Philip Urban1, Eduardo Aptecar2, Merkely Béla3, Christian Descaves4, Vincenzo Filippone5, Andrejs Erglis6, Mario Lombardi7, Do Quan Huan8, Ahmet Tastan9, Andre Georges Vuilliomenet10, Xu-Ming Zhang11, Gian Battista Danzi12 1Hôpital de la Tour, Meyrin, Switzerland; 2Clinique les Fontaines, Melun, France; 3Semmelweis University of Budapest, Budapest, Hungary; 4Clinique Saint Laurent, Rennes, France; 5A.O.V. Cervello, Palermo, Italy; 6Riga University hospital, Riga, Latvia; 7Azienda Ospedaliera Villa Sofia, Palermo, Italy; 8Heart institute of HCMC, Ho Chi Minh, Viet Nam; 9Sifa Hospital, Istanbul, Turkey; 10Kantonsspital Aarau, Aarau, Switzerland; 11Kiang Wu Hospital, Macao, Macao; 12Maggiore policlinico, Milano, Italy

Le recours a l’imagerie non invasive dans la strategie diagnostique des coronaropathies chroniques est recommande pour les patients presentant une probabilite de coronaropathie « intermediaire » apres examen clinique. L’utilisation des techniques d’investigation est discutee en fonction de la probabilite d’atteinte coronaire estimee a partir de l’examen clinique et des tests d’effort. Il existe deux types d’approche de detection de la maladie coronaire : la premiere, anatomique, est liee au pourcentage d’obstruction vasculaire (reduction du diametre ou de la surface luminale) et l’autre, physiologique, vise a authentifier la presence d’une ischemie myocardique secondaire a l’existence de ces lesions. Le scanner coronaire (coro-TDM) est une technologie recente ; sa place dans la strategie diagnostique n’a pas encore ete clairement determinee dans les recommandations des societes savantes. Nous discutons ici l’efficacite diagnostique de cette technique chez des malades pour lesquels on suspecte une coronaropathie chronique et de sa place actuelle dans le diagnostic de la maladie.

Pendant longtemps l’abord percutane par voie femorale (technique de Seldinger) a ete employe pour la realisation de procedures diagnostiques et therapeutiques coronaires. L’abord radial, developpe ces vingt dernieres annees, est maintenant prefere par beaucoup de cardiologues interventionnels, notamment en France, grâce a ses avantages indeniables, en particulier l’hemostase facile, qui se traduit par une incidence extremement faible de complications au niveau du site de ponction, plus de confort pour les patients, alitement plus court, et duree et couts d’hospitalisations reduits. L’artere cubitale est aussi facile d’acces et d’hemostase que l’artere radiale, souvent elle est aussi large, voir plus que celle-ci. Neglige pendant longtemps, les resultats publies ces dernieres annees de quelques series, et de deux etudes randomisees, ont montre que l’abord cubital pour des procedures diagnostiques et therapeutiques coronaires (et certaines peripheriques) est possible, faisable, efficace et sur. En fait, le taux de succes par voie cubitale est eleve et similaire a celui obtenu avec l’abord radial. Qui plus est, les complications locales et systemiques sont tres rares et similaires avec les deux techniques. Comme pour la voie radiale, la cubitale exige une courbe d’apprentissage, rapidement accomplie par les radialistes confirmes, et la presence d’arcades palmaires fonctionnelles (facilement evaluees avec le test d’Allen), pour eviter des complications ischemiques en cas d’occlusion de l’artere, ce qui survient en post-procedure dans 3 a 5 % des cas. L’abord par voie cubitale ne devrait pas etre oublie des cardiologues interventionnels, qui apprecieraient d’etre a l’aise avec cette technique, particulierement dans les cas ou l’abord radial n’est pas possible ou echoue, leur evitant ainsi de passer a la voie femorale.

