Rotational ablation: back to the future

In the late 1980s, many alternative methods to coronary angioplasty were sought, among which rotational ablation was one of the most popular. With the huge development of coronary stents, this technique, however, was progressively left aside. More recently, though, rotational ablation has reappeared as a unique technique for the most calcified lesions and is used in a small but not negligible percentage of patients with success rates over 95% in recent series.     

Infarctus du myocarde secondaire à l’occlusion aiguë simultanée des portions proximales de la circonflexe et de la coronaire droite : à propos d’un cas

Acute myocardial infarction due to simultaneous occlusion of two major coronary arteries is a rare phenomenon. We report a case of a 53-year-old man with many cardiovascular risk factors, who presented to the emergency with an acute coronary syndrome with ST segment elevation in anterior and inferior leads, complicated by atrioventricular block and cardiogenic shock. The coronary angiogram showed proximal occlusion of left circumflex artery and right coronary artery. Both arteries were treated successfully with thrombectomy followed by coronary stent implantation. Some similar cases have been reported, but the exact physiopathological mechanism is unknown. There is no clear strategy established for the therapeutic coverage, however, percutaneous revascularisation seems to be actually appropriated treatment.     

Utilisation des ballons actifs dans l’angioplastie coronaire : indications actuelles et perspectives

The paclitaxel-eluting balloon is an emerging percutaneous coronary angioplasty tool which aim is to prevent restenosis by delivering a high intravessel paclitaxel dose during balloon inflation. It has been already approved in the treatment of bare metal stent restenosis and is being investigated in drug-eluting stent restenosis. For the treatment of de novo lesions, it could be used alone or in combination with bare metal stent implantation. Most interesting results were obtained by a drug-eluting balloon alone strategy in small vessels angioplasty. Current and upcoming results of this evolving technology are reviewed.     

Résultats immédiats et à long terme après angioplastie coronaire avec stents actifs de lésions de bifurcation par la technique du « crush stenting »

The most common approach in the treatment of bifurcation lesions is stenting only the main branch (MB) with provisional T-stenting of the side branch (SB). However, some bifurcation lesions may have extensive disease within a large SB requiring stenting of this vessel. The “crush” technique, which has been proposed as an alternative approach to other strategies to treat complex bifurcations, is a relatively simple technique that ensures complete coverage of the SB ostium. Previous series have reported its safety and feasibility, but limited data are available about the long-term outcomes. We report our experience on 21 consecutive patients (pts) treated with the “crush” technique with drug-eluting stents (DES) between November 2005 and March 2007. Clinical follow-up was 18 ± 7 months for 19 pts (90%), and angiographic follow-up was completed in 66% of pts (N = 14), at a mean time of 8.5 ± 4 months. Mean pt age was 70 ± 11 years; 33% (N = 7) had diabetes mellitus, and mean preoperative logistic EUROSCORE predicted 11% mortality rate. The left anterior descending artery/diagonal and the distal left main were the most frequent bifurcation locations (52 and 43% of cases respectively), with a type 1,1,1 of the Medina classification of bifurcation lesions in 62% of pts, and an angulation MB-SB below 50° in 66% of cases. Final kissing balloon dilation was performed in 90% of pts (N = 20). Stent diameter and length were similar between MB and SB. The procedure was successfull in 100% of cases in the MB and 95% of cases in the SB. Procedure-related CK elevation above 2 ULN was seen in two pts (9.5%), without ECG modification. One pt had subacute stent thrombosis 5 days after his procedure. At the end of follow-up, target vessel revascularization (TVR) was required in four pts (19%), and target lesion revascularisation (TLR) in three pts (14%) whom had focal restenosis in the SB ostium (one pt) and in the MB and SB ostia (one pt). Sudden death occurred in one pt 14 months after his procedure. In conclusion, when an effective strategy for stenting both branches is planned, the “crush” technique with final kissing balloon can be safely used by experienced operators to treat complex bifurcation lesions with DES. The safety profile and TLR rate in our small series of “crush” stenting were similar to that of other studies reported thus far.     

Le syndrome de platydéoxie-orthopnée : à propos d’un cas

We report the case of an 80-year-old woman with symptomatic postural hypoxaemia caused by a right-to-left shunt through a patent foramen ovale. The hypoxaemia was enhanced by the supine position and disappeared in upright position. Potential mechanisms underlying postural variations of the shunt seemed to be similar to those describe in platypnea-orthodeoxia syndrome. Patient became asymptomatic after shunt resolution.     

