The double-balloon and Inoue techniques in percutaneous mitral valvuloplasty: comparative results in a series of 232 cases.

Immediate hemodynamic results of percutaneous mitral valvuloplasty were compared in two consecutive series of unselected patients from the same institution undergoing valvuloplasty with the double-balloon (161 patients) or the Inoue balloon (71 patients) technique. Before valvuloplasty, the patient series were comparable with regard to average age, gender repartition and most clinical, electrocardiographic, X-ray and hemodynamic variables. Poor anatomic forms of mitral stenosis were equally distributed in both series (41% vs. 45%, p = NS). The magnitude of mitral valve area increase and of mean mitral gradient decrease during percutaneous mitral valvuloplasty did not differ significantly in the Inoue balloon and double-balloon series (mean +/- SEM 1.1 +/- 0.2 to 1.95 +/- 0.5 and 1.0 +/- 0.2 to 1.97 +/- 0.5 cm2, respectively, for mitral valve area and 12 +/- 3 to 5 +/- 2 and 13 +/- 4 to 5 +/- 2 mm Hg, respectively, for mean mitral gradient). Four cases of 3+ mitral regurgitation occurred in the Inoue balloon series and 7 in the double-balloon series (p = NS). A good immediate result--defined as mitral valve area greater than or equal to 1.5 cm2 with greater than or equal to 25% in mitral valve area gain and mitral regurgitation less than 2+ at the end of the procedure--was observed in 78% of patients in both series. Three cases of tamponade due to chamber perforation and 14 cases of transient air embolism in the right coronary system due to balloon rupture were observed in the double-balloon series.(ABSTRACT TRUNCATED AT 250 WORDS)

Isotopic findings in anomalous origin of the left coronary artery from the pulmonary artery: report of an adult case.

Anomalous origin of the left coronary artery from the main pulmonary trunk results in myocardial ischemia or infarction, and may be a cause of death in the first months of life. Some patients, however, develop satisfactory coronary collateral circulation and remain asymptomatic into adulthood. In these patients, myocardial perfusion and left ventricular function are not well understood. We report the case of a 17-yr-old female patient, suffering from anomalous origin of the left coronary artery from the main pulmonary trunk, who underwent reimplantation of the left coronary artery to the aorta. The preoperative permanent 201Tl defect of the left antero-lateral ventricular wall and the abnormal regional wall motion induced by stress exercise testing were fully reversed after the operation.

Effects of early high-dose streptokinase intravenously on left ventricular function in acute myocardial infarction.

One hundred seven patients who recently had acute myocardial infarction were randomly assigned either to standard heparin therapy or to intravenous streptokinase within 5 hours after the onset of symptoms in 7 hospitals without catheterization facilities. In the third week, the patients were referred to a university hospital, where the patency rate of the infarct-related artery was studied by selective coronary arteriography and left ventricular function by radionuclide angiography. Fifty-five patients received heparin and 52 streptokinase within a mean period of 190 minutes after the onset of symptoms. Seven patients in the heparin group and 4 in the streptokinase group died in hospital. The patency rate of the infarct-related artery was identical in both groups (69% in the heparin group vs 68% in the streptokinase group). Left ventricular ejection fraction was not statistically different (0.44 +/- 0.13 in the heparin group vs 0.45 +/- 0.12 in the streptokinase group). Left ventricular ejection fraction was significantly higher in patients with a patent infarct-related artery than in patients with an obstructed infarct-related artery (0.49 +/- 0.12 vs 0.41 +/- 0.15, p less than 0.01). In patients with inferior wall infarction, left ventricular ejection fraction was identical (0.50 +/- 0.10 in the heparin group vs 0.52 +/- 0.09, in the streptokinase group). In patients with anterior wall infarction, left ventricular ejection fraction was significantly higher in the streptokinase group than in heparin group (0.40 +/- 0.10 vs 0.33 +/- 0.09, p less than 0.05). Analysis of regional wall motion revealed that improvement occurred in the lateral wall of the left ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)

[Magnesium and arrhythmia]. / Magnésium et troubles du rythme.

