[Which elderly with stable angina should be referred for cardiac surgery?] / Quel patient âgé, ayant un angor stable, doit être adressé en chirurgie cardiaque ?

The choice of revascularization of coronary patients, if it is well codified in the general population, remains in the elderly subject a daily dilemma for the clinician. We report 4 clinical cases (80 years and over) elective for coronary artery bypass or percutaneous coronary transluminal angioplasty (PTCA). No randomized studies dedicated to this population are available. Nevertheless, according to the registries, surgery versus PTCA has a superior benefit in the medium and long term, despite higher mortality and stroke. The coronary lesions in this population are actually more complex, usually leading to surgery compared to a younger population. However, the choice of the revascularization method is difficult depending on the co-morbidities and the higher surgical risk. What must be taken into account here are the cognitive abilities, the risk of cognitive decline, the frailty of the patient (correlated with mortality), frailty being a subjective data given without a consensually recognized scoring system. The indication of the revascularization method should include mortality risks as well as morbidity, in particular the potential risk of deterioration of the general condition and autonomy of patients, particularly the elderly. Randomized studies dedicated to this population, taking into account mortality and morbidity, and in particular the "concept of frailty", would make it possible to describe the specificities of aging subjects in recommendations and good practices.

[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.

[Lympho-epithelial thymoma revealed by a cardiac tamponade]. / Thymome lympho-épithélial révélé par une tamponnade.

The authors report the case of a 62 year old patient admitted for a tamponade, revealing a mixed lympho-epithelial thymoma with invasion of the pericardium, the aorta and of the pulmonary arteria. The histological diagnosis was confirmed by a surgical biopsy performed after emergency pericardiocentesis. A neoadjuvant chemotherapy was administered followed by incomplete surgical resection and then a post operative radiotherapy. A local relapse was diagnosed at one year follow up by CT scan and a second line chemotherapy was administered. No further relapse occurred and patient was alive at four years.