Coronary-to-bronchial artery communication: report of two patients successfully treated by embolization.

We report two cases of coronary-to-bronchial artery communication responsible for coronary steal. In both cases the anastomosis originated from the proximal circumflex artery and developed because of bronchiectasis. In both cases closure of the anastomosis was achieved successfully by embolization. To date, the patients remained free from symptoms.

Comparative efficacy of the intravenous administration of linsidomine, a direct nitric oxide donor, and isosorbide dinitrate in severe unstable angina. A French multicentre study. French Group of Investigators.

AIMS: Although linsidomine shares common properties with nitrovasodilators, it releases nitric oxide directly without catalytic involvement by thiols. We conducted a prospective, randomized, multicentre, parallel group, single-blind study to compare the efficacy of intravenous administration of linsidomine with that of isosorbide dinitrate in unstable angina. METHODS AND RESULTS: Between November 1990 and July 1992, 568 patients with suspected unstable angina (class IIIB of the Braunwald classification) received a continuous infusion of either linsidomine (1 mg.h-1 on average) or isosorbide dinitrate (2.5 mg.h-1 on average) for 72 h. All patients received concomitant aspirin and intravenous heparin, 81% beta-blockers and 38% calcium antagonists. Holter monitoring was performed in all patients and analysed blindly. Only 25% of the patients had at least one episode of chest pain during the study (24.6% vs 25.8% in the linsidomine and isosorbide dinitrate groups, P = 0.74), of which 12% were associated with ECG changes. Holter criteria yielded similar results in both groups: 33% of patients presented episodes of myocardial ischaemia (32.6% vs 33.9% in the linsidomine and isosorbide dinitrate groups, P = 0.74), while 45% showed episodes of ventricular arrhythmia (43.5% vs 46.5% in the linsidomine and isosorbide dinitrate groups, P = 0.48). The incidence of serious clinical events at 72 h (death, myocardial infarction or myocardial revascularization) was 6.5% (5% vs 8% in the linsidomine and isosorbide dinitrate groups, P = 0.17). CONCLUSION: Intravenous linsidomine is at least as efficacious as isosorbide dinitrate in the stabilization of patients with severe unstable angina.

Familial incidence of late ventricular potentials and electrocardiographic abnormalities in arrhythmogenic right ventricular dysplasia.

Familial forms of arrhythmogenic right ventricular dysplasia (ARVD) have been described. Signal-averaged electrocardiograms (SAECGs) and standard electrocardiograms have been used to detect ARVD. The purpose of this prospective study, for a given family member, was to evaluate the risk of having ARVD or only belonging to an affected family. To address these issues, we assessed the incidence of late ventricular potentials and electrocardiographic (ECG) abnormalities in the families of our patients with ARVD. SAECGs and electrocardiograms were recorded in 101 eligible family members and compared with those recorded in ARVD patients with sustained ventricular tachycardia (13 patients in 12 families), and in 37 control subjects with a normal electrocardiogram. The incidence of late ventricular potentials was significantly higher in family members than in control subjects (16% vs 3%, p <0.05). The incidence of ECG abnormalities was 34% in family members. When the incidence of late ventricular potentials and/or ECG abnormalities were added up, results were 38% abnormal findings in family members. Late ventricular potentials and/or ECG abnormalities were found in members of all 7 families; these abnormalities were initially thought to be sporadic forms, and thereafter were classified as familial forms. Thus, SAECGs and standard ECG recordings in ARVD family members showed 38% abnormal findings, and that all cases of ARVD could be classified as familial forms. The incidence of familial forms of ARVD was greater than was previously believed, which is highly suggestive of a genetic transmission of the disease in our geographic area.

Long-term (10 years) prognostic value of a normal thallium-201 myocardial exercise scintigraphy in patients with coronary artery disease documented by angiography.

