Management of spontaneous coronary artery dissection: review of the literature and discussion based on a series of 12 young women with acute coronary syndrome.

Spontaneous coronary artery dissection (SCAD) is a rare pathology, principally affecting young women free of atheroma risk factors. Its physiopathology remains little understood, and the prognosis for such acute coronary syndromes is poor, as they occur suddenly. Management is often difficult, and no guidelines exist. The present single-center retrospective study concerns 12 cases of SCAD occurring between 2001 and 2008 in female patients under the age of 60. Eleven patients survived, with a favorable long-term evolution. Only 2 had conservative medical therapy, the other 10 undergoing percutaneous coronary intervention (2 procedures involving a coronary artery bypass graft). On the basis of this series and data from the literature, we suggest a strategy to improve the often dire prognosis of SCAD. Emergency angiography to confirm diagnosis is essential. Treatment should be guided by the extent of the lesions, the myocardial ischemia and the hemodynamic status. Conservative medical therapy is a reasonable approach in the case of distal dissection or conserved coronary flow. Percutaneous coronary intervention is feasible in the acute phase to restore coronary perfusion and hemodynamic stability. Surgery - emergency bypass or assisted circulation - should be restricted to cases where percutaneous coronary intervention has failed or is impossible.

Clinical and microcirculatory effects of transcutaneous CO2 therapy in intermittent claudication. Randomized double-blind clinical trial with a parallel design.

BACKGROUND: This randomized, double blind trial determined the short and long-term clinical and hemodynamic vasodilator effects induced by percutaneous applications of natural CO2 gas in patients with moderate Fontaine stage II. PATIENTS AND METHODS: 62 patients with intermittent claudication (100-500 meters) were randomized to 18 consecutive days of CO2 treatment or placebo (air). The gas fluids were applied at a constant temperature of 30 degrees C on pre-humidified skin. The effects of the treatment were evaluated by total distance walked (primary criterion) and hemodynamic and microcirculatory findings. Patients also answered a quality of life questionnaire. RESULTS: The Strandness test showed a significant increase in total distance walked (+ 131 meters, 66%; p = 0.001) and pain-free distance (+ 81 meters, 73%; p = 0.02) after 18 days of CO2 treatment. The improvement was maintained 3 and 12 months later. The systolic pressure index (ABI) increased by 37% (p = 0.001) 1 minute after treadmill walking and ABI recovery time decreased significantly by 38% (p = 0.002). Microcirculatory findings showed an increase in systolic pressure of the great toe (13%; p < 0.0001), in baseline pO2 (20%; p = 0.01) and in vasomotion (78%; p = 0.001) in the treatment group. The improvement in total walking distance was correlated with the increase in ABI and peripheral cutaneous oxygenation. Patients' subjective assessments corroborated the benefits. No significant change was observed in the placebo group. CONCLUSIONS: This study demonstrates that 18 consecutive days of percutaneous CO2 treatment significantly increases walking distance in patients with moderate intermittent claudication. This effect, which was associated with an increase in peripheral systolic pressure and pO2, is evidence of a better ability to withstand effort.

Trend towards increased arterial stiffness or intima-media thickness in ankylosing spondylitis patients without clinically evident cardiovascular disease.

OBJECTIVES: Increased incidence of cardiovascular disease (CVD) has been observed in AS. The reasons of this increase are not fully understood (greater prevalence of traditional cardiovascular risks, consequences of treatment (NSAID) or biological inflammation). The objectives of this study are to assess intima-media thickness (IMT) and arterial stiffness (i.e augmentation index AIx), markers of sub-clinical atherosclerosis in AS patients and to examine the effects of TNF-alpha inhibitors on arterial stiffness in active AS patients. METHODS: Sixty AS patients were enrolled with 60 healthy controls. Their BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and BASFI (Bath Ankylosing Spondylitis Functional Index) scores, ESR and CRP levels were recorded. Subclinical atherosclerosis was assessed by measurement of AIx by pulse wave analysis and IMT by carotid echography. RESULTS: We found significantly increased IMT in the AS group compared with healthy controls. After adjustment for confounding factors, an underlying trend towards increased IMT was still present (P = 0.06). No difference was found in arterial stiffness between the two groups. AS patients, treated or not with anti-TNF-alpha at baseline, had significantly increased IMT and AIx or a trend towards increase. IMT was positively correlated with tobacco use, WHR and blood pressure but not correlated with CRP level. Despite improvement in markers of disease activity, arterial stiffness was unchanged after 14 weeks of treatment with TNF antagonists. CONCLUSION: This study shows a trend towards increased subclinical atherosclerosis in AS patients. TNF-alpha blockade does not seem to improve arterial stiffness in AS patients, but our results lack statistical power.

