[Increased secretion of Nt-proBNP immediately after percutaneous coronary intervention: about 90 cases]. / Elévation de la sécrétion du Nt-proBNP dans les 24 heures suivant une angioplastie coronaire: à propos de 90 cas.

Nt-proBNP have emerged as useful biomarker for the diagnosis and prognostic of heart failure but also recently in acute coronary syndrome. Myocardial ischemia is probably an important stimulus for Nt-proBNP release. Transient myocardial ischemia is inducing by balloon inflation during percutaneous coronary intervention (PCI). The authors propose to determine the Nt-proBNP secretion after uncomplicated coronary intervention in patients with preserved cardiac function. Ninety patients were enrolled in this study. Plasma Nt-proBNP was increased significantly from 135.5 to 157.8 pg/ml and 202.5 pg/ml at 8 and 24 hours following PCI, respectively. History of myocardial infarction and complex lesions were the most powerful predictors of higher Nt-proBNP peak concentration. Prognostic value must be evaluated in larger studies.

Kinetic study of the Ca2+ pump in erythrocytes from essential hypertensive patients.

Ca2+ pump kinetics were investigated in erythrocytes from 22 essential hypertensive patients and 20 normotensive controls (under initial-rate and steady-state conditions, using Sr2+ as a Ca2+ analogue). The mean value of the apparent dissociation constant for total internal Ca2+ (KCa) was slightly but significantly increased in the hypertensive population (73 +/- 7 versus 55 +/- 3 mumol/l cells, mean +/- s.e.m., P = 0.042 Mann-Whitney U-test). The statistical analysis showed that this was due to six essential hypertensives who exhibited a dissociation constant for Ca2+ that was higher than the upper 95% normal confidence limit (KCa = 116 +/- 7 mumol/l cells), and abnormally high maximal pump rates (7.7 +/- 0.6 versus 5.0 +/- 0.2 mmol/l cells per h in normotensives, P less than 0.001). In addition, the apparent dissociation constant for Ca2+ was inversely correlated with plasma renin activity, although the correlation was only borderline (P = 0.076). In the remaining 16 hypertensive patients, all kinetic parameters of the Ca2+ pump were within the normal range. Finally, a simultaneous study of Na+ transport kinetics suggested that erythrocyte Ca2+ and Na+ transport abnormalities were independent phenomena. Our results do not support the concept that primary hypertension (as a whole entity) is associated with a ubiquitous defect in the plasma membrane Ca2+ pump. However, in some essential hypertensive patients (about 25%) the erythrocyte Ca2+ pump exhibited an apparent decreased affinity for internal Ca2+. A similar defect in vascular smooth muscle may induce a delayed Ca2+ extrusion after the opening of Ca2+ channels, a disturbance likely to be translated into increased vascular reactivity.

Prospects for cardioreparation.

The structure of the myocardium has 2 principal components, a myocytic compartment and a non-myocytic compartment that consists primarily of interstitial tissue. It appears that increased collagen production is mainly responsible for the functional consequences of structural remodelling. The concept of cardioreparation implies both a restoration of structural abnormalities and a return of cardiac function to or toward normal. In spontaneously hypertensive rats with left ventricular hypertrophy and adverse structural remodeling of the cardiac interstitium, angiotensin-converting enzyme inhibition has resulted in restoration of myocardial integrity and stiffness toward normal. Further research needs to be undertaken to identify the molecular mechanisms involved in the development of interstitial myocardial fibrosis, and reliable methods for assessing the interstitium and the changes that occur within it in clinical practice need to be developed.

Intraoperative coronary artery endarterectomy with excimer laser.

