[Primary coronary angioplasty for myocardial infarction--the view of the cardiologic surgeon]. / L'angioplastie primaire dans l'infarctus du myocarde vue par l'angioplasticien.

The aim of this article is not to present a general academic review on primary angioplasty in patients with ST-elevation myocardial infarction, but rather to focus on some practical points that directly concern cardiologists who perform primary percutaneous interventions in these patients. We detail recent data about the use of the radial artery approach, thromboaspiration, new oral inhibitors of P2Y12, selective use of anti-GPIIb/IIIa, high dose of peri-procedural statin therapy, choice of the best stent, and the best approach for treating non-culprit lesions in patients with multivessel coronary artery disease. The changes observed in the overall management of patients undergoing primary PCI for ST-elevation myocardial infarction are likely to have participated in the decrease in mortality observed in several registries. New European guidelines on the management of STEMI, taking into account these diverse aspects, have just been published.

Late results with bioprosthetic valves in the elderly.

AIM: We report the long-term outcome of aortic and mitral bioprostheses in patients over 65 years of age at the time of implantation. The aim was to determine actuarial patient survival, causes of death, and the rate of documented primary structural deterioration. METHODS: One hundred ten patients > or = 65 years of age (mean, 73.4; range, 65-82) underwent successful bioprosthetic valve replacement (aortic, n = 71; mitral, n = 32; both, n = 7) from 1979 to 1985. The valve was pericardial in 39 cases and porcine in 78. The mean follow-up was 8.5 years (101.9 months-total; 934 patient-years; range, 2 months to 15 years). RESULTS: Actuarial patient survival was 79.6% (71-86) at 5 years and 62.4% (52-71) at 10 years. Forty-four patients died, 21 from valve-related causes and 23 from other causes. Thirteen patients (11.8%) had reoperation for valve-related complications: 10 structural deteriorations, 2 paravalvular leaks, and 1 case of endocarditis. One surgical death occurred (7.7%). Twenty-six percent of the patients were receiving anticoagulants because of atrial fibrillation, and 6.4% developed severe bleeding (2.9% patient-years). CONCLUSIONS: Long-term follow-up of these patients > 65 years of age, undergoing bioprosthetic value replacement surgery revealed a low rate of documented primary structural deterioration (0.95% per patient-year), a low mortality rate on reoperation (7.7%), and a high mortality rate due to non-value-related causes (52.3%).

[Tolerance of amlodipine in left ventricular dysfunction of ischemic origin]. / Tolérance de l'amlodipine dans la dysfonction ventriculaire gauche modérée d'origine ischémique.

The aim of this study was to assess the effects of amlodipine on left ventricular function at rest and on effort, at least 30 days after myocardial infarction. The 30 patients included in the study had resting isotopic ejection fractions of 40 to 60%. At inclusion and after 15 days treatment with 10 mg of amlodipine, the patients underwent exercise stress testing with a standard Bruce protocol and resting and exercise isotopic left ventricular ejection fractions were measured. The association of betablockers was allowed but vasodilator therapy was prohibited. During the second exercise stress test, the duration of exercise increased (437 +/- 167 to 518 +/- 154 s; p < 0.002) and the work level rose from 140 +/- 56 to 169 +/- 60 Watts; p < 0.04. The number of electrically positive tests did not change significantly (33 vs 26.7%; NS). The resting ejection fraction did not increase after 15 days treatment with amlodipine (47.4 +/- 6.7 vs 48.3 +/- 8.9%; NS). Similar results were observed with respect to the exercise ejection fraction (51.4 +/- 10.4 vs 52.6 +/- 8.6%; NS). These patients may however be divided into two subgroups. In the first subgroup of 10 patients, the resting ejection fraction rose by more than 5% with amlodipine whereas the exercise ejection fraction remained unchanged (54.4 +/- 7.7% vs 54.5 +/- 7.5% with amlodipine). In the second subgroup of 20 patients, the resting ejection fraction decreased slightly with amlodipine (48 +/- 6.9% vs 45.3 +/- 8%; p = 0.04) but increased significantly on exercise (45.3 +/- 8% vs 51.7 +/- 9.1%; p < 0.0002). Therefore, amlodipine, a new generation calcium antagonist, does not induce any deleterious effect after myocardial infarction with mild left ventricular dysfunction.

[Influence of post-infarction myocardial revascularization on the prevalence of delayed potentials]. / Influence de la revascularisation myocardique après infarctus sur l'incidence des potentiels tardifs.

