[Myocardial infarction in young women: apropos of 22 cases. Pathogenic and prognostic approach]. / L'infarctus du myocarde chez la femme jeune: à propos de vingt-deux cas. Approche pathogénique et pronostique.

The authors report 22 cases of myocardial infarction documented by selective left ventriculography and coronary angiography in women under 45 years of age. The average age in this series was 36 +/- 6.8 years. Two patient groups were identified: Group I (n = 16) with the cardiovascular risk factor of oral contraception (mean age 33.9 +/- 5 years); and Group II (n = 6) comprising older patients (43.8 +/- 1.8 years) with a high prevalence of other risk factors (hyperlipidaemia, hypertension, diabetes). Myocardial infarction tended to be the inaugural event in Group I (9 out of 16 cases, 56.2%) whereas symptoms of effort angina were commonly observed in Group II (5 out of 6 cases, 83.3%). Coronary angiography showed more severe coronary lesions in Group II (score 1.5) than in Group I (score 0.75) in which isolated, single vessel disease mainly affecting the left anterior descending artery or normal coronary angiography was observed. Thrombolytic therapy was performed in 8 patients: percutaneous transluminal angioplasty was performed in 4 patients in the first month with a primary success in 3 cases. Coronary bypass surgery was performed in 1 case. The outcome during follow-up lasting 44.5 +/- 4.2 months was mainly favourable as 15 of the 20 patients had no secondary complications. Nevertheless, 2 patients died in the hospital period (1 from cardiogenic shock and 1 from complications of transluminal coronary angioplasty), 2 patients died less than 1 year after acute myocardial infarction (1 sudden death, 1 cardiogenic shock). Although oral contraception was withdrawn in all cases, many women continued to smoke.(ABSTRACT TRUNCATED AT 250 WORDS)

Systolic intra-cavitary gradients following aortic valve replacement: an echo-Doppler study.

Systolic left ventricular flow was studied by pulsed and continuous wave Doppler in 41 patients following aortic valve replacement for severe stenosis (mean valvular area: 0.58 cm2; range 0.3-0.75 cm2). Maximal left ventricular velocities by continuous wave Doppler study, were higher than 2.5 m.s-1 with a sharp peak at end-systole in five patients in basal condition and in four others after amyl nitrite inhalation. Pulsed Doppler study showed that the high velocities started from the apex or mitral papillary muscle level with a marked chamber narrowing at two-dimensional echography. Only one patient had a systolic anterior motion (SAM) of the anterior mitral leaflet with mitral-septal contact. The left ventricular dimensions, as measured by M-mode echography were compared in the various patient groups. High velocities seemed statistically associated with the smaller systolic and diastolic diameters of the left ventricle and outflow tract and the larger relative thickness of the posterior wall. The highest pressure gradients disappeared after correction of hypovolaemia (one patient), clearance of pericardial effusion (one patient), or beta-blocker treatment (three patients). The present study confirms that left intra-ventricular dynamic gradients can occur after clearance of fixed outflow obstruction, for which Doppler examination is a reliable and innocuous diagnostic means. Haemodynamically, this syndrome resembles hypertrophic obstructive cardiomyopathy, but the scarcity of the systolic anterior motion of the mitral leaflets is suggestive of a different mechanism that could be cavity obliteration or mid-ventricular obstruction.

[Diagnosis of coronary artery disease by thallium 201 myocardial scintigraphy during atrial pacing]. / Diagnostic de l'insuffisance coronaire par tomoscintigraphie myocardique au thallium 201 sous stimulation auriculaire.

