[Long-term clinical benefits of using active stents in diabetic patients: two year follow-up of a consecutive series of 122 patients]. / Bénéfice clinique à long terme de l'utilisation des stents actifs chez les patients diabétiques: suivi à deux ans d'une série consécutive de 122 patients.

The objective of our study is to evaluate the long-term results of coronary angioplasty using active stents in a population of diabetic patients. This is a single-centre study on a consecutive series of 122 diabetic patients (40% of them insulin dependent) who between January 2003 and June 2004 underwent angioplasty with implantation of an active stent (sirolimus Cypher(R) or paclitaxel Taxus(R)) for one or more de novo coronary lesions. The mean age was 66 +/- 10 years and a total of 171 coronary segments were treated. The lesions treated were complex (type B2 + C) in 69% of the cases, with a mean stent length of 21 +/- 15 mm and a mean stent diameter of 2.7 +/- 0.3 mm. Follow-up at two years for 119 patients (3 lost to follow-up) revealed a mortality rate of 4.2%, and a myocardial infarction rate of 7.5%. The rates for revascularisation of the target lesion and the target vessel were 11.4% and 17.8% respectively, with a rate of major cardiac events of 22.5%. During this period, 25.2% of the patients underwent revascularisation of at least one vessel. This study confirms the benefits of using active stents for revascularisation of the target lesion in diabetic patients. However, it serves as a reminder that the progression of coronary atheroma is global, and that the prognosis for these patients depends essentially upon managing risk factors, and particularly on controlling their diabetes.

[Mycotic coronary aneurysm with Escherichia coli sepsis: a case report]. / Anévrisme coronaire mycotique consécutif à une septicémie à Escherichia coli: à propos d'un cas.

We report the case of a patient who was admitted for acute coronary syndrom associated with fever originating from urinary tract. Coronary arteriography revealed a huge coronary aneurysm which ruptured a short time after diagnosis. After surgery, it was proven to be mycotic aneurysm related to Escherichia Coli sepsis.

Influence of cigarette smoking on rate of reopening of the infarct-related coronary artery after myocardial infarction: a multivariate analysis.

OBJECTIVES: This study sought to determine whether the reopening of the infarct-related vessel is related to clinical characteristics or cardiovascular risk factors, or both. BACKGROUND: In acute myocardial infarction, thrombolytic therapy reduces mortality by restoring the patency of the infarct-related vessel. However, despite the use of thrombolytic agents, the infarct-related vessel remains occluded in up to 40% of patients. METHODS: We studied 295 consecutive patients with an acute myocardial infarction who underwent coronary angiography within 15 days (mean [+/- SD] 6.7 +/- 3.2 days) of the onset of symptoms. Infarct-related artery patency was defined by Thrombolysis in Myocardial Infarction trial flow grade > or = 2. Four cardiovascular risk factors--smoking, hypertension, hypercholesterolemia and diabetes mellitus--and eight different variables-age, gender, in-hospital death, history of previous myocardial infarction, location of current myocardial infarction, use of thrombolytic agents, time interval between onset of symptoms, thrombolytic therapy and coronary angiography--were recorded in all patients. RESULTS: Thrombolysis in current smokers and anterior infard location on admission were the three independent factors highly correlated with the patency of the infarct-related vessel (odds ratios 3.2, 3.0 and 1.9, respectively). In smokers, thrombolytic therapy was associated with a higher reopening rate of the infard vessel, from 35% to 77% (p < 0.001). Nonsmokers did not benefit from thrombolytic therapy, regardless of infarct location. CONCLUSIONS: These observational data, if replicated, suggest that in patients with acute myocardial infarction, thrombolytic therapy may be most effective in current smokers, whereas nonsmokers and ex-smokers may require other management strategies, such as emergency percutaneous transluminal coronary angioplasty.

[Acute or sub-acute thrombosis of steel stents]. / Thrombose aiguë ou subaiguë des stents en acier. A propos d'une série consécutive de 2 997 patients.

