Relationships between angiotensin I converting enzyme gene polymorphism, plasma levels, and diabetic retinal and renal complications.

Insulin-dependent diabetes mellitus (IDDM), cardiovascular morbidity, and vital prognosis are linked to diabetic nephropathy, which is probably determined by renal hemodynamic abnormalities and by a genetic predisposition. Angiotensin I converting enzyme (ACE) regulates systemic and renal circulations through angiotensin II formation and kinins metabolism. Plasma and cellular ACE levels are genetically determined; an insertion/deletion polymorphism of the ACE gene is strongly associated with ACE levels, subjects homozygote for insertion (genotype II) having the lowest plasma values. We studied the relationship between the ACE gene polymorphism or plasma levels and microcirculatory disorders of IDDM through two independent studies: one involved 57 subjects with or without diabetic retinopathy, and the other compared 62 IDDM subjects with diabetic nephropathy to 62 diabetic control subjects with the same characteristics (including retinopathy severity) but with normal kidney function. The ACE genotype distribution was not different in diabetic subjects with or without retinopathy and in a healthy population. Conversely, an imbalance of ACE genotype distribution, with a low proportion of II subjects, was observed in IDDM subjects with diabetic nephropathy compared with their control subjects (P = 0.006). Plasma ACE levels were mildly elevated in all diabetic groups, independently of retinopathy, but they were higher in subjects with nephropathy than in those without nephropathy (P = 0.0022). The II genotype of ACE gene is a marker for reduced risk for diabetic nephropathy.

Renin release regulation during acute renin inhibition in normal volunteers.

Blockade of the renin-angiotensin system by an angiotensin converting enzyme (ACE) inhibitor or an angiotensin II (Ang II) antagonist is accompanied by a reactive rise in renin release. This rise is generally attributed to interruption of the short feedback loop between Ang II and renin release. Similarly, after the administration of a renin inhibitor, the plasma concentrations of active and total renin are increased and plasma renin activity is suppressed. The aim of the present study was to investigate if a fall in the plasma Ang II level is the unique determinant of the rise in the active renin (AR) level that follows renin inhibition. Six normal male volunteers participated in three successive 240-minute experiments at weekly intervals according to a single-blind randomized Latin square design. For experiment 1, Ang II was infused at 2 ng/kg/min from 0 to 60 minutes and at 4 ng/kg/min from 60 to 120 minutes. For experiment 2, 0.3 mg/kg of the new potent renin inhibitor Ro 42-5892 was injected at 30 minutes followed by infusion at 0.1 mg/kg/hr from 30 to 240 minutes. For experiment 3, Ang II and Ro 42-5892 were administered simultaneously at the same doses as described above. The mean +/- SEM Ang II concentration increased from 10.2 +/- 1.6 to 33.7 +/- 11.2 pg/ml after infusion of exogenous peptide. It decreased from 9.5 +/- 0.9 to 1.4 +/- 0.3 pg/ml after the injection of Ro 42-5892 and increased from 15.6 +/- 2.9 to 37.1 +/- 11.8 pg/ml after the simultaneous infusion of both compounds.(ABSTRACT TRUNCATED AT 250 WORDS)

Exercise-induced platelet activation in myocardial infarction survivors with normal coronary arteriogram.

Platelet activation may participate in the pathophysiology of myocardial infarction occurring in patients with normal coronary arteriogram. We investigated this possibility in a series of 9 such patients (group A) during a standardized bicycle exercise test as myocardial infarction had occurred in all of them during or soon after strong physical exercise. Twelve patients with effort-induced angina and coronary atherosclerosis (group B) and eleven healthy subjects (group C) served as test groups. Peripheral venous blood was collected by separate venipuncture before, at peak exercise and during recovery. As a sensitive index of activation, the shape of the circulating platelets was examined with a phase contrast microscope after instantaneous fixation of the whole blood. The percentage of non strictly disc-shaped platelets with one or more thin pseudopods was determined. Simultaneously, the plasma levels of platelet factor 4 (PF4) and of beta-thromboglobulin (beta-TG) were measured. At rest, there was no significant difference in the platelet morphology nor in the plasma levels of platelet specific proteins between the three groups. During exercise, a significant change in platelet shape occurred in group A and B patients and not in the healthy subjects. This platelet activation was not related to myocardial ischemia since it occurred to a similar extent in group B patients who developed electrocardiographic changes and in group A patients who did not. There was no detectable release of platelet proteins during exercise in any group.