Compared with continuous-wave lasers, excimer lasers exhibit several in vitro advantages: nonthermal ablation process and linear relation between the number of pulses and the depth of the crater. A 308 nm, 20 nsec pulse duration, 1 to 5 repetition rate laser was specifically designed for clinical application. At the time of cardiopulmonary bypass in 10 symptomatic patients, before bypass grafting, a 1 mm diameter core specifically ultraviolet-tipped fiberoptic scope was introduced via the coronary arteriotomy and placed upstream (seven patients) and downstream (three patients) in contact with the stenosis. Laser power was increasingly delivered up to the clearing of the stenosis or occlusion. Quality of angioplasty was controlled by calibration of the neolumen, cardioplegic solution output through the laser-treated segment, and an eighth day or sixth month coronary arteriogram. In the first three patients studied on the eighth day, all laser-treated coronary artery segments showed an early parallel-linked patent neolumen despite competitive bypass graft flow. In the patients studied after 6 months, all recanalized segments were patent except one; in one patient the venous graft was occluded, but the upstream laser angioplasty was patent. The main limitation of the method lies in the fact that laser coronary recanalization is confined to the fiber core diameter. We conclude that (1) excimer laser angioplasty may be safe and efficient during surgical procedure and (2) as catheter flexibility remains the most critical problem, we are now assuming an appropriate tool with a multifiber system that is suitable for intraoperative as well as percutaneous routes.

Intrathoracic gossypiboma: magnetic resonance features.

Gossypiboma, a term used to describe a mass within the body composed of a cotton matrix which usually refers to a retained surgical sponge, is a rare complication of cardiac surgery. We report one case revealed by the recurrence of the anginal symptoms after successful myocardial revascularisation surgery. The preoperative diagnosis was suspected by a combination of imaging techniques and subsequently confirmed by surgical removal. We review the literature to summarise the diagnostic and therapeutic features of gossypibomas.

Erythrocyte ion transport as indicator of sensitivity to antihypertensive drugs.

Multiple ion transport defects have been characterized in red blood cell membranes from essential hypertensive patients. These seem to be biochemical markers of at least three different types of essential hypertension. A first type is characterized by low pump, low cotransport fluxes in erythrocytes. These hypertensive patients are apparently identical to the salt-sensitive, low-renin hypertensive patients, in whom low pump and cotransport seem to result from the presence of circulating endogenous ouabain-like and bumetanide-like factors. These hypertensive patients are sensitive to diuretic drugs and to vaso-relaxants with salidiuretic activity, as expected from a reduction in plasma volume and circulating levels of endogenous ion transport inhibitors. A second type of essential hypertension is characterized by increased red cell Na+:Li+ countertransport and [Na+, K+, Cl-] cotransport. These hypertensive patients tend to present normal or high plasma renin activity, disorders in lipid metabolism, and left ventricular hypertrophy. Hypertensive patients belonging to this group seem to be resistant to diuretic drugs but sensitive to vasorelaxants. A third type of essential hypertension is characterized by both high membrane sodium leak and high [Na+, K+, Cl-] cotransport in erythrocytes. Hypertensive patients in this group are resistant to diuretics, angiotensin-converting enzyme (ACE) inhibitors, calcium antagonists, and centrally acting drugs.

XeCl excimer laser coronary angioplasty: a convergence of favourable factors.

The results of recent studies on the application of an XeCl laser to coronary angioplasty are presented. Several points are examined: the quality of the cut in human post-mortem artery, the cutting rates and threshold fluences in different media, the risks of carcinogenesis and thrombosis, and the transmission of suitable fluences in optical fibres. Recent human in vivo procedures are reported.

XeCl laser action at medium fluences on biological tissues: fluorescence study and simulation with a chemical solution.

A rat heart, isolated and perfused, was irradiated with a XeCl excimer laser at 308 nm. The evolution of the fluorescence spectrum was measured. For an incident energy E greater than 4 kJ m-2 per pulse the fluorescence changed with time in a complex and spectrally non-uniform way. The proposed interpretation is that the radiation acts on the cellular respiratory chain. Buffered solutions of NADH, cytochrome c and FAD, which play a role in the respiratory chain, were irradiated in order to simulate the in vivo findings. The conclusion of this study is that XeCl radiation introduces a modification in the functioning of the respiratory chain: it accelerates electron transfer, but this quickly leads to an interruption of the respiratory chain.

[Permeability of aortocoronary bypass after 6 months. A multicenter French study]. / Etude de la perméabilité des pontages aortocoronaires à 6 mois. Etude multicentrique française.

