Intravenous anisoylated plasminogen streptokinase activator complex versus intravenous streptokinase in evolving myocardial infarction. Preliminary data from a randomised multicentre study.

The efficacy of a single intravenous bolus of anisoylated plasminogen streptokinase activator complex (APSAC 30U in 4 to 5 minutes) versus an intravenous infusion of streptokinase (1.5 X 10(6) U in 60 minutes) was assessed in 86 patients with evolving myocardial infarction of less than 6 hours duration in a cooperative randomised study. The patency of the infarct-related artery was assessed by coronary angiography at, on average, 90 minutes after therapy (mean time: APSAC 95 minutes, streptokinase 105 minutes). The treatment groups were similar with respect to sex, age, location of myocardial infarction and the delay from onset of pain to treatment. The 90-minute patency rate (grade 2 to 3) was 71.8% in the APSAC group and 55.8% in the streptokinase group; the difference was not statistically significant. There was no difference between the drop in fibrinogen concentrations in the 2 groups at 3 or 24 hours. The minimal concentration obtained at the first assessment was +/- 0.2 g/L in the streptokinase group and 0.5 g/L in the APSAC group. One patient in the APSAC group, who had a previous meningeal bleeding, had a non-fatal cerebrovascular accident. In a subgroup of 38 patients who had 3 control coronary angiograms at 90 minutes, 24 hours and 3 weeks, the patency rate was 63, 82 and 93%, respectively, in the APSAC group and 48, 88 and 92%, respectively, in the streptokinase group (the difference was not statistically significant). None of the patients in the APSAC group presented with reocclusion, whilst 3 patients in the streptokinase group had reocclusions.(ABSTRACT TRUNCATED AT 250 WORDS)

Spin echo MRI in the evaluation of pericardial disease.

As in other pathological processes of the heart, the contribution of MRI is not limited to optimal anatomical evaluation but also offers functional or etiological information (approach of tissue characterization). In this work we report on our experience in evaluating normal and pathological pericardium with MRI spin echo sequences. The results with 41 patients, including pericardial effusion, thickening, and mass are discussed and confronted with previously reported data. Contrary to classical echocardiographic notions, pericardial effusions are more frequently in the anterior than posterior location (26/30 vs. 19/30 p less than 0.03). Not only does MRI provide a precise and positive diagnosis, but also a rather clear distinction appears in spin echo sequences between hemopericardium with high signal intensity and other effusions with lower signal (high intensity found in 6/6 patients with hemopericardium versus only 8/24 in the remaining group; p less than 0.01). When constriction signs are present, MRI solves the difficult differential diagnosis between pericardial thickening and restrictive cardiomyopathy. In paracardiac primary or metastatic tumors pericardial involvement is clearly demonstrated. Distinction between paracardiac, respectively pericardial cyst or false aneurysm is possible. We conclude that MRI is a new imaging method, complementary to echocardiography and/or computed tomography in the evaluation of pericardial pathology especially when hemopericardium, constrictive pericarditis, or tumoral etiologies are suspected. Important technological improvements are needed to solve the problem of long acquisition time and to improve the possibilities of tissue discrimination.

Detection and quantification of recent myocardial infarction: diagnostic value of multiecho multislice spin echo imaging.

Thirty-four patients with documented transmural MI were studied with gated three echo, multislice MR imaging. In 12 patients MRI MI size was compared with CK release measurement, Tl-201 SPECT defect, and with Tc-99m LVEF. Infarct was visualised in 29/34 patients on 3rd echo images (18/34 on 2nd and 6/34 on 1st echo images). Mean MR infarct size (planimetered from 3rd echo images): 33.1 +/- 9% overestimated the SPECT defect (mean value of 23.8 +/- 15%). However, the overall correlation between MRI and Tl-201 sizing was significant: r = 0.82; p less than 0.001; SEE = 5.5%. The correlation with LVEF also appeared significant: r = -0.61; p less than 0.038.

