François Funck

Left radial approach for coronary angiography: Results of a prospective study

Although radial approach has been shown to be feasible for coronary angiography, angioplasty, and even stent placement, there have been no prospective evaluations of ease and safety of left radial approach for coronary angiogram. We examined procedural duration and success as well as complications in 415 consecutive patients. Radial artery occlusion was assessed immediately post-procedure and at 2 month follow-up using echo-Doppler measurements. Procedure failure rate was 9%, mean time for sheath insertion was 4.7 +/- 4.7 min, and mean procedure duration was 19.1 +/- 8.2 min. No major complications occurred. Asymptomatic radial artery occlusion was noted in 71% of the first 49 patients, decreased to 24% in the next 119 receiving 2,000-3,000 units of heparin, and to 4.3% in the last 210 receiving 5000 (p < 0.05). Comparison with the femoral approach in the same laboratory suggested that the radial approach took longer, but provided similarly high-quality results without great difficulty in coronary cannulation. Hence, the left radial approach for coronary angiography (with heparin administration) allows immediate ambulation and may be especially useful for outpatients and when the femoral approach is not possible.

Direct stent implantation without predilatation using the multilink stent

The standard coronary stent implantation technique requires routine predilatation of the target lesion with a balloon catheter. In this study, we prospectively studied the feasibility and efficiency of elective coronary stent implantation without predilatation. In 94 patients who presented with various ischemic syndromes, direct implantation of 100 balloon expandable ACS MultiLink stents (7 over-the-wire, 93 rapid exchange) was attempted in 100 coronary lesions selected to have favorable characteristics. The stent crossed the lesion without predilatation in 97 cases (97%) and was successfully deployed in 93 (95.8%). In 4 patients, adjunctive high-pressure postdilatation was necessary to achieve optimal stent expansion. Reference vessel diameter was 3.12+/-0.77 mm and lesion length 8.8+/-2.7 mm. Minimal luminal diameter increased from 0.95+/-0.38 mm to 2.98+/-0.28 mm and diameter stenosis decreased from 71+/-11% to 8+/-11% after stenting. One occlusive dissection was treated by a second stent. There were no major in-hospital complications. At 1 month follow-up, 1 subacute thrombotic occlusion occurred. These results indicate that in a carefully selected coronary lesion subset, elective stent implantation without predilatation can be safely and effectively performed. The long-term results of this approach and possible advantages over the conventional implantation techniques remain unclear and need to be evaluated in further clinical studies.

Short-term effects of sinus rhythm restoration in patients with lone atrial fibrillation: a hormonal study.

It is well known that atrial fibrillation can lead to heart failure, and is attributed to rapid ventricular rate (tachycardia‐induced cardiomyopathy). Some recent studies suggest the possible existence of an intrinsic left‐ventricular factor related to atrial fibrillation, irrespective of other elements. In order to demonstrate the implication of this factor, we measured B‐type Natriuretic Peptide, known as a functional marker of left‐ventricular dysfunction, in 40 consecutive patients with chronic non‐valvular atrial fibrillation, with low ventricular rate and absence of clinical heart failure or echocardiographic left‐ventricular dysfunction. In all patients, Brain Natriuretic Peptide (BNP) plasma level was high and dramatically decreased 24 h after external electrical cardioversion (61.4 pg/ml before cardioversion, 23.5 pg/ml 1 day after cardioversion, P<0.002). Our study demonstrates that atrial fibrillation, in absence of high ventricular rate, induces an asymptomatic cardiac alteration that is not detectable by echocardiography.

Bedside B-type natriuretic peptide and functional capacity in chronic heart failure.

To determine if B‐type natriuretic peptide (BNP) measurement could be useful in determination of functional capacity in patients suffering from chronic heart failure.

Myocardial contractile reserve under low doses of dobutamine and improvement of left ventricular ejection fraction with treatment by carvedilol.

To examine the ability of myocardial contractile reserve (MCR) assessment to predict the improvement of left ventricular ejection fraction with treatment by carvedilol, a prospective study was undertaken in 85 patients with chronic heart failure and left ventricular ejection fraction <45%. Low dose dobutamine echocardiography (DSE), a 6‐min walk test and measured brain natriuretic peptide (BNP) were assessed in all the patients. Patients were separated into two groups. Group A were patients without any myocardial reserve and group B patients with a myocardial contractile reserve defined as an increment of more than 20% of the resting left ventricular ejection fraction during dobutamine infusion. The two groups differed for percentage of ischemic cardiomyopathy (67.8 in group A vs. 29.7% in group B P‐0.028), 6‐min walk test performance (respectively, 343 vs. 415 meters P<0.05) and BNP plasma levels (respectively, 184.5 vs. 70.1 P<0.02) but not for left ventricular ejection fraction or NYHA class. During DSE, MCR and heart rate variation was higher in group B than in group A. At the end of the follow up, LVEF increased and NYHA class decreased in group B but not in group A. In multivariate analysis the existence of MCR could predict the improvement of LVEF with treatment by carvedilol. In our study, studying MCR could help to predict patients who will improve their LVEF with carvedilol prior to the administration of the treatment.

