Improvement of left ventricular function after percutaneous transluminal coronary angioplasty.

Cardiac function and left ventricular dynamics were measured in seven consecutive patients 1 day before and 6 months after percutaneous transluminal balloon angioplasty of subtotal proximal stenosis of the left anterior descending coronary artery. Before angioplasty all patients had obvious left ventricular dysfunction during exercise and to a smaller degree during isoproterenol infusion; the condition of all patients was greatly improved 6 months after angioplasty. After angioplasty, left ventricular end-diastolic pressure was normal at rest and decreased from a mean (+/- standard error of the mean) of 33.8 +/- 1.6 to 19.2 +/- 0.5 mm Hg on exercise. Left ventricular ejection fraction, measured by a gated blood pooling technique with technetium-99m, improved on exercise from 46 +/- 5.0 percent to 69 +/- 1.0 percent. Cardiac output and stroke volume index increased significantly with exercise after angioplasty. The peak negative rate of pressure reduction in the left ventricle (dP/dt/min), an index of left ventricular relaxation, was highly abnormal on exercise before (2,307 +/- 260 mm Hg/s) and increased to the normal range (3,154 +/- 200 mm Hg/s) after angioplasty. The improvement in left ventricular function after transluminal angioplasty in these cases of proximal left anterior descending coronary arterial stenosis is extremely encouraging.

[Severity of stabilized angina pectoris and indication for coronary bypass-implications for prognosis]. / Sévérité de l'angine de poitrine stable et indication au pontage coronarien-implication pour le pronostic.

The prognosis in patients with mild or moderate angina pectoris (class I or I-II) and significant coronary artery lesions (70% or more luminal diameter reduction) is controversial. Since 1967 these cases have not been operated upon in our Division. To assess the justice of this approach, 61 mildly symptomatic, non-operated patients (group I) were compared with 65 markedly symptomatic (class II to IV) patients in whom coronary artery bypass procedures were indicated but not performed (group II). These patients either had refused surgery or the lesions were considered unsuited to revascularization. Although 44 patients in group I had 70% or more stenosis of one or more coronary arteries, the 8-year mortality rate in group I was 17% compared with 40% in group II. For patients with single vessel disease (32 patients in group I, 35 patients in group II) the 8-year mortality was 9.4% in group I and 34% in group II; the difference is significant. This retrospective study suggests that mild and moderate angina pectoris (class I or I-II with or without medical treatment) is associated with a rather favourable prognosis (one single death during the first four years in group I). It may be concluded that an aggressive approach can be delayed until further symptoms develop despite adequate medical therapy.

[Effect of dynamic exercise on left ventricular hemodynamics in obstructive cardiomyopathy]. / Effet d'un effort dynamique sur l'hémodynamique du ventricule gauche lors d'une cardiomyopathie obstructive.

The behavior of left ventricular (LV) outflow tract obstruction in hypertrophic obstructive cardiomyopathy (HOCM) during dynamic exercise was studied in 9 patients during cardiac catheterization. Pressure measurements were carried out with high fidelity tip manometers and cardiac output was measured by the thermodilution method. Resting intraventricular pressure gradients varied from 5 to 75 mm Hg (mean 41 +/- 30 mm Hg) and all patients had postextrasystolic gradients of more than 100 mm Hg. Under supine bicycle exercise (mean work load 80 watts) heart rate increased from 74 +/- 9 to 97 +/- 10 min-1, cardiac output rose from 4.32 +/- 0.7 to 8.36 +/- 2.0 l/min, and LV intraventricular pressure gradient dropped significantly to 16 +/- 4 mm Hg. This improvement of LV outflow tract obstruction was associated with an increase in LV enddiastolic pressure from 14 +/- 5 mm Hg to 25 +/- 2 mm Hg, an augmentation of dP/dt max from 1225 +/- 300 to 1748 +/- 200 mm Hg/sec and a deterioration of systolic to diastolic pressure-time index ratio. These preliminary results indicate partial normalization of the LV outflow tract obstruction in HOCM during supine bicycle exercise; this favorable effect is probably due to an increased enddiastolic LV volume.

Congestive heart failure in normotensive man. Haemodynamics, renin, and angiotensin II blockade.

