Fatal derecruitment of occluded left anterior descending collaterals after left circumflex revascularization

Coronary arteries are not definitely functionally terminal arteries, as previously thought; indeed, they are linked and interconnected by a rich network of collaterals. Chronic total occlusions [CTOs] represent a subset of frequent lesions encountered in everyday catheterization laboratory practice, generally associated with a developed system of collateral connections. These latter have the capacity to prevent myocardial necrosis and may even uphold metabolic supply to the ischemic territory to maintain its contractile capacity. Authors have reported a rapid and progressive reduction of collateral function and their decline after antegrade flow restoration, resulting in higher myocardial susceptibility to ischemia in the CTO territory. Here, we report the case of a fatal derecruitment of collaterals for a left anterior descending CTO not reopened, after left circumflex subocclusion revascularization

Usefulness of SYNTAX score II in complex percutaneous coronary interventions in the setting of acute coronary syndrome

Background: SYNTAX score II [SS II] integrates anatomical SS with clinical characteristics allowing an individualized prediction of long-term mortality

Aims: We sought to assess to evaluate the usefulness of SS II in a real-world acute coronary syndromes [ACS] population with severe coronary artery disease [CAD] undergoing percutaneous coronary intervention [PCI]

Methods: From August 2011 to May 2013, out of 1591 consecutive patients admitted for ACS, 217 [13.6%] showed severe CAD [three-vessel disease and/or left main involvement]. Among the latter, 100 patients underwent PCI and were enrolled into the study. SS II was calculated in all patients. One-year clinical follow-up was performed; major adverse cardiac and cerebrovascular events [MACCE] were defined as a composite of death, nonfatal myocardial infarction, stroke, or repeat revascularization

Results: The median SS II was 29 [range, 14-59]. Overall, MACCE occurred in 25% of patients [cardiac death 4%, myocardial infarction 4%, stroke 0%, and repeat revascularization 17%]. The 1-year MACCE-free survival was significantly lower in patients with SS [>/=29], than in those with SS II [<29] [64.2% vs. 87.2%, respectively; p=0.007]. In multivariate Cox regression analysis, the presence of unprotected left main stenosis [hazard ratio 2.52, 95% confidence interval [CI]: 1.02-5.85; p=0.031] and SS II >/=29 [hazard ratio 2.74, 95% CI: 1.30-8.21; p=0.011] were the only predictors of MACCE at 1-year clinical follow-up. The c-index of SS score II was 0.70 [95% CI: 0.58-0.81]. For patients who experienced MACCE, the SS II reclassification improved by 36%, while in nonevent patients the reclassification improved by 22%. The net reclassification index was 0.24 [p=0.09]

Conclusion: SS II might represent a useful tool to predict clinical events in not only ideal stable patients, but also an unrestricted, real world population of patients with ACS and severe CAD undergoing PCI

Invasive assessment modalities of unprotected left main stenosis

Among all coronary lesions, the decision-making process for the treatment of unprotected left main [ULM] stem lesions is still challenging. Indeed, the optimal therapeutic strategy for patients with ULM disease remains controversial: coronary artery bypass grafting was established as the gold standard, but it is without doubt that percutaneous coronary intervention [PCI] performed by experienced operators achieves good results at long term follow up, especially in cases where the ostium and/or shaft of ULM are treated. Thanks to the widespread use of invasive assessment of atherothrombotic ULM stenosis, improved selection of PCI cases and techniques of stenting, better outcomes are now possible. This review seeks to define the place of PCI in ULM disease by describing the different modalities of ULM stenosis assessment

Guideliner Catheter: a useful tool in the armamentarium of the interventional cardiologist

