Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients: risk stratification by low-dose dobutamine echocardiography.

OBJECTIVES: We sought to assess risk stratification by using dobutamine stress echocardiography (DSE) in patients with aortic stenosis (AS) and severe left ventricular (LV) dysfunction. BACKGROUND: Few data are available on risk stratification for valve replacement in patients with AS, LV dysfunction and low transvalvular gradients. METHODS: Low-dose DSE was performed in 45 patients (16 women and 29 men; median [quartile range] age in years: 75 [69 to 79]; left ventricular ejection fraction: 0.29 [0.23 to 0.32]; aortic valve area [cm2]: 0.7 [0.5 to 0.8]; mean transaortic gradient [mm Hg]: 26 [21 to 33]). Patients were classified into two groups: group I (n = 32, LV contractile reserve on DSE) and group II (n = 13, no contractile reserve). Valve replacement was performed in 24 and 6 patients in groups I and II, respectively. RESULTS: Perioperative mortality was 8% in group I and 50% in group II (p = 0.014). Survival at five years after the operation was 88% in group I. Compared with medical therapy, valve surgery was associated with better long-term survival in group I (hazard ratio for death [HR-D] 0.13, 95% confidence interval [CI] 0.002 to 0.49) and reduced survival in group II (HR-D 19.6, 95% CI 2.7 to 142). The effect of valve surgery on survival remained significant in both groups after adjustment for age, diabetes, respiratory disease and hypertension. Medical therapy had the same effect in both groups. CONCLUSIONS: In patients with AS, LV dysfunction and low transvalvular gradients, contractile reserve on DSE is associated with a low operative risk and good long-term prognosis after valve surgery. In contrast, operative mortality remains high in the absence of contractile reserve.

Alteration of left ventricular diastolic function during coronary angioplasty-induced ischemia: a color M-mode Doppler study.

OBJECTIVES: The aim of this study was to assess the effects of ischemia on diastolic function by analyzing flow propagation velocity with color M-mode Doppler echocardigraphy. BACKGROUND: Color M-mode Doppler echocardiography has been proposed as a method of assessing left ventricular filling. METHODS: Color M-mode Doppler echocardiography and measurement of hemodynamic data were performed simultaneously at baseline and during angioplasty-induced ischemia. Tau was compared with flow propagation velocity. Late diastolic indexes, left ventricular pressure and flow cessation time were also investigated. RESULTS: During ischemia, left ventricular relaxation rate (tau) increased, whereas flow propagation velocity decreased, from (mean +/- SD) 46.8 +/- 10 ms to 72.6 +/- 18.3 ms and from 59.8 +/- 15.8 cm/s to 30 +/- 8 cm/s, respectively (all p < 0.0001). The maximal slowing of flow propagation velocity was observed 20 to 30 s after the beginning of the inflation, coexisting with a notch on the ascending limb of the negative rate of rise of the left ventricular pressure (dP/dt) curve. Flow propagation velocity was correlated with tau both at baseline (r = 0.53, p < 0.05) and during inflation (r = 0.53, p < 0.03). Left ventricular end-diastolic pressure increased during ischemia from 13.5 +/- 8 mm Hg at baseline to 27.5 +/- 7 mm Hg, while a premature cessation of the entering flow occurred -13.8 +/- 23 ms before the next Q wave onset, compared with 4.5 +/- 19.6 ms after the Q wave onset at baseline (all p < 0.0001). CONCLUSIONS: The analysis of flow propagation velocity showed that early filling is highly dependent on left ventricular relaxation rate, particularly through the phenomenon of asynchrony. During ischemia, the premature cessation of late filling is associated with increased diastolic pressures.

Prediction of functional recovery of viable myocardium after delayed revascularization in postinfarction patients: accuracy of dobutamine stress echocardiography and influence of long-term vessel patency.

