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Background With the emergence of coronary computed tomography (CT) angiography, anomalous aortic origin of a coronary artery (ANOCOR) is more frequently diagnosed. Fractional flow reserve derived from CT (FFRCT) is a noninvasive functional test providing anatomical and functional evaluation of the overall coronary tree. These unique features of anatomical and functional evaluation derived from CT could help for the management of patients with ANOCOR. We aimed to retrospectively evaluate the physiological and clinical impact of FFRCT analysis in the ANOCOR registry population. Methods and Results The ANOCOR registry included patients with ANOCOR detected during invasive coronary angiography or coronary CT angiography between January 2010 and January 2013, with a planned 5‐year follow‐up. We retrospectively performed FFRCT analysis in patients with coronary CT angiography of adequate quality. Follow‐up was performed with a clinical composite end point (cardiac death, myocardial infarction, and unplanned revascularization). We obtained successful FFRCT analyses and 5‐year clinical follow‐up in 54 patients (average age, 60±13 years). Thirty‐eight (70%) patients had conservative treatment, and 16 (30%) patients had coronary revascularization after coronary CT angiography. The presence of an ANOCOR course was associated with a moderate reduction of FFRCT value from 1.0 at the ostium to 0.90±0.10 downstream the ectopic course and 0.82±0.11 distally. No significant difference in FFRCT values was identified between at‐risk and not at‐risk ANOCOR. After a 5‐year follow‐up, only one unplanned percutaneous revascularization was reported. Conclusions The presence of ANOCOR was associated with a moderate hemodynamic decrease of FFRCT values and associated with a low risk of cardiovascular events after a 5‐year follow‐up in this middle‐aged population.

International audience; We describe a patient with coronavirus disease 2019 (COVID-19) and multiple concomitant thromboses occurring on the 9th day of hospital stay. Thromboses were found in distinct zones of the aorta, as well as in the renal, humeral, and pulmonary arteries. The extensive biological workup performed following this catastrophic thrombotic syndrome found no evidence for underlying prothrombotic disease. In light of current evidence regarding endothelium abnormalities related to COVID-19, this extreme case of catastrophic thrombotic syndrome suggests that COVID-19 can induce severe arterial thrombosis following intense endothelial activation.

Patients with familial hypercholesterolemia (FH) are prone to develop acute myocardial infarction (AMI) at a younger age.The aim of the present study was to assess 5-year outcomes after AMI according to the presence of FH in a large multicenter cohort of patients.The French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction consists of nationwide surveys recruiting patients over a 1- to 2-month period every 5 years. Patients recruited in 2005 and 2010 were followed up to 5 years.Of 5147 patients discharged alive and in whom FH status could be assessed, 2.8% had probable/definite FH, using an adapted Dutch Lipid Clinic score. They were 12 years younger, on average, than non-FH patients. Before adjustment, their 5-year survival and event-free survival did not differ from non-FH patients. After adjustment, however, both mortality (hazard ratio [HR] 1.82, 95% confidence interval [CI] 1.15-2.89; P = .011) and the combined endpoint of death, AMI, or stroke (HR 2.22, 95% CI: 1.51-3.26; P .001) were higher in FH patients. The higher risk in FH patients was also present in patients receiving high-intensity lipid-lowering therapy at discharge: adjusted HR for mortality 2.29, 95% CI: 1.18 to 4.47, P = .015; HR for cardiovascular events 2.57, 95% CI: 1.48 to 4.48, P = .001. Concordant results were observed in propensity score-marched cohorts.The risk of long-term mortality and cardiovascular events is twice as high in FH than in non-FH patients, when adjusted on baseline characteristics, even for those receiving high-intensity lipid-lowering therapy. Additional therapeutic measures are needed in these patients.

INTRODUCTION Infectious endocarditis is still a challenge with a high mortality and complication rate despite the progress made in its management. DESCRIPTION OF CLINICAL CASE A 58 years old female, with a history of mitral and aortic mechanical prosthesis for rheumatic valvular disease and mitral infectious endocarditis with Aggregatibacter Actinomycetemcomita due to an apical abscess was referred to our service for persistent fever. The clinical examination revealed irregular mechanical prosthesis beats, with no heart murmurs and no signs of heart failure, but with a tender splenomegaly. The laboratory tests showed an inflammatory syndrome, but no positive blood cultures. An extensive panel for endocarditis was negative for Coxiella burnetii, Brucella Spp, Legionella Spp, Mycoplasma Spp and for the immunology markers (rheumatoid factor, antinuclear antibodies and anti-cardiolipin antibodies) ECG AF, 88 bpm, PVC bigeminy, LBBB. Infectious endocarditis was the most likely diagnosis considering the fever, the inflammatory syndrome, the presence of the mechanical valves and the history of endocarditis. An echocardiography was performed that showed a non-dilated left ventricle with a preserved EF, no aortic prosthesis dysfunction, nor mitral; a dilated RV with normal function, moderate tricuspid regurgitation, no intracardiac masses and no pericardial effusion. The TEE revealed no vegetation, no abscess or pseudoaneurysms and no dehiscence of the prosthetic valves. The Endocarditis Team was reunited and empirical antimicrobial therapies with Amoxiciline, Gentamicine and Cloxaciline for 6 weeks, as well as a PET scan were recommended. The PET-CT revealed abnormal fixation in the posterior-inferior part of the aortic valve. As we had only one major criterion and two minor criteria for the diagnosis of endocarditis a radiolabeled leukocytes SPECT CT that showed no pathological fixation was realised. The result was inconclusive as it was performed at the end of the antimicrobial treatment. A computed tomography of the brain, thorax, abdomen and pelvis didn’t reveal any vascular phenomena. The tender splenomegaly was secondary to two hemangiomas. Also a dental computed tomography revealed an apical abscess of 1.2 that was treated after discharge with antibiotic prophylaxis. DISCUSSION This clinical case confirms that the diagnosis on infectious endocarditis can be challenging in patients with prosthetic valves. The multimodality imaging is of major importance for the diagnosis of these patients. Additionally the microbiological criteria was not met in this case as it was a blood culture-negative endocarditis with a history of previous antibiotic therapy. CONCLUSION Our knowledge of infectious endocarditis is constantly evolving. Blood culture negative endocarditis accounts for one third of cases and is still a challenge. The Endocarditis Team and multimodality imaging play a central role in the diagnosis and treatment of these patients. Abstract P1266 Figure. PET-CT showing AV abnormal fixation

