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Biomedical subjects

A Cribier

Publications and source records attributed to A Cribier.

At least 19 recordsLinked to original sources
PubMed1997

A new treatment for severe pulmonary embolism: percutaneous rheolytic thrombectomy.

BACKGROUND: The rheolytic thrombectomy catheter has been specially designed to remove intravascular thrombus from coronary and peripheral arteries. It demonstrates a practical application of Bernoulli's principle relating to a low-pressure zone in the region of a high-velocity jet. In this device, this effect is created by direct high-pressure saline jets located at the tip. Thrombus is drawn into this region and, because of the large pressure difference, undergoes mechanical thrombolysis due to the powerful mixing forces. The resulting microparticles are aspirated through the same catheter and removed from the body. METHODS AND RESULTS: We report the use of this device in two patients presenting with severe pulmonary embolism and contraindications to thrombolytic therapy. The two procedures were successfully performed with an excellent immediate angiographic result at the site of the rheolytic thrombectomy. In both cases, the clinical improvement was maintained at follow-up with the same good angiographic result and a decrease to a normal level of the systolic pulmonary pressure. CONCLUSIONS: This preliminary results suggest that this easy technical method may be useful in the treatment of life-threatening pulmonary embolism in patients with absolute contraindications to thrombolytic therapy. A larger cohort of patients is necessary to determine whether this treatment should be proposed as an alternative to the use of fibrinolytics in selected patients.

Aged↗
PubMed1997

Early versus late coronary stenting following acute myocardial infarction: results of the STENTIM I Study (French Registry of Stenting in Acute Myocardial Infarction).

This study was undertaken to determine the feasibility and safety of coronary stenting in acute myocardial infarction (AMI). In AMI, primary percutaneous transluminal coronary angioplasty (PTCA) is accepted as the preferred method of reperfusion for patients presenting at highly experienced centres. Until recently, however, stenting has been avoided during AMI because of a potential high risk of thrombosis. This prospective observational study carried out in 20 centres and included 648 consecutive patients who underwent PTCA with stent implantation for AMI. Of these 648 patients, 269 (41.5%, Group 1) were dilated early (< 24 hr) after the onset of the symptoms (75% treated by direct PTCA) and 379 (58.5%, Group 2) were dilated between 24 hr and 14 days after AMI. Combined therapy with ticlopidin and aspirin was used after the procedure. Bailout stenting occurred more often in Group 1 than in Group 2 (17% vs. 9.5%)(P < 0.05). Angiographic successful stenting was similar in both groups of patients (96% vs. 97%). During the hospital follow-up period, stent thrombosis occurred in eight patients (3%) in Group 1 and in six patients (1.6%) in Group 2 (NS). There was 14 deaths (5.2%) in Group 1 and 11 deaths (3.9%) in Group 2 (NS). After multivariate analysis bailout stenting was identified as the sole predictor of stent thrombosis (P < 0.0001). Vascular access-site complications occurred in six patients (1%) with no difference between the two groups. This study indicates that patients who receive a coronary stent in AMI can be managed safely with antiplatelet therapy. Randomized studies are needed to determine the precise indication for coronary stenting as an adjunct to primary PTCA.

Adult↗
PubMed1997

Adaptation to myocardial ischemia during coronary angioplasty demonstrated by clinical, electrocardiographic, echocardiographic, and metabolic parameters.

It has been shown that brief episodes of myocardial ischemia can render the heart more resistant to a prolonged subsequent ischemic episode. This phenomenon, called "preconditioning," has been described in human beings during coronary angioplasty with the use of clinical, electrocardiographic (ECG), or metabolic parameters. The goal of this study was to assess this phenomenon further with the use of echocardiographic and metabolic parameters in addition to clinical and ECG parameters. Eighteen patients with isolated stenosis of the left anterior descending coronary artery and a normal left ventricular function were included. Angioplasty consisted of four consecutive balloon inflations. Sequential changes in clinical, ECG (intracoronary ECG), echocardiographic, and metabolic parameters of myocardial ischemia were compared between the first and the fourth balloon inflations. Improved tolerance to myocardial ischemia with repeated coronary occlusions was demonstrated by a significant reduction in the severity of angina, ST-segment elevation, wall motion abnormalities, and lactate production. This study confirms the adaptation of myocardial ischemia to repeated coronary occlusions through measurement of clinical, ECG, echocardiographic, and metabolic parameters.