The use of coronary endoprostheses has greatly contributed to the improvement in the results of coronary angioplasty. Nevertheless, the risk of stent thrombosis remains a major preoccupation. We studied a retrospective series of 2997 patients who had undergone coronary angioplasty between 1999 and 2003. 36 patients (1.2%) had an acute or sub-acute stent thrombosis, occurring in two thirds of cases in the first 4 days with particularly serious clinical consequences: 5 deaths (13.8%) and 27 myocardial infarctions (75%). A comparison between the 2 groups of patients with thrombosis (n = 36) and without thrombosis (n = 2961) using multivariate analysis determined predictive factors for thrombosis: systolic LV dysfunction < 40% (p < 0.0001 OR 3.8 [2-7.3]), angioplasty for lesions on the anterior interventricular artery (p < 0.0001 OR 2.7 [1.4-5]), angioplasty performed in the acute phase of MI (p < 0.05 OR 13.9 [6.7-29.2]), B2-type complex lesions (p < 0.01 OR 2.5 [1.3-5]), residual dissection at the dilated site (p < 0.02 OR 5.1 [1.4-18.2]). More than ever, acute thrombosis remains a topical subject. This study emphasises the incidence of steel stent thrombosis; the clinical consequences and the predictive factors for early occlusion.

[Mortality prognostic factors of cardiogenic shock complicating an acute myocardial infarction and treated by percutaneous coronary intervention]. / Facteurs pronostiques de mortalité chez les patients en etat de choc cardiogénique primaire traités par angioplastie en phase aiguë d'infarctus.

OBJECTIVE: To determine the in-hospital prognosis and late outcome of cardiogenic shock complicating acute myocardial infarction treated by early (< 24 hours) percutaneous coronary intervention (PCI). METHODS: Retrospective monocentric study of a consecutive cohort of patients undergoing early PCI (< 24 heures) for cardiogenic shock complicating acute myocardial infarction from 1994 to 2004. RESULTS: The cohort included 175 patients (mean age = 65 +/- 14 years, 68% male). A successful PCI was obtained in 69% of patients. The in-hospital mortality was 43%. Independent risk factors associated with an increased mortality were: absence of TIMI three flow (P < 0.0001), absence of smoking (P < 0.009) and the need for mechanical ventilation (P < 0.002). Nor stent use or anti GP IIb/IIa infusions were predictors of a better outcome. At hospital discharge, mean left ventricular ejection fraction (LVEF) was 38 +/- 12%. Kaplan-Meier estimate of survival was 63% for in-hospital survivors (maximum follow-up = 9 years). Independent predictors of an impaired long-term outcome were: a LVEF < 0.3 (P < 0.028) and 3-vessel disease on coronary angiography (P < 0.004). CONCLUSION: In-hospital mortality of patients suffering cardiogenic shock complicating acute myocardial infarction and treated by PCI remains high despite PCI improvement. The long-term survival appears, however, to be better than that of patients with coronary artery disease and low LVEF.

A simplified normalized ejection phase index measured by Doppler echocardiography for the assessment of left ventricular performance.

Although useful for the assessment of directional changes in contractility in individual patients, resting peak aortic blood velocity is of limited value for differentiating among patients with different levels of basal cardiac function. A dimensional analysis based on fluid dynamics shows that peak aortic blood velocity is not only generated by the contracting myocardium but also reflects the convective acceleration of blood from the left ventricle to the aorta. The reduction of cross-sectional area from the midleft ventricle to the aorta at the time of peak aortic blood velocity generates the convective acceleration. Accordingly, a higher convective acceleration due to left ventricular (LV) enlargement as observed in cardiomyopathy may explain why peak aortic blood velocity can be maintained as normal although myocardial contractility is depressed. This study tested the hypothesis that peak aortic blood velocity normalized by the ratio of midleft ventricle to aortic cross-sectional areas might provide a reliable index of LV performance. Nine normal control subjects and 25 patients undergoing catheterization were studied by M-mode, 2-dimensional and Doppler echocardiography. The normalized peak velocity measured noninvasively showed a high correlation with angiographic ejection fraction (r = 0.90, p less than 0.0001). Peak aortic blood velocity and the ratio of midleft ventricle to aortic cross-sectional areas alone correlated less well with ejection fraction (r = 0.76 and r = 0.75, p less than 0.0001, respectively). Furthermore, peak aortic blood velocity showed a significant overlap between patients with normal and those with abnormal LV function, whereas normalized peak aortic blood velocity was a better discriminator.(ABSTRACT TRUNCATED AT 250 WORDS)

A new Doppler method of assessing left ventricular ejection force in chronic congestive heart failure.