The EPPAC (Etude de la perméabilité des pontages aortocoronaires) is a randomised prospective (18 centres) double blind trial designed to compare the patency of coronary bypass grafts in two groups of coronary patients after surgery: one group treated with oral vitamin-K antagonists and placebo (n = 196, age 57 +/- 5 years, 2.09 grafts/patient) and the other group with vitamin-K antagonists and dipyridamole (n = 182, age 56 +/- 6 years, 1.99 grafts/patient), the principal criterion of evaluation being the patency of the grafts at coronary angiography performed 6 months after surgery, interpreted by two independent observers. Of the 469 patients included (average ejection fraction 59.5 +/- 2.2%), 378 underwent the control coronary angiography at the 6th month and 773 saphenous vein grafts were evaluated. At the end of the study, there were 12 deaths, 10 due to perioperative myocardial infarction, and 24 nonlethal myocardial infarctions. The frequency of occlusion of at least one graft per patient was 18.2%, the patency of the graft at the distal anastomosis was 89.9%. The following factors played a major role: the cardiological center: the occlusion rate per patient ranged from 7.1 to 57.1% and per anastomosis from 2.8 to 28.6%; the internal diameter of the artery grafted: when 2 mm or more, the occlusion rate was 17.6% compared with 42.3% (p less than 0.001); the technique used for distal anastomosis: 9.2% of grafts with single outflow sites occluded, compared with 4.3% of grafts with multiple outflow sites. Early occlusion of saphenous vein aorto-coronary grafts is the main problem of this form of therapy and the addition of dipyridamole to oral anticoagulants does not seem to reinforce the anti-thrombotic effect at 6 months after surgery.

[Left ventricular remodeling and hypertension. Course with antihypertensive therapy]. / Remodelage ventriculaire gauche et hypertension artérielle. Evolution sous traitement antihypertenseur.

Changes in left ventricular remodeling due to antihypertensive therapy have been demonstrated in experimental animal studies although no quantitative relationship has been shown between correction of blood pressure and regression of myocardial mass. As regards the qualitative aspects of regression, only the ACE inhibitors have been shown to prevent the development and induce regression of the excess collagen content of the myocardium submitted to chronic pressure overload. The problems posed by remodeling in clinical practice are more complex: should regression of myocardial mass itself be the therapeutic objective in the absence of a practical method of analysing the interstitial factor of hypertensive disease or should we concentrate on the satellite problems of hypertrophy which are correction of ischemia, left ventricular filling abnormalities and arrhythmias. For each of these clinical problems, the benefits attributed to changes in remodeling, though probable, are to a large degree hypothetical. The benefits offered by these drugs which reduce ventricular hypertrophy are, however, considerable.

[Cocaine and the heart: a clinical reality]. / Cocaïne et coeur: une réalité clinique.

Cocaine is a drug which has been relatively little used in France until recently but its abuse seems to be on the increase with nearly 1% of 20 year-old-men admitting to having taken it more than 10 times in 1993. The cardiovascular manifestations of cocaine consumption should be known to all cardiological emergency units because of their prevalence and severity. Acute toxicological expertise and retrospective analysis allows formal diagnosis.

[Traumatic tricuspid insufficiency]. / L'insuffisance tricuspide traumatique.

Traumatic tricuspid insufficiency is a rare condition. The diagnosis is difficult because of the slow progression of this pathology and the presence of more clinically acute lesions. Non-penetrating chest trauma is responsible for 90% of cases. Echocardiography is the investigation of choice for assessing the mechanism of the tricuspid regurgitation and for diagnosing associated lesions. It should be performed systematically in patients with multiple trauma. The surgical indications are difficult to determine and depend on the patients' symptoms and the type of anatomical lesions. It should be undertaken before right ventricular myocardial dysfunction. Several techniques may be used from valvuloplasty to valve replacement mainly with bioprostheses in symptomatic patients.

[Coronary dissection associated with exercise: unusual cause of myocardial infarction]. / La dissection coronaire liée à l'effort: une cause rare d'infarctus du myocarde.

A case of coronary artery dissection occurring immediately after weight training is reported in a young adult with no cardiovascular risk factor. The patient had an anterior myocardial infarction treated by primary coronary angioplasty and stenting. Other rare but similar cases have been reported in the literature with a generally poor prognosis. The physiopathological mechanisms acting during exercise or the immediate recovery period are thought to be either trauma of the arterial wall by the myocardium itself or coronary artery spasm. Present management of this condition is based on coronary angioplasty with stenting.