[Correspondence between general practitioners and cardiologists: Consensus from a study Delphi]. / Contenu des courriers échangés entre médecins généralistes et cardiologues : consensus d'après une étude Delphi.

AIM OF THE STUDY: To obtain a consensus from a panel of experts (GP and cardiologists) on the elements to appear on the correspondence sent by GP at the patient's first consultation with the cardiologist and on the response of the cardiologist. METHOD: A list of proposals concerning the content of the exchanges between the GP and the cardiologist was established by a scientific council of three GPs and one cardiologist, based on a review of the literature and their practices. This list was submitted for evaluation to a panel of GP and cardiologists experts using the modified RAND/UCLA Delphi method. RESULTS: Twenty nine experts (16 MG and 13 cardiologists) participated in the two evaluation rounds. For the contents of the letter written by the GP, 11 themes have reached consensus: administrative data, reason for consultation, history of the disease, recent constants, current treatments, current or previous pathologies and cardiovascular risk factors, physical activity, psychosocial context, test results, question asked to the cardiologist, cardiologist's perimeter of action. For the contents of the letter of the cardiologist's response, 11 themes were agreed: administrative data, reason for consultation, previous information, clinical examination, ECG, ultrasound, other complementary examinations, answer to the question asked by the GP, dietary treatments, proposed treatments, proposal for follow-up and management. CONCLUSION: This study have reached consensus on the elements to appear on the letters exchanged between the GP and the cardiologist.

[The Williams-Beuren syndrome: reconstruction of the thoracic aorta combining surgery and endovascular treatment]. / Syndrome de Williams-Beuren: reconstruction étendue de l'aorte thoracique combinant chirurgie et traitement percutané

The Williams-Beuren syndrome is the association of elf-like facies, mental retardation with cardiovascular anomalies, the most common of which is supravalvular aortic stenosis. This lesion may be focal or associated with hypoplasia of the distal aorta. The treatment is surgical and the role of interventional cardiological treatment is poorly defined. The authors report the case of a child with typical Williams-Beuren syndrome. An initial, very localised surgical aortic repair was performed at 3 months of age for a discrete supravalvular aortic stenosis. Two months later, a second operation was required for a new stenosis of the distal anastomosis associated with marked hypoplasia of the aortic arch. The progressive constitution of an isthmic coarctation led to the percutaneous implantation of a stent followed by two balloon dilatations. Only the first two endoluminal procedures successfully reduced the transisthmic pressure gradient. An antihypertensive treatment was given and regular echocardiography allows monitoring of the adaptation of the left ventricle.

[Kawasaki disease is also a disease of adults: report of six cases]. / La maladie de Kawasaki est aussi une maladie de l'adulte: a propos de six observations.

Kawasaki disease is an inflammatory arterial disease of unknown cause usually affecting young children, the principal complication of which is coronary artery aneurysm. Early treatment with immunoglobulins and aspirin prevents this complication. The diagnosis requires expert clinical criteria and, in atypical forms, a more recent decisional diagnostic tree has to be used. The authors report 6 cases of adult Kawasaki disease. As in the other sixty or so cases in the literature, hepatic forms were the commonest (5/6). Only three of the six cases met the classical clinical criteria and the diagnosis was made by the decisional tree or after coronary complications in the oldest subject. The five treated patients progressed favourably after a course of immunoglobulins. Echocardiography detected 100% of children with coronary disease but it was more difficult in adults in whom new non-invasive methods of coronary imaging (fast CT and MRI) and stress testing should complete the investigations. The association of prolonged pyrexia, clinical criteria and a biological inflammatory syndrome should, after exclusion of the differential diagnoses, suggest a diagnosis of Kawasaki disease in the adult as in the child. The possibility of coronary disease, even though extremely rare, should be recognised by the cardiologist and lead to diagnostic and therapeutic managements as aggressive as in children.