Conservative management is the first-line treatment for spontaneous coronary artery dissection (SCAD) with stable haemodynamic status and thrombolysis in myocardial infarction three flow on angiography. However, in a few very specific patients, recurrent ischemia, or haemodynamic instability necessitates revascularization. Here, we describe a case of successful optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) with a cutting balloon. We performed fenestration at multiple decompression sites prior to stenting in an intramural haematoma with luminal compression. Rescue management of SCAD with luminal compression is a critical issue, because SCAD is an emergent clinical condition affecting young patients with a severe prognosis. To our knowledge, there are no large published series evaluating procedural success rates and long-term follow-up of this technique.

Objectives We evaluated the predictors of in-stent restenosis (ISR) and the angiographic patterns for ostial lesions of the right coronary artery (RCA) to better identify this population at risk. Background Although the prevalence of ISR of the RCA is diminishing, the mechanisms of restenosis are still unknown. Methods Between January 2003 and December 2017, we recruited 550 consecutives patients undergoing a coronarography for ostial lesion of RCA. 149 angioplasties are realized for acute coronary syndrome (ACS) or stable angina. Restenosis, defined as a stenosis within 5 mm distance, proximal or distal to the previously placed stent, with ≥ 50% diameter stenosis, appeared for 46 patients. These patients were included in the IRS+ group. We defined also an IRS- group composed by 44 patients without restenosis in the initial population. We used Chi square test and Mann Whitney test for univariable analysis of ISR predictors. Multiple logistic regression analysis was used to determine the independent factors of ISR, and the adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were calculated. Results We diagnosed 46 of 149 patients with RCA-ISR, which were classifiable between 19,8% of restenosis in case of implantation of a drug-eluting stent (DES) and 53,6% of restenosis in case of bare metallic stent (BMS). By univariable analysis we found 7 statistically significant predictors of ISR in our population: mono-troncular lesions, ad-hoc angioplasty, BMS stenting, guiding-catheter diameter, early generation DES, post-dilatation, anti-platelet drugs. After multivariable analysis, ad-hoc angioplasty and the BMS stenting were the only independent predictors of ISR (aOR, 0.23; 95% CI, 0.39–0.58; P = 0.009 and respectively aOR, 0.21; 95% CI, 0.39–0.55; P = 0.002) ( Fig. 1 ). Conclusion We found a high prevalence of RCA-ISR in our study population. The risk of ISR is higher in patients with ad-hoc angioplasty or in case of BMS implantation.

An 83-year-old female was admitted to the cardiac care unit of Hopital Emile Muller (Mulhouse, France) due to acute respiratory distress. She had a history of recurrent pulmonary emboli that had led to group-IV chronic thromboembolic pulmonary hypertension (CTEPH) according to the classification of pulmonary arterial hypertension (PAH) set by the World Health Organization (WHO). CTEPH was treated from 2013 with long-term oxygen therapy and oral anticoagulation. She presented with a dramatic increase in dyspnoea accompanied by acute chest pain with dorsal irradiation. She was in respiratory distress with blood saturation at 70% in ambient air. She showed signs of right-heart failure (turgid jugular veins, lowerlimb oedema). Under 5 l of O2, arterial blood gases were 81 mm Hg for paO2 and 50 mm Hg for paCO2, whereas bicarbonate was −29 mmol/l, brain natriuretic peptide was 167 ng/l, and D-dimer was 1151 ng/ml. Right-axis deviation with right ventricular hypertrophy was found upon electrocardiography. Chest radiography revealed reticular/ nodular densities in the right base with alveolar opacity in the left base, which led us to suspect pneumonia. Trans-thoracic echocardiography (TTE) demonstrated: normal left ventricular ejection fraction

Resume But de l’etude La bivalirudine, inhibiteur direct de la thrombine, a montre une amelioration du pronostic des syndromes coronariens aigus principalement par une diminution des complications hemorragiques graves. Cette etude observationnelle a evalue l’evolution hospitaliere de patients presentant un infarctus aigu traite en prehospitalier par bivalirudine avant angioplastie primaire. Patients et methodes Nous avons inclus, de juin 2010 a juin 2012, tous les patients avec un infarctus aigu recevant en prehospitalier de la bivalirudine administree en bolus de 0,75 mg/kg suivie d’une perfusion de 1,75 mg/kg par heure jusqu’a l’arrivee en salle de catheterisme et eventuellement poursuivie apres l’angioplastie primaire. Resultats Nous avons inclus 152 patients âges de 57,6 ± 11,6 ans. Une dose de charge de 60 mg de prasugrel a ete donnee en prehospitalier chez 77 % des patients. La coronarographie principalement par voie radiale (77,6 %) precedait une angioplastie reussie dans 97,3 % des cas. La bivalirudine a ete poursuivie apres la procedure dans 81,6 % des cas. L’evolution a ete marquee par deux deces (1,3 %) et deux re-infarctus (1,3 %) dont un lie a la seule thrombose de stent (0,6 %). Les complications hemorragiques graves s’averaient egalement limitees selon la definition Gusto (0,6 %), Timi (0,6 %) ou Horizons-MI (4,6 %). Le risque hemorragique n’apparaissait pas plus important quand la bivalirudine etait maintenue apres l’angioplastie primaire. Conclusion L’administration en prehospitalier de bivalirudine en vue d’une angioplastie primaire apparait efficace et sure sur le risque ischemique et hemorragique lors de la phase hospitaliere.

