Ischaemic stroke represent more than 80% of the total stroke instances. The location of the occlusion and the amount of brain tissue involved determines the effect of the stroke. Stroke can result in paralysis, memory loss, speech impairment and even a “lock-in” state. The amount of neuronal damage will determine whether these symptoms will be temporary or permanent. Stroke is deemed the second leading cause of death for individuals over the age of 60. According to the World Stroke Organization (WSO) every six seconds stroke claims a life, regardless of age or gender. Stroke is a global burden and the medical costs and disability related to stroke in America for 2010 was projected at almost $73.7 billion. The morphology of platelets, fibrin networks and erythrocytes as well as the differential white blood cell counts of 20 thrombo-embolic ischaemic stroke patients were investigated. Internal and external alterations were revealed in the platelets of stroke patients when compared to healthy controls. The decreased numbers of alpha granules in the platelets of the stroke patients indicated these platelets to be activated. Substances released by activated platelets promote fibrin network structure, specifically the formation of fibrin strands and accumulation of additional platelets. The fibrin network of healthy individuals consists of major, thick fibers with minor, thin fibers distributed between them. The fibrin network of stroke patients exhibited an abnormally layered and matted ultrastructure comprising of mainly thin, minor fibrin fibers packed closely together. An uncharacteristic circular morphology was also observed. These alterations in the fibrin network indicate the activated platelets to be actively involved in the thrombotic event. Neuronal damage related to stroke is also advanced by the vasoactive substances released by activated platelets. It can therefore be deduced that the morphology of the fibrin network is altered long before the concrete thrombotic event transpire. Large numbers of abnormal erythrocytes were distinguished in the blood of stroke patients. Among these abnormal forms of erythrocytes specifically codocytes, knizocytes, stomatocytes and echinocytes were identified. Abnormal erythrocyte forms were significantly increased in hypertensive patients and females independently. Alterations in the ultrastructure of erythrocytes disturb blood flow in the microcirculation and could possibly augment the ischaemic event. Inflammation is closely related to ischaemic stroke. An increased monocyte count and a reduced number of neutrophils were a significant feature among all the stroke patients of this study. Patients with hypertension as well as patients consuming aspirin on a daily basis showed the greatest influence on the observed differential white blood cell counts. These morphological alterations observed in the platelets, fibrin network and erythrocytes as well as the differential white blood cell count could be incorporated in an analysis regime that could probably indicate an impending thrombotic event. Therefore treatment could be initiated before the ischaemic event to possibly prevent the stroke. For future studies a larger study population, a more refined patient enrolment as well as the analysis of follow-up blood samples from patients could substantiate the above-mentioned findings and provide additional information concerning the thrombotic event and the effectiveness of treatment procedures. / Dissertation (MSc)--University of Pretoria, 2010. / Anatomy / Unrestricted

L’infarctus du myocarde est une des premières causes de décès dans le monde. Sa prise en charge repose sur une reperfusion précoce. De façon paradoxale, la reperfusion induit des lésions délétères qui participent à la nécrose de l’organe. Parmi les stratégies de cardioprotection qui visent à limiter la formation de ces lésions, il a été décrit que l’utilisation d’anticoagulants au moment de la reperfusion avait un effet bénéfique sur la taille finale d’infarctus chez l’animal. La cardioprotection induite par ces molécules serait liée à la modulation des phénomènes thrombo-inflammatoires impliqués dans la formation des lésions de reperfusion. Nous nous sommes intéressés à deux anticoagulants inhibant le facteur X activé, le fondaparinux et le rivaroxaban, à l’aide d’un modèle d’ischémie-reperfusion (IR) myocardique chez le rat et de modèles cellulaires d’hypoxie-réoxygénation. Nos résultats montrent que ces deux molécules ont un effet cardioprotecteur à la phase aigue de la reperfusion via des mécanismes différents. La cardioprotection induite par le fondaparinux n’est pas liée à un effet anti-inflammatoire. En revanche, cet anticoagulant induit une modulation du phénotype endothélial au cours de l’IR avec l’augmentation de l’expression de deux molécules cytoprotectrices, la thrombomoduline et le récepteur endothélial de la protéine C. Concernant le rivaroxaban, son effet bénéfique serait lié à un effet cytoprotecteur au niveau des cardiomyocytes. Cette étude confirme l’intérêt des anticoagulants dans la cardioprotection et précise les cibles cellulaires impliquées, ouvrant des perspectives intéressantes concernant l’inhibition de la coagulation au cours de l’IR. / Myocardial infarction is a leading cause of death worldwide. Prompt reperfusion therapy is essential to limit the infarct size. Paradoxically, reperfusion itself can induce deleterious lesions contributing to necrosis, called reperfusion injuries. Among cardioprotective strategies aiming to reduce the formation of these lesions, the use of anticoagulants during reperfusion has been proven to be effective in animals. Anticoagulants-induced cardioprotection would be related to the modulation of thrombo-inflammatory phenomenoms involved in the formation of reperfusion injuries. We studied two anticoagulants inhibiting activated factor X, fondaparinux and rivaroxaban, in a myocardial ischemia-reperfusion (IR) model in rat and in cellular models of hypoxia-reoxygenation. Our results showed that these two anticoagulants were cardioprotective at early-stage reperfusion via distinct mechanisms. Fondaparinux protective effet was not associated with anti-inflammatory properties. However, this anticoagulant increased the expression of two cytoprotective endothelial molecules, thrombomodulin and endothelial protein C receptor. Rivaroxaban beneficial effect was related to cytoprotective effect on cardiomyocytes. This study confirms the of use anticoagulants as a relevant cardioprotective strategy and specifies the cellular targets involved, opening new perspectives regarding the inhibition of coagulation in the setting of IR.

