Arrhythmogenic response to isoproterenol testing vs. exercise testing in arrhythmogenic right ventricular cardiomyopathy patients.

Aims: To compare the arrhythmic response to isoproterenol and exercise testing in newly diagnosed arrhythmogenic right ventricular cardiomyopathy (ARVC) patients. Methods and results: We studied isoproterenol [continuous infusion (45 µg/min) for 3 min] and exercise testing (workload increased by 30 W every 3 min) performed in consecutive newly diagnosed ARVC patients. Both tests were evaluated with regard to the incidence of (i) polymorphic premature ventricular contractions (PVCs) and couplet(s) or (ii) sustained or non-sustained ventricular tachycardia (VT) with left bundle branch block [excluding right ventricular outflow tract VT]; and compared to a control group referred for the evaluation of PVCs without structural heart disease. Thirty-seven ARVC patients (63.5% male, age 38 ± 16 years) were included. The maximal sinus rhythm heart rate achieved during isoproterenol testing was significantly lower compared to exercise testing (149 ± 17 bpm vs. 166 ± 19 bpm, P < 0.0001). However, the incidence of polymorphic ventricular arrhythmias was much higher during isoproterenol testing compared to exercise testing [33/37 (89.2%) vs. 16/37 (43.2%), P < 0.0001]. Interestingly, isoproterenol testing was arrhythmogenic in all 15 patients in whom baseline PVCs were reduced or suppressed during exercise testing. During both isoproterenol and exercise testing, control group presented a low incidence of ventricular arrhythmias compared to ARVC patients (8.1% vs. 89.2%, P < 0.0001 and 2.7% vs. 43.2%, P < 0.0001, respectively). Conclusions: The incidence of polymorphic ventricular arrhythmias is significantly higher during isoproterenol compared to exercise testing in newly diagnosed ARVC patients, suggesting its potential utility for the diagnosis.

Peri-infarct ischaemia assessed by cardiovascular MRI: comparison with quantitative perfusion single photon emission CT imaging.

OBJECTIVE: To develop a new method for the cardiac MR (CMR) quantification of peri-infarct ischaemia using fused perfusion and delayed-enhanced images and to evaluate this method using quantitative single photon emission CT (SPECT) imaging as a reference. METHODS: 40 patients presenting with peri-infarct ischaemia on a routine stress (99m)Tc-SPECT imaging were recruited. Within 8 days of the SPECT study, myocardial perfusion was evaluated using stress adenosine CMR. Using fused perfusion and delayed-enhanced images, peri-infarct ischaemia was quantified as the percentage of myocardium with stress-induced perfusion defect that was adjacent to and larger than a scar. This parameter was compared with both the percent myocardium ischaemia (SD%) and the ischaemic total perfusion deficit (TPD). The diagnostic performance of CMR in detection of significant coronary artery stenosis (of ≥70%) was also determined. RESULTS: On SPECT imaging, in addition to peri-infarct ischaemia, reversible perfusion abnormalities were detected in a remote zone in seven patients. In the 33 patients presenting with only peri-infarct ischaemia, the agreement between CMR peri-infarct ischaemia and both SD% and ischaemic TPD was excellent [intraclass coefficient of correlation (ICC) = 0.969 and ICC = 0.877, respectively]. CMR-defined peri-infarct ischaemia for the detection of a significant coronary artery stenosis showed an areas under receiver-operating characteristic curve of 0.856 (95% confidence interval, 0.680-0.939). The best cut-off value was 8.1% and allowed a 72% sensitivity, 96% specificity, 60% negative predictive value and 97% positive predictive value. CONCLUSION: This proof-of-concept study shows that CMR imaging has the potential as a test for quantification of peri-infarct ischaemia. ADVANCES IN KNOWLEDGE: This study demonstrates the proof of concept of a commonly known intuitive idea, that is, evaluating the peri-infarct ischaemic burden by subtracting delayed enhancement from first-pass perfusion imaging on CMR.

