Occlusive coronary thrombosis and oral anticoagulants.

The results of post-mortem examination in 173 patients followed over an average period of five and a half years after their initial myocardial infarction are described. These 173 patients were divided into four groups according to whether or not they had received an oral anticoagulant and if so how adequately. An index of coronary and myocardial lesions was established for each heart. Recent occlusive coronary and myocardial lesions was established for each heart. Recent occlusive coronary thromboses were four times less frequent in the group of patients who had received adequate anticoagulant therapy than in the other three groups of patients (p less than 0,001). There was no significant difference between the inadequately treated groups and the untreated group. The recurrences of myocardial infarction were associated in 90 per cent of the cases with a recent occlusive thrombosis in the corresponding coronary artery and were found four times less frequently in the group subjected to effective long-term anticoagulant therapy (p less than 0,001).

Noninvasive estimation of pulmonary arterial wedge pressure with Doppler transmitral flow velocity pattern in patients with known heart disease.

Pulmonary arterial wedge pressure (PAWP) is an important marker of cardiac function. Regrettably, it requires catheterization, which can occasionally result in serious complications. A noninvasive method of estimating PAWP would thus be helpful. Recent studies have indicated that the Doppler transmitral flow velocity pattern was strongly dependent on preload and could provide an estimate of PAWP. This study was therefore designed to evaluate the relation between doppler transmitral flow velocity indexes and measured PAWP in 91 patients (learning group: 73 men, mean age 57 +/- 13 years) with ischemic heart disease (n = 41), dilated (n = 29) or hypertrophic cardiomyopathy (n = 4), or aortic stenosis (n = 17). Multiple regression analysis was used to derive an equation for estimation of PAWP, which was subsequently tested in a separate group of 33 patients (testing group: 28 men, mean age 58 +/- 12 years) with similar cardiac conditions. PAWP ranged from 4 to 48 mm Hg in the learning group and from 7 to 40 mm Hg in the testing group. In the learning group, PAWP correlated with the E/A ratio (r = 0.95), atrial filling fraction (r = -0.80), peak E velocity (r = 0.79), isovolumic relaxation period (r = -0.75), and deceleration time (r = -0.61). In the learning group, PAWP was best predicted as PAWP = 18.4 + [17.1.In(E/A ratio)]. This equation allowed prediction of PAWP within 3 mm Hg of the measured value in 24 of 33 patients (73%) in the testing group. In 8 additional patients, the equation also accurately predicted the changes in PAWP induced by volume loading or intravenous nitrates (r = 0.98).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of constrictive fibrous endocarditis.

Between 1971 and 1980, 20 patients with fibrous endocarditis were treated by resection of ventricular endocardium and replacement of the atrioventricular valve. There were 13 male and seven female patients whose ages ranged between 12 and 58 years. Thirteen were white and the remaining seven were black Africans. Nine presented a right-sided form, five a left-sided one, and six presented involvement of both ventricles. The role of hypereosinophilia is discussed in the etiology of the disease. The operation was performed according to the techniques we had developed in our first operative case-excision of the atrioventricular valve. Complete resection of the endocardium, and valvular replacement. There were three operative deaths. Complete atrioventricular dissociation was observed in seven of our patients. particularly in those with right-sided endocarditis. At late follow-up, we have not observed any case of recurrence of the disease. On the basis of our experience and the results previously published in the literature, we believe that endocardiectomy is the best current treatment of this disease.

[Pregnancy interruption in cardiac patients]. / L'interruption de la grossesse chez les cardiaques

PIP: Aspects of pregnancy interruption in cardiac patients are discussed on the basis of 18 such operations performed during the past 12 years. The most frequent indication was rheumatic heart valve disease, but cases of congenital heart defects and primary myocardial disease were also seen. Abortion was usually decided upon when clear clinical or radiological signs of cardiac disturbance were observed. (The electrocardiogram was usually unchanged.) Resistance of the condition to medical and/or surgical treatment constitutes a valid indication. Abortion is accomplished by abdominal hysterotomy (70%) or vaginal curettage (30%), usually accompanied by tubal ligation, during the first trimester of pregnancy. Infectious, occlusive, or hemorrhagic complications were observed in 37.5% of cases. Pregnancy should therefore not be terminated except to save the life of the mother, an increasingly rare medical eventuality.^ieng