[Implantation of mechanical pulmonary and tricuspid valve prostheses at a distance from complete repair of Tetralogy of Fallot]. / Implantation de deux prothèses mécaniques, pulmonaire et tricuspide, à distance d'une réparation complète de tétralogie de Fallot.

The authors report the case of a 39 years old woman operated for tetralogy of Fallot at the age of 6. Multiple complications due to postoperative atrioventricular block and a poor surgical result on the pulmonary outflow tract led to several reoperations. Right ventricular dysfunction with pulmonary regurgitation and mitral tricuspid valve disease in a context of endocarditis on the pacing catheter led to double pulmonary and tricuspid valve replacement with mechanical prostheses. The outcome at follow-up at 3 years is good. To the authors' knowledge, this is the first reported case of double mechanical valve replacement of the right heart after complete repair of tetralogy of Fallot.

[Idiopathic intrahepatic portosytemic shunts in 4 children]. / Anastomoses portosystémiques intrahépatiques idiopathiques: à propos de 4 observations.

Intrahepatic portosystemic anastomoses are macroscopic communications between the venous portal system and the systemic circulation and located partly in the liver. We report 4 new cases of type II shunts, which illustrate the circumstances of the diagnosis of these exceptional anomalies. For 2 children, the diagnosis was done antenataly by US and spontaneous involution in a few months was observed. In the third case the malformation was evidenced fortuitously at 3 weeks of life, and this 6-year-old child remains completely asymptomatic so far. Then, in the fourth case, a cerebral venous thrombosis was fortuitously and antenatally evidenced in an otherwise uneventful pregnancy and portosystemic shunt was demonstrated postnataly in the extensive work up of the neonate.

[Impact of transcatheter aortic valve implantation in the treatment of aortic valve disease after previous coronary artery bypass]. / Impact des techniques interventionnelles dans le traitement de la valvulopathie aortique après revascularisation myocardique chirurgicale préalable.

INTRODUCTION: Patients with a history of coronary artery bypass and aortic valve disease constitute a high-risk group for conventional redo surgery. The transcatheter aortic valve implantation (TAVI) may be an alternative for high-risk patients. The purpose of this study is to evaluate the impact of TAVI in the treatment of aortic valve disease after previous surgical coronary artery revascularization. PATIENTS AND METHODS: This is a single-center retrospective, observational study, including 87 patients undergoing surgery for surgical heart valve replacement or TAVI from January 2007 to December 2013. RESULTS: The introduction of transcatheter aortic valve implantation techniques has doubled the number of redo patients treated for aortic valve disease. From 2010 to 2013, the patients treated by conventional surgery diminished by 30%, with improved postoperative outcomes. This study allowed us to notice differences in patient's in terms of operative risk factors. For the same reasons no comparison was possible between 2 subgroup of patients. Hospital mortality was 6.4% for conventional aortic surgery and 20% for transcatheter aortic valve treatment. CONCLUSION: Surgery remains the standard treatment for aortic valve disease even in redo patients, but TAVI becomes a very interesting tool as it may represent a tailored approach for our patients.

[Sudden transformation of pulmonary stenosis to trilogy of Fallot in a 65 year old patient]. / Transformation brutale d'un rétrécissement pulmonaire en trilogie de Fallot à 65 ans. Traitement par cathétérisme interventionnel.