In order to assess the prognostic significance of normal exercise thallium-210 myocardial scintigraphy in patients with documented coronary artery disease, we studied the incidence of cardiac death and non-fatal myocardial infarction in 69 symptomatic patients without prior Q wave myocardial infarction, who demonstrated one or more significant coronary lesions (stenosis > or = 70%) on an angiogram performed within 3 months of scintigraphy (Group 1). These patients were compared to a second group of 136 patients with an abnormal exercise scintigram, defined by the presence of reversible defect(s) and angiographically proven coronary artery disease (Group 2), and to a third group of 102 patients with normal exercise scintigraphy without significant coronary lesions (stenosis < or = 30%) or with normal coronary angiography (Group 3). In contrast to coronary lesions observed in Group 2, patients in Group 1 presented more frequently with single-vessel disease (83% vs 35%, P < 0.0001) and with more distal lesions (55% vs 23%, P < 0.0001). Over a mean follow-up period of 8.6 years, one fatal and eight non-fatal cases of myocardial infarction were observed in Group 1. The majority of patients in Group 1 were treated medically: only 24 (35%) underwent myocardial revascularization, usually by coronary angioplasty. There was no significant difference in the incidence of combined major cardiac events (cardiac death, non-fatal myocardial infarction) in patients with normal exercise scintigraphy, with or without documented coronary artery disease (Groups 1 and 3), while the incidence was higher in Group 2. However, while the mortality remained very low in Group 1, the incidence of non-fatal myocardial infarction was not different from that of Group 2, where most patients underwent revascularization procedures. In conclusion, patients with coronary artery disease and a normal exercise thallium-201 myocardial scintigram usually have mild coronary lesions (single-vessel disease, distal location) and good long-term prognosis, with a low incidence of cardiac death.

[Linsidomine, direct donor of EDRF/NO: a new treatment for unstable angina]. / Linsidomine, donneur direct d'EDRF/NO: un nouveau traitement de l'angor instable.

Linsidomine 10 mg, administered intravenously, has become available for the treatment of unstable angina since the beginning of 1996. It reinforces a range which consists of oral molsidomine, 2 and 4 mg, and the 1 mg intracoronary linsidomine dosage, thereby providing a more complete management of symptomatic coronary patients. Linsidomine is a direct donor of EDRF/NO which has an action on blood vessels (reduction of preload and dilatation of the large epicardial coronary vessels) and on platelets (inhibition of aggregation) without risk of tolerance. Linsidomine was compared with parenteral isosorbide dinitrate in a large scale French trial in patients with severe unstable angina (Braunwald's Class IIIb). The results showed linsidomine to be an effective treatment of unstable angina, controlling 75% of patients with a low incidence of severe clinical events (death, myocardial infarction, emergency myocardial revascularisation). In addition, intravenous linsidomine was well tolerated clinically, especially in terms of symptomatic hypotension.

Hemodynamics, tolerability, and pharmacokinetics of linsidomine (SIN-1) infusion during the acute phase of uncomplicated myocardial infarction.

To determine a dose regimen and evaluate the hemodynamic effects of linsidomine administered by continuous intravenous (i.v.) infusion, 10 patients were studied during the acute phase of uncomplicated myocardial infarction (MI). Systolic, diastolic, and mean (SBP, DBP, MBP) systemic blood pressure and heart rate (HR) were measured noninvasively. Pulmonary artery pressures were monitored after insertion of a Swan-Ganz catheter, which also enabled measurement of cardiac output (CO) and cardiac index (CI) by thermodilution. After baseline hemodynamic values (period A) were determined, linsidomine (SIN-1) was infused at a rate of 0.8 mg/h and subsequently adjusted to obtain a 10% decrease in MBP from its baseline value (period B). The infusion was then continued for 3 h at a constant rate (period C), and pressures were monitored for 1 h after the infusion was discontinued (period D). There were no significant changes in systemic or pulmonary arterial pressures or in HR between period B and period C. In contrast, CI decreased moderately (p < 0.05), with no clinical consequences. Return to baseline hemodynamics was obtained at the end of period D. Our findings indicate that continuous i.v. administration of SIN-1 (at a mean flow rate of 1 mg/h) is well tolerated and appears to be suitable for use in acute coronary syndromes.

