Usefulness and clinical impact of a fractional flow reserve and angiographic targeted strategy for coronary artery stenting: FROST III, a multicenter prospective registry.

BACKGROUND: Fractional flow reserve (FFR) is correlated with angiographic and intravascular ultrasound assessments of stent placement. Post-stenting FFR has been described as a good predictor of clinical events after 6 months. OBJECTIVE: To evaluate the feasibility and clinical impact of targeting an FFR > 0.95 via incremental in-stent inflation pressures. METHODS: In this multicenter prospective study, 100 consecutive patients underwent FFR measurement at baseline, after balloon predilatation, and after stenting with 4-atm inflation pressure increments from 8 to 20 atmospheres. Inflations were stopped when FFR increased above 0.95 and angiographic stenosis was less than 20%. RESULTS: FFR > 0.95 was achieved in 81% of cases; this FFR target was reached at 8 atm in 47% of patients, 12 atm in 16 %, 16 atm in 15%, and 20 atm in 3%. Fifty percent of patients with adequate angiographic result had an FFR less than 0.95 and needed further higher inflations. FFR was correlated with residual stenosis when the total procedure was evaluated, and this correlation persisted when in-stent inflations alone were considered. Final FFR was significantly correlated with anginal status after 6 months. CONCLUSIONS: Angiography guided PCI does not allow optimization of FFR. Since optimal post stenting FFR is correlated to better anginal status at 6-months, this suggests that FFR guided PCI is required to achieve optimal functional results of PCI.

Renal lesions in Von Hippel-Lindau disease: the benign, the malignant, the unknown.

OBJECTIVES: To describe the features and treatment of renal lesions in von Hippel-Lindau disease (VHL) from a series of patients, to highlight important issues in the management of these lesions. MATERIALS AND METHODS: We performed a retrospective study in 7 patients with VHL who underwent surgery for renal lesions between January 1990 and July 1996. The initial evaluation consisted of an abdominal CT scan and renal arteriography. RESULTS: The mean age of patients at the time of discovery was 38 (+/- 12.01 years). All cases were of type 1. Radiology assessment underestimated the gravity of the lesions in 5 patients. In all patients, unilateral surgery was performed with the kidney being conserved in 4 cases. Of the 44 lesions removed, 23 had signs of progressiveness (atypical or malignant cyst, renal cell carcinoma), most of the cancers were of low grade. 84% of the lesions did not exceed 3 cm and 48% were

How to manage patients with severe left ventricular dysfunction and valvular regurgitation.

BACKGROUND AND AIMS OF THE STUDY: The purpose of this study is to analyze treatment options for valvular regurgitation with severe left ventricular dysfunction. MATERIAL AND METHODS: Results of valvular surgery in 98 patients with mitral or aortic regurgitation and severe systolic left ventricular dysfunction (LVD) were analyzed. Selection criteria were the absence of significant coronary heart disease and a resting ejection fraction (EF) < 40% for aortic and < 50% for mitral regurgitation. RESULTS: In patients with aortic regurgitation (n = 46) operative mortality was higher but not significantly so than in a control group of 238 cases (6.5% vs. 3.4%). The actuarial survival rates at five and 10 years were 84% and 55% vs. 84% and 67%, respectively. Independent preoperative predictors of severe postoperative LVD were rheumatic etiology and increased left ventricular end-systolic diameter. In patients with mitral regurgitation (n = 52), operative mortality was not significantly different from that of a control group of 273 cases (3.8% vs. 2.6%), whether the surgical procedure was valve replacement or valve repair. Perioperative morbidity was frequent (30% of cases), mainly low cardiac output, after valve replacement. The actuarial survival rates at eight years were respectively for the groups with and without LVD: 81% and 89% after valve repair, 60% and 75% after valve replacement. Independent predictors of severe postoperative LVD were increased left ventricular end-systolic volume and the type of surgery. Better results were observed after valve repair. CONCLUSIONS: It is concluded that a low EF is not a predictive factor of operative mortality but it influences late survival as do the degree of left ventricular dilatation, etiology in aortic and type of surgery in mitral regurgitation. Alternatives to valvular surgery have been envisaged but information on vasodilators in these patients is scant and results of heart transplantation are known only from a few small series.

Immediate and mid-term results of percutaneous mitral commissurotomy.

