Non-fistulous idiopathic coronary artery aneurysm. Report of three cases and literature review.

Non-fistulous idiopathic aneurysm of coronary arteries is a rare anomaly, often localized on the left coronary trunk and diagnosed in young patients following myocardial ischemia. Diagnosis before death is only possible since advent of selective coronary angiography. Idiopathic etiology can be inferred when the aneurysm is found in the absence of atherosclerosis and calcification of other arteries and if there is an absence of risk factors for atherosclerosis. Inflammatory etiology is excluded by a negative clinical history and lack of histologic inflammatory features. However, cumulating observations suggest that angeitis or other acquired process cannot definitely be disapproved. Advances in coronary artery surgery have permitted resection of aneurysms and grafting of involved coronary artery since the early seventies. Three cases of non-fistulous idiopathic aneurysms of coronary arteries are presented. The literature has been reviewed and the clinical, anatomic, angiographic findings and management are discussed.

Exercise and heart transplantation. A review.

Results of heart transplantation as therapy for end-stage cardiac diseases are encouraging not only because of actuarial survival curves but also because of the recovered quality of life for the heart transplant recipient. Although heart transplantation drastically improves the physical capacity of the patients, heart recipients still have a reduced maximal aerobic capacity compared to healthy people. Altered resting and exercise haemodynamics, due to cardiac denervation, are a common finding after orthotopic heart transplantation: increases in heart rate and stroke volume at exercise are first linked with the augmented venous return and later with the increased plasmatic nor-adrenaline level. Maximal heart rate and stroke volume are both reduced when compared to innervated heart. Reduced cardiac output response to exercise therefore results in early anaerobic metabolism, acidosis, hyperventilation and diminished physical capacity. In spite of an altered ventilatory adaptation to exercise, characterised by hyperpnoea in most transplant patients, ventilation is not the limiting factor for exercise in heart recipients without associated obstructive pulmonary disease. Endurance training restores lean tissue, decreases submaximal minute ventilation, increases peak work output, maximal ventilation and peak heart rate. Guidelines for prescribing exercise are not yet standardised due to the limited number of studies on a sufficient cohort of heart recipients. Nevertheless, recommendations similar to those used for persons with coronary heart disease, with modifications due to the denervated heart, seem to be used. The cardiocirculatory and pulmonary capacity of heart transplant recipients allow them to undertake endurance sports activities such as walking, jogging, cycling and swimming, and these should be encouraged.

[MRI of acute myocardial infarction with injection of Gd-DOTA (15 patients)]. / IRM de l'infarctus myocardique aigu avec injection de Gd-DOTA (quinze patients).

We studied 15 patients 4 to 8 days after myocardial infarction by using ECG gated MR before and after administration of 0.2 mmol/kg Gd-DOTA. The diagnosis in each patient was confirmed by electrocardiographic criteria, elevated levels of fractionated creatine kinase (CK) isoenzyme, thallium scintigraphy, ventriculography and coronarography. T1-weighted, spin-echo images, were obtained before and immediately after injection of Gd-DOTA and were repeated 15 min later. The site of infarction was visualised in 10 patients as an area of high signal intensity after the injection of Gd-DOTA. Contrast between normal and infarcted myocardium was greatest 15 min after injection. Three patients were excluded because of failure to acquire adequate MR studies. In 2 other patients, the infarct were not detected. Before injection of Gd-DOTA, only 2 infarcts were detected. These results suggest that Gd-DOTA can improve MR visualisation and detection of acute myocardial infarction.

Hemodynamic effects of SIN-1 in acute left heart failure.

To assess the hemodynamic effects of SIN-1, the active metabolite of the venodilator molsidomine, after acute as well as chronic intravenous administration, ten patients with exacerbation of chronic heart failure were studied. After a mean bolus dose of 2 mg of SIN-1, mean right atrial pressure (MRAP), mean pulmonary artery pressure (MPAP), and pulmonary capillary wedge pressure (PCAP) decreased significantly up to the 60th minute; pulmonary vascular resistance (PVR) decreased significantly up to the 30th minute, while cardiac index (CI) and systemic vascular resistance (SVR) remained unchanged. During a 24-hour continuous infusion of SIN-1, MRAP, MPAP, and PCAP decreased significantly, while CI, PVR, and SVR remained largely unaltered. No dose adjustment was required to maintain the hemodynamic effects over 24 hours. The absence of noteworthy side effects and tolerance during this prolonged administration indicate that SIN-1 is a potentially useful drug in the management of patients admitted with exacerbation of heart failure.

[Myocardial infarction: secondary prevention with betablockers]. / Infarctus myocardique: prévention secondaire par bêtabloquants.

Invasive or pharmacological treatments at the onset of a myocardial infarction or a few days later, make it possible to decrease the mortality and morbidity through prevention of the ventricular fibrillation, decrease of the size of the infarction, inhibition of platelet aggregation and other mechanisms. Early administration of betablockers results in a significant decrease of the mortality at one year, in patients undergoing an active treatment. Later treatment also results in decreased coronary mortality and morbidity. This article intends to review the most recent information concerning the potential preventive value of beta-blockers after myocardial infarction.

Secondary prevention after myocardial infarction: effects of beta blocking agents and calcium antagonists.

