Impairment of cardiac neuronal function in acute myocarditis: iodine-123-MIBG scintigraphy study.

UNLABELLED: Abnormalities of norepinephrine uptake have been found to reflect impairment in adrenergic nerve function that has influenced the cardiac outcome of patients with heart failure. The aim of this study was to explore the cardiac neuronal function by using 123I-metaiodobenzylguanidine (MIBG) scintigraphy in patients with acute myocarditis. METHODS: We studied 15 patients (age range 42 +/- 10 yr) with clinical, biological, electrocardiographic and radionuclide left ventricular ejection fraction (LVEF) (41% +/- 7%) data indicating myocarditis and 10 normal subjects (age range 36 +/- 7 yr, mean radionuclide LVEF 69% +/- 8%, p < 0.05). Fourteen patients had positive histologic findings of myocarditis and 1 had nonspecific histological data. All patients underwent planar cardiac imaging after intravenous injection of 185 MBq 123I-MIBG and right ventricular biopsy within 7 days. A chest anterior view was acquired 4 hr later. Heart-to-mediastinum ratio activity was measured, as previously described in our laboratory. RESULTS: Significant impairment of cardiac neuronal uptake of MIBG was observed and based on a reduction of heart-to-mediastinum ratio (148% +/- 16% versus 234% +/- 36%, p < 0.05). A significant correlation was observed between LVEF and MIBG uptake in patients (y = 1.58x +/- 83.7, r = 0.72, p < 0.01). CONCLUSION: Acute myocarditis is associated with an injury of the cardiac adrenergic neuronal function. In addition to the inflammatory injury of the myocytes, the impairment of adrenergic function may be involved in the cardiac pump failure induced by myocarditis.

Iodine-123-metaiodobenzylguanidine SPECT of regional cardiac adrenergic denervation in Brugada syndrome.

We present the case of 44-yr-old man who presented syncope with ventricular tachycardia in the setting of Brugada syndrome. In addition to the electrocardiographic evidence of the syndrome and the absence of apparent structural heart disease, clear defects of myocardial neuronal metaiodobenzylguanidine (MIBG) uptake on MIBG SPECT imaging also were found in inferior, apical and septal walls. Thallium-201 SPECT distribution was homogeneous along the left ventricle. Thus, cardiac MIBG scintigraphy provides information about left ventricular dysinnervation in a patient with Brugada syndrome, enhancing the clinical utility of myocardial MIBG SPECT imaging in life-threatening ventricular arrhythmias.

Improvement of cardiac neuronal function after carvedilol treatment in dilated cardiomyopathy: a 123I-MIBG scintigraphic study.

UNLABELLED: Carvedilol can induce important clinical and hemodynamic improvements in patients with chronic heart failure resulting from severe left ventricular (LV) dysfunction. This study examines the impact of carvedilol on cardiac neuronal function using 123I-metaiodobenzylguanidine (MIBG) scintigraphy in dilated cardiomyopathy. METHODS: Twenty-two patients with chronic heart failure (19 men, 3 women; mean age, 54 y; age range, 34-64 y) assessed as New York Hospital Association (NYHA) class II or III and with initial resting radionuclide LV ejection fractions (LVEF) < 0.40 were enrolled in the study. Patients had long histories of symptomatic LV dysfunction despite optimal diuretics and angiotensin-converting enzyme inhibitor treatment. Over a 6-mo period, 50 mg/day carvedilol was administered to these patients. Planar 123I-MIBG scintigraphy provided measurements of cardiac neuronal uptake (as heart-to-mediastinum count activity ratio [HMR]), 4h after intravenous injection of 185 MBq MIBG. Hemodynamic, clinical, radionuclide LVEF and HMR data measured at the outset and after 6 mo of carvedilol were compared. RESULTS: Resting heart rate decreased from 81 +/- 13 to 71 +/- 9 bpm (P = 0.003). After carvedilol therapy NYHA functional classification for these patients improved from 2.6 +/- 0.5 to 2.3 +/-0.5 (P = 0.04), LVEF improved from 22% +/- 9% to 30% +/- 13% (P = 0.005), and HMR improved from 145% +/- 23% to 170% +/- 25% (P = 0.0001). CONCLUSION: Carvedilol induces improvements of clinical symptoms and cardiac neuronal and systolic functions in patients with dilated cardiomyopathy and chronic optimal treatment.

