Olivier Gach

Importance of left ventricular longitudinal function and functional reserve in patients with degenerative mitral regurgitation: assessment by two-dimensional speckle tracking.

BACKGROUND The aim of this study was to determine whether two-dimensional speckle tracking of longitudinal myocardial deformation can detect limited contractile reserve during exercise in patients with asymptomatic degenerative mitral regurgitation (MR). METHODS Seventy-one patients with degenerative MR and normal left ventricular (LV) ejection fractions underwent quantitative exercise echocardiography. RESULTS Compared with 23 normal subjects matched for age and sex, LV volumes were greater in patients with MR. At rest, global longitudinal strain (GLS) was lower in patients, indicating subclinical LV dysfunction. During exercise, the extent and the magnitude of changes in GLS were larger in controls than in patients with MR. On multivariate regression analysis, left atrial volume at rest and changes in GLS at peak exercise were independently associated with changes in LV ejection fraction. CONCLUSION In asymptomatic patients with degenerative MR, subnormal LV function can be reliably identified by two-dimensional strain imaging. Limited exercise LV longitudinal contractile recruitment during exercise predicts postoperative LV dysfunction.

Early release of neutrophil markers of activation after direct stenting in patients with unstable angina.

ObjectiveTo assess polymorphonuclear neutrophils activation after stenting in acute coronary syndromes studied by myeloperoxydase, lactoferrin and elastase release in this clinical setting. MethodsMyeloperoxydase, lactoferrin, elastase, C-reactive protein and cytokines serum levels were assessed in 20 patients undergoing catheterization for unstable angina. Serial sampling starting before arteriography and continued up to 24 h was carried out in 15 patients undergoing direct stenting (group A) and in five patients assessed by coronary angiography only (group B). ResultsMyeloperoxydase, lactoferrin and elastase levels remained unchanged following catheterization, whereas a significant increase in myeloperoxydase (P=0.0009) and lactoferrin (P=0.004) was observed after stenting. No change in levels of tumour necrosis factor &agr;, interleukin (IL)-8 and IL-11 was found in group B after catheterization at the different sampling times, although IL-8 and IL-11 levels increased transiently following stenting. IL-6 values increased in both groups. Baseline values of C-reactive protein were similar in each group. A progressive increase in C-reactive protein was noted in both groups and appeared to be larger following stenting (group A: P=0.0002; group B: P=0.01). ConclusionsIn patients with unstable angina, stenting is associated by immediate neutrophil activation followed by release of inflammatory cytokines (IL-6, IL-8, IL-11) and C-reactive protein elevation. This study points out a potential role of myeloperoxydase as a trigger for inflammatory reaction in patients with unstable coronary syndromes undergoing percutaneous coronary intervention.

Femoral access management : comparison between two different vascular closure devices after percutaneous coronary intervention

Objectives — Several devices have been proposed as an alternative to manual compression (MC) for femoral access management (FAME) following catheterization.Although these devices allow earlier ambulation, they have not always been shown to reduce vascular complications. As a consequence, their cost efficacy is not obvious. Methods — During MC a special catheter deployed temporarily within the artery to achieve haemostasis (Bio-DISC™) (BD) was compared with an anchor-collagen based system Angio-Seal™ (AS) among 463 consecutive patients undergoing PCI.We examined vascular or systemic complications, nursing time spent to puncture site management and patient’s satisfaction. Results — Relative contra-indications to the use of vascular closure devices were encountered in 158 patients. There were no significant differences in baseline characteristics between the patients assigned to each of the 3 treatment groups.The deployment success rate was 98% for AS and 90% for BD (p = 0.037).Vascular complications occurred in 10.8%, 4.0% and 5.8% (p: NS) of MC, AS and BD patients, respectively.The longer sheath dwell time contributed to most of the complications in MC and BD. Nursing time spent for access management was 48.9 min in MC; 28.1 min in BD and 9.9 min in AS (p < 0.0001). Satisfaction score above 70 was noted in 46%, 86% and 92% of patients managed by MC, BD and AS, respectively. Conclusion — AS use is associated with fewer complications, improved patient well being and saves 39 minutes of nursing time.The additional cost of AS is justified when used in selected patients undergoing PCI.

