State of art in 11C labelled radiotracers synthesis.

Positron Emission Tomography has become a powerful scientific and clinical tool probing biochemical processes in the human body. Their clinical applications have proven to be vital in the evaluation and diagnosis of diseases. This is due, in large part, to advances in instrumentation and synthetic chemistry. Carbon-11 is a valuable radionuclide in PET as it virtually permits the synthesis of radiolabelled versions of any compound of interest. The syntheses with carbon-11 present several features: limited number of labelled precursors, sub-micromolar amounts of the starting materials, and a need for the introduction of the radioisotope as late as possible in the synthesis. All of these reasons have restricted complex radiosyntheses. The short half-life of carbon-11 (20.4 min) requires the rapid preparation and purification of carbon-11 labelled molecules. Those have to be carried out immediately before use from cyclotron produced precursors ([11C]CO2, [11C]CO, [11C]CH4) or reagents rapidly prepared from them ([11C]CH3I, [11C]COCl2, [11C]HCN). As a consequence carbon-11 has been underused compared to fluorine-18. However, because of the increasing molecular complexity and diversity of biologically active compounds, there is a need for new methodologies giving access in short time and high yield to radioactive (11)C-probes. The aim of this review is to emphasize the methodologies used in this field and to give a comprehensive overview of the numerous advances, which occurred over the past decade. In addition, for each labelling technique or reaction reported, a special attention has been brought to classify the applications in function of the targeted medical domain.

[Is training on basic skills and management of critical events responsible of ethical considerations in anaesthesia and intensive care?]. / L'apprentissage des gestes invasifs et de la gestion d'une situation critique pose-t-il des problèmes éthiques en anesthésie-réanimation?

OBJECTIVE: To provide information on morbidity and ethical questions associated with learning of invasive techniques (tracheal intubation, positioning of central venous or epidural catheters) and management of anaphylactic shock. STUDY DESIGN: Retrospective survey. METHODS: Written questionnaire to 54 anaesthesiologists and 55 residents. RESULTS: Training was primarily performed by residents having a 6 months-experience for general anaesthesia and by more experienced residents for epidural analgesia. Residents observed first two or three procedures performed by seniors, but did not have theoretical lectures in 30 to 50% of cases. Dead bodies or manikins were rarely used. Despite the presence of experienced anaesthesiologists during the first attempts, there was a high morbidity rate which was considered by 22 to 37% of the interviewed anaesthesiologists a loss of benefit for the patients. Despite a high level of coaching, a high morbidity rate was associated with the first attempts. However, only few residents explicitly stated to be concerned by ethical questions. Among anaesthesiologists, who had yet to manage anaphylactic shock, 21 and 35% of them reported that diagnostic and treatment could have been performed faster. Virtual learning was misunderstood but 46% of anaesthesiologist described numerous advantages in using simulator of anaesthesia. CONCLUSION: Despite an apparent morbidity with a loss of benefit, informed consent of the patients were rarely obtained.

[Butyrylcholinesterase deficiency: how to analyse the cholinesterase activity in small children?]. / Déficit génétique de la butyrylcholinestérase: comment interpréter l'activité cholinestérasique chez le jeune enfant ?

We report the case of a prolonged neuromuscular blockade in an 18-month-old age girl following administration of a usual dose of succinylcholine. The diagnosis was highly suggested by the clinical history while cholinesterase activity was included in adult normal values but below values of a personal series of 41 small children. The familial analysis of dibucaine and fluoride number confirmed the hypothesis of an atypical variant (AA phenotype). The cholinesterase activity is higher in small children than in adult and has to be analysed according to the age.

[Unusual haemostasis disorder in a seriously burned patient]. / Trouble inhabituel de l'hémostase au cours d'une brûlure grave.

We report the case of a woman severely burned during a gas explosion with an unusual disorder of haemostasis. The prothrombin time was very elevated, essentially by a drop in factor II. This abnormality persisted for a long time after the correction of the dilutional and consumption coagulopathy which followed immediately the burn. Blood analysis found fluindione and benzodiazepine derivatives. Such a disorder during a potentially suicidal burn must evoke a toxic aetiology.