Experimental and clinical studies have shown the antiarrhythmic activity of magnesium salts and the arrhythmogenic effect of hypomagnesemia. Both are observed mainly but not exclusively during treatment with digitalis. The Mg++ plays an essential role in transmembrane K+ exchange in that a deficit of magnesium leads to a loss of intracellular K+ which cannot be compensated simply by administering K+ supplements if the magnesium equilibrium is not restored. In vitro, changes in the atrial action potential induced experimentally by a fall in extracellular K+ or by digitalis overdose can be corrected by increasing the Mg++ concentration in the medium. Contrary to classical theory, Mg++ does not seem to act on Na+-K+-ATP-ase activity, the origin of potassium disturbances and, therefore, arrhythmias. On the other hand, given the known antagonism between Ca++ and Mg++ on the contractility of the muscular fibre, a similar antagonism might be active with regards to electrogenesis. The role of the inward calcium current in the induction of abnormal automaticity observed particularly in digitalis toxicity is well known. The antiarrhythmic effect of Mg++ would seem to be related mainly to its moderating effect on this calcium inflow which, conversely, would be favored by hypomagnesemia. We conclude that, in practice, prophylaxis of arrhythmias in patients on digitalis and diuretic therapy, should include prevention of magnesium loss.

[Severe thrombopenia from heparin: value of the use of low molecular weight heparin. Apropos of 6 cases]. / Les thrombopénies graves à l'héparine: intérêt de l'utilisation de l'héparine à bas poids moléculaire. A propos de 6 observations.

Severe heparin-induced thrombocytopaenia associated with thromboembolism is a well known complication, although the exact pathogenic mechanism remains unclear. It sets the problem of whether to continue heparin therapy because standard heparin must be withdrawn. Heparin is a mucopolysaccharide composed of fractions of different molecular weights. The fractions with high molecular weights have been held responsible for these severe thrombocytopenias and so, the use of low molecular weight heparin has been suggested. The authors used subcutaneous low molecular weight heparin (CY 216 Choay Institute) at empirical doses of 350 to 1 500 units/kg/24 hour in six cases of severe heparin-induced thrombocytopaenia. Platelet counts rapidly returned to normal (4 days on average) in 5 cases. Thrombocytopaenia persisted with low molecular weight heparin in 1 case. The study of platelet aggregation was positive with low molecular weight heparin in this case and the platelet count returned to normal when the treatment was withdrawn. The authors conclude that, although low molecular weight heparin is useful in severe heparin-induced thrombocytopaenia, its efficacy remains modest. Not only may platelet aggregation persist with low molecular weight heparin which rekindles the debate as to its pathogenic mechanism, but also low molecular weight heparin may have a slight antithrombin effect which limits its use in patients at high risk of thromboembolism, imposing treatment with fast acting vitamin K antagonists.

[Severe thrombopenias during heparin therapy. A phenomenon of intra-vascular platelet aggregation]. / Les thrombopénies majeures au cours d'un traitement héparinique. Phénomène d'agrégation plaquettaire intra-vasculaire.

Haemorrhage or thromboembolism during heparin therapy are usually attributed to a prescribing error. However, these clinical manifestations--especially thromboembolism--may occur with heparin therapy during severe thrombocytopenia. The authors describe the clinical, biological and physiopathological features characterising this thrombocytopenia with reference to 7 personal cases and a review of the literature. The incidence of heparin-induced thrombocytopenia varies between 0.5 and 1%. It seems to be more common (4%) during heparin therapy for thromboembolic disease. The thrombocytopenia appears 8 days after the onset of heparin therapy. It is characterised by the high incidence of thromboembolism (70% of cases) compared to haemorrhagic phenomena (10% of cases). Thrombocytopenia is asymptomatic in 20% of cases. The thrombocytopenia is peripheral, i.e. the bone marrow is normal, and isolated, i.e. there are no deficiencies in the factors of coagulation. One of our cases was of special interest because it was complicated by disseminated intravascular coagulation. Eight cases of disseminated intravascular coagulation have previously been reported. Analysis of platelet aggregation demonstrates the relationship between heparin and thrombocytopenia. Mixing the plasma of patients with thrombocytopenia and plasma rich in platelets in the presence of heparin lead to thrombo-agglutination. In contrast, in control and non-thrombocytopenic heparinised subjects, no reaction was found. These observations prove the existence of a platelet aggregant factor in the plasma during thrombocytopenia. This disappears 6 weeks to 2 months after stopping heparin. This platelet aggregant factor initiates platelet aggregation which is responsible for thrombocytopenia and for the initiation of phenomena of coagulation, so explaining the thromboembolic phenomena.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary anomalies associated with the Williams-Beuren syndrome. Apropos of 2 cases]. / Anomalies coronaires associées au syndrome de Williams-Beuren. A propos de deux observations.

