[Fulminant myocarditis: clinical value of extracorporeal life support]. / Myocardites fulminantes : intérêt de l'assistance circulatoire temporaire.

Fulminant myocarditis is a rare cause of cardiogenic shock which usually occurs in young adults without known cardiac disease. Initial course may be complicated by a cardiogenic shock refractory to optimal medical treatment. Temporary circulatory assistance using an extracorporeal life support is of great clinical value in this setting, since myocardial systolic function usually fully recovers after a short time delay.

[The "forgotten ones of reperfusion" in acute myocardial infarction: lessons from the ESTIM Limousin registry]. / Les "oubliés de la reperfusion" dans l'infarctus du myocarde aigu. Leçons du registre ESTIM limousin.

The management of acute coronary syndrome (ACS) with ST elevation in daily practice does not always comply with the official guidelines. In effect, many patients do not benefit from coronary recanalisation despite being eligible. They could be described as the 'reperfusion forgotten ones'. The Limousin ESTIM study allowed us to evaluate their numbers and characteristics between 2001 and 2003. Between 1 June 2001 and 31 December 2003, 958 patients with ST+ ACS were managed within 24 hours. Among this cohort, 47% of patients did not benefit from reperfusion treatment with fibrinolysis or angioplasty. In spite of early management, the rate of non-reperfusion was significant: 30% before the third hour, and 50% between 3 and 6 hours. With univariate and multivariate analysis, the predictive features for non-reperfusion were age, length of time between onset of pain and presentation, type of admission route, absence of a call to the emergency ambulance service, and the characteristics of the ECG tracing. These data have prompted education and training, adapted for specific regions. Despite some significant improvements, the rate of non-perfusion in 2004 still remains 35% in the first 24 hours, comparable with figures in the recent literature. Being aware of this problem, taking specific action and continued evaluation with surveys like this remain important.

[Refractory shock after converting enzyme inhibitor administration. Usefulness of angiotensin II]. / Choc réfractaire après administration d'un inhibiteur de l'enzyme de conversion. Intérêt d'un traitement par angiotensine II.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors are commonly used during the early phase after myocardial infarction but severe hypotension and shock have been described. CASE REPORT: A 42-year old woman underwent a conservative management for an anterior acute myocardial infarction, initially associated with a pulmonary edema. Two hours after the initiation of a treatment with ACE inhibitor administered orally (lisinopril, Zestril), a circulatory failure in conjunction with an acute renal insufficiency occurred. Right heart catheterization disclosed markedly decreased systemic vascular resistance in the presence of a preserved cardiac index. Repeated fluid challenges and intravenous administration of norepinephrine failed to improve the hemodynamic status. The refractoriness of shock raised the hypothesis of a dysregulation of the renin-angiotensin system, secondary to the treatment by ACE inhibitor. Accordingly, the patient was given angiotensin II intravenously (Hypertension) which markedly raised systemic vascular resistance, and result in subsequent regression of shock. The patient was discharged after an otherwise uneventful course. DISCUSSION: We reported a refractory shock to fluid challenges and norepinephrine after the first dose of ACE inhibitor during acute myocardial infarction. Regression of shock was possible only with angiotensin II.

Is the morning peak of acute myocardial infarction's onset due to sleep-related breathing disorders? A prospective study.

Many studies have shown that the risk of experiencing a myocardial infarction (MI) is increased during the first hours of the morning. Sleep apnea syndrome (SAS) is associated with an enhanced adrenergic activity, prolonged a few hours after awakening. We aimed at assessing whether sleep breathing disorders could be a culprit for the morning excess rate of MI. We studied 40 middle-aged men admitted for an acute MI. An overnight polysomnographic study was performed 37.4 +/- 9.4 days after the MI. The prevalence of SAS was high (30%). The prevalence of SAS was significantly higher in patients with the MI onset during the morning. The circadian pattern was significantly different in patients with or without SAS: those with SAS presented an important peak of MI onset during the period between 06.00 and 11.59 h. None of them had their MI during the period between 24.00 and 05.59 h. This different nyctohemeral pattern underlines the potential role of sleep breathing disorders as a trigger of MI.

Sleep apnoea syndrome and the extent of atherosclerotic lesions in middle-aged men with myocardial infarction.

