[Complications of coronary invasive procedures in nonagenarians: A case-control study]. / Complications des procédures invasives coronaires chez les nonagénaires : une étude cas-témoins.

INTRODUCTION: Coronary heart disease is the leading cause of morbidity and mortality in nonagenarians, whose numbers have doubled in twenty years. In the absence of recommendations, the place of coronary invasive strategy in this population remains a therapeutic challenge and its interest as well as its risks are poorly established. The aim of our study was to evaluate the safety of coronary invasive practice in the nonagenarian population for all indications. POPULATION AND METHODS: This was a monocentric case-control study conducted from January 1, 2010 to May 30, 2019. The patients included were all nonagenarians who had undergone coronary angiography at the centre hospitalier de Troyes during this period. For each patient included, two controls matched on sex, date of procedure and procedure were drawn at random. The main judgment criterion was the occurrence of immediate per- or post-procedure complications during the stay in which the procedure was performed. The main secondary outcome measures were average length of stay, occurrence of intercurrent events during the stay (nosocomial infections, confusional syndrome), and loss of autonomy. RESULTS: In all, 59 nonagenarians and 118 controls were included in our study. We identified 30.5% major complications in the nonagenarians versus 10.2% in the controls (P=0.001; OR=0.26 [0.1-0.6]), with a significant difference in the occurrence of cardiogenic shock (P=0.04), heart failure (P=0.02) and ventricular rhythm disorders (P=0.04). Post-procedure acute renal failure was greater in the nonagenarians (P=0.02; OR=0.20 [0.05-1.57]). The mean length of stay was on average twice as long in the nonagenarians. CONCLUSION: Nonagenarian patients are subject to more complications when undergoing coronary invasive procedures compared to patients under 75.

[Impact of a Home Return Assistance Service (PRADO-IC) on the re-hospitalisation rate for heart failure patients]. / Étude de l'impact d'un service d'aide au retour à domicile (PRADO-IC) sur le taux de réhospitalisation des patients insuffisants cardiaques.

BACKGROUND: Heart failure is a public health problem. Since 2013, the National Insurance has been offering the PRADO-IC service for the return home of patients hospitalised for cardiac decompensation. The aim of this study was to assess the impact of PRADO on the rate of re-hospitalisation of patients with heart failure at the centre hospitalier de Troyes (CHT). MATERIAL AND METHODS: This was a 26-month monocentric retrospective study. Patients who were hospitalised for congestive heart failure in the cardiology department of the Troyes Hospital Centre from January 1, 2017 to August 31, 2018, and discharged home with the PRADO-IC service were included in the study. The primary outcome was the assessment of the number of readmissions for heart failure, 6 months before and 6 months after inclusion in the program. Secondary outcomes were the evaluation of the number of all-cause readmissions, the average length of stay and the time to readmission. RESULTS: The average number of hospitalisations for cardiac decompensation before inclusion in the PRADO decreased from 0.34 to 0.25 (P=0.53) at 6 months. The average number of all-cause hospitalisations before inclusion increased from 0.57 to 0.58 (P=0.50) at 6 months. There was no significant difference in average length of stay and time to re-admission. CONCLUSION: We did not highlight the impact of PRADO on the rate of re-hospitalisation of heart failure patients.

Reduction of radiation exposure associated with renewal of the radiologic systems in coronary interventions.

PURPOSE: Interventional coronary procedures are an important source of radiation. This study sought to evaluate the effect of the renewal of the radiologic system on patient exposure during diagnostic coronary angiography (DCA) and percutaneous coronary interventions (PCIs). METHODS: DCA and PCIs were obtained from three centres, which renewed their radiologic systems during their participation in the multicentre prospective observational RAY'ACT-2 study. Data were analysed from the months before and after the radiologic system was changed. The primary outcomes were the dose reduction estimated by the kerma.area product (KAP in Gy·cm2) and the ratio of the KAP to fluoroscopy time (Gy·cm2·min-1). RESULTS: A total of 2148 patients underwent DCA (1575 before and 573 after the system change), and 1563 underwent PCI (1196 before and 367 after). A change in the radiologic system was associated with a KAP reduction of 43% for DCA (median [interquartile range]: 18.1Gy·cm2 [10.2-34.0] versus 31.5 [19.0-49.0], P<0.0001), and 38% for PCI (42.2Gy·cm2 [23.8-81.7] versus 70.1 [42.0-109.0], P<0.0001). Fluoroscopy time did not vary significantly, and the ratio KAP to fluoroscopy time significantly decreased by 54%. The dose reduction was homogeneous between the three centres and between different manufacturer's systems. CONCLUSIONS: In this multicentre study, the renewal of the radiologic system was associated with a highly significant 40%-50% reduction in radiation dose, irrespective of the manufacturer. A close interaction between manufacturers and operators is needed to optimise the use of new equipment and the effectiveness of radiation reduction tools and techniques.

