Stent placement compared with balloon angioplasty for small coronary arteries: in-hospital and 6-month clinical and angiographic results.

BACKGROUND: Stenting has been demonstrated to be superior to balloon angioplasty in de novo focal lesions located in large native vessels. However, in small vessels, the benefit of stenting remains questionable. METHODS AND RESULTS: A total of 381 symptomatic patients with de novo focal lesion located on a small coronary segment vessel (<3 mm) were randomly assigned to either stent implantation (192 patients; 197 lesions) or standard balloon angioplasty (189 patients; 198 lesions). The primary end point was the angiographic restenosis rate at 6 months, as determined by quantitative coronary angiography. On intention-to-treat analysis, angiographic success rate and major adverse cardiac events were comparable: 97.9% and 4.6% versus 93.9% and 5.8% in the stent group and the balloon group, respectively. After the procedure, a larger acute gain was achieved with stent placement (1.35+/-0.45 versus 0.94+/-0.47 mm, P=0.0001), resulting in a larger minimal lumen diameter (2.06+/-0.42 versus 1.70+/-0.46 mm, P=0.0001). At follow-up (obtained in 91% of patients), angiographic restenosis rate was 21% in the stent group versus 47% in the balloon group (P=0.0001), a risk reduction of 55%. Repeat target lesion revascularization was less frequent in the stent group (13% versus 25%, P=0.0006). CONCLUSIONS: Elective stent placement in small coronary arteries with focal de novo lesions is safe and associated with a marked reduction in restenosis rate and subsequent target lesion revascularization rate at 6 months.

Zein of maize grain: I--Isolation by gel filtration and characterization of monomeric and dimeric species.

Unreduced zein chromatographed on Sephadex G 200 in 8 M urea, on G 100 in 1.5 or 2.5% sodium dodecyl sulfate (SDS) and on hydroxypropylated G 100 in 70% ethanol was resolved into two minor fractions A and B and two major ones D and M irrespective of the medium. The quantitative importance of the fraction M was dependent on the isolation conditions of zein. It decreased from 53% of the proteins contained in ethanolic extract and chromatographed as they were extracted, to 40% of the purified zein. The molecular weight values obtained from SDS-polyacrylamide gel electrophoresis and amino acid compositional data indicated that fractions D and M, as isolated from purified zein in the presence of ethanol, represented respectively dimeric and monomeric forms of a mixture of Mr 22 000 and 24 000 polypeptides with threonine or phenylalanine as NH2-terminal residue. Electrophoretic analysis of selectively carbamylated fraction M on starch gel at pH 3.5 revealed that zein subunits comprised several polypeptides differing in the number and the nature of basic amino acids. At least one of these polypeptides contained one lysyl residue.

Zein of maize grain: II--The charge heterogeneity of free subunits.

The subunits present as monomers in unreduced zein and isolated as fraction M by gel filtration, were chromatographed on sulfoethyl-cellulose. Three major subfractions were detected and characterized. Each of them, submitted to electrophoresis at pH 3.5, migrated as a single band corresponding to each of the three major electrophoretic forms seen in fraction M at the same pH. The presence of lysine in some polypeptides, suggested by amino acid composition data, was confirmed by electrophoretic analysis of carbamylated subfractions at pH 3.5. At pH 8.9 each subfractions was further resolved into three cationic bands in starch gel and three (or more) anionic bands in polyacrylamide gel. The same fractionation was also obtained by submitting the major electroforms of fraction M, as isolated at pH 3.5, to isoelectric focusing. Based on these observations, the most probable distributions of basic amino acids in subunits detected by electrophoresis at pH 8.9 were specified and compared to those recently published for several zein clones. The presence per polypeptide chain of three carboxyl groups and occasionally of one lysine would be a feature of zein originating from maize hybrid Inra 260.

Placement of coronary stents in bifurcation lesions by the "culotte" technique.

