Philippe Asseman

Free-Floating Thrombi in the Right Heart Diagnosis, Management, and Prognostic Indexes in 38 Consecutive Patients

BACKGROUND Floating right heart thrombi (FRHTS) are a rare phenomenon, encountered almost exclusively in patients with suspected or proven pulmonary embolism and diagnosed by transthoracic echocardiography. Their management remains controversial. METHODS AND RESULTS We report on a series of 38 consecutive patients encountered over the past 12 years. Thirty-two patients were in NYHA class IV, 20 in cardiogenic shock. Echocardiography usually demonstrated signs of cor pulmonale: right ventricular overload (91.7% of the population), paradoxical interventricular septal motion (75%), and pulmonary hypertension (86. 1%). The thrombus was typically wormlike (36 of 38 patients). It extended from the left atrium through a patent foramen ovale in 4 patients. Pulmonary embolism was confirmed in all but 1. Mortality was high (17 of 38 patients) irrespective of the therapeutic option chosen: surgery (8 of 17), thrombolytics (2 of 9), heparin (5 of 8), or interventional percutaneous techniques (2 of 4). The in-hospital mortality rate was significantly linked with the occurrence of cardiac arrest. Conversely, the outcome after discharge was usually good, because 18 of 21 patients were still alive 47.2 months later (range, 1 to 70 months). CONCLUSIONS Severe pulmonary embolism was the rule in our series of FRHTS (mortality rate, 44.7%). The choice of therapy had no effect on mortality. Emergency surgery is usually advocated. However, thrombolysis is a faster, readily available treatment and seems promising either as the only treatment or as a bridge to surgery. In patients with contraindications to surgery or lytic therapy, interventional techniques may be proposed.

Comparison of Thrombolysis Followed by Broad Use of Percutaneous Coronary Intervention With Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Acute Myocardial Infarction : Data From the French Registry on Acute ST-Elevation Myocardial Infarction (FAST-MI)

Background— Intravenous thrombolysis remains a widely used treatment for ST-elevation myocardial infarction; however, it carries a higher risk of reinfarction than primary PCI (PPCI). There are few data comparing PPCI with thrombolysis followed by routine angiography and PCI. The purpose of the present study was to assess contemporary outcomes in ST-elevation myocardial infarction patients, with specific emphasis on comparing a pharmacoinvasive strategy (thrombolysis followed by routine angiography) with PPCI. Methods and Results— This nationwide registry in France included 223 centers and 1714 patients over a 1-month period at the end of 2005, with 1-year follow-up. Sixty percent of the patients underwent reperfusion therapy, 33% with PPCI and 29% with intravenous thrombolysis (18% prehospital). At baseline, the Global Registry of Acute Coronary Events score was similar in thrombolysis and PPCI patients. Time to initiation of reperfusion therapy was significantly shorter in thrombolysis than in PPCI (median 130 versus 300 minutes). After thrombolysis, 96% of patients had coronary angiography, and 84% had subsequent PCI (58% within 24 hours). In-hospital mortality was 4.3% for thrombolysis and 5.0% for PPCI. In patients with thrombolysis, 30-day mortality was 9.2% when PCI was not used and 3.9% when PCI was subsequently performed (4.0% if PCI was performed in the same hospital and 3.3% if performed after transfer to another facility). One-year survival was 94% for thrombolysis and 92% for PPCI (P=0.31). After propensity score matching, 1-year survival was 94% and 93%, respectively. Conclusions— When used early after the onset of symptoms, a pharmacoinvasive strategy that combines thrombolysis with a liberal use of PCI yields early and 1-year survival rates that are comparable to those of PPCI.

Mechanical thrombectomy in patients with deep venous thrombosis.

AbstractPurpose: To report our experience with mechanical thrombectomy in proximal deep vein thrombosis (DVT). Methods: Eighteen patients with a mean (±SD) age of 37.6±16.1 years who presented with DVT in the iliac and femoral vein (n=3), inferior vena cava (n=5), or inferior vena cava and iliac vein (n=10), were treated with the Amplatz Thrombectomy Device after insertion of a temporary caval filter. Results: Successful recanalization was achieved in 15 of 18 patients (83%). Overall, the percentage of thrombus removed was 66±29%: 73±30% at caval level and 55±36% at iliofemoral level. Complementary interventions (seven patients) were balloon angioplasty (n=2), angioplasty and stenting (n=2), thrombo-aspiration alone (n=1), thrombo-aspiration, balloon angioplasty, and permanent filter (n=1), and permanent filter alone (n=1). There was one in-hospital death. Follow-up was obtained at a mean of 29.6 months; three patients had died (two cancers, one myocardial infarction); 10 had no or minimal sequelae; one had post-phlebitic limb. Conclusion: Mechanical thrombectomy is a potential therapeutic option in patients presenting with proximal DVT.

