[Role of percutaneous coronary intervention in diabetic patients]. / Rôle de la revascularisation coronarienne chez le patient diabétique avec maladie coronarienne stable.

Clinical outcomes after revascularization, both for surgery and percutaneous coronary intervention (PCI), is significantly worse in diabetic patients compared with non-diabetic patients. While in acute coronary syndrome, PCI is favored because of the increased risk of surgery performed during ongoing infarction, in stable patients assessment of clinical factors, such as coronary anatomy and comorbidities should guide decision of the revascularization modality (e.g., surgical, PCI, or conservative). Surgery should be favored in patients with multivessel coronary disease and acceptable surgical risk. Overall, the threshold for surgery compared to PCI should be lower in diabetic patients compared with non-diabetic ones.

[Perioperative management of new antiplatelet drugs]. / Gestion péri-interventionnelle des nouveaux agents antiplaquettaires.

The management of antiplatelet drugs in the perioperative setting is based on an individual evaluation of the thrombotic and bleeding risks. When the bleeding risk is deemed low, continuation of the dual antiplatelet therapy is usually recommended, especially in high thrombotic risk settings. When the bleeding risk is deemed moderate, at least one antiplatelet agent should be continued, usually aspirin, and clopidogrel and ticagrelor should be discontinued 5 days and prasugrel 7 days before surgery. In some rare instances of high bleeding risk, discontinuation of aspirin 3 days before surgery is usually acceptable. In high thrombotic settings, bridging with an intravenous antiplatelet drug with a short half-life may be considered.

[New techniques for the endovascular treatment of peripheral arterial disease]. / Nouvelles techniques endovasculaires dans le traitement de l'artériopathie des membres inférieurs.

Peripheral arterial disease of the lower limb is a manifestation of atherosclerosis, with a prevalence ranging from 4 to 12% in the adult population and increasing up to 20% in elderly individuals (i.e.>70 years old). Peripheral arterial disease is a marker of systemic atherosclerosis and is associated with increased cardiovascular morbidity and mortality. Therapeutic strategies are firstly aimed at reducing systemic cardiovascular risk burden. Therefore, intensive risk factor modification, and antiplatelet therapy should be implemented in all patients with peripheral arterial disease. Endovascular and surgical treatment are often highly valuable to improve rest pain and ulcer healing. The initial work-up includes non-invasive measurement of the ankle-brachial index, as well as measurement of the toe pressure. In case of a severe ischemia-ankle pressure inferior or equal to 50 mmHg and/or toe pressure inferior or equal to 30 mmHg--a revascularisation attempt should be proposed. We discuss here some recent advances in the endovascular field. Technical aspects of sub-intimal vs intraluminal recanalisation will be discussed, focusing on the different kinds of devices (e.g. crossing, reentry, debulking devices) actually at the interventionist's disposal. As endovascular techniques are constantly evolving, a multidisciplinary approach, including all cardiovascular specialists, is often needed.

Incidence of atrial fibrillation after percutaneous closure of patent foramen ovale and small atrial septal defects in patients presenting with cryptogenic stroke.

OBJECTIVE: The occurrence of atrial fibrillation after percutaneous closure of a patent foramen ovale for cryptogenic stroke has been reported in a variable percentage of patients. However, its precise incidence and mechanism are presently unclear and remain to be elucidated. DESIGN: Prospective follow-up study. PATIENTS: Ninety-two patients undergoing a percutaneous patent foramen ovale closure procedure (closure group) for cryptogenic stroke were compared with a similar group of 51 patients, who were medically treated. METHODS: A systematic arrhythmia follow-up protocol to assess the incidence of AF was performed including a 7-day event-loop recording at day 1, after 6 and 12 months in patients of the closure group and compared with those of the medically treated group. RESULTS: The incidence of AF was similar in both study groups during a follow-up of 12 months, including 7.6% (95% CI: 3.1-15.0%) in the closure and 7.8% (95% CI: 2.18-18.9%) in the medically treated group (P=1.0). The presence of a large patent foramen ovale was the only significant risk factor for the occurrence of AF as demonstrated by a multivariate Cox regression analysis (95% CI, 1.275-20.018; P=0.021). CONCLUSIONS: Our findings indicate that patients with cryptogenic stroke and patent foramen ovale have a rather high incidence of AF during a follow-up of 12 months. Atrial fibrillation occurred with a similar frequency whether the patent foramen ovale/atrial septal defect was successfully percutaneously closed or was medically managed. The presence of a large patent foramen ovale was the only significant predictor of AF occurrence during follow-up.

[The concept of aspirin "resistance": mechanisms and clinical relevance]. / Le concept de "résistance" à l'aspirine: mécanismes et pertinence clinique.

Aspirin, a 110-year-old molecule, is a cornerstone in the treatment of atherothrombotic patients. The concept of aspirin "resistance" emerged approximately 15 years ago and is of growing interest. Aspirin resistance, defined as a lack of inhibition of cyclo-oxygenase-1 (COX-1), is a rare phenomenon and its clinical relevance can hardly be studied. On the contrary, residual platelet hyperactivity is more common and affects 20 to 30% of aspirin-treated patients. This latter phenomenon corresponds to sustained platelet reactivity despite a proper inhibition of COX-1 by aspirin. Several meta-analyses suggest that residual platelet hyperactivity could be a risk factor for the recurrence of ischemic events in aspirin-treated patients. Causes of biological non-responsiveness to aspirin are discussed, including the role of compliance, drug-drug interactions, genetic polymorphisms and diabetes mellitus. Ongoing studies are designed to find out the mechanisms of residual platelet hyperactivity, determine its potential clinical relevance and delineate the more appropriate assays in order to identify patients who may benefit of a tailored antiplatelet therapy.

