Adenosine plasma level correlates with homocysteine and uric acid concentrations in patients with coronary artery disease.

The role of hyperhomocysteinemia in coronary artery disease (CAD) patients remains unclear. The present study evaluated the relationship between homocysteine (HCys), adenosine plasma concentration (APC), plasma uric acid, and CAD severity evaluated using the SYNTAX score. We also evaluated in vitro the influence of adenosine on HCys production by hepatoma cultured cells (HuH7). Seventy-eight patients (mean age ± SD: 66.3 ± 11.3; mean SYNTAX score: 19.9 ± 12.3) and 30 healthy subjects (mean age: 61 ± 13) were included. We incubated HuH7 cells with increasing concentrations of adenosine and addressed the effect on HCys level in cell culture supernatant. Patients vs. controls had higher APC (0.82 ± 0.5 µmol/L vs 0.53 ± 0.14 µmol/L; p < 0.01), HCys (15 ± 7.6 µmol/L vs 6.8 ± 3 µmol/L, p < 0.0001), and uric acid (242.6 ± 97 vs 202 ± 59, p < 0.05) levels. APC was correlated with HCys and uric acid concentrations in patients (Pearson's R = 0.65 and 0.52; p < 0.0001, respectively). The SYNTAX score was correlated with HCys concentration. Adenosine induced a time- and dose-dependent increase in HCys in cell culture. Our data suggest that high APC is associated with HCys and uric acid concentrations in CAD patients. Whether the increased APC participates in atherosclerosis or, conversely, is part of a protective regulation process needs further investigations.

[Acute stent thrombosis due to resistance to clopidogrel ? A case report]. / Implication de la résistance au clopidogrel dans la thrombose aiguë de stent ? A propos d'un cas.

The authors report the case of a 65 year old man who presented with an acute coronary syndrome without ST elevation due to acute stent thrombosis 12 hours after implantation. Recent reports in the literature suggest the role of resistance to antiplatelet drugs in acute, subacute or late stent thrombosis. This patient was included in a protocol studying the response to antiplatelet drugs in patients undergoing coronary stenting and fulfilled the criteria of resistance to clopidogrel. This clinical case illustrates the possible role of "resistance" to antiplatelet drugs in stent thromboses.

High post-treatment platelet reactivity identified low-responders to dual antiplatelet therapy at increased risk of recurrent cardiovascular events after stenting for acute coronary syndrome.

BACKGROUND AND OBJECTIVES: Low response to antiplatelet therapy may be a risk factor for the development of ischemic complications in patients with non-ST segment elevation acute coronary syndrome (NSTE ACS) undergoing coronary stenting. METHODS: We prospectively studied the platelet response to both clopidogrel and aspirin in 106 NSTE ACS consecutive patients undergoing percutaneous coronary intervention (PCI) with stenting. A single post-treatment blood sample was obtained just before PCI and analyzed by platelet aggregometry using both ADP and arachidonic acid (AA) as agonists to explore the responses to clopidogrel and aspirin, respectively. Patients were divided into quartiles according to the ADP or AA induced maximal intensity of platelet aggregation. Patients of the highest quartile (quartile 4) were defined as the 'low-responders'. RESULTS: Twelve recurrent cardiovascular (CV) events occurred during the 1-month follow-up. Clinical outcome was significantly associated with platelet response to clopidogrel [Quartile 4 vs. 1, 2, 3: OR (95% CI) 22.4 (4.6-109)]. Low platelet response to aspirin was significantly correlated with clopidogrel low response (P = 0.003) but contributed less to CV events [OR (95%CI): 5.76 (1.54-35.61)]. CONCLUSIONS: A post-treatment ADP-induced platelet aggregation performed just before PCI identifies low responders to dual antiplatelet therapy with an increased risk of recurrent CV events.

[Myocardial infarction during post-abortion DIC]. / Infarctus du myocarde au cours d'une CIVD du post-abortum.