OBJECTIVES: We sought to evaluate dobutamine stress echocardiography (DSE) for predicting recovery of viable myocardium after revascularization with cineangiography as a gold standard for left ventricular (LV) function. We studied the influence of late vessel reocclusion on regional LV function. BACKGROUND: Dobutamine stress echocardiography is a well established evaluation method for myocardial viability assessment. In previous studies the reference method for assessing LV recovery was echocardiography, long-term vessel patency has not been systematically addressed. METHODS: Sixty-eight patients with a first acute myocardial infarction (AMI) and residual stenosis of the infarct related artery (IRA) underwent DSE (mean +/- standard deviation) 21 +/- 12 days after AMI to evaluate myocardial viability. Revascularization of the IRA was performed in 54 patients by angioplasty (n = 43) or bypass grafting (n = 11). Coronary angiography and LV cineangiography were repeated at four months to assess LV function and IRA patency. RESULTS: Sensitivity and specificity of DSE for predicting myocardial recovery after revascularization were 83% and 82%. In the case of late IRA patency, specificity increased to 95%, whereas sensitivity remained unchanged. In the 16 patients with myocardial viability and late IRA patency, echocardiographic wall motion score index decreased after revascularization from 1.83 +/- 0.15 to 1.36 +/- 0.17 (p = 0.0001), and left ventricular ejection fraction (LVEF) increased from 0.52 +/- 0.06 to 0.57 +/- 0.06 (p = 0.0004), whereas in five patients, reocclusion of the IRA prevented improvement of segmental or global LV function despite initially viable myocardium. CONCLUSIONS: Dobutamine stress echocardiography is reliable to predict recovery of viable myocardium after revascularization in postinfarction patients. Late reocclusion of the IRA may prevent LV recovery and influence the accuracy of DSE.

Prehospital use of APSAC: results of a placebo-controlled study.

Thrombolytic treatment efficacy is greater when the delay between onset of pain and treatment is short. To give treatment before admission to a coronary care unit, responsibility needs to be transferred from cardiologists to other physicians working in mobile care units. We conducted a 2-part feasibility study to investigate this strategy. Part 1 evaluated the diagnostic accuracy of mobile care unit physicians. Results from this study indicate that with regard to the diagnosis of acute myocardial infarction, the risk of a wrong diagnosis is low. Part 2 was a placebo-controlled trial involving 100 patients in which 57 received anisoylated plasminogen streptokinase activator complex (APSAC) (30 U) at home and 43 received placebo at home. Patients receiving placebo at home were reevaluated on arrival in a coronary care unit and received APSAC (30 U) if indicated. The main results were that (1) diagnostic accuracy was good--all patients had an acute coronary syndrome and 97 of 100 patients had myocardial infarction; (2) time gain was approximately 60 minutes; (3) coronary patency rate was 72%; (4) ejection fraction was higher in the prehospital group (56.7%) than in the control group (53.4%), but the difference was not significant; (5) there was no rhythmic or bleeding complication related to the prehospital treatment; (6) 5 patients died from cardiogenic shock--2 between home and hospital and 3 in the hospital (3 received thrombolytic treatment at home and 2 received placebo at home and APSAC in the hospital); and (7) prehospital administration of APSAC did not induce a delay in arrival to the coronary care unit.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of regional myocardial velocities assessed by quantitative 2-dimensional and M-mode color Doppler tissue imaging: influence of the signal-to-noise ratio of color Doppler myocardial images on velocity estimators of the Doppler tissue imaging system.

M-mode color Doppler imaging of the myocardium affords a greater sampling rate and signal-to-noise (S/N) ratio than 2-dimensional (2D) imaging. In this study, we compared myocardial velocities assessed by 2D and M-mode Doppler tissue imaging (DTI) at the same site and evaluated the influence of the S/N ratio on velocity estimates of the currently used DTI systems. In patients with and without impaired regional left ventricular function, myocardial velocities assessed by 2D DTI were lower than those obtained with M-mode DTI. The difference between regional velocities derived from both imaging techniques was positively correlated with the extent of the "black zone," which could be considered as indirectly reflecting the S/N ratio for each frame. Thus in the clinical setting and on currently used echocardiographs, 2D DTI may provide underestimated regional myocardial velocities when compared with M-mode, mainly because of the influence of the lower sampling rate and S/N ratio on velocity estimators of the imaging system.