The authors report the case of a 64 year old woman with typical valvular pulmonary stenosis in whom spontaneous and sudden reopening of the foramen ovale resulted in cyanosis. Transthoracic echocardiography with injection of contrast provides a complete diagnosis: valvular pulmonary stenosis with a mean pressure gradient of 83 mmHg and massive right-to-left interatrial shunt. The malformation was treated by interventional catheterisation in a two-stage procedure: pulmonary valvuloplasty followed by closure of the foramen ovale because of the persistence of a right-to-left interatrial shunt. The functional improvement was followed by the appearance of effort angina. Coronary angiography showed single vessel disease of the left anterior descending artery treated by stenting. The long-term outcome was satisfactory.

Comparison between 180 degrees and 360 degrees data collection in technetium-99m MIBI SPECT of the myocardium.

In a series of 12 patients presenting with a single-vessel coronary artery disease and who were injected with 370 MBq of 99mTc-2-methoxyisobutylisonitrile at peak exercise, two consecutive single photon emission computed tomography (SPECT) data collections, i.e., 32 views of 30 sec during a 180 degrees rotation and 64 views of 15 sec during a 360 degrees rotation, were performed 1 hr later. In both cases, transverse sections were reconstructed using (a) a backprojection method with a ramp filter, (b) a correction for downscatter, (c) a correction for depth attenuation by the Chang method, or (d) both corrections. Each reconstructed myocardium was then divided into four short-axis sections which were radially divided into nine sectors. Sectors with an activity below 80% of the maximum were considered as abnormal. Sensitivity and specificity were calculated relative to a sector-by-sector theoretical anatomic distribution of the perfusion abnormalities. Results demonstrate that, of all situations, the best balance between sensitivity and specificity was achieved with the 180 degrees data collection and no correction at reconstruction. Using the 360 degrees data sampling technique mainly lowered the sensitivity in the patients with a circumflex or right coronary artery disease. It is concluded that there does not seem to be any definite advantage in performing a 360 degrees rather than a 180 degrees data collection in 99mTc myocardial SPECT.

Use of left ventricular function as an end point of thrombolytic therapy.

In recent acute myocardial infarction, early reperfusion of the infarct-related artery by intracoronary or intravenous thrombolytic therapy induces a significant limitation of infarct size, provided reperfusion occurs within a time frame that myocardial salvage can still be expected. Limitation of infarct size reduces scar tissue formation, aneurysm formation, infarct zone expansion, left ventricular volume enlargement, and eventually results in higher left ventricular ejection fraction. Infarct size limitation and left ventricular function preservation occur with all thrombolytic agents currently in clinical use: streptokinase, alteplase and, more recently, anistreplase. When anistreplase is compared with conventional heparin therapy, a 31% reduction in infarct size is found (estimated from single photon emission computed tomography, or SPECT). This translates into a significant preservation of left ventricular ejection fraction as observed in anistreplase-treated patients compared with heparin-treated patients (0.53 +/- 0.13 vs 0.47 +/- 0.12, p less than 0.002). In comparative trials of 2 thrombolytic agents, anistreplase was demonstrated to be as efficient as alteplase on left ventricular ejection fraction preservation and infarct size limitation.

Limitation of myocardial infarct size and preservation of left ventricular function by early administration of APSAC in myocardial infarction.

In cases of acute myocardial infarction (MI), it has been shown that preserving left ventricular function and limiting infarct size with early reperfusion of the occluded artery by means of a thrombolytic agent could eventually result in a reduced mortality rate. The aim of the APSIM study (anisoylated plasminogen streptokinase activator complex [APSAC] dans l'infarctus du Myocarde) was to demonstrate that early administration of APSAC in patients with recent acute MI could limit the infarct size and preserve left ventricular systolic function. In all, 231 patients with a first acute MI were randomly allocated to either APSAC (30 U over 5 minutes) or to conventional heparin therapy (5,000 IU in bolus injection) within 5 hours of the onset of symptoms. Of these patients, 112 received APSAC and 119 received heparin within a mean period of 188 +/- 62 minutes after the onset of symptoms. The patency rate of the infarct-related artery was 77% in the APSAC group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the APSAC than in the heparin group. This was true for the entire population (0.53 +/- 0.13 vs 0.47 +/- 0.13, p = 0.002) as well as for the subgroups of anterior and inferior wall infarctions (0.47 +/- 0.13 vs 0.4 +/- 0.16, p = 0.004 and 0.56 +/- 0.11 vs 0.51 +/- 0.09, p = 0.02). At 3 weeks, the difference remained significant for patients with anterior MI.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison between thallium-201 and technetium-99m methoxyisobutyl isonitrile defect size in single-photon emission computed tomography at rest, exercise and redistribution in coronary artery disease.

