Normal left ventricular volumes and ejection fraction: assessment with quantitative digital cardioangiography.

The aim of this study was to assess the accuracy and precision of a digital angiography system, the General Electric DX system, as compared to conventional left ventricular cineangiography. After a phantom study, sixty patients with normal coronary arteries and normal left ventricles (LV) were studied. The LV contours were manually traced from raw or subtracted digital runs and from the cine films in an independent manner. A regression formula was used to adjust the DX derived data to the cine film results (Vcorrected = 0.693 Vmeasured +8.65 ml). There was an excellent correlation between the two methods in the end-diastolic volume index (r = 0.97, sd = 4.2 ml/m2), the end-systolic volume index (r = 0.95, sd = 2.7 ml/m2), the stroke volume index (r = 0.93, sd = 4.1 ml/m2), and the ejection fraction (r = 0.85, sd = 3.45%). We conclude that manual tracing of LV contours from either raw or subtracted digital images provides reliable and accurate measurement of LV volume and ejection fraction.

Effect of nadroparin, a low-molecular-weight heparin, on clinical and angiographic restenosis after coronary balloon angioplasty: the FACT study. Fraxiparine Angioplastie Coronaire Transluminale.

BACKGROUND: Experimental studies suggest that the antiproliferative effect of heparin after arterial injury is maximized by pretreatment. No previous studies of restenosis have used a pretreatment strategy. We designed this study to determine whether treatment with nadroparin, a low-molecular-weight heparin, started 3 days before the procedure and continued for 3 months, affected angiographic restenosis or clinical outcome after coronary angioplasty. METHODS AND RESULTS: In a prospective multicenter, double-blind, randomized trial, elective coronary angioplasty was performed on 354 patients who were treated with daily subcutaneous nadroparin (0.6 mL of 10,250 anti-Xa IU/mL) or placebo injections started 3 days before angioplasty and continued for 3 months. Angiography was performed just before and immediately after angioplasty and at follow-up. The primary study end point was angiographic restenosis, assessed by quantitative coronary angiography 3 months after balloon angioplasty. Clinical follow-up was continued up to 6 months. Clinical and procedural variables and the occurrence of periprocedural complications did not differ between groups. At angiographic follow-up, the mean minimal lumen diameter and the mean residual stenosis in the nadroparin group (1.37+/-0.66 mm, 51.9+/-21.0%) did not differ from the corresponding values in the control group (1.48+/-0.59 mm, 48.8+/-18.9%). Combined major cardiac-related clinical events (death, myocardial infarction, target lesion revascularization) did not differ between groups (30.3% versus 29.6%). CONCLUSIONS: Pretreatment with the low-molecular-weight heparin nadroparin continued for 3 months after balloon angioplasty had no beneficial effect on angiographic restenosis or on adverse clinical outcomes.

Early versus late coronary stenting following acute myocardial infarction: results of the STENTIM I Study (French Registry of Stenting in Acute Myocardial Infarction).

This study was undertaken to determine the feasibility and safety of coronary stenting in acute myocardial infarction (AMI). In AMI, primary percutaneous transluminal coronary angioplasty (PTCA) is accepted as the preferred method of reperfusion for patients presenting at highly experienced centres. Until recently, however, stenting has been avoided during AMI because of a potential high risk of thrombosis. This prospective observational study carried out in 20 centres and included 648 consecutive patients who underwent PTCA with stent implantation for AMI. Of these 648 patients, 269 (41.5%, Group 1) were dilated early (< 24 hr) after the onset of the symptoms (75% treated by direct PTCA) and 379 (58.5%, Group 2) were dilated between 24 hr and 14 days after AMI. Combined therapy with ticlopidin and aspirin was used after the procedure. Bailout stenting occurred more often in Group 1 than in Group 2 (17% vs. 9.5%)(P < 0.05). Angiographic successful stenting was similar in both groups of patients (96% vs. 97%). During the hospital follow-up period, stent thrombosis occurred in eight patients (3%) in Group 1 and in six patients (1.6%) in Group 2 (NS). There was 14 deaths (5.2%) in Group 1 and 11 deaths (3.9%) in Group 2 (NS). After multivariate analysis bailout stenting was identified as the sole predictor of stent thrombosis (P < 0.0001). Vascular access-site complications occurred in six patients (1%) with no difference between the two groups. This study indicates that patients who receive a coronary stent in AMI can be managed safely with antiplatelet therapy. Randomized studies are needed to determine the precise indication for coronary stenting as an adjunct to primary PTCA.

