[Acute myocardial infarction in octogenarians treated by primary coronary angioplasty: in hospital outcome, social evolution and long-term mortality. About a forty-seven consecutive patients study]. / Infarctus du myocarde chez l'octogénaire traité par angioplastie primaire: pronostic hospitalier, devenir social et mortalité à long terme. Etude à propos d'une série de 47 patients.

This study evaluated the hospital outcome of octogenarian patients treated by primary angioplasty for acute myocardial infarction less than 12 hours. The long-term mortality and social outcome were evaluated, social outcome was based on IADL and IADL-E scales corresponding to physical autonomy and level of dependence. We included from 1999 to 2005 47 old patients of 83.5+/-3.2 years. The reperfusion of the obstructed coronary artery was obtained in 45 patients (95.7%) with TIMI 3 flow. Hospital mortality was 25.5% and 4.2% without hemodynamic complication. A multivariate analysis identified a Killip score>1 as predictive factor of hospital mortality (OR=8.9 and p=0.05). The long-term survival without death with a follow-up of 26.3+/-18.3 months was 82.2% at 24 months and 70.6% at 48 months according to the Kaplan-Meier method. In an multivariate analysis, hospitalization exit without aspirine was associated with a higher long term mortality (OR=34.8 and p=0.04). According to the evolution of scores of IADL and IADL-E scales, patients had an excellent autonomy and good capacities before the infarction and they kept them on the long term. Thus octogenarians with acute myocardial infarction treated by primary angioplasty have a high in hospital and long term mortality but the survivors preserve an excellent daily autonomy.

[Primary angioplasty in acute coronary syndromes with ST-segment elevation: experience of three Alsacian centers]. / Angioplastie primaire dans les syndromes coronaires aigus avec sus-decalage du segment ST: experience de 3 centres alsaciens.

The guidelines of the European Society of Cardiology, published in 2003, consider primary angioplasty as the preferred treatment strategy in acute coronary syndromes with ST-segment elevation, if the procedure can be performed within 90 min after first medical contact. We report the experience of three Alsacian centers running a common prospective registry with 2504 consecutive patients enroled between January 1999 and December 2004. The average age of the patients was 62 years with a proportion of 24% women. The time delay "pain to admission" was > or =3 hours in 55.9% of the cases. The treatment delay "door to catheterisation needle" was 59 min and the mean delay "door-to-reperfusion" was 79 min. The study population was representative of the real world including subsets of patients with a particulary high risk profile: age > or =70 years in 33%, a Killip grade > or =3 in 11.5%, rescucitated sudden death in 6.6% and cardiogenic shock in 10.9% of the patients respectively. The immediate procedural success rate (Timi 3 flow) in the treated coronary artery was 96.5%. The overall inhospital mortality-rate was 9.3%. The combinations of rescucitated sudden death--cardiogenic shock or age > or =75 years--cardiogenic shock were associated with a poor clinical outcome and mortality rates of 69% and 72.6% respectively, where as in the absence of abovementioned clinical high risk settings, the mortality rate was as low as 1.4%. The overall bleeding complication rate was 1.4%. The policy of systematic primary angioplasty in acute coronary syndromes with ST-Segment elevation appears to be coherent. The procedural complications and the in-hospital mortality rates were low, except in the presence of above mentioned clinical high risk settings.

[Acute STEMI in old and very old patients. The real life]. / Infarctus du myocarde du 3e et 4e âge. Une expérience de terrain.

OBJECTIVES: From a prospective multicenter registry, we evaluated in three non-academic interventional cardiologic centers (Alsace/France), the coverage and the feasibility of the percutaneous coronary angioplasty (PTCA) in the acute phase of STEMI in the elderly (patients 75-years old and more). METHODS: We studied clinical characteristics and angiographic data of patients older than 75 years, and the PTCA results: the revascularisation rates and the intrahospital events were analysed. These data were compared with those of the younger patients and confronted with the literature data. RESULTS: Of a total of 1672 patients admitted for a STEMI, 342 (20.45%) were older than 75 years. These patients represented a high-risk group with a high proportion of women (50%), and many co-morbidities (e.g.: hypertension and diabetes mellitus), and three-vessel disease was found more often than in younger patients. Mortality rate was high in this subgroup and always more severe as compared to younger subjects, but remains variable according to the initial clinical profile. The global mortality was 20.47% but fell to 5.41% if we excluded the patients with cardiogenic shock, in Killip III and after resuscitation. PTCA is a coronary reperfusion technique particularly indicated in the management of the elderly presenting a STEMI. It is an effective technique in term of revascularisation, the reperfusion success (exclusively TIMI III flow) was indeed raised in the elderly even though it is lower than in younger patients (93.88 vs 97.18%). It is a quickly accessible technique, cath-lab accessibility provided, allowing a fast reperfusion and reducing hospitalization to a minimum. The management of the elderly presenting a STEMI has to focus on reducing the preadmission delay since this subgroup of patients hesitates to call the emergency (SMUR) when presenting an acute coronary symptomatology. The shorter the delay till admittance, the better the outcome. CONCLUSION: PTCA is a technique particularly indicated in the elderly in Alsace because of regional specificities: first of all geographic (proximity of the SMUR for virtually all the population of Alsace), and secondly the medical infrastructure since the strategy of exclusive primary PTCA is granted by numerous interventional cardiologic teams. In Alsace, the proportion of elderly patients (> or = 75 years) is going to increase significantly with a parallel rise of STEMI--"a frightening perspective". We have to take into account this evolution, this reperfusion technique presenting numerous advantages and very few complications.