It has been shown that the presence of ventricular late potentials is a predictive factor of ventricular tachycardia and sudden death after myocardial infarction. The value of thrombolysis in the reduction of the prevalence of ventricular late potentials is now well established. However, the effects of other modes of revascularisation is less well known and more controversial. The authors undertook a retrospective study of 139 consecutive patients undergoing coronary angiography after primary myocardial infarction. The presence of ventricular late potentials fulfilling two of the three usual criteria was sought after a revascularisation procedure. The overall prevalence of ventricular late potentials was 30.9%. This was not affected either by the site of infarction of by the single or multiple character of the coronary artery disease. In addition, the left ventricular ejection fraction was not significantly different in patients with positive ventricular late potentials compared with the others. On the other hand, revascularisation of the culprit lesion responsible for the infarction was strongly correlated with a lower incidence of ventricular late potentials (p < 10 (-5)). In particular, the different incidence of positive late potentials between the dilated (9.3%) and non-dilated group (49.2%) was statistically significant (p < 10 (-6)) without any correlation to the single or multiple character of the coronary disease. The authors discuss the different reports in the literature concerning the effects of angioplasty and coronary bypass surgery on the incidence of ventricular late potentials. Conclusion; the review of the literature shows that thrombolysis significantly reduces the incidence of late potentials after myocardial infarction and the present study suggests that angioplasty and coronary bypass surgery may also be effective.

Bioprosthetic valve replacement in the elderly.

One hundred and ten patients aged more than 65 years (mean, 73.4; range, 65-82) underwent successful bioprosthetic valve replacement (aortic, n = 71; mitral, n = 32; both, n = 7) from 1979 to 1985. The valve was pericardial in 39 cases and porcine in 78. The mean follow-up was 75 months (total, 688 patient-years; range, 2 months to 12 years). Actuarial patient survival was 79.4% at 5 years and 55.2% at 10 years. Thirty-seven patients died: 18 from valve-related causes and 19 from other causes. Eight patients have been reoperated on for valve-related complications (1.17% per patient-year): five primary deteriorations, two paravalvular leaks and one case of endocarditis. One surgical death occurred (12.5%). Twenty-five percent of the patients were receiving anticoagulants because of atrial fibrillation, and 5.4% developed severe bleeding (3.8% patient-year). Mid-term follow-up of these patients aged more than 65 years and undergoing bioprosthetic valve replacement surgery revealed a low rate of documented primary structural deterioration (0.9% per patient-year), a low mortality rate on reoperation (12.5%) and a high mortality rate due to non valve-related causes (51.4%).

[Thrombolysis after 75 years of age: benefits, risks, indications]. / La thrombolyse après 75 ans; bénéfices, risques, indications.

Hospital mortality of myocardial infarction in patients over 75 years of age ranges from 25 to 33% without thrombolysis. Large scale trials of intravenous thrombolytic therapy including elderly patients showed that age itself is not a contra-indication to thrombolytic therapy. However, on the one hand, contra-indications are more common, and, on the other, the characteristics of infarction in the elderly are unsuitable so that thrombolysis is rarely used: in the MITI study, only 15% of over 75 years old patients would have benefitted from this therapy. The benefits of this treatment in patients over 75 years of age have been demonstrated: they were significant in Collin's meta-analysis (hospital mortality 24.9 vs 28.8%). In a more recent analysis (FFT study) the benefits of thrombolytic therapy after 75 years of age were shown providing the delay of inclusion (< 6 hours) and classical electrocardiographic criteria (ST elevation) were respected. Moreover, age is a risk factor for cerebral haemorrhage (prevalence 2.08% in patients over 75 years of age in the GUSTO study). The results of this study showed that, despite the development of thrombolysis, age was the main risk factor for hospital mortality and was independent of other risk factors. Therefore, the indication of intravenous thrombolytic therapy in elderly patients should be considered with respect to the characteristics of infarction (delay, site, presence of subendocardial ischaemia), the contra-indication related to potential bleeding and the possibilities of performing emergency angioplasty.

Comparison of tolerance to intravenous nitroglycerin during nicorandil and intermittent nitroglycerin patch in healthy volunteers.