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal.

Introdução: O tromboembolismo é uma grave complicação da fibrilação atrial (FA), particularmente em pacientes que vão se submeter à cardioversão, química ou elétrica. Para reduzir esse risco, os pacientes submetem-se à anticoagulação clássica, que vem sendo praticada há várias décadas. Apesar desta abordagem, em pacientes plenamente anticoagulados, não se conhece a prevalência de trombo ou contraste espontâneo no átrio esquerdo (AE). Por essa razão, alguns autores sugerem a realização do ecotransesofágico (ECOTEE) para confirmar o sucesso do tratamento e reduzir o risco de complicações tromboembólicas após a reversão. Os objetivos deste estudo foram: a) avaliar a prevalência de trombos e contraste espontâneo ao ECOTEE em pacientes que vão ser submetidos à cardioversão sob regime de anticoagulação plena; b) avaliar a incidência de tromboembolismo até 30 dias após o procedimento; c) avaliar a influência das variáveis clínicas (doenças associadas) e do ECOTEE (tamanho e volume indexado do AE, fração de ejeção ventricular; velocidade de fluxo no apêndice atrial esquerdo), além do escore CHA2DS2VASc e níveis de pró-BNP plasmático sobre a formação de trombo/contraste espontâneo. Métodos: Foram incluídos 85 pacientes (62 homens; média de idade 61±12 anos) com FA não valvar com indicação para cardioversão. Todos receberam varfarina com controle da taxa de INR. Quando se considerava o paciente plenamente anticoagulado (INR ente 2 e 3 por três semanas consecutivas), era prescrito um fármaco antiarrítmico (propafenona, sotalol ou amiodarona) cuja escolha se baseou em critérios clínicos. Na ausência de normalização do ritmo, eram encaminhados para cardioversão elétrica (CVE). No dia da CVE, os pacientes submetiam-se ao ECOTEE cujo resultado só era conhecido no dia seguinte após a cardioversão. Os pacientes recebiam alta com anticoagulante e retornavam ao ambulatório após 30 dias quando realizavam outro ECOTEE. Resultados: Todos os pacientes foram cardiovertidos com INR na faixa terapêutica (2,9±0,7). A reversão com fármacos ocorreu em 9/85 pacientes (10,6%); 67/76 pacientes submeteram-se à CVE e, destes, 58/67 (86%) reverteram ao ritmo sinusal. O ECOTEE antes da CVE evidenciou trombo no AE em 8/85 pacientes (9,4%) e contraste espontâneo em 36/85 pacientes (42,3%). Nenhuma variável clínica, escore CHA2DS2VASc, níveis plasmáticos de pró-BNP ou variáveis ecocardiográficas identificou pacientes com maior probabilidade de apresentar trombo/contraste espontâneo no AE. Após 30 dias, houve normalização das variáveis do ECOTEE. Em 5/8 (62,5%) pacientes, os trombos desapareceram e surgiu em outros dois pacientes (2,3%). O contraste espontâneo desapareceu em 24/38 (63%) pacientes. Não houve registro de nenhum caso de tromboembolismo sistêmico em 30 dias. A taxa de recorrência de FA foi de 21%. Conclusões: a) trombo atrial/contraste espontâneo foi detectado em 9,4% da população e nenhuma variável clínica ou ecocardiográfica identificou pacientes de risco; b) houve melhora das variáveis do ECOTEE após a reversão ao ritmo sinusal; d) o sucesso global da cardioversão foi de 88% e a taxa de recorrência de FA de 21% em 30 dias; c) não