We report the case of a 40 year old woman admitted for dilatation and curettage at 12 weeks of amenorrhoea with post-abortion partial placental retention. Clinically she had developed disseminated intravascular coagulation (DIC) complicated by an acute coronary syndrome with persistent ST elevation in the inferior leads. Management of her myocardial ischaemia was symptomatic, due to the underlying complex coagulation disorder making coronary reperfusion techniques impossible. After treatment for the cause of DIC, coronary angiography revealed no detectable angiographic lesion or spasm. In this context, the most likely aetiological hypothesis is a thrombus related to the DIC in an otherwise healthy heart, which was spontaneously lysed.

[Endomyocardial fibrosis: a rare case of restrictive cardiomyopathy in a Caucasian female]. / Fibrose endomyocardique: une cause rare de cardiomyopathie restrictive chez une patiente caucasienne.

The authors report the case of endomyocardial fibrosis diagnosed in a young Caucasian female presenting with progressive congestive cardiac failure. The diagnosis was suspected on the echocardiographic, magnetic resonance imaging and cardiac catheterisation findings in association with the clinical presentation. After a short course of symptomatic medical therapy, the patient underwent the only curative treatment of this pathology, surgical endocardectomy and combined valvular surgery. The confirmation of the diagnosis was obtained a posteriori by histopathological examination of the operative findings which showed appearances of endomyocardial fibrosis similar to those observed in tropical regions. The patient was discharged on the eighth postoperative day, much improved clinically, and follow-up at one year was very satisfactory.

[Beneficial effect of a loading dose of 600 mg of clopidogrel on platelet parameters in patients admitted for acute coronary syndrome]. / Bénéfice d'une dose de charge de 600 mg de clopidogrel sur les paramètres plaquettaires chez les patients admis pour syndrome coronaire aigu.

INTRODUCTION: Despite the beneficial effect of an aspirin-clopidogrel combination in acute coronary syndrome, the incidence of ischaemic recurrences remains significant and very probably implicates a variability in the response to anti-platelet agents. OBJECTIVE: We sought to demonstrate the evidence for a beneficial effect, in terms of anti-platelet effect, of a higher loading dose of 600 mg of clopidogrel compared to the usual 300 mg in patients admitted to our centre with acute coronary syndrome. MATERIALS AND METHODS: Platelet reactivity was evaluated with the ADP 10_mol test and the degree of platelet activation by the expression of P-selectin. 178 consecutive patients admitted for acute coronary syndrome received 250 mg of intravenous aspirin together with either a loading dose of 300 mg of clopidogrel (n = 104) or 600 mg (n = 74) administered 12 to 24 hours prior to coronary angiography. RESULTS: The patients who received 600 mg of clopidogrel had an average aggregation intensity to ADP and a rate of platelet high reactivity post treatment that was significantly lower [48+20 vs 58+18, p = 0.0011 and 11 patients (15%) vs 26 patients (25%), p = 0.0003 respectively]. The degree of platelet activation evaluated with P-selectin was significantly lower in patients receiving 600mg [0.33 + 0.17 vs 0.50+0.29, p < 0.001]. CONCLUSION: Our study provides evidence for a beneficial effect of a loading dose of 600mg of clopidogrel compared to the usual 300 mg in terms of platelet reactivity and platelet activation post treatment.

[Platelet function after a high dose bolus of tirofiban immediately after coronary angioplasty]. / Etude de la fonction plaquettaire après bolus de tirofiban a haute dose au décours immédiat de I'angioplastie coronaire.

