ABSTRACT
To investigate myocardial manifestations in progressive systemic sclerosis, we studied three patients with transthoracic echocardiography, cardiac catheterization with coronary angiography, thallium scans with dipyridamol completed by thoracic cold exposure and endomyocardial biopsy with immunohistology. Two patients were symptomatic. In the three cases, abnormalities of myocardial perfusion were detected without coronary stenosis. Two patients had myocardial fibrosis with a coronary spasm in one case. The immunohistological study always showed an unusual expression of HLA class II antigen on cardiac fibroblasts.
Subject(s)
Cardiomyopathies/etiology , Scleroderma, Systemic/complications , Aged , Autoimmune Diseases , Biopsy , Cardiac Catheterization , Cardiomyopathies/diagnostic imaging , Cardiomyopathies/physiopathology , Coronary Vessels/pathology , Echocardiography , Electrocardiography , Female , Fibrosis , Humans , Male , Microcirculation , Middle Aged , Myocardium/pathology , Radionuclide Imaging , Scleroderma, Systemic/physiopathologyABSTRACT
We studied myocardial manifestations of systemic sclerosis in three patients. Two patients were symptomatic. A transthoracic echocardiography, a coronary angiography, a cardiac catheterization, thallium scans with dipyridamol completed by thoracic cold exposure and endomyocardial biopsy with immunohistological study were performed. None of them have coronary stenosis. In the three cases abnormalities of myocardial perfusion were detected, two of them have fibrosis. The immunohistological study always showed an anusual expression of HLA DR on cardiac fibroblasts.
Subject(s)
Cardiomyopathies/etiology , Scleroderma, Systemic/complications , Aged , Cardiomyopathies/diagnosis , Female , Humans , Male , Middle AgedABSTRACT
Single photon emission computed tomography (SPECT) is superior to conventional radionuclide scintigraphy. The most widely used marker is thallium-201, despite the fact that it is not exclusively flow-dependent. Thallium-201 SPECT can be performed in patients at rest, during exercise followed by a redistribution study, under dipyridamole or nitrate infusion, or combined with spasm provocation test. When performed at rest, it is helpful to diagnose and, above all, quantify a myocardial infarction. Under nitrate infusion, it delineates the viable muscle remaining around the infarct. During exercise or under dipyridamole infusion, it is more effective than any other non-invasive method in detecting myocardial ischaemia (sensitivity 95%, specificity 90%). Following surgical revascularization, a normal exercise SPECT indicates a functional aorto-coronary bypass in 80% of the cases. It is a good method to detect post-angioplasty restenosis (sensitivity 82%, specificity 86%, negative predictive value 93%). Like all paraclinical examinations, SPECT has its limitations: left bundle branch block, reverse redistribution, non-ischaemic (i.e. dilated or hypertrophic) cardiopathies.
Subject(s)
Coronary Disease/diagnostic imaging , Tomography, Emission-Computed, Single-Photon , Tomography, Emission-Computed , Heart/diagnostic imaging , Humans , Myocardial Infarction/diagnosis , Myocardial Infarction/diagnostic imaging , Myocardial Infarction/surgery , Postoperative Complications/diagnostic imagingABSTRACT
A study of factors predicting mortality was performed in 201 patients with dilated cardiomyopathy (163 men, 38 women, mean age: 48 +/- 11 years) by multivariate analysis (Cox Model) of 51 clinical, electrocardiographic, echocardiographic and haemodynamic parameters, 56 patients died during follow-up (mean follow-up: 57.1 +/- 29.9 months). 5 year survival was 77 +/- 3%. The following parameters were independent predictors of mortality: first symptom: pulmonary oedema, peripheral oedema, syncope; duration of symptoms at the time of inclusion; end systolic left ventricular volume; end diastolic left ventricular diameter; pulmonary artery systolic pressure; and their combination had the most accurate predictive value for death. A quantitative score (s) was calculated and used to define three subgroups: A:s less than or equal to 4.5; B: 4.5 less than s less than 6; C:s greater than or equal to 6. Five-year survival was 90 +/- 5% in group A; 84 +/- 4% in B and only 53 +/- 7% in C. In conclusion, overall survival was good in this population of all stage dilated cardiomyopathy; factors related to clinical severity, left ventricular dilation, systolic pulmonary artery pressure and duration of symptoms defined a subgroup of patients with poor prognosis.