A noninvasive method using Doppler echocardiography was developed to determine the force exerted by the left ventricle in accelerating the blood into the aorta. The value of this new Doppler ejection index in the assessment of left ventricular (LV) performance was tested in 36 patients with chronic congestive heart disease undergoing cardiac catheterization and in 11 age-matched normal control subjects. The 36 patients were subgrouped into 3 groups based on angiographic ejection fraction (LV ejection fraction greater than 60, 41 to 60 and less than or equal to 40%). According to Newton's second law of motion (force = mass X acceleration), the LV ejection force was derived from the product of the mass of blood ejected during the acceleration time with the mean acceleration undergone during that time. In patients with LV ejection fraction less than or equal to 40%, LV ejection force, peak aortic velocity and mean acceleration were severely depressed when compared with the other groups (p less than 0.001). In patients with LV ejection fraction of 41 to 60%, LV ejection force was significantly reduced (22 +/- 3 kdynes) when compared with normal subjects (29 +/- 5 kdynes, p = 0.002) and with patients with LV ejection fraction greater than 60% (29 +/- 7 kdynes, p = 0.009); peak velocity and mean acceleration did not differ between these 3 groups. The LV ejection force showed a good linear correlation with LV ejection fraction (r = 0.86) and a better power fit (r = 0.91). Peak aortic blood velocity and mean acceleration showed less good linear correlations with LV ejection fraction (r = 0.73 and r = 0.66, respectively). The mass of blood ejected during the acceleration time also showed a weak linear correlation with LV ejection fraction (r = 0.64). An LV ejection force less than 20 kdynes was associated with a depressed LV performance (LV ejection fraction less than 50%) with 91% sensitivity and 90% specificity. Thus, these findings suggest that LV ejection force is a new Doppler ejection phase index that appears to be more accurate than peak aortic blood velocity and mean acceleration for the assessment of systolic LV function.

Noninvasive assessment of coronary flow dynamics before and after coronary angioplasty using transesophageal Doppler.

Recent invasive studies using intracoronary Doppler catheters or guide wires reported improved coronary flow dynamics after successful percutaneous transluminal coronary angioplasty. Transesophageal Doppler enables the measurement of coronary flow velocities within the left anterior descending artery. The present study was designed to test: (1) whether transesophageal Doppler may detect coronary flow velocity changes in patients undergoing angioplasty for left anterior descending artery stenosis, and (2) whether this technique may help to evaluate non-invasively the results of the procedure. Twenty-three patients undergoing angioplasty of the left anterior descending artery were studied by transesophageal Doppler before and < or = 24 hours after the interventional procedure. Coronary flow velocities were measured in the proximal part of the left anterior descending artery with the use of pulsed Doppler guided by color flow imaging. The degree of stenosis was measured by computerized quantitative coronary arteriography. Coronary flow velocity signals were successfully obtained in 19 of 23 patients (83%). In 16 successful angioplasty procedures, peak diastolic velocity increased from 37 +/- 14 cm/s before angioplasty to 51 +/- 16 cm/s after (p = 0.0001). In the 3 patients in whom angioplasty was unsuccessful, transesophageal Doppler showed no significant increase in peak diastolic coronary flow velocity. In a total of 19 angioplasty procedures, a good linear relation was found between the percent changes in coronary flow diastolic velocity and the reduction in the degree of stenosis (r = 0.85; p = 0.0001). All patients with > 20% increase in peak diastolic velocity had > 40% stenosis reduction.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in immediate outcome of percutaneous transluminal coronary angioplasty in multivessel coronary artery disease in 1990 to 1991 versus 1994 to 1995.

Coronary angioplasty has undergone major technical changes since the period of inclusion in the randomized trials, comparing it with surgery, particularly with the increased use of coronary stents. This study shows improved in-hospital outcome in terms of primary success and complication rates in patients treated with coronary angioplasty for multivessel disease from 1994 to 1995, compared with the 1990 to 1991 period.

Doppler echocardiographic measurement of low velocity motion of the left ventricular posterior wall.