[Primary cardiogenic shock in the acute phase of myocardial infarction treated by angioplasty: experience of three non-university public centers in Alsace]. / Choc cardiogénique primaire à la phase aiguë de l'infarctus traité par angioplastie: expérience de trois centres alsaciens publics non universitaires.

OBJECTIVE AND METHOD: Evaluation of angioplasty for primary cardiogenic shock in acute myocardial infarction in three non-universitary alsacians centres between 1999 and 2002. RESULTS: One hundred and eighty-two patients were included. Hospitalisation survival rate is 43.96% after hospital discharge. One hundred and forty-nine patients were treated by primary angioplasty. Angioplasty is successful in 79.12%. The predictives factors of death are: age > 75, TIMI = 0 at the admission, three vessels disease. Twenty-four months survival is 91% (follow-up data available on 28.75% of the patients alive at hospital discharge). CONCLUSION: Angioplasty seems to be the right choice in case of acute myocardial infarction complicated by cardiogenic shock, the results are better than medical treatment at short- and mid-term.

[Off-pump beating heart coronary artery bypass. Technical points of view and surgical results]. / Pontage coronaire à coeur battant. Aspects techniques et résultats hospitaliers.

A consecutive series of 746 patients undergoing heart beating myocardial revascularization was reviewed. An average of 2.30 grafts/patients was performed. The rate of mortality in the first 30 postoperative days was 0.28%. Two cases had to be terminated on-pump. We used the inotropic drugs in 0.6% of cases. The postoperative events were: atrial fibrillation (12.6%), myocardial infarction (0.3%). The rate of transfusion was 7.4%. The extubation was performed in the first 24 h postoperatively in 94.7% of cases. The majority of patients (91.3%) left the hospital in the first 8 d postoperatively. Off pump coronary artery bypass grafting gives good result for the most of the patients even for those with multiple vessel disease and high operating risk.

[Subacute infectious endocarditis due to the agent of cat scratch fever: Bartonella henselae]. / Endocardite infectieuse subaiguë due à l'agent de la maladie des griffes du chat: Bartonella henselae.

The diagnosis of severe mitral stenosis with left atrial thrombus was rectified at valvular replacement in a 48-year old immuno-competent man who was a cat owner. The mass in the left atrium was, in fact, a large endocarditic vegetation. Pre- and postoperative blood cultures were negative as was culture of the excised mitral valve. The diagnosis of infectious endocarditis (IE) due to Bartonella Henselae was made from a positive serological test (1600) and identification of the germ by genetic amplification. Antibiotic therapy was continued for 6 months and the patient was cured with a follow-up of 4 years. Bartonella Henselae IE is very rare (14 reported cases) and affects mainly the aortic valve, often giving rise to very large vegetations which, in half the cases, are complicated by systemic emboli. Germs like Batonella are sensitive to most antibiotics, especially the aminosides and macrolides. In Bartonella Henselae IE, valve replacement is the rule (13 out of 14 cases) and the prognosis is usually good. Sero-diagnosis of Bartonellosis should be part of the systematic investigation of all blood culture negative IE.

[Communication between the left ventricle and the right atrium in infectious endocarditis. Diagnosis using Doppler-echocardiography]. / Communication entre le ventricule gauche et l'oreillette droite au cours d'une endocardite infectieuse. Diagnostic par l'échocardiogramme-doppler.

The diagnosis of a communication between the left ventricle and right atrium was made by transthoracic and transoesophageal echocardiography in a 67 year old man with a recurrence of a methicillin-resistant staphylococcus aureus infectious endocarditis complicating aortic valve replacement with a bioprosthesis seven weeks previously. This diagnosis was confirmed at surgery; the left ventricular-right atrial communication was closed by suturing its edges and a new aortic valve prosthesis was implanted. Unfortunately, the patient died 4 months later of myocardial dysfunction although the infectious endocarditis seemed to have been sterilised by antibiotic therapy. Doppler echocardiography, especially using the transoesophageal approach is the best diagnostic method for rare complications of infectious endocarditis, usually of the aortic valve, the prognosis of which is improved by early surgery and appropriate antibiotic therapy for the causal organisms.