Coronary lesions due to aortic valve disease. II -- Results and indications of aortocoronary bypass surgery]

454 cases of aortic valve replacement were studied: 217 had no significant coronary artery disease, 197 had associated aorto-coronary bypass surgery and 40 coronary artery disease without revascularization surgery:-- The early mortality in the three groups was 5.5%, 21% and 12.5% respectively, the only statistically significant difference being between the first two groups. -- The coronary artery disease was signigicantly more severe in the group which underwent associated aorto-coronary bypass surgery. The early mortality was significantly raised in the group without bypass surgery in cases with severe coronary artery disease (28%) and in the group with bypass surgery with unsuitable coronary artery lesions (35.5%). On the other hand, the long term survival and functional capacity of patients who underwent associated bypass surgery approached that of the non-coronary patients. Combined aortic valve replacement and coronary bypass surgery should therefore be continued in selected cases.     

Primary angioplasty is cost-minimizing compared with pre-hospital thrombolysis for patients within 60 min of a percutaneous coronary intervention center: the Comparison of Angioplasty and Pre-hospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) cost-efficacy sub-study

OBJECTIVES: This ancillary study of the Comparison of Angioplasty and Pre-hospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) trial sought to assess the cost-efficacy ratio of primary coronary angioplasty (PCA) and pre-hospital thrombolysis (PHT) in patients suffering from an acute myocardial infarction (AMI) (<6 h) close to (<60 min journey) a percutaneous coronary intervention (PCI) center. BACKGROUND: In the CAPTIM study, at 30 days follow-up PCA was as equally effective as PHT with rescue angioplasty if needed. The cost efficacy of these two strategies has not yet been compared. METHODS: Data were prospectively collected for 299 patients in three centers. The efficacy analysis was extended at one-year follow-up for those patients. Direct fixed and variable actual costs were assessed with a piggyback data collection. RESULTS: The one-year primary end point event-rate (death, non-fatal myocardial infarction, and stroke) was not different after PCA or PHT (14% vs. 16. 4%, p = NS). Costs were lower in the PCA group either during the in-hospital period (8,287 vs. 9,170 $, p = 0.0001) and after one-year follow-up, in relation to a higher rate of subsequent revascularizations in the PHT group (49% vs. 23%, p < 0. 01), leading to a longer hospital stay (10 vs. 9.1 days, p = 0. 03). CONCLUSIONS: After AMI in patients less than 1 h from a PCI center, PCA is as effective and less costly than a combined strategy of PHT followed by rescue angioplasty.     

The role of CT-scan assessment of muscle mass in predicting postoperative surgical complications after renal transplantation

International Urology and Nephrology - Despite a high rate of undernutrition in renal transplantation recipients, prognostic value of sarcopenia remains unclear. We evaluated the relation between...     

Study of new thrombolytic agents in myocardial infarction: a multicenter randomized trial (APSAC versus rt-PA)]

A hundred and eighty three patients with a primary myocardial infarction less than 4 hours old were included in a double blind trial versus placebo comparing an isolated plasminogen streptokinase activator complex (APSAC: 30 mu in 5 mn) and tissue type plasminogen activator (rt PA: 10 mg bolus followed by 90 mg in 130 mn). Clinical evolution, side effects, patency of the artery responsible for infarction, left ventricular contractile function (contrast angiography on the 7th day and angioscintigraphy on the 21st day) and infarct size were studied. The two groups were comparable in age (54 +/- 11 years), delay in randomisation (170 +/- 50 mn), infarct site and severity of cardiac failure. There was no significant difference in hospital mortality (7 in the rt PA group and 5 in the APSAC group) or in adverse effects (haemorrhage: rt PA: 9 patients, APSAC: 11 patients). The patency was 72% in the APSAC and 76% in the rt PA group. Left ventricular function and infarct size were comparable in the two groups: angiographic EF (0.50 +/- 0.1 in the APSAC and 0.52 +/- 0.1 in the rt PA group: NS); asynergic score (11.3 +/- 1.7 in the APSAC and 10.5 +/- 1.8 in the rt PA group: NS); infarct size (10.9 +/- 8.0 in the APSAC and 9.4 +/- 7.2 in the rt PA group: NS). This trial shows that these two thrombolytic agents have the same efficacy. The authors recommend adaptation of the dosage of rt PA to body weight.     