Changes in blood pressure and renal function following subtotal parathyroidectomy in renal transplant patients presenting with persistent hypercalcemic hyperparathyroidism.

The aims of this retrospective study were to assess renal function and blood pressure after subtotal parathyroidectomy (PTx) performed in renal transplant (RT) patients presenting with persistent hypercalcemic hyperparathyroidism. We identified 34 patients (group A) from our records who had undergone PTx between 1981 and 1994. Group A included 18 women and 16 men with a mean age of 45 +/- 12 years and a mean time on dialysis therapy of 102 +/- 59 months. Thirty of the patients received cyclosporine A (CsA) with or without steroids and/or azathioprine (AZA) and the remaining 4 patients received conventional therapy i.e. AZA and steroids. Twenty-three patients were treated for hypertension and 11 were normotensive. PTx was performed in 21 patients within the first year following renal transplantation and in 13 patients after this period. The study was divided into 3 periods: period 1-pre-PTx; period 2-the month following PTx; period 3-six months after PTx. Parameters were assessed for every patient in each of these periods. Results of group A were compared to those observed in 34 matched (control) RT patients (group B) who did not experience secondary hyperparathyroidism. PTx was associated with a significant decrease in parathyroid hormone (PTH) levels (45 +/- 8 pg/ml vs 338 +/- 54 pg/ml; p = 0.0002) and in calcemia (2.32 +/- 0.18 mmol/l vs 2.75 +/- 0.15 mmol/l; p = 0.0003) during period 3. However, we observed a significant increase in serum creatinine (124 +/- 30 mumol/l vs 110 +/- 25 mumol/l, p = 0.0016) in this group during period 3. Nevertheless, an increase in serum creatinine greater than 30% from baseline which still persisted six months after PTx was only observed in 8 patients (23.5%). There were more hypertensive patients in this latter subgroup (7 out of 8 i.e. 87.5%) than in the rest of the group (16 out of 26 i.e. 64.5%). Renal function impairment in group A was not related to pre-PTx SBP, DBP, MBP, calcemia, creatinine, CsA whole blood trough levels or PTH levels. Conversely, we did not observe significant changes in serum creatinine in the control group during the same periods. During period 2 there was a significant decrease in SBP (134 +/- 16 vs 140 +/- 16 mmHg; p = 0.046), DBP (81 +/- 9 vs 85 +/- 9 mmHg; p = 0.03) and MBP (99.5 +/- 10.5 vs 103.5 +/- 11 mmHg; p = 0.03) of group A. These differences persisted in period 3, with the exception of SBP, although they were no longer statistically significant. Following PTx we were able to discontinue (n = 4) or decrease (n = 4) antihypertensive drugs. In the control group baseline SBP, DBP and MBP were lower than in the PTx group, although the difference was statistically significant only for SBP (132.5 +/- 17 vs 140.5 +/- 16 mmHg; p = 0.05). During the study periods there was no significant changes in SBP, DBP or MBP in the control group. This study shows that RT patients with hypercalcemic hyperparathyroidism are often hypertensive (68%). Subtotal PTx is associated with a significant but transient decrease in SBP, DBP and MBP. Surprisingly we observe a significant and persistent increase in serum creatinine levels in 8 patients (23.5%), particularly in those presenting with hypertension before PTx. These results could reflect a dual effect of parathyroid hormone i.e. a balance between a vasodilating and hypertensive effect.

Primary malignant fibrous histiocytoma of the right ventricle and main pulmonary trunk with a review of the literature.

