Percutaneous aortic valve interventions in heart failure patients.

The onset of symptoms of heart failure is a landmark in the natural history of aortic stenosis, and is associated with a dramatic reduction in survival. Aortic valve replacement markedly increases life-expectancy in such patients. However, the presence of heart failure and/or left ventricular dysfunction are strong predictors of poor acute and late mortality after cardiac surgery and the most frequent conditions leading to deny surgical aortic valve replacement in elderly patients. The last decade has witnessed the development of transcatheter aortic valve implantation (TAVI) and, consequently, the resurgence of percutaneous balloon aortic valvuloplasty (PBAV) and, both, are currently routine therapy for high-risk patients. These minimally invasive procedures are appealing therapeutic options for the subset of patients with heart failure and or/left ventricular systolic dysfunction. The available evidence on the results of PBAV and TAVI therapies in this setting is discussed and a management strategy is proposed.

[Percutaneous approaches to mitral valve disease]. / Approches percutanées des valvulopathies mitrales.

Percutaneous approaches to mitral valve disease consist in modifications of existing surgical techniques, aiming to replicate the favourable outcomes of surgery, with less procedure-related risk, due to their less invasive nature. While some of these techniques are clearly indicated for the management of certain valve diseases, other appear as possible alternatives to surgery among patients deemed at high-risk or considered inoperable, or are still under clinical investigation. Major development of these percutaneous approaches is expected within the future, thus hopefully allowing treatment of a larger proportion of patients with mitral valve disease.

[Percutaneous exclusion of the left atrial appendage: perspectives]. / Exclusion percutanée de l'auricule gauche : perspectives.

With its high prevalence and well-known thromboembolic risk, atrial fibrillation (AF) is a crucial component of the 2010-2014 actions plan, ongoing in France to reduce the annual incidence of stroke. The stroke risk is stratified well with the CHA(2)DS(2)-VASc score. With the current guidelines, most patients with AF should be on oral anticoagulant regimen, a treatment recognized as effective but whose bleeding risks limit its use. In clinical practice, warfarin is often not prescribed in patients with high risk of stroke. Thus, the exploration of new ways in preventing thromboembolic events in patients with AF is needed. Beside new more convenient anticoagulant agents, the exclusion of the left atrial appendage recognized as main source of thrombi, may be an alternative in patients with both high risk of thrombotic and haemorrhagic events. Surgical experience showed that the results depend on the quality of the exclusion. For over the past 10 years, several percutaneous exclusion systems of the left atrial appendage have been developed. A randomized study (PROTECT AF) demonstrated the non-inferiority of the percutaneous exclusion in comparison with the warfarin. However, the place of this interventional therapy remains to be clarified, particularly the definition of the target population. This often multidisciplinary approach will have to be accompanied by a reduction of periprocedural complications, increase in rate of complete occlusion, and enough long clinical follow-up to assess the efficiency of this strategy.

An unusual cause of pacemaker-induced severe tricuspid regurgitation.

Pacemaker (PM) induced tricuspid regurgitation (TR) is a common echocardiographic finding. Although mild or moderate TR is frequently observed, severe TR is rare. We report the exceptional observation of a severe TR due to leaflet malcoaptation occurring late after PM implantation and in the following weeks after an aortic valve replacement. Our hypothesis is that the aortic valve surgery has been responsible for conformational changes between cardiac cavities, tricuspid valve and PM leads resulting in a severe TR.

[Treatment of intrastent restenosis by drug eluting stents: experience from one cardiology centre]. / Traitement des resténoses intrastent par un stent actif: experience monocentrique.

Many interventional treatments have been proposed for intrastent stenosis, in particular by drug-eluting stents, with encouraging results. The aim of this study was to assess the clinical outcome of patients with restenosis of an ordinary uncovered stent treated by a drug eluting stent in a prospective series. The register included 43 patients (50 intrastent restenoses) treated by a drug eluting stent (Cypher or Taxus). The restenosis lesion was focal in 32% of cases with an average length of 14.8 +/- 8 mm and diameter inferior to 2.5 mm in 48% of cases. A Cypher stent was implanted in 44% of cases and a Taxus stent in 56% of cases. After an average follow-up of 6.7 +/- 1.3 months, the major adverse cardiac event rate was 9.3%. It included one transmural infarct in a patient, due to stent thrombosis, and symptomatic restenoses in 3 patients (clinical restenosis rate: 7%). An angiographic control was performed in 15 patients (35%) identifying focal restenosis at the exit of the stent in the 3 symptomatic patients. As in previously reported studies, these results show that with well conducted platelet antiaggregant therapy, the treatment of intrastent restenosis with a drug eluting stent is effective with a low rate of adverse cardiovascular events which compares favourably with previously proposed techniques of management.

