Conclusions: TLR rate at the LCx-ostium is high irrespective of LMCA-LCx or LMCA-LAD stenting.The former also seems to be associated with high TLR at the LAD-ostium.It may therefore be important to evaluate alternative strategies for treating distal LMCA disease that extends into the LCx but not LAD.

La dissection de l’aorte ascendante est une complication rare pouvant survenir au cours d’une coronarographie ou d’une angioplastie. Les options thérapeutiques sont avant tout dictées par l’état hémodynamique du patient, l’origine et l’étendue de la dissection et la capacité de restaurer la circulation coronaire native. Le plus souvent, il s’agit d’une dissection localisée pour laquelle un traitement conservateur peut être suffisant. L’entrée de la dissection peut être également stentée en cas de dissection peu étendue. Enfin, la prise en charge chirurgicale est à réserver aux patients instables en dernier recours. Nous rapportons le cas d’un homme de 52 ans qui a présenté une dissection de l’ostium de la coronaire droite avec extension à l’aorte ascendante lors d’une angioplastie d’une lésion serrée du premier segment de la coronaire droite. Le patient a été pris en charge avec un traitement conservateur, sans stenting (échec angioplastie) et sans chirurgie. La dissection aortique a été surveillée par échographie transœsophagienne et par scanner répétés qui ont démontré une régression spontanée de la dissection. L’évolution a ensuite été favorable. Les causes, la fréquence et la prise en charge des dissections iatrogène sont discutées dans cet article.Iatrogenic acute dissection of the ascending aorta following coronary angiography and percutaneous intervention is rare. The options for treatment are dictated by patient stability, nature of dissection of the coronary vessel, ability to restore the coronary circulation and extent of aortic dissection. Usually localized aortic dissections have been managed conservatively or treated by sealing the entry with a coronary stent. Extensive dissections may require a surgical intervention. We report the case of a 52-year-old man with iatrogenic dissection of the right coronary artery ostium and extension of the dissection to the ascending aorta during intraluminal angioplasty of an obstructive lesion in the first portion of the right coronary artery. The patient was managed conservatively without stenting (failure stenting of the right coronary artery) and without surgery. Aortic dissection was monitored by means of transesophageal echocardiography. Serial computed tomography scans demonstrated spontaneous resolution of the dissection. The evolution of the patient was satisfactory. Causes, frequency and treatment procedures of this iatrogeny are discussed.

A 76-year-old man—past smoker with hypertension and history of anterior myocardial infarction treated 12 years ago by early balloon angioplasty of the left anterior descending coronary artery (LAD)—was referred to our attention for progressive exertional dyspnoea, cough and scanty mucosal expectoration. The previous angiographic examination performed three …

OBJECTIVESThis prospective multicenter study assessed the prevalence and feasibility of percutaneous coronary angioplasty (PTCA) in the acute phase of ST-elevation myocardial infarction (STEMI) in 3 nonacademic interventional cardiology centers (Alsace, France).METHODSWe studied the clinical characteristics, angiographic data, and PCTA results of all STEMI patients and analyzed the revascularization rates and adverse events during hospitalization. We compared patients at least 75 years of age and younger patients for these data and with the literature.RESULTSOf the 1672 patients admitted for STEMI, 342 (20.45%) were at least 75 years of age. Half the patients in this high-risk subgroup were women. These patients had more co-morbidities (e.g., hypertension and diabetes mellitus) than younger patients, and more of them had three-vessel disease. Mortality rate was high in this subgroup and always higher than for comparable younger subjects, but it varied according to the initial clinical profile. Their global mortality rate was 20.47%, but it fell to 5.41% when we excluded patients with cardiogenic shock or in Killip stage ill, and those who were resuscitated. PTCA is a coronary reperfusion technique especially indicated for elderly patients with STEMI. It is an effective revascularization technique, with a reperfusion rate (exclusively TIMI III flow) reaching 93.88% in the elderly group, only slightly lower than among younger patients (97.18%).CONCLUSIONPTCA is a technique particularly indicated in the elderly in Alsace because of regional geographic and medical specificities: nearby emergency services are available to virtually the entire population of Alsace, and most interventional cardiology teams apply a strategy of exclusive primary PTCA.