[Lemierre's syndrome: Diagnosis, exploration, treatment]. / Syndrome de Lemierre : diagnostic, exploration, traitement.

Lemierre's syndrome is a rare and severe sepsis that can rapidly lead to a life-threatening condition in the absence of early management. This syndrome described at the beginning of the 20th century combines oropharyngeal infection complicated with septic thrombosis of the internal jugular vein and septic emboli predominantly pulmonary. Fusobacterium necrophorum, anaerobic germ, Gram negative bacillus is the main germ in this "necrobacillosis". The diagnosis is should be confirmed precociously with cervicothoracic CT-scan, reference exam, and bacteriological examinations (especially in atypical forms). Its management consists of an emergency antibiotic treatment, combining a third-generation cephalosporin or a betalactam with metronidazole, anticoagulant therapy to be reserved for high-risk situations related to thrombosis. Surgical treatment may be required.

[Stress cardiomyopathy: report of 2 cases]. / Cardiomyopathie de stress: à propos de deux cas.

The authors reported two cases of acute catecholamines cardiomyopathy expressed clinically by chest pain and dyspnea, without any previous cardiac history. The diagnosis of human stress cardiomyopathy is established on: typically rapid onset aftermath of intense emotional stress, left ventricular apical akinesis and hyperkinetic motion of basal walls imaged by two-dimensional echocardiography. Rapid reversal clinical course and normal coronary arteriography. Similar finding have been observed in conjunction with pheochromocytoma who have been excluded by normal levels of urinary catecholamines metabolites.

[Dobutamine doppler echocardiography in severe aortic stenosis with left ventricular dysfunction. Comparison with postoperative examination]. / Apport de l'échocardiographie Doppler sous dobutamine dans le rétrécissement aortique serré avec dysfonction ventriculaire gauche. Comparaison aux données postopératoires.

The association of left ventricular dysfunction with aortic stenosis worsens the spontaneous prognosis and increases operative mortality. The aim of this prospective study was to assess the predictive value of dobutamine Doppler echocardiography on the indices of left ventricular contractile function in patients with aortic stenosis and left ventricular dysfunction (LVEF < 0.45) undergoing aortic valve replacement. Eighteen patients, including 9 with coronary artery disease, were included in a protocol consisting of analysis of left ventricular function and of the severity of aortic stenosis before, during dobutamine infusion, and after valvular replacement. The dobutamine was given in progressive increments of 5 micrograms/Kg up to a maximum of 20 micrograms/Kg. During pharmacological stress, the functional aortic valve area increased from 0.46 +/- 0.15 to 0.56 +/- 0.23 cm2. Tolerance of the procedure was good. All but 2 patients improved their postoperative ejection fraction with values equivalent to those observed during the last increment of dobutamine (r = 0.73; p < 0.003). The patients with initial mean pressure gradients > 50 mmHg normalised their LVEF after valve replacement. The authors conclude that dobutamine echocardiography is useful for predicting the values of postoperative left ventricular contractile indices when severe aortic stenosis is associated with systolic dysfunction. It allows evaluation of the expected short term benefits to these indices after aortic valve replacement.

[Incidence and predictive factors of mitral insufficiency in surgically treated aortic stenosis. Transthoracic and transesophageal ultrasonographic evaluation]. / Incidence et facteurs prédictifs de l'insuffisance mitrale dans le rétrécissement aortique chirurgical. Evaluation échographique transthoracique et transoesophagienne.

