[Characteristics and management of ST-elevation myocardial infarction in France: Regional variations in 2010]. / Prise en charge du syndrome coronaire aigu avec sus-décalage de ST en France : variations régionales en 2010.

Data on regional variations in the characteristics, management and early outcome of patients admitted with ST-elevation myocardial infarction (STEMI) in France are limited. We used data from the FAST-MI 2010 registry to determine whether regional specificities existed, dividing the French territory into 6 larger geographical regions. Variations in the patients' characteristics were found, partly related to regional variations in demography. Acute reperfusion strategy showed more use of primary percutaneous coronary intervention in the greater Paris area, compared to other regions, which would be expected owing to geography and local availability of catheterization laboratories. Overall, however, in-hospital management showed more similarities than differences across regions. Complications, and in particular in-hospital mortality, did not differ significantly among regions.

[The "forgotten ones of reperfusion" in acute myocardial infarction: lessons from the ESTIM Limousin registry]. / Les "oubliés de la reperfusion" dans l'infarctus du myocarde aigu. Leçons du registre ESTIM limousin.

The management of acute coronary syndrome (ACS) with ST elevation in daily practice does not always comply with the official guidelines. In effect, many patients do not benefit from coronary recanalisation despite being eligible. They could be described as the 'reperfusion forgotten ones'. The Limousin ESTIM study allowed us to evaluate their numbers and characteristics between 2001 and 2003. Between 1 June 2001 and 31 December 2003, 958 patients with ST+ ACS were managed within 24 hours. Among this cohort, 47% of patients did not benefit from reperfusion treatment with fibrinolysis or angioplasty. In spite of early management, the rate of non-reperfusion was significant: 30% before the third hour, and 50% between 3 and 6 hours. With univariate and multivariate analysis, the predictive features for non-reperfusion were age, length of time between onset of pain and presentation, type of admission route, absence of a call to the emergency ambulance service, and the characteristics of the ECG tracing. These data have prompted education and training, adapted for specific regions. Despite some significant improvements, the rate of non-perfusion in 2004 still remains 35% in the first 24 hours, comparable with figures in the recent literature. Being aware of this problem, taking specific action and continued evaluation with surveys like this remain important.

Carotid intima-media thickness as predictor of secondary events after coronary angioplasty.

AIM: Subjects with symptomatic or asymptomatic peripheral arterial or cerebro-vascular disease have an increased risk of death or cardiovascular event. The aim of this study was to determine whether intima-media thickening of the common carotid artery and/or a low ankle brachial index (ABI) are related with an increased risk of cardio-vascular event after percutaneous coronary angioplasty (PTCA). METHODS: One hundred and thirteen consecutive, patients (88 males, 25 females, mean age: 62 years) undergoing PTCA were included. Intima media thickness (IMT) of the common carotid artery and ABI were measured within the 2 days following the PTCA. Subjects were followed up for 10.2 +/- 4 months. The end-point was a composite criterion associating death, non fatal acute myocardial infarction, recurrence or worsening of angina pectoris, hospitalisation for heart failure, new positive exercise stress testing. RESULTS: In the follow-up study a common carotid IMT >0.7 mm was a predictor of event (p=0.03) in the univariate analysis. The other risk factors were unstable angina (p=0.001) and PTCA on the left descending coronary artery (p<0.05). We did not find any relation between the end-point and ABI or presence of atheroma on the common femoral artery. In the logistic regression analysis unstable angina was associated with a 3.14 fold increased risk (IC 95%: 1.51-6.4, p=0.002), subjects without HMG-CoA inhibitors drugs at the inclusion had also an increased risk of 2.5 (IC 95%:1.09-5.75, p=0.02). CONCLUSION: This study suggest that CCA-IMT is associated with an increased risk of cardiac events after PTCA. The measurement of subclinical disease could be useful for identifying high-risk patients.

[Ventricular tachycardia by branch to branch re-entry. Familial case with Steinert's disease]. / Tachycardie ventriculaire par réentrée de branche à branche. Cas familial avec maladie de Steinert.