[Anaesthesia and prostate surgery]. / Anesthésie et chirurgie de la prostate.

OBJECTIVES: To review the current data about anaesthetic management in prostate surgery with special regards on analysis and prevention of specific risks, appropriate anaesthetic procedure keeping with surgery and patient, recognition and treatment of adverse events. DATA SOURCES AND EXTRACTION: The Pubmed database was searched for articles (1990-2004) combined with references analysis of major articles on the field. DATA SYNTHESIS: It is strongly recommended to settle germfree urine in the preoperative period. The thromboembolic risk of radical retropubic prostatectomy for cancer parallels lower abdomen oncologic surgery and is prolonged. Preoperative evaluation of cardiovascular, respiratory, neurological and metabolic comorbidity is a source of prognostic information and an essential tool in the management of elderly patients with prostate disease. Extreme patient positioning applied in prostate surgery induces haemodynamic and respiratory changes and are associated with severe muscular and nervous injuries. The laparoscopic access for radical prostatectomy is a growing alternative to the open surgical procedure. Acute normovolaemic haemodilution is a consistent and cost-effective blood conservation strategy in reducing allogenic blood transfusion for radical retropubic prostatectomy. Whether open transvesical or transurethral prostatectomy for treatment of benign hypertrophy depends on the size of the gland: transurethral resection is safe up to 80 g. Intrathecal anaesthesia with a T9 cephalad spread of sensory block, produces adequate conditions for transurethral prostatectomy and allows a rapid diagnosis of irrigating fluid absorption syndrome. In spite of recommended preoperative antibiotic prophylaxis, bacteriemias are frequent during transurethral prostate resection.

Common carotid haemodynamic and metabolic effects of acutely administered nifedipine in human subarachnoid haemorrhage.

Although the drugs known as "calcium antagonists" exert inhibitory actions on vascular smooth muscle, there are no quantitative data concerning the clinical use of these vasodilator agents in human subarachnoid haemorrhage. In the present clinical study, we have measured the effects of nifedipine (20 mg tablet) on common carotid artery diameter (D) blood flow velocity (V) common carotid blood flow (CCBF) as an index of cerebral blood flow, systolic (Qs) and diastolic (Qd) blood flow fractions using a pulsed Doppler apparatus and on carotid arterial pressure (CAP), heart rate (HR) and oxygen consumption (VO2). Eight patients with subarachnoid haemorrhage were studied during anaesthesia for cerebral angiography. Thirty minutes after sublingual nifedipine, diameter (P less than 0.05), blood flow velocity (P less than 0.001), CCBF (P less than 0.001), Qs (P less than 0.05), and Qd (P less than 0.05) increased with a decrease in Qs/Qd ratio (P less than 0.05). carotid vascular resistance (CVR) fell (P less than 0.02) and oxygen consumption of the brain increased (P less than 0.01). Systolic, diastolic, and mean carotid blood pressure, heart rate, and arteriovenous difference in oxygen were unchanged. The increase in CCBF was closely correlated with the vascular resistance in the control state (r = 0.928, P less than 0.001) and with oxygen consumption (r = 0.869, P less than 0.001). We conclude that in vivo, nifedipine exerts a preferential action on cerebral vessels, vasodilating large arteries and arterioles. This action is more powerful if the vessels are already vasoconstricted. Thus, the use of nifedipine could be fruitful in cerebral ischaemia that is secondary to subarachnoid haemorrhage.

Search for common haplotypes on chromosome 22q in patients with schizophrenia or bipolar disorder from the Faroe Islands.

