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Background: Chronic heart failure, is increasing due to the aging population and improvements in heart disease detection and management. The prevalence is estimated at ~10% of the French general practice patient population over 59 years old. The primary objective of this study is to improve the quality of life for heart failure patients though a complex intervention involving patient and general practitioner (GP) education in primary care., Methods: A randomised, cluster controlled trial, stratified over 4 areas of the Auvergne region in France comparing intervention and control groups. The inclusion criteria are: patients older than 50 years with New York Heart Association (NYHA) stage I, II, or III heart failure, with reduced ejection fraction or with preserved ejection fraction. Heart failure should be confirmed by the patient's cardiologist according to the European Society of Cardiology guidelines criteria. The exclusion criteria include: severe cognitive disorders, living in an institution, participating in another clinical trial, having NYHA stage IV heart failure, or a lack of French language skills. The complex intervention consists of training at the GP practice with an interactive 2-day workshop to provide a patient's education programme. GPs are trained to perform case management, lifestyle counselling and motivational interviewing, to educate patients on the main topics including clinical alarm signs, physical activity, diet and cardiovascular risk factors. The patients' education sessions are scheduled at 1, 4, 7, 10, 13 and 19 months following the start of the trial. The primary outcome to be assessed is the impact on the quality of life as determined using two questionnaires: the Minnesota Living with Heart Failure Questionnaire and SF-36. To detect a difference in the mean quality of life at 19 months, we anticipate studying a minimum of 400 patients from 80 GPs., Discussion: This trial will provide insight into the effectiveness of a complex intervention to educate patients with heart failure including a 2-day GP workshop and patients' education programme in the setting of a GP consultation to improve the quality of life in patients with chronic heart failure. This complex intervention tool could be used during initial and further medical training., Trial Registration: ETIC is a cluster-randomised, controlled trial registered on ClinicalTrials.gov [ NCT01065142 , 2010, Feb 8] and the French drug agency [Agence Nationale de Sécurité du Médicament et des produits de santé; registration number: 2009-A01142-55, on March 5th, 2010].

The purpose of this study was to examine the limitations of therapeutic education for patients with cardiovascular risk factors during short hospital stays. The paper presents the results of a qualitative study conducted over the course of a year involving 18 case studies of professional practices and 18 interviews with 5 health professionals and 13 patients. The results show that professionals and patients have conflicting views about the time spent in hospital, as well as conflicting concerns and expectations, thus limiting the effectiveness of educational care. The findings suggest that after acute myocardial infarction or a stroke, patients tend to view themselves as survivors during their experience of short-term hospitalization in a care unit. As a result, short-term hospitalization may not be conducive to the mobilization of patients' cognitive and emotional capacities in a therapeutic education program.

Background: Optical coherence tomography is an imaging method that enables cardiologists to study atheromatous plaques, and to check the implantation and evolution of coronary stents. It is an invasive technique, providing high-resolution (10 microm) in vivo images, but with limitations and artefacts that need to be understood before the field of application can be extended., Aim: To determine the feasibility and limitations of optical coherence tomography coronary imaging from a single-centre experience., Methods: We analysed the first 301 optical coherence tomography (version M2, LightLab Imaging) sequences obtained in our department from examination of 73 patients., Results: Results showed that 92% of sequences for selected lesions were usable, with a mean examination time of 17 min. Only one complication occurred (ventricular fibrillation, reduced by external electroshock). In our registry, sequence quality depended on operator experience (improving after 20 examinations), and was impaired by artefacts, especially in right coronary analysis and in arteries of greater than 3.5 mm calibre., Conclusions: Proximal coronary occlusion and the distal flush quality currently required for quality imaging should no longer be indispensable with the new generation of optical coherence tomography systems., (Copyright 2010 Elsevier Masson SAS. All rights reserved.)

