FOCUS: fast Monte Carlo approach to coherence of undulator sources

FOCUS (Fast Monte CarlO approach to Coherence of Undulator Sources) is a new GPU-based simulation code to compute the transverse coherence of undulator radiation from ultra-relativistic electrons. The core structure of the code, which is written in the language C++ accelerated with CUDA, combines an analytical description of the emitted electric fields and massively parallel computations on GPUs. The combination is rigorously justified by a statistical description of synchrotron radiation based on a Fourier optics approach. FOCUS is validated by direct comparison with multi-electron Synchrotron Radiation Workshop (SRW) simulations, evidencing a reduction in computation times by up to five orders of magnitude on a consumer laptop. FOCUS is then applied to systematically study the transverse coherence in typical third- and fourth-generation facilities, highlighting peculiar features of undulator sources close to the diffraction limit. FOCUS is aimed at fast evaluation of the transverse coherence of undulator radiation as a function of the electron beam parameters, to support and help prepare more advanced and detailed numerical simulations with traditional codes like SRW.

Describing Intimate partner violence against ever-partnered women in Europe and perpetrator’s characteristics. Results from the Violence against women EU-wide survey

Available data on intimate partner violence (IPV) are derived from asynchronous and heterogeneous studies. Definition of IPV varies, is often partial, and only a limited number of potential determinants are considered. The Violence against women survey collected data consistently and simultaneously on all dimensions of IPV. Women were also asked about the perpetrator's characteristics. The present study aims to describe prevalence of physical, sexual and psychological IPV against European women, and reported perpetrator's characteristics. Face-to-face interviews were conducted with randomly selected women aged between 18 and 74, by the European Union Agency for Fundamental Rights.

IPV was defined by a positive answer to at least one question about violence perpetrated by current or ex-partner. Among the 40357 ever-partnered women, lifetime prevalence of overall IPV was 51.7% (95%CI 51.2-52.2). Prevalence of physical, sexual and psychological IPV were respectively 20.0% (19.6-20.4), 8.4% (8.2-8.7) and 48.5% (48.1-49.0). Partners' or ex-partners characteristics associated with IPV perpetration included: lower education level, unemployment or staying at home, earning less than the woman, a relationship lasting between 1 to 10 years, high frequency of drunkenness, and perpetration of other type of violence.

Lifetime prevalence of IPV in EU is high and likely to be underestimated. Specific trajectories and profiles of perpetrators should be characterized to ground the interventions. The risk of underreporting violence should be addressed as it jeopardizes the efficacy of interventions for prevention. They may be undifferentiated and differentiated, targeted and time-sensitive, respectively dedicated to general audience and high-risk populations.

A surface spectroscopy study of a Pseudomonas fluorescens biofilm in the presence of an immobilized air bubble

A linear spectral mapping technique was applied to monitor the growth of biomolecular absorption bands at the bio-interface of a nascent Pseudomonas fluorescens biofilm during and after interaction with a surface-adhered air bubble. Attenuated total reflection Fourier-transform infrared (ATR-FTIR) spectra were obtained in different locations in a microchannel with adequate spatial and temporal resolution to study the effect of a static bubble on the evolution of protein and lipid signals at the ATR crystal surface. The results reveal that the presence of a bubble during the lag phase modified levels of extracellular lipids and affected a surface restructuring process, many hours after the bubble's disappearance.

[TAVI simplification: A focus]

After a first procedure carried out in 2002 by Pr Cribier's, Transcatheter Aortic Valve Replacement or TAVR revolutionized the management of aortic stenosis with a constant increase in the number of procedures performed worldwide. Experience of operators and teams and evolution of the technique has been accompanied by a drastic reduction in complications in patients at lower surgical risk. In parallel, the procedure was considerably simplified, carried out more and more under local anesthesia, with percutaneous femoral approach, secondary radial approach, prosthesis implantation without predilatation, rapid pacing on left ventricle wire and early discharge. Thus, the "simplified" TAVR adopted in most centers nowadays is a real revolution of the technique. However, simplified TAVR must be accompanied upstream by a rigorous selection of patients who can benefit from a minimalist procedure in order to guarantee its safety.

[TAVI in women, very encouraging results]

The population of elderly patients comprises a high percentage of women. This population is more vulnerable due to the presence of numerous comorbidities and is, therefore, particularly exposed to the risk of aortic valve degeneration, resulting in aortic valve stenosis whose symptoms are predictors of poor short-term outcomes. In the presence of symptomatic aortic stenosis, the recommended therapeutic option in this vulnerable population is the implementation of transcatheter aortic valve implantation, preferably via the femoral route. The outcomes of this procedure are better in women than in men despite a more frequent occurrence of vascular, bleeding and cerebral complications. Several hypotheses have been reported in the literature regarding the reasons for such differences. Among other reasons, it is likely that in female patients, the myocardium adjusts better to the occurrence of aortic stenosis and that recovery after valve treatment is also more optimal. Another explanation is the higher frequency of coronary artery disease in this older population. This has a considerable impact on the outcome even when coronary lesions are treated prior to valve implantation. There is still room for improvement and progress can be achieved by further reducing the size of the equipment used in order to decrease the diameter of the vascular access, and by continuing to simplify TAVI procedures. Less invasive techniques should result in decreased complication rates. In addition, dedicated studies should allow us to further improve our practice in this growing population of vulnerable patients.