[Genetics of dilated cardiomyopathies]. / Génétique des cardiomyopathies dilatées.

So-called idiopathic dilated cardiomyopathy is a multifactorial condition. Its familial nature is increasingly commonly observed in genealogical studies. The Cardiomyopathy Working Group of the French Cardiological Society has recensed 31 families with two or more members with dilated cardiomyopathy. This led to the search for genetic abnormalities in this condition, as it has been performed in other diseases, especially primary hypertrophic cardiomyopathies.

[Detection of recent myocardial infarction by spin-echo MRI. Value of the third echo]. / Détection de l'infarctus myocardique récent par l'IRM en écho de spin. Intérêt du troisième écho.

Seventeen patients underwent MRI spin-echo imaging (Magniscan 5000) 7 to 21 days after acute myocardial infarction (10 anterior, 7 inferior--average 13.1 +/- 3.7 days). The success rate of visualisation of AMI evaluated independently by a qualitative score (from 0 to 4) based on the brilliance of the myocardial signal after taking steps to eliminate the brillance of pericardial fat and subendocardial flow signals, was 3.1 +/- 0.87 in anterior AMI (10 out of 10) and 1.28 +/- 1.25 (4 out of 7) in inferior AMI (p less than 0.007). The diagnostic sensitivity was increased when images of the third echo were used (13 out of 17) compared to those of the second echo (8 out of 17, p less than 0.016). The value of the 3rd echo is explained and emphasised. Abnormal intramyocardial signals were not recorded in a control group of 10 patients under similar conditions of multi-echo imaging. Finally, significant correlations were observed between peak CPK concentrations and the MRI score (r = 0.62; p less than 0.01) and between peak CPK and the number of sections in which the hyperbrilliant signal was observed (r = 0.74; p less than 0.001): this may open the day to quantification of myocardial necrosis by MRI.

[Coronary-left ventricular fistulae]. / Fistules coronaro-ventriculaires gauches.

The authors report a case of fistulae between the right and left coronary arteries and the left ventricle. A 58 year old man was investigated for inaugural unstable angina without infarction. Coronary angiography showed multiple communications between the terminal branches of the septal arteries of the left anterior descending, the terminal segments of the left diagonal and the terminal portion of the right coronary artery and the apical region of the left ventricle. Angiography in the ascending aorta confirmed the diagnosis of coronary-left ventricular fistulae. The dilatation and rapid emptying of the entire coronary circulation were indirect signs of increased flow due to the shunt. There was no coronary alternation or stenosis. The rarity of coronaro-cardiac fistulae, especially involving both main coronary arteries and the left ventricle, is emphasised. The symptoms of angina are explained by the coronary "steal" syndrome : the diagnosis is angiographic; rare cases with high flow and a favourable anatomical set up may be managed surgically.

[Drug therapy of acute myocardial infarction without cardiogenic shock and thrombolytic therapy excluded]. / Les traitements médicamenteux de l'infarctus aigu du myocarde en dehors du choc cardiogénique et à l'exclusion de la thrombolyse.

Myocardial infarction is responsible for 25,000 deaths per year in France and is a real problem of public health. The management of patients victims of this condition is an important feature of medical practice. Thrombolytic therapy has resulted in significant improvements in the reduction of the size of the infarct, in the conservation of left ventricular function and in the reduction of mortality. Treatment of the acute phase of myocardial infarction, especially when there are contra-indications to thrombolysis, comprises other approaches, some of which are old, which are reviewed in the light of the results of the latest large scale therapeutic trials.

[Two-dimensional echocardiography of ventricular aneurysm. Study of 38 cases with angiographic correlation]. / L'échocardiographie bidimensionnelle de l'anévrysme ventriculaire. Etude de 38 cas avec corrélation angiographique.