[Survey of cardiovascular risk assessment and the behaviour of a sporting population]. / Enquête sur les comportements et l'évaluation du risque cardiovasculaire dans une population de sportifs.

In order to better understand the risk factors and behaviour of a general sports population, a questionnaire was handed to 603 consecutive sportsmen of various disciplines during a specific sports medicine consultation and a half-marathon. Among the discovered risk factors, smoking was the most common (19.3% for the entire study population), predominantly in the youngest group (26%). A resting ECG had been performed very frequently within the previous year in those over 40 years (86.5%), but less often in the younger sportsmen (44.8%). An exercise test had also very often been performed in those aged over 40 years (69.2 vs 10.6%). Behaviour associated with cardiovascular risk was common. Undertaking physical activity while febrile (58%) and smoking just before or after exertion (13.1%) were widespread behaviours. This population appeared casual in its approach to possibly suspicious cardiac symptoms of exercise, particularly the females and paradoxically the subjects doing the most sport. Lastly, only a minority of sportsmen knew the telephone number for the emergency medical service (45%) or claimed to be competent at first aid (32%). This survey underlines a practice relatively in accordance with the recommendations for detecting cardiovascular pathology, but shows a failure of preventive education.

[Prognosis and risk evaluation of postoperative coronary patients (PERISCOP). Methodology and study population characteristics]. / Pronostic et évaluation du risque chez le coronarien opéré (PERISCOP). Méthodologie et caractéristiques de la population incluse.

The aim of the PERISCOP study was to evaluate the predictive value of cardiological investigations performed after recent coronary bypass surgery with regards to cardiac event and mortality at one year. The treatment of lipid abnormalities was also analysed. This first article describes the methodology and patient characteristics at inclusion. This prospective national multicenter trial included 2065 patients (86% men) with an average age of 63.1 +/- 9.9 years. The number of diseased vessels was 2.6 +/- 0.6. Preoperative left ventricular function was normal (ejection fraction 60 +/- 13%). Revascularisation was complete in 73% of cases (22% of arterial grafts). The cardiological investigations were performed at Day 20 +/- 10 after surgery. The duration of exercise on stress testing was 429 +/- 170 seconds. It was positive or doubtful in 9% of cases. Ventricular arrhythmias were observed in 6.5% of cases. The blood pressure response was abnormal in 6% of cases. Holter monitoring showed a median number of ventricular extrasystoles over 24 hours of 44. Three per cent of patients had one episode of ventricular tachycardia and 7% had ischaemic episodes. The echocardiographic index of segmental contractility was on average 1.75 (ejection fraction: 52.6%). The lipid analysis performed at one month, under lipid therapy in 34% of cases, showed a total cholesterol level at 1.91 +/- 0.10 g/l, an LDL-cholesterol of 1.27 +/- 0.08 g/l. The therapeutic target (LDL-cholesterol < 1 g/l) was attained in 46% of cases with treatment and in 18% of cases without treatment.

[Significance of exercise induced ST elevation in patient without a history of previous myocardial infarct]. / Signification d'une élévation du segment ST liée à l'effort chez des patients sans antécédent d'infarctus.

