7-year results of cell therapy in patients with severe ischemic cardiomyopathy.

BACKGROUND: Intracoronary infusion of autologous bone marrow cells (CTX) has been shown to improve myocardial function in post infarct patients and in patients with chronic ischemic cardiomyopathy. Long term results of CTX are unknown. METHODS AND RESULTS: In this small pilot study, eleven patients with chronic ischemic cardiomyopathy and ejection fraction (EF) of 19 +/- 1% were treated with CTX and followed for 7 years. Four patients died during follow-up, all because of progressive heart failure. All patients received an implantable cardioverter defibrillator (ICD) during the course of the study but only 1 patients developed ventricular tachycardia after CTX. One patient received resynchronization therapy. The overall clinical benefit of CTX was modest (NYHA 3.0 +/- 0.1 pre and 2.5 +/- 0.2 post CTX, p= 0.06). CTX was not associated with reverse remodeling. However, left ventricular EF (19 +/- 1% pre and 18 +/- 6% post) and left ventricular end-diastolic volumes (289 +/- 71 ml pre and 294 +/- 123 ml post) remained remarkably stable over 7-year follow-up in the survivors of this very sick population. CONCLUSIONS: During 7-year follow-up, CTX was associated with stabilization of EF and ventricular volumes but without significant clinical benefit or evidence of reverse remodeling.

Does a flat panel detector reduce the patient radiation dose in interventional cardiology?

An internal audit has been performed to evaluate the patient radiation dose in the clinical use of X-ray cardiac flat panel detector (FPD) systems. Fluoroscopy and image acquisition (cine mode) programs are optimised for low-dose settings. The diagnostic and therapeutic interventional cardiac procedures are performed at 6 pulse s(-1) for fluoroscopy and 15 frames s(-1) for image acquisition. The FPD entrance dose is configured for 29 nGy pulse(-1) in the fluoroscopy mode and 0.10 microGy frame(-1) in the cine mode. From the data collected, the following local reference levels for coronary angiography and angioplasty have been obtained: kerma-area products 23 and 44 Gy cm(2), cumulative doses 376 and 776 mGy, fluoroscopy times 5 and 15.5 min and cine images 617 and 1163 images.

[Measurement of ventricular twist by 2D speckle tracking early after acute myocardial infarction. Comparison between anterior and inferior infarction]. / Mesure du twist ventriculaire par 2D speckle tracking dans la phase précoce de l'infarctus du myocarde. Comparaison entre l'infarctus antérieur, l'infarctus inférieur et un groupe contrôle.

INTRODUCTION: Left Ventricular twist (LV twist) is defined as the apical counter-clockwise rotation relative to the clockwise basal rotation. It has been shown that LV twist decreases after myocardial infarction (MI) and that it is well correlated with left ventricular ejection fraction. Most studies have only evaluated anterior wall MI. The aim of our study was to determine whether LV twist is dependent on the infarct territory (anterior vs. inferior) and whether there is a correlation between LV twist and matrix metalloproteinase-9, a marker of LV remodeling. METHODS: We measured LV twist using echocardiography with 2D speckle tracking in patients with acute MI and in a control group. RESULTS: We evaluated 27 controls and 35 patients with acute MI, 15 with anterior wall and 20 with inferior wall MI. LV twist was significantly decreased after MI, compared to the control group (10.93 +/- 2.05 vs 15.5 +/- 2.29; p = 0.003). There was no difference between anterior and inferior MI. LV rotation was decreased in the infarct area. We did not observe a correlation between LV twist and MMP-9, or creatine phosphokinase. CONCLUSION: With this study we confirm that LV twist decreases after acute MI. Moreover, we show that LV apical rotation is mostly decreased after large anterior MI. As apical rotation is important for ejection and aspiration (untwisting), this could be a possible mechanism of LV dysfunction after MI.

Changing from image intensifier to flat detector technology for interventional cardiology procedures: a practical point of view.

A small-scale internal audit has been used to evaluate the impact of the use of a dynamic flat panel detector in the clinical routine in the National Interventional Cardiology Centre in Luxembourg. The parameters tested during commissioning and constancy control of an X-ray system, the introduction of new clinical protocols, the patient and the personal staff dosimetry were considered. The technical parameters tested by the hospital physicist stay the same as for the image intensifier. No innovative protocols have been adopted due to the existence of the flat panel detector. A reduction in dose was noted after the installation of a flat detector, due mostly to the continuing education of the interventional cardiologists as well as the initial calibration of the radiological system. The understanding of the X-ray system and its possibilities is vital for the optimisation of clinical procedures in patient and staff exposure.

Dynamic flat panel detector versus image intensifier in cardiac imaging: dose and image quality.

The practical aspects of the dosimetric and imaging performance of a digital x-ray system for cardiology procedures were evaluated. The system was configured with an image intensifier (II) and later upgraded to a dynamic flat panel detector (FD). Entrance surface air kerma (ESAK) to phantoms of 16, 20, 24 and 28 cm of polymethyl methacrylate (PMMA) and the image quality of a test object were measured. Images were evaluated directly on the monitor and with numerical methods (noise and signal-to-noise ratio). Information contained in the DICOM header for dosimetry audit purposes was also tested. ESAK values per frame (or kerma rate) for the most commonly used cine and fluoroscopy modes for different PMMA thicknesses and for field sizes of 17 and 23 cm for II, and 20 and 25 cm for FD, produced similar results in the evaluated system with both technologies, ranging between 19 and 589 microGy/frame (cine) and 5 and 95 mGy min(-1) (fluoroscopy). Image quality for these dose settings was better for the FD version. The 'study dosimetric report' is comprehensive, and its numerical content is sufficiently accurate. There is potential in the future to set those systems with dynamic FD to lower doses than are possible in the current II versions, especially for digital cine runs, or to benefit from improved image quality.