Pose des voies veineuses périphériques sous échographie par les infirmières de réanimation

La pose sous échographie des voies veineuses périphériques (VVP) par les infirmières est une technique innovante qui se développe au sein des services de réanimation où la présence médicale est permanente. Elle permet de mettre en place un abord veineux chez des patients oedématiés ou ayant un capital veineux faible et pour lesquels l’accessibilité à la pose de VVP en méthode classique est difficilement réalisable. La visualisation échographique du réseau veineux de ces patients évite ainsi de recourir au cathétérisme central. L’acquisition de cette technique par l’infirmière est conditionnée à la mise en oeuvre d’une formation théorique et pratique. La technique de pose de la VVP sous échographie est similaire sur un certain nombre de points avec la technique classique. Le recours à l’échoguidage nécessite un certain entraînement mais s’acquiert facilement par les infirmières de réanimation. La ponction diffère car elle est réalisée à une seule main, et le regard de l’opérateur ne se porte plus sur le bras du patient mais sur l’écran de l’échographe. Il est indispensable d’optimiser l’installation du patient, de l’opérateur et du matériel pour minimiser les facteurs d’échecs. L’acquisition de cette nouvelle compétence, au travers de la compréhension des principes échographiques et de la maîtrise technique de l’appareil, constitue une source de motivation pour l’infirmière de réanimation.

Position paper of French Interventional Group (GACI) for TAVI in France in 2018

Aortic stenosis is a frequent disease in the elderly. Its prevalence is 0.4% with a sharp increase after the age of 65, and its outcome is very poor when the patient becomes symptomatic. The interventional procedure known as TAVI (trans-catheter aortic valve implantation), which was developed in France and carried out for the first time in Rouen by Prof. Alain Cribier and his team in 2002, has proven to be a valid alternative to surgical aortic valve replacement. At first, this technique was shown to be efficient in patients with contra-indications to surgical treatment or deemed to be at high surgical risk. Given the very promising outcomes achieved as a result of close heart team collaboration, appropriate patient selection, simplified procedures and reduced complication rates, transfemoral (TF) TAVI is now preferred in symptomatic intermediate risk patients>75 years old according to the latest ESC guidelines. In 2017, in France, TAVI is currently performed in 50 centers with on-site cardiac surgery. The 2016 TAVI outcomes recorded in the French national TAVI registry (France TAVI) are very encouraging and show that for 7133 patients treated (age 83.4±7 years, logistic Euroscore 14%), 87% of whom via the TF approach, cross-over to surgery was very low (0.5%) with a 3.0% in-hospital mortality rate. The substantial increase in TAVI indications and the improvement of its outcomes may in the near future call for a reconsideration of the number of high volume centers authorized to carry out this technique.

A quantitative analysis of the supercontraction-induced molecular disorientation of major ampullate spider silk

Spider silks exhibit remarkable properties, among which the so-called supercontraction, a physical phenomenon by which fibers undergo a longitudinal shrinkage and a radial swelling when exposed to water. The process is marked by a significant decrease in chain orientation resulting from plasticisation of the amorphous phase. Despite several studies that determined the Hermans orientation function, more quantitative data are required to be able to describe theoretically the macroscopic water-induced shrinkage from molecular reorganization. Here, we have examined the supercontraction of the major ampullate silk single fibers of Nephila clavipes (Nc) and Araneus diadematus (Ad) using polarized Raman spectromicroscopy. We determined the order parameters, the orientation distribution and the secondary structure content. Our data suggest that supercontraction induces a slight increase in β-sheet content, consistently with previous works. The β-sheet orientation is slightly affected by supercontraction compared to that of the amorphous phase, which becomes almost isotropic with shrinkage. Despite an initially lower orientation level, the Ad fiber shows a larger orientation decrease than Nc, consistently with its higher shrinkage amplitude. Although they share similar trends, absolute values of the orientation parameters from this work differ from those found in the literature. We took advantage of having determined the distribution of orientation to estimate the amplitude of shrinkage from changes in macromolecular size resulting from molecular disorientation. Our calculations show that more realistic models are needed to correlate molecular reorientation/refolding to macroscopic shrinkage. This work also underlines that more accurate data relative to molecular orientation are necessary.

[Transfemoral TAVI procedure in women: Minimally-invasive technique]

Demographic data point to a substantial proportion of women in the population of elderly patients with an increasing prevalence of aortic stenosis. Implantation of an aortic bioprosthesis via an endovascular approach known as Transcatheter aortic valve implantation (TAVI) in patients presenting with a symptomatic tight aortic stenosis (severe aortic stenosis) (AS) is an alternative therapeutic option to surgical aortic valve replacement in patients at high surgical risk or ineligible for surgery. The literature has shown that this technique seems to be particularly beneficial in female patients. In the Partner A trial, the 1-year mortality rate was significantly lower in women compared to their male counterparts. Other data revealed that although women have a higher risk of experiencing periprocedural complications (vascular events, bleeding and stroke), their outcome is good and often better than that of men. These results are continuously improving thanks to the enhancement of techniques and devices. In view of the published reports reflecting the increasing experience of the teams, it clearly appears that the simplification of TAVI procedures has resulted in improved outcomes. We report here the case of a patient treated by means of a "minimalist" approach to TAVI allowing a reduction of the risks inherent in the procedure. This simplified strategy relies on an optimal use of CT scan findings prior to TAVI. The procedure is carried out under local anesthesia and the main access site is sutured percutaneously (Proglides). The radial artery is used as a secondary access site. Contrast medium is diluted and stimulation is administered via the intraventricular guidewire. Direct stenting is performed when deemed feasible on the basis of CT scan results. Simplified procedures such as these contribute to the improvement of TAVI outcomes. However, further studies focusing on female patients are warranted in order to corroborate these findings.