The guidelines of the European Society of Cardiology, published in 2003, consider primary angioplasty as the preferred treatment strategy in acute coronary syndromes with ST-segment elevation, if the procedure can be performed within 90 min after first medical contact. We report the experience of three Alsacian centers running a common prospective registry with 2504 consecutive patients enroled between January 1999 and December 2004. The average age of the patients was 62 years with a proportion of 24% women. The time delay "pain to admission" was > or =3 hours in 55.9% of the cases. The treatment delay "door to catheterisation needle" was 59 min and the mean delay "door-to-reperfusion" was 79 min. The study population was representative of the real world including subsets of patients with a particulary high risk profile: age > or =70 years in 33%, a Killip grade > or =3 in 11.5%, rescucitated sudden death in 6.6% and cardiogenic shock in 10.9% of the patients respectively. The immediate procedural success rate (Timi 3 flow) in the treated coronary artery was 96.5%. The overall inhospital mortality-rate was 9.3%. The combinations of rescucitated sudden death--cardiogenic shock or age > or =75 years--cardiogenic shock were associated with a poor clinical outcome and mortality rates of 69% and 72.6% respectively, where as in the absence of abovementioned clinical high risk settings, the mortality rate was as low as 1.4%. The overall bleeding complication rate was 1.4%. The policy of systematic primary angioplasty in acute coronary syndromes with ST-Segment elevation appears to be coherent. The procedural complications and the in-hospital mortality rates were low, except in the presence of above mentioned clinical high risk settings.

À partir d'un registre prospectif multicentrique, nous avons évalué dans 3 centres de cardiologie interventionnelle alsaciens non universitaires la prise en charge et la faisabilité de l'angioplastie coronaire transluminale (ACT) à la phase aiguë du syndrome coronaire aigu. Nous avons inclus tous les malades admis dans un des centres participants du 1er janvier 1999 au 31 décembre 2002 et ayant un infarctus avec sus-décalage du segment ST. Nous avons étudié les caractéristiques cliniques et angiographiques de ces patients en comparant 2 groupes : âgés de plus et de moins de 75 ans. Nous avons analysé les taux de revascularisation et les événements survenus au décours de l'angioplastie. Sur un total de 1672 patients, 342 (soit 20,5 %) étaient âgés de plus de 75 ans. Ces sujets représentaient un groupe à haut risque avec une proportion élevée de femmes (50 %), de nombreuses comorbidités (hypertension artérielle et diabète de type 2) et des atteintes tri-tronculaires en nombre plus élevé que chez les sujets de moins de 75 ans. Le taux de mortalité était élevé chez les plus de 75 ans et toujours plus sévère par rapport aux sujets de moins de 75 ans. La mortalité globale des plus de 75 ans était de 20,5 % mais de 5,4 % en excluant les patients en état de choc, en Killip III et après mort subite récupérée. Le succès de reperfusion (exclusivement flux Timi III retenu) de l'angioplastie était très élevé chez les plus de 75 ans, même s'il était un peu plus faible que chez les patients de moins de 75 ans (93,9 %vs 97,2 %). L'ACT est une technique particulièrement indiquée chez les sujets âgés en Alsace du fait des particularités de la région : géographique d'une part, avec une proximité des Smur pour la quasi totalité de la population alsacienne, et médicale d'autre part, la politique interventionnelle étant acquise dans de nombreuses équipes de cardiologie. This prospective multicenter study assessed the prevalence and feasibility of percutaneous coronary angioplasty (PTCA) in the acute phase of ST-elevation myocardial infarction (STEMI) in 3 nonacademic interventional cardiology centers (Alsace, France). We studied the clinical characteristics, angiographic data, and PCTA results of all STEMI patients and analyzed the revascularization rates and adverse events during hospitalization. We compared patients at least 75 years of age and younger patients for these data and with the literature. Of the 1672 patients admitted for STEMI, 342 (20.45%) were at least 75 years of age. Half the patients in this high-risk subgroup were women. These patients had more co-morbidities (e.g., hypertension and diabetes mellitus) than younger patients, and more of them had three-vessel disease. Mortality rate was high in this subgroup and always higher than for comparable younger subjects, but it varied according to the initial clinical profile. Their global mortality rate was 20.47%, but it fell to 5.41% when we excluded patients with cardiogenic shock or in Killip stage III, and those who were resuscitated. PTCA is a coronary reperfusion technique especially indicated for elderly patients with STEMI. It is an effective revascularization technique, with a reperfusion rate (exclusively TIMI III flow) reaching 93.88% in the elderly group, only slightly lower than among younger patients (97.18%). PTCA is a technique particularly indicated in the elderly in Alsace because of regional geographic and medical specificities: nearby emergency services are available to virtually the entire population of Alsace, and most interventional cardiology teams apply a strategy of exclusive primary PTCA.