[Methods of evaluating proposed treatments in the secondary prevention of myocardial infarction]. / Méthodes d'évaluation des traitements proposés dans la prévention secondaire de l'infarctus du myocarde.

Attempts at quantitative evaluation by imaging methods of left ventricular dys-synergism consecutive to ischaemia meet with a number of problems. These include such methodological and technical factors as corrections for heart movements in the thorax during contractions, or for the heterogeneity of segmental dynamics in both space and time. In addition, several biological factors must be considered, such as the possible expansion of a necrotic wall, the presence of systolic dysfunction in the area adjacent to the infarct, the lack of proportion between the degree of dys-synergism and the reduction in coronary arterial flow, and the frequent delay in improvement of contractile function after blood flow has been restored in the ischaemic area. A knowledge of all these factors is important to quantify myocardial ischaemia by imaging methods, and especially to evaluate the size of an acute infarct and the beneficial effects of early therapeutic measures on that size.

[Pre-hospital thrombolysis]. / Thrombolyse préhospitalière.

Too few myocardial infarctions are thrombolysed, and the thrombolytic agent is usually administered too late. This situation can conceivably be improved by educating both physicians and patients, by promoting thrombolysis in all hospitals and by performing thrombolysis before admission. We report here our experience of pre-hospital thrombolysis with Eminase in the Val-de-Marne department. This preliminary study is just a small stone added to the big heap of small series of thrombolysis at home published throughout the world. But while the feasibility of pre-admission thrombolysis has been well demonstrated, its effectiveness remains to be accurately determined. Two studies involving large groups of patients are currently in progress: one in Seattle with the left ventricular function as principal criterion of judgment, the other in Europe (The European Myocardial Infarction Project) with mortality as main criterion of judgment. We must wait for the results of these studies to know whether pre-hospital thrombolysis will become the standard treatment of myocardial infarction and if so, to implement the relevant changes required in health structures.

[Methods for evaluating thrombolytic drugs]. / Méthodes d'évaluation des médicaments thrombolytiques.

There are two conceptually quite separate objectives to be attained in evaluating a new class of therapeutic agents: the establishment of benefit-risk relationships which allow assessment of their clinical utility; the evaluation of the underlying physiopathological concepts. These two distinct objectives overlap; the criteria of assessment of the benefit-risk studies are based on the physiopathological concepts. Similarly, the relationships observed after analysing the results of the benefit-risk studies increase our understanding of the physiopathology of a disease process. With respect to the use of thrombolytic drugs in the acute phase of myocardial infarction: --the usual criteria of evaluation of the benefits of treatment are coronary artery patency, left ventricular ejection fraction and patient mortality; the severity of blood clotting abnormalities and the frequency of haemorrhage are used to assess the risks; --the physiopathological reasoning behind this choice of criteria of assessment is the direct relationship between coronary artery patency, ejection fraction and mortality. Also, the severity of blood clotting abnormalities seems to be related to the frequency of haemorrhagic complications; We have reviewed these criteria of assessment of the benefit-risk ratio of thrombolysis in the acute stage of myocardial infarction. Our analysis indicates that mortality is the only indiscutable criterion of assessment and that the classical physiopathological concepts are not validated by the results of therapeutic trials.

[Physiopathologic basis of the use of thrombolytic agents during the acute phase of myocardial infarction]. / Bases physiopathologiques de l'utilisation des thrombolytiques à la phase aiguë de l'infarctus du myocarde.

Experimental animal studies have shown that coronary occlusion is followed by myocardial infarction and that coronary reperfusion can limit infarction size. Myocardial necrosis and the recovery of function are progressive phenomena in these animal models. Similarly, human myocardial infarction is caused by coronary occlusion and the size and severity of the infarct can be reduced by spontaneous or therapeutic coronary reperfusion. However, there are important differences between the animal models and clinical myocardial infarction. The results of randomised therapeutic trials of thrombolytic drugs show that the theoretical equation between reperfusion, myocardial protection and reduction of mortality has not yet been fully validated. This may be explained either by the fact that the intermediary criteria of assessment (patency at 90 minutes and ejection fraction at the 3rd week) have been badly chosen or by the fact that some of the therapeutic benefit of thrombolytics on mortality is not due to reperfusion or myocardial protection. The physiopathological rationale behind the use of thrombolytics in the acute phase of myocardial infarction is coronary reperfusion, but is reperfusion beneficial in all myocardial infarcts? What is or are the intermediary factors between reperfusion and the decrease in mortality? Is reperfusion the only benefit of thrombolysis? Clear answers to these questions are not yet available.

