[Rotational coronary angiography]. / Angiographie coronaire rotationnelle.

CONTEXT: Rotational angiography (RA) is a radiological technique that provides multiple views of a vessel for a single injection of contrast. Its significance in the field of coronary angiography is poorly known at present. This study aimed to compare the radiation dose as well as the volume of contrast used during RA compared to standard angiography (SA), and to evaluate its diagnostic precision. METHOD: 78 patients sent for diagnostic coronary angiography were explored using the radial approach. The patients were randomised between RA (3 acquisitions for the left coronary and 1 for the right coronary) or SA. Once a decision to undertake angioplasty had been made following the angiography (RA or SA), the initial study was complemented using the alternative technique (SA or RA) before the angioplasty procedure was performed at a later stage. The severity of the lesions as shown by RA and SA was compared by four experienced coronary angiography operators. RESULTS: 65 patients (mean age 61+/-10 years--mean BMI 26+/-4 Kg/m2) underwent complete RA+SA investigation. The total x-ray dose used during ciné-angiography, the dose received by the patient, and the volume of contrast were significantly reduced in the RA group compared to the SA group (-25%; -36%; -33% respectively). An evaluation of the severity of the stenoses was performed on 168 arterial segments. There was a significant correlation between the two techniques (R=0.95--p<0.001) and the intra-observer variability was non significant (3.7+/-6.8%--p=NS). CONCLUSIONS: Rotational angiography allows the radiation dose and the volume of contrast to be reduced, while retaining a diagnostic precision similar to that of standard angiography.

Procedural characteristics of primary coronary angioplasty in diabetic patients with acute anterior myocardial infarction.

BACKGROUND: Mortality and morbidity rates are higher in diabetics compared to non-diabetics after acute myocardial infarction (AMI). Previous angiographic studies regarding primary angioplasty for the treatment of AMI found that angioplasty was similarly successful in diabetics and non-diabetics. However, it is noteworthy that patients of "real life" are often far from the population randomised in prospective protocols. The aim of this study was to examine the procedural characteristics of consecutive diabetic patients hospitalised for anterior AMI and treated with primary angioplasty as compared to non-diabetics. METHOD: We analysed 28 consecutive diabetics and 74 non-diabetics who underwent primary angioplasty for anterior AMI (< 12 h from the onset of symptoms) during 15 consecutive months between 2000 and 2001 in our institution, depending on the presence or absence of diabetes. RESULTS: Among analysed data, we found that in diabetics compared to non diabetics: (i) the delay before arrival in the cath-lab was significantly longer (5.5 +/- 2.7 vs 4.2 +/- 2.8 h); (ii) there was a less important collateral flow coming from the non-culprit arteries towards the culprit artery; (iii) there was a less important rate of recovery of a normal flow (TIMI 3) in the culprit artery after coronary angioplasty (67% vs 91%). CONCLUSION: Our study demonstrates that several procedural characteristics could explain the poorer prognosis of AMI treated by primary angioplasty in the diabetic population. The longer delay found in diabetics before arrival in hospital could probably be improved.

Ventricular function and arterial compliance in patients with congestive cardiomyopathy.

In order to study the interrelationship between left ventricular afterload, estimated from the mean left ventricular wall stress, and the mechanical properties of the aorta, we have simultaneously measured systemic arterial compliance and left ventricular wall stress in 19 patients with congestive cardiomyopathy. The strong linear relationship between the ejection fraction of the left ventricle and systemic arterial compliance, and between left ventricular wall stress and systemic arterial compliance, suggests that systemic arterial compliance is an important determinant of left ventricular afterload and thus of left ventricular function.

Relationships between single-vessel coronary artery obstructions and wall motion dysfunction analyzed by four computer-based methods.

We analyzed regional wall motion in 238 patients by using cineangiograms recorded in the 30 degrees right anterior oblique projection. The sample was divided into three groups: a normal group (n = 71), a group with isolated obstruction of the left anterior descending coronary artery and previous anterior myocardial infarction (n = 85), and a group with isolated obstruction of the right coronary artery and previous inferior myocardial infarction (n = 82). Both anterior and inferior groups also had motion abnormality within the corresponding anterior or inferior wall as judged by the qualitative analysis of cineangiograms. Four quantitative methods were compared: a long axis method and a center of mass method using internal reference systems, a method derived from the Stanford model and an area-based method using external reference systems. Normal regional values were determined from the normal group to evaluate the specificity and sensitivity of the methods. The area-based method was the most sensitive in the anterior infarction group, whereas the center of mass method was the most sensitive in the inferior infarction group. We conclude that there is no evidence that any method, among those tested, is superior to others for every expected location of wall motion abnormality.

Hemodynamic evaluation of hypotension during chronic hemodialysis.

