Is the duration of dual antiplatelet therapy (DAPT) excessive in post-angioplasty in chronic coronary syndrome? Data from the France-PCI registry (2014-2019).

Background: while the duration of dual antiplatelet therapy (DAPT) following coronary angioplasty for chronic coronary syndrome (CCS) recommended by the European Society of Cardiology has decreased over the last decade, little is known about the adherence to those guidelines in clinical practice in France. Aim: To analyze the real duration of DAPT post coronary angioplasty in CCS, as well as the factors affecting this duration. Methods: Between 2014 and 2019, 8.836 percutaneous coronary interventions for CCS from the France-PCI registry were evaluated, with 1 year follow up, after exclusion of patients receiving oral anticoagulants, procedures performed within one year of an acute coronary syndrome, and repeat angioplasty. Results: Post-percutaneous coronary intervention (PCI) DAPT duration was > 12 months for 53.1% of patients treated for CCS; 30.5% had a DAPT between 7 and 12 months, and 16.4% a DAPT ≤ 6 months. Patients with L-DAPT (>12 months) were at higher ischemic risk [25.0% of DAPT score ≥2 vs. 18.8% DAPT score ≥2 in S&I-DAPT group (≤12 months)]. The most commonly used P2Y12 inhibitor was clopidogrel (82.2%). The prescription of ticagrelor increased over the period. Conclusions: post-PCI DAPT duration in CCS was higher than international recommendations in the France PCI registry between 2014 and 2019. More than half of the angioplasty performed for CCS are followed by a DAPT > 12 months. Ischemic risk assessment influences the duration of DAPT. This risk is probably overestimated nowadays, leading to a prolongation of DAPT beyond the recommended durations, thus increasing the bleeding risk.

Feasibility and acceptability of rapid HIV test screening (DEPIVIH) by French family physicians.

BACKGROUND: In France, around 50,000 people were unaware of their HIV positivity at the end of 2008. The latest guidelines recommend routine screening of all adults. Family physicians have been identified as key persons for this new policy. Rapid HIV tests (RHT) have been proposed as an alternative to conventional blood tests. OBJECTIVES: The authors assessed the feasibility and acceptability of RHT test based screening in French community practice. METHOD: We made a prospective interventional study of the BioMerieux VIKIA(®) HIV 1/2 RHT among French family physicians. Data on the RHT was posted in the physician's waiting room. RESULTS: Sixty-two French physicians, mostly family practitioners, included 383 patients with a mean age of 36.2 years, from June to October 2010. Twenty-two percent (83) of these patients had never been tested for HIV. The RHT was proposed and 382 tests were accepted and performed (acceptability rate of 99.7%). Sixty-five percent of the tests were made on the patient's request. The tested population represented 1.5% of consulting patients during the study period (feasibility rate). Patients were quite satisfied but physicians less so. Test steps and capillary blood sampling were the main source of difficulty mentioned. At the end of the study, 59% of physicians were ready to continue using RHT in their daily practice. CONCLUSION: Routine RHT screening in community practice is feasible and well accepted by patients. It was the first screening test for 22% of our patients. Its feasibility was limited by capillary blood sampling technique and time constraints during consultation.

[Bifocal lung cancer: the same histology?]. / Cancer bronchique bifocal: une même histologie?

Whereas synchronous lung cancer is rare, synchronous small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) are exceptional. The authors report the case of a 61-year-old man with synchronous unilateral adenocarcinoma and small cell lung cancer, raising the question as to the need for the histology of all of the lesions in the same lobe or same lung as well as the treatment. The medical history, biology, CT and (18)F-FDG TEP-CT did not support a diagnosis of synchronous lung cancer. The prognosis was poor and only surgery could improve the prognosis. This is a rare case and illustrates the difficulty in the diagnosis of multiple lung cancer and the difficulty in treating synchronous lung cancer with different histologies (SCLC and NSCLC).

[Pulmonary malignant melanoma: primary or metastatic?]. / Mélanome malin pulmonaire: primitif ou métastase ?