UNLABELLED: Between 1980 and 1995, we observed twenty-five patients (22 males, 3 females) at the mean age of 50.6 +/- 13 years, without previous myocardial infarction who presented exercise induced ST elevation on a bicycle stress test. METHODS: Significant ST elevation was defined as a > or = 1 mm change present in > or = 1 lead measured 0.08 sec after the J point and in 3 consecutive beats. All patients have undergone coronary angiography in the days following the exercise test. RESULTS: Most of patients (56%) presented a history of typical angina that was either purely exertional (8 pts) or also occurred at rest (6 pts). Others (36%) had non typical angina or no angina (8%); 78% of pts were smokers. Sixteen patients (group I) had ST elevation during exercise (exercise duration: 7.6 +/- 4 min; peak heart rate: 135.5 +/- 29 batt/min; ST = 3.5 +/- 1.5 mm) and nine (group II) during the recovery phase (exercise duration 16.3 +/- 1.6 min; p < 0.05; peak heart rate 168 +/- 22 batt/min; p < 0.05; ST: 5.8 +/- 3 mm; p < 0.05). In group I, 1 patient had no vessel disease, 12 had one vessel disease, 3 had multivessel disease with 6 cases of hypersevere coronary stenose (> 90%). In group II, 4 patients had normal coronary arteries, there was one vessel coronary artery disease in 4 patients and multivessel in one subject, without hypersevere coronary stenosis. Correlation between anatomic location of stenosis and electrocardiographic ST elevation was excellent, particularly in case of single vessel disease (100%). All patients underwent one or more new exercise tests after therapeutic intervention (surgery n = 3; angioplasty n = 7; medical treatment n = 15), only 2 patients had persistent exercise induced ST elevation. During follow-up (5 +/- 3 years), 3 patients died (2 cardiac deaths) and 3 had recurrent angina controlled by new treatment. CONCLUSION: Exercise-induced ST elevation is a rare phenomenon in patients without prior myocardial infarction. When occurring purely during exercise, coronary lesions are frequent and often servere, in the other hand ST elevation of the recovery phase is frequently associate with normal arteries or less severe lesions. In most cases, revascularisation or medical therapy can abolish clinical and electrocardiographic abnormalities.

[Third degree atrio-ventricular block induced by interferon alpha. Report of a case]. / Apparition d'un bloc auriculo-ventriculaire du troisième degré sous interféron alpha. A propos d'un cas.

Iatrogenic third degree atrioventricular block due to alpha interferon is rare. The authors present a case which occurred with low dosage, regressed when treatment was withdrawn and reappeared when treatment was reintroduced. The physiopathological mechanism of disease of the conduction pathways and its general cardiotoxicity is not yet understood. The secondary effects of this increasingly widely used anti-tumoral and anti-infectious drug should be recognised in order to prevent them. Initial cardiological investigation and follow-up are indicated to ensure this prevention.

[Preoperative management of patients with high-risk cardiovascular conditions]. / Quels bilans préopératoires chez le patient à risque cardiovascularie?

The growing numbers of elderly and cardiac patients are the consequence of progress in the prevention of the complications of coronary artery and valvular heart disease by surgery and revascularisation and improved treatment of hypertension which delays target organ complications by at least fifteen years. The elderly are particularly exposed to surgical risk: nearly half the patients with ischaemic heart disease die of cancer; a high proportion of elderly people require orthopaedic surgery either as an emergency (fractured femur) or as a standard procedure (knee surgery); nearly a quarter of patients requiring peripheral vascular surgery have coronary artery disease which may be silent. A preoperative consultation with the anaesthetist has been made compulsory, except in emergencies, giving time for preoperative investigations. The decrees of the Court of Cassation have also affected the traditional relationship of trust between patients and their doctors, leading to an increase in the cost of preoperative investigations without an accurate assessment of their benefits with regards to postoperative complications and the cost that they entail. Contrary to present tendencies reflected in the literature, the screening of risks should be simplified: clinical history and examination and resting ECG, often completed by stress testing, are sufficient in the large majority of cases. More importance should be attributed to the functional status than to the lesions. When the cardiac disease is asymptomatic, the chances are that it will remain so during and after surgery.... The main difficulty is not in identifying high risk patients: it is preventing cardiovascular events when surgery is unavoidable. The experience and collaboration between the quartet of anaesthetist, surgeon, cardiologist and general practitioner, are much more useful than the very incomplete bibliographical data concerning this side of the problem.

[Fortuitous discovery of Brugada syndrome in an asymptomatic 70-year-old sportsman]. / Découverte fortuite d'un syndrome de Brugada chez un septuagénaire sportif asymptomatique.

