ST2 as a predictor of late ventricular remodeling after myocardial infarction.

Out of 163 STEMI patients, 33 presented left ventricular remodeling (LVR) as assessed by multiple cardiac magnetic resonance (CMR) scans. LVR patients were identified as EarlyLVR (LVR occurring between baseline and 3 months) or LateLVR (LVR occurring between 3 months and one year), and matched to non-remodeler patients in term of age, gender, anterior infarction, baseline LV ejection fraction and infarct size. ST2 and NT-proBNP were measured at baseline and 3 months. Systolic wall stress (SWS) was calculated by CMR. At baseline, mean levels of ST2, NT-proBNP and SWS were 67.1 ±â€¯54.1 ng/mL, 1529 ±â€¯1702 ng/L and 17.9 ±â€¯7.1 103 N·m-2, respectively, and did not differ among the groups. At 3 months, EarlyLVR patients presented significant higher ST2, NT-proBNP and SWS (31.6 ±â€¯12.7 ng/mL, 1142 ±â€¯1069 ng/L, 25.5 ±â€¯9.7 103 N·m-2), compared to the corresponding non-remodelers (20.5 ±â€¯8.6 ng/mL, 397 ±â€¯273 ng/L, 18 ±â€¯7.3 103 N·m-2; with p = 0.017, 0.040, and 0.036, respectively). LateLVR patients presented higher ST2 at 3 months than their non-remodelers (33.6 ±â€¯15.9 versus 23.66 ±â€¯8.7 ng/mL, p = 0.046), while NT-proBNP and SWS were not different between groups at both timepoints.

Treatment of drug-eluting stents in-stent restenosis with paclitaxel-coated balloon angioplasty: Insights from the French "real-world" prospective GARO Registry.

BACKGROUND: Data about paclitaxel-eluting balloon (PCB) angioplasty to treat drug-eluting stents (DES) in-stent restenosis (ISR) were mainly collected in selected patient populations in the setting of randomized trials. The main goal of this prospective registry was to confirm the positive findings of these studies in an unselected population in clinical practice. METHODS: Consecutive patients with DES-ISR treated by PCB angioplasty were recruited in this prospective real-world registry. The primary endpoint was clinically driven target-lesion revascularization (TLR) at 9 months. Secondary endpoints included acute technical success, in-hospital outcomes, 9-month major adverse cardiac events (MACE) a composite of death, myocardial infarction (MI) and TLR and the occurrence of target vessel revascularization. RESULTS: A total of 206 patients (67.7 ± 10.2 years, 80.6% male, 41.3% diabetics) with 210 lesions were recruited. Unstable coronary artery disease was present in 55.3% of patients. The time from DES implantation to DES-ISR was 3.0 ± 2.4 years. Quantitative analyses revealed that patterns of treated DES-ISR were focal in 55.7% and diffuse in 44.3%. The reference diameter was 2.76 ± 0.64 mm. The 9-month follow-up rate was 90.8% (187/206). At 9 months, the TLR rate was 7.0% (13/187) whereas the rates for MACE, MI and cardiac death were 10.7% (20/187), 4.8% (9/187) and 2.1% (4/187) respectively. Results were consistent in patients with paclitaxel and non-paclitaxel-eluting stents (PES) ISR. CONCLUSION: This large prospective registry demonstrated acceptable rates of TLR and MACE at 9 months after treatment of DES-ISR by PCB angioplasty. PCB angioplasty was equally effective in patients with PES-ISR and non PES-ISR.

No post-conditioning in the human heart with thrombolysis in myocardial infarction flow 2-3 on admission.

AIMS: Proof-of-concept evidence suggests that mechanical ischaemic post-conditioning (PostC) reduces infarct size when applied immediately after culprit coronary artery re-opening in ST-elevation myocardial infarction (STEMI) patients with thrombolysis in myocardial infarction 0-1 (TIMI 0-1) flow grade at admission. Whether PostC might also be protective in patients with a TIMI 2-3 flow grade on admission (corresponding to a delayed application of the post-conditioning algorithm) remains undetermined. METHODS AND RESULTS: In this multi-centre, randomized, single-blinded, controlled study, STEMI patients with a 2-3 TIMI coronary flow grade at admission underwent direct stenting of the culprit lesion, followed (PostC group) or not (control group) by four cycles of (1 min inflation/1 min deflation) of the angioplasty balloon to trigger post-conditioning. Infarct size was assessed both by cardiac magnetic resonance at Day 5 (primary endpoint) and cardiac enzymes release (secondary endpoint). Ninety-nine patients were prospectively enrolled. Baseline characteristics were comparable between control and PostC groups. Despite comparable size of area at risk (AAR) (38 ± 12 vs. 38 ± 13% of the LV circumference, respectively, P = 0.89) and similar time from onset to intervention (249 ± 148 vs. 263 ± 209 min, respectively, P = 0.93) in the two groups, PostC did not significantly reduce cardiac magnetic resonance infarct size (23 ± 17 and 21 ± 18 g in the treated vs. control group, respectively, P = 0.64). Similar results were found when using creatine kinase and troponin I release, even after adjustment for the size of the AAR. CONCLUSION: This study shows that infarct size reduction by mechanical ischaemic PostC is lost when applied to patients with a TIMI 2-3 flow grade at admission. This indicates that the timing of the protective intervention with respect to the onset of reperfusion is a key factor for preventing lethal reperfusion injury in STEMI patients. CLINICAL TRIAL NUMBER: NCT01483755.

