Relationship between mixed venous oxygen saturation and cardiac index in patients with chronic congestive heart failure.

The use of mixed venous oxygen saturation (SvO2) in patients with chronic congestive heart failure (CHF) has been advocated to analyze the action of therapy on cardiac index (CI). To evaluate the relationship between CI and SvO2, ten CHF patients (mean age 65 years) were studied before and one, two, three, four (T4), six, eight and 24 hours after oral administration of an angiotensin converting enzyme (ACE) inhibitor (perindopril, 4 mg). At T4, a 12 percent increase in CI (p less than 0.01) was associated with a 16 percent decrease in arteriovenous oxygen difference (p less than 0.01), a 13 percent increase in mixed venous oxygen pressure (PvO2) (p less than 0.01), and a 9 percent increase in SvO2 (p less than 0.05) with no significant change in arterial oxygen pressure. There was no correlation between CI and SvO2 (r = 0.22) and between CI and PvO2 (r = 0.23). Individual analyses were performed and patients were divided into two groups based on CI versus SvO2 r value; group 1, n = 6, r greater than 0.65 (0.65-0.90), group 2, n = 4, r less than 0.65 (0.14-0.20). The lack of correlation in group 2 was due to a drug-dependent increase in oxygen consumption (VO2) +18 percent vs -3 percent in group 1 (p less than 0.05) associated with a lack of increase in PvO2 +3 percent vs +14 percent in group 1 (p less than 0.05) despite a similar increase in oxygen availability +19 percent versus +16 percent. It was concluded that (1) a correlation between CI and SvO2 is not found in every patient with CHF; (2) the lack of correlation in four out of our ten patients was due to an associated and significant increase in CI and VO2 in group 2; (3) group 2 patients probably had an important oxygen debt before treatment; (4) SvO2 cannot be used instead of CI to determine the hemodynamic consequences of the use of cardiovascular drugs.

[Contribution of perindopril to the treatment of chronic congestive cardiac insufficiency. Multicenter pilot double blind study versus placebo]. / Apport du perindopril au traitement de l'insuffisance cardiaque chronique congestive. Etude pilote multicentrique en double aveugle contre placebo.

Cardiac decompensation occurred in three patients of the placebo group, but not in the perindopril group. The effectiveness of perindopril in heart failure was demonstrated by the improvement observed in exercise test and severity score and by the decrease of cardiothoracic ratio. Changes in SAP, and serum creatinine levels, in particular, showed that the drug was well tolerated.

Value of perindopril in the treatment of chronic congestive heart failure. Multicenter double-blind placebo-controlled study.

Right cardiac catheterization studies have demonstrated an improvement in cardiac hemodynamics in patients with heart failure following the administration of perindopril (per): reduction in ventricular filling pressures (pulmonary capillary wedge pressure, right atrial pressure) and systemic resistance and an increase in cardiac output. The intensity and duration of these modifications were frequently insufficient after 2 mg, but were significant over 24 hours after 4 mg. A randomized, double-blind multicenter study versus placebo (pla) was conducted for 3 months, following a preinclusion period of 15 days, in 103 heart failure patients (stages II and III of the NYHA classification) treated with diuretic +/- digitalis. The following parameters were evaluated before (be), after 1 month (1m) and after 3 months (3 m) treatment: duration of stress test (DST) (sec), clinical severity score (SS), cardiothoracic ratio (CTR), serum creatinine (Cr) (mumol/l), systolic blood pressure (SBP) (mm Hg) in the supine (s) and erect (e) positions. 50 patients received per and 53 received pla; 46 patients in each group completed the double-blind period. Perindopril was administered at doses of 2 mg (n = 6) and 4 mg (n = 40). The following results were obtained: (table; see text) Three cases of acute heart failure occurred in the placebo group compared with none in the peridopril group. The efficacy of perindopril in heart failure was demonstrated by the improvement in effort capacity and severity score and by the reduction in cardiothoracic ratio. The variation in SBP and serum creatinine, in particular, reflected the good safety.

[Acute immunoallergic interstitial nephritis due to noramidopyrine]. / Néphrite interstitielle aiguë immuno-allergique à la noramidopyrine.