Coronary angioplasty of bifurcation lesions remains a technical challenge. Balloon angioplasty induces recoil and the "snow-plow" effect with a risk of side branch occlusion. The late result is associated with a high rate of reintervention. Randomized studies in nonbifurcated lesions have demonstrated better short- and midterm results after stent placement. We propose the "culotte" technique as a new technique to place intracoronary stents in bifurcation lesions: implantation of 2 similar stents in 2 steps in the main branch and in the side branch with overlapping of the 2 stents in the main branch before bifurcation. We performed this technique in 50 patients (in the left anterior diagonal branch in 33, in the left circumflex obtuse marginal branch in 12, in the right coronary artery in 4, and in the left main coronary artery in 1). The clinical success rate was 94% with 3 non-Q-wave myocardial infarctions. Late results indicated a 24% target lesion revascularization rate, which improved when a true kissing balloon inflation was used to achieve final deployment of both stents. This culotte technique is highly feasible and provides excellent short-term results. Assessment of its midterm benefit requires further study.

Relations between Doppler tracings of pulmonary regurgitation and invasive hemodynamics in acute right ventricular infarction complicating inferior wall left ventricular infarction.

To test the hypothesis that flow characteristics from pulmonary regurgitation (PR) can predict right ventricular (RV) involvement in patients with inferior wall acute myocardial infarction, we prospectively recorded continuous-wave Doppler tracings and right-sided cardiac hemodynamics in 48 consecutive patients with inferior wall acute myocardial infarction and PR. Right heart hemodynamics enabled the identification of 29 patients with (group 1) and 19 without (group 2) RV involvement. In patients with RV involvement, the pulmonary regurgitant flow pattern was characterized by a rapid rise in flow velocity to a peak level followed by an abrupt deceleration in mid-diastole, whereas in patients without RV involvement, the deceleration in mid-diastole was gradual. The pressure half-time of PR (PHTPR) and the lowest mid-diastolic to peak early diastolic velocity ratio were significantly lower in group 1 than in group 2 (91 +/- 31 vs 214 +/- 57 ms [p < 0.001], 0.35 +/- 0.08 vs 0.59 +/- 0.13 [p < 0.001], respectively). The best diagnostic accuracy (95%) was obtained with cut-off values of PHTPR < or = 150 ms and the lowest mid-diastolic to peak early diastolic velocity ratio < or = 0.5: sensitivity 100%, specificity 89%, positive predictive value 94%, and negative predictive value 100%. Using multiple logistic regression analysis, we found that PHTPR was the strongest predictor of RV involvement. Thus, these parameters, derived from pulmonary regurgitant tracings, are useful in the noninvasive bedside diagnosis of RV infarction.

Hemodynamic criteria for diagnosis of right ventricular ischemia associated with inferior wall left ventricular acute myocardial infarction.

To test the diagnostic value of different hemodynamic indexes for the diagnosis of acute right ventricular (RV) ischemic dysfunction, we studied 2 groups of consecutive patients admitted for an acute left ventricular inferior wall myocardial infarction: 51 patients with (group 1) and 32 patients without (group 2) RV ischemia as determined by coronary angiography. In both groups, we analyzed by right-sided cardiac catheterization right-sided heart pressures, pulmonary capillary wedge pressure, and cardiac index. We also calculated pressure ratios (mean right atrial pressure or RV end-diastolic over pulmonary capillary wedge pressures), pulmonary vascular resistance, and RV stroke work index. We found significant differences (p < 0.01) between the 2 groups when comparing mean right atrial pressure, RV end-diastolic pressure, ratio of these 2 pressures over pulmonary capillary wedge pressure, RV stroke work index, and right atrial and RV pressure waveforms. The best combined sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were found for the right atrial M or W waveform pattern, isolated or combined with a disproportionate elevation of RV end-diastolic over pulmonary capillary wedge pressures (respectively, 92%, 94%, 90%, 87%, and 89%). Volume loading was performed in 27 patients (18 with and 9 without RV ischemia). Right heart pressures and RV stroke work index increased significantly and similarly in both groups. Cardiac index increased significantly only in patients without RV ischemia (p = 0.02). However, volume loading did not significantly modify the diagnostic value of the different hemodynamic criteria studied.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of novel di- and tricarboxylic acids in fine tropical aerosols.