We report the case of a 76-year-old man with a malignant fibrous histiocytoma of the right ventricle and main pulmonary trunk, diagnosed through echocardiography and catheterization. Extensive resection of the right ventricular outflow tract, pulmonary valve apparatus, and main pulmonary trunk was performed, and the defect was repaired with a valveless ventriculo-pulmonary Dacron graft. The patient recovered uneventfully, and was doing well 18 months after surgery. To our knowledge, this is only the 15th case of primary malignant fibrous histiocytoma of the heart that has been documented in the literature since histologic criteria and cases were published in 1977-78, and the 2nd such case of a primary tumor that has arisen in a right cardiac chamber. The case is presented in detail, along with a review of the literature since 1978.

[Unstable angina in patients over 70 years of age]. / Angor instable chez le sujet de plus de 70 ans.

Between October, 1985 and June, 1987, 125 patients aged 70 years or more were admitted to the Cardiology Department of Purpan Hospital, Toulouse for unstable angina pectoris. 107 of these patients have been followed up, i.e.: 76 men and 31 women aged from 70 to 85 years (mean 74.5 +/- 3.2 years). 49 patients (46 p. 100) had angina at rest of the intermediate syndrome type; 46 (43 p. 100) had rapidly progressive effort angina, and 12 (11 p. 100) had effort angina de novo. The patients' general condition was preserved in 85 p. 100 of the cases and altered in 15 p. 100. ECG was normal in only 10 p. 100 of the patients; it showed signs of established ischaemia in 70 p. 100 of the cases and sequelae of infarction in 23 p. 100. The mean cardiothoracic ration was 49.9 +/- 4.8 p. 100. The ejection fraction was 62 +/- 14.6 p. 100, the end-diastolic volume 86.9 +/- 32.2 ml/m2 and the left ventricular end-diastolic pressure 15.8 +/- 7.2 mmHg. 69 patients (64.5 p. 100) had calcifications in their coronary arteries. At coronary arteriography 21 patients (19.6 p. 100) showed stenosis of the main stem, 11 patients (10.3 p. 100) had a single vessel disease, 28 (26.2 p. 100) a two-vessel disease and 47 (43.9 p. 100) a three-vessel disease. Treatment was medical in 41 patients (38.3 p. 100) and surgical in 44 patients (41.12 p. 100); transluminal coronary angioplasty (TCA) was performed in 23 patients (21.5 p. 100).(ABSTRACT TRUNCATED AT 250 WORDS)

[Myocardial infarct in a 15-year-old boy. Normal coronary arteriogram; value of cutaneous biopsy]. / Infarctus du myocarde chez un garçon de 15 ans. Contrôle coronarographique normal, intérêt de la biopsie cutanée

A 15 year-old boy was admitted for myocardial infarction, of spontaneous occurrence, complicated by atrio-ventricular block and cardiac failure. Three months later, a ventricular-wall aneurysm was demonstrated by angiography, and the coronary arteries found to be normal. Skin biopsy revealed very premature signs of ageing. The comments concerned the frequency and aetiology of these infarctions in adolescents, the pathogenic problems in relation with the absent coronary obstruction, and the interest of skin biopsy, the changes of which might suggest an abnormally premature ageing of the coronary artery wall, a possible starting point for thrombosis.

[Treatment of coronary artery vasospasm during coronary arteriography]. / Traitement du spasme artériel coronaire pendant l'artériographie coronaire.

Coronary spasm was first demonstrated by Gensini in 1962, and the diagnostic value of spontaneous spasm during coronary angiography is now generally accepted. In its absence, provocation tests with ergonovine or its derivatives form part of routine hemodynamic investigation for confirming the spastic nature of atypical chest pain or pain suggestive of Prinzmetal angina. The coronary spasm so induced gives rise to reduced coronary flow, an increase in coronary resistance and myocardial ischemia as shown by an increased lactate extraction in coronary sinus blood; therefore, once it is documented, it must be treated in order to avoid myocardial necrosis or ventricular arrhythmias. Three groups of drugs of drugs are used to counteract spontaneous or provoked spasm: alpha-blockers, especially phentolamine, nitrate derivatives, trinitroglycerine or isosorbide dinitrate, and calcium inhibitors nifedipine or diltiazem, which have a direct antispastic effect. The hemodynamic and pharmacological actions of these three groups of drugs depend on whether they are given orally, intravenously or by intracoronary injection. Twenty six coronary spasms were observed in 23 patients out of a total of 780 coronary angiographies (3,3 per cent) performed between June 1980 and June 1981: 12 spasms were spontaneous (1,5 per cent), 6 provoked by the catheter (0,8 per cent) and 8 by methylergometrine. There were no complications. Five coronary spasms were also observed during 70 coronary angioplasties (7,1 per cent). The spasm was relieved in all cases by intravenous injection of 1,5 to 3 mg of trinitrin (Lenitral). Calcium inhibitors, especially nifedipine, have been used successfully by Hugenholtz and Bertrand who consider that nifedipine has a slower action and the coronary dilatation obtained is never as great with the nitrate derivatives. Trinitrin remains the treatment of choice for the rapid relief of provoked spasm.