Chromosome 22q may harbor risk genes for schizophrenia and bipolar affective disorder. This is evidenced through genetic mapping studies, investigations of cytogenetic abnormalities, and direct examination of candidate genes. Patients with schizophrenia and bipolar affective disorder from the Faroe Islands were typed for 35 evenly distributed polymorphic markers on 22q in a search for shared risk genes in the two disorders. No single marker was strongly associated with either disease, but five two-marker segments that cluster within two regions on the chromosome have haplotypes occurring with different frequencies in patients compared to controls. Two segments were of most interest when the results of the association tests were combined with the probabilities of identity by descent of single haplotypes. For bipolar patients, the strongest evidence for a candidate region harboring a risk gene was found at a segment of at least 1.1 cM including markers D22S1161 and D22S922 (P=0.0081 in the test for association). Our results also support the a priori evidence of a susceptibility gene to schizophrenia at a segment of at least 0.45 cM including markers D22S279 and D22S276 (P=0.0075). Patients were tested for the presence of a missense mutation in the WKL1 gene encoding a putative cation channel close to segment D22S1161--D22S922, which has been associated with schizophrenia. We did not find this mutation in schizophrenic or bipolar patients or the controls from the Faroe Islands.

Dobutamine in the treatment of depressed cardiac function: a study in patients with ischaemic heart disease during the early post-operative period.

Dobutamine was administered by intravenous infusion to 10 patients with ischaemic heart disease who had a low cardiac output syndrome following abdominal surgery. The dosage of dobutamine started from 2.5 mcg kg-1 min-1 and was increased stepwise to 5, 7.5, 10, 12.5 and 15 mcg kg-1 min-1. Cardiac index increased significantly from 2.05 +/- 0.32 to 3.03 +/- 0.61. min-1 min-2 with 15 mcg kg-1 min-1. Heart rate was unchanged with 7.5 mcg kg-1 min-1 but increased significantly from 97.7 +/- 18.5 to 126.1 +/- 21.5 beats. min-1 with 15 mcg kg-1. min-1. Stroke index increased significantly from 21 +/- 4.4 to 25.4 +/- 5.1 ml m-2. beat-1 with 7.5 mcg kg-1 min-1. Pulmonary wedge pressure fell significantly from 14 +/- 2.9 to 9.1 +/- 2.4 mmHg with 2.5 mcg kg-1 min-1. Mean arterial pressure showed no significant change. No side effects were observed in these patients. We conclude that in patients with depressed cardiac function dobutamine at low doses of 2.5 mcg kg-1 min-1 decreases afterload and filling pressures. At the average doses of 5 - 7.5 mcg kg-1 min-1 stroke index and cardiac index are increased. At higher doses of 10 - 15 mcg kg-1 min-1 heart rate and cardiac index increase while stroke index fails to increase further.

Left ventricular function in tetanus: influence of therapy.

Nine patients hospitalized for tetanus were studied under the same protocol which included two haemodynamic studies with a preload trial (PLT). The first being made during therapy (diazepam barbiturate association), on the sixth day of hospitalisation, and the second one after recovery. The comparison of the results shows that before PLT the mean arterial pressuure (MAP) is significantly increased (p less than 0.05) in patients after recovery in comparison to the same patients undergoing therapy. After PLT there is no significant difference between the two groups. Lastly, the variation of the left ventricular function points under PLT shows no significant difference between patients during therapy and after recovery. These results suggest that the diazepamphenobarbital combination does not alter the left ventricular function of the patients undergoing this therapy during tetanus.

A dose-response study of epidural liposomal bupivacaine in rabbits.

Liposomes are drug delivery systems used to prolong local effects of bupivacaine. We studied the relationships between motor and hemodynamic changes and epidural doses of plain bupivacaine (P) and liposomal bupivacaine (L) in rabbits equipped with chronical lumbar epidural and femoral arterial catheters. Liposomal (phosphatidylcholine-cholesterol) suspensions contained 20 mg ml-1 of lipid, and different doses of bupivacaine (Lipo 7.5=7.5-; Lipo 3.7=3. 75-; Lipo 2.5=2.5-; Lipo 1.2=1.25-; and Lipo 0.7=0.65-mg of bupivacaine per ml). Forty rabbits were randomly assigned to five groups to receive epidural anesthesia (1 ml) as follows: Groups I to V received 0.65 to 7.5 mg of bupivacaine as P then as L. Release rate of bupivacaine from liposome was significantly slower using Lipo 3.7 than after Lipo 2.5 (Td was 3.9 h and 1.7 h respectively). Increasing the doses of L and P resulted in faster onset time for complete motor blockade and in a prolonged duration of motor effects. Liposomal formulation appears to be a powerful delivery system to prolong the motor effects of bupivacaine since E50 was lower and Emax higher than after the use of plain solution (E50 4.49+/-1.81 mg and Emax 152+/-40 min for P; and E50 2.61+/-0.23 mg and Emax 202+/-9 min for L). Hemodynamic changes were linearly related to doses of bupivacaine injected. The best bupivacaine-to-lipid ratio to prolong motor effects using our model was 3.75 mg and 20.0 mg respectively (Lipo 3.7).

