Percutaneous Left Atrial Appendage Closure Is a Reasonable Option for Patients With Atrial Fibrillation at High Risk for Cerebrovascular Events

Background—

Percutaneous left atrial appendage (LAA) closure is an emerging option for patients with atrial fibrillation at high risk for cerebrovascular events. The multicenter FLAAC registry (French Nationwide Observational LAA Closure Registry) was established to assess LAA closure outcomes in everyday practice.

Methods and Results—

Four hundred thirty-six patients referred from April 2013 to September 2015 to 33 French interventional cardiology centers for percutaneous LAA closure were included prospectively in the FLAAC registry. Mean age was 75.4±0.4 years. The stroke risk was high (mean CHA 2 DS 2 –VASc score, 4.5±0.1) and most patients had experienced clinically significant bleeding (HAS-BLED score, 3.1±0.05). The device used was Amplatzer LAA occluder in 58% and the Watchman device in 42% of the patients. The procedural success rate was 98.4%. Median postprocedure follow-up was 12.0 (11.8–12.0) months and a single patient was lost to follow-up. During the periprocedural and subsequent follow-up period, procedure-related severe adverse events occurred in 21 (4.9%) and 10 (2.3%) patients, respectively. One-year cumulative incidences of ischemic stroke and cerebral hemorrhage were 2.9% (1.6–5.0) and 1.5% (0.7–3.2), respectively. Overall, 1-year mortality was 9.3% (6.9–12.5) with 7 of the 39 deaths related or possibly related to the device or procedure.

Conclusions—

This nationwide prospective registry shows that, in the French population, LAA closure is mainly used in patients with high comorbidity rates and a poor prognosis. LAA closure in such patients seems reasonable to decrease the stroke rate. The overall health status of these patients should be taken into account during the preprocedural evaluation process.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02252861.

Retrospective Analysis of Pathologic Criteria in 446 Patients with pT1a and pT1b Breast Cancer: A Study from Two French Anti-Cancer Centers

Background: To assess the risk of recurrence and survival after locoregional and systemic treatment regarding biological features among women with a 1cm-maximal size of breast cancer.Material and Methods: Individual clinicopathological data were collected from 446 patients, treated in the Oscar Lambret and Claudius Regaud centers between 2003 and 2006. 5 patients had bilateral breast cancer. Median age was 59y (range: 26-92). None of the patient had node involvement, but patients could have isolated cells. Surgery consisted of lumpectomy, quadrantectomy or total mastectomy in 95%, 1%, 4% of the patients respectively. Sentinelle node biopsy and axillary dissection were performed in 87% and 13% of the patients, respectively. Estrogen receptor (ER, n=447) and Progesterone receptor (PR, n=448) were determined from tumor tissue microarrays using immunohistochemistry (IHC). Cut-off used for ER and PR positivity was 10% of stained cells. Radiation therapy was delivered to 432 breasts (96%; 45-50Gy) and a boost to 296 (69%; 6-16Gy). Nodal RT was delivered in 29% of the patients. Systemic therapy consisted of hormonotherapy in 380 (85%) including aromatase inhibitors in 38%. Chemotherapy was administered in 18 patients. Only two patients received 1 year of trastuzumab.Results:Pathological tumor size was ranged between 1.0 and 10.0 mm (median: 8.0 mm). The majority of tumors (n= 383 or 85%) were ductal infiltrant carcinoma and 42 (9%) were lobular infiltrant. 189 tumors (48%) contained a ductal carcinoma in situ component. 11/381 (3%) presented lymphovascular invasion. The majority were grade III (n=194 or 45%). Only 53 tumors (12%) were ER negative and 129 (28.8%) were PR negative. Nineteen (5.2%) tumors and 4 (0.9%) patients presented tumors with Her 2 overexpression or gene amplification, respectively.After a median survival of 26 months, 8 patients presented locoregional or distant recurrence. Local, locoregional, and distant metatstases were observed in 3, 2 and 4 patients. Among these 8 patients ¾ were aged more than 50y, all of them had tumors > 5mm and grade II or III. 6 out of the 9 patients were HR+. Presences of lymphovascular invasion and Her2+ status were not correlated to recurrence.ConclusionMammographic screening increased the rate of small tumors diagnosed and reduces mortality in breast cancer. It is not known if this reduction is more pronounced in certain groups of patients. In the new era of tumor biology new markers that could predict the sensitivity of tumours to local and systemic therapy have to be determined in further studies for more tailored treatments in small tumors. Further pathologic analyses are ongoing and will be presented.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6026.

