Impact of hypovitaminosis D and alfacalcidol therapy on survival of hemodialysis patients: results from the French ARNOS study.

BACKGROUND: In chronic kidney disease and dialysis patients, vitamin D deficiency is associated with mortality. In some observational studies, calcitriol analogue therapy was associated with a better survival rate in hemodialysis (HD) patients. The aim of this study was to determine the relationship between serum 25-hydroxyvitamin D (25-OHD) levels and alfacalcidol therapy with HD patients' outcomes. METHODS: We measured baseline 25-OHD levels using a cross-sectional analysis in 648 HD prevalent patients from the regional ARNOS French cohort. A 42-month survival analysis was applied according to serum 25-OHD level and calcitriol analogue therapy. RESULTS: The prevalence of 25-OHD insufficiency <30 ng/ml was high (73%), with only 22% taking native vitamin D supplementation. A baseline 25-OHD level above the median value (18 ng/ml) was associated with lower all-cause mortality [hazard ratio (HR), 0.73 (0.5-0.96); p = 0.02] after adjustment for age, gender, dialysis vintage, calcemia, phosphatemia, cardiovascular disease, and diabetes. Only in monovariate analysis was low-dose oral alfacalcidol therapy associated with a better survival rate in patients with and without 25-OHD deficiency [HR, 0.7 (0.5-0.92); p = 0.05]. CONCLUSIONS: Our study shows that, among prevalent HD patients, low 25-OHD levels affect mortality. Alfacalcidol therapy, especially in small doses, may provide compensation, but this needs to be further confirmed using prospective controlled studies comparing native and active vitamin D compounds.

Association between very low PTH levels and poor survival rates in haemodialysis patients: results from the French ARNOS cohort.

INTRODUCTION: A very low parathyroid hormone (PTH) level (VLPL) is associated with an increased risk of adynamic bone disease, vascular calcification, and mortality in haemodialysis (HD) patients. The aim of the study was to assess the frequency, the associated factors, and the prognosis of non-surgical VLPL in a cohort of prevalent HD patients. METHODS: In July 2005, a cross-sectional study was performed on the French ARNOS cohort in 1,348 prevalent HD patients from 24 dialysis centres in the Rhône-Alpes area. Patients with a baseline intact PTH level <50 pg/ml (VLPL, Group 1) and ≥ 50 pg/ml (Group 2) were compared and a 42-month survival analysis was performed. Patients with prevalent or incident parathyroidectomy were excluded. RESULTS: We studied 1,138 prevalent HD patients. As compared to patients of Group 2 (n = 1,019), patients with VLPL (Group 1, n = 119) had lower serum albumin levels (34.5 ± 5 vs. 36.4 ± 5 g/l, p < 0.0001), less protein intake (nPCR 0.99 ± 0.28 vs. 1.1 ± 0.28 g/kg/day, p = 0.01), higher calcaemia (2.30 ± 0.2 vs. 2.26 ± 0.2 mmol/l, p = 0.01) and were more frequently treated with calcium carbonate (67 vs. 54%, p < 0.001). Patients with VLPL had a higher mortality rate (HR: 1.4 (1.07-1.8), p = 0.006) after adjustment for age, gender, diabetes, and dialysis vintage. The odds ratios of mortality for patients with VLPL remained higher in all calcaemia and serum albumin quartiles. Only 3/119 patients in Group 1 did not receive any PTH-lowering therapies (i.e. calcium carbonate (67%), alfacalcidol (38%), cinacalcet (10.1%), and dialysate calcium ≥ 1.5 mmol/l (94%)). CONCLUSION: In this observational French cohort, VLPL was observed in 10% of prevalent HD patients and was associated with poor survival rates. An inadequate therapeutic strategy could be responsible for this observation. The real consequences of this iatrogenic adynamic bone disease remain hypothetical, but it may be related to the risk of developing vascular calcification. It is hypothesized that a more adequate strategy, using fewer PTH-lowering therapies in cases of VLPL, may help in improving the poor prognosis.

Relation of minor cardiac troponin I elevation to late cardiac events after uncomplicated elective successful percutaneous transluminal coronary angioplasty for angina pectoris.