Serum digoxin levels related to plasma propafenone levels during concomitant treatment.

Nine patients with supraventricular rhythm disorders were treated during 5-day periods with different oral doses (300, 450, 600, and 900 mg daily) of propafenone concomitantly to long-term digoxin treatment. A poor correlation (r = .398; P less than .05) was obtained when the difference between the mean digoxin serum level (calculated with the Cmin data determined each of the 5 days) observed during a given propafenone dose and the mean digoxin serum level observed before propafenone treatment, was correlated with the dose of propafenone; but an evident correlation (r = .778; P less than .01) was found when the difference in digoxin level was correlated with the plasma propafenone concentration. The propafenone effect of increasing digoxin blood levels was thus concluded to be poorly dose dependent but strongly concentration dependent. The association of propafenone to a long-term digoxin treatment can be considered with a low risk of toxicity when plasma propafenone concentration does not exceed about 1000 ng/mL. Propafenone plasma levels are unpredictable in view of their wide interindividual variation for a given dose, so their measurement is advised to detect high levels and consequently to prevent a rise in digoxin serum concentrations with the possibility of toxicity. In clinical practice, when propafenone concentration determinations are not readily available, digoxin serum levels at least have to be carefully monitored.

Pharmacological approaches to the prevention of restenosis after coronary angioplasty.

Restenosis in the months following a successful percutaneous transluminal coronary angioplasty (PTCA) remains the main limitation to this technique for myocardial revascularisation. Despite intensive investigation in this area, no pharmacological therapy has yet been found to be useful in preventing restenosis after conventional balloon angioplasty. The occurrence of restenosis, which is now known to be caused by both vessel remodelling and neointimal hyperplasia, might be reduced in the future by a combined mechanical and pharmacological approach. Although systemic administration of 'antirestenosis' drugs has not yet been tested to prevent restenosis after coronary stenting, it is very likely that pharmacological inhibition of neointimal hyperplasia within coronary stents will take advantage of local delivery techniques. In addition to local drug delivery catheters that are available, the stent itself may be coated with polymers and serve as a platform for drug delivery. The continued attractiveness of PTCA, as an alternative to medical treatment or bypass surgery for patients with coronary artery disease, will depend upon our ability to control the restenotic process.

Attentional effects of caffeine in man: comparison with drugs acting upon performance.

The aim of this study was to observe if a method useful for measuring attentional effects could be applied in testing the differential effects of caffeine, the beta-stimulant salbutamol, and the beta-blocker propranolol. Caffeine (300 mg) was administered to a sample of 19 normal subjects compared to two samples of 40 controls. Caffeine was found to increase attention and vigilance by augmenting the number of repetitions of responses to a verbal stimulus in a free word association test. This pattern was also seen with salbutamol and propranolol, but to a lesser degree.

[Thromboses of the right cardiac cavities: echocardiographic diagnosis and therapeutic indications apropos of 2 cases and review of the literature]. / Thromboses des cavités cardiaques droites: diagnostic échocardiographique et indications thérapeutiques à propos de 2 cas et d'une revue de la littérature.

Two cases of pulmonary emboli are reported: a thrombus was detected by echocardiography in the right atrium in the first case and in the right ventricle in the second. Following a review of the 28 cases published to date, criteria are given for distinguishing between those thrombi embolizing from the peripheral veins and those arising in the right cavities of the heart. Therapeutic recommendations are also given.

[Value of echocardiography in the diagnosis of arrhythmias]. / Intérêt de l'échocardiographie dans le diagnostic des troubles du rythme.