[Lateralization of renin secretion in renovascular hypertension with bilateral arterial stenosis]. / Latéralisation de la sécrétion de rénine dans l'hypertension réno-vasculaire avec sténose artérielle bilatérale.

A retrospective analysis of peripheral and renal vein plasma renin activity has been performed in 9 patients with bilateral renal artery stenosis (3 fibromuscular dysplasia and 7 atherosclerosis). In all cases angiography showed a reduction of the arterial diameter of more than 70 p. 100. The renal artery was occluded in 3 cases. All patients received a constant sodium diet (100 mEq/day). Peripheral PRA values were classified as normal or low in 6 cases (less than 2.8 ng/ml/h) and high in one case (greater than 2.8 ng/ml/h): this values concerned 2 cases with renal artery occlusion and 1 case with a narrowing of 90 p. 100. Renal venous renin ratio of 1.5 or more has been found in 8 cases. In one case, the stenosis was quite symmetrical (70 p. 100) and the ratio less than 1.5. The secretion index has been calculated as the ratio between the venoarterial difference of both affected and unaffected side over the arterial value of PRA (V-A/A). On the more stenosed side, was found a V-A/A ratio of 0.5 or more. This ratio is particularly high in case of artery thrombosis, but there is no correlation between the ratio and the degree of stenosis. On the contralateral side, where the lesions were less important, the V-A/A ratio was low, ranging from 0 to 0.2; this estimation of renin secretion was found despite a significant stenosis on the angiography. 7 patients underwent PTA or surgery. 2 kidneys with arterial thrombosis were nephrectomized. In 5 cases the surgical treatment is performed on the 2 sides during the same procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical, angiographic aspects and 18-month follow-up of 134 cases of left coronary trunk stenosis]. / Caractères cliniques, angiographiques et suivi à 18 mois de 134 cas de sténoses du tronc commun de la coronaire gauche.

A series of 134 patients with left main coronary stenosis was followed up for an average of 18 months. The majority of patients presented with unstable angina and per-critical ECG changes. Coronary angiography showed that left main coronary stenosis is rarely an isolated entity but generally associated with diffuse coronary atherosclerosis. Left ventricular function is usually normal. Treatment is surgical whenever the coronary lesions, left ventricular function and general condition of the patient allow it. The medium-term surgical results are excellent on clinical symptoms and quality of life at the price of low perioperative mortality and morbidity.

[False aneurysm associated with mitral insufficiency due to rupture of the heart at the point of insertion of the anterior papillary muscle. A successfully operated case]. / Association faux anévrisme - insuffisance mitrale par rupture du coeur au point d'insertion du pilier antérieur. A propos d'un cas opéré avec succès.

Although rupture of a mitral papillary muscle during myocardial infarction is well known, and post-infarction transmural ruptures causing false aneurysms occasionally reported, the association of rupture of the anterior papillary muscle and a underlying transmural parietal rupture giving rise to a false aneurysm is quite exceptional, and, to the best of our knowledge, has not previously been reported. Despite the serious nature of the disease, surgical cure of the aneurysm with mitral valve replacement was successful, due to the limitation of the anatomical disruption by early pericardial symphysis.

[Coronary recanalization by transluminal angioplasty in the acute phase of myocardial infarct]. / Désobstruction coronaire par angioplastie transluminale à la phase aiguë de l'infarctus du myocarde.