Rotational atherectomy with adjunctive balloon angioplasty versus conventional percutaneous transluminal coronary angioplasty in type B2 lesions: Results of a randomized study

A randomized pilot study was performed comparing conventional balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA] group) and rotational atherectomy (RA) with a medium size burr (50% to 70% burr/artery ratio) with systematic adjunctive balloon angioplasty (RA group) in type B2 stenosis. A total of 64 patients were included. Primary success was 93.7% in the RA group and 87.5% in the PTCA group (p = NS). Technical failure with no complication occurred once in each group. Acute complications occurred in three patients in the PTCA group and in one in the RA group. Angiographic restenosis rates were similar (RA group: 39%, PTCA group: 42%, p = NS) with a follow-up rate of 93%. In type B2 lesions, when compared with conventional angioplasty, RA with systematic balloon angioplasty does not seem to increase procedural success, and the restenosis rate remains comparable. However, these results must be confirmed in a larger series of patients.

Impact of heart failure management unit on heart failure-related readmission rate and mortality

BACKGROUND Heart failure is the leading cause of hospital admissions and an economic burden. In accordance with European guidelines, a dedicated heart failure unit was created in René Dubos Hospital (Pontoise, France) in 2002. AIM To evaluate the impact of an in-hospital heart failure management unit on heart failure prognosis. METHODS We conducted a descriptive study of all-cause in-hospital mortality and heart failure related readmission rates in the year after the first admission for heart failure, from January 1997 to December 2007. The Chi(2) test, a trend test and linear regression were performed. RESULTS There were no significant differences in patient characteristics (age, sex, diabetes mellitus, left ventricular ejection fraction<45%) other than renal insufficiency, in patients admitted for heart failure from 1997 to 2007. After the creation of the heart failure unit, we observed a significant decrease in heart failure related readmission rate from 21.7% in 2002 to 15.6% in 2007 (p<0.0001), whereas there was no difference in this rate before the creation of the unit (34.3% in 1997 and in 2001; p=0.90). All-cause in-hospital mortality rate decreased from 9.3% in 1997 to 5.1% in 2007 (p<0.0001) and showed a tendency to decrease after the creation of the heart failure unit (p=0.06). CONCLUSION Heart failure related readmission rates in new patients in the year after the first admission for heart failure reduced dramatically after the creation of the heart failure unit. All-cause in-hospital mortality in heart failure patients decreased over the 10-year study period.

Unités d'insuffisance cardiaque. Concept, organisation, résultats

Resume L’insuffisance cardiaque est une maladie au pronostic sombre et dont l’evolution est emaillee de nombreuses rehospitalisations. En depit de progres importants realises dans cette pathologie en particulier sur le plan pharmacologique, le taux de readmission apres une premiere decompensation reste eleve. Certains auteurs ont mis en avant l’effet benefique d’un changement de l’organisation de la prise en charge de l’insuffisance cardiaque sur la morbide mortalite et le cout induit par ces patients. C’est ce type d’organisation concertee de l’insuffisance cardiaque que nous avons developpe depuis de nombreuses annees au centre hospitalier de Pontoise pour acceder finalement a la mise en place d’une unite therapeutique d’insuffisance cardiaque de 10 lits. Cette unite repose sur un concept associant une equipe specialement consacree a l’insuffisance cardiaque, la mise en place d’une demarche educative destinee aux patients et a leurs proches et une evaluation reguliere.

731-5 Early Reocclusion After Successful Coronary Angioplasty of Chronic Total Occlusions

Total reocclusion is frequent after successful coronary angioplasty (PTCA) of chronic total occlusions (CTO) and is often clinically silent. In a prospective study involving 2568 consecutive pts who underwent elective PTCA (success rate 92%, major complications rate 1.3%), 367 of the 3081 lesions (12%) attempted were CTO. Repeat angiography was performed 24 hours after successful PTCA in 2508 lesions. Total occlusion within 24 h was observed in 57 lesions (2.3%). Repeat PTCA at 24 h follow-up was required in 22 pts and elective CABG in 3 pts. Lesions with CTO were compared with subtotal stenoses (SS). CTO SS p Patients 292 2065 Lesions (n) 367 3081 Major complications 5 (1.7%) 28 (1.4%) NS Procedural success 246 (67%) 2920 (95.5%) l 0.001 24 h angio follow-up 198 (80%) 2310 (79%) NS Early reocclusion: 16 (8%) 41 (1.8%) l 0.001 –with prior dissection 3 (15%) 10 (25%) NS –with chest pain 2 (13%) 26 (64%) l 0.01 Conclusion Reocclusion within 24 hours after successful PTCA of CTO occurs in 8% of cases, is more frequent than in PTCA of SS and is often silent. Routine repeat angiography at 24 hours may be useful in this lesion subset.

Preliminary clinical experience with the Bard XT coronary stent

BACKGROUND The Bard XT stent is a balloon expandable stent with a new design, consisting of discrete zigzag modules welded onto a flexible longitudinal spine. METHODS To assess the safety and efficacy of this recently introduced coronary stent, we studied 81 patients (107 lesions) who underwent implantation of 108 such stents (66% elective). RESULTS Primary success in stent delivery was 97.1% and angiographic success was achieved in all cases. Reference segment diameter was 2.69+/-1.4 mm and average lesion length 10.9 mm. Mean minimal luminal diameter before the procedure was 0.79+/-1.11 mm and increased to 2.55+/-1.09 mm after stenting. Diameter stenosis decreased from 76%+/-24% to 9%+/-12%. One Q wave and 1 non-Q-wave myocardial infarction occurred but no other significant complications were observed. At 1-month follow-up, angiographically documented subacute thrombosis occurred in 2 cases at days 1 and 3. Conclusions These preliminary data suggest that the Bard XT stent has a promising design for the safe and effective treatment of coronary lesions, even in the presence of high-risk clinical and unfavorable angiographic characteristics.