New report of severe coronary artery disease in an eighteen-year-old girl with pseudoxanthoma elasticum. Case report and review of the literature.

An eighteen-year-old woman with pseudoxanthoma elasticum (PXE) suffered from mild angina pectoris over a ten-year period. Severe triple-vessel disease with mild left ventricular dysfunction was demonstrated on angiography. No revascularization was feasible. Despite a reported high frequency of angina pectoris among patients with PXE, only 10 convincing reports have appeared in the literature. Careful coronary artery evaluation is required in young patients with PXE, even though asymptomatic, because coronary artery disease (CAD) seems to be frequent and because no precise feature can be distinguished between types with or without severe vascular disease. Through very rare reports, surgical revascularization appears feasible and beneficial in a less severe form of CAD in patients with PXE. The risk of premature and severe diffuse CAD in PXE does not seem to be explained only by the combination of increased Lp [a] (or any other risk factor) and PXE.

[Optimization of coronary angiographic views. Qualitative and quantitative evaluation of a new system]. / Optimisation des vues angiographiques coronaires. Evaluation qualitative et quantitative d'une nouvelle fonctionnalité.

A coronary angiographic view is said to be "optimal" when the directing radius of the X-ray beam is perpendicular to the long axis of a stenosis. The object was to fulfill two criteria: 1) the accurate calculation of the spatial orientation of the stenosis to obtain the optimal position, 2) rapid and optimal positioning of the angiographic material with easy rotation around the axis of the stenosis. Two combined solutions were proposed:the Advantx L/C (GE Medical systems) angiocardiographic system with three motorised axes of rotation and a specific software. This software takes into account two longitudinal axes of the stenosis traced by the operator in two conventional incidences and then determines the angles of optimal positioning (accuracy +/-5 degrees). During 97 consecutive coronary angiograms, the software was used in 23 cases (24%) and judged to be useful in 16 cases (70%). In 2 of the 23 cases (8%) the mechanical angles calculated could not be used, the incidences being incompatible with the patient's position. During the angiograms, the best two images of stenosis (one conventional, one optimal) were retained to form a pair of images. Eight observers analysed 37 pairs of images shown side by side. 65% of the images selected from each pair as being the best descriptive appearance of the stenosis came from the optimised system. During quantitative analysis, only the length of stenosis differed statistically between the two modes of acquisition (1.26 +/- 0.36 mm; p = 0.0014). This system is useful during coronary angiography for providing optimal views of stenosis free from any geometric distorsion and without superimposition of adjacent branches.

Can we optimize our angiographic views every time? Qualitative and quantitative evaluation of a new functionality.

RATIONALE AND OBJECTIVES: For determining the optimum angulations of the x-ray beam with respect to the vascular morphology of a given patient, the authors present a solution combining a single-plane angiographic system and a dedicated procedure. METHODS: The clinical evaluation of the vessel profiling acquisitions focuses on qualitative appraisal and quantitative analysis of conventional and optimum projections. RESULTS: The qualitative evaluation demonstrates the pitfall for an operator to discern optimum from conventional projections. The 70% of preferences for vessel profiling bear witness to the constraints imposed occasionally by the optimum angulations, which may be impracticable for various reasons. However, vessel profiling yields lesions inspection at an optimum view, free of geometric foreshortening. Moreover, there is less risk of superimposition with other branches. From a quantitative standpoint, vessel profiling unveils the lesion with a length significantly longer than in conventional view. CONCLUSIONS: Vessel profiling offers a qualitative optimization of angiographic images and more exact quantitative analysis.

[Pericardial constriction caused by epicardial patches of automatic implantable defibrillators. Apropos of 3 cases]. / Constriction péricardique due aux patchs épicardiques des défibrillateurs automatiques implantables. A propos de 3 cas.

The authors report three cases of pericardial constriction secondary to implantation of an automatic defibrillator. In one case, the pericardial constriction occurred 1 year after implantation and was associated with ascending infection of the patch electrodes from the stimulator; the patient died when the patch electrodes were removed, the infection having eroded the left ventricular wall. In the other two cases, signs of constriction appeared 2 years after implantation. In one of these patients, surgery showed a fibrous pericardial reaction deforming the patch electrodes with a favourable outcome when the electrodes were removed. The other patient refused surgery. In the three cases, the diagnosis was confirmed by right heart catheterisation and ventriculography which showed signs of adiastole and severe deformation of the ventricular contours. Pericardial constriction due to patch electrodes is a potentially serious complication of implantable automatic defibrillators, the prevalence of which may be underestimated. The use of endocavitary or extra-pericardial electrodes should avoid this complication.

