[Why I don't give up the femoral approach!]. / Pourquoi je n'abandonne pas la voie fémorale!

Since its introduction in 1989, the safety of transradial approach compared to the femoral approach is mainly due to reducing entry site complications, allowing early ambulation, but at the price of a higher rate of procedural failure, arterial occlusion and radiation for operators and patients. Nevertheless, these advantages can be minimized with a modern femoral approach requiring a 4-French catheter for diagnostic angiography and a low dose heparin, new antithrombotic drugs and a reasonable use of glycoprotein (GB)IIb-IIIa for angioplasty. The radial approach is the best way to go in hemorrhagic high-risk patients and the femoral approach is safer in complex procedures. The operator has to hold the two accesses and to know when to switch to another approach to minimize complications, procedure time, radiation and contrast use.

[Balloon catheter dilation of severe pulmonary restenosis 11 years after surgical valvulotomy]. / Dilatation par cathéter à ballonnet d'une resténose pulmonaire serrée 11 ans après valvulotomie chirurgicale.

A young girl who underwent repair of an atrial septal defect and pulmonary valvulotomy when 6 years of age, presented with clinical and haemodynamic signs of pulmonary restenosis 11 years later: right ventricular systolic pressure (RVSP) of 130 mmHg with a systolic RV/PA pressure gradient of 105 mmHg. Pulmonary valvuloplasty was performed using a balloon catheter (20 mm X 40 mm). Two inflations were necessary to correct the hour glass deformity of the balloon caused by the stenosis. After valvuloplasty the RVSP was 75 mmHg and the RV/PA gradient 55 mmHg. The calculated pulmonary valve surface area increased from 0.36 cm2 to 0.72 cm2. Angiography performed immediately after dilatation showed improved valvular mobility but here was persistant severe infundibular hypertrophy. The intensity of the pulmonary systolic murmur decreased. The good result obtained in this case shows that percutaneous valvuloplasty may be considered when restenosis occurs several years after surgical valvulotomy. Control catheterisation performed two months after dilatation confirmed the good initial haemodynamic result.

[Cerebral embolism without apparent cause: angiographic study of minor predisposing cardiac anomalies. Prospective study of 64 patients]. / Embolies cérébrales sans cause apparente: recherche par angiographie d'anomalies cardiaques mineures prédisposantes. Etude prospective sur 64 patients.

The heart is the source of about 50 p. 100 of cerebral emboli. In the absence of clinically obvious cardiac disease, the heart is nevertheless suspected to be the origin, especially in young patients without atherosclerosis. Cardiac catheterisation and angiography were performed systematically to detect minor predisposing cardiac abnormalities which did not appear on standard clinical examination, and which could increase the risk of recurrent embolism. 64 patients aged 21 to 69 years were studied prospectively a few weeks after a cerebral vascular accident attributed to embolism on the results of complementary neurological investigation, or, more rarely, after systemic embolism to one of the limb arteries. Clinical examination, chest X-ray and the electrocardiogram were normal in all cases. The investigation consisted in right and left cardiac catheterisation, global angiography after right atrial injection, selective left ventricular angiography and coronary angiography in all patients over 40 years of age. Unsuspected cardiac abnormalities were detected in 39 of the 64 patients (60 p. 100); the main abnormalities were mild or moderate mitral valve prolapse (30 p. 100 of cases) and slight decreases in left ventricular contractility possibly related to a minor form of cardiomyopathy (23 p. 100 of cases). Ambulatory 24 hour monitoring showed supraventricular arrhythmias in 30 p. 100 of cases. The results of echocardiography were disappointing in the diagnosis of these minor abnormalities. In conclusion, cardiac abnormalities were detected in the majority of cases of cerebral embolism by cardiac catheterisation. These results support the indications for long-term anticoagulant and/or anti-arrhythmic treatment in these patients.

[Prazosin in the treatment of chronic cardiac insufficiency]. / Apport de la prazosine dans le traitement de l'insuffisance cardiaque chronique.