Spontaneous coronary artery dissection (SCAD) is a rare pathology, principally affecting young women free of atheroma risk factors. Its physiopathology remains little understood, and the prognosis for such acute coronary syndromes is poor, as they occur suddenly. Management is often difficult, and no guidelines exist. The present single-center retrospective study concerns 12 cases of SCAD occurring between 2001 and 2008 in female patients under the age of 60. Eleven patients survived, with a favorable long-term evolution. Only 2 had conservative medical therapy, the other 10 undergoing percutaneous coronary intervention (2 procedures involving a coronary artery bypass graft). On the basis of this series and data from the literature, we suggest a strategy to improve the often dire prognosis of SCAD. Emergency angiography to confirm diagnosis is essential. Treatment should be guided by the extent of the lesions, the myocardial ischemia and the hemodynamic status. Conservative medical therapy is a reasonable approach in the case of distal dissection or conserved coronary flow. Percutaneous coronary intervention is feasible in the acute phase to restore coronary perfusion and hemodynamic stability. Surgery - emergency bypass or assisted circulation - should be restricted to cases where percutaneous coronary intervention has failed or is impossible., ((c) 2009 S. Karger AG, Basel.)

Background: Intrastent thrombosis, while rare, has a poor prognosis. Strut non-coverage is one causal factor, especially in cases of resistance to or premature discontinuation of dual antiplatelet therapy., Aim: To compare neointimal coverage with paclitaxel and zotarolimus drug-eluting stents, using optical coherence tomography (OCT)., Methods: Twenty-two drug-eluting stents (11 paclitaxel-eluting stents and 11 zotarolimus-eluting stents) were examined by OCT, 6 months after implantation. Mean neointimal strut-coverage thickness and percentage neointimal hyperplasia were measured every millimetre. On each OCT image, struts were classified into one of four categories: well-apposed to vessel wall with apparent neointimal coverage; well-apposed to vessel wall without neointimal coverage; malapposed to the vessel wall; or located on a major side branch., Results: OCT analysis showed a lower percentage of neointimal hyperplasia with paclitaxel-eluting stents than with zotarolimus-eluting stents (17% vs 38% and mean thickness 154 microm vs 333 microm, respectively; p<0.0001). The rate of strut-coverage was greater with zotarolimus-eluting stents than with paclitaxel-eluting stents (99.1% vs 87.1%, respectively; p<0.0001). A non-covered/covered strut ratio greater than 0.3 was observed in 0.5% of zotarolimus-eluting stent OCT images compared with 18% of paclitaxel-eluting stent OCT images (p<0.0001)., Conclusion: Six months after implantation, neointimal hyperplasia was greater with zotarolimus-eluting stents compared with paclitaxel-eluting stents. Conversely, neointimal strut-coverage was better with zotarolimus-eluting stents.

Introduction: Thromboembolic accidents and haemorrhage are the main complications observed during long-term follow-up of mechanical heart valve patients. Several suggestions for improving anticoagulation quality have been made, including international normalised ratio (INR) self-monitoring., Objectives: We report the preliminary results of a single-centre, open, randomised study (scheduled population of 200 patients), which compares monthly laboratory monitoring (group A) versus weekly self-monitoring of INR (group B). The primary aim is INR stability improvement within the target range, and the secondary aim is adverse events reduction., Patients and Methods: Between May 2004 and June 2005, 67 patients with an average age of 56.6 years (+/-9.6), were enrolled in the study (group A: 34 patients, group B: 33 patients). The mean follow-up was 47 weeks (+/-11.5). The two groups differed only in the sex ratio (44.1 and 21.2% of women in groups A and B respectively, p=0.0459). Mechanical heart valves were aortic in 73% of patients, mitral in 13.5%, and multiple in 13.5%. Sixty-five patients (97%) were treated with fluindione, the others with acenocoumarol. The intraclass correlation coefficient between the self- and laboratory-monitored INR was 0.75., Results: The time spent in the INR target range (group A: 53+/-19%, group B: 57+/--19%, p=0.45) and the time spent in the INR therapeutic range, between 2 and 4.5, (group A: 86+/-14%, group B: 91+/-7%, p=0.07) are longer in group B, but not significantly so. For patients outside the range, the absolute mean deviation of INR from the target or therapeutic range (range standardized between 0 and 100) is lower for the self-monitoring group (41.1+/-39.3 and 11.27+/-11.2) than for the control group (62.4+/-72.6 and 39.2+/-52.8). This difference is significant (p=0.0004 and p=0.0005). Eighteen adverse events were reported: 17 haemorrhages, 13 in group A (9 mild, 4 serious) and four in group B (all mild), and one sudden death in group B, two days after the patient's discharge. No thromboembolic events were reported. Six patients (8.8 %), 3 in each group, dropped out of the study., Conclusion: This first study evaluating INR self-monitoring in France shows that this method leads to better stability of the INR within the target range. On the basis of these preliminary data, this appears to be related to a decrease in serious haemorrhages (11.8% serious haemorrhage cases in group A versus 0% in group B, p=0.06, NS).