This is a study of the data supplied by cross-sectional echocardiography in the diagnosis of post-infarction aneurysm. It involves 38 confirmed cases of myocardial infarction. The clinical, electrical, radiological and echocardiographic data (in M mode) were specified. Right anterior oblique ventriculography showed 21 posterior and 17 anterior aneurysms (4 antero-lateral, 5 apical, 8 antero-apical), and 14 mitral regurgitations. Cross-sectional echocardiography using a (30 degrees or 90 degrees) mechanical sector scanner allowed the study of the kinetics of 6 segments following 5 viewing angles: one longitudinal, two transversal, two apical. Each segment was classified according to its shape and motion: akinetic, dyskinetic or aneurysmal, and the papillary muscles of the mitral valve were assessed as normal or pathological (dense and motionless on the echogram). 35 of the 38 aneurysms seen at angiography, were detected by cross-sectional echocardiography; in one case the diagnosis could not be made for technical reasons; in two cases echocardiography was in favour of akinesia. An abnormal papillary muscle was observed in the 14 cases of mitral insufficiency. The causes of error in localisation were considered. In conclusion, cross-sectional echocardiography appears to be an excellent atraumatic procedure for the diagnosis of aneurysms and papillary muscle dysfunction.

[Angina pectoris in a hypertensive patient with left ventricle hypertrophy: echo-angiographic comparisons]. / L'angor de l'hypertendu avec hypertrophie ventriculaire gauche. Confrontations écho-angiographiques.

Not every case of angina pectoris occurring in a hypertensive patient is indicative of coronary atherosclerosis. Nine patients with essential hypertension of moderate degree had attacks of angina of sufficient severity to require investigation by arteriography. In these patients, the coronary arteriogram was normal but ventriculography showed hypertrophy of the walls of the left ventricle of restrictive or obstructive type. These appearances were confirmed by echocardiography which also showed hypertrophy of the septum and, in certain cases, confirmed the involvement of the ventricle, while by contrast the electrocardiogram and radiological appearances of the heart were essentially normal. The beta-blockers may have an important part to play in such conditions, and echocardiography is suggested as part of the routine investigation in cases of hypertension.

[Echography after regularization of atrial fibrillation]. / Echographie après régularisation de la fibrillation auriculaire.

An echographic study was carried out on 17 patients before and after conversion of atrial fibrillation to normal rhythm. It showed up the moment of return of atrial contraction as a movement of the posterior wall of the left auricle and a reappearance of the 'a' wave or the anterior cusp of the mitral valve. The contraction can appear immediately after the electric shock, or may be delayed.

[Myocardiopathy with lipid overload and leukocyte palmityl carnitine transferase (PCT) deficiency]. / Myocardiopathie avec surcharge lipidique et déficit en palmityl carnitine transférase (PCT) leucocytaire.

Histological changes of the skeletal muscle with moderate fatty infiltration and varied abnormalities of the muscle fibres and conjunctivo-vascular tissue were demonstrated in three adult patients with apparently primary cardiomyopathy with dilatation. Leukocyte PCT activity was decreased and plasma carnitine was increased. In two cases, postmortem cardiac biopsy showed a massive accumulation of lipids and an intense progressive fibrosis dissociating the atrial and ventricular cardiac fibres. A disturbance of lipid metabolism could be the cause of this cardiac and skeletal muscle disease, but the reduced PCT activity could be a sign of more diffuse myocardial disease as suggested by the fibrous lesions and vascular abnormalities observed in our cases. These cases emphasise the value of routine investigation of PCT activity in primary cardiomyopathy and of ultrastructural studies of skeletal muscle, even in the absence of clinical involvement, which may show relatively severe changes reflecting the state of the myocardium.

[Clinical value of thallium-201 myocardial scintigraphy with dipyridamole performed before and after aortocoronary bypass]. / Intérêt clinique de la scintigraphie myocardique au thallium 201 sous dipyridamole pratiquée avant et après pontage aorto-coronarien.

