Incidental visceral and renal artery stenosis in patients undergoing coronary angiography.

PURPOSE: The study aimed to examine the association between incidentally discovered mesenteric artery stenosis, renal artery stenosis (RAS) and coronary artery disease in patients undergoing coronary angiography. MATERIALS AND METHODS: We performed a prospective analysis of consecutive patients undergoing routine cardiac catheterisation. Abdominal aortograms in lateral and antero-posterior view were obtained to assess arterial stenosis of the coeliac axis, superior mesenteric artery and renal arteries. Significant arterial stenosis was defined as a narrowing of at least 50% compared with the normal artery. Demographic data and cardiovascular risk factors were analysed. RESULTS: The prevalence of visceral artery stenosis (VAS) was 63/450 (14%) including 48/450 (10.6%) cases of coeliac axis stenosis and 15/450 (3.3%) cases of superior mesenteric artery stenosis. Female sex (p = 0.01), older age (p = 0.03) and the presence of coronary artery disease (p = 0.05) were significant predictors for the presence of VAS in univariate analysis. The determinants for VAS in multivariate analysis were female sex and three-vessel coronary artery disease, while two- and three-vessel coronary artery disease was significant for RAS. CONCLUSION: Screening for VAS and RAS in female patients older than 60 years with more than two diseased coronary segments could have a high diagnostic value.

[Silent myocardial ischemia in type 2 diabetes. Predictive value of intima-media thickness]. / Ischémie myocardique silencieuse chez le diabétique de type 2. Valeur prédictive de l'épaisseur intima-media.

CONTEXT: The carotid intima-media thickness (CIT) is correlated with the prevalence of cardiovascular diseases. We studied the relationship between the thickness of the carotid intima-media and the existence of myocardial ischemia, detected by scintigraphy in a population of type 2 diabetic patients without coronary antecedents. METHODS: We conducted repeated Doppler measurements of the CIT of primitive carotid arteries in 52 diabetic patients aged 49 to 75. All these asymptomatic patients, without coronary antecedents, diabetic for more than 10 years and exhibiting at least one cardiovascular risk factor, had undergone myocardial scintigraphy. RESULTS: The CIT was greater in the group with positive scintigraphies and is the best predictive factor of the presence of ischemia. For a CIT value < 0.55 mm, the negative predictive value of the CIT was of 77% with 80% sensitivity; in non-smokers the predictive negative value increased to 92% with 95% sensitivity. CONCLUSIONS: Reliable and reproducible, measurement of CIT correlates well with myocardial scintigraphy and could be an interesting alternative screening policy in asymptomatic, type 2 diabetic patients.

Factors associated with early atrial fibrillation after ablation of common atrial flutter. A single centre prospective study.