Angioplasty, Balloon, Coronary↗
PubMed1997

Angioscopic evaluation of rotational atherectomy followed by additional balloon angioplasty versus balloon angioplasty alone in coronary artery disease: a prospective, randomized study.

OBJECTIVES: This study sought to compare, by angioscopy, the morphologic changes induced by rotational atherectomy, followed by additional angioplasty, with those observed after balloon angioplasty alone. BACKGROUND: Rotational atherectomy and balloon angioplasty act by different mechanisms, which could explain the difference in morphologic changes induced by these two techniques. METHODS: The study group included 50 patients with 50 lesions who were randomly assigned to undergo rotational atherectomy (n = 24) or balloon angioplasty (n = 26). Rotational atherectomy with a single burr (approximately equal to 70% of coronary diameter) was systematically followed by additional balloon angioplasty. Angioscopy was performed immediately after the procedure. Abnormal angioscopic findings were 1) flaps, graded from 1 to 3 (1 = intimal flap; 2 = flap protruding into < 50% of the lumen; 3 = flap protruding into > or = 50% of the lumen); 2) thrombi, graded from 1 to 3 (1 = flat deposits; 2 = protruding but nonocclusive thrombus; 3 = occlusive thrombus); 3) subintimal hemorrhage; 4) longitudinal dissection. The two groups were comparable for clinical and angiographic baseline data. RESULTS: On angioscopy, flaps were observed less frequently after rotational atherectomy followed by additional balloon angioplasty (8 [33%] of 24 lesions) than after balloon angioplasty alone (14 [54%] of 26 lesions, p = 0.08) and were also less severe (grade 1 in 6 lesions, grade 2 in 2 and grade 3 in none vs. grade 1 in 4 lesions, grade 2 in 5 and grade 3 in 5). Longitudinal dissections were also significantly less frequent: one versus six (p = 0.05). There was no difference in the incidence of angioscopic thrombi (p = 0.16) or subintimal hemorrhage (p = 0.15), but the power to detect a significant difference was low for these variables (37% and 26%, respectively). CONCLUSIONS: Rotational atherectomy followed by additional balloon angioplasty leads to fewer angioscopic dissections and a trend toward fewer intimal flaps than balloon angioplasty alone. However, our angioscopic differences did not lead to an outcome difference between the two groups.

Aged↗
PubMed1997

[Comparison of myocardial velocities by tissue color Doppler imaging in normal subjects and in dilated cardiomyopathy].

The authors studied 35 normal subjects (41 +/- 6 years) and 22 patients with idiopathic dilated cardiomyopathy 48 +/- 7 years; ejection fraction: 31 +/- 12%) in order to determine normal values of myocardial velocities and to demonstrate the sensitivity of Doppler tissue imaging in detecting a significant decrease in myocardial velocities in patients with abnormal left ventricular contractility. Interventricular septal and left ventricular posterior wall velocities were recorded by M mode long axis parasternal views. In normal subjects, a velocity gradient in the posterior wall was observed, higher in the endocardium than in epicardium, in systole (5.1 +/- 1.5 versus 2.8 +/- 1 cm/s, p < 0.01), and early diastole (13.7 +/- 3.5 versus 5.7 +/- 2 cm/s, p < 0.001) and late diastole at the time of atrial contraction (2.7 +/- 2.1 versus 1.8 +/- 1.7 cm/s, p < 0.01). Moreover, the velocities are higher in the posterior wall than in the interventricular septum throughout the cardiac cycle. Finally, the velocities are higher in early diastole than in systole, both in the interventricular septum and posterior wall. In the group of patients with idiopathic dilated cardiomyopathy, the intramyocardial velocities were lower than in normal subjects. In addition, the velocity gradient in the posterior wall was absent in 15 of the 22 patients. The authors conclude that Doppler tissue imaging provides new information in the analysis of myocardial function both in systole and diastole.

