk of coronary artery disease. In the setting of stable angina or atypical precordial chest pain, CCTA is indicated in patient with low to medium risk when functional test are non-contributory or unavailable, or ECG is non-interpretable. CCTA is a complement to coronary angiography for morphological evaluation of some lesions prior to angioplasty and stent placement (long segment occlusion, proximal lesions involving LAD and circumflex arteries). In selected patients, CCTA may replace coronary angiography prior to valvular surgery.

[Hot issues in bifurcation lesions PCI in 2019]. / Angioplastie des lésions coronaires de bifurcation en 2019 : questions brûlantes ?

Coronary bifurcations are involved in 15-20% of all percutaneous coronary interventions (PCI) and remain one of the most challenging lesions in interventional cardiology in terms of procedural success rate as well as long-term cardiac events. The optimal management of bifurcation lesions is still debated but involves careful assessment, planning and a sequential provisional approach. The preferential strategy for PCI of bifurcation lesions remains to use main vessel (MV) stenting with a proximal optimisation technique (POT) and provisional side branch (SB) stenting as a preferred approach. Final kissing balloon inflation is not recommended in all cases. In the minority of lesions where two stents are required, careful deployment and optimal expansion are essential to achieve a long-term result. Intracoronary imaging techniques (IVUS, OCT) and FFR are useful endovascular tools to achieve optimal results.

[Left atrial appendage occlusion in elderly]. / Fermeture d'auricule gauche percutanée chez le sujet âgé.

Left atrial appendage occlusion (LAAO) is an alternative option to oral anticoagulation therapy in patients with non-valvular atrial fibrillation. According to French regulations, this procedure is currently reserved for patients with formal contraindications to VKA and direct thrombin inhibitors. LAAO procedures reduce ischemic and stroke risks compared to no treatment and also reduce bleeding events compared to VKA therapy in eligible patients. The peri-procedural complications risk has been reported to be limited in the different series published so far. Although elderly patients (>75 years) have either higher ischemic and bleeding risk than younger subjects, they hardly benefit from optimal anticoagulation. Thus, these subjects might greatly benefit from LAAO. Published studies reported excellent feasibility and efficiency of LAAO procedure in elderly patients. Yet there is a trend towards a higher incidence of peri-procedural complications (including tamponade), long-term safety is excellent and comparable to what is observed in patients<75 years. Therefore, interventional percutaneous LAAO is an attractive strategy in elderly patients with atrial fibrillation that should be incorporated in a multidisciplinary management.

[The contribution of computed tomography coronary angiography in Kawasaki disease in adult patients. Report of two cases]. / Apport du scanner coronaire dans la prise en charge de la maladie de Kawasaki chez l'adulte. A propos de deux cas.

OBJECTIVES: During the past few years, multislice computed tomography coronary angiography has made great progress in terms of spatial and temporal resolution. Results on detection and quantification of stenoses are excellent. We found interesting reporting its achievements in aneurismal coronaropathies such as the Kawasaki disease. METHODS: We searched for young adults with Kawasaki disease who had a multislice computed tomography coronary angiography available. Several hospitals in the Paris area have been contacted and only two observations have been kept. RESULTS: Computed tomography provided higher performance than coronarography for the measurement of the real diameter of an aneurism taking into account the mural thrombus, evaluation of its links with the collateral branches and the other aneurisms, assessment of the development of recanalized vessels and the degree of development of collateral vessels, and visualization of non-circulating aneurisms which were not detected with coronary angiography. In addition, the evaluation of the location and the degree of the stenoses by the computed tomography matched the coronary angiography data. It was not possible to conclude with this observations that the computed tomography is better for the diagnostic of Kawasaki disease. CONCLUSION: Multislice computed tomography coronary angiography will be likely more and more used to detect and follow coronary anomalies in case of Kawasaki disease among teenagers and young adults. It is recommended for monitoring medium or large aneurisms in order to evaluate their progression to stenosis.

[Visualization of the intra-stent lumen in the coronary arteries and detection of restenoses with 64-slices tomography scanners with cardiac synchronization: first experience]. / Visualisation de la lumière intrastent des artères coronaires et détection des resténoses au scanner 64 coupes avec synchronisation cardiaque: première experience.