The role of the renin angiotensin system was evaluated in 18 normotensive patients with chronic congestive heart failure and in 5 controls. No correlation was observed between plasma renin activity and cardiac index. There was a significant inverse correlation between renin and pulmonary capillary wedge pressure (r = -0.61, P less than 0.01). Renin values of the patients appeared to be increased when compared with controls with similar left ventricular filling pressure. Specific angiotensin II inhibition by saralasin decreased arterial pressure in 8 out of 14 patients: their renin was significantly higher than that of the remaining 6 patients (P less than 0.01). The 2 patients with the lowest renin levels responded to saralasin with a blood pressure increase. Left ventricular filling pressure decreased in all but these latter 2 patients with either little change or an increase in stroke volume. Thus, renin levels appear to be increased in normotensive patients with congestive heart failure when related to left ventricular filling pressure. Renin via angiotensin II plays a role in the blood pressure control of many patients with congestive heart failure. In some patients angiotensin II blockade appears to improve cardiac function by unloading the left ventricle.

Angiotensin II blockade in congestive heart failure.

Five of 11 normotensive patients with congestive heart failure responded to an infusion of the specific angiotensin II antagonist, saralasin, by reducing systemic vascular resistance from 2274 +/- 418 to 1690 +/- 351 dynes/sec/cm-5 (mean +/- standard error). This decrease was accompanied by a reduction in left ventricular filling pressure from 19.4 +/- 5.9 to 11.6 +/- 4.0 mm Hg, an increase in cardiac index from 2.2 +/- 0.4 to 2.7 +/- 0.4 l/min/m2 and a decrease in mean arterial pressure from 95 +/- 9.8 to 86 /+- 8.6 mm Hg. In the other 6 patients with congestive heart failure and in 4 controls, saralasin produced either no change or slight increases in systemic vascular resistance. Plasma renin activity did not differentiate responders from non-respnders. Specific inhibition of angiotensin may provide a means for reducing inappropriately high peripheral resistance in some patients with congestive heart failure.

[The role of reduction of the heart rate in the favorable effect of the beta blockers on myocardial ischemia due to isoprenalin in patients with angina pectoris]. / Le rôle du ralentissement de la fréquence cardiaque dans l'effet favorable des béta-bloquants sur l'ischémie du myocarde provoquée par l'isoprénaline chez l'angineux.

In the patient suffering from angina, the protective effect of oxprenolol in the isoprenaline test is demonstrated by the reduction of disappearance of ischemic-type electrocardiographic alterations and of angina and rhythm disturbances. In our study, these results were obtained in spite of neutralization of the negative chronotropic effect of the beta-blocker through the use of an endo-auricular pacemaker. This points indirectly to the role played by the contractile state of the myocard in catecholamine-induced modifications of the oxygen intake of cardiac muscle.

[Exercise test in coronary insufficiency diagnosis]. / Les épreuves d'effort dans le diagnostic de l'insuffisance coronarienne

If the anamnesis is not conclusive for a definite diagnosis of angina pectoris or if a complementary test is adviseable the ECG, which is hardly ever significant at rest, can become very significant under the influence of physical activity. The easiest methodology is a bicycle ergometer or a treadmill performance test which can be performed under ideal safety conditions and which gives the best possible information. Compared to the coronarography results in 319 patients, the performance test at either maximum heart rate or up to the appearance of the typical electrocardiographic alterations was positive in 75.5% of the cases. It is less instructive if the test is not systematically exhaustive. Its validity also varies depending on the number of coronary arteries affected by stenosis, on the type of the angina pectoris, and the aspect of the ECG at rest. If the test is performed up to the maximum heart rate, its sensitivity is superior to the ones using lsoprenaline or right atrial pacing as a means for influencing the ventricular function.

[Electrocardiographic diagnosis of coronary insufficiency by means of right atrial pacing]. / Diagnostic électrocardiographique de l'insuffisance coronarienne par entraînement électrosystolique auriculaire droit

In 285 patients who underwent selective coronary arteriography and atrial pacing for electrocardiographic diagnosis of suspected coronary failure, the sensitivity of this test was found to be rather poor: 43% positive results for atrial pacing compared to 50% for the submaximal exercise test, 75% for the maximal exercise test and 63% for the isoprenaline infusion test. In our experience atrial pacing is of diagnostic value only where uncertainty persists after a negative isoprenaline infusion test and an exercise test likewise negative but for some reason submaximal.