Amniocentesis and amnioinfusion during pregnancy. Report of four complicated cases.

We report two foetal complications after amnioinfusion with dye injection for evaluation of severe oligohydramnios in pregnancy. In the first case, an underskin colouring was to disappear within a few days. In the second case, an irreversible skin after-effect with muscular atrophy and lesion of the underskin tissues developed progressively, although the trained practitioner did not notice any particular resistance during the injection of the dye and the ultrasonographer did not point out that the foetus had been stuck by the needle. Both later reported cases concern two life threatening maternal complications due to amniocentesis for foetal karyotyping indicated by maternal age, a septic shock occurred 24h after entering the amniotic cavity, leading to a long stay in intensive care units. In one of those cases, the patient recovered from a cardiac arrest. We come to the conclusion that the essential continuous ultrasonographic monitoring cannot avoid all complications, some of which may lead to severe adverse foetal effects and others may need an intensive medical care for the mother, mainly after iatrogenic chorioamnionitis. Experience of the perinatologist remains an important factor to limit the complications without avoiding them completely. The indications must be carefully evaluated, the information given to the patients must be clear and in the future, intraamniotic injections of dyes will have to be avoided and replaced by non-invasive tests for diagnosis of preterm premature rupture of membranes, such as diamine-oxidase, foetal fibronectin or PROM-tests. The rules of a good practice will have to be defined and widely spread.

Gonadotropin releasing hormone (GnRH) induced luteinizing hormone (LH) secretion from perifused equine pituitaries.

In vitro responsiveness of the horse anterior pituitary (AP) gonadotropes to single and multiple GnRH challenges was examined. The pituitaries were collected from reproductively sound mares in estrus (n = 5) and diestrus (n = 5). Uniform 0.5 mm AP slices were subdivided using a 3 mm biopsy punch and then bisected for use in the perifusion chamber. Four bisected sections per chamber were perifused at 0.5 ml/min at 37 C for 560 min in Medium 199 saturated with 95% 0(2)/5% CO2. Ten minute fractions were collected after an initial 2 hr equilibration period. Four different treatment regimes of GnRH (10(-10) M) were evaluated: (A) three consecutive 10 min GnRH pulses separated by 80 and 100 min, respectively; (B) a single 120 min GnRH infusion; (C) a 10 min GnRH pulse followed 80 min later by a 120 min GnRH infusion and (D) two 10 min GnRH pulses separated by 60 min followed 80 min later by a 120 min GnRH infusion. Estimated total pituitary LH content was higher in estrous than diestrus mares (p less than 0.05). The total amount of LH released in response to GnRH tended to be greater in estrus than diestrus (p less than 0.1), whereas the percentage of LH released in estrus and diestrus was similar. An increase in the area under the LH response curve was noted with each successive 10 min pulse of GnRH during both estrus and diestrus (p less than 0.05), demonstrating a self-priming effect of GnRH. In addition, a significant increase in the peak LH amplitude (p less than 0.05) and the slope to peak amplitude (p less than 0.05) were observed for the 120 min GnRH pulse in regime C and D indicating that prior exposure to short-term pulses of GnRH increased the acute LH secretory response. These results suggest that in the cycling mare (1) the responsiveness of the pituitary (amount of LH released as percent of total LH) is similar in both estrus and diestrus, however, the magnitude of the LH response (total microgram amount of LH released) differs with the stage of the estrous cycle, being highest in estrus, and appears to be related, in part, to pituitary LH content and (2) GnRH self-priming occurs independently of the stage of the estrous cycle. Furthermore, we have demonstrated that the pulsatile mode of GnRH can act directly on the anterior pituitary to dictate the pulsatile release pattern of LH in the cycling mare.