Regardless of the clinical setting, a good back-up represents one of the most important conditions to ensure guide wire and balloon advancement and stent delivery. As a "mother and child" system, the GuideLiner catheter [Vascular Solutions Inc., Minneapolis, MN, USA] provides an extension to the guide catheter with better coaxial alignment and stability. We report two didactic cases showing the usefulness of the GuideLiner device in everyday catheterization laboratory practice. The first case was a primary percutaneous coronary intervention [PCI] in a 71-year-old diabetic man admitted for inferior STelevation myocardial infarction, related to tight proximal stenosis in a dominant tortuous and calcified left circumflex. The second case was an elective PCI in a 76-year-old man admitted for stable angina [Canadian Cardiovascular Society [CCS] class III], related to focal intra-stent restenosis of a saphenous venous graft to the left anterior descending. In both cases, the GuideLiner catheter provided a good back-up insuring the success of PCI and drug-eluting stents implantation, with a good in-hospital outcome

Mechanical post-conditioning in STEMI patients undergoing primary percutaneous coronary intervention

Although early myocardial reperfusion via primary percutaneous coronary intervention [PCI] allows the preservation of left ventricular function and improves outcome, the acute restoration of blood flow may contribute to the pathophysiology of infarction, a complex phenomenon called reperfusion injury. First described in animal models of coronary obstruction, mechanical post-conditioning, a sequence of repetitive interruption of coronary blood flow applied immediately after reopening of the occluded vessel, was able to reduce the infarct size. However, evidence of its real benefit remains controversial. This review describes the mechanisms of post-conditioning action and the different protocols employed focusing on its impact on primary PCI outcome

Coronary perforation with tamponade successfully managed by retrograde and antegrade coil embolization

In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate of revascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult to negotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication of coronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic total occlusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronary perforation with tamponade, and successfully managed by coil embolization

Characteristics of deep vein thrombosis in the elderly

Deep vein thrombosis is a common condition in geriatric. The identification of risk factors for venous thrombosis in the elderly is important because it allows an appropriate prescription of preventive treatments. The purpose of this study is to identify the etiologic and therapeutic characteristics of deep vein thrombosis of the lower limbs in the elderly. A retrospective study of 155 patients with lower limb deep vein thrombosis confirmed by venous Doppler. These patients were divided into two groups: group 1 [patients aged 65 years or more] and group 2 [patients whose age was below 65 years]. A comparison between these two groups was performed. The average age of patients in group 1 was 74.89 years [ +/- 6.43]. The sex ratio in this group was 0.68. The thrombosis was more frequently proximal in patients of group 1. Patients of group 1 had significantly more risk factors than those of group 2 [p <0.05]. Among risk factors studied, only the cancers were significantly more frequent in group 1 [p = 0.002]. The frequency of hemorrhagic events in both groups was comparable but bleeding was more common in patients of group 1 with cancer. Our study confirms the multifactorial origin of deep vein thrombosis in the elderly and the incidence of malignant etiology. The results of this study also call for vigilance in the use of anticoagulants in the elderly especially in the presence of cancer because it is an additional risk factor for bleeding

Cardiac hydatid cyst revealed by ventricular tachycardia

Hydatid disease is a human parasitic infestation caused by the larval stage of Echinococcus Granulosus. The liver and the lungs are the most common locations. Cardiac involvement is rare and accounts for 0.5-2% of all hydatid disease. We report an unusual presentation of cardiac hydatid cyst revealed by ventricular tachycardia in a patient with a history of cerebral hydatid cyst

[Hémophagocytic syndrome: a study of 11 patients in Tunisian population]

