Search

In interventional cardiology, percutaneous transluminal coronary angioplasty (PTCA) definitely represents a revolution in the history of medicine, illustrating the medical community intention to replace aggressive revascularization intervention by less invasive procedure. Rapidly adopted by physicians and patients, its utilization has grown exponentially and in parallel, numerous technical progresses have pushed forward the frontiers of its indications. This article summarizes the principal evolution of this revascularization technique from its beginning until its last innovations, describing some technical characteristics and emphasizing on some changes and extension of its indications.

The Micra® leadless pacemaker has demonstrated both safety and efficacy in the short and mid-term as an alternative to conventional transvenous pacemakers. This technology provides a new solution, especially for patients without conventional venous approach and for older patients with atrial fibrillation presenting with symptomatic bradycardia. The advantages of this approach are multiple : a miniature technology therefore less invasive, short procedure, no stimulation leads, or need to create a surgical pocket with a reduced risk of infection. The pacemaker's battery has a life expectancy similar to that of a conventional transvenous pacemaker. In this article, we discuss the characteristics of Micra® versus the traditional transvenous pacemaker.

Coronarography consists in selective angiography of the coronary arteries obtained invasively. It represents the gold standard for the anatomical exploration of the coronary arteries and establishes the first step for the indication of possible percutaneous or surgical revascularisation. According to substantial progress, it represents an essential diagnostic tool frequently used with, despite its invasive characteristic, a very low complication's rate. The present article describes the patient's preparation for this procedure, technical modalities, major indications, contraindications and possible complications.

According to technical and pharmacological innovations and to a better comprehension in pathophysiology, interventional cardiology has continuously progressed to push forward the frontiers of its indications. Despite these evolutions, it still uses an imaging modality based on X-ray, which presents numerous limitations in interpreting three-dimensional structures. The present chapter describes two available additive technologies used to optimize the resolution and the information obtained by intravascular imaging, adding key complementary information to angiography imaging : intravascular ultrasound (IVUS) and intravascular optical coherence tomography.

The management of complex cardiovascular disease has changed considerably with the development of new care strategies. In cardiology, the «Heart Team» or literally «Equipe du cœur» occupies a prominent place in the latest European and American recommendations, particularly in the management of complex coronary or valvular diseases and in heart failure patients. The concept of «Heart Team» is based on the need for a multidisciplinary holistic approach based on evidence (respect of the recommendations of the scientific societies), the patient as a whole (comorbidities, preferences), risks and long-term benefits of the treatment selected and performed, as well as on the level of local expertise. It aims to determine the best management strategy for the patient, and perhaps to guarantee a better result (prognosis).

Alcohol septal ablation has become an attractive alternative to surgical myomectomy in symptomatic patients with obstructive hypertrophic cardiomyopathy. Its purpose is to achieve a therapeutic infarction in the sub-aortic territory responsible of the obstruction. It is indicated in symptomatic patients resistant to optimal medical treatment and having a left intraventricular gradient equal or higher than 50 mmHg, spontaneous or with exercise. The selection of candidates must be rigorous and the procedure must be performed in an experienced center, associating interventionalists and echocardiographists. Alcohol septal ablation is preferred in cases of favourable coronary anatomy, sub-aortic obstruction and absence of associated mitral valve defect. The septal alcohol technique is fast, effective and safe. The per-procedural contrast echocardiography helps identifying whether the myocardial segment is vascularized by the septal branch to be occluded. The benefits of alcohol septal ablation are comparable to those seen with surgical myectomy in terms of functional class, exercise capacity, and gradient regression. The morbidity and mortality observed in the short and mid terms are globally equivalent to that of the surgical intervention. The major complication is dominated by the occurrence of complete atrioventricular block requiring the implantation of a definitive pacemaker, a complication in sharp decline since the contrast ultrasound-guided technique has become widespread.

Percutaneous or surgical coronary revascularization must only be realized if myocardial ischemia is clearly demonstrated. In practice, this ischemia is most often seeked by non-invasive tests. These ones are unfortunately not systematically realized or may bring equivocal results compared to angiographic images. Coronary angiography remains the test of choice for the evaluation of coronary disease, but visual analysis of coronary stenosis does not confirm their hemodynamic significance. The measurement of coronary flow reserve by FFR ("fractional flow reserve") or iFR («instantaneous wave-free ratio») is a simple method to invasively assess the hemodynamic impact of a coronary lesion. Spastic angina, when suspected by clinical history, can also be confirmed during coronary angiography by the provocative methylergonovine test.