Docetaxel therapy for advanced hepatocellular carcinoma developed in healthy liver: report of three cases

Systemic chemotherapy is generally ineffective in patients with advanced hepatocellular carcinoma (HCC). This could be partly explained by the frequent underlying cirrhosis, which induces serious toxicity requiring dose attenuation or drug discontinuation. We present observations of three patients with HCC developed in healthy liver and treated with docetaxel (100 mg/m(2) every 3 weeks in one patient; 30 mg/m(2) weekly, three times every 4 weeks in two patients). An objective partial response with long-term survival was obtained in all cases without severe toxicity. These results suggest that chemotherapy, and especially docetaxel, could be safe and effective in patients with HCC developed in healthy liver, and should be assessed in specific trials.

[Accelerated partial breast irradiation: a concept to individualize treatment in breast cancer]

Whole breast irradiation delivering an equivalent dose of 50 Gy in 5 weeks, followed by a 10 to 16 Gy-boost to the tumor bed is the standard of care after breast-conserving surgery for early-breast cancer. Accelerated partial breast irradiation (APBI) is currently under investigations in large multi-institutional, prospective, randomized trials to objectively address the critical endpoints of treatment efficacy, toxicity and cosmesis. Patient's selection for this new approach is crucial to individualise treatments and define the subgroups of patients who will really benefit from APBI in terms of quality of life without decreasing long-term results of the disease control and cosmesis. In this review, we will discuss the patients' profiles selection for APBI regarding their general and tumor criteria. The differences between APBI techniques either performed intra or post operatively will be also discussed.

VTAMN--a smart clothe for ambulatory remote monitoring of physiological parameters and activity

The prototype of a communicating underclothe for medical remote monitoring was realized. It delivers physiological information on the subject (Cardiac Frequency, Breathing Frequency, surface and mid-temperature) as well as the environment and activity parameters (ambient temperature, fall detection). It also enables the automatic data transfer on event, with the localization of the subject.

Évaluation de la radiosensibilité tumorale par l'imagerie fonctionnelle et métabolique : de la recherche à l'application clinique. Revue de la littérature

During the last half of century considerable research on radiosensitivity biomarkers has been published. However, to date there is no non-invasive marker of cellular radiosensitivity identified for clinical routinely use. In this review, the main functional and metabolic imaging isotopic techniques for tumor radiosensitivity that have been explored over the last years are being described. This indirect evaluation fall into 3 topics associated with tumor proliferation rate or apoptosis, tumor hypoxic fraction, neoangiogenesis and the intrinsic radiosensitivity of clonogenic tumor cells. The final objective of the radiosensitivity monitoring during radiotherapy would be to adapt treatment strategy for overcoming the identified radioresistance mechanism such as hypoxia by the addition of radiosensitisers for example. This would allow better tumor control rather than continue inefficient and costly treatment delivery, which in addition could compromise outcome.

[Acute myocardial infarction in myocardial bridge treated by coronary stent]

The authors report the case of a symptomatic myocardial bridge treated in the acute phase of anterior wall myocardial infarction by classical stenting of the mid and distal left anterior descending artery. One and a half months later, intrastent restenosis at the two dilated sites, led to another angioplasty procedure with implantation of sirolimus-eluding stents. The outcome was good with no recurrence of angina at 16 months and control coronary angiography was totally normal at the 8th month.