Primary pulmonary malignant melanoma is rare (0.01% of pulmonary cancers); only 25 cases are published in the literature. The diagnosis of primary pulmonary malignant melanoma is controversial, the pathogenesis is unknown and a pulmonary metastasis from a mucocutaneous melanoma is the main differential diagnosis. The diagnosis is based on the strict application of the Jensen criteria published in 1967. We report the case of an asymptomatic 82-year-old man presenting with a fortuitously discovered primary pulmonary malignant melanoma according to the Jensen criteria and treated by lobectomy (cT1N0M0). Surgery seems to be the gold standard treatment on account of the poor sensitivity of melanoma to chemotherapy and radiotherapy. Surgical resection and the absence of nodal involvement suggest a good prognosis even though the small number of cases does not produce useful statistical data. This observation raises the question of (18)FDG CT-PET in this situation, particularly of the whole body, by extrapolation from the recommendations in mucocutaneous melanoma. The lack of increased uptake on (18)FDG CT-PET could be a new paraclinical diagnostic criterion to add to the clinical criteria of Jensen. This report is the first, which shows the results of (18)FDG CT-PET (standard and whole-body) under this situation.

Evaluation of the effectiveness of botulinum toxin injections in the lower limb muscles of children with cerebral palsy. Preliminary prospective study of the advantages of ultrasound guidance.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of injecting botulinum toxin A into the lower limbs of children with cerebral palsy, according to age, dose, dilution, injection site and needle placement technique (manual or ultrasound guidance). MATERIALS AND METHODS: Any child with cerebral palsy examined between May 2005 and May 2006 who needed botulinum toxin A injections in the adductor, hamstring, gastrocnemius and/or soleus muscles could be included. Fifty-four (54) children participated in the study, 30 of whom were injected under ultrasound guidance. The pre- and post- toxin evaluations were done through analytical clinical examination and the Gross Motor Function Measure (GMFM-88). RESULTS: We found an overall clinical effectiveness for 51% of the children. This effectiveness was significantly higher for children under 6 years old or over 12, especially when the doses were greater than 0.8 UI/kg per muscle of Botox, when the injected muscles were hamstrings or gastrocnemius, and when the injections were guided by ultrasound. Dilution had no effect on clinical effectiveness. Function after one month was better for 24% of the children. This functional improvement was significantly better for children under 6 years old with the injections under ultrasound control. CONCLUSIONS: This study confirms that the effectiveness of botulinum toxin injections is higher in younger children, with injected doses higher than 0.8 UI/kg per muscle of Botox and injections guided by ultrasound.

The effect of multimodal stimulation and cutaneous application of vegetable oils on neonatal development in preterm infants: a randomized controlled trial.

BACKGROUND: Preterm newborns admitted to the Neonatal Intensive Care Unit are deprived of sensory stimulation. Tactile/kinaesthetic stimulation results in weight gain. Studies involving the cutaneous application of vegetable oils have shown improvement in somatic growth and on skin barrier function. OBJECTIVE: To assess the neurodevelopmental and biological benefits of the simultaneous use of multimodal stimulation (SMS) and the cutaneous application of vegetable oils. Setting Tertiary referral centre serving the Poitou-Charentes region of France. METHODS: Randomized controlled trial of 49 low-risk preterm infants, born at 31- to 34-week gestation. Each infant was randomly assigned to one of three treatment groups, Sensori-Tonico-Motor (STM) touch for 10 days with either: sweet almond oil, ISIO4 blended oil, or placebo - normal saline, or to a control group who did not receive any intervention. The primary outcome was weight gain. Secondary outcomes were linear growth, neurological maturation, psychomotor development and number of days of admission. Analysis was by intention-to-treat. RESULTS: The group who received STM with ISIO4 oil demonstrated enhanced weight gain (+57%, 95% CI 37-76) compared with controls (P = 0.030). All STM groups showed shorter admission times (mean reduction 15 days, 95% CI 23-50 days hospitalised, P = 0.005), and an increase in body length (P = 0.030). Both groups of oil massaged babies (almond and ISIO4) showed an increased neurological score (P = 0.001) compared to controls. The infants receiving ISIO4 oil had an associated increase in psychomotor scores (P = 0.028), time spent in quiet wakefulness (P = 0.036), improved orientation (P = 0.036), and enhanced development of the oculomotor (P = 0.012) and sensorimotor (P = 0.003) systems. An additional benefit seen was improved moisturization (P = 0.001), and quicker recovery of dermatological conditions. No adverse dermatological events were observed. CONCLUSIONS: The combination of STM and cutaneous application of oils to healthy preterm babies resulted in enhanced weight gain and neurological development, and a shorter stay in hospital.