[Treatment of essential hypertension with Transicor 80 and Esidrex K under medical practice conditions]. / Behandlung der essentiellen Hypertonie mit Trasicor 80 und Esidrex-K unter Praxisbedingungen

This study was designed to obtain information under general practice conditions on the efficacy and tolerability of a fixed combination of the beta-blocking agent oxprenolol 80 mg (Trasicor 80) and hydrochlorothiazide + KCl (Esidrex-K) in the treatment of moderate essential hypertension. Patients with a diastolic pressure of 100 to 130 mm Hg were covered by the study. The dosage of Trasicor was kept relatively low and at a constant level, i.e. one tablet twice daily throughout. In the group of 370 patients whose record had been completed according to the treatment plan, the systolic and diastolic pressures fell on the average by 28 and 17 mm Hg respectively. After 10 weeks of therapy, the diastolic pressure was normalized (i.e. below 95 mm Hg) in 226 patients. The mean decreases in pressure were statistically significant after two weeks' treatment. The mean pulse rate fell from 79 to 73. Tolerance of the regimen was very good in 75% of patients; 57 patients were withdrawn from the study for various reasons.

[Proceedings: Results of the surgical treatment of valvulopathies and ischemic heart disease in patients older than 65 years]. / Résultats du traitement chirurgical des valvulopathies et des cardiopathies ischémiques chez des patients de plus de 65 ans

53 patients aged from 65 to 76 years underwent surgery for valvulopathies (23 patients), atherosclerotic heart disease (24 patients) or both diseases combined (6 patients). All these cases were in NYHA fonctional classes III and IV except for one patient in class II. Hospital mortality after surgical treatment of these cardiopathies was 3.8% (2 deaths). The late mortality of 19% (10 deaths), though high, was of non-cardiac origin in 7 of these patients. The clinical and hemodynamic findings in the two patients who died in the postoperative period were compared with those in the others. These two patients were more severely ill and had a greater degree of cardiomegaly than the average patient in the surviving group. The satisfactory clinical improvement in these elderly cardiac patients suggests that surgery can be recommended at least up to 75 years of age if there are no obvious contraindications. Life expectancy of 13-16 years for patients aged 65 and 8-9 years for patients aged 75 is a further reason for advocating surgical intervention.

[Proceedings: Evaluation of the hemodynamic condition during the recuperative phase after the diagnostic isoproterenol test in a patient with coronary disease]. / Evaluation de la condition hémodynamique lors de la phase de récupération après l'épreuve diagnostique à l'isoprotérénol chez le coronarien

Previous investigations concerning isoproterenol infusion (PI) in the diagnosis of myocardial ischemia have shown that ischemic ECG changes are only significant if they persist or appear after discontinuing PI. In an effort to explain the mechanisms of this delayed response, hemodynamic parameters were measured in 10 patients with angiographically proven coronary disease before, during and after PI. It was found that the principal determinants of myocardial oxygen consumption (TTI and contractility) remain significantly elevated in the recuperation phase, but that aortic pressure and systemic arterial resistance, which diminish during PI, return to pre-infusion levels immediately after halting PI. The combined effects favor the late appearance of ischemic changes in the ECG. The coronary vasodilatation with resultant increased oxygen delivery to the myocardium seen during PI may be sufficient to meet the increased myocardial oxygen demand during PI but disappears immediately if PI is discontinued.

[Development of persistent atrial paralysis secondary to acute leukemia]. / Evolution d'une paralysie auriculaire persistante secondaire à une leucémie aiguë

The authors report a further well-documented case of long-standing atrial palsy, which they feel should be called "persistant" rather than "permanent", as "specific" treatment seems to have been responsible for its regression after about two and a half months. The case was one of atrial palsy with leukaemic infiltration of the auricles (acute leukaemia with paramyeloblasts), an aetiology without precedent in the published literature. Treatment with corticosteroids and antimitotic drugs resulted simultaneously in remission of the leukaemia and conversion to atrial fibrillation. Remission of the dysrhythmia is probably attributable to the specific treatment of the underlying pathology, which makes this case so unusual.