Two coronary artery anomalies associated with the Williams-Beuren syndrome are reported. The first case was a 14 year old child with severe supra-aortic stenosis associated with severe hypoplasia of the ascending aorta; 2 D echocardiography and angiography showed a voluminous aneurysm of the left main coronary artery. Aortoplasty with a patch gave a good early result. The second case was a two and a half months old baby operated as an emergency after cardiac arrest and who died at the end of surgery. The baby had severe supra-aortic stenosis, occlusion of the left coronary ostium by the left anterior cusp which was abnormally adherent to the aortic wall with subendocardial infarction and reaction fibroelastosis. The frequency of coronary anomalies associated with the Williams-Beuren syndrome is probably underestimated. Because of their severity they must be looked for routinely, by echocardiography and angiography. Their tendency to progress is an indication for early surgical correction of severe supra-aortic stenosis.

[Value of the subxiphoid approach in 2-dimensional echocardiography for the diagnosis of ductus arteriosus in premature infants and infants]. / Intérêt de la voie sous-xiphoïdienne en échocardiographie bidimensionnelle pour le diagnostic du canal artériel du prématuré et du nourrisson.

The preliminary results of our experience with the "inverted" subxiphoid approach for 2D echocardiographic visualisation of patent ductus arteriosus (PDA) in premature neonates and infants are reported. Eight premature ventilated neonates weighting 870 to 1,200 g with an isolated PDA were examined by this technique using a mechanical sector scanner and a 7.5 MHz transducer; three views were obtained (left ventricular outflow tract or "long axis"; an oblique view through the two atria and aortic arch; short axis view of the ventricles). A PDA was directly visualised in 6 of the 8 patients. It was possible to measure its diameter and observe its tortuous or rectilinear trajectory; the outcome of Indomethacin therapy or surgical ligature could also be evaluated. In the 2 patients in whom the PDA was not visualised, there were no clinical symptoms or echocardiographic signs of shunt: these PDA were therefore probably extremely small. In the neonate and infant, it is relatively easy to demonstrate a PDA by this approach. The PDA can also be followed up in "ductus dependent" congenital heart disease during treatment with Prostaglandin E. In conclusion, the subxiphoid approach represents an interesting alternative for the visualisation of PDA, especially in premature neonates in whom the suprasternal and parasternal views are often difficult to obtain.

[Evaluation of the size of atrial septal defects by subxiphoid approach in two-dimensional echocardiography]. / Estimation de la taille des communications interauriculaires par voie sous-xiphoïdienne en échocardiographie bidimensionnelle.

In order to assess whether subxiphoid two-dimensional echography is a reliable method to evaluate the size of atrial septal defects (ASD), we compared echocardiographic and per-operative measurements. We then tried to determine whether the size of the defect correlated with the importance of the shunt at catheterization. The records of 23 patients (16 female, 7 male) operated upon for uncomplicated ASD were selected. Mean age was 23.5 +/- 17.3 years (range: 8 months to 62 years). Two-dimensional echocardiography was performed by the "reversed" subxiphoid route, using two projections: "4-cavity section" and an oblique section, perpendicular to the first one, through the atria and the aortic arch. The greater echographic diameter was compared with the greater diameter measured at surgery. The ASD area, assimilated at echography to a circle, was compared with the per-operative area (elliptic or circular opening depending on whether 1 or 2 dimensions were available). Per-operative diameter and area related to body surface were then correlated with the haemodynamic QP/QS ratio. The location of the ASD proved correct in all cases (ostium secundum 19, sinus venosus 3, inferior vena cava 1). Mean diameters were 22.4 +/- 6.4 mm (range: 12-40 mm) at echocardiography and 23.6 +/- 7 mm (range: 12-45 mm) at surgery. The mean area at echography was slightly superior to that measured per-operatively: 4.3 +/- 2.6 cm2 (1.4-12.5 cm2) versus 3.8 +/- 2.1 cm2 (1.4-8.9 cm2). There was a very good correlation between echographic and per-operative diameters (r = 0.91; p less than 0.001) and areas (r = 0.89; p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Early postoperative (10th day) thrombosis of a Starr mitral prosthesis. Successful fibrinolytic treatment]. / Thrombose postopératoire précoce (10e jour) d'une prothèse de Starr mitrale. Succès du traitement fibrinolytique.