Occurrence of natural Anopheles arabiensis swarms in an urban area of Bobo-Dioulasso City, Burkina Faso, West Africa

The swarming behaviour of natural populations of Anopheles arabiensis was investigated by conducting transect surveys on 10 consecutive days, around dusk, from March to April and from September to October 2012 in Dioulassoba, a district of Bobo-Dioulasso city in Burkina Faso (West Africa). Swarms were observed outside, around identified larval breeding sites on the banks of the Houet River, as well as in the open-air courtyards found at the centre of many homes in the region. Swarms were found to occur in open sunlit spaces, mostly located above physical or visual cues somehow visually distinct from the surrounding area. Overall 67 and 78 swarms were observed, respectively, during the dry season (March-April) and the rainy season (September-October) of 2012, between 1.5m and 4.5m above the ground at their centre. 964 mosquitoes were collected and analysed from dry season swarms, of which most were male, and all were An. arabiensis, as were the few resting mosquitoes collected indoors. Larvae collected from breeding sites found on the banks of the Houet River mostly consisted of An. arabiensis and only a minority of Anopheles coluzzii (formerly identified as An. gambiae M form). Of 1694 mosquitoes analysed from 78 swarms in the rainy season collections, a few An. gambiae (formerly known as An. gambiae S form) males were identified, and the remainders were An. arabiensis. The majority of larvae collected during the wet season from the same breeding sites were identified as An. arabiensis followed by An. coluzzii and An. gambiae. The same pattern of species composition was observed in resting mosquitoes, though the proportion of An. arabiensis was less overwhelming. These data support the conclusion that An. arabiensis is the most prevalent species in this area, though the difference in species composition when using different population sampling techniques is noteworthy. Further studies are required for more detailed investigations of male dispersal, feeding behaviour and mating patterns in this urban setting.

[The use of the Five-in-Six System for stent delivery in challenging coronary lesions: a multi-center experience]

BACKGROUND

The mother and child "5-in-6" technique using the Heartrail II catheter is a novel tool allowing stent delivery in challenging lesions, when conventional techniques have failed.

METHODS

A total of 147 consecutive patients underwent percutaneous coronary intervention (PCI) using the "5-in-6" Heartrail II catheter was restrospectively identified in the Institut Cardiovasculaire Paris Sud, (Jacques-cartier hospital), Institut hospitalier Claude-Galien (Claude-Galien hospital) and European hospital of Paris between July 2009 and September 2012.

RESULTS

Ten interventional cardiologists treated 147 patients with the new device. The patients mean age was 68.5 ± 21.5 years, 78% were men. Radial access was used in 128 cases (87.9%). The treated vessels were the right coronary artery in 82%, left anterior descending in 22%, left circumflex in 18%, marginal branch in 9%, the posterior descending artery in three patients, retroventricular artery in one patient and a saphenous graft in two patients. Most lesions (70%) had American Heart Association/American College of Cardiology (AHA/ACC) type B2 or C, and greater than 50% were located in distal vessel segments. Mean lesion length was 16 ± 4 mm, which is indicative of long lesion. Most (62%) lesions were moderately to heavily calcified and 22 (14%) were chronic total occlusions. Problems with stent delivery were due to poor guide catheter support or excessive calcification. Introduction of the "Heartrail II" catheter allowed successful stent delivery in 139 cases (94%).

CONCLUSION

The "5 in 6" Heartrail II catheter is a simple and easy-to-use device that can improve the success of stent delivery in challenging coronary interventions.

[Renal artery denervation for treating refractory hypertension]

Arterial hypertension is a major healthcare issue affecting between 30 and 40% of the adult population in industrialized countries. Despite the availability of numerous pharmaceutical treatments, arterial hypertension often remains uncontrolled. A non-negligible percentage of patients are refractory to multiple-drug therapy, which exposes them to an increased risk of cardiovascular events. Percutaneous, renal denervation using a catheter connected to a low energy radiofrequency generator has proven effective in decreasing arterial pressure in patients resistant to medical therapy, by reducing afferent nerve activity. In order to be eligible for this therapeutic approach, patients must have uncontrolled essential hypertension despite treatment with a combination of three anti-hypertensive drugs including a diuretic agent, and ≥ 45mL/min glomerular filtration rate. The initial registry study demonstrated that catheter-based sympathetic renal denervation was a simple and safe procedure resulting in a significant and durable reduction in arterial pressure. Subsequently, a randomized controlled trial (the Symplicity HTN-2 trial) showed a mean 32/12 mmHg decrease in blood pressure measurements in the group of patients who underwent renal denervation whereas no difference was observed in the control group. The reduction in blood pressure was still present at 24-month follow-up. No procedure-related complications were reported and no instances of renal artery stenosis or aneurysmal dilatation were evidenced during the follow-up period. No cases of renal function impairment or deterioration were recorded. This technique seems to be a promising strategy in patients suffering from this serious condition. In order to demonstrate the actual benefit of this technique, we report the case of two patients who underwent renal denervation in our institution.

[Percentage of transradial approach for interventional cardiology in the world and learning the technique]

The transradial approach has been used for the first non selective coronary angiographies but was quickly replaced by the femoral approach until a new birth in 1989 for coronary angiography in 1989 and coronary angioplasty in 1992. Transradial approach use is extremely heterogeneous in the world, dominated by some countries in Europe, Canada, and eastern Asia (India, Taiwan, China, Japan). Risk factors of failure have been well described, allowing two kinds of learning: systematic attempt in all kind of patients when working with a proctor; patient selection when beginning the technique alone in order to get a high and stable success rate from the beginning. Systematic radial approach for coronary angiography is a must to learn the technique.

[Why perform PCI of coronary chronic occlusion and how?]

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

Trypanosoma brucei brucei induces alteration in the head proteome of the tsetse fly vector Glossina palpalis gambiensis

Parasitic manipulations of host behaviour are known from a wide range of host-parasite associations. However, the understanding of these phenomena is far from complete and detailed investigation of their proximate causes is needed. Many studies report behavioural modifications, such as altered feeding rates in tsetse fly (Glossina) infected with the mature transmissible stage (i.e. metacyclic) of the trypanosomes. Here, bidimensional (2D) gel electrophoresis and mass spectrometry were employed to analyse and compare the head proteome between four Glossina palpalis gambiensis categories (uninfected, refractory, mature infection, immature infection). Twenty-four protein spots specifically present or absent in the head of metacyclic-infected flies were observed. These protein spots were subsequently identified and functionally classified as glycolitic, neurotransmiter synthesis, signalling, molecular chaperone and transcriptional regulation proteins. Our results indicate altered energy metabolism in the head of metacyclic-infected tsetse flies. Some of the proteins identified, such as casein kinase 2 and jun kinase have previously been shown to play critical roles in apoptosis in insect neurones. In addition, we found two pyridoxal-dependent decarboxylases (dopa decarboxylase and alpha methyldopa hypersensitive protein), suggesting a modification of serotonin and/or dopamine in the brain of metacyclic-infected tsetse flies. Our data pave the way for future investigation of the alteration of the glossina central nervous system during infection by trypanosomes.