In addition to preoperative coronary angiography, 63 patients undergoing coronary bypass surgery also had myocardial scintigraphy with dipyridamole 1 to 2 days before surgery, resting scintigraphy 10 after bypass and a repeat scintigraphy with dipyridamole 3 to 6 months later. The myocardium was divided into 5 segments. In each segment the perfusion was classified as: normal, presence of a reversible defect (redistribution), presence of a permanent defect (no redistribution). A comparison of pre-and postoperative scintigraphies led to the following conclusions. Three to six months after bypass, improved perfusion was observed in 65.6% os ischaemic segments, showing that surgery was very effective. On the other hand, the immediate postoperative control (10 days) only showed improved perfusion in 42.5% of the ischaemic segments: this interval was too short to appreciate the benefits of coronary bypass. There was a good correlation between the scintigraphic improvement after surgery and the reversibility of the zones of hypofixation of Thallium before surgery. When the defect was reversible, 80% of the revascularised segments were improved. Fifty-eight per cent of non-reversible defects before surgery were unchanged by the revascularisation procedure. However, the absence of redistribution during preoperative scintigraphy was not synonymous with definitive myocardial lesions and does not represent a contra-indication to coronary bypass surgery; in fact, improved perfusion was observed in 42% of these constant defects. The quality of recovery depends on the condition of the muscle: only segments with normal motion can be improved. Degradation of the clinical condition of patients was always related to aggravation(lack of improvement in 1 case) of scintigraphy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of transesophageal auricular stimulation for evaluating the accessory pathway and effect of treatment in Wolf-Parkinson-White syndrome]. / Intérêt de la stimulation auriculaire transoesophagienne pour évaluer la voie accessoire et l'effet du traitement dans le syndrome de Wolff-Parkinson-White.

In order to assess the value of the various atrial pacing techniques employed to evaluate the anterograde conduction of the accessory pathway and the effect of antiarrhythmic agents in Wolff-Parkinson-White syndrome, transesophageal atrial pacing was performed in 12 patients before and during treatment with oral flecainide acetate in doses of 200 mg per day. Before treatment, the shortest interval conducted with a 1/1 atrioventricular conduction by the accessory pathway ranged from 225 to 600 ms (mean 311 +/- 98 ms), and the effective refractory period of the accessory pathway, measured by the extrastimulus method in 11 patients, varied from 240 to 320 ms (mean 273 +/- 22 ms). These two values were very close in each patient and correlated well with each other (r = 0.90; p less than 0.001). Atrial fibrillation could be induced in 3 patients. Three patients were considered "at risk" since their effective refractory period or minimal R-R interval in atrial fibrillation was 250 ms or less. Tachycardia was induced in 8 patients, and it was possible to induce arrhythmias in the 6 patients for whom we had recordings in spontaneous tachycardia. Under treatment with flecainide acetate, an anterograde conduction block appeared in 3 patients. In the remaining 9 patients the shortest interval conducted with a 1/1 atrioventricular conduction by the accessory pathway was longer in every case: it ranged from 270 to 540 ms (mean 407 +/- 84 ms; p less than 0.001), which corresponded to a 20 to 240 ms prolongation (mean 133 +/- 78 ms).(ABSTRACT TRUNCATED AT 250 WORDS)

[Nuclear magnetic resonance in the diagnosis of aortic diseases]. / Apport de la résonance magnétique nucléaire dans le diagnostic des affections aortiques.

The diagnostic value of nuclear magnetic resonance imaging was assessed in a number of aortic pathologies: aneurysms of the thoracic and abdominal aorta, sinus of Valsalva aneurysms and dissection of the aorta. The imager was equipped with a resistor magnet providing a field of 0.15 Tesla. An electrocardiographic gating system was perfected. The images obtained were very satisfactory as they provided three dimensional morphological information and a qualitative assessment of blood flow. Further studies are now required with comparison with other invasive and non-invasive diagnostic methods to determine the clinical role of NMR imaging and to evaluate the diagnostic sensitivity and specificity of this new technique.

[Familial polymorph ventricular extrasystole associated with Pierre Robin syndrome]. / Extrasystolie ventriculaire polymorphe familiale associée à un syndrome de Pierre Robin.