There is little information about the relation between mild cardiac troponin I (cTn-I) increase after coronary interventions and late outcome. We therefore focused on the long-term outcome and the clinical, morphologic, and procedural correlates of elevation of cTn-I compared with cardiac troponin T, creatine kinase (CK), CK-MB activity and mass, and myoglobin in 105 patients with successful elective percutaneous transluminal coronary angioplasty (PTCA) for stable or unstable angina. Patients with myocardial infarction and those with unstable angina who had a detectable increase in serum markers before PTCA were excluded. Markers were measured before and after the procedure and for 2 days. Patients were followed up to record recurrent angina, myocardial infarction, cardiac death, repeat PTCA, or elective coronary artery bypass graft surgery. Procedure success was achieved in all cases. Elevation in cTn-I (> or =0.1 microg/L) was observed in 23 of 105 patients (22%) (median peak: 0.25 microg/L); 18% had cardiac troponin T (cTn-T) release (> or = 0.1 microg/L, median peak 0.21); 11.4% CK-MB mass (> or =5 microg/L), and 7.6% myoglobin (> or =90 microg/L) release. Five and 2 patients had elevated CK and CK-MB activity, respectively. Fourteen of 18 patients with cTn-T elevation had a corresponding elevation in cTn-I (kappa 0.68; p = 0.001). Patients positive for cTn-I had more unstable angina (p = 0.042) and heparin before PTCA (p = 0.046), and had longest total time (p = 0.004) and single inflation (p = 0.01). By multivariate logistic regression, predictors of postprocedure cTnI elevation were maximum time of each inflation (odds ratio 9.2; p = 0.0012), type B lesions (odds ratio 6.6; p = 0.013), unstable angina (p = 0.041), and age > or =60 years (p = 0.032). Clinical follow-up was available in 103 patients (98%) (mean 19+/-10 months). Kaplan-Meier survival analysis showed that cTn-I elevation was not an important correlate of cardiac events (p = 0.34, by log-rank analysis). The incidence of recurrent angina, myocardial infarction, cardiac death, and repeat revascularization after 12 months was not different in patients positive or negative for cTn-I. We conclude that cTn-I elevation after successful PTCA is not associated with significantly worse late clinical outcome. Levels of cTn-I allow a much higher diagnostic accuracy in detecting minor myocardial injury after PTCA compared with other markers, but there is no association with periprocedural myocardial cell injury and late outcome when cTn-I and other markers are considered.

[Evaluation of beta-adrenergic blockader therapy in vasovagal syncope reproduced by head-up tilt test]. / Evaluation du traitement bêtabloquant dans les syncopes vasovagales reproduites par le test d'inclinaison.

Increased sympathetic tone is one physiopathological mechanism of vasovagal syncope. In this case, betablocker therapy is logical. The reports in the literature suggest that the head-up tilt test can reliably reproduce vasovagal syncope. Ten patients (4 men and 6 women, mean age 59 +/- 18 years) who suffered from recurrent vasovagal syncopes (2 to 10 attacks in 6 patients and more than 10 in the other 4) with a positive initial head-up tilt test (syncope or severe dizziness with marked hypotension after a maximum of 40 minutes at 60 degrees) were treated with atenolol (200 mg daily in 7 cases and 100 mg daily in the other 3). A second head-up tilt test was performed 15 +/- 6 days later under betablocker therapy; this test was negative in 7 and remained positive in 3 cases. Irrespective of the result, the 10 patients followed the same therapy at the same dosage. After 9 +/- 5 months, 3 patients had another syncopal attack; 2 stopped taking their medication and the third patient continued the betablocker because there was a marked reduction in the frequency of his attacks. There were no further syncopal episodes during follow-up of the other 7 patients. The medium-term efficacy could not be predicted from the results of the second head-up tilt test. The following conclusions may be drawn from this study: The head-up tilt test becomes negative in 70% of cases after introducing betablocker therapy, assuming a 100% reproductivity. This treatment is effective in over half the patients at medium term and should be considered in patients with recurrent vasovagal syncope.

[Elastic recoil after transluminal coronary angioplasty; implications of clinical and angiographic data]. / Le retour élastique après angioplastie transluminale coronaire; implications respectives des données cliniques et angiographiques.

