[Indications of coronary angioplasty after thrombolysis]. / Indications de l'angioplastie coronaire après thrombolyse.

Thrombolysis is the most widely used method of coronary reperfusion in the acute phase of myocardial infarction. The indications of angioplasty after thrombolysis have been subject of considerable controversy over the last few years. Three randomised trials (TIMI 2, TAMI, ECSG) have shown that it is not desirable to perform systematic immediate angioplasty after intravenous thrombolysis with rt-PA. Angioplasty may be carried out as a "salvage" procedure in cases of failure of thrombolysis. The validity of this approach was confirmed recently by the "RESCUE" trial in anterior myocardial infarction. The practical application of its results is confronted by logistical problems inherent to the practice of angioplasty in the acute phase of myocardial infarction and to the inadequacy of non-invasive methods for the detection of coronary reperfusion after thrombolysis. Angioplasty may also be necessary in cases of left ventricular failure or cardiogenic shock. The efficacy of a rapid angioplasty in cases of recurrence of ischaemia after thrombolysis has been proved in reducing mortality and preserving left ventricular function. The results of TIMI IIB and SWIFT trials show that secondary angioplasty, several days after thrombolysis, is only usually indicated in patients with residual clinical ischaemia or positive stress tests. This attitude should however be modulated in the light of the "open artery" theory and the limitations of methods of evaluating myocardial viability. The present strategies will no doubt be modified with the introduction of new thrombolytic and/or antithrombotic agents and the use of coronary stents.

[Thrombosis of mechanical tricuspid valve prosthesis: treatment by tissue-type plasminogen activator. Success after a 18 month-follow-up]. / Thrombose d'une prothèse mécanique en position tricuspide: traitement par l'activateur tissulaire du plasminogène. Succès avec un recul de 18 mois.

Four years after a triple valve replacement, a 51 year old woman presented with signs of thrombosis of her tricuspid Saint Jude valve prosthesis, confirmed at echocardiography and fluoroscopy. Treatment with tissue-type plasminogen activator was completely successful with a result which was sustained at 18 months. A review of the literature confirms the superiority of thrombolytic therapy of first intention in the treatment of thrombosis of tricuspid mechanical prosthetic valves.

[Factors influencing survival after surgery of pure non-ischemic mitral insufficiency]. / Facteurs influençant la survie après chirurgie de l'insuffisance mitrale pure non ischémique.

Uni and multifactorial (Cox) statistical analysis of the results of surgery in a series of 247 patients operated between 1969 and 1988 for pure, non-ischaemic mitral regurgitation was undertaken to determine the factors influencing operative and late mortality. All but 3 cases were adults, average age 51 years, and very symptomatic (75 per cent Class III et IV of NYHA Classification). Dystrophic or degenerative lesions were responsible for 53 per cent of cases of regurgitation whilst rheumatic valvular disease was only observed in 30 per cent of cases. Mitral valve replacement was performed in 137 patients (96 mechanical and 41 bioprostheses) and conservative surgery was possible in 110 cases. There were 12 operative deaths (4.9%); the operative risk increased with age and with the practice of valve replacement. Eleven of the 235 survivors (4.7%) were lost to follow-up. During the follow-up period (average 58 months) there were 37 late deaths of which nearly a half were due to left ventricular dysfunction. Multifactorial analysis identified cardiothoracic ratio and atrial fibrillation as predictive factors of late mortality whilst left ventricular ejection fraction and the type of surgery were related to the development of left ventricular dysfunction. The postoperative left ventricular ejection fraction was significantly lower after valve replacement than after valvuloplasty (11 +/- 13% vs 3 +/- 13%; p less than 0.01). These results are therefore in favour of early correction of severe mitral regurgitation by conservative surgery whenever possible.

[Hemodynamic evaluation of Ionescu-Shiley pericardial bioprostheses]. / Evaluation hémodynamique des bioprothèses péricardiques de Ionescu-Shiley.

36 patients with a total of 39 pericardial Ionescu-Shiley bioprostheses (20 aortic, 13 mitral and 3 double valve replacements) were studied. The population consisted if 12 women and 24 men with an average age of 33 +/- 11 years. The control was performed on average 7 +/- 4 months after surgery. At the time of investigation all patients were in functional classes I or II of the NYHA. The average cardio-thoracic ratio was 0.51 +/- 0.05. The catheter data showed a mean pulmonary capillary pressure of 10 +/- 2.7 mmHg, a mean cardiac index of 3.2 +/- 0.9 l/min/m2, a mean end diastolic volume of 132 +/- 33 ml/m2 and a mean ejection fraction of 0.53 +/- 0.12. Haemodynamic data was obtained under basal conditions and during intravenous infusion of isoproterenol. The average transvalvular pressure gradient was measured by transseptal catheterisation. The cardiac output was measured by dye dilution and the functional surface area calculated using the Gorlin formula (k = 44.5 for the aortic valve and k = 31 for the mitral valve). Perivalvular leaks were excluded by selective left ventriculography or aortography. The average transvalvular pressure gradients for the aortic valve prostheses (no 19 = 1, no 21 = 4, no 23 = 3, no 25 = 7, no 27 = 8) were 17 +/- 7 mmHg for no 19 and 21, 12 +/- 5 mmHg for no 23 and 25, and 9.7 +/- 2.7 mmHg for no 27.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic criteria and prognosis of perioperative myocardial infarction following coronary bypass.