Subject(s)
Cardiomyopathy, Dilated/mortality , Cardiomyopathy, Dilated/genetics , Female , Humans , Male , Middle Aged , Prognosis , Proportional Hazards Models , Risk Factors , Survival Analysis , Survival RateABSTRACT
Eighteen patients with pure aortic stenosis without coronary artery disease underwent equilibrium radionuclide angiography to evaluate the adaptation of their left ventricular function to exercise. The left ventricular ejection fraction, peak left ventricular ejection, and fillings, and their timing were calculated from time-activity curves and their first derivatives at rest and at the maximum of exercise. There were no clinical complications. The ST segment and T wave changes of 14 patients were accentuated and 3 patients developed anginal pain. The ejection fraction was normal at rest and did not change significantly during exercise. The peak ejection did not vary but peak left ventricular filling was prolonged by exercise. There was a correlation between peak ventricular ejection at rest and the aortic valve surface area at catheterisation. This isotopic parameter was inversely correlated with LVEDP. There was a close correlation between age and peak ventricular filling on exercise. The variation between resting and exercise values of this parameter was inversely correlated with age. This study shows that exercise stress testing can be undertaken without risk in patients with aortic stenosis. The results of radionuclide angiography show that peak left ventricular ejection is a valuable parameter. The interpretation of the diastolic parameters is however more difficult because they are age-related.
Subject(s)
Aortic Valve Stenosis/physiopathology , Exercise , Heart Ventricles/physiopathology , Radionuclide Angiography , Adult , Aged , Aging/physiology , Aortic Valve Stenosis/diagnostic imaging , Female , Heart Ventricles/diagnostic imaging , Humans , Male , Middle Aged , Stroke Volume , Time FactorsABSTRACT
UNLABELLED: An analysis of factors predictive of mortality was undertaken in a group of 201 patients with dilated cardiomyopathy (163 men, 38 women; average age 46 +/- 11 years) using a multivariate analysis (Cox's model) of 51 clinical electrocardiographic, echocardiographic and haemodynamic parameters. The average follow-up period was 57.1 +/- 29.9 months. Fifty-six patients died and the probability of 5-year survival was 77 +/- 3 per cent. The best predictive factor of survival was determined by the combination of the following parameters: presenting symptom: pulmonary oedema, peripheral oedema, syncope; duration of symptoms before inclusion into the study; left ventricular end diastolic volume; left ventricular end diastolic dimension; systolic pulmonary artery pressure. A quantitative score "S" was calculated which enabled identification of 3 subgroups: A (S less than 4.5); B (4.5 less than S less than 6); C (S greater than 6). The probability of 5-year survival was 90 +/- 5 per cent in Group A, 84 +/- 4 per cent in Group B and 53 +/- 7 per cent in Group C. IN CONCLUSION: global survival was relatively long in this patient population with dilated cardiomyopathy at different stages of evolution; the combination of factors related to clinical severity, left ventricular dilatation, systolic pulmonary artery pressure and duration of symptoms allows identification of a subgroup of patients with a poor prognosis.
Subject(s)
Cardiomyopathy, Dilated/mortality , Adult , Cardiomyopathy, Dilated/epidemiology , Cardiomyopathy, Dilated/physiopathology , Causality , Cause of Death , Echocardiography , Electrocardiography , Female , Follow-Up Studies , Hemodynamics , Humans , Male , Middle Aged , Multicenter Studies as Topic , Multivariate Analysis , Prognosis , Retrospective Studies , Survival AnalysisABSTRACT
UNLABELLED: After a successful coronary angioplasty (less than 50 p. 100 residual stenosis and no complication), can restenosis be detected by a non-invasive method? We tested the value of stress thallium 201 myocardial scintigraphy by comparing this method with clinical angina and the conventional exercise-induced angina test. The study was prospective and involved 85 patients (74 men, 11 women; mean age 54.7 years, range 33-78 years). Sixty patients were suffering from angina, 13 had post-infarction angina and 12 had mild necrosis. Angioplasty had been performed on a single vessel (LAD in 57 cases, right in 18 cases and CX in 10 cases). After 6.4 +/- 1.8 months, all patients were re-evaluated under treatment, undergoing successively an exercise test, a stress and recovery myocardial scintigraphy and a coronary angiography. Restenosis was defined as a more than 50 p. 100 reduction of diameter on two orthogonal planes and was observed in 22 cases (26 p. 100). 19 patients were suffering from angina, 12 had restenosis, 10 were asymptomatic but had restenosis. Eighteen exercise tests were pathological; 10 corresponded to restenosis and 12 were normal in spite of restenosis. Myocardial scintigraphy was regarded as positive when, outside a necrotic territory, a lack of uptake at stress was reversible or became worse at redistribution. 27 tests were positive, 18 corresponded to restenosis, 4 were normal in spite of restenosis. The diagnostic values of the three methods were compared: (Table: see text). CONCLUSIONS: (1) stress myocardial scintigraphy has the best sensitivity and specificity; (2) if it is negative, restenosis is very unlikely; (3) coronary angiography may be performed only in case of symptoms and/or of positive stress scintigraphy.