PTCA is a technique particularly indicated in the elderly in Alsace because of regional specificities: first of all geographic (proximity of the SMUR for virtually all the population of Alsace), and secondly the medical infrastructure since the strategy of exclusive primary PTCA is granted by numerous interventional cardiologic teams. In Alsace, the proportion of elderly patients (> or = 75 years) is going to increase significantly with a parallel rise of STEMI--"a frightening perspective". We have to take into account this evolution, this reperfusion technique presenting numerous advantages and very few complications.

Objectifs. – À partir d'un registre prospectif multicentrique, nous avons évalué dans trois centres de cardiologie interventionnelle alsaciens non universitaires, la prise en charge et la faisabilité de l'angioplastie coronaire transluminale (ACT) à la phase aiguë du syndrome coronaire aigu avec sus-décalage persistant du segment ST (SCA ST+) chez les sujets âgés de plus de 75 ans.

OBJECTIVES We investigated the effect of oral verapamil on clinical outcome and angiographic restenosis after percutaneous coronary intervention (PCI).BACKGROUND Thus far, there is no established systemic pharmacologic approach for the prevention of restenosis after PCIs. Five small studies reported encouraging results for calcium channel blockers.METHODS Our randomized double-blind trial included 700 consecutive patients with successful PCI of a native coronary artery. Patients received the calcium channel blocker verapamil, 240 mg twice daily for six months, or placebo. Primary clinical end point was the composite rate of death, myocardial infarction, and target vessel revascularization (TVR) during one-year follow-up; the angiographic end point was late lumen loss at the six-month follow-up angiography.RESULTS We obtained complete clinical follow-up in 95% of the patients, and scheduled angiography was performed in 94%. The proportion of patients treated with stents was 83%. The primary clinical end point was reached in 67 (19.3%) patients on verapamil and in 103 (29.3%) patients on placebo (relative risk [RR] 0.66 [95% confidence interval (CI) 0.48 to 0.89]; p = 0.002). This difference between the groups was driven by TVR (17.5% with verapamil vs. 26.2% with placebo; RR 0.67 [95% CI 0.49 to 0.93]; p = 0.006). Late lumen loss was 0.74 +/- 0.70 mm with verapamil and 0.81 +/- 0.75 turn with placebo (p = 0.11). Compared with placebo, verapamil reduced the rate of restenosis greater than or equal to75% (7.8% vs. 13.7%; RR 0.57 [95% CI 0.35 to 0.92]; p = 0.014).CONCLUSIONS Verapamil compared with placebo improves long-term clinical outcome after PCI of native coronary arteries by reducing the need for TVR. This was caused by a reduction in the rate of high-grade restenosis. U (C) 2004 by the American College of Cardiology Foundation.