Telemonitoring of vital parameters with newly designed biomedical clothing

The paper describes the development of biomedical clothing for ambulatory telemonitoring of human vital parameters. VTAM (Vetement de Tele-Assistance Medicale) presents a T-shirt made from textile with woven wires and incorporating four smooth dry ECG electrodes, a breath rate sensor, a shock/fall detector and two temperature sensors. The garment is equipped for the signal pre-computing and transmission through a miniature GSM/GPRS module kept on a belt together with the power supply. Three VTAM prototypes have been tested on persons in a normal state of health using a medical protocol to assess the biomedical data that include an ECG reading, a pneumogram, temperature and fall detection in mobile situations.

Resistance to thienopyridines: clinical detection of coronary stent thrombosis by monitoring of vasodilator-stimulated phosphoprotein phosphorylation

We carried out a prospective evaluation of a new vasodilator-stimulated phosphoprotein (VASP) phosphorylation assay in order to detect patients with high-risk coronary subacute stent thrombosis (SAT) despite thienopyridine regimen. Twenty healthy donors (group 1) without any medication were compared to 16 stented patients (group 2) treated by ticlopidin or clopidogrel initiated 2 days before stenting and aspirin (250 mg/day). No difference in platelet reactivity was noted between group 1 and group 2 treated only with aspirin (72.00% +/- 4.17% vs. 69.73% +/- 5.62%, respectively; P = NS). Significant differences were found between patients of group 2 treated with aspirin alone (69.73% +/- 5.62%), after 2.0 days (60.14% +/- 9.60%; P < 0.05), and after 4.8 +/- 1.3 days (48.37% +/- 11.19%; P < 0.05) with thienopyridine-aspirin. Among 1,684 consecutive stented patients, 16 patients who presented an SAT (group 3) were compared with 30 other stented patients free of SAT (group 4). We found a significant difference between group 3 (63.28% +/- 9.56%) and group 4 (39.80% +/- 10.9%; P < 0.0001). VASP phosphorylation analysis may be useful for the detection of coronary SAT.

HUMEX, a study on the survivability and adaptation of humans to long-duration exploratory missions, part I: lunar missions

The European Space Agency has recently initiated a study of the human responses, limits and needs with regard to the stress environments of interplanetary and planetary missions. Emphasis has been laid on human health and performance care as well as advanced life support developments including bioregenerative life support systems and environmental monitoring. The overall study goals were as follows: (i) to define reference scenarios for a European participation in human exploration and to estimate their influence on the life sciences and life support requirements; (ii) for selected mission scenarios, to critically assess the limiting factors for human health, wellbeing, and performance and to recommend relevant countermeasures; (iii) for selected mission scenarios, to critically assess the potential of advanced life support developments and to propose a European strategy including terrestrial applications; (iv) to critically assess the feasibility of existing facilities and technologies on ground and in space as testbeds in preparation for human exploratory missions and to develop a test plan for ground and space campaigns; (v) to develop a roadmap for a future European strategy towards human exploratory missions, including preparatory activities and terrestrial applications and benefits. This paper covers the part of the HUMEX study dealing with lunar missions. A lunar base at the south pole where long-time sunlight and potential water ice deposits could be assumed was selected as the Moon reference scenario. The impact on human health, performance and well being has been investigated from the view point of the effects of microgravity (during space travel), reduced gravity (on the Moon) and abrupt gravity changes (during launch and landing), of the effects of cosmic radiation including solar particle events, of psychological issues as well as general health care. Countermeasures as well as necessary research using ground-based test beds and/or the International Space Station have been defined. Likewise advanced life support systems with a high degree of autonomy and regenerative capacity and synergy effects were considered where bioregenerative life support systems and biodiagnostic systems become essential. Finally, a European strategy leading to a potential European participation in future human exploratory missions has been recommended.

