Treatment of drug-eluting stents in-stent restenosis with paclitaxel-coated balloon angioplasty: Insights from the French "real-world" prospective GARO Registry.

BACKGROUND: Data about paclitaxel-eluting balloon (PCB) angioplasty to treat drug-eluting stents (DES) in-stent restenosis (ISR) were mainly collected in selected patient populations in the setting of randomized trials. The main goal of this prospective registry was to confirm the positive findings of these studies in an unselected population in clinical practice. METHODS: Consecutive patients with DES-ISR treated by PCB angioplasty were recruited in this prospective real-world registry. The primary endpoint was clinically driven target-lesion revascularization (TLR) at 9 months. Secondary endpoints included acute technical success, in-hospital outcomes, 9-month major adverse cardiac events (MACE) a composite of death, myocardial infarction (MI) and TLR and the occurrence of target vessel revascularization. RESULTS: A total of 206 patients (67.7 ± 10.2 years, 80.6% male, 41.3% diabetics) with 210 lesions were recruited. Unstable coronary artery disease was present in 55.3% of patients. The time from DES implantation to DES-ISR was 3.0 ± 2.4 years. Quantitative analyses revealed that patterns of treated DES-ISR were focal in 55.7% and diffuse in 44.3%. The reference diameter was 2.76 ± 0.64 mm. The 9-month follow-up rate was 90.8% (187/206). At 9 months, the TLR rate was 7.0% (13/187) whereas the rates for MACE, MI and cardiac death were 10.7% (20/187), 4.8% (9/187) and 2.1% (4/187) respectively. Results were consistent in patients with paclitaxel and non-paclitaxel-eluting stents (PES) ISR. CONCLUSION: This large prospective registry demonstrated acceptable rates of TLR and MACE at 9 months after treatment of DES-ISR by PCB angioplasty. PCB angioplasty was equally effective in patients with PES-ISR and non PES-ISR.

Swimming-induced immersion pulmonary edema while snorkeling can be rapidly life-threatening: case reports.

It is well known that immersion pulmonary edema can be life-threatening for divers using a self-contained underwater breathing apparatus (scuba). Swimming-induced pulmonary edema in otherwise healthy individuals is not an object of dispute but its real severity is not well known and is probably underestimated. We report two cases of life-threatening acute respiratory distress while swimming and snorkeling, one of which is well documented for swimming-induced pulmonary edema. The interest of these case reports lies in the suddenness of these life-threatening events. Such accidents can mimic a loss of consciousness due to cardiac dysrhythmia and lead to drowning. In the case of swimming-induced pulmonary edema, the prognosis is far better than for a cardiac disorder, but it is also dependent on the efficiency of the supervision. Swimmers, divers, race organizers and supervising physicians should be given knowledge of this pathology and its potentially acute occurrence. Adequate organizational dispositions are mandatory to prevent swimming-induced pulmonary edema-related deaths.

Contribution of cardiac MRI in the comprehension of peripartum cardiomyopathy pathogenesis.

Pathogenesis of peripartum cardiomyopathy (PPC) is still discussed. We report one case of PPC in which a cardiac magnetic resonance imaging analysis allowed to exclude some "classical" pathogenesis hypotheses. We would like to emphasize the benefits of cardiac MRI in the comprehension of the mechanism(s) involved in the genesis of PPC.

[Contribution of cardiac MRI in the etiologic diagnosis of chest pain syndrome with a normal angiographic aspect of the coronary arteries]. / Apport de l'IRM cardiaque dans le diagnostic étiologique des syndromes douloureux thoraciques à réseau coronaire angiographiquement normal.

The etiologic diagnosis of chest pain with elevation of specific cardiac enzymes, repolarization abnormalities and a normal angiographic aspect of the coronary arteries is difficult. In this situation, the role of cardiac MRI is growing, frequently allowing to precise the etiology of the chest pain. We present a literature review concerning the semiology of the cardiac MRI in the three main involved etiologies: myocarditis, takotsubo syndrome, and myocardial ischemia with a normal angiographic aspect of the coronary arteries.