Therapeutic interventions in patients with myocardial infarction, whether during the first hours after coronary occlusion or several days later, aim to reduce mortality and morbidity by several mechanisms: Prevention of fatal ventricular fibrillation, limitation of infarct size, and inhibition of platelet aggregation are some examples of such mechanisms. Results from early intervention trials with beta blocking agents, particularly from ISIS-I, suggest that 1-year mortality is significantly lower in selected patients randomized to active treatment. Late intervention studies also suggest a significant reduction in coronary mortality and morbidity with beta blockade, particularly when data are pooled. Studies with the calcium channel blockers nifedipine and verapamil were unable to demonstrate any beneficial effects of these drugs on mortality or reinfarction. In this review article, attention will be directed to the most recent information about the preventive value of beta adrenergic blocking drugs and slow calcium channel inhibitors.

Detection of right atrial myxoma by Fourier phase analysis.

The usefulness of radionuclide imaging in the detection of cardiac tumors has been demonstrated previously in left atrial myxomas. We report a case of right sided myxoma successfully diagnosed by radionuclide imaging and evaluated by cine display, Fourier phase analysis and paradox image. These three techniques are now available in many computer programs for gated cardiac blood pool imaging and provide an additional tool for assessing cardiac tumors. Particularly, functional paradox and Fourier phase analysis seem promising tools in the detection of both left and right sided tumors.

Calcium channel blockers cannot prevent pure vasospastic myocardial infarction.

Coronary artery spasm is a recognized cause of myocardial infarction. This report describes a case of myocardial infarction attributed to pure coronary spasm which was halted by a double perfusion with streptokinase and nitroglycerin. Further coronary artery spasm leading to a myocardial infarction could not be avoided several weeks later, although the patient was left on calcium channel blocker therapy. The two attacks were not preceded by warning angina pectoris, contrary to accepted belief. The best objective of end-point drug therapy and its assessment in vasospastic angina are discussed.

[Hemodynamic effects of microencapsulated delayed-release nitroglycerin in acute myocardial infarction]. / Effets hémodynamiques de la nitroglycérine microencapsulée à libération prolongée dans l'infarctus aigu du myocarde.

The hemodynamic effects following an oral dose of 19.5 mg of nitroglycerin microencapsulated to give prolonged release have been studied in 10 patients during the 48 hours which followed the establishment of a myocardial infarct complicated by moderate left cardiac insufficiency. The right auricular pressure and the pulmonary capillary pressure diminished significantly 20 minutes after the dose; 4 hours later the persistence of these effects is significant. A transient diminution of the systolic arterial pressure was observed initially (p less than 0.05). We observed that the cardiac index tends to increase although the increase did not attain the threshold of significance. No difference was observed in cardiac frequency, diastolic and mean arterial pressure and in the systemic vascular resistance. We conclude that in the patient presenting an acute myocardial infarct, 19.5 mg of NTG, microencapsulated to give prolonged release, essentially produce a reduction of the preload, with an early onset of action and a hemodynamic efficacy lasting at least 4 hours.

Anomalous origin of an accessory coronary artery from the main pulmonary artery: report of a case with arrhythmia, precordial pain and left heart failure.

Anomalous origin of the coronary arteries from the main pulmonary artery is a rare congenital malformation. While this anomaly rarely produces cardiac symptoms, the more frequently encountered anomalous left coronary artery arising from the main pulmonary artery is poorly tolerated, the majority of patients dying in infancy. This report describes a symptomatic sixty-year old man with anomalous posterior descending coronary artery arising from the pulmonary trunk and details the angiographic findings.

[Immunogenic cardiac amyloidosis. Value of ultrasonography and endomyocardial biopsy]. / Amyloïdose cardiaque immunogénique. Apport de l'échographie et de la biopsie endomyocardique.

The development of one dimensional, and more especially two dimensional, cardiac ultrasonography associated with a safe technique of percutaneous endomyocardial biopsy has radically changed the diagnostic approach to cardiac amyloidosis. Prior to the widespread use of these techniques, the ante-mortem diagnosis was only made in 25 p. cent of patients presenting this form of infiltrating cardiomyopathy. The description of a recent case serves as an introduction to a brief review of cardiac amyloidosis based essentially on the two new diagnostic techniques of cardiac ultrasonography and endomyocardial biopsy.

Clinical and hemodynamic observations on orally administered sulmazol (ARL115BS) in refractory heart failure.

The acute effects of an oral preparation of sulmazol, a recently synthesized cardiotonic agent, were assessed by means of a Swan-Ganz catheter in 10 patients who had advanced heart failure that persisted despite treatment with digitalis, diuretics and nitrates. All patients demonstrated a hemodynamic improvement. Pulmonary wedge pressure decreased significantly 1 h after administration from 26 +/- 2 to 16 +/- 3 mm Hg (mean +/- SEM; 32%; p less than 0.01) and this decrease remained significant at least 6 h after intake. The cardiac index increased from 1.8 +/- 0.1 to 2.4 +/- 0.1 1/min/m2 (33%; p less than 0.01) and remained significant up to 6 h later. Total systemic and pulmonary resistances were also significantly decreased (peak changes 28% and 46%, respectively) up to 6 h later. Heart rate and mean blood pressure were unaffected. Once the duration of action was assessed for each patient, a short-term oral therapy was initiated for 48 h. Hemodynamic measurements performed 24 h and 36 h following the commencement of this chronic therapy showed the sustained hemodynamic improvement. 7 patients were continued on sulmazol therapy for 3 weeks to 6 months. Side effects were nausea and vomiting (which were likely to be dose-related), worsening arrhythmias and a possible rebound phenomenon after withdrawal. Although orally administered sulmazol shows promise as a potentially useful agent in the treatment of advanced heart failure, the safety of this drug remains to be established.