[Rotational ablation: back to the future]. / Le Rotablator: le retour.

In the late 1980s, many alternative methods to coronary angioplasty were sought, among which rotational ablation was one of the most popular. With the huge development of coronary stents, this technique, however, was progressively left aside. More recently, though, rotational ablation has reappeared as a unique technique for the most calcified lesions and is used in a small but not negligible percentage of patients with success rates over 95% in recent series.

[Large coronary aneurysm diagnosed during an acute coronary syndrome. A case report and review of the literature]. / Volumineux anévrisme coronaire découvert a l'occasion d'un syndrome coronaire aigu. A propos d'un cas et revue de la littérature.

Coronary aneurysm is an uncommon variant of coronary atherosclerosis. It usually involves the right coronary artery and is often associated with significant coronary stenosis. It may be revealed by an acute coronary syndrome (ACS). We report the case of a 49 year-old woman in whom a large coronary aneurysm of the left anterior descending artery was revealed by an ACS. Coronary angiography remains the gold standard diagnosis procedure, but spiral computed tomography may be of interest to specify the location and nature of the aneurysm, and thus guide surgical or percutaneous treatment.

[Acute myocardial infarction complicating primary antiphospholipid syndrome after aspirin and steroids withdrawal]. / Survenue d'un infarctus du myocarde après arrêt de l'aspirine et des corticoïdes oraux chez une patiente présentant un syndrome des antiphospholipides.

A 24-year-old woman, with known antiphospholid antibodies (APS), presented with an acute myocardial infarction (AMI) that occurred three months after delivery. No risk factors for arteriosclerosis and no past history of arterial/venous thrombosis were noted. During pregnancy, aspirin prophylaxis was prescribed and followed by steroids after caesarian section. Steroids withdrawal was followed by AMI. Immediate coronary angiography revealed thrombotic occlusion of the left descending coronary artery; PTCA was successfully performed. She was discharged with an antiplatelet and anticoagulant regimen. No recurrent coronary event occurred during follow-up.

[Diastolic heart failure. Physiopathology]. / Insuffisance cardiaque diastolique. Physiopathologie.

BACKGROUND: Systolic dysfunction of the left ventricle is not the only mechanism of heart failure. An increasing number of patients are found to have heart failure with an ejection fraction > or = 40%. The proportion of heart failure patients with "diastolic" (or more appropriately preserved systolic function) heart failure increases with age. This clinical entity currently accounts for 30 to 40% of all hospitalizations for heart failure and in patients over 80 is found in more patients than is systolic dysfunction. PATHOPHYSIOLOGY: Diastolic heart failure generally associates prolonged ventricular relaxation with reduced left ventricular capacity for distention. The main causes are ischemic, hypertensive and age-related heart disease. Concentric remodeling of the left ventricle, with or without hypertrophy, always leads to diastolic functional disorders. A triggering factor is almost always found for episodes of acute congestion. CONCLUSION: The incidence of "diastolic" heart failure increases with age. Physicians should be aware of the complex underlying pathophysiological mechanisms.

[Diastolic heart failure. Signs and diagnosis]. / Insuffisance cardiaque diastolique. Signes et diagnostic.

A WELL-RECOGNIZED ENTITY: Diastolic heart failure is an increasingly common diagnosis. Signs may be misleading and positive etiological diagnosis remains difficult. CLINICAL SIGNS AND COMPLEMENTARY INVESTIGATIONS: Fatigue, and most importantly dyspnea, are the cardinal signs of diastolic heart failure. Cor pulmonale is often the inaugural sign. The physical examination contributes little to diagnosis. The chest x-ray shows a small heart. Electrocardiographic anomalies are almost always found. A hemodynamic exploration of the right heart, the key diagnostic tool not always performed in routine work-ups, evidences increased filling pressure of the left ventricle. Doppler-echocardiography is used widely. It demonstrates preservation of the left ventricle function (normal ejection fraction) and visualizes the anatomic subtratum of the diastolic dysfunction, quantifying filling and relaxation disorders and allowing an indirect estimation of pulmonary pressures. In the future, it will be possible to assay atrial natriuretic peptide which will provide a most useful tool for the positive diagnosis of this type of heart failure. CONCLUSION: The diagnosis of diastolic heart failure is complex, warranting rigorous, and critical, evaluation of left ventricular filling using noninvasive methods, particularly Doppler-echocardiography.

[Diastolic heart failure. Treatment]. / Insuffisance cardiaque diastolique. Traitement.

THERAPEUTIC OPTIONS: Many therapeutic options are proposed for the treatment of diastolic heart failure although no consensus has been established. In experimental trials, several drugs have demonstrated a potentially beneficial effect on ventricular diastolic dysfunction and could be used for diastolic heart failure: nitrate derivatives, converting enzyme inhibitors, angiotensin II antagonists, spirolactones and bradycardia agents. CLINICAL PRACTICE: In everyday clinical practice, low-dose diuretics and treatments aimed at reducing the triggering factor leading to episodes of heart failure are used alone or in combination with treatments aimed at the underlying cause of the diastolic dysfunction: betablockers, calcium inhibitors or nitrate derivatives for ischemic heart disease, drug therapy for hypertension, anti-diabetes agents, anti-arrhythmic agents for atrial fibrillation. Digitalics are not indicated. In experimental trials, converting enzyme inhibitors and angiotensin II antagonists have demonstrated interesting properties for the left ventricle but to date are not warranted for diastolic heart failure. TREATMENT OF THE CAUSE: Due to the lack of consensus on the optimal treatment for diastolic heart failure, most clinicians rely on treating the underlying heart disease and triggering factors.