[Evaluation of the cardiac risks in non-cardiac surgery in patients with heart failure]. / Evaluation du risque cardiaque en chirurgie non cardiaque chez l'insuffisant cardiaque.

Cardiac insufficiency represents a major risk factor in patients about to undergo non-cardiac surgery. The post-operative mortality is linked to the severity of the pre-operative functional impairment: rising from 4% in NYHA class 1 to 67% in class IV. The operative risk is greater when the cardiac insufficiency is more disabling, the patient is older (> 70 years) and if there is a history of acute pulmonary oedema and a gallop bruit on auscultation. The use of metabolic equivalents (Duke Activity Status Index) is recommended: the functional capacity is defined as excellent if > 7 MET, moderate between 4 and 7, or poor if < 4. A non-invasive evaluation of left ventricular function is necessary in each patient with obvious congestive cardiac insufficiency or poor control under the American consensus, but it is rare that the patient has not already been seen by a cardiologist. The degree of per-operative haemodynamic constraint is linked to the surgical technique and is stratified according to the type of surgical intervention and whether or not it is performed as an emergency. An intervention duration > 5 hours is associated with an increased peri-operative risk of congestive cardiac insufficiency and non-cardiac death. Deaths from a cardiac cause are thus twice as frequent after intra-abdominal, non-cardiac thoracic or aortic surgery and the post-operative cardiac complications are six times more frequent. Numerous studies have attempted to document the impact of different anaesthetic techniques on the prognosis for the population at increased risk of post-operative cardiovascular complications. It is advisable to opt for peripheral nerve blocks. The cardiovascular morbidity and overall mortality do not differ between general anaesthetic, epidural anaesthetic or spinal nerve block. The ASA (American Society of Anesthesiologists) classification is widely used to determine the overall risk. The ASA class and the age are however too coarse as methods of evaluation for the individual risk and for giving judicious pre-operative advice. Multifactorial cardiac risk indexes such as that of Goldman allow overall evaluation (taking the patient and the intervention into account) of the peri-operative cardiovascular risk in non-cardiac surgery as a function of predictive clinical elements. Nine variables concerning the patient's history, the physical examination and several simple supplementary examinations are identified for which the relative weight is recorded under a points system. The average risk score for a given procedure is converted into an average risk for a given patient using a nomogram such as Detsky's. Surgical acts which do not impose major constraints on the cardiocirculatory apparatus (ophthalmic surgery for example) do not require supplementary examinations. The risk of post-operative cardiac complications is low in the absence of the 9 risk factors defined by Goldman, as is an ischaemic syndrome (angina on light physical activity, unstable angina, myocardial infarction). Certain risk factors (jugular congestion, gallop bruit, recent myocardial infarction, non-sinus rhythm, extrasystoles, aortic stenosis) obviously require appropriate treatment beforehand. The sometimes difficult process demands a dialogue between the cardiologist and the surgeon, the recognition of the risk of surgery in a given centre, and the opinion of the patient duly informed of the terms of the discussion about him.

Effects of systemic morphine and epidural bupivacaine on postoperative oxygen consumption during rewarming.