[Clinical and angiographic parameters affecting the quality of 16 slice spiral CT in the diagnosis of restenosis after stenting the left main coronary artery]. / Paramètres cliniques et angiographiques influant sur la qualité de l'angioscanner spiralé 16 détecteurs dans le diagnostic de resténose après stenting du tronc commun de la coronaire gauche.

The metallic component of coronary stents makes it difficult to study their lumen by angio scanner. The object of this preliminary study was to appreciate the factors influencing the diagnosis of restenosis after stenting the left main coronary artery by 16-slice spiral angio CT. This Monocentric study included 27 patients who underwent 16-slice spiral angio CT six months after stenting of the left main coronary artery. It was possible to assess the stent lumen in 21 patients (78%) and no cases of > 50% restenosis were observed. In 4 patients, hypodense zones adjacent to the stent links were observed suggesting moderate intimal hyperplasia. The tests for ischaemia were normal in 3 of these patients. Coronary angiography and endocoronary ultrasound excluded significant restenosis in the fourth patient. In univariable analysis, the facors associated with good or excellent angioscanner quality (45% of patients) were Ostial stenosis (p = 0.03), no or minimal calcification on initial coronary angiography (p = 0.0S), stent diameters > 3.5mm (p = 0.03), heart rates < 60/min (p = 0.04), absence of extrasystoles (p = 0.05) during acquisition. In multivariable analysis, the only significant factors were absent or minimal calcification and stent diameters > 3.5mm (p = 0.02). The multidetector scanner seems a very promising method of investigating patients who have undergone stenting of the left main coronary artery but this study shows that certain clinical and angiographic parameters are limiting factors of surveillance with a 16-slice angioscanner.

[Pilot study of a strategy combining coronary angioplasty with valvular and/or coronary surgery on the same day]. / Etude pilote d'une stratégie combinée associant une angioplastle coronaire a une chirurgie valvulaire et/ou coronaire le même jour.

A strategy combining percutaneous coronary angioplasty followed by valvular and/or coronary surgery was recently proposed as an alternative to the classical surgical only approach. The aim of this study was to assess the feasibility and the results of such a combined strategy with the two procedures performed the same day. The population comprised 34 patients including 17 with valvular disease and revascularisable coronary lesions (15 symptomatic severe aortic stenoses and two acute mitral insufficiencies) plus 17 multitrunk coronary patients without valvular disease but with an indication for revascularisation. Angioplasty was performed several hours prior to surgery and a loading dose of 300mg clopidogrel was administered immediately postoperatively; all patients were on aspirin before the procedure. The average age was 67 +/- 11 years, NYHA class 2.3 +/- 0.7, angina 73%, LVEF 58 +/- 10%. Single coronary artery disease was present in 26%, two vessel disease in 35% and three vessel disease in 39%. The success rate for angioplasty plus stent was 98%. 60 stents were active. Bypasses were exclusively arterial (left or right internal mammary arteries). We observed 4 in-hospital deaths, one of which was due to an infarct and three due to extra-cardiac causes (1 non-cardiogenic acute respiratory distress syndrome, 1 respiratory tract infection and 1 pyelonephritis). Further surgery was necessary in 4 cases: for haemorrhage and one episode of digestive tract haemorrhage. There were no additional deaths, coronary events nor haemorrhage at the end of an average follow-up of 15 +/- 6 months. The results of this combined strategy are encouraging in this population and merit further evaluation in a prospective study.

[Sudden death disclosing abnormal origin of the left coronary vessel from the pulmonary artery trunk]. / Mort subite révélant une naissance anormale de la coronaire gauche à partir du tronc de l'artère pulmonaire.