[Assessment of myocardial function and perfusion by MRI two days and four months after acute myocardial infarction revascularised by primary angioplasty]

The extent of gadolinium enhancement assessed by cardiac MRI is an accepted marker of myocardial necrosis. The correlation between late enhancement and other parameters of infarct size after myocardial infarction have previously been described. However, the prognostic value of the extent of late enhancement in terms of myocardial recovery remains controversial especially in revascularised infarcts analysed by early MRI. In order to clarify this question the authors compared the results of MRI at two days and four months after myocardial infarction benefiting from early revascularisation. Between July 2002 and November 2004, the authors included patients with myocardial infarction treated by primary angioplasty and examined by MRI (Siemens Symphony 1.5 T) at two days and three to five months after myocardial infarction. The left ventricular ejection fraction, volume, mass and wall thickness were measured. Perfusion at first passage (PP) and late enhancement were analysed after injection of 20 cc of gadolinium. An eight segment short axis model was used for PP and analysis of late enhancement. Each segment was assessed for transmural or subendocardial hypoperfusion for PP assessment and the wall thickness with late enhancement (1-25%, 26-50%, 51-75%, and 76-100%) was measured to calculate the percentage of myocardial mass showing late enhancement. Thirty-nine patients (thirty three men) were included. The average age was 59 +/- 10 years. TIMI III flow was obtained in all but one (TIMI II) patient. Cardiac MRI was performed 2.1 +/- 1.5 days and 4.6 +/- 1.7 months after myocardial infarction. The ejection fraction increased from 48.7 +/- 12.6% to 54.2 +/- 11.1%, p<0.05, and was related to infarct size (p<0.01). Forty-eight per cent of dysfunctional segments at the initial MRI improved their contractility and the extent of transmural late enhancement was inversely correlated with wall thickening at initial (p<0.01) and four month MRI (p<0.01). The PP improved significantly (regression from 9.5 +/- 8.2% to 2.8 +/- 4.1% of segments with abnormal myocardial perfusion, p<0.01). The late enhancement with respect to total myocardial mass decreased from 20.0 +/- 10.7% to 13.0 +/- 8.1%, p<0.01). Despite restoring TIMI III flow, early myocardial reperfusion is incomplete and improves in the medium term. The authors also observed a reduction in late enhancement at four months, indicating that the results immediately after myocardial infarction may overestimate the infarct size and that this sign does not represent necrotic tissue alone but also viable myocardium with a potential for recovery.

Hairworm anti-predator strategy: a study of causes and consequences

One of the most fascinating anti-predator responses displayed by parasites is that of hairworms (Nematomorpha). Following the ingestion of the insect host by fish or frogs, the parasitic worm is able to actively exit both its host and the gut of the predator. Using as a model the hairworm, Paragordius tricuspidatus, (parasitizing the cricket Nemobius sylvestris) and the fish predator Micropterus salmoïdes, we explored, with proteomics tools, the physiological basis of this anti-predator response. By examining the proteome of the parasitic worm, we detected a differential expression of 27 protein spots in those worms able to escape the predator. Peptide Mass Fingerprints of candidate protein spots suggest the existence of an intense muscular activity in escaping worms, which functions in parallel with their distinctive biology. In a second step, we attempted to determine whether the energy expended by worms to escape the predator is traded off against its reproductive potential. Remarkably, the number of offspring produced by worms having escaped a predator was not reduced compared with controls.

[Drug-eluting stents in complex lesions]

Interventional cardiology has evolved tremendously over the past two years with the advent of drug-eluting stents. The RAVEL trial was the first randomized study conducted with sirolimus-eluting stents in a selected population of patients in whom a 0% rate of binary restenosis was achieved. The objective of the SIRIUS trial conducted in a more complex patient population was to test the efficacy of the sirolimus-eluting stent in high-risk settings such as coronary bifurcation lesions.

Stenting of bifurcation lesions: a rational approach

The occurrence of stenosis in or next to coronary bifurcations is relatively frequent and generally underestimated. In our experience, such lesions account for 15%-18% of all percutaneous coronary intervention > (PCI). The main reasons for this are (1) the coronary arteries are like the branches of a tree with many ramifications and (2) because of axial plaque redistribution, especially after stent implantation, PCI of lesions located next to a coronary bifurcation almost inevitably cause plaque shifting in the side branches. PCI treatment of coronary bifurcation lesions remains challenging. Balloon dilatation treatment used to be associated with less than satisfactory immediate results, a high complication rate, and an unacceptable restenosis rate. The kissing balloon technique resulted in improved, though suboptimal, outcomes. Several approaches were then suggested, like rotative or directional atherectomy, but these techniques did not translate into significantly enhanced results. With the advent of second generation stents, in 1996, the authors decided to set up an observational study on coronary bifurcation stenting combined with a bench test of the various stents available. Over the last 5 years, techniques, strategies, and stent design have improved. As a result, the authors have been able to define a rational approach to coronary bifurcation stenting. This bench study analyzed the behavior of stents and allowed stents to be discarded that are not compatible with the treatment of coronary bifurcations. Most importantly, this study revealed that stent deformation due to the opening of a strut is a constant phenomenon that must be corrected by kissing balloon inflation. Moreover, it was observed that the opening of a stent strut into a side branch could permit the stenting, at least partly, of the side branch ostium. This resulted in the provocative concept of "stenting both branches with a single stent." Therefore, a simple approach is currently implemented in the majority of cases: stenting of the main branch with provisional stenting of the side branch. The technique consists of inserting a guidewire in each coronary branch. A stent is then positioned in the main branch with a wire being "jailed" in the side branch. The wires are then exchanged, starting with the main branch wire that is passed through the stent struts into the side branch. After opening the stent struts in the side branch, kissing balloon inflation is performed. A second stent is deployed in the side branch in the presence of suboptimal results only. Over the last 2 years, this technique has been associated with a 98% angiographic success rate in both branches. Two stents are used in 30%-35% of cases and final kissing balloon inflation is performed in > 95% of cases. The in-hospital major adverse cardiac events (MACE) rate is around 5% and 7-month target vessel revascularization (TVR) is 13%. Several stents specifically designed for coronary bifurcation lesions are currently being investigated. The objective is to simplify the approach for all users. In the near future, the use of drug-eluting stents should reduce the risk of restenosis.

