Multiple atherosclerotic plaque rupture in acute coronary syndrome: a three-vessel intravascular ultrasound study.

BACKGROUND: To test the hypothesis of general atherosclerotic plaque destabilization during acute coronary syndrome (ACS), the present study sought to analyze the 3 coronary arteries by systematic intravascular ultrasound scan (IVUS). METHODS AND RESULTS: Seventy-two arteries were explored in 24 patients referred for percutaneous coronary intervention after a first ACS with troponin I elevation. Fifty plaque ruptures (mean, 2.08 per patient; range, 0 to 6) were diagnosed by the association of a ruptured capsule with intraplaque cavity. Plaque rupture on the culprit lesion was found in 9 patients (37.5%). At least 1 plaque rupture was found somewhere other than on the culprit lesion in 19 patients (79%). These lesions were in a different artery than the culprit artery in 70.8% and were in both other arteries in 12.5% of these 24 patients. Complete IVUS examination of all 3 coronary axes in patients who had experienced a first ACS revealed that multiple atherosclerotic plaque ruptures were detected by IVUS; these multiple ruptures were present simultaneously with the culprit lesion; they were frequent and located (in three quarters of cases) on the 3 principal coronary trunks; and the multiple plaque ruptures in locations other than on the culprit lesion were less severe, nonstenosing, and less calcified. CONCLUSION: Although one single lesion is clinically active at the time of ACS, the syndrome seems nevertheless associated with overall coronary instability.

Risk factors for systemic emboli in infective endocarditis.

A retrospective study was undertaken to analyse the risk factors for systemic emboli in infective endocarditis. Patients (n = 80; 70% males; mean age 65 years; range 20-91 years) with infective endocarditis, as defined by the Duke criteria and diagnosed using transoesophageal echocardiography during the period January 1995 to March 2001, were included. The average time between the start of the illness and the beginning of antibiotic treatment was 55 days (range 0-405 days). The pathogens identified were streptococci (n = 47), staphylococci (n = 11), enterococci (n = 9), and others (n = 4). In nine cases, blood cultures were sterile. Thirty patients with at least one embolic episode were compared with 50 control patients. According to univariate analysis, the main risk factor for systemic emboli was the size of the vegetation (12.4 mm vs. 7.8 mm; p = 0.0005). The risk of emboli was 57% when the vegetation measured > 10 mm and only 22% when it was < 10 mm (p = 0.003). The mobility of the vegetation was also a risk factor: 48% if the vegetation was mobile; and 9% if fixed (p = 0.003). Sex, age, pathogen, antibiotic treatment, type of valve and the number and position of the vegetations were not found to be risk factors. With multivariate analysis, only mobility was identified as a risk factor. Overall, mobile vegetations > 10 mm in size were associated with an increased risk of embolic episodes in infective endocarditis.

[Prognosis of primary non-obstructive cardiomyopathies]. / Etude pronostique des myocardiopathies primitives non obstructives.

The prognosis of congestive cardiomyopathy was studied in 132 consecutive patients (110 male, 22 female, average age 45 +/- 11 years) in whom a thorough clinical evaluation had excluded a secondary cause. The patients presented with left ventricular failure, a history of systemic embolism, syncope or radiological cardiomegaly. Right (100 p. 100) and left (81 p. 100) heart catheterisation was performed and left ventricular endiastolic volumes (202 +/- 77 ml/m2) and ejection fractions (31 +/- 12 p. 100) calculated from angiography in the 30 degrees right anterior oblique projection. Regional abnormalities of contraction were observed in 32 patients. The average follow up period was 40,4 +/- 23,8 months. At the end of the study 48 patients (37 p. 100) had died and 2 had been lost to follow up. Survival rates were calculated by actuarial methods. Age, sex, the period they had been symptomatic, alcoholic intoxication and the degree of cardiac dilatation were not significant prognostic factors. Patients in Class IV NYHA had the worst prognosis: 63 p. 100 2 year mortality. Atrioventricular conduction defects were observed in 56 patients and were associated with a significantly increased mortality rate (43 p. 100 compared with 23 p. 100, p < 0.001). Atrial fibrillation (32 patients) was a better prognostic factor than the persistence of sinus rhythm; 2 year mortality 11,1 p. 100 compared to 37,6 p. 100 (p < 0.001). Increased left ventricular end diastolic pressures greater than 20 mmHg were related with a mortality of 51,5 p. 100. Also, the patients with a ejection fraction of 30 p. 100 and a 2 year mortality rate of 44 p. 100 compared to 17,5 p. 100 when the ejection fraction was greater than 30 p. 100 (p < 0,001). In conclusion : 1. Regional abnormalities of left ventricular contraction are not rare in primary cardiomyopathy. 2. The prognosis is directly related to the degree of cardiac failure and the extent of left ventricular dysfunction.