PURPOSE: to assess the value of the new high spatial resolution 64-slice CT (0.4 mm collimation) technology for non-invasive visualization of coronary artery stent lumen and the characterization of significant in-stent restenosis. MATERIALS AND METHODS: a total of 100 stents were visualized in 50 consecutive patients. All CT examinations were performed with a 64-slice CT (sensation 64; Siemens), with a slice thickness of 0.75 mm at 0.5 mm intervals with retrospective gating. Images were evaluated by two readers and the quality of the in-stent lumen was classified on 5-point scale (1 = not visible; 5 = excellent visibility). Fifty-eight stents in 29 patients were also examined by conventional coronary angiography one week after CT examination. Attenuation values were measured in the vessel upstream from the stent and within the stent, using 1 mm2 regions of interest. The intra stent attenuation ratio (ISAR) was calculated as vessel enhancement/intra stent hypodense area. Interobserver agreement was evaluated by kappa statistics, RESULTS: the interobserver agreement was k= 0.82. The in-stent lumen was visible (score > or =3) in 88 stents (88%), with good visibility (> or = 4) in 54% of stents. Unsatisfactory in-stent lumen visibility was associated with heart rate > 65 beat/min (p < 0.001) and stent size < 3 mm (p < 0.0001). In-stent visibility was also lower in circumflex than other arteries (p= 0.02). Thirteen stenoses or occlusions were detected in 8 patients. In-stent restenosis was associated with hypodense areas within the stent. A ISAR>2 was an accurate criteria (2 false positives, 0 false negative) for detection of significant (> 50%) intra-stent restenosis. CONCLUSION: high resolution 64-slice CT allows reliable in-stent visualization for stents of 3 mm or more in diameter, if heart rate is below 65 bpm. Significant restenosis can be detected with a high sensitivity by determining the ISAR. Arch Mal

[Multislice computed tomography to detect coronary stenosis among asymptomatic patients with cardiovascular risk factors and equivocal prior stress test: preliminary study]. / Apport du scanner multicoupes dans le dépistage des lésions coronaires chez des patients asymptomatiques à risque: étude préliminaire.

UNLABELLED: Multislice computed tomography (MSCT) is a non-invasive and validated technique to detect coronary stenoses. Some questions remain about its accuracy to detect coronary stenoses (CS), especially for asymptomatic patients (P) when a prior stress test isn't conclusive. METHODS: MSCT was performed among 45 asymptomatic men (mean age: 58,3 +/- 16), with a high ten year risk of fatal cardiovascular disease (SCORE 2003 data for low-risk regions of Europe), without any previous coronary history and with previous non conclusive exercise testing. When significant (> 50%) CS was suspected at MSCT, an angiocoronarography (AC) was done. RESULTS: Eighteen MSCT were normal, unsignificant CS (< 50%) were detected on 14 MSCT and significant coronary stenoses (SCS) for 13 P. Among this 13 P, 19 SCS were identified: 2 SCS of left main coronary artery (CA), 9 of the left descending CA, 6 of the right CA and 2 of the left circumflex CA. 13 CS were confirmed at AC. Finally, because of critical angiographic lesions +/- ischemia at nuclear tomoscintigraphy (NT), 9 P had coronary revascularization (7 catheter based, 2 surgical bypass), 4 P had medical treatment. DISCUSSION: Benefits of this preliminary study are obvious: 9 coronary revascularization/45 P. However, the place of MSCT for the screening of CS is uncertain, but may be usefull as a complement for the screening of coronary arterial disease.

Intra-coronary thrombus evolution during acute coronary syndrome: regression assessment by serial optical coherence tomography analyses.

AIMS: We investigated the feasibility of thrombus quantification by frequency-domain optical coherence tomography (FD-OCT) methods in patients with highly thrombotic acute coronary syndrome (ACS) treated by deferred stenting strategy. METHODS AND RESULTS: Patients were suitable for inclusion if they presented (i) an ACS that was successfully revascularized by manual thrombo-aspiration and (ii) a large residual thrombus on coronary angiography and initial FD-OCT analysis. These patients underwent a second procedure including FD-OCT analysis after several days of optimal antithrombotic therapy. Serial area measurements within the athero-thrombotic culprit lesion were performed to evaluate the OCT-thrombus score, volume, and length. Sixteen patients (88% men/age = 59.3 ± 4.1 years/94% STEMI) were included in the study. The mean delay between OCT analyses was 3.9 ± 0.3 day. No adverse event was observed during this interval. We observed a reduction of thrombus burden between the two analyses, as assessed by the significant reductions in OCT-thrombus score (22.3 ± 2.6 vs. 10.3 ± 1.3, P < 0.001), OCT-thrombus volume (9.6 ± 2.3 vs. 3.6 ± 0.9 mm(3), P = 0.003), and OCT-thrombus length (11.1 ± 1.4 vs. 7.4 ± 0.8 mm, P = 0.01). The percentages of OCT-thrombus score and volume reduction were highly correlated with the inter-OCT analyses delay (respectively ρ = 0.65 and ρ = 0.84, P < 0.01 for both). CONCLUSION: FD-OCT assessment of thrombus volume in selected ACS patients is feasible, safe, and could allow clot regression monitoring in vivo.

