[Management of ST-elevation myocardial infarction in 2012]. / Prise en charge de l'infarctus du myocarde en 2012.

Improvement of myocardial reperfusion with a greater use of primary percutaneous coronary intervention, adjunctive pharmacological and mechanical therapies have contributed to a spectacular decrease in mortality of patients presenting with ST-elevation myocardial infarction.

[Prognostic value of S-100B protein plasma measurement after cardiac arrest]. / Intérêt pronostique du dosage de la protéine S-100B sérique au décours d'un arrêt cardiaque en milieu extrahospitalier : données préliminaires françaises.

S-100B protein is selectively synthesized by glial cells, and is released in biological fluids after acute brain damage. We analyzed initial levels and evolution of plasma S-100B protein concentrations after resuscitated cardiopulmonary arrest (CPA). S-100B levels were determined in 27 subjects at the time of CPA (H0) then 12, 24 and 48 h after resuscitation. Initial levels of S-100B and kinetics revealed that: 1) 95% the of subjects with a concentration of protein S-100B greater than 0.80 microg/L at H0 did not survive; 2) 62% of subjects with a concentration of protein S-100B lower than 0.80 microg/L at H0 survived; 3) 100% of subjects with a protein S-100B level lower than 0.80 microg/L at H0 and whose evolution kinetics of S-100B levels showed a decrease survived; 4) 100% of the subjects whose S-100B levels increased from H12 died. In summary, this study suggests that the threshold of 0.80 microg/L for S-100B plasma levels at H0 could be predictive for the outcome of the CPA, when associated with the kinetic study of S-100B plasma concentration.

[2008 update of the 8th Consensus Development Conference of the Francophone Society of Medical Emergencies of 1999. The treatment of adult renal colic by the emergency services and in emergency rooms]. / Actualisation 2008 de la 8e Conférence de consensus de la Société francophone d'urgences médicales de 1999. Prise en charge des coliques néphrétiques de l'adulte dans les services d'accueil et d'urgences.

The care in the emergencies of the renal colic at the adult was the object in 1999 of a conference of consensus of the French Society of Emergency (SFMU) in association with the French Association of Urology and the Society of Nephrology. This already former text was the object of an update in 2008 by the subcommittee of scientific monitoring of the SFMU and was presented to the congress 2008. This public presentation in the presence of an expert urologist allowed to confront this new text with the practices and to publish an updating of the conference of consensus of 1999. A survey of practice was led with the emergency physicians, whose results are presented.

[Value of biochemistry performed in pre-hospital cardiology]. / Apport de la biologie embarquée en cardiologie préhospitalière.

For a long time, the diagnosis of an acute myocardial infarction (AMI) seen in outdoor patients, was only relying on ECG findings. For that reason a certain amount of patients suffering from an AMI showing an atypical or not contributive ECG had not been identified as such and in consequence did not benefit from any prehospital treatment or had not been admitted in coronary care unit (CCU). With the arrival of the biological bed side monitoring in the SAMU, it became possible to measure via TRIAGE Cardiac the biological parameters of an AMI (myoglobin, troponin Ic and CKMB) and so confirm or exclude the diagnosis in certain cases. Other markers became measurable, such as BNP (brain natriuretic protein) a marker for early detection of heart failure. This natriuretic peptide is used during hospitalisation as a prognostic value in acute coronary syndrome with no cardiac insufficiency associated. More recently a semi quantitative test CardioDetect using the early release of h-FABP (heart fatty acid binding) showed a better sensibility in the first hours after chest-pain onset in out-door patients. The experience of the use of these biological bed side tests in the prehospital phase is only recent, but already permits a better management of out door patients. The future of there employ is promising. The combined use of these different markers in out door patients will probably allow in the near future identifying high risk patients.

[Antithrombotics in pre-hospital phase of acute coronary syndromes]. / Antithrombotiques durant la phase préhospitalière des syndromes coronaires aigus.

Antithrombotic therapies are the corner stone of acute coronary syndrome management. We have the proof that many of them should be initiated during the prehospital care because their clinical benefit is time-dependent. The hypothesis that anticoagulation therapy is an effective treatment of STEMI, which benefit is time-dependent, is now validated. It is also fair to affirm that GP lIb/IIIa receptor inhibitors are the adjuvant therapy of choice for primary PCI. Indeed, these medications reduce short-term and long-term mortality. This clinical benefit is time dependent. Clopidogrel therapy is probably also a medication of the prehospital phase. It is well established now that the biological efficacy of this pro drug is loading dose dependent. It is also demonstrated that its clinical efficacy depends on the time delay between symptom onset and initiation of the therapy. However, the clinical benefit of prehospital administration remains to be established.

Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction.