[Prognosis of asymptomatic or slightly symptomatic chronic aortic insufficiency. Apropos of 54 patients followed for an average of 36 months]. / Pronostic des insuffisances aortiques chroniques asymptomatiques ou paucisymptomatiques. A propos de 54 patients suivis en moyenne pendant 36 mois.

A series of 54 patients with chronic aortic insufficiency with little (38) or no symptoms (16) were studied. All had severe regurgitation leading to discussion of aortic valve replacement. All patients (44 male and 10 female) underwent clinical, radiological, electrocardiographic, hemodynamic and angiographic investigation with assessment of left ventricular volume by monoplane 30 degrees cineangiography on entry to the study. They were then followed-up for an average of 36 months and the data assessed in a prospective study. At the end of the 36 months period, 4 patients had been lost to follow-up but were still alive, 31 patients were unchanged (Group A) and 19 patients had deteriorated (Group B). The parameters characterising Group B (P less than 0.001) were: corrected cardiac surface area of 1,72 +/- 0,13, a Sokolow index of 60,1 +/- 18,8 mm an ejection fraction of 56.2 +/- 14 % and a left ventricular end diastolic value of 225,3 ml/m2. Therefore, in chronic asymptomatic aortic incompetence, the parameters of cardiac dilatation, cardiac surface area greater than 1,70 and left ventricular end diastolic volume greater than 170 ml/m2, would appear to be good indications for aortic valve replacement. However, the values are nor formal criteria because a discrepancy between symptoms and the volumetric measurements may be observed in some cases, and also large variations in these measurements may be observed in patients in the same functional class.

[Assessment of ejection fraction and left ventricular and diastolic volume by non-invasive methods: echocardiography and isotopic technics. Comparison with angiography in 30 patients]. / L'évaluation de la fraction d'éjection et du volume télédiastolique du ventricule gauche par les méthodes non invasives: échocardiographie et techniques isotopiques. Comparaison avec les données angiographiques à propos de 30 patients.

Three methods of measuring the ejection and the left ventricular end-diastolic volume were compared in 30 consecutive patients (all adults, 3 normal, 3 congestive cardiomyopathy, 6 mixed aortic valve disease, 9 pure aortic stenosis and 9 pure aortic incompetence). The haemodynamic and angiographical data was compared to the results of M-mode echocardiography and gammaangiocardiography. The global results of the ejection fractions were compared: angiography gave the lowest values (0,58 +/- 18). The non-invasive methods gave very similar results (0,67 +/- 15 for the echo and gammaangio). A better correlation was obtained in the group with pure aortic incompetence; the results in pure aortic stenosis were not reliable. The global results of end-diastolic volume showed constant underestimation by the non-invasive methods compared to angiography. The choice of method in each technique may influence the results obtained; each laboratory should determine its normal values; results should not be accepted without a critical assessment. Standardisation of techniques would be desirable.

[Analysis of interobserver variations in the estimation of myocardial volume, thickness and mass in right anterior oblique monoplanar angiocardiography]. / Analyse des variations interobservateurs dans l'estimation des volumes, de l'épaisseur et de la masse myocardique dans l'incidence angiocardiographique monoplane oblique antérieure droite.

The parameter derived from right anterior oblique angiocardiography (end diastolic and end systolic volumes, stroke volume, ejection fraction, wall thickness and myocardial mass) are used to decide the most appropriate management of cardiac disease. It is important to assess their reliability especially as other clinical data may be underestimated and the objective results may play a prominent role in the decision. Therefore, good quality cinefilms of 31 patients were reinterpreted by three observers (A, B and C); the contours were traced on a Vanguard console with an electromagnetic pet and the data treated automatically by the SNIASS SYSCOMORAN program (Simpson's method, assimilating the left ventricle to an ellipsoid divided into n identical cylinders). The interobserver variability (A and B; A and C; B and C) was good in the assessment of end diastolic volume (R = 0,96; 0,98; 0,99), end systolic volume (R = 0,96; 0,96; 0,98). On the other hand, it was poor in the measurement of wall thickness (R = 0,63; 0,73; 0,69) and myocardial mass (R = 0,85; 0,83; 0,89). In addition, the ejection fraction and end systolic volume were perfectly reproducible from one observer to another whether or not the left ventricle was dilated. End diastolic volumes seemed to be more reproducible in dilated cavities (EDV greater than 104 ml/m2). These results confirm that monoplane RAO cineangiography remains a good method of assessing left ventricular performance.