IF 4.638; International audience; Background: Few clinical trials have focused on populations with a history of distant myocardial infarction (MI). The PEGASUS trial assessed the impact of dual antiplatelet therapy in such patients, selected by enrichment criteria of high cardiovascular risk. Whether the PEGASUS population reflects the risk of a broader post-MI population is questionable. We analyzed whether 4-year mortality of a routine-practice population would differ according to the inclusion and exclusion criteria used in PEGASUS.Methods: FAST-MI is a nationwide French registry recruiting acute MI patients in November 2005; 2490 patients alive and without recurrent MI at one year were classified into three groups: Group 1 ("PEGASUS-like" population; n = 1395; 56%), Group 2 (population having = 1 exclusion criterion for the trial; n = 677; 27%), and group 3 (population meeting neither the PEGASUS inclusion nor exclusion criteria; n = 418, 17%).Results: Group 1 patients were older than Group 3 patients, with higher GRACE scores, more comorbidity, and less STEMI, but were younger than the PEGASUS trial population. Enrichment criteria successfully defined a population at higher risk: 4-year survival 83% in Group 1, 97% in Group 2, and 68% in Group 3 (P < 0.001). Among risk-enrichment criteria, age alone was highly discriminant: in PEGASUS-like patients, survival was 78% in those = 65 versus 94% in those

Resume But de l’etude Ce travail a evalue l’evolution hospitaliere et a long terme de patients fumeurs de moins de 50 ans traites pour un infarctus inferieur a 12 heures par angioplastie coronaire. Patients et methode C’est une etude retrospective avec analyse de survie par methode de Kaplan-Meier chez des patients inclus de decembre 2003 a fevrier 2008. Resultats Nous avons inclus 93 patients âges de 42,8 ± 5,2 ans avec une intoxication tabagique de 27,7 ± 12,7 paquets-annee. Trente et un patients (33,3 %) etaient dyslipidemiques et 36 patients (42,4 %) avaient un antecedent familial de coronaropathie. Trente patients (32,3 %) presentaient un infarctus anterieur et quatre patients (4,4 %) etaient en Killip superieur a 2. Une angioplastie coronaire a retabli un flux TIMI 3 dans le vaisseau coupable dans 96,8 % des cas. Un patient est decede de choc cardiogenique. Avec un suivi de 85 patients sur 20,0 ± 15,6 mois, on observait une survie sans deces de 98,2 % et une survie sans evenement cardiaque de 87,9 % a 24 mois. Soixante-douze patients (85,7 %) prenaient un betabloquant, 81 patients (96,4 %) de l’aspirine, 75 patients (89,3 %) une statine et 64 patients (76,2 %) un inhibiteur de l’enzyme de conversion. Seulement 50 patients (58,8 %) etaient non fumeurs. Conclusion Ainsi, l’evolution hospitaliere et a long terme de l’infarctus du jeune sujet fumeur, traite par angioplastie coronaire, est de bon pronostic. L’adhesion au traitement preventif secondaire est correcte mais il persiste un fort taux d’echec du sevrage tabagique.

Among 10% of all patients presenting with non ST elevation acute coronary syndromes (ACS), coronary angiography do not show non lesions at all (50%) or mild atheromatous stenosis (50%). ACS without angiographic stenosis are more prevalent in female sex and young patients but can be seen in older ones and in men. Pathogenic mechanisms include acute evolution of vulnerable non-significant plaques and endothelial dysfunction. In hospital and mean term prognosis is not as benign as expected. Six months deaths and myocardial infarction incidence is around 6%. Numerous rehospitalizations due to ischemic recurrences are also very often seen. Therefore, such surprising coronary angiograms do not preclude a fair follow-up. These patients need a careful therapeutic strategy.

Resume Cette etude a evalue le pronostic hospitalier de patients octogenaires pris en angioplastie primaire pour un infarctus du myocarde de moins de 12 heures. Le devenir a long terme s'est interesse a la mortalite et a l'evolution sociale a partir des echelles IADL et IADL-E correspondant a l'autonomie physique et au niveau de dependance. Nous avons inclus de 1999 a 2005, 47 patients âges de 83,5 ± 3,2 ans. Une desobstruction de l'artere coupable avec flux TIMI 3 a ete obtenue chez 45 patients (95,7 %). La mortalite hospitaliere etait de 25,5 et de 4,2 % en l'absence de complication hemodynamique. Une analyse multivariee identifiait un score de Killip superieur a 1 comme facteur predictif de mortalite hospitaliere (OR = 8,9 et p = 0,05). Le taux de survie sans deces sur un suivi de 26,3 ± 18,3 mois etait de 82,2 % a 24 mois et de 70,6 % a 48 mois selon la methode de Kaplan-Meier. En analyse multivariee, une absence d'aspirine en sortie d'hospitalisation etait associee a un moins bon taux de survie sans deces (OR = 34,8 et p = 0,04). D'apres l'evolution des scores IADL et IADL-E, les patients jouissaient, avant l'infarctus, d'une excellente autonomie et de bonnes capacites au quotidien qu'ils ont gardees sur le long terme. Ainsi, l'infarctus aigu chez l'octogenaire traite par angioplastie primaire reste greve d'une lourde mortalite sur le court et le long terme mais les survivants conservent une excellente autonomie au quotidien.