In 40 years of existence, interventional cardiology has witnessed the introduction of numerous tools and techniques that have contributed to the important application's broadening of percutaneous techniques, particulary in anatomical situations previously unfavourable, and which were, at that time, subject to surgical revascularization. Among these hostiles situations, one of the principal consists in failure to adequately dilate the lesions and/or to the inability to deliver and implant a stent appropriately, situations frequently associated with a high rate of procedural complications and poor long-term clinical outcomes. Thanks to the development of complementary dedicated techniques such atherectomy device, the treatment of most fibrotic and heavily calcified lesions has become feasible and safe. The present article describes the rotational atherectomy procedure, its indications and its clinical results.

Since the first transcatheter aortic valve implantation (TAVI) in 2002, the paradigm for the treatment of severe aortic stenosis has changed. In the recent past, medical therapy with or without balloon aortic valvuloplasty was the only option for inoperable patients but now, TAVI has become the treatment of choice for these patients and the preferred alternative for high-risk operable patients. Surgical aortic valve replacement (SAVR) currently remains the gold standard for patients at low operative risk. As randomized trials have demonstrated comparable (or better results with TAVI) between TAVI and SAVR in the high-risk population, there is now a clear trend towards performing TAVI even in intermediate-risk. Nevertheless, there are still questions regarding TAVI involving paravalvular leak, stroke, pacemaker requirements, and durability, which remain to be more definitively answered before TAVI can routinely be performed in lower risk and younger population. Improvements in patient selection, multimodal imaging, and third generation devices have significantly decreased the incidence of TAVI complications. A role for post-procedure antithrombotic or anticoagulant management remains unanswered. Waiting for current studies to provide us with clear answers to these questions, it is the Heart Team's task to determine the optimal treatment for each patient based on risk scores, frailty metrics, comorbidities, patient's preference, and potential for improvement in quality of life.

Acute coronary syndromes represent a major cause of mortality in our country. There is a very wide spectrum of clinical presentation since the actual classification of acute coronary syndromes is based on electrocardiographic presentation, that is to say based on absence or presence of ST segment elevation. When dealing with an acute chest pain, once the probability of acute coronary syndrome is established, the emergency care must follow the scientific guidelines. One of the critical steps is represented by the evaluation of ischaemic and hemorrhagic risk in order to tailor optimally antithrombotic and anticoagulation therapies and revascularization timing. This article summarizes the main points of the emergency care from the diagnosis to risk stratification.

The endothelium plays a vital role as part of the cardiovascular continuum. Risk factors such as hypertension and dyslipidemia unbalance angiotensin II - bradykinin homeostasis, leading to endothelial dysfunction and changes in vascular structure that promote atherosclerosis and thrombosis. When dealing with risk factors, treatment should focus on the prevention and restoration of endothelial function. Not all cardiovascular drugs are able to reverse vascular and structural endothelial dysfunction. Increasing levels of bradykinin is an effect of the use of angiotensin-converting enzyme inhibitors (ACE-Is), and also a fundamental part of their mode of action. The cardiovascular protection observed with ACE-I, and not with sartans, can be explained rationally by the specific effects of bradykinin on the endothelium. In the pharmacological class of ACE-Is, perindopril likely produces the strongest effects on bradykinin, which may explain, at least in part, the documented superiority of this drug in the prevention and treatment of cardiovascular disease.

Despite an incidence of about 15% of the patients undergoing coronary angiography, total chronic occlusions (CTO) are rarely revascularized by percutaneous angioplasty (PCI). Nevertheless, current evidence suggest that successful CTO-PCI improve symptoms, quality of live and long-term survival. During the last years, improvement of specific techniques for these complexes procedures and increasing experience of operators allow actually to obtain success and complications rates almost equivalent to non-CTO lesions angioplasty. This review focus on the clinical benefits of CTO revascularization and on appropriate patient selection.

In patients suffering from systemic arterial hypertension, coronary artery disease, or heart failure, beta-blockers and angiotensin-convertase enzyme inhibitors play a major therapeutic and preventive role. Coronary artery disease remains the leading cause of mortality in industrialized countries. Unless adapted preventive strategy, notably pharmacological interventions, cardiovascular events in these patients remain high. One reason for this relative failure is represented by non-adherence to treatment. A treatment consisting in an association in one pill of several different molecules should confer a higher treatment compliance and thus efficacy. This article describes the characteristics of the first available dual association between a cardioselective beta-blocker agent, bisoprolol, and an angiotensin-convertase enzyme inhibitor, perindopril arginine.

Arrhythmogenic right ventricular dysplasia is a rare, but not exceptional pathology combining the occurrence of potentially fatal arrhythmias with a gradual deterioration of the structure and function of the right ventricle. In this article, we discuss the etiopathology of the disease and emphasize the diagnostic approach.