[A case of atypical pericarditis]. / Une péricardite atypique.

INTRODUCTION: An acute viral pericarditis may reveal a congenital pericardial abnormality. CASE HISTORY: We report the case of a young man of 29 years in whom the development of rapidly progressive dyspnoea and fever led to the echocardiographic diagnosis of a pericardial tumour. The thoracic CT scan showed a mass arising in the superior mediastinum with no evidence of spread. Surgical exploration allowed the excision of a soft mutilobular mass adherent only to the aorta. Histological examination revealed an intrapericardial bronchogenic cyst. CONCLUSION: After a review of bronchogenic cysts we point out the properties of this rare intra-pericardial localisation, one of which is the frequently observed secretion of CA 19-9.

[Treatment of stable angina. Coronary angioplasty versus medical treatment]. / Traitement de l'angor stable. Angioplastie coronaire versus traitement médical.

Stable angina is a common clinical condition in everyday practice. Several studies (ACME, MASS, RITA 2) compared the efficacy of angioplasty with medical management in this context with concordant results: significant reduction in the frequency of angina and improved exercise capacity, without reduction in the number of serious events (death, infarction). Even though developments in the field of angioplasty have provided better clinical results, especially with the use of stents, the indication of dilatation should be clearly defined by a series of clinical and angiographic parameters. Although resistance to well conducted medical treatment is an indication for revascularisation when possible, the indications should be reconsidered if persistent ischaemia with medical therapy has not been proved.

[Angioplasty with stent of the common trunk of the left coronary artery with abnormal origin at the level of the right anterior sinus and with a retro-aortic trajectory]. / Angioplastie avec stent d'un tronc commun de la coronaire gauche à naissance anormale au niveau du sinus antéro-droit et à trajet rétro-aortique.

The authors report a case of angioplasty with implantation of a stent in an anomalous left main coronary artery arising from the right anterior sinus of Valsalva with a retro-aortic trajectory. The introduction of stenting has made angioplasty of anomalous coronary arteries a possible alternative to surgery with the reserve of a high risk of restenosis when the lesion is distal and situated at a bifurcation.

[Transluminal coronary angioplasty in the acute phase of myocardial infarction]. / Place de l'angioplastie transluminale des coronaires dans le traitement de l'infarctus du myocarde à la phase aiguë.

The objective of the treatment of myocardial infarction is to reestablish patency of the occluded artery as soon as possible. Two methods have been validated: intravenous thrombolysis which is easy to perform, and transluminal coronary angioplasty requiring expensive infrastructures and a skilled medical team but which has a higher success rate of restoring arterial patency. Angioplasty is indicated in cardiogenic shock and cases in which there is diagnostic uncertainty or a contraindication to thrombolysis. In addition, its superiority over thrombolysis has been clearly demonstrated in the following indications: 1) primary angioplasty if proper facilities with an experienced team are available in less than 45 minutes and 2) after failed thrombolysis (rescue angioplasty). The use of stents improves the results of primary angioplasty. Angioplasty and thrombolysis are not rival techniques: the choice depends on local conditions (proximity to a catheterization laboratory with a trained medical team) and the clinical context (presence of "high-risk" criteria). Their association (prehospital thrombolysis followed by immediate angioplasty) is the object of prospective clinical trials.