[Long-term course of nonoperated tricuspid insufficiency following surgical correction of mitral and mitro-aortic valve diseases]. / Evolution à long terme des insuffisances tricuspides non opérées après correction chriurgicale des valvulopathies mitrales et mitro-aortiques

This study concerns 120 patients with tricuspid incompetence (TI) combined with mitral or mitral-aortic valve disease. This first part is devoted to the 48 patients TI of whom was not corrected, and the long-term course (average 40 months) after mitral-aortic lesions correction was analysed. Assessment of the degree of TI at operation differed markedly from its pre-operative clinical assessment; surgical findings agreed with the clinical estimations in 10 of 12 cases of TI considered to be negligible, but only in 4 of 24 cases with a TI considered as intense clinically. The long-term unfavourable courses (TI with persistent right ventricular failure) were more common in the group of TI considered intense clinically (59%) than in the TI considered clinically as negligible (23%). Assessment by the surgeon during operation of the degree of TI seemed a less accurate element of valuation of the long-term prognosis. The mean pulmonary artery pressure measured at operation did not have, in the patients studied, a significant influence on the long-terme course after mitral-aortic valve correction. On the contrary, the results were less favourable in the group of patients whose TI was old-standing and in the group of patients with a cardio-thoracic ration higher than 0.65. It seems therefore legitimate to recommend correction of both the cases of TI considered to be intense by the surgeon, and those considered to be intense clinically, even if the surgeon finds them to be negligible. This attitude is the more justified the older the TI and the larger the heart enlargement.

[Long-term course of tricuspid insufficiency operated during the surgical correction of mitral and mitro-aortic valve diseases]. / Evolution à long terme des insuffisances tricuspides opérées au cours de la correction chriurgicale des valvulopathies mitrales et mitro-aortiques

This study concerns 120 patients with tricuspid incompetence (TI) combined with mitral or mitral-aortic valve disease. This second part is devoted to the 72 patients whose TI was corrected together with the mitral-aortic valve lesions, and the long-term post-operative course (average 40 months) was analysed. The results were correlated with pre-operatice clinical intensity of the TI: un unfavourable course (persistent TI and right ventricular failure) was noted in 56% of the cases of TI judged to be intense and in 29% only of the cases of TI judged to be clinically negligible (p is less than 0.5). The course varied according to the mode of tricuspid valve repair with a good long-term result in 37% of the 30 cases with Kay's annuloplasty, 62% of the 26 prosthetic valve replacements and 69% of the 13 cases treated by Carpentier's annuloplasty. This latter technique seems to represent the most efficient means of correction for TI, when the anatomical lesions allow for it. In the group of the patients studied, the course is independent from the degree of heart enlargement and from the pulmonary artery pressure level before operation.

[Coronary thrombosis and long term anticoagulant treatment. Results of 173 autopsies after myocardial infarction]. / Thromboses coronaires et traitement anticoagulant au long cours Résultats de 173 autopsies après infarctus du myocarde

Report of an anatomical-clinical study concerning 173 patients with an average follow-up period of 5 and 1/2 years after the onset of myocardial infarction. They were subdivided into four comparable groups differing only in the quality of the long-term antivitamin K treatment which was administered. A survey of the coronary artery and myocardial lesions was performed for every heart. Acute occlusive coronary artery thromboses were four times less frequent in the correctly treated group then in the other three groups (p less than 0.001). There was no significant difference between the insufficiently treated groups and the untreated group. Recurrent myocardial infarctions were accompanied in 90 per cent of cases by acute occlusive coronary artery thromboses and were four times less frequent when treatment was efficient (p less than 0.001). These results confirm the part played by coronary artery thrombosis in the aggravation of coronary atherosclerosis and justify the attempts at long-term prophylaxis. The provide the proof that antivitamin K administration, at efficient dosage, maintained for a long time, has a significant influence on the cause of death in these patients, by decreasing the number of coronary artery thrombosis. Long-term anticoagulant treatment, in spite of its haemorrhagic complications and limits, should not be given up until a new efficient treatment is available.