[EDRF/NO and endothelial functions]. / EDRF/NO et fonctions endothéliales.

Our appreciation of the vascular endothelium has changed considerably over the last decade. This organ, finally recognized as such, participates actively in vasomotor regulation and haemostasis. It secretes several relaxing and contracting factors which act locally to determine resting vascular tone. One of the relaxing factors, EDRF/NO plays an important physiological role as it contributes to the rapid adaptation of blood flow to various pharmacological and mechanical stimuli, thereby ensuring maintenance of adequate tissue perfusion. Nitric oxide (NO) is an ubiquitous factor which was crowned "molecule of the year 1992" by the scientific review Science. Its effects extend well beyond those on the cardiovascular system. Endothelial dysfunction is observed in many pathological states such as atherosclerosis, reperfusion injury, postangioplasty endothelial regeneration, degeneration of venous bypass grafts, pure spastic angina, hypertension and diabetes. It is associated with decreased production of EDRF/NO, which probably contributes significantly to the aggravation of endothelial and parietal lesions and to the natural progression of atherosclerotic disease in general. This article describes the principal vasoactive factors secreted by the endothelium and goes on to list the physiologic cardiovascular effects of EDRF/NO in detail, and to review the different pathologies associated with a disorder of secretion of this factor.

Early exercise testing after acute myocardial infarction in the elderly: clinical evaluation and prognostic significance.

Early exercise testing (EET) after acute myocardial infarction (MI) is a well-established means of detecting patients at high risk for subsequent cardiac events. However, the value of this test is not well documented in elderly patients. We evaluated the clinical and prognostic significance of EET in 188 patients, aged 70 years or more, 14 +/- 3 days after an uncomplicated acute MI. The mean follow-up period was 3.6 years (range 1 to 6 years) in 95% of the patients. The total mortality rate was 13.5% (24/178) and the cardiac-related mortality rate was 7.8% (14/178), with 64% of the deaths occurring in the first 3 years. There were no complications during EET. The following parameters measured during EET on a bicycle ergometer were predictive of subsequent cardiac death: an increase in systolic blood pressure of less than 30 mm Hg (p < 0.001), an increase in the double product of less than 12,500 mm Hg.beats/min (p < 0.001), a maximal load less than 60 W (p < 0.001), and a total duration of exercise less than 5 minutes (p < 0.001). The combination of these four parameters increased the predictive value of the test (p < 0.0001). ST segment depression and ventricular arrhythmias during exercise were not correlated with the incidence of subsequent cardiac death, but the degree of ST segment depression was directly and significantly (p < 0.0001) associated with the incidence of subsequent nonlethal cardiac events (coronary bypass surgery, coronary angioplasty, reinfarction, or unstable angina).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of planar imaging and single-photon emission computed tomography for the detection and localization of coronary artery disease.

Although single photon emission computed tomography (SPECT) has become widely utilized, the superiority of this technique compared to planar conventional imaging remains controversial. In order to compare these two techniques, we retrospectively analysed the results obtained in 70 patients who performed a thallium-201 exercise scintigraphy with a double acquisition during the same test, and who also underwent coronary and ventricular angiography. Overall, SPECT imaging yielded a higher sensitivity (93% vs 82% for SPECT and planar imaging respectively, p < 0.05), especially in the inferior and anterior regions. SPECT was also more sensitive for the detection of a single-vessel disease (90% vs 74% for SPECT and planar imaging respectively, p < 0.01). The specificity was assessed for both techniques with the help of circumferential computerized analysis, avoiding known causes of false positive scintigrams. We found a high specificity for both SPECT and planar imaging, without any significant difference between the two methods (87% vs 91% for the overall specificity of SPECT and planar imaging respectively, p = NS). Therefore, SPECT imaging analysed with discrimination shows an enhanced reliability over planar imaging for the detection and the localization of coronary artery disease, without increasing the risk of false positive tests.