BACKGROUND: When administered in conjunction with primary coronary stenting for the treatment of acute myocardial infarction, a platelet glycoprotein IIb/IIIa inhibitor may provide additional clinical benefit, but data on this combination therapy are limited. METHODS: We randomly assigned 300 patients with acute myocardial infarction in a double-blind fashion either to abciximab plus stenting (149 patients) or placebo plus stenting (151 patients) before they underwent coronary angiography. Clinical outcomes were evaluated 30 days and 6 months after the procedure. The angiographic patency of the infarct-related vessel and the left ventricular ejection fraction were evaluated at 24 hours and 6 months. RESULTS: At 30 days, the primary end point--a composite of death, reinfarction, or urgent revascularization of the target vessel--had occurred in 6.0 percent of the patients in the abciximab group, as compared with 14.6 percent of those in the placebo group (P=0.01); at 6 months, the corresponding figures were 7.4 percent and 15.9 percent (P=0.02). The better clinical outcomes in the abciximab group were related to the greater frequency of grade 3 coronary flow (according to the classification of the Thrombolysis in Myocardial Infarction trial) in this group than in the placebo group before the procedure (16.8 percent vs. 5.4 percent, P=0.01), immediately afterward (95.1 percent vs. 86.7 percent, P=0.04), and six months afterward (94.3 percent vs. 82.8 percent, P=0.04). One major bleeding event occurred in the abciximab group (0.7 percent); none occurred in the placebo group. CONCLUSIONS: As compared with placebo, early administration of abciximab in patients with acute myocardial infarction improves coronary patency before stenting, the success rate of the stenting procedure, the rate of coronary patency at six months, left ventricular function, and clinical outcomes.

A comparison of standard cardiopulmonary resuscitation and active compression-decompression resuscitation for out-of-hospital cardiac arrest. French Active Compression-Decompression Cardiopulmonary Resuscitation Study Group.

BACKGROUND: We previously observed that short-term survival after out-of-hospital cardiac arrest was greater with active compression-decompression cardiopulmonary resuscitation (CPR) than with standard CPR. In the current study, we assessed the effects of the active compression-decompression method on one-year survival. METHODS: Patients who had cardiac arrest in the Paris metropolitan area or in Thionville, France, more than 80 percent of whom had asystole, were assigned to receive either standard CPR (377 patients) or active compression-decompression CPR (373 patients) according to whether their arrest occurred on an even or odd day of the month, respectively. The primary end point was survival at one year. The rate of survival to hospital discharge without neurologic impairment and the neurologic outcome were secondary end points. RESULTS: Both the rate of hospital discharge without neurologic impairment (6 percent vs. 2 percent, P=0.01) and the one-year survival rate (5 percent vs. 2 percent, P=0.03) were significantly higher among patients who received active compression-decompression CPR than among those who received standard CPR. All patients who survived to one year had cardiac arrests that were witnessed. Nine of 17 one-year survivors in the active compression-decompression group and 2 of 7 in the standard group, respectively, initially had asystole or pulseless electrical activity. In 12 of the 17 survivors who had received active compression-decompression CPR, neurologic status returned to base line, as compared with 3 of 7 survivors who had received standard CPR (P=0.34). CONCLUSIONS: Active compression-decompression CPR performed during advanced life support significantly improved long-term survival rates among patients who had cardiac arrest outside the hospital.

[Stunned myocardium or hibernating myocardium? Apropos of a case]. / Myocarde sidéré ou myocarde hibernant? A propos d'une observation.

The authors relate a case report of unstable angina pectoris accompanied by a well-documented stunned myocardium phenomenon. Stunned and hibernating myocardium resulting from an acute or chronic coronary ischaemia on the myocardium are notions which widely govern revascularisation indications, especially after a myocardial infarction. At present, their detection is based on isotopic methods and stress echocardiography.

Abdominal aortic aneurysmectomy in a renal transplant patient: protection of the kidney without adjunctive measures.

Abdominal aneurysmectomy in kidney transplant recipients can be successfully performed without adjunctive protective measures if the period of renal ischaemia is short. A technique that attains this goal is described here. An aortic aneurysm (5 cm) was removed 2 years after kidney transplantation to the left external iliac vessel. The right common iliac artery was divided first and anastomosed to the right branch of the bifurcated graft. Aortic anastomosis was then performed; the period of renal ischaemia was only 20 min. Arterial flow was re-established in the right common iliac artery, providing profuse collateral flow to the transplanted kidney through the internal iliac arteries during the time necessary to complete the left common iliac artery anastomosis. This procedure is feasible unless the internal iliac artery is severely stenosed, occluded or terminally anastomosed to the transplanted renal artery. In all other cases, this technique may be the optimal procedure to protect the kidney during elective abdominal aorta aneurysmectomy in renal transplant recipients by reducing the period of ischaemia to that of one anastomosis only.

Atherosclerotic disease of the innominate artery: current management and results.

