Zied Ibn Elhadj

Coronary perforation with tamponade successfully managed by retrograde and antegrade coil embolization

In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate of revascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult to negotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication of coronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic total occlusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronary perforation with tamponade, and successfully managed by coil embolization.

Cardiac hydatid cyst revealed by ventricular tachycardia

Hydatid disease is a human parasitic infestation caused by the larval stage of Echinococcus Granulosus. The liver and the lungs are the most common locations. Cardiac involvement is rare and accounts for 0.5-2% of all hydatid disease. We report an unusual presentation of cardiac hydatid cyst revealed by ventricular tachycardia in a patient with a history of cerebral hydatid cyst.

Does Ramadan fasting affect the intensity of acenocoumarol‐induced anticoagulant effect?

Each year, during the holy month of Ramadan, millions of healthy adult Muslims refrain from eating and drinking from dawn to dusk. Although fasting is not obligatory for the sick, many patients with stable diseases and taking oral medications are motivated to observe Ramadan fasting, including those treated with vitamin-K antagonists (VKAs) the main oral anticoagulants used to prevent and treat many thrombotic disorders. It is well known that the dose–response to VKA can be affected by various factors, such as diet (Cust odio das Dôres et al, 2007) and drug interactions (Ansell et al, 2008). During Ramadan, not only are eating patterns altered but also the amount and types of food. The daily medication schedule is also changed because of fasting. Thus, the relationship between dose and response to VKA may be affected during Ramadan. However, data on the effects of Ramadan fasting on VKA-anticoagulant activity are scarce. This study evaluated the effects of Ramadan fasting on International Normalized Ratio (INR) stability in patients treated with long-term acenocoumarol. A total of 67 patients (29 females, 38 males, mean age 60 11 4 years) were included in this prospective, open, single-centre study. Exclusion criteria were an INR <1 7 or >4 5 before Ramadan. To study the effect of fasting on INR stability, the INR of patients was assessed at three time-points: an initial visit at 3 d before Ramadan began (INR1), a second visit on the 15th day of Ramadan (INR2), and a third visit just before the end of Ramadan (INR3). INR3 was assessed only in those patients with an INR2 < 4 5. Asymptomatic AVK overdose was defined as INR >4 5. The INR values were determined by measuring the prothrombin time using a fully automated STA-R coagulation analyser (Diagnostica Stago, Asnier, France). All statistical analyses were performed using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA). INRs values were compared with the non-parametric Wilcoxon test. A P-value of <0 05 was considered statistically significant. The INR increased acutely during the first 2 weeks of Ramadan for the majority of patients. Indeed, the mean INR2 value was significantly higher than that of INR1 (4 1 1 7 vs. 2 9 0 8; P < 0 0001, respectively) (Fig 1) and a mean variation of +46 5% (range: 35% to +256 4%) was observed between INR1 and INR2. Furthermore, 25 (37 3%) patients had an INR2 > 4 5. These patients were excluded from the second part of the study. A significant increase in the INR was also observed during the last 2 weeks of Ramadan (Fig 1). Indeed, the mean INR3 value recorded at the end of Ramadan was significantly higher than that of INR2 (3 4 0 88 vs. 2 9 0 6; P < 0 0001, respectively). However, only five (11 9%) patients reached an INR3 > 4 5. Baseline INR value and acenocoumarol daily dosage were significantly higher in patients with an INR >4 5 (n = 30) compared to those with an INR ≤4 5 (n = 37) (Table I). Multivariate analyses identified two independent predictors factors were associated with a high INR (INR>4 5) during Ramadan: baseline INR > 3 [odds ratio (OR) = 10 6; 95% confidence interval (CI) 2 49–27 02; P < 0 001] and acenocoumarol dosage ≥4 mg/d (OR = 4 15; 95% CI 1 14–15 09; P = 0 003). Five bleeding episodes were recorded (7 4%) during the whole study period. According to the Bleeding Academic Research Consortium (Mehran et al, 2011), one was classified as type 3c (intracranial haemorrhage) and four were classified as type 1 (two cases of bleeding gums, one of small bruising and one nosebleed). All of the bleeding events occurred in patients with an INR > 7. This pilot study showed that Ramadan fasting significantly affects the INR stability of patients treated for long-term with acenocoumarol. Indeed, about half (44 8%) of our patients reached a VKA overdose (INR >4 5) and bleeding complications occurred in 7 4% of the patients during the study period.

Predictive scores in chronic total occlusions percutaneous recanalization: only fashionable or really useful?

Chronic total occlusions (CTOs) remain one of the last challenges in percutaneous coronary intervention (PCI). During the last decade, following the Japanese pioneers, the interest of interventionalists’ community in CTO PCI has dramatically increased leading to an important development in equipment and techniques (1,2), and a growing expertise among dedicated operators, both resulting in increased success rates (3).

The IMPACTOR-CTO Trial

Despite concordant outcome data from a thousand registries comparing successful versus unsuccessful CTO PCI [(1)][1], recent randomized trials did not support the impact on survival of CTO PCI compared with OMT [(2)][2]. In contrast, more certainty exists about its importance in improving QoL [(2)][