houve registro de tromboembolismo sistêmico em 30 dias, em ritmo sinusal ou em FA. / Introduction: Thromboembolism is a serious complication of atrial fibrillation (AF), particularly in patients who will undergo chemical or electrical cardioversion. To reduce this risk patients receive classic anticoagulant therapy, which has been practiced for several decades. Despite this approach, it is not known the prevalence of thrombus or spontaneous contrast in the left atrium (LA) in patients fully anticoagulated. For this reason, some authors have recommended the transesophageal echocardiogram (TEECHO) to reduce the risk of thromboembolic complications after cardioversion. The objectives of this study were: a) to evaluate the prevalence of thrombus and spontaneous contrast by TEECHO in patients about to undergo cardioversion under full anticoagulation regime; b) evaluate the incidence of thromboembolism within 30 days after the procedure; c) evaluate the influence of clinical variables (associated diseases) and TEECHO parameters (LA size and LA indexed volume, ventricular ejection fraction, flow velocity in the left atrial appendage), CHA2DS2VASc score and plasma pro-BNP levels on thrombus/spontaneous contrast formation. Methods: We included 85 patients (62 men; mean age 61 ± 12 years) with non-valvular AF referred for cardioversion. All received warfarin with INR control. When considering the patient fully anticoagulated (INR in the range of 2 to 3 for three weeks) it was prescribed an anti-arrhythmic drug (propafenone, sotalol or amiodarone) whose choice was based on clinical criteria. In the absence of normal rhythm, patients were referred for electrical cardioversion (ECV). On the day of ECV, all patients were submitted to the ECOTEE whose result was known only the next day after cardioversion. The patients were discharged with anticoagulant and returned to the clinic after 30 days when another ECOTEE was performed. Results: All patients were cardioverted with INR in the therapeutic range (2.9±0.7). Sinus rhythm was restored with drugs in 9/85 patients (10.6%); 67/76 patients underwent ECV and 58/67 (86%) reverted to sinus rhythm. The TEECHO before cardioversion showed a thrombus in LA in 8/85 patients (9.4%) and spontaneous contrast in 36/85 patients (42.3%). No clinical variable, CHA2DS2VASc score, pro-BNP plasma levels or echocardiography variables identified patients with an increased likelihood of thrombus/spontaneous contrast in LA. After 30 days, there was normalization of TEECHO variables. In 5/8 (62.5%) patients thrombi disappeared and appeared in two patients (2.3%). Spontaneous contrast disappeared in 24/38 (63%) patients. There were no reports of any case of systemic thromboembolism in 30 days. The AF recurrence rate was 21%. Conclusions: a) LA thrombus/ spontaneous contrast were detected in 9.4% of the population and no clinical or echocardiography variable identified patients at risk; b) there was an improvement of TEECHO variables after reversion to sinus rhythm; d) the overall success of cardioversion was 88% and the AF recurrence rate was 21% in 30 days; c) there was no systemic thromboembolism in 30 days, in patients in sinus rhythm or AF.