Commissurotomie mitrale percutanée associée à une communication interauriculaire type sinus venosus et un retour veineux anormal partiel : à propos d’un cas

Lutembacher's syndrome refers to the rare combination of congenital atrial septal defect and acquired mitral stenosis. It is rarely associated to partial anomalous pulmonary venous connection. This condition is treated surgically by mitral commissurotomy or mitral valve operation with concomitant closure of the atrial septal defect with correction of the abnormal pulmonary venous connection. Percutaneous mitral commissurotomy before surgery can be a therapeutic alternative when mitral valve stenosis is severe and valve anatomy is favourable. The authors bring back the case of a 24 years old man having mitral stenosis in sinus rhythm associated to sinus venosus septal defect and partial anomalous pulmonary venous connection. The diagnosis was made for the age of 17 years old on the occasion of dyspnea. He benefited in February 2003 of rescue percutaneous mitral commissurotomy because of pulmonary oedema. Mitral valve area increased from 0.7 cm² to 1.6 cm². The patient was clinically approved, so that he refused surgery and was lost sight. Seven years later (August 2010) he was taken back for a second rescue percutaneous mitral commissurotomy because of a very severe mitral stenosis (mitral valve area was 0.8 cm²), in pulmonary oedema with echocardiographic evaluated pulmonary hypertension at 68 mmHg. The trans-septal complicated of a false road from the right atrium, towards the pericardic cavity. The patient was operated as the matter of urgency, and benefited from a mitral valve replacement by mechanical prosthesis, of closure of sinus venosus septal defect by PTFE patch and correction of abnormal pulmonary venous connection. Operating suites were simple, and the postoperative echocardiography concludes to a good prosthesis profile, the absence of residual shunt and a decrease of pulmonary artery blood pressure from 68 to 40 mmHg. In conclusion, percutaneous mitral commissurotomy may be a waiting procedure for surgery of this disease or emergency treatment of it's valve anomaly, with regular monitoring while awaiting surgery faster and in better conditions.     

Fistule coronaire : rapport d’un cas opéré et revue de la littérature

The coronary fistula is a rare abnormality making communicate a coronary artery with a cardiac cavity or a great vessel, so bypassing the myocardial capillary network. The majority of these fistulas are congenital but can nevertheless arise after a cardiac surgery. The right coronary artery and the left anterior descending coronary artery are mostly concerned. The circumflex coronary artery is rarely involved. The most frequent site of drainage is the right ventricle. We report the case of a 2-year-old child, brought by his parents for dyspnoea of effort. The diagnosis of coronary fistula was confirmed by the coronary angiography which showed an aneurysmal circumflex artery, draining into the right ventricle. The intervention was led under cardiopulmonary bypass. We proceeded to the longitudinal opening of the aneurysm then to the blindness of the fistula. The postoperative course was simple.     

Angioplastie coronaire : indications, limites et résultats en dehors des syndromes coronaires aigus en 2009

Most of percutaneous coronary interventions are performed on stabilized patients. Although these procedures have recently been challenged for this type of patient following the publication of the recent Courage study in 2007 (which in fact has only confirmed previous studies), their efficacy is now well established for lowering the frequency of episodes of angina and increasing the performance under load in stabilized high risk patients. In practice, the evaluation of patients (case by case) is essential to establish their risk (low, intermediate or high) in order to offer the most suitable treatment. The aim of this paper is to overview the indications, limitations and results of coronary angioplasties performed in stabilized patients in France in 2009.     

L’utilisation du cathéter Heartrail II « 5-in-6 » dans l’angioplastie coronaire complexe : expérience multicentrique

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.     

Expérience multicentrique de l’utilisation du Sheathless 6.5 French dans l’angioplastie coronaire des lésions de bifurcation : faisabilité et sécurité

Background

Transradial intervention of coronary lesion is increasing in frequency and is associated with lower major vascular access site complications. However, the small size of the radial artery is a major limitation of this technique, especially for bifurcation lesions, because 6-French guiding catheters are necessary to optimize the technique. A Sheathless guiding catheter has recently been introduced, optimizing a large lumen with a small size.