A new noninvasive method using pulsed Doppler echocardiography was developed to assess left ventricular (LV) posterior wall motion dynamics. Seventeen normal subjects and 23 patients undergoing cardiac catheterization were prospectively studied. The sample volume was placed within the LV posterior wall endocardium just apical to the mitral valve sulcus using a posteriorly angulated low parasternal view. The wall filter was set at 100 Hz to record the low velocities of the LV posterior wall motion. The Doppler signal was morphologically similar to the rate of change of the LV posterior wall endocardium excursion obtained by a digitized M-mode echocardiogram, and showed 3 major waves: a systolic wave (S), an early diastolic wave (E) and a late diastolic wave (A). The peak velocities of LV posterior wall endocardium excursion were also determined by M-mode echocardiographic technique. We found a significant linear correlation between peak E-wave velocity and M-mode peak diastolic endocardial velocity (r = 0.90, p less than 0.001) and between peak S-wave velocity and M-mode peak systolic endocardial velocity (r = 0.81, p less than 0.001). M-mode peak systolic endocardial velocity showed an important overlap between control subjects and patients with normal and patients with abnormal LV posterior wall motion on the angiogram. In contrast, peak S-wave velocity was a better discriminator, and a peak S-wave velocity less than 7.5 cm/s was associated with abnormal LV posterior wall motion with an 83% sensitivity, 100% specificity and 95% accuracy. In patients with coronary artery disease but normal systolic LV posterior wall motion and normal global systolic LV function, peak S-wave velocity was not different when compared to control subjects. Peak E-wave velocity and E/A were significantly lower than in control subjects (p less than 0.01) and peak A-wave velocity was greater (p less than 0.01). In conclusion, these data suggest that pulsed Doppler echocardiography can be used for the direct analysis of LV posterior wall instantaneous low velocities and appears to be more informative than M-mode technique for systolic measurements. Thus, detection of abnormal LV posterior wall diastolic motion by pulsed Doppler echocardiography may, upon additional confirmation, be used as a new noninvasive method to gain insight into global LV diastolic performance.

Effect of diltiazem on myocardial infarct size estimated by enzyme release, serial thallium-201 single-photon emission computed tomography and radionuclide angiography.

Diltiazem is a calcium antagonist with demonstrated experimental cardioprotective effects. Its effects on myocardial infarct size were studied in 34 patients admitted within 6 hours after the first symptoms of acute myocardial infarction. These patients were randomized, double-blind to placebo or diltiazem (10-mg intravenous bolus followed by 15 mg/hr intravenous infusion during 72 hours, followed by 4 X 60 mg during 21 days). Myocardial infarct size was assessed by plasma creatine kinase and creatine kinase-MB indexes, perfusion defect scores using single-photon emission computed tomography with thallium-201 and left ventricular ejection fraction measured by radionuclide angiography. Tomographic and angiographic scanning was performed serially before randomization, after 48 hours and 21 days later. Groups were comparable in terms of age, sex, inclusion time and baseline infarct location and size. Results showed no difference in creatine kinase and creatine kinase-MB data between controls and treated patients, a significant decrease in the perfusion defect scores in the diltiazem group (+0.1 +/- 3.0 placebo vs -2.2 +/- 1.9 diltiazem, p less than 0.02) and a better ejection fraction recovery in the diltiazem group (-4.2 +/- 7.4 placebo vs +7.7 +/- 11.2 diltiazem, p less than 0.05). Myocardial infarct size estimates from perfusion defect scores and enzyme data were closely correlated. These preliminary results suggest that diltiazem may reduce ischemic injury in acute myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Two-dimensional echocardiographic assessment of the right ventricle in patients with chronic obstructive lung disease.

A consecutive series of 40 patients (39 men, one woman; mean age 54.1 +/- 8.2 years) with chronic obstructive lung disease (COLD) underwent right heart catheterization and 2-D echocardiographic examination within 72 hr. An adequate 2-D echocardiographic study was obtained in 32 patients (80 percent) using the apical and/or subcostal views. Mean pulmonary artery pressure at rest and during exercise were correlated with right ventricular diameters and areas in end-systole and end-diastole (r = 0.63 to 0.73). Correlations between right ventricular free wall thickness and pulmonary artery pressure were weak (r = 0.51 and 0.57). Right ventricular end-diastolic pressure was also weakly correlated with right ventricular dimensions (r = 0.45 to 0.51), whereas right ventricular area fractional shortening was not correlated with hemodynamic parameters. Patients with previous episode of right heart failure had larger right ventricles than those without such episodes. Thus, 2-D echocardiography appears useful to study the right heart chambers in patients with COLD.

Dilated cardiomyopathy: long-term follow-up and predictors of survival.

