Diagnostic value of image processing in myocardial scintigraphy.

The diagnostic value of stress myocardial analog scintigrams, and of five image-processing methods, was assessed by a decisional analysis in 96 patients undergoing coronary arteriography. The methods involved digitalization, nine-point binomial smoothing, background subtraction by linear interpolation, stationary filtering, and a combination of them. The difference between after-test probabilities of having the disease with a positive or a negative examination provided a discriminant index for different prevalences of the disease. Though the processing methods failed to improve the detection of a circumflex stenosis, the stationary filter significantly increased the diagnostic value for the detection of stenosis in a left anterior descending artery for a large range of prevalence, and in a right coronary artery at high prevalence. Thus, the filter seemed to provide a useful tool for enhancing the diagnostic value of myocardial scintigraphy.

[Arterial pressure during exertion in patients operated on for aortic coarctation]. / Etude de la tension artérielle à l'effort des coarctations aortiques opérées.

19 patients were studied after operation for coarctation of the aorta. The average age at operation was 13.7 years. Crafoord's operation was performed in 16 cases and in the other three an aortic patch was necessary. The average post-operative period was 4.7 years. 14 cases were classified as good results: normal femoral pulses and arterial blood pressure. The other 5 cases were considered as unsatisfactory: 2 mediocre results with normal arterial blood pressure but diminished femoral pulses and oscillometric indices; 3 poor results with hypertension at rest. On exercise with bicycle ergometry the following results were obtained: the systolic blood pressure rose in a comparable manner to that observed in normotensive individuals of the same age on exercise except in 2 cases. These two patients had an aortic patch and one had a residual intraaortic pressure gradient. The pronostic significance of these findings is not known. However the use of an aortic patch is often associated with abnormal blood pressures at rest or on exercise. The fact that the majority of patients operated for coarctation of the aorta have normal blood pressure profiles on exercise should be emphasised.

[Aortocoronary bypass permeability explored by tomodensitometry. Preliminary study]. / Perméabilité des pontages aorto-coronaires explorés par tomodensitométrie. Etude préliminaire.

The patency of 24 aorto-coronary grafts was studied by tomodensitometry. --16 out of the 18 bypasses examined within the two weeks following surgery were seen. --4 older bypasses were not visible, either by scanner or by angiography and were therefore occluded: two more, performed more than a year previously, were patent on tomodensitometric examination. The interpretation of the results, discussed taking into account the small number of angiographic check ups does not permit any formal conclusion as to the validity of the procedure. The results of this technique seem satisfactory and quite comparable with other non invasive methods used in the study of aorto-coronary grafts.

[Aortic insufficiency caused by incomplete rupture of the ascending aorta. Conservative surgical treatment]. / Un cas d'insuffisance aortique par rupture incomplète de l'aorte sus-sigmoïdienne. Traitement chirurgical conservateur.

Commissural disorganisation secondary to incomplete rupture of the ascending aorta was found at surgery for massive aortic incompetence in a young man with previous hypertension. The lesions were repared by a conservative procedure with an excellent result 3 years after surgery. Incomplete spontaneous rupture of the ascending aorta occurs in the same terrain as dissection of the aorta (hypertension, aortic media necrosis) of which it represents a minor form. It may remain asymptomatic but it is usually complicated either by secondary intrapericardial rupture, by aortic aneurysm or by aortic incompetence due to valvular prolapse. When valvular prolapse is associated with another lesion which aggravates the regurgitation (aortic valve disease, aortic ring dilatation) aortic valve replacement should be performed with a prosthesis; on the other hand, when commissural disorganisation giving rise to valvular prolapse is the cause, a conservative procedure may be envisaged.

[Noninvasive evaluation of aortocoronary bypass graft patency with tomodensitometry and exercise myocardial scintigraphy]. / Evaluation atraumatique de la perméabilité des pontages aorto-coronariens par la tomodensitométrie et la scintigraphie myocardique à l'effort.