Occult cardiac injury following blunt trauma is more common than generally suspected. Myocardial contusion is not rare, however, it is generally a benign disorder which often remains undiagnosed. We report a case of a right atrial rupture after blunt chest trauma causing a tamponade. A 24-year-old man was involved in a violent car accident and he presented in a state of collapse. A multislice computed tomography indicated a pericardial effusion (Figure 1). A transthoracic echocardiography was performed and confirmed pericardial effusion which was hyperechoic (Figure 2, Movie 1). Concerns about a possible mass in the right atrium led to examination with transesophageal echocardiography (Figure 3, Movie 2) which revealed the presence of a voluminous mass in the right atrium. The patient successfully underwent cardiac surgery to remove the mass, identified as a blood clot, and to repair the atrial tear. The present case is of special interest because of the rarity of documented incidents of blunt chest trauma causing right atrial tear and illustrates the usefulness of transesophageal echocardiography in completing the diagnosis in the event of haemopericardium.

Kawasaki disease is an inflammatory arterial disease of unknown cause usually affecting young children, the principal complication of which is coronary artery aneurysm. Early treatment with immunoglobulins and aspirin prevents this complication. The diagnosis requires expert clinical criteria and, in atypical forms, a more recent decisional diagnostic tree has to be used. The authors report 6 cases of adult Kawasaki disease. As in the other sixty or so cases in the literature, hepatic forms were the commonest (5/6). Only three of the six cases met the classical clinical criteria and the diagnosis was made by the decisional tree or after coronary complications in the oldest subject. The five treated patients progressed favourably after a course of immunoglobulins. Echocardiography detected 100% of children with coronary disease but it was more difficult in adults in whom new non-invasive methods of coronary imaging (fast CT and MRI) and stress testing should complete the investigations. The association of prolonged pyrexia, clinical criteria and a biological inflammatory syndrome should, after exclusion of the differential diagnoses, suggest a diagnosis of Kawasaki disease in the adult as in the child. The possibility of coronary disease, even though extremely rare, should be recognised by the cardiologist and lead to diagnostic and therapeutic managements as aggressive as in children.

The authors report the case of a 39 years old woman operated for tetralogy of Fallot at the age of 6. Multiple complications due to postoperative atrioventricular block and a poor surgical result on the pulmonary outflow tract led to several reoperations. Right ventricular dysfunction with pulmonary regurgitation and mitral tricuspid valve disease in a context of endocarditis on the pacing catheter led to double pulmonary and tricuspid valve replacement with mechanical prostheses. The outcome at follow-up at 3 years is good. To the authors' knowledge, this is the first reported case of double mechanical valve replacement of the right heart after complete repair of tetralogy of Fallot.