Secondary elastic recoil after transluminal coronary angioplasty is a constant and immediate phenomenon after successful coronary angioplasty. It was studied by quantitative coronary angiography in 75 consecutive patients undergoing transluminal coronary angioplasty. This procedure was performed on lesions presumed to be responsible for the clinical presentation. The population was divided into 3 groups: stable angina (25 patients), unstable angina (25 patients) and recent post-infarction ischaemic syndromes (25 patients). There were 57 men and 18 women (mean age 59 +/- 11 years) with 31 left anterior descending (LA), 29 right coronary (RC) and 15 left circumflex (Cx) dilatations. The lesions dilated were eccentric in 29 cases and calcified in 37 cases whereas only one thrombus was detected at coronary angiography. The elastic recoil appreciated 10 mn after the last balloon inflation was 0.97 +/- 0.28 mm for the whole population. There was no significant difference between the 3 groups studies (respectively 0.94 +/- 0.24 mm; 0.96 +/- 0.26 mm; 0.99 +/- 0.33 mm). This appeared to be greater than the RC (1.06 +/- 0.30 mm) with respect to the Cx (0.86 +/- 0.23: p < 0.02) or LAD (0.92 +/- 0.25 mm: p < 0.04). Overall, a balloon to vessel diameter ratio > 1 and a lesion length > 10 mm were parameters predicting greater secondary elastic recoil (p < 0.07 and p < 0.001 respectively), whereas the degree of eccentricity only played a role in the post-infarction ischaemic syndromes and calcification only in unstable angina (p < 0.01 and p < 0.001 respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

[Regression of dilated cardiomyopathy in a chronic alcoholic patient after abstinence from alcohol]. / Régression d'une cardiomyopathie dilatée chez un éthylique chronique après arrêt de l'intoxication.

The authors report the case of a 28 year old alcoholic who was admitted to hospital for cardiac failure in 1982 due to a dilated cardiomyopathy. The clinical and paraclinical signs disappeared after cessation of alcohol intake. Three years after abstaining from alcohol, the electrocardiogram, echocardiogram and isotopic ventriculography are normal. This case illustrates the necessity of absolute cessation of alcohol intake in patients with dilated cardiomyopathies.

[Permanent cardiac stimulation after aortic valve replacement: incidence, predictive factors and long-term prognosis]. / Stimulation cardiaque définitive après remplacement valvulaire aortique: incidence, facteurs prédictifs et pronostic à long terme.

Between January 1981 and June 1992, 382 patients, operated by the same surgical team, underwent aortic valve replacement for pure severe aortic stenosis. This population was divided into 2 groups according to whether or not surgery was complicated by the development of a conduction defect (atrioventricular and/or intraventricular block), necessitating permanent cardiac pacing. The aim of this study was to analyse not only the incidence and predictive factors but also the long-term prognosis of the paced patients (Group II: 22 patients) in comparison with the control group (Group I: 360 patients). The results showed: the incidence of permanent cardiac pacing after this type of surgery remains low (5.7%); the predictive factors of atrioventricular block requiring permanent pacing were: pre-existing conduction defect (p < 0.02), decreased ejection fraction (p < 0.05), calcification extending to the subaortic interventricular septum (p < 0.0001); the long-term prognosis of the patients was good with 5 and 10 year actuarial survival rates of 95.4% and 68.9% respectively, identical to those of the control group.

[Patency of the artery responsible for myocardial infarction: role on ventricular function and long-term outcome]. / Perméabilité de l'artère responsable de l'infarctus myocardique: influence sur la fonction ventriculaire et évolution à long terme.

Out of 3,171 consecutive patients referred for coronary angiography, 240 were selected on the following criteria: recent primary myocardial infarction, single vessel coronary disease, no angioplasty or coronary surgery after the angiography which was performed 20 to 90 days after the onset of myocardial infarction. The patients were divided into 2 groups according to whether the artery responsible for infarction was patent (Group I: 115 patients) or not (Group II: 125 patients). The left ventricular ejection fraction was significantly higher in Group I (58 +/- 10.8%) than in Group II (53.7 +/- 11.3%) and end systolic and end diastolic left ventricular volumes were greater in Group II (51.8 +/- 22 ml/m2 and 88 +/- 22 ml/m2 respectively). Long-term follow-up (56 +/- 25 months in Group I and 61 +/- 26 months in Group II) was possible in 112 patients in Group I and 123 patients in Group II. Of the 7 patients who died in group II, 4 deaths were of cardiac origin; in addition, 2 cases of sustained ventricular tachycardia were observed in this group. None of the 6 deaths observed in Group I was of cardiac origin and there were no cases of ventricular tachycardia (p = 0.05). The functional status was identical in the two groups at the end of the study. These results suggest that the patency of the coronary artery responsible for myocardial infarction at a distance from the acute event is associated with better left ventricular function and a better long term prognosis.