Pour ce travail de thèse, nous avons réalisé cinq études originales en utilisant trois technologies d'imageries cardiovasculaires non-invasives.-Nous avons démontré, à partir d'une étude ex-vivo sur des artères coronaires humaines, que le scanner64 détecteurs ne permettait pas de caractériser précisément les différents composants des plaques. Ladistinction des plaques fibreuses et des plaques lipidiques est en effet impossible. Par ailleurs, notretravail a montré que l'IVUS ne devait pas servir d'imagerie de référence lors des études sur la plaque carcet examen présente lui aussi de nombreuses imprécisions.-Notre travail sur la thrombo-aspiration rapporte un effet très significatif de l'extraction effective dethrombus lors des thrombo-aspirations à la phase aiguë des STEMI, avec une réduction de la taille du no-reflow et de l'infarctus, évaluées en IRM ; une thrombo-aspiration positive représentant par ailleurs dansnotre travail, un critère indépendamment lié à la taille finale de l'infarctus. L'extraction effective dethrombus pourrait être considéré, en salle de cathétérisme, comme un critère de jugement de l'efficacitéde la thrombo-aspiration.-Notre étude sur les syndomes coronaires à coronaires angiographiquement normales a confirmé l'intérêtde l'IRM dans le bilan étiologique de cette présentation clinique, permettant un diagnostic étiologiquedans 2/3 des cas. Par ailleurs, nous avons observé une excellente évolution pour le tiers des patients chezqui l'IRM ne décèle pas d'anomalie myocardique. Des études d'une plus grande envergure serontnécessaires afin de confirmer nos résultats.-A partir d'IRM cardiaque réalisées chez des patients ayant présenté un premier épisode de STEMI, nousavons pu déterminer une valuer seuil de troponine prédictive de la survenue d'un no-reflow.-Enfin, à partir d'analyses en Speckle Tracking, nous avons mis en évidence une dysfonction systolique VD,objectivée par une altération des valeurs de Strain longitudinal VD, chez les patients présentant une EPgrave ou de gravité intermédiaire, comparativement à un groupe de patients avec une EP non grave. / In this doctoral thesis, we report on five original studies that use three différent non-invasive cardiovascular imaging techniques:- In an ex vivo study of human coronary arteries, we show that 64-slice computed tomography (CT) scan isnot capable of distinguishing between différent components of plaques. Indeed, it is impossible todifferentiate between fibrous and lipid plaques. Our study also showed that intravascular ultrasound(IVUS) should not be used as thé référence method in studies of plaque composition, since this techniquealso suffers from numerous limitations.- Our study of thé efficacy of thrombo-aspiration showed a significant benefit with effective extraction ofthrombus during thrombo-aspiration at thé acute phase of ST élévation myocardial infarction (STEMI),notably with a réduction of thé extent of no-reflow and of infarct size as evaluated by magnetic résonanceimaging (MRI). Productive thrombo-aspiration was shown in our study to be an independent predictor offinal infarct size. Effective extraction of thrombotic material could be considered in thé cathlab as acriterion for evaluating thé success of thé thrombo-aspiration procédure.- Our study of acute coronary syndromes with normal coronary arteries confirmed thé utility of MRI inestablishing thé etiology of this clinical présentation, and made it possible to establish an etiologicaldiagnosis in two-thirds of patients. We also observed excellent outcomes in thé third of patients in whomMRI did not find any myocardial anomalies. Larger studies are warranted to confirm thèse findings.- Based on cardiac MRI performed in patients presenting a first épisode of STEMI, we established athreshold value of troponin that predicts thé occurrence of no-reflow.- Lastly, using speckle-tracking analysis, we demonstrated impaired systolic right ventricular function inpatients with intermediate to high risk pulmonary embolism (PE), evaluated by altérations in longitudinalstrain values at thé level of thé right ventricle, compared to a control group of patients with low risk PE.

Introdução: O tromboembolismo é uma grave complicação da fibrilação atrial (FA), particularmente em pacientes que vão se submeter à cardioversão, química ou elétrica. Para reduzir esse risco, os pacientes submetem-se à anticoagulação clássica, que vem sendo praticada há várias décadas. Apesar desta abordagem, em pacientes plenamente anticoagulados, não se conhece a prevalência de trombo ou contraste espontâneo no átrio esquerdo (AE). Por essa razão, alguns autores sugerem a realização do ecotransesofágico (ECOTEE) para confirmar o sucesso do tratamento e reduzir o risco de complicações tromboembólicas após a reversão. Os objetivos deste estudo foram: a) avaliar a prevalência de trombos e contraste espontâneo ao ECOTEE em pacientes que vão ser submetidos à cardioversão sob regime de anticoagulação plena; b) avaliar a incidência de tromboembolismo até 30 dias após o procedimento; c) avaliar a influência das variáveis clínicas (doenças associadas) e do ECOTEE (tamanho e volume indexado do AE, fração de ejeção ventricular; velocidade de fluxo no apêndice atrial esquerdo), além do escore