Comparison of transthoracic echocardiography using second harmonic imaging, transcranial Doppler and transesophageal echocardiography for the detection of patent foramen ovale in stroke patients.

AIMS: The comparison of three imaging methods to determine which is the most accurate and reliable for the detection of right-to-left shunt. METHODS AND RESULTS: One hundred and seven patients who were hospitalized for stroke underwent: a transthoracic echocardiography (TTE) using second harmonic, a transcranial Doppler (TCD) and a transesophageal echocardiography (TEE) from August 2003 to April 2004. All studies were recorded on a videotape and were studied by a physician blinded to the study. With TTE and TEE, we found 44 (41%) patent foramen ovales. All contrast tests were positive with TCD for these 44 patients. For two patients, the contrast test was positive only with TTE and TCD. We found four false negative contrast tests with TTE. Among the 63 patients who had a negative contrast test with TEE and TTE, the results were the same with TCD for 59 of them; we were not able to determine a cause for the four positive tests. CONCLUSION: This study confirms that transesophageal echocardiography has limitations in the diagnosis of patent foramen ovale. In this study, the negative predictive value of transcranial Doppler was excellent. Therefore, this examination is able to exclude a patent foramen ovale with a high level of confidence.     

Myocardial emission tomography with thallium-201

The usefulness of transverse, sagittal, and frontal tomographic images was assessed in the study of the myocardium labelled with thallium-201. In a series of 20 patients with myocardial infarcts in various locations documented by clinical, electrocardiographical, and biochemical data in 15 cases and uncertain diagnosis in 5 cases, the sections reconstructed from 32 views obtained with a rotating scintillation camera were compared to the conventional views. Quantitatively, the mean myocardium-to-background activity ratio improved significantly from 1.60 to 2.57 (P<0.001); qualitatively, the presence, site, and size of the defect were more easily determined on the sections and generally showed a sharp contrast to the normal tissue; transverse sections enabled us to explore the anterior infarcts, but sagittal or frontal views were required for inferior locations. The tomographic exploration was normal in only one patient whose diagnosis was uncertain. These results suggest that threc-dimensional emission tomography can improve both detection and quantification of the myocardial infarct.     

Right atrial tear associated with a tumour in the right atrium after blunt chest trauma

Occult cardiac injury following blunt trauma is more commonthan generally suspected. Myocardial contusion is not rare,however, it is generally a benign disorder which often remainsundiagnosed. We report a case of a right atrial rupture afterblunt chest trauma causing a tamponade. A 24-year-old man was involved in a violent car accident andhe presented in a state of collapse. A multislice computed tomographyindicated a pericardial effusion (Figure 1). A transthoracicechocardiography was performed and confirmed pericardial effusionwhich was hyperechoic (Figure 2, Movie 1). Concerns abouta possible mass in the right atrium led to examination withtransesophageal echocardiography (Figure 3, Movie 2) whichrevealed the presence of a voluminous mass in the right atrium.The patient successfully underwent cardiac surgery to removethe mass, identified as a blood clot, and to repair the atrialtear. The present case is of special interest because of therarity of documented incidents of blunt chest trauma causingright atrial tear and illustrates the usefulness of transesophagealechocardiography in completing the diagnosis in the event ofhaemopericardium.     

Vascular interventional procedures in oncology

Indications for interventional radiology have increased, and various arterial and venous procedures are nowadays possible in oncology. Besides emergency procedures, scheduled palliative or curative procedures require multidisciplinary cooperation emphasizing on cautions related to iodine contrast media and concerning immunosuppresion, hemostasis disorders, analgesia, and the choice of the adequate approach. Diagnostic endovascular biopsies and venous sampling may be performed. Embolisation procedures are useful for achieving hemostasis, tumor devascularisation, or chemo-embolisation. Revascularisation procedures concern central vein obstructions, catheter occlusion or arterial stenoses and occlusions. Vena cava filtering, retrieval of intravascular foreign bodies and percutaneous implantation of ports can also be indicated, as well other treatments of central venous access complications. The principles, technical aspects, results, and indications of these various endovascular procedures are described in this review.