Three unknown di- and tricarboxylic acids were characterized in the fine size fraction of aerosols which were collected during the wet season in the Amazon basin (Rondonia, Brazil). For the structural characterization of the methyl esters of these unknown compounds, mass spectrometry with electron ionization (EI) and tandem mass spectral techniques combined with gas chromatographic (GC) separation were employed. Fragment and parent ion spectra were recorded during elution of the GC peaks by linked scanning of the B and E sectors in combination with high-energy collision-induced dissociation. The fragmentation patterns of significant ions in the first-order EI spectra were also obtained for nonanedioic acid, which was examined as a model compound. The compounds were tentatively identified as 4-acetyloxyheptanedioic acid and cis and trans isomers of 5-hexene-1,1,6-tricarboxylic acid. Since there were indications of biomass burning during the aerosol sampling the di- and tricarboxylic acids characterized in the present work could be markers for biomass burning. Furthermore, the characterization of di- and tricarboxylic acids in the fine size fraction of atmospheric aerosols may be important for assessing the effects of organic aerosols in cloud formation.

Severe falciparum malaria in children: a comparative study of 1990 and 2000 WHO criteria for clinical presentation, prognosis and intensive care in Dakar, Senegal.

The relevance of WHO criteria for severe and complicated malaria has been debated for a while, especially as regards children. Recent data led WHO experts to modify the definition of severe malaria. The objective of this study was to evaluate retrospectively the significance of the new definition on severity, lethality and intensive care distribution in children admitted with falciparum malaria (in 1997-99) to Hôpital Principal de Dakar, Senegal. We used the paediatric risk of mortality score (PRISM) to compare the 2 definitions, WHO 2000 and WHO 1990. Finally, we evaluated the impact of the new definition in terms of major therapeutic interventions (MTIs): mechanical ventilation, haemodynamic support, transfusion, haemodialysis, and the use of sedatives. Among 311 patients, the frequencies of severe malaria cases and case-fatality rates thereof were 52% (n = 161) and 17% (n = 28) respectively using the 1990 WHO criteria, and 75% (n = 233) and 12% (n = 28) using the 2000 WHO criteria. Mean PRISM score among severe cases decreased with the new definition (6.5 versus 8.6). Both definitions predicted neurological sequelae and deaths with 100% sensitivity. One or more MTIs were required in severe malaria cases in 86% (n = 139) under the 1990 criteria and 73% (n = 170) under the 2000 criteria. In this area of low and seasonal transmission, the 2000 WHO definition of severe malaria proved broader and less specific, but was easier to apply and retained the high sensitivity of the earlier definition in identifying life-threatening infections.

Is dobutamine stress echocardiography useful for noninvasive differentiation of ischemic from idiopathic dilated cardiomyopathy?

Dobutamine stress echocardiography was performed in 56 consecutive patients, mean age: sixty-two +/- twelve years. Twenty-two patients had an idiopathic dilated cardiomyopathy (group 1) and 34 had angiographically proven ischemic dilated cardiomyopathy (group 2). Wall motion score index and left ventricular ejection fraction were determined at baseline, 5 micrograms/kg/min, peak, and ten minutes after stepwise dobutamine infusion. Worsening or no change in global wall motion score was observed in 9 group 2 patients (26%) and 1 group 1 patient (5%, P = .07). No significant difference was observed with regard to wall motion score index decrease between baseline and peak dose. Left ventricular ejection fraction increase during dobutamine infusion was comparable in both groups. Thus, an ischemic response was observed more often in the coronary artery disease group, yielding a good specificity and positive predictive value although sensitivity was low. However, left ventricular function improvement did not help to discriminate patients with or without significant CAD.

[Isolated anomalous origin of a septal artery from a third coronary ostium. Apropos of a case]. / Naissance anormale isolée d'une artère septale par un troisième ostia coronaire. A propos d'un cas.

The authors report the case of a patient undergoing coronary angiography for angina who had an anomalous origin of the septal perforator artery from a separate ostium. Anomalies of the coronary arteries may consist not only of anomalous trajectories and coronary fistulae but also of anomalous origins of the main coronary arteries. The anomalous origin of a septal artery from a separate ostium is very rare accounting for 0.5% of cases in the medical literature. In some cases, this artery provides a collateral circulation for occluded main coronary vessels, thereby preserving left ventricular contractility.