One-week and six-month angiographic controls of stent implantation after occlusive and nonocclusive dissection during primary balloon angioplasty for acute myocardial infarction.

We prospectively assessed in 124 consecutive patients by means of 1-week and 6-month follow-up angiograms the rate of reocclusion and restenosis of coronary stenting with Palmaz-Schatz stents after occlusive and nonocclusive dissection during primary balloon angioplasty for acute myocardial infarction (AMI). Patients were further evaluated clinically at 1 year. Stenting was performed on large (>3.2 mm) coronary arteries for suboptimal results (47%), occlusive (8%), or nonocclusive dissections (45%) after balloon angioplasty. Stents were delivered using the bare stent technique and high pressure inflations (>12 atm). All patients received ticlopidine 250 mg (500 mg if weight was >80 kg) and aspirin 100 mg for 1 month. No patient received warfarin. At 1 week, 6 patients died of cardiogenic shock and 2 of right ventricular infarction. One subacute occlusion occurred at day 14. At 6 months, in 95 patients, the angiographic restenosis rate (>50% diameter stenosis) was 19%. One-year clinical follow-up, available in 55 patients, indicated cardiac death in 5, and repeat revascularization in 3. Thus, coronary stenting on large (>3.2 mm) coronary arteries after occlusive and nonocclusive dissection during primary balloon angioplasty for AMI using bare Palmaz-Schatz stents, high pressures, ticlopidine, and aspirin is safe. Our reocclusion and restenosis rates are similar to those of trials on elective stenting in stable patients.

[In coronary surgery can both internal mammary arteries be used systematically? Apropos of 560 patients]. / En chirurgie coronaire l'utilisation des deux artères mammaires internes peut-elle être systématique? A propos de 560 patients.

The grafts commonly used in coronary bypass surgery are the left internal mammary artery and the saphenous veins of the legs: the use of both internal mammary arteries, with potential long-term benefits, is only justified if the operative risk is not increased. Since 1987, the authors use both internal mammary arteries systematically in patients under 70 years of age and in good general condition. The retrospective analysis of 560 patients having undergone this surgery from 1987 to 1994 was undertaken to determine if this surgical option is justified without increased operative risk. The dissection of the mammary arteries is performed in a special manner by skeletonization technique. The total hospital complication rate was 12% with 9 deaths in the first 30 postoperative days (1.6%). Mediastinitis was observed in 6 patients (1.1%) Early angiographic controls showed a patent mammary graft rate of 98%. The use of both internal mammary arteries does not therefore increase postoperative morbidity or mortality. It may be proposed systematically in patients in good general condition and may provide long-term benefits in graft patency rates.

[Coronary angiography by left radial approach. A bi-center prospective pilot study]. / Coronarographie par voie radiale gauche. Une étude pilote prospective bicentrique.

The aim of this study was to assess prospectively the feasibility, safety and quality of coronary angiography performed by a left radial arterial approach. The investigation was performed under local anesthesia with a Lidocaine gel using Judkins 5f catheter. A bolus of heparin was injected intravenously at the start of the procedure (no heparin in phase 0.2 to 3.000 IU during phase 1 and 5.000 IU in phase 2). Between March 1994 and January 1996, after exclusion of 108 patients (15.1%) mainly because of an abnormal Allen test, coronary angiography was carried out in 540 patients aged 58.4 +/- 11.7 years, 85% of whom were men. The failure rate was 8%. The quality of opacification of the left coronary artery (scale 1 to 3) was 2.91 +/- 0.27 and of the right coronary artery was 2.96 +/- 0.18. There were no complications during the procedure. Analysis of the learning curve showed a failure rate decreasing to less than 5% after 60 procedures/operator. In the last 100 procedures, the failure rate fell to 3%, the canulation time was 2.2 +/- 2.5 min, the duration of fluoroscopy was 6.5 +/- 3.9 min and the duration of the procedure was 17.5 +/- 4.7 min (14.7 +/- 3.8 min, p < 0.01, by the femoral approach). Clinical and Doppler ultrasonographic follow-up revealed one in-hospital complication (a spontaneously regressive compressive haematoma). No clinical complications were observed at 3 months. Doppler ultrasonography showed the radial artery occlusion rate to be 71% in phase 0.32% in phase 1 and 3.2% in phase 2 (p < 0.0001). These results show that the left radial arterial approach for coronary angiography is safe and effective but requires a period of training. A 5.000 IU dose of heparin limits the risk of radial artery occlusion to 3%. The absence of complications in this large series which included the training period and the patient comfort suggest that this technique may be an excellent alternative to the femoral approach and especially the brachial approach when the Allen test is normal.

