Eduardo Aptecar

French Institute of Health and Medical Research, Lutetia Parisorum, Île-de-France, France

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Publications (88)387.52 Total impact


  • No preview · Article · Mar 2013 · Journal des Maladies Vasculaires
  • P Dupouy · J-M Pernès · E Aptecar · A Ferrrario · M Auguste

    No preview · Article · Mar 2013 · Journal des Maladies Vasculaires
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    ABSTRACT: Role of Coronary CT in the diagnosis of chronic coronary artery disease The use of non-invasive imaging in the diagnosis of chronic coronary diseases is recommended for patients with clinical "intermediary" probability. We discuss the use of several techniques of investigation in relation to clinical signs and results of stress tests. Two different approaches of classification of the coronary disease can be used: the first, anatomical, based on the diameter or luminal reduction of the artery and the second, physiological, based on signs of myocardial ischemia. The coronary CT has recently been introduced in routine practice but official guidelines are still not very precise. This article discusses the use and the diagnostic efficiency of the CT coronary scan in patients with suspected coronary disease.
    No preview · Article · May 2012 · Sang Thrombose Vaisseaux
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    ABSTRACT: The percutaneous Seldinger technique using a femoral approach has been employed to perform cardiac catheterization for years, both for diagnostic and therapeutic procedures. The radial approach, developed in the last twenty years, is now preferred by many interventional cardiologists, particularly in France, because of its true advantages, namely easy hemostasis and consequently an extremely low incidence of complications at the access site, better patient comfort, shorter bed rest and lower hospitalization time and costs. The ulnar artery shares with the radial artery its easy access and hemostatic qualities and is often as large or larger than the radial artery. Previously ignored, in the last years some series and two randomized studies have shown that the ulnar approach for coronary (and some peripheral) interventions is possible, feasible, efficacious, and safe. In fact, the success rate using the ulnar approach is high and similar to that of radial approach. Moreover, local and systemic complications are extremely low and similar with both approaches. As in the radial approach, the ulnar approach requires a learning curve, which is rapidly accomplished by trained radial artery operators, and the presence of functional palmar archs (easily evaluated with Allen's test), avoids ischemic complications in case of thrombotic occlusion, which occurs in 3 to 5% of cases. The ulnar approach should not be forgotten by interventional cardiologists, who would appreciate feeling at ease with this technique, particularly in cases when the trans-radial access in not possible or fails, before reverting to the trans-femoral approach.
    No preview · Article · Feb 2012 · Sang Thrombose Vaisseaux
  • J.-M. Pernes · Mario Auguste · Patrick Dupouy · Eduardo Aptecar
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    ABSTRACT: Acute 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 endo-vascular 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 PTS 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.
    No preview · Article · Nov 2011 · Sang Thrombose Vaisseaux