Feasibility, safety, cost-effectiveness and 1 year follow-up of coronary stenting without predilation: a matched comparison with the standard approach.

BACKGROUND: We evaluated the feasibility, safety, procedural cost-effectiveness, radiation dose and time and 1-year target vessel revascularization rate of direct unprotected mounted stenting without previous balloon dilatation (DS) in native coronary artery lesions. METHODS: DS was attempted in 119 patients; 39 had a recent myocardial infarction, 62 had unstable angina, and 18 had stable angina. The clinical follow-up was obtained at 14+/-5 months (range 6 to 24 months). These results were compared with those for a consecutive group of 160 patients matched for type and length of lesions and who had a stent only if the post-balloon residual stenosis was >30%. RESULTS: The feasibility of DS was 112/119 (94%). The number of inflations, the length of the stent/length of the lesion ratio, the time and the dose of radiation were dramatically lower in the DS group (P<0.001). DS conferred a slight reduction in procedure-related cost [$820+/-157 for DS vs. 894+/-427 for standard dilatation (SD) per patient]. The 1-year target vessel revascularization rate was similar in both groups [nine (8%) for DS vs. 17 (11%) patients for SD, ns]. CONCLUSIONS: DS is feasible and safe in selected coronary lesions. This method provides a low rate of repeat revascularization and reduces the time and the dose of radiation compared with the standard approach.

[Immediate collateral coronary circulation after a methylergometrin test]. / Apparition immédiate d'une circulation collatérale coronaire après test à la méthylergométrine.

The development of a collateral coronary circulation has been well studied by angiography in two main clinical situations: myocardial infarction (by durable coronary occlusion) and angina (due to significant coronary artery stenosis), but only rarely in spastic angina. The authors report the case of severe spasm at the site of non-significant stenosis after a methylergometrine test, with immediate contro-lateral collateral circulation in a patient with a short history of spastic angina without myocardial infarction. This observation demonstrates that collateral circulation may develop very rapidly in spastic angina (without basal ischaemia in the absence of significant coronary stenosis), because this patient only had seven ten-minute episodes of clinical ischaemia. As collateral circulation may mask clinical and electrical signs in spastic angina, this case suggests that angiographic control should be systematic during the methylergometrine test.

[Diagnosis of acute myocardial infarction using multislice computed tomography in emergency room]. / TDM coronaire en urgence dans le diagnostic d'infarctus à la phase aiguë.

Managing chest pain in emergency remains a diagnostic challenge because of the speediness and the accuracy that request. The authors report the case of a 40 years old patient admitted for chest pain with suspected aortic dissection. Multislice computed tomography (sixteen-slice CT) was performed at the patient's admission, initial diagnosis was rapidly corrected, showing both and accurately show both antero-septal defect perfusion and an acute occlusion of the proximal left anterior descending artery. Angioplasty was performed in emergency within the 6 first hours after onset of the symptoms. Multislice computed tomography was able to identify accurately not only the chest pain etiology but also to show the culprit artery, leading to quick and oriented percutaneous coronary intervention.

[Angioplasty of intra-stent restenosis of a saphenous graft complicated by massive embolism]. / Angioplastie d'une resténose intra-stent de greffon saphène compliquée d'embolie massive.

The main risk of angioplasty of saphenous vein aortocoronary bypass grafts is myocardial infarction by distal embolism, explaining the introduction of systems of distal protection with encouraging results. Although embolism of an atheromatous stenosis is classical, that of intra-stent restenosis is exceptional. The authors report a very unusual case of atheromatous and/or thrombotic embolism occurring during angioplasty of an intra-stent restenosis which was recovered by a micropore filter system.