[Coronary angioplasty using 5 or 6 F guide catheters. Results of a comparative, monocentric, prospective randomized study]. / Angioplasties coronaires par cathéters guides 5 ou 6 F. Résultats d'une étude comparative, monocentrique, prospective, randomisée.

Improvement of balloon and stent profile allows to use smaller-diameter catheters to avoid vascular complications by reduce the size of puncture site. First studies using 5 F guiding catheters showed good results in term of safety and feasibility. The authors performed a prospective, randomised study to define exactly the place of such small catheter compared to 6 F approach. One hundred forty eight patients were randomised, 77 in the 5 F group. The success rate per lesions was not significantly different but was less in the 5 F group (91.1 vs 96.5%). The crossover to 6 F allows good results in mainly cases. Limitations are unstable back up, worse opacification, and inability to use covered stent and to treat bifurcation lesions. There are no advantages in term of vascular complications. So, these catheters seem to be limited to treat simple lesion, allowing using the same sheath immediately after coronarography, but these results must be confirmed in a large, multicentric study.

[Antihypertensive effects of captopril, hydrochlorothiazide, alone or in combination, with different categories of essential hypertensive patients]. / Effet antihypertenseur du captopril, de l'hydrochlorothiazide, seuls ou en association, chez différentes catégories de malades hypertendus essentiels.

30 male essential hypertensive patients were submitted to a "washout" of 8 days and at D (0) divided into two groups receiving 25 mg/day of Hydrochlorothiazide or 50 mg/day of Captopril. At D (45) the treatment was crossed, at D (90) all the patients received both drugs and at D (135) the treatment was stopped. According to the antihypertensive response, the patients were divided into: (i) R: responders, PAS (systolic arterial pressure) less than or equal to 140 mmHg and PAD (diastolic) less than or equal to 90 mmHg, ii) M: moderate responders, 140 less than PAS less than or equal to 160 mmHg and/or 90 less than PAD less than or equal to 100 mmHg and (iii) F: therapeutic failure, PAS greater than 160 mmHg and/or PAD greater than 100. A parallel study was carried out in erythrocytes. At D (0), 40 ml of blood were drawn and the hypertensive patients were classified in: (i) (+)NaT patients, 19 patients having one or more of the following erythrocyte abnormalities: increased Na+: Li+ counter-transport, increased Na+ leak, decreased affinity of the Na+, K+-pump and/or Na+, K+ cotransport system for internal Na+ and (ii) (-)NaT patients, 11 patients without the above erythrocyte abnormalities. During monotherapy treatment (with captopril or hydrochlorothiazide) 8 out of 11 (-)NaT patients normalized blood pressure (responders) against only 5 out of 19 (+)NaT patients (p less than 0.05, chi 2 test).(ABSTRACT TRUNCATED AT 250 WORDS)

[Outcome of traumatic tricuspid insufficiency, treated surgically. Apropos of 9 cases]. / Devenir de l'insuffisance tricuspide traumatique opérée. A propos de neuf cas.

Between 1983 and 1992, 9 patients with traumatic tricuspid regurgitation underwent surgical correction. The population consisted of young male adults (mean age 39 years). The trauma was usually due to a road traffic accident (n = 6). The mean interval to diagnosis was long (11 years). Echocardiography was diagnostic and showed the mechanisms. The usual lesion observed at surgery was subvalvular rupture of the anterior papillary muscle (n = 5). Surgery consisted of valve repair with annuloplasty and eight valve replacements for chronic retractile lesions. Six patients are still being followed up (average 7 years). There were no peroperative complications. Two patients underwent a second valve replacement for degeneration of a bioprothesis. Conduction defects requiring permanent cardiac pacing were not uncommon (n = 3) The delay before diagnosis may be explained by the diversity of lesion of the tricuspid valve, associated cardiac disease and the requesting of echocardiography. Surgical indications are mainly based on clinical signs. Even if long-term results are satisfactory, earlier diagnosis would probably allow more conservative surgery with preservation of right ventricular geometry and function.