Mitral regurgitation is common in adults with aortic stenosis. When severe, it may aggravate the clinical condition and pose an additional therapeutic problem. The authors studied 40 consecutive patients with severe surgical aortic stenosis prospectively by transthoracic echocardiography and pre-operative transoesophageal echocardiography to determine the incidence, mechanism and degree of mitral regurgitation and its eventual relationship to the aortic stenosis. Mitral regurgitation was detected in all cases when both investigations were taken into consideration. It was usually mild, evaluated grade 2 by measuring the surface of the colour Doppler regurgitant jet, or mild to minimal of transoesophageal echocardiography in 35/40 patients (87.5% of cases). Rarely, a case of significant, autonomous mitral regurgitation (2 cases of valvular dystrophy, 1 pure severe mitral stenosis). On the other hand, calcification of the mitral annulus is common (14/40 patients, 35% of cases). The severity of the regurgitation in univariate analysis was significantly correlated mainly to the age of the patients (p = 0.027). The severity of the aortic stenosis (p = 0.0082) and the parameters related to the effects of stenosis, such as ventricular wall thickness and left atrial size. In multivariate analysis, the severity of the aortic stenosis and of its consequences were confirmed to play a role in the genesis of mitral regurgitation, the severity of which was correlated on transthoracic echocardiography to the aortic valve surface area and the left ventricular ejection fraction and, on transoesophageal echocardiography, to the transvalvular pressure gradient.

Randomized evaluation of four versus five French catheters for transfemoral coronary angiography.

BACKGROUND AND HYPOTHESIS: In coronary angiography there is a trend toward using smaller catheters to avoid puncture site complications. An increased utilization of outpatient facilities may result. This study was undertaken to determine whether using 4Fr diagnostic catheters in comparison with 5Fr catheters would reduce the vascular complication rate, after patient ambulation following 4 h bedrest, without altered technical performance and or procedural duration. METHODS: The study population comprised 100 consecutive, unselected patients, who were randomly assigned for transfemoral coronary angiography with 4 or 5Fr diagnostic catheters. Procedural characteristics, quality of angiogram, and clinical assessment of puncture site at 4, 12, and 24 h were analyzed. RESULTS: No significant difference was demonstrated concerning procedural characteristics, ventriculography, coronary contrast quality, or local vascular damage. However, two patients crossed over in the 4Fr group and one in the 5Fr group. CONCLUSION: As a consequence, the feasibility, reliability, and utility of catheter size on vascular complication rates must be considered to be similar with either 4Fr or 5Fr diagnostic catheters.

[Transthoracic echocardiography and diagnosis of acute pulmonary embolism. Change in the diagnostic valve with respect to thresholds of classification]. / Echocardiographie transthoracique et diagnostic d'embolie pulmonaire aiguë. Variation de la valeur diagnostique en fonction des seuils de classification.

The diagnostic value of transthoracic echocardiography in acute pulmonary embolism is not well established. Although many parameters are abnormal, the thresholds used vary according to the authors, limiting the contribution of the investigation to the diagnosis. In a prospective study of 70 patients with suspected acute pulmonary embolism without previous cardio-respiratory disease, the authors tried to determine the diagnostic thresholds using discriminating linear analysis and ROC curves. Parameters easily recorded in an emergency were analysed: end diastolic ventricular dimensions, ratio of these diameters and maximal velocity of tricuspid regurgitant flow. Thirty-one patients had pulmonary embolism quantified by the Miller index (average: 16 +/- 7, range 2 to 28). Measurements of left ventricular dimension were disappointing (sensitivity: 0.52, specificity: 0.73 for a threshold value of 45 mm). The right ventricular dimension was a better predictive parameter (sensitivity: 0.70, specificity: 0.86 for a threshold value of 25 mm). However, the ratio of right to left ventricular dimension had a better diagnostic value (sensitivity: 0.85, specificity: 0.78 for a threshold value of 0.5). The best diagnostic parameter was the maximal velocity of tricuspid regurgitation (sensitivity: 0.93, specificity: 0.82 for a threshold value of 2.5 m/s). The authors conclude that the maximal velocity of tricuspid regurgitation with a threshold of 2.5 m/s and the ratio of the ventricular dimensions with a threshold value of 0.5 are valuable diagnostic indicators for acute pulmonary embolism.