Subject(s)
Angioplasty, Balloon, Coronary , Coronary Disease/diagnostic imaging , Tomography, Emission-Computed , Adult , Aged , Constriction, Pathologic/diagnostic imaging , Constriction, Pathologic/therapy , Coronary Disease/therapy , Exercise Test , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Prospective Studies , Recurrence , Thallium RadioisotopesABSTRACT
Two hundred thirty-one patients with a first acute myocardial infarction were randomly allocated within 5 h after the onset of symptoms either to treatment with anisoylated plasminogen streptokinase activator complex (APSAC), 30 U over 5 min, or to conventional heparin therapy, 5,000 IU in a bolus injection. Heparin was reintroduced in both groups 4 h after initial therapy at a dosage of 500 IU/kg per day. One hundred twelve patients received APSAC and 119 received heparin within a mean period of 188 +/- 62 min after the onset of symptoms. Both groups were similar in age, location of the acute myocardial infarction, Killip functional class and time of randomization. Elective coronary arteriography was performed on an average of 4 +/- 1.2 days after initial therapy. Follow-up radionuclide angiography and thallium-201 single photon emission computed tomography were performed before hospital discharge. Infarct size was estimated from single photon emission computed tomography and expressed as a percent of total myocardial volume. The patency rate of the infarct-related artery was 77% in the APSAC group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the APSAC group than in the heparin group. This was true for the entire study group (0.53 +/- 0.13 versus 0.47 +/- 0.12; p = 0.002) as well as for the subgroups of patients with anterior and inferior wall infarction (0.47 +/- 0.13 versus 0.40 +/- 0.11; p = 0.04 and 0.56 +/- 0.10 versus 0.51 +/- 0.11; p = 0.02, respectively). At 3 weeks, the difference remained significant for the anterior myocardial infarction subgroup. A significant 31% reduction in infarct size was found in the APSAC group (33% for the anterior infarction subgroup [p less than 0.05] and 16% for the inferior infarction subgroup [p = NS]). A close inverse relation was found between the values of left ventricular ejection fraction and infarct size (r = -0.73, p less than 0.01). By the end of a 3 week follow-up period, seven APSAC-treated patients and six heparin-treated patients had died. In conclusion, the early infusion of APSAC in acute myocardial infarction produced a high early patency rate, significant limitation of infarct size and significant preservation of left ventricular systolic function, mainly in anterior wall infarction.
Subject(s)
Myocardial Infarction/drug therapy , Plasminogen/therapeutic use , Streptokinase/therapeutic use , Acute Disease , Aged , Angiography , Anistreplase , Clinical Trials as Topic , Coronary Angiography , Coronary Artery Bypass , Heart/diagnostic imaging , Heart/physiopathology , Humans , Myocardial Infarction/pathology , Myocardial Infarction/physiopathology , Plasminogen/adverse effects , Streptokinase/adverse effects , Tomography, Emission-ComputedABSTRACT
In a series of 12 patients presenting with a single-vessel coronary artery disease and who were injected with 370 MBq of 99mTc-2-methoxyisobutylisonitrile at peak exercise, two consecutive single photon emission computed tomography (SPECT) data collections, i.e., 32 views of 30 sec during a 180 degrees rotation and 64 views of 15 sec during a 360 degrees rotation, were performed 1 hr later. In both cases, transverse sections were reconstructed using (a) a backprojection method with a ramp filter, (b) a correction for downscatter, (c) a correction for depth attenuation by the Chang method, or (d) both corrections. Each reconstructed myocardium was then divided into four short-axis sections which were radially divided into nine sectors. Sectors with an activity below 80% of the maximum were considered as abnormal. Sensitivity and specificity were calculated relative to a sector-by-sector theoretical anatomic distribution of the perfusion abnormalities. Results demonstrate that, of all situations, the best balance between sensitivity and specificity was achieved with the 180 degrees data collection and no correction at reconstruction. Using the 360 degrees data sampling technique mainly lowered the sensitivity in the patients with a circumflex or right coronary artery disease. It is concluded that there does not seem to be any definite advantage in performing a 360 degrees rather than a 180 degrees data collection in 99mTc myocardial SPECT.