Blood conservation techniques for cardiac surgery: a survey of French centres.

A survey resulting from a partnership between CECEC (Centre d'Etudes en Circulation Extra-Corporelle) and Laboratoires Hoechst, France was carried out amongst all French adult cardiac surgery centres. The aim of this study was to investigate the various strategies used to decrease blood loss during open-heart surgery. Due to an exceptionally high response rate, we are able to report the current practice of French cardiac centres which account for 75% of open-heart adult surgery. The three most interesting strategies for blood conservation appear to be haemodilution, blood salvage from the extracorporeal circuit and previously deposited autologous blood transfusion, yet the three methods which are predominantly used are haemodilution (92.7%), aprotinin therapy (87.8%) and blood salvage from the extracorporeal circuit (82.9%).

Limits of thallium-201 exercise scintigraphy to detect coronary disease in patients with complete and permanent bundle branch block: a review of 134 cases.

We reviewed the records of 68 patients with right bundle branch block (RBBB) and 66 patients with left bundle branch block (LBBB), who had undergone thallium-201 exercise scintigraphy and coronary arteriography, to determine the sensitivity, specificity, and positive and negative predictive values of thallium-201 imaging for the detection of coronary artery disease in the presence of intraventricular conduction abnormalities. In patients with RBBB the sensitivity, specificity, and positive and negative predictive values were, respectively, 83%, 89%, 79%, and 92% for the anteroseptal region and 83%, 84%, 83%, and 84% for the inferoposterior region. In patients with LBBB these values were, respectively, 94%, 33%, 36%, and 93% for the anteroseptal region and 77%, 90%, 81%, and 88% for the inferoposterior region. In this second group defects limited to the septal region were a good predictor of false positive scintigrams (9/10 cases), but if apical defects used as the sole criterion for detecting lesions in the left anterior descending artery improved the specificity to 85%, the sensitivity was greatly reduced (35%). We conclude that exercise scintigraphy is a reliable method for detection of coronary lesions in patients with RBBB and in patients with LBBB and inferoposterior perfusion defects, but it is unable to discriminate between normal subjects and patients with coronary disease in the presence of LBBB and anteroseptal perfusion defects. In addition, limited septal defects are highly suggestive of false positive scintigrams in this latter group of patients.

Effects of oral isradipine on left ventricular function at rest and during exercise in patients with stable chronic angina: a double-blind, placebo-controlled crossover study.

We evaluated the effects of a single oral dose of 5 mg of isradipine compared to placebo in a randomized, double-blind, crossover study using gated radionuclide angiography at rest and during exercise in 20 patients with stable chronic angina. Isradipine improved both anginal symptomatology and ST-segment depression during exercise, with a concomitant favorable effect on the isotopic parameters exploring systolic and diastolic left ventricular function. There was a marked increase of the ejection fraction during exercise with isradipine compared to placebo (61 +/- 14% vs. 55 +/- 15%, respectively, p less than 0.001) as well as a significant improvement in the peak ejection rate and the peak filling rate at rest [2.56 +/- 0.62 vs. 2.16 +/- 0.54 end diastolic volume (EDV) per second and 2.14 +/- 0.59 vs. 1.87 +/- 0.37 EDV/s, respectively] and during exercise (3.49 +/- 0.97 vs. 3.10 +/- 1.07 EDV/s and 4.05 +/- 1.34 vs. 3.65 +/- 1.25 EDV/s, respectively). We conclude that isradipine has a beneficial effect on the clinical and electrocardiographic signs of exercise-induced ischemia, leading to a significant improvement of the systolic and diastolic parameters of left ventricular function. Therefore, isradipine is potentially a useful treatment for patients with exertional angina and hypertension, alone or associated with beta blocker medication.