The control of the patency of aortocoronary bypass grafts necessitates further coronary angiography, an invasive investigation which is difficult to perform routinely because over 60 p. cent of operated patients are asymptomatic. Non-invasive methods have been proposed for this task, including computerised axial tomography (CAT) and exercise Thallium 201 myocardial scintigraphy (EMS). The aim of this study was to assess the relative value of CAT and EMS, alone and in association, in comparison with coronary angiography. Thirty six patients (35 men, 1 woman) with a mean age of 54 years were studied. These patients had a total of 59 bypass grafts inserted an average of 23 months before investigation (20 single, 10 double, 5 triple and 1 quadruple bypass grafts). CAT scanning was performed the day before coronary angiography. Sections of the thorax 7 mm thick were recorded after intravenous injection of contrast medium. A patent graft was identified as an opacity increasing after the injection of contrast on one of the aortic walls. During coronary angiography a graft was declared to be patent when it was opacified selectively or during aortography, and when the grafted coronary artery was seen to be revascularised. The quality of the distal coronary bed was also evaluated (implantation of the graft, distal and collateral vessels). Twenty three patients (with a total of 36 grafts) also underwent EMS on the same day as CAT scanning. Normal fixation in the revascularised territory was taken as evidence of a patent graft. --Coronary angiography showed that 44/59 grafts were patent at 24 months. --CAT scanning was unable to evaluate 12/59 grafts. Thoracic metallic clips created stratified artifacts and analysis of the section was impossible (20 p. cent of CAT investigations were non-contributive); of the interpretable investigations, 40/47 grafts were correctly assessed (85 p. cent): 30/32 patent grafts and 10/15 occluded grafts. --The results of EMS were less reliable; 23/36 grafts correctly assessed (64 p. cent), 18/27 patent grafts and 5/9 occluded grafts. However, EMS provides complementary information to that provided by CAT scanning, especially with respect to the distal coronary bed. When the two methods were used together, 15/15 good surgical results (patent grafts with good distal vascularisation) and 6/8 poor results (patent grafts but poor distal vascularisation), were identified. We conclude that these two atraumatic methods, CAT scanning and EMS, which may be performed on out-patients, are valuable for the routine assessment of the patency of coronary bypass grafts. Coronary angiography could therefore be reserved for those patients in whom further surgery is being considered.

[Use of isosorbide dinitrate (Risordan) injection in left ventricular failure following acute myocardial infarction (author's transl)]. / Utilisation de l'isosorbide dinitrate injectable dans l'insuffisance ventriculaire gauche de la phase aiguë de l'infarctus du myocarde.

Haemodynamic and echocardiographic studies of isosorbide dinitrate were conducted in 12 patients (8 men and 4 women) with left ventricular failure consecutive to recent myocardial infarction. The groups: group I received 5 mg/h and group II 10 mg/h Risordan intravenously. After one hour treatment, group I patients showed a significant fall in both PAP (from 32.3 +/- 5.3 to 26.7 +/- 6.9 mmHg; p less than 0.01) and PCP (from 21.8 +/- 4.7 to 17.3 +/- 7.7 mmHg; p less than 0.05). These haemodynamic changes were amplified after a second hour of treatment: PAP fell to 24 +/- 7.9 mmHg (p less than 0.01) and PCP to 14.2 +/- 4.4 mmHg (p less than 0.001). RAP decreased from 7.2 +/- 5.1 to 3.5 +/- 5 (p less than 0.05). There were no changes in heart rate, systemic arterial pressure, peripheral resistance, cardiac index, forward stroke work nor, on echocardiography, in ventricular diameters, shortening fraction and VCF. After one hour treatment, group II patients showed a fall in PAP (from 30.5 +/- 4.7 to 21.7 +/- 3.5 mmHg; p less than 0.01), PCP (from 21.7 +/- 4.8 to 14.8 +/- 4.9 mmHg: p less than 0.001) and RAP (from 10.3 +/- 2.9 to 7.2 +/- 2; p less than 0.01). The systolic diameter of the left ventricle was reduced from 66.3 +/- 10.6 to 64.3 +/- 11.3 (p less than 0.01). After 4 hours, improvement in PAP and PCP was maintained; the other values remained stable. The effectiveness of Risordan i.v. in left ventricular failure consecutive to acute myocardial infarction is due to reduction of filling pressures in the left ventricule. With the 10 mg/h dose, as opposed to the 5 mg/h dose, the systemic arterial pressure and the double and triple products tend to be reduced, which suggests greater effectiveness.