The authors report a case of early postoperative thrombosis of a Starr-Edwards mitral valve prosthesis in a 36 year old female who had undergone closed heart surgery nine years previously for tight mitral stenosis. Severe restenosis led to mitral valve replacement in 1980, and the insertion of a Starr-Edwards prosthesis. On the 8th postoperative day thrombosis of the prosthesis presented with pulmonary oedema and a change in the prosthetic valve sounds which regressed with therapy. The diagnosis was confirmed on the 9th postoperative day by left heart catheterisation and angiography. Fibrinolytic treatment was instituted on the 10th postoperative day with 4500 u/Kg of Urokinase for 24 hours. Pulmonary oedema regressed at the 6th hour of treatment and the prosthetic valve sounds reverted to normal. No significant complication was observed. The good result has been maintained up to the 6th postoperative month. This case demonstrates the possibility of using fibrinolytic therapy in the early postoperative period after valve replacement: this should be weighed in the balance against the mortality of reoperation in such cases of early thrombosis of prosthetic heart valves.

[Truncular auriculo-ventricular block disclosing isolated corrected transposition of great vessels]. / Bloc auriculo-ventriculaire tronculaire révélateur d'une transposition corrigée des gros vaisseaux isolée.

A case of atrioventricular and ventriculo-arterial discordance with L-transposition of the great arteries (corrected transposition of the great arteries), complicated by complex atrioventricular block is reported. The points of interest in this case were the association of an atrioventricular block and isolated corrected transposition, revealing the underlying malformation, and the intrahisian location of the block which seems only to have been reported on three previous occasions in this context.

[HLA-DRW grouping in obstructive myocardiopathy]. / Le groupage "HLA-DRW" dans la myocardiopathie obstructive.

Hypertrophic myocardiopathy with obstruction (HOMC) is a disease of unknown aetiology with a high familial incidence. This study was undertaken to determine its relationship to the HLA system, as proved in a number of other conditions. The clinical suspicion of HOMC was confirmed in all cases by echocardiography. In addition, 4 patients were also catheterised, confirming the presence of an intraventricular pressure gradient. One patient was investigated after surgery. None of the patients was hypertensive. In two cases, a positive family history of HOMC confirmed the hereditary nature of the condition. The HLA-A and B grouping was performed by the micro-lymphocytotoxic technique. The HLA-DRW was carried out with B lymphocytes separated either by column filtration or by rosetting on a Ficoll gradient. We did not find a statistically significant prevalence of any of the antigens tested on the A, B on DRW loci. Our results were compared with previously published data. They support the findings of Bloch et al. in a genetically comparable study population (HLA A and B only) but contradict those of Matsumori (oriental population). We were unable to demonstrate a liaison between antigens of the HLA system and HOMC. However, as was shown in our study, HLA grouping is valuable in familial forms of HOMC (mechanism of transmission, detection of clinically latent forms).

[Percutaneous mitral valvuloplasty by Inoue's technique. Apropos of an experience of 71 cases]. / La valvuloplastie mitrale percutanée selon la technique d'Inoue. A propos d'une expérience de 71 cas.

Seventy-one consecutive, unselected patients underwent percutaneous mitral valvuloplasty by Inoue's technique between February and November 1990. The mean age was 53 years (range 32 to 75 years). Fifteen of the 71 patients had previously undergone surgical mitral commissurotomy. Three patients had Björk aortic valve prostheses. The mitral valve surface area increased from 1.1 +/- 0.2 cm2 to 1.95 +/- 0.5 cm2 (p less than 0.01) and the mean transmitral pressure gradient fell from 12 +/- 3 mmHg to 5 +/- 2 mmHg (p less than 0.05). Grade 3+ mitral regurgitation was observed in 4 patients. There were no cases of cardiac perforation or tamponade. The only complications were related to the catheterisation and not to the technique valvuloplasty (one case of prolonged fever which regressed with antibiotic therapy, one case of arteriovenous fistula at the site of femoral artery puncture). The QP/QS ratio was 1.1 +/- 0.2 at the end of the procedure. A QP/QS ratio greater than 1.5 was observed in one patient. A left-to-right shunt was observed in 53% of cases in the immediate post-valvuloplasty period with Doppler color flow imaging. In all, 78% of patients had a satisfactory result (mitral surface area greater than 1.5 cm2 and mitral regurgitation less than or equal to 2/4). These results are identical to those observed with the double balloon technique with a lower rate of complications. The duration of the procedure (104 +/- 13 min p less than 0.02) and of radioscopy (16 +/- 8 min, p less than 0.02) were shorter than with the double balloon technique.(ABSTRACT TRUNCATED AT 250 WORDS)