[Lesions of the right branch of the bundle of His. Clinical, electrocardiographic and histologic study of 33 cases]. / Les lésions de la branche droite du faisceau de His. Etude clinique, électrocardiographique et histologique de 33 cas

The topography and severity of lesions of the right branch of the bundle of His have been studied as a function of the electrocardiographie changes and the associated heart disorder in 33 cases with more than 50% of the fibres destroyed. It appears that lesions of the right branch of the bundle of His, while severe and diffuse in cases of chronic complete right branch block, were severe but localised in 5 of the 6 cases with a stable incomplete right block. Total, subtotal or partial destruction of the right branch of the bundle of His was associated with lesions of the A-V node and/or the main truck of the bundle of His in the five cases with a complete atrio-ventricular block. The lesions of the right bundle branch involved the superior, middle and inferior portions in the case of aortic valve lesions, the middle portion in mitral valve disease, and the inferior portion in those with myocardial infarction. Ventricular hypertrophy seems to play an important in deciding whether the axis of the QRS, complex is left or right.

[Anatomic study of early failures of aortocoronary venous bypass]. / Etude anatomique des échecs précoces des pontages veineux aorto-coronaires

A post-mortem study of 10 patients who died soon after an aorto-coronary by-pass procedure (16 grafts) showed that 5 grafts were blocked by recent thrombus (31%) in 5 patients, 3 of whom had infarcts as a result. It seems that the two main causative factors of early thrombosis were: -the wider calibre of the saphenous graft; the ratio of the circumference of the graft to the circumference of the coronary artery at the site of anastomosis is greater when there is a graft thrombosis (5.6/1 +/- 2.2) than when the graft is permeable (2.3/1 +/- 1.1) (p less than 0.01); -stenosing atherosclerosis of the artieal tree beyond the anastamosis. Changes in the endothelium of the vein, especially those caused by suturing, could equally well play a part in thrombus formation. Certain other factors, such as an insufficiently large graft ostium into the aorta, and poor outflow in the distal arterial bed, or an insufficiently large territory of supply belonging to the artery which has been bypassed, may also influence the degree of myocardial revascularisation brought about by the operation. A by-pass procedure requires a vein graft with a reasonably small diameter which matches, if at all possible, that of the coronary artery, and a good flow in the distal arterial bed, which must be confirmed at operation.

[Effects of intravenous trinitrin infusion on systemic and coronary circulations during atrial electric stimulation]. / Effets de la perfusion intraveineuse de trinitrine sur les circulations systémique et coronaire au cours de la stimulation électrique auriculaire.

Intravenous infusion of trinitrin (0.38 +/- 0.25 mg/hour) during rapid atrial pacing reduced pulmonary capillary pressures, cardiac output, coronary blood flow and myocardial oxygen consumption. At these dosages trinitrin allows patients with ischaemic heart disease to undergo atrial pacing in the best conditions by maintaining the pulmonary capillary and systemic arterial pressures and myocardial lactate production within limits close to the basal values. The beneficial effects last during the recovery period after the termination of pacing and of the intravenous infusion.

[Rate-pressure product and myocardial oxygen requirements]. / Double produit et besoins myocardiques d'oxygène.