CHA2DS2VASc e níveis de pró-BNP plasmático sobre a formação de trombo/contraste espontâneo. Métodos: Foram incluídos 85 pacientes (62 homens; média de idade 61±12 anos) com FA não valvar com indicação para cardioversão. Todos receberam varfarina com controle da taxa de INR. Quando se considerava o paciente plenamente anticoagulado (INR ente 2 e 3 por três semanas consecutivas), era prescrito um fármaco antiarrítmico (propafenona, sotalol ou amiodarona) cuja escolha se baseou em critérios clínicos. Na ausência de normalização do ritmo, eram encaminhados para cardioversão elétrica (CVE). No dia da CVE, os pacientes submetiam-se ao ECOTEE cujo resultado só era conhecido no dia seguinte após a cardioversão. Os pacientes recebiam alta com anticoagulante e retornavam ao ambulatório após 30 dias quando realizavam outro ECOTEE. Resultados: Todos os pacientes foram cardiovertidos com INR na faixa terapêutica (2,9±0,7). A reversão com fármacos ocorreu em 9/85 pacientes (10,6%); 67/76 pacientes submeteram-se à CVE e, destes, 58/67 (86%) reverteram ao ritmo sinusal. O ECOTEE antes da CVE evidenciou trombo no AE em 8/85 pacientes (9,4%) e contraste espontâneo em 36/85 pacientes (42,3%). Nenhuma variável clínica, escore CHA2DS2VASc, níveis plasmáticos de pró-BNP ou variáveis ecocardiográficas identificou pacientes com maior probabilidade de apresentar trombo/contraste espontâneo no AE. Após 30 dias, houve normalização das variáveis do ECOTEE. Em 5/8 (62,5%) pacientes, os trombos desapareceram e surgiu em outros dois pacientes (2,3%). O contraste espontâneo desapareceu em 24/38 (63%) pacientes. Não houve registro de nenhum caso de tromboembolismo sistêmico em 30 dias. A taxa de recorrência de FA foi de 21%. Conclusões: a) trombo atrial/contraste espontâneo foi detectado em 9,4% da população e nenhuma variável clínica ou ecocardiográfica identificou pacientes de risco; b) houve melhora das variáveis do ECOTEE após a reversão ao ritmo sinusal; d) o sucesso global da cardioversão foi de 88% e a taxa de recorrência de FA de 21% em 30 dias; c) não houve registro de tromboembolismo sistêmico em 30 dias, em ritmo sinusal ou em FA. / Introduction: Thromboembolism is a serious complication of atrial fibrillation (AF), particularly in patients who will undergo chemical or electrical cardioversion. To reduce this risk patients receive classic anticoagulant therapy, which has been practiced for several decades. Despite this approach, it is not known the prevalence of thrombus or spontaneous contrast in the left atrium (LA) in patients fully anticoagulated. For this reason, some authors have recommended the transesophageal echocardiogram (TEECHO) to reduce the risk of thromboembolic complications after cardioversion. The objectives of this study were: a) to evaluate the prevalence of thrombus and spontaneous contrast by TEECHO in patients about to undergo cardioversion under full anticoagulation regime; b) evaluate the incidence of thromboembolism within 30 days after the procedure; c) evaluate the influence of clinical variables (associated diseases) and TEECHO parameters (LA size and LA indexed volume, ventricular ejection fraction, flow velocity in the left atrial appendage), CHA2DS2VASc score and plasma pro-BNP levels on thrombus/spontaneous contrast formation. Methods: We included 85 patients (62 men; mean age 61 ± 12 years) with non-valvular AF referred for cardioversion. All received warfarin with INR control. When considering the patient fully anticoagulated (INR in the range of 2 to 3 for three weeks) it was prescribed an anti-arrhythmic drug (propafenone, sotalol or amiodarone) whose choice was based on clinical criteria. In the absence of normal rhythm, patients were referred for electrical cardioversion (ECV). On the day of ECV, all patients were submitted to the ECOTEE whose result was known only the next day after cardioversion. The patients were discharged with anticoagulant and returned to the clinic after 30 days when another ECOTEE was performed. Results: All patients were cardioverted with INR in the therapeutic range (2.9±0.7). Sinus rhythm was restored with drugs in 9/85 patients (10.6%); 67/76 patients underwent ECV and 58/67 (86%) reverted to sinus rhythm. The TEECHO before cardioversion showed a thrombus in LA in 8/85 patients (9.4%) and spontaneous contrast in 36/85 patients (42.3%). No clinical variable, CHA2DS2VASc score, pro-BNP plasma levels or echocardiography variables identified patients with an increased likelihood of thrombus/spontaneous contrast in LA. After 30 days, there was normalization of TEECHO variables. In 5/8 (62.5%) patients thrombi disappeared and appeared in two patients (2.3%). Spontaneous contrast disappeared in 24/38 (63%) patients. There were no reports of any case of systemic thromboembolism in 30 days. The AF recurrence rate was 21%. Conclusions: a) LA thrombus/ spontaneous contrast were detected in 9.4% of the population and no clinical or echocardiography variable identified patients at risk; b) there was an improvement of TEECHO variables after reversion to sinus rhythm; d) the overall success of cardioversion was 88% and the AF recurrence rate was 21% in 30 days; c) there was no systemic thromboembolism in 30 days, in patients in sinus rhythm or AF.