In a family of 9 persons over 3 generations, 6 had incessant polymorphic ventricular extrasystoles, often in salves, resembling unsustained bidirectional ventricular tachycardia. Ventricular repolarisation was abnormal with giant U waves. Five persons had suffered syncopes. All had a facial abnormality: one woman had a complete Pierre Robin syndrome with mandibular hypoplasia, glossoptos and cleft palate; in the other cases, minor forms were observed, with micrognathia and ogival palate. Two patients had bone abnormalities of the feet with total agenesis of the last 2 phalanges of several toes. This familial polymorphic ventricular extrasystole with repolarisation abnormalities has many features in common with the congenital long QT syndrome; associated with the Pierre Robin syndrome and bone abnormalities of the extremities it would seem to be a new multiple congenital abnormalities syndrome.

[Value of nuclear magnetic resonance in dilated cardiomyopathy. Approach to intraventricular hemodynamics]. / Intérêt de l'IRM dans les myocardiopathies dilatées. Approche de l'hémodynamique intraventriculaire.

The value of magnetic resonance imaging (MRI) with multiechoes spin-echo sequences was investigated in 22 patients with dilated cardiomyopathy (group I) and 25 normal subjects serving as controls (group II). The results of MRI in group I were compared with those of echocardiography and radionuclide ventriculography. Measurements of left ventricular dimensions at echography and MRI showed a tendency, with MRI, to overestimate wall thickness and underestimate ventricular diameter. Thus, for diastolic LV we had 63.8 +/- 10.5 mm with MRI vs 70.6 +/- 7.6 mm with echography, the corresponding figures for posterior wall thickness being 112 +/- 1.4 mm vs 9.9 +/- 1.1 mm respectively. These differences seem to be due to MRI introducing a partial volume effect dependent on the thickness of slices and of their orientation in relation to the cardiac axis. MRI evaluation of left ventricular function by calculation of myocardial fibre shortening fractions correlated poorly with the echocardiographic value of the same parameter and with the radionuclide ejection fraction (r = 0.58 and 0.575 respectively; p less than 0.05). For better quantification of the cardiac pump function, planimetry of the endocardial contour during diastole and systole is required. It would seem that the value of MRI resides in the possibility it offers to explore left intraventricular haemodynamics by studying the "flow signal" obtainable from multiechoes sequences at different moments of the cardiac cycle. During systole, we found a left intraventricular signal that was reinforced on even echoes and much more intense in cardiomyopathy patients (scores = 1.61 +/- 1.06) than in controls (score = 0.77 +/- 0.7; p less than 0.01). The intensity score for this signal correlated with the ejection fraction in group I subjects (r = 0.82).

[Leiomyosarcoma of the left side of the heart with a mitral symptomatology. Echocardiographic study]. / Léiomyosarcome du coeur gauche à symptomatologie mitrale. Etude échocardiographique

A patient presented with the clinical findings of mitral stenosis, and angiocardiography revealed an intracardiac tumour. It was found at surgery to be a leiomyosarcoma, occupying almost the whole of the left auricle, and infiltrating the inter-atrial septum, the atrio-ventricular ring at the posterior commissure, and the posterior surface of the left ventricle. A mass with three lobes and a pedicle attaching it to the posterior wall and the ring of the mitral valve was found within the cavity of the left ventricle. The findings on echocardiography corresponded with the anatomical findings; but after surgery, ultrasonic investigation was found to be unreliable at detecting the unresected portion of the tumour, which was situated in the right postero-inferior region of the auricle of the left atrium.

[The spatial vectorcardiogram loop. Estimation of its planarity by the calculation of a distortion coefficient. Trial of clinical evaluation]. / Etude de la boucle du vectorcardiogramme spatial. Appréciation de sa planéité par le calcul d'un coefficient de gauchissement. Essai d'évaluation clinique.