Aims: The comparison of three imaging methods to determine which is the most accurate and reliable for the detection of right-to-left shunt., Methods and Results: One hundred and seven patients who were hospitalized for stroke underwent: a transthoracic echocardiography (TTE) using second harmonic, a transcranial Doppler (TCD) and a transesophageal echocardiography (TEE) from August 2003 to April 2004. All studies were recorded on a videotape and were studied by a physician blinded to the study. With TTE and TEE, we found 44 (41%) patent foramen ovales. All contrast tests were positive with TCD for these 44 patients. For two patients, the contrast test was positive only with TTE and TCD. We found four false negative contrast tests with TTE. Among the 63 patients who had a negative contrast test with TEE and TTE, the results were the same with TCD for 59 of them; we were not able to determine a cause for the four positive tests., Conclusion: This study confirms that transesophageal echocardiography has limitations in the diagnosis of patent foramen ovale. In this study, the negative predictive value of transcranial Doppler was excellent. Therefore, this examination is able to exclude a patent foramen ovale with a high level of confidence.

Fibroblastic endocarditis is a classic complication of prolonged hypereosinophilic syndrome, whatever the cause. In France, it is most frequently encountered in cases of idiopathic hypereosinophilic syndrome. It commonly involves the apex of the ventricles, with a clinical picture of restrictive cardiomyopathy of unfavorable prognosis, and the auriculoventricular valves. We report the case of a 77-year-old man in whom atypical cardiac involvement disclosed idiopathic hypereosinophilic syndrome. In addition to the usual features of obliteration of the apex and restrictive cardiomyopathy, echocardiographic examination showed severe left ventricular dysfunction and intracardiac tumors, one of which was unusually localized to an aortic valve. Treatment, which comprised strict control of the eosinophilic process, standard treatment for cardiac failure, and anticoagulation therapy, produced rapid and long-lasting improvement of his clinical status and left systolic and diastolic ventricular function, and on echocardiography the intracardiac tumors had totally disappeared. The patient suddenly died of septic shock 16 months after first being seen.

The authors report the case of a 64 year old woman with typical valvular pulmonary stenosis in whom spontaneous and sudden reopening of the foramen ovale resulted in cyanosis. Transthoracic echocardiography with injection of contrast provides a complete diagnosis: valvular pulmonary stenosis with a mean pressure gradient of 83 mmHg and massive right-to-left interatrial shunt. The malformation was treated by interventional catheterisation in a two-stage procedure: pulmonary valvuloplasty followed by closure of the foramen ovale because of the persistence of a right-to-left interatrial shunt. The functional improvement was followed by the appearance of effort angina. Coronary angiography showed single vessel disease of the left anterior descending artery treated by stenting. The long-term outcome was satisfactory.

Objectives: This ancillary study of the Comparison of Angioplasty and Pre-hospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) trial sought to assess the cost-efficacy ratio of primary coronary angioplasty (PCA) and pre-hospital thrombolysis (PHT) in patients suffering from an acute myocardial infarction (AMI) (<6 h) close to (<60 min journey) a percutaneous coronary intervention (PCI) center., Background: In the CAPTIM study, at 30 days follow-up PCA was as equally effective as PHT with rescue angioplasty if needed. The cost efficacy of these two strategies has not yet been compared., Methods: Data were prospectively collected for 299 patients in three centers. The efficacy analysis was extended at one-year follow-up for those patients. Direct fixed and variable actual costs were assessed with a piggyback data collection., Results: The one-year primary end point event-rate (death, non-fatal myocardial infarction, and stroke) was not different after PCA or PHT (14% vs. 16. 4%, p = NS). Costs were lower in the PCA group either during the in-hospital period (8,287 vs. 9,170 $, p = 0.0001) and after one-year follow-up, in relation to a higher rate of subsequent revascularizations in the PHT group (49% vs. 23%, p < 0. 01), leading to a longer hospital stay (10 vs. 9.1 days, p = 0. 03)., Conclusions: After AMI in patients less than 1 h from a PCI center, PCA is as effective and less costly than a combined strategy of PHT followed by rescue angioplasty.