The alterations in hemodynamics and oxygen consumption as a consequence of continuous epidural infusions of bupivacaine at room temperature and conventionally administered morphine were studied during recovery from general anesthesia for total hip replacement. Twenty-four patients were randomized to receive either bupivacaine or morphine in the recovery room. The bupivacaine group received from 6 to 12 ml per hour of 0.25% bupivacaine epidurally. Patients in the morphine group received 0.1 mg/kg of morphine intramuscularly no more frequently than every 4 hours. A pulmonary artery flotation catheter was inserted into each patient to determine hemodynamics and oxygen consumption at three instances: before analgesia, when pulmonary artery blood temperature reached 36 degrees C, and when it reached 37 degrees C. During the rewarming there was a decrease in mean arterial blood pressure and the systemic vascular resistance index and an increase in heart rate. The whole body oxygen consumption index increased in the bupivacaine group at the last measuring point but was stable in the morphine group. There was no effect on the arterial-venous oxygen content difference in either group. At 37 degrees C, the cardiac index and oxygen consumption index were significantly higher in the bupivacaine group than in the morphine group. In contrast to regional analgesia, systemic morphine administration can partially antagonize cardiovascular response to postoperative rewarming because it induces a stable oxygen demand.

Spinal or systemic analgesia after extensive spinal surgery: comparison between intrathecal morphine and intravenous fentanyl plus clonidine.

STUDY OBJECTIVE: To compare two different methods of postoperative analgesia after extensive spinal fusion. DESIGN: Double-blind, randomized study. SETTING: University-affiliated hospital. PATIENTS: Twenty four adult patients undergoing scoliosis correction. INTERVENTIONS: Before the end of surgery, patients received either intravenous clonidine 0.3 micrograms/kg/hr and fentanyl 25 micrograms/kg (after an hourly dose of clonidine 2.5 micrograms/kg) or intrathecal morphine 0.3 mg. A saline infusion was administered to patients receiving morphine intrathecally. MEASUREMENTS AND MAIN RESULTS: Pain and sedation scores, hemodynamic data, and blood gases were collected in the recovery room at tracheal extubation and then every 2 hours for the next 14 hours. Tracheal extubation was performed at the same time in both groups (i.e., an average of 4 hours after the analgesic regimens were started). Intrathecal morphine provided a mean score of 20 mm on a visual analog scale ranging from 0 mm (no pain) to 100 mm (severe pain), but it resulted in increased PaCO2 at extubation (44 +/- 7 mmHg) and 2 hours later (42 +/- 7 mmHg). PaCO2 was greater than 50 mmHg in four patients receiving intrathecal morphine. Fentanyl-clonidine resulted in equipotent analgesia but was accompanied by sedation (sleeping but arousal by light tactile stimulation) and moderate hypotension (up to 69 +/- 9 mmHg for mean arterial pressure). CONCLUSIONS: This study shows that there is a major risk of respiratory depression with a single intrathecal dose of morphine 0.3 mg to control postoperative pain after scoliosis surgery. Systemic clonidine-fentanyl may be a possible approach to the postoperative pain treatment of this surgery.

[Preoperative evaluation of coronary circulation]. / Evaluation préopératoire de la circulation coronaire.

It is not easy to define a plan for the preoperative assessment of the coronary circulation: some studies carried out in the context of vascular surgery are contradictory and no method has a sensitivity and specificity of 100%. Nevertheless, it is essential to select patients with a high risk of perioperative cardiac complications so that their medical treatment can be reinforced or anatomical correction envisaged. A first assessment is obtained from the history, the clinical examination and simple investigations (resting ECG, chest X-ray). Surgical operations which do not impose a major strain on the cardiovascular system do not require further investigations. The risk of postoperative cardiac complications is low in the absence of the nine risk factors defined by Goldman and/or an ischemic syndrome (residual angina after mild physical activity, unstable angina, myocardial infarct). The problem arises in patients with the Goldman risk factors and/or a history of coronary insufficiency and/or coronary insufficiency risk factors (diabetes, tobacco, hypercholesterolemia, age > 70 years, arterial hypertension), who require an operation likely to cause a particularly serious strain on the cardiovascular system. An exercise ECG, by the Holter method, is helpful, particularly in known or potential coronary arteriopaths who cannot exercise. Echocardiography under dobutamine has good sensitivity and good specificity when exercise is impossible. Thallium-dipyridamole scanning has not been shown to be helpful in vascular surgery. This method could be refined by a quantitative analysis of the number of areas and segments involved. Finally, patients showing ischaemic changes on continuous ECG recording, abnormalities on echocardiography under dobutamine, abnormalities on thallium-dipyridamole myocardial scanning or on exercise ECG, should be considered for coronary angiography with a view to a preliminary anatomical correction.