Ventricular tachycardia by branch to branch reentry is a rare arrhythmia. It occurs in cardiomyopathies associated with conduction defects. During tachycardia a His potential precedes each QRS complex which usually has a left bundle branch block appearance. The authors report two familial cases of ventricular branch to branch tachycardia (son and mother) without cardiomyopathy. The diagnosis of Steinert's disease was made post-mortem in these two patients. In cases of branch to branch ventricular tachycardia, the diagnosis of myotonic dystrophy should be excluded. Conversely, endocavitary electrophysiological investigation with ventricular stimulation should be proposed for symptomatic patients (dizzy spells, syncope) to diagnose branch to branch ventricular tachycardia, even in cases with conduction defects which could also explain the symptoms.

Is the morning peak of acute myocardial infarction's onset due to sleep-related breathing disorders? A prospective study.

Many studies have shown that the risk of experiencing a myocardial infarction (MI) is increased during the first hours of the morning. Sleep apnea syndrome (SAS) is associated with an enhanced adrenergic activity, prolonged a few hours after awakening. We aimed at assessing whether sleep breathing disorders could be a culprit for the morning excess rate of MI. We studied 40 middle-aged men admitted for an acute MI. An overnight polysomnographic study was performed 37.4 +/- 9.4 days after the MI. The prevalence of SAS was high (30%). The prevalence of SAS was significantly higher in patients with the MI onset during the morning. The circadian pattern was significantly different in patients with or without SAS: those with SAS presented an important peak of MI onset during the period between 06.00 and 11.59 h. None of them had their MI during the period between 24.00 and 05.59 h. This different nyctohemeral pattern underlines the potential role of sleep breathing disorders as a trigger of MI.

Emergency coronary artery bypass surgery following coronary angioplasty and stenting: results of a French multicenter registry.

This study investigates the influence of coronary stenting on the risk of emergency bypass surgery performed within 24 hr of percutaneous transluminal coronary angioplasty (PTCA) with particular concern for incidence and indication. Since 1995, coronary stenting has been increasingly performed in France during angioplasty procedures, altering significantly the role of emergency bypass surgery. The outcome of elective stenting and widespread use of coronary stenting and its influence on emergency surgery have not been evaluated so far. Through a retrospective (1995) and prospective (1996) registry, we analyzed the incidence, indication and results of emergency bypass surgery performed within 24 hr of PTCA in 68 and 57 centers, respectively, accounting for nearly half of all angioplasty procedures in France. Data were collected through questionnaires consisting of separate forms for every case report that were sent to every center. Over the two years, 26,885 and 27,497 procedures were investigated with a stenting rate of 46% and 64%, respectively. The observed need for emergency surgery was constantly low throughout this period (0.38% and 0.32%, respectively). Indications for surgery included complications directly due to stent in 37% of cases in the 2-year period. Outcome remained poor, with in-hospital mortality in 10% and 17% and myocardial infarction in 27% and 25% of cases, respectively. A comparison of the results in centers with and without surgical facilities showed no differences in outcome, despite a longer time to surgery (359 min +/- 406 min vs. 170 min +/- 205 min, P = 0.0001) and a lower incidence of emergency surgery (0.25% vs. 0.44%, P = 0.0001) in centers without on-site surgery backup. The French multicenter registry reveals an increase in the use of stents together with a dramatic decrease in the incidence of emergency bypass surgery (below 0.5%) following PTCA. There has been a significant evolution in the indication, and stent implantation now accounts for a third of the indications for emergency bypass surgery.

Sleep apnoea syndrome and the extent of atherosclerotic lesions in middle-aged men with myocardial infarction.