Adolescent↗
PubMed1997

[Peripheral and coronary artery dissections in a young woman. A rare case of type IV Ehlers-Danlos syndrome].

Spontaneous coronary dissection is rare and the diagnosis is usually post-mortem. Less than 60 cases have been diagnosed at coronary angiography. The authors report, to the best of their knowledge, the first case of multiple spontaneous coronary artery dissections in a type IV Ehlers-Danlos syndrome in a young woman admitted to hospital for acute myocardial infarction. She had a previous history of regressive complete tetraplegia due to dissection of the basilar artery and episodes of dizziness related to a dissecting aneurysm of the left vertebral artery. The diagnosis of type IV Ehlers-Danlos syndrome was established after skin biopsy had shown typical histological changes. The patient died several months later after an acute abdominal syndrome probably related to dissection of the aorta. An autopsy was refused by her family. The authors believe this to be the first case of spontaneous coronary dissection related to a type IV Ehlers-Danlos syndrome.

Adult↗
PubMed1996

Intracoronary stent implantation without ultrasound guidance and with replacement of conventional anticoagulation by antiplatelet therapy. 30-day clinical outcome of the French Multicenter Registry.

BACKGROUND: Stenting reduces both acute complications of coronary angioplasty and restenosis rates but increases subacute thrombosis rates and hemorrhagic complications when used with coumadin anticoagulation. METHODS AND RESULTS: To simplify postcoronary stenting treatment and to reduce these drawbacks, we evaluated the 1-month outcome of a prospective registry of 2900 patients in whom successful coronary artery stenting was performed without coumadin anticoagulation. Patients received 100 mg/d aspirin and 250 mg/d ticlopidine for 1 month. Low-molecular-weight heparin (LMWH) treatment was progressively reduced in four consecutive stages, from 1-month treatment to none. Event-free outcome at 1 month was achieved in 2816 patients (97.1%). Major stent-related cardiac events were subacute closure in 51 patients (1.8%), including death in 12 (0.5%), acute myocardial infarction in 17 (0.6%), and coronary artery bypass graft surgery in 9 (0.3%). Stent thrombosis was more frequent with balloon size of < 3.0 mm (< or = 2.5 mm, 10%; 3.0 mm, 2.3%; > or = 3.5 mm, 1.0%; P < .001), bail-out situations (6.67% versus 1.38%, P < .001), and patients with unstable angina or acute myocardial infarction (2.2% versus 1.12%, P = .02). Bleeding complications that required transfusion, surgical repair, or both occurred in 55 patients (1.9%). Bleeding complications were related to female gender (4.0% versus 1.51%, P < .001), duration of LMWH treatment (3.83% in phase II/III versus 0.69% in phase IV/V, P < .001), sheath size (6F, 0.52%; 7F, 1.04%; > or = 8F, 4.23%; P < .001), bail-out situations (4.76% versus 1.67%, P < .01), and saphenous graft stenting (4.38% versus 1.75%, P = .04). CONCLUSIONS: These results suggest that poststenting treatment by ticlopidine/aspirin is an effective alternative to coumadin anticoagulation, achieving low rates of subacute closure and bleeding complications. LMWH treatment does not improve subacute reocclusion rates but increases bleeding complications. Furthermore, as bleeding complications were independently related to sheath size, we suggest that stenting with 6F guiding catheters may prevent local complications. Furthermore, the ticlopidine/aspirin combination allows a low-cost stenting strategy without ultrasound assessment of stent deployment and permits short inhospital stay.

Aged↗
PubMed1996

Effects of prolonged sequential balloon inflations on results of coronary angioplasty.