The authors report the case of an elderly sportsman presenting with the electrical signs of the syndrome described by Brugada. The absence of any serious clinical events in this patient questions the pejorative prognosis usually reported and the specific identity of this syndrome in relation to right ventricular arrhythmogenic dysplasia.

[Value and limits of exercise radionuclide ventriculography in chronic aortic insufficiency. Apropos of 47 operated cases]. / Intérêts et limites de la ventriculographie radio-isotopique d'effort dans l'insuffisance aortique chronique. A propos de 47 cas opérés.

The role of exercise radionuclide angiography in the therapeutic strategy of chronic aortic insufficiency remains controversial. In order to assess the value of this technique, 47 patients with pure chronic aortic insufficiency were evaluated before and one year after valve replacement. The preoperative EF decreases or does not increase on exercise (51.9% vs 48 +/- 10%; p < 0.001) in the majority of patients (78%), whereas, after surgery, the EF tends to increase on exercise (55 +/- 11% vs 57 +/- 11%; NS). Despite optimal surgical correction, 16 of the surviving 46 patients still had left ventricular dysfunction at one year after surgery. The preoperative parameters correlating with this dysfunction were, in order, resting radionuclide EF (r = 0.65; p = 0.0001) and the echocardiographic parameters: left ventricular endosystolic dimension, fractional shortening, and the radius/thickness ratio. The preoperative exercise radionuclide parameters did not correlate with postoperative left ventricular dysfunction. In patients without postoperative left ventricular dysfunction, the EF increased on exercise, contrary to the other group. The exercise EF remains valuable for retrospective evaluation of surgical benefit. The exercise radionuclide EF does not reflect myocardial contractile reserve alone but also the conditions of left ventricular load. This study confirms the superiority of the resting radionuclide EF and echocardiographic parameters over exercise radionuclide EF for the prediction of postoperative left ventricular dysfunction.

[Secondary prevention of atherosclerosis: effects on coronary plaques and on myocardial ischemia]. / Prévention secondaire de l'athérosclérose: effets sur les plaques coronaires et sur l'ischémie myocardique.

The coronary atherosclerotic plaque progresses in successive stages, determined by phenomena such as spasm, thrombosis and inflammation. Studies of regression are hindered by methodological problems involving the variability of angiographic results over intervals of several years. Longitudinal clinical studies are probably more useful. For long-term clinical outcome, it appears that stabilisation of young plaques is more important than regression of older plaques. To this end, cessation of smoking seems the most effective means; progressive plaques are most often seen early in the disease, in patients under 60 years of age, of whom more than 70% are smokers. The inevitable lack of studies as rigorous as those dealing with hyperlipidaemia reduction should not be used as a pretext for scruples leading to ignoring the results of clinical practice. Prevention by diet is no doubt essential, but prospective studies are still rare and biases are numerous. The same is true for physical exercise.

[Myxoma of atypical manifestation and morphology]. / A propos d'un myxome de révélation et de morphologie atypique.

The authors report a case of myxoma of the left atrium unusual by its clinical presentation, very calcified radiological appearance and histological findings. The topographic description, facilitated by transoesophageal echocardiography, is also emphasized.

[Prognosis and predictive factors of mortality in patients with inoperable coronary disease]. / Devenir et facteurs prédictifs de mortalité des coronariens inopérables.

In the period between September 1979 and December 1986, 105 out of 2,178 consecutive patients with coronary artery disease (men 93, women 12; age : 58.1 +/- 10 years; previous myocardial infarction : 67%) were considered inoperable because of poor distal coronary circulation (84.8%), left ventricular dysfunction (3.8%) or both (11.4%). Fifty-four clinical, ergometric and angiographic parameters were examined at inclusion. The mean follow-up was 69 +/- 40.2 months (1 to 146 months). The Kaplan Meier 10 year survival rate was 43%. Only 25% of the population remained free of major cardiac events. Multivariate analysis showed that only the coronary angiographic score had a significant predictive value. The authors conclude that the long-term prognosis of these patients is poor. Some did undergo coronary bypass surgery secondarily, and their prognosis was good, suggesting that revascularisation, even if only partial and at high risk, should be considered.