BACKGROUND: The occurrence of early atrial fibrillation (< or = 6 months) after ablation of common atrial flutter is of clinical significance. Variables predicting this evolution in ablated patients without a previous atrial fibrillation history have not been fully investigated. OBJECTIVES: The aim of the present study was: (1) to identify predictive factors of early atrial fibrillation (< or = 6 months) in the overall population following atrial flutter catheter ablation; (2) to identify predictive variables of early atrial fibrillation following (< or = 6 months) atrial flutter catheter ablation within a subgroup of patients without documented prior atrial fibrillation. METHODS: This study prospectively included 96 consecutive patients (age 65 +/- 13 years; 18 women) over a 12-month period. Their counterclockwise flutter was ablated by radiofrequency, by the same operator, with an 8-mm-tip catheter. Clinical, electrophysiological and echocardiographic data were collected and 27 variables were retained for analysis: age; gender; type of atrial flutter (permanent vs paroxysmal); symptom duration (months +/- SD); pre-ablation history of atrial fibrillation; structural heart disease; left ventricular ejection fraction (%); left atrial size (mm); cava--tricuspid isthmus dimension; septal isthmus dimension; systolic pulmonary pressure > or < or = 30 mmHg; right atrial area; left atrial area; isthmus block; number of radiofrequency applications (+/- SD); antiarrhythmic drugs at discharge; left ventricular diastolic diameter; left ventricular systolic diameter; left ventricular telediastolic volume; left ventricular telesystolic volume; A-wave velocity (cm . s(-1)); E-wave velocity (cm . s(-1)); E/A; isovolumetric relaxation time; E-wave deceleration time; significant mitral regurgitation and flutter cycle length (ms). RESULTS: Of the 96 consecutive ablated patients, early atrial fibrillation was documented in 16 patients (17%). Atrial fibrillation occurred 30 +/- 46 days (range 1 to 171 days) after ablation. Univariate analysis associated an early occurrence of atrial fibrillation with: atrial fibrillation history, left ventricular ejection fraction, left atrial size, left ventricular telesystolic volume, A-wave velocity, significant mitral regurgitation and flutter cycle length. Multivariate analysis using a Cox model found that the only independent predictors of early atrial fibrillation were left ventricular ejection fraction and pre-ablation history of atrial fibrillation. In the subgroup without prior atrial fibrillation history (n=63; 66%), the only independent predictor of early atrial fibrillation was the presence of a significant mitral regurgitation. CONCLUSIONS: In a subgroup of patients without atrial fibrillation history, 8% of patients revealed an early atrial fibrillation. Mitral regurgitation is a strong predictive factor of early atrial fibrillation occurrence with 80% sensitivity, 78% specificity and 98% negative predictive value. These data should be considered in post-ablation management.

Clinical characteristics, aetiological factors and long-term prognosis of myocardial infarction with an absolutely normal coronary angiogram; a 3-year follow-up study of 91 patients.

OBJECTIVES: The purpose of this study was to evaluate the clinical outcome of a large cohort of patients who suffered an acute myocardial infarction with absolutely normal epicardial coronary arteries at the post-myocardial infarction coronary angiogram. The aetiological and prognostic factors in this population were also analysed. BACKGROUND: Few data exist concerning the outcome, and aetiological and prognostic factors, of patients with myocardial infarction and angiographically absolutely normal coronary arteries. METHODS: Ninety-one patients (34 females/57 males; mean age 50+/-13 years, range 24--78 years) admitted with an acute myocardial infarction had absolutely normal coronary arteries at the angiogram performed 6.2+/-4 days (range 1--15 days) after the myocardial infarction, defined by smooth contours and no focal reduction (NC). Of the 91 NC patients, 71 were evaluated prospectively, alongside a systematic search of all aetiological factors reported in the literature. The NC patients were matched for age, sex, and the same period of myocardial infarction onset with a group of 91 patients with coronary artery stenosis (>50% diameter stenosis) at the angiogram performed 7.3+/-4 days (range 1--15 days) after the myocardial infarction (SC). RESULTS: The percent of smokers was similar between the two groups; higher prevalence rates of coronary heart disease family history, obesity, hypertension, hypercholesterolaemia and diabetes mellitus were found in SC (P=0.043 to 0.0001). In NC, coronary spasm was found in 15.5%, congenital coagulation disorders in 12.8%, collagen tissue disorders in 2.2%, embolization in 2.2%, and oral contraceptive use in 1.1%. Left ventricular ejection fraction at hospital discharge was higher in NC (60%+/-13%) than in SC (55%+/-13%, P=0.04). The mean follow-up was 35 months (range 1--100 months). Kaplan-Meier event-free survival, with the combined end-point defined as death, reinfarction, heart failure and stroke was 75% in NC vs 50% in SC (P<0.0001). Survival rate was 94.5% in NC compared to 92% in SC (ns). Univariate predictors of events in NC were left ventricular ejection fraction (P=0.03), age (P=0.02), diabetes (P=0.01), and smoking (P=0.03). Using Cox multivariate analysis, independent predictors of long-term outcome in NC patients were left ventricular ejection fraction (P=0.003) and diabetes (P=0.004). CONCLUSION: Aetiological factors, predominantly coronary spasm and inherited coagulation disorder, can be detected in only one third of the patients with myocardial infarction and absolutely normal coronary angiograms despite a systematic search in a prospective population. Mortality rates are similar but morbidity is lower in myocardial infarction patients with absolutely normal coronary angiography compared with those with coronary artery stenosis. The only two independent factors predictive of poor outcome in myocardial infarction patients with normal coronary arteries are left ventricular function and diabetes.