Automatic techniques for interpreting the electrical activity of the heart are based more and more on vectorcardiographic parameters, especially information provided by the spatial vectorcardiographic loop. This data has been shown to be a useful complement to classical electrocardiography. The aim of this study was to define a method of calculation of the planes of the vectorcardiographic loops of depolarisation and repolarisation, and to calculate a coefficient of left-sidedness obtained by the sum of squares of the distances between the points on the loop in the plane. This value is then normalised with respect to the size of the loop. Normal values of this coefficient were first defined in a healthy reference population of 70 subjects: the values are expressed in (MV/10)2 or in mm2, and are 0,28 +/- 0,05 for the QRS and 0,0026 +/- 0,0008 for the ST-T. The coefficient was then calculated in different pathological groups, the diagnosis of which had been formally confirmed: ventricular hypertrophy, valvular heart disease, conduction defects, coronary artery disease. The highest values (four times normal) were obtained in right ventricular hypertrophy, right bundle branch block and infarction associated with conduction defects. The discriminative value of the coefficient of left-sidedness is discussed with the aim of distinguishing the normal from the pathological.

[Coronary lesions in myocardial infarction]. / Bilan lésionnel coronarien dans l'infarctus du myocarde.

The authors analyse the coronary lesions in 285 patients with primary myocardial infarction (164 anterior, 121 inferior infarcts) undergoing coronary angiography an average of 4 months after infarction. The statistical study of the analytical table of the lesions according to severity and site, demonstrated a significant difference in each group (p less than 0,001): --there was a very clear dominance of occlusion of the LAD artery in anterior infarction but severe narrowing (greater than or equal to 70%) was observed mainly on the right coronary and left circumflex arteries; --in inferior infarction, the incidence of occlusion was higher on the right coronary artery and severe narrowing was divided between the LAD and left circumflex arteries. Controlateral, double or triple vessel disease was present in 74% of anterior and 85% of inferior infarcts. There were many more patients with double and triple vessel lesions than with single vessel disease. Residual angina gave no indication of the extension of the lesions in anterior infarction but patients with this complication after inferior infarction had a higher rate of triple vessel disease. Stress testing is exploitable in inferior infarction but did not give any discriminating results. In this series, angina and stress testing only allowed triple vessel disease to be suspected in patients with inferior infarction. A coronary arteriographic study, by showing the severity and controlateral extension of the lesions, comparable in primary anterior and inferior infarction, gives important prognostic information and allows assessment of surgical possibilities.

[Induction of ventricular tachycardia by esophageal stimulation. Apropos of 2 cases]. / Déclenchement d'une tachycardie ventriculaire par stimulation oesophagienne. A propos de 2 observations.

The utility of transesophageal atrial pacing in sustained left ventricular tachycardia is reported in two cases. A 46 year old man without any apparent cardiac disease presented with invalidating but undocumented palpitations. Transesophageal atrial pacing with isoproterenol infusion induced wide complex tachycardia with a right bundle branch block morphology and left axis deviation. Atrio-ventricular dissociation was observed and it was possible to reduce the ventricular complex width by rapid transesophageal atrial pacing: the tachycardia was terminated by an injection of verapamil. It was not possible to reinduce the tachycardia after treatment with atenolol 100 mg/day, introduced because of the catecholinergic nature of the arrhythmia. The patient is symptom free after 2 years of treatment with this drug. Regular wide complex tachycardia with right bundle branch block and left axis deviation without any detectable atrial activity was recorded in a 50 year old man without known cardiac disease. Transesophageal atrial pacing with isoproterenol infusion induced an identical tachycardia. The tachycardia started after a normally conducted atrial extrastimulus followed by ventriculo-atrial dissociation and it was possible to overdrive with atrial pacing. The tachycardia could not be reinduced after treatment with atenolol and the patient is asymptomatic 12 months later. These reports show that it is possible to study certain ventricular tachycardias by transesophageal atrial pacing. The efficacy of antiarrhythmic therapy can be controlled simply by this non-invasive technique.