Applications of phase-contrast velocimetry sequences in cardiovascular imaging.

AIMS: To describe and illustrate the main applications of phase-contrast flow quantification in cardiovascular imaging. CONCLUSION: Phase-contrast velocimetry sequences provide an accurate, reliable, reproducible and non-invasive study of blood flow, information which is sometimes not available from other investigation methods. The haemodynamic information obtained from these complement MRI angiography images. They appear to have a range of clinical applications, firstly improving pathophysiological understanding but also contributing to the treatment and follow-up strategy after surgical or endovascular treatment.

[Current indications for cardiac MR imaging]. / Indications cliniques appropriées de l'IRM en pathologie cardio-vasculaire.

MRI has acquired over the years a role in the evaluation of cardiovascular pathology especially with regards to its ability to assess right and left ventricular function and delayed postcontrast "viability" sequences. Current class I clinical indications include: viability for patients with ischemic cardiomyopathy and acute coronary syndrome, etiology and prognostic evaluation of non-ischemic cardiomyopathies including myocarditis and arrhytmogenic right ventricular cardiomyopathy, chronic pericarditis and cardiac masses, non-urgent aortic aneurysm and dissection, congenital cardiopathies: vascular malformations and follow-up after curative or palliative surgery. MRI provides a complete non operator dependent evaluation, and is particularly useful for follow-up since it may be repeated due to its absence of ionizing radiation

Chronic erythropoietin treatment decreases post-infarct myocardial damage in rats without venous thrombogenic effect.

OBJECTIVES: Whereas administration of erythropoietin (EPO) acutely after myocardial infarction (MI) reduces infarct size and chronic EPO therapy attenuates post-MI remodeling, the safety of chronic EPO therapy following MI is unknown. Therefore, we examined the thrombogenic effects of a chronic EPO therapy after MI. METHODS: Rats underwent coronary occlusion followed by reperfusion. They were assigned to one of the following groups: EPO-A, single injection of EPO 5,000 U/kg at the time of reperfusion; EPO-C, injection of EPO 5,000 U/kg at the time of reperfusion followed by 300 U/kg/week; PBS-C, injection of vehicle only. After eight weeks of treatment they were exposed to a validated prethrombotic test based on partial stenosis of the inferior vena cava. RESULTS: As compared to the rats receiving vehicle only, the rats treated with EPO exhibited a significant reduction in MI size (28.7 +/- 2.1% and 25.8 +/- 1.9 vs. 39.8 +/- 3.0% in EPO-A, EPO-C and PBS-C, respectively; p < 0.05). Whereas the hematocrit was significantly increased in EPO-C (59.7 +/- 2.0% vs. 44.7 +/- 0.9% in EPO-A, p < 0.001), the proportion of rats in which a thrombus occurred was similar in all groups (p = 0.52). CONCLUSION: Chronic EPO therapy added to the single high dose of EPO injected acutely did not induce venous pro-thrombotic effect in rats.

[Acute myocarditis revealing a pheochromocytoma]. / La myocardite aiguë, un mode de révélation peu fréquent du phéochromocytome Revue de la littérature à propos d'une observation.

We report a 29-year-old woman with an acute myocarditis documented by MRI as presenting manifestation of a pheochromocytoma, and we review the literature.

[Tumor like presentation of primitive amyloidosis: amyloidoma]. / Forme pseudotumorale d'une amylose primitive: l'amyloïdome.