[Pathology and dental care in the context of cardiovascular conditions: myths, beliefs and realities]. / Pathologies et soins dentaires dans le cadre des affections cardiovasculaires: mythes, croyances et réalités.

The knowledge regarding the links between dental and cardiac affections are generally based on empirical concepts and lead to unjustified clinical practices. Infectious endocarditis (IE) is the principal cardiac diseases concerned with dental procedures. Although in France, the incidence of IE is stable, the incidence of oral bacteria at the origin of IE is diminishing. The risk of IE and thus the indication of antibioprophylaxis depend upon the subjacent cardiopathy and dental treatment. Antibioprophylaxis has to be very strict in patients with high or moderate risks of IE but is not necessary in low risk patients. In all cases, a good oral and dental hygiene and a regular dentist follow up are the most effective methods of preventing IE. Coronary artery disease and dental affections are associated because they present similar risk factors (i.e. smoking, excessive sugar consumption) and also because inflammation increases the risk of acute coronary syndrome. Today, dental cares are not contraindicated in patients with recent coronary syndrome if precise protocols are followed. Concerning the hemorrhagic risk during dental care in patients treated by anticoagulants and/or antithrombotics, dental cares and extractions are possible if INR or heparinemy are within the therapeutic limits and local haemostasis is meticulous. In addition, aspirin does not require to be stopped before minor dental treatments. Finally a better collaboration between dentists and cardiologists would allow an optimum management of patients with cardiac disease requiring dental cares.

[Adaptation to effort in patients with chronic cardiac insufficiency; study by post-exercise Doppler echocardiography, comparative results with a control population]. / Adaptation à l'effort chez l'insuffisant cardiaque chronique; étude par échocardiographie doppler post-effort, résultats comparatifs avec une population témoin.

Adaptation to exercise was studied by post-exercise Doppler echocardiography in patients with chronic cardiac failure and an apparently healthy control population matched for age. This post-exercise Doppler echocardiographic method initially introduced for the detection of myocardial ischaemia has already been validated in normal subjects for the analysis of haemodynamic changes caused by exercise providing the data is recorded in the first 5 minutes following recovery in the recumbent position. Eleven patients with chronic cardiac failure in NYHA classes II or III with a mean age of 54 +/- 11 years and 6 controls (mean age: 46 +/- 9 years) were investigated. The patients had been stabilised for at least 3 months with a vasodilator and diuretic therapy: the control subjects had no medication. After bicycle ergometry performed to 70% of maximum capacity, the subjects were positioned in the left lateral recumbent position. Doppler echocardiography was then performed in the immediate recovery phase. When compared to the control population, the patients with cardiac failure had a reduced chronotropic reserve, a smaller increase in the parameters of myocardial contractility (maximal aortic velocity, maximal aortic acceleration and left ventricular fractional shortening) without an increase in left ventricular end diastolic dimensions in subjects with severe dilatation under basal conditions (left ventricular end diastolic dimension 69 +/- 3 mm). This result suggests the absence of a Frank-Starling effect. The lack of adaptation of the peripheral vascular system was demonstrated by the lack of reduction of left ventricular end systolic stress, already greatly increased at rest (176 vs 77 +/- 10 g/cm2 for patients, compared with controls; p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Physiopathological basis of the treatment of heart failure]. / Bases physiopathologiques du traitement de l'insuffisance cardiaque.