Vasodilators may be required when signs of cardiac failure persist, despite adequate digitalo-diuretic therapy. Prazosin is a post-synaptic alpha-blocker which acts on both cardiac preload and afterload. For this reason, it has been widely used in the treatment of cardiac failure. We used prazosin in an open uncontrolled trial in 17 patients with an average of 59 years, in whom Stage III or IV cardiac failure persisted despite digitalis and diuretic therapy. Haemodynamic data obtained with a Swan Ganz catheter was used to judge the effectiveness of an initial dose of prazosin and long-term results were assessed by repeat studies after 6 and 10 weeks of continuous therapy. After the first, we observed a marked fall in pulmonary capillary (15.5% 7.4 vs 22.9% 8.8 mm Hg, p less than 0.01) and mean pulmonary artery pressures (23.8% 9.2 vs 34.2 +/- 10.6 mm Hg, p less than 0.001). Systemic vascular resistances were also significantly reduced (1 370 +/- 406 vs 1 983 +/- 464 dynes.s.cm-5, p less than 0.001). There was a moderate fall in mean systemic blood pressure (80.8% 10.6 vs 95.6 +/- 129 mm Hg, p less than 0.001). Cardiac index increased significantly (2.7 +/- 0.68 vs 2.13% 0.56 1/min/m2, p less than 0.01). The heart rate was constant. The maintenance dose was 5 mg three times daily in 9 cases, and 10 mg three times daily in the other 8 cases. The medium term results were assessed in 14 patients as 2 patients died and 1 stopped treatment for undetermined reasons. The symptomatic improvement was marked (class 2.5 +/- 0.76 vs 3.64 +/- 0.49, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Captopril in cardiac insufficiency. Immediate and long-term effects]. / Le captopril dans l'insuffisance cardiaque. Effets immédiats et à long terme.

Captopril was administered to 23 patients in cardiac failure refractory to digitalo-diuretic therapy. Four patients had a large fall in systolic blood pressure (less than 70 mmHg) with a single dose of 25 mg of captopril. In the other 19 patients a significant fall in mean pulmonary capillary pressure (16,8 +/- 6,1 mmHg vs 27,2 +/- 8,5 mmHg, p less than 0,001), mean pulmonary artery pressure (26,3 +/- 11,3 mmHg vs 38,3 +/- 12,4 mmHg, p less than 0,001), mean right atrial pressure (5 +/- 5 mmHg vs 8 +/- 6 mmHg, p less than 0,01) was observed: there was a moderate fall in mean systemic arterial pressure (13%, p less than 0,001). There was a significant fall in pulmonary resistance (27%, p less than 0,001). The cardiac index increased (2,8 +/- 0,5 l/min/m2, p less than 0,001) and systemic resistance fell by 25% (p less than 0,001). The heart rate decreased by an average of 7 beats/min (p less than 0,02). The treatment was stopped in one patient because of the inefficacy of captopril at 100 mg per dose. The average daily dose in the 18 patients on long-term treatment was 212,5 +/- 106,8 mg. At the second month, the haemodynamic parameters were remeasured before the morning dose of captopril. The effects observed after the single dose were maintained apart from the systemic blood pressure, heart rate and systemic resistances which had returned to the value observed before administration of captopril. The mean pulmonary capillary pressure was significantly lower than before treatment but was higher than after the single dose.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracoronary thrombolysis in evolving myocardial infarction. Sequential angiographic analysis of left ventricular performance.