INTRODUCTION: AL-amyloidosis is a rare disease due to monoclonal immunoglobulin deposits, secondary to lymphoproliferative disorder or primitive. The deposits of amyloidosis have usually a systemic repartition. We report a tumor like presentation of amyloidosis, so-called amyloidoma. EXEGESIS: A 72-year old woman lost 10 kg within 6 months, associated with epigastric and mediastinal bulks. The biopsy of the abdominal mass showed AL-amyloidosis with kappa light chains. Since no secondary etiology could be found, the final diagnosis of primary AL-amyloidosis in a tumour like presentation, or amyloidoma, was performed. Investigations showed cardiac involvement with MRI findings, as well as kidney and bone marrow involvement. Oral melphalan as monotherapy was administered. The prognosis and the treatment of this unusual disease are discussed. CONCLUSION: Amyloidoma is a rare presentation of amyloidosis which should be evocated in front of a soft tissue mass with no clear etiology.

Is smoking tobacco an independent risk factor for HIV infection and progression to AIDS? A systemic review.

OBJECTIVES: To systematically review the evidence of the relation between smoking tobacco and HIV seroconversion and progression to AIDS. METHODS: A systematic review was undertaken of studies to look at tobacco smoking as a risk factor for either HIV seroconversion or progression to AIDS. RESULTS: Six studies were identified with HIV seroconversion as an outcome measure. Five of these indicated that smoking tobacco was an independent risk factor after adjusting for important confounders with adjusted odds ratios ranging from 1.6 to 3.5. 10 studies were identified using progression to AIDS as an end point of which nine found no relation with tobacco smoking. CONCLUSIONS: Tobacco smoking may be an independent risk factor for HIV infection although residual confounding is another possible explanation. Smoking did not appear to be related to progression to AIDS although this finding may not be true in developing countries or with the longer life expectancies seen with highly active antiretroviral therapy.

[Long term evolution of chronic constrictive pericarditis. A study of 56 patients]. / Evolution a long terme des péricardites constrictives chroniques. A propos de 56 patients.

OBJECTIVE AND METHOD: We retrospectively analysed 56 consecutive patients with a confirmed diagnosis of chronic constrictive pericarditis over a period of 23 years. The objective was to analyse the evolution of the annual frequency of constrictive pericarditis, its aetiology and to define the prognostic factors for mortality. RESULTS: The annual frequency of constrictive pericarditis has not diminished over the 23 years of this study, remaining at 2.4 cases per year. Cases with a tuberculous origin have diminished progressively, being replaced by complications of cardiac surgery and mediastinal radiotherapy. Pericardectomy was performed in 41 patients and the average follow up was 9.5 +/- 8.6 years. By the end of the study, 34 patients had died (61.8%), 18 from a cardiovascular cause (38.3%). The independent predictive factors for overall mortality were a history of mediastinal radiotherapy, the age, and plasma sodium level. Only the presence of first degree atrio-ventricular block was an independent predictive factor for cardiovascular mortality. In the pericardectomy group, 24 patients died (60%). A history of mediastinal radiotherapy and the presence of pre-operative hyponatraemia were independent predictive factors for overall mortality. CONCLUSION: Constrictive pericarditis remains a serious pathology. Pericardectomy allows a clear functional improvement, but following pericardectomy more than 60% of patients will die within 10 years of the diagnosis being made.

[Acute coronary syndromes and myocardial perfusion. Cardiac magnetic resonance imaging and ultrafast CT]. / Syndromes coronaires aigus et perfusion myocardique. Les acquis de l'IRM cardiaque, les perspectives du scanner multibarrettes.

Imaging myocardial perfusion is essential in the management of acute coronary syndromes without ST elevation (ACS ST-) confirming the diagnosis of coronary lesions and quantifying the myocardial ischaemia, an important factor in the stratification of coronary risk. In ACS ST-, perfusion imaging allows evaluation of myocardial viability, diagnosis of residual ischaemia and also the detection of no-reflow phenomena after reperfusion procedures. Although myocardial scintigraphy is the reference method in clinical practice, it has many limitations such as its spatial resolution, its irradiation, its attenuation artefacts, and also the fact that it does not visualise the coronary arteries. This has led to the rapid development of two new non-invasive imaging techniques: cardiac MRI and ultrafast CT. The major advantage of MRI is the possibility of associating analysis of myocardial perfusion with that of cardiac muscle function by investigating right and left ventricular function at rest and during myocardial ischaemia stress tests and by analysis of myocardial viability. More recently, ultrafast CT has been clinically validated for coronary imaging. However, analysis of myocardial perfusion and ventricular function by CT scan is still only at the research stage.

Reducing inequalities in access to health care: developing a toolkit through action research.