Therapeutic advances have changed the mode of presentation of cardiac failure over the last decades: the main cause, nowadays, is myocardial ischaemia. The modern treatment of cardiac failure is based on relatively simple physiopathological mechanisms which take into account the different aspects of cardiac physiology: a pump, a muscle, a coronary circulation supplying oxygen to the myocardium, an automatic contraction. The concept of vasodilatation and the blocking of vasoconstrictive systems introduced during the 70s is the basis of modern treatment of cardiac failure which involves angiotensin converting enzyme inhibitors and, increasingly, betablockers. In the near future, with earlier treatment of cardiac failure, the stimulation of vasodilator systems could become a new therapeutic strategy. Early detection of ischaemia and its complications with the aim of limiting the loss of cardiac myocytes is a priority for slowing the progression of cardiac failure. The prevention of cardiac failure also depends on educating cardiologists to treat rapidly the factors predisposing to or prolonging episodes of even mild cardiac failure.

[Prehospital thrombolysis. Evaluation of preliminary experiences at Val-de-Marne]. / Thrombolyse préhospitalière. Bilan d'une expérience préliminaire menée dans le Val-de-Marne.

Benefits of thrombolysis have been shown to be greater when therapy is administered early, and this led us to consider the value of starting thrombolytic treatment in the patient's home. However, this implies the transfer of responsibility of patient management from the cardiologist to the physician in charge of the mobile emergency care team. A study was undertaken in the Val-de-Marne department to assess the benefits and risks of this therapeutic approach. The first phase was designed to evaluate the reliability of the emergency care team's diagnosis and the second phase of the study was a randomised double blind prehospital therapeutic trial of a thrombolytic agent, acylated streptokinase (intravenous bolus of 30 units in 4 minutes) against placebo. The nature of prehospital treatment was revealed on hospital admission and thrombolytic therapy was immediately given to those patients allocated to placebo at home providing the admitting cardiologist confirmed the indication. A total of 100 patients were included; 57 were allocated to thrombolytic therapy and 43 to placebo in the prehospital phase. The diagnosis of acute coronary insufficiency was confirmed in all cases and 97 p. 100 of patients had signs of acute myocardial infarction. No complications were attributable to prehospital administration of the thrombolytic. The average time gain in instituting treatment was 60 minutes. At control coronary angiography, 72 p. 100 of the coronary arteries thought to the responsible for the infarct were shown to be patent. The global left ventricular ejection fraction of patients treated with thrombolysis at home was 56.7 p. 100 compared with 53.4 p. 100 in the placebo group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Enoximone and the therapeutic strategy in patients awaiting emergency cardiac graft]. / Enoximone et stratégie thérapeutique chez des patients en attente d'une greffe cardiaque en urgence.

Enoximone is a positive inotropic agent belonging to the group of phosphodiesterase F-III inhibitors. The drug was tested in 34 patients uncontrolled by sympathomimetic drugs and referred to our department for urgent heart transplantation or circulatory assistance. After insertion of a Swan-Ganzgatheter and a radial artery catheter for haemodynamic monitoring, enoximone was administered as a 15-minute intravenous bolus injection of 1 to 2.5 mg/kf every 8 hours, in addition to sympathomimetic agents. Clinical and haemodynamic improvement was observed after thirty minutes in 30 patients. The cardiac index rose from 1.82 to 2.67 l/min/m2 and the pulmonary wedge pressure fell from 30.8 to 18.9 mmHg. Systemic arterial resistance decreased from 2170 to 1520 dyn. s. cm-5, and pulmonary resistance from 5.5 to 4.6 Wood units (p less than 0.01 for all values). Four patients had no haemodynamic improvement and were put on circulatory assistance, using a Jarvik 7 total artificial heart in 3 of them and heterotopic circulatory assistance in one. After clinical investigation for contra-indication to heart transplantation, and as their improved haemodynamic status permitted, 12 of the 30 patients were considered suitable (group B) for heart transplantation. Transplantation was performed within a week of admission in 11 patients without any need for mechanical assistance. One of the group B patients who required implantation of a Jarvik 7 artificial heart died after 12 hours of assistance. Eighteen patients were considered unsuitable for transplantation (group A) and treated medically.(ABSTRACT TRUNCATED AT 250 WORDS)

[6 months' results of coronary angioplasty after thrombolysis of myocardial infarction]. / Résultats à six mois de l'angioplastie coronaire faite après thrombolyse pour un infarctus du myocarde.