Hypotensive episodes occur frequently during hemodialysis; they are often sudden and difficult to prevent despite careful clinical control. Their etiology was studied by investigating the hemodynamic response of five patients submitted to ultrafiltration during their three first dialyses. A Swan Ganz catheter was inserted and left in position for 5 days. Simultaneous determination of cardiac output, mean pulmonary artery (PAP) and capillary and systemic arterial pressures were recorded. 10 hypotensive episodes were observed. In 3 patients in whom the first hypotensive episode occurred 10 minutes after the start of dialysis, there was a significant drop in PAP, cardiac index and stroke index while heart rate and peripheral resistance remained unchanged. Paradoxical bradycardia was observed. In 4 patients hypotension was observed more than one hour after initiation of dialysis. Before the hypotensive episode there was moderate elevation of heart rate and peripheral resistance and an insignificant reduction in PAP. Cardiac index and stroke index were diminished. The decrease in MAP was only 2 mm Hg. Hypovolemia is the most important factor in hemodialysis-induced hypotension but other factors such as vagal stimulation, autonomic neuropathy and osmotic disequilibrium can interfere with blood pressure control and trigger hypotension. Methods of preventing hypotension during dialysis, including the infusion of low molecular weight dextran, are discussed.

[A simplified arteriographic analysis of systolic pressure and of the pressure-time index]. / Evaluation angiographique simplifiée de la tension systolique et de l'index tension-temps.

Systolic stress has been measured in 20 ms periods during ventricular ejection by monoplanar angiographic method, both under basal conditions and after infusion of trinitro-glycerine (TNG) in 8 coronary patients. None of them showed significant segmental contraction abnormality. No correlation was found between the corresponding values of mean systolic stress sigma and mean systolic pressure P, either under basal conditions (r=0.48) or after reduction of the load (r=0.24). On the other hand, values of sigma correlated closely with the corresponding values of the stress sigmas at the end of the isovolumic contraction phase, both under basal conditions (r=0.95) and after TNG (r=0.98. A similar correlation was found between the corresponding values of the peak of systolic stress and of sigmas both under basal conditions (r=0.94) and after TNG (r=0.96). Determination of sigmas is technically simple, and only requires the calculation of ventricular end-diastolic volume, together with measurement of end-diastolic thickness and aortic diastolic pressure. This simplified angiographic method is useful to express the determinants of myocardial energy using parietal stress values instead of intracavitary pressure values.

[Quantitative analysis of ventricular volumes by digital two-dimensional echocardiography]. / Analyse quantitative des volumes ventriculaires par échocardiographie bidimensionnelle numérisée.

The purpose of this study was to assess the usefulness of digital enhancement of two-dimensional echocardiographic images by cardiac cycle-synchronized summation and digital manipulation of the resulting images. We developed a system which provides for: (1) real-time storage of end-diastolic and end-systolic cardiac cycle images irrespective of rhythm variations; (2) exclusion from summation of end-diastolic and end-systolic images altered by respiratory movements or transducer displacements; (3) performance on the resulting images of various mathematical operations (3*3 convolutions, colour scale-guided manipulation of grey shades); (4) performance of complex mathematical calculations from the extracted edges including, in particular, reconstruction of ventricular volumes by Simpson's crossed method from a transverse and an apical section or from two apical sections. This method was used to collect echocardiographic images from 32 patients who had undergone left ventricular quantitative angiography during the same week. Qualitatively, digital enhancement of two-dimensional echocardiographic images undoubtedly facilitated the identification of endocardial edges and reduced image noise, notably in patients whose ventricular edges were virtually unrecognizable by any other method. Moreover, summation improved correlations with angiography and reduced the variability of quantitative ventricular volume assessment. Finally, the ease and rapidity with which this "real-time" system can be used enables quantitative analysis of left ventricular function to be routinely carried out.

[Effect of nitroglycerin and N-ethoxycarbonyl-3-morpholinosydnonomine on the walls of large arteries]. / Action de la nitroglycérine et de la N. éthoxycarbonyl-3-morpholinosydnonimine sur les parois de gros troncs artériels.

Systemic arterial compliance was measured in 20 patients with left ventricular failure due to congestive cardiomyopathy. The method consisted in evaluating arterial compliance by analysing the exponential fall of the arterial pressure curve on a simple visco-elastic model. In the patient group, significant correlations were found between arterial compliance and age (r = 0,64 ; p less than 0,01) and arterial compliance and systolic blood pressure (r = -0,58 ; p less than 0,001). These relationships suggest that arterial compliance depends on the height of the systolic blood pressure and/or the elasticity of the arterial walls. Two groups of patients were defined : Group I (10 patients) given a single oral dose of 7,5 mg of nitroglycerine (Lenitral), and Group II (10 patients) giben a single oral dose of 4 mg N ethoxycarbonyl-3-morpholinosydnonomine (Molsidomine). There was no significant difference in the hemodynamic parameters or arterial compliance between the two groups before administration of these drugs. However, systolic blood pressure was significantly lower (p less than 0,01) and compliance significantly higher (p less than 0,05) after treatment in Group II. In Group I, nitroglycerine caused a significant increase in compliance (p less than 0,01), a significant decrease in systolic (p less than 0,02) and mean blood pressure (p less than 0,05) whilst heart rate, cardiac output and total systemic resistance remained unchanged. In Group II, Molsidomine caused a significant increase in arterial compliance (p less than 0,01), a decrease in systolic (p less than 0,001), diastolic (p less than 0,01) and mean blood pressure (p less than 0,01) and in cardiac output (p less than 0,01), whilst heart rate and total systemic resistance remained unchanged. This study shows that both drugs studied had significant effects on the walls of the large arteries.