To evaluate the incidence of perioperative myocardial infarction (PMI), serial determinations of serum creatine kinase isoenzymes (CK-MB), electrocardiograms (ECGs), and pyrophosphate myocardial scans were performed in 112 patients undergoing isolated coronary bypass grafting. An abnormal increase in total CK-MB liberation (Q greater than 9.8 IU ml-1 kg) occurred in 25 patients (22.3%), new Q waves were present at ECG in 10 patients (8.9%), and the pyrophosphate myocardial scan was abnormal in 13 patients (11.6%). All tests were negative in 81 patients (72.3%). A diagnosis of PMI was established if confirmed by at least two of the techniques; this diagnosis was made in 15 patients (13.4%). The pattern of CK-MB liberation in patients with a PMI, characterized by a high peak and a prolonged release, was significantly different from that of patients without a PMI. The most important predictive factor for PMI was the duration of myocardial ischemia during the operation. Patients who had a PMI had more frequent early complications, and their prognosis at 2 years showed a 51% probability of remaining free of new cardiac events as compared to 96% for the group of patients without a PMI (p less than 0.001). PMI is not a benign complication of coronary bypass, and its detection appears improved by a combination of diagnostic tests.

[Hemodynamic and angiographic results following surgical correction of mitral insufficiency. Apropos of 51 repeated catheterizations]. / Résultats hémodynamiques et angiographiques après correction chirurgicale de l'insuffisance mitrale. A propos de 51 cathétérismes itératifs.

The benefits of surgical correction of mitral incompetence were assessed in 51 patients by comparing pre and postoperative catheter and quantitative angiographic results. The mean age of the patients was 43.5 +/- 12.3 years. The mitral lesions were elongation or ruptured chordae (27 cases), valvular perforation due to endocarditis (1 case) and the usual rheumatic disease in 23 cases. Hemodynamic investigation was carried out on average 2 months before operation and 29 +/- 22 months after surgery. The following angiographic parameters were measured : indexed end diastolic and end systolic volumes (EDV and ESV), ejection fraction (EF), myocardial mass (MM) and its ratio to EDV (hypertrophy coefficient : HC) and the geometry of the ventricle as assessed by diastolic and systolic coefficients of excentricity (DE and SE). Surgery comprised 13 mitral valvuloplasties and 38 valve replacements. Patients who suffered perioperative myocardial infarction or who had a residual valvular lesion were excluded from the study. After surgery, the hemodynamic state was considerably improved with a significant decrease in pulmonary capillary pressures (11 +/- 5 compared to 17 +/- 6 mmHg, p less than 0.09) and mean pulmonary artery pressures (19 +/- 7 compared to 27 +/- 11, p less than 0.01) and increase in cardiac index (2.8 +/- 0.7 compared to 2.3 +/- 0.6 l/min/m2, p less than 0.01). There was an associated decrease in ventricular volumes (EDV : 115 +/- 44 compared to 165 +/- 43, p less than 0.01) (ESV : 60 +/- 39 compared to 77 +/- 22, p less than 0.001). The reduction in myocardial mass was less spectacular (129 +/- 40 compared to 148 +/- 32, p less than 0.01) with a resulting increase in the HC (1.10 +/- 0.26 compared to 0.88 +/- 0.17, p less than 0.001). The geometry of the LV was less spherical in diastole (DE 0.76 +/- 0.08 compared to 0.70 +/- 0.08, p less than 0.001) and in systole (SE = 0.83 +/- 0.06 compared to 0.77 +/- 0.08, p less than 0.001). The EF fell slightly but this was not statistically significant (0.51 +/- 0.13 compared to 0.53 +/- 0.09 NS). The surgical result of 14 patients with PCP greater than or equal to 13 mmHg was considered hemodynamically incomplete, and this was confirmed by a lower cardiac index than in the remaining 37 patients (2.4 +/- 0.5 compared to 3.0 +/- 0.7, p less than 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

Acute effects of intravenous prifuroline and amiodarone on canine cardiac automaticity, conduction, and refractoriness.

We compared the acute electrophysiologic properties of prifuroline (P), a new aminopyrroline derivative, to those of amiodarone (A) in pentobarbital-anesthetized dogs using His bundle recordings and programmed stimulation. Ten dogs received in randomized order four cumulative doses of P (2.5-20 mg/kg) and of A (1.25-10 mg/kg) with a 14-day interval between drug administrations. In a control group of four dogs receiving the diluent of the drugs, no significant changes occurred in cardiac automaticity, conduction, and refractoriness except for the atrioventricular (AV) nodal functional refractory period (RP), which increased with time (p less than 0.05). P and A produced a significant dose-related decrease in heart rate and in sinus node recovery time, with A being 3.7-3.1 times more potent than P. While atrionodal conduction time increased with both drugs, only P resulted in a significant dose-related increase in the His-Purkinje system conduction time. Prifuroline was 2.9 times more potent than A in increasing the atrial effective refractory period, while A was 2.5 times more potent than P in increasing the ventricular effective refractory period. Both drugs increased the AV nodal refractoriness in a dose-dependent way. These results suggest that the new compound prifuroline possesses some properties similar to intravenous amiodarone on sinus automaticity, atrionodal conduction, and atrial and ventricular refractoriness. However, its effects on the His-Purkinje System are typical of those of a class I quinidine-like agent.

Surgery of post-myocardial infarction scars. Early and late results in 70 patients.

Immediate and late postoperative results in 70 patients undergoing resection of a true left ventricular aneurysm (50 patients) and of an asynergic area (20 patients) are presented. The operative mortality was 14 per cent. Predicted survival by actuarial methods was 80 per cent at one year after operation and 65 per cent at six years. Functional improvement was obvious with most of the survivors falling in NYHA class I or II. Factors influencing operative mortality were the clinical indication for operation and the anatomical lesion. Late postoperative results were better for true aneurysms than for asynergic areas. An asynergic area was usually associated with multiple coronary vessel lesions and a diffusely ischaemic myocardium. An aneurysm was often associated with a single coronary vessel disease and with good function of the non-infarcted myocardiun.