PROBLEM: Healthcare organisations are expected both to monitor inequalities in access to health services and also to act to improve access and increase equity in service provision. DESIGN: Locally developed action research projects with an explicit objective of reducing inequalities in access. SETTING: Eight different health care services in the Yorkshire and Humber region, including community based palliative care, general practice asthma care, hospital based cardiology clinics, and termination of pregnancy services. KEY MEASURES FOR IMPROVEMENT: Changes in service provision, increasing attendance rates in targeted groups. STRATEGIES FOR CHANGE: Local teams identified the population concerned and appropriate interventions using both published and grey literature. Where change to service provision was achieved, local data were collected to monitor the impact of service change. EFFECTS OF CHANGE: A number of evidence based changes to service provision were proposed and implemented with variable success. Service uptake increased in some of the targeted populations. LESSONS LEARNT: Interventions to improve access must be sensitive to local settings and need both practical and managerial support to succeed. It is particularly difficult to improve access effectively if services are already struggling to meet current demand. Key elements for successful interventions included effective local leadership, identification of an intervention which is both evidence based and locally practicable, and identification of additional resources to support increased activity. A "toolkit" has been developed to support the identification and implementation of appropriate changes.

Usefulness and clinical impact of a fractional flow reserve and angiographic targeted strategy for coronary artery stenting: FROST III, a multicenter prospective registry.

BACKGROUND: Fractional flow reserve (FFR) is correlated with angiographic and intravascular ultrasound assessments of stent placement. Post-stenting FFR has been described as a good predictor of clinical events after 6 months. OBJECTIVE: To evaluate the feasibility and clinical impact of targeting an FFR > 0.95 via incremental in-stent inflation pressures. METHODS: In this multicenter prospective study, 100 consecutive patients underwent FFR measurement at baseline, after balloon predilatation, and after stenting with 4-atm inflation pressure increments from 8 to 20 atmospheres. Inflations were stopped when FFR increased above 0.95 and angiographic stenosis was less than 20%. RESULTS: FFR > 0.95 was achieved in 81% of cases; this FFR target was reached at 8 atm in 47% of patients, 12 atm in 16 %, 16 atm in 15%, and 20 atm in 3%. Fifty percent of patients with adequate angiographic result had an FFR less than 0.95 and needed further higher inflations. FFR was correlated with residual stenosis when the total procedure was evaluated, and this correlation persisted when in-stent inflations alone were considered. Final FFR was significantly correlated with anginal status after 6 months. CONCLUSIONS: Angiography guided PCI does not allow optimization of FFR. Since optimal post stenting FFR is correlated to better anginal status at 6-months, this suggests that FFR guided PCI is required to achieve optimal functional results of PCI.

[Intra-aortic balloon pumping and variations in flow in the dilated coronary artery in acute myocardial infarction]. / Contrepulsion intra-aortique et variation du flux de l'artère coronaire dilatée à la phase aiguë de l'infarctus du myocarde.

The object of this study of acute anterior myocardial infarction uncomplicated by cardiogenic shock, a context in which the role of intra-aortic balloon pumping (IABP) remains controversial, was to analyse the effects of IABP on coronary flow in the culprit artery. Twenty-one patients admitted for angioplasty in the acute phase of anterior myocardial infarction were included. The IABP was performed in 6 patients (Group 1) because of clinical signs of cardiac failure. Fifteen patients (Group 2) had no signs of cardiac failure. Coronary flow velocity was recorded by a Doppler catheter after successful angioplasty. The following parameters were analysed: average peak velocity (APV), average diastolic peak velocity (ADPV), average systolic peak velocity (ASPV), diastolic to systolic velocity ratio (DSVR) and maximum peak velocity (MPV). Intra-aortic balloon pumping was associated with an increase in the diastolic indices (APV 17.9 +/- 3.5 vs 14.9 +/- 3.6 cm/s; p < 0.05; ADPV 27.6 +/- 5.2 vs 19.7 +/- 4.7 cm/s; p < 0.05), and a decrease in the systolic index ASVP (3.8 +/- 1.3 vs 7.6 +/- 2.6 cm/s; p < 0.05). The diastolic indices recorded with IABP did not change in Group 2. The velocity spectra changed with the appearance of abnormalities usually described in the presence of microcirculatory abnormalities ("no reflex" phenomenon): decrease in anterograde systolic flow, rapid deceleration of diastolic velocities with appearance of a retrograde systolic flow. The authors conclude that IABP increases diastolic velocities of coronary flow in the acute phase of revascularised anterior myocardial infarction complicated by left ventricular failure but does not seem to be accompanied by improved myocardial perfusion.

[Is it necessary to operate quickly in patients with significant left main coronary stenosis?]. / Faut-il opérer rapidement tous les patients atteints d'une sténose significative du tronc commun de la coronaire gauche?