To determine long-term survival and the prognostic factors of dilated cardiomyopathy, we retrospectively studied a consecutive series of 111 patients (95 men, 16 women, mean age: 45.5 +/- 8.1 years) undergoing cardiac catheterization and diagnostic coronary angiography from January 1970 to December 1979. The inclusion criteria were: normal coronary angiography, diffuse hypokinesia of the left ventricle and left ventricular ejection fraction less than 50%. Base-line clinical data were collected from the hospital records and follow-up data were obtained from the general practitioners and cardiologists. A questionnaire was sent to all living patients. The length of follow-up ranged from 6 to 16 years. Six patients (5%) were lost to follow-up. At the time of catheterization, a majority of the patients had dyspnea and were in New York Heart Association (NYHA) classes II (41%) and III (31%). Clinical history revealed an excessive alcohol consumption in 56% of the patients. During follow-up, 66 patients (63%) died (heart failure: 37%; sudden death: 19%; non-cardiac death: 15%; unknown cause: 27%). Actuarial survival was 90, 50, and 33% at 1, 5, and 10 years, respectively. Univariate analysis revealed that 10-year mortality was related to: left ventricular ejection fraction less than 30%; left ventricular end-diastolic pressure greater than 10 mm Hg; cardiothoracic ratio greater than 54%; episodes of heart failure; left ventricular end-diastolic volume greater than 200 ml/m2, dyspnea of NYHA class III or IV; absence of smoking; absence of moderate systemic hypertension; electrocardiographic evidence of left ventricular hypertrophy and mean systemic arterial pressure greater than 95 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous peripheral rotational ablation using the Rotablator: immediate and mid term results. Single center experience concerning 146 lesions treated.

In order to assess the role of percutaneous peripheral rotational ablation using Rotablator (PPRA), 95 symptomatic patients (58 M, 37 F, m. age: 77 +/- 1 y) (r: 50-90 y) having 146 peripheral vascular lesions (PVL) were treated by PPRA. 59% were below the knee and 41% above. The runoff status (n of distal leg art. involved) was as follows: 3:52 pts, 2:23 pts, 1:14 pts, 0:6 pts. The femoral lesions were significantly longer than those at other sites (5.27 +/- 0.43 vs 2.97 +/- 0.3 cm) (p < 0.001). The mean length was 3.73 +/- 0.26 cm (r: 1-20 cm). Complementary PTA was significantly (p < 0.001) more frequent in femoro-popliteal (32 PTA/48 Fem, 5 PTA/12 Pop) than in distal leg lesions (10/86.). RESULTS. After PPRA alone (99 PVL) the stenosis % decreased from 81 +/- 0.75 to 18 +/- 1.1. The residual stenosis was greater at femoral (26 +/- 2.3%) than at distal leg level (16 +/- 1.2%) (p < 0.01). Complementary PTA (47 PVL) lowered residual stenosis from 44% to 13%. 52 complications (spasm, perforation, dissection, distal emboli, no reflow, others) were cured in 47 PVL. Thus our primary technical success per PVL was 97% and per pt 95%. The mean follow-up period was 11 +/- 1 mths (r: 1-37 m). Among 78 pts having a follow-up period > or = 4 mths, 74 pts representing 115 treated PVL underwent an angiography control (2 deaths, 2 lost for follow-up). 87 lesions (76%) showed no restenosis and 28 lesions (34%) showed restenosis of 83 +/- 2.4% (r: 50-100%). The restenosis rate was higher in femoral (12/21: 36%) than in distal (15/58: 21%) or popliteal arteries (1/8: 12%). Restenosis was more frequent for PVL > or = 7 cm (67% vs 16%) (p < 0.001) at all sites. This result together with the complication rate would seem to indicate that lesions > or = 6.7 cm would be a limitation for PPRA. CONCLUSIONS. In our experience Percutaneous Peripheral Rotational Ablation has taken a pre-eminent position in the treatment of distal leg arteries. Our results lead us to broaden its indications to complex vascular lesions. The possibility of runoff treatment should allow an improvement in the long-term patency of PTA and bypass grafts.

[Results of coronary transluminal angioplasty following Prinzmetal's angina or fixed stenosis with associated spasm]. / Résultats de l'angioplastie transluminale coronaire après angor de Prinzmétal ou sur sténose fixe avec spasme surajouté.