[Effect of high-dose verapamil on systolic and diastolic cardiac function of non-cardiological patients and review of the literature]. / Effet du vérapamil oral à forte dose sur la fonction cardiaque systolique et diastolique de patients non cardiologiques et revue de la littérature.

We studied the effects of high doses of oral verapamil (480 mg daily) in a group of 28 patients undergoing intravenous drug therapy for terminal digestive tumor. One additional patient was prematurely withdrawn from the study due to the occurrence of second degree atrioventricular block, which regressed after the interruption of verapamil. Gated radionuclide angiocardiography was performed before and after treatment (mean duration 2 days). Verapamil induced a significant reduction of blood pressure and heart rate (132 +/- 19 mm Hg vs 124 +/- 18 mm Hg, p = 0.005 for systolic blood pressure, 80 +/- 13 mm Hg vs 76 +/- 9 mm Hg, p = 0.04 for diastolic blood pressure and 81 +/- 17 bpm vs 77 +/- 13 bpm, p = 0.02 for heart rate). Left ventricular ejection fraction and peak filling rate were not impaired (65 +/- 7% vs 64 +/- 7%, p = NS and 2.52 +/- 0.65 EDV/s vs 2.42 +/- 0.51 EDV/s, p = NS), while peak ejection rate decreased slightly (2.96 +/- 0.72 EDV/s vs 2.72 +/- 0.50 EDV/s, p = 0.01). Conversely, there was significant alteration of right ventricular systolic indexes (50 +/- 7% vs 46 +/- 7%, p = 0.01 for the ejection fraction and 2.06 +/- 0.53 EDV/s vs 1.88 +/- 0.44 EDV/s, p = 0.008 for the peak ejection rate), without change in the peak filling rate (1.54 +/- 0.46 EDV/s vs 1.46 +/- 0.46 EDV/s, p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

[Determination of transmitral blood flow by pulsed echodoppler. Correlation with aortic blood flow in 30 patients]. / Détermination du débit transmitral par écho-doppler pulsé, corrélation avec le débit aortique chez 30 patients.

The aim of this study was to assess the validity of mitral valve blood flow measured by pulsed Doppler echocardiography (PDE) with the sample volume positioned at the tips of the mitral leaflets. Thirty patients with a mean age of 38.4 years underwent calculation of transmitral blood flow: by Touche's method (A) in which the mitral orifice is assumed to be an ellipse with a constant long axis equal to the diameter of the mitral annulus and a variable short axis equal to the distance between the mitral leaflets measured on the M mode recording. The velocities are recorded by PDE with the sample volume at the tips of the mitral leaflets. The instantaneous cardiac output is equal to the surface multiplied by the instantaneous velocity. The integration of the instantaneous outputs throughout the whole of diastole by a computer programme provides the stroke volume; by a simplification of this method (B) which considers the short axis of the mitral ellipse to be constant and equal to the mean mitral valve leaflet separation measured from the M mode recording, and; by Hoit's method (C) which calculates mitral valve surface area from the M mode recording alone. The transmitral blood flow was calculated by these three methods and compared to the classical PDE aortic cardiac output measurement during the same examination, the accuracy of which has been previously demonstrated.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of left ventricular diastolic function at rest and during exercise by gated radionuclide angiocardiography in coronary artery disease patients.

The peak filling rate (PFR) is an index of the diastolic function and has been proposed as an excellent parameter for the evaluation and early detection of left ventricular (LV) dysfunction. This study contributes to the assessment of LV diastolic function at rest and during submaximal exercise in 19 normal subjects and in 42 patients with coronary artery disease (CAD). The PFR was compared to the ejection fraction (EF) and the peak ejection rate (PER)--both indexes of systolic LV function--after acquiring a high-resolution time-activity curve (time/frame between 10 and 30 msec) with gated radionuclide angiocardiography. In 23 patients with normal EF at rest (greater than or equal to 50%), PFR and PER were abnormally low in 87% and 43% of the cases respectively. During submaximal exercise in 13 CAD patients, EF, PFR and PER varied very little from baseline values but were significantly reduced compared to the values of normal subjects. The PFR proved to be a very sensitive indicator of LV dysfunction in coronary patients but was not capable of discriminating between one-, two- or three-vessel disease. Our results tend to show the PFR to be a good indicator of LV dysfunction at rest and during exercise and its usefulness for the assessment of LV function is becoming more and more evident in clinical practice.