Rapid advancement in telecommunication technology has made possible automatic periodic transmission of pacemaker and implantable defibrillator data to the attending physician (home monitoring). Furthermore, technology using remote control software allows, through device programmers, interrogation of the device memory, permitting remote monitoring by physicians or technical support of the manufacturer. Potential applications of these two capabilities include a close watch over the functioning of the devices, ability to obtain an earlier diagnosis (and management) of arrhythmic events, and assistance at the time of implant procedure and routine follow up. Finally these new tools raise several questions concerning safety aspects (including reliability of transmission, encrypted transfer, restricted access of the central database), economic aspects, and physician and manufacturer's liability.

Floating thrombus in the aortic arch is a rare and often under-diagnosed source of peripheral arterial embolic events. We report a case of a patient seen with arterial embolic events: ischemia of the left superior limb and transient stroke. The diagnosis was performed with transesophageal echocardiography and computed tomography. The thrombus completely disappeared after 15 days of oral anticoagulant therapy. Although rare, this diagnosis mustn't be overlooked in the search for an etiology of recurrent and disseminated peripheral ischemic events because the detrimental functional risk related to a delayed diagnosis.

Background: Although both prehospital fibrinolysis and primary angioplasty provide a clinical benefit over in-hospital fibrinolysis in acute myocardial infarction, they have not been directly compared. Our aim was to find out whether primary angioplasty was better than prehospital fibrinolysis., Methods: We did a randomised multicentre trial of 840 patients (of 1200 planned) who presented within 6 h of acute myocardial infarction with ST-segment elevation, initially managed by mobile emergency-care units. We assigned patients to prehospital fibrinolysis (n=419) with accelerated alteplase or primary angioplasty (n=421), and transferred all to a centre with access to emergency angioplasty. Our primary endpoint was a composite of death, non-fatal reinfarction, and non-fatal disabling stroke at 30 days. Analyses were by intention to treat., Findings: The median delay between onset of symptoms and treatment was 130 min in the prehospital-fibrinolysis group and 190 min (time to first balloon inflation) in the primary-angioplasty group. Rescue angioplasty was done in 26% of the patients in the fibrinolysis group. The rate of the primary endpoint was 8.2% (34 patients) in the prehospital-fibrinolysis group and 6.2% (26 patients) in the primary-angioplasty group (risk difference 1.96, 95% CI -1.53 to 5.46). 16 (3.8%) patients assigned prehospital fibrinolysis and 20 (4.8%) assigned primary angioplasty died (p=0.61)., Interpretation: A strategy of primary angioplasty was not better than a strategy of prehospital fibrinolysis (with transfer to an interventional facility for possible rescue angioplasty) in patients presenting with early myocardial infarction.

The authors report a spontaneous, unusual complication of coarctation of the aorta. An 11 year old child was admitted for investigation of chest pain. Cardiovascular examination revealed typical clinical signs of coarctation of the aorta. Neurological examination found neck stiffness without headache or deficit. The presumptive diagnosis of dissection of the aorta was infirmed by echocardiography and MRI. The latter investigation, with views of the spinal cord, revealed a compressive medullary extradural haematoma. Antihypertensive therapy and corticosteroids with strict bed rest resulted in complete regression of the haematoma and the coarctation was operated 6 months later. Medullary complications of coarctation of the aorta are usually postoperative. Spontaneous complications are exceedingly rare but very serious: medullary compression by the dilated anterior spinal artery or rupture of an aneurysmal collateral vessel. In this case, magnetic resonance imaging led to diagnosis and effective early treatment of this complication before the patient developed a neurological deficit and the coarctation was treated surgically thereafter.

Dobutamine stress echocardiography (DSE) and exercise stress echocardiography (ESE) are widely used for diagnosis of coronary artery disease. Each of these methods has limitations: secondary effects of Dobutamine, poor imaging quality, difficulty in attaining the maximal heart rate. The authors evaluated a test associating pedalling exercise at a constant low load (30-60 watts) with Dobutamine infusion (10-20-30-40 j/Kg/min +/- Atropine) (DES + E) in 42 patients referred for suspected coronary artery disease. All patients underwent coronary angiography on Day 1. There was significant coronary disease (> 50% stenosis) in 19 of the 42 patients. Sensitivity, specificity, negative predictive value, positive predictive value and overall diagnosis value were respectively 84, 87, 84, 87 and 86%. In the first 20 patients, the DES + E was compared directly with DES: There was only one undesirable side effect (hypertension) with DES + E compared with 5 with DES alone. The target heart rate was attained with lower doses of Dobutamine with DES + E (32.35 vs 39.42 j/Kg/min, p = 0.05). DES + E therefore seems to be a promising technique which is better tolerated than DES alone with very satisfactory diagnostic performances. However, these results require further confirmation in larger numbers of patients.