Rapid atrial pacing may reveal myocardial ischemia but the sensitivity for the diagnosis of coronary artery disease is not high enough for routine use. Therefore, the value of atrial pacing coupled with Thallium 201 scintigraphy was evaluated. Sixty-two patients (53 men and 9 women) referred for investigation of angina or chest pain were divided into two groups: a control group of 13 patients (9 men and 4 women, average age: 57.1 years) with insignificant coronary lesions (less than 50%) (N = 5) or normal coronary angiography (N = 8), and a group of 49 patients (44 men and 5 women, average age: 55.5 years) 27 of whom had a history of myocardial infarction (17 posterior, 10 anterior). Coronary angiography showed single vessel disease in 44.9% of cases, double vessel disease in 34.7% and triple vessel disease in 18.4% of cases, and 1 patient with left main stem disease. All 62 patients underwent the same study protocol which comprised: incremental atrial pacing (to the calculated maximal heart rate), Thallium 201 myocardial scintigraphy immediately after pacing and during the redistribution phase, and coronary angiography. The sensitivities of anginal pain (36.7%) and ECG changes during atrial pacing (57.1%) were too low for the diagnosis of myocardial ischemia. On the other hand, Thallium 201 scintigraphy with atrial pacing was more sensitive (87.8%) and specific (84.6%) for coronary artery disease. Stenosis of the left anterior descending artery was diagnosed with a sensitivity of 96.4% and that of the right coronary artery with a sensitivity of 90.9%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Stenosis of the branches of the pulmonary artery caused by Hodgkin's lymphadenopathies]. / Sténoses des branches de l'artère pulmonaire par des adénopathies hodgkiniennes.

A 22 year old patient was admitted to hospital for dyspnoea and haemoptysis. Cardiac catheterisation showed a pressure gradient between the main pulmonary artery and its branches. Pulmonary angiography showed appearances of extrinsic compression of the branches of the pulmonary artery. This was shown to be caused by lymphadenopathy on CT scan and Hodgkin's disease was diagnosed after surgical biopsy. The pressure gradient between the main pulmonary artery and its distal branches almost completely regressed after chemotherapy and radiotherapy.

Implantation of an endoluminal prosthesis at the distal anastomosis of a bypass graft for abrupt closure following balloon angioplasty.

A coronary Wallstent was implanted in a 10-year-old saphenous vein bypass graft following a PTCA that was complicated by abrupt closure. Anterograde flow was restored and no myocardial necrosis resulted. One week later, bypass surgery was performed due to a bleeding complication associated with the anticoagulation regimen.

[Chronology and incidence of restenosis after coronary angioplasty. Comparison of patients with stable and unstable angina]. / Chronologie et incidence de la resténose après angioplastie coronaire. Comparaison des patients présentant un angor stable à ceux présentant un angor instable.

The aim of this prospective study was to compare the incidence of restenosis after percutaneous transluminal coronary angioplasty (PTCA) in patients with stable and unstable angina before the procedure. Between January 1984 and February 1986, 344 patients with stable angina and 228 patients with unstable angina underwent PTCA. The primary success rate was 86.3 per cent in patients with stable angina (297 patients) and 87.7 per cent in patients with unstable angina (200 patients). The patients were recalled for systematic control coronary arteriography at 30, 60, 90, 120 or 150 days, and was obtained in 83.8 per cent of patients with stable angina and in 86 per cent of patients with unstable angina. The degree of stenosis before and the angiographic changes after PTCA and at control coronary arteriography were evaluated by a computer-assisted automatic contour detection system. The three criteria of restenosis were: 1) over 50 per cent loss of the benefit of PTCA, 2) residual post-PTCA stenosis increasing from less than 50 per cent to more than 50 per cent at control arteriography, 3) a decrease in the minimum intraluminal diameter of at least 0.72 mm with respect to the immediate post-PTCA result. A comparison between the two groups of patients showed that the average age was slightly greater in patients with unstable angina (56 +/- 9 years vs 58 +/- 9 years, p = 0.047). Apart from this difference, the two groups were comparable with regards to the average number of lesions dilated per patient, the date of control arteriography, the severity of the coronary artery disease and previous bypass surgery, angioplasty and infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

[Implantation of endoprostheses in aortocoronary bypass. Preliminary experience at the Thoraxcenter of Rotterdam]. / Implantation d'endoprothèses dans les pontages aorto-coronaires. Expérience préliminaire du thoraxcenter de Rotterdam.

