Colchicine for postoperative pericardial effusion: a multicentre, double-blind, randomised controlled trial.

OBJECTIVES: Pericardial effusion is common after cardiac surgery. Growing evidence suggests that colchicine may be useful for acute pericarditis, but its efficacy in reducing pericardial effusion volume postoperatively has not been assessed. METHODS: This randomised, double-blind, placebo-controlled study conducted in 10 centres in France included 197 patients at high risk of tamponade (ie, with moderate to large-sized persistent effusion (echocardiography grades 2, 3 or 4 on a scale of 0-4)) at 7-30 days after cardiac surgery. Patients were randomly assigned to receive colchicine, 1 mg daily (n=98), or a matching placebo (n=99). The main end point was change in pericardial effusion grade after 14-day treatment. Secondary end points included frequency of late cardiac tamponade. RESULTS: The placebo and the colchicine groups showed a similar mean baseline pericardial effusion grade (2.9±0.8 vs 3.0±0.8) and similar mean decrease from baseline after treatment (-1.1±1.3 vs -1.3±1.3 grades). The mean difference in grade decrease between groups was -0.19 (95% CI -0.55 to 0.16, p=0.23). In total, 13 cases of cardiac tamponade occurred during the 14-day treatment (7 and 6 in the placebo and colchicine groups, respectively; p=0.80). At 6-month follow-up, all patients were alive and had undergone a total of 22 (11%) drainages: 14 in the placebo group and 8 in the colchicine group (p=0.20). CONCLUSIONS: In patients with pericardial effusion after cardiac surgery, colchicine administration does not reduce the effusion volume or prevent late cardiac tamponade. CLINICAL TRIAL REG NO: NCT01266694.

[BNP and echocardiography can predict the occurrence of acute cardiac decompensation during titration of bisoprolol in chronic systolic heart failure]. / Le BNP et l'échocardiographie prédisent la survenue de décompensation cardiaque aigue au cours de la titration du bisoprolol dans l'insuffisance cardiaque chronique systolique.

OBJECTIVES: Based on the fact that NYHA class, plasma BNP level, and echocardiographic indices of left ventricular filling pressures are prognostic factors in chronic systolic heart failure, we evaluated their predictive value for acute decompensation following initiation and titration of bisoprolol in this illness. METHODS AND RESULTS: Bisoprolol was initiated and/or increased according to the ESC/ACC/AHA recommendations in 50 patients with stable chronic systolic heart failure (age: 60+/-2 years, males: 88%) in NYHA class? 2 with a left ventricular ejection fraction (LVEF)<40% and a plasma creatinine<250 micromol/l. The clinical parameters, plasma BNP levels and echocardiographic indices were measured blind on the same day, on admission and then once a week for three weeks. On admission, the NYHA was 2.9+/-0.1, mean plasma creatinine 99+/-3 micromol/l, plasma BNP 503+/-57 pg/ml, LVEF 29+/-1%, E/A ratio 1.9+/-0.2, E/Ea ratio 8.8+/-0.3, E wave deceleration time 155+/-9 ms, systolic pulmonary artery pressure 40+/-2 mmHg and the diameter of the inferior vena cava was 16+/-1 mm. Over the course of follow up, an episode of acute decompensation occurred in 16% of the patients (8/50). Using univariate analysis, age and initial (admission) values for NYHA class, blood pressure, plasma BNP level, E/A ratio, E wave deceleration time, E/Ea ratio and the systolic pulmonary arterial pressure allowed prediction of the occurrence of acute decompensation following initiation and titration of bisoprolol. The use of the initial value of NYHA class alone allowed prediction of the occurrence of acute decompensation in just 56% of the patients, and the absence of an occurrence of acute decompensation in 93% of them. Normal results for the echocardiographic indices (systolic pulmonary arterial pressure<40 mmHg or E/A ratio<1.4 or E wave deceleration time>145 ms) as recorded on admission were associated with the absence of an occurrence of acute decompensation is 100% of cases. The combined use of NYHA class>3 and either a BNP>398 pg/ml or echocardiographic indices in favour of an elevation in left ventricular filling pressures (systolic pulmonary arterial pressure>40 mmHg, E/A ratio>1.4 or E wave deceleration time<145 ms) allowed prediction of the occurrence of acute heart failure in 100% of cases CONCLUSION: The combined use of NYHA class, BNP level and echocardiographic indices for measuring left ventricular filling pressures is more pertinent than the isolated use of clinical parameters for predicting tolerance to bisoprolol in chronic heart failure with a LVEF<40%.