Subject(s)
Coronary Disease/diagnostic imaging , Nitriles , Organometallic Compounds , Technetium , Tomography, Emission-Computed/methods , Adult , Aged , Humans , Male , Middle Aged , Rotation , Technetium Tc 99m SestamibiABSTRACT
In a multicenter randomized double-blind trial comparing heparin and a new fibrinolytic agent, anisoylated plasminogen streptokinase activator complex (APSAC), 231 patients presenting with a less than 5 hr acute myocardial infarction underwent a contrast angiography (CA) before the end of the first week of admission, and radionuclide cardiac blood-pool imaging and a 201Tl single photon emission computed tomography (SPECT) study before the end of the third week. Left ventricular ejection fraction (LVEF) and a wall motion score (WM) were calculated from CA. LVEF was also obtained from cardiac blood-pool imaging, and defect size (DS) from 201Tl SPECT. Results demonstrated that all parameters were significantly improved in patients treated with APSAC versus heparin (contrast LVEF 53 +/- 13 vs. 47 +/- 14 p less than 0.01, WM 9.8 +/- 6.5 vs. 13.3 +/- 7.9 p less than 0.001, radionuclide LVEF 43 +/- 12 vs. 40 +/- 13 p less than 0.05, DS 14 +/- 12 vs. 18 +/- 14 p less than 0.05). When the patients were divided according to infarct site and infarct-related coronary artery patency, it was demonstrated with all four parameters that the beneficial effect of APSAC can be largely explained by the lower incidence of vessel obstruction in this group (37% vs. 77% in the heparin group, p less than 0.001). It is concluded that (a) when compared with heparin and in the conditions of the trial, APSAC significantly improves the cardiac function and decreases the DS and (b) DS measured by 201Tl SPECT is as valuable a quantitative parameter of therapeutic evaluation as are LVEF and WM.
Subject(s)
Fibrinolytic Agents/therapeutic use , Heparin/therapeutic use , Myocardial Infarction/diagnostic imaging , Plasminogen/therapeutic use , Streptokinase/therapeutic use , Thallium Radioisotopes , Tomography, Emission-Computed , Anistreplase , Clinical Trials as Topic , Double-Blind Method , Humans , Myocardial Infarction/drug therapy , Random Allocation , Stroke VolumeABSTRACT
The left ventricular volumes, the left ventricular ejection fraction, the stroke volume index and the cardiac index were non-invasively determined in 47 patients suffering from moderate to severe pure aortic stenosis using radionuclide angiography at rest and at peak supine exercise. Each patient was previously submitted to right and left heart catheterization and to selective coronary angiography. The left ventricular ejection fraction decreased significantly during exercise (0.62 +/- 0.09 to 0.59 +/- 0.09, P less than 0.01). End-systolic volume, end-diastolic volume, stroke volume index and cardiac index increased significantly. The stroke volume variations were linked to the end-diastolic volume variations by a strong relationship (r = 0.84, P less than 0.001) and to left ventricular mass by a weak, but significant, inverse relationship (r = -0.42, P less than 0.05). No relation existed between stroke volume index variations and any other variables, particularly systolic gradient, aortic valve area and resting left ventricular ejection fraction. The results suggest that, in aortic stenosis, the adaptation of the left ventricular pump function during exercise is mostly dependent upon the diastolic properties of the left ventricular wall and is limited by the progression of left ventricular hypertrophy, i.e. diastolic stiffness. By contrast, the role of the basal systolic pump function and of the severity of the valvular obstruction seems of limited importance.
Subject(s)
Aortic Valve Stenosis/physiopathology , Heart/physiopathology , Adult , Aged , Aortic Valve Stenosis/diagnostic imaging , Exercise Test , Female , Heart/diagnostic imaging , Heart Ventricles , Hemodynamics , Humans , Male , Middle Aged , Radionuclide Angiography , Stroke VolumeABSTRACT
Myocardial thallium 201 tomography was performed in 112 patients admitted to hospital in the acute stage of a first myocardial infarction. Our quantification method for the myocardial lacuna, validated by animal studies, is described. The necrotic mass evaluated is compared with enzymatic (CPK) (r = 0.89) and angiographic (r = 0.78) quantitative assessments. Thallium 201 tomographic quantification has an unquestionable prognostic value. Thus, among patients whose infarcted mass represented more than 25% of the total myocardial mass, 71% died or developed severe heart failure. Conversely, 93% of patients with a small infarct (less than 20% of total myocardial mass) were asymptomatic on a 24-month follow-up. Myocardial thallium 201 tomography provides a reasonable quantification of the infarct. Its prognostic value seems to be satisfactory.