Pour ce travail de thèse, nous avons réalisé cinq études originales en utilisant trois technologies d'imageries cardiovasculaires non-invasives.-Nous avons démontré, à partir d'une étude ex-vivo sur des artères coronaires humaines, que le scanner64 détecteurs ne permettait pas de caractériser précisément les différents composants des plaques. Ladistinction des plaques fibreuses et des plaques lipidiques est en effet impossible. Par ailleurs, notretravail a montré que l'IVUS ne devait pas servir d'imagerie de référence lors des études sur la plaque carcet examen présente lui aussi de nombreuses imprécisions.-Notre travail sur la thrombo-aspiration rapporte un effet très significatif de l'extraction effective dethrombus lors des thrombo-aspirations à la phase aiguë des STEMI, avec une réduction de la taille du no-reflow et de l'infarctus, évaluées en IRM ; une thrombo-aspiration positive représentant par ailleurs dansnotre travail, un critère indépendamment lié à la taille finale de l'infarctus. L'extraction effective dethrombus pourrait être considéré, en salle de cathétérisme, comme un critère de jugement de l'efficacitéde la thrombo-aspiration.-Notre étude sur les syndomes coronaires à coronaires angiographiquement normales a confirmé l'intérêtde l'IRM dans le bilan étiologique de cette présentation clinique, permettant un diagnostic étiologiquedans 2/3 des cas. Par ailleurs, nous avons observé une excellente évolution pour le tiers des patients chezqui l'IRM ne décèle pas d'anomalie myocardique. Des études d'une plus grande envergure serontnécessaires afin de confirmer nos résultats.-A partir d'IRM cardiaque réalisées chez des patients ayant présenté un premier épisode de STEMI, nousavons pu déterminer une valuer seuil de troponine prédictive de la survenue d'un no-reflow.-Enfin, à partir d'analyses en Speckle Tracking, nous avons mis en évidence une dysfonction systolique VD,objectivée par une altération des valeurs de Strain longitudinal VD, chez les patients présentant une EPgrave ou de gravité intermédiaire, comparativement à un groupe de patients avec une EP non grave. / In this doctoral thesis, we report on five original studies that use three différent non-invasive cardiovascular imaging techniques:- In an ex vivo study of human coronary arteries, we show that 64-slice computed tomography (CT) scan isnot capable of distinguishing between différent components of plaques. Indeed, it is impossible todifferentiate between fibrous and lipid plaques. Our study also showed that intravascular ultrasound(IVUS) should not be used as thé référence method in studies of plaque composition, since this techniquealso suffers from numerous limitations.- Our study of thé efficacy of thrombo-aspiration showed a significant benefit with effective extraction ofthrombus during thrombo-aspiration at thé acute phase of ST élévation myocardial infarction (STEMI),notably with a réduction of thé extent of no-reflow and of infarct size as evaluated by magnetic résonanceimaging (MRI). Productive thrombo-aspiration was shown in our study to be an independent predictor offinal infarct size. Effective extraction of thrombotic material could be considered in thé cathlab as acriterion for evaluating thé success of thé thrombo-aspiration procédure.- Our study of acute coronary syndromes with normal coronary arteries confirmed thé utility of MRI inestablishing thé etiology of this clinical présentation, and made it possible to establish an etiologicaldiagnosis in two-thirds of patients. We also observed excellent outcomes in thé third of patients in whomMRI did not find any myocardial anomalies. Larger studies are warranted to confirm thèse findings.- Based on cardiac MRI performed in patients presenting a first épisode of STEMI, we established athreshold value of troponin that predicts thé occurrence of no-reflow.- Lastly, using speckle-tracking analysis, we demonstrated impaired systolic right ventricular function inpatients with intermediate to high risk pulmonary embolism (PE), evaluated by altérations in longitudinalstrain values at thé level of thé right ventricle, compared to a control group of patients with low risk PE.