[Painless myocardial ischemia. Comparison of 2 groups of patients with a positive exercise test after myocardial infarction]. / Ischémie myocardique indolore. Comparaison de deux groupes de patients ayant une épreuve d'effort positive après un infarctus du myocarde.

Myocardial ischemia usually presents with chest pain, the characteristics of which are well known. However, anginal pain may be absent during true ischemia, an entity known as painless or silent myocardial ischemia. Does this type of ischemia have special clinical, angiographic or ergometric characteristics after posterior myocardial infarction (MI)? In order to answer this question 183 consecutive patients with recent posterior MI who had undergone coronary angiography and who had positive exercise stress tests on bicycle ergometers were separated into two groups depending on whether they had experienced at least one episode of pain after the acute phase of myocardial infarction or during the exercise stress test (Group S: 83 patients, average age 54 +/- 10 years) or not (Group A: 100 patients, average 54 +/- 8 years). The following parameters were commoner in Group A: cigarette smoking, heart rate and load developed during exercise stress testing provoking electrical signs of ischemia, single vessel disease on coronary angiography, long-term medical treatment. On the other hand, the following parameters were statistically more frequent in Group S: hypercholesterolemia, preinfarction angina, degree of ST depression during exercise testing, reperfusion of the distal vessels of the occluded artery responsible for the infarct by a collateral circulation, triple vessel disease and surgical treatment. However long-term follow-up (average 3 years) shows that mortality and recurrence of MI are similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the normal bioprosthetic Intact aortic valve by Doppler echocardiography]. / Evaluation écho-doppler de la bioprothèse Intact normale en position aortique.

The Medtronic Intact is a recently commercialized porcine bioprosthesis. Its function and ultrasonic characteristics have not been widely studied. The authors performed a prospective Doppler echocardiographic study of 38 patients with Intact bioprosthesis (n. 19:1, n. 21:10, n. 23:9, n. 25:14, n. 27:3, n. 29:1) implanted in the aortic position and without clinical signs of dysfunction over a period of 8 +/- 5 months after surgery. The following parameters were measured: maximum and mean velocities, maximum and mean transprosthetic pressure gradients, permeability index (PI) or the ratio of subaortic to transprosthetic velocities, and the effective prosthetic surface area (S) calculated using the continuity equation. The PI and S were calculated by two methods, the first using the ratio of maximum velocities (PI1 and S1) and the second using the ratio of the velocity-time integrals (PI2 and S2). The global results were: Vmax 2.65 +/- 0.4 m/s range 1.9 to 3.7 m/s), maximum pressure gradient 29 +/- 9 mmHg (range 15-55 mmHg), mean pressure gradient 16.8 +/- 5.6 mmHg (range 9-32 mmHg), PI1 37.8 +/- 4.5 p. 100 (range 26-48%), PI2 39.1 +/- 5.5 p. 100, S1 1.25 +/- 0.19 cm2 (range 0.96-1.7 cm2) and S2 1.29 cm2 +/- 0.17 cm2. Minimal central prosthetic valve regurgitation was observed in 2 cases (5%). No correlations were found between the size of the prosthesis and blood flow velocities, pressure gradients or permeability indices. On the other hand, a correlation was observed between S and the size of the prosthesis (r = 0.88, p less than 1.10(-6) (S1); r = 0.80, p less than 1.10(-6) (S2)).(ABSTRACT TRUNCATED AT 250 WORDS)

[Left auricular dilatation in calcified aortic stenosis in adults]. / Dilatation auriculaire gauche dans le rétrécissement aortique orificiel calcifié de l'adulte.