Recanalization by transluminal coronary angioplasty (TCA) was attempted as the first measure in 41 patients having symptoms for less than 4h. The obstruction could rapidly be removed (between 14 and 50 min) in 38 patients (92%). Five patients (12%) died: one in shock at the end of the operation, two died on the 5th and 8th postoperative day and two from heart failure on the 8th and 15th postoperative day. Three patients were urgently operated on for severe tritruncal lesions after a successful TCA. Among the 27 patients under control between 1 and 12 months, six reocclusions were noted (5 asymptomatic, 1 with clinical recurrence), 5 had recurrent stenosis (3 of them were treated by a 2nd angioplasty) and 16 (60%) exhibited permanent good results. The global ejection fraction was not modified, neither the telediastolic and telesystolic volumes. A significant improvement in segmental kinetics was observed in 6 patients with anterior and in 5 patients with inferior infarction. In this group of patients the ejection fraction was improved (67.2 +/- 2.3 vs 52.8 +/- 2.2, p less than 0.001), the IVDT was unchanged (81.7 +/- 6.8 vs 90.7 +/- 5.1, NS). IVTS was lower (27.5 +/- 3.5 vs 41.9 +/- 2.8, p less than 0.001). Further work is, however, needed to confirm these results.

[Angiocardiographic study of obstructive cardiomyopathies. Attempt to evaluate the role of the interventricular septum and the great mitral valve in the obstructive phenomenon]. / Etude angiocardiographique des cardiomyopathies obstructives. Essai d'évaluation du rôle du septum interventriculaire et de la grande valve mitrale dans le phénomène obstructif

Images of the left ventricles, taken in two planes at ventriculography in 45 established cases of obstructive cardiomyopathy, were subjected to a special type of analysis which allowed certain sectional and angular measurements to be made. In particular we calculated and end-systolic index of obstruction, and two measures of the contribution of the septum and the mitral valve to the subaortic obstruction. It then proved possible to study the part played in the stenosis by the interventricular septum and the mitral valve respectively, and to classify the obstructive cardiomyopathies by these criteria. The orientation of the sigmoid floor also seems to play a vital role in determining the dominance of the septum or the mitral valve. These three factors, when examined together, allow us to conclude that there are fixed factors which determine the existance of obstructive cardiomyopathy, to calculate the degree of mitral contribution to the obstruction, and to realise that the orientation of the sigmoid floor helps us to distinguish the type of obstruction. The combination leads to an angiocardiographic classification of the obstructive cardiomyopathies, and the prognostic and surgical significance of this classification are discussed.

[Emboligenic calcification of posterointernal chordae of the mitral valve. Apropos of a surgically treated case]. / Calcifications emboligènes des cordages postéro-internes de la valve mitrale. A propos d'un cas opéré.

We report the case of a 74-year old man who experienced two transient cerebral ischaemic accidents at 24 days' interval, showing that the isolated calcifications on chordae of the mitral valve posterior leaflet responsible for these accidents were exceptionally malformed. Two-dimensional echocardiography was the key examination, as it revealed a left intraventricular mass beneath the smaller mitral valve leaflet. Having excluded other cardiac causes of cerebral ischaemic accident, and faced with the recurrent character of these accidents, we decided to operate. Surgery confirmed the diagnosis. It consisted of resection of the calcified and ulcerated mass, combined with repair of the smaller mitral valve leaflet. Isolated calcifications of the mitral valve chordae are an exceptional cause of embolic accidents of cardiac origin.

[Prognostic value at 12 months of two-dimensional echocardiography performed during the acute phase of myocardial infarction. A prospective study of 140 patients]. / Valeur pronostique à 12 mois d'une échocardiographie bidimensionnelle réalisée en phase aiguë d'un infarctus du myocarde. Etude prospective de 140 patients.