Giant left main coronary artery aneurysm revealed by a myocardial infarction

A 73-year-old woman was admitted for acute chest pain lasting for 2 h. She had no cardiovascular risk factor except her age. Her previous medical history was unremarkable. On admission, her heart rate was 90 bpm and blood pressure was 120/70 mm Hg. An electrocardiogram revealed ST-segment elevation in anteroseptal leads. No acute heart failure was found on examination. Fibrinolysis was successfully performed with ST-segment regression. Transthoracic echocardiogram showed impaired left ventricular systolic function (ejection fraction: 40%). Coronary angiography revealed a large, partially thrombosed left main aneurysm; no other coronary significant stenosis was observed (Fig. 1). Hence, we concluded a diagnosis of embolic myocardial infarction originating from the left main aneurysm. Syphilis serology tests and immunological investigations were negative. A computed tomography scan was performed showing a 5 × 3-cm partially thrombosed aneurysm of the left main coronary artery (LMCA) (Figs. 2, 3). Surgical exclusion of the aneurysm was indicated; however, it was rejected by the patient. Double anti-aggregation (aspirin + clopidogrel) associated with oral anticoagulation for six months were prescribed, followed by the association of aspirin and oral anticoagulation. At the time of writing, the patient is asymptomatic after an uneventful three-year follow-up. In 1761, Morgagni published the first pathologic description of aneurysmal coronary artery disease [Morgagni JB. De sedibus et causis morborum. Tom 1. Venetus: 1761: Epis 27, Art 28]. Coronary artery aneurysms are defined as dilated segments larger than 1.5 times the diameter of adjacent coronary arteries. The LMCA location is extremely rare. Common causes are atherosclerosis, autoimmune diseases (Kawasaki disease, systemic lupus erythematous, Behçet’s disease, Takayasu disease), dissection, and trauma. In our case, the most probable aetiology was atherosclerosis. The clinical presentations of coronary artery aneurysms are extremely variable. Our patient presented with acute myocardial infarction, probably due to distal embolisation originating from the left main aneurysm thrombus. Rupture is the other severe life threatening complication that may occur. Although invasive coronary angiography is still the gold standard for aneurysm assessment, computed tomography and magnetic resonance imaging can adequately evaluate these aneurysms. Echocardiography has also been shown to be useful, especially in children. The management of coronary aneurysm is controversial: both conservative and surgical treatments can be used. Medical treatment is based on antiplatelet agents alone or associated with anti-coagulants. Successful percutaneous obliteration of left main aneurysm using a covered stent was described, with good short-term outcome. Nonetheless, surgical revascularisation, either by aneurysm repair using a pericardial patch or by resection associated with coronary artery bypass, remains the recommended gold standard therapy.

Which diuretic for which hypertensive patient

We have read with great interest the editorial by Mishra. Diuretics represent a heterogeneous class of drugs, differing from each other by structure, site and mechanism of action. They are largely prescribed in different cardiovascular diseases, particularly in hypertension and heart failure. However, despite the available data on their efficacy, diuretics are still underused in the management of hypertension. Formerly, diuretics were considered to be one of the most potent antihypertensive treatments. Nowadays, after the onset of new efficient anti-hypertensive drugs, diuretics may be no longer considered the most privileged first-line strategy. Indeed, most of the current guidelines downgraded the place of thiazide diuretics in themanagement of hypertension from the preferential initial therapy to one of the possible first-line alternatives among a large armamentarium of anti-hypertensive drugs. Interestingly, thiazide and thiazide like diuretics are those recommended as first-line strategy for primary hypertensive treatment in different guidelines. Thiazide and thiazide like diureticsneitherhave the same structure nor the same site of action, and that would explain the huge disparities concerning their efficiency and side effects. However, despite their differences, the recommendations generally do not favor any agent on the other. Whereas, other types of diuretics are barely mentioned in different guidelines and therebyare evermore underutilized indaily practice. Hence, although recommendations encouraged a treatment approach based on considering patients characteristics, the majority of guidelines are based on evidence for drug classes rather than individual drugs. Only NICE recommendations encourage when initiating or changing treatment, to prescribe a thiazide-like diuretic, such as chlorthalidone or indapamide in preference to a conventional thiazide diuretics. For the above reasons, we should not think any more if patient with hypertension needs or not a diuretic. Indeed, a new question should arise in light: which diuretic for which patient? Much evidence support the inferiority of hydrochlorothiazide compared to other thiazide like agents. In fact, hydrochlorothiazide duration of antihypertensive action is less than 24h, while indapamide has even in the immediate release form, at least 24-h duration of action for blood pressure reduction. In addition, a network analysis demonstrated that hydrochlorothiazide was less effective in preventing cardiovascular events as compared with chlorthalidone and the association hydrochlorothiazide-amiloride. Moreover, it is inferior to indapamide in improving endothelial function and longitudinal strain in patients with hypertension and diabetes. Hydrochlorothiazide is also inferior to spironolactone in improving coronary flow reserve. Many authors suggest that indapamide is by far the most efficient and tolerable diuretic for hypertensive patients. Compared to hydrochlorothiazide, it was demonstrated to be more efficient in improving micro-albuminuria (in diabetics), reducing left ventricular mass index, inhibiting platelet aggregation, and reducing oxidative stress. Indapamide was also shown to reduce left ventricular hypertrophy more than enalapril. Importantly, indapamide do not share with thiazide diuretics their adverse effects on lipid and glucide metabolism, thereby it can be safely prescribed in diabetic [64_TD

Mechanical post-conditioning in STEMI patients undergoing primary percutaneous coronary intervention

DIFF]patients. However, despite this strong evidence, one of the reasons explaining the huge disparities of thiazide/thiazide like diuretics prescription may be due to that chlorthalidone is only commercialized with atenolol and azilsartan. Likewise, indapamide is only combined with perindopril. The only [65_TD

Reply to “Effect of cardiac rehabilitation on ventricular repolarization in patients with type 2 diabetes and coronary heart disease: Non-invasive quantification via transmural dispersion of repolarization”

DIFF]advantages of hydrochlorothiazide seem [66_TD

Percutaneous coronary intervention of chronic total occlusions in patients with low left ventricular ejection fraction

DIFF][63_TD