Comparison of color duplex ultrasound and computed tomography scan for surveillance after aortic endografting.

Endovascular repair of abdominal aortic aneurysms (AAA) requires regular surveillance for early detection of endograft failure. CT scanning is the gold standard surveillance procedure. The purpose of this study was to assess the reliability of color duplex ultrasound (CDU) in comparison to CT scanning for detection of endoleaks and changes in aneurysmal diameter. From November 1996 to September 1999, a total of 41 patients treated by aortic endografting underwent regular surveillance with both CT scanning and CDU. There were 39 men and 2 women with a mean age of 71 years (range, 50-83). Endovascular treatment involved deployment of a straight aorto-aortic stent in 6 cases, bifurcated stent in 33, and aorta-to-unilateral iliac artery stent in 2. Stent deployment failed in one case; the procedure was conversion to open surgery. Primary or secondary endoleaks were detected in 17 patients (42%). Our findings indicated that CDU is less reliable than the CT scan for detection of endoleaks, but that reliability of CDU for surveillance of aneurysmal diameter is fair.

[Infections secondary to implantation of cardiac pacemakers]. / Infections secondaires à l'implantation d'un stimulateur cardiaque.

Infectious complications of pacemaker implantation are not common but may be particularly severe. Localised wound infections at the site of implantation have been reported in 0.5% of cases in the most recent series with an average of about 2%. The incidence of septicaemia and infectious endocarditis is lower, about 0.5% of cases. The operator's experience, the duration of the procedure and repeat procedures are considered to be predisposing factors. The main cause of these infections is though to be local contamination during the implantation. The commonest causal organism is the staphylococcus (75 to 92%), the staphylococcus aureus being the cause of acute infections whereas the staphylococcus epidermis is associated with cases of secondary infection. The usual clinical presentation is infection at the site of the pacemaker but other forms such as abscess, endocarditis, rejection of the implanted material, septic emboli and septic phlebitis have been described. The diagnosis is confirmed by local and systemic biological investigations and by echocardiography (especially transoesophageal echocardiography) in cases of right heart endocarditis. There are two axes of treatment: bactericidal double antibiotherapy and surgical ablation of the infected material either percutaneously or by cardiotomy. Though controversial, and unsupported by scientific evidence, the role of systematic, preoperative, prophylactic antibiotic therapy in the prevention of these complications seems to be increasing.

Use of the continuity equation for transesophageal Doppler assessment of severity of proximal left coronary artery stenosis: a quantitative coronary angiography validation study.

OBJECTIVES: We tested the value of transesophageal Doppler echocardiography (TEDE) for quantitating proximal left coronary artery (LCA) stenosis by using the continuity equation. BACKGROUND: The continuity equation applied to a stenosis states that the ratio of the time-velocity integral (TVI) of prestenotic to stenotic flow velocities is equal to the ratio of stenotic to prestenotic cross-sectional areas. TEDE allows the measurement of coronary blood flow velocities within the proximal part of the LCA. METHODS; Forty-one patients with a stenosis of the proximal or mid left anterior descending coronary artery or with a nonostial stenosis of the left main coronary artery were studied. Coronary flow velocities were recorded by TEDE guided by color flow imaging. Prestenotic velocities were recorded by pulsed Doppler echocardiography and transstenotic velocities were recorded by pulsed or high pulse repetition frequency or continuous wave Doppler echocardiography. The prestenotic and transstenotic diastolic TVIs were calculated and the TEDE-derived percent area stenosis was calculated as (1 - TVI ratio) x 100. Quantitative angiography lesion analysis was performed using a computer-assisted automated edge-detection system. RESULTS: TEDE recordings were successful in 35 of the 41 patients. A good linear correlation was found between TEDE and quantitative angiographically derived percent area stenosis (r = 0.89, p = 0.0001, SEE 5.7). However, TEDE measurements underestimated the actual percent area stenosis (slope of regression 0.54). A better agreement (slope 1.08) was obtained after dividing prestenotic velocity by 2 in the continuity equation, based on the assumption of a parabolic cross-sectional velocity profile in the prestenotic segment. CONCLUSIONS: TEDE may be used for quantitating stenosis of the proximal part of the LCA with the use of a modified continuity equation that takes into account the parabolic velocity profile in the normal prestenotic segment.

Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis.

BACKGROUND: Infection remains a serious complication after permanent pacemaker implantation. Antibiotic prophylaxis is frequently prescribed at the time of insertion to reduce its incidence, although results of well-designed, controlled studies are lacking. METHODS AND RESULTS: We performed a meta-analysis of all available randomized trials to evaluate the effectiveness of antibiotic prophylaxis to reduce infection rates after permanent pacemaker implantation. Reports of trials were identified through a Medline, Embase, Current Contents, and an extensive bibliography search. Trials that met the following criteria were included: (1) prospective, randomized, controlled, open or blind trials; (2) patients assigned to a systemic antibiotic group or a control group; (3) end point events related to any infection after pacemaker implantation: wound infection, septicemia, pocket abscess, purulent secretion, right infective endocarditis, inflammatory signs, a positive culture, septic pulmonary embolism, or repeat operation for an infective complication. Seven trials met the inclusion criteria. They included 2023 patients with established permanent pacemaker implantation (new implants or replacements). The incidence of end point events in control groups ranged from 0% to 12%. The meta-analysis suggested a consistent protective effect of antibiotic pretreatment (P=.0046; common odds ratio: 0.256, 95% confidence interval: 0.10 to 0.656). CONCLUSIONS: Results of the present meta-analysis suggest that systemic antibiotic prophylaxis significantly reduces the incidence of potentially serious infective complications after permanent pacemaker implantation. They support the use of prophylactic antibiotics at the time of pacemaker insertion to prevent short-term pocket infection, skin erosion or septicemia.

Prevalence of factor V Leiden (APCR) and other inherited thrombophilias in young patients with myocardial infarction and normal coronary arteries.

OBJECTIVE: To investigate the role of activated protein C resistance (APCR, factor V Leiden) in coronary artery thrombosis. METHODS: The prevalence of APCR and of congenital deficiencies of antithrombin III, protein C, protein S, plasminogen, and factor XII was investigated in adult patients under 45 years of age with acute myocardial infarction. The results were compared with those of a group of 53 age and sex matched control subjects. RESULTS: Among 75 patients under the age of 45 years who were admitted from November 1994 to April 1996 for acute myocardial infarction, 22 (29.3%) had normal coronary arteriography (group I) and 53 (70.7%) had significant coronary artery disease (group II). Inherited thrombophilia was more often found in group I (4/22, 18.2%) than in group II (4/53, 7.5%) but the difference was not significant (F test: p = 0.22). The prevalence of APCR was 9.1% (2/22) in group I, 3.8% (2/53) in group 2 (p = 0.57), and 3.8% (2/53) in the normal control group (p = 0.57). CONCLUSIONS: The prevalence of congenital thrombophilias, including APCR, does not seem to be increased in young patients with myocardial infarction and normal coronary angiograms, compared with young patients with coronary atherosclerosis and with normal control subjects. However, the statistical power of the study is too low to detect a significant difference and these results are published to allow a meta-analysis of this problem in the future.

[Severe coronary events and corticoids bolus. An update apropos of 3 new cases]. / Accidents coronaires graves et bolus de corticoïdes. Mise au point à propos de trois nouvelles observations.