BACKGROUND: To determine whether extended atherosclerotic lesions are correlated to the presence of sleep breathing disorders. EXPERIMENTAL DESIGN: A prospective clinical study. SETTING: A tertiary regional referral center. PATIENTS: 40 male patients < or =65 years consecutively admitted to the cardiac care unit for an acute myocardial infarction with serous creatinine phosphokinase (CPK) > or =350 IU/l and a CPK-MB fraction > or =10%. Exclusion criteria were: cardiac surgery on emergency, stroke, major neurological and/or psychiatric disturbances, alcohol consumption >50 g/day, toxicomania, clinical or biological hypothyroidism, clinical acromegaly and chronic obstructive pulmonary disease. MEASURES: Duplex ultrasonography was performed on carotid arteries, femoral arteries and their bifurcations. An overnight polysomnography was performed after hospital discharge. Patients with an apnoea index >5/hour or apnoea-hypopnea index >10/hour of sleep are considered to have sleep apnoea syndrome (SAS). Patients with additive peripheral atherosclerotic lesions are compared to patients with normal carotid and femoral arteries, regarding to standard cardiovascular risk factors and apnoeas or hypopnoeas during sleep. RESULTS: Duplex revealed in 18 patients carotid and/or femoral atherosclerotic lesions. The prevalence of SAS in patients with at least one peripheral arterial lesion was significantly higher (61% vs 18%, p<0.01). A nearly significant difference was also noted in patients with carotid lesions alone compared to those with normal carotid arteries (57% vs 27%, p=0.06). CONCLUSIONS: These results suggest a possible link between sleep breathing disorders and the pathogenesis of atherosclerotic lesions.

[Predictive factors of smoking cessation after myocardial infarction. Review of the literature]. / Facteurs prédictifs de l'arret du tabac apres un infarctus du myocarde. Revue de la littérature.

This paper reviews the current state of knowledge about smoking after myocardial infarction in smokers. After presenting results emphasizing the value of post-infarction smoking cessation, all of the predisposing factors to smoking cessation are analysed. The objective of this review of the literature is to recognize these factors in order to more precisely define the various medical, psychological and social aspects of an assistance programme adapted to post-infarction smoking cessation.

[Lactobacillus acidophilus endocarditis]. / Endocardite à Lactobacillus acidophilus.

BACKGROUND: Lactobacillus is a commensal germ found in the buccal cavity, the digestive tract and the vagina. Usually non-pathogenic except in case of dental caries, it can occasionally be the causal agent in severe endocarditis. CASE REPORT: A 70-year-old woman developed endocarditis on an aortic valve bioprosthesis. Lactobacillus acidophilus was isolated from blood cultures of the valve after surgery. COMMENTS: Forty-four cases of Lactobacillus endocarditis have been reported in the literature to date. Mortality is high (26%). The main difficulty in treatment is germ tolerance to penicillin and aminosides found in all cases. Cure requires high dose parenteral antibiotics and surgery in many cases (26%).

Effect of the direct nitric oxide donors linsidomine and molsidomine on angiographic restenosis after coronary balloon angioplasty. The ACCORD Study. Angioplastic Coronaire Corvasal Diltiazem.

BACKGROUND: Nitric oxide (NO) donors, in addition to their vasodilator effect, decrease platelet aggregation and inhibit vascular smooth muscle cell proliferation. These actions could have beneficial effects on restenosis after coronary balloon angioplasty. METHODS AND RESULTS: In a prospective multicenter, randomized trial, 700 stable coronary patients scheduled for angioplasty received direct NO donors (infusion of linsidomine followed by oral molsidomine) or oral diltiazem. Treatment was started before angioplasty and continued until 12 to 24 hours before follow-up angiography at 6 months. The primary study end point was minimal lumen diameter, assessed by quantitative coronary angiography, 6 months after balloon angioplasty. Clinical variables were well matched in both groups. However, despite intracoronary administration of isosorbide dinitrate, the reference diameter in the NO donor group was significantly greater than in the diltiazem group on the preangioplasty, postangioplasty, and follow-up angiograms. Pretreatment with an NO donor was associated with a modest improvement in the immediate angiographic result compared with pretreatment with diltiazem (minimum luminal diameter, 1.94 versus 1.81 mm; P = .001); this improvement was maintained at the 6-month angiographic follow-up (minimal lumen diameter, 1.54 versus 1.38 mm; P = .007). The extent of late luminal narrowing did not differ significantly between groups (loss index in the NO donor and diltiazam groups, 0.35 +/- 0.78 and 0.46 +/- 0.74, respectively; P = .103). Restenosis, defined as a binary variable (> or = 50% stenosis), occurred less often in the NO donor group (38.0% versus 46.5%; P = .026). Combined major clinical events (death, nonfatal myocardial infarction, and coronary revascularization) were similar in the two groups (32.2% versus 32.4%). CONCLUSIONS: Treatment with linsidomine and molsidomine was associated with a modest improvement in the long-term angiographic result after angioplasty but had no effect on clinical outcome. The improved angiographic result related predominantly to a better immediate procedural result, because late luminal loss did not differ significantly between groups.