Two groups of patients of comparable age, one comprising 12 subjects without detectable cardiac disease and the other comprising 38 patients with calcific aortic stenosis (CAS) underwent clinical, electrocardiographic, echocardiographic and haemodynamic studies to assess the degree and significance of left atrial hypertrophies in CAS. The volume of the left atrium (LA) was globally increased in CAS (maximum volume 68 per cent: 26/38) and LA ejection fraction was decreased in 60 per cent of patients (23/38). However, the maximum volume was only moderately greater than that of normal subjects (+38 per cent). The most specific non-invasive investigation for left atrial assessment is echocardiography. There was a linear relationship between LA angiographic volume and echocardiographic antero-posterior dimension (r = 0.43; p less than 1 x 10(-2)). The duration of the P wave in S2 was a specific (75 per cent) but relatively insensitive (27 per cent) sign of LA dilatation in pure CAS. On the other hand, the Morris index based on the surface of the P terminal force in V1 was quite sensitive (77 per cent) but not very specific (25 per cent). The maximum LA volume was not related to left ventricular volume, the severity of CAS, diastolic indices of compliance or left ventricular mass. However, the minimum LA volume (after atrial systole) was related to left ventricular end diastolic (r = 0.35, p less than 0.05) and end systolic volume (r = 0.34, p less than 0.05). The LA ejection fraction was inversely related to mean pulmonary capillary pressure (r = 0.34, p less than 5 x 10(-2).(ABSTRACT TRUNCATED AT 250 WORDS)

[Sequential revascularization of anterior myocardium using the internal mammary artery. A year-long clinical and angiographic follow-up]. / Revascularisation séquentielle du territoire myocardique antérieur au moyen de l'artère mammaire interne. Suivi clinique et angiographique à 1 an.

One hundred and twenty-one consecutive patients (104 men, 17 women; mean age 56 +/- 7.8 years) underwent sequential mammary artery grafting for anterior (left anterior descending or diagonal arteries) wall revascularisation. There was one death (0.8%) and five myocardial infarctions (4.2%) including two anterior infarcts during the first 30 postoperative days. All survivors were reviewed at one year. Of these 120 patients, 77 (64%) accepted control coronary angiography on average 456 +/- 143 days after surgery. One internal mammary artery anastomosed to 2 diagonal arteries was occluded. All the other latero-lateral anastomoses were patent. There was, however, one 60% stenosis. Three termino-lateral anastomoses on the left anterior descending artery were occluded and 2 others stenosed (40% and 60% luminal narrowing, respectively). Four internal mammary arteries were narrowed 2 because of stenosis and 2 because of the small calibre of the receiving artery. The patency rate considering the total number of anastomoses was therefore 96.8%. These results show that sequential internal mammary artery grafting for myocardial revascularisation does not increase the number of perioperative complications and is associated with a low rate of occlusion on the left anterior descending artery at one year. This surgical technique may therefore be used routinely.

[Contribution of doppler echocardiography to the diagnosis of the first attack of acute rheumatic fever]. / Apport de l'échographie-doppler cardiaque au diagnostic de la première poussée de rhumatisme articulaire aigu.

Since 1944, the Jones criteria for the diagnosis of acute rheumatic fever have been regularly revised to integrate technical and diagnostic innovations. Echographic and Doppler criteria, however, remain unrecognised due to valvular insufficiency in healthy subjects. The aim of this study was to determine the cardiac lesions occurring in acute rheumatic fever and the diagnostic value of Doppler echocardiography. One hundred patients with an average age of 10 years were admitted to hospital because of a first attack of acute rheumatic fever between January 1991 and September 1992. Eighty-six had articular signs, 5 had chorea, but none had cutaneous lesions. Forty-seven murmurs of mitral insufficiency (MI) and eight of aortic insufficiency (AI) were detected; 10 children had signs of cardiac failure. Conduction defects were recorded in 12 cases. Echocardiography showed 7 pericardial effusions; often, the left heart chambers were dilated without alteration of the fractional shortening. The commonest lesions of the mitral valve were thickening of the two leaflets, the reduced mobility of the posterior leaflet, the rigidity of the anterior leaflet and 2 cases of ruptured chordae tendinae. The Doppler mode showed 73 cases of MI, 26 of which were at least moderately severe. These cases of MI were commonly excentric jets behind the posterior leaflet. There were 47 cases of AI, 10 of which were at least moderately severe. If all cases of moderately severe or mild AI and MI are considered as pathological when associated with suggestive morphological valve changes, the number of cases of carditis increased from 50 without the Doppler mode to over 80 with this mode. Doppler echocardiography validated the Jones criteria in 16 children. The authors propose Doppler echocardiography criteria for the validation of carditis.