[Does ambulatory determination of blood pressure allow the measurement of white coat effect?]. / L'enregistrement ambulatoire de la pression artérielle permet-il de mesurer l'effet blouse blanche?

UNLABELLED: The aim was to find an objective indicator in order to evaluate white coat effect (WE). The first hour average values after placing an ambulatory blood pressure recorder (15 mn intervals) were compared to those of the 4 following hours of diurnal activity. A first hour systolic arterial blood pressure (SBP 1H) increase of 10 mmHg or more was considered as an ambulatory WE positive (AWE+) and was compared to clinical WE (CWE). CWE+ was observed in 78 pts and AWE+ in 72 among a group of 172 unselected pts referred for hypertension. RESULTS: the correlation between AWE and CWE is weak (r = 0.49) but significant (p < 0.001). There was no difference between the two groups in age, sex, clinical blood pressure, heart rate or ambulatory BP after the first hour (table). There was a significant difference in SBP between the 2 groups (p < 0.001) during the first hour only. [table: see text] CONCLUSION: Ambulatory blood pressure recording is able to recognize and evaluate the white coat effect. We suggest to consider independently the first hour of each recording and to compare it with the mean pressure measured during the period of diurnal activity.

[Syncopal ventricular tachycardia complicating paroxysmal atrial fibrillation in severe myocardial ischemia]. / Tachycardies ventriculaires syncopales compliquant une fibrillation auriculaire paroxystique lors d'une ischémie myocardique sévère.

The authors report two cases of spontaneous paroxysmal atrial fibrillation closely followed by syncopal ventricular tachycardia resulting in cardiac arrest requiring defibrillation. Both patients, men aged 62 and 64 years, had a past history of myocardial infarction without arrhythmias; atrial fibrillation occurred during severe myocardial ischaemia; coronary arteriography showed tight stenoses of the left main coronary artery with normal left ventricular function. Ventricular tachycardia (or fibrillation) during spontaneous paroxysmal atrial fibrillation is a rare occurrence. This sequence of events has been described in patients with accessory conduction pathways or in hypertrophic cardiomyopathy. It is an exceptionally rare complication of ischemic heart disease with only a very few previously reported cases. Myocardial ischaemia is probably the cause of the arrhythmia in together with irregularity of the ventricular contractions responsible for long cycle-short cycle sequences which are particularly arrhythmogenic and changes in sympathetic tone.

[Left ventricular kinetics studied by the color kinesis method. Comparison of bidimensional echographic and angiographic data]. / Etude de la cinétique ventriculaire gauche par la technique du color kinesis. Comparaison aux données échographiques bidimensionnelles et angiographiques.

The object of this study was to assess the value of CK in the evaluation of left ventricular wall motion. Fifteen coronary patients aged 56 +/- 12 years were included: 8 patients were examined after acute myocardial infarction and 7 after unstable angina with a history of myocardial information. The left ventricle was divided into 7 segments after a modified Heger model, excluding the basal septal and basal lateral segments not seen on angiography. The left ventricular wall motion was assessed in two-dimensional echocardiography (2DE) and colour kinesis (CK) by two observers and compared with the results of left ventriculography, considered the reference method. Over all the 105 segments studied (7 segments for each of the 15 patients), CK was significantly better than 2DE (80% of segments correctly evaluated by CK vs 68% by 2DE, p < 0.05). Colour kinesis significantly improved the study of all segments except the interventricular septum (67% vs 60%, p = NS). The inter-observer variability in 2DE and CK evaluated over 135 segments (9 per patient) by the kappa was improved by colour kinesis (0.57 in 2DE, 0.7 in CK). The authors conclude that CK enables evaluation of left ventricular wall motion with greater precision and less inter-observer variability.

[Myocardial infarction in a pregnant woman during salbutamol therapy]. / Infarctus du myocarde chez une femme enceinte au cours d'un traitement par salbutamol.