A two-dimensional echocardiography was performed in the acute phase of myocardial infarction in 140 consecutive patients admitted to hospital for transmural infarction 12 +/- 3 days on average after necrosis was formed. The examination consisted of 4 ventricular sections, including 2 through the apex: 8 ventricular segments were individualized, to be interpreted only when 50 p. 100 of the endocardium was visualized. An echocardiographic score was devised for the kinetics of each ventricular segment, i.e.: -1:dyskinetic, 0:akinetic, +1:hypokinetic, +2: normal, +3:hyperkinetic. The maximum score corresponding to normal contraction of all segments was 16. The hospital results were a mean score of 6.52 +/- 2.90 for 73 anterior and/or lateral infarctions and a mean score of 12.5 +/- 2.38 for 67 inferior infarctions (p less than 0.001). Correlations between echographic scores and angiographic ejection fractions were studied in 99 of the 140 patients. Good correlation between the two examinations was found in 91 cases, with a less than or equal to 6/16 score corresponding to a less than or equal to 40 p. 100 ejection fraction, and a greater than or equal to 7/16 score to a less than or equal to 40 p. 100 ejection fraction. This showed that echocardiography can be relied upon to detect abnormalities of left ventricular kinetics in myocardial infarction. 137 patients were followed up for a mean period of 16.4 months (range: 12 to 25 months). The follow-up was clinical and included angina, recurrent or extended infarction, heart failure, aorto-coronary bypass and mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

[Usefulness of a percutaneous endoprosthesis in the treatment of renal artery stenoses]. / Utilité d'une endoprothèse percutanée dans le traitement des sténoses de l'artère rénale.

In approximately 10 p. 100 of the cases stenosis of the renal artery cannot be satisfactorily dilated by percutaneous transluminal angioplasty (PTA), and about 10 p. 100 of the patients successfully dilated have short-term restenosis. The excellent results obtained experimentally and clinically with the implantation of percutaneous intravascular stents have prompted us to use this material in the renal arteries. Stents were implanted in 10 patients who were followed up for periods of 1 to 16 months. Eight of them had restenosis after PTA; five of these stenoses were due to atheroma, 2 to fibromuscular dysplasia and 1 to Takayasu's disease. Two patients were implanted from the start owing to the insufficient results of PTA. Seven patients had severe arterial hypertension most probably of renovascular origin. Three patients had hypertension associated with moderate renal failure. Implantation was performed after a previous PTA. Adjuvant treatments and monitoring were the same in every case with, in particular, radiological control examination after one and six months. The implantations themselves were uneventful, and immediate control showed almost perfect anatomical restoration in all patients. On subsequent controls, arterial patency was preserved in all but one case. All patients showed significant clinical improvement. These results are most encouraging. They suggest that intravascular stents constitute an interesting solution when PTA is insufficient in the treatment of renal artery stenosis.

[Study of left ventricular diastolic function using pulsed Doppler in myocardial infarct in hypertensive subjects]. / Etude de la fonction ventriculaire gauche diastolique par doppler pulsé dans l'infarctus du myocarde chez l'hypertendu.

To determine if impairment of left ventricular filling is influenced by acute myocardial infarction in patients with arterial hypertension, left ventricular diastolic function was assessed by pulsed doppler echocardiography in 46 patients (pts) subdivided into four groups (Gr): G.1 (n = 12 pts) with acute myocardial infarction and hypertensive heart disease. G.2 (n = 12 pts) acute myocardial infarction without arterial hypertension. G.3 (n = 10 pts) arterial hypertension without history of coronary artery disease. G.4 (n = 12 pts) healthy subjects. Coronary angiography and left ventricular cineangiogram was performed in 24 pts (G.1 + G.2). Peak mitral flow velocity (cm/s) in early diastole (E), atrial systole (A), A/E and int A/int E ratios were measured by pulsed doppler. Age and heart rate were statistically similar in all groups. No difference was found among G.1 and G.2 in ejection fraction, and left ventricular segmental kinetic. (tables; see text) Conclusion left ventricular filling is impaired in pts with arterial hypertension and in pts with acute myocardial infarction; acute myocardial infarction increase the impairment of left ventricular diastolic function in pts with hypertensive heart disease.

[Systemic fibrinolytic treatment in the acute phase of myocardial infarction. Effects on coronary repermeation and left ventricular function]. / Traitement fibrinolytique par voie générale à la phase aiguë de l'infarctus du myocarde. Effets sur la reperméabilisation coronaire et sur la fonction ventriculaire gauche.