Acute St-Segment Elevation in Neisseria Meningitis

Meningitis due to Neisseria meningitidis occurred in a young man. On admission, he was in septic shock and the electrocardiogram revealed convex upwards ST-segment elevation in inferior and lateral leads. Rapid and complete normalisation of the ECG was observed and the patient had a favourable evolution with intensive therapy.The mechanisms of the ECG abnormalities in this disease are unclear. In this patient, ST-segment elevation was probably related to severe transmural ischaemia or prolonged coronary artery spasm as suggested by increase and decrease of cardiac enzymes and transient echocardiographic wall motion abnormalities without pericarditis. However, myocarditis could not be completely ruled out.

An immunological method to combine the measurement of active and total myeloperoxidase on the same biological fluid, and its application in finding inhibitors which interact directly with the enzyme

Abstract Myeloperoxidase (MPO) is a pro-oxidant enzyme involved in inflammation, and the measurement of its activity in biological samples has emerged essential for laboratory and clinical investigations. We will describe a new method which combines the SIEFED (specific immunological extraction followed by enzymatic detection) and ELISA (ELISAcb) techniques to measure the active and total amounts of MPO on the same human sample and with the same calibration curve, as well as to define an accurate ratio between both the active and total forms of the enzyme. The SIEFED/ELISAcb method consists of the MPO extraction from aqueous or biological samples by immobilized anti-MPO antibodies coated onto microplate wells. After a washing step to eliminate unbound material, the activity of MPO is measured in situ by adding a reaction solution (SIEFED). Following aspiration of the reaction solution, a secondary anti-MPO antibody is added into the wells and the ELISAcb test is carried out in order to measure the total MPO content. To validate the combined method, a comparison was made with SIEFED and ELISA experiments performed separately on plasma samples isolated from human whole blood, after a neutrophil stimulation. The SIEFED/ELISAcb provides a suitable tool for the measurement of specific MPO activity in biological fluids and for the estimation of the inhibitory potential of a fluid. The method can also be used as a pharmacological tool to make the distinction between a catalytic inhibitor, which binds to MPO and inhibits its activity, and a steric inhibitor, which hinders the enzyme and prevents its immunodetection.

Recurrent Stress Cardiomyopathy With Variable Pattern of Left Ventricle Contraction Abnormality

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 76-year-old Caucasian woman with a history of hypertension but no clinical history of coronary artery disease had 3 different patterns of left ventricular contraction abnormality related to stress

Baseline inflammation is not predictive of periprocedural troponin elevation after elective percutaneous coronary intervention.

High-sensitivity C-reactive protein predicts future cardiovascular events in both healthy individuals and patients with unstable and stable coronary syndromes. Few data are available about the incidence and the relation to inflammation of troponin elevation following percutaneous coronary intervention (PCI), a potential predictor of longterm outcome. We sought to confirm the impact of embolization on long-term outcome and evaluate the ability of baseline inflammation to predict troponin elevation induced by PCI. We prospectively analyzed 200 patients treated by PCI for stable or Braunwald IIA class unstable angina. The patients were recruited between January 1997 and May 1999, and the population was followed during a mean follow-up of 32 months. Major adverse cardiac events (MACEs) were defined as the occurrence of death, myocardial infarction or recurrent angina requiring repeat PCI, or coronary artery bypass grafting. During the follow-up period, 58 MACEs were observed. By multivariate analysis, independent predictors for the occurrence of MACEs were unstable angina and troponin I level after PCI (P < 0.0001 for both). No correlation was found between baseline inflammation and significant troponin I elevation post PCI and by multivariate analysis, no biological variable was a predictor of troponin I elevation post PCI. Baseline inflammation cannot predict onset of minor myonecrosis damage (expressed by troponin elevation) induced by PCI, a significant predictor of long-term outcome in this setting.

Diagnostic accuracy of computed tomography coronary angiography in routine practice.