[Ventricular late potentials and sleep apnea syndromes]. / Potentiels tardifs ventriculaires et syndromes d'apnées du sommeil.

This prospective study in 37 patients evaluated the prevalence of ventricular late potentials in sleep apnea syndrome, a condition associated with an increased risk of ventricular rhythm disorders and sudden death. A comparative analysis was conducted among a group of patients considered free of coronary heart disease and admitted for suspected sleep apnea syndrome based on clinical symptoms and simple blood gas measurements. The prevalence of ventricular late potentials was 56% in the subgroup with and 14% in the subgroup without polygraphy evidence of apnea (F < 0.01). The analysis of clinical, respiratory, and echocardiographic findings in the apneic subgroup failed to detect any factors associated with the presence of ventricular late potentials. Only long-term follow-up studies involving invasive heart rhythm testing could define the prognostic significance of ventricular late potentials in sleep apnea syndrome. However, our data demonstrate that there is an association between ventricular late potentials and sleep apnea syndrome.

[Acute upper limb ischemia in a young adult without cardiac disease. Value of transesophageal echocardiography]. / Ischémie aiguë des membres supérieurs chez une adulte jeune sans cardiopathie. Intérêt de l'échographie transoesophagienne.

The authors report the case of a 34-year old woman with no previous cardiovascular disease who was admitted to hospital for acute ischaemia of the right arm due to embolism, preceded by two episodes of pain and tingling of the left arm related to subacute ischaemia. After right embolectomy, with no possibility of controlateral disobliteration an effective anticoagulation, no cardiac source of embolism could be found; However, transoesophageal echography showed a large mobile thrombus in the aortic arch implanted just before the origin of the left subclavian artery. The only explanation for embolism to the right arm was a retro-oesophageal subclavian artery which was confirmed by scanner. Doppler and arteriography. These investigations, however, did not allow visualisation of the aortic thrombus. In view of the risk of recurrent embolism, a thrombectomy was performed without cardiopulmonary bypass, associated with correction of the vascular abnormality with no complications. This case shows that oesophageal echography is a useful investigation in the work up of acute arterial obstruction in young patients with no cardiac disease.

[Value of transesophageal echocardiography in post-infarction septal ruptures]. / Intérêt de l'échographie transoesophagienne dans les ruptures septales postinfarctus.

The role of transoesophageal echocardiography in the diagnosis of ventricular septal defect in the acute stage of myocardial infarction, was evaluated in 15 consecutive patients (10 men and 5 women) with a mean age of 72 years in the period between June 1991 and April 1995. The patients had 11 anterior infarcts and 4 inferior infarcts with extension to the right ventricle. One patient was in Killips class I,7 patients in class II, 2 in class III and 5 in class IV. Only 8 of the 15 septal ruptures could be visualised directly by conventional transthoracic echocardiography, though all 15 were suspected from continuous Doppler and colour Doppler analysis. Transoesophageal echocardiography was successfully performed in 14 of the 15 patients with a monoplane probe in 11 cases and a multiplane probe in 3 cases. The average duration of the procedure was 12 minutes and clinical and haemodynamic tolerance was good. Ventricular septal defect was directly visualised in all cases in the short axis transgastric view and in 7 cases in transoesophageal views. Transoesophageal echocardiography was concordant with peroperative findings with regards to the site of ventricular septal defect (8 apical, 5 postero-basal and 1 median), their type (6 punched-out defects, 5 fissures, and 3 perforated aneurysms), their size (average 9.3 mm), their number with 5 multiple defects, and associated lesions (4 right ventricular extensions, 4 hemopericardiums and 1 free wall fissure). Transoesophageal echocardiography completes traditional transthoracic echocardiographic examination in the diagnosis of post-infarction ventricular septal defect. It is well tolerated and, in the authors' experience, allows limitation of invasive procedures to coronary angiography alone.

Use of transthoracic Doppler echocardiography combined with clinical and electrocardiographic data to predict acute pulmonary embolism.