[Severe pulmonary artery involvement of Takayasu arteritis. 3 cases and review of the literature]. / Formes artérielles pulmonaires graves de l'artérite de Takayasu. trois observations et revue de la littérature.

Three cases of pulmonary arterial disease were identified out of a cohort of 75 cases of Takayasu's disease. In the first case, pulmonary hypertension considered to be idiopathic caused massive haemoptysis and the death of a 48 year old Spanish woman; autopsy revealed characteristic stenoses of the common carotid arteries. In the second case, haemoptysis led to pneumonectomy in a 23 year old West Indian woman with a diagnosis of agenesis of the right pulmonary artery. Disease of the supraaortic vessels occurred several months later and a retrospective diagnosis of Takayasu's disease of the pulmonary artery was made. In the third case, systematic pulmonary angiography in a 41 year old French woman referred for Takayasu's disease of the supraaortic arteries showed severe stenosis of the right pulmonary artery. She developed severe haemoptysis four years later which led to an attempted balloon angioplasty of the right pulmonary artery and embolisation of a branch of the right coronary artery thought to be the cause of the haemoptysis. This was complicated by posterior wall myocardial infarction but the haemoptysis did not recur thereafter. These three cases and a review of the literature show that the pulmonary lesions of Takayasu's disease occur mostly on the main right pulmonary artery but they may be more distal and involve the pulmonary arterioles. A coronaro-broncho-pulmonary collateral circulation may develop distal to the stenosed segments. The main complications are pulmonary hypertension and massive haemoptysis. Surgery is possible in cases of stenosis of the right main pulmonary artery. The potential role of endoluminal angioplasty is discussed.

Cardiovascular effects of the somatostatin analog octreotide in acromegaly.

OBJECTIVE: To determine the cardiovascular effects of the somatostatin analog octreotide in patients with acromegaly. DESIGN: Prospective nonrandomized study. SETTING: Referral-based endocrinology clinic. PATIENTS: Seven patients with active acromegaly, three of whom had refractory congestive heart failure. The other four patients were free of symptoms associated with heart failure. INTERVENTIONS: All patients were treated with octreotide, 100 to 500 micrograms subcutaneously three times daily. The three patients with heart failure continued to receive cardiovascular therapy (angiotensin converting enzyme inhibitors, digitalis, diuretics). MEASUREMENTS AND MAIN RESULTS: During octreotide therapy, patients showed a rapid decrease in growth hormone and insulin-like growth factor 1 (IGF-1): Mean levels (+/- SD) fell from 28.1 +/- 32.7 micrograms/L to 5.2 +/- 8.3 micrograms/L and 740 +/- 126 micrograms/L to 372 +/- 64 micrograms/L, respectively (P less than 0.025). Plasma volume returned to normal and heart rate decreased significantly. In the four patients without heart failure, right-heart catheterization done before and after 3 months of octreotide therapy showed an 18.3% +/- 11% reduction in stroke volume and a return to normal of the cardiac index. The three patients with congestive heart failure, evaluated before and after 40 days and up to 2 years of therapy, showed a dramatic clinical improvement that was associated with an increase in stroke volume (by 24% to 51%). In these patients, the cardiac index remained in the normal range, filling pressures were markedly decreased, and pulmonary wedge pressure returned to normal. This improvement was sustained for up to 3 years in the two patients with heart failure who were receiving long-term treatment. CONCLUSION: The rapid and sustained cardiac improvement seen in our patients shows that octreotide therapy for patients with acromegaly may be highly beneficial, even in those patients with advanced cardiac failure.

[Massive delayed-action verapamil poisoning]. / Intoxication massive par le vérapamil à libération prolongée.

An 18-year old woman developed cardiogenic shock after ingestion of 16.8 g of a sustained release form of verapamil. Severe left ventricular diastolic dysfunction was demonstrated. For the first time muscular involvement was observed with myalgia and elevation of the MM isoenzyme of creatinine kinase. The efficacy isoproterenol and the need for prolonged treatment are emphasised.

[An unusual complication of percutaneous aortic valvuloplasty: rupture of an aberrant mitral chorda]. / Une complication exceptionnelle de la valvuloplastie aortique percutanée: la rupture d'un cordage mitral aberrant.