BACKGROUND: Nitrate tolerance is associated with a loss in the hemodynamic response to nitrate during repeated administration. Nicorandil is a new potassium channel agonist with additional nitrate properties. The aim of this study was to determine whether 7-day nicorandil (10 mg orally twice a day) administration attenuates the response to single-dose intravenous nitroglycerin (0.45 mg over 1 minute) in comparison with 7-day intermittent nitroglycerin patch administration (10 mg for 16 of 24 hours). METHODS: This was an open, randomized crossover study performed in 12 healthy volunteers. Blood pressure, heart rate, and their oscillations were measured with use of a noninvasive device. Low-frequency oscillations (66 to 129 mHz) of blood pressure reflect sympathetic activity. Reflex sympathetic activation was measured as after versus before intravenous nitroglycerin difference in low frequency oscillations of blood pressure and heart rate on day 0 and day 7 of each treatment period. Measurements after single-dose intravenous nitroglycerin included the maximum decrease in systolic blood pressure and maximum increase in heart rate and sympathetic activation. Tolerance in each group was assessed as the difference in each parameter between day 7 and day 0. RESULTS: Attenuation of the intravenous nitroglycerin-induced decrease in systolic blood pressure (day 7 - day 0) was - 10 +/- 10 mm Hg during use of the nitroglycerin patch and -2 +/- 11 mm Hg during nicorandil (p = 0.03). Similarly, the change in low frequency oscillations of systolic blood pressure was -79 +/- 144 mm Hg-Hz-1/2 during nitroglycerin administration and 60 +/- 139 mm Hg-Hz-1/2 during nicorandil administration (p = 0.04). CONCLUSION: These results indicate that 7-day administration of nicorandil does not attenuate single-dose intravenous nitroglycerin-induced hemodynamic changes or sympathetic activation. In healthy volunteers and at this dosage (10 mg twice a day), cross tolerance between nicorandil and nitroglycerin does not occur.

[Coronary angioplasty, a privileged method of myocardial revascularization of the elderly]. / L'angioplastie coronaire, méthode privilégiée de revascularisation myocardique du sujet âgé.

Coronary angioplasty is a myocardial revascularisation technique of choice in the elderly, avoiding the need for general anesthesia as well as the complications of thoracotomy and extracorporeal circulation. Used in a continuous series of 62 patients, it provided a 79% primary success rate in this situation, where reaching the coronary artery and penetrating the stenosis may be difficult. Femoral complications (hematoma, false aneurysm) are commoner in this age group, but appear to be beneficially influenced by the replacement of heparin by ticlopidine peri-operatively. With 24 months follow-up, the proportion of patients free of any major cardiac event and NYHA classes I and II is 66%, actuarial survival rate without infarction is 76%. These results would tend to restrict the indications for bypass after the age of 75 to cases of stenosis of the left main coronary artery, failure of angioplasty or multi-vessel atheroma with a "culprit lesion" inaccessible to dilatation.

Coronary angioplasty in patients 75 years and older; comparison with coronary bypass surgery.

From November 1988 to May 1992, 108 patients (79 men, 29 women) 75 years or older (mean 78 +/- 3, range 75-90 years) underwent coronary angioplasty (group I: n = 62) or coronary bypass surgery (group II: n = 46). Group II patients were younger (76 +/- 2 vs 79 +/- 4, P = 0.002) and had a higher proportion of multivessel disease. The two groups were comparable with regard to the presence of unstable angina, left ventricular ejection fraction and Q wave infarction. In-hospital mortality was similar in the two groups (6.4% vs 4.3%). Complete revascularization (72% vs 47%, P < 0.05) and left anterior descending artery revascularization (100% vs 45%, P < 0.01) were more frequent in group II. Two-year infarction-free survival was similar (group I: 76 +/- 6%; group II: 79 +/- 6%) but recurrent class III or IV angina (36% vs 9%, P < 0.05) and repeat procedures (26% vs 0%, P < 0.05) were more frequent in group I.

[Concept of causal implication in unexpected effects of drugs. An example of cardiotoxicity caused by anthracyclines]. / Notion d'imputabilité des effets inattendus des médicaments. Exemple d'un cas de cardiotoxicité aux anthracyclines.

Over the last 30 years, considerable progress have been made in developing methodologies to analyze unwanted drug effects. The aim of this study is to explain the French method utilized to impute the side effects of a drug. An example of anthracycline cardiotoxicity will be discussed.

[Third angioplasty, and after that?]. / La troisième angioplastie, et après?