[Aortocoronary bypass with 10 years' follow-up. Apropos of 183 cases]. / Les pontages aorto-coronaires avec 10 ans de recul. A propos de 183 observations.

Between 1970 and 1972, 183 patients were admitted to the CMC Foch (Pr D. Guilmet) for saphenous vein aorto-coronary bypass surgery. Ten years later a questionnaire was sent to the patient and his cardiologist and the two replies were analysed. Before surgery, all patients had invalidating angina: 12 p. 100 had unstable angina, 61 p. 100 had previous myocardial infarction. Preoperative coronary angiography showed triple vessel disease in 64,5 p. 100, double vessel disease in 18,6 p. 100 and single vessel disease in 14,2 p. 100. There hundred and thirty two grafts were performed (average 1,8 per patient); 42 endarteriectomies were also carried out, 35 on the right coronary artery. Complete revascularisation was achieved in 95 cases (52 p. 100). The incidence of perioperative infarction was 17,5 p. 100 and operative mortality was 7,6 p. 100. Thirty two patients (19 p. 100) died during the 10 year study period; 11 deaths were of cardiovascular origin. The 10 year actuarial survival rate was 66 p. 100. Half the patients are asymptomatic and nearly two thirds take no anti-anginal therapy. The patency of the grafts was chacked in about half the cases and was found to be 72,8 p. 100 at one year. From the professional point of view, two thirds of patients returned to full time working one year after surgery. The degree of activity at 10 years is only known in 87 cases; half these patients are working and a quarter have retired normally. This study shows that: --coronary bypass surgery has excellent long-term effects on symptoms; --the incidence of infarction and survival are comparable to other reported studies; --patients with triple or double vessel disease may have lived longer after surgery than had they been treated medically.

[Dilated cardiomyopathies in severe cardiac failure in chronic alcoholics: clinical course after complete withdrawal]. / Cardiomyopathies dilatées en insuffisance cardiaque sévère chez des éthyliques chroniques: évolution clinique après sevrage complet.

We have prospectively evaluated 6 patients admitted for a severe heart failure in alcoholic patients with dilated cardiomyopathy. We concluded that complete abstinence results in a short-term clinical improvement, associated to a significant increase in left ejection fraction.

[One year results of sequential mammary artery anastomoses. 120 clinical cases. Angiographies: 71 patients]. / Résultats à un an des anastomoses mammaires séquentielles. Cliniques: 120 cas--Angiographies: 71 patients.

From 1985 to november 1989, 270 patients underwent sequential anastomosis with left internal mammary artery (LIMA) on left descending artery (LDA) and diagnonal artery (DA). The first 120 cases have 100% one year follow-up. The perioperative status was: angina stage III or IV: 59%; myocardial infarction (MI): 45%, stenosis of 3 vessels: 52.5%; stenosis of main coronary artery: 10.8%. 2.25 anastomoses were performed per patient. Side-to-side anastomosis (kissing) were not diamond anastomoses but axial and longitudinal. The use of fibrin gllude provides regular curves of the graft between anastomosis. Mortality was 0.8%, morbidity was: MI: 4.2% (2 small infarcts in anterior vessels, 3 others in non-grafted vessels); mediastinitis: 1%; severe bleeding (reoperation): 1%. At one year 93% of patients are free from angina and 71 patients underwent angiographic assessment (145 LIMA anastomosis). Results are as follow: side-to-side anastomosis patency: 98.5%; distal anastomosis obliteration: 3%; LDA anastomosis patency: 95.7% overall sequential anastomosis patency: 97.6%. These results have led our cardiologist in Brest to naturally prefer a surgical approach than percutaneous angioplasty when LDA and DA are involved.

[Anterior interventricular revascularization using the internal mammary artery. Short and medium-term follow-up of 140 patients]. / Revascularisation de l'interventriculaire antérieure au moyen de l'artère mammaire interne. Suivi à court et moyen terme de 140 patients.