[Anomalies in myocardial contrast uptake revealed by multislice cardiac CT during acute myocarditis]. / Anomalies de la prise de contraste myocardique mises en évidence par le scanner cardiaque multicoupes au cours de myocardites aiguës. A propos de 2 cas.

Acute myocarditis can display many various clinical appearances. Endomyocardial biopsy is an invasive investigation for which the sensibility is insufficient in mild cases and when it is performed too early. Multislice cardiac CT with ECG synchronisation and injection of contrast medium allows visualisation of the coronary arteries and the study of myocardial contrast uptake. We report the cases of two patients with a mild myocarditis where multislice CT performed early showed multiple areas of increased myocardial contrast uptake consistent with a diffuse inflammatory disorder. Coronary angiography was normal in these two patients. Multislice cardiac CT could be a useful non-invasive investigation for the early diagnosis of this disease.

[Angor with occlusion of the left main coronary artery treated with angioplasty]. / Angor avec occlusion du tronc commun gauche traité par angioplastie.

The occlusion of the left main coronary artery is rare and generally fatal. However, some subjects do survive. The two conditions necessary for survival appear to be the existence of a dominant right coronary artery and above all a rapidly functional left-right collaterality. The time lapse between occlusion and the introduction of an efficient collateral system is fundamental to patient survival. If the time lapse is too long, there is a risk of myocardial infarction, often complicated by cardiogenic shock, with a poor prognosis even after deocclusion. In this study, the case is reported of a patient with left main coronary artery occlusion presenting as unstable angor without an increase in enzymatic levels, and with a totally functional left-right collaterality. Deocclusion angioplasty was successfully performed. Finally, the short- and medium-term results of left main coronary artery angioplasty have been discussed.

[Non-invasive coronarography: myth or reality]. / La coronarographie non invasive: mythe ou réalité.

Slice Imaging technology progress allows a good approach of coronary arteries. MRI and Multislice Computed Tomography (MSCT) are in competition. Inspite of important progress, MRI of coronary artery disease remains "disappointing". With this imaging technology, there is a good plaque burden and myocardium visualisation. MST, and particularly with 16 slice technology, allows a good coronary stenosis identification. This technology enables soft plaque and myocardial ischemia detection. It is now possible to detect coronary heart disease with MSCT, which can replace or help a coronary angiogram in some indications.

[Prognostic value of normal coronary angiography]. / Valeur pronostique d'une coronarographie normale.

Coronary angiography is the "gold standard" for coronary artery disease (CAD). It is considered either normal or subnormal without any lesion (endocoronary echography often demonstrates atheroma), or in presence of a < 50% stenosis. Nevertheless, the risk of plaque rupture is not well correlated with the degree stenosis. Despite the frequent presence of non-significant atheroma, is a normal coronarography really of a good prognosis? Between January and September 1997, 136 of 600 (22.6%) angiographies were considered as normal. The indications were: "CAD suspicion" (n = 77), "preoperative angiography of valvulopathy" (n = 38), and "angioplasty control" (n = 22). The arteries were strictly normal for 86 patients (63%) and a < 50% stenosis was found in 50 patients (37%); 108 patients (80.1%) were followed for 18 +/- 3 months: eight non coronary deaths were reported: four postoperative deaths in "valvular group", two pulmonary embolisms and two pulmonary neoplasm's in "CAD suspicion group". No myocardial infarction was reported and one unstable angina was documented. Despite the frequency of non-significant atheroma, an acute coronary syndrome exceptionally complicates a "normal" coronarography.

[Medical treatment after implantation of intracoronary stents]. / Traitement médical après implantation de stents intracoronaires.

RATIONALE FOR ANTITHROMBOSIS THERAPY: Introducing a foreign body into the coronaries raises the risk of thrombosis in the acute phase and for the 4 following weeks. The objective of antithrombotic therapy is to inhibit platelet adhesion and aggregation or to induce hypocoagulability. AT IMPLANTATION: High-dose heparin is given in a bolus following pretreatment with aspirin. ASPIRIN-TICLOPIDINE COMBINATION: The risk of subacute thrombosis is low, about 1%, and the rate of vascular complications is minimal. Treatment is simple and compatible with short hospitalization.

[Visceral form of human anthrax imported from Africa]. / Forme viscérale de charbon humain importée d'Afrique.