[Intracardiac echography]. / Echographie intracardiaque.

The role of echocardiography during non-coronary interventions is of increasing importance. They include percutaneous closure of atrial septal defects (ASD) or patent foramen ovale (PFO), percutaneous balloon mitral valvuloplasty (PMV), septal alcoholization, or interventional procedures managing arrhythmia. In all cases, echographic monitoring enables to guide the procedures, optimize and assess their results and avoid complications. This role could even increase with the development of other interventional techniques such as left auricle appendage exclusion or the percutaneous treatment of valvular diseases. This article reviews this new approach and its value in interventional cardiology.

[A pitfall of transseptal catheterisation for percutaneous mitral commissurotomy: interruption of the inferior vena cava with azygos continuation]. / Piège du cathétérisme transseptal pour commissurotomie mitrale percutanée: l'interruption de la veine cave inférieure avec continuation azygos. A propos d'un cas et revue de la littérature.

Transseptal catheterisation is a widely used technique in interventional cardiology. The authors report the case of a 37 year old woman admitted for percutaneous mitral commissurotomy of a symptomatic rheumatic mitral stenosis in whom transseptal catheterisation was impossible because of a rare congenital anomaly: interruption of the inferior vena cava with azygos vein continuation.

[Echocardiography in the catheterization unit]. / L'échocardiographie en salle de cathétérisme.

Non-coronary interventional cardiology has for about ten years been undergoing significant development, with the arrival of new percutaneous procedures in various domains. Some of them have already been well validated, notably percutaneous mitral comissurotomy, percutaneous closure of inter-atrial (IA) communications and patent foramen ovale, trans-septal catheterisation, and alcohol septal ablation of hypertrophic obstructive cardiomyopathy. Other interventional techniques are still in the validation phase, such as the techniques for percutaneous occlusion of the left atrium, percutaneous implantation of valvular prostheses, or the new approaches to percutaneous treatment of mitral valvulopathy. The rapid development of these techniques has benefited widely from the use of echocardiography in the catheter suite, providing a very precise clarification of the anatomy and continuous guidance during procedures. This echocardiographic guidance provides optimal results for the interventional procedure and reduces the incidence of complications.

[Feasibility of percutaneous exclusion of the left atrial appendage: results of 11 cases]. / Faisabilité de l'exclusion percutanée de l'auricule gauche. A propos de 11 cas.

Atrial fibrillation is associated with a risk of cerebral embolism, the only proven effective prevention of which is anticoagulant therapy. There is no known alternative in cases with contra-indications to this treatment. Percutaneous exclusion of the left atrial appendage by the implantation of a prosthesis (PLAATO System, ev3 Inc., Plymouth, Minnesota) is a new approach to the prevention of these complications. The authors report the results observed in a series of 11 consecutive patients (7 men, mean age 72 +/- 9 years) in whom this procedure was proposed. All patients had atrial fibrillation for over 3 months, were at high risk and had contra-indications to oral anticoagulants. The implantation of the prosthesis was performed after treatment with aspirin and clopidogrel, under general anaesthesia radioscopy and transoesophageal echocardiographic guidance with success in 9 cases (1 implantation refused in the catheter laboratory and 1 failure). The only complication observed was transient ST elevation treated by emergency angioplasty. The echographic and angiographic criteria of success of left atrial appendage exclusion were fulfilled in all implanted patients. The hospital course was uncomplicated. One recurrence of stroke was observed at the second month: transoesophageal echocardiography confirmed the absence of thrombosis, of migration of the prosthesis and its impermeability in all the patients. After 7 +/- 5 months' follow-up, no other adverse event was observed. This new procedure is technically feasible. Despite encouraging results, its long-term efficacy in the prevention of thromboembolic complications of atrial fibrillation remains to be demonstrated.

[Angioplasty of saphenous vein grafts in the acute phase of myocardial infarction. Short and mid-term results]. / Angioplastie des greffons saphènes à la phase aiguë de l'infarctus du myocarde. Résultats à court et moyen termes.