Arterial repair through a sternotomy has long been considered the procedure of choice for innominate artery atherosclerotic disease. Of 22 patients presenting with 21 occlusive lesions and one aneurysm, 17 patients underwent a bypass procedure, and two, an endarterectomy through a sternotomy, whereas three patients underwent cervical procedures. Their postoperative course was uneventful. Early and late results were satisfactory. We conclude that in patients with innominate artery atherosclerotic disease, the procedure employed depends on both the type of lesion and the clinical status of the patient. In most cases, a bypass graft via a sternotomy is the best option, since endarterectomy is not always possible and risks an aortic tear or dissection. In selected cases, balloon angioplasty performed either percutaneously, combined with cerebral protection by an occlusive balloon in the carotid artery or through a carotid arteriotomy in order to flush out embolic material may be sufficient. A by-pass graft from the right to the left common carotid artery is the best procedure in patients with neurological symptoms when angioplasty seems inappropriate, and when sternotomy is contraindicated for either reasons of poor health or a prior mediastinal operation.

[Is it possible to cure various disorders of stability or vertigo by surgical correction of tight stenosis of a supra-aortic artery?]. / Peut-on guérir certains troubles de stabilité ou vertiges en corrigeant chirurgicalement une sténose serrée d'une artère supra-aortique?

While the efficacy of vertebral arteries revascularisation on the symptoms of vertebrobasilar insufficiency (VBI = IVB in text) is well established, the effect of correction of stenosis of vessels other than the vertebral arteries on stability disorders and vertigo do not appear to have been studied to any extent. Furthermore, vertigo is not considered as specific to VBI. A retrospective study was therefore carried out to determine the outcome in 33 patients with static disorders or vertigo operated upon for a severe stenosis of a brachiocephalic trunk, a carotid artery or a subclavian artery, with or without associated stenosis of a vertebral artery which in all cases had been neglected. Two patients (6%) died during the early stages of this series. Mean duration of follow up was a little longer than 5 years. One month post-operation 61% of the survivors were asymptomatic, all the others reported marked improvement in their symptoms and all had resumed their social life. At a later stage two patients had a clinical relapse associated with new arterial stenosis. Findings in this small series suggest that it is possible to cure or improve patients with stability disorders or vertigo by the surgical correction of a severe stenosis of a supra-aortic artery other than a vertebral artery.

[Aorto-bifemoral bypass. Evaluation of Milliknit prosthesis]. / Pontages aortobifémoraux. Evaluation des prothèses Milliknit.

Since there is no consensus as to the choice of an optimal prosthesis for aortobifemoral bypass, we have retrospectively evaluated the outcome with 162 Milliknit prostheses laid in cases of obliterating atherosclerosis. Such prostheses were preferentially used when the distal anastomosis were to be located on the deep femoral arteries. Intraoperatively, we noted the absence of fraying and the easy manipulation, owing to the flexibility and thinness of the wall, which are similar to those of the deep femoral artery: however, the blood loss before achieving complete tightness was greater than with most other knitted prostheses, and in 7.4% of the operated patients, defribination on clamp removal caused an additional bleeding averaging 1 litre. There was no graft sepsis during the postoperative period, may be because of the excellent healing of this prosthesis. One prosthesis only presented with excess dilatation accounting for thrombosis. The average length of follow-up was 3.6 years, the primary actuarial patency at 1, 5 and 10 years respectively was 98.7, 93.9 and 92.8%. Secondary patency at the same times was 99, 97.5 and 95.9%. These patency rates are among the best published in the literature. As a conclusion, this prosthesis is perfectly appropriate when the shunts must be located on thin femoral arteries, but a reduction of the intraoperative blood loss through an impregnation process would be desirable.

[Surgery of aneurysms of the abdominal aorta in 1992. Lessons of a decade]. / La chirurgie des anévrysmes de l'aorte abdominale en 1992. Les leçons d'une décennie.

Perioperative mortality of abdominal aortic aneurysm (AAA) remains at a mean of 3% in asymptomatic cases, 6% when symptomatic and 50% when ruptured while many patients with ruptured AAA die prior to surgery. This has changed little over the last decade. The causes of this stagnation are analyzed, strategic choices as a function of clinical situations, size of aneurysm, and associated lesions exposed, and means explored to improve the prognosis. Since the perioperative mortality rate appears incompressible, an improvement in the prognosis of AAA can be obtained only by a combined medical effort. This requires the more rapid recognition of prodromal symptoms of rupture, the detection of a larger number of asymptomatic AAA and improved postoperative life expectancy, already reasonable, by more rigorous vascular and cardiologic surveillance.

Adventitial cystic disease of the popliteal artery: treatment by cyst removal.

Controversy still exists concerning the optimal treatment for adventitial cystic disease of the popliteal artery: complete removal of the cyst without arterectomy or arteriectomy with venous replacement. In the two cases presented here, it was possible to completely excise the cyst and to preserve a solid arterial wall despite the magnitude of lesions documented on preoperative angiograms. Good functional and anatomic outcome has been maintained for 5 and 9 years, respectively. According to the available literature on pathologic data, complete cyst excision without arterial reconstruction is often feasible. Our results, as well as those published by others, suggest that short- and long-term outcome is better after complete cyst removal without than that with arterial reconstruction. As most patients are generally young adults, cystic excision should be preferred to venous bypass whenever feasible and whenever the remaining arterial wall seems to be healthy and solid.