[Benefits and risks of exercise training in coronary artery disease patients]. / Reconditionnement a l'effort des patients coronariens stables: bénéfices et risques.

Cardiac rehabilitation programs improve vital and functional prognosis in patients suffering from stable angina or after myocardial infarction. The studies focusing on the balance risks/benefits of cardiac rehabilitation are relatively old; therefore, the patients included in these studies are different from today's patients mainly because of different management of the acute phases and of modifications of the medical treatment in stable angina (ABCDE protocols). The authors present the preliminary results of a French multicentric register focusing on complications during cardiac rehabilitation conducted on behalf of the French Society of Cardiology. Complications are rare: one resuscitated cardiac arrest/1.3 millions exercise training hours and no death was reported. It must be highlighted that, in some patients, the antianginal medical treatment must be reinforced in order to allow exercise training without myocardial ischaemia.

[Exercise training in cardiac patients: usefulness of the cardiopulmonary exercise test]. / Réadaptation des patients porteurs d'une cardiopathie: intérêt de la mesure des echanges gazeux a l'effort (VO2).

Exercise training is currently including in the treatment of coronary arterial disease patients, in patients with left ventricular dysfunction as well as in patients who underwent cardiac transplantation or cardiac surgery. However methods of prescribing exercise-training programs are difficult to determine and must be adapted for each patient Exercise test with gas analysis through the determination of anaerobic threshold may help to understand the physiopathological mechanism related to exercise limitation in these patients. Exercise test may help to precise exercise intensity during cardiac rehabilitation and may assess the benefits on exercise tolerance.

[Best of functional evaluation and cardiac rehabilitation in 2005]. / L'essentiel de l'anné 2005 en évaluation fonctionnelle et réadaptation des cardiaques.

The latest in cardiac rehabilitation has been impacted by: The East German PET publication which showed fewer ischaemic events and progression of the atheromatous disease in symptomatic and stable coronary patients who carry out regular physical exercise in comparison with patients who underwent angioplasty with stenting. Two meta-analyses updated the data showing the benefits of physical training: a 20% reduction in global mortality in coronary disease and 35% in cardiac failure. Two French studies reporting reassuring data for our daily practice: the serious complications of cardiac rehabilitation are exceptionally rare: the register for 2003 with data from 65 French centres, over 25,000 patients and 743,000 patient/exercise hours. Physical training two weeks after mitral valvuloplasty is not harmful for the valve repair and is beneficial in terms of exercise capacity for the patient. Epidemiological studies showing that women and elderly patients are, unfortunately, often excluded from programmes of cardiac rehabilitation.

[Heart failure and cachexia]. / Insuffisance cardiaque et cachexie.

Cachexia is related to a malnutrition state related to hypercatabolism. Initially described in cancer, it is also related to several chronic diseases including heart failure. Defined by an unintentional weight loss exceeding 7.5% of body mass during more than 6 months, it is presented by the association of nutritional deficiencies, digestive and/or urinary losses as well as metabolic abnormalities causing fat and lean mass loss and is associated to a poor prognosis. The pathophysiology of cachexia and heart failure presented some similarities associating especially neuro-hormonal activation, a cortisol/DHEA ratio imbalance, as well as pro-inflammatory cytokines activation. Currently the treatment of cachexia is mainly preventive, based on ACE-inhibitors and beta-blockers therapy and physical reconditioning. The benefits of hormonal and nutritional substitutes remains to be evidenced.

[Stress test and aortic stenosis]. / Epreuve d'effort et rétrécissement aortique.

