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.

[Ambulatory venous thromboembolitic disease. Clinical, etiological and evolutive data]. / Maladie veineuse thrombo-embolique ambulatoire. Données cliniques, étiologiques et évolutives.

OBJECTIVES: Venous stasis in bedridden patients is recognized as one of the risk factors for venous thromboembolism but the phenomena is known to occur in ambulatory subjects and another cause must be involved. We investigated a series of consecutive ambulatory patients with venous thromboembolism in order to distinguish the particular clinical manifestations and possible aetiologies. METHODS: We compared a retrospective series of 120 consecutive patients with deep vein thromboembolism of the lower limbs and 127 patients with the same disease who had been bedridden at onset. In addition to the physical examination, the aetiological work-up included echography (n = 14), abdominal computed tomography (n = 38) and/or haemostasis studies (n = 61). Mean follow up was 23 +/- 13 months (range 1-45 months). RESULTS: Family history of deep venous thromboembolism was found in 17 patients and recurrence was observed in 50 patients. Phlebitis was on the right in 52 cases, on the left in 47 and bilateral in 17. Proximal locations were more frequent (74%) and pulmonary embolism occurred in one-half of the patients (n = 58). A cause was identified in 61 cases (50.8%): cancer (n = 24, 17 known, 7 previously unknown), dyscrasia (n = 17, protein S or C deficiency (5), increased plasminogen activator inhibitor I (8), circulating anticoagulants (3), hypofibrinogen (1), idiopathic varicose veins (n = 7), pregnancy (n = 5), oral contraceptives (n = 4) and other causes (n = 4). No cause was identified in 59 patients. Pulmonary embolism led to death in 4 cases. Seven patients were lost to follow-up and anticoagulation therapy was taken by 79 (72%) then interrupted in the others 3 to 6 months later. Eighteen patients died, 14 due to the underlying disease, 2 from new cancers and 12 after recurrent thromboembolism. CONCLUSION: Ambulatory venous embolism is as frequent as embolism in bedridden patients and the cause can be observed in 50% of the cases.

[Comparison of continuous and intermittent treatment with glyceryl trinitrate by the transdermal route in stable effort angina]. / Comparaison du traitement continu et discontinu de trinitrine par voie transdermique dans l'angor d'effort stable.

The anti-angina efficacy of the continuous (C) transdermal application of nitroglycerin may lessen or disappear over the course of time. Pharmacological tolerance, which is probably responsible, might be prevented by intermittent (I) application. However few studies have compared the C and I methods. The effects of transdermal patches containing 10 mg, applied for 24 hours/day and for 15 hours/day for one week were evaluated in twelve patients. Exercise tests were performed before and 4 hours after the initial application and after one week of each type of treatment prescribed in random order with a 7 day wash-out between each treatment phase. Plasma nitroglycerin concentrations were measured at the same time. Total work and ischemia and angina thresholds after 4 hours application all increased significantly in comparison with baseline values. All these values persisted after one week of I treatment. With C treatment they decreased though remained significantly above baseline values with the exception of angina thresholds. I treatment appeared significantly better than C treatment regarding ischemia threshold (3,974.7 kpm v. 3,037.5-p < 0.01). Plasma nitroglycerin levels were the same during each treatment phase. These results suggest that the anti-ischemic efficacy of transdermal patches persists after one week of treatment, though with superiority of intermittent treatment. Continuous treatment tends to induce pharmacodynamic tolerance since there was no difference in plasma nitroglycerin levels.

[Results of cardiac surgery in patients over 70 years of age. Apropos of a retrospective study of 170 patients]. / Résultats de la chirurgie cardiaque chez les patients âgés de plus de 70 ans. A propos d'une étude rétrospective concernant 170 patients.

The ever increasing age of the general population and the frequency of coronary and aortic lesions in patients aged 70 or older make cardiac surgery in the elderly a topic of current interest. In a retrospective study of 170 cases the overall mortality rate was 14 p. 100 (4.7 p. 100 in 1986). During the past two years (1985 and 1986), the mortality rates in patients with coronary disease who underwent elective surgery were 10 p. 100 and 4 p. 100 respectively. Emergency surgery (left coronary trunk and unstable angina excluded) and associated operations on the heart made the prognosis worse with overall mortality rates of 13 p. 100 and 15 p. 100 respectively (9 p. 100 in 1985, 10 p. 100 in 1986). In aortic valve surgery, hospital mortality rates were 28 p. 100 in 1985 and 6 p. 100 in 1986. Post-operative morbidity was high (52 p. 100 of patients) and consisted mostly of respiratory and neurological complications (14.7 p. 100 and 9.4 p. 100 respectively of all patients). Only 4 p. 100 of the patients developed peri-operative myocardial infarction. Functional results were satisfactory in both coronary disease and heart valve disease patients. The survival rate at 4 years was 74.5 +/- 10 p. 100 globally and 87.3 +/- 9 p. 100 in coronary patients operated upon electively. Thus, the considerable advances in surgical techniques and post-operative intensive care achieved during the last few years have significantly improved the results obtained in this population.(ABSTRACT TRUNCATED AT 250 WORDS)