BACKGROUND: To determine whether extended atherosclerotic lesions are correlated to the presence of sleep breathing disorders. EXPERIMENTAL DESIGN: A prospective clinical study. SETTING: A tertiary regional referral center. PATIENTS: 40 male patients < or =65 years consecutively admitted to the cardiac care unit for an acute myocardial infarction with serous creatinine phosphokinase (CPK) > or =350 IU/l and a CPK-MB fraction > or =10%. Exclusion criteria were: cardiac surgery on emergency, stroke, major neurological and/or psychiatric disturbances, alcohol consumption >50 g/day, toxicomania, clinical or biological hypothyroidism, clinical acromegaly and chronic obstructive pulmonary disease. MEASURES: Duplex ultrasonography was performed on carotid arteries, femoral arteries and their bifurcations. An overnight polysomnography was performed after hospital discharge. Patients with an apnoea index >5/hour or apnoea-hypopnea index >10/hour of sleep are considered to have sleep apnoea syndrome (SAS). Patients with additive peripheral atherosclerotic lesions are compared to patients with normal carotid and femoral arteries, regarding to standard cardiovascular risk factors and apnoeas or hypopnoeas during sleep. RESULTS: Duplex revealed in 18 patients carotid and/or femoral atherosclerotic lesions. The prevalence of SAS in patients with at least one peripheral arterial lesion was significantly higher (61% vs 18%, p<0.01). A nearly significant difference was also noted in patients with carotid lesions alone compared to those with normal carotid arteries (57% vs 27%, p=0.06). CONCLUSIONS: These results suggest a possible link between sleep breathing disorders and the pathogenesis of atherosclerotic lesions.

[Intra-arterial thrombolysis of acute mesenteric ischemia]. / Thrombolyse intra-artérielle d'une ischémie aiguë mésentérique.

A 73-year-old man with pre-existing cardiac failure, coronary artery and chronic obstructive pulmonary disease was presented for an acute mesenteric ischaemia, resulting from an embolic obstruction of the superior mesenteric artery. An intra-arterial fibrinolysis with a bolus of 250 000 units of streptokinase, followed by an infusion of 150 mg rtPA with adequate heparin dosage was performed 10 hours after the first symptoms. An abdominal guarding occurred 24 hours later, despite radiological improvement, justifying emergency surgery which confirmed the partial efficiency of the medical therapy. Unfortunately, a cardiogenic shock occurred preoperatively and the patient died five days later from intractable cardiovascular failure.

[Syncopal angina caused by sinus arrest; cured by transluminal coronary angioplasty and calcium inhibitor]. / Angor syncopal par arrêt sinusal; guérison par angioplastie coronaire transluminale et inhibiteur calcique.

The authors report the case of a 42 year old man who smoked and who presented with recurrent spontaneous anginal chest pain followed by syncope due to sinus arrest. The mechanism underlying these symptoms was spasm of the left circumflex artery at the site of severe stenosis of its middle segment just before the origin of the sinus node artery. Treatment with a calcium antagonist with transluminal coronary angioplasty of the narrowed segment of the circumflex artery resulted in complete regression of all symptoms with a follow-up of 15 months. Seven other reports of the same type were found in the literature concerning 6 men and 1 woman, with an average age of 49 years, presenting with the same symptoms and sinus arrest associated with the minimal coronary artery disease. The proof of coronary spasm was documented in 6 of the 7 cases by a positive ergometrine stress test or by the observation of spontaneous spasm during coronary angiography or rapid atrial pacing. The outcome was good with calcium antagonist therapy in 5 cases, and with slow release nitrate derivatives in 1 case. One patient, treated by betablockers, died. It is useful to investigate some sino-atrial blocks to diagnose the underlying ischaemic mechanism as the patients may be treated simply with calcium antagonists rather than undergo implantation of a pacemaker.

[Frequency of angiographic restenosis after 6 months and long-term outcome of coronary angioplasty]. / Fréquence des resténoses angiographiques à 6 mois et devenir à long terme après angioplastie coronaire.

