Comparison of the angiographic myocardial blush grade with delayed-enhanced cardiac magnetic resonance for the assessment of microvascular obstruction in acute myocardial infarctions.

BACKGROUND: Both myocardial blush grade (MBG) and cardiac magnetic resonance (CMR) are imaging tools that can assess myocardial reperfusion after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). OBJECTIVES: We studied the relation between MBG and gadolinium-enhanced CMR for the assessment of microvascular obstruction (MVO) in patients with acute ST-elevated myocardial infarction (STEMI) treated by primary PCI. MATERIAL AND METHODS: MBG was assessed in 39 patients with initial TIMI 0 STEMI successfully treated by PCI, resulting in TIMI 3 flow grade and complete ST-segment resolution. These MBG values were related to MVO determined by CMR, performed between 2 and 7 days after PCI. Left ventricular (LV) volumes were determined at baseline and at 6-month follow-up. RESULTS: No statistical relation was found between MBG and MVO extent at CMR (P = 0.63). Regarding MBG 0 and 1 as a sign of MVO, the sensitivity and specificity of these scores were 53.8 and 75%, respectively. In this study, CMR determined MVO was the only significant LV remodeling predicting factor (beta = 31.8; P = 0.002), whatever the MBG status was. CONCLUSION: MBG underestimates MVO after an optimal revascularization in AMI compared with CMR. This study suggests the superior accuracy of delayed-enhanced magnetic resonance over MBG for the assessment of myocardial reperfusion injury that is needed in clinical trials, where the principal endpoint is the reduction of infarct size and MVO.

[Innovations in emergency management of chest pain with CT angiography]. / Nouveautés dans la prise en charge angioscanographique des douleurs thoraciques dans le cadre de l'urgence.

Recent technological innovations modify the diagnosis opportunities of multislice CT angiography. Emergency chest pain management is therefore optimised and still oriented by clinical presentation. Aortic CT angiography allows the diagnosis and classification of aortic dissection or intramural haematoma. It also shows the extension to aortic thoracoabdominal branches and visceral involvement. Pulmonary embolism diagnosis will be completed by scanographic evaluation of its seriousness. Chest pain caused by pulmonary or digestive diseases will also be documented. A late phase imaging seems useful to diagnose acute myocardial pathology.

[Coronary stents and anaesthesia]. / Endoprothèses coronaires et anesthésie.

The coronary stents are widely used to prevent coronary restenosis after percutaneous coronary intervention. Dual antiplatelet therapy (acetyl salicylic acid and a thienopyridine-clopidogrel or ticlopidine) are prescribed at least during six weeks after conventional stent and six months after drug eluting stent insertion to prevent stent thrombosis. When an invasive procedure is required, a risk of stent thrombosis arises after stopping antiplatelet therapy and a risk of bleeding when continuing this treatment. Therefore, cardiologists should choose carefully the type of coronary stent before insertion and concerned physicians (anaesthesiologists, surgeons, cardiologists) should decide a perioperative strategy in these high-risk patients.

Endovascular repair of the descending thoracic aorta: mid-term results and evaluation of magnetic resonance angiography.

AIM: The endoluminal stent-grafting represents an alternative to surgery in the treatment of lesions of the descending thoracic aorta. The purpose of the present study was to evaluate the mid-term results of the Talent stent-graft in the different indications of aortic disease and the use of magnetic resonance angiography (MRA) in the diagnosis of complications. METHODS: Over a 3-year period, 23 patients with a high surgical risk and presenting a localized lesion of the descending thoracic aorta had an implantation of a Talent stent-graft. Indications were degenerative aneurysm (n=13), false aneurysm (n=7) and penetrating atherosclerotic ulcer (n=3). The feasibility of the endovascular treatment and sizing of the aorta and stent-grafts were determined pre-operatively by MRA and intraoperative angiography. Immediate and mid-term technical and clinical success were assessed by clinical and MRA follow-up. RESULTS: Endovascular treatment was completed successfully in all patients with no conversion to open repair. There was no intraoperative mortality. The mean operative time was 38+/-7 min. Primary success rate was 100%. We didn't have perioperative mortality. The mean follow-up period was 15+/-5 months. The survival rate was 97% (n=22). Regression of the aneurysmal size was observed in 70% (n=16). MRA diagnosed 3 over 4 postoperative endoleaks that were not diagnosed with the CT-scan, and did not interfere with the nitinol structure of the stent-graft. CONCLUSIONS: Endovascular treatment of the various localized diseases of the descending thoracic aorta is a promising, feasible, alternative technique to open surgery in well selected patients. MRA is well adapted to diagnose postoperative endoleaks.

[Ictero-haemorrhagic leptospirosis with a cardiac presentation in a patient returning from an endemic zone]. / Leptospirose ictéro-hémorragique de presentation cardiaque chez une patiente de retour de zone d'endémie.