Transthoracic echocardiography and continuous wave Doppler were prospectively performed in 132 out-patients with suspicion of pulmonary embolism, and who had no previous history of severe cardiac or pulmonary disease. Bedside echocardiography determined diagnosis other than pulmonary embolism in 55 patients. Further study was completed in 70 patients; pulmonary embolism was found in 31 and excluded in 39. Significant differences were found as regards right ventricular diameter (27 +/- 8 vs 22 +/- 5 mm, P < 0.001), left ventricular diameter (41 +/- 9 vs 49 +/- 7 mm, P < 0.001), right over left ventricular diameter ratio (0.67 +/- 0.23 vs 0.43 +/- 0.15, P < 0.0001), tricuspid regurgitant flow peak velocity (2.9 +/- 0.4 vs 2.4 +/- 0.7 m.s-1, P < 0.0001), and abnormal septum motion (12 vs 4, P < 0.01). Multivariate analysis of echocardiographic data included a tricuspid regurgitant flow peak velocity greater than 2.5 m.s-1 and a right over left ventricular diameter ratio greater than 0.5 in a logistic model (sensitivity 93%, specificity 81%). The combination of echocardiographic and non-echocardiographic data included the two previous echocardiographic variables, together with signs of deep vein thrombosis, a deep S wave in lead D1, and a Q wave in lead D3 on the electrocardiogram in a logistic model (sensitivity 96%, specificity 83%). It can be concluded that emergency echocardiography, alone or combined with clinical examination and electrocardiogram, satisfactorily predicts acute pulmonary embolism.

Floating right heart thrombi and pulmonary embolism: diagnosis, outcome and therapeutic management.

The aim of this study was to analyze clinical and echographic findings and to assess therapeutic management in 14 floating right atrial thrombi diagnosed with systematic echocardiography in 200 consecutive patients with proven pulmonary embolism. Auscultatory findings were abnormal in 7 cases, 4 of them showing signs of tricuspid obstruction. Echocardiography displayed a mobile ovoid, polycyclic or worm-like right atrial mass, always associated with signs of cor pulmonale. Four patients (29%) died, 2 of them before any treatment could be started. Regarding the remaining 10 patients with favorable outcome, surgical embolectomy was carried out in 7. Our data suggest that echocardiographic examination is necessary in all suspected pulmonary embolisms and has to be done quickly for emergency treatment in patients with floating right atrial thrombus.

[Pulmonary embolism and thrombi of the right heart]. / Embolie pulmonaire et thrombus des cavités droites.

In general, there are two types of right heart thrombi diagnosed by echocardiography: mobile and non-mobile thrombi, more often located in the atrium than in the ventricle and a potential source of pulmonary embolism. However, they differ in several points: clinical context, clinical and echocardiographic presentations, embolic potential, prognosis and treatment. The result of peripheral venous thrombosis, mobile thrombus it is usually diagnosed during echocardiographic investigation of pulmonary embolism. The appearances are often that of serpentine thrombus floating in the right heart chambers associated with signs of acute cor pulmonale. It is a marker of imminent and often fatal embolism as it completes a previous and usually severe pulmonary embolism; the mortality is over 40%. It is a contra-indication for pulmonary angiography because of the risk of embolism and a therapeutic emergency. Some groups advocate surgical embolectomy and others thrombolysis. Its precise frequency in the acute stage of pulmonary embolism and its treatment remain to be determined by a prospective, multicentre clinical trial. The adherent non-mobile thrombus is usually implanted on the free wall of the right atrium or the interatrial septum. Its formation, in situ, is due to stasis secondary to decompensated congenital or acquired cardiac disease or to the presence of an intracardiac foreign body such as a pacing wire. It is less likely to cause pulmonary embolism. It decreases or disappears with anticoagulant therapy and the outcome is usually good. The differential diagnosis between a mobile thrombus and a Chiari network, or between an adherent thrombus and a vegetation on a intracardiac pacing wire may be difficult and requires transoesophageal echocardiography. The investigation of pulmonary embolism requires systematic echocardiography, one of the objectives of which is to search for right sided thrombi.

[Transesophageal echocardiographic diagnosis of left ventricular parietal rupture, a complication of myocardial infarction]. / Diagnostic par échographie transoesophagienne d'une rupture pariétale du ventricule gauche sur infarctus du myocarde.