Although coronary bypass surgery is performed rapidly in the majority of cases of left main coronary stenosis to prevent cardiovascular complications, there is no reported consensus in the literature about the ideal interval between diagnostic coronary angiography and surgery. The aim of this multicenter study was to make an inventory of the serious vascular cardiovascular events which occurred between coronary angiography and surgery to determine possible predictive factors for complications and thereby identify a high risk subgroup requiring immediate revascularisation. The population comprised 283 patients with significant left main coronary disease, out of a total of 8,205 patients who underwent coronary angiography in the university hospitals of Angers, Brest, Nantes, Poitiers and Rennes. A surgical indication was retained in 216 patients. The choice of the operation date depended on clinical data in the presence of an acute coronary syndrome, patients remaining in the intensive care unit and undergoing revascularisation rapidly. Serious cardiac events (death, myocardial infarction, refractory unstable angina and left ventricular failure) occurring while waiting for surgery were rare, observed in only 6.5% of patients. Recent myocardial infarction and, to a lesser degree, unstable angina and/or left ventricular systolic dysfunction, were predictive of serious cardiac complications before surgery. The severity of the left main coronary disease and the association of right coronary disease did not increase the risk of serious cardiac events in the preoperative period. The low incidence of complications demonstrates that this strategy enables patients to wait for surgery with an acceptable risk without having to operate all patients with left main coronary disease as an emergency.

[Very long-term outcome of 68 vena cava filters percutaneously implanted]. / Devenir à très long terme de 68 filtres caves implantés par voie percutanée.

Between January 1987 and December 1991, 68 consecutive patients aged 71.5 +/- 12.0 years underwent percutaneous implantation of a vena caval filter, mainly the LGM (N = 64). Fifty seven patients had pulmonary embolism, 61 had deep vein thrombosis of the lower limbs. The average follow-up interval was 4.9 +/- 3.3 years (7.0 +/- 2.7 years for the patients still alive). The follow-up included a telephonic enquiry to determine the date and cause of death, recurrent deep vein thrombosis and/or pulmonary embolism; surviving patients underwent clinical examination, plain abdominal X-ray with a lateral decubitus view and duplex ultrasonography of the lower limb veins to assess the patency of the filter. Fifty three per cent of the patients died. Four predictive factors for mortality were identified: a contra-indication to anticoagulant therapy, chronic post-embolic cor pulmonale, an indication of prophylactic implantation in the elderly and the presence of underlying malignant disease. There were 5.8% recurrences of pulmonary embolism, 26.1% of lower limb deep vein thrombosis and 25% of filter thrombosis. The only predictive factor of thrombosis was a proximal venous thrombus and was associated in 50% of filter thrombosis. Seventy per cent of the plain abdominal X-rays were abnormal with 9 displacements. 9 migrations and 10 closures of the filters. There was a significant correlation between closure on plain abdominal X-ray and caval thrombosis and between recurrent deep vein thrombosis and caval thrombosis. The frequency of long-term complications after implantation of a caval filter in this study suggests that interruption of the vena cava should be reserved for the only validated indications in the presence of a formal contra-indication to or failure of anticoagulant therapy. Other indications require evaluation with prospective randomised trials.

A tale of two countries: costs and financial incentives for provisional stenting during percutaneous coronary intervention in France and the United States.

Provisional stenting is associated with longer physician time but the use of fewer stents. This randomized controlled trial in tertiary care in French hospitals compared strategies of systematic and provisional stenting. We estimated the costs and financial incentives associated with each strategy, based on individual data on 12-month resource use drawn from a 251-patient database. Resources were evaluated using French costs; data on costs in the United States were drawn from the literature and interviews with hospital administrators in one center. In France 1-year costs were 8,267+/-528 dollars for provisional stenting and 7,973+/-553 dollars for systematic stenting, compared to 18,715 dollars and 18,632 dollars in the United States. Given the uncertainty of longterm results, the choice between stenting strategies might be guided by financial incentives. In the United States financial incentives favor systematic stenting, while in France public hospitals and physicians are neutral.

Discovery of a parachute mitral valve complex (Shone's anomaly) in an adult.

Parachute mitral valve complex is an unusual congenital anomaly described by Shone et al. It is characterized by a parachute deformity of the mitral valve associated with additional forms of left heart anomalies, such as aortic valvular stenosis and coarctation of the aorta. Fewer than 50 cases of Shone's complex have been reported in the literature, and it has only been observed in children. We report the case of a 33-year-old man who was referred to our department because of atrial fibrillation. Echocardiographic evaluation and aortogram evidenced a Shone's complex, including a parachute mitral valve anomaly, an aortic bicuspid valvular anomaly, and a coarctation of the aorta.