[Detection of anterior interventricular involvement after primary posterior wall infarct]. / Dépistage d'une atteinte de l'interventriculaire antérieure après primo-infarctus postérieur.

Forty-five patients (average age 53.3 +/- 9.4 years) underwent exercise stress testing coupled with exercise myocardial scintigraphy and right heart catheterisation on exercise during the 3rd week after primary posterior wall infarction. Coronary angiography and ventriculography were carried out 24 to 48 hours later. Significant (greater than or equal to 75%) left anterior descending disease was present in 9 patients (Group I) and absent in 36 patients (Group II). Tolerance of maximal exercise stress testing was good in all patients. The results were uninterpretable in on third of the cases because the theoretical maximal heart rate was not attained. No significant difference was noted between groups I and II with respect to: mean age, percentage of theoretical maximal heart rate attained, mean pulmonary capillary pressures at rest and during exercise, basal and exercise cardiac index, end diastolic index and angiographic left ventricular ejection fraction. The sensitivity and specificity for the detection of LAD disease were 80% and 84% for the exercise stress testing (n = 30), 44% and 75% for exercise right heart catheterisation (n = 30), 60% and 92% for exercise myocardial scintigraphy (n = 30), 100% and 75% for combined exercise stress testing and myocardial scintigraphy (n = 30) and 78% and 64% for combined exercise stress testing and myocardial scintigraphy and exercise right heart catheterisation (n = 45). These results show that in patients capable of performing maximal exercise stress tests, the best method of early detection of significant LAD disease after primary posterior infarction was combined exercise stress testing and exercise myocardial scintigraphy. These investigations are useful for the selection of candidates for coronary angiography.

[Non-invasive measurement of cardiac output by Doppler echography]. / Mesure non vulnérante du débit cardiaque par échographie Doppler.

In this review paper the theoretical and technical bases of cardiac output measurement in the thoracic extracted from the literature and obtained by the authors themselves are summarized. The main physiological assumptions required for calculations (flat velocity profile in the aorta) and the main technical options (pulsed or continuous emission of ultrasounds, spectral or simplified Doppler signal analysis, evaluation or non-evaluation of the angle of incidence by two-dimensional imaging, echographic mode of measurement of the aortic diameter) are discussed. The need for controlled studies of each equipment and method on large populations of patients is emphasized.

[Clinical study of the action of dobutamine in acute cardiac insufficiency]. / Etude clinique de l'action de la dobutamine dans l'insuffisance cardiaque aiguë.

78 patients were treated with dobutamine for a severe episode of heart failure at a mean dose of 9.51 micrograms . kg-1 . min-1 for an average of 5 days. 59 of these patients had ischaemic heart disease, including 34 with recent infarcts. The monitoring of treatment was essentially clinical, consisting of repeated measurement of the heart rate, the systolic and diastolic blood pressure and the diuresis. A haemodynamic survey was performed in only 25 cases. 48 patients were improved. 24 of these patients had no clinical or radiological signs of heart failure at the end of the treatment. Dobutamine significantly increases the blood pressure (97.7 +/- 24.9 to 105.8 +/- 21 mm Hg), the diuresis and the cardiac index (2.02 +/- 0.51 to 2.52 +/- 0.54 l . min-1 . m-2) and it significantly decreases the mean capillary pressure (25.36 +/- 6.20 to 21.03 +/- 6.94 mm Hg). The tolerance was very satisfactory, particularly in terms of the heart rate, ventricular excitability and the progression of the coronary disease. This clinical study confirms the value of dobutamine in the treatment of severe heart failure, either alone or in combination with vasodilators. The authors do not believe tha haemodynamic monitoring is essential at the doses used, which means that dobutamine could be used more widely in these indications.

[Exercise myocardial scintigraphy for the positive and topographic diagnosis of coronary disease. Study in 115 patients without antecedents of myocardial infarction]. / Contribution de la scintigraphie myocardique à l'effort au diagnostic positif et topographique de la maladie coronarienne. Etude chez 115 patients sans antécédents d'infarctus du myocarde.

In a group of 53 subjects (prevalence of the disease = 91%), the sensitivity of stress myocardial scintigraphy is lower (66%); the predictive value of a negative SMS is only 28 per cent: these results can be explained by the clinical profile of the subjects included in this group (men with an average age of 50 with typical effort angina), but also by the high incidence of one vessel stenoses of the right coronary artery or the circumflex artery (19/35) which are less accessible to SMS. For the series as a whole, the combination of the two tests provided optimal results: double positivity (SMS+/stress ECG+) has a predictive value of 97 per cent; double negativity (SMS-/SE-) corresponds to 83 per cent true negatives. Furthermore, the combination of SMS+/SE+ is suggestive of more severe coronary disease (defined by the presence of a tight stenosis of the IVA or multi-vessel disease). Such severe disease is encountered in less than 7 per cent of cases when the two tests are negative.