In the TARGET trial, the lower incidence of cardiac events at one month with abciximab compared with tirofiban was attributed to a lack of efficacy in the first hour because of suboptimal dosage. The object of this study was to confirm that high dose tirofibal is associated with over 90% platelet inhibition during the first hour and to analyse the effect of this new dosage on platelet activation. Thirty-three patients treated with clopidogrel and aspirin for an acute coronary syndrome without ST elevation were given before angioplasty a bolus of 25 microg/Kg of tirofiban injected in 3 minutes, followed by an infusion of 0.15 microg/kg/min. Blood samples were taken before the treatment (TO) and at the 45th minute (T1) to measure platelet aggregation induced by ADP, the expression of P-selection, the quantification of circulating monocyte-platelet aggregates and the phospholyration of VASP protein. The results showed that all patients had over 90% (100%) inhibition of platelet aggregation at T1. The expression of P-selection was significantly reduced (T0: 0.195 +/- 0.057 MFI; T1: 0.186 +/- 0.055 MFI, p = 0.03). There was no significant difference in the number of monocyte-platelet aggregates or in the phosphorylation of VASP. In conclusion, a bolus of 25 microg/Kg/3 min of tirofiban provides over 90% inhibition of platelet aggregation in the first hour. The initial platelet proactivator effect at this dosage was shown to have disappeared with an inhibition of platelet activation.

An unusual mid term complication of coronary rupture.

A 55-year-old man was admitted with a four-month history of lethargy, dyspnea and ascites. An idiopathic liver cirrhosis was suspected to be responsible for these symptoms and for elevated hepatic enzymes on blood tests. A few months before he had an angioplasty on the left anterior descending artery for an acute coronary syndrome (ACS). The intervention was complicated by coronary perforation which required the implantation of a polytetrafluoroethylene-covered (PTFE) stent to seal the rupture. On admission, pressure measurements during cardiac catheterism revealed a typical right ventricular dip-plateau consistent with the diagnosis of constrictive pericarditis (CP). Magnetic resonance imaging (RMI) showed localized pericardial thickening next to the right ventricle. We suspect hemopericardium, due to coronary perforation, is responsible for constrictive pericarditis. This mid-term complication of coronary rupture has not been reported before and should be suspected in this particular clinical setting.

[Tako-tsubo: a rare form of transient left ventricular dysfunction]. / Tako-tsubo: une forme rare de dysfonction ventriculaire gauche transitoire. A propos d'une observation.

The authors report the case of a 67 year old caucasian female admitted for suspected acute coronary syndrome with ST segment elevation. Coronary angiography did not show any coronary lesion but ventriculography revealed akinesia of the middle and apical segments with hyperkinesia at the base. An isolated moderate elevation of troponine Ic was noted. On the 10th day the methergin test was negative and ventriculography showed complete recovery of the left ventricular segmental kinetics. Left ventricular transient apical ballooning, or tako-tsubo syndrome, is characterised by reversible akinesia of the middle and apical segments with no associated coronary lesion or enzymatic elevation concordant with the extent of the akinetic areas. It mainly affects women between 50 and 60 years old and follows emotional or physical stress. The prognosis is excellent in survivors with a rapid return of normal systolic function. The pathophysiology remains debatable, excluding myocarditis in favour of sideration.

[Adult apico-aortic shunts. A case followed for 6 years]. / Dérivation apico-aortique chez l'adulte. A propos d'un cas suivi durant 6 ans.

An apico-aortic shunt enables a reduction in the aortic transvalvular pressure gradient. It is recommended for patients with symptomatic severe stenosis when anatomical constraints contra-indicate valvular replacement. The authors report the case of a patient who underwent this uncommon procedure, which was indicated due to previous coronary bypass surgery using both mammary arteries, plus massive calcification of the ascending aorta. Angio-haemodynamic investigation and MRI performed three years and five years respectively following the procedure confirmed its efficiency. An analysis of the few reported series confirms the value of this special procedure.

Laparoscopic inguinal hernia repair results: 131 cases.

