Kinetics of oxygen consumption during and after exercise in patients with dilated cardiomyopathy. New markers of exercise intolerance with clinical implications.

OBJECTIVES: This study analyzed the kinetics of oxygen consumption during and after a maximal cardiopulmonary exercise test in patients with dilated cardiomyopathy. The prognostic information derived from indexes of recovery was also studied. BACKGROUND: Previous studies have examined the kinetics of oxygen consumption during a short recovery period in a limited number of patients. To our knowledge, no study has examined the prognostic information derived from indexes of recovery. METHODS: We studied 153 patients and 55 control subjects. We calculated the ratio between total oxygen consumption during exercise and recovery, the half-recovery time of peak oxygen consumption, the time constant of recovery, the recovery time and the ratio between duration of exercise and recovery time. RESULTS: Recovery of oxygen consumption was significantly delayed in patients, and this delay was related to the degree of exercise intolerance. After a median follow-up period of 439 days, for the total study group, percent of predicted peak oxygen consumption (p = 0.003) and ejection fraction (p = 0.03) were independent predictors of survival. In a subgroup of patients with moderate exercise intolerance (percent peak oxygen consumption > 40%), the ratio between total oxygen consumption during exercise and recovery (p = 0.013) and the ejection fraction (p = 0.013) were independent predictors of survival. CONCLUSIONS: The kinetics of oxygen consumption during recovery was delayed in patients with dilated cardiomyopathy. Although indexes of recovery were not prognostic markers in the total study group, the ratio between total oxygen consumption during exercise and recovery was an independent prognostic marker in patients with moderate exercise intolerance.

Plasma levels of endothelin-1 at rest and after exercise in patients with moderate congestive heart failure.

Plasma levels of endothelin-1 are increased in patients with severe congestive heart failure related to various etiologies. However, conflicting data have been published in patients with moderate congestive heart failure. Moreover, the effect of exercise on plasma levels of endothelin-1 is not precisely known. We determined the plasma levels of endothelin-1 in a homogenous group of patients with idiopathic dilated cardiomyopathy in stage II of the New York Heart Association functional classification at rest and at peak exercise. In this group of patients, plasma levels of endothelin-1 were increased compared to a control group (2.9 +/- 0.27 vs. 1.96 +/- 0.24 pmol/l, P < 0.01, mean +/- S.E.M.), as were plasma levels of atrial natriuretic peptide (26.3 +/- 6.3 vs. 2.95 +/- 0.7 pmol/l, P < 0.001), plasma renin activity (12.6 +/- 2.98 vs. 1.75 +/- 0.23 ng/ml per h, P < 0.001) and plasma levels of aldosterone (217 +/- 29.3 vs. 154 +/- 18.8 pg/ml, P < 0.05). In contrast to the other hormones, exercise did not increase plasma levels of endothelin-1. There was no correlation between plasma levels of endothelin-1 and plasma levels of atrial natriuretic peptide, and no correlation between left ventricular ejection fraction, peak oxygen consumption and hormonal values. In conclusion, plasma levels of endothelin-1 are increased in a homogeneous group of patients with idiopathic dilated cardiomyopathy and moderate congestive heart failure. Endothelin-1 could participate in the progression of heart failure. Exercise did not increase the plasma levels of endothelin-1 in contrast to the other hormones.

Pregnancy after myocardial infarction.

UNLABELLED: The occurrence of pregnancy in a patient after myocardial infarction remains a dilemma for both the cardiologist and the obstetrician. The majority of obstetricians and cardiologists are very reticent about pregnancy in a woman suffering from coronary disease. AIMS: The aims of this study are to evaluate the risks, the prognosis of pregnancy for women who had suffered from myocardial infarction and to propose guidelines for pre-pregnancy counselling and medical supervision of the pregnancy and delivery. METHODS: A review of literature has revealed 30 cases, 14 of which are sufficiently documented. Only one of these patients requested pre-pregnancy counselling. We add to this experience the case of a patient who, having had an infarction, was authorized to begin pregnancy. RESULTS: Most of the pregnancies in these patients evolve satisfactorily if the more frequent cardiovascular complications are diagnosed and treated rapidly. During the pregnancy, rest is the rule and any situation which risks to increase the myocardial work-load should be avoided. Normal vaginal delivery with epidural anesthesia is the preferred method. CONCLUSION: The maternal and fetal prognosis is good on condition of performing a pre-pregnancy examination and of setting up a multi-discipline surveillance of the pregnancy. The review of the literature does not confirm the surrounding pessimism concerning the patients becoming pregnant after myocardial infarction.

Multifocal peripheral and coronary angioplasties.