Acute deep venous thrombosis: a new field for endovascular techniquesAcute deep venous thrombosis (DVT) therapies have been judged primarily on their ability to prevent symptomatic pulmonary embolism, early thrombus progression, and recurrent venous thromboembolism (VTE). The cornerstones of current management of DVT, supported by the 2008 American College of Chest Physicians (ACCP) guidelines, are the routine use of anticoagulant therapy, graduated elastic compression stockings, and early ambulation. In selected patients with extensive acute proximal DVT, despite the fact that the French guidelines (Afssaps 2009) still consider thrombolysis not to be indicated, ACCP now recommends in-situ thrombolysis in addition to anticoagulation to reduce the risk of subsequent post-thrombotic syndrome (PTS) and recurrent DVT(Grade 2 B recommendation). The PTS has been increasingly recognized as a frequent and serious long-term complication of DVT. Its risk is thought to be higher when DVT is not managed aggressively and this concern has contributed to the greater emphasis on early thrombolytic management in extensive proximal DVT. Contemporary invasive endovascular treatments, so-called pharmaco-mechanical treatment, mitigate the drawbacks (major bleeding) historically associated with thrombolytic approaches, by means of intra-thrombus delivery of drugs followed by mechanical dispersion to accelerate lysis and then aspiration of remaining drug and clot debris. Evidence in favour of the concept of the "open vein hypothesis", that a strategy of early thrombus removal can reduce the incidence of PIS in the long term, has been reported progressively. Randomized trials (ATTRACT trial with a 2016 target completion date) are currently under way and could lead to a paradigm shift in the management of acute DVT focused on active thrombus removal.

stv.2011.0572 Auteur(s) : Angel Ferrario1,2, Eduardo Aptecar1,2, Alice Nahoaniko3, Mario Augusto1,2, Jean-Marc Pernes1,,2 j.marc.pernes@wanadoo.fr 1 Hopital prive d’Antony, pole cardio-vasculaire, 92160 Antony, France 2 Clinique Les Fontaines, 77000 Melun, France 3 Hopital Marc Jacquet, 77000 Melun, France Tires a part : J. Pernes Observation M. B., âge de 44 ans, nous a ete adresse en consultation pour « faux anevrysme » de la carotide interne gauche (CIG). Il n’a pas [...]

L'anatomie descriptive des lesions coronaires a toujours failli pour predire la survenue d'evenements coronariens. Seul le caractere ischemiant a ete correle au pronostic vital ou ischemique. Le guide pression est un outil simple a utiliser qui permet de mesurer la fractional flow reserve (FFR) definie comme le ratio entre la pression coronaire distale a la lesion et la pression aortique mesurees en hyperhemie maximale. Cette hyperhemie maximale est induite par l'injection veineuse ou intracoronaire de papaverine ou d'adenosine. La valeur seuil de 0,80 a ete validee, en dessous de laquelle la lesion a un retentissement fonctionnel justifiant une revascularisation. Plusieurs etudes scientifiquement rigoureuses ont permis de valider avec force ce concept dans les lesions intermediaires, les lesions pluritronculaires et meme la cardiopathie ischemique, traduisant le caractere universel de cette methode d'evaluation fonctionnelle des lesions coronaires malheureusement sous-utilisee et insuffisamment diffusee en raison, en particulier, d'une absence de reconnaissance budgetaire.

Coronary lesions descriptive anatomy always failed to predict cardiac events. Only ischemia has been shown to predict survival ischemic prognosis. Pressure catheter is a simple tool which allows mesasurement of fractional flow reserve (FFR) defined as the ratio between coronary pressure distal to lesion and aortic pressure. The measurement has to be done during maximal hyperaemia induced by venous or intracoronary infusion of papaverine or adenosine. A threshold of 0.80 has been validated values less than which indicate that the lesion is functionally significant and has to be revascularised. Numerous multicentric and scientifically rigorous studies have validated this concept in intermediate lesions, multivessel disease and post-infarctus which confirm the unique and universal impact of this lesion functional evaluation tool and which is unfortunately under used and under diffused in France.