Resume Objectif Evaluer les resultats et la faisabilite de la technique de fermeture percutanee des foramens ovals permeables (FOP) avec anevrisme du septum interauriculaire (ASIA) chez des patients jeunes ayant presente un accident neurologique aigu embolique cryptogenique. Patients et methodes Dix-huit patients : 14 accidents vasculaires cerebraux (AVC) et quatre accidents ischemiques transitoires (AIT) avec un FOP large (grade III a l'epreuve de contraste) et un ASIA important (excursion superieure a 15 mm) a l'echographie transœsophagienne (ETO). L'âge moyen est de 48,2 ans : homme 61 %, femmes 39 %. Les patients ont peu de facteur de risque cardiovasculaire (0,83/patient) et 38 % ont presente des accidents neurologiques multiples. La fermeture percutanee est realisee sous anesthesie generale avec ETO et implantation d'une prothese Amplatzer. Un controle ETO est realise six mois apres la fermeture. Resultats Aucune complication perprocedure n'est survenue. Apres 72 heures, un patient a presente une complication majeure : une fistule arterioveineuse femorale necessitant une chirurgie. Cinq patients ont presente une complication mineure : deux hematomes non compliques du Scarpa, deux troubles du rythme supraventriculaire transitoires, un deplacement secondaire minime asymptomatique de prothese sans necessite de chirurgie. Dix-sept patients ont au un controle ETO a six mois : le shunt a disparu pour 95 % des patients, aucun thrombus n'est retrouve. Aucun des 18 patients n'a presente de recidive d'evenement embolique (suivi moyen 19,2 mois). Conclusion La mise en place d'une technique de fermeture des FOP-ASIA est a faible risque et effective.

Resume Objectifs A partir d’un registre prospectif multicentrique, nous avons evalue dans 3 centres de cardiologie interventionnelle alsaciens non universitaires la prise en charge et la faisabilite de l’angioplastie coronaire transluminale (ACT) a la phase aigue du syndrome coronaire aigu. Methodes Nous avons inclus tous les malades admis dans un des centres participants du 1er janvier 1999 au 31 decembre 2002 et ayant un infarctus avec sus-decalage du segment ST. Nous avons etudie les caracteristiques cliniques et angiographiques de ces patients en comparant 2 groupes : âges de plus et de moins de 75 ans. Nous avons analyse les taux de revascularisation et les evenements survenus au decours de l’angioplastie. Resultats Sur un total de 1672 patients, 342 (soit 20,5 %) etaient âges de plus de 75 ans. Ces sujets representaient un groupe a haut risque avec une proportion elevee de femmes (50 %), de nombreuses comorbidites (hypertension arterielle et diabete de type 2) et des atteintes tri-tronculaires en nombre plus eleve que chez les sujets de moins de 75 ans. Le taux de mortalite etait eleve chez les plus de 75 ans et toujours plus severe par rapport aux sujets de moins de 75 ans. La mortalite globale des plus de 75 ans etait de 20,5 % mais de 5,4 % en excluant les patients en etat de choc, en Killip III et apres mort subite recuperee. Le succes de reperfusion (exclusivement flux Timi III retenu) de l’angioplastie etait tres eleve chez les plus de 75 ans, meme s’il etait un peu plus faible que chez les patients de moins de 75 ans (93,9 %vs 97,2 %). Conclusion L’ACT est une technique particulierement indiquee chez les sujets âges en Alsace du fait des particularites de la region : geographique d’une part, avec une proximite des Smur pour la quasi totalite de la population alsacienne, et medicale d’autre part, la politique interventionnelle etant acquise dans de nombreuses equipes de cardiologie.

Resume L’infarctus aigu sur occlusion tardive de stent est une complication reconnue de la brachytherapie endocoronaire. Le risque d’une telle complication n’est cependant pas clairement precise au decours d’une angioplastie conventionnelle. Le but de l’etude a ete de determiner, dans une population de patients ayant fait l’objet d’une angioplastie de l’artere interventriculaire anterieure avec implantation de stent, l’incidence des infarctus aigus par occlusion tardive (> 30 jours apres la procedure initiale) d’une endoprothese et d’en preciser les eventuels facteurs predictifs. Ce travail a inclus 930 angioplasties consecutives de janvier 1999 a decembre 2001 chez 920 patients (667 hommes et 263 femmes) d’un âge moyen de 63 ± 12 ans. L’artere interventriculaire anterieure etait la seule artere dilatee dans 592 procedures (63,6 %). La duree moyenne du suivi a ete de 451 ± 255 jours. Quatorze patients ont presente cette complication a un delai moyen de 135 ± 131 jours soit un taux de survie sans thrombose de stent de 97,6 % a trois ans (methode de Kaplan Meier). La recherche de facteur predictif fait apparaitre un risque significatif de thrombose tardive de stent apres angioplastie de la bifurcation artere interventriculaire anterieure-diagonale (p = 0,01) ou apres endoprothese placee a l’ostium diagonale (p = 0,01) et un risque dependant du nombre de stents dans l’artere interventriculaire anterieure (p = 0,04). Conclusion : l’infarctus aigu par thrombose tardive de stent de l’artere interventriculaire anterieure est une eventualite rare mais possible apres angioplastie conventionnelle. Le risque semble etre lie a la complexite de la procedure et notamment a la refection de la bifurcation artere interventriculaire anterieure-diagonale. Cette observation pourrait inciter a la poursuite de l’association des antiagregants plaquettaires au-dela du premier mois dans ce cas de figure precis.