Predictive factors of effectiveness of streptokinase in deep venous thrombosis

In a prospective study, 174 patients (118 women and 56 men, average age 44 years, range 14 to 82) with proximal extensive thrombosis received streptokinase (100,000 U/hour) for an average of 2.8 days (range 0.5 to 7) through the catheter of a temporary caval filter. Twenty-seven of 45 (60%) patients with nonocclusive clots were completely free of clots at the second phlebography versus 17 of 116 (14%) with occlusive clots (p less than 0.001). Among nonocclusive clots, proximal ones (caval, iliac and femoral) were more easily lysed than popliteal clots (88 of 116 [76%] vs 26 of 58 [45%]; p less than 0.001). In 41 of 132 (31%) patients, a daily injection of contrast medium through the filter-carrying catheter enabled the observation of a clot in the filter, which was lysed by streptokinase. Seventy patients with follow-up greater than 2 years (median 34 months) were examined clinically. Nineteen of 22 (86%) patients with venograms free of clots at discharge were free of clinical sequelae versus 16 of 48 (33%) without normal venograms (p less than 0.001). It is concluded that: (1) in the case of occlusive clots, only a few patients were normalized after streptokinase; (2) proximal nonocclusive clots were most effectively lysed; (3) when venograms were free of clots at discharge, the majority of patients did not have venous sequelae at follow-up; and (4) embolic migration seems to occur frequently with streptokinase.

Enhanced Monocyte Tissue Factor Response After Experimental Balloon Angioplasty in Hypercholesterolemic Rabbit: Inhibition With Dietary l-Arginine

BACKGROUND There is evidence that tissue factor (TF) is a major contributor to the thrombogenicity of a ruptured atherosclerotic plaque. Nitric oxide (NO) has antiatherogenic and antithrombotic properties. We investigated whether L-arginine (L-arg), the endogenous precursor of NO, might affect the ability of monocytes to produce TF. METHODS AND RESULTS We studied TF expression in 18 rabbits with atherosclerosis induced by bilateral iliac damage and 10 weeks of a 2% cholesterol diet. Six weeks after the initiation of the diet, an angioplasty was performed. After angioplasty, the surviving rabbits (n=15) were randomized to receive L-arg (2.25%) supplementation in drinking water (L-arg group, n=8) or no treatment (untreated group, n=7). TF expression was evaluated in mononuclear cells from arterial blood in the presence and absence of endotoxin stimulation. Monocyte TF expression, as assessed with an amidolytic assay, did not differ significantly before or after the induction of atherosclerotic lesions (87+/-15 versus 70+/-12 mU of TF/1000 monocytes, P=NS). Endotoxin-stimulated TF activity increased significantly 4 weeks after angioplasty (138+/-22 versus 70+/-12 mU of TF/1000 monocytes, P=0.02). This increase was blunted by L-arg (43+/-16 mU of TF/1000 monocytes, P=0.01). CONCLUSIONS This study demonstrates that angioplasty-induced plaque rupture is associated with a marked increase in monocyte TF response that is blunted by the oral administration of L-arg. This suggests that the documented antithrombotic properties of NO may be related in part to an inhibitory effect on monocyte TF response.

Relationship of Intimal Flap Position to Endovascular Treatment of Malperfusion Syndromes in Aortic Dissection

Purpose: To propose a classification system based on the position and extension of the intimal flap to assist in the endovascular repair of aortic dissection complicated by a malperfusion syndrome. Methods: Forty-one patients (34 men; mean age 58 years, range 22–78) with 19 type A and 22 type B dissections complicated by a malperfusion syndrome were treated with stenting, fenestration, or both for the peripheral ischemia. A retrospective review of the preprocedural imaging studies (computed tomographic angiography and arteriography) was performed to determine and categorize the position of the aortic intimal flap. In type 1, the flap was either parallel to or perpendicular to the origin of the malperfused collateral artery; type 2 referred to extension of the dissection into the collateral vessel, while type 3 represented the presence or absence of an avulsed branch ostium. Results: Patients treated with stenting (n = 19) alone had type 2 or type 3 arterial dissections, whereas the 12 patients who were treated with fenestration alone had type 1 lesions. Ten patients treated with stenting and fenestration had arterial lesions in which a type 1 dissection was associated with types 2 or 3. Conclusions: This appearance-based imaging approach combined with the symptoms of malperfusion syndromes during aortic dissection can help guide the endovascular treatment strategy.