Intra-coronary thrombolysis with streptokinase or lys-plasminogen/urokinase in acute myocardial infarction: effects on recanalization and blood fibrinolysis.

Forty-two patients with total occlusion of a coronary vessel were treated with intracoronary fibrinolytic agents. Four therapeutic protocols were compared: group I received streptokinase (SK) as a continuous infusion; group II and III received SK as a bolus at different doses and group IV received lysplasminogen (Pg) plus urokinase (UK); maximal doses were 350,000 IU of SK and 250,000 IU of UK plus 75 microK of Pg. Thrombolysis was assessed by coronary angiography. Coagulation studies were performed prior to, 15 min and 6 hr after the end of the thrombolytic treatment. Recanalization was achieved in 27 of the 31 SK-treated patients (87%) and in 7 of the 11 Pg-UK-treated patients (63.6%). The recanalization frequency was the same in the three SK-treated groups, even though when SK was administered as a bolus, the dose was significantly less than when administered on a continuous infusion. Although systemic fibrinolysis occurred in all 4 groups of patients, this effect was less pronounced in the UK-treated patients than in the three SK-treated groups. This study also shows that recanalization can be achieved with a dose of SK lower than the anti-SK antibody level. Haemorrhagic side effects were minimal in all patients studied. Severe defibrination is usually considered a risk of haemorrhage. These preliminary results suggest that bolus injection of SK or the use of UK plus lys-Pg can reduce the level of defibrination and thus the haemorrhagic risk.

[Visualization by bidimensional echocardiography of the trunk of the left coronary artery. Affirmation of its integrity before coronary angiography]. / Visualisation par échocardiographie bidimensionnelle du tronc de la coronaire gauche. Affirmation de son intégrité avant coronarographie.

The aim of this study was to visualise and analyse the status of the main left coronary artery by 2D echocardiography before coronary angiography. Fifty two patients were studied. The recordings were performed from the left parasternal position on video cassettes and played back frame by frame for each patient, to analyse the left main coronary artery and its bifurcation. The patients had known stenosis of this vessel; there were echocardiographic abnormalities in all 10 cases; the stenosis was visualised directly in 5 patients and the vessel was considered to be abnormal in the other 5 patients. Forty two patients underwent 2D echo before coronary angiography. The echo of the left main coronary artery was considered to be abnormal in 8 patients: these results were compared with those of coronary angiography. In 33 cases there were no echocardiographic abnormalities and there were no angiographic lesions. The false positive results were due to the inability to record the bifurcation (proximal stenosis of the LAD interpreted as stenosis of the left main coronary) or to the direction of the left main coronary which is curved and thus cannot be analysed in the plane of the transducer. False negative results corresponded to slight stenosis (less than 50 p. 100). The bifurcation can be visualised in 60 p. 100 of patients with normal left main coronary arteries. It is only in these cases that the absence of significant lesions can be confirmed before coronary angiography.

[Treatment with intracoronary streptokinase in the acute phase of myocardial infarct. Preliminary results apropos of 20 cases]. / Traitement par streptokinase intra-coronarienne à la phase aiguë de l'infarctus du myocarde. Résultats préliminaires à propos de 20 cas.

Twenty patients with primary myocardial infarction (mean age 55 years +/- 6) were treated with intracoronary streptokinase in the acute phase. The mean interval between the onset of chest pain and treatment was 4 hours 30 minutes (extremes, 30 minutes and 6 hours). The total quantity of streptokinase required to obtain coronary revascularisation varied from patient to patient and with the technique used, but it was less than 350,000 units in all cases. The immediate results were favourable in 80 p. 100 of cases with respect to the coronary obstruction, in 50 p. 100 of cases with respect to relief of pain and in 35 p. 100 of cases with respect to ST elevation. It is not possible to confirm the efficacy of this therapy in left ventricular function from the results of this preliminary study. The authors observed, however, that the best results as assessed by 2D echocardiography, left ventricular angiography, and Thallium 201 myocardial scintigraphy were obtained in patients treated early (before the 3rd hour). They emphasise the need to check the level of antistreptokinase antibodies before starting treatment to assess the optimal total dosage for each individual patient, in order to obtain a local effect without disturbing the overall coagulation mechanism.

Effects of droperidol on left ventricular performance in humans.