Transluminal coronary angioplasty (TCA) has become the treatment of choice of residual stenosis after thrombolysis for myocardial infarction, but the long-term results of TCA are imperfectly evaluated. Seventy patients underwent TCA after thrombolysis on account of a significant (greater than 50 p. 100) residual stenosis of the artery responsible for the infarction. TCA was performed less than 6 hours after the onset of symptoms in 15 patients who had neither clinical nor electrocardiographic evidence of reperfusion; 4 of these patients were in a state of cardiogenic shock. In the remaining patients TCA was performed 1 to 10 days (mean 3.2 days) after thrombolysis. A primary success was obtained in 64 patients (91 p. 100). Two patients had emergency aorto-coronary bypass. During their stay in hospital, 5 patients presented with symptoms of reocclusion which in 4 of them occurred less than 24 hours after TAC, and 2 of these 4 patients had to be reoperated upon; 2 patients died suddenly. During a 6 to 18 months' follow-up period (mean 10.5 months), the infarction recurred in 3 patients; the recurrence took place during the 3rd month in 2 of them (1 had another thrombolysis and later TAC) and during the 6th month in the third one. At 6 months, 4 patients were suffering from exertion angina and 2 asymptomatic patients had a positive exercise test. Fifty-two control coronary arteriographies were performed at 6 months. Thirteen patients (25 p. 100) had an occluded artery which was clinically silent in 11; 39 patients had a patent artery with restenosis in 7.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of chronic left ventricular insufficiency]. / Traitement de l'insuffisance ventriculaire gauche chronique.

Left ventricular failure results from many myocardial diseases: the symptoms of left ventricular failure are the consequence of adaptations which the left ventricle and circulatory system activate to counteract the initial myocardial disease. The aims of treatment of cardiac failure are diverse depending on whether treatment is directed to correct the initial myocardial disease, its myocardial consequences, its circulatory consequences or, more simply, the patient's symptoms. The ideal treatment of cardiac failure would include a drug acting on the cause, a drug restoring left ventricular contraction and relaxation adapted to the conditions of cardiac load, a drug correcting regional blood flow disturbances and a drug relieving symptoms related to salt retention. An ideal drug for chronic left ventricular failure does not exist, and so treatment is a composite effort. Should it be in first intention? This is the current trend.

[Hospital mortality in cardiology. Analysis of deaths occurring in the Federation of Cardiology of a university hospital center]. / Mortalité hospitalière en cardiologie. Analyse des décès survenus au sein de la fédération de cardiologie d'un centre hospitalo-universitaire.

The aim of this study was to examine the nature of cardiovascular deaths occurring in a University Hospital. All the hospital files of 1999 of the Federation of Cardiology of Henri Mondor Hospital, Creteil, of patients who died in the department or after transfer to the intensive care unit or cardiac surgery department, were analysed. Myocardial ischaemia was the leading cause of death, occurring either in the acute phase of transmural infarction or in patients with chronic cardiac failure. Deaths occurring during acute myocardial infarction were associated with late treatment and/or non-reperfusion of the culprit artery. The delay of diagnosis seemed to be secondary to late consultation or difficulty in diagnosis. This resulted in severe left ventricular dysfunction and, in a quarter of cases, mechanical complications. They led to the early death of the patients (2.9 +/- 3.5 days after admission). Campaigns of patient information and education of doctors who see these patients would seem to be the most appropriate approach to reduce the delay before hospital admission in order to reduce mortality related to myocardial infarction. Cardiac failure is a common cause of death in cardiology departments. The deaths of patients occurred after a long follow-up and several days after hospital admission (11 +/- 10 days). Optimisation of the treatment of cardiac failure, the investigation of ischaemic heart disease, the search for new therapeutic strategies of acute cardiac failure and information of patients about their disease, seem to be the principal measures to take to improve the poor prognosis of this disease.

[Medical strategy in patients awaiting emergency heart transplantation]. / Stratégie médicale chez les patients en attente de greffe cardiaque en urgence.

