Several testing options are available to detect asymptomatic coronary artery disease (CAD). Dobutamine stress echocardiography (DSE) has been reported to increase the sensitivity and specificity of ...stress testing to detect CAD. Most studies concerned patients with known or suspected CAD who have a high pretest probability of disease. We aimed to perform a preliminary evaluation of DSE in atherothrombotic stroke.
Patients with transient ischemic attack or nondisabling ischemic stroke attributable to an atherothrombotic source were prospectively recruited. Patients with a history of angina pectoris or electrocardiographic signs of previous myocardial infarction were excluded. DSE was considered positive when regional reduction or deterioration of myocardial thickening developed in 1 segment. Coronary angiography was performed in patients with positive DSE.
Sixty-four patients were recruited. Analysis of DSE was possible in 60 patients. Overall the test provided clinically useful information in 60/64 patients studied (>90%). DSE was positive in 9 patients (15%). Coronary angiography was performed in 8 patients, high-grade focal lesions were found in 3 patients, and 5 patients showed diffuse atheroma. Univariate logistic regression analysis showed that the main factor predictive of a positive DSE was the presence of an aortic arch atheroma (p = 0.003). Multivariate logistic regression analysis showed that two factors had an independent predictive value of positive DSE: aortic arch atheroma (p = 0.007) and dyslipidemia (p = 0.09).
DSE may improve prevention of further vascular events in patients with an atherothrombotic source of ischemic stroke. This screening may be of particular benefit to patients with an aortic arch atheroma.
Thanks to improved technology and the advent of transcatheter aortic valve implantation (TAVI), balloon aortic valvuloplasty (BAV) has reappared in the management of high risk patients with severe ...aortic stenosis in a critical clinical state in three different therapeutic strategies: 1) palliative care A 2) bridge to surgery B 3) bridge to TAVI C. Our main objective was to assess the safety, the effiency and the pertinence of BAV.
Thirty six patients with severe aortic stenosis and prohibitive surgical risk (logistic Euroscore
>
15% or severe commorbidities) underwent 39 BAV: 8 in strategy A, 20 in strategy B, 11 in strategy C. 3 patients underwent a second BAV due to early restenosis.
There was a significant improvement of the hemodynamic parameters after BAV: the peak to peak transaortic gradient was reduced by 56% (47
mmHg vs 30
mmHg; p
<
0.001) and index valve area was increased by 48% (0.35 vs 0.52
cm
2/m
2; p
<
0.001). There was no severe procedural complication (no death due to procedure, no massive aortic insuffisiency, no tamponade). Two patients (5.1%) needed a pacemaker implantation for postprocedure atrioventricular block and 6 patients (15.4%) had moderate bleeding of the femoral artery site. The mortality and follow up for the three strategies are summarized in the table.
BAV is a safe and efficient transient therapeutic strategy for patients with severe aortic stenosis with prohibitive surgical risk. BAV appears to be more pertinent in bridge to surgery or brige to TAVI than in palliative care. For patients in critical clinical state, BAV stabilizes the hemodynamic status and allows the assessment of anatomical selection criteria for TAVI
Stratégy A
(n
=
8)
Stratégy B
(n
=
20)
Stratégy C
(n
=
11)
Age (mean, min-max)
80 (61–94)
73 (44–85)
81 (60–87)
Mean logistic Euroscore (%)
48
22.6
44.2
Death n (%)
6 (75)
8 (40)
5 (45)
Cardiovascular death n (%)
4 (50)
3 (15)
2 (18)
Time of occurrence (days, min-max)
12 (0–47)
66 (0–130)
155 (10–316)
Aortic valve replacement n (%)
-
14 (70)
-
TAVI n (%)
-
-
2 (18)
Between November 1989 and September 1990, a cardiomyoplasty procedure was performed in 12 male patients with a mean age of 59 years. All patients were in New York Heart Association class III. ...Reinforcement cardiomyoplasty was isolated in 4 patients and associated with a cardiac procedure in 8. There were no perioperative deaths. Failure of cardiomyoplasty occurred in 5 patients because of recurrence of disabling congestive heart failure: 3 patients died late, and 2 had heart transplantation. The actuarial survival rate was 83% at 1 year and 73% at 2 years. Hemodynamic studies were done preoperatively in all patients, at 6 months postoperatively in 11 patients, at 1 year in 8, and at 2 years in 7. At the 2-year follow-up, 6 of the 7 survivors who did not have transplantation were functionally improved with reduced medical treatment. The following indices improved significantly at the 2-year evaluation compared with baseline: exercise capacity (63 +/- 13 W versus 83 +/- 17 W); left ventricular (LV) end-diastolic pressure (20 +/- 7 mm Hg versus 11 +/- 5 mm Hg); and angiographic LV ejection fraction (0.25 +/- 0.09 versus 0.40 +/- 0.15). Pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac index remained unchanged. Four patients underwent beat-to-beat analysis of LV function at 2 years; during skeletal muscle stimulation, stroke volume increased by 7% to 35% and LV end-systolic pressure, by 5% to 9%. In the 5 patients with failed cardiomyoplasty, mean pulmonary artery pressure and LV end-diastolic volume were higher preoperatively than in the 7 survivors.
The probability of being a stone former (PSF) was calculated in 3 groups of idiopathic calcium stone formers with normocalciuria (NC), dietary hypercalciuria (DH) and idiopathic hypercalciuria (IH) ...in 4 conditions: while on a free diet; on a calcium- and oxalate-restricted diet during 4 days; after an oxalate load, while on a 1.5-gram calcium diet, and after an oxalate load while on a calcium-restricted diet. Combined calcium and oxalate restriction significantly decreased PSF only in NC and DH whereas the decrease was not significant in IH because of a concomitant significant increase in oxalate excretion. Increase of PSF with the oxalate load was significantly greater during a calcium-restricted diet than during the 1.5-gram calcium diet in all groups of patients (4, 6 and 12 times greater in NC, DH and IH, respectively). These data show the critical role of oxalate restriction when calcium is restricted in order to decrease the PSF. This combined restriction is however not sufficient in idiopathic hypercalciuric patients to decrease their PSF.
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