[Relationship between symptoms and hemodynamics in aortic insufficiency (author's transl)]. / Relations entre la symptomatologie et l'hémodynamique dans l'insuffisance aortique.

To determine the relationship between functional classes (NYHA) and hemodynamics in patients (pts) with chronic aortic insufficiency, indices of left ventricular (LV) function derived from hemodynamic and biplane left cineventriculographic data were compared with the clinical status in 51 AI pts, including 15 pts in class I, 26 pts in class II and 10 pts in class III. Regurgitant fraction (0.55 +/- 0.15 mean +/- SD), cardiac index (3.1 +/- 0.7 l/mn/m2) and LV end-diastolic pressure (14 +/- 7 mmHg) were of the same order of magnitude in 3 classes patients. A significant correlation was evidenced between functional classes and 1/LV ejection fraction (0.53 +/- 0.13, 0.50 +/- 0.39, 0.42 +/- 0.17 in class I, II, III pts, respectively, p less than 0.04), 2/LV end-systolic volume (88 +/- 48, 90 +/- 31, 138 +/- 68 ml/m2 in class I, II and III pts, respectively p less than 0.02), 3/ and LV mass (168 +/- 57, 204 +/- 94, 291 +/- 128 g/m2 in class I, II and III pts respectively, p less than 0.003). Only the latter parameter could discriminate symptomatic from asymptomatic AI pts.

[Acute mitral incompetence of ischemic origin (author's transl)]. / L'insuffisance mitrale aiguë d'origine ischémique.

Clinical findings and results of treatment in 17 patients with acute mitral incompetence are described. The lesions were secondary to a recent myocardial necrosis causing severe cardiac failure (shock, or acute left ventricular failure), and the presence of mitral incompetence was confirmed by right catherization (15 cases) and/or left ventricular angiography (13 cases). The anatomical lesions are described in 14 cases: rupture of the posterior mitral papillary muscle in 7 cases, and acute dysfunction of the muscle in 7 other cases. Eight patients were treated by an intra-aortic balloon to assist circulation, and 14 were given vasodilators (phentolamine, trinitrin) associated in 5 cases with positive inotropic drugs. Surgical treatment was given (mitral valve replacement) in 7 cases. The respective effects of vasodilators and circulatory assistance are discussed, as well as the indications for, and results of urgent surgical treatment (6 successes in 7 operations).

Comparison of short-term efficacy of diltiazem and propranolol in unstable angina at rest--a randomized trial in 70 patients.

The short-term efficacy of diltiazem (D) has been compared to that of propranolol (P), in a group of 70 patients hospitalized in the Coronary Care Unit for unstable angina, defined as recent (less than one month) appearance or aggravation of spontaneous chest pains. Among the 70 patients, 24 had angina only at rest. The patients have been divided into two groups according to ST-T changes during chest pain: 29 with ST elevation (group A) and 41 with other repolarization abnormalities (group B). Treatment was then randomized in each group. Treatment Treatment was considered successful only if spontaneous chest pains disappeared completely. Thirty-four patients were treated with D (282 +/- 102 mg/day) and 36 with P (158 +/- 81 mg/day). In the whole group and in groups A and B considered individually, responses to D and P did not differ. Among the 24 patients with angina exclusively at rest, nine successes and four failures were observed with D. There was no symptomatic relief among the 11 patients treated by P (P = 0.001). Moreover, the number of episodes of angina was decreased by D and unchanged by P, while eight out of the 11 failures with P were immediate successes when treatment was replaced with D. These results suggest that D is preferable to P for management of unstable angina in patients with angina which is exclusively spontaneous.