[Triangular or rectangular rehabilitation after myocardial infarction. Comparative study by drawing of lots evaluating performance and respiratory gas exchange]. / Réadaptation triangulaire ou rectangulaire après infarctus du myocarde. Etude comparative par tirage au sort évaluant la performance et les échanges gazeux respiratoires.

Triangular and rectangular rehabilitation techniques were assessed by comparative exercise performance and respiratory evaluation in twenty six phase II post-myocardial infarction patients. Patients all performed a standard exercise test with measurement of VO2, before and after 40 rehabilitation sessions. Clinical, exercise and ventilatory parameters were identical in the two groups before rehabilitation (triangular--n = 13; rectangular--n = 13). Exercise capacity was increased by 18% and 19% respectively after rehabilitation. Maximum aerobic capacity nevertheless remained unchanged (27.6 +/- 7.1 before; 28.3 +/- 6.7 ml/kg/min after) in all patients. Analysis of variance failed to reveal superiority of one of the two rehabilitation techniques over the other.

[Role of physical effort in the monitoring of coronary disease: under medical treatment, after bypass, after angioplasty]. / Place de l'épreuve d'effort dans la surveillance de la maladie coronaire: sous traitement médical, après pontage, après angioplastie.

Exercise tests must be performed only in hospitals and private clinics equipped for intensive care. Electrocardiographs must be fitted with a computer-assisted system for averaging and smoothing. In all but special cases it would be preferable to interrupt or delay the anti-angina treatment, so that the degree of ischaemia can be quantified. In this way, the severity of coronary lesions, the risk of arrhythmia and the prognosis for life can be predicted with good statistical certainty. In addition, the patient's fitness for work can easily be evaluated. As years go by, the ischaemia may be found to have become worse, and it might be decided to revascularize the myocardium in due course. Following revascularisation exercise tests are used to evaluate its benefits and follow their persistence. In addition, exercise tests are a very useful means of adjusting the antianginal treatment. Finally, exercise tests create a special link between patients and their medical team since they participate, both physically and psychologically, in their own diagnosis and evaluation of treatment.

The benefit of graded physical exercise in chronic heart failure.

A new program of rehabilitation is less demanding on cardiac output than standard programs. Twenty-five patients with chronic heart failure (ejection fraction [EF]: 0.26 +/- 0.10) were randomized into 2 groups: a control group with 13 patients and a rehabilitation group of 12 patients. In the control group, 2 did not complete the study (cancer, cardiac transplantation). For the 11 others, the different parameters studied were comparable at day 0 with group R and did not significantly change over 3 months outside of a spontaneous improvement in endurance performance by 22%. In the rehabilitation group (40 sessions over 90 days; specialized equipment) there were no incidents. Tolerance was excellent (heart rate during sessions less than 115 bpm) and all functional parameters improved. Training did not modify the isotopic ejection fraction. The quality of life score increased respectively by 52% (p less than 0.0001 in comparison with the control group) and by 63% (p less than 0.0001); 80% of the patients requested that training be prolonged. The functional improvement obtained by purely peripheral effect had no adverse effect on the heart.

[Which coronary investigation should be performed in patients with peripheral arterial diseases?]. / Quel bilan coronarien faut-il faire chez un patient présentant une artériopathie périphérique?

In the context of peripheral vascular disease, the clinical history provides a means of evaluating coronary risk. The key features are: age, previous myocardial infarction especially when recent (under 6 months), anginal pain, smoking, diabetes and ventricular arrhythmias. Treadmill testing, often limited by symptoms of claudication, may reveal severe coronary ischemia and thereby the patients at very high risk. Upper limb exercise stress testing gives results similar to standard protocols of non-atherosclerotic patients when correctly performed and a reliable detection and evaluation of coronary lesions. Thallium dipyridamol myocardial scintigraphy is a very useful diagnostic method but requires special radionuclide facilities. This technique demonstrates the site of ischemia. Coronary angiography should be reserved for special cases because the risks of the procedure are always greater in patients with peripheral vascular disease.