Defect size on myocardial tomograms was measured in 30 patients who underwent 2 separate studies, 1 with thallium-201 (TI-201), the other with technetium-99m-methoxyisobutyl isonitrile (MIBI). A group of 15 patients with myocardial infarction was studied at rest and received both tracers on the same day. The other 15 patients had documented coronary artery disease. They were were given injections of TI-201 at peak exercise and underwent imaging immediately after exercise and again 4 hours later. They then received a dose of MIBI for imaging at rest. A week later they underwent a second exercise test with the same work load and received a second dose of MIBI. Defect size on single-photon emission computed tomographic images was measured and repeated twice. Results were expressed in percentage of the volume of the whole myocardium. Reproducibility of the defect size measurement was high for TI-201 (r = 0.978; SEE = 1.59) as well as for MIBI (r = 0.981; SEE = 0.80). In patients with coronary artery disease the mean size of the defects was significantly larger with TI-201 than with MIBI at exercise (6.7 +/- 5.2 vs 4.6 +/- 5.2%, respectively, p less than 0.05) and at redistribution (5.1 +/- 4.4 vs 2.8 +/- 3.2%, respectively, p less than 0.05), where no difference was seen in patients with myocardial infarction studied only at rest (11.2 +/- 10.4 vs 12.0 +/- 11.5%, respectively, p = not significant). Smaller MIBI defect sizes, when compared with TI-201, in the exercise and redistribution studies were not due to technical artefacts since there was no difference when they were compared at rest.

Intracardiac ectopic thyroid.

The case of a patient with an intracardiac ectopic thyroid is reported. A lesion was found in a 25-year-old man and was diagnosed by two-dimensional echocardiography as a right intraventricular tumor. An operation was performed. Histologic and ultrastructural studies showed that the tumor was a thyroid mass. The origin of intracardiac ectopic thyroids is probably to be found in disturbances occurring early in embryogenesis.

Systemic-pulmonary shunt with a right retroesophageal subclavian artery.

A 19-day-old child suffering from cyanosis due to tetralogy of Fallot was palliated by using his right retroesophageal subclavian artery. It was anastomosed side-to-side onto the ascending aorta and end-to-side onto the right pulmonary artery. The palliation obtained with this systemic-pulmonary shunt was satisfying. The right brachial vascular flow was normal.

Traumatic aortic ruptures diagnosed by transesophageal echocardiography.

The aim of this study was to determine the diagnostic efficiency of transesophageal echocardiography (TEE) in isthmic aortic ruptures and to describe the echocardiographic Doppler anomalies. TEE was performed prospectively for 18 months in 33 patients with serious polytraumas requiring intensive care. The average age was 40.75 years (range, 17 to 78 years). Single or biplanar TEE was used. In three patients with aortic transection, echocardiography showed an intimal flap thicker than that of dissections. The flaps were torn and retracted on the free edge. It was difficult to distinguish the periaortic hematoma. Doppler imaging showed turbulent flows in several places around the aorta. These flows were especially visible at the beginning of the intimal flap. They were visible on M-mode color imaging during systole and diastole. During diastole, a large color flow was observed in the middle of the aortic lumen. It was turbulent in some places and mimicked the systolic filling of the aorta. These flows create the characteristic "to and fro sign" spectrum of Doppler imaging, usually seen in peripheral false arterial aneurysms. TEE findings were confirmed in two cases by surgery and in one case by aortography. TEE seems to be an effective means of detecting isthmic rupture, with the diagnosis resting on the data obtained from echocardiography and Doppler imaging. A suspected isthmic disruption should be assessed by an emergency TEE and aortography used only for uncertain or complex cases.