The results of percutaneous mitral commissurotomy (PMC) were assessed in a series of 600 patients (pts) with mitral stenosis. Their mean age was 43 +/- 15 years (13-86). One hundred and eight had had a previous surgical commissurotomy; 464 were in NYHA class III or IV; atrial fibrillation was present in 188. One hundred and fifty-nine had valvular calcification and angiography disclosed a mild regurgitation (MR) (1/4) in 255. Technical failure occurred in 19 pts. In the remainder, PMC improved valve function: valve area (VA) increased from 1.1 +/- 0.3 cm2 to 2.2 +/- 0.5 cm2 (P less than 0.0001) as assessed by haemodynamics, and from 1 +/- 0.2 to 2 +/- 0.4 cm2 (P less than 0.0001) as assessed by two-dimensional echocardiography. Complications were as follows: death (0.5%), haemopericardium (0.8%), severe MR (3.8%), embolism (3.3%), atrial shunt (14%). Secondary surgery for complications following PMC was necessary in 4.8% of cases. There were poor results (VA less than 1.5 cm2 and/or MR greater than 2/4) in 13%; their predictors being valve anatomy (P less than 0.001), initial valve area (P less than 0.01) and previous surgical commissurotomy (P less than 0.05). Among the 437 pts resident in France, 98% were followed-up 15 +/- 11 months after PMC (range 1-48). After 42 months, the actuarial rates of survival, freedom from need for reoperation and good functional results were respectively: 87 +/- 6%, 81 +/- 3% and 72 +/- 6%.(ABSTRACT TRUNCATED AT 250 WORDS)

[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.

[Intravenous thrombolysis with tissue plasminogen activator (rt-PA) at the prehospital phase of acute myocardial infarction. Apropos of 49 cases]. / Thrombolyse intraveineuse par l'activateur tissulaire du plasminogène (rt-PA) à la phase préhospitalière dans l'infarctus myocardique aigu. A propos de 49 cas.

In acute myocardial infarction, the earlier intravenous thrombolysis is performed the more effective its action. Pre-hospital intravenous thrombolysis with 100 mg rt-PA was carried out in 49 patients within 3 hours of myocardial infarction. Male preponderance was conspicuous with 44 men (92%) and only 5 women (8%). Mean age was 50.2 +/- 8 years. The infarction was inferior in 48% of the cases. Out of the 49 thrombolyses performed by the mobile intensive care unit, 3 were discontinued on admission (2 diagnostic errors, 1 external heart massage). The time gained by pre-hospital thrombolysis was 52 +/- 25 minutes. There were few complications of thrombolysis: blood effusion at the site of puncture occurred in 4 cases (9%) and haematemesis in 1 case (2%). No cerebral or lethal haemorrhage was observed. Major complications of MI were seldom encountered at the pre-hospital phase: 1 patient died of extensive anterior necrosis with left ventricular dysfunction, and 2 had reversible ventricular fibrillation before treatment was initiated. There was no haemorrhagic complication. The earlier the patient was treated the lower the mortality and morbidity rates. Pre-hospital thrombolysis therefore seems to be feasible when performed by a mobile intensive care unit, and it represents an important gain of time.

Relation between transpulmonary pressure and right ventricular isovolumetric pressure change during respiratory support.

Simultaneous recordings of airway pressure, pleural pressure, and right ventricular (RV) pressure were obtained during mechanically controlled ventilation in a group of patients requiring respiratory support. Changes in transpulmonary pressure (calculated as airway pressure minus pleural pressure) were measured at end-expiration and end-inspiration during intermittent positive pressure ventilation with or without the application of a positive end-expiratory pressure, and were related to RV isovolumetric pressure changes at the onset of systole. It was found that any increase in transpulmonary pressure by intermittent positive pressure ventilation, or positive end-expiratory pressure (PEEP), or both, was associated with a proportional increase in RV isovolumetric pressure change. Moreover, when lung volume was progressively increased by incremental increases in tidal volume or PEEP level, transpulmonary pressure and RV isovolumetric pressure changes were strongly and linearly correlated. These results suggest that: 1) RV isovolumetric pressure change might be used as an index of RV output impedance during respiratory support by mechanically controlled ventilation; and 2) lung inflation resulting from the use of a positive airway pressure during respiratory support can increase RV output impedance and thereby contribute to the decrease in RV stroke output.