[Brucella endocarditis of bicuspid aortic valve. Surgical treatment with successful result]. / Endocardite brucellienne sur bicuspidie aortique. Guérison par traitement chirurgical.

The authors report a case of Brucella Melitensis endocarditis of a bicuspid aortic valve which caused rapid progression of the hemodynamic signs of aortic stenosis, and was associated with a para-aortic abscess and a pericardial effusion. Surgery resulted in correction of the hemodynamic abnormalities and cured the infection: the results were sustained 10 months after operation. This case illustrates the precision of the Doppler, echocardiographic diagnosis of the lesions, which was confirmed at surgery so that potentially dangerous cardiac catheterisation could be avoided.

Magnetic resonance imaging of an anomalous origin of the left coronary artery from the pulmonary artery.

This report describes a 34-year-old woman with an anomalous origin of the left coronary artery from the pulmonary artery. The angiographic pattern was clearly demonstrated by magnetic resonance imaging (MRI) performed before surgery. This case suggests that MRI could play an important role in the pre-operative assessment of coronary anomalies.

[Ultrasonic study of gallbladder motility during exclusive continuous enteral feeding]. / Etude échographique de la motricité vésiculaire au cours de l'alimentation entérale continue exclusive.

Total parenteral nutrition may be responsible for gallbladder sludge and lithiasis which might possibly be related to gallbladder bile stasis. Gallbladder motility has not yet been studied during constant-rate enteral nutrition. We performed serial ultrasonographic studies of gallbladder volume and contents in ten patients receiving constant-rate enteral nutrition during 35 +/- 17 days. Each patient had two weekly examinations at 9 AM and 2 PM on the same day. None of the patients developed gallbladder sludge or lithiasis. The gallbladder was frequently seen to be contracted. Mean gallbladder volume during constant-rate enteral nutrition was not significantly different from mean gallbladder volume after Bladex. Individual gallbladder volume changed significantly from one measurement to another. This study showed that gallbladder motility is preserved during constant-rate enteral nutrition. The persistence of gallbladder contractions may prevent the development of biliary sludge ad lithiasis.

[Medium term outcome of 191 cases of coronary insufficiency technically operable and treated medically]. / Devenir à moyen terme de 191 cas d'insuffisance coronaire techniquement opérables et traités médicalement.

After evaluation by clinical examination, stress testing and coronary angiography, coronary patients may be classified into several subgroups according to the therapeutic orientation: 1) surgical and operable, 2) surgical but inoperable, 3) operable, but not immediately, 4) inoperable and not referred for operation. Groups 1 and 2 have severe ischaemia at rest or on exercise and an incomplete response to medical therapy: surgical revascularisation may be possible (Group 1) or not (Group 2). The surgical indication in Group 4 is not formal, but would be this so the operation would not be possible technically: this is the case for example in isolated thrombosis of the right coronary or left anterior descending arteries after infarction in their territories. This study concerns cases in Group 3; a total of 196 patients were deliberately treated medically after exercise stress testing had indicated a probable good prognosis despite patent coronary lesions (1.76 vessels with over 70% stenosis or thrombosis). Of the 1,181 patients who underwent exercise stress testing without therapy before coronary angiography between January 1979 and March 1983, 700 were operated (Group 1), 200 were inoperable (Group 2), 50 were inoperable and not referred for surgery (Group 4) and 196 were deliberate abstentions (Group 3); 35 patients underwent angioplasty; the average age of these 196 patients (168 men and 27 women) was 57.6 +/- 9 years (range 29 to 76 years). The incidence of single, double and triple vessel disease in this subgroup was 42%, 38% and 20%, respectively; 37% had previous infarction; 16% had atypical chest pain; 40% had stable angina, recent in 44% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)