[Coronary bypass surgery. Results after 5 years : mortality - morbidity]. / La chirurgie de pontage coronarien. Résultats après 5 ans : mortalité - morbidité.

The improvement in the expectation and quality of life of patients undergoing coronary bypass surgery has been studied in the short term but there are relatively few studies with follow-up periods of over five years. The results in 239 patients operated on between 1970 and 1976 are presented. The preoperative data was obtained from a computerised filing system; studies were made at 3 months, at an average of 60 months, and in 78 patients with follow-up exceeding 5 years. Actuarial survival rates were calculated. The operative mortality was 9 patients (3,7%); late mortality was 21 patients (9,2%). Most deaths were due to cardiac causes. The following factors did not appear to be associated with a poor prognosis: sex, the number of cardiovascular risk factors, the number of bypass grafts; however, age and poor left ventricular function as identified by ECG (p less than 0,01), the presence of clinical cardiac failure (p less than 0,001) and by angiography (p less than 0,001) were associated with a poor prognosis. The long-term functional results were interesting: 67% patients followed up to 5 years and 56% patients followed up for over 5 years had no angina. Myocardial infarction occurred in 16,7% of patients at 5 years. Preexisting left ventricular failure which affected the operative and immediate postoperative results was also found secondarily in 9% of patients at 5 years. In the long term, the annual mortality rate seemed to be less in patients with triple vessel disease after myocardial revascularisation. The annual mortality rate of patients with left anterior descending disease alone did not seem to be improved when compared with medically treated patients until after the third year. Once again, the extent of myocardial disease was shown to be the essential prognostic factor whatever the coronary profile of the patient. In this study patients with severe angina or unstable angina who had been treated medically before surgery had the same results as those treated surgically by first intention; this fact is an argument in favour of initial medical management in all forms of angina.

[Prognosis following mitral valve replacement with the Starr-Edwards 6120 prosthesis]. / Facteurs pronostiques après remplacement valvulaire mitral par la prothèse de Starr-Edwards modèle 6120.

Between 1970-78, 302 mitral valve replacements with the SE 6120 prosthesis were performed, with an average postoperative follow-up of 50,7 months, using the 3 M size (206 cases) and 2 M (96 cases with small left ventricles). Early postoperative mortality was 5,6%, late postoperative mortality: 17,2%, the 5 year actuarial survival rate: 77,4% and the 9 year survival rate 71,8% (early mortality included). There was no significant difference in survival after mono- (143 cases) and polyvalvular replacement (159 cases); only a voluminous left atrium (p less than 0,05) and left atrial thrombosis (p less than 0,01) were statistically significant prognostic factors of global mortality. Late haemorrhage due to anticoagulant therapy (3%) (0,6 per 100 patient years). The most common complication was systemic embolism (3,7 per 100 patient years). Actuarial studies showed that 86,6% at 5 years and 80,1% at 9 years, escaped this complication. Statistically the favorising roles of permanent atrial fibrillation (p less than 0,05), the size of the left atrium (p less than 0,02) of isolated demonstrated. 90,4% of the survivors were clinically improved: the functional result was better when that 86,6% at 5 years and 80,1% at 9 years, escaped this complication. Statistically the favorising roles of permanent atrial fibrillation (p less than 0,05), the size of the left atrium (p less than 0,02) of isolated demonstrated. 90,4% of the survivors were clinically improved: the functional result was better when that 86,6% at 5 years and 80,1% at 9 years, escaped this complication. Statistically the favorising roles of permanent atrial fibrillation (p less than 0,05), the size of the left atrium (p less than 0,02) of isolated demonstrated. 90,4% of the survivors were clinically improved: the functional result was better when the valve replacement was not a reoperation (p less than 0,02), when the patient was not in functional Class IV (p less than 0,01), in permanent excessively dilated (p less than 0,01) and in patients without severe tricuspid regurgitation (p less than 0,01). There was no significant difference in global mortality, the percentage of embolic events and the quality of the functional postoperative result between patients with the 3 M and those with the 2 M SE 6120 prosthesis.

[Early and late term results of triple valve replacements. Use of a tricuspid bioprosthesis]. / Résultats précoces et tardifs des triples remplacements valvulaires. Utilisation d'une bioprothèse en position tricuspidienne.