The authors studied retrospectively a series of 39 patients with a documented second restenosis after coronary angioplasty between January 1987 and November 1992, 33 of whom (31 men, 2 women) underwent a third procedure. The artery dilated was the left anterior descending (n = 17 including 9 proximal stenoses), the right coronary (n = 10), the left circumflex or its branches (n = 5) and the left main stem (n = 1). The lesions were confirmed to one vessel in 25 cases (75%) and affected two vessels in 8 cases (25%). The third angioplasty procedure was performed on a single artery in all cases. The average left ventricular ejection fraction was 60% (43%-75%). The diameter of the dilated artery was over 3.25 mm in 24% of cases (8/33). The primary success rate was 100% without any complications. The average period between the first and second angioplasties was 16 +/- 10 weeks, and between the second and third angioplasties 19 +/- 12 weeks. Angioplastic controls of the 3rd angioplasty were performed in 25 cases (75%). A third restenosis (n = 7) was treated by surgical bypass (n = 1), repeat angioplasty (n = 4), endocoronary stenting (n = 1) or medically (n = 1), with a global follow-up of 22 months (2-56 months), 2 patients underwent coronary bypass grafting, 2 have residual angina (contralateral lesion which could not be dilated), 1 had an infarct in the territory of an undilated artery, and 28 (85%) were asymptomatic. The restenosis rate after the third angioplasty procedure was 28% (7/25).(ABSTRACT TRUNCATED AT 250 WORDS)

[Mid-term results of bioprosthesis in patients over 65 years]. / Résultats à moyen terme des bioprothèses après 65 ans.

Between 1979 and 1985, 79 patients over 65 years of age (mean 70.8; range 65-82 years) underwent valvular replacement with a bioprosthesis (aortic: 48, mitral: 26, aortic and mitral: 5). Of the 84 valves implanted, 56 were porcine and 28 were pericardial bioprostheses. The average follow-up was 66 months (total: 434 patient-years; range: 2 months-12 years). Twenty-three patients (29%) died; 13 of these deaths were related to the prosthesis and 10 were not formally related to the bioprosthesis. Of the latter 10 deaths, 7 were caused by malignant disease. Seven patients were reoperated for a complication due to the prosthesis (1.6% per patient-year): 5 primary tissue failure, 1 endocarditis, 1 perivalvular leak. Sixteen patients (20.3%) received oral anti-coagulants for atrial fibrillation; 6 of them (7.6%) had severe haemorrhagic complications (3 deaths). The actuarial survival was 76.2% at 5 years and 53.4% at 10 years. Actuarial survival without reoperation was 76% at 5 years and 42% at 10 years. Analysis of survival with respect to the type of bioprosthesis (porcine of pericardial), the valve orifice (mitral or aortic) and age (under or over 70 years) did not show any significant differences. Follow-up of patients over 65 years of age showed a high rate of haemorrhagic complications related to oral anticoagulant therapy for atrial fibrillation (6.8% per patient-year), a low rate of primary tissue failure (1.1% per patient-year) and a low reoperative mortality (1 death for 7 reoperations).

[A rare course of spastic angina with normal coronary arteries]. / Une modalité évolutive rare de l'angor spastique à coronaires normales.

The authors report the case of a 65-year-old woman smoker monitored for spastic angina. A first coronary arteriogram in 1986 failed to reveal any significant coronary lesion and was complicated by reversible occlusive spasm of the anterior interventricular artery. A second coronary arteriogram 6 years later because of recurrence of angina revealed the development of 70% stenosis of the coronary segment affected by the spasm. Such an outcome is rarely reported in the literature and raise the question of a possible link between spasm and the progression of atheroma.

Percutaneous coronary angioplasty in patients over 75 years old: immediate and mid-term results.

Ninety-five patients 75 years or older (range 75-90, mean 79) underwent PTCA from 1987 to 1991. Forty-two patients were 80 years or older. Forty-four had prior MI, 5% had prior coronary bypass surgery (CBS), 13% had a prior history of recent cardiac failure, and 81% (77/95) presented with unstable angina, refractory to intravenous treatment in 31 cases. The mean left ventricular ejection fraction was 62% (range 34%-80%). Thirty-nine percent had single vessel disease, 41% had two vessel disease, and 20% had three vessel disease. Coronary calcifications were present in 28%. A single vessel was dilated in 81 patients, two vessels in 14 patients; complete revascularization was achieved in 41%. The clinical angiographic primary success rate was 79% (75/95). There were five procedural deaths, five MI, five CBS and, ten hematomas. Follow-up data were obtained in 100% cases, with a mean follow-up duration of 12 months (ranging from 1-36). There were four deaths, one MI, and two CBS. Twenty percent (15/74) of patients had a second PTCA with a 73% success rate. Finally, 70% of the initial population was asymptomatic after first or second PTCA at mid-term follow-up. We conclude that PTCA is safe and effective in elderly patients, with 70% clinical success rate at mid-term follow-up in spite of frequent incomplete revascularization limited to the culprit lesion.