Identification of auricular activity is important for the diagnosis of arrhythmias. P waves however are often difficult to recognize. Using M-mode and 2-D echocardiographic techniques, it is often possible to recognize atrial contraction at the level of the atrial septum or of the free wall of the right atrium. Diagnosis can be made in cases of sinus tachycardia, supra ventricular tachycardia with and without aberrancy and ventricular tachycardia with dissociation. Ventricular tachycardia with one to one retrograde conduction or with atrial fibrillation cannot be recognized by this method.

Role of coronary spasm in the genesis of myocardial infarction: study of a case treated by isosorbide dinitrate in situ then by transluminal angioplasty.

We report the observation of a 62-year-old patient who was admitted for unstable angina. A prolonged chest pain (more than two hours) with a major electrocardiographic lesion in the posterior leads needed an urgent coronary arteriography in order to attempt a recanalization. Antecedents of arteriopathy of the lower limbs with aortobifemoral bypass required an axillary artery right side approach. A selective right coronary opacification showed complete occlusion at the junction of segments 1 and 2. An intracoronary injection of isosorbide dinitrate relieved a coronary spasm and allowed a complete visualization of the right coronary artery. This appeared to be very atherosclerotic with several severe narrowings, and a subocclusive lesion at the site of the initial occlusion. Percutaneous transluminal coronary angioplasties (PTCA) were performed and led to real 'restructuring' of the right coronary artery. The clinical outcome was excellent without recurrent angina pectoris. An angiographic control performed 6 months after PTCA demonstrated the persistence of the coronary recanalization and an evident improvement of the segmental contractility. This report emphasizes the role of coronary spasm in the genesis of myocardial infarction and shows that PTCA may be performed as a first approach at the acute phase of myocardial infarction; to our knowledge it is the first PTCA performed by an axillary approach at the acute stage of myocardial infarction.

Coronary artery perforation during coronary angioplasty.

In one patient percutaneous transluminal coronary angioplasty was complicated by coronary artery perforation of the left anterior descending coronary artery with light pericardial effusion. The outcome was favorable without either pericardiocentesis or emergency surgery.

Peritoneal ultrafiltration and refractory congestive heart failure.

This prospective nonrandomized study enrolled 16 patients with congestive heart failure [NYHA (New York Heart Association) III and IV] refractory to a maximal well-tolerated drug therapy. The aims were to evaluate if peritoneal ultrafiltration (PUF) could improve clinical conditions and to determine morbidity secondary to resistant congestive heart failure (RCHF) and PUF. There were 16 patients (12 male, 4 female) with a mean age of 65.4 years (56-81 years) and follow-up of 15.6 months (4-33 months). Thirteen patients had RCHF without end-stage renal disease. Patients were classified as NYHA class IV (n = 11) or class III (n = 5). One anuric patient had been on previous hemodialysis and switched to APD. PUF was obtained with a 2-L hypertonic dialysis solution, once a day (n = 7) or every 2 days (n = 4). Clinical improvement was obtained for all the patients. Weight decreased from 72.2 to 66.7 kg with a weekly ultrafiltration of 3.74 L (2.2-6.5 L). Sodium removal was 79 mmol/day (urinary 43%, peritoneal transport 57%). During the follow-up period, 2 patients received a cardiac transplant since 7 died due to cardiac reasons. Mean hospitalization time was 4.4 and 1.20 per patient per day before and after PUF, respectively. Hospitalization was in keeping with either RCHF (36%), dialysis complications (16%), or miscellaneous causes (48%). Our experience showed that a functional improvement and a better quality of life were achieved for all these patients with a low rate of hospitalization.

Detection of cardiac myxoma by F-18 FDG PET.

Intracardiac tumors occur infrequently and are difficult to diagnose with CT and MRI. The authors describe the successful imaging of a right atrial myxoma with F-18 FDG PET.

The reversibility of cardiac neuronal function after removal of a pheochromocytoma: an I-123 MIBG Scintigraphic Study.