In percutaneous transluminal coronary angioplasty (PTCA), prolonged balloon inflations using perfusion balloon catheters have shown a higher procedural success rate and fewer in-hospital complications than short balloon inflations. However, perfusion balloons have well-recognized limits for routine use. This study assessed the effects of a prolonged cumulative occlusion time obtained with sequential balloon inflations using a routine balloon catheter, applicable to all lesions, and compared these results with those obtained with standard short balloon inflations. Three hundred ten lesions (in 289 patients) were randomized to either standard (3 to 5 inflations < or = 1 minute each; n = 161) or prolonged (3 to 5 inflations of 3 to 5 minutes each; n = 149) balloon inflations. Angiographic success (residual stenosis <50% and no dissection > or = D1) was assessed at the end of this "protocol" phase. Further dilatation was performed if required ("adjunctive" phase). Systematic repeat catheterization was scheduled 4 to 6 months later. Cumulative inflation time was 198 +/- 58 seconds in the "standard" group versus 782 +/- 303 seconds in the "prolonged" group. At the end of the protocol phase, the success rate was higher after prolonged than after standard dilatation (92% vs 80%; p <0.002), with less frequent dissections (14% vs 30%; p = 0.0009). At the end of the adjunctive phase, required for 12 patients in the prolonged group and 32 patients in the standard group (p = 0.003), results were comparable in the 2 groups and the restenosis rate was similar at 6 months. The prolonged cumulative occlusion time achieved with sequential balloon inflations using a routine balloon catheter improves the immediate results of PTCA. Repeat catheterization shows no effect of prolonged sequential inflations on the restenosis rate.

Aged↗
PubMed1996

Utility of Pilot wire in angioplasty of tortuous and highly angulated coronary arteries.

We present a case of severe proximal circumflex artery tortuosity with two 90 degrees bends and then a tight stenosis in the mid part of first obtuse marginal branch. Conventional method used to cross the lesion by wire failed. However, a commercially available new wire with ability to change the degree of tip angulation (Pilot wire, USCI Bard) was then used successfully to cross the stenosis. In addition, the wire straightened the tortuosities and provided good trackability to the balloon. Thus, this new wire is a valuable addition to the angioplasty armamentarium.

Adult↗
PubMed1996

[Value of dobutamine echocardiography in the detection of coronary disease in heart transplant patient. Groupe de Recherche VACOMED].

The value of Dobutamine stress echocardiography in the detection of coronary artery disease in heart transplant patients was studied in 64 patients at control coronary angiography 39 +/- 14 months after transplantation. Dobutamine was infused at progressively increasing doses (5 to 40 micrograms/kg/min) at 5 minute intervals, in order to reach 85% of the theoretical maximal heart rate or an ischaemic event. Echocardiography was analysed in the 4 standard views which were digitised allowing calculation of a regional wall motion score under basal conditions and at peak dosage in 16 left ventricular segments. Coronary angiography identified three groups: group I: 29 patients with normal coronary arteries; group II: 17 patients with non-significant coronary disease (diffuse or localised stenosis < 50%); group III: 9 patients with significant (> 50%) coronary disease. Dobutamine stress echocardiography showed regional wall motion abnormalities in 2/29 patients in group I, 13/17 patients in group II and all patients in group III (global sensitivity: 85%; specificity: 97%). The contractility score was significantly higher under basal conditions in group III (1.45 +/- 0.54) than in group I (1) and group II (1.17 +/- 0.23). At peak dose, the contractility score was unchanged in group I and increased significantly (p < 0.01) in the other two groups. The authors conclude that Dobutamine echocardiography is a reliable, non-invasive method of detecting coronary disease in cardiac transplant patients, and is particularly valuable for demonstrating myocardial ischaemia related to coronary lesions judged to be not significant at coronary angiography.

Adult↗
PubMed1996

[Myocardial adaptation to ischemia. A study during repeated prolonged coronary occlusions in angioplasty].

Coronary angioplasty provides an ideal model for studying ischemic preconditioning in humans. Four coronary occlusions, each lasting 5.2 +/- 1.3 min, separated by 3 min of reperfusion, were performed during angioplasty of isolated stenosis of the left anterior descending artery of 18 patients with stable angina and normal left ventricular function. The ischaemia was evaluated and compared during the first and fourth coronary occlusion with the aid of clinical, electrocardiographic, echocardiographic and metabolic parameters. We analysed: 1) interval to chest pain and its intensity; 2) degree of ST change on the intracoronary electrocardiogram; 3) regional wall motion abnormalities on 2D echocardiography; 4) coefficient of myocardial lactate extraction. The results showed that during the fourth occlusion: chest pain occurred later (93 +/- 57 vs 60 +/- 49 s; p < 0.05) and ST elevation was less (0.69 +/- 0.5 vs 1.03 +/- 0.8; p < 0.05). During the fourth occlusion, there was a delay in appearance and a decrease in the regional wall motion abnormalities: anterior wall hypokinesia occurred later: 26 +/- 15 vs 19 +/- 19 s (p = 0.08). Akinesia observed in 10 patients out of 13 (77%) during the first occlusion, was only observed in 8 patients (62%) and dyskinesia, observed in 5 patients out of 13 (38%) during the first occlusion was not observed thereafter in any patient. The production lactate was less important during the fourth occlusion than during the first one: -3 +/- 17% vs -12 +/- 19% (p < 0.05). This study confirms that, in man, preconditioning allows myocardial adaptation to successive episodes of acute ischaemia.