Chez les patients traités par angioplastie primaire pour un infarctus du myocarde, l'occlusion aiguë du tronc commun (OATC) coronaire gauche est rare. Nous rapportons une série rétrospective de six patients traités par angioplastie primaire dans un hôpital général sans service de chirurgie cardiaque.La base de données de coronarographie entre 2002 et 2009 a été interrogée. Parmi les 746 procédures d'angioplastie primaire pour syndrome coronarien aigu (SCA) avec sus-décalage persistant du segment ST, six occlusions aiguës du tronc commun ont été identifiées (0,7 %). Les caractéristiques cliniques et angiographiques des patients ainsi que les particularités thérapeutiques et évolutives ont été analysées.L'âge moyen était de 64 ± 7 ans. Cinq étaient des hommes. La présentation clinique était sévère avec un choc cardiogénique chez cinq patients dont quatre ont été intubés et ventilés mécaniquement. Chez tous les patients, la dominance est droite et l'occlusion du tronc commun est distale. Tous les patients ont eu une angioplastie avec mise en place d'endoprothèses nues avec succès angiographique dans cinq cas. Trois patients sont décédés en intrahospitalier. Un autre patient est décédé deux mois plus tard par insuffisance cardiaque réfractaire. Les deux survivants ont eu un pontage coronaire au quatrième et 12e mois de l'infarctus et sont vivants avec un recul de 72 et 12 mois.Nous montrons la faisabilité de l'angioplastie primaire dans l'infarctus par OATC. Malgré un taux élevé de succès angiographique, le pronostic reste mauvais, lié au choc cardiogénique.Acute main left coronary artery occlusion is rarely observed during primary angioplasty in myocardial infarction. This retrospective study reports the results of six patients treated by angioplasty in a hospital without cardiac surgery department.From 2002 to 2009, 746 patients were treated by primary angioplasty for acute coronary syndromes with ST elevation. Among those patients, six (0,7%) had acute non protected main left coronary occlusion. We report clinical, angiographical data and follow-up.The population was composed of six patients (five males) with an average age of 64 ± 7 years. Five patients were admitted with cardiogenic shock and four were mechanically ventilated. Distal occlusion of main left coronary artery and dominant right coronary artery were noted in all cases. Sub-occluded lesion of right coronary artery was noted in one case. Successful procedure with bare metal stent was achieved in five cases. Mortality rate was 66% (n = 4): three patients died in hospital and another 1 or 2 months later of congestive heart failure. Coronary artery bypass grafting was performed at 4 and 12 months later for two patients. They are alive after 12 and 72 months of follow-up.We demonstrate the feasibility of percutaneous coronary intervention of acute main left coronary occlusion. Inspite successful procedure, intrahospital mortality rate is still high and prognosis is related to cardiogenic shock.

Les nouvelles recommandations concernant la réanimation cardio-pulmonaire (RCP) spécialisée des arrêts cardiaques (AC) publiées fin 2020 par l’AHA et début 2021 par l’ERC confirment certains points présentés en 2015 et introduisent de nouvelles notions immédiatement intégrables dans la pratique des équipes françaises. Ainsi, il ne faut pas oublier dans la pratique que des signes prémonitoires peuvent annoncer l’AC et que leur reconnaissance peut même éviter sa survenue. Pour l’administration des médicaments, la voie intraveineuse reste le premier choix la voir intra-osseuse étant une alternative. L’adrénaline reste le médicament de base du traitement des asystoles et des rythmes non chocables. Il faut l’administrer le plus précocement possible pour obtenir un meilleur résultat neurologique pour les survivants. Le contrôle des voies aériennes est avant tout une affaire de compétence. Les équipes médicalisées bien entraînées peuvent recourir de première intention l’intubation orotrachéale. Au cours de la réanimation, l’échographie peut être utile dans des mains expertes pour objectiver une cause réversible de l’AC. Elle ne doit pas provoquer une interruption prolongée et donc dangereuse du massage cardiaque externe. Enfin, la circulation extracorporelle (ECMO ou ECPR) est un traitement de sauvetage de plus en plus utilisé. Elle s’intègre dans un système de soins performant. Ses indications et des modalités sont mieux connues mais doivent encore être précisées.The new Advanced Cardiac Life Support (ACLS) guidelines published at the end of 2020 by the AHA and at the beginning of 2021 by the ERC confirm certain points presented in 2015 and introduce new concepts that can be immediately integrated into the practice of French teams. Thus, it should be remembered in practice that premonitory signs can announce CA and that their recognition can even prevent its occurrence. For the administration of drugs, the intravenous route remains the first choice and the intra-osseous route is the first alternative. Adrenaline remains the key point of the treatment of asystole and non-shockable rhythms. It should be administered as early as possible to obtain a better neurological outcome for survivors. The control of the airways is above all a matter of competence. Well-trained medical teams can use orotracheal intubation first. During resuscitation ultrasound can be useful in expert hands to objectify a reversible cause of CA. It must not cause a prolonged and therefore dangerous interruption of the external cardiac massage. Finally, extracorporeal circulation (ECMO or ECPR) is an increasingly used rescue treatment. It has to be integrated into a high-performance healthcare system. Its indications and modalities are better known but still need to be specified.