[Biochemical markers of myocardial damage after high-energy radiofrequency ablation of atrial flutter. Value of troponin I]

Creatinine phosphokinase and its MB iso-enzyme do not allow assessment of the degree of tissue necrosis after radiofrequency ablation. Cardiac Troponin I and myoglobin, new markers of myocardial lesions, are rarely used in this indication. The aim of this prospective study was to measure and compare serum markers of myocardial damage after high energy radiofrequency ablation of atrial flutter with an 8 mm distal electrode catheter. The authors measured serum cardiac Troponin I, myoglobin, creatinine phosphokinase and its MB iso-enzyme levels before and 4, 12 and 24 hours after radiofrequency ablation of common atrial flutter in 23 consecutive patients. The same markers were also measured in a control group of 9 patients undergoing electrophysiological investigation without radiofrequency ablation. All ablation procedures were simple with an average of 12.6 +/- 6 applications of radiofrequency. Bidirectional isthmic block was obtained in 22 of the 23 patients. The mean Troponin I levels were 0.01 microgram/l before ablation, 0.87 +/- 0.77 at the 4th hour (p < 0.001 versus control), 1.16 +/- 1.2 at the 12th hour (p < 0.001 versus control) and 0.7 +/- 0.63 microgram/l at the 24th hour (p < 001 versus control) after ablation. Only 13% of patients had cardiac troponin levels greater than the threshold of significant myocardial damage (> 2 micrograms/l) with a higher average number of radiofrequency applications than the rest of the group: 15.2 +/- 1 versus 11.5 +/- 5.1 (p < 0.05). An abnormally high level of markers was found in the ablation group for 19 patients (84%) with Troponin I (> 0.4 microgram/l), for 10 patients (43%) with the MB iso-enzyme (> 8 Ul/L), and for 1 patient (4%) with myoglobin (> 90 micrograms/l), and in no patient for creatinine phosphokinase (> 290 IU/L). All values were normal in the control group. The authors conclude that cardiac Troponin I is the most sensitive marker for myocardial cellular damage after high energy radiofrequency ablation of atrial flutter. The level of cardiac Troponin I seems to correlate with the number of applications of radiofrequency.

[Antithrombotic treatment protocols in interventional cardiology]

The use of coronary stents has become routine in interventional cardiology, for which anti-platelet drugs are part of the daily antithrombotic routine. The association of ticlopidine and aspirin may be replaced definitively by that of clopidogrel and aspirin. A rapid biological test of the efficacy of these thienopyridines would allow identification of possible drug resistance. The anti-GP IIb/IIIa agents with an immediate onset of action are also widely used in the acute phase of MI and in acute coronary syndromes without ST elevation when the troponin levels could enable selection of high risk patients more likely to benefit from an aggressive antithrombotic strategy. Finally, the superiority of enoxaparin over unfractionated heparin must be emphasised in these same acute coronary syndromes.

Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 140 elective procedures

OBJECTIVES

We sought to evaluate immediate and late outcomes after stenting for left main coronary artery (LMCA) stenosis.

BACKGROUND

Conventional percutaneous transluminal coronary angioplasty (PTCA), for which coronary artery bypass grafting (CABG) has been the gold standard therapy for years, has yielded poor results in unprotected LMCA lesions. The development of coronary stents, together with their dramatic patency improvement provided by new antiplatelet regimens and their validation against restenosis, warrants a reappraisal of angioplasty in LMCA stenosis.

METHODS

From January 1993 to September 1998, 140 consecutive unselected patients with unprotected LMCA stenosis underwent elective stenting. Group I included 47 high-CABG-risk patients, and group II included 93 low-CABG-risk patients. Ticlopidine without aspirin was routinely started at least 72 h before the procedure and continued for one month. Patients were reevaluated monthly. A follow-up angiography was requested after six months.

RESULTS

The procedure success rate was 100%. One-month mortality was 9% (4/47) in group I and 0% in group II. A follow-up angiography was obtained in 82% of cases, and target lesion revascularization was required in 17.4%. One-year actuarial survival was 89% in the first 29 group I patients and 97.5% in the first 63 group II patients.