Since November 1979 left ventricular angiography and coronary arteriography have been performed in 80 patients with evolving acute myocardial infarction in order to attempt coronary recanalisation by local streptokinase infusion. The average delay between the onset of symptoms and streptokinase infusion was 3.6 hours. Thrombolysis was successful in 64% of cases. No serious complications related to the procedure were noted. Of the 12 patients in cardiogenic shock, recanalisation was achieved in only four, of whom two survived. To evaluate the left ventricular salvage resulting from early recanalisation the last 58 patients had a second left ventricular angiogram and further coronary arteriograms 21 +/- 10 days later and 16 patients had a third study three months later. From the left ventricular angiogram in the right anterior oblique projection the ejection fraction and two graphic variables of regional wall motion were computed quantifying the hypokinetic zone. Patients were divided into two groups, according to the patency of the infarct related artery at the second control: group 1 consisted of 28 patients with successful recanalisation confirmed, and group 2 of 30 patients in whom no recanalisation was achieved or secondary reocclusion had occurred. At the second study the ejection fraction was unchanged in group 1 but had significantly decreased in group 2. Regional wall motion improved in group 1 and worsened in group 2, more so in patients without recanalisation than in those in whom secondary reocclusion had occurred. The third study showed a further decrease in ejection fraction in group 2. A progressive decrease in percentage residual stenosis was observed in group 1. This sequential angiographic study confirms the partial myocardial salvage resulting from early coronary recanalisation during acute myocardial infarction.

[Evaluation of functional myocardial recovery after emergency revascularization by intracoronary fibrinolysis in the acute infarct period]. / Evaluation de la recupération fonctionnelle du myocarde après revascularisation en urgence par fibrinolyse intracoronarienne à la période aiguë de l'infarctus.

An angiographic study was carried out to evaluate myocardial recovery in 50 patients who had undergone coronary angiography in the first six hours of myocardial infarction with the object of attempting emergency revascularisation by a selective intracoronary infusion of streptokinase. Left ventriculography performed before initial coronary arteriography and 2 to 10 weeks later was compared. The ejection fractions and two indices obtained by quantitative analysis of regional contractility, the surface (SHK) and extent (EHK) of the ischemic zones were calculated. The patients were divided into two groups according to results: Group I, 25 patients with patent arteries at the second control, and Group II, 25 patients not revascularised or with a reobstructed artery at the second angiographic control. In Group I, the ejection fraction remained stable (47 +/- 11 p. 100 to 48 = 10 p. 100 N.S.) but SHK (13 +/- 6 cm2 to 10 +/- 5 cm2, p less than 0,01) and EHK in percentage of ventricular circumference (48 +/- 12 p. 100 to 42 +/- 11 p. 100, p less than 0,05) fell significantly. In Group II, the ejection fraction fell (55 +/- 9 p. 100 to 44 +/- 11 p. 100, p less than 0,001) whilst SHK (7 +/- 4 cm2 to 11 +/- 5 cm2, p less than 0,001) and EHK (34 +/- 11 p. 100 to 43 +/- 14 p. 100, p less than 0,001) increased significantly. These results show that revascularisation may result in significant functional myocardial recovery and, consequently, that some ischemic myocardium can be salvaged in these patients.

[Immediate and long-term effects of prazosin on hemodynamics in chronic cardiac insufficiency]. / Effets hémodynamiques immédiats et à long terme de la prazosine dans l'insuffisance cardiaque chronique.

Prazosine was studied in the treatment of chronic heart failure in 17 patients. The immediate effects were a reduction in pulmonary capillary pressure (22,9+/-8,8 mmHg to 15,5+/-7,4 mmHg, p less than 0,001), mean pulmonary artery pressure (34,2+/-10,6 mmHg to 23,8+/-9,2 mmHg, p less than 0,001), an increase in cardiac index (2,13+/-0,5 to 2,70+/-0,68 l/mn/m2 p less than 0,01), a reduction in mean systolic blood pressure (95,6+/-12,9 to 80,8+/-10,6 mmHg, p less than 0,001) and systemic resistance (1983+/-464 to 1 370+/-406 dynes.sec.cm-5). Heart rate did not change significantly. The long-term effects were assessed after 2 months continuous treatment in 14 patients. There was a clear-cut symptomatic improvement in the patients. This was without doubt related to the increase in cardiac output (+24 p. 100) which persisted at long term. On the other hand, the preload rose to its pre-treatment levels as did the blood pressure. This study confirms the value of Prazosine in the long-term treatment of chronic cardiac failure.