Resume Objectifs. – A partir d'un registre prospectif multicentrique, nous avons evalue dans trois centres de cardiologie interventionnelle alsaciens non universitaires, la prise en charge et la faisabilite de l'angioplastie coronaire transluminale (ACT) a la phase aigue du syndrome coronaire aigu avec sus-decalage persistant du segment ST (SCA ST+) chez les sujets âges de plus de 75 ans. Methodes. – Nous avons etudie les caracteristiques cliniques et angiographiques des patients âges de plus de 75 ans ainsi que les resultats : les taux de revascularisation et les evenements survenus au decours de l'angioplastie ont ete analyses. Ces donnees ont ete comparees a celles des patients plus jeunes et confrontees aux donnees de la litterature. Resultats. – Sur un total de 1672 patients admis pour un SCA ST+, 342 (soit 20,45 %) sont âges de plus de 75 ans. Ces sujets representent un groupe a haut risque avec une proportion elevee de femmes (50 %), de nombreuses comorbidites (HTA et diabete de type 2) et des atteintes tritronculaires en nombre plus eleve que les sujets plus jeunes. Le taux de mortalite est eleve dans ce sous-groupe de patients et toujours plus severe par rapport aux sujets plus jeunes, mais il reste variable en fonction du profil clinique initial. La mortalite globale des plus de 75 ans est de 20,47 % mais chute a 5,41 % si on exclut les patients en etat de choc, en Killip III et apres mort subite. L'angioplastie est la technique de reperfusion coronaire particulierement indiquee dans la prise en charge du SCA ST+ du sujet âge. C'est une technique efficace en termes de revascularisation, le succes de reperfusion (exclusivement flux TIMI III retenu) reste tres eleve dans cette population, meme s'il est un peu plus faible que chez les patients plus jeunes (93,88 vs 97,18 %). C'est une technique rapidement accessible, sous couvert d'une accessibilite des salles de coronarographie, permettant une reperfusion rapide. Dans la prise en charge des patients âges presentant un SCA ST+, c'est sur le delai avant admission qu'il faut axer nos efforts, les patients âges tardant a appeler les secours en cas de symptomatologie coronarienne. Or plus ce delai est court, meilleur est le pronostic du sujet âge. Conclusion. – L'ACT est la technique de reperfusion indiquee chez les sujets âges en Alsace du fait des particularites de la region : geographique d'une part, avec une proximite des SMUR pour la quasi-totalite de la population alsacienne, et medicale d'autre part, la politique interventionnelle etant acquise dans de nombreuses equipes de cardiologie. En Alsace, la part des personnes âges de plus de 75 ans va sensiblement augmenter, et on peut craindre dans les annees a venir une augmentation du nombre de cas de SCA ST+ du sujet âge. Il faut tenir compte de cette evolution, d'autant plus que cette technique de reperfusion allie de nombreux avantages avec tres peu de complications.

The intrinsic muscles of the hand are of interest in spinal cord injury (SCI) and other myelopathies, because they are innervated by the most caudal cord segments innervating the upper limb. In addition, abnormalities of the peripheral nervous system, such as peripheral nerve entrapments, often affect hand intrinsic muscle strength of SCI patients. Therefore, measuring hand intrinsic strength may allow for early diagnosis of neurologic decline.A method was developed for measuring strength of hand intrinsic muscles with a handheld myometer. With the use of a handheld myometer, this study examined the distribution of strength measurements for second-digit abductors, fifth-digit abductors, and thumb opposers in able-bodied participants and in individuals with weakness. The quantitative measurements were compared with manual muscle test scores and interrater reliability is described for these hand intrinsic strength measurements. Thirty-one able-bodied individuals participated (17 men, 14 women; mean age = 37.7 years). In addition, 24, patients with SCI participated (23 men, 1 woman; mean age = 53.5 years; 9 with paraplegia and 14 with tetraplegia as a primary diagnosis). The Bland-Altman method was used to test for interrater reliability.Mean strength of able-bodied participants was 5.0 kg for second-digit abduction, 3.1 kg for fifth-digit abduction, and 5.0 kg for thumb opposition, and the lower limits of normal were 3.0, 1.8, and 3.4 kg, respectively. The 95th percentile of interrater differences were 29.3% for second-digit abduction, 38.5% for fifth-digit abduction, and 43.7% for thumb opposition.Abnormal hand intrinsic strength should be suspected if values are lower than the 5th percentile values listed above or if strength change exceeds the 95th percentile for interrater differences shown above. These quantitative hand strength measurements may allow for earlier diagnosis of secondary neurologic complications and may aid in monitoring neurologic recovery in persons with SCI.

Resume Objectif et methode. – Evaluation de la prise en charge par angioplastie primaire du patient en choc cardiogenique en phase aigue d’infarctus du myocarde dans trois centres alsaciens non universitaires ; suivi hospitalier et a moyen terme pour la periode de 1999 a 2002. Resultats. – Cent quatre-vingt-deux patients etaient inclus. La survie hospitaliere est de 43,96 %. Cent quarante-neuf patients ont ete revascularises par angioplastie, le taux de succes d’angioplastie est de 79,12 %. Les facteurs predictifs de deces en phase hospitaliere sont : l’atteinte tritronculaire, l’âge superieur a 75 ans, le TIMI 0 a l’admission. La survie a moyen terme semble bonne avec 91 % de patients vivant a 24 mois (suivi a cette date sur 28,75 % des patients). Conclusion. – L’angioplastie primaire en phase aigue d’infarctus chez les patients en choc cardiogenique primaire semble l’option therapeutique de choix et permet une meilleure survie hospitaliere et a moyen terme par rapport au traitement conventionnel.

A consecutive series of 746 patients undergoing heart beating myocardial revascularization was reviewed. An average of 2.30 grafts/patients was performed. The rate of mortality in the first 30 postoperative days was 0.28%. Two cases had to be terminated on-pump. We used the inotropic drugs in 0.6% of cases. The postoperative events were: atrial fibrillation (12.6%), myocardial infarction (0.3%). The rate of transfusion was 7.4%. The extubation was performed in the first 24 h postoperatively in 94.7% of cases. The majority of patients (91.3%) left the hospital in the first 8 d postoperatively. Off pump coronary artery bypass grafting gives good result for the most of the patients even for those with multiple vessel disease and high operating risk.

Background: Syphilitic involvement of the nervous system can present in many different ways. We report a patient who presented with rapidly evolving paraparesis secondary to syphilitic menmgomyelitis.Methods: Case report.Findings: Cerebrospinal fluid (CSF) studies confirmed the diagnosis of neurosyphilis. Spinal magnetic resonance imaging (MRI) studies were indicative of leptomenmgeal and thoracic spinal cord disease. Treatment with IV penicillin resulted in marked clinical, radiologic, and CSF improvement. MRI imaging provided documentation of spinal cord involvement and was useful in monitoring recovery. This patient's progressive neurologic improvement was monitored for 2 years and documented by periodic Functional Independence Measure scores.Conclusion: Recognition of this unusual complication of secondary neurosyphilis is important, because it is a treatable cause of paraparesis with potential for good recovery.

International audience; 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.