Décrire les caractéristiques de la population décédée dans un hôpital pédiatrique, les maladies en cause et les modalités de décès.Il s'agit d'une étude épidémiologique rétrospective, descriptive, réalisée sur six ans. Ont été inclus les enfants décédés dans notre hôpital entre le 1er janvier 1990 et le 31 décembre 1995. Ont été exclus les enfants arrivés morts à l'hôpital (morts subites du nourrisson, enfants décédés pendant le transport, corps déposés) et ceux pour lesquels le dossier n'a pu être retrouvé.La population étudiée comportait 375 enfants décédés dont 195 nouveau-nés. Le sexratio était de 1,3. Au total, 91 % des décès ont eu lieu dans trois principaux services : en réanimation, en neurochirurgie-neurologie et en oncologie. La médiane de la durée d'hospitalisation était de trois jours. Les maladies les plus fréquemment en cause étaient accidentelles, neurologiques (notamment les nouveau-nés) et tumorales. L'analyse des modalités de décès a montré que 41,1 % d'entre eux faisaient suite à un échec des manœuvres de réanimation, 38,9 % à un arrêt des soins curatifs ou à une décision de ne pas réanimer et 21,6 % à un coma dépassé. L'évolution des modes de décès sur six ans a montré une diminution des échecs de réanimation, une augmentation des décisions de ne pas réanimer et des arrêts de soins curatifs, un nombre stable de comas dépassés. Douze prélèvements d'organes ont pu être effectués parmi les 81 enfants en coma dépassé.La maladie d'origine accidentelle reste la première cause de décès. Les décès consécutifs à un arrêt des soins curatifs sont aujourd'hui plus fréquents qu'il y a quelques années.To define the characteristics of patients dying in a pediatric hospital, including causes and modes of death.This retrospective, descriptive, epidemiologic study was performed between 1 January 1990 and 31 December 1995. All patients who died in the hospital between these dates were included. Patients already dead on arrival (sudden infant death syndrome, children deceased during their transport), and those whose hospital records could not be found, were excluded.A total of 375 children were studied, including 195 neonates. The sex ratio was 1.3. Ninety-one percent of deaths took place in three departments: intensive care, neurosurgeryneurology and oncology. Median duration of hospitalization was three days. The most common causes of deaths were accidents, neurologic diseases (particularly among neonates) and tumours. Analysis of modes of death revealed that 41.1% occurred following unsuccessful resuscitation, 38.8% were the result of withdrawal of life-support or a ‘do not resuscitate’ order and 21.6% resulted from brain death. Evolution of modes of death over the six years showed a reduction of cases with unsuccessful resuscitation, an increase in decisions of 'do not resuscitate'orders and withdrawal of life-support and no change in rates of brain death. Organs were made available for transplantation from 12 of the 81 children with brain death (14.8%).Accidents were the most common cause of death. The distribution of deaths showed a clear increase in withdrawal or withholding of life-support care, relying on ethical decisions, which are more frequent than some years ago.

OBJECTIVE AND METHOD:Evaluation of angioplasty for primary cardiogenic shock in acute myocardial infarction in three non-universitary alsacians centres between 1999 and 2002.RESULTS:One hundred and eighty-two patients were included. Hospitalisation survival rate is 43.96% after hospital discharge. One hundred and forty-nine patients were treated by primary angioplasty. Angioplasty is successful in 79.12%. The predictives factors of death are: age > 75, TIMI = 0 at the admission, three vessels disease. Twenty-four months survival is 91% (follow-up data available on 28.75% of the patients alive at hospital discharge).CONCLUSION:Angioplasty seems to be the right choice in case of acute myocardial infarction complicated by cardiogenic shock, the results are better than medical treatment at short- and mid-term.

Objectif et méthode. – Évaluation de la prise en charge par angioplastie primaire du patient en choc cardiogénique en phase aiguë d’infarctus du myocarde dans trois centres alsaciens non universitaires ; suivi hospitalier et à moyen terme pour la période de 1999 à 2002.