The authors report the case of a 31 year old woman at 30 weeks' gestation who developed a non-Q wave postero-lateral myocardial infarction during treatment with salbutamol. There were no complications and delivery took place at term normally. Coronary angiography was performed 3 months post-partum and was normal: the Methergin test was negative. Myocardial ischaemia occurring during treatment with a beta-2 mimetic in pregnancy is rare and hardly ever progresses to myocardial infarction. The usual mechanism of ischaemia is an imbalance of myocardial oxygen demand and supply. Myocardial oxygen consumption is naturally increased during pregnancy and excess intracellular calcium secondary to the beta-1 stimulation occurring with the use of beta-2 mimetic drugs further aggravates matters. This hypothesis raises the question of the value of calcium inhibitors in these forms of myocardial ischaemia.

[Cardiobacterium hominis on a aortic valve prosthesis]. / Endocardite à Cardiobacterium hominis sur prothèse valvulaire aortique.

A new case of late bacterial endocarditis caused by Cardiobacterium hominis is reported. The infection developed on an aortic valve prosthesis and responded favourably to medical treatment. The main characteristics of the micro-organism and of the oslerian graft are reviewed in the light of published data. The problem of endocarditis with negative blood cultures is discussed since C. hominis is reputed difficult to cultivate, although this was not the case in our patient.

[Myocardial infarction due to spontaneous coronary dissection during the postpartum period]. / Infarctus du myocarde par dissection coronaire spontanée lors du post-partum.

The authors report the case of a 34 year old woman, admitted to hospital because of myocardial infarction two months after delivery of her fifth child. The infarction was caused by spontaneous dissection of the left main coronary and left anterior descending arteries. Twenty-three months later, the patient was well with medical therapy. This case is an example of spontaneous post-partum coronary dissection which is the commonest cause of infarction occurring in that period. The physiopathology of this complication is not fully understood. The prognosis is poor, lethal in two thirds of cases. However, it must be emphasised that coronary dissection may regress spontaneously. Patients were previously referred systematically for surgery, but now it is usually reserved for cases with persistent myocardial ischaemia despite medical therapy. Angioplasty may be preferred despite the risks and may be successful in some cases.

[Early constrictive pericarditis after coronary revascularization. Apropos of a case]. / Péricardite constrictive précoce après revascularisation coronaire. A propos d'un cas.

The authors report a case of severe constrictive pericarditis occurring 6 weeks after coronary bypass surgery and in the absence of any other predisposing factor. The diagnosis was confirmed by CT scan and cardiac catheterisation which showed signs of a diastole. The patient died despite early surgical reoperation because of the severity of the pericardial fibrosis.

[Clinical, echocardiographic and Doppler outcome in ischemic right ventricular dysfunction associated with inferior wall infarction]. / Evolution clinique, échocardiographique et Doppler de la dysfonction ischémique ventriculaire droite associée à un infarctus inférieur.

Right ventricular involvement during inferior wall myocardial infarction does not seem to alter long-term clinical prognosis but its specific outcome has not been clearly studied. We have previously demonstrated that pulmonary regurgitant (PR) flow tracings doppler analysis allows the accurate diagnosis of RV involvement, especially when the pressure half-time of PR was < or = 150 ms and the ratio of the minimal velocity to the maximal velocity was < or = 0.5. We studied 40 patients with acute inferior wall myocardial infarction and with PR flow. Doppler echocardiography was obtained during the first day, before discharge (early control) and between 12 and 24 months follow-up (late control). Among 22 patients with RV involvement defined with PR-derived doppler parameters (RVIPR). 8 had right ventricular enlargement and/or wall motion abnormalities, observed in 6 cases at early control and in 4 at late control. Doppler analysis showed remnant RVIPR parameters in 9 patients at early control and 8 among these at late contorl, with no relation with pulmonary artery pressure or other echocardiographic parameters. No clinical, angiographic or therapeutic data predicted these distinct echocardiographic and doppler patterns and the long-term prognosis was not different. At late control, among 12 RVIPR patients which PR-derived doppler parameters were normal at early control, two patients had still RVIPR pattern at late control and described ischemic recurrence. PR flow doppler analysis is a useful tool for diagnosis and outcome evaluation of RV involvement and shows a remnant diastolic dysfunction in half of the patients with acute RV involvement.

[Pre-hospitalization treatment with Abciximab in the preparation of patients for primary angioplasty in the acute phase of myocardial infarct. Immediate and long-term (one month) results]. / Traitement préhospitalier par abciximab des patients candidats à une angioplastie primaire en phase aiguë d'infarctus du myocarde. Résultats immédiats et à l mois.