CONCLUSIONS

Stenting of unprotected LMCA stenosis provided excellent immediate results, particularly in good CABG candidates. Medium-term results were good, with a restenosis rate of 23%, similar to that seen after stenting at other coronary sites. Stenting deserves to be considered a safe and effective alternative to CABG in institutions performing large numbers of PTCAs.

Coronary artery stenting without anticoagulation, aspirin, ultrasound guidance, or high balloon pressure: prospective study of 1,051 consecutive patients

Between March 1994 and November 1995, 1,212 coronary stents were implanted in 1,051 consecutive patients at our institution with the following protocol: daily pre- and poststenting treatment with ticlopidine 500 mg without aspirin, implantation under angiographic guidance, without ultrasound, with semi-compliant balloons inflated at 10 bars. Stenting was indicated after failure of balloon angioplasty (bail-out, dissection, elastic recoil) in 27% of the patients and considered as elective (de novo, restenosis, chronic occlusion, saphenous vein grafts) in 73% of the cases. During the 30-day follow-up period, stent thrombosis occurred in 11 patients (1.0%) and vascular access-site complications in three patients (0.3%). Thirteen patients (1.1%) died, 10 from previous left ventricular failure, 3 (0.3%) from subacute thrombosis. Multivariate analysis revealed that the size of the last balloon used was associated with subacute stent thrombosis Thus, in nonselected patients, placement of coronary stents may be safely achieved without use of warfarin, post procedural heparin, high balloon pressure, or ultrasound guidance. Antiplatelet therapy with ticlopidine and angiographic guidance result in a stent thrombosis rate of 1% and a vascular complication rate of 0.3%.

Retrograde left main stenting

Percutaneous transluminal coronary angioplasty of protected left main coronary artery stenosis is usually performed by an antegrade approach. In this case report, we describe left main coronary artery stenting by a retrograde approach through a saphenous venous graft in a patient in whom the antegrade approach was considered less appropriate due to chronic ostial occlusion.

ECG changes during the experimental human dive HYDRA 10 (71 atm/7,200 kPa)

Electrocardiogram (ECG) analysis was performed in three human divers during a 71 atm (7,200 kPa) saturation dive (COMEX HYDRA 10 experiment). The inhaled gas mixture was slightly hyperoxic; its composition was basically helium and oxygen. Hydrogen was introduced during compression and its partial pressure reached 20 atm. ECG changes were the same in the three divers. Marked bradycardia rapidly appeared at the beginning of compression, then this response adapted throughout the dive. P-R, QRS, and Q-T intervals and the S-T segment did not change significantly. The QRS axis remained stable. However, a rightward shift occurred in P and T vector angles. These changes were correlated with time and gas density, respectively. The modifications of ventricular repolarization during compression are similar to those we observed during the HYDRA 9 COMEX dive. They may correspond to changes in duration of myocardial cell repolarization due to increased intrathoracic pressure changes with dense-gas breathing. A marked global diminution of voltage occurred during the decompression period. This suggests that accumulation of micro bubbles in tissues may influence the impedance, causing an artifact in the amplitude of ECG complexes.

[Rotablator and endoprosthesis on the left main coronary trunk]

A 78 year old woman with unstable angina due to significant stenosis of the left main coronary artery and occlusion of the right coronary artery was treated medically for 29 months because of a surgical contraindication. Resistance to drug therapy led to referral for complex angioplasty of the left main, left anterior descending and left circumflex arteries, successively by rotablator and balloon angioplasty. An immediate elastic recoil on the left main coronary artery led to implantation of a Palma-Schatz stent. There were no complications and the patient is asymptomatic twenty months later.