[Neurosurgical aspects of fronto-ethmoidal osteomas; report of 6 cases and review of the literature]. / Aspectos neurocirrgicos dos osteomas fronto-etmoidais; relato de 6 casos e revisão da literatura.

The cases of six patients with fronto-ethmoidal osteomas which have produced intracranial complications are reported. The patients have been divided in two groups depending on their clinical aspects, from cranio-facial deformities to exophtalmus, rinorrhea, pneumocephalus, meningitis and mucocele. A review of the literature is made and the importance of such lesions is stressed together with a critical analysis of the methods proposed for their surgical treatment. The results obtained with a frontal approach and a plastic closure of the dura were uniformelly good with restoration of functions in all patients.

[Giant cell tumors of the sphenoid bone. Report of 3 cases and review of the literature]. / Tumores de celulas gigantes do esfenoide Relato de 3 casos e revisão da literatura

Three cases of giant cell tumor of the sphenoid bone are reported together with a revision of the previously reported cases in the neurosurgical literature. The importance of this tumor in the neurosurgical pathology is stressed, mainly to the impossibility of a correct diagnosis on a clinical and radiological basis. A good prognosis is possible with a least agressive surgery, transphenoidal biopsy and decompression, folowed by radiotherapy.

[Preoperative evaluation of coronary circulation]. / Evaluation préopératoire de la circulation coronarienne.

To define a strategy for coronary circulation assessment is a difficult task as most of the studies have been carried out in vascular surgery, as some of them are controversial, and as no test has a 100% sensitivity and specificity. However patients with high perioperative risk of cardiac events have to be identified, in order to intensify medical treatment or to consider myocardial revascularisation. A first evaluation is based on history, physical examination and simple tests, such as rest electrocardiogram and thorax X-Ray. Additional tests are not required when surgery does not elicit a major activity of the cardiocirculatory system. Postoperative cardiac risk is low when none of the nine risk factors defined by Goldman and/or coronary insufficiency (residual angina elicited by minor physical activity, unstable angina, myocardial infarction) are present. The problem remains in patients with Goldman risk factors and/or at risk of coronary artery disease because of diabetes mellitus, heavy smoking, hypercholesterolaemia, arterial hypertension, undergoing major abdominal, thoracic or vascular surgery. Preoperative electrocardiographic Holter monitoring is still of value, especially in patients with known or supposed ischaemic heart disease and unable to make a physical effort. A poor exercise capacity and changes in electrocardiographic stress testing are factors of poor prognosis. The dobutamine stress echocardiography has a good sensitivity and specificity when an effort test cannot be performed. The value of dipyridamole-thallium 201 scintigraphy could be improved by a quantitative analysis of the number of affected segments and territories. Patients with angina or ischaemic episodes on continuous electrocardiogram, or with dobutamine echocardiography kinetic disturbances and with stress myocardic scintigraphy or stress exercise testing abnormalities could undergo a coronarography, in order to consider myocardic revascularization prior to surgery.

[Anesthesia for cesarean section in a patient with McArdle disease and hereditary dilated cardiomyopathy]. / Anesthésie pour césarienne chez une patiente atteinte d'une maladie de McArdle et d'une cardiomyopathie dilatée familiale.

A caesarean section was indicated in a 29-year-old parturient affected by a muscular deficit in myophosphorylase responsible for a type V glycogen storage disease (McArdle disease). This metabolic myopathy had been diagnosed two years previously, whereas the patient already suffered from a hereditary form of dilated cardiomyopathy. The muscular disease was invalidating on the functional level with exercise intolerance. The cardiopathy was little symptomatic but the dysfunction of the left ventricle worsened during the pregnancy with an ejection fraction calculated to 43%. In this case, we report the realization of a general anaesthesia in a patient who had epidural anaesthesia for a previous caesarean section.