[Silent myocardial ischemia]. / L'ischémie myocardique silencieuse.

The frequency of silent myocardial ischemia (SMI) is 2 to 5% in an asymptomatic population, 25 to 30% after a myocardial infarction and 40% in stable angina. Although the prognosis of coronary insufficiency is related to the number of stenosed vessels and to left ventricular function, the presence of a silent ischemia constitutes an additive risk factor. The beneficial effect bypass surgery in terms of survival has been demonstrated in high risk patients (main coronary artery stenosis, three branch lesions with left ventricular insufficiency), while in the absence of symptoms those of medical treatment, and coronary angioplasty, have still to be demonstrated.

[Can patients with severe left ventricular dysfunction be treated by coronary artery bypass surgery?]. / Peut-on ponter les coronariens ayant une dysfonction ventriculaire gauche sévère?

Forty three men and 3 women, with an average age of 59 years (13 to 78 years) underwent aorto-coronary bypass surgery despite severe left ventricular dysfunction (ejection fraction < 35%); 96% of the patients had previous infarction; 60% (N = 28) had unstable angina, 52% (N = 24) had had pulmonary oedema or an episode of congestive cardiac failure. The average ejection fraction was 29 +/- 4%, range 17 to 35%. Thirteen patients had ventricular aneurysms, 4 had grade 3 or 4 mitral regurgitation. The coronary lesions were usually multivessel left main coronary (6), triple vessel disease (27), double vessel disease (12), single vessel disease (1). The average number of bypass grafts per patient was 2.3. The average aorting clamping time was 63 minutes (range 26 to 133 minutes). There were 4 mitral valve replacements, 4 resections of ventricular aneurysms and 1 double procedure (aneurysmectomy and valve replacement). The operative mortality was 2.1% (1 death). During an average follow-up period of 27 months (range 3 to 90 months), there were: 2 recurrent infarctions, 13 episodes of cardiac failure and 8 cardiac deaths (cardiac failure: 5, sudden death: 2, recurrent infarction: 1). Two patients underwent cardiac transplantation. The regression of angina (90% of operated patients were asymptomatic) and the low operative risk, justify aortocoronary bypass surgery despite left ventricular dysfunction in patients with severe symptoms (unstable angina, chronic, invalidating angina). The medium-term results indicate a high risk of cardiac failure which is partially responsible for the secondary mortality rate of 17% at 2 years.

[Tamponade without cardiac rupture after repetitive thrombolysis in acute myocardial infarction]. / Tamponnade sans rupture cardiaque après thrombolyse itérative dans l'infarctus aigu du myocarde.

The authors report the case of tamponade without cardiac rupture 48 hours after a second course of intravenous thrombolytic therapy undertaken for unstable angina in laterobasal infarction in a 72 year old woman. The outcome after ultrasonic guided pericardiocentesis and surgical drainage (700 cc) was favourable. This is a rare complication of thrombolytic therapy (10 cases) and usually observed after anterior myocardial infarction.

[Do calcium inhibitors have any role in secondary prevention of myocardial infarction?]. / Les inhibiteurs calciques ont-ils une place dans la prévention secondaire de l'infarctus du myocarde?

The value of using calcium blockers in post-infarction secondary prevention is controversial. The HELD meta-analysis (1989) involving 17,759 patients concluded that they made no contribution in this indication (9.8% mortality rate vs 9.3% in the control group). The findings of the DAVIT II study with verapamil demonstrate a significant reduction in the infarction recurrence rate (18% vs 21.6%) in the treatment group. In the patients without heart failure, there was some benefit in terms of reduced mortality (7.7% vs 11.8%). The true contribution of calcium channel inhibitors, relative to that of beta-blockers in post-infarction medication should be analyzed in function of the various infarction sub-groups (no Q-wave, thrombolytic, with or without left ventricular dysfunction), of the calcium channel inhibitor being investigated and of the administration regimen.