The authors report two new cases of angina and/or myocardial infarction and one sudden death after an infusion of a bolus of high dose steroids. Coronary spasm, demonstrated in one of the cases and highly probable in the other two, is proposed as the mechanism of ischaemia. The authors underline the importance of the underlying pathology, previous coronary history, and the modes of administration. This type of treatment is often essential in clinical medicine and therefore the potentially severe secondary effects must be understood. Therefore, a previous history of myocardial infarction constitutes a definitive contra-indication and the duration of injection must be over one hour for doses greater than 250 mg. In all cases, a detailed medical history and an ECG are essential before starting treatment.

[Periaortic fibrosis with pericardial and perirenal involvement: apropos of a case]. / Fibrose périaortique avec envahissement péricardique et périrénal: à propos d'un cas.

The authors report a case of right ventricular insufficiency by constrictive pericarditis revealing aortic and retroperitoneal fibrosis. Only one similar case has been published. We discuss the etiology of this affection, the possible analogies with idiopathic systemic fibrosis and Takayasu's disease and the possible participation of thyroiditis disease and therapy (particularly propranolol).

[Myocardial infarction following rapid perfusion of corticoids]. / Infarctus du myocarde au décours d'une perfusion rapide de corticoïdes.

The authors report the case of myocardial infarction occurring immediately after rapid intravenous infusion of a high dose of corticosteroids prescribed for a relapse of multiple sclerosis. Ventriculography confirmed the myocardial damage but the coronary arteries were normal. An aetiological investigation was negative. The authors review the cardiac secondary effects which may be very serious and even fatal. Coronary insufficiency is rare (only 3 previously published cases); it is therefore difficult to determine the prognosis. The possible mechanisms of infarction are discussed. Finally, the authors underline the importance of recording an ECG before treatment, of ECG monitoring during the infusion, and the need for repeating the recordings and of prolonging hospital admission when necessary.

Myocardial infarction and nicotine patch: a contributing or causative factor?

A case of angina pectoris revealed by nicotine patch treatment is described in a patient who continued to smoke and subsequently suffered a myocardial infarction. The various side effects of nicotine and its derivatives are recalled. The action of nicotine on coronary vasomotricity and its mediators is discussed.

[Painless infarction in antiphospholipid syndrome]. / Infarctus indolore au cours du syndrome des antiphospholipides.

The authors report a rare case of myocardial infarction secondary to coronary thromboses caused by the antiphospholipid syndrome. The relations between the cardiac pathology, especially the coronary disease, and antiphospholipid antibodies are recalled. The importance and methods of monitoring the anticoagulant therapy are emphasised.

[Left bundle-branch block and chest pain of simultaneous occurrence during exercise]. / Bloc de branche gauche et douleur thoracique d'apparition simultanée à l'effort.

The authors report a new case of left bundle branch block with pain during exercise, with arteriographically normal coronary arteries. Clinical findings and the course of the condition are reviewed. Pathophysiological mechanisms are discussed, with attribution of first place to an ischemic theory.

[Markers of hemostasis and myocardial infarction in persons under 40 years of age]. / Marqueurs de l'hémostase et infarctus du myocarde avant 40 ans.

Coronary disease before the age of 40 has special clinical and pathogenic features. The authors sought evidence of the existence of abnormalities of hemostasis markers in 39 patients aged under 40, several weeks after a myocardial infarction (MI). Blood samples were drawn a mean of 8 months after the MI. These laboratory studies included assay of C and S proteins, fibrinogen, clotting factors VII and VIII and antithrombin III, as well as detection of any possible circulating anticoagulant. Plasma levels of platelet factor 4 (PT4) and of beta-thromboglobulin (BTG) were measured in the same sample, enabling determination of the BTG/PF4 ratio. Only fibrinogen and plasma levels of platelet proteins were abnormal, revealing a significant difference between patients with multi-vessel disease and those with single vessel disease or free of severe angiographic lesions. Platelet activation appeared to persist some time after the MI, chiefly in patients with multi-vessel disease, and showing no relation to either age or treatment. Conclusions require prudence in view of difficulties in interpreting plasma assays of PF4 and of BTG.