[Enhancement of the effect of captopril in the 1st 48 hours of treating refractory heart failure. A comparison with intravenous trinitrine]. / Amélioration de l'effet du captopril au cours des 48 premières heures de traitement de l'insuffisance cardiaque réfractaire. Comparaison avec la trinitrine intraveineuse.

The favourable haemodynamic effects of vasodilator drugs in refractory cardiac failure sometimes alter rapidly after the initial dose. This tachyphylactic phenomenon was looked for during captopril therapy in 14 patients with chronic cardiac failure resistant to digitalo-diuretic therapy and conventional vasodilator drugs. The average age of the patients was 64,4 +/- 3,8 years. Eleven patients had signs of congestive cardiac failure while the remaining three patients had only left ventricular failure. Four patients were classified as Stage III and the other ten Stage IV of the NYHA classification. Right heart catheter studies were performed with a Swan Ganz catheter and systemic pressures were measured by femoral artery catheterisation. Right and left pressures and cardiac output were measured under basal conditions, and 1 and 5 hours after a single dose of captopril (early and late periods). Captopril was given in between meals in 3 to 6 daily doses; in 10 of the 14 cases the dose was 50 mg 6 hourly. The haemodynamic parameters were recorded again during the early and late periods after the dose of captopril 24 and 48 hours after starting therapy. Captopril is a mixed vasodilator and is effective from the first hour of administration. It preferentially lowered pulmonary capillary pressure (PCP) from 29,6 +/- 0,92 mmHg to 21,4 +/- 1,04 mmHg (delta PCP: -27,7%, p less than 0,01). Mean systemic blood pressure (MBP) fell less from 92,4 +/- 3,51 mmHg to 76,6 +/- 3,4 mmHg (delta MBP: -17%, p less than 0,01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiovascular manifestations of systemic elastorrhexis (the Grönblad-Strandberg-Touraine syndrome)]. / Les manifestations cardiovasculaires de l'élastorrhexie systématisée (syndrome de Grönblad-Strandberg-Touraine).

Peripheral arterial involvement is common in pseudoxanthoma elasticum. It can be the first symptom. Small and medium size arteries are most often involved. The arterial lesions are diffuse, stenotic and often with marked calcium deposition. This arterial involvement can be developed early and if happening in young patients it is of great diagnostic significance. Peripheral vascular disease is most common in the limbs. Its evolution is remarkably slow. Coronary arterial disease can induce angina pectoris but seldom myocardial infarction. In cerebral arteries, lesions consist in stenoses and aneurysmal dilatation. They are responsible for thrombotic or hemorrhagic accidents. High blood pressure is frequent. It increases the hemorrhagic risk. Aortic lesions are exceptional, and if encountered one must discuss a Marfan disease association. Visceral hemorrhages, gastrointestinal or uterine, often the first symptom, are secondary to arteriolar lesions. Histologic studies reveal narrowed arterial lumen, due to medial thickening. Media is invaded by irregular and anarchic elastic fibers. Elastic laminae are fragmented and disorganized. The abnormal elastic tissue tends to be calcified. When compared to the arterial lesions, cardiac involvement is uncommon. It has been described in the first case of literature. It essentially consists in an endocardial thickening of the auricles and of the mitral and tricuspid valves.

[Study of coronary perfusion by radioisotopes]. / Etude de la perfusion coronarienne par les radio-isotopes.

The study of coronary blood flow by radio isotpopes may determine the casual relationship between coronary artery narrowing and myocardial ischemia. Total coronary flow is measured without cardiac catheterisation by double counter technique using 84 Rb and by radionuclide angiography using 42 K and 113m in fixed on siderophilin. This is an easier method, which is very reproductible and which may be sensitised by atrial pacing. The measurement of regional coronary flow gives a better estimation of the physiological effects of coronary artery disease. Two indicators are used; radioactive gases (113 Xe and more recently 81 m Kr) and microspheres tracers. Selective coronary injection of biodegradable microspheres labelled with 99m Tc and 113m In may be used to assess the hyperemic reaction in the coronary arteriolar territory to the triiodide contrast media used in coronary angiography, and to estimate the reserve coronary blood flow. The transmural perfusion may be studied in animal experiments with non-biodegradable microspheres. Tomographic techniques should allow quantification of myocardial perfusion in man.

[Induced coronary spasm: immediate revascularization by the opposite coronary artery. Use of myocardial scintigraphy]. / Spasme coronaire provoqué revascularisation immédiate par suppléance hétérocoronarienne. Apport de la scintigraphie myocardique.

The case reported analyses the instantaneous revascularisation distal to a coronary spasm by electrocardiography and thallium scintigraphy. The patient, a 48 year old man, had an 18 months history of spontaneous anginal chest pain sensitive to trinitrin. No electrocardiogrammes had been recorded during an attack. Coronary angiography was normal apart from a slight reduction in calibre of a dominant right coronary artery. Injection of 0.4 mg methylergometrine provoked an occlusive spasm of this artery after 4 minutes. At the same time the patient experienced angina and 4,5 mm depression of the ST segment, without ST changes in D3 and AVF, was observed. Opacification of the left coronary artery during spasme of the right showed retrograde revascularisation of the posterior interventricular artery which was reversed when the coronary spasm was terminated with trinitrin. Thallium scintigraphy was performed during another spasm provocation test four days later which gave identical clinical and electrical changes. A zone of hypofixation with blurred limits over the inferior myocardial wall was demonstrated. In the absence of ST elevation and of lacuna on myocardial scanning, the myocardial ischaemia induced by this occlusive spasm could not be considered to be total. Therefore the immediate revascularisation of the coronary artery in spasm seemed to have played the role of an effective collateral circulation.