The impact of the progress of interventional cardiology on the improved prognosis of myocardial infarction due to occlusion of a saphenous vein bypass graft is not well known. The aim of this study was to report the modalities and results at short and medium term of revascularisation by angioplasty of venous grafts in the acute phase of myocardial infarction. Out of a total of 870 consecutive patients treated by angioplasty in the first 6 hours of myocardial infarction with persistent ST elevation between 1990 and 2002, 16 (2%) had acute occlusion of a saphenous vein graft. Twelve of the 16 patients had previous myocardial infarction; perfusion was obtained in 7 patients. The attempt failed in 9 patients because of "no-reflow" (n=5), the extensive nature of the thrombosis (n=2) and technical failure (n=2). Three patients died in hospital, all after failed angioplasty. At 6 months, of the 13 survivors of the hospital period, 2 had been readmitted for a revascularisation procedure. At 2 years, 3 patients had died, 2 were readmitted for recurrent myocardial infarction and 8 patients remained free of a major cardiovascular event. Reperfusion by angioplasty of an occluded saphenous vein graft in the acute phase of myocardial infarction remains imperfect and the prognosis at short and medium term is poor.

[Myocardial infarction and disseminated lupus erythematosus]. / Infarctus du myocarde et lupus érythémateux disséminé. A propos de 7 observations.

Myocardial infarction is an underestimated complication of disseminated lupus erythematosus (DLE). Its features, treatment and prognosis are poorly understood. From June 1988 to December 2002, out of 1572 consecutive patients admitted during the first hours of acute myocardial infarction with ST elevation, 7 (5 women, aged 38 +/- 7 years) had DLE. The commonest risk factor was smoking (N = 4). There was a higher incidence of anterior infarction (N = 5). The infarct occurred 7 +/- 5 years after diagnosis of DLE. There were other complications of DLE in all cases. Three patients had antiphospholipid syndromes. The culprit artery was usually the left anterior descending (N = 5). The lesions included stenosing atheroma (N = 5) and extensive thrombosis (N = 5). The coronary disease was usually limited to a single vessel (N = 5). Revascularisation procedures include pre-hospital thrombolysis (N = 3) followed by immediate angioplasty (N = 2) or primary angioplasty (N = 4). TIMI grade 3 flow was obtained in all cases, 278 +/- 162 min after the onset of symptoms. The clinical course was characterised by acute reocclusion in 3 patients, recurrent in 2 patients with an antiphospholipid syndrome, and death in 1 case. Acute myocardial infarction occurs in already complicated cases of DLE, in young patients, associating atherosclerosis and extensive thrombosis. The risk of early reocclusion after reperfusion is high, especially in cases with the antiphospholipid syndrome.

[Changes in reperfusion strategies in the acute phase of myocardial infarction from 1988 to 2001]. / Evolution des stratégies de reperfusion en phase aiguë d'infarctus du myocarde entre 1988 et 2001.

The objective of this study was to evaluate the evolution of therapeutic strategies in the course of myocardial infarction. Two successive periods were studied: 1988/96 (700 patients) and 1996/2001 (700 patients). The following parameters were compared: patient characteristics, management methods, and results on the hospital morbidity and mortality. The patient characteristics were little changed, in terms of age and sex, with a drop in the frequency of anterior infarcts during the second period (46 vs 51%, p = 0.0001). The average delay to admission remained stable over both periods, 186 vs 189 min. During the second period, primary angioplasty was favoured (66 versus 44%, p = 0.0001), associated with a wider use of stents (47 against 4%, p = 0.0001) and anti GP IIb/IIIa (24 against 0.5%, p = 0.0001). In the acute phase, TIMI3 reperfusion was obtained in 81% of cases (88/96 period) against 88% during the second period (p = 0.02). The hospital mortality was reduced by 1.2% (8.9 against 7.7%, NS). Without cardiogenic shock, the mortality was comparable between the two groups (5%), whereas it diminished in the small group of patients (5%) in cardiogenic shock, from 76 to 66% (NS). Haemorrhagic complications were reduced, but the rate of symptomatic reocclusion remained stable (2.5%). With multivariate analysis, the independent predictive mortality factors were identical in the two groups: age and cardiogenic shock on admission. Currently, TIMI3 reperfusion is possible in close to 90% of patients in the acute phase of infarction. Our efforts should focus on earlier management, especially for older patients, too often excluded without reason, and for those in cardiogenic shock, which constitutes a therapeutic quest for the future. The theory of angioplasty facilitated by anti GP IIb/IIIa and/or prehospital thrombolysis must be evaluated scientifically with the goal of early and efficient reperfusion for the greatest number of patients.

[Femoral artery hemostasis after coronary angioplasty with moderate dose of heparin]. / Hémostase artérielle fémorale après angioplastie coronaire avec dose modérée d'héparine.