An intraluminal stent was implanted in 5 patients after dilatation of an aorto-coronary venous graft. In the first 4 patients the procedure was motivated by restenosis after angioplasty. In the 5th patient the stent was implanted as a first-line measure in a case of dilated venous bypass stenosis. Stent implantation carries a risk of thrombosis and requires effective anticoagulation. Thus, one of our patients had to be reoperated upon for prosthetic thrombosis facilitated by the withdrawal of anticoagulants owing to a gastrointestinal haemorrhage. After a 3-month follow-up, the results seem to be encouraging in spite of a case of restenosis located at the proximal end of the tutor. However, more time will be needed to determine precisely the effectiveness of stents in the prevention of restenosis after venous graft dilatation.

[Effects and chronology of coronary restenosis after percutaneous transluminal coronary angioplasty. Quantitative angiographic analysis at 1, 2, 3, 4 and 5 months]. / Incidence et chronologie de la resténose coronaire après angioplastie coronarienne transluminale percutanée. Analyse angiographique quantitative aux 1er, 2e, 3e, 4e et 5e mois.

Coronary restenosis occurs fairly early after transluminal coronary angioplasty, as suggested by anatomico-clinical, isotopic and angiographic studies. Its incidence, as reported in the literature, varies according to the clinical selection of patients, to the number of patients with follow-up angiography and the timing of this procedure, and to the criteria used to define restenosis. In this prospective study we endeavoured to determine the exact date at which restenosis takes place, as well as its true incidence, by means of 6 different angiographic criteria. The population studied was divided into five groups and each group underwent coronary arteriography at a different date: during the 1st, 2nd, 3rd, 4th and 5th post-angioplasty months respectively. In 424 of the 500 patients thus examined (84.8 p. 100), coronary angiography involved automatic detection of contours and made quantitative analysis possible. Coronary restenosis was found to occur early, with a peak of incidence in the 3rd month. Its incidence varied considerably depending on the criterion used. A critical analysis of the data has prompted us to use a criterion based on absolute values determined by quantitative angiographic analysis.

[Assessment of immediate geometric changes in coronary stenosis after implantation of stents by quantitative angiographic analysis]. / Appréciation des modifications géométriques immédiates de la sténose coronaire après implantation de tuteurs par analyse angiographique quantitative.

In order to assess the immediate geometric changes in coronary stenosis that occur after implantation of intra-coronary stents, a quantitative angiographic analysis (automatic delineation of contours) was performed in 18 patients. Following angioplasty, the implantation of a stent significantly increases the diameter and area of the stenotic segment in absolute values. This improvement is attended by a significant decrease in resistance and in the theoretical trans-stenotic pressure gradient. Beside its role as mechanical support of the dilated arterial wall, the stent possesses an intrinsic force of dilatation confirmed by the results of quantitative angiographic analysis.

[Percutaneous mitral commissurotomy. Apropos of 130 cases]. / La commissurotomie mitrale percutanée. A propos de 130 cas.