M-CSF serous rate evolution during post-transplantation days in a heterotopic heart graft model mice.

BACKGROUND: On heterotopic heart graft in mice, aged 7 weeks (C3H and B57), we investigate the variations of Macrophage Colony stimulating factor serous rate. The macrophage colony stimulating factor (M-CSF) is a cytokine involved in the immune response during transplantation. METHODS: Five groups were determined, group 1 with a heterotopic transplant without immunosuppressive treatment (N=24); group 2 with a heterotopic transplant and Corticoid treatment after the graft (N=29); group 3 with a heterotopic transplant and cyclosporine treatment after the graft (N=34); group 4 with an isogenic transplant (N=31) and group 5 undergoing a laparotomy (N=31). The mice are sacrificed at D4, D7, D10 or D14 and the M-CSF dosage are done by ELISA method. RESULTS: The serous rate of M-CSF is stable in the group with an isogenic transplant or with only a laparotomy. But in the group with a heterotopic transplant the M-CSF values increase (x1.5). If we use an immunosuppressive treatment the raising of M-CSF is less important. When we have a rejection graft, the serous rate of M-CSF increases but not significantly (Mann-Whitney test). CONCLUSIONS: We conclude M-CSF seems to be a reliable index of disorder during immune response, but is not a good marker of the rejection.

[Calcified aortic valvular disease associated with adult progeria]. / Valvulopathie aortique calcifiée associée à une progeria de l'adulte.

Adult's progeria or Werner's syndrome is a rare condition of autosomal-recessive inheritance, characterized by an apparent acceleration of many of the processes associated with aging. We describe the cardiovascular findings in a 44 year-old man with this disorder. Slightly elevation of urinary hyaluronic acid level contributes to the diagnosis.

[Postoperative transparietal Doppler ultrasonographic study of the internal mammary artery graft flow with respect to quality of the underlying myocardium]. / Etude en écho-doppler transpariétal postopératoire du flux du greffon mammaire interne en fonction de la qualité du myocarde sous-jacent.

The authors studied flow in the internal mammary artery by Doppler ultrasonography after bypass surgery of the left anterior descending artery to determine the correlation between the flow pattern and the quality of the distal run off. A pulsed Doppler was used to record flow from the right and left internal mammary arteries in the first, second and third intercostal spaces and the supraclavicular fossa. Only the best quality recordings with the highest amplitudes were retained for analysis. Forty-nine patients (average age 61 +/- 10 years), 43 men and 6 women, were included and were examined between the 10th and 15th postoperative days. All had stenosis of the left anterior descending on coronary angiography: three subgroups were identified ad the time of evaluation: (I) revascularisation of an infarcted zone with important angiographic and echographic sequellae. (II) revascularised zones with slight wall motion abnormalities. (IIIa) revascularisation of myocardium with no abnormality (including a subgroup of 5 patients (IIIb) characterised by a postoperative low output state and echocardiographic changes not present before surgery). Significant changes were observed in the flow patterns of the different groups. (I) an exclusively systolic flow (diastolic velocity time integral = 2.85 cm), (II) systolodiastolic flow (diastolic velocity time interval = 9 cm) similar to that in group IIIb, and IIIa predominantly diastolic flow (diastolic velocity time integral = 15.2 cm). The amplitude of diastolic flow in the mammary artery graft was therefore related to previous ischaemia of the revascularised myocardium; detection of stenosis by Doppler ultrasonography should therefore take into account the previous history of the patient.