[Postoperative course of systolic and diastolic indices of left ventricular function in aortic valve stenosis in adults. Exercise test with radionuclide angiography]. / Evolution postopératoire des indices systoliques et diastoliques de fonction ventriculaire gauche dans la sténose aortique de l'adulte. Etude par angioscintigraphie à l'effort.

Resting and stress radionuclide angiography was performed before and, on average, one year after surgery for adult aortic stenosis in 26 patients. The left ventricular ejection fraction, ventricular volumes, left ventricular stroke volume and peak velocity of ventricular filling were studied under basal conditions and at the peak of exercise. Right and left heart catheterisation and coronary angiography were performed before surgery with determination of the conventional indices of left ventricular function. Investigations were completed by pre and postoperative echocardiography. The same procedures were carried out in a control population of the same age. Before surgery, hemodynamic adaptation to exercise, judged by the change in left ventricular stroke volume, solicits the passive properties of the left ventricle: the left ventricular stroke volume increases by an increase in the end diastolic volume. In the control group, the increase in stroke volume is obtained by a decrease in end systolic volume, that is to say by increasing systolic shortening. The peak velocity of ventricular filling increases on exercise but to a lesser degree than in the control population. After surgery the hemodynamic adaptation to exercise results from an improved systolic shortening of the left ventricle but also from an increase in end diastolic volume. The peak velocity of left ventricular filling increases with respect to the preoperative values but remains less than that observed in the control population. No relationship was observed between the hemodynamic adaptation to exercise, the peak velocity of ventricular filling and myocardial mass whichever method was used for calculating the latter parameter.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anisoylated plasminogen streptokinase complex during the acute phase of myocardial infarction. Results of a multicenter double-blind study versus heparin]. / Le complexe streptokinase plasminogène acylé à la phase aiguë de l'infarctus du myocarde. Résultats d'une étude multicentrique en double aveugle versus héparine.

Two hundred and thirty-one patients admitted to hospital within 5 hours of the onset of symptoms of a primary myocardial infarction were randomised into 2 groups: one received thrombolytic therapy [anisoylated plasminogen streptokinase activator complex (APSAC): 30 IU in 5 minutes] and the other was given conventional heparin therapy (5,000 IU). Heparin was given to both groups 4 hours later (500 IU/kg/day); the APSAC (N = 119) was identical with respect to age, location of infarct, Killip classification, delay before randomisation (188 +/- 62 minutes). Coronary angiography and ventriculography were performed after 3.4 +/- 1.2 days, and angioscintigraphy and myocardial scintigraphy after 19 +/- 2.5 days to determine the size of the infarct and the quality of left ventricular function. Coronary patency was much higher in the APSAC group (77%) than the heparin group (37%) (p less than 0.001). The angiographic ejection fraction was significantly greater in the thrombolytic group than in the heparin group (53 +/- 13% vs 47 +/- 12%, p less than 0.002), the difference being statistically significant in the anterior and inferior infarct subgroups. At the third week, the difference remained significant in the anterior infarct subgroup: a 31 per cent reduction in necrosed myocardial mass was observed in the APSAC group (33% in anterior infarcts: p less than 0.05 and 16% in inferior infarcts: NS). The limitation of infarct size explained the smaller reduction in left ventricular systolic function (r = 0.73; p less than 0.01). The hospital and one year mortality was comparable in the two groups which was not surprising given the small number of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Dystrophic aortic insufficiency: influence of dilatation of the ascending aorta on secondary outcome]. / Insuffisance aortique dystrophique: influence de la dilatation de l'aorte ascendante sur l'évolution secondaire.