In order to evaluate the effectiveness and risks of percutaneous mitral commissurotomy (PMC), we tried this procedure in 130 patients. Nine attempts were unsuccessful due to pre-PMC complications (haemopericardium 2, air embolism 1) or to technical failure (6 cases, 5 of which occurred in the first 15 attempts). PMC could be performed in 121 patients: 88 women and 33 men aged from 13 to 79 years (mean 42 + 15 years); 22 patients had previously been operated upon, 5 had a history of embolism, 99 were in functional stage III or IV. Echocardiography divided these patients into 3 groups: 29 had calcified leaflets (group 1), 42 had flexible leaflets and little alteration of the subvalvar system (group 2), and 49 had flexible leaflets with alteration of the subvalvar system (group 3). Mitral regurgitation grade 1/4 was present in 32 cases. PMC was performed with one balloon (Trefoil 3 x 12 mm) in 14 patients and therafter with two balloons (Trefoil 3 x 10 mm plus conventional 15 or 19 mm balloon) in 107 patients. PMC resulted in significant improvement in haemodynamic values: the mean capillary pressure fell from 20 +/- 7 to 11 +/- 5 mmHg (p less than 0.0001) and the mean mitral gradient from 16 +/- 6 to 6 +/- 2 mmHg (p less than 0.0001), while the cardiac index rose from 2.7 +/- 0.6 to 3.1 +/- 0.7 l/mn/m2 (p less than 0.001) and the mitral valve area (MVA) from 1.1 +/- 0.2 to 2.2 +/- 0.5 cm2 (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous transluminal valvuloplasty of the mitral valve]. / Perkutane transluminale Valvuloplastie der Mitralklappe.

Percutaneous transluminal balloon valvuloplasty for mitral stenosis represents an alternative method of treatment to standard surgical procedures of open or closed commissurotomy as well as valve replacement. In this overview, our results will be reported with respect to derivation of a summary of indications and contraindications for the procedure. Valvuloplasty for mitral stenosis was carried out in 62 patients, mean age 43 +/- 17 years, 48 women and 14 men. In 14 of the patients surgical procedures had been performed previously including an open or closed commissurotomy or isolated aortic valve replacement. Nine patients were in NYHA class II, 50 in class III and three in class IV. Markedly impaired motion of the valve and calcification was present in 15 patients. In 47 patients, the valve motion was relatively good and associated with mild changes in the subvalvular apparatus in 29 and marked changes in 18. In 54 patients the valvuloplasty was carried out with a combination of two balloon catheters, one 3 X 10 mm trefoil catheter and a single-balloon catheter of 15 mm (n = 16) or 19 mm (n = 38) diameter. Both catheters were inserted via the right femoral vein. The procedure required an average of one and one-half hours. Before and after valvuloplasty, complete right heart catheterization with oxymetric determinations were carried out to detect possible shunts at the atrial level and left ventriculography for detection of mitral regurgitation was performed in addition to echocardiography and Doppler examinations with continuous, pulsed-wave and color Doppler studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of calcified aortic stenosis: surgery or percutaneous transluminal aortic valvuloplasty?

A total of 546 patients with severe aortic stenosis (AS) were retrospectively reviewed to assess the efficacy of percutaneous transluminal valvuloplasty (PTV) and valve replacement (VR). Of these, 490 underwent VR between 1968 and 1986 (mean age 62 +/- 12 years, 71.7% were in NYHA class III or IV), 68.8% received mechanical prostheses, and in 11.8% a bypass graft was associated. The operative mortality was 6.9% (4% since 1983). The mean follow-up was 57.6 months. The actuarial survival rate was 77% at five years, 60% at 10 years, and 40% at 15 years. Over 70 years of age, operative mortality was 6.2% since 1983, and the actuarial survival rate was 67.5% at five years. From February 1986 to May 1987, PTV was attempted in 56 patients and was effective in 52 patients (mean age 79 +/- 5 years, 93% in Class III or IV). Immediate mortality was 7.1%. The morbidity was due to tamponade (1.8%), myocardial infarction (3.6%), vascular trauma (5.3%), or cerebrovascular accident (9%). Forty three patients were followed after PTV (mean value 4.2 +/- 3, range 1-14 months): 12 patients (28%) died and 46% were functionally improved in NYHA Class II. PTV significantly improved the aortic valve area as shown by haemodynamics (0.49-0.75 cm2; P less than 0.0001) and these findings were corroborated by Doppler study (0.46-0.70 cm2, P less than 0.001). In conclusion, this series shows that surgery provides satisfactory results in AS with a low mortality and good long-term results, even in the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)