Radiation exposure after cardiac X-ray imaging: risk and prevention in daily practise Cardiac computed tomography (CT) angiography (CCTA) has emerged as a useful diagnostic imaging modality in the assessment of coronary artery disease. However, the potential risks due to exposure to ionizing radiation associated with CCTA, and generally with low-dose ionizing radiation (5 to 100 mSv) in the population have raised concerns. The effective dose (E), expressed in units of millisieverts (mSv), is a parameter meant to reflect the risk of the biological effects of ionizing radiation. The hypothetical complication of diagnostic medical radiation exposure that is of greatest concern, the risk of inducing malignancies, is a stochastic, or random, effect in which the interaction of radiation with cellular molecules may cause damage sufficient that a malignancy may result later (30 to 40 years after). Among hypotheses applied to the discussion of carcinogenesis at low radiation doses, the linear no-threshold hypothesis states that there is no threshold below which radiation cannot cause malignancies and that the risk of malignancies increases linearly with radiation dose. The consensus opinion in the BEIR VII report advocates the conservative approach of the linear no-threshold hypothesis. In that report and a prior report by the National Commission for Radiation Protection (ICRP), the age-and gender averaged lifetime risk of dying of a malignancy attributable to radiation exposure was estimated to be 5 to 7.9 in 100 individuals of the general population per 1 Sv of E. There is conflicting evidence regarding the potential presence and degree of carcinogenesis at the levels and types of radiation associated with medical imaging : The ICRP emphasizes that E is intended for use as a parameter in radiation protection and should not be used for epidemiological evaluation or for estimations of specific human exposures; Even though the accuracy of radiation-dose estimates and the relationship between the radiation dose received from cardiac imaging and the risk of malignancies may be uncertain, National and European regulation supports the concept of keeping patient doses as low as reasonably achievable (ALARA principle) but consistent with obtaining the desired medical information. A variety of algorithms for reducing dose in CCTA are available for use in daily practice. Most of the described dose-saving strategies can be combined, resulting in an efficacious reduction of overall radiation exposure. With updated technology, the measured E can be decreased to 1 MsV, much less than the dose recorded after conventional coronarography or SPECT.

Until recently, the optimal work-up of patients with stable coronary artery disease (CAD) was based on non-invasive functional tests. Coronary CTA (CCTA) now challenges this standard work-up due to its efficacy to exclude significant coronary artery disease. Current indications for CCTA include symptomatic patients with intermediate pre-test probability of CAD with altered ECG (LBBB, repolarization abnormalities) rendering stress tests useless or patients unable to achieve sustained stress effort, and patients with indeterminate or uninterpretable results on ischemic work-up. A more agressive position is to consider CCTA as the cornerstone of patient management because the limitations and pitfalls of non-invasive techniques open the door to an alternative diagnostic imaging technique, either alone, or in combination with other Imaging techniques after reorganizing the sequence of imaging work-up. Without dismissing the dogma of initial détection of CAD along with prognostic stratification using functional tests, the recent availability of a minimally invasive anatomical test in the management of patients with stress angina, given the known limitations of traditional tests, changes the standard work-up algorithms. This suggests that the diagnostic work-up of patients with CAD is likely to be modified to increase the rôle of CCTA.

Until recently, the optimal work-up of patients with stable coronary artery disease (CAD) was based on non-invasive functional tests. Coronary CTA (CCTA) now challenges this standard work-up due to its efficacy to exclude significant coronary artery disease. Current indications for CCTA include symptomatic patients with intermediate pre-test probability of CAD with altered ECG (LBBB, repolarization abnormalities) rendering stress tests useless or patients unable to achieve sustained stress effort, and patients with indeterminate or uninterpretable results on ischemic work-up. A more agressive position is to consider CCTA as the cornerstone of patient management because the limitations and pitfalls of non-invasive techniques open the door to an alternative diagnostic imaging technique, either alone, or in combination with other Imaging techniques after reorganizing the sequence of imaging work-up. Without dismissing the dogma of initial détection of CAD along with prognostic stratification using functional tests, the recent availability of a minimally invasive anatomical test in the management of patients with stress angina, given the known limitations of traditional tests, changes the standard work-up algorithms. This suggests that the diagnostic work-up of patients with CAD is likely to be modified to increase the rôle of CCTA.

Destiné aux PCR, ce poster met à leur disposition un support pédagogique pour dispenser l’enseignement obligatoire de radioprotection aux personnels travaillant en zones. Des tableaux et des schémas simples illustrant les messages clés sont proposés. Selon le code du travail, la PCR doit dispenser au sein de son établissement un enseignement de radioprotection aux personnels porteurs du dosimètre passif en présence du médecin du travail et au moins tous les trois ans. L’exposé doit être court mais délivrer quelques messages et chiffres clés, il doit être vivant et devra être « mis au style » de l’orateur tout en laissant la place aux questions.