Since its introduction, laparoscopic inguinal hernia has been plagued with multiple technical problems. A series of 131 laparoscopic inguino-femoral hernia repairs is presented. The technique used was an original transabdominal pre-peritoneal approach using a SurgiPro mesh with two technical variations. In the beginning, this procedure was only offered to patients less than 50 years of age. These guidelines were eliminated as the study progressed. For our first 10 cases, our average operating time was 1 hour and 39 minutes. For the last 40 cases, it averaged 63 minutes. All but four patients were discharged the same day. Ninety-six per cent of all patients felt minimal pain or discomfort within 72 hours. Four per cent felt pain or discomfort until the tenth post-operative day. All patients were ambulatory the day of surgery, and 94 per cent of all patients resumed regular activities before the tenth postoperative day. No significant morbidity and no mortality were identified with the exception of five postoperative inguinal seromas, which were successfully aspirated. No recurrence was demonstrated, but this series is clearly insufficient to establish a rate of recurrence. The cost of these procedures appeared to be higher than for a conventional repair; however, it has recently been reduced. The procedures remain difficult, but the rate of recovery for these patients is shown to be significantly improved. The superiority of this procedure over its open counterpart has not yet been proven.

Laparoscopic inguinal hernia repair: optimal technical variations and results in 1700 cases.

A follow-up series of 1700 laparoscopic inguinofemoral herniorrhaphies by a single surgical team is presented (1381 patients). Two standard techniques were used: transabdominal preperitoneal (1452 cases) and totally extraperitoneal (248 cases). Mean follow-up was 5.3 years. There were 348 patients with bilateral hernias, 121 with recurrent hernias, and 27 with incarcerated hernias. Numerous technical variations were used as the study progressed. A SurgiPro mesh (USSC, Norwalk, CT) with staple/tack fixation was used in all patients. Average operating time was 41 minutes for unilateral repairs, and 97.3 per cent of the procedures were outpatient procedures. Five recurrences were reported. The postoperative permanent neuropathy rate was found to be negligible, but a 5.1 per cent rate of uncomplicated ipsilateral postoperative seromas is reported. All patients were instructed to return to unrestricted physical activities on postoperative day one. Ninety per cent of the patients were able to do so within 5 days versus 93 per cent in 7 days. Ninety-six per cent of all patients felt minimal pain and discomfort after 72 hours. There was no significant difference in recovery or morbidity between the transabdominal preperitoneal and totally extraperitoneal repairs. To date laparoscopic inguinal herniorrhaphy continues to be a difficult procedure with a significant learning curve. The reported surgical performance data and the described optimal technical variations make this procedure a viable and competitive repair in the surgical management of inguinofemoral hernia.

Transabdominal preperitoneal laparoscopic inguinal herniorrhaphy: results of 509 repairs.

A follow-up series of 509 transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repairs is presented. The technique used was an original TAPP approach using a SurgiPro Mesh with two technical variations. Age restrictions were removed after the first few cases; thereafter, all patients cleared for general anesthesia were entered into this study without restrictions. Our average operating time was 48 minutes for unilateral hernia repairs. All procedures were outpatient procedures with the exception of 11 overnight admissions for urinary retention. The procedure was well tolerated. Ninety-three per cent of all patients reported minimal pain or discomfort within 72 hours. All patients were instructed to resume unrestricted physical activities within 24 to 48 hours after the procedure; 89 per cent were able to resume activities within 5 days, 94 per cent within 7 days, and 97 per cent within 10 days. No significant morbidity nor mortality were reported, with the exception of two postoperative neuropathies. Nineteen patients developed postoperative seromas that were successfully aspirated. One recurrence has been reported to date. Due to the lack of long term follow-up, these results remain inadequate to establish an accurate recurrence rate. This procedure remains technically difficult and is subject to a learning curve, but the rate of recovery for these patients is significantly improved. In conclusion, the superiority of this procedure in comparison to its open counterpart cannot be proven until long term follow-up becomes available.

[Acute complications of coronary angioplasty: prevention and management]. / Complications aiguës de l'angioplastie coronaire: prévention et prise en charge.

