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Résumé: But du travail: Examiner l’effet d’un antécédent d’angioplastie sur les résultats péri-opératoires de la revascularisation chirurgicale. Méthodes: Deux de cent quarante patients consécutifs candidats à une revascularisation chirurgicale ont été inclus, groupe A (Gp A) (n =35) ayant un antécédent d’angioplastie et groupe B (Gp B) (n =205) sans procédures d’angioplasties préalables. Résultats: Les patients du Gp A avaient plus d’antécédents d’infarctus (48,6 % vs 36,6 ; p =0,003), une atteinte coronaire plus diffuse (p =0,0001) et présentaient plus d’angor instable (45,7 % vs 39 % ; p =0,04). Le nombre de pontage réalisé était de 2,6 (Gp A) vs 2,07 (Gp B) (p =0,017). Les pics moyens de troponine I étaient de 4,36 (Gp A) vs 4,26 (Gp B) (p = ns), le volume moyen de saignement à 24 heures était de 962mL (Gp A) vs 798mL (Gp B) (p =0,004), le nombre moyen de transfusion par culot globulaire était de 3,63 (Gp A) vs 2,5 (Gp B) (p =0,006). Un antécédent d’angioplastie ressort comme un facteur prédictif indépendant de mortalité hospitalière (OR 2,24, 95 % CI (1,52–2,75), p <0,01). Conclusion: Les patients aux antécédents d’angioplastie ont une atteinte coronaire sévère et plus diffuse. La morbimortalité postopératoire semble être significativement plus marquée que chez les patients sans angioplastie préalable. [ABSTRACT FROM AUTHOR]

Abstract: Background: Radiofrequency ablation for incessant and symptomatic premature ventricular complex (PVC) localized in a left papillary muscle is uncommon. 3D mapping and cardiac MRI may be useful to achieve ablation success. Clinical Case: A fifty-four-years-old man was referred for palpitations. His medical history included placement of a right coronary artery stent six years before and a normal ejection fraction (EF). The Holter monitoring under beta-blocker therapy (46% PVCs) and ECG showed monomorphic PVCs with a right bundle branch block, positive concordance with V5 transition and a superior axis, with no R/T phenomenon. During two separate electrophysiologic procedures (recurrence), a 3D mapping (Velocity, ST-Jude Medical™) system was used combined with an irrigated tip catheter. The earliest site of PVC activation documented with the mapping system was near the posterior papillary muscle. Pace mapping in this area showed nearly 90% concordance. After 2126 seconds of radiofrequency applications, there were no more PVC and no inducible arrhythmia. Post procedure cardiac MRI showed scar in the inferior-lateral area of the left ventricle including a section of the posterior papillary muscle. Scar included 50% of the thickness of the wall (previous 2005 myocardial infarction and radiofrequency lesions). Residual EF was 55%. At 2 months of follow-up, the patient was asymptomatic, with only 53 PVCs on 24-hour Holter monitoring. Patient was maintained under beta-blocker therapy for his coronary artery disease. At six-month follow-up, he is still asymptomatic. Conclusion: This case report stresses the role of cardiac MRI and 3D cartography systems for successful treatment of papillary muscle PVCs associated with ischemic cardiomyopathy, which still represent a therapeutic challenge. [Copyright &y& Elsevier]

Abstract: The aim of this article is not to present a general academic review on primary angioplasty in patients with ST-elevation myocardial infarction, but rather to focus on some practical points that directly concern cardiologists who perform primary percutaneous interventions in these patients. We detail recent data about the use of the radial artery approach, thromboaspiration, new oral inhibitors of P2Y12, selective use of anti-GPIIb/IIIa, high dose of peri-procedural statin therapy, choice of the best stent, and the best approach for treating non-culprit lesions in patients with multivessel coronary artery disease. The changes observed in the overall management of patients undergoing primary PCI for ST-elevation myocardial infarction are likely to have participated in the decrease in mortality observed in several registries. New European guidelines on the management of STEMI, taking into account these diverse aspects, have just been published. [Copyright &y& Elsevier]