[Induction of Prinzmetal's angina by stopping exercise. Apropos of 3 cases]. / Induction d'un angor de Prinzmetal par arrêt de l'effort. A propos de 3 cas.

Three cases of anginal pain with ST elevation occurring at the end of exercise are reported. In 2 cases, there was a symptom-free interval between exercise, which was well tolerated, and the clinical and electrical changes. The coronary circulation was angiographically normal, although one of the patients had have previous transmural myocardial infarction. Spontaneous coronary spasm was observed during coronary angiography in this patient. The third case was characterised by exclusively spontaneous angina. ST elevation was observed very early in the recovery phase after stress testing. This patient had severe triple vessel disease. Angiospastic manifestations were noted in the immediate postoperative period after myocardial revascularisation surgery. A review of the litterature shows two types of behaviour. In the rare cases of ST elevation after maximal stress testing (7 cases apart from those reported here) the coronary vessels were normal. On the other hand, when ST elevation occurred during exercise and/or followed ST depression, coronary artery disease was demonstrated: significant 52 cases (81%), less than 70%: 12 cases (19%). Overall, these results indicate that when ST elevation is observed in the recovery phase after stress testing, the coronary arteries are angiographically normal (specificity: 0,9).

[Coronary disease in homozygous twins. Respective roles of heredity and environment]. / Coronaropathie chez les jumeaux homozygotes. Rôles respectifs de l'hérédité et de l'environnement.

Two 44 year old female homozygote twins presented with cardiac ischaemia due to coronary atheroma, at 39 years of age and 43 years of age, respectively. The coronary risk factors (hypertension, cigarette smoking, hypercholesterolaemia, obesity, oral contraception) were comparable in both cases. Although presenting at different times, the electrocardiographic changes were in the same territory and coronary angiography showed a similar anatomical and lesional distribution. The literature is reviewed with respect to these cases to try to determine the respective roles of heredity and the environment in the initiation and progression of coronary atheroma.

[The heart and cocaine]. / Coeur et cocaïne.

Cocaine abuse should be considered in everyday cardiological practice for three reasons. The first one is epidemiological as there is an unprecedented increase in cocaine abuse in France and it may result in serious complications, mainly cardiovascular. The second reason concerns modality of consumption: it is usually associated with other toxic substances (including tobacco) and poly-intoxication is a more serious problem and the diagnostic difficulties are greater. Finally, chest pain is the first symptom of myocardial infarction in about 6% of cases. In cardiological practice, young adults with this symptom should be suspected of cocaine abuse and the diagnosis should be eventually confirmed by toxicological analysis.

[Effects of oral sotalol on the conduction of accessory atrioventricular pathways]. / Effets du sotalol per os sur la conduction des voies accessoires auriculo-ventriculaires.

The effects of oral Sotalol were assessed by electrophysiological investigations in 6 patients with ventricular preexcitation (Wolff-Parkinson-White syndrome) and a short anterograde refractory period (less than or equal to 280 ms) of the accessory pathway. After 27 to 80 days (mean 41 +/- 19 days) of oral Sotalol (160 mg daily in 5 patients, 320 mg daily in 1 patient). The effective anterograde refractory period of the accessory pathway increased from 268 +/- 13 ms to 318 +/- 33 ms (less than 0.05); the shortest QR interval with appearances of preexcitation increased either during rapid atrial pacing (272 +/- 19 ms to 374 +/- 74 ms: p less than 0.05) or during induced atrial fibrillation (258 +/- 61 to 335 +/- 56 ms: p less than 0.01). The effective refractory period could only be measured in 4 cases during Sotalol therapy and increased by 10 ms, 130 ms and by at least 220 and 300 ms. During the repeat electrophysiological investigation the plasma concentrations of Sotalol ranged from 0.33 to 2.3 g/ml. These results show that oral Sotalol significantly increases the effective refractory periods of accessory pathways even when they are short under basal conditions. This product could therefore be effective in preventing the rapid ventricular response to atrial fibrillation in patients with the WPW syndrome and also in the prevention of reciprocating tachycardias.