Triple valve replacement (TVR) is associated with an increased operative and long-term mortality rate. The aim of this study was to reduce operative mortality by effective myocardial protection (coronary perfusion with moderate hypothermia) and to improve long-term results by the optimal choice of valve prosthesis and, in particular, by the systematic use of xenografts for tricuspid valve replacement. Twenty TVR were performed between 1970 and 1977. Björk-Shiley prostheses were used for aortic valve replacement, Starr Edwards 6120 valves for mitral valve replacement and xenografts (7 aortic valve and 13 Hancock xenografts) for tricuspid valve replacement. This series represented 3.2% of the total number of valve replacements carried out during this period. The average postoperative follow-up was 52.6 +/- 15.2 months. Only one patient died in the first postoperative month (early mortality 5%). There were 2 late deaths, one from heart failure and one from accidental causes; the actuarial 5 year survival rate was 87.9%. Seventeen long-term survivors were studied; 6 were functionally improved. Significant (p less than 0.02) but moderate regression of cardiomegaly was observed. Abnormal auscultatory findings in the tricuspid area were found in 64.7% of survivors, and signs of mild right ventricular failure were elicited in 30.4%. There were no early or late complications due to the tricuspid valve xenograft. Thirteen patients had cardiac catheterisation over one year after operation: right atrial and mean pulmonary artery pressures were significantly reduced (p less than 0.001 and p less than 0.01 respectively); there was a moderate increase in cardiac index( p less than 0.001). Late clinical complications were rare, only one regressive cerebral embolism was observed. Triple valve replacement, when necessary, carried a limited early postoperative risk, and satisfactory functional and haemodynamic results may be obtained in the long term.

[Multiple ruptures of atherosclerotic plaques in acute coronary syndrome. Endocoronary ultrasonography study of three arteries]. / Ruptures multiples de plaques d'athérosclérose dans les syndromes coronaires aigus. Etude échographique endocoronaire des trois artères.

The aim of this study was to assess the three coronary arteries systematically by endocoronary ultrasonography in patients with unstable angina to check the hypothesis of global destabilisation of atherosclerotic plaques in acute coronary syndromes (ACS). Sixty two coronary arteries were examined (2.6 per patient). Fifty plaque ruptures were diagnosed (2.08 per patient). Rupture of a plaque of the culprit lesion of the ACS was clearly detected in 9 patients (37.5%). At least one ruptured plaque on a site other than the culprit lesion was observed in 19 patients (79%), on another artery in 70.8% of cases and on two other arteries in 12.5% of cases. A complete endocoronary ultrasonic examination of the three coronary arteries in patients with a first ACS demonstrated that: multiple atherosclerotic plaque rupture may be detected by endocoronary ultrasonography; these multiple plaque ruptures occur simultaneously with the culprit lesion; they are frequent and can be situated on the three main coronary vessels and multiple plaque rupture other than the culprit lesion are less severe, non stenotic and less calcified. Thus, although a single lesion is clinically symptomatic, ACS seems to be associated with global coronary instability.

[Long-term results of isolated anterior interventricular bypasses: analysis of the prognostic factors. Apropos of a series of 187 patients operated on between]. / Résultats à long terme des pontages isolés de l'interventriculaire antérieure: analyse des facteurs pronostiques. A propos de 187 opérés entre 1970 et 1980.

A total of 187 patients underwent isolated aorto-left anterior descending artery (LAD) bypass grafting with the internal saphenous vein (ISV) (= 65) and left internal mammary artery (IM) (n = 122). The respective indications of the two techniques were not systematized: the comparison of the main preoperative data of the two groups showed a statistically higher number of risk factors (p less than 0,01), more multivessel coronary lesions (p less than 0,02) and more patients with dyskinetic left ventricles (p less than 0,05) in the ISV bypass group. There were no statistical differences between the two groups in early postoperative mortality (IM: 0,8 p. 100, ISV: 1,5 p. 100), early postoperative infarction (IM: 2,5 p. 100, ISV: 1,5 p. 100), or late postoperative infarction (IM: 3,8 p. 100, ISV: 2,6 p. 100). The survival rates in the two groups were very similar with a global 90 p. 100 survival at 5 years and 78 p. 100 at 9 years. A comparison of the functional result in the two groups did not reveal significant difference: globally, 56 p. 100 of patients had no recurrence of angina 5 years, and 41 p. 100 after 9 years. Age, sex previous infarction, the number of cardiovascular risk factors, the technique used, had no prognostic significance on survival or on the quality of the postoperative functional results, contrary to the quality of left ventriculography and the number of coronary stenoses (83 subjects with isolated LAD disease, 104 subjects with multiple vessel disease). Nevertheless, patients with multiple coronary lesions had their vital prognosis improved (annual mortality less than 3 p. 100) compared to the spontaneous risk by isolated isolated aorto-LAD artery bypass surgery.