Adaptation, Physiological↗
PubMed1995

Standard orthotopic heart transplantation versus total orthotopic heart transplantation. A transesophageal echocardiography study of the incidence of left atrial thrombosis.

BACKGROUND: After standard orthotopic heart transplantation (Sd HT), the enlarged resultant atria may promote atrial thrombosis. The purpose of this study was to compare the incidence of spontaneous echo contrast and left atrial thrombosis after Sd HT and total orthotopic (Tot HT) heart transplantation. METHODS AND RESULTS: Transesophageal echocardiography (TEE) was performed in 75 patients with Sd HT and in 20 patients with Tot HT. Despite the use of antiplatelet therapy, an acute arterial embolism occurred in 11 (15%) of the 75 patients with Sd HT but in none of the 20 Tot HT patients. All patients were in sinus rhythm. Left ventricular ejection fraction was similar in Sd HT and Tot HT patients. Left atrial diameter was smaller in Tot HT patients than in Sd HT patients (41 +/- 4 versus 58 +/- 6 mm, P < .001). In Sd HT patients, spontaneous echo contrast was present in 43 patients (57%) and was associated with left atrial thrombus in 20 patients (on the left atrial appendage in 12 patients, on the posterior wall in 6, and on the suture in 2). No thrombus was detected by transthoracic echocardiography; all thrombi were detected by TEE. On the other hand, no left atrial thrombus was observed in Tot HT patients, and only 1 patient had spontaneous echo contrast. Of the 11 Sd HT patients who experienced an arterial embolism, 5 had both spontaneous echo contrast and left atrial thrombus and 5 had only spontaneous echo contrast. CONCLUSIONS: This study demonstrates a high rate of left atrial thrombus after Sd HT and emphasizes the role of TEE in the follow-up of these patients. The therapeutic implications are the need for a preventive anticoagulant therapy in the high-risk population receiving Sd HT diagnosed with TEE and the consideration of Tot HT as a better surgical approach as far as thrombotic complications are concerned.

Adult↗
PubMed1995

Dobutamine stress echocardiography in orthotopic heart transplant recipients. VACOMED Research Group.

OBJECTIVES: This study sought to determine whether dobutamine stress echocardiography could accurately identify coronary artery disease after heart transplantation. BACKGROUND: After heart transplantation, coronary artery disease is related to either diffuse concentric intimal thickening or focal stenosis and may be underdiagnosed by coronary angiography. METHODS: We enrolled 41 patients, a mean (+/- SD) of 40 +/- 20 months after heart transplantation, at the time of their routine control coronary angiogram. Three patients were excluded because of poor echogenicity on the angiogram and one because of ventricular premature beats. Standard echocardiographic views were acquired at baseline and at incremental dobutamine infusion levels (from 5 to a maximal dose of 40 micrograms/kg body weight per min at 3-min intervals). Regional wall motion score was calculated from a 16-segment model, and each segment was graded from 1 (normal) to 4 (dyskinesia). Coronary angiography was performed 24 h after dobutamine stress echocardiography, and angiograms were analyzed in blinded manner. RESULTS: Twenty-three (62%) of 37 patients had normal coronary angiographic findings. Dobutamine stress echocardiography showed abnormalities in only 2 of 23 patients. Fourteen patients (38%) had abnormal angiographic findings, seven of whom had stenoses > 50%. Dobutamine stress echocardiography correctly identified the corresponding hypoperfused segments in these seven patients. More of interest were the other seven patients, of whom three had angiographic nonsignificant stenoses (< 50%), and four had minor diffuse coronary irregularities. Dobutamine stress echocardiography showed hypokinesia in five of these seven patients despite nonsignificant lesions at coronary angiography. The respective overall sensitivity and specificity of dobutamine stress echocardiography were 86% and 91%. At follow-up, 2 of the 37 patients had an acute myocardial infarction. Both had abnormal findings on dobutamine stress echocardiography: One had normal coronary angiographic results, and one had significant coronary lesions. CONCLUSIONS: Dobutamine stress echocardiography is a useful technique for the diagnosis of coronary artery disease after heart transplantation. These preliminary results indicate that dobutamine stress echocardiography may have a predictive value for further ischemic events in heart transplant recipients.