  • No preview · Article · Jan 2011 · Sang Thrombose Vaisseaux
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    ABSTRACT: 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 nothreshold 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.
    No preview · Article · Dec 2010 · Sang Thrombose Vaisseaux
  • Patrick Dupouy · Eduardo Aptecar · J.-M. Pernes
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    ABSTRACT: 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 thanwhich 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.
    No preview · Article · May 2010 · Sang Thrombose Vaisseaux
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    ABSTRACT: Multislices Cardiac CT scan (MSCT) is a current non invasive coronary arteries imaging modality which is increasingly used. Radiation dose to which the patient is exposed remains a major problematic issue. Prospective Dose modulation protocol (DMP) allows marked dose reduction when correctly used.Aim and Methodsin order to figure out how DMP impacts Dose radiation to patient in daily life practice we prospectively studied 187 consecutive patients referred to our center for a 64 slices MSCT over a 2 months period. DMP was variabely used according to the operator's discretion wheather to modulate (1 to 3 EKG phases) or not based on patient's heart rate. Radiation measured by Dose length product (DLP), percent of modulation induced dose reduction, qualitative quality of the image (assessed by two blinded expert cardiologists) and signal on noise ratio were compared for each patient according to the DMP status.ResultsMSCTs were divided in modulated vs non modulated acquisition and the modulated group was divided in 4 groups according to the dose modulation protocol used : no DMP (n=24), DMP 1 phase (n=97), DMP 2 phases (n=51), DMP 3 (n=15) phases. All groups were comparable considering age, sex ratio and body mass index. Kilovolt and intensity were comparable between groups. DLP was signicantly lower in the modulated group compared to non modulated (734 □ 311 mGy.cm vs 1100 □ 371 mGy.cm, p<0.0001). Percent of dose reduction was only significantly higher for DMP 1 phase compared to other groups (-40 □ 7% DMP 1 vs -15 □ 6 DMP 2, -10 □ 3 DMP 3, 0 DMP 0; p<0.0001). Global image quality was significantly better in the modulated vs non modulated group (p=0.0016) and there was no quality difference between DMP 1 vs others. S/N ratio was not affected by the use or not of DMP.ConclusionDMP has a very positive impact in MSCT dose reduction with no deterioration of image quality. DMP allows the best dose reduction when modulation is conducted over 1 phase and should be used in that way.
    Preview · Article · Jan 2010 · Archives of Cardiovascular Diseases Supplements
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    ABSTRACT: 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.
    No preview · Article · Jun 2009 · Journal de Radiologie
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    ABSTRACT: 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.
    Full-text · Article · May 2009 · Journal de Radiologie
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    ABSTRACT: 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.Points clésSelon 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.
    No preview · Article · Oct 2008 · Journal de Radiologie
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    ABSTRACT: Objectifs pédagogiques Sensibliser le radiologue au rôle potentiel majeur du scanner coronaire dans un futur proche et aux enjeux pour la spécialité. Familiariser le radiologue aux contraintes techniques spécifiques du scanner pour l’étude du cœur. Expliquer en les démystifiant les connaissances cardiologiques cliniques indispensables légitimant le rôle du radiologue dans le domaine
    Full-text · Article · Oct 2006 · Journal de Radiologie
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    ABSTRACT: Coronary vasomotor responses to sympathetic stimulation vary with endothelial-layer integrity or presence of atherosclerosis. Our study objective was to assess the effects of phenylephrine-induced alpha-adrenergic stimulation on coronary vasomotion in heart transplant recipients with and without graft atherosclerosis. Intracoronary phenylephrine (alpha(1)-selective agonist) was injected in 6 control subjects, 9 recipients with angiographically normal coronary arteries and 8 recipients with mild or moderate atherosclerosis. Coronary flow velocity was measured using a Doppler guide-wire. The diameters of 3 epicardial segments of the left coronary artery and coronary blood flow and resistance were assessed at baseline, after infusion of increasing acetylcholine doses (10(-7) and 10(-6) mol/liter) and after phenylephrine (150- to 200-microg bolus). Systemic and coronary hemodynamic parameters were measured immediately after acetylcholine and 1, 3, 5, 7, 10 and 15 minutes after phenylephrine. Phenylephrine induced similar significant increases in rate pressure product in the 3 groups. Acetylcholine induced epicardial vasodilation in controls and vasoconstriction in transplant recipients. Phenylephrine induced epicardial vasodilation in controls and in angiographically normal recipients; subsequent vasoconstriction occurred in this last group. In the recipients with angiographic abnormalities, sustained vasoconstriction occurred. At peak phenylephrine effect, coronary blood flow (CBF) increased significantly (p < 0.001 vs baseline) in all 3 groups. Coronary resistance decreased in the 3 groups but the decrease was smaller in the recipients with angiographic abnormalities (p < 0.05 vs controls). In heart transplant patients, graft atherosclerosis unmasks the direct coronary vasoconstricting effects of pharmacologic alpha-adrenergic stimulation.
    No preview · Article · Sep 2006 · The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation
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    ABSTRACT: To compare in terms of efficacy and safety the transulnar to the transradial approach for coronary angiography and angioplasty. Background: Opposite to the transradial approach, which is now widely used in catheterization laboratories worldwide, the ulnar artery approach is rarely used for cardiac catheterization. Diagnostic coronarography, followed or not by angioplasty, was performed by transulnar or transradial approach, chosen at random. A positive (normal) direct or reverse Allen's test was required before tempting the radial or the ulnar approach, respectively. MACE were recorded till 1-month follow-up. Doppler ultrasound assessment of the forearm vessels was scheduled for all the angioplastied patients. Successful access was obtained in 93.1% of patients in the ulnar group (n = 216), and in 95.5% of patients in the radial group (n = 215), P = NS. One hundred and three and 105 angioplasty procedures were performed in 94 and 95 patients in ulnar and radial group, with success in 95.2% and 96.2% of procedures in ulnar and radial group, respectively (P = NS). Freedom from MACE at 1-month follow-up was observed in 93 patients in both groups (97.8% for ulnar group and 95.8% for radial group), P = NS. Asymptomatic access site artery occlusion occurred in 5.7% of patients after transulnar and in 4.7% of patients after transradial angioplasty. A big forearm hematoma, and a little A-V fistula were observed, each in one patient, in the ulnar group. The transulnar approach for diagnostic and therapeutic coronary interventions is a safe and effective alternative to the transradial approach, as both techniques share a high success rate and an extremely low incidence of entry site complications. The transulnar approach has the potential to spare injury to the radial artery in anticipation of its use as a coronary bypass conduit.
    No preview · Article · May 2006 · Catheterization and Cardiovascular Interventions
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    ABSTRACT: The aim of the present study was to assess the effects of selective B1-receptor stimulation with des-Arg9-bradykinin on coronary vasomotion in transplanted and non-transplanted patients. Bradykinin B1-receptors have been identified on endothelial and smooth muscle cells in human coronary arteries in vitro; however, their physiologic role in the coronary circulation is unknown. Twelve heart transplant patients were compared with 10 control subjects at 3.2 +/- 2.2 months after surgery. Coronary flow velocity was measured using guide-wire Doppler. The diameter of 3 epicardial segments of the left coronary artery and coronary blood flow were assessed at baseline, immediately after infusions of increasing doses of des-arginine(Arg9)-bradykinin at estimated coronary blood concentrations of 5.4 x 10(-9), 5.4 x 10(-8), 5.4 x 10(-7) and 1.6 x 10(-6) mol/liter, and of acetylcholine at 10(-8), 10(-7) and 10(-6) mol/liter). Des-Arg9-bradykinin induced a similar decrease in all measured epicardial diameters in both groups and no change in coronary blood flow. Vasoconstriction was significant only at the 2 highest concentrations: -6 +/- 9% (p < 0.01) and -7 +/- 11% (p < 0.01) in control subjects, and -8 +/- 8% (p < 0.001) and -9 +/- 11% (p < 0.001) in heart transplant patients. Acetylcholine induced significant epicardial vasodilation in control subjects and vasoconstriction in transplant patients. The presence of allograft rejection did not modify the responses to des-Arg9-bradykinin with regard to both conductance and resistance vessels. Kinin B1-receptors exist and can be stimulated in humans. The vasoconstrictive action on epicardial coronary arteries of des-Arg(9)-bradykinin in humans argues for a predominant action of B1-receptor stimulation at the level of smooth muscle cells.
    No preview · Article · Feb 2006 · The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation
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    ABSTRACT: While the transradial approach is now a well-established alternative to the conventional femoral approach for cardiac catheterization, the ulnar artery is rarely used. The objective of this prospective study was to evaluate the feasibility and safety of transulnar catheterization for routine diagnostic and therapeutic coronary interventions. Among 210 consecutive patients referred for diagnostic coronary angiography and or angioplasty and screened for appropriateness of the ulnar approach, 172 (172 of 210, 82%) underwent attempted ulnar artery catheterization, which was successful in 158 (158 of 172, 91%). The 173 procedures successfully performed via the ulnar approach included 122 diagnostic coronary angiographies, 38 coronary angiographies followed by angioplasty, and 13 elective angioplasties. Access site complications consisted of one case each of silent ulnar artery thrombosis, pseudoaneurysm, and hematoma due to ulnar artery wall rupture during an unsuccessful catheterization attempt. No cardiac or systemic complications were recorded. The transulnar approach appears feasible and safe for routine coronary diagnostic and therapeutic interventions.
    No preview · Article · Jul 2005 · The Journal of invasive cardiology
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    ABSTRACT: Background: Fractional flow reserve (FFR) is correlated with angiographic and intravascular ultrasound assessments of stent placement. Post-stenting FFR has been described as a good predictor of clinical events after 6 months. Objective: To evaluate the feasibility and clinical impact of targeting an FFR > 0.95 via incremental in-stent inflation pressures. Methods: In this multicenter prospective study, 100 consecutive patients underwent FFR measurement at baseline, after balloon predilatation, and after stenting with 4-atm inflation pressure increments from 8 to 20 atmospheres. Inflations were stopped when FFR increased above 0.95 and angiographic stenosis was less than 20%. Results: FFR > 0.95 was achieved in 81% of cases; this FFR target was reached at 8 atm in 47% of patients, 12 atm in 16 %, 16 atm in 15%, and 20 atm in 3%. Fifty percent of patients with adequate angiographic result had an FFR less than 0.95 and needed further higher inflations. FFR was correlated with residual stenosis when the total procedure was evaluated, and this correlation persisted when in-stent inflations alone were considered. Final FFR was significantly correlated with anginal status after 6 months.Conclusions: Angiography guided PCI does not allow optimization of FFR. Since optimal post stenting FFR is correlated to better anginal status at 6-months, this suggests that FFR guided PCI is required to achieve optimal functional results of PCI.
    Full-text · Article · May 2005 · EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology

  • No preview · Article · Sep 2004 · Journal de Radiologie

  • No preview · Article · Sep 2004 · Journal de Radiologie

Publication Stats

1k Citations
387.52 Total Impact Points

Institutions

  • 1989-2006
    • French Institute of Health and Medical Research
      Lutetia Parisorum, Île-de-France, France
  • 1999-2001
    • Hôpital Henri Mondor (Hôpitaux Universitaires Henri Mondor)
      • Service de Cardiologie 2
      Créteil, Île-de-France, France
  • 1992-1995
    • French National Centre for Scientific Research
      Lutetia Parisorum, Île-de-France, France