[Cardiac disorders in Steinert's disease. Indication of pacemaker in two patients of the same family]. / Anomalies cardiaques dans la maladie de Steinert. A propos de l'indication de pacemaker chez deux patients de la même fratrie atteints par la maladie.

From the study of two cases of Steinert's disease in the same family, who have benefited by the implantation of pacemaker for troubles of conduction, we propose to make a review of the present knowledge related to this pathology with a particular emphasis on the cardiac symptomatology.

[Yield of the thoracoscopic biopsy in experimental pulmonary infections in the immunosuppressed rabbit]. / Rendement de la biopsie thoracoscopique dans les infections pulmonaires expérimentales chez le lapin immunodéprimé.

Using thoracoscopy lung biopsy we investigated the bacteriological diagnostic yield in immunodepressed and/or infected NZ rabbits. 84 rabbits were used: 18 controls, 30 immunodepressed rabbits and 36 rabbits immunodepressed and then infected with Aspergillus fumigatus. Candida albicans or B.C.G. The thoracoscopy technique was the one we designed for humans, the instruments were adapted to the size of animals. Thoracoscopy biopsy results were compared to those of surgical biopsies made in the same animals. The results of both techniques were similar: indeed, the sensitivity of thoracoscopy biopsy was 88.9% in immunodepressed rabbits (versus 100% with surgical biopsies), 86% in the group of rabbits infected with B.C.G. (versus 86%), 90.1% in rabbits infected with Aspergillus fumigatus (versus 100%) and 88.9% in rabbits infected with Candida albicans (versus 100%). The indications for thoracoscopic lung biopsy in immunodepressed patients with infectious lung diseases are drawn from these experimental data, from our experience and the known mortality and morbidity of surgical lung biopsy.

[Tubercular myocarditis: two case reports and review of the literature]. / Myocardites tuberculeuses: à propos de deux observations et revue de la littérature.

We report here the cases of two patients developing tubercular myocarditis with a different clinical presentation, the first one with a myopericarditis, the second one presenting as pseudo-infarction complicated by cardiogenic shock. We discuss here the different anatomical and clinical presentations, the diagnostic approach, the indications of myocardic biopsy and the prognosis of this pathology.

[Hemodynamic effects of beta blockers]. / Les effets hémodynamiques des bêta-bloquants.

Beta-blockers have been used in cardiology for the past 15 years in three directions: angina pectoris, cardiac arrhythmias, and hypertension. The haemodynamic effects are real: --imposed bradycardia, whether the basal rhythm be sinus or atrial fibrillation; --confirmed myocardial depression which reduces the energy needs of the myocardium; --fall in systolic pressure, the mechanism of which remains open to discussion. The theories explaining these haemodynamic effects are reviewed. The harmful effects of these substances are defined, together with the drug combinations which may avoid or counteract them.

[Tricuspid valve replacement with aortic valve allograft. Clinical and haemodynamic results more than five years after (author's transl)]. / Remplacement de la valve tricuspide par homogreffe valvulaire aortique. Résultats cliniques et hémodynamiques à plus de 5 ans.

Between 1970 and 1974, twenty-three patients with advanced multivalve lesions underwent tricuspid valve replacement with a human aortic valve allograft (26-28 mm in diameter) mounted on a Shumway ring. The mean follow-up was 76.7 months. Early post-operative mortality was 4.4% and late mortality 17.4%. The actuarial survival rate was 86.6% at 5 years and 74.2% at 8 years. In 1979, 17 out of 18 survivors (one was lost sight of) were reinvestigated by cardiologists. Late functional improvement z found in 82.2% of the cases; two patients failed to improve owing to recurrent mitral stenosis. On clinical examination 12 out of 15 subjects showed no sign of right ventricular failure. In 54% the cases phonocardiography revealed abnormal tricuspid sounds indicating variable and moderate deterioration of the allograft. Haemodynamic studies showed a significant decrease in mean right atrial pressure (p less than 0.001) and mean pulmonary artery pressure (p less than 0.001), and an increase in cardiac index (p less than 0.01). The diastolic gradient through the graft was always inferior to 3 mmHg (mean 1.2 mmHg), with little change on exercise. This was significantly less than the 3.9 mmHg gradient observed with tricuspid valve replacement using Hancok valve. These were the only tricuspid valve replacements performed in our unit in 1970-74. The satisfactory long-term results obtained contrast with the frequent deterioration observed in aortic valve replacements carried out during the same period by the same team, using the same technique