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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.

SPIRIT 2013 Checklist: Recommended Items to address in a clinical trial protocol and related documents. (PDF 167 kb)

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.

Objectives We investigated whether maintenance therapy with clopidogrel 150 mg/day produces greater platelet inhibition than the standard 75-mg/day dose and whether the higher maintenance dose increases platelet inhibition in low responders to clopidogrel 75 mg/day. Background Patients show interindividual variability in their platelet response to clopidogrel. Low responders could potentially obtain greater clinical benefit from greater doses of clopidogrel. Methods One hundred fifty-three elective percutaneous coronary intervention patients were randomized to clopidogrel 150 mg/day (n = 58) or 75 mg/day (n = 95) for 4 weeks, with vasodilator-stimulated phosphoprotein assay-guided switching to clopidogrel 150 mg/day after 2 weeks in low responders (platelet reactivity index ≥69%). All patients received aspirin 75 mg/day. Results After 2 weeks, clopidogrel 150 mg/day produced a significantly lower platelet reactivity index than clopidogrel 75 mg/day (43.9 ± 17.3% vs. 58.6 ± 17.7%; p l 0.0001). The proportion of low responders was significantly lower in patients randomized to clopidogrel 150 mg/day than in those randomized to clopidogrel 75 mg/day (8.6% vs. 33.7%; p = 0.0004). In the clopidogrel 75 mg/day group, 64.5% (20 of 31) of low responders became responders after switching to clopidogrel 150 mg/day for 2 weeks. No major bleeds occurred during the study; the incidence of minor bleeds was similar in each treatment group. Conclusions In elective percutaneous coronary intervention patients, a 150-mg/day clopidogrel maintenance dose produces greater inhibition of platelet function than clopidogrel 75 mg/day. In low responders to clopidogrel 75 mg/day, switching to clopidogrel 150 mg/day overcomes low responsiveness in a majority of patients. These findings warrant further clinical evaluation. (VASP-02; EudraCT number: 2004-005230-40).

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.

This study investigates the influence of treatment of plastic and extracellular matrix (ECM) proteins with chlorhexidine or benzalkonium chloride on subsequent adherence of Candida albicans. Three concentrations were tested for each antiseptic: (i) chlorhexidine, MIC (6.25-12.5 mg/L), 80 x MIC and 800 x MIC; and (ii) benzalkonium chloride, MIC (3.12 mg/L), 40 x MIC and 1600 x MIC. Chlorhexidine and benzalkonium chloride activities were correlated with the tested concentrations. Antiseptics used at MIC were unable to modify the adherence to plastic or ECM proteins. Chlorhexidine (80 x MIC) induced a decrease in plastic adherence of 31% of the 15 strains used and an increase in ECM protein adherence of 13% of strains. Benzalkonium chloride (40 x MIC) induced a decrease in adherence to ECM proteins or plastic of 13-27% of strains. Our results indicated that the treatment with 1600 x MIC benzalkonium chloride could induce the opposite effect on adherence, depending on the surface: 60% of the strains showed an increase in their adherence to ECM proteins, whereas 93% of the strains showed a decrease in their adherence to plastic. A similar phenomenon was observed after treatment with 800 x MIC chlorhexidine: 60% of the strains showed an increase in their adherence to ECM proteins, whereas 67% showed a decrease in adherence to plastic. Treatment of medical devices with at least 5000 mg/L of chlorhexidine or benzalkonium chloride could therefore reduce C. albicans adherence to plastic surfaces, but would be unable to prevent fungal adherence to ECM proteins.

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.

International audience; In the context of a rapidly growing energy demand and concerns about global climate change, renewable energies and in particular photovoltaic (PV) power are considered long-term solutions towards secured energy supply and for the reduction of greenhouse gas emissions. However, is solar PV a truly sustainable solution? Climate change will certainly not be the only environmental issue we will have to deal with. Regarding the issue of mineral resources, current research efforts aim at reducing raw material consumption in the manufacturing of PV panels. But, how do we assess the environmental efficiency of a panel, especially concerning the raw material consumption? Moreover, the PV industry consumes raw materials which are principally produced in non-EU countries such as Cadmium (Cd), Gallium (Ga) and Indium (In). How do we consider the issue of critical substance and accessibility? Required materials for PV modules may also be used in other applications (for example Gallium and Indium in electrical appliance production). Should competitiveness between applications be taken into account in a sustainability assessment? Are we going to valorize the PV module ability to use substitute substances? In addition to responsible resource management indicators, many other aspects have to be taken into account in order to achieve a complete sustainability assessment, especially recyclability, viability of PV industry, equilibrium along the value chain or social indicators such as social acceptability... Designing sustainability metrics is a new and complex research field. The whole value chain has to be evaluated and all dimensions (environmental, economic, and social) need to be explored. The paper will discuss the issues in defining sustainability metrics and propose some methodologies and a system of indicators to lassess the sustainability of a PV module.