The case of a 77-year old woman who died of refractory pulmonary oedema 36 hours after percutaneous valvuloplasty for tight calcified aortic valve stenosis is reported. Post-mortem examination showed satisfactory opening of the aortic orifice but also rupture of an aberrant chorda which crossed the outflow tract below the aortic sigmoid valves, between the mitral valve and the interventricular septum. This case suggests that before all aortic valvuloplasties the absence of aberrant chorda or suspicious subaortic acceleration should be confirmed by Doppler echocardiography; moreover, during the procedure the balloon should not be inserted too deeply into the left ventricle.

[Coronary angioplasty 1987]. / Angioplastie coronaire 1987.

Percutaneous transluminal coronary angioplasty (PTCA) is currently a common technique in the treatment of coronary artery disease, since the first dilatation was performed with success by A. Gruentzig (1977). If clinical indication is reserved to symptomatic angina pectoris, angiographic indications have been enlarged on account of progress in techniques and technology. Immediate success is good, about 90% with a low rate of mortality (1%), sometimes despite an emergency surgical revascularization. Restenosis is frequent, about 30% a few months after PTCA, with necessity of a new PTCA in almost half the cases. Long-term follow-up is satisfactory, about two third patients are asymptomatic. Immediate efficacy of this simple technique, and good results on a long-term follow-up, are explications of the increase in the number of PTCA during the last ten years.

[Aortic valvuloplasties: treatment of calcified aortic stenosis in elderly subjects]. / Valvuloplasties aortiques: traitement des rétrécissements aortiques calcifiés du sujet âgé.

Since September 1985, transluminal balloon catheter aortic valvuloplasty has been developed in France (Cribier and al.) and all around the world. Indications are still limited, in almost all catheterization laboratories, to elderly patients, with Monckeberg's disease, and with a very high operative risk. Immediately after aortic valvuloplasty, there is a moderate but a significant increase in valve area, without serious complications. Subjective improvement is often spectacular during few months after the valvuloplasty. In long-term evolution, there is sometimes a symptomatic restenosis which require a new valvuloplasty. So, if percutaneous valvuloplasty is efficacy in aortic stenosis in the elderly, long-term evaluation of this new technique is necessary.

[Non-obstructive hypertrophic cardiomyopathy and systolic compression of 3 coronary arteries. Long-term improvement with verapamil]. / Cardiomyopathie hypertrophique non obstructive et compression systolique des trois artères coronaires. Amélioration à long terme avec le vérapamil.

Systolic compression of the three main coronary vessels was observed during the investigation of a 23 year old African with hypertrophic cardiomyopathy. The patient was admitted in 1982 for evaluation of retrosternal chest pain and one syncopal attack during exercise. The ECG showed left ventricular hypertrophy with important ST-T wave changes which became more severe on exercise. Diffuse myocardial hypertrophy without obstruction was confirmed by echocardiography and cardiac catheterisation. Coronary angiography showed systolic compression of the three main coronary arteries. There was no coronary vasodilatory response to rapid atrial pacing; increased left ventricular end diastolic pressure confirmed the poor tolerance of exercise. The therapeutic failure of betablockers suggested a possible coronary spasm. Long-term (4 years) clinical improvement was obtained with calcium antagonists (Verapamil 360 mg/day) without significant regression of the hypertrophy. Coronary vasodilation under Verapamil led to improved tolerance of rapid atrial pacing. Control angiography showed only mild systolic compression of the three main coronary vessels. The improvement of this functional coronary insufficiency with Verapamil was attributed to its negative inotropic effects associated with improved myocardial relaxation and ventricular filling.

[Left ventricular hypertrophy. Advantages and drawbacks]. / Hypertrophie ventriculaire gauche. Avantages et inconvénients.

The increase of the muscular mass of the left ventricle represents, for the ventricular pump, a mechanism of adaptation to a normal process (growth, sport, etc.) or a pathological process (mechanical overload or cardiomyopathy). The geometrical variations which are associated, tend to normalize the performances and/or the systolic constraints, determining elements of the metabolic needs of the myocardium. If left ventricular hypertrophy is not quantitatively, geometrically and functionally adequate and if the contractility and precharge reserves become exhausted, the systolic performance of the ventricular pump is altered and becomes extremely dependent upon the systolic constraints which are then increased. It may be difficult to take into consideration an insufficiency of the contractility of the ventricular muscle in front of clinical signs of cardiac insufficiency which is conditioned by abnormalities in the filling of the ventricular pump. In addition, some "pathological" hyperthophies may secondarily induce an alteration of the intrinsic properties of the muscle (during its contraction, relaxation an/or extension), susceptible to induce or aggravate a ventricular insufficiency. The causes remain uncertain, since a metabolic imbalance of the myocardium by increase of the needs as well as a decrease of the coronary reserve and the exchange capabilities are commonly accepted. What are the mediators of these mechanisms of quantitative, geometric adaptation and also--at least in some animals--structural adaptation (isoenzymes of myosin)? Why do they seem, at times, strangely absent or quickly out-of-date, or sometimes excessive, with all the drawbacks specific to hypertrophy? The answer to these questions would perhaps represent a new therapeutic approach to left ventricular insufficiency.