The relationship between the rate-pressure product, myocardial oxygen consumption and the production or uptake of lactate by the myocardium was studied in 45 patients under basal conditions and rapid atrial pacing (except in 3 cases with atrial fibrillation). The underlying pathology was ischemic heart disease in 25 cases, non obstructive cardiomyopathy in 9 cases, and obstructive cardiomyopathy in 11 cases. Contrary to what has been reported in normal subjects, a significant linear relationship between the rate-pressure product or indexed rate-pressure (multiplied by body surface area) and myocardial oxygen uptake. The divergence of these results may be due to the method of measuring coronary sinus blood flow, these authors having used the N 20 whereas in this study the flow was measured by thermodilution. In particular, it is possible that this divergence results from abnormalities of ventricular volume, compliance and contractility in the patients under study: these abnormalities may disturb the relationship between the rate-pressure product and myocardial oxygen consumption in normal subjects. A double linear relationship, different in each of these groups, was observed at rest between the indexed rate-pressure product and oxygen uptake, and the uptake or production of lactate: in myocardial ischemia without ischemia at rest, in non obstructive cardiomyopathy in sinus rhythm. The significance of these relations differed in each of these groups. Under atrial pacing, the increase in indexed rate-pressure product compared to basal conditions was proportional to the presence of absence of ischemia. Variations of the indexed rate-pressure product seem to be related to myocardial oxygen consumption and not to myocardial oxygen requirements. The variations of the rate-pressure product, during the administration of drugs, for example, do not reflect myocardial oxygen needs. During exercise ECG, the maximal increase in the indexed rate-pressure product reflect the functional reserve of the myocardium.

[Changes in the exercise electrocardiogram after aortocoronary bypass. Long-term results in 50 patients]. / Evolution de l'électrocardiogramme d'effort après pontage aorto-coronaire. Résultats à long terme chez 50 patients.

A comparative study of exercise electrocardiogrammes before and after aorto-coronary bypass surgery was carried out in 50 patients over a 2 year period. Coronary arteriography was used to assess the chirurgical results qualitatively ((electrocardiographic appearances) and quantitatively (work capacity and effort tolerance) with respect to the coronary lesions and permeability of the aorto-coronary vein grafts. Exercise electrocardiography has a place in the follow up of patients with aorto-coronary bypass grafts but it only gives information on the permeability of the grafts if all the significant stenosis are bypassed at surgery.

[Effects on the systemic and coronary circulation of 2 nitrate derivatives, intravenous trinitrin and sublingual isosorbide dinitrate, administered during atrial pacing]. / Effets sur les circulations systémique et coronaire de deux dérivés nitrés, trinitrine intraveineuse et dinitrate d'isosorbide sublingual, administrés au cours de la stimulation électrique auriculaire.

The changes in the systemic and coronary circulations produced by intravenous trinitrin 0.38 +/- 0.125 mg/hour and sublingual isosorbide dinitrate 5 mg were studied in 24 patients with coronary artery disease. When given during rapid atrial pacing both drugs decreased pulmonary capillary pressures (p less than 0.001), cardiac and coronary output (p less than 0.001 and p less than 0.01) and myocardial oxygen consumption (p less than 0.01). At these dosages, intravenous trinitrin has no significant effect on average systemic blood pressure or left ventricular work index; the coronary arterial resistances increased (p less than 0.005). Isosorbide dinitrate significantly decreased average systemic blood pressure and the left ventricular work index (p less than 0.001); there was no significant difference in the coronary arterial resistances; the decrease in coronary blood flow observed after sublingual isosorbide dinitrate seems partly due to a decreased perfusion pressure. The beneficial effect of these nitrite derivatives seems to be mainly related to a reduced preload.

[Starr-Edwards mitral valve prosthesis and secondary clinical deterioration. Hemodynamic study in 14 patients]. / Prothèse de Starr-Edwards mitrale et aggravation clinique secondaire. Etude hémodynamique de 14 malades.