Hemophagocytic syndromes are mostly associated with underlying pathology, they can reveal: immunodeficiency, infections, hemopathies, cancers and auto-immune diseases. To investigate clinical, biological features, outcome characteristics and underlying pathology of Tunisian patients with hemophagocytic syndromes. A retrospective study of patients with hemophagocytic syndromes admitted in an internal medicine department in Tunis over the period 2009-2012. There were 11 patients included, 4 men and and 7 women. Mean age was 47,3years. Purpura was observed in 3 cases, hepatosplenomegaly in 6 cases and peripheral lymph nodes in 3 cases. Hemorrhagic complication was noted in 2 cases. There were an increase of inflammatory indices in all the cases. Eight patients had pancytopenia and 3 had bicytopenia. Six patients developed intravascular dissiminated coagulation. High levels of triglyceridemia was noted in 5 cases and an hyperferritinaemia in all cases. Cytological examination of bone marrow confirmed hemophagocytosis in ten cases. Hemophagocytosis was associated to infectious diseases in 6 cases, there were 2 cases of leishmaniasis, septicemia to E.Coli and staphylococcus aureus and lymph nodes tuberculosis with HIV. We also noted a case of lymphoma, myelodysplasic syndrome, rheumatoid polyarthritis, adult onset still's disease. In one patient, the origin of hemophagocytosis remained indefinite. Visceral leishmaniose were treated by Glucantime[registered sign], adult Still's disease by corticosteroids and méthrotrexate[registered sign], lymphoma by chemotherapy. In lymph nodes tuberculosis, there were good evolution. Six patients died. Hemophagocytic syndrome is a rare and life-threatening disease. Pejorative prognosis requires an early therapy with etiological treatment

innovation of composite core dual coil coronary guide-wire technology: a didactic coronary chronic total occlusion revascularization case report

The treatment of coronary chronic total occlusions [CTO] continues to solicit technical innovations. As success primarily depends on crossing the lesion with a wire, all aspects regarding tip shape retention, torque precision, and penetration ability of the guide-wire have greatly influenced new techniques and strategies. The world of interventional cardiology has to look carefully at these developments, and to use them accordingly to improve the success rate in ordinary percutaneous coronary interventions. We present a didactical case report of a CTO revascularization treated with a new 'dual core' technology guide-wire

Successful pregnancy and delivery in a woman with a single ventricle and Eisenmenger syndrome

Patients with a single ventricle represent a rare abnormality found in 1% of patients with congenital heart disease, often discovered during childhood. Without pulmonary stenosis, the disease can progress to fixed pulmonary hypertension. Both pregnancy and delivery are risky events capable of increasing the right-to-left shunt. Pregnancy is contraindicated. We report the case of a 27-year-old woman with a single ventricle without pulmonary protection and fixed pulmonary hypertension at 60 mmHg, discovered during a pregnancy. The delivery was obtained by cesarean section with epidural anesthesia and the patient was perioperatively treated with nitric oxide. Though contraindicated, pregnancy and delivery were successfully achieved in this patient. Patients with single ventricle and Eisenmenger syndrome rarely reach adult life. Pregnancy with this condition is exceptional and fundamentally perturbs hemodynamic stability. In spite of the development of anesthesia and resuscitation and the description of some cases in literature, pregnancy with Eisenmenger syndrome is contraindicated.

[ cas de meningite tuberculeuse chez un enfant vaccine]

The tuberculous meningitis stays dangerous because of its high lethality and frequent severe neurological permanent repercussions. Its prognosis is directly in relation with the precocity of its diagnosis. Well, this diagnosis is often difficult. In this work, we report a case of tuberculous meningitis in children aged 13, who is properly vaccinated. The diagnosis was made on clinical and radiological and was confirmed by late positive cultures of CSF on Lowenstein-Jensen highlighting Mycobacterium bovis BCG. TB treatment and steroids were initiated, followed by an improvement in general condition. Unfortunately, a relapse was observed after one year. The occurrence of TB meningitis in our patient leaves have two hypotheses: either an immune deviciency or ineffectiveness of the BCG vaccine. Indeed, the standard rate of immunoglobulins and the absence of recurrent infections were ruled out a deficit of humoral immunity. The study of lymphocyte markers by immunophenotyping excluded an abnormal number and distribution of T lymphocytes. An abnormality of cell proliferation was also excluded given the normal response to various antigens and mitognes. The study of the functionality of the polymorphonuclear neutrophils was normal. These normal immunological explorations showed that our patient has no immune deficiency. Several studies show that there is a genetic susceptibility to tuberculosis and it is polygenic. Hence the study of molecular genetic to research of mutations has been proposed. Others studies have highlighted the protective efficacy of BCG vaccination in children and bring into question the role of revaccination