Stent placement compared with balloon angioplasty for small coronary arteries: in-hospital and 6-month clinical and angiographic results

BACKGROUND

Stenting has been demonstrated to be superior to balloon angioplasty in de novo focal lesions located in large native vessels. However, in small vessels, the benefit of stenting remains questionable.

METHODS AND RESULTS

A total of 381 symptomatic patients with de novo focal lesion located on a small coronary segment vessel (<3 mm) were randomly assigned to either stent implantation (192 patients; 197 lesions) or standard balloon angioplasty (189 patients; 198 lesions). The primary end point was the angiographic restenosis rate at 6 months, as determined by quantitative coronary angiography. On intention-to-treat analysis, angiographic success rate and major adverse cardiac events were comparable: 97.9% and 4.6% versus 93.9% and 5.8% in the stent group and the balloon group, respectively. After the procedure, a larger acute gain was achieved with stent placement (1.35+/-0.45 versus 0.94+/-0.47 mm, P=0.0001), resulting in a larger minimal lumen diameter (2.06+/-0.42 versus 1.70+/-0.46 mm, P=0.0001). At follow-up (obtained in 91% of patients), angiographic restenosis rate was 21% in the stent group versus 47% in the balloon group (P=0.0001), a risk reduction of 55%. Repeat target lesion revascularization was less frequent in the stent group (13% versus 25%, P=0.0006).

CONCLUSIONS

Elective stent placement in small coronary arteries with focal de novo lesions is safe and associated with a marked reduction in restenosis rate and subsequent target lesion revascularization rate at 6 months.

The problem of arteria lusoria in right transradial coronary angiography and angioplasty

The retroesophageal right subclavian artery (arteria lusoria) is one of the anatomical abnormalities encountered by interventional cardiologists who perform right transradial procedures. We report on 11 patients with arteria lusoria in whom 14 right transradial coronary angiography or angioplasty procedures were attempted among a series of 3,730 consecutive right transradial attempts. This abnormality can be easily detected by angiographic visualization, in the anteroposterior projection, of the angle of the catheter when it engages the ascending aorta, and by manual angiography at the ostium of the right subclavian artery. In such a case, catheterization of the ascending aorta may be difficult or even impossible (7.1%). Selective catheterization of both coronary arteries is more difficult, takes longer, and requires more catheters. The Judkins catheters are recommended, although they are seldom used for the left coronary artery via the right radial approach, for both arteries. All catheter exchanges should be performed on long guidewires.

Conformational rearrangement of beta-lactoglobulin upon interaction with an anionic membrane

Interactions between beta-lactoglobulin (beta-lg) and dimyristoylphosphatidylglycerol (DMPG) bilayers were studied using one- and two-dimensional infrared spectroscopy above (pD 7.4) and below (pD 4.4) the protein's (beta-lg's) isoelectric point (pI=5.2). The aim of the study was threefold: (1) gain a better understanding of beta-lg-phospholipid interaction; (2) provide information relative to the structure of beta-lg as it interacts with membranes; (3) determine whether the conformational modifications of the protein in the presence of lipids are strictly caused by thermal effects or whether they are modulated by the chain-melting phase transition. At pD 7.4, the lipid thermotropism, the acyl-chain order, and the membrane interfacial region were essentially unaffected by the presence of beta-lg, whereas the protein amide I region showed dramatic alterations. The results suggested the predominance of beta-sheets and alpha-helix elements, with a lost of structural integrity. At pD 4.4, beta-lg induced an approximately 2 degrees C downshift of the transition temperature, whereas the conformational order of the lipid chain decreased in the gel phase and increased in the liquid-crystalline phase. The hydration state of the DMPG C==O groups increased in the liquid-crystalline phase. The conformation of beta-lg at pD 4.4 in the presence of DMPG showed similarities with that observed at pD 7.4, but an increase in the alpha-helix content and a reduced thermal stability were noticed. In contrast to the protein alone, beta-lg aggregates in the presence of DMPG at pD 4.4 above 50 degrees C. At both pD values, the charged surface of the membrane seemed to be the main factor for inducing protein conformational changes by altering the intramolecular interactions that stabilize the native structure. However, protein incorporation within the membrane seemed to be involved at pD 4.4. The two-dimensional analysis performed with spectra recorded upon heating showed that spectral intensity changes at pD 4.4 and 7.4 occurred at the same frequencies in the amide I' region. The heat-induced structural changes of beta-lg were not correlated with the conformational modifications of the phospholipids along the phase transition, indicating that the thermal behavior of the protein was not modulated by the lipid chain melting, but rather represented the heat-induced protein rearrangement in the presence of DMPG.