The authors report the case of postero-lateral myocardial infarction complicated by free wall rupture at the 48th hour. The diagnosis was suspected clinically and transoesophageal echocardiography showed the appearance of pericardial effusion in a patient difficult to examine by conventional echocardiography. Transoesophageal echocardiography was performed and well tolerated. The transgastric view showed a thrombus adjacent to a thinned and lacerated postero-lateral wall. The clinical outcome was favourable after surgical repair.

Diagnostic accuracy of echocardiography-Doppler in acute pulmonary embolism.

We studied prospective recording of clinical, electrocardiographic, Doppler and echographic parameters in 32 patients with proven pulmonary embolism, matched with 32 patients with clinically suspected pulmonary embolism and normal perfusion scan or angiography. Thirty-seven per cent of cases and 16% of control subjects had clinical signs of right ventricular overload; S1-Q3-T3 ECG pattern was found in 11 cases and one control. Other clinical and ECG parameters did not reach significant difference. Echographic septum motion was abnormal in 42% of cases and 9% of controls (P < 0.05), end-diastolic right ventricular diameter was > 25 mm in 67% of cases and 11% of controls, ratio of end-diastolic right over left ventricular diameters increased over 0.6 in 67% of cases and 11% of controls, while Doppler examination found tricuspid regurgitant peak flow velocity > 2.5 m/s in 84% of cases vs. 10% of controls. According to these parameters, Doppler-echocardiography was normal in 6% of cases and 87% of control subjects (P < 0.001 for each). In suspected pulmonary embolism, our study shows that Doppler-echocardiography may be both sensitive and specific in emergency conditions and help the decision making for further invasive investigations.

[Value of transesophageal echography in the detection of left intraventricular masses. Apropos of a case of apical thrombus]. / Intérêt de l'échographie transoesophagienne biplan dans la détection des masses intra-ventriculaires gauches. A propos d'une observation de thrombus apical.

The authors report a case of left intraventricular thrombus investigated by two-dimensional transesophageal echocardiography (TEE). Three longitudinal views obtained by rotation, left lateral inclination and by advancing the probe, enabled the precise evaluation of a mass situated at the apex of the left ventricle, together with ventricular morphology and kinetics. Two-dimensional TEE is electively indicated for confirmation of the diagnosis of left intraventricular apical masses, in particular in hypoechogenic patients and to guide possible surgery. The two-plane probe provides a certain number of sections which remain relatively limited but this problem is resolved with the development of multidimensional probes.

[Doppler echocardiography under dipyridamole after thrombolyzed early myocardial infarction. Comparison with coronarographic data]. / Echocardiographie Doppler sous dipyridamole après infarctus du myocarde inaugural thrombolysé. Comparaison aux données de la coronarographie.

The reliability and safety of Doppler echocardiography with dipyridamole (0.84 mg/kg in 10 min) were evaluated in 63 patients an average of 7 days after a thrombolysed early lateral infarct and 24 hours before follow-up coronary arteriography. The aims of the test were the detection of tight stenoses (diameter reduced by more than 75%) affecting the artery responsible for the infarct as well as the other coronary vessels, using the vasodilator action of dipyridamole. The echocardiographic manifestation of induced coronary steal consisted of transitory asynergism in the territory of the artery involved. Clinical tolerability of the test was good. The brief onset of anginal pain was nevertheless seen in 6 patients. Analysis of the zone corresponding to the necrosed area was possible in only 43 cases. Sensitivity of the test for detection of a post-infarction residual stenosis was 64% (39-89) and specificity 90% (79-100). Study of other territories was possible in 59 cases. Sensitivity of the test for the diagnosis of multiple vessel disease was 70% (42-98) and specificity 94% (88-100). In the population as a whole, Doppler study of variations in anterograde mitral flow revealed a sensitivity of 40% (27-53) and specificity of 87% (78-96). Variations in sub-aortic flow were analysed only in the final 27 patients, with a sensitivity and specificity of 100%. The specificity of dipyridamole echocardiography after infarction is good, both for the detection of residual stenosis and that of multiple vessel disease, the chief limiting factor being the impossibility of analysis of the infarcted region in the presence of initial akinesis.(ABSTRACT TRUNCATED AT 250 WORDS)