Objectives

The aim of this study is to report our preliminary experience performing bifurcated transradial interventions using a 6.5 French Sheathless guide catheter.

Patients and methods

From March 2009 to February 2012 in three hospitals, 46 consecutive patients were enrolled in this study who underwent transradial approach (TRA) for percutaneous bifurcation coronary interventions using the 6.5 French Sheathless Eaucath guiding catheter system because of small radial artery caliber.

Results

In this study, 46 patients were enrolled with mean age of 72.13 ± 16.41 years. The majority of patients were females with sex-ratio 0.53. Procedural success using the 6.5 French Sheathless guide catheter system was 100 % with no cases requiring conversion to a conventional guide and catheter system. During procedures, adjunctive devices used in this cohort included IVUS (2 patients), 35 bifurcated lesions were treated with a kissing-balloon technique in the group of 46 patients undergoing bifurcation PCIs, one patient required rotational atherectomy, thrombus-aspiration catheters had used in four patients, FFR-guided angiography in four patients. We report one case of chronic total occlusion bifurcated lesion successfully treated using this hydrophilic catheter. There were no radial artery site complications.

Conclusion

The treatment of coronary bifurcation lesions with 6.5 French Sheathless guiding catheter by transradial approach is feasible and appears safe in this multicenter study.     

Radioprotection et voies d’abord en cardiologie interventionnelle

Since its introduction as a routine arterial route for interventional cardiology, the radial route has been associated with higher X-rays doses, either to the patient and the operator. There is less evidence for this association in recent studies, probably due to the learning curve for this approach, improvement in radiological equipments and in radiation protection techniques. Coronary angiography and percutaneous coronary interventions can be performed by radial route routinely with very low levels of exposure for the patient (<50% of the reference levels). However, for a fixed dose to patient, the operator's exposure remains higher by radial route, compared to femoral route. Optimized individual radiation protection devices for operators are mandatory when procedures are performed by radial approach.     

Intermediate lesion and multivessels disease: Interest of fractional flow reserve (FFR) to determine the strategy of revascularization

Most patients undergoing a catheterization did not have any previous non-invasive testing. Therefore, most decisions about revascularization are taken solely on the basis of the angiogram. Nowadays, it is possible to gain reliable functional information during catheterization by measuring fractional flow reserve (FFR). FFR is obtained by simple pressure measurements distal to the stenosis during maximal hyperemia. FFR-guided revascularization provides better clinical outcomes than angiographically-guided decisions. This is especially relevant in patients with multi-vessel disease and mild to moderate coronary plaque burden. FFR is able to determine the hemodynamic significance of each lesion individually and enables therefore guidance of the revascularization treatment. The case of a 62-year-old man with stable angina is reported. He underwent percutaneous coronary intervention of the left anterior descending 10 years ago. Repeat coronary angiogram revealed multi-vessel disease with a moderate stenosis in all main coronary arteries. Non-invasive functional assessment by myocardial perfusion imaging was inconclusive to evaluate presence or absence of ischemia. The use of FFR in this clinical scenario may be very useful to determine treatment strategy.     

Lésion ostéolytique chez une patiente splénectomisée : à propos d’un cas d’échinococcose alvéolaire vertébrale

Introduction

Osteolytic lesions are not always related to malignancies.

Case report

We report an 82-year-old woman suffering from subcostal pain. The patient underwent a splenectomy 40 years previously. CT-scan and MRI highlighted a calcified hepatic lesion associated with an osteolytic lesion of the L5 vertebra. Osteolytic and hepatic lesions were attributed to an alveolar echinococcosis based on positive serological assays.

Conclusion

To our knowledge, this is the first report of an alveolar echinococcosis in a patient with splenectomy and secondary lesions. We suggest that the splenectomy could have promoted the parasite spreading to vertebra.     

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.     

Syndrome de Barraquer-Simons au cours d’un lupus érythémateux systémique

Barraquer–Simons syndrome is a rare disorder characterized by a partial lipodystrophy. It is often associated with positive C3 nephritic factor and various glomerular nephropathy. Its association with some autoimmune diseases has also been reported. We report a 30-year-old woman with partial lipodystrophy, lupus erythematosus, hypothyroidism and vitiligo.