Between February 1983 and June 1987, 140 patients underwent surgery for anterior interventricular revascularization using the left internal mammary artery (the right had been used once). Operative mortality was 3.5%, but this value decreased to 2.2% when the familiarization period for the technique was taken into account. 112 patients were monitored for at least 11 months, and 85 of these accepted an angiographic examination at the end of the follow-up period. No graft was occluded. Only two were thin due to an inadequate stenosis of the anterior interventricular septum. One graft was 90% stenosed at its anastomosis. Moderate competitive flux was noted in five cases. These results are in agreement with published findings, and comparison with literature reports confirms that the internal mammary artery is superior to the saphenous vein as graft material.

[Calcified aortic valve stenosis in adults. Analysis of supra- and infra-hissian conduction disorders]. / Rétrécissement valvulaire aortique calcifié de l'adulte. Analyse des troubles conductifs sous- et intra-hisiens.

The association of intraventricular or atrio-ventricular conductive disorders with a calcified aortic stenosis, is a classical notion demonstrated by the close anatomical relationships between aortic valve and conduction pathways. These conductive disorders have been, for quite some time, analyzed on standard electrocardiograms, but, since a few years, the recording of the bundle of His potential has become the technique of choice. However, studies regarding this subject are few, based on very small and sometimes heterogeneous groups of patients. Sixty six consecutive patients hospitalized for a narrow aortic stenosis have agreed to be subjected, before valve replacement, to a recording of the bundle of His potential. Thirteen of them (19.7%) show a HV interval exceeding 55 ms or a pathological H deflexion (twisted and lasting 35 ms). None of the pre-operative parameters that were analyzed (black-out, left ventricular function, ventriculo-aortic gradient, calculated valvular area, magnitude of valvular and ring calcifications), seem correlated with the increased HV interval. These results cross-check those reported in most of the literature.

[Value of the head-up tilt test in the etiologic diagnosis of syncope]. / Intérêt du test d'inclinaison dans le diagnostic +57etiologique des pertes de connaissance.

The cause of brief syncopes is discovered in only two-thirds of the cases at most. The purpose of this study was to quantify the value of the head-up tilt test in patients whose syncope remained "causeless" after a "conventional" investigation. Forty-nine patients entered the study on the following criteria: at least one syncope, no conduction disturbances or normal electrophysiological study, physiological response to carotid sinus massage, absence of postural hypotension and assessable tilt test. The head-up tilt test was performed under blood pressure and electrocardiographic monitoring in three stages: dorsal decubitus during 20 min, 60 degrees tilting during 20 min and, if nothing happened, isoprenaline injection. The test was positive (i.e. produced syncope or at least lipothymia) in 12 patients (24.5 per cent). In all cases the loss of consciousness was associated with a deep fall in blood pressure, but prolonged ventricular pause never occurred (2 patients had bradycardia at about 30 beats/min). The head-up tilt test is a non-invasive examination which in one-quarter of the cases provides a diagnosis of vasovagal syncope when no other diagnosis could be made; it reproduces the syncope, which is rarely done by other investigations, and it deserves to be include in the evaluation of unexplained syncopes.

[Carotid sinus hypersensitivity associated with a treated otorhinolaryngologic cancer. Study of 103 patients]. / Hypersensibilité sino-carotidienne associée à un cancer oto-rhino-laryngologique traité. Etude chez 103 malades.

The incidence and characteristics of carotid sinus hypersensitivity were investigated in a homogeneous population of patients undergoing radiotherapy and surgery for ear, nose and throat (E.N.T.) cancers. Among the 103 patients who were thus treated but had none of the risk factors usually correlated with the disease investigated, 30 percent showed evidence of mainly vasodepressive (87 percent) carotid hypersensitivity when subjected to carotid sinus massage accompanied by electrocardiography and intra-arterial blood pressure measurement. The large number of positive responses, as well as the good reproductibility of this provocation test and its concordance with the site of local treatment suggest that surgery contributes to the genesis of the abnormality. Owing to the considerable variations in the type of response obtained, carotid sinus hypersensitivity should systematically and repeatedly be searched for in cases of syncope in patients treated for E.N.T. cancer.