The objective of permanent pacemaker implantation is to provide against an increased risk of death or to improve quality of life by abolishing symptoms. In both cases, certain indications for pacing have clearly demonstrated to be strongly beneficial in well selected patients, but other are still controversial, due to the lack of convincing and converging published data, or to the absence of general consensus among specialists, or because selection criteria for pacing have been poorly defined. We try to clarify when to pace or not to pace in such conditions as first degree AV block, type I second degree AV block, intracardiac conduction defects, including those occurring at the acute stage of myocardial infarct or after cardiac surgery, sick sinus syndrome in cardiac transplant recipients, carotid sinus syndrome, vasovagal syncope, and unexplained syncopes.

In this prospective study we evaluated the efficacy of a battery of noninvasive tests including clinical evaluation (CE), exercise testing (ET), and dobutamine stress echocardiography (DSE) for assessment of cardiac risk in 90 patients indicated for aortic reconstruction. As the gold-standard reference technique, coronary arteriography was performed in each patient after noninvasive evaluation. The sensitivity of CE was low (61%). ET proved to be more sensitive (71.4%) and highly specific (95.8%) but feasibility (77%) and diagnostic accuracy (42%) were low. DSE demonstrated acceptable sensitivity (78%) and specificity (75.5%) with high feasibility (94.5%) and diagnostic accuracy (100%). None of the four patients with false negative ET results and only one of seven with false-negative DSE required coronary bypass. On the basis of these findings we conclude that a combination of CE and ET with DES, if necessary, can reliably assess cardiac risk before aortic reconstruction. Noninvasive assessment is a reliable alternative to routine coronary arteriography.

Although coronary stenting reduces the incidence of post-angioplasty restenosis, it remains a problem. The influence of lipoproteins on the development of atherosclerosis has been demonstrated but their role in restenosis is controversial. Contradictory results have been published on the subject of the influence of the APO E genotype. In an initial study, the authors showed a closer correlation between Lp (a) and coronary artery disease in women than in men. A sub-group of women who underwent angioplasty and whose lipid profile had been well established, was analysed with respect to APO E alleles. The 59 patients who underwent angioplasty included 35 single, 20 twin and 4 triple vessel diseases. Control coronary angiography was performed in 40 of these women. A telephonic interview was carried out between 12 and 22 months after dilatation on the whole population. The apolipoproteins A1, B, Lp (a) and Lp A1 were measured by immunological, turbidimetric or electroimmunological techniques. The APO E genotyping was performed with the Inno-Lipa kit. The results showed 18 angiographic restenoses (Group A), 20 coronary artery disease without restenosis (Group B), 41 without angiographic (20) or clinical (21) restenosis (Group C). In Group A, the Lp (a) was well above the threshold value of 0.30 g/l. The e4 allele was associated with the highest values of total and LDL cholesterol fractions. There was no significant difference between the APO E genotype of the different groups or with respect to the severity of lesions. The authors conclude that if the e4 is more commonly associated with high LDL-cholesterol and Lp (a), its role in the process of restenosis remains unproven. A greater number of patients is required and further studies are desirable to determine the inflammatory and/or immunological mechanisms through which APO E could influence restenosis.