[Carotid stenting: an alternative to surgery?]. / Stenting de la carotide: une alternative à la chirurgie?

A stenosis of the internal carotid artery may cause 10-20% of all ischemic strokes. In symptomatic patients, carotid revascularization is indicated in the presence of a stenosis 50%. in asymptomatic patients, the indication for revascularization based on randomized trials is given at > or = 60% stenosis, as long as the estimated perioperative death or stroke risk is < 3%. In clinical practice however, asymptomatic stenoses are usually treated only if luminal narrowing exceeds 70-80%. The choice of the revascularization strategy (endarterectomy versus stenting) should be based on the surgical risk profile of the patient and on the locally available expertise. Carotid artery stenting is particularly beneficial in patients at high risk for surgery.

Impending paradoxical embolism. When and how to treat?

Impending paradoxical embolism (IPDE) is the presence of an entrapped thrombus through the patent foramen ovale (PFO). Usually IPDE are diagnosed by echocardiography or thoracic CT-scan performed during the evaluation of patient presenting with a suspicion of pulmonary embolism (PE). We report the case of a 73-year-old patient presenting with a very large IPDE successfully treated with cardiac surgery and we focus our discussion on the treatment modalities of this rare entity (anticoagulation alone, fibrinolytic regimens, cardiac surgery, percutaneous thrombectomy) and on PFO management after IPDE.

Sinus arrest and moderate hyperkalemia.

Hyperkalemia, especially if severe, is a frequent cause of cardiac rhythm pathologies. Sinus arrest of sudden onset is more likely to occur when the potassium level is very high (e.g. > 8 mmol/l) but in concomitance with negative chronotropic drugs it may occur even in presence of a moderate hyperkalemia. This case report highlights the fact that these kinds of drugs, especially in combination, are probably to be avoided in patients at risk of developing hyperkalemia (e.g. diabetics, renal failure, etc.), even of moderate degree, considering this life-threatening cardiac complication.

[Acute myocardial infarction due to spontaneous coronary artery dissection]. / Infarctus aigu du myocarde secondaire a une dissection coronaire spontanée. A propos de 6 cas.

BACKGROUND: Spontaneous coronary dissection is a rare cause of acute myocardial infarction (AMI). Its aetiology and treatment have not yet been well defined. In this report, we review the clinical presentation, the aetiology, the risk factors and the treatment of 6 cases of AMI due to spontaneous coronary dissection. METHODOLOGY AND RESULTS: We have reviewed 1100 cases of AMI having undergone coronary angiography in our institution during the period December 1999 to January 2004. Six cases (0.5%; 5 men, mean age: 38 years) in which spontaneous coronary dissection had been retained as final aetiology were further analyzed. Four patients had no cardiovascular risk factors but, interestingly, in all 6 patients we found a clear triggering factor of the acute event: extreme physical stress (5), or psychological stress (1). Thrombolysis had been performed in 5 patients, and the coronary angiography carried out thereafter showed a dissection of the left anterior descending coronary (2 cases), of the right coronary artery (3 cases) or of the left circumflex artery (1 case). All patients had a preserved coronary flow (TIMI 3). On the basis of the angiographical findings, medical treatment (4 patients), coronary artery by-pass grafting (1 patient), or percutaneous angioplasty with stenting (1 patient) were performed. The only major cardiac adverse event observed in the early follow up was a sudden acute thrombosis of the coronary stent. CONCLUSION: In young patients without cardiovascular risk factors and presenting with AMI subsequent to a physical or emotional stress, spontaneous coronary artery dissection should imperatively be taken into consideration as a possible diagnosis. Since intravenous thrombolysis may worsen the dissection, we recommend primary emergency coronarography as a diagnostic and (sometimes) therapeutic treatment option.

Extrahepatic arterioportal fistula: three-dimensional reconstruction of computerized tomodensitometric scan for diagnosis and morphologic assessment.

Arterioportal fistulae (APFs) are rare. An asymptomatic APF was suspected by computed tomography. Multiplanar, maximum intensity projection, and surface shaded display reconstructions showed its anatomy. To our knowledge, this is the first report using such reconstructions to analyze the architecture of an extrahepatic APF. Complete assessment of APF can be achieved noninvasively, and initial endovascular treatment can be planned.

Telemedicine for cardiac surgery candidates.

BACKGROUND: Cardiac surgery is generally well or over-represented in many Western countries. Since the southern part of Switzerland relies on 300 km distance centers for cardiac surgery, we started a project of telemedicine for the distant evaluation of cardiac surgery candidates. We report our experience of the results of the diagnosis made by telemedicine and by direct scrutiny of coronary angiograms. METHODS: Coronary angiography was performed at the distant hospital by an invasive cardiology team. Teletransmission of images was performed using three Integrated Service Digital Network (ISDN) lines by direct transmission of recent recording. A total of 98 cases were reviewed (87 aorto-coronary bypass candidates, seven valvular and four congenital heart disease). We further performed a prospective blinded comparison of 47 consecutive cases with severe coronary artery disease (CAD) with respect to localization and number of significant coronary lesions, obtained by direct scrutiny of the original angiograms and the evaluation obtained with the teletransmitted images. RESULTS: In 89 cases of the 98 analyzed (91%) correct diagnosis and surgical approach could be established by distant transmission. In nine cases (9%, all aortocoronary bypass candidates) definitive diagnosis and treatment was feasible only by direct scrutiny of the original angiograms. Five critically ill patients were urgently referred to the surgical care center based on the correct distant diagnosis. The blinded comparison of distant diagnosis and direct scrutiny of angiograms in defining 1-2-3 vessel CAD was good: r=0.87, P<0.01. CONCLUSION: Initial experience using non-sophisticated telemedical transmission of angiograms of cardiac surgery candidates seems to be a promising facility for distantly located centers.