Left radial approach for coronary angiography: results of a prospective study.

Although radial approach has been shown to be feasible for coronary angiography, angioplasty, and even stent placement, there have been no prospective evaluations of ease and safety of left radial approach for coronary angiogram. We examined procedural duration and success as well as complications in 415 consecutive patients. Radial artery occlusion was assessed immediately post-procedure and at 2 month follow-up using echo-Doppler measurements. Procedure failure rate was 9%, mean time for sheath insertion was 4.7 +/- 4.7 min, and mean procedure duration was 19.1 +/- 8.2 min. No major complications occurred. Asymptomatic radial artery occlusion was noted in 71% of the first 49 patients, decreased to 24% in the next 119 receiving 2,000-3,000 units of heparin, and to 4.3% in the last 210 receiving 5000 (p < 0.05). Comparison with the femoral approach in the same laboratory suggested that the radial approach took longer, but provided similarly high-quality results without great difficulty in coronary cannulation. Hence, the left radial approach for coronary angiography (with heparin administration) allows immediate ambulation and may be especially useful for outpatients and when the femoral approach is not possible.

Rotational atherectomy with adjunctive balloon angioplasty versus conventional percutaneous transluminal coronary angioplasty in type B2 lesions: results of a randomized study.

A randomized pilot study was performed comparing conventional balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA] group) and rotational atherectomy (RA) with a medium size burr (50% to 70% burr/artery ratio) with systematic adjunctive balloon angioplasty (RA group) in type B2 stenosis. A total of 64 patients were included. Primary success was 93.7% in the RA group and 87.5% in the PTCA group (p = NS). Technical failure with no complication occurred once in each group. Acute complications occurred in three patients in the PTCA group and in one in the RA group. Angiographic restenosis rates were similar (RA group: 39%, PTCA group: 42%, p = NS) with a follow-up rate of 93%. In type B2 lesions, when compared with conventional angioplasty, RA with systematic balloon angioplasty does not seem to increase procedural success, and the restenosis rate remains comparable. However, these results must be confirmed in a larger series of patients.

[Management during the first hours following myocardial infarction. Round table]. / Prise en charge dans les premières heures de l'infarctus du myocarde. Table ronde.

Myocardial infarction, due to complete occlusion of a coronary artery, is a frequent disease which must be diagnosed as rapidly as possible on the basis of clinical and electrocardiographic arguments in order to allow rapid medicalized management; medical ambulance, followed by admission to the intensive care unit. Treatment is designed to disobstruct the coronary occlusion as rapidly as possible, either by intravenous fibrinolysis or by percutaneous transluminal coronary angioplasty in a specialized centre. The subsequent assessment (stress test, coronary angiography) guides the indications for secondary revascularization.

[Doppler echocardiographic evaluation of left ventricular wall stress in aortic stenosis]. / Evaluation en échocardiographie doppler des contraintes pariétales du ventricule gauche dans le rétrécissement aortique.