Abstract: Bivalirudin, with provisional GP IIb/IIIa inhibitor use allows the same protection against ischemic complications while reducing the hemorrhagic complications compared with the systematic association of a GP IIb/IIIa inhibitor plus heparin (The Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events-2 [Replace-2]). In clinical practice, the use of heparin is not systematically associated with a GP IIb/IIIa inhibitor. That''s why we studied the clinical and economic interest of bivalirudin only versus heparin (UFH) only. Opened pragmatic monocentric study carried out in 2007. We made a chronological matching: for each patient treated with bivalirudin, we included the next patient with the same clinical presentation treated with unfractionated heparin. Ninety-two patients were included (46 in each group). The need for a GP IIb/IIIa inhibitor during the PCI was not significantly different between the two groups (p =0.11). No major hemorrhagic complications were observed in the two groups. Prevalence of ecchymosis was not significantly different: 22 % in the UFH group versus 13 % in the bivalirudin group (p =0.27). The average troponin level the next day was significantly higher in the bivalirudin group (p =0,049), although the change in troponin levels before and after the procedure was similar in the two groups. The average cost by patient of anticoagulation by bivalirudin and HNF is very different, respectively 473±150 and 51±146 € (p =0.0001). Bivalirudin can be an interesting alternative for patients with a high risk of having complications. But considering its cost this therapy must be used only for selected patients. [Copyright &y& Elsevier]

Abstract: Percutaneous coronary interventions (PCI) of complex coronary lesions in patients with severely depressed left ventricular (LV) function may increasingly constitute an alternative to surgical revascularization. The availability of hemodynamic support devices offers a promising option to reduce PCI-related complications in such high-risk procedures. We report the case of a successful distal left main coronary artery T-stenting supported by the Impella Recover LP 2.5 assist device in a patient with severe LV dysfunction. [Copyright &y& Elsevier]

Abstract: This review was undertaken to objectively analyse the cumulated medical literature on techniques of myocardial revascularization (angioplasty, bare metal stenting, drug eluting stenting, coronary artery surgery) in multivessel coronary artery disease. Randomized trials, meta analyses and registries comparing these treatment modalities show a short and long term advantage of surgery over percutaneous techniques for angina recurrence and need for repeat revascularization, although mortality and myocardial infarction rate do not seem statistically different. Diabetes mellitus, chronic renal failure and female gender represent high risk subgroups. Data on drug eluting stents are to date limited to the short term; however, it does not seem that drug eluting stents have resolved the need for repeat revascularization. Stenting addresses focal lesion whereas future revascularization occurs on other coronary sites by progression of coronary disease. Cardiologists should objectively inform the consenting coronary multivessel disease patient on the risk of repeat revascularization inherent to percutaneous techniques and on the weight of actual data favouring surgery in multivessel disease. [Copyright &y& Elsevier]

Abstract: Angioplasty of coronary chronic total occlusion (CTO), defined by complete occlusion of coronary vessel with TIMI 0 flow greater than 3 months, has been avoided for many years, single vessel diseases being medically treated and multivessel diseases sent to surgeons mainly because a low success and high restenosis rates. Major improvements in devices and techniques mainly coming from Japan created a new concern about when and how to perform PCI of CTO. Clearly CTO are stable lesions but during the last years it was demonstrated that while comparing success and failure of recanalization, success improved symptoms, ischemia, left ventricular function, and even survival. Reopening CTOs can also decrease the risk of death and cardiogenic shock associated with a future acute coronary event. Selection of cases for PCI is based on well-known predictors of failure (calcifications, tortuosities, length of occluded segment and age of occlusion), on operator''s experience and on a proof of viability and ischemia of the myocardium depending from occluded vessel (MRI). Many specific devices (powerful wires, microcatheters and coaxial balloons, specific guiding catheters, Tornus) and techniques (anterogrades and retrogrades through trans-septal collateral vessels) have been developed to increase success rate (70 to 90% in high volume operator hands). Outside of coronary perforations which are no more frequent in CTO lesions, some specific problems are important limitations: X-Ray exposure, contrast medium volume, and cost. With the success rate these complications are good reasons to have these procedures (or the most complex) performed by specialists. [Copyright &y& Elsevier]

The techniques of video-assisted surgery have been recently applied to aortoiliac surgery. The choices between first the retroperitoneal approach or the transperitoneal approach and the place of video-assisted surgery in relation to totally laparoscopic surgery are at the centre of debates. The aim of this clarification is to relate the evolution of laparoscopic aortoiliac surgery for occlusive disease and aneuvrysms through a review of the literature on this subject. [Copyright &y& Elsevier]

Summary: We compared 88 octogenarians who had a coronary surgery with 165 patients aged between 60 and 70, the two groups having been paired according to the main risk factors. Operative mortality was similar in both groups. Long-term survival was lower for the octogenarians but higher than for the same age French population. [Copyright &y& Elsevier]