Le rôle du fibrinogène dans les coagulopathies par hémorragie a fait récemment l'objet de travaux importants, la plupart hors du champ obstétrical. L'adaptation de la coagulation et du fibrinogène au cours de la grossesse est méconnue même si sa mise en jeu paraît indispensable à l'hémostase utérine lors de la délivrance. Nous avons donc étudié les modifications gestationnelles du fibrinogène et analysé leurs impacts sur la coagulation et l'hémorragie de la délivrance (HDD). Nous avons montré que le fibrinogène augmentait progressivement pendant la grossesse pour atteindre [3,5-6,5 g/L] (5ème-95ème p.) au 3ème trimestre. L'étude en thromboélastométrie (TEM) a révélé une élévation progressive du "potentiel coagulant" et de la fermeté du caillot chez la femme enceinte. Nous avons ensuite analysé le lien entre le taux initial de fibrinogène lors d'une HDD et le risque d'aggravation (Etude PITHAGORE 6). Le taux de fibrinogène était le meilleur marqueur du risque d'évolution grave. Des seuils de fibrinogène inférieurs à 2 et 3 g/L étaient associés à un risque accru d'aggravation par rapport aux femmes avec un taux > 3 g/L (respectivement OR=11,99 ; IC95% [2,56-56,06] et OR=1.90; IC95% [1,16-3,09]. Enfin l'étude en TEM a montré que les paramètres précoces CA5- et CA15-FIBTEM étaient étroitement corrélés aux taux de fibrinogène lors des HDD permettant l'optimisation du monitorage de la coagulation. Nos résultats nous conduisent à proposer deux scores de coagulopathie obstétricale prenant en compte les spécificités de la grossesse. Des essais seront nécessaires pour valider la pertinence de ces scores et pour évaluer le bénéfice de la compensation précoce en fibrinogène dans les HDD / The role of fibrinogen in haemorrhage-induced coagulopathies has recently been the subject of important work, most of it outside the field of obstetrics. The changes in coagulation and fibrinogen during pregnancy are poorly understood, even though its involvement is essential for uterine haemostasis during the afterbirth. We thus studied the course of fibrinogen levels during pregnancy and analysed their effects on coagulation and postpartum (third-stage) haemorrhage (PPH). We showed that fibrinogen increases progressively during pregnancy, reaching [3.5-6.5 g/L] (5th-95th p.) during the 3rd trimester. The thromboelastometry (TEM) study revealed a progressive increase in the coagulant potential and firmness of clots in pregnant women. We then analysed the association between the initial fibrinogen level during PPH and the risk of aggravation (in the PITHAGORE 6 study). A woman's fibrinogen level was the best marker of the risk that her condition would worsen. Thresholds below 2 and 3 g/L were associated with higher risks of aggravation than in women with fibrinogen concentrations >3g/L (respectively OR=11.99 ; 95% CI [2.56-56.06] and OR=1.90; 95% CI [1.16-3.09]. Finally the TEM study showed that FIBTEM assessment of the early indicators, clot amplitude at 5 and 15 minutes (CA5 and CA15), was closely correlated with fibrinogen levels during PPH and thus helped to optimise coagulation monitoring. Our results lead us to suggest two obstetric coagulopathy scores that take the specificities of pregnancy into account. Trials will be necessary to validate their relevance and to assess the benefits of early fibrinogen replacement in PPH

Procoagulant extracellular vesicles (EV) and platelet activation have been associated with gestational vascular complications. EV-induced platelet-mediated placental inflammasome activation has been shown to cause preeclampsia-like symptoms in mice. However, the effect of EV-mediated placental thrombo-inflammation on trophoblast differentiation remains unknown. Here, we identify that the EV-induced thrombo-inflammatory pathway modulates trophoblast morphology and differentiation. EVs and platelets reduce syncytiotrophoblast differentiation while increasing giant trophoblast and spongiotrophoblast including the glycogen-rich cells. These effects are plateletdependent and mediated by the NLRP3 inflammasome. In humans, inflammasome activation was negatively correlated with trophoblast differentiation marker GCM1 and positively correlated with blood pressure. These data identify a crucial role of EV-induced placental thrombo-inflammation on altering trophoblast differentiation and suggest platelet activation or inflammasome activation as a therapeutic target in order to achieve successful placentation.