The haemodynamic and angiocardiographic data of 19 patients with Starr-Edwards mitral valve prosthesis were analysed to determine the causes of secondary deterioration observed in 14 of them. This was shown to be due to: 1. Surgical complications or progression of pre-existing valvular lesions which were not, or only partially, corrected (3 cases) (adiastole due to pericardial effusion, aortic valve disease and severe tricuspid incompetence); average diastolic pressure gradient CPW-LV 4.7 +/- 1.5 mmHG, the functional valve surface area (FVA) 1.37 +/- 0.2 cm2, LVEDP 17.7 +/- 4 mmHg, LVEDV 57.5 +/- 11 ml/m2, and EF 73.5 +/- 8 p. 100; 2. Deterioration of left ventricular contractility with LVEDP greater than 13 mmHg, LVEDV greater than 100 ml/m2 and EF less than 45 p. 100 (4 cases); CPW-LV gradient 9.8 +/- 4 mmHG, FVSA 1.30 +/- 0.2 cm2, LVEDP 20.5 +/- 8 mmHG, LVEDV 212 +/- 168 ml and EF 38 +/- 21 p. 100; 3. Significant reduction of left ventricular volume (LVEDV 22 ml/m2 1 case); 4. Left atrial thrombosis (1 case); 5. Prosthetic valve dysfunction (5 cases) one paravalvular leak and 4 thromboses. In these 4 cases, the PCW-LV gradient was 15 +/- 5 mmHg, FVSA 0.95 +/- 0.1 cm2 LVEDP 8 +/- 2 mmHg, LVEDV 132.8 +/- 93 ml/m2 and EF 45 +/- 28 p. 100; these results were different to whose found in the other patients and those investigated systematically (PCW-LV gradient 8.2 +/- 3 mmHg, FVSA 1.38 +/- 0.3 cm2, LVEDP 11 +/- 4 mmHg, LVEDV 66.4 +/- 33 ml/m2, EF 53 +/- 13 p. 100). The significant haemodynamic criteria in favour of thrombosis of the prosthesis were: CPW-LV gradient greater than 12 mmHg under basal conditions or after exercise and a FVSA less than 1.1 cm2.

[Study of the effects on coronary circulation and myocardial metabolism of a single intravenous dose of dihydralazine in 10 cases of primary myocardiopathy]. / Etude des effets sur la circulation coronaire et le métabolisme myocardique d'une dose intraveineuse unique de dihydralazine dans 10 cas de myocardiopathie primitive.

The effects of a single intravenous injection of dihydralazine (0.1 mg/kg) on coronary blood flow and myocardial metabolism were studied in 10 patients with primary congestive cardiomyopathy. Cardiac output and coronary blood flow increased significantly (p < 0,001 and p < 0,05); myocardial oxygen consumption, cardiac work and the coronary arteriovenous difference in lactates did not change significantly. However, the effects of dihydralazine are variable; coronary blood flow decreased in 2 patients; myocardial oxygen consumption increased in 3 patients; the coronary arteriovenous difference of lactate concentration fell or inversed in 5 patients. This data suggests that dihydralazine may have an undesirable effect on myocardial metabolism in some cases of congestive cardiomyopathy. Further long term studies are indicated to define the role of this drug in cardiac therapeutics.

[Myocardiopathy of pregnancy in white women]. / Myocardiopathie de la grossesse chez la femme blanche.

Over the course of 17 years, 7 women have had heart disease either during the last three months of pregnancy or during the first three months post-partum, which appear to be associated with their pregnancy. Enquiries made throughout the country and relating to the last decade have yielded 11 additional cases so far unpublished. The clinical features of these cases do not differ from those of other non-obstructive cardiomyopathies occurring other than in pregnancy. The prognosis depends essentially on the factor of cardiac volume during the first few months of the disorder: if significant cardiomegaly persists, death will follow in one case out of two. There exists the problem of the criteria for making a diagnosis of myocardial disease of pregnancy. It should be emphasised that only 4 of the 18 cases were different from the usual cases of myocardial disease, in that they progressed to recovery which is unusual in this condition. One case was particularly illustrative of this, as clinical cure was followed by a relapse at subsequent pregnancy. Because the pregnancy itself seems to be the cause in such a tiny number of cases, a new hypothesis seems right; this is that pregnancy does no more than aggravate an associated or already existent myocardial disorder.

[Study of hemodynamic effects of the methoxamine in 8 cases of obstructive cardiomyopathy with mitral valve insufficiency]. / Etude des effets hémodynamiques de la méthoxamine dans 8 cas de myocardiopathie obstructive avec insuffisance mitrale.