The chemical and mineralogical behaviour of Pb in shooting range soils from central Sweden

Recently investigations have shown that the annual flux of lead from shotgun pellets to shooting range soils is significant in some countries. This paper presents the data of chemical and mineralogical analyses of soils and Pb-pellet crusts from five shooting ranges in Sweden and, based on these results, evaluates the retention of lead in these shooting range soils. In the soils, Pb-pellets and bullets are readily decomposed and transformed to crust materials composed of Pb-bearing minerals. The transformation products in the crust materials, identified by X-ray diffraction, are predominantly hydrocerussite [Pb(3)(CO(3))(2) (OH)(2)], associated with cerussite (PbCO(3)) and anglesite (PbSO(4)). In a period of 20-25 years, an average of 4.8% metallic lead in the pellets has been transformed to lead carbonate and lead sulphate, where the former is the more stable mineral in the surface environment. However, in soils relatively rich in humus an average of 15.6% metallic lead in the pellets was transformed to secondary lead compounds in the same period. The results of the chemical analyses indicate that Pb is rather immobile in the soil profile. The surficial horizon contains higher concentrations of lead (52-3400 mg kg(-1)), while lower concentrations of lead were found in the E and B horizons where the total Pb concentrations (8-37 mg kg(-1)) are within about one standard deviation of the mean reference sample concentration. An inverse relationship is revealed between the aluminium hydroxide content of the soil fraction and EDTA-extractable Pb, which suggests that these compounds have affected the retention of lead.

[Pilot study of the efficacy of ticlopidine in early patency of coronary endoprostheses]

Subacute thrombosis of coronary stents is the main complication of this technique. The authors studied the outcome of 387 patients and 400 coronary arteries who underwent implantation of 427 stents between December 1989 and February 1994 and followed up one month after the procedure: all patients receive 500 mg of ticlopidine daily from three days before angioplasty throughout the hospital period and continued for at least one month. Anticoagulation with heparin was undertaken by the intravenous route after implantation and relayed with subcutaneous heparin for one week until control coronary angiography performed in the first 300 patients. At one month, 96.9% of patients were free of clinical coronary events. The following major complications were observed: 5 deaths (1.3%), 5 Q wave myocardial infarctions (1.3%); no emergency bypass surgery. The peripheral vascular complication rate was 3.6%. Univariate analysis three risk factors of subacute thrombosis: age (p = 0.0058), arterial diameter of less than 3 mm (p < 0.01) and implantation for occlusive dissection (p = 0.03). Multivariate analysis showed two independent risk factors: age (p = 0.001) and arterial diameter of less than 3 mm (p = 0.01). This pilot study shows a particularly low subacute thrombosis rate in unselected indications with an acceptable level of vascular complications.

Ticlopidine and subcutaneous heparin as an alternative regimen following coronary stenting

Subacute thrombosis of coronary stents may occur up to the end of the first month after their implantation and remains the major problem associated with the technique. A cohort of 238 patients with placement of one or more stents in 244 arteries was monitored for this period. All patients were given 500 mg/day of ticlopidine (started 3 days before) and a push dose of 10,000 IU of heparin during the procedure, then 1,000-1,500 IU/hr for 20 hr. Following removal of the arterial introducer, they were kept on subcutaneous heparin for 1 week and ticlopidine (500 mg/day) for 3-6 months. Nine patients (3.8%) showed evidence of thrombosis at 7 days. The overall thrombosis rate at 30 days was 4.2% (3.5% for elective stents, as compared with 7.9% associated with occlusive dissections). Emergency treatment by further angioplasty (8 cases) and intracoronary thrombolysis (5 cases) was undertaken. Complications were as follows: 5 deaths (2%), 3 MI (1.2%), 2 non-Q MI (1.7%). Three predictive factors for subacute thrombosis were identified: age < 70 (p = 0.00006), unstable angina (p = 0.006) and arterial diameter less than 3 mm (p = 0.043). The peripheral vascular complication rate was 4.6%. This study suggests that preventive treatment with ticlopidine appears to reduce the incidence of subacute thrombosis of stents in patients > 70 years of age. Furthermore, the combination of ticlopidine and heparin facilitates laboratory monitoring after stenting. Stenting is thought to represent definitive treatment in situations where placement for occlusive dissection is the indication.