Cardiac transplantation is theoretically the optimal final treatment of terminal cardiac failure but the indications, especially in the emergency situation, should be carefully considered. Sympathomimetic agents are of limited use in patients with severe cardiac failure partly because of the down regulation of the myocardial beta-receptors. The phosphodiesterase inhibitors, represented by enoximone, are valuable because of their action on the cardiac muscle (inotropic and lusitropic) and their direct systemic vasodilator effect. Enoximone can be administered by intravenous bolus resulting in a rapid onset of action (peak at 30 minutes) with a prolonged effect due to its hepatic metabolites. The authors' experience in this indication dates over 5 years and over 50 patients were included. A preliminary study in 34 patients with cardiac failure resistant to betamimetic drugs, referred to the intensive care unit for urgent cardiac transplantation, or, in the absence of a donor, circulatory assistance is reported. A Swan Ganz catheter and radial artery canula were inserted for haemodynamic monitoring and enoximone was administered in an intravenous bolus over 15 minutes every 8 hours in addition to sympathomimetic agents. A haemodynamic improvement was observed after the 30th minute in 30 patients. The cardiac index increased from 1.82 to 2.67 l/mn/m2 and the pulmonary capillary pressures decreased from 30.8 to 18.9 mmHg. Systemic arterial resistances fell from 2,170 to 1,520 dynes.s.cm-5. No haemodynamic improvement was observed in 4 patients who were treated by mechanical ventricular assistance. After investigations to detect contra-indications to cardiac transplantation, 12 of the 30 patients remained candidates for cardiac transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

[New thrombolytic agents. Effect on the organization of care in myocardial infarction]. / Les nouveaux thrombolytiques. Incidence sur l'organisation des soins des infarctus du myocarde.

In the last few years, intravenous thrombolysis has widely become the treatment of reference in the acute phase of myocardial infarction. Among the new thrombolytic agents which are currently being evaluated, two are particularly ahead of the group: 1) the plasminogen tissue activator, known at this time for a revascularizing effect exceeding that of streptokinase for a lesser fibrinogenolytic activity; its effectiveness in terms of mortality remains to be defined; 2) the acyl-streptokinase presents the advantage over the classic streptokinase of being injected in one single injection of 5 minutes. The revascularizing activity of this product seems to exceed that of streptokinase, and the fibrinolytic activity is the same as streptokinase's. The effectiveness in terms of mortality remains to be evaluated. The better effectiveness of the new thrombolytic agents should not let us forget that the main problem is to organize patient's care and that improvement of the effectiveness of thrombolytic therapy is mainly obtained through improvement of the screening and an early diagnosis of myocardial infarctions. Organization or patient's care in central hospitals and at the level of emergency transportation services will perhaps enable, in the years to come, to increase a great deal the number of patients who can benefit from thrombolysis and thus to decrease hospital and post-hospital mortality of myocardial infarction.

[Future molecules in heart failure]. / Molécules du futur dans l'insuffisance cardiaque.

TODAY: The management of heart failure (HF) has considerably progressed over the last two decades. Treatment today relies on prevention and treatment of congestion (limited salt intake, diuretics, converting enzyme inhibitors) and limiting neurohormone stimulation (converting enzyme inhibitors +/- aldactone, beta-blockers). IN THE YEARS TO COME: Based on new concepts, several therapeutic strategies are interesting: blocking over vasoconstrictor systems which have not been taking into account; stimulation of vasodilator and natriuretic systems; modulation of cardiac remodelling; modulation of the immune and inflammatory systems; modification in intrinsic contractility; prevention of rhythm disorders. Among these differing strategies and molecules, it is not easy to predict those that will change the HF prognosis. In any event, their efficacy and safety remain to be demonstrated with large cohort randomised studies. THE PRINCIPLES: To reduce the number of drugs administered, two options appear particularly interesting: measurement of hormone levels (BNP) in order to adjust treatment and administration of molecules with greatest efficacy and safety profiles; limit cardiac remodelling by using new imaging techniques to detect it more precisely and select the molecule(s) exerting the required effect. To target the new molecules better, patients should be classified according to their etiology, stage and progressive profile of their disease, cardiac remodelling, expression of principle endocrine systems and pro-inflammatory cytokines, expression of inflammatory and immune systems and inherent genetic characteristics and response to treatment. This would permit the adaptation of treatment to each individual patient with heart failure.