Widespread vaccination has largely eliminated anthrax in Europe (the last case was reported in France in 1972) but the disease remains endemic in many developing countries. The usual cutaneous presentation (malignant pustules) is much more familiar than the various visceral manifestations including digestive tract, pulmonary or meningeal signs. We report a case of a 33-year-old immigrant living in France who was hospitalized for asthenia, dyspnoea, mucopurulant expectoration and moderate diarrhoea 3 days after a 3-month stay in Senegal and Gambia. The temperature was 39 degrees C at admission and blood pressure 110/70 mmHg. Crepitants were heard at the base of the right lung and the rest of the physical examination was normal. Blood was drawn for culture. Laboratory tests and the chest X-ray led to the diagnosis of pneumopathy and a treatment of amoxicillin and clavulanic acid was given with oxygenotherapy. The patient's temperature returned to normal but over the next 48 hours the dyspnoea worsened together with the black diarrhoea. The abdomen was painful. There were no skin lesions. The chest X-ray revealed an extension of the bilateral pulmonary images and bilateral pleural effusion. Laboratory tests revealed thrombopenia (platelet count 38,000/mm3) hyperleukocytosis (WBC 48,000/mm3) and haemolysis (Hb 4 milligrams). The diagnosis was made on the basis of the initial blood cultures which were positive for Bacillus anthracis. All other samples were negative, including HIV serology. Despite adapted antibiotic therapy (penicillin G, 8MU/day, was initiated on day 2), multiple organ failure occurred with septic shock and pulmonary oedema. The patient died in the intensive care unit on day 7. Fatal outcome due to anthrax is described in 25% of the visceral forms but reaches 100% in cases of septicaemia. The haemolysis observed in this case is not mentioned in the classical descriptions of anthrax. When treating septic syndromes in patients who have returned from endemic zones, clinicians should entertain the diagnosis of anthrax since the risk of fatal outcome is increased greatly in case of delayed diagnosis.

Percutaneous transluminal angioplasty of ostial lesions of internal mammary artery grafts.

The internal mammary artery (IMA) is currently the best graft for coronary bypass surgery and is therefore preferentially anastomosed to major arteries, usually the left anterior descending (LAD) artery. This graft may develop a stenosis, most often at the distal anastomosis. Ostial stenoses are rare and their pathophysiology uncertain. While angioplasty of distal anastomotic lesions provides adequate results, the very small number of published cases of angioplasty of ostial lesions explains the lack of knowledge on results of this type of procedure. The authors report six procedures of this type on five patients, including two with stenting. The primary success rate was 100%, with only one hospital complication in the form of pulmonary edema. Mean follow-up for 35 months revealed one sudden death due to probable restenosis, another death 3 years after angioplasty from rapid fatal shock without complementary investigation, and one case of unstable angina secondary to intrastent restenosis. These results suggest that this type of angioplasty is technically feasible with low risk, and that the restenosis rate seems relatively high, potentially presenting as sudden death, in the same way as unprotected dilatation of the native left main artery. A very close clinical follow-up of these patients is therefore necessary, with angiographic control in case of suspected ischemia.

In vivo assessment of neurotransmitter system in cardiovascular diseases. Clinical issues.

Cardiac neurotransmitter systems, especially the adrenergic receptor pathway, are impaired in heart diseases. In patients with heart failure, these abnormalities contribute to arrhythmogenesis and to progression of cardiac dysfunction. The use of MIBG with single photon imaging has provided useful information on the mechanisms of ventricular arrhythmias, and on the causes of death in patients with heart failure or hypertrophic cardiomyopathy. It has been suggested as a prognostic indicator in patients with heart failure. Positron Emission Tomography (PET) now allows us to obtain noninvasively the quantitative determination of regional receptor density and affinity in humans as well as innervation integrity and functioning. These measurements are based upon the synthesis of a radioligand, usually either a selective receptor antagonist or a false neurotransmitter labeled with a positron-emitting radioisotope. Mathematical compartmental models are fitted to activity-versus-time curves obtained during saturation or displacement experiments in order to calculate the rate constants and the receptor density in the myocardium. PET has only recently begun to be applied to the study of cardiac physiology and disease. PET and SPECT cardiac neuroimaging techniques are able to demonstrate the physiological regulation of receptors, and to provide the possibility of studying regional abnormalities of cardiac neurotransmission, especially in arrhythmogenic cardiomyopathy. Furthermore these non invasive techniques could be useful in exploring the alteration of neurotransmission in the early stage of heart disease and could allow repeated scintigraphic examinations in order to evaluate the effects of cardiac medications.