Transluminal coronary angioplasty (TCA) was carried out in 130 patients (109 men and 21 women) with an average age of 51 years (range 20 to 76 years) between April 1980 and December 1982. The most commonly affected artery was the LAD (100). All patients were on heparin, coronary vasodilators and calcium antagonists before the procedure, and on calcium antagonists and platelet antiaggregant drugs after TCA. The material and methods used were those described by Gruntzig. In this population, we identified a group of patients, Group I, with fixed stenosis and associated coronary spasm--either Prinzmetal angina (13 cases, 6 of which had both ST-T elevation and other ECG changes) or spontaneous spasm with a variable degree of stenosis (2 cases). The stenosis remained greater than or equal to 70% in all cases after intracoronary injection of nitrate derivatives. There were no differences between this group and that of fixed stenosis (Group II) with respect to age and type of diseased vessel (although the right coronary artery was more commonly involved in cases of spasm). The overall primary success rate was 72.8% (14/15--93%--in Group I, and 85/121--70.2%--in Group II: no statistically significant difference). The angiographic relapse rate at 6 months was significantly higher in Group I (8/12: 67%) than in Group II (15/63: 23.8%) p less than 0.02. When "redilatation" with stable success is taken into consideration the difference is not significant (33% and 22.2% respectively). The relapses may be dissociated in Group I (2 cases with recurrent spastic angina and normal angiography).(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparative study of different methods of evaluation of left ventricular volume by monoplane angiocardiography]. / Etude comparative de différentes méthodes d'évaluation du volume ventriculaire gauche par angiocardiographie monoplane.

The authors compare 5 methods of evaluating left ventricular volume and the ejection fraction by monoplanar angiocardiography in the 30 degrees right oblique incidence: the method of Green (1 and 2), Snow and Dodge, and by trapezoidal integration which was used as a reference. The have calculated the regression ordinates and the correlation coefficients for various systolic and diastolic volumes as well as for various ejection fractions. For these latter, Dodge's quadratic equation can also be used. Provided there is no gross distorsion of ventricular contolr, there is fairly good correlation, but there is a marked discrepancy for large volumes or small ejection fractions (less than 0.40). When more elaborate methods are not available, it seems reasonable to use a single method to calculate these parameters, but it is essential to have recourse to other techniques when there are gross changes in the left ventricle.

[An attempt to estimate the value of myocardial contractility in left ventricular aneurysms]. / Tentative d'appréciation de la valeur contractile du myocarde dans les anévrysmes ventriculaires gauches.

Using monoplanar angiography at 30 degrees, the authors have attempted to quantify the effectiveness of the non-aneurysmal myocardium in 50 patients (17 of them having undergone surgery) with an aneurysm of the left ventricle. Having fixed the position of two points during systole and diastole, they first delimit the aneurysmal zone and/or neighbouring dyskinetic zones in relation to the zones which are still 'healthy'. By a method of integration based on the formula of the three levels, they first measure the global volume of the left ventricle and its ejection fraction, and gain an idea of the size of the aneurysm. They then evaluate the ejection fraction and the volumes of each of the other zones. They have shown that the prognosis depends upon the ejection fraction and the end-diastolic volume of the ventricle which is presumed to be healthy, these measurements being corrected according to the size, expressed as an ejection volume, of the adjacent dyskinetic zone, which can be assessed by an index (volume of the dyskinetic zone as a proportion of the total 'healthy' and dyskinetic zones, in turn expressed as a ratio of the ejection fraction). The application of this work is to be found in seeking a limit of operability for extensive left ventricular aneurysms with cardiac failure.

[Emergency coronary surgery after transluminal angioplasty. Immediate results and long-term outcome of 100 operations]. / La chirurgie coronaire en urgence après angioplastie transluminale coronaire. Résultats immédiats et évolution à long terme à propos de 100 interventions.