Echocardiographic assessment of left ventricular dyssynchrony and correlation with QRS width in chronic heart failure

Echocardiographic parameters of mechanical dyssynchrony may improve patients selection for cardiac resynchronisation therapy in chronic heart failure. This study aimed to define the prevalence of inter, intra and atrio-ventricular dyssynchrony in heart failure patients with different QRS duration and to evaluate inter and intra-observer variability in collecting different echocardiographic dyssynchony parameters. Twenty patients with chronic heart failure of any origin, NYHA functional class II-III with LVEF < 40%, were evaluated by complete echocardiographic examination including tissue Doppler imaging [DTI] and Tissue Tracking. Three patients had an atrio-ventricular dyssynchrony with a mean left ventricular filling time to cardiac cycle of 33 +/- 5%. Six patients had an interventricular mechanical delay [IVMD] > 40 milliseconds, all of them had a QRS duration >/= 120 milliseconds. Overall, no statistically significant correlation was found between IVMD and QRS duration [r=0.35, p=0.4]. The mean septal to posterior wall-motion delay [SPWMD] was 83 +/- 64 ms. 7 patients had SPWMD >/= 130 ms. The baseline QRS duration did not correlate with SPWMD [p=0.7]. The mean LV dyssynchrony determined by deltaS-peak was 74 +/- 42 ms. Seven patients had LV dyssynchrony. Linear regression did not demonstrate a relation between QRS width and intraventricular dyssynchrony [p=0.34]. There was no concordance between intra-ventricular spatial or longitudinal dyssynchrony determined by DTI method and by Tissue Tracking [p=0.3 and 0.6 respectively]. The intraobserver reproducibility of LVFT/RR, IVMD and deltaS-peak [ICC= 0.99, 0.98 and 0.99, respectively], as well as the interobserver reproducibility [ICC: 0.96, 0.94 and 0.92, respectively], were very high. However, we observed a high variability for SPWMD measure [ICC=0.27, p=0.31]. Mechanical dyssynchrony did not correlate with QRS duration, despite the poor variability in collecting different echocardiographie parameters

[Cardiac amylodosis]

Amyloidosis is a rare infiltrative disease characterized by multiple clinical features. Various organs are involved and the cardiovascular system is a common target of amyloidosis. Cardiac involvement may occur with or without clinical manifestations and is considered as a major prognostic factor. To analyze the clinical features of cardiac involvement, to review actual knowledgement concerning echocardiographic diagnostic and to evaluate recent advances in treatment of the disease. An electronic search of the relevant literature was carried out using Medline and Pubmed. Keys words used for the final search were amyloidosis, cardiopathy and echocardiography. We considered for analysis reviews, studies and articles between 1990 and 2007. Amyloidosis represents 5 to 10% of non ischemic cardiomyopathies. Cardiac involvement is the first cause of restrictive cardiomyopathy which must be evoked. In front of every unexplained cardiopathy after the age of forty. The amyloid nature of cardiopathy is suggested if some manifestations were associated as a peripheral neuropathy, a carpal tunnel sydrome and proteinuria > 3g/day. Echocardiography shows dilated atria, a granular sparkling appearance of myocardium, diastolic dysfunction and thickened left ventricle contrasting with a low electric voltage. The proof of amyloidosis is brought by an extra-cardiac biopsy, the indications of endomyocardial biopsy are very limited. The identification of the amyloid nature of cardiopathy has a direct therapeutic implication: it indicates the use of digitalis, calcium channel blockers and beta-blockers. Today the treatment of amyloidosis remains very unsatisfactory especially in the cardiac involvement. An early diagnosis before the cardiac damage may facilitate therapy and improve prognosis