A total of 73 cases of Plasmodium vivax infections acquired in Western or Central Africa were diagnosed on microscopical criteria in French travellers from 1995 to 1998. We report a case of P. vivax infection in a non immune traveller confirmed by polymerase chain reaction and presenting an atypical P. ovale morphology. The infection was acquired in Western or Central Africa. These microscopical observations, together with the molecular evidence for P. vivax in Western and Central Africa suggest that P. vivax is transmitted in this area despite lacking the Duffy receptor in autochthonous population.

This paper reports on three cases of patients with an apparently normal heart admitted for sustained monomorphic ventricular tachycardia. The only abnormal finding showed in the electrocardiogram (ECG) in sinus rhythm that exhibited an entity associated with incomplete right bundle-branch block and persistent ST-segment elevation. The ECG entity was variable and disappeared transiently. Spontaneous ventricular tachycardia in one patient was inducible by programmed stimulation. There was no underlying heart disease. The origin of the ventricular tachycardia in one patient was located by pace mapping in the left ventricle at the left ventricular basal septum. The follow-up (from 6 months up to 6 years) demonstrated a good prognosis. This particular ECG entity associated with monomorphic ventricular tachycardia could have been missed because of the variations in the ECG in sinus rhythm and was associated with a favorable prognosis.

Background— The value of prehospital initiation of glycoprotein IIb/IIIa inhibitors remains a controversial issue. We sought to investigate whether in-ambulance initiation of abciximab in patients with ST-segment elevation myocardial infarction (STEMI) improves ST-segment elevation resolution (STR) after primary percutaneous coronary intervention (PCI). Methods and Results— MISTRAL (Myocardial Infarction with ST-elevation Treated by Primary Percutaneous Intervention Facilitated by Early Reopro Administration in Alsace) is a prospective, randomized, double-blind study. Two hundred and fifty-six patients with acute STEMI were allocated to receive abciximab either in the ambulance (ambulance group, n=127) or in the catheterization laboratory (hospital group, n=129). The primary end point was complete (>70%) STR after PCI. Complete STR was not significantly different between the 2 groups (before PCI, 21.6% versus 15.5%, P =0.28; after PCI, 70.3% versus 65.8%, P =0.49). Thrombolysis In Myocardial Infarction (TIMI) 2 to 3 flow rates before PCI tended to be higher in the ambulance group (46.8% versus 35%, P =0.08) but not after PCI (70.3% versus 65.8%, P =0.49). Slow flow tended to be lower (5.6% versus 13.4%, P =0.07), and distal embolization occurred significantly less often in the ambulance group (8.1% versus 21.1%, P =0.008). One- and 6-month major adverse cardiac event rates were low and similar in both groups. Conclusions— Early ambulance administration of abciximab in STEMI did not improve either STR or TIMI flow rate after PCI. However, it tended to improve TIMI flow pre-PCI and decreased distal embolization during procedure. Larger studies are needed to confirm these results. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00638638.

We report a case of onychomycosis with melanonychia due to Candida parapsilosis alone. Candida parapsilosis is now identified in the great majority of candidal onychomycosis, mainly in association with other yeasts. The criteria allowing the distinction between invasion and colonization, the risk factors and the treatment of C. parapsilosis onychomycosis are discussed.

We report the case of a 59-year-old man with a dilated nonischemiccardiomyopathy who had chronic rapid atrial fibrillation despite severaltherapies. Radiofrequency modification of the atrioventricular (AV) junctionslowed the mean ventricular rate from 120 beats per minute (bpm) to 60 bpm.Five hours after the procedure and during the following 1 week, despiteventricular pacing at 90 bpm, the patient developed nonsustained orsustained polymorphic ventricular tachycardias. Finally, pacing at 90 bpmwas successfully used in this patient. In conclusion, patients who haveundergone modification of AV conduction may be at high risk oflife-threatening ventricular arrhythmias in the first week following theprocedure.

Percutaneous coronary intervention (PCI) as a treatment of coronary artery disease can be a simple, rapid procedure with a clear benefit for the patient, but it could also become a complex procedure with fatal consequences. These complications depend on the lesion itself, material used and also on operating staff. In this case we report a coronary artery dissection of the circumflex (CX) artery caused by inflation of an oversized balloon. We discuss here the management and evolution of this complication.

Fungus ball of the paranasal sinus is the growth of a fungal mass (mycetoma) within the sinus cavity, usually caused by molds; endoscopic surgery is the usual treatment ([2][1], [4][2]). Because of the poor viability of the fungi, diagnosis based on fungal cultures of nasal secretion or material

Four cases of Saccharomyces boulardii fungemia, a very rare side effect of Saccharomyces boulardii therapy, are reported. The clinical impact of Saccharomyces boulardii infection appeared to be moderate. However, even though organ involvement was never demonstrated, septic shock with no other etiology was observed in one of our patients. All patients had an indwelling vascular catheter. Contamination of the air, environmental surfaces, and hands following the opening of a packet suggests that catheter contamination may have been a source of infection. To prevent catheter contamination it is recommended that packets or capsules of Saccharomyces boulardii be opened with gloves, outside the patient's room.

Supraventricular tachyarrhythmias (SVTA) may occur in patients with the arrhythmogenic right ventricular dysplasia (ARVD). The purpose of the study was to evaluate the incidence of SVTA in 47 patients with ARVD proved by right ventricular angiography. Thirty-three men and 14 women, aged 21 to 72 years (mean 44 +/- 18) were admitted for nonsustained or sustained ventricular tachycardia. Eight patients had a history of spontaneous SVTA several years before ventricular tachycardia occurrence. Protocol of the study consisted of programmed atrial stimulation with one and two extrastimuli delivered during sinus rhythm and two driven rhythms (600 and 400 msec), programmed ventricular stimulation with up to three extrastimuli and was performed in the control state and after infusion of isoproterenol. The results of programmed atrial stimulation were compared with those obtained in 36 asymptomatic subjects without heart disease and with a mean age of 50 +/- 18 years (control group). Sustained SVTA (1 minute) was induced in seven of eight patients with spontaneous SVTA, in 27 (69%) of those with ARVD, who did not have spontaneous SVTA, and in two control subjects (5.5%) (p0.001). SVTA was inducible in the control state, but ventricular tachycardia induction required isoproterenol in 11 of 27 patients. Two patients without SVTA history but with inducible SVTA developed later spontaneous SVTA. ARVD was associated with a significantly higher incidence of inducible SVTA than in a control population. Supraventricular tachycardias may precede ventricular tachycardias. This association argues for a diffuse myocardial disorder in ARVD.