[Paraneoplastic arterial thrombosis. Apropos of 2 cases]. / Thromboses artérielles paranéoplasiques. A propos de deux cas.

The search for a cancer is part of the classical investigation of unexplained venous thrombosis. Arterial thrombosis associated with neoplasia is more rare. The authors report two cases in which arterial thrombosis was the final event of their malignant disease. The first case had abacterial thrombotic endocarditis and disseminated intravascular coagulation at the origin of multiple thrombotic complications. The initially unknown cancer was a pancreatic adenocarcinoma. The second case presented with acute occlusion of the iliac artery after ablation of a malignant melanoma. Despite embolectomy with a Fogarty catheter and effective anticoagulation, the thrombosis recurred several times at the same site. The clinical features and the mechanisms of these two cases suggestive of Trousseau's syndrome are discussed.

[Syncopal angina caused by sinus arrest; cured by transluminal coronary angioplasty and calcium inhibitor]. / Angor syncopal par arrêt sinusal; guérison par angioplastie coronaire transluminale et inhibiteur calcique.

The authors report the case of a 42 year old man who smoked and who presented with recurrent spontaneous anginal chest pain followed by syncope due to sinus arrest. The mechanism underlying these symptoms was spasm of the left circumflex artery at the site of severe stenosis of its middle segment just before the origin of the sinus node artery. Treatment with a calcium antagonist with transluminal coronary angioplasty of the narrowed segment of the circumflex artery resulted in complete regression of all symptoms with a follow-up of 15 months. Seven other reports of the same type were found in the literature concerning 6 men and 1 woman, with an average age of 49 years, presenting with the same symptoms and sinus arrest associated with the minimal coronary artery disease. The proof of coronary spasm was documented in 6 of the 7 cases by a positive ergometrine stress test or by the observation of spontaneous spasm during coronary angiography or rapid atrial pacing. The outcome was good with calcium antagonist therapy in 5 cases, and with slow release nitrate derivatives in 1 case. One patient, treated by betablockers, died. It is useful to investigate some sino-atrial blocks to diagnose the underlying ischaemic mechanism as the patients may be treated simply with calcium antagonists rather than undergo implantation of a pacemaker.

[Frequency of angiographic restenosis after 6 months and long-term outcome of coronary angioplasty]. / Fréquence des resténoses angiographiques à 6 mois et devenir à long terme après angioplastie coronaire.

Five hundred patients with a mean age of 59 years were followed up for an average of 32 months after coronary angioplasty. All patients were included in a prospective study comprising coronary angiography at 6 months for 379 patients (91% primary successes). The long-term outcome was evaluated by a questionnaire or telephone interview in all cases. The global primary success rate was 84.4% in this series. The primary failures include 1.8 fatalities, 0.6% myocardial infarction, 2% emergency coronary bypass surgery and 11.2% without immediate clinical consequences. At 6 months, there were 48% of restenoses (182/379 patients) and 28% underwent immediate repeat angioplasty (141/500 patients) with a primary success rate of 91%. After the repeat angioplasty, the restenosis rate was 43% but this varied according to the time from the first restenosis: 60% when the interval was short (under 2 months) compared with 21% when the interval was 6 months (p < 0.01). The actuarial survival rates at 4 years were 95% after successful angioplasty 96% after uncomplicated failures or medically treated restenosis and 98% after bypass surgery. The predictive factors for secondary death were age of over 70 years, previous non-thrombolized myocardial infarction and complications of angioplasty. The long-term outcome was good despite the 48% 6 months restenosis rate requiring revascularisation procedure in 73% of cases.

[Significant stenosis of the common trunk of the left coronary artery. Retrospective study of 227 cases]. / Sténose significative du tronc commun de l'artère coronaire gauche. Etude rétrospective de 227 cas.