Renal resistance index and its prognostic significance in patients with heart failure with preserved ejection fraction

BACKGROUND Functional renal impairment is a common feature of heart failure with preserved ejection fraction (HFpEF). The link between functional renal impairment and HFpEF remains incompletely understood. With hypertension and diabetes as frequent co-morbidities, patients with HFpEF are at risk of developing intra-renal vascular hemodynamic alterations that may lead to functional renal impairment and impact on prognosis. METHODS Renal resistive index (RRI) was non-invasively determined by Doppler ultrasonic examination in 90 HFpEF patients and 90 age- and sex-matched hypertensive patients without evidence of heart failure (HF) who served as controls. Clinical, laboratory and cardiac echocardiography data were obtained in HFpEF patients and controls. To investigate its possible clinical relevance, RRI was evaluated as a prognostic index of all-cause mortality and hospitalization for HF. RESULTS Mean RRI was substantially greater in HFpEF patients than in controls (P < 0.0001), while mean blood pressure, glomerular filtration rate, hemoglobin and serum protein levels were significantly lower in HFpEF patients than in controls. On multivariable analysis, mean RRI was independently associated with HFpEF. In addition, increased mean RRI was an independent predictor of poor outcome [hazard ratio = 1.06 95% confidence interval (1.01-1.10), P = 0.007] and remained significantly associated with the outcome after adjustment for univariate predictors that included low mean blood pressure, low hemoglobin concentration and low glomerular filtration rate. Conclusion. Patients with HFpEF exhibit intra-renal vascular hemodynamic alterations. The severity of intra-renal vascular hemodynamic alterations correlates with a poor outcome.

Pathology of inverted Takotsubo cardiomyopathy

Myocardial dysfunction without coronary involvement may occur in acute cerebral diseases. The inverted Takotsubo pattern has been recently recognized as a novel heart neurologic stress-related syndrome. We report on the case of a 40-year-old woman presenting with massive subarachnoid hemorrhage and brain death. Echocardiography revealed an extensive left ventricular circumferential akinesis except at the apex. Histologic analysis of the heart confirmed the absence of myocardial infarction and revealed only sparse foci of myocyte necrosis with contraction bands in the akinetic areas.

Right atrial thrombi: percutaneous mechanical thrombectomy.

The current therapeutic options for right atrial thrombi—surgical embolectomy and thrombolysis— are associated with high mortality and such patients often have contraindications to these therapeutic options. the purpose of this study was to evaluate the feasibility of endovascular right atrial embolectomy. Two patients with contraindications to thrombolysis and surgery were treated by a femoral approach. A catheter was placed in the right atrium, under fluoroscopic control, and a basket device was used to trap the thrombus. The location and extent of the thrombus was established before the procedure by transesophageal echocardiography (TEE) and the procedure was performed with TEE and fluoroscopy. Thrombi were withdrawn in the basket into the inferior vena cava (IVC) and a filter was inserted by a jugular approach and positioned in the IVC, just above the thrombi. The basket was removed leaving the thrombus below the filter. One patient died immediately after the procedure. In conclusion, endovascular extraction of right atrial thrombi may represent a potential therapeutic alternative, particularly in patients with contraindications to thrombolysis and surgery.

Impact of valvuloarterial impedance on left ventricular longitudinal deformation in patients with aortic valve stenosis and preserved ejection fraction.

BACKGROUND Left ventricular (LV) longitudinal deformation is a good marker of intrinsic myocardial dysfunction in pressure overload cardiomyopathies. AIM To assess the effect of valvuloarterial haemodynamic load on LV longitudinal deformation in patients with aortic valve stenosis (AVS) and preserved LV ejection fraction (LVEF). METHODS Global LV longitudinal strain (GLS) was measured using speckle tracking imaging in a series of 82 consecutive patients with AVS (mean age 75+/-10 years; 50% men). The global (valvular+arterial) haemodynamic load imposed on the LV was estimated by the valvuloarterial impedance (Z(va)), and was calculated using either arm-cuff systolic peripheral blood pressure or systolic central aortic blood pressure estimated by SphygmoCor. RESULTS Among this series of 82 patients with preserved LVEF, 79% had reduced LV GLS (<-18%). LV GLS correlated weakly with AVS severity, systemic vascular resistance and systemic arterial compliance. However, there was a good inverse correlation between increase in Z(va) and impairment of LV GLS (r=0.41 p<0.0001). On multivariable analysis, impaired GLS was associated with increased Z(va) (p<0.0001), increased E/Ea ratio (p=0.001) and increased LV end-diastolic volume index (p=0.021), while indices of valvular load were not. Utilization of estimated central aortic blood pressure in place of brachial pressure did not improve the performance of Z(va) to predict GLS. CONCLUSION The magnitude of the global haemodynamic load as reflected by Z(va) is a powerful determinant of altered LV longitudinal deformation in AVS patients with preserved LVEF. The calculation of Z(va) may be useful to identify the patients who are potentially at higher risk for the development of myocardial dysfunction. Use of estimated central aortic pressure in the calculation of Z(va) does not appear to provide any incremental predictive value over that calculated with the simple measurement of brachial pressure.