In patients with severe asymptomatic aortic stenosis (AS), the decision to operate is difficult. In effect, the operative mortality is not negligible (about 5% in subjects age over 75 years) while spontaneous mortality from sudden death is low (about 0.4% per year). The aim of the stress test is to detect patients who are falsely asymptomatic (due to subconscious self limitation of daily physical activity) for whom aortic valvular replacement should be proposed because of the risk of sudden death. On the other hand, if the stress test is negative (normal blood pressure elevation on effort, the absence of either any symptoms, ST segment depression of more than 2 mm, or severe ventricular rhythm disorders linked to effort), surgical intervention could (and probably should) be postponed. This article presents the studies which have allowed integration of the stress test as an aid to the decision of when to operate in patients with asymptomatic severe AS with good left ventricular function into the European and North American recommendations.

[Does symptomatic stable coronary artery disease still exist in France?]. / Y a t-il encore des coronariens stables symptomatiques en France?

In spite of the continuous growth of myocardial revascularisation techniques, stable angina remains an important clinical burden. In France, and based upon estimates from the European Society of Cardiology and from diverse epidemiological sources, 2 million people are likely to have stable angina. Though primary and secondary prevention are improving, this figure is likely to increase further, in particular because of the constant aging of the population (20% of patients more than 80 years of age have angina), but also because of the epidemics proportions that diabetes mellitus and obesity take.

[Treatment of left intraventricular thrombosis with low molecular weight heparin]. / Traitement des thrombus intraventriculaires gauches par héparine de bas poids moléculaire.

UNLABELLED: Following the discovery of a left intra ventricular thrombus (LIVT), the classical approach consists of treatment with non-fractionated heparin (NFH) followed by oral anticoagulants. The use of NFH for this indication has only been evaluated in one open, non randomised study of 23 patients with no control group. Low molecular weight heparins (LMWH) have not been the object of any study although they are routinely used by certain teams. The objective of this study was to evaluate the feasibility of the use of LMWH in the treatment of left intra ventricular thrombus. This was an open, non randomised prospective study. All patients having a newly diagnosed LIVT between September 2000 and September 2002 were treated with enoxaparine (100 IU/kg twice daily) for an average duration of 13 days; replacement with fluindione was started on the fifth day. The progression of the LIVT was followed using twice weekly transthoracic echocardiography for 3 weeks. RESULTS: 19 LIVT were discovered in 2 years (13 complicating an anterior infarct and 6 with a dilated cardiomyopathy). The average area was between 2.64 +/- 0.41 cm2 and 0.43 +/- 0.21 cm2 (p < 0.0001). Thirteen out of 19 thrombi disappeared with treatment (68.5%). There was no thrombocytopenia or haemorrhage. One transient ischaemic attack was noted. CONCLUSION: This preliminary work shows that LMWH are well tolerated and effective to make a thrombus disappear or to reduce its size.

[Occlusion of a coronary endoprosthesis after a negative stress test]. / Occlusion d'endoprothèse coronaire au décours d'une épreuve d'effort négative.

The frequency of early occlusion of coronary stents has fallen with the use of a powerful association of platelet antiaggregants (ticlopidine and aspirin) in the first month. The authors report the case of coronary stent occlusion after a negative exercise stress test, 11 days after implantation in a centre of cardiac rehabilitation. According to the literature, this type of complication would appear to be rare and related to the small size of the stent and the conditions of implantation (acute phase). It would be useful to compile a registry of complications related to coronary angioplasty during rehabilitation to determine their prevalence and, if necessary, change the protocols of physical training of these patients.

[Iatrogenic acute renal failure caused by overdosage of flecainide acetate]. / Insuffisance rénale aiguë iatrogène à l'origine d'un surdosage en acétate de flécaïnide.

BACKGROUND: Rapid degradation of renal function may occur in patients given drug regimens combining a converting enzyme inhibitor, a diuretic and a nonsteroidal anti-inflammatory drug. CASE REPORT: A patient given flecainide and an enalapril /hydrochlorothiazide combination in a well-tolerated long-term regimen suddenly developed acute renal failure when a nonsteroidal anti-inflammatory drug was introduced leading to an overdose of the anti-arrhythmic drug. DISCUSSION: A poor understanding of the elimination routes for anti-arrhythmic drugs and the risks involved when combined with nonsteroidal anti-inflammatory drugs modifying glomerular hemodynamics can lead to dangerous prescriptions and life-threatening situations in patients on multiple drug regimens.