[Changes in the physical properties of the arterial system and left ventricular performance with age and in permanent arterial hypertension: their interrelation]. / Modifications des propriétés physiques du système artériel et de la performance ventriculaire gauche avec l'âge et au cours de l'hypertension artérielle permanente: leurs interrelations.

The purpose of this work was to study interactions between physical properties of the arterial system and left ventricular performance during aging in normal and in hypertensive patients. 50 patients were studied; 28 normal patients (age range 22 to 68 years) and 22 patients with essential hypertension (age range 23 to 63 years). In hypertensive patients, the end systolic pressure-volume ratio (ESP/ESV), modulus of chamber stiffness (kp), left ventricular wall thickness (h), mass (m), m/LVEDV ratio (LVEDV: left ventricular end diastolic volume), systemic arterial resistance (SAR), pulse wave velocity (C) and characteristic impedance of the ascending aorta (Zc) were increased compared to normal subjects of similar age. The ejection fraction (EF), the mean velocity of fiber shortening (VCF) and dp/dt max were unchanged. In normal patients: the ESP/ESV ratio, kp, h, m, m/LVEDV ratio, SAR, C and Zc increased with age; there were no age related changes in EF, VCF or dp/dt max. In both groups, there was a close relationship between the m/LVEDV ratio and Zc, the characteristic impedance of the ascending aorta. These results suggest that: 1. aging and arterial hypertension lead to similar changes in the physical properties of the arterial system and in left ventricular performance; 2. in both cases, the development of concentric cardiac hypertrophy is closely related to the physical properties of the arterial system.

[Recurrent ventricular tachycardia due to right ventricular dysplasia. Association with left ventricular anomalies]. / Tachycardies ventriculaires récidivantes par dysplasie ventriculaire droite. Association à des anomalies du ventricule gauche.

The authors report a case of arrhythmogenic right ventricular dysplasia in a 61year old male with a 9 year history of recurrent ventricular tachycardia with a left bundle branch block configuration and without any signs of cardiac failure. A right ventricular angiography showed morphological changes suggestive of Uhl's anomaly and left ventricular angiography showed segmental wall dysfunction. In the absence of coronary artery disease, this case raises the questions of left ventricular extension of right ventricular dysplasia and of the value of left ventricular angiography in adult forms of Uhl's anomaly.

[Adiastole caused by a secondary cardiac hemochromatosis. Successful treatment with an iron chelating agent]. / Adiastolie par hémochromatose cardiaque secondaire. Guérison par traitement chélateur du fer.

Severe congestive cardiac failure developed in a few weeks in a 44 year old man who had undergone porto-caval anastamosis for post-hepatitis cirrhosis one year previously and then treated for anaemia by repeated blood transfusion and chronic daily oral iron therapy. Infiltrative, congestive and restrictive cardiomyopathy was diagnosed in the presence of global cardiomegaly, electrocardiographic changes (microvoltage, diffuse ST-T wave changes), echocardiographic appearances (dilatation of the left ventricle, with hypertrophic and hypokinetic walls), and hemodynamic signs of adiastole with equalisation of filling pressures at 15 mmHg and a cardiac index of 1,88 l/min/m2. Cardiac haemochromatosis was confirmed by the laboratory (serum iron: 35 mumol/l; siderophilin saturation: 100 p. 100; serum ferritin: 1854 ng/ml; induced siderouria: 51 mg/24 hours) and histological findings (endomyocardial biopsy showing pigment overload). The absence of a family history, of homozygote A3 antigen, of diabetes, of iron overload on hepatic biopsy one year previously, excluded the diagnosis of familial idiopathic haemochromatosis. A secondary form of the disease was diagnosed on a possible genetic predisposition (heterozygote A3 antigen) and on environmental factors (blood transfusions, iron therapy, cirrhosis, alcoholism and perhaps the porto-caval anastamosis. Cardiac haemochromatosis was cured in this case by iron chelating therapy comprising daily subcutaneous infusions of 2 g of desferrioxamine for 2 months. The cure was confirmed by regression of the signs of clinical cardiac failure and of cardiomegaly, the increase in QRS voltages and the near normalisation of the hemodynamic and laboratory findings.