Multifocal atherosclerotic lesions are frequent. It could thus be expected that multifocal angioplasties (performed in one particular patient on several [iliofemoral, renal, subclavian, mesenteric, coronary] sites) are frequent. To study multifocal angioplasty, we considered the 5344 angioplasties (PTA) (4151 coronary and 1193 peripheral PTA) which had been performed over 10 years in our institution. Eighty PTA (1.5%) were considered as multifocal angioplasty. They were performed in 30 patients who were followed up during 7 to 132 months (mean = 55). In case of primary PTA (72 PTA), the most frequent involved site was the iliofemoral site (47%) followed by renal (35%), coronary (8%), subclavian (7%) and mesenteric sites (3%). Eight PTA were performed after primary failure (3 cases) or after restenosis (5 cases). The 30 patients were divided into 2 groups according to the chronology of multifocal PTA. In group I, 20 patients had multifocal lesions on the first workup and multifocal angiopathy over a short operative period (< 3 months). The 10 patients of group II initially had a single procedure. They subsequently had multifocal angioplasty over a longer period (> 2 years) on different sites of the first PTA. Compared to group I, mean age was lower in group II (46 vs 52 year; ns), primary success rate higher (100 vs 90%; p < 0.05), complications less frequent (3 vs 20%, p < 0.05) and restenosis rate lower (7 vs 21%; p < 0.01). In conclusion, multifocal angioplasty is infrequent. A specific group of patients who had multifocal angioplasty spread over several months or years could be individualized.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative diagnostic value of ankle-to-brachial index and transcutaneous oxygen tension at rest and after exercise in patients with intermittent claudication.

BACKGROUND: Few studies have compared sensitivities of ankle-to-brachial index (ABI) and transcutaneous oxygen tension (TcPO2) in a large group of patients with Leriche stage II intermittent claudication. METHOD AND RESULTS: 111 patients (138 limbs) with a stable chronic (> three months) intermittent claudication and significant peripheral vascular disease (PVD) proved by angiography were studied. They performed a treadmill test (10%, 3 km/hr) limited by limb pain. ABI and TcPO2 were measured before, just after exercise, and after three and ten minutes of recovery in supine position. Sensitivities per patient for ABI and TcPO2 were respectively at rest: 82.9% and 28.8%, and after exercise: 88.3% and 62.2%. Sensitivities per leg (n = 138) for ABI and TcPO2 were respectively at rest: 73.9% and 26.8%, and after exercise: 82.6% and 34%. The sensitivity of TcPO2 increased to 56.5% after three minutes of recovery but was always less than that of ABI, which was maximal just after exercise (82.6%). The sensitivity of the regional perfusion index was similar to that of TcPO2. The sensitivity of TcPO2 increased with respect to the Leriche stage and the number of lesions but was always lower than that of ABI. There was a weak correlation between TcPO2 and ABI after exercise, but no correlation was noted between maximal walking distance, ABI, and TcPO2. CONCLUSION: TcPO2 is not required in patients with Leriche stage II intermittent claudication but might be useful either in severely affected patients (Leriche stage III or IV) or in selected patients.

Long-term follow-up after peripheral and coronary angioplasty in patients undergoing both types of procedure.

Restenosis rates after peripheral and coronary angioplasties have been assessed only in patients who had either peripheral angioplasty or coronary angioplasty but never in patients who had both types. Among the 6364 angioplasties performed in the authors' institution since 1980, they studied 38 patients (36 men, 2 women, mean age fifty-five years, range thirty-four to seventy-seven) who had both peripheral and coronary angioplasty. The peripheral angioplasties were most often performed on iliac artery stenoses. They were performed before coronary angioplasty in 22 patients (58%) and after coronary angioplasty in 16 patients (42%). The follow-up after peripheral angioplasty was based on clinical data; ultrasound investigation was performed when the result of the clinical follow-up was poor (maximal walking distance lower than 500 meters). Follow-up after coronary angioplasty was assessed by a systematic coronary angiography at six months and with long-term clinical follow-up. The mean durations of the follow-up after peripheral or coronary angioplasty were not significantly different (respectively fifty-six +/- eleven and forty-two +/- nine months [mean +/- 2 SEM]). No patient was lost to clinical follow-up; 17 (45%) ultrasound investigations, 12 (32%) peripheral angiographies, and 34 (89%) coronary angiographies were performed. The restenosis rate after peripheral angioplasty was 18% and that after coronary angioplasty was 34%. These rates are similar to the classic rates observed in the literature. In conclusion, as reported for either procedure alone, the restenosis rates after peripheral angioplasty and after coronary angioplasty are different when assessed in patients who undergo both types of angioplasty.