Outcome after combined reperfusion therapy for acute myocardial infarction, combining pre-hospital thrombolysis with immediate percutaneous coronary intervention and stent

BACKGROUND

Primary therapies in acute myocardial infarction (thrombolysis and angioplasty) have inherent limitations which may be overcome by combining them. So far, no trial has demonstrated a clinical benefit in combining mechanical and pharmacological treatment strategies.

METHODS

From January 1995 to December 1999, out of 1010 patients admitted to our institution for acute myocardial infarction, 148 had received pre-hospital full dose thrombolysis within 12 h of onset. One hundred and thirty-one patients were included and underwent immediate angioplasty and stenting when suitable, independent of the infarct-artery patency (TIMI grade flow 0-3). In-hospital outcome was assessed and clinical information was collected for a mean (+/-SD) of 2+/-1 years.

RESULTS

Ninety-minute angiography revealed a patent (TIMI grade 3) infarct artery in 65 patients (49%). Immediate angioplasty was performed in 119 patients (91%) with stent implantation in 114 (96%). Angioplasty achieved TIMI 2, 3 flow in 98%, and complete patency (TIMI 3 flow) in 92%. Six other patients underwent deferred revascularization (surgery in one patient, angioplasty in five) and six received medical treatment. Stent thrombosis and reinfarction occurred in three patients (2.3%). In-hospital death occurred in six patients (4.6%), including four patients presenting with cardiogenic shock. Major bleeding was observed in 2.3% of cases. No patient had emergency surgery. Freedom from death and reinfarction at 2 years was 90% and freedom from death, reinfarction and target vessel revascularization was 83%.

CONCLUSION

A strategy of combined reperfusion using full dose pre-hospital thrombolysis and immediate angioplasty with stent implantation in a non-selected acute myocardial infarction population is safe and achieves high and early patency rates. This preliminary experience suggests that a combined strategy in acute myocardial infarction may have a significant impact on both early and long-term outcomes.

Amplatzing a 6 Fr Judkins right guiding catheter for increased success in complex right coronary artery anatomy

Stent supported angioplasty is being performed in an increasing number of patients and, with advances in device technology, more morphologically complex lesions are being treated. In such a setting, it is extremely important to deliver the device to the target lesion. We describe a new technique that allows successful stent delivery in complex right coronary anatomy using the Judkins right guiding catheter. Cathet Cardiovasc Intervent 2001;53:405-409.

Coronary angiography through the radial or the femoral approach: The CARAFE study

In a previous study, the radial approach for coronary angiography was shown to be associated with a lower success rate and longer procedural and X-ray times compared to the femoral approach. However, this approach is associated with a steep learning curve. A series of 210 consecutive nonselected patients were randomized to femoral versus right radial approach or femoral versus left radial approach by two experienced operators. Clinical characteristics were similar in the three groups. Technical failure occurred in one patient in the right radial group with subsequent crossover to left radial artery. The number of coronary catheters used was lower in the right radial group (1.4 +/- 0.7 vs. 2.1 +/- 0.4 for the two other groups). The procedural duration was longer with left radial (14.2 +/- 3.3 min; P < 0.05) approach than with right radial (12.4 +/- 5.8 min) and femoral (11.2 +/- 3.3 min) without significant differences between femoral and right radial. X-ray exposure was shorter in the femoral group (3.1 +/- 1.7 min) than in both radial groups (right: 3.8 +/- 2.2 min; left: 4.2 +/- 1.7 min). The angiographic quality was not different between the three groups for RCA, but was less good for LCA through right radial approach. Bed rest and hospital stay were shorter in the two radial groups. The comfort was judged better with the transradial approach. An ad hoc PTCA was performed in 45.7% of femoral patients, 41.4% of right radial, and 44.3% of left radial with immediate sheath withdrawal (closure device for femoral group). There were no severe complications in the three groups, but two patients from the femoral group were discharged later because of vascular complications. The total cost of coronary angiography was higher in the femoral group. In conclusion, after the learning period, transradial coronary angiography can be performed with a high success rate, low rate of complication, and good angiographic quality. It is associated with a slight increase in procedural (LR) and fluoroscopy times, but permits earlier ambulation and discharge, improves patient comfort, and reduces the cost.

Molecular differences in the formation and structure of fine-stranded and particulate beta-lactoglobulin gels

In order to reveal at a molecular level differences between fine-stranded and particulate gels, we present an Fourier transform infrared spectroscopic study of the thermal behavior of beta-lactoglobulin (beta-lg) in salt-free D(2)O solutions and low ionic strength at different pDs. Differences are found in the denaturation mechanism, in the unfolded state of the protein, in the aggregate formation, and in the strength of the intermolecular interactions. For fine-stranded gels (pD 2.8 and 7.8), heating induces the dissociation of the dimers into monomers. The protein undergoes extensive structural modifications before aggregation begins. Aggregation is characterized by the appearance of a new band attributed to intermolecular beta-sheets which is located in the 1613-1619 cm(-1) range. For particulate gels (pD 4.4 and 5.4), the protein structure is almost preserved up to 75-80 degrees C with no splitting of the dimers. The band characteristic of aggregation originates from the component initially located at 1623 cm(-1), suggesting that at the beginning of aggregation, globular beta-lg in the dimeric form associate to constitute oligomers with higher molecular mass. Aggregation may result in the association of globular slightly denatured dimers, leading to the formation of spherical particles rather than linear strands. The aggregation band is always located in the 1620-1623 cm(-1) range for particulate gels showing that hydrogen bonds are weaker for these aggregates than for fine-stranded ones. This has been related to a more extensive protein unfolding for fine-stranded gels that allows a closer alignment of the polypeptide chains, and then to the formation of much stronger hydrogen bonds. Small differences are also found in protein organization and in intermolecular hydrogen bond strength vs pD within the same type of gel. Protein conformation and protein-protein interactions in the gel state may be responsible of the specific macroscopic properties of each gel network. A coarse representation of the different modes of gelation is described.