UNLABELLED: Early retraction of the arterial introducer facilitates patient management after coronary angioplasty. Closure systems permit rapid haemostasis, but are costly and do not avoid all serious vascular complications. Moderate doses of heparin, used often at the moment, could allow immediate retraction of the introducer with rapid and safe haemostasis by manual compression. METHODS: We evaluated prospectively in 350 consecutive patients the safety and efficacy of immediate retraction of the 6F introducer after coronary angioplasty performed by the femoral route with a moderate dose of heparin (70 IU. kg-1). Only procedures during acute infarction or using abciximab electively were excluded. RESULTS: Retraction of the introducer was immediate in 340 patients (97%). The dose of heparin administered was 5300 +/- 800 IU and the compression time was 11 +/- 4 minutes. The activated clotting time at retraction of the introducer was 254 +/- 46 s. Six (1.7%) serious vascular complications (4 significant haematomas and 2 false aneurysms) were noted during the hospital phase. A single patient (0.6%) was transfused and no vascular surgical procedure was necessary. The average duration of stay after angioplasty was 2.6 +/- 2.2 days and 73% of patients left before 48 hours. CONCLUSION: Immediate retraction of the arterial introducer is possible with simple manual compression, after coronary angioplasty performed with a moderate dose of heparin.

[Myocardial revascularization at the acute phase of myocardial infarction in the octogenarian]. / Revascularisation myocardique à la phase aiguë de l'infarctus du myocarde chez les octogénaires.

Elderly patients are at high risk of complications in acute myocardial infarction (AMI). In this population, myocardial reperfusion at the acute phase improves the prognostic. The mortality rate is above 50% in the absence of reperfusion strategy, and decreases at less than 20% in case of such treatment. The thrombolytic use is limited in those patients, coronary angioplasty is taking an important place in this reperfusion therapy, but is not well evaluated in patients older than 80 years. Prospective registry of patients older than 80 years admitted in Hôpital Bichat for acute myocardial infarction within the first 6 hours (n = 92), between 1990 january to 1999 december. Eight patients (10%) received a thrombolytic therapy. Coronary angiogram was achieved in eighty patients (87%). In 58 (63%) patients a coronary angioplasty was performed. The success rate of the coronary angioplasty was 86%. In-hospital mortality rate was 26% (death in 24 patients), 20% in the absence of cardiogenic shock and 62% when this complication was noted. Two patients (2%) were treated by emergent coronary artery bypass surgery. The results comparison between the periods of 1990 to 95 and 1955 to 99 showed, a real trend of decrease mortality rate (28 to 13% in the absence of cardiogenic shock, p = 0.10), an increase of the proportion of patients treated by angioplasty. These results are more and more encouraging. Coronary reperfusion by primary angioplasty in possible in patients older than 80 years with a low rate of complications. Technical progress such as stents and GpIIb/IIIa inhibitors must be evaluated in this population.

[Revision of the "Smoker's Paradox": smoking is not a good prognostic factor immediately after myocardial infarction]. / Révision du "paradoxe du fumeur": le tabac n'est pas un facteur de bon pronostic au décours immédiat de l'infarctus du myocarde.

In order to determine the reasons for the low mortality after myocardial infarction in smokers compared with non-smokers (the smoker's paradox), the authors analysed the initial clinical data, the therapeutic interventions and hospital mortality in 790 consecutive patients (555 smokers, 235 non-smokers) admitted to hospital within 6 hours of the first symptoms of acute myocardial infarction and treated by intravenous thrombolytic agents and/or coronary angioplasty. Multivariate analysis with linear regression was used to identify the predictive factors of hospital mortality. The main differences between smokers and non-smokers were age (56 vs 67 years, p < 0.0001), gender (male, 90 vs 60%, p < 0.01), cardiogenic shock on admission (3 vs 8%, p < 0.01). TIMI 3 flow was obtained in the culprit artery in 84% of smokers and 79% of non-smokers (NS). Hospital mortality was 5% in the smoking population and 16% in non-smokers (p < 0.0001). In multivariate analysis, the variables of cardiogenic shock, age, gender and hypertension provided most of the prognostic information and tobacco consumption did not appear to have a protective effect. In patients admitted to hospital with acute myocardial infarction, identical incidences of early reperfusion are obtained in smokers and in non-smokers. However, mortality is higher in the non-smoking group due to more severe clinical characteristics on admission. Tobacco consumption is not a protective factor in the immediate period after acute myocardial infarction.