Significant left main coronary artery disease is a separate disease entity in coronary artery disease. The prognosis is classically poor and the treatment of choice is surgical. A retrospective study of patients with left main coronary disease, diagnosed and treated at the CHRU Dupuytren, Limoges, between 1/01/80 and 15/06/91 was undertaken to determine the aetiological, clinical and therapeutic factors which influence mortality related to this condition. During this period, 8198 coronary angiographies were performed in the cardiology department. The diagnosis of significant left main coronary disease (> or = 50% stenosis) was made in 250 cases (3% of all investigations). Of these 250 cases, 227 were treated medically or surgically by our group during the study period. Twenty patients were treated in another centre and 3 underwent surgery after the 15/06/91. Seven patients died in the period immediately after coronary angiography. Of the 220 survivors of coronary angiography, 185 (85%) were referred for surgery (direct or sequential venous and/or arterial bypass or coronary endarteriectomy). Four patients died within 30 days of surgery. Thirty five patients were treated medically. The therapeutic decision was based on the absence of surgical contra-indications. The retrospective, non-randomized nature of this study with allocation of patients to surgical or medical treatment without control invalidated statistical analysis. At the date of the last follow-up appointment, arbitrarily chosen as the 1/01/93, 163 operated patients (88.1%) of which 130 (79.7%) were asymptomatic and 13 medically treated patients (37%) were alive. The prognostic factors after surgery in this study were: stage IV dyspnoea at the time of diagnosis, severe abnormalities on catheter study (end diastolic pressure over 18 mmHg after angiography), left ventricular wall abnormalities (functional score > 10) and incomplete revascularization. The risk of coronary angiography in this condition were confirmed in this study.

[Isolated iliac aneurysms. Sixty-seven cases in forty-eight patients]. / Anévrysmes iliaques isolés. A propos de soixante-dix-sept cas chez quarante-huit patients.

77 pure iliac aneurysms where detected in a group of 48 patients along a period of 21 years, and represented 12.3% of all patients having aortic, iliac, or aorto-iliac aneurysms. The study group comprised 42 men and 6 women, 48-86 years old (mean 67.8 years). The aneurysm was located on the right side in 51.9%, on left side in 48.1%. The affection of the common iliac arteries (70.1%) was more frequent than it was on the internal iliac arteries (18.2%), or in the external iliac arteries (11.7%). The diameter was from 2 to 10 cms. 44 patients out of 48 (91.6%) where symptomatic, and 15 presented a rupture syndrome (31.3%). 10 patients (20.8%) had a pulsating mass. The etiology was unknown in 8 cases (16.7%); 2 patients had a mycotic aneurysm (4.2%). The remaining 38 patients (79.1%) had an aneurysm of atheromatous origin. 5 arteritic patients (10.4%) did not have any cure for their aneurysm, because it was considered threatening for 4 of them. The fifth patient was not treated because the artery was so calcified that it could not be clamped. A lumbar sympathectomy on the same side of the lesion was realised, in addition to the peripheral surgical act for arteritis. One patient had an endoaneurysmorrhaphy, another had an exclusion by ligature section of the aneurysm. For the remaining 41 patients (83.1%) the aneurysms where flattened, and vascular continuity was re-established by a prosthesis. 7 patients (12%) decreased post-operatively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute dissection of the infrarenal aorta and horseshoe kidney. Apropos of a case and review of the literature]. / Dissection aiguë de l'aorte sous rénale et rein en fer à cheval. A propos d'un cas et revue de la littérature.

We report about one case of acute dissection of the infrarenal abdominal aorta associated with a horseshoe kidney. A few points in the history of this 47-year-old patient deserve being underscored: the absence of an "etiological" factor of aortic dissection, the presence of five renal arteries, illustrating the complex vascularity of a horseshoe kidney, the specific surgical problems arising from both a lesion of the aortic junction and a horseshoe kidney. On the basis of the literature, we underline the incidence of dissection of the infrarenal aorta (1 to 3%), that of horseshoe kidney (0.15%) and that of pathology of the aortic junction in patients with a horseshoe kidney, which seems to be accidental.