A 46-year old patient under noramidopyrine treatment was admitted for acute renal failure. Renal biopsy was performed and showed acute interstitial nephritis without staining at immunofluorescent microscopy. In vitro and in vivo immunological tests using noramidopyrine as antigen were all negative. Abnormal serum creatinine levels were still present 4 months later. To our knowledge, noramidopyrine has rarely been the cause of interstitial nephritis (only one other case has been published), but it has frequently been responsible for drug-induced blood diseases, and noramidopyrine-related drugs have previously been involved in drug-induced nephritis. As the renal damage can probably be explained by a delayed hypersensitivity reaction, an early corticosteroid treatment would help in improving renal function.

[Role of surgery in the treatment of chronic aortic insufficiency]. / L'heure de la chirurgie dans le traitement de l'insuffisance aortique chronique.

The long-term prognostic factors which determine the indications for surgery are studied on the basis of a series of 198 cases operated for chronic aortic incompetence, in terms of their influence on the actuarial long-term mortality rate due to heart disease and irreversible myocardial dysfunction. The mortality in the first month after surgery is 5 per cent. The factors which significantly modify the long-term outcome of operated patients are clinical (cardiomegaly, degree of preoperative heart failure, ventricular extrasystole, functional grade) and haemodynamic (mean pulmonary artery pressure, end-systolic and-end diastolic left ventricular pressures, left ventricular ejection fraction). Multifactorial studies have shown that ventricular dilatation is the most important prognostic factor. Left ventricular function is severely altered, even in patients with few or no symptoms, but, in the absence of marked functional disturbance, the prognosis is usually good, whatever the repercussions on the myocardium. Surgery should be performed routinely in patients with severe functional disturbance, in the absence of reliable individual criteria capable of predicting when the indications have been exceeded. Surgery is also legitimate in patients with few or no symptoms when investigations reveal severe effects on the left ventricular function.

Combined hemodynamic effects of dopamine and dobutamine in cardiogenic shock.

In eight mechanically ventilated patients in cardiogenic shock, we assessed the hemodynamic effects of an infusion of dopamine and dobutamine and evaluated its role in preventing the deleterious effects of administering each amine alone. Each patient received three infusions in a randomly assigned order: dopamine, 15 micrograms/kg/min; dobutamine, 15 micrograms/kg/min; and a combination of dopamine, 7.5 micrograms/kg/min, and dobutamine, 7.5 micrograms/kg/min. Stroke volume index increased similarly with the three infusions, but dopamine alone increased oxygen consumption (p less than 0.05 vs dobutamine alone and dopamine-dobutamine combined). The dopamine-dobutamine combination increased mean arterial pressure (p less than 0.05 vs dobutamine), maintained pulmonary capillary wedge pressure within normal limits (p less than vs dopamine), and prevented the worsening of hypoxemia induced by dopamine (p less than 0.05). The dopamine-dobutamine combination appears to be useful in the management of mechanically ventilated patients in cardiogenic shock.

[Aortic insufficiency and Takayasu disease]. / Insuffisance aortique et maladie de Takayasu.

Six cases of this rare association (7 to 10 p. 100 of Takayasu's disease) are reported. The authors also review 73 previously reported cases. The valvular lesion is usually detected secondarily during follow-up (2/3 of cases), but is observed at the same time as the arterial disease in about 1 out of 5 cases. In rare cases, it may be the presenting feature before the vascular disease becomes clinically apparent. Quantification of the regurgitation may be difficult because of stenosis of the thoracic aorta and the supra aortic vessels. In some cases it is severe and poorly tolerated but has no particular distinguishing features apart from the incidence of aortic wall calcification (ascending aorta to all of the aortic arch). Twenty five anatomical observations (operative or autopsy) are sufficiently well documented to show the mechanism of the aortic incompetence. It is caused by an inflammatory aortitis: valvular lesions were found in 2/3 of cases but other causes may be observed, dilatation of the aortic ring (1 out of 4 cases), disunion of the commissures (1 out of 4 cases) and changes in aortic compliance causing systolic hypertension. Aortic valve replacement is rare (11 cases including 3 personal cases) and sometimes completed by resection of an aneurysmal ascending aorta.