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital abnormality with a poor prognosis in the newborn. Adult forms are, therefore, very rare, presenting with angina, cardiac failure or sudden death. The authors report the case of a 41 year old woman who was asymptomatic until admitted as an emergency after ventricular fibrillation. Coronary angiography established the diagnosis. Despite the absence of reversible ischaemia on exercise myocardial scintigraphy, the patient underwent coronary bypass surgery of the left anterior descending artery with a pediculated internal mammary artery graft and closure of the left coronary ostium on the pulmonary artery. The echocardiographic abnormalities regressed within a few weeks. An automatic defibrillator was not implanted. The physiopathology of this rare cardiac lesion, the mechanisms of sudden death and the different techniques of surgical repair are discussed.

[Opacification of a coronary vein during left ventriculography with inadvertent myography in a 78-year-old woman with aortic stenosis]. / Opacification d'une veine coronaire lors d'une angiographie ventriculaire gauche avec myographie accidentelle chez une femme de 78 ans porteuse d'un rétrécissement aortique serré.

A 78 year-old woman had a NYHA II dyspnoea, which was related to a calcified aortic stenosis. Functional aortic valvular surface was calculated to 0.75 cm2 by echocardiography. In addition, there were important mitral calcifications without mitral stenosis. The left ventricular contractility was normal, but there was a significant left ventricular hypertrophy. At the time of the coronary angiography, the aortic valve was crossed with difficulty. A "pigtail" probe was positioned and during left ventricular angiography, an unexpected aspect of myography was observed with an unusual opacification of the interventricular posterior coronary vein, draining in the coronary sinus. The patient remained strictly asymptomatic during all the procedure. Two echographic controls carried out in the 24 following hours appeared normal, without pericardial effusion nor new parietal anomaly of the left ventricle. Five weeks later, the patient underwent an aortic valve replacement without complication.

Stent placement compared with balloon angioplasty for small coronary arteries: in-hospital and 6-month clinical and angiographic results.

BACKGROUND: Stenting has been demonstrated to be superior to balloon angioplasty in de novo focal lesions located in large native vessels. However, in small vessels, the benefit of stenting remains questionable. METHODS AND RESULTS: A total of 381 symptomatic patients with de novo focal lesion located on a small coronary segment vessel (<3 mm) were randomly assigned to either stent implantation (192 patients; 197 lesions) or standard balloon angioplasty (189 patients; 198 lesions). The primary end point was the angiographic restenosis rate at 6 months, as determined by quantitative coronary angiography. On intention-to-treat analysis, angiographic success rate and major adverse cardiac events were comparable: 97.9% and 4.6% versus 93.9% and 5.8% in the stent group and the balloon group, respectively. After the procedure, a larger acute gain was achieved with stent placement (1.35+/-0.45 versus 0.94+/-0.47 mm, P=0.0001), resulting in a larger minimal lumen diameter (2.06+/-0.42 versus 1.70+/-0.46 mm, P=0.0001). At follow-up (obtained in 91% of patients), angiographic restenosis rate was 21% in the stent group versus 47% in the balloon group (P=0.0001), a risk reduction of 55%. Repeat target lesion revascularization was less frequent in the stent group (13% versus 25%, P=0.0006). CONCLUSIONS: Elective stent placement in small coronary arteries with focal de novo lesions is safe and associated with a marked reduction in restenosis rate and subsequent target lesion revascularization rate at 6 months.

[Patient information and coronary angiography: experience of the Rennes group]. / Information du patient et coronarographie: l'expérience rennaise.

The object of this study was to assess the degree of patient information of subjects referred for coronary angiography and their reaction to a detailed protocol of information. The enquiry was performed in 3 stages: an oral evaluation of the degree of information with a standardised questionnaire; the giving of written documents from the French Federation and Society of Cardiology mentioning the risks of the procedure; the continuation of the interview with evaluation of the degree of satisfactions with the information provided. Two hundred and thirty one patients referred by cardiologists for non-urgent coronary angiography were interrogated (175 men, 56 women; mean age 63 years, range: 27-83 years). In the 164 subjects who had never had this investigation: 56 (34.1%) did not appreciate the invasive nature of the procedure 111 (67.6%) totally ignored the risks of the procedure 70 (42.6%) were not informed of the possibility of a surgical procedure or of an angioplasty as a result of the procedure. 89% were satisfied with the information concerning the risks of the investigation. In a second group of 100 patients, the comprehension of the information was checked by the same questionnaire used a posteriori. These results show that patient information is very often incomplete. Despite some reticence, the new procedures seem to be globally well accepted but would be more effective if used before hospital admission.