Left triatrial heart is defined as division of the left atrium into two chambers, proximal and distal, by a variably perforated membrane. The data of appearance of symptoms, often in early childhood, is related to the degree of obstruction and the presence or not of an inter-atrial shunt. Widescale usage of echocardiography, the investigation of choice for this diagnosis, has led to the detection of this abnormality in older patients, sometimes asymptomatic, without pulmonary hypertension. Three adults were referred for transthoracic and transoesophageal echocardiography to investigate systemic embolic disease (2 cerebral, 1 mesenteric). Two other adults underwent the same investigations for diagnosis of the aetiology of atrial fibrillation with mitral regurgitation. Two cases were asymptomatic children, one with a clinically benign murmur and the other with ventricular extrasystoles with no malignant features. In these seven cases, transthoracic (n = 5) and/or transoesophageal (n = 7) echocardiography demonstrated a left atrial membrane corresponding to the classical description of cor triatrium. The Doppler study showed no obstruction in 6 cases and minimal obstruction in 1 case. In our series, as in similar cases reported in the literature, the diagnosis of a left atrial membrane did not lead to surgery. Although we do not know the long-term outcome of this abnormality in asymptomatic children, the observations of complications in the adult suggest a potential of evolution which poses the question of optimal management.

Objectives: This study sought to determine whether pravastatin affects clinical or angiographic restenosis after coronary balloon angioplasty., Background: Experimental data and preliminary clinical studies suggest that lipid-lowering drugs might have a beneficial effect on restenosis after coronary angioplasty., Methods: In a multicenter, randomized, double-blind trial, 695 patients were randomized to receive pravastatin (40 mg/day) or placebo for 6 months after successful balloon angioplasty. All patients received aspirin (100 mg/day). The primary angiographic end point was minimal lumen diameter (MLD) at follow-up, assessed by quantitative coronary angiography. A sample size of 313 patients per group was required to demonstrate a difference of 0.13 mm in MLD between groups (allowing for a two-tailed alpha error of 0.05 and a beta error of 0.20). To allow for incomplete angiographic follow-up (estimated lost to follow-up rate of 10%), 690 randomized patients were required. Secondary end points were angiographic restenosis rate (restenosis assessed as a categoric variable, > 50% stenosis) and clinical events (death, myocardial infarction, target vessel revascularization)., Results: At baseline, clinical, demographic, angiographic and lipid variables did not differ significantly between groups. In patients treated with pravastatin, there was a significant reduction in total and low density lipoprotein cholesterol and triglyceride levels and a significant increase in high density lipoprotein cholesterol levels. At follow-up the MLD (mean +/- SD) was 1.47 +/- 0.62 mm in the placebo group and 1.54 +/- 0.66 mm in the pravastatin group (p = 0.21). Similarly, late loss and net gain did not differ significantly between groups. The restenosis rate (recurrence > 50% stenosis) was 43.8% in the placebo group and 39.2% in the pravastatin group (p = 0.26). Clinical restenosis did not differ significantly between groups., Conclusions: Although pravastatin has documented efficacy in reducing clinical events and angiographic disease progression in patients with coronary atherosclerosis, this study shows that it has no effect on angiographic outcome at the target site 6 months after coronary angioplasty.

The detection of coronary artery disease is essential before abdominal aortic surgery. In view of the limitations of the usual methods of investigation, dobutamine stress echocardiography was assessed in this indication. Eighty-five patients with an aortic abdominal aneurysm or obstructive arterial disease underwent dobutamine stress echocardiography followed by coronary angiography. Depending on the results, vascular surgery was performed directly, after myocardial revascularisation or not at all. Significant coronary lesions (stenosis > or = 50%) were found in 32 of the 85 patients (38%). Dobutamine stress echocardiography had a sensitivity of 78% and a specificity of 75%, and positive and negative predictive values of 66 and 85% respectively. The relative risk of coronary disease was 4.4. In this series, 15 patients had severe coronary lesions: 2 were turned down for surgery and 13 underwent myocardial revascularisation; 14 of them (93%) had a positive stress echo. The only 2 non-fatal cardiac complications of peripheral surgery (3%) occurred after a positive dobutamine stress echo. This study confirms both the necessity of preoperative assessment of coronary risk and the efficacy of dobutamine stress echocardiography in this indication. Dobutamine stress echocardiography is reliable, non-invasive, economical and a real alternative to isotopic methods. Its good predictive value justifies using coronary angiography only for patients with a positive result.