[Left intraventricular gradients measured by Doppler echocardiography at rest, during exercise and during isoproterenol test in hypertrophic cardiomyopathy]. / Gradients intraventriculaires gauches, mesurés par échocardiographie Doppler au repos, à l'effort et lors d'un test à l'isoprotérénol, au cours de la cardiomyopathie hypertrophique.

Doppler echocardiography has been shown to be an accurate method of assessing left ventricular outflow obstruction in hypertrophic cardiomyopathy (HCM). One of the characteristics of this pressure gradient is its variability and, therefore, we measured this parameter during dynamic exercise testing in 33 patients. The results were compared with those recorded during isoproterenol infusion, the reference stress test for patients with HCM. Submaximal exercise in the recumbent position is usually well tolerated and resulted in a 43% increase in heart rate and a 47% increase in pressure gradient. There was a significant correlation between resting and exercise outflow obstruction (r = 0.90; p = 0.001). Moreover, exercise echo revealed obstruction in 26% of patients without resting pressure gradients (latent obstruction). The interpretation of results obtained with isoproterenol infusion is more difficult: this test resulted in an important increase in the left ventricular pressure gradient (231%) and "revealed" obstruction in 84% of cases. Therefore, we believe that exercise is more physiological and better tolerated than isoproterenol stress infusion and should be adopted as the investigation of choice in HCM even without obstruction at rest. If it is not possible to perform the exercise or no outflow tract obstruction can be demonstrated, an isoproterenol infusion may be used but this is not always well tolerated and the results should be interpreted with caution.

[Value of spiral computed tomography with three-dimensional reconstruction in the investigation of renal arteries. An initial clinical experience apropos of 16 cases]. / Intérêt de l'angioscanner spiralé avec reconstruction tridimensionnelle dans l'exploration des artères rénales.

Renovascular hypertension represents 1 to 2% of all causes of hypertension. It is important to make the diagnosis as radical treatment may be proposed. Digitised arteriography is the reference diagnostic method. Spiral angiotomography is a new diagnostic technique for the investigation of the aorta and its branches. The examination was performed with a Siemens Somatom Plus S spiral scanner. The images were acquired after intravenous injection of 140 ml of iodine contrast medium in the forearm. Three dimensional reconstruction of the renal arteries may be performed secondarily. The results of 16 examinations were compared with those of arteriography. Nine stenoses were suspected after spiral angiotomography and confirmed in 7 cases by arteriography (sensitivity 100%; specificity 77%); two adrenal abnormalities were also detected by spiral tomography. In this series, spiral angiotomography detected all cases of renal artery stenosis with good specificity. Moreover, this investigation also allowed evaluation of the adrenal glands. The simple, non-invasive and polyvalent nature of this method should, if the results are confirmed in a large series, lead to its use as the investigation of first intention for suspected secondary causes of hypertension.

[Rhabdomyolysis caused by pravastatin and type 1 macrocreatine kinase]. / Rhabdomyolyse sous pravastatine et macrocréatine kinase de type 1.

The authors report a case of rhabdomyolysis which occurred in a 61 year old woman who was receiving pravastatin and who was also found to present with type 1 macrocreatine kinase. Drug induced rhabdomyolysis is common, particularly with HMG Coenzyme A reductase inhibitors. The authors describe the onset of an adverse effect of this type with pravastatin, a recently marketed drug, as has been previously described for lovastatin and simvastatin. The concomitant detection of macrocreatine kinase, the incidence of which is estimated to be between 2 and 5% in the population, raises the question of whether rhabdomyolysis of this type may occur preferentially in patients with this biological anomaly.

[Current respective role of surgery and permanent endocavitary stimulation in the treatment of hypertrophic cardiomyopathies]. / Place respective actuelle de la chirurgie et de la stimulation endocavitaire permanente dans le traitement des cardiomyopathies hypertrophiques.