[Amaurosis fugax of cardiac origin]. / Amaurose fugace d'origine cardiaque.

We present the case of a 49 year old woman who was admitted to the emergency department for dyspnoea, transient amaurosis and limbs oedema. During hospitalisation a full workup revealed multisystemic thrombosis and dilated cardiomyopathy in relation with viral myocarditis due to Coxackie B infection. Diagnosis and treatment will be discussed in light of the litterature.

Objective effects of a 6 months' endurance and strength training program in outpatients with congestive heart failure.

PURPOSE: The aim of this study was to assess the feasibility and the effects of a long-term training program with endurance and strength elements for patients with advanced congestive heart failure (CHF). METHODS: We studied 14 patients, mean age 57 yr, mean NYHA class 2.7, mean LVEF 29%, and mean VO2max 17.2 mL x kg(-1) x min(-1). They underwent a 6 months' outpatient "in-hospital" training program (80 sessions). After an introduction period the program was subdivided into four cycles in which endurance and strength were revalued and progressively increased. Endurance was measured by spiro-ergometric exercise testing with concomitant lactate determination, while strength was measured on an isokinetic dynamometer. RESULTS: The compliance ratio was 89% and there were no major problems during training. NYHA class improved from a mean of 2.7 to 1.5 (P = 0.0001), working capacity from 83 to 100 W (P = 0.001), VO2 from 16.7 to 18.4 mL x kg(-1) x min(-1) (P = 0.02), and maximal exercise lactate from 4.1 to 5.2 mmol x L(-1) (P = 0.01). At isokinetic testing we found a significant 18% increase in muscular endurance of knee flexors (P = 0.008) and 25% increase of knee extensors (P = 0.007). The increase of peak torque, total work, and average power reached statistical significance only for the knee extensors. CONCLUSION: This pilot study showed that progressively adapted global strength training in association with traditional endurance training is feasible for selected patients with CHF. Additional larger studies should be done to test the effects, the safety, and the composition of such supervised "in-hospital" training programs.

["Malignant Kent" arrhythmia, clinical case and literature review]. / Le "Kent Malin", cas cliniques et revue de la littérature.

The Wolff-Parkinson-White syndrome is considered as benign disorder. However, some electrophysiological properties of the accessory pathway may lead to a life-threatening affection due to rapid anterograde conduction over the accessory pathway. We report on four young patients admitted to our hospital in a haemodynamic shock. We strongly recommend to perform to all patients with preexcitation or suspected to have one, a 24 hour ambulatory ECG, an exercise stress testing and if necessary a transoesophageal electrophysiological study or an invasive electrophysiological study in order to detect patients at high risk of sudden death.

[Treatment of massive arterial thrombosis caused by thrombocytopenia induced by heparin with local thrombolysis]. / Traitement par thrombolyse locale d'une thrombose artérielle massive par thrombopénie induite par l'héparine.

The authors report the case of a patient treated by subcutaneous injection of calcium heparin after deep vein thrombosis with floating thrombus and pulmonary embolism. She was readmitted to hospital after 16 days' treatment because of a massive aorto-iliac thrombosis due to heparin-induced thrombocytopenia (platelet count = 29.000). This thrombosis was treated by local injection of Urokinase (total dose = 7.425.000 U) over 93 hours without any major complications. The aorto-iliac circulation was completely restored to normal after treatment. Thrombotic complications secondary to immuno-allergic heparin-induced thrombocytopenia are relatively common because of the widespread use of heparin. From the therapeutic point of view, it is imperative to stop the heparin, which makes surgery very difficult, and the platelet-fibrin composition of these thrombi suggests that local thrombolysis with Urokinase is the treatment of choice in this syndrome.

[Exercise test after myocardial infarct. Correlations with data of coronary angiography and ventriculography]. / L'épreuve d'effort après infarctus du myocarde. Corrélations avec les données de l'angiographie coronaire et de la ventriculographie.

The authors have studied the exercise test carried out at least three months (3-6 months: 52 cases; greater than 6 months: 48 cases) after myocardial infarction in the anterior position (50 cases), in the "inferior" position (42 cases), and of a diffuse type (8 cases), in patients who were taking no treatment which might interfere with interpretation of the test. For the anterior infarctions there was a good correlation between ST elevation (J max greater than or equal to 1 mm, or better than the sun of the J greater than or equal to 2 mm) and the presence of severe involvement of the left ventricle. A depressed ST segment beyond the area of necrosis corresponds to a stenosis greater than or equal to 75 p. 100 in 36 p. 100 of cases. In inferior infarctions, the correlation between ST elevation and left ventricular involvement is also specific but less sensitive. ST depression outside the area of necrosis corresponds to a stenosis greater than or equal to 75 p. 100 in 66 p. 100 of cases; it is then lateral, but may extend as far as V2. They also indicate a mirror image, especially when the depressed area slopes upwards, and is localised in V2-V3. The other changes which were found have no practical application.