The immediate results of transluminal coronary angioplasty (TCA) have improved considerably during recent years. Balloon dilatation of the arterial stenosis is the basis of this technique of revascularisation but new tools may be used to treat specific lesions. Coronary occlusion is the most feared complication of TCA. It may cause myocardial infarction or death of the patient. It is usually secondary to dissection and/or thrombus of the artery. The implantation of a stent successfully treats most cases of dissection. New anti-platelet (GP IIb/IIIa) drugs seem to be very effective in the prevention and treatment of the thrombosis. The systematic use of ticlopidine limits the risk of stent occlusion. Improved features enable satisfactory implantation of stents in the majority of cases. In some patients, the clinical consequences of occlusion may be limited by vascular bypass techniques, especially intra-aortic balloon pumping. In other cases, emergency coronary bypass surgery may be necessary. When TCA is considered to be a very high risk procedure, effective surgical cover is essential.

[Acute myocarditis and eosinophilic pneumonia: good outcome after medical treatment and long-term follow-up]. / Myocardite aiguë et pneumopathie à éosinophiles: évolution favorable après traitement médical et suivi à long terme. A propos d'un cas.

The authors report a case of acute eosinophilic myocarditis (AEM) with acute left ventricular failure preceded by an acute hypoxaemic eosinophilic pneumonia. The diagnosis of myocarditis was confirmed histologically. That of the eosinophilic pneumonia was base on the abundance of eosinophilic polynuclear cells in the bronchoalveolar lavage and appearances on computerised tomography. The pulmonary lesions rapidly and definitely regressed and complete recovery of left ventricular function was obtained by long-term steroid therapy. This favourable outcome has been sustained after 11 years of follow-up despite the presence of chronic mild hypereosinophilia. In the absence of specific clinical and paraclinical data, the diagnosis of AEM was based on the demonstration of an inflammatory infiltrate rich in polynuclear eosinophils and necrotic myocardial lesions. This histological signature may be obtained in vivo by endomyocardial biopsy, the indication of which must be rapidly recognised. Only the instauration of early and intensive steroid therapy seems to influence the outcome which is frequently poor. The synthesis of the anatomo-clinical and experimental data suggests a myocardial aggression by cytotoxic effects of granular protein components released during activation of polynuclear eosinophils. The role of AEM is discussed in the different aspects of cardiac hypereosinophilia.

[Mitral insufficiency related to a spasm of the left anterior descending artery. A case report]. / Insuffisance mitrale due à un spasme de l'IVA. A propos d'un cas.

We report the case of a female patient of 76 years old admitted to our hospital for a pre-operative assessment of a symptomatic mitral regurgitation (MR) whose transthoracic echocardiography revealed only a trivial regurgitation. The occurrence during hospital stay of an acute pulmonary edema contemporary to the occurrence of a huge MR permitted to suspect the diagnosis of a paroxystic ischemic MR. Angiographic and hemodynamic evaluation revealed only a non-significant atheromateous plaque located in the distal LAD. The infusion of Methylergometrine triggered a severe spasm at the site of that plaque, associated with a huge MR visualized by TTE with restricted movements of both leaflets, responsible for an acute pulmonary edema occurring on the table of the catheterization laboratory. Recovery was quickly obtained after intravenous injection of Nitroglycerin, which removed the spasm and valvular regurgitation. The diagnosis of paroxystic ischemic mitral regurgitation was confirmed and a treatment based on high dosage of calcium-blocker was decided. After a follow-up of more than one year, the patient remains asymptomatic and the regurgitation has never occurred.

[Physiopathology of acute coronary syndromes]. / Physiopathologie des syndromes coronariens aigus.

Coronary atherosclerosis and its thrombotic complications represent one of the leading causes of lesions usually consists of successive acute episodes, either silent or in the form of an acute coronary syndrome such as unstable angina, non-Q-wave myocardial infarctions, transmural myocardial infarctions or sudden death. This mode of progression does not exclude phases of regression, or more frequently stabilization of plaques, which, depending on their haemodynamic repercussions, are then responsible for chronic myocardial ischaemia. Acute coronary syndrome (ACS) correspond to the same pathophysiological process: rupture of an atheromatous plaque initiating harmful thrombotic, inflammatory and vasomotor phenomena. This is not a new concept, but progress over recent years suggests that the composition and biology of the plaque are factors involved more in the initiation of ACS than the size of the plaque. "Soft" lesions, rich in lipids, are clearly not only the most unstable lesions, but also the most thrombogenic because of their large tissue factor content. After describing the structure of vulnerable plaques, the authors discuss the causes of their rupture and the resulting cascade or events, responsible for life-threatening clinical situations.

