Safety of device implantation under antipatelet therapy with ticagrelor: About 20 cases.

INTRODUCTION: Management of antiplatelet therapy at the time of device implantation remains controversial. This study aimed to assess the risk of bleeding complications in patients receiving ticagrelor at the time of cardiac device surgery. METHODS: We performed a multicentre (N=4), retrospective study from January 2015 to January 2016. The survey included all patients (pts) treated with ticagrelor before undergoing pacemaker, implantable-cardioverter defibrillator (ICD) implantation or generator replacement. We report haemorrhagic post-procedural complications at 1 month. A significant bleeding complication was defined as pocket hematoma requiring a surgical evacuation or prolonged hospitalization, hemothorax, pericardial effusion or tamponade. RESULTS: A total of 20 patients underwent a permanent pacemaker or ICD implantation while taking a combination of antipatelet therapy with ticagrelor and aspirin. The mean age of the patients was 65±9 years, 95% were male, 25% of patients were diabetics, 55% had hypertension and 50% presented a history of heart failure. All the patients had a history of acute coronary syndrome (6 [4-26] months before the procedure). The majority of implanted devices were ICDs (17, 85%) with 5 single chamber, 4 dual chambers and 9 triple chambers ICDs. Subclavian venous approach was utilized in 9 patients. The mean duration of procedure was 60minutes. One per-procedure bleeding was described due to high venous pressure, without post-procedure hematoma. A post-procedure pocket hematoma has been experienced by one patient. The subclavian approach was used for the 2 patients. No blood transfusion was needed for these 2 cases. CONCLUSION: Ticagrelor treatment at the time of heart rhythm device procedures does not seem to be associated with an increased risk of significant bleeding complications. In our study, 2 patients experienced non significant bleeding complications.

[Safety of device implantation under antipatelet therapy with ticagrelor: About 20 cases]. / Implantation de pacemaker et de défibrillateurs cardiaques sous ticagrelor : à propos de 20 patients.

INTRODUCTION: Management of antiplatelet therapy at the time of device implantation remains controversial. This study aimed to assess the risk of bleeding complications in patients receiving ticagrelor at the time of cardiac device surgery. METHODS: We performed a multicentre (n=4), retrospective study from January 2015 to January 2016. The survey included all patients (pts) treated with ticagrelor before undergoing pacemaker, implantable cardioverter-defibrillator (ICD) implantation or generator replacement. We report hemorrhagic post-procedural complications at 1 month. A significant bleeding complication was defined as pocket hematoma requiring a surgical evacuation or prolonged hospitalization, hemothorax, pericardial effusion, or tamponade. RESULTS: A total of 20 patients underwent a permanent pacemaker or ICD implantation while taking a combination of antipatelet therapy with ticagrelor and aspirin. The mean age of the patients was 65±9 years, 95% were male, 25% of patients were diabetics, 55% had hypertension and 50% presented a history of heart failure. All the patients had a history of acute coronary syndrome [6 (4-26) months before the procedure]. The majority of implanted devices were ICDs (17, 85%) with 5 single chamber, 4 dual chambers and 9 triple chambers ICDs. Subclavian venous approach was utilized in 9 patients. The mean duration of procedure was 60minutes. One per-procedure bleeding was described due to high venous pressure, without post-procedure hematoma. A post-procedure pocket hematoma has been experienced by one patient. The subclavian approach was used for the 2 patients. No blood transfusion was needed for these 2 cases. CONCLUSION: Ticagrelor treatment at the time of heart rhythm device procedures does not seem to be associated with an increased risk of significant bleeding complications. In our study, 2 patients experienced nonsignificant bleeding complications.

[Renal denervation for resistant hypertension without general anesthesia: advantage of a MEOPA morphine protocol. Preliminary experience]. / Dénervation rénale pour HTA réfractaire sans anesthésie générale : intérêt d'un protocole MEOPA Morphine. Expérience préliminaire.

UNLABELLED: Renal denervation using the technique of radiofrequency is used only recently for the treatment of resistant hypertension. Normally, it is done under general anesthesia because the ablation point technique is painful. We suggest an alternative to general anesthesia comprising an association of morphin 0.1mg/kg IV to MEOPA (gas combining oxygen and azot protoxyd) delivered through an oxygen mask. Our series includes 12 consecutive patients treated between October 2011 and June 2013, the first five patients (group 1) have received only an hydroxizin and morphin sedation. Every five have felt the ablation painful, in two cases bearable pain (EVA<5), in three cases intense (EVA>5) pain leading to increasing doses of morphin, (total dose of 0.25mg/kg in two cases, 0.17mg in one case). For the seven following patients, a protocol including hydroxyzin, morphin and MEOPA given through a mask has been set up. Only one patient has felt a mild pain (EVA 5) leading to an increasing dose of morphin (total dose 0.17mg/kg). None of the six other patients has felt any pain during the procedure. The average dose of morphin is 0.17mg/kg in group 1, 0.11mg/kg in group 2. This is a preliminary study; if confirmed, it will allow a lot of hospitals without on-site possibilities of general anesthesia, to realize such procedures. CONCLUSION: regarding pain, the procedure of renal ablation was well tolerated for six among seven patients receiving the association MEOPA and IV morphin. In contrast, in the five patients treated only with IV morphin, we observed a less good tolerance to pain and the need to increase the doses of IV morphin.

[Coronary artery spasm during dobutamine stress echocardiography: prevalence, clinical and echocardiographic characteristics and prognosis]. / Spasme coronaire et échographie de stress à la dobutamine : prévalence, profil clinique et échocardiographique et aspects évolutifs.

OBJECTIVES: To assess the prevalence of coronary artery spasm during dobutamine stress chocardiography (DSE), to describe clinical and echocardiographic characteristics and prognosis. PATIENTS AND METHODS: We evaluated all the patients with known or suspected coronary artery disease (CAD) referred to our echocardiography laboratory for dobutamine stress test between January 2004 and June 2012, (10013 exams). Those with abnormal DSE underwent coronary angiograms with a systematic methylergometrine intracoronary injection in case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients who had spontaneous occlusive coronary spasm or positive methylergometrine test but no significant stenoses were included. RESULTS: One thousand and four patients had abnormal DSE, 78 (7.7%) fulfilled the inclusion criteria. There were 57 males and 21 females, mean age was 57.9 years, 37 patients had a known history of CAD. Twenty-four patients had a spasm on the left anterior artery (31%), 37 on the right coronary artery (47%) and 17 on the circumflex (22%). There was a good correlation between spastic arteries and dobutamine induced wall motion abnormalities territories. No complications occurred during the exams or during the provocation test. After 46 months mean follow up; one case of myocardial infarction with normal coronary arteries was noted and six patients experienced recurrent angina responding to treatment intensification. CONCLUSION: Coronary artery spasm during DSE but is a rare and under-diagnosed finding; it has, though, to be recognized as it may partly explain some erroneously labelled "false positive" exams. Methylergometrine provocation test should be performed in such a situation to establish the diagnosis. Prognosis appears favourable.