Real time quality factor and dose equivalent meter "CIRCE" and its use on-board the Soviet orbital station "MIR"

During the French-Soviet space mission "Aragatz," the experiment CIRCE (Compteur Integrateur de Rayonnement Complexe dans l'Espace) recorded the dose rate and quality factor values inside the MIR station. This paper presents results obtained with a new active dose equivalent meter based on microdosimetric techniques and using a low pressure tissue equivalent proportional counter. In terms of lineal energy CIRCE device works in the 0.2-1200 keV micrometer-1 range in tissue. Preliminary studies were performed in photon, neutron and heavy ion beams, and in the real stratosphere cosmic radiation field. Long term measurements on-board MIR station from December 1988 to April 1989 gave an average quality factor value equal to 1.9 +/- 0.3. Through the South Atlantic Anomaly (SAA), the quality factor was equal to 1.4. The temporal orbital variations of the dose rates and quality factors have been established in space dosimetry for the first time.

[Successful cardiac transplantation after 38 days of circulatory assistance with a heterotopic artificial heart]

The survival of a patient with irreversible cardiac failure on the cardiac transplantation waiting list was assured for 38 days by circulatory assistance with heterotopic Pierce Donachy prosthetic ventricles and followed by successful cardiac transplantation. This method of circulatory assistance is relatively simple to install from the technical point of view and provides a satisfactory haemodynamic result whilst waiting for a compatible donor organ. Several complications, some of them serious, were observed. Some were related to the patient's poor preoperative condition: acute renal failure, disorders of coagulation. These regressed slowly when the patient's haemodynamic status improved. On the other hand, septic problems and local haemorrhage were inherent to this technique. These are the commonest complications reported by other authors. Although the mortality rate during the period of circulatory assistance may appear to be high, this technique remains a valuable method of survival for selected patients and does not affect the chances of success of ulterior cardiac transplantation.

[Percutaneous coronary transluminal angioplasty with extracorporeal circulation: preliminary results]

Percutaneous transluminal coronary angioplasty (PTCA) in patients with low ejection fraction (EF) and/or a large area of remaining viable myocardium served by the target vessel can cause hemodynamic collapse in case of acute closure. We report 11 patients in whom the cardiopulmonary bypass support (CPS) was instituted because of contraindication to surgery (Group I) or unstable angina associated with low EF and/or a large amount of myocardium perfused by the target artery (Group II). Nine were male and 2 female, mean ages of 70, with Canadian angor class I (1), II (1), or IV (9) and EF ranging from 12 to 65% (mean 34%). Thirty were the lesions to dilate; 28 were dilated successfully; in 2 an aortic dilation was also performed. One death occurred after the procedure related to collapse due to hypovolemia; another death occurred 8 months after PTCA because of pulmonary neoplasia. The other 9 patients followed-up at 1 to 8 months (mean 3.9) disclosed Canadian angor class I. The procedure's technique and the related complications are discussed. We conclude that cardiopulmonary bypass support can be used safely in patients refused to surgery and with high risk PTCA; such a procedure may expand the indication of PTCA.

[Infective endocarditis of a valve prosthesis. Multicenter study (179 cases)]

Over a 5-year period (1982-1986) 176 cases of infective endocarditis on prosthesis (IEP) were recorded in 40 cardiology departments. 65 p. 100 of the patients were male, and the mean age of the population was 51 years. Mechanical prostheses were involved in 57 p. 100 of the cases and bioprosthesis in 43 p. 100. There was a high proportion of initial indications for bacterial endocarditis (18 p. 100) and for reoperation on prosthesis (10 p. 100). IEP developed early in 40 cases and late in 139 cases; 19 (48 p. 100) of the early IEPs were staphylococcal, while 31 p. 100 of late IEPs were streptococcal (p less than 0.01). 143 patients were reoperated upon within less than 1 month in 41 p. 100 of the cases, with a pre-operative antibiotic therapy of less than 10 days in 39 p. 100. Reoperation was performed in stage IV or as an emergency in 45 p. 100 of the cases. Abscesses were three times more frequent with aortic prostheses than with mitral prostheses (58 p. 100 vs 20 p. 100, p less than 0.001). Vegetations were more frequent on mechanical prostheses than on bioprostheses (43 p. 100 vs 31 p. 100, NS). The operative mortality rate was 25 p. 100; the mortality rate of unoperated patients was even higher (31 p. 100). The survival rate in operated IEP was 51 p. 100 at 30 months, as against 46 p. 100 at 12 months in unoperated IEP.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of cardiac surgery in patients over 70 years of age. Apropos of a retrospective study of 170 patients]