Proteolytic activities were detected in a cytosoluble 100 000 g extract of Cryptococcus neoformans using 7-amido-4-methylcoumarin substrates. The main proteolytic activity cleaved the L-arginine-AMC substrate. This protease was purified by high performance liquid chromatography and had a molecular weight of 80 kDa as demonstrated by SDS-PAGE in the presence of reducing conditions. The enzyme was inhibited by EDTA and o -phenanthroline which are metallopeptidase inhibitors. The protease displayed high enzymatic activity between pH 5.8 and 7, and its pl was localised at pH 5.04. Furthermore, this metallopeptidase was not secreted in culture supernatants, but was able to degrade partially or totally some of the extracellular matrix components, as fibronectin or laminin, and host lgG.

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.

Berthonneau, J., Rodier, M. H., El Moudni, B., and Jacquemin, J. L. 2000. Toxoplasma gondii: Purification and characterization of an immunogenic metallopeptidase. Experimental Parasitology95, 158–162. A Toxoplasma gondii aminopeptidase specific for the fluorogenic substrate L -arginine 7-amino-4-methylcoumarin was identified in cell-free extract. This enzyme was purified by high-performance liquid chromatography using first size exclusion, then anion exchange, followed by a second size exclusion. The purified enzyme exhibited a pl of 4.7 by chromatofocusing and had an apparent molecular weight of 110 kDa, as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis under reducing conditions. The purification factor was 80.9 and the yield was 14%. The optimal activity was at pH 7.4 and was strongly inhibited by EDTA and o-phenanthroline. Antibodies against this T. gondii metallopeptidase were detected by immunoprecipitation and immunoblotting in human sera obtained from patients undergoing toxoplasmosis.

Among potential virulence factors of Candida albicans, enzymes seem to play an important role. Many studies concern the secreted aspartic proteinases (saps), and the degradation of some components of the subendothelial extracellular matrix by the isoenzyme sap2 has been proved. Nevertheless, other proteolytic enzymes could be involved in the pathogenicity of the yeast. We studied the degradation of four constitutive proteins of the extracellular matrix: type I and IV collagens, laminin and fibronectin, by a 95-kDa metallopeptidase, localised in the cell wall of C. albicans. Each of these constituents was incubated with the purified enzyme and its degradation products analysed by an electrophoretic method. We observed that type I collagen and fibronectin were totally degraded by the enzyme whereas type IV collagen and laminin were only partially degraded. The C. albicans metallopeptidase may play a role in the degradation of the subendothelial extracellular matrix components. This enzyme could facilitate the migration of the yeast in the tissues after crossing the endothelial layer, allowing the fungal invasion of target organs.

Resume Nous avons teste la nouvelle trousse de detection des anticorps antipaludeens Malaria IgG Celisa ® (BMD) et l'avons comparee a la technique Falciparum-spot IF ® (Biomerieux). Tous patients confondus, la sensibilite est de 81 %, la specificite de 99 %, la valeur predictive positive de 95 % et la valeur predictive negative de 95 %. Parmi les 24 malades, huit avaient un frottis positif a P. falciparum sur les 23 pratiques, la serologie Elisa etait negative cinq fois pour ces acces palustres confirmes. Dans les deux cas ou l'acces palustre etait recent, la serologie etait negative meme avec l'immunofluorescence indirecte (IFI). Chez les 109 donneurs de sang, deux serums etaient trouves positifs par IFI et negatifs par Elisa. Seize etaient trouves douteux par IFI et negatifs par Elisa, les resultats douteux s'elevant a 13,5 % pour l'IFI, contre 1,5 % pour l'Elisa. Pour l'analyse des donnees, nous avons prefere le calcul du coefficient k au test du χ 2 , car il permet de mesurer le degre de l'accord entre les deux methodes. Celui-ci est ici modere. Le choix d'une technique immunoenzymatique pour le depistage du paludisme chez les donneurs de sang se heurte actuellement au doute qui persiste quant a la sensibilite de la technique, par rapport a l'IFI prise comme technique de reference.