La Maladie Thrombo-Embolique Veineuse (MTEV) est une maladie dont les facteurs de risque sont à la fois environnementaux et génétiques. Les facteurs de risque génétiques bien établis sont les déficits en anti-thrombine, en protéine S, en protéine C, la mutation du Facteur V de Leiden (FVL), la mutation du Facteur (F) II G20210A, ainsi que le gène ABO dont les allèles A1 et B augmentent le risque de MTEV par rapport aux allèles A2 et O. Alors qu’une part importante de l’héritabilité de la MTEV reste inexpliquée, les études contemporaines se heurtent à un manque de puissance pour découvrir de nouveaux facteurs génétiques dont les effets sont de plus en plus faibles. En vue d’augmenter la puissance de détection de nouveaux gènes de susceptibilité à la MTEV, j’ai recherché les déterminismes génétiques de deux de ses phénotypes intermédiaires : les taux d’activité plasmatique du FVIII et les taux d’antigénémie de sa protéine de transport, le Facteur de von Willebrand (vWF). Dans un premier temps, j’ai réalisé une analyse de liaison des taux de FVIII et de vWF à partir d’un échantillon de cinq grandes familles franco-canadiennes (totalisant 255 personnes) recrutées via un cas de MTEV avec mutation FVL. Quatre régions liées aux taux de FVIII et/ou vWF ont été identifiées. L’une de ces régions correspondait au locus du gène ABO déjà connu pour influencer les taux de FVIII et vWF. La recherche de gènes candidats au sein des autres signaux de liaison s’est effectuée par l’étude in silico d’une analyse d’association pangénomique de la MTEV incluant 419 cas et 1228 témoins. Deux gènes candidats ont été identifiés : STAB2 et BAI3. J’ai ensuite réalisé des études d’associations de cinq polymorphismes de BAI3. L’un d’entre eux était d’une part associé à une élévation des taux de vWF (résultat obtenu dans un échantillon de 108 familles nucléaires en bonne santé et reproduit dans un échantillon de 916 patients non apparentés atteints de MTEV), et d’autre part associé au risque de survenue de MTEV parmi les sujets non porteurs de mutations FVL et FII de deux échantillons cas-témoins (respectivement 916 cas et 801 témoins, et 250 cas et 607 témoins). Quant à STAB2, durant le courant de ma thèse, deux de ces polymorphismes ont été décrits comme associés aux taux de FVIII et vWF au cours d’une vaste étude d’association pangénomique (GWAS) menée par le consortium CHARGE rassemblant 23 600 personnes. Dans un second temps, j’ai réalisé une méta-analyse de trois GWAS des taux de FVIII et vWF. Ces analyses avaient été conduites avec l’échantillon des cinq grandes familles franco-canadiennes et deux échantillons de 972 et 570 patients atteints de MTEV. Elles étaient ajustées sur les polymorphismes du gène ABO permettant de distinguer les allèles A1, A2, B et O, dans l’optique d’augmenter la puissance des analyses en diminuant la variance résiduelle des phénotypes. Aucun polymorphisme n’était associé ni aux taux de vWF ni à ceux de FVIII après prise en compte de la correction de Bonferroni pour tests multiples (p<10-7). Cependant, parmi les onze gènes qui présentaient des polymorphismes associés aux taux de vWF ou de FVIII avec une significativité p<10-5, de manière intéressante se trouvait STAB2. Cette étude a de plus permis de confirmer les associations nouvellement découvertes de polymorphismes situés dans les gènes VWF, STXBP5 et STX2. / The Venous Thromboembolism (VTE) risk factors are environmental and genetic. The well established risk factors are anti-thrombin, protein C, protein S deficiency, Factor V Leiden and factor II mutation and ABO gene, with A1 and B allele increasing the risk of VTE. While an important part of VTE heritability remains unexplained, contemporary studies fail to discover new susceptibility genes with weaker effects. In order to increase the discovery power, I searched for genetic geterminism of two intermediary phenotypes of VTE : Factor VIII plasmatic activity (FVIII) and von Willebrand factor antigenemia (vWF)First, I performed a linkage study of FVIII and vWF from a sample of 5 large pedigrees (N=255). Four loci have been identified. One included ABO gene. I searched for candidate genes located in the others loci by studying in silico results from o Genome Wide Association Study (GWAS) of the VTE including 419 cases and and 1228 controls. témoins. Two candidate genes were identified : STAB2 et BAI3. Then I performed association studies of five SNPs in BAI3 with FVIII and vWF. One of them was associated to vWF (in a sample of 108 nuclear families and 916 VTE patients), and associated to VTE in two case-controls samples (respectively 916 cases and 801 controls, and 250 cases et 607 controls).Second, I performed a meta-analysis of three GWAS of FVIII and vWF from the same 5 pedigrees and two samples of VTE (N=972 and 570) adjusted on ABO blood group. No polymorphisms were significant after Bonferoni correction (p<10-7). Nevertheless, among 11 genes carrying polymorphisms with a p<10-5, interestingly was STAB2. Futhermore, this study allowed to confirm newly discoverd association with VWF, STXBP5 et STX2.