The authors present a novel method to estimate absolute blood flow velocity in coronary arteries from biplane angiograms. Spatial and temporal velocity variations are derived giving simultaneously a direct geometric and an indirect functional index of stenosis severity, stenosis ratio and coronary flow reserve. No prior assumption concerning stenosis geometry is made. Deformable models are used to track a coronary artery segment dynamically in three dimensions. A densitometric map is obtained by summing densities across sections at every position along the previously calculated path and at every time of the cardiac cycle. An advection relationship between density and velocity is observed. The spatiotemporal velocity map is a solution of a nonlinear least-squares scheme. A simulation protocol based on simple geometric conformations and blood flow properties is used to assess numerical stability and immunity towards noise. Predicted results for temporal velocity variations are compared with the intracoronary Doppler recordings to test the model assumptions for basal state and hyperaemia examinations of the same patient. The stenosis ratio was accurate to within 3% for a simulated additive Gaussian noise with a standard deviation of 0.14. The limits of agreement between angiographic and Doppler velocities were -11.4 and 11.8 cm s-1 for a peak value of 23 cm s-1 (basal state) and -16.8 and 13.5 cm s-1 for a peak value of 52 cm s-1 (hyperaemia), corresponding to 18 and 3.5% errors on the average peak values and a 16% error on the coronary flow reserve. To summarize, the advection model derivation and its solution are presented. Simulated and experimental results corroborate the validity of the numerical schemes and support clinical applicability.

The aim of this study was to determine the diagnostic efficiency of transesophageal echocardiography (TEE) in isthmic aortic ruptures and to describe the echocardiographic Doppler anomalies. TEE was performed prospectively for 18 months in 33 patients with serious polytraumas requiring intensive care. The average age was 40.75 years (range, 17 to 78 years). Single or biplanar TEE was used. In three patients with aortic transection, echocardiography showed an intimal flap thicker than that of dissections. The flaps were torn and retracted on the free edge. It was difficult to distinguish the periaortic hematoma. Doppler imaging showed turbulent flows in several places around the aorta. These flows were especially visible at the beginning of the intimal flap. They were visible on M-mode color imaging during systole and diastole. During diastole, a large color flow was observed in the middle of the aortic lumen. It was turbulent in some places and mimicked the systolic filling of the aorta. These flows create the characteristic "to and fro sign" spectrum of Doppler imaging, usually seen in peripheral false arterial aneurysms. TEE findings were confirmed in two cases by surgery and in one case by aortography. TEE seems to be an effective means of detecting isthmic rupture, with the diagnosis resting on the data obtained from echocardiography and Doppler imaging. A suspected isthmic disruption should be assessed by an emergency TEE and aortography used only for uncertain or complex cases.

Silent or painless myocardial ischaemia is common: it can occur in totally asymptomatic patients, in stable or unstable angina sufferers, or after infarction. In most instances, it is detected electrocardiographically (or ambulatory recording by treadmill test). It is essential to establish a firm diagnosis because patients are high-risk subjects. Tomoscintigraphy or echocardiography, on exertion or after drug stimulation, are therefore to be used before it is decided to perform coronary angiography. In all cases treatment is required to suppress ischaemia. It should primarily be medical, the choice being governed by the results of exploration, and should bear upon anatomical lesions and their functional effects. Revascularization, generally by angioplasty, is thus increasingly indicated despite the fact that, in contrast to painful ischaemia, there are no comparative studies available on painless ischaemia to help guiding the treatment decision.

Chronic total coronary occlusion remains one of the limitations of percutaneous transluminal coronary angioplasty, and few therapeutic devices are specifically designed to address this problem. Among such devices, low-speed rotational angioplasty could improve the primary success rate of the procedure but has never been studied in a controlled trial. One hundred consecutive patients with total coronary occlusion (duration 10 days to 1 year) and an indication