The action of droperidol on left ventricular (LV) performance was examined before angiography in nine unpremedicated patients undergoing cardiac catheterization for stable uncomplicated coronary artery disease. Using local anesthesia, catheters were placed in the left ventricle, thoracic aorta, and pulmonary artery. Cardiac output (CO) and LV pressure derivatives were measured before and 2, 5, 10, 15, and 20 min after intravenous administration of 0.15 mg/kg droperidol. Droperidol administration induced a time-dependent decrease of mean arterial pressure (MAP) (significant at 2, 10, 15, and 20 min) and of cardiac index (CI) (significant at 15 and 20 min) with maximal changes observed at 20 min (-14 per cent for MAP and -15 per cent for CI). in addition, the following changes occurred in variables related to LV performance: 1) a transient increase in both heart rate (HR) (2, 5, and 10 min) and maximum rate of rise of left ventricular pressure/instantaneous left ventricular pressure (dP . dt-1 max . IP-1) (+ 15 per cent for HR and + 14 per cent for dP .dt-1 max . IP-1); 2) an early (2 min) and sustained (5, 10, 15, and 20 min) decrease of left ventricular end-diastolic pressure (LVEDP), maximum at 5 min (-30 per cent); 3) no change in systemic vascular resistance (SVR). This study shows that the fall in MAP which occurs after intravenous administration of clinical doses of droperidol is primarily due to decreased CO, secondary to decreased LVEDP and not to changes in cardiac contractility and in SVR.

[Intracoronary thrombolytic treatment in the acute phase of myocardial infarction (author's transl)]. / Traitement thrombolytique par voie coronarienne directe à la phase aiguë de l'infarctus du myocarde.

Thrombolysis by intracoronary injection of streptokinase was attempted in 18 patients with recent myocardial infarction. Streptokinase was administered by continuous i.v. infusion or by repeated injections to a maximal total dose of 250 000 units. Complete recanalization was obtained in 13 out of 16 patients with total occlusion of one vessel confirmed by angiography of the coronary arteries. Pain was relieved in 12 of these 13 patients and there was immediate and significant reduction of the lesion current in 9. The treatment was well tolerated. Arrhythmias in an usually minor form (ventricular ectopy) may occur during thrombolysis. No haemorrhage has been reported. There is no systemic fibrolysis in most cases.

[Predictive value of the ajmaline test for the diagnosis of distal paroxysmal atrioventricular block (author's transl)]. / Valeur prédictive du test à l'ajmaline dans le diagnostic des blocs auriculo-ventriculaires paroxystiques distaux.

An ajmaline test was conducted in 120 patients with a history of disorders of consciousness : Adams-Stokes syndrome (n = 49), loss of consciousness (n = 42), or lipothymia (n = 29). Four types of response were observed after ajmaline : VH less than 80 ms (n = 63); VH between 80 and 100 ms (n = 19); VH greater than 100 ms (n = 17); distal block (n = 21). One hundred and fifteen of these patients were followed-up for from three to six years (mean 56 months). Pacemakers had been fitted in 46 of them. Atrioventricular block was eventually detected in 37 patients but was excluded in the other 78 cases, either because the syncope attacks did not recur or because another cause was demonstrated. The predictive value of the ajmaline test was confirmed by the subsequent course of the disorders. Based on only clinical findings, diagnosis was confirmed in 42 p. cent, excluded in 12 p. cent, and impossible to define in 46 p.cent of cases. After the ajmaline test, diagnosis was confirmed in 79 p.cent, excluded in 6 p.cent, and impossible to define in 15 p.cent. The risk of atrioventricular block can be evaluated as 1-6 p.cent when the increase in VH is less than 80 ms, 35.3 p.cent when the increase is between 80 and 100 ms, 62.5 p.cent when it is greater than 100 ms, and 100 p.cent when there is a distal block. The indications for fitting a pacemaker depend upon the results of this test. If contra-indications are respected (recent history of an infarct, cardiac failure, marked enlargement of the heart), complications are rare, being observed in less than 3 p.cent of cases.

[Echocardiographical study of 2 cases of aortic dissection]. / Etude echocardiographicque de deux cas de dissection aortique

The authors report two cases of acute dissection of the ascending aorta and aortic arch. An urgent ultrasonic investigations showed, in both cases, signs of reduplication of the parietal image, which is highly suggestive of the condition; this was confirmed by angiography. These two cases enable us to discuss the criteria for this diagnosis, the limitations of the method, and its very real application in problems of differential diagnosis of acute chest pain.

[Fistula between a systemic artery and the pulmonary arterio-venous system. Apropos of a case. Review of the literature]. / Fistule entre artère systémique et système artério-veineux pulmonaire. A propos d'une observation. Revue de la littérature

The authors present the case of a 19 year old man with a continuous murmurin the right latero-thoracic region, with no functional symptomatology. Complementary examination demonstrated the presence of an angiomatosis which had developed at the expense of the right internal and external mammary vessels, and communicating with the pulmonary arterio-venous system.