Systematic use of transradial approach or suture of the femoral artery after angioplasty: attempt at achieving zero access site complications

Access site complications occur in 5-15% of cases according to the various series. The predictive factors most often reported in the literature are the size of the puncture site and the intensity of the antiplatelet or anticoagulant treatment associated with the angioplasty procedure. Six senior cardiologists in a high volume Cardiology center (>1,500 procedures a year) with an individual experience >500 procedures in either the radial approach or the percutaneous suture of the femoral artery with the Techstar/Prostar system, conducted a prospective study from January 1 to December 31, 1999. The aim of this study was to eliminate the occurrence of access site complications by using either one of two techniques that were at the operator's discretion, i.e., systematic radial approach, or percutaneous suture of the femoral artery. A total of 956 patients were included over the study period; 60.7% of these patients had percutaneous arterial closure of the femoral artery and the remaining 39.3% were treated via the radial approach; 88.7% were stented. The patients were administered a mean 9,000 IU of heparin during the procedure; 1.9% had been fibrinolyzed and Reopro was used in 5.9%. No complications were documented in the radial group. Of the 580 patients in the femoral suture group, 96.9% had femoral suture, immediately effective in 508 cases (90.4%). Only 3 patients required additional prolonged compression. One significant hematoma (0.2%) necessitating blood transfusion was reported in the femoral group. Infection at the puncture site with subsequent antibiotic treatment was reported in 2 patients (0.3%). No further access site complications were observed at one-month follow-up. After completion of the learning curve, the two techniques (radial approach and percutaneous arterial suture) permit the almost total elimination of access site complications.

Interaction of beta-lactoglobulin with phospholipid bilayers: a molecular level elucidation as revealed by infrared spectroscopy

Fourier transform infrared (FTIR) spectroscopy has been used to study, at a molecular level, the interactions between beta-lactoglobulin (BLG), the most abundant globular protein in milk, and some lipids (sphingomyelin, SM; dimyristoylphosphatidylcholine, DMPC; dipalmytoylphosphatidylcholine, DPPC; dimyristoylphosphatidylserine-sodium salt, DMPS; dipalmitoylphosphatidylserine-sodium salt, DPPS) constituting the milk fat globule membrane (MFGM). The interactions were monitored with respect to alteration in the secondary structure of BLG, as registered by the amide I' band, and phospholipid conformation, as revealed by the acyl chain and carbonyl bands. The results show that neither the conformation nor the thermotropism of neutral bilayers containing DMPC or DPPC is affected by BLG. Reciprocally, the secondary structure and thermal behaviour of pure BLG remain the same in the presence of PC. These results suggest that no interaction occurs between PC and BLG, in agreement with previous studies. However, it is found that BLG interacts with neutral bilayers constituted by milk SM lipids, increasing gauche conformers and thus conformational disorder of the lipid acyl chains. This perturbing effect has been attributed to a partial penetration of BLG into the hydrophobic core of the bilayer, which allows hydrophobic interactions between BLG and SM. Moreover, the fact that SM possesses the same headgroup of PC implies that the head group does not prevent the occurrence of BLG-lipid interactions and other lipid regions can control the binding of BLG to lipids. Furthermore, BLG was found to interact electrostatically with charged bilayers containing PS, leading to a rigidification of the lipid hydrocarbon chains and a dehydration of the interfacial region. This last effect suggests that the protein limits the accessibility of water molecules to the interfacial region of the phospholipids by its presence at the membrane surface.

Coronary angioplasty using 5 French guiding catheters: preliminary experience

In a retrospective study of 40 patients, we evaluated the effectiveness of the new 5 Fr 0.058" lumen diameter guiding catheter in routine PTCA. A total of 54 balloon angioplasties were performed. The mean age was 62.1+/-12.8 years, with 71% men. The artery dilated was the LAD in 50%, the RCA in 37%, and the circumflex in 13%. Sixty percent of the lesions dilated were proximal lesions, with only 25% defined as distal lesions. Significant calcifications were present in 20% of the lesions. Stents were implanted in 96%, and mean stent length was 14.0 mm, ranging from 8 to 24 mm. Mean balloon diameter was 2.7 mm, ranging from 2.0 to 3.5 mm. The procedure was a success in 95%, with only two failures. No other complications occurred. We concluded that the 0.058" 5 Fr guiding catheter could be suitable in the majority of noncomplex, selected PTCA cases. However, limitations and advantages over the standard 6 Fr technique are yet to be defined.

A randomized study comparing two guidewire strategies for angioplasty of chronic total coronary occlusion

Chronic total coronary occlusions were more frequently crossed using the Crosswire as a primary guidewire strategy than with the conventional strategy. This strategy resulted in a lower number of guidewires being used, a trend toward shorter procedural and fluoroscopy times, and decreased use of contrast media.