We compared the prognostic significance of prior angina pectoris in 151 patients > or = 75 years of age admitted for acute myocardial infarction. There was a similar in-hospital course, but the long-term outcome was poorer in patients with prior angina.

Hypertrophic cardiomyopathy may be associated with both supraventricular and ventricular arrhythmias, which may play a role in the genesis of syncope. The aim of this study was to assess the findings of electrophysiological study and programmed atrial and ventricular stimulation and their possible role in syncope. Programmed atrial and ventricular stimulation using up to two extrastimuli in right atrium and three in right ventricle at three cycle lengths (600, 400 ms and spontaneous) was systematically performed in 56 patients with hypertrophic cardiomyopathy. Thirty seven had unexplained dizzinesses or syncopes (group I) and 19 did not present loss of consciousness (group II). Patients with syncopes had a higher prevalence of induced sustained supraventricular tachyarrhythmia (73%) than those of group II (16%) (P0.05). Inducible supraventricular tachycardia was the only finding in 16 patients with syncopes. During the follow-up (3 years+/-6 months), empirical antiarrhythmic therapy suppressed the symptoms, except in two patients who developed atrial fibrillation despite therapy. The high incidence of inducible atrial tachycardia of these patients was not correlated with particular Holter findings or echocardiographic data. However, their mean age was rather high (58+/-12 years). In conclusion, atrial tachyarrhythmias may play a role in syncopes of middle-aged patients with hypertrophic cardiomyopathy. Moreover programmed atrial stimulation is an useful means to identify this syncope mechanism.

An abnormal signal-averaged electrocardiogram (SAECG) has predictive value for arrhythmic events in patients with idiopathic dilated cardiomyopathy and a normal conduction. The purpose of this study was to investigate whether the presence of a complete bundle branch block (BBB) affects prognostic information of the SAECG. We prospectively obtained SAECGs in 128 patients with idiopathic dilated cardiomyopathy. Forty-three of them had BBB and 85 had a normal QRS duration. According to their clinical history and results of ventricular programmed stimulation, patients were divided into 4 groups: (1) group IA with BBB and ventricular tachycardia (VT) (n = 18); (2) group IB with BBB but without VT (n = 25); (3) group IIA without BBB but with VT (n = 40); (4) group IIB without BBB and without VT (n = 45). Patients were compared with 129 patients without heart disease and without VT. Fifty-seven of them had BBB (group III) and 72 had normal conduction (group IV). The filtered QRS duration was longer in group IB than in group III (175 +/- 21 vs 149 +/- 16 ms, p0.001), and in group IIB than in group IV (111 +/- 19 vs 96 +/- 12 ms, p0.05). QRS duration was similar in groups IA and IB (176 +/- 24 vs 175 +/- 21 ms) but longer in group IIA than in group IIB (131 +/- 24 vs 111 +/- 19 ms, p0.001). The low-amplitude signal duration (LAS) and the root-mean-square voltage (RMS) of the last 40 ms of the filtered QRS did not differ between groups IB and III and IA and IB. LAS and RMS were, respectively, longer (44 +/- 20 vs 31 +/- 13 ms, p0.01) and lower (21 +/- 20 vs 43 +/- 33 microV, p0.001) in groups IIA and IIB. In groups IA and IB the combination of 2 of the 3 available criteria: QRS duration170 ms, RMS20 microV, LAS45 ms lead up to the best overall statistical result, with a sensitivity and specificity of 78% and 56%, respectively. In groups IIA and IIB, using conventional late potential criteria, the sensitivity and specificity of the SAECG for VT detection were 65% and 73%, respectively. The risk of sudden death was not predicted by the SAECG, and total cardiac mortality was only dependent on left ventricular ejection fraction. In conclusion, QRS duration was prolonged in all of the patients with a dilated cardiomyopathy compared with those without heart disease. BBB did not change the sensitivity but decreased the specificity of the SAECG to predict any VT risk in dilated cardiomyopathy. The risk of sudden death and total cardiac mortality could not be predicted by the SAECG.

The purpose of the study was to report the prevalence of inducible supraventricular tachyarrhythmias (SVTA) in 827 consecutive patients aged 17 to 90 years who did not have spontaneous documented SVTA and who had unexplained presyncope and/or syncope. The electrophysiologic study (EPS) included programmed atrial and ventricular stimulation up to two extrastimuli at three cycle lengths, and the study of sino-atrial and AV conduction. The results were as follows. EPS was normal in 386 patients. Inducible junctional tachycardia or atrial flutter and fibrillation was the only finding in 187 patients (23%). In the remaining patients we found ventricular tachycardia in 103 (12%), heart block in 67 (8%), sick sinus syndrome in 56 (7%) and increased vagal tone in 28 (3%). The presence of an underlying heart disease (47%) and salvos of atrial premature beats on Holter monitoring (39%) were significantly correlated with the induction of SVTA. However, the comparison with similar groups without syncope indicates that only the induction of SVTA in patients with hypertrophic cardiomyopathy and mitral valve prolapse was significantly correlated with the history of syncope. In patients without heart disease or with prior myocardial infarction or decreased left ventricular function, the induction of SVTA, which is not associated with hypotension in the supine position, could require an induction after head-up tilting, because of the lack of specificity of programmed stimulation in these patients. Programmed atrial stimulation should be systematically performed in patients with unexplained syncope, in particular in those with hypertrophic cardiomyopathy and mitral valve prolapse, who require a specific treatment, if a SVTA is induced. In other patients the results of programmed atrial stimulation should be interpreted cautiously.