Assessment of stenosis severity using a novel method to estimate spatial and temporal variations of blood flow velocity in biplane coronarography.

The authors present a novel method to estimate absolute blood flow velocity in coronary arteries from biplane angiograms. Spatial and temporal velocity variations are derived giving simultaneously a direct geometric and an indirect functional index of stenosis severity, stenosis ratio and coronary flow reserve. No prior assumption concerning stenosis geometry is made. Deformable models are used to track a coronary artery segment dynamically in three dimensions. A densitometric map is obtained by summing densities across sections at every position along the previously calculated path and at every time of the cardiac cycle. An advection relationship between density and velocity is observed. The spatiotemporal velocity map is a solution of a nonlinear least-squares scheme. A simulation protocol based on simple geometric conformations and blood flow properties is used to assess numerical stability and immunity towards noise. Predicted results for temporal velocity variations are compared with the intracoronary Doppler recordings to test the model assumptions for basal state and hyperaemia examinations of the same patient. The stenosis ratio was accurate to within 3% for a simulated additive Gaussian noise with a standard deviation of 0.14. The limits of agreement between angiographic and Doppler velocities were -11.4 and 11.8 cm s-1 for a peak value of 23 cm s-1 (basal state) and -16.8 and 13.5 cm s-1 for a peak value of 52 cm s-1 (hyperaemia), corresponding to 18 and 3.5% errors on the average peak values and a 16% error on the coronary flow reserve. To summarize, the advection model derivation and its solution are presented. Simulated and experimental results corroborate the validity of the numerical schemes and support clinical applicability.

Comparison of the myocardial distributions of 201Tl and 99Tcm-MIBI on SPECT images.

The distributions of 201Tl and 99Tcm-MIBI on stress images were quantitatively measured in a series of 15 patients presenting with documented coronary artery disease. Following two sequential, one-week apart, peak-exercise injections of either 74 MBq of 201Tl or 370 MBq of 99Tcm-MIBI, tomographic views of the myocardium were reconstructed and two thick, central short-axis sections were divided into nine sectors. A sector was considered as showing a defect if its relative activity was lower than 30, 40, 50 or 60% of the highest level of activity in the 18 sectors. Results demonstrate that there were more defects with 201Tl than with 99Tcm-MIBI. However, the difference disappeared if the inferior wall was not included. These results suggest that depth attenuation could be, at least partly, responsible for the higher rate of positive results observed in single photon emission computed tomography with 201Tl than with 99Tcm-MIBI.

Effects on infarct size and left ventricular function of early intravenous injection of anistreplase in acute myocardial infarction. The APSIM Study Investigators.

A total of 231 patients suffering from a first acute myocardial infarction were randomly allocated within 4 hours following the onset of symptoms either to anistreplase or anisoylated plasminogen streptokinase activator complex (APSAC), 30 U over 5 minutes, or to conventional heparin therapy, 5000 IU in bolus injection. Heparin was reintroduced in both groups 4 h after initial therapy at a dosage of 500 IU/kg per day. A total of 112 patients received anistreplase and 119 received heparin within a mean period of 188 +/- 62 min following the onset of symptoms. Infarct size was estimated from single photon emission computerized tomography and expressed in percentage of the total myocardial volume. The patency rate of the infarct-related artery was 77% in the anistreplase group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the anistreplase group than in the heparin group (6 absolute percentage point difference). A significant 31% reduction in infarct size was found in the anistreplase group (33% for the anterior wall infarction subgroup [p less than 0.05] and 16% for the inferior wall infarction subgroup, NS). A close inverse relation was found between the values of left ventricular ejection fraction and infarct size (r = -.73, p less than 0.01). In conclusion, early infusion of anistreplase in acute myocardial infarction produced a high early patency rate, a significant limitation of infarct size, and a significant preservation of left ventricular systolic function, mainly in the anterior wall infarctions.