Safety and effectiveness of the association ezetimibe-statin (E-S) versus high dose rosuvastatin after acute coronary syndrome: the SAFE-ES study.

BACKGROUND: Statin therapy is a cornerstone therapy for secondary prevention after acute coronary syndrome (ACS). However, the use of these drugs can be limited by side effects, mainly muscular pain. Ezetimibe is a newer lipid-lowering agent, with fewer side effects. AIMS: The present study was designed to compare a commercially available association of ezetimibe and simvastatin (E-S) to high dose Rosuvastatin on cholesterol and muscular enzyme levels and occurrence of muscular pain. METHODS: All consecutive ACS statin-naïve patients with LDL cholesterol (LDL-C)>100mg/dL randomly received either high dose statin (Rosuvastatin 20mg) or E-S 10/40-mg. All patients had one-month follow-up with biological testing and clinical examination. We compared the two groups on the biological efficiency and incidence of muscular pain. RESULTS: One hundred and twenty-eight patients were randomized; 64 received E-S and 64 Rosuvastatin. In the two groups, the lowering of LDL-C level (Δ=51%) at one month was significant (P<0.01) without any difference in the rate of lowering on LDL-C or HDL-C suggesting that E-S is as effective as high dose Rosuvastatin (P=0.77 and P=0.99). The rate of patients reaching the objective of LDL-C<100mg/dL (45%) and LDL-C<70mg/dL (51%) was not different in the two clusters (P=0.65). Incidence of muscular pain was 15% higher in patients treated with Rosuvastatin (P=0.01) without any difference on CPK level (P=0.6). CONCLUSION: Using an association of E-S in an effective alternative strategy to high dose Rosuvastatin with a lower incidence of muscular pain, which might impact adherence to medication after ACS.

[Contribution of cardiac MRI in the initial evaluation and follow-up of myocarditis mimicking acute coronary syndrome: a series of 43 patients]. / Apport de l'IRM cardiaque dans l'évaluation initiale et le suivi des myocardites mimant un syndrome coronaire aigu : à propos d'une série de 43 patients.

AIMS: The diagnosis of acute myocarditis is complex, especially when the clinical presentation mimics an acute coronary syndrome. This condition may promote the progression to dilated cardiomyopathy and the occurrence of severe arrhythmias. A reassessment integrating a cardiac MRI at three months after the acute episode could help identify patients with a poor prognosis. PATIENTS AND RESULTS: This prospective series of 43 consecutive patients hospitalised for acute myocarditis included 36 men and seven women, with a mean age of 32 years, with no indication of heart failure. All patients presented elevated levels of troponin I. Echocardiography showed moderate left ventricular dysfunction in six cases and segmental wall motion abnormalities in 22 cases. After gadolinium injection, a subepicardial late enhancement was observed in 39 cases. Three months after the acute episode, all patients were asymptomatic. The echocardiography and laboratory tests were normal. In 23 cases, the MRI showed persistence of the late enhancement without segmental wall motion abnormality. After a mean follow-up of three years, one patient was lost to follow-up and only one suffered a heart failure revealing a dilated cardiomyopathy complicated by ventricular arrhythmias. CONCLUSION: On admission, the subepicardial localisation of late enhancement in the cardiac MRI is reliable criteria for the diagnosis of acute myocarditis, enabling to rule out an acute coronary syndrome. During follow-up, the persistence of late enhancement has no impact on prognosis. In this series, after a mean follow-up of three years, it was not associated with clinical or paraclinical abnormalities, except in one patient.