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.

Bivalirudin, a direct thrombin inhibitor, demonstrated an improvement in the prognosis of acute coronary syndromes by a decrease in major bleeding complications. This observational study evaluated inhospital outcome of patients with acute myocardial infarction treated by prehospital bivalirudin before primary angioplasty.We included, from June 2010 to June 2012, all patients with acute myocardial infarction receiving prehospital bivalirudin with bolus of 0.75mg/kg followed by an infusion of 1.75mg/kg per hour until the arrival in the catheterization laboratory. Bivalirudin was possibly continued after primary angioplasty.We included 152 patients aged 57.6±11.6 years. A prehospital 60mg loading dose of prasugrel was given in 77% of patients. Coronary angiography with radial access (77.6%) was performed before a successful angioplasty in 97.3% of cases. The bivalirudin infusion was continued after the procedure in 81.6% of patients. Inhospital outcome showed two deaths (1.3%) and two re-infarctions (1.3%) of which one was related to the single acute stent thrombosis (0.6%). Major bleeding complications were limited irrespective of the Gusto (0.6%), Timi (0.6%) or Horizons-MI (4.6%) classification. Bleeding complications rate was similar when bivalirudin was followed or not after primary angioplasty.The use of bivalirudin in the prehospital setting for primary angioplasty seems to be effective and safe about ischemic and bleeding complications during the inhospital outcome.

A novel aminopeptidase was purified by high performance liquid chromatography from a cytosoluble 100,000 g extract of Candida albicans on the basis of its ability to cleave L-arginine 7-amino-4-methylcoumarin. The purification factor was 36 and the yield was 20%. The native enzyme had a mol. wt of 52 kDa as demonstrated by SDS-PAGE in the presence or absence of reducing conditions and exhibited an iso-electric point of 4.3. The aminopeptidase showed optimum activity at pH 7.2, a Michaelis constant of c. 50 microM and a Vmax at 19 mM AMC released/min/mg of protein for L-Arg-AMC. This enzyme was shown to cleave at low affinity L-leucine-7-amino-4-methylcoumarin as demonstrated by the spectrofluorimetric method. The enzyme was strongly inhibited by specific metallo-enzyme inhibitors-EDTA and o-phenanthroline. Furthermore, there is evidence that a similar or identical enzyme occurs in other C. albicans clinical isolates and other Candida spp.

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.

Rodier, M.-H., El Moudni, B., Ghazali, M., Lacroix, C., and Jacquemin, J.-L. 1994. Electrophoretic detection of cytoplasmic serine proteinases (gelatinases) in Candida albicans. Experimental Mycology 18: 267-270. Proteolytic activities of Candida albicans were identified using sodium dodecyl sulfate-polyacrylamide gel electrophoresis with gels containing gelatin as proteinase substrate. Cytoplasmic extracts of five isolates were tested with this method. Two major proteolytic activities of Mr 50,000 and 60,000 were conserved between isolates whereas two other less intense activities of Mr 90,000 and 120,000 were only detected in three isolates. The two bands of proteolysis of Mr, 50,000 and 60,000 were revealed between pH 5.0 and pH 8.0, optimally active at pH 7.0, and their isoelectric point was 4.5. They were not influenced by the presence of 2-mercaptoethanol. Their sensitivity to phenylmethylsulfonyl fluoride and chymostatin allowed them to be characterized as serine proteinases. These two neutral proteinases were not secreted in culture supernatant.

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.

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.

To evaluate the results and the feasibility of the technique of percutaneous closing of patent foramen oval (PFO) with Atrial Septal Aneurysm (ASA) among young patients having presented a cryptogenic cerebral ischemia.Eighteen patients: 14 cryptogenic stroke and 4 TIA with a broad PFO (rank III) and an important ASA (excursion higher than 15 mm) at transesophageal echocardiography (TEE). The average age is 48.2 years: man 61%, women 39%. The patients have little cardiovascular risk factor (0.83/patient) and 38% presented recurrent thromboembolic events. Percutaneous closing is carried out under general anaesthesia with TEE and Amplatzer devices implantation. A control TEE is carried out 6 months after closing.No complication occurred at the time of the procedures. After 72 hours, one patient presented a major complication: one arteriovenous fistula requiring a surgery. Five patients presented a minor complication: two non complicated femoral hematoma, two atrial arrhytmias and one asymptomatic secondary displacement of the device without need for surgery. Seven-teen patients had TEE at six months: the shunt disappeared for 95% from the patients, no thrombus was found. No recurrent thromboembolic event appeared for the 18 patients (median follow-up 19.2 months).The installation of a technique of percutaneous closing of the PFO+ASA is safe and effective.