ST-segment elevation in precordial leads: anterior or right ventricular myocardial infarction?

Isolated acute right ventricular (RV) infarction is rare, and ECG diagnosis may be difficult. We report two cases of acute myocardial infarction with ST-segment elevation in anterior precordial leads caused by such an RV involvement. Potential mechanisms for the relationship are given.

[Unstable angina in the elderly]. / L'angor instable du sujet âgé.

Unstable angina and acute coronary syndromes without persistent ST-segment elevation are frequent and their prognosis is poor in the elderly. Indeed, age is the most powerful predictor of in-hospital mortality in this setting. The clinical benefit of interventional strategies, as demonstrated by FRISC II and TACTICS TIMI 18 studies, seems to be most important in this age subset. PURSUIT trial demonstrates that the efficacy of eptifibatide, a IIb/IIIa platelet receptor inhibitor, increases in elderly patients who simultaneously undergo revascularization interventions. Individual application of such treatment strategies may be difficult. Potential triggering factors of unstable angina and comorbidities have to be taken into account, and the overall management should be highly individualized in elderly patients. The aim remains to achieve appropriate myocardial revascularization, as often as possible by focusing coronary angioplasty on the culprit vessel. Coronary surgery generally should be reserved for coronary lesions which are not suitable for percutaneous revascularization. Clinical improvement is maximal in patients with severe initial presentation.

Reperfusion syndrome: relationship of coronary blood flow reserve to left ventricular function and infarct size.

OBJECTIVES: We tested the hypothesis that the reperfusion syndrome (RS), defined as an additional elevation of the ST segment upon reperfusion, may be a marker of microcirculatory reperfusion injury during acute myocardial infarction (AMI). BACKGROUND: The pathophysiology of the RS is unknown, and its prognostic implications are controversial. METHODS: Twenty-one patients with an anterior AMI treated < or =12 h after onset by primary coronary angioplasty (PTCA) were studied. Coronary velocity reserve (CVR), an index of microcirculatory function, was measured using a Doppler guidewire. Left ventricular (LV) ejection fraction, infarct size (percent defect) and LV end-systolic volume index (LVESVi) were evaluated by radionuclide ventriculography, 201T1 single-photon emission computed tomography and contrast ventriculography, respectively. RESULTS: Baseline ST elevation and pain-to-TIMI 3 time were similar in patients with and without RS. Patients with RS (10/21) had a lower post-PTCA CVR than patients without RS (median [95% confidence interval]: 1.2 [1-1.3] vs. 1.6 [1.5-1.7], p < 0.005). Even though predischarge CVR was similar in the two groups, infarct size at six weeks (26 [21 to 37] vs. 14 [10-17]% 201T1 defect, p = 0.001) and predischarge LVESVi (45% [40 to 52] vs. 30% [29 to 38] mL/m2, p = 0.001) were larger, and LV ejection fraction at six weeks (40% [37 to 46] vs. 55% [50 to 60], p = 0.004) was lower in patients with RS than in patients without RS. CONCLUSIONS: Patients with RS during primary PTCA for an anterior AMI have a transiently lower CVR than patients without RS, but sustained LV dysfunction and larger infarct size, suggesting that RS is a marker of microcirculatory reperfusion injury.

[Angioplasty in acute myocardial infarction]. / Angioplastie en phase aiguë d'infarctus du myocarde.

Primary PTCA has become a common method for achieving recanalization of the infarct vessel in acute myocardial infarction. The excellent results of large randomised trials comparing it to intravenous thrombolysis however have not been consistently duplicated in large registries reflecting clinical practice in the real world. Therefore, there is a need for critical and careful assessment of angioplasty performance, specifically criteria related to operator and center volume as well as the ability to implement angioplasty rapidly after diagnosis. It has been specifically established that intra-hospital delays in the time to balloon angioplasty are associated with clear increases in mortality rates. It is therefore necessary to implement quality insurance programs to continuously monitor centers using primary PTCA as their reperfusion method of choice. Recent studies have demonstrated that stents and adjuvant pharmacological therapies, specially GpIIb/IIIa antagonists are associated with improved results. Despite the high patency rates achieved with angioplasty, a consistent series of experimental and clinical observations indicate that the quality of myocardial reperfusion downstream of the epicardial coronary vessel is a critical determinant of prognosis. Specifically, no-reflow, which can be ascertained using perfusion imaging techniques, but also indirectly, using the electrocardiogram, is an ominous element. The challenge of the coming years will be to test effective preventive or curative treatments for no-reflow.