The increasing application of percutaneous transluminal coronary angioplasty (PTCA) requires evaluation of emergency coronary artery surgery for complications of this procedure. In a consecutive series of 2,576 angioplasties performed between April 1980 and January 1990, 100 patients (82 men and 18 women, average age 54 +/- 10 years, 3.9%) underwent emergency coronary artery surgery because of complications. The artery involved was the left anterior descending artery in 81% of cases. The causal lesion was a dissection and/or thrombus in 95% of cases; 85% of patients were referred for surgery with acute myocardial infarction. The average delay before surgery was 110 +/- 15 minutes (interval between coronary occlusion and starting cardiopulmonary bypass) and 155 coronary grafts were implanted (1.5 per patient). The hospital mortality was 19%; the infarction rate was 57%. The left ventricular ejection fraction decreased from 63 +/- 10% (preoperatively) to 52 +/- 9% (postoperatively), p less than 0.001. Hospital mortality was significantly related to three factors, old age, unstable angina before PTCA, and cardiogenic shock or the necessity for external cardiac massage. In the subgroup of patients developing cardiogenic shock (n = 7) or requiring external cardiac massage during transfer to the operating theatre (n = 16) the mortality was 44%. Among the 81 survivors, the global 7 year survival rate was 96% (Kaplan-Meier) with 3 cardiac deaths, 2 other patients developing myocardial infarction and 4 undergoing repeat angioplasty. After an average follow-up of 55 +/- 38 months, 80% of patients are asymptomatic, 34% have no antianginal drugs and 73% of those who were previously employed have returned to work.(ABSTRACT TRUNCATED AT 250 WORDS)

[Normal coronary angiography. Have the indications changed during the 1980's?]. / La coronarographie normale. Les indications ont-elles varié au cours des années 1980?

If the indications of coronary angiography are well chosen, the percentage of normal coronary angiographies should decrease. The authors analysed 7858 primary coronary angiographies performed between 1981 and 1990 in patients without valvular or congenital heart disease. The second 5 years were compared to the first. The percentage of primary coronary angiographies decreased (63% vs 75%; p < 0.01), the percentage of women increased (21.7% vs 18.4%; p < 0.001), and the mean age increased (58.5 +/- 0.3 vs 53.9 +/- 0.3; p < 10(-9)). The lesions were less extensive: 16.3% triple vessel disease versus 24.2% (p < 0.001); 31.3% double vessel disease versus 28.1% (p < 0.02); 49.1% single vessel disease versus 44.2% (p < 0.001). The percentage of normal coronary angiographies remained constant: 20.2% in the second five years versus 19.9% in the first. Over the 10 year period, there was no significant difference one year from another. The percentage of normal investigations remained the same in men (15.7%), decreased in women (34.7 vs 40.1%, p < 0.04), remained constant in patients under 60 years of age (24.5 vs 23.8%), but increased in the more elderly (14.9 vs 10.2%; p < 0.001). The percentage remained unchanged in stable angina (19.6 vs 19.8%) and in unstable angina (12.3 vs 11.2%): it increased in cases of atypical chest pain (72.2 vs 54.3%; p < 0.01). Although, globally, the number of normal coronary angiographies was unchanged at 20%, the indications of this investigation were more selective in the younger patients, especially women, in the second five years, but coronary angiography was more commonly performed in elderly patients because of the possibility of benefiting from coronary angioplasty.

[Early detection of myocardial alterations in mitral insufficiency with the angiotensin test]. / Dépistage précoce des altérations myocardiques de l'insuffisance mitrale par le test à l'angiotensine.

Left ventricular function was assessed at rest and after increasing systemic arterial resistance by angiotensin in 40 patients with isolated mitral insufficiency. Angiotensin was administered intravenously at a dose of 0,4 micrograms/mn until the systolic blood pressure rose by at least 30 mm Hg. Left ventricular and aortic pressures, cardiac index and left ventriculography in the 30 degree right anterior oblique projection (50 frames per second) were recorded before and during angiotensin infusion. The mean rise in systolic left ventricular pressure was 40 +/- 2,8 mm Hg; the heart rate increased slightly but significantly; left ventricular and diastolic pressure rose from 12,0 +/- 1,0 to 24,0 +/- 1,2 mmHg. The systolic index (Fick's method) was significantly decreased (37 +/- 1,6 ml/m2 to 26 +/- 1,6 ml/m2) though the angiographic systolic index remained unchanged. This is explained by an increase in the regurgitant fraction (51 +/- 2,5% ao 65 +/- 3%). The end diastolic volume index was unchanged; the ejection fraction was significantly decreased. The resting hemodynamic status was only slightly disturbed in 29 patients (mean capillary pressure less than 15 mm Hg, 8,8 +/- 0,52 mmHg). The left ventricular function curves with angiotensin distinguished two groups of patients: Group A (20 patients) with left ventricular dysfunction induced by angiotensin, Group B (9 patients) who maintained the systolic index despite the increase in left ventricular end diastolic pressure. These results suggest that the angiotensin test may be useful for detecting early left ventricular dysfunction in patients with isolated mitral insufficiency and virtually normal resting hemodynamic parameters.