On returning from a tropical area, the occurrence of rapidly evolving cardiogenic shock in an infectious context should quickly suggest the diagnosis, for which specific treatment can affect the outcome. The dramatic case of a young female presenting with ictero-haemorrhagic leptospirosis diagnosed post-mortem, demonstrated this pathology with the unusual association of complete atrio-ventricular block and myocarditis in a haemorrhagic context.

[Coronary pressure measurement for functional evaluation and treatment of intermediate angiographic stenosis]. / Apport des guides de pression intracoronaire pour l'évaluation fonctionnelle et le traitement des sténoses angiographiques intermédiaires.

Accurate understanding of the physiopathology of a coronary stenosis is a major objective in management during diagnostic coronary angiography. Measurement of fractional flow reserve (FFR) by coronary pressure measurement is a reliable method for evaluating the functional consequences of a lesion of the myocardium. This retrospective monocentric study of 114 patients showed that routine coronary pressure measurement for assessing the functional consequences of intermediate (30 to 70% stenosis) lesions or those of ambiguous topography: was necessary in 4% of diagnostic coronary angiographies enabling an immediate management decision. Using this method, 34% of complementary investigations were not performed (stress test, myocardial scintigraphy, dobutamine stress echocardiography). Seventeen per cent of unnecessary angioplasties were also avoided so that acute coronary event were also avoided when lesions with a FFR >0.75 were not treated by angioplasty. A 10-14% reduction in cost was achieved compared with a strategy of systematic angioplasty in respectively mono- or multivessel disease patients and 39% compared with performing ambulatory myocardial scintigraphy in patients with multivessel disease.

[Heart failure and myocardial infarction in the elderly. For its more specific management]. / Insuffisance cardiaque et infarctus myocardique chez le sujet âgé. Pour une prise en charge plus déterminée.

UNLABELLED: TWO NEGATIVE FACTORS: Heart failure, whether present during the first hours of myocardial infarction, whether it worsens or whether it occurs during the first days, or persists during the acute phase, is a highly unfavourable predictive factor of hospital mortality and mortality secondary to myocardial infarction. Furthermore, old age is the most negative predictive factor of late mortality following myocardial infarction. THERAPEUTIC IMPLICATIONS: These two negative predictive elements that considerably enhance immediate and secondary mortality after myocardial infarction, notably when they are combined, require more specific and voluntary management (in terms of medical--thrombolysis, beta-blockers, CEI--and interventional treatments) in these patients. THE NEED TO EXTEND THE INDICATIONS: Since the efficacy of these medical treatments and myocardial revascularisation techniques (during the acute phase in the case of contraindication for thrombolysis or during the secondary phase) is even greater, in terms of immediate and secondary mortality after myocardial infarction in patients at high risk (elderly patients and those suffering from heart failure), it would appear essential to widen their indications to this group of patients in whom the spontaneous prognosis is worst.

Severe morbidity after coronary artery surgery: development and validation of a simple predictive clinical score.

AIMS: To develop a predictive clinical risk score of post-operative morbidity after coronary artery bypass grafting. METHODS AND RESULTS: Data were collected retrospectively from 679 patients undergoing emergency or planned bypass surgery between 1 January and 31 December 1996. The incidence of morbidity was 23%. Multivariate stepwise logistic regression analysis on two-thirds of the patients identified eight independent risk factors for severe morbidity. Six of these were pre-operative: symptomatic right heart failure, previous ventricular arrhythmias, previous coronary bypass surgery, chronic pulmonary disease, ST changes on pre-operative electrocardiogram, body mass index <24 kg. m-2, and two were intra-operative factors: the surgeon who operated, and the cardiopulmonary bypass time. A predictive clinical risk score was developed with the six pre-operative risk factors. The negative predictive value of the model is 87% and the area under the receiver operating characteristic curve is 0.77. When tested on the remaining patients not used for developing the model, the area under the curve is 0.65. CONCLUSION: This pre-operative risk score provides a simple method of risk stratification for patients undergoing coronary artery surgery. However, as for all predictive models, the performance of the score decreases when applied to a population other than that used to develop it.

[Selective embolization of ruptured mycotic aneurysm of the duodeno-pancreatic arcade disclosing infectious endocarditis]. / Embolisation sélective d'un anévrysme mycotique rompu de l'arcade duodéno-pancréatique révélant une endocardite infectieuse.

The authors report a case of rupture of a mycotic aneurysm of the duodenal pancreatic arcade in a 68 year old man presenting with shock, abdominal pain and rigidity, complicating a case of infectious endocarditis. Emergency treatment consisted of selective embolisation with a coil. This treatment, proposed in view of the clinical condition of the patient and the anatomical particularity of the regional arterial vascularisation, may be a valuable alternative to classical surgery in this type of pathology.