Percutaneous transluminal coronary angioplasty (PTCA) is an alternative to fibrinolysis in the treatment of acute myocardial infarction (AMI). However, after balloon PTCA, the rate of early re-occlusion, of re-infarctus and of restenosis remains high. Stent implantation with antiplatelet drug regimen (aspirin, ticlid) limits these risks. Abciximab (new GPIIb/IIIa receptors inhibitor) reduces PTCA complications rate in the acute coronary syndromes. Intravenous administration of abciximab can restore a normal flow in the infarcted related coronary artery (IRA) after few minutes. A monocentric, non randomized, prospective pilot study was iniated to assess the feasibility of pre-hospital treatment with abciximab in preparation to primary PTCA stenting in AMI (primary endpoint) and to appreciate potential benefits in initial IRA patency as well as prevention of PTCA thrombotic complications (secondary endpoint). Between April 1997 and January 1998, 38 AMI were treated with abciximab in pre-hospital phase (group A). Mobil Intensive Care Unit (MICU) team implemented the treatment and guaranteed immediate transport to the cathlab (abciximab bolus-coronary angiography time = 37 +/- 17 min). Immediate results were compared to those of 198 paired patients who were treated for AMI during the same period (Group T). Initial IRA flow TIMI grade 3 was significantly higher in group A, 24%, than in group T, 9% (p < 0.017). The rates of per-procedural complications (no flow, distal embolism), of local complications, of transfusions were not significantly different. During 1 month follow-up, there was no significant difference between group A and group T concerning death, re-MI, stent thrombosis and new revascularization. To conclude, the pre-hospital treatment with abciximab in AMI is feasible by MICU medical team without any delay of the cathlab admission. It is associated with no increased hemorrhagic complications rate. The abciximab pre-hospital treatment improves the initial IRA patency. These encouraging preliminary results expect to be confirmed by larger, multicentric, randomized and prospective studies.

[Medium-term follow-up after percutaneous aortic valvuloplasty in the elderly. Clinical study apropos of 102 cases]. / Suivi à moyen terme après valvuloplastie aortique percutanée du sujet âgé. Etude clinique à propos de 102 procédures.

Percutaneous transluminal balloon aortic valvuloplasty was introduced in 1985 and, owing to its sometimes dramatic short-term results, it has rapidly become a useful procedure in the management of aortic stenosis in elderly subjects. The purpose of this study was to determine its clinical results at medium-term and to identify possible prognostic factors in order to improve the selection of patients suitable for this technique. Between January 1986 and December 1987, 78 patients (30 men, 48 women, aged from 60 to 93 years, mean 80 +/- 6.7 years) totalling 85 procedures were selected among 102 dilatations on the basis of a primary success without complications. Dilatation was performed by a technique similar to that described by Cribier et al. The follow-up period was 10 +/- 5.7 months (range: 1 to 27 months). The aortic valve area increased from 0.47 +/- 0.15 cm2 to 0.77 +/- 0.23 cm2, i.e. from 0.29 +/- 0.09 cm2/m2 to 0.48 +/- 0.13 cm2/m2 as regards the indexed area. The hospital mortality rate was 3.3 p. 100. At the end of the follow-up period 55 p. 100 of the patients were in NYHA class I or II; 29 p. 100 had died, 10 p. 100 had undergone a second dilatation and 13 p. 100 had had aortic valve replacement. This distribution into functional classes and major cardiac events was not significantly different in the subgroup of patients with an aortic valve area greater than 0.9 cm2 or in the subgroup of primary failure. The patients who died for cardiac reasons were older (p less than 0.01), had a lower cardiac output before and after dilatation (p less than 0.001) and a lower ejection fraction after dilatation (p less than 0.05) or even before in case of early death (p less than 0.05). Mortality and morbidity therefore were high at medium-term and unrelated to the haemodynamic effect of dilatation. On the other hand, the left ventricular systolic function was determinant, mainly because it could improve or remain stable when initially altered. These results suggest that only patients for whom aortic valve replacement is truly contra-indicated and who have a limited alteration of left ventricular function should be selected for aortic valvuloplasty.