Surgery and cardiac pacing are the two main non-drug treatments for hypertrophic cardiomyopathy. Various surgical techniques have been proposed over the last 35 years: myotomy, myotomy-septal myomectomy, isolated mitral valve replacement, heart transplantation. Patients eligible for surgery are those with severe symptoms (NYHA stage III or IV) and refractory or no longer responding to drug treatment. The choice between the various techniques is based on morphological and haemodynamic criteria (significant subaortic gradient associated with increased septal thickness, severe and/or organic mitral regurgitation, either isolated or associated with obstruction, or less severe or heterogeneous septal thickness [< 18 mm]) or therapeutic criteria (failure of primary myomectomy, depletion of all surgical possibilities). Analysis of the results of surgery is complicated by the variety of techniques performed and the experience of the various teams. The operative mortality was markedly decreased (between 2 and 11% at the present time); the complications of myomectomy (ventricular septal defect, disturbances of conduction requiring continuous pacing) are still frequent. Intraoperative transoesophageal ultrasonography could help to further decrease the operative risk. Surgery improves functional symptoms and exercise tolerance. This beneficial effect appears to be more marked, more frequent and more lasting than that of medical treatment. Surgical treatment does not ensure permanent cure, as the symptoms related to pathophysiological abnormalities other than intraventricular obstruction (abnormalities of diastolic filling, myocardial ischaemia, arrhythmias) may develop subsequently. No controlled trial has demonstrated a favourable effect on survival. Continuous pacing, introduced more recently, can now be considered to be a therapeutic method in its own right.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary-left ventricular fistula in post-infarction of the myocardium. Apropos of a new case. Review of the literature]. / Fistule coronaro-ventriculaire gauche post-infarctus du myocarde. A propos d'un nouveau cas. Revue de la littérature.

The authors report a new case of acquired corono-left ventricular fistula found in a 46-year-old man four months after a first myocardial infarction treated by fibrinolysis then conventional angioplasty. This is one of the rare cases of post-infarction corono-ventricular fistula, only five of which have been reported in the literature. While their described features seem relatively constant, enabling their distinction from post-angioplasty corono-ventricular fistulas (also rarely described: four cases), certain doubts persist as to their treatment, and above all their mechanism. Monitoring for four years by coronary angiography, which is the special feature of the case reported here, leads us to include this entity within the wider context of post-infarction ventricular remodelling, of which it would then be a very rare complication.

[Arterial thromboses and essential thrombocythemia in young patients]. / Thromboses artérielles et thrombocytémie essentielle chez le sujet jeune.

The authors report two cases of essential thrombocythemia (ET) which occurred in young subjects (25 and 33 years) and revealed by arterial thromboses. The first case was one of myocardial infarction: in the second case, ischemic signs in the left leg led to cutaneous necrosis. Thrombotic signs are commonplace in ET and are generally considered to be attributable to an impaired underlying vascular territory. The cases reported by the authors conflict with these data and it would seem, therefore, that the onset of thrombosis in the absence of any associated cardiovascular risk can be envisaged. With regard to therapy, if thrombotic signs occur, myelosuppressive treatment must be undertaken; in asymptomatic patients, due to the potential and unpredictable risk of thrombosis, this treatment should be initiated if the platelet count rises above 800 x 10(9)/l. Hydroxyurea is generally prescribed (particularly in young patients) since it is generally considered to be devoid of any leukemogenic potential.

[Cardiovascular manifestations caused by Mycoplasma pneumoniae. Apropos of a case of recurrent pericarditis complicated by tamponade]. / Les manifestations cardiovasculaires dues à Mycoplasma pneumoniae. A propos d'un cas de péricardite récurrente compliquée de tamponnade.

The authors report a case of recurrent pericarditis complicated by tamponade, a complication rarely reported in the literature, due to Mycoplasma pneumoniae infection. The frequency and the characteristics of the pericarditis caused by this microorganism are reviewed and the diagnostic criteria and pathogenic mechanisms are discussed.

[Infarction and pregnancy. Review of the literature. A case report]. / Infarctus et grossesse. Revue de la littérature, à propos d'une observation.

UNLABELLED: BUT: Assess risk factors and pathogenesis of myocardial infarction in young women and evaluate cardiologic and obstetrical management of myocardial infarction during pregnancy as well as assess the prognosis of pregnancy in patients with a prior myocardial infarction. METHODS: Fra a personal observation of pregnancy after myocardial infarction, we reviewed the literature on two distinct themes: myocardial infarction during pregnancy and pregnancy after myocardial infarction. RESULTS: Pregnancy was deliberately authorized in a 21-year-old who had myocardial infarction 3 years earlier. The pregnancy was uneventful and cesarean section with epirual analgesia at 37 weeks gestation delivered a healthy 2,350 g boy. Unfortunately the patient died at her home 18 month later. Acardiac cause was retained although death due to ventricular rhythm disorder or recurrent myocardial infarction could not be confirmed due to lack of an autopsy. The prognosis of pregnancies after myocardial infarction would not appear to be catastrophic although this case raises some doubts as to whether pregnancy should be authorized in these patients. The major difference in mortality according to whether the infarction occurs before or during pregnancy would suggest that risk might be reduced by a haling period after the infarction. CONCLUSION: It appears that pregnancy in women with a prior myocardial infarction would be possible if sufficient precautions are taken. All situations increasing cardiac work should be avoided. Stress and pain must be avoided during delivery and the post-partum period. Intensive cardiological and obstetrical supervision supervision are required for correct management of the pregnancy.