The haemodynamic effects of intravenous Methoxamine were studied in 8 patients with hypertrophic obstructive cardiomyopathy (HOCM) with mitral incompetence (group I) and 8 patients with mitral incompetence due to valvular, subvalvular or other causes (group II). In both groups the left ventricular end-diastolic pressure rose significantly without any great change in the end diastolic surface area: the ventricular distensibility is reduced in both cases. The mean capillary pressure, the V wave/mean capillary pressure ratio, and the degree of regurgitation of the two groups changed in opposite ways : in mitral incompetence due to varying causes (group II) the regurgitation increased, but in mitral incompetence due to HOCM (group I), it decreased. The left ventricular intracavitary gradient in HOCM tended to disappear under the effect of Methoxamine as the systolic aortic pressure approached the basal values recorded in the apical area.

[Silent mitral insufficiency caused by partial dislocation of a Starr-Edwards valve. Apropos of 2 cases with 1 being successfully re-operated]. / Insuffisance mitrale muette par désinsertion partielle de valve de Starr-Edwards. A propos de deux cas dont un réopéré avec succès

Silent mitral incompetence due to partial dislocation of the Starr-Edwards valve, leading to an apparently unexplained cardiac failure, has been observed in two patients, one two months and the other 35 months postoperatively. There was a fatal outcome in the first patient, no operation being carried out. Cardiac catheterisation with arteriography of the left anterior descending artery established the diagnosis, and led to a successful reoperation in the second case. It is therefore essential to carry out a haemodynamic and angiocardiographic investigation of any case who, after an initial trouble-free interval post-operatively, develops a deterioration of function which cannot be explained.

Comparison of angiographic aspects and anatomical lesions of coronary arteries. / Comparaison entre les aspects angiographiques et les lésions anatomiques des artéres coronaires

The coronary angiograms of 32 patients were compared with the anatomical lesions found during the postmortem examinations which were done early after the X-ray examination. The angiographic and anatomical data coincided in 81.6 per cent of all the coronary artery segments studied. The best coincidence was observed for the right coronary artery and the less accurate for the left coronary trunk (nevertheless, with 77 per cent good correlations). On the whole, the observer tends to underestimate the severity of the stenoses involving the large trunks (left coronary trunk and anterior descending artery) and to overestimate the involvement of the distal segments, especially if their size is small. Habitually, the errors noted are insufficient to modify the therapeutic attitude. Rarely, on the anterior descending artery, they have led to the performance of an uneccessary aorta-to-coronary by-pass (1 case) or to an unjustified conservative attitude (2 cases). Equally, over-estimation of a distal bed to a left circumflex artery was responsible for an abusive contra-indication (1 case). Thus, if on the whole coronary angiography is a fiable examination, it is necessary to resort to new incidences to improve its results.

[Nodoventricular Mahaim fibres. 2 cases confirmed by electrophysiological study]. / Fibres de Mahaim nodo-ventriculaires. Deux cas mis en évidence à l'exploration électrophysiologique.

Two adolescents with no obvious cardiac were investigated for paroxysmal tachycardia at a rate of about 200/mn with wide QRS complexes showing left bundle branch block, reduced by vagal manoeuvres. Atrial pacing showed shortening of the HV interval associated with widening of the QRS complex to appearances identical to those of the tachycardia, suggesting right ventricular preexcitation masked in sinus rhythm. The progressive prolongation of the atrio-ventricular conduction time with increasing prematurity of the extrastimulus and atrioventricular block after intravenous injection of ATP were more in favour of right nodo-ventricular Mahaim fibres (NV) than a Kent bundle. These properties of the NV pathway and the recording of a "gap" phenomenon during the measurement of the refractory period of the accessory pathway are explained by the proximal part of the AV node not being short-circuited. Paroxysmal tachycardia was easily induced by atrial and ventricular stimulation; the tachycardia QRS complexes always showed appearances of left bundle branch block with a His potential at the onset of the ventricular complex. The NV pathway therefore always depolarised in the anterograde direction in tachycardia; the retrograde pathway is discussed: His, latent Kent bundle or purely intranodal reentry.