Hélène Kovacsik

Intracoronary administration of darbepoetin-alpha at onset of reperfusion in acute myocardial infarction: Results of the randomized Intra-Co-EpoMI trial

BACKGROUND Several trials investigating erythropoietin as a novel cytoprotective agent in myocardial infarction (MI) failed to translate promising preclinical results into the clinical setting. These trials could have missed crucial events occurring in the first few minutes of reperfusion. Our study differs by earlier intracoronary administration of a longer-acting erythropoietin analogue at the onset of reperfusion. AIM To evaluate the ability of intracoronary administration of darbepoetin-alpha (DA) at the very onset of the reperfusion, to decrease infarct size (IS). METHODS We randomly assigned 56 patients with acute ST-segment elevation MI to receive an intracoronary bolus of DA 150 μg (DA group) or normal saline (control group) at the onset of reflow obtained by primary percutaneous coronary intervention (PCI). IS and area at risk (AAR) were evaluated by biomarkers, cardiac magnetic resonance (CMR) and validated angiographical scores. RESULTS There was no difference between groups regarding duration of ischemia, Thrombolysis in Myocardial Infarction flow grade at admission and after PCI, AAR size and extent of the collateral circulation, which are the main determinants of IS. The release of creatine kinase was not significantly different between the two groups even when adjusted to AAR size. Between 3-7 days and at 3 months, the area of hyperenhancement on CMR expressed as a percentage of the left ventricular myocardium was not significantly reduced in the DA group even when adjusted to AAR size. CONCLUSION Early intracoronary administration of a longer-acting erythropoietin analogue in patients with acute MI at the time of reperfusion does not significantly reduce IS.

Impact of Preoperative Marking Coils on Surgical and Pathologic Management of Impalpable Lung Nodules

BACKGROUND The management of occult lung lesions, particularly subsolid opacities, is a new challenge because they are difficult to localize during surgery and the number of lesions detected by computed tomography (CT) is increasing. METHODS Between February 2008 and December 2011, preoperative CT-guided marking with coils was systematically carried out to localize presumed impalpable nodules before video-assisted thoracoscopic surgery (VATS). The procedure feasibility, reliability, and safety as well as its impact on the resection volume and on the pathologic examination strategy were examined. RESULTS This preoperative marking procedure was used for 68 nodules in 60 consecutive patients. The mean procedural time was 25 minutes/patient and complications included minimal asymptomatic pneumothorax (42 cases, 70%) and hemorrhagic suffusion (21 patients, 35%). Patients with non-retrieved coils during VATS required larger resection volumes (94.88 mm3 vs 20.65 mm3; p=0.008). The presence of a coil loop in the pleural space was not statistically associated with higher resected lung volume. Primary pulmonary adenocarcinoma was found in 42 patients (71.2%). Five nodules were associated with atypical adenomatous hyperplasia. Pathologic examination was considered to be improved by the presence of a coil next to the lesion but not within it. Coil placement modified the pathology practices for intraoperative analysis, as tissue sampling in the immediate vicinity of the coil was preferred to systematic sampling. CONCLUSIONS Impalpable lung nodules can be safely marked with coils preoperatively to improve their surgical and pathologic management.

Imaging of postoperative complications following surgery for lung cancer.

The complications following surgery for lung cancer vary depending upon the comorbidities and the type of surgery. Hemorrhage, infections and pulmonary edemas are not specific to the type of resection but frequently occur following pneumonectomies. Morbidity following pneumonectomies is related to the significant changes in the contents of the intrathoracic space. Pulmonary infarction and torsion are emergency situations that develop following lobectomy. CT shows features of localized congestion and stenosis or occlusion of a vein or bronchus. Rapid identification of severe events, in particular by systematic CT is essential for appropriate management of a postoperative or delayed complication of lung cancer surgery.

Management of Part-Solid Nodules

Editor: We read with interest the article by Dr Naidich and colleagues in the January 2012 issue of Radiology (1) about the Fleischner Society recommendations for the management of subsolid pulmonary nodules. This is an important contribution for daily practice insofar as the number of cases with this finding is rising. However, we would like to express concerns with the recommendations made regarding solitary ground-glass nodules (GGNs) with a Disclosures of Conflicts of Interest: S.B. No relevant conflicts of interest to disclose. H.V.K. No relevant conflicts of interest to disclose. J.L.P. No relevant conflicts of interest to disclose.