Five hundred patients with a mean age of 59 years were followed up for an average of 32 months after coronary angioplasty. All patients were included in a prospective study comprising coronary angiography at 6 months for 379 patients (91% primary successes). The long-term outcome was evaluated by a questionnaire or telephone interview in all cases. The global primary success rate was 84.4% in this series. The primary failures include 1.8 fatalities, 0.6% myocardial infarction, 2% emergency coronary bypass surgery and 11.2% without immediate clinical consequences. At 6 months, there were 48% of restenoses (182/379 patients) and 28% underwent immediate repeat angioplasty (141/500 patients) with a primary success rate of 91%. After the repeat angioplasty, the restenosis rate was 43% but this varied according to the time from the first restenosis: 60% when the interval was short (under 2 months) compared with 21% when the interval was 6 months (p < 0.01). The actuarial survival rates at 4 years were 95% after successful angioplasty 96% after uncomplicated failures or medically treated restenosis and 98% after bypass surgery. The predictive factors for secondary death were age of over 70 years, previous non-thrombolized myocardial infarction and complications of angioplasty. The long-term outcome was good despite the 48% 6 months restenosis rate requiring revascularisation procedure in 73% of cases.

[Significant stenosis of the common trunk of the left coronary artery. Retrospective study of 227 cases]. / Sténose significative du tronc commun de l'artère coronaire gauche. Etude rétrospective de 227 cas.

Significant left main coronary artery disease is a separate disease entity in coronary artery disease. The prognosis is classically poor and the treatment of choice is surgical. A retrospective study of patients with left main coronary disease, diagnosed and treated at the CHRU Dupuytren, Limoges, between 1/01/80 and 15/06/91 was undertaken to determine the aetiological, clinical and therapeutic factors which influence mortality related to this condition. During this period, 8198 coronary angiographies were performed in the cardiology department. The diagnosis of significant left main coronary disease (> or = 50% stenosis) was made in 250 cases (3% of all investigations). Of these 250 cases, 227 were treated medically or surgically by our group during the study period. Twenty patients were treated in another centre and 3 underwent surgery after the 15/06/91. Seven patients died in the period immediately after coronary angiography. Of the 220 survivors of coronary angiography, 185 (85%) were referred for surgery (direct or sequential venous and/or arterial bypass or coronary endarteriectomy). Four patients died within 30 days of surgery. Thirty five patients were treated medically. The therapeutic decision was based on the absence of surgical contra-indications. The retrospective, non-randomized nature of this study with allocation of patients to surgical or medical treatment without control invalidated statistical analysis. At the date of the last follow-up appointment, arbitrarily chosen as the 1/01/93, 163 operated patients (88.1%) of which 130 (79.7%) were asymptomatic and 13 medically treated patients (37%) were alive. The prognostic factors after surgery in this study were: stage IV dyspnoea at the time of diagnosis, severe abnormalities on catheter study (end diastolic pressure over 18 mmHg after angiography), left ventricular wall abnormalities (functional score > 10) and incomplete revascularization. The risk of coronary angiography in this condition were confirmed in this study.

[Failure and complications of transesophageal echocardiography. Apropos of 1500 consecutive cases]. / Echecs et complications de l'échocardiographie transoesophagienne. A propos de 1,500 examens consécutifs.

Transesophageal echocardiography (TEE) requires the introduction of a flexible probe into the oesophagus and therefore cannot be strictly considered to be non-invasive. This manipulation exposes the patient to complications which are benign in the large majority of cases. The authors report their experience in a prospective study analysing the failures and complications of TEE in the first 1,500 cases performed in their laboratory between May 1988 and May 1992, in mainly adult and ambulatory patients. The probe could not be introduced in 24 patients (1.6%), including 5 cases during the initial learning period. No serious complications were observed during of after TEE. Minor incidents were noted in 28 cases (1.9%) intolerance of the probe (12 cases), nausea and/or vomiting (4 cases), dyspnea (4 cases) due to tracheal intubation in 2 patients, laryngeal in 1 patient and to cardiac failure in 1 case. Pharyngeal haemorrhage (2 cases), atrial fibrillation (3 cases), vertigo (1 case), mandibular dislocation (1 case) and salivary hypersecretion affecting the quality of the imaging (1 case), were also observed. The investigation had to be interrupted prematurely in 12 cases (0.8%) usually because of intolerance of the probe. These results show that TEE is not dangerous in trained hands. Failure to introduce the probe is usually encountered during the learning period, which reinforces the need for apprenticeship in a teaching center. The safety of this technique, plus its considerable diagnostic value in many clinical indications, justify its present role in everyday cardiological practice.