[Recording of the his bundle potential at the surface of the thorax in healthy volunteers. Application to the study of propranolol]. / Enregistrement du potentiel hissien à la surface du thorax chez le volontaire sain. Application à l'étude du propranolol.

New analogic-digital technology contributions to standard electrocardiography may allow to record the his bundle potential from the body surface. The aim of this work has been to study the validity of this method by its application to estimate the dromotropic effect of propranolol in healthy volunteers. His bundle potential from body surface was recorded in 19 out of 26 enrolled subjects. The negative dromotropic effect of propranolol (40 mg orally) was observed in only 10 volunteers. The direction of the PR and PH interval changes was used to estimate sensibility (0.9) and specificity (0.89) of this method. There was also a significant correlation (0.89 less than p 0.05) between PR and PH interval changes. This new non-invasive method could be used in clinical pharmacology but the subjects must be preselected.

[Hemorrhagic risk in intravenously administered thrombolytic treatment in acute myocardial infarction]. / Le risque hémorragique dans les traitements thrombolytiques par voie intraveineuse dans l'infarctus myocardique aigu.

163 patients aged from 27 to 70 years (mean 52 +/- 10 years), including 152 men and 11 women, received a thrombolytic treatment within the first 6 hours (mean 192 +/- 73 mn) of a myocardial infarction. 61 patients received streptokinase (SK) intravenously (group 1), 64 patients, single-chain rt-PA (group 2), 11 patients, two-chain rt-PA (group 3), 11 patients, rt-PA followed by intracoronary streptokinase (group 4), and 16 patients, acyl enzyme (group 5). In addition, all patients had heparin and 86 (53%) had aspirin. Immediately after thrombolysis, coronary arteriography was performed in 95 patients (58%), and this was followed by transluminal angioplasty in 49 of them (30%). The infarction was either anterior (n = 81) or inferior (n = 78) or lateral (n = 4). No fatal or neurological bleeding occurred. 17 haemorrhagic complications were observed; 5 of these (3%) were severe, requiring blood transfusion and, in 1 case, surgery; 12 were significant (7.4%) and produced changes in haematocrit. Nine of the 17 haemorrhages were associated with catheterization and localized to the site of arterial puncture. Severe bleeding occurred in patients treated with intravenous SK (3/61) or with rt-PA followed by intracoronary SK (2/11). There was a significant difference in the incidence of spontaneous bleeding between the SK group (4/61) and the single-chain rt-PA group (0/64; p less than 0.05). In the latter group, the minimum fibrinogen level was lower in patients who had a haemorrhagic complication.(ABSTRACT TRUNCATED AT 250 WORDS)

[Doppler measurement of transvalvular gradients. Simultaneous Doppler-catheterization recordings on 78 patients]. / Mesure des gradients transvalvulaires par le Doppler. Enregistrements simultanés Doppler-cathétérisme chez 78 patients.

Several studies have demonstrated the value of Doppler ultrasound as a means of measuring gradients across cardiac valves. However, in view of sudden variations in cardiac output gradients should be measured simultaneously by Doppler and catheterization in order to validate the former method and determine its accuracy. We conducted a prospective study with simultaneous recordings in 78 patients with aortic valve stenosis (33) or mitral valve stenosis (19) or cardiac valve prosthesis (26). Mean age of the patients was 55 +/- 14 years, and 50% of them were male. Subjects with pure or predominant regurgitation were excluded from the study. In the whole of the population studied, correlation between Doppler ultrasound and haemodynamics was very good with r = 0.98, p less than 0.001 for maximum gradient and r = 0.96, p less than 0.001 for mean gradient. The perfect simultaneity of the haemodynamic and ultrasonic recordings was confirmed by comparing the duration of gradients measured by the two methods (r = 0.996, p less than 0.001). There also was very close correlation between ultrasounds and catheter in patients with mitral stenosis (maximum gradient r = 0.98, p less than 0.001; mean gradient r = 0.97, p less than 0.001). Mean Doppler-catheter differences were not significant, and no underestimation by Doppler reached or exceeded 5 mmHg. Correlations were also satisfactory in patients with aortic stenosis (maximum gradient r = 0.97, p less than 0.01; mean gradient r = 0.90, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)