This cooperative study recensed 89 cases of patients operated for aortic regurgitation in whom the dystrophic process was confirmed on anatomical (thin, translucent valves without symphysis, multilation or sclerosis) and histological criteria (mucinous infiltration). They included 81 men (91%) and the average age was 52 +/- 14 years. The valvular degeneration was part of a generalised dystrophy of elastic tissue in 8 patients (6 "formes frustes" of Marfan's syndrome, 2 Lobstein's syndrome). The patients were divided into 2 groups according to the diameter of the ascending aorta measured by echocardiography and/or aortography. In Group 1 (n = 40), the aorta was not dilated (diameter less than 40 mm) whereas in Group 2 (n = 49), the diameter of the ascending aorta was dilated (40-55 mm) but not aneurysmal (loss of parallelism of the aortic walls). The two groups were comparable before surgery with respect to age, sex, functional class, degree of left ventricular dilatation, left ventricular ejection fraction and presence of associated coronary disease). There were no differences in the operative parameters but aortic parietal biopsy (n = 35) revealed clear signs of cystic medianecrosis more often in Group 2 than in Group 1 (14/25 versus 1/10, p less than 0.05). No operative procedure was performed on the ascending aorta during aortic valve replacement. One operative death occurred in each group. After an average follow-up of 4 years, there was a higher mortality in Group 2: the actuarial 7 year survival rate being 74% in Group 1 and 54% in Group 2. This was explained by a higher incidence of ascending aortic complications. Only 1 patient in Group 1 developed an aneurysm of the ascending aorta requiring reoperation compared to 14 patients in Group 2, 8 of whom were reoperated (p less than 0.01). These results suggest that non-aneurysmal dilatation of the ascending aorta in patients with dystrophic aortic regurgitation is a poor prognostic factor because of the high incidence of secondary aortic parietal complications (aneurysm, dissection).

[Exertion-induced parameters of left ventricular function in patients with chronic cardiac insufficiency. An isotope study]. / Evolution à l'effort des paramètres de fonction ventriculaire gauche chez des patients atteints d'une insuffisance cardiaque chronique. Etude isotopique.

Exercise-induced changes in haemodynamic values were studied by radionuclide ventriculography in 21 patients with permanent systolic dysfunction (15 with non-obstructive cardiomyopathy and 6 with ischaemic heart disease). The results were compared with those obtained in 8 control subjects with normal heart. In healthy subjects, during exercise the ejection fraction increased due to constant diminution of the end-systolic volume; the end-diastolic volume and the systolic ejection volume did not significantly vary; the cardiac output augmented only because of the accelerated heart rate. In patients with permanent left ventricular dysfunction, the ejection fraction remained unchanged during exercise, whereas the end-systolic volume increased significantly. Yet the systolic ejection volume increased due to a rise in end-diastolic volume. Heart rate and cardiac index increased, but not as much as in normal subjects. There was a close correlation between changes in end-diastolic and end-systolic volumes. It was the relative importance of changes in these two ventricular volumes that determined the direction and amplitude of variations in ejection fraction. It is concluded that in patients with permanent left ventricular dysfunction: (1) the end-systolic volume increases during exercise, thus betraying a worsening of the systolic dysfunction; (2) however, the systolic ejection volume is maintained or increases due to an increase in end-diastolic volume; (3) the changes in ejection fraction observed during exercise are of little value to characterize the modifications that occur in left ventricular work performance.

[Course of ejection fraction, regurgitation fraction and ventricular volumes during exertion in chronic aortic insufficiency. Study using technetium 99m gamma-cineangiography]. / Evolution au cours de l'effort de la fraction d'éjection, de la fraction de régurgitation et des volumes ventriculaires dans l'insuffisance aortique chronique. Etude par gamma-ciné-angiographie au technetium 99 m.