Randomised comparison of coronary stenting with and without balloon predilatation in selected patients.

BACKGROUND: The SWIBAP (stent without balloon predilatation) prospective randomised trial was designed to compare direct coronary stenting with stenting preceded by lesion predilatation with an angioplasty balloon. OBJECTIVE: To determine the feasibility and safety of direct stenting in non-complex coronary lesions in a prospective study. PATIENTS AND DESIGN: All patients < 76 years of age scheduled to undergo angioplasty of a non-complex, non-calcified lesion in a coronary artery of > 3.0 mm, who granted their informed consent, were randomised into the trial. In group I, the stent was placed without balloon predilatation, while in group II stent implantation was preceded by balloon predilatation. The primary end point was the angiographic result according to procedure assigned by randomisation. An intravascular ultrasound substudy was performed in 60 patients. RESULTS: Stent implantation was successful without predilatation in 192 of the 197 group I patients (97.5%), and with predilatation in 197 of the 199 group II patients (99%) (NS). No in-hospital stent thrombosis or death occurred. Overall procedural times, fluoroscopy times, and volumes of contrast agent given (mean (SD)) in group I v group II were 23.50 (13.54) min v 27.96 (15.23) min (p = 0.002), 6.04 (4.13) min v 6.67 (3.65) min (NS), and 135 (65) ml v 157 (62) ml (p < 0.001), respectively. No major adverse cardiovascular events had occurred by 30 days. CONCLUSIONS: The feasibility and safety of direct stenting of selected and non-complex coronary lesions is confirmed. This technique was as successful as the conventional approach and was associated with a minor reduction in fluoroscopic exposure and procedure time and the administration of less contrast agent.

CARDIOMEDIA: a communicable multimedia medical record on Intranet and digital optical memory card.

As part of French health reform, French physicians were computerised by the end of 1998. A specific Intranet network will be used to communicate medical data between the health professionals. The objectives of the CARDIOMEDIA project were to develop and evaluate the feasibility of a coronary multimedia data record stored on an optical card and communicable on Intranet within the hospital. Patients treated by angioplasty at the University Hospital of Rennes participated in the experiment. In general, patients are treated in the University Hospital and are followed up by another health care provider closer to their home. The patient leaves the University Hospital with his card, which is directly available elsewhere for emergency or for consultation. This approach is assumed to reduce the number of examinations and to offer a better patient follow-up. The CARDIOMEDIA card is a specialised record including various data types: text, images, image sequences of coronarography and ECG signals. For this purpose an optical card with its large memory is very convenient. We used the DICOM format for image exchange and management. It is combined with CARDIOMEDIA specific compressing software. For the multimedia record the HTML format and web Intranet method are chosen. This provides an intuitive interface which can combine various data types and helper applications like a DICOM image viewer.

Aneurysms and pseudoaneurysms of saphenous vein coronary artery bypass grafts.

Aneurysms of saphenous vein grafts to coronary arteries are unusual complications of coronary artery bypass graft (CABG) surgery. Three patients (men aged 47, 62, and 68 years) are presented with spontaneous chest pains 10, 21, and 17 years after CABG surgery. In one case, the saphenous vein graft had eroded into the right atrium and had established a fistula between the graft and the right atrium. Diagnosis of saphenous vein graft aneurysms was confirmed by echocardiography, computed tomography or magnetic resonance imaging, and by arteriography. Two patients were treated surgically, the third by percutaneous coil embolisation followed by balloon angioplasty of the right coronary artery.