Coronary angiography and 2D echocardiography were performed at the 24th hour and 21st day of acute myocardial infarction in 18 patients to study the effects of peripheral fibrinolytic therapy on coronary repermeabilisation and left ventricular function. The treatment was the same for all patients included in the study. The left ventricular ejection fraction and sequential left ventricular contractility were analysed. The first coronary angiographic control study (24th hour) showed coronary repermeabilisation in 18 cases, occurring in significantly stenosed vessels in 15 cases and in angiographically normal vessels in 3 cases, demonstrating appearances of thrombosis. Transluminal coronary angioplasty was performed in 8 cases. Coronary angiography at the 21st day showed 4 secondary occlusions in patients who had not undergone angioplasty. The comparative study of left ventricular function did not show a statistically significant difference between the 24th hour and the 21st day studies. Biochemical studies showed on early massive elevation of the specific myocardial enzyme CPK MB and a rapid fall in the fibrinolytic activity of all patients. The treatment was well tolerated and mortality was nil.

[Myocardial infarct of effort with normal coronaries. Study of in vivo platelet activation]. / Infarctus du myocarde d'effort à coronaires saines. Etude de l'activation plaquettaire in vivo.

Platelet activation may play a part in causing myocardium infarction with angiographically normal coronary arteries. We investigated this possibility by performing ergometric stress testing in a series of 9 patients (Group A) who had suffered myocardial infarction after a violent effort with angiographically documented coronary insufficiency responsible for a stable effort angina (Group B) and 11 healthy subjects (Group C). Blood samples were taken separately before exercise, at the peak of exercise, and during the recovery period. Platelet morphology, a sensitive indication of the degree of platelet activation, was studied by phase contrast microscopy after immediate fixation of the blood. The percentage of non-discoidal platelets presenting with one or several spicules was measured. At the same time, the plasma concentrations of platelet factor 4 (PF4) and beta-thromboglobulin (beta-TG) were measured. At rest, there was no difference in platelet morphology or specific platelet proteins between the 3 groups. At the peak effort, there was a significant increase of the number of morphologically modified platelets in Groups A and B but not in healthy subjects. This platelet activation could not be linked to the presence of myocardial ischaemia because it was found both in patients with a negative maximal exercise stress test (Group A). Finally, no increase of the plasma concentrations of the platelet protein was observed in any of the groups.

[Transluminal angioplasty of the coronary vessels. Preliminary results]. / Angioplastie transluminale des coronaires. Résultats préliminaires.

Transluminal coronary angioplasty is a new therapeutic procedure perfected by Gruntzig in 1977 consisting of compressing atheromatous plaques and dilating the arterial lumen with an inflatable balloon-tipped catheter of fixed external diameter. This catheter is introduced into the coronary artery through a preformed catheter guide under radioscopic control. The authors describe their experience of 36 attempts at coronary angioplasty performed over a one year period. The stenosis was catheterised in 30 cases and a good immediate result was obtained in 28 patients (77%). The percentage narrowing was reduced from an average of 79 +/- 8% to 26 +/- 12% (p less than 0.001) and the trans stenotic gradient from 40 +/- 11 mm Hg to 4 +/- 8 mm Hg (p less than 0.001). No serious complications were observed during these procedures. The 8 other patients underwent aorto-coronary bypass surgery as an emergency (2 cases) or otherwise (5 cases). 26 patients with good immediate results are asymptomatic at medium term follow-up, 1 has improved from functional Class IV to II, and I has recurrent Class IV effort angina. 15 patients have been followed up after six months. 14 remain asymptomatic with negative maximal exercise stress testing; 1 has angina. 14/15 stenoses remain dilated, 1 stenosis has progressed (60%). 2 patients developed a new stenosis, 1 of whom underwent another angioplasty procedure (functional Class III). In the 13 remaining patient, clinical improvement was confirmed by exercise stress testing. With strict selection of patients and a prudent operative technique this method seems to be an attractive intermediate therapeutic procedure (over 60% good results at medium term) between medical and surgical management of patients with severe angina and a tight monotruncular stenosis.