New European guidelines about the management of non-ST elevated acute coronary syndromes emphasize the importance of early risk stratification. This article summarizes the modifications in the guidelines about risk stratification and invasive management of these syndromes.

We present the case of a patient who felt faint after a strenuous exercise. A coronary angiography was performed because of an elevated level of troponin, but it failed to demonstrat any significant coronary stenosis. We discuss the effect of strenuous exercise on cardiac biomarkers. Most previous published studies involved young trained populations. The frequency of these abnormalities in older, less trained people is unknown. Moreover, the possible impact of these abnormalities on mid- or long-term outcome is a matter of debate. Seniors practising intensive sport activities should systematically be submitted to a cardiological evaluation.

We report the case of a 81-year-old man presenting with stable exercise angina pectoris. The stress test is positive and the coronaro-angiographic evaluation demonstrates a coronary fistula between the left anterior descending (LAD) artery and the pulmonary artery trunk. The mid LAD presents a significant lesion after the origin of the fistula. A cardiac computed tomography is used before surgical treatment. Coronary artery fistulas are unusual congenital or acquired coronary artery abnormalities in which blood is shunt into a cardiac chamber, great vessel or other structure. Low-pressure structure is the most common site of drainage of the coronary fistula. The clinical presentation of coronary fistulas is mainly dependent on the severity of the left-to-right shunt. Various cardiac imaging modalities are used for diagnosis and anatomical exploration before surgical or percutaneous intervention if the closure of the fistula is indicated.

Cardiac imaging has always been a challenge because of the continuous movement of the heart. Cardiac computed tomography (CT) has undergone an accelerated progression over the past decade, due to the combination of the high-speed rotation of the X-ray tube, the ECG-gating technique and the infra-millimeter spatial resolution. Multidetector CT allows visualisation of the coronary artery lumen and the detection of coronary stenosis after intravenous injection of contrast medium. Studies have demonstrated a high negative predictive value of CT coronary angiography (CTCA). CTCA may be reasonably used for the assessment of symptomatic patients, especially in the setting of equivocal treadmill or functional testing. Also, CTCA allows assessment of coronary bypass graft patency and recognition of aberrant coronary arteries. Limitations in the use of this technique exist: atrial fibrillation and other cardiac arrhythmias remain a contraindication; severe calcifications are the most frequent reason for impaired assessment of coronary arteries. High radiation doses prohibit the use of this test as a screening tool for asymptomatic patients.

Inflammation plays a pivotal role in atherosclerosis; being present in all steps of the pathology, from initiation to the progression of the lesions to the development of vulnerable plaques and clinical destabilisation. Therefore, systemic markers of inflammation have emerged to predict future cardiovascular events in patients initially admitted for unstable syndromes, but also in healthy subjects. These markers can identify high risk patients and they are used to adapt ideal treatment to the patient's profile. The implication of the inflammation process in the treatment strategies is described in the last part of the article.

Chest pain represents a frequent motivation for consultation in which the differential diagnosis is not always easy. We present a case where a misdiagnosis lead to serious complications. Therefore we review the clinical and electrocardiographic characteristics of the evoked diagnosis.

Acute coronary syndromes are a major health care problem which remains associated with high rates of mortality, myocardial infarction and rehospitalisation after hospital discharge for acute treatment. The general practitioner has a critical role in the management of these patients. Physicians have to ensure an adequate control of all coronary risk factors. Systematic use of statines and aspirin is recommended. Also, the use of clopidogrel, fibrates, beta blockers and ACE inhibitors should be considered in some circumstances. Conversely, hormone replacement therapy in women, antioxydants and nitrates in the absence of angina are ineffective.

We report the case of a 54 year old man presenting atypical chest pain. The echocardiogram showed a dilatation of the coronary sinus. Subsequently the angiographic evaluation with cardiac catheterization demonstrated a coronary artery fistula between the circumflex artery and the coronary sinus and between a megaanevrysmal right coronary artery and the coronary sinus. No significant left to right shunt was discovered, however.

Mitral valve repair has demonstrated its superiority over valve replacement. Mitral valve repair constitutes the optimal therapeutic option in case of degenerative dystrophic, rheumatic, congenital or ischemic mitral valve disease. These surgical techniques can also be successfully and advantageously applied in case of bacterial endocarditis or tumoral valvular disease. We report a case of staphylococcal endocarditis and another case of posterior leaflet fibroelastoma to show the place of conservative mitral surgery in these unusual indications.

We report here the case of a 33-year-old woman admitted in hospital for eclampsia. An infectious course led to the diagnosis of tuberculosis breast abscess with laryngitis and tuberculous bilateral excavated bronchopneumonia. The isolated strain demonstrated resistance to the principals antituberculous agents. However outcome was favorable after cesarean and treatment adapted to sensitivity studies.