Acute myocardial infarction is a rare complication of dobutamine stress echocardiography (DSE). We report the case of a 60-year-old man with moderate apical sequela of a myocardial infarction (MI) which had an inferior MI complicated with cardiogenic shock and circulatory arrest two hours after a positive DSE in that very circulatory topography. Emergency coronarography objectivizes a dissection of the circumflex artery. The patient required a circulatory assistance device. He survived the episode and left the hospital with 50% left ventricular ejection fraction.

This study evaluated the hospital outcome of octogenarian patients treated by primary angioplasty for acute myocardial infarction less than 12 hours. The long-term mortality and social outcome were evaluated, social outcome was based on IADL and IADL-E scales corresponding to physical autonomy and level of dependence. We included from 1999 to 2005 47 old patients of 83.5+/-3.2 years. The reperfusion of the obstructed coronary artery was obtained in 45 patients (95.7%) with TIMI 3 flow. Hospital mortality was 25.5% and 4.2% without hemodynamic complication. A multivariate analysis identified a Killip score1 as predictive factor of hospital mortality (OR=8.9 and p=0.05). The long-term survival without death with a follow-up of 26.3+/-18.3 months was 82.2% at 24 months and 70.6% at 48 months according to the Kaplan-Meier method. In an multivariate analysis, hospitalization exit without aspirine was associated with a higher long term mortality (OR=34.8 and p=0.04). According to the evolution of scores of IADL and IADL-E scales, patients had an excellent autonomy and good capacities before the infarction and they kept them on the long term. Thus octogenarians with acute myocardial infarction treated by primary angioplasty have a high in hospital and long term mortality but the survivors preserve an excellent daily autonomy.

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.

This prospective multicenter study assessed the prevalence and feasibility of percutaneous coronary angioplasty (PTCA) in the acute phase of ST-elevation myocardial infarction (STEMI) in 3 nonacademic interventional cardiology centers (Alsace, France).We studied the clinical characteristics, angiographic data, and PCTA results of all STEMI patients and analyzed the revascularization rates and adverse events during hospitalization. We compared patients at least 75 years of age and younger patients for these data and with the literature.Of the 1672 patients admitted for STEMI, 342 (20.45%) were at least 75 years of age. Half the patients in this high-risk subgroup were women. These patients had more co-morbidities (e.g., hypertension and diabetes mellitus) than younger patients, and more of them had three-vessel disease. Mortality rate was high in this subgroup and always higher than for comparable younger subjects, but it varied according to the initial clinical profile. Their global mortality rate was 20.47%, but it fell to 5.41% when we excluded patients with cardiogenic shock or in Killip stage ill, and those who were resuscitated. PTCA is a coronary reperfusion technique especially indicated for elderly patients with STEMI. It is an effective revascularization technique, with a reperfusion rate (exclusively TIMI III flow) reaching 93.88% in the elderly group, only slightly lower than among younger patients (97.18%).PTCA is a technique particularly indicated in the elderly in Alsace because of regional geographic and medical specificities: nearby emergency services are available to virtually the entire population of Alsace, and most interventional cardiology teams apply a strategy of exclusive primary PTCA.

The objective of the study was to assess the frequency of late stent-thrombosis-related acute myocardial infarction in patients with LAD stents. A series of 930 PCI procedures involving LAD stenting were performed in 920 patients (mean age: 63 years, 667 men) from January 1999 to December 2001. Among those 14 patients had late (30 days), thrombosis-related acute myocardial infarction after a mean delay of 135 +/- 131 days. Three-year thrombosis-free survival was 97.6%. By univariate analysis, risk of late thrombosis was associated with LAD-diagonal bifurcation stenting, placement of a stent on the ostium of a diagonal branch and number of stents implanted on the LAD. Patients with these risk factors might be appropriate candidates for long-term combined antiplatelet therapy.