Previous studies have shown that variations of the ejection fraction (EF) during exercise were representative of the contractile state of the left ventricle: an increased EF on effort is considered to be physiological, whilst a decrease would indicate latent LV dysfunction unmasked during exercise. This hypothesis was tested by performing Technetium 99 gamma cineangiography at equilibrium under basal conditions and at maximal effort in 8 healthy subjects and 44 patients with pure, severe aortic regurgitation to measure the ejection and regurgitant fractions and the variations in end systolic and end diastolic LV volume. In the control group the EF increased and end systolic volume decreased significantly on effort whilst the regurgitant fraction and end diastolic volume were unchanged. In the 44 patients with aortic regurgitation no significant variations in EF, end systolic and end diastolic volumes were observed because the individual values were very dispersed. Variations of the EF and end systolic volume were inversely correlated. The regurgitant fraction decreased significantly on effort. Based on the variations of the EF and end systolic volume three different types of response to effort could be identified: in 7 patients, the EF increased on effort and end systolic volume decreased without any significant variation in the end diastolic volume, as in the group of normal control subjects; in 22 patients, a reduction in EF was observed on effort, associated with an increased end systolic volume. These changes indicated latent IV dysfunction inapparent at rest and unmasked by exercise; in a third group of 15 patients, the EF decreased on effort despite a physiological decrease in end systolic volume due to a greater decrease in end diastolic volume.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intravenous streptokinase versus heparin in recent acute myocardial infarction. Randomized multicenter study in the Franche-Comté]. / Streptokinase intraveineuse versus héparine dans l'infarctus du myocarde aigu récent. Etude randomisée multicentrique franc-comtoise.

A multicentre randomised therapeutic trial was undertaken in 8 hospitals in the Franche-Comté department of France (Belfort, Besançon, Dole, Lons-le-Saunier, Luxeuil, Montbéliard, Vesoul, Pontarlier) in which 101 patients with acute primary myocardial infarction were treated within 5 hours of onset of symptoms with either intravenous streptokinase (1,500,000 U in 30 mn) or conventional heparin therapy. The results were assessed on the clinical outcome, arterial patency in the necrosed territory and global and regional ejection fractions (EF) at the 3rd week. After randomisation, 51 patients were given heparin and 50 received streptokinase. Seven patients died in the heparin group and 4 in the streptokinase group (NS). At the third week, the artery in the necrosed zone was patent in 69% of the heparin group and in 68% of the streptokinase group (NS). The EF was significantly higher in the patients with patent arteries in the necrosed zone than in those with occluded arteries (0.49 +/- 0.12 vs 0.41 +/- 0.15, p less than 0.01). There was no significant difference in EF between the heparin and streptokinase groups. The EF was significantly higher in patients with anterior infarction who received streptokinase than in those who received heparin (0.40 +/- 0.10 vs 0.33 +/- 0.09 p less than 0.05). Segmental wall motion was significantly better at the apex and free wall. There was no significant difference between the two groups in posterior infarction. These results show that reestablishment or maintenance of arterial patency in the necrosed zone improves left ventricular function and that patients with anterior wall infarction are the ones most likely to benefit from streptokinase therapy.

[Determination of ventricular volumes by a non-geometric method using gamma-cineangiography]. / Détermination des volumes ventriculaires par une méthode non géométrique utilisant la gamma-cinéangiographie.

The authors suggest a new way of determining ventricular volume by a non-geometric method using gamma-cineangiography. The results obtained by this method were compared with those obtained by a geometric methods and contrast ventriculography in 94 patients. The new non-geometric method supposes that the radioactive tracer is evenly distributed in the cardiovascular system so that blood radioactivity levels can be measured. The ventricular volume is then equal to the ratio of radioactivity in the LV zone to that of 1 ml of blood. Comparison of the radionuclide and angiographic data in the first 60 patients showed systematic values--despite a satisfactory statistical correlation (r = 0.87, y = 0.30 X + 6.3). This underestimation is due to the phenomenon of attenuation related to the depth of the heart in the thoracic cage and to autoabsorption at source, the degree of which depends on the ventricular volume. An empirical method of calculation allows correction for these factors by taking into account absorption in the tissues by relating to body surface area and autoabsorption at source by correcting for the surface of isotopic ventricular projection expressed in pixels. Using the data of this empirical method, the correction formula for radionuclide ventricular volume is obtained by a multiple linear regression: corrected radionuclide volume = K X measured radionuclide volume (Formula: see text). This formula was applied in the following 34 patients. The correlation between the uncorrected and corrected radionuclide volumes and the angiographic volumes was improved (r = 0.65 vs r = 0.94) and the values were more accurate (y = 0.18 X + 26 vs y = 0.96 X + 1.5).(ABSTRACT TRUNCATED AT 250 WORDS)