Objectives — The recent newer advances in computed tomography have dramatically changed our approach to imaging cardiac disease. This study sought to compare the diagnostic value of 16-multi-detector spiral computed tomography (MSCT) for detecting coronary artery stenosis. Methods — A total of 88 consecutive patients (52 men, mean age 68 ± 8 years) with atypical chest pain, stable angina or suspicion of ischaemia at stress test were studied by MSCT and invasive coronary angiography (ICA).The MSCT images and multiplanar reconstructions were analysed regarding the presence of > 50% coronary artery lesion. Results — All 88 scans obtained at a mean heart rate of 68 ± 8 beats/min were interpretable. Sixteen coronary segments were evaluated in each patient. Of the 1320 segments examined, 148 (11%) showed poor image quality.A total of 150 significant lesions were detected using ICA, and 80 of 150 (53%) were detected by MSCT. Sensitivity, specificity, positive and negative predictive values were as follows: 53%, 97%, 68%, and 94%. Fifty-four patients had > 50% coronary stenosis.The diagnosis was confirmed by MSCT in 42 patients and correctly ruled out in 30. By patient-based analysis, positive and negative predictive values were 91% and 71%. Conclusion — Although its specificity is high, the sensitivity of 16-slice MSCT for detecting > 50% coronary stenosis in non-selected patients submitted to ICA is rather low suggesting that for daily practice the diagnostic value of this technique should be improved.

Predictors of early and late outcome of percutaneous coronary intervention in octogenarians

Objective — To evaluate the short and long-term results of percutaneous coronary interventions (PCI) in patients aged 80 years or older and to identify predictors of event-free survival. Methods and results — Clinical and angiographic data from all patients undergoing percutaneous coronary intervention in our institution are prospectively collected and stored in a computerized database. The clinical and angiographic characteristics of all patients aged 80 years or older undergoing percutaneous coronary intervention between January 1994 and December 1999 were analysed retrospectively. Follow-up was obtained by interview or through the referring physician. One hundred and fifty-eight patients aged 80 years or older (median: 83.4; range: 80.2-92.2) underwent percutaneous coronary intervention in our institution during the study period.The initial angiographic success rate was 92%. In-hospital mortality was 8.2% and procedural success 84.8%. One-year and two-year survival were 81% and 72.2% respectively, while event free survival at 1 year and 2 years was 65.8% and 57%. Using the Cox proportional hazards method, we identified incomplete revascularization and low left ventricular ejection fraction (LVEF) as predictors of death at 2 years. Complete revascularization and stenting were independent predictors of 2-year event-free survival. Conclusion — Percutaneous coronary intervention can be performed safely in octogenarians. Complete revascularization, stenting and preserved left ventricular ejection fraction were independent predictors of better outcome in this population.

Evaluation of vascular healing of polymer-free sirolimus-eluting stents in native coronary artery stenosis: a serial follow-up at three and six months with optical coherence tomography imaging

AIMS Our aim was to assess vascular response after polymer-free sirolimus-eluting stent (SES) implantation by using an optical coherence tomography (OCT)-derived vascular healing score (HS), quantifying the deficiency of healing. METHODS AND RESULTS In a prospective, multicentre, single-arm, open-label study, OCT examinations were performed at three months in 45 patients (47 lesions). Per protocol, 24 lesions which had not reached adequate vascular healing according to study criteria were scheduled for OCT examination at six months. The HS was calculated at two time points. Serial OCT imaging demonstrated that the proportion of covered stent struts increased from a median of 87.1% at three months to 98.6% at six months (p<0.001). The neointimal thickness increased from a median of 82.8 µm to 112.2 µm (p<0.001), whereas the median percentages of malapposed struts were 0.2% and 0.0% at the two respective time points. Neointimal volume obstruction increased from 6.3% to 12.8%, and the HS decreased from a median of 28.1 at three months to 2.4 at six months. CONCLUSIONS In patients who had inadequate vascular healing three months after polymer-free SES implantation, serial OCT showed almost complete vascular healing at six months.