PURPOSE: Twelve patients with proved pheochromocytoma evaluated in our institution between 1991 and 1997 are described. METHODS: The patients' urinary excretion rates and their metabolites (vanylmandelic acid and metanephrines) were significantly greater than normal before surgery. Echocardiography showed normal left ventricular ejection fractions (72% +/- 8%). All of the patients underwent planar I-123 metaiodobenzylguanidine (MIBG) scintigraphy to assess cardiac neuronal uptake 4 hours after and locate a pheochromocytoma 24 hours after intravenous injection of 185 MBq (3 mCi) I-231 MIBG. Ten patients with pheochromocytoma had positive tumoral findings with I-123 MIBG scintigraphy. Twelve patients had significant impairment of cardiac neuronal uptake of MIBG, with a heart:mediastinum ratio averaging 142% +/- 18% (normal value, 230% +/- 30%, P < 0.05). Postoperative cardiac MIBG imaging was performed in all patients (at 6 +/- 3 months). RESULTS: After surgical removal of the pheochromocytoma, cardiac MIBG uptake and the heart:mediastinum uptake ratios improved significantly (197% +/- 20%, P < 0.05) in all the patients. Urinary excretion rates and metabolites returned to the normal range. However, no significant correlation was found between cardiac MIBG uptake and urinary excretion rates and metabolites after the tumors were removed. CONCLUSION: Removing a pheochromocytoma reversed cardiac neuronal function as assessed by MIBG scintigraphy.

[Distomatosis and cardiac disease. Apropos of 2 new cases. Trials of classification and pathogenetic hypotheses]. / Distomatose et cardiopathie. A propos de deux nouvelles observations. Essais de classification et hypothèses pathogéniques.

The authors report two new cases of cardiac disease associated with distomatosis: one case of biventricular fibroblastic parietal endocarditis affecting mainly the left side in a young female of 26 years, and one case of cardiomyopathy with atrial endocardial fibrosis, affecting especially the left ventricle in a man of 47. Bearing in mind the five cases reported in the literature, the authors propose a classification of cardiac disorders supposed to be due to distomatosis using three groups (endocardial fibrosis, cardiomyopathy, myocarditis) and relate them to a common pathogenesis based on immuno-allergic theory.

[Transient Q wave in adrenergic myocarditis. Contribution of echocardiography apropos of a case]. / Onde Q transitoire au cours d'une myocardite adrénergique. Apport de l'échocardiographie à propos d'un cas.

The authors report the occurrence of a transient Q wave in a case of adrenergic myocarditis consecutive to a hypersecretory phaeochromocytoma. There was no biochemical evidence of anatomical infarction. During a hyperadrenergic clinical attack, electrocardiography displayed a pattern of incipient anteroseptal infarction with a Q wave of necrosis, while echocardiography recorded a very low and paradoxical septal contraction together with marked abnormalities of mitral valve kinetics. Under medical treatment the Q wave totally regressed within a few hours, without rise in enzyme levels. The echocardiographic abnormalities gradually disappeared over a few days. After surgical excision of the phaeochromocytoma, both electrocardiography and echocardiography were perfectly normal. In such cases the Q wave is most probably due to a direct impact of catecholamines of the myocardium, with deep but reversible alterations of cellular metabolism. The echocardiographic abnormalities reflect an acute disorder of ventricular filling responsible for delay in mitral valve opening and disappearance of the E wave. The paradoxical septal kinetics are more difficult to explain; they seem to be related to adrenergic hyperactivity.

[Left coronaro-ventricular fistula after myocardial infarction. Apropos of a case]. / Fistules coronaro-ventriculaires gauches après infarctus du myocarde. A propos d'un cas.

Coronary artery-cardiac fistulae are uncommon and usually congenital abnormalities. The majority of these fistulae communicate with the right heart chambers. Acquired coronary-left heart fistulae are very rare: secondary to trauma, cardiac surgery, angioplasty or endomyocardial biopsy. Fistulae secondary to myocardial infarction are rare but have been described. The authors report the case of a man with anterior wall infarction treated by fibrinolysis and by angioplasty of the left anterior descending artery (LAD) 48 hours later. This dilatation was complicated by repeated occlusion but a good result was obtained after in situ and then systemic fibrinolysis. Control coronary angiography after angioplasty performed 6 months later showed the presence of micro-fistulae between the distal part of the LAD, the left diagonal entry and the left ventricular chamber which were not present on the coronary angiogram before the angioplasty. The fistulae appeared to be secondary to a localised infarct which occurred after distal thrombosis of the LAD during angioplasty.