The ever increasing age of the general population and the frequency of coronary and aortic lesions in patients aged 70 or older make cardiac surgery in the elderly a topic of current interest. In a retrospective study of 170 cases the overall mortality rate was 14 p. 100 (4.7 p. 100 in 1986). During the past two years (1985 and 1986), the mortality rates in patients with coronary disease who underwent elective surgery were 10 p. 100 and 4 p. 100 respectively. Emergency surgery (left coronary trunk and unstable angina excluded) and associated operations on the heart made the prognosis worse with overall mortality rates of 13 p. 100 and 15 p. 100 respectively (9 p. 100 in 1985, 10 p. 100 in 1986). In aortic valve surgery, hospital mortality rates were 28 p. 100 in 1985 and 6 p. 100 in 1986. Post-operative morbidity was high (52 p. 100 of patients) and consisted mostly of respiratory and neurological complications (14.7 p. 100 and 9.4 p. 100 respectively of all patients). Only 4 p. 100 of the patients developed peri-operative myocardial infarction. Functional results were satisfactory in both coronary disease and heart valve disease patients. The survival rate at 4 years was 74.5 +/- 10 p. 100 globally and 87.3 +/- 9 p. 100 in coronary patients operated upon electively. Thus, the considerable advances in surgical techniques and post-operative intensive care achieved during the last few years have significantly improved the results obtained in this population.(ABSTRACT TRUNCATED AT 250 WORDS)

[Peculiar indications and results of the use of a blood cell saver apparatus in cardiac surgery]

Results are reported of the use of autotransfusion by means of the blood cell saver in a group of patients at high risk for hemorrhage in Heart Surgery Department. Methods employed are described, and results are discussed: these were encouraging both from the clinical and biological viewpoints. The cost benefits of this procedure are emphasized and technical perspectives outlined with respect to recovery of plasma and platelets.

[False subaortic aneurysm after surgery of calcified aortic stenosis. Apropos of a case treated successfully]

The authors report a case of false aneurysm of the posterior subaortic region of the left ventricle after a technically difficult surgical decalcification in a case of aortic stenosis. At reoperation, the surgeon used the femoral artery and both vena cavae for canulation. A direct approach of this "vascular" tumour, which was exterior to the great vessels, confirmed the diagnosis and enabled the localisation of the internal orifice inside the left ventricle. This was closed simply by suturing. No previous cases of this kind were found in the literature. This report underlines the necessity of taking the greatest care when decalcifying this region in order to avoid this type of serious complication.

[Serum profile of inflammatory reaction proteins in arteriopathies of the lower limbs, stage II]

The serum content of proteins involved in the inflammatory process was investigated, partly through kinetic immunodiffusion, in 85 men subdivided as follows: 45 men (aged 57 +/- 5 years) with intermittent claudication due to arteriosclerosis obliterans; 20 controls matched for sex and age; 20 sex-matched controls whose mean age was 25 +/- 3 years. Patients with obliterating arteriosclerosis had signs of both subacute and chronic inflammation. Compared to controls, they had a higher sedimentation rate, a lower percentage of serum albumine, higher percentages and absolute serum contents os alpha 1, alpha 2 and beta globulins, and higher serum concentrations of fibrin, orosomucoid, C3 complement fraction and IgA. In addition, the modifications of these proteins were closely correlated. These results are consistent with previous reports concerning patients with coronary heart disease. They point out the relationship between inflammation and atherosclerosis.