Clinical and angiographic results of stenting for long coronary arterial atherosclerotic lesions.

A prospective registry of 187 patients who underwent percutaneous coronary angioplasty with attempted long NIR stent delivery was performed. A successful stent delivery was achieved in 93% of cases with a low rate of major cardiovascular events, and 6-month follow-up showed low rates of clinical events, new revascularization procedures, and angiographic restenosis.

Early versus late coronary stenting following acute myocardial infarction: results of the STENTIM I Study (French Registry of Stenting in Acute Myocardial Infarction).

This study was undertaken to determine the feasibility and safety of coronary stenting in acute myocardial infarction (AMI). In AMI, primary percutaneous transluminal coronary angioplasty (PTCA) is accepted as the preferred method of reperfusion for patients presenting at highly experienced centres. Until recently, however, stenting has been avoided during AMI because of a potential high risk of thrombosis. This prospective observational study carried out in 20 centres and included 648 consecutive patients who underwent PTCA with stent implantation for AMI. Of these 648 patients, 269 (41.5%, Group 1) were dilated early (< 24 hr) after the onset of the symptoms (75% treated by direct PTCA) and 379 (58.5%, Group 2) were dilated between 24 hr and 14 days after AMI. Combined therapy with ticlopidin and aspirin was used after the procedure. Bailout stenting occurred more often in Group 1 than in Group 2 (17% vs. 9.5%)(P < 0.05). Angiographic successful stenting was similar in both groups of patients (96% vs. 97%). During the hospital follow-up period, stent thrombosis occurred in eight patients (3%) in Group 1 and in six patients (1.6%) in Group 2 (NS). There was 14 deaths (5.2%) in Group 1 and 11 deaths (3.9%) in Group 2 (NS). After multivariate analysis bailout stenting was identified as the sole predictor of stent thrombosis (P < 0.0001). Vascular access-site complications occurred in six patients (1%) with no difference between the two groups. This study indicates that patients who receive a coronary stent in AMI can be managed safely with antiplatelet therapy. Randomized studies are needed to determine the precise indication for coronary stenting as an adjunct to primary PTCA.

Cardiomedia: a multimedia portable medical record on optical memory card.

The main objective of the CARDIOMEDIA project is to produce and evaluate a coronarian multimedia data record stored on an optical card. The experimentation concerns patients treated by angioplasty at university hospital of Rennes. Often patients treated in the Regional University Hospital are followed up by another Health structure closer to their home. The patient leaves hospital with his card, which is directly available elsewhere for emergency or for consultation. This will optimize the number of examinations and offer a better patient follow-up. The CARDIOMEDIA card is a specialized record which includes various data type: text, image, image sequence of coronarography and ECG signal. For this purpose optical card with its large memory size is very convenient. For medical imaging, we use in this project the DICOM format for image exchange and management, it is combined with a CARDIOMEDIA specific compressing software. For multimedia record, the HTML format and web intranet method are chosen, this allows intuitive interface which can combine various data type and helpers like DICOM image viewer.

[Loss of a stent in the left main coronary artery and secondary migration into the left circumflex artery needing surgical extraction. Apropos of a case]. / Perte dans le tronc commun de la coronaire gauche d'une endoprothèse et migration secondaire dans l'artère circonflexe ayant conduit à une extraction chirurgicale. A propos d'un cas.

The authors report a case of accidental loss of a coronary stent in the coronary arteries and its migration into the circumflex artery. This complication occurred during revascularisation of the left anterior descending artery. In view of a dissection at the site of angioplasty and the migration of the stent, emergency surgery was undertaken comprising bypass grafting of the left anterior descending and arteriology of the left circumflex arteries to recover the stent. This is a rare complication, the frequency is probably underestimated. The authors discuss the factors predisposing to failure of implantation and the means of recovering the stents. The consequences of loss of a stent in the coronary or systemic circulations are also commented.