Stenting of bifurcation lesions: classification, treatments, and results

Percutaneous transluminal balloon coronary angioplasty (PTCA) of coronary bifurcations is associated with a low success rate, high rate of complications, and high incidence of target vessel revascularization (TVR). The strategy of systematic coronary stenting in bifurcation lesions involving a side branch >/= 2.2 mm in diameter was prospectively evaluated in a single-center observational study during a 35-month inclusion period. All patients meeting these criteria were consecutively included. Bifurcation lesions and treatment were predefined in the study. The study included 366 patients (12.1% of PTCA) with 373 bifurcation lesions, mean age 63.7 +/- 11.6 years, 79.2% male, 46.7% with unstable angina, and 8.3% acute MI. The left anterior descending/diagonal bifurcation was involved in 55.2% of cases, circumflex/marginal 22. 2%, PDA/PLA 10.4%, left main bifurcation in 6.8%, and others 5.4%. The main branch (2.78 +/- 0.42 mm reference diameter) was stented in 96.3% of cases and the side branch (2.44 +/- 0.43 mm) in 63.2% (the two branches were stented in 59.5% of cases). Procedural success was obtained in 96.3% in both branches and 99.4% in the main branch. At1-month follow-up, The major cardiac event rate (MACE) was 4.8% (death 1.1%, emergency CABG 0.6%, Q-wave MI 0.9%, acute or subacute closure 1.4%, repeat PTCA 1.1%, and non-Q-wave MI 2.3%). At 7-month follow-up, the total MACCE rate was 21.6%, including a TVR rate of 17.2%. Analysis of the 7-month outcome according to two study periods (period I, 1 January 1996 to 31 August 1997, 182 patients; period II, 1 September 1997 to 30 June 1998, 127 patients) showed that the TVR rate decreased from 20.6% to 13.8% (P = 0.04) and the MACE rate from 29.2% to 17.1% (P < 0.01) in period I and II, respectively. This was associated by univariate analysis with an increasing use of tubular stents deployed in the main branch (94.2% vs. 59.1%, P < 0.001) and kissing balloon inflation after coronary stenting (75.4% vs. 18.1%, P < 0.001). Bifurcation lesions are frequent. Procedural success of coronary stenting is high with a low rate of in-hospital MACE. TVR rate at follow-up is relatively low. In-hospital and follow-up results are influenced not only by the learning curve but also by the use of tubular stents in the main branch and final kissing balloon inflation.

Stenting of bifurcation lesions: classification, treatments, and results

Percutaneous transluminal balloon coronary angioplasty (PTCA) of coronary bifurcations is associated with a low success rate, high rate of complications, and high incidence of target vessel revascularization (TVR). The strategy of systematic coronary stenting in bifurcation lesions involving a side branch >/= 2.2 mm in diameter was prospectively evaluated in a single-center observational study during a 35-month inclusion period. All patients meeting these criteria were consecutively included. Bifurcation lesions and treatment were predefined in the study. The study included 366 patients (12.1% of PTCA) with 373 bifurcation lesions, mean age 63.7 +/- 11.6 years, 79.2% male, 46.7% with unstable angina, and 8.3% acute MI. The left anterior descending/diagonal bifurcation was involved in 55.2% of cases, circumflex/marginal 22. 2%, PDA/PLA 10.4%, left main bifurcation in 6.8%, and others 5.4%. The main branch (2.78 +/- 0.42 mm reference diameter) was stented in 96.3% of cases and the side branch (2.44 +/- 0.43 mm) in 63.2% (the two branches were stented in 59.5% of cases). Procedural success was obtained in 96.3% in both branches and 99.4% in the main branch. At1-month follow-up, The major cardiac event rate (MACE) was 4.8% (death 1.1%, emergency CABG 0.6%, Q-wave MI 0.9%, acute or subacute closure 1.4%, repeat PTCA 1.1%, and non-Q-wave MI 2.3%). At 7-month follow-up, the total MACCE rate was 21.6%, including a TVR rate of 17.2%. Analysis of the 7-month outcome according to two study periods (period I, 1 January 1996 to 31 August 1997, 182 patients; period II, 1 September 1997 to 30 June 1998, 127 patients) showed that the TVR rate decreased from 20.6% to 13.8% (P = 0.04) and the MACE rate from 29.2% to 17.1% (P < 0.01) in period I and II, respectively. This was associated by univariate analysis with an increasing use of tubular stents deployed in the main branch (94.2% vs. 59.1%, P < 0.001) and kissing balloon inflation after coronary stenting (75.4% vs. 18.1%, P < 0.001). Bifurcation lesions are frequent. Procedural success of coronary stenting is high with a low rate of in-hospital MACE. TVR rate at follow-up is relatively low. In-hospital and follow-up results are influenced not only by the learning curve but also by the use of tubular stents in the main branch and final kissing balloon inflation.

Transcatheter closure of apical ventricular muscular septal defect combined with arterial switch operation in a newborn infant

This report describes a case of transposition of the great arteries and apical muscular ventricular septal defect in a newborn infant successfully treated by transcatheter closure of the septal defect with the Amplatzer duct occluder device followed by an arterial-switch operation within the first 2 weeks of life. Cathet. Cardiovasc. Intervent. 49:173-176, 2000.

[Immediate revascularization by angioplasty and coronary stents in patients over age 80 with myocardial infarction]

The aim of this study was to assess the results of revascularisation by angioplasty and stenting in octogenarians in the acute phase of myocardial infarction. One hundred and four patients over 80 years of age were identified between January 1995 and April 1995 out of 906 patients admitted within 24 hours of the onset of myocardial infarction. The average age was 85 +/- 4 years with a female predominance (63.4%) and a high incidence of cardiogenic shock (28.8%). Ninety eight patients underwent angioplasty with coronary stenting in 81 patients (82.6%) within 39 +/- 35 min of hospital admission. A primary success was obtained in 96% of cases with restitution of TIMI 3 flow in 83.6% of cases. Hospital mortality was 26.5%, highly influenced by the presence of cardiogenic shock (60.7% versus 12.8% without shock). Univariate analysis showed cardiogenic shock (p < 0.0001) and ejection fraction (p = 0.009) to be predictive of mortality, and a tendency in favour of TIMI 3 flow (p = 0.07) and stent implantation (p = 0.09). Complications were rare: 1% of minor cerebrovascular accidents and 4% of vascular complications. There were no cases of emergency bypass surgery and only one patient had a recurrence of ischaemia at 30 days. The authors conclude that the results at 1 month in a high risk group of octogenarians seem to be in favour of an invasive management with coronary stenting in the acute phase of myocardial infarction.

Rescue left main angioplasty on first post-operative day of coronary artery bypass graft surgery ischemia

Percutaneous revascularization has been used for the treatment of post-coronary bypass graft ischemia. This report illustrates the use of emergency left main coronary artery stenting in protected left main on the first post-operative day for management of perioperative coronary artery bypass graft surgery ischemia.