Effects of prostacyclin on the pulmonary vascular tone and cardiac contractility of patients with pulmonary hypertension secondary to end-stage heart failure.

Long-term administration of prostacyclin (PGI2) improves the hemodynamic state, symptoms, and survival in patients with primary pulmonary hypertension, but it increases mortality in patients with heart failure despite obvious hemodynamic benefits when it is given acutely. We evaluated the mechanisms of action of PGI2 in patients with heart failure and secondary pulmonary hypertension. Nineteen patients with end-stage heart failure and pulmonary hypertension, all candidates for heart transplantation, underwent right- and left sided cardiac catheterization with micromanometer-tipped catheters and were tested for PGI2 at incremental doses. PGI2 infusion significantly improved pulmonary hemodynamics with a 47% reduction in pulmonary vascular resistance (p=0.0003) and a doubling of pulmonary artery compliance (p <0.0001), reflecting improvement in pulmonary vascular tone. The dose of PGI2 necessary to reach this hemodynamic effect correlated significantly to the baseline severity of pulmonary artery compliance (r=0.54, p=0.01). Furthermore, PGI2 produced a significant positive inotropic effect (contractile element maximum velocity increased from 1.10+/-0.09 to 1.33+/-0.13 circ/s, p <0.009). The hemodynamic effects of PGI2 infusion were independent of the plasma and urinary levels of endogen prostaglandins. Thus, PGI2 at therapeutic doses exerts a positive inotropic effect in patients with heart failure, which may explain the increased mortality rate observed with the long-term use of PGI2 in this type of patient. The spectacular acute benefits on right ventricular afterload, however, may be useful in unstable patients with heart failure and secondary pulmonary hypertension or in transplanted patients with acute right ventricular failure of the donor heart.

[Right retroauricular hematoma of late manifestation. Contribution of cardiac imaging]. / Hématome rétro-auriculaire droit de révélation tardive. Apport de l'imagerie cardiaque.

Right intrapericardial retroatrial haematomas are usually discovered in an acute context of tamponade, following cardiac surgery. The original feature of this case was the asymptomatic nature of a right retroatrial haematoma, after surgical closure of an ostium secundum atrial septal defect, with a free interval of more than 20 years between the surgical procedure and the first relatively minor symptoms, consisting of supraventricular arrhythmias. It can be difficult to determine the intra- or extra-atrial topography of a right-sided mass by transthoracic echocardiography. On the other hand, transoesophageal echocardiography and ultrafast CT can provide a precise topographic diagnosis and appear to be complementary to assess the nature of pericardial masses.

[Shoshin beriberi. A rapidly curable hemodynamic disaster]. / Le shoshin béribéri. Une catastrophe hémodynamique rapidement curable.

Shoshin beriberi, a uncommon cause of hemodynamic instability (or cardiac shock) and acute heart failure may go undiagnosed in Western countries where prevalence is low. This severe heart condition due to thiamine deficiency is rapidly fatal unless specific therapy is given. The most frequent cause in France is chronic alcoholism. There are no specific signs on the electrocardiogram in a patient with acute heart failure due to shoshin beriberi. The chest x-ray simply shows signs of pulmonary edema and heart enlargement. The echocardiography may be normal although hypokinesia and/or dilatation of the left ventricle (due to thiamine deficiency) are sometimes noted. Diagnosis is suspected in patients with chronic alcoholism who develop acute global heart failure with lactic acidosis. Right catheterism confirms low cardiac output resulting from arteriovenous shunts. Blood tests (red cell transacetolase activity, measurement of effect of pyrophosphatase, plasma and intraerythrocyte thiamine) confirm the diagnosis a posteriori. Clinical improvement is rapid after intravenous infusion of vitamin B1. The danger of fulminant beriberi heart failure in undernourished alcoholic patients emphasizes the need for regular prescription of vitamin B1.