Kais Mrabet [Orateur] (1), Romain Chopard (1), Nicolas Meneveau (1), Sidney Chocron (2), Jean-Eric Wolf (3), Jean-Christophe Eicher (4), Olivier Bouchot (4), Laurent Jacquemin (5), Nicolas Bischoff (5), Francois Schiele (1) (1) CHU Besancon, Cardiologie, Besancon, France (2) CHU Besancon, Chirurgie Cardiaque, Besancon, France (3) CHU Dijon, Cardiologie, Dijon, France (4) CHU Dijon, Dijon, France (5) CH Mulhouse, France

The CYP2C19*2 genetic variant is known to contribute to low responsiveness to clopidogrel treatment, leading to a higher rate of cardiovascular events. Systematic identification of the 2C19*2 carriers to predict the individual patient's response to clopidogrel is a matter of debate.Data of the VASP-02 study comparing patients’ responsiveness to 75 and 150 mg/day maintenance dose of clopidogrel (Aleil et al., J Am Coll Cardiol Intv 2008) were reanalyzed by determining the 2C19*2 carrier status of the patients. Platelet reactivity index (PRI) was determined using the VASP method. A PRI>69% defines low responsiveness to clopidogrel.In the 37 non responder patients, 42.4% were 2C19*2 carriers versus 22.0% in the responder patients (p=0.022). After multivariate analysis, 2C19*2 polymorphism and high body weight were two independent predictors of high PRI (odds ratio [95% confidence interval] 3.39 [1.06-10.84] p=0.039 and 3.14 [1.19-8.30] p=0.021) respectively. Increasing the maintenance dose of clopidogrel from 75 to 150 mg/day in non responder patients resulted in a significant decrease of PRI from 76.4±4.6 to 62.8±10.4% (p

The recent discovery of self-resolving Cryptosporidium infection in immunocompetent patients has aroused growing interest in this parasite, which has thus far been known to affect mainly immunodeficient individuals. Following the hospitalization of two children attending the same day-care center in February 1986 Cryptosporidium oocysts were found in the stools of one of them. This led to an epidemiological investigation to assess the frequency of Cryptosporidium oocysts in the stools of children attending the 7 day-care centers in the city of Poitiers, France. Testing for Cryptosporidium oocysts was performed on formalinized stools, after smear staining by the modified Ziehl-Neelsen procedure. Each positive stool was also submitted to virological and bacteriological examination. Stool specimens from 235 children were studied: 9 (3.8%) of them had Cryptosporidium oocysts in their stools. Four of the children had diarrhea, and 5 (2.2%) were asymptomatic. The existence of healthy carriers should lead to caution in the interpretation of stool parasitology.

Hyperglycemia is a powerful predictor of worse outcome after ST segment-elevation myocardial infarction (STEMI). Previous studies showed that hyperglycemia could be related to impaired myocardial reperfusion. This relation may be explained by absolute or relative insulin deficiency resulting in increasing toxic effect of circulating free fatty acids or in reducing glucose use in anaerobic manner in myocardium. The present study evaluates glycemic parameters, plasma insulin level, insulin resistance by index Quicki (1/log insulin + log glycemia in mg/dL) and index Homa (insulin x glycemia in μmol/L/22.5) in 105 patients with STEMI and successful percutaneous primary coronary intervention (PCI). The maximum ST elevation of single electrocardiogram (ECG) lead before and 60 minutes after PCI was measured and patients were then divided into 2 groups according to the degree of ST-segment resolution (STR): not complete ( Of the 105 patients, 62 (59.0%) had complete STR, 43 (41.0%) experienced not complete STR. Not complete STR group had a trend to a higher mean admission glucose level (1.8 ± 1.5 g/l vs 1.4 ± 0.5 g/l, p = 0.1) and a significative higher glycated haemoglobin level (6.8 ± 1.9% vs 6.1 ± 0.9%, p = 0.008). However no difference was observed for plasma insulin level (21.4 ± 23.6 mU/l vs 21.1 ± 18.4 mU/l), index Quicki (0.32 ± 0.07 vs 0.30 ± 0.04) and index Homa (142.3 ± 171.4 vs 146.7 ± 158.6) respectively in complete and not complete STR groups. In conclusion, this study confirms the association between hyperglycemia and electrocardiographic signs of complete reperfusion in patients with STEMI after PCI but this relation does not seem to be related to a absolute plasma insulin deficiency or an insulin resistance.

Background This prospective study evaluated pre-hospital anti-thrombotic association of bivalirudin (bolus 0.5 mg/kg followed by an infusion of 1.75 mg/kg/ hour) and prasugrel (60 mg loading dose) on in-hospital outcome in patients with acute myocardial infarction treated by primary angioplasty. Methods and results From June 2010 to October 2011 seventy-one consecutive patients of 54.2±9.2 years old were included, including 27 patients (38.0%) with anterior myocardial infarction and 15 patients (21.1%) with a TIMI risk score >2. The culprit artery was occluded in 46 patients (64.8%). Primary coronary angioplasty was performed 5.0±8.6 hours after symptom onset, with radial access in 58 patients (81.7%). TIMI III culprit vessel recanalisation was obtained in 71 patients (100%). Angioplasty procedure used 1.1±0.7 stents with effective thrombectomy in 31 patients (60.7%) in 51 thrombectomy attempts. AntiIIBIIIA glycoprotein treatment was administered during angioplasty in 15 patients (21.1%). Peak troponin I reached 211.9±882.9 ng / ml, left ventricular ejection fraction was 51.6±9.4%. During hospitalization we observed a MACE rate of 4.2% (1 death, 1 ischemic target vessel revascularisation and 1 reinfarction) and no stent thrombosis. Bleeding complication rate was 2.6% according to HORIZON criteria and 0% for severe or intermediate bleeding and 2.6% for moderate bleeding according to GUSTO classification. Conclusion In-hospital outcome in patients treated by primary angioplasty after pre-hospital bivilarudine and prasugrel treatment seems to have a low risk of ischemic and bleeding complications.