Cardiac Catheterization↗
PubMed1995

High incidence of left atrial thrombus detected by transoesophageal echocardiography in heart transplant recipients.

The aim of the study was the detection of spontaneous echo contrast (SEC) and left atrial thrombus by transoesophageal echocardiography (TEE) in patients who had undergone orthotopic heart transplantation. TEE was prospectively performed in 64 heart transplant recipients (53 males, 11 females, mean age 51 years). Since surgery (mean time: 31 months), all heart transplant recipients had received either aspirin (39), or dipyridamole (22), or both (3). Despite the antiplatelet treatment, an acute arterial embolism (two strokes, one popliteal and one mesenteric ischaemia) occurred in four patients who subsequently received an oral anticoagulant therapy. TEE was performed with a biplane high-frequency transducer after lidocaine pharyngeal anaesthesia, midazolam intravenous injection and antibiotic prophylaxis. Mean ejection fraction was 63 +/- 10%. None had evidence of rejection at endomyocardial biopsy performed on the same day as TEE and analysed in a blinded fashion. All were in sinus rhythm. Left atrial SEC was found in 35 patients (55%) and was associated with left atrial thrombus in 18 patients (28%). These thrombi were localized in the donor left atrial appendage in 10 cases, on the posterior wall of the left atrium in six cases, on the donor part of inter-atrial septum in one case and on the suture line in one case. They were not detected by transthoracic echocardiography (TTE). When compared with patients without thrombus, no difference was found concerning left atrial size, left ventricular ejection fraction, pulmonary artery pressure and number of previous episodes of rejection. However, cardiac index was significantly lower in patients with left atrial thrombus.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial Function, Left↗
PubMed1995

Angioscopic evaluation of prolonged vs standard balloon inflations during coronary angioplasty. A randomized study.

UNLABELLED: To study the immediate effects of prolonged total balloon inflation during PTCA, 41 patients (44 lesions) with chronic stable angina were randomized for prolonged sequential inflations (three to five inflations of 3 to 5 min each, for a total duration of > or = 12 min, group 1, n = 20 lesions) or 'standard' sequential inflations (three to five inflations of < or = 1 min each, for a total duration of < or = 3 min, group 2, n = 24 lesions). The mean duration of total balloon inflation time was 958 +/- 129 s in group 1 vs 205 +/- 46 s in group 2. Results of angioplasty were assessed on both angiography and percutaneous transluminal coronary angioscopy performed immediately after the procedure. High quality imaging of the coronary lumen and lesion morphology was possible on angioscopy in all patients without any complications. Post-PTCA angiographic percent diameter stenosis was significantly less in group 1 compared to group 2: 26 +/- 10% vs 36 +/- 8% (P < 0.05). On angioscopy, flaps were seen in 16 patients in group 2, but in only six in group 1 (P < 0.02). There was no difference in the incidence of thrombi on angioscopy between the two groups (group 1: nine cases, group 2: 10 cases). Sensitivity of angiographic detection of flaps and thrombi was poor: 10% and 12% respectively. One patient in each group developed a longitudinal dissection, detected on both angiography and angioscopy. CONCLUSIONS: (1) prolonged sequential balloon inflations lead to less residual luminal stenosis after PTCA, with a decreased incidence of intimal flaps in comparison with standard inflations. (2) Post-PTCA transluminal coronary angioscopy is safe and offers better assessment of luminal effects of PTCA than angiography.

Adult↗