Subject(s)
Myocardial Infarction/diagnostic imaging , Thallium Radioisotopes , Tomography, Emission-Computed , Adult , Aged , Female , Humans , Male , Middle Aged , Myocardial Infarction/enzymology , Prognosis , Radiography , Time FactorsABSTRACT
Thirty patients with peripheral vascular disease (grade II) were studied by way of thallium-201 (Tl-201) muscular scan in order to assess a possible muscular effect of the Royat spa natural gas. Immediately after a 1.1 MBq/kg Tl-201 IV injection, a dynamic scintigraphic study was performed during 15 minutes in order to obtain a time-activity curve (characterized by Tmax) over the thighs, at rest. Then static anterior and posterior views were performed over thighs and calves during 4 minutes each. Perfusion ratios were calculated as thigh/knee and calf/ankle. The GE maxi 400 T gamma-camera was connected to an Informatek treatment system, zones of interest being chosen to obtain anterior and posterior thigh/knee, leg/ankle uptake ratios. Two studies were realized: the first one in basal conditions, the second one 7 days later, immediately after a s/c injection of natural gas. The later study was preceded by a static counting to subtract the residual muscular activity. After gas injection, one observed that Tmax was shorter, on the average, and that the difference between time-activity curves observed during the first study disappeared for patients with unilateral disease. A significant Tl-201 uptake increase was observed for the anterior image of the calf, while no difference was noted on posterior images, natural gas being injected on the front face of legs. This was particularly clear for patients with unilateral disease and receiving only unilateral gas injection.
Subject(s)
Arterial Occlusive Diseases/therapy , Gases/therapeutic use , Health Resorts , Leg/blood supply , Muscles/diagnostic imaging , Arterial Occlusive Diseases/diagnostic imaging , France , Humans , Male , Radioisotopes , Radionuclide Imaging , ThalliumABSTRACT
The authors report the case of a 35 year old man with no known previous cardiac disease. One month after a tic bite causing diffuse abdominal erythema, he was admitted to hospital with fever, breathlessness and bradycardia. The electrocardiogramme showed first degree atrioventricular block with a sinoatrial block (SA = 200 ms, AH = 240 ms). Echocardiography eliminated the diagnosis of pericardial effusion. Thallium 201 myocardial scintigraphy was pathological and showed irregular global uptake suggesting cardiomyopathy. Gallium 67 scintigraphy showed increased uptake in the left ventricle. The evolution was uncomplicated with normalisation of clinical, ECG and radiological changes. Cardiac catheterisation and angiography eliminated ischaemic and primary cardiomyopathy. Control radionuclide investigations were normal at one month: there was no persistent abnormal Gallium uptake. The diagnosis of Lyme's syndrome was confirmed by positive serology with successive titres of 1/1024 and 1/2048 (significant at titres over 1/256). This unusual case illustrates: the risk of myocardial disease in Lyme's syndrome; the diagnostic value of Gallium 67 scintigraphy in acute myocarditis: Gallium seems to fix specifically on inflamed tissues, so distinguishing myocarditis from primary cardiomyopathies.
Subject(s)
Gallium Radioisotopes , Lyme Disease/complications , Lyme Disease/diagnostic imaging , Myocarditis/diagnostic imaging , Acute Disease , Adult , Humans , Male , Myocarditis/etiology , Radionuclide ImagingABSTRACT
12 patients (group II) suffering from an arteriopathy of the lower limbs, stage II, were examined by thallium 201 muscular scanning. The aim of this study was to look for a possible muscular effect of Royat thermal gas injected subcutaneously. A preliminary study was conducted at rest, and consisted of recording the initial decay curve of thallium in the thighs and the study of the muscular fixation by different segments of the limbs, including the determination of the ratios of amounts fixed by the muscular and non-muscular zones. The results were compared with those obtained in 11 healthy subjects (group I) and no significant difference was noted between the two groups at rest. On the other hand, a considerable improvement of the fixation in the legs was observed after subcutaneous injection of thermal gas. The results are discussed in relation to the clinical and paraclinical data.