The measurement of wall stress allows study of morphological adaptation of the left ventricle, especially in conditions associated with symmetric hypertrophy (hypertension, aortic stenosis). The calculation is performed in hypertensive heart disease but not in aortic stenosis because of the ventriculo-aortic pressure gradient. In a preliminary study, the authors validated the peak systolic left ventricular pressure calculated by adding the systolic brachial artery pressure to the maximal transvalvular pressure gradient by comparing the value with that obtained by catheterization in 21 patients with aortic stenosis. The second phase of the study was to measure meridian and circumferential wall stress prospectively in 35 patients with aortic stenosis (29 symptomatic, 6 asymptomatic) and to compare the results with those observed in 21 normal subjects. In the latter group, the values were 151 +/- 22 and 311 +/- 37 10(3) dynes/cm2 respectively, whereas in asymptomatic aortic stenosis the stresses were 136 +/- 28 and 303 +/- 41 10(3) dynes/cm2 respectively (NS) and in symptomatic aortic stenosis 210 +/- 55 and 437 +/- 94 10(3) dynes/cm2 respectively (p < 0.0001). None of the cases of asymptomatic aortic stenosis had raised wall stress values whereas only 6 symptomatic aortic stenosis patients had normal wall stress. The values of wall stress obtained using the method proposed were comparable to those reported by other authors with invasive investigations. Non-invasive measurement of wall stress by Doppler echocardiography may be proposed as a method of evaluation of left ventricular adaptation, especially in severe stenosis and in patients with a patent geometric abnormality (abnormal dilatation or even an inadequately hypertrophied wall).

Early angiography cannot predict postthrombolytic coronary reocclusion: observations from the GUSTO angiographic study. Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries.

OBJECTIVES: The purpose of this study was to determine whether early qualitative or quantitative angiographic features can predict reocclusion after initially successful coronary thrombolysis. BACKGROUND: Although both the benefits of early reperfusion and the consequences of subsequent reocclusion after thrombolysis for acute myocardial infarction have been well described, efforts to describe angiographic markers of lesions at high risk for reocclusion have produced conflicting results. The Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) angiographic trial provides the opportunity to examine these relations in the largest single, prospective patient cohort studied to date. METHODS: We studied 559 patients undergoing follow-up angiography at 90 min and 5 to 7 days after thrombolysis in the GUSTO trial. Patients received one of four thrombolytic regimens: 1) streptokinase with intravenous heparin; 2) streptokinase with subcutaneous heparin; 3) accelerated-dose recombinant tissue-type plasminogen activator (rt-PA) with intravenous heparin; or 4) a combination of streptokinase and conventionally dosed rt-PA with intravenous heparin. Qualitative variables examined at 90-min angiography included Thrombolysis in Myocardial Infarction (TIMI) flow grade, visible thrombus and lesion morphology. Quantitative variables included percent diameter stenosis, percent area stenosis, minimal lumen diameter and lesion length. The study contained a power > 0.85 to detect clinically important differences in percent diameter stenosis, percent area stenosis and minimal lumen diameter between the groups with subsequent reocclusion and sustained patency at the p = 0.05 level. RESULTS: At follow-up, 33 patients (5.9%) had reocclusion. The reocclusion rate for patients with early TIMI grade 2 flow was 6.3% versus 5.6% for TIMI grade 3 flow (p = NS). When the group with reocclusion was compared with the group with continued patency, there were no differences in presence of early visible thrombus, complex lesion morphology, percent diameter stenosis, percent area stenosis, minimal lumen diameter or lesion length. CONCLUSIONS: Our findings demonstrate that neither qualitative nor quantitative angiographic variables at 90 min after initiation of thrombolytic therapy can be used to predict subsequent coronary reocclusion.

[Coronary embolism revealing mitral valve stenosis]. / Embolie coronaire révélatrice d'un rétrécissement mitral.

We report a case of myocardial infarction with normal coronary arteriography in a 39-year-old woman presenting with tight mitral stenosis complicated by atrial extrasystoles and spontaneous atrial contrast at echocardiography. The diagnosis of coronary embolism was most probable. Coronary embolism is a rare disease, usually due to a blood clot or, less frequently, to a vegetation of endocarditis starting in a heart valve. The left network is usually involved, with typical myocardial necrosis. Coronary arteriography is sufficient to make the diagnosis. Preventive treatment is essential.