[Myoglobin and CPK-MM isoforms during the acute phase of myocardial infarction]. / Myoglobine et isoformes des CPK-MM à la phase aiguë de l'infarctus du myocarde.

The biological diagnosis is usually late with respect to clinical and electrocardiographic signs of acute myocardial infarction. Recent laboratory methods have stimulated renewed interest in very early marker of infarction: myoglobin and CPK isoforms. The authors undertook a prospective study of the diagnostic sensitivity of myoglobin (MG), CPK and CPK-MM isoforms in 30 consecutive patients undergoing intravenous thrombolytic therapy in the acute phase of myocardial infarction. Blood samples were obtained on admission and every 30 minutes for 1 h 30. The Mb contributed to diagnosis of infarction on admission in 89% of patients. This percentage fell to 44% for the ratio MM3/MM1 > 0.5 to 27% for the CPK and to 24% for the ratio MM3/MM1 > 1. The sensitivity of all tests increased in the later blood samples but it remained low in the CPK and MM3/MM1 > 1 criteria. The diagnostic sensitivity of the first sample was also better in patients admitted after the 3rd hour (Mb = 100%; MM3/MM1 > 0.5: 58%; CPK: 41%) compared with those admitted before the 3rd hour (Mb = 82%; MM3/MM1 > 0.5: 35%; CPK: 17%). These results show that the diagnostic sensitivity of biological markers of myocardial infarction is very different. The serum myoglobin is an earlier and more sensitive marker than the CPK or CPK-MM isoforms.

[Tumoral vascularization in a case of asymptomatic myxoma]. / Vascularisation tumorale dans un cas de myxome asymptomatique.

A 67 year old woman was admitted for assessment of asymptomatic aortic stenosis. A large left atrial myxoma was demonstrated by 2D and M mode echocardiography. Coronary angiography was performed as part of the investigation of the aortic stenosis and showed that the tumour depended on the right coronary artery for its blood supply. Careful frame-by-frame study showed the presence of a true right coronary-left coronary fistula through the tumour. The authors discuss the different clinical presentations of left atrial myxomas and their vascularisation in the rare cases in which it has been described.

[Abnormal origin of the left coronary artery from the pulmonary artery, fortuitously discovered in an adult]. / Naissance anormale de la coronaire gauche à partir de l'artère pulmonaire, découverte fortuitement chez un adulte.

The authors report a case of an anomalous left coronary artery discovered by chance in a totally asymptomatic 39 year old man. Appearances of anterior myocardial infarction were observed on routine preoperative ECG in a man with multiple injuries. Coronary angiography showed an anomalous left coronary artery arising from the main pulmonary artery. Left ventricular function was poor with associated mitral regurgitation. Surgical correction consisted in an end-to-end venous graft between the ostium of the coronary artery detached from the pulmonary artery and the right anterior border of the ascending aorta. Left ventricular function did not improve four months after surgical correction. The irreversibility of the myocardial lesions argues in favour of an early correction of this malformation.

[Cardiac tumors with neonatal disclosure. Apropos of a case with spontaneously favorable development]. / Tumeurs cardiaques à révélation néonatale. A propos d'un cas d'évolution spontanément favorable.

The authors report the case of a cardiac tumour documented by 2 D echocardiography, presenting in the newborn with cardiac arrest. The echocardiographic features of multiple nodules disseminated in the ventricular walls suggested a diagnosis of rhabdomyoma. The initial course was complicated by poorly tolerated attacks of tachycardia which were rapidly brought under control with amiodarone. The long term outcome was clinically favourable with a rapid regression of the number and size of the tumours on echocardiography, and a tendency to normalisation of the electrocardiogramme. The possibility of regression, which has already been reported by many investigators, suggests that these cardiac tumours may have a better prognosis than previously thought.