[Long-term course of septal rupture operated on during the acute phase of a myocardial infarct]. / Evolution à long terme des ruptures septales opérées à la phase aiguë d'un infarctus du myocarde.

Between 1970 and 1979, 28 patients (18 men and 10 women, aged 46 to 76 years, average 62 years) with acute myocardial infarction complicated by septal rupture survived surgery performed during the acute phase. In the same period 62 patients were admitted to the Cardiology Department and were operated early for septal rupture complicating myocardial infarction. The site of infarction was the anterior wall in 22 cases and the posterior wall in 6 cases; septal rupture occurred on average after 4.2 days (range 1 to 10 days); 15 patients including 13 with cardiogenic shock underwent intraaortic balloon pumping for an average of 3:7 (range 1 to 11 days) before surgery; the operation performed after an average interval of 11 days consisted in direct suture of the defect in 3 cases and a patch repair in the other 25 cases, associated in all cases with infarctectomy and LAD coronary bypass grafting in 1 case. The immediate postoperative course was simple; three patients with residual shunts were not reoperated. Five to 14 years later, in 1984, 4 patients had been lost to follow-up; 4 patients had died, 2 of cardiac causes (LVF after 1 year and an arrhythmia after 4 years). Of the 20 survivors, 2 were successfully reoperated (1 coronary bypass after 10 years and 1 false aneurysm after 5 years). Only one patient had recurrent myocardial infarction. The quality and longevity of long-term survival encourage early surgery. The factors affecting long-term survival are discussed: correction of associated valvular defects, resifual shunts, conservation of left ventricular function and evaluation of the coronary circulation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary angiography and coronary bypass in patients over 70 (valvular disease excluded). Indications and results]. / Coronarographie et pontage coronaire au-delà de 70 ans (valvulaires exclus). Indications et résultats.

Between 1982 and 1984, 30 patients aged 70 or over underwent coronary angiography for isolated coronary artery disease, complicated in 8 cases by an infarct and uncontrolled by major medical treatment, including triple therapy on 28 mmHg (range 5-30 mmHg). Coronary angiography was performed under intravenous trinitrin in 9 cases, under intra-aortic balloon pumping in 1 case, without any serious complications. The majority of patients had triple vessel disease (18 cases) and stenosis of anterior interventricular (27 cases). The left main stem was diseased in 5 patients. Twenty-four patients, with an EF of over 0.40, underwent a coronary bypass with an average of 27 grafts/patients; 4 myocardial infarcts and 5 postoperative deaths were observed. Nineteen patients survived at medium term follow-up and had an excellent clinical result. Of the non operated patients, there was one early death and 3 patients remained severely incapacitated. In the absence of a major contra-indication to surgery, coronary angiography can be offered to patients over 70 years old in cases of severe coronary insufficiency, resistant to major medical treatment. Coronary bypass is justified by the spectacular functional improvement which it alone can bring about.

Relationships between single-vessel coronary artery obstructions and wall motion dysfunction analyzed by four computer-based methods.

We analyzed regional wall motion in 238 patients by using cineangiograms recorded in the 30 degrees right anterior oblique projection. The sample was divided into three groups: a normal group (n = 71), a group with isolated obstruction of the left anterior descending coronary artery and previous anterior myocardial infarction (n = 85), and a group with isolated obstruction of the right coronary artery and previous inferior myocardial infarction (n = 82). Both anterior and inferior groups also had motion abnormality within the corresponding anterior or inferior wall as judged by the qualitative analysis of cineangiograms. Four quantitative methods were compared: a long axis method and a center of mass method using internal reference systems, a method derived from the Stanford model and an area-based method using external reference systems. Normal regional values were determined from the normal group to evaluate the specificity and sensitivity of the methods. The area-based method was the most sensitive in the anterior infarction group, whereas the center of mass method was the most sensitive in the inferior infarction group. We conclude that there is no evidence that any method, among those tested, is superior to others for every expected location of wall motion abnormality.