Normal postoperative appearances of lung cancer

The major lung resections are the pneumonectomies and lobectomies. The sublobar resections are segmentectomies and wedge resections. These are performed either through open surgery through a thoracotomy or by video-assisted mini-invasive surgery for lobectomies and sublobar resections. Understanding the procedures involved allows the normal postoperative appearances to be interpreted and these normal anatomical changes to be distinguished from potential postoperative complications. Surgery results in a more or less extensive physiological adaptation of the chest cavity depending on the lung volume, which has been resected. This adaptation evolves during the initial months postoperatively. Chest radiography and computed tomography can show narrowing of the intercostal spaces, a rise of the diaphragm and shift of the mediastinum on the side concerned following major resections.

Infectious chest complications in haematological malignancies

The management of infections in haematology is dictated by the patients type of acquired or induced immune deficiency (neutropenia, deficiency in cell-mediated or antibody-mediated immunity), and findings from clinical examination, laboratory studies, or morphologic investigations. The CT scan dominates in the initial management and follow-up of these patients, since clinical features very often appear to be non-specific. The radiologists role is to guide the clinician towards a specific diagnosis such as aspergillosis or pneumocystosis, or to point them towards a non-infectious cause: tumour localisation, hypervolaemia, bronchiolitis obliterans suggestive of GVH disease, drug toxicity, or embolism.

An hs-TNT Second Peak Associated with High CRP at Day 2 Appears as Potential Biomarkers of Micro-Vascular Occlusion on Magnetic Resonance Imaging after Reperfused ST-Segment Elevation Myocardial Infarction

Introduction: Micro-vascular occlusion (MVO) in a myocardial infarction (MI) is associated with an increased risk of heart failure and mortality. Hs-T-troponin has a double peak kinetic after MI. The aim was to determine if this kinetic was correlated to MVO evaluated by cardiac magnetic resonance imaging (MRI) after MI. Methods: This is a monocentric retrospective study. Inclusion criteria were hospitalization for MI, Thrombolysis In Myocardial Infarction flow 0 at coronary angiography, reperfusion within 12 h from the onset of chest pain, cardiac MRI within the first month, and a 5-days’ biological follow-up with at least hs-T-Troponin and C-reactive protein (CRP). Statistics were performed using the R software. Results: Ninety-eight patients were included. Fifty-three patients (54.1%) had MVO at MRI. The existence of MVO was associated with a trend of more kissing procedure during primary percutaneous coronary intervention (p = 0.06), a significantly more frequent second peak of troponin (p = 0.048), a significantly higher CRP level (p < 0.0001) and a longer time to balloon (p = 0.01). The association of CRP level above 40 mg/L at day 2 and the observation of a second peak of troponin were associated to 95% of MVO in ST-segment elevation MI patients. By contrast, in the absence of these 2 criteria, MVO was absent in 78% of the cases. This score was associated with a higher rate of hospitalisation at 2 years. Conclusion: A biological score integrating hs-TNT second peak and CRP might help to predict MVO and predict outcomes after reperfused MI in our population.

Software-assisted Computed Tomography Quantification of Airway Remodeling in the Normal Aging Process

calfactant trial by Willson and colleagues (9) using the same dose protocol reported significantly decreased mortality in patients with direct ARDS. In both these successful studies (8, 9), calfactant administration was associated with rapid improvement in oxygenation. In contrast, two recent controlled trials with calfactant in pediatric (6) and adult patients (7) with direct ARDS disappointingly reported no clinical benefits, including no improvements in oxygenation. Because calfactant has documented alveolar activity in enhancing respiratory function, this implies that it was not present in the alveoli in pharmacologic concentrations. Importantly, in these unsuccessful trials (6, 7), calfactant was concentrated and given in a reduced volume dose of approximately 1.3 ml/kg to lower instilled fluid load in ventilated patients. Computational modeling indicates that this lower volumetric dose led to a reduced delivery efficiency of instilled surfactant (Figure 1). The higher surfactant concentration may also have increased viscosity at low shear rates, adversely affecting delivery. Two additional unsuccessful controlled trials of surfactant therapy in adults with ARDS by Spragg and colleagues (5, 10) also used concentrated low-volume doses (1 ml/kg) of instilled recombinant surfactant protein C–based surfactant (Venticute) that likely had reduced alveolar delivery based on our modeling. In addition, Spragg and colleagues (5) also reported surfactant stability issues that may have affected drug activity. An important implication from our computational modeling (4) is that future trials of surfactant therapy in ARDS would benefit from animal models similarly sized to the patient and prospective in silico simulations, specifically to assess drug delivery and aid in detailed protocol development to enhance study replicability. Instilled surfactant volumes obviously cannot be overly large in patients with ARDS, but, within acceptable patient care limits, they must generate a pharmacologically adequate alveolar dose in clinical trials. Otherwise, intrinsic therapeutic efficacy is not really being tested. n