Determination of left ventricular inflow by pulsed Doppler echocardiography: influence of mitral orifice area and blood velocity measurements.

Pulsed Doppler echocardiography was performed in 30 patients to assess the influence of mitral orifice area and velocity on the determination of mitral stroke volume and inflow. Aortic forward stroke volume and outflow were measured at the centre of the aortic annulus, and compared with mitral flow measurements calculated by three methods. Both mitral stroke volume and inflow derived from an instantaneous velocity-area method showed an excellent correlation with aortic flow measurements. The other two methods, which determined mitral stroke volume and inflow based on a mean mitral valve area and diastolic velocity integral, significantly underestimated mitral flow measurements. This study indicates that the instantaneous velocity-area method offers a reliable means for quantitating left ventricular inflow.

[Study of left ventricular filling by gamma-angiography and echocardiography]. / Exploration du remplissage ventriculaire gauche par la gamma-angiographie et l'échocardiographie.

In order to establish which indices of early diastolic function obtained by Doppler echocardiography and the time/activity curve of 99mTc radionuclide angiography are the most useful clinically, the two investigations were performed in 41 subjects aged 52 +/- 15 years. The maximum velocity of LV filling and mitral E wave provided the best correlation (r = 0.48); the Doppler A wave did not correlate with its scintigraphic homologue. The correlations with the morphological data (mass, thickness/radius ratio) were better with radionuclide angiography. Variance analysis of E and maximum velocity of filling showed that gamma angiography was significantly more accurate (FE LVF greater than 10 p = 10 - 4); on the other hand, the A wave best illustrated the transfer of filling to late diastole. In conclusion, left ventricular filling may be assessed clinically by Doppler echocardiography; the greater accuracy of the radionuclide measurements with respect to left ventricular volumes makes this a more appropriate method when quantitative information is required.

[Exploration of left ventricular relaxation using gamma-angiography in 70 hypertensive subjects. Practical consequences and implications]. / Exploration de la relaxation ventriculaire gauche par gamma-angiographie chez soixante-dix hypertendus. Implications et conséquences pratiques.

This study was performed to evaluate the incidence ant the practical consequences of left ventricular diastolic dysfunction in hypertensive. In 70 mild to moderate hypertensive subjects group [systolic 161 +/- 16 and diastolic blood pressure 104 +/- 9 mmHg 18 women, 52 men, 51 +/- 7 years old] and in a 15 normal subjects control group, the peak filling rate (PFR) and the time to peak filling rate (TPFR) were measured with the time/activity curve of the rest equilibrium blood pool scintigraphy. The ejection fraction and the stress test were normal in all patients [EF 0.66 +/- 0.05, ranging from 0.59 to 0.88]. The PFR was not significantly different in the hypertensive group but 59/70 patients [84 p. 100] showed an individual value lower than the theoretical age and heart rate expected value. The TPFR was not significantly different (183 +/- 33 ms-vs 180, p = ns). In a Holter-defined sub-group of patients (n = 22) exhibiting a high prevalence of supra-ventricular premature beats or a paroxysmal atrial fibrillation, the PFR was significantly slower than in the total hypertensive group [1.92 +/- 0.33 EDV/s-1, p = 0.02]. Early indices of diastolic function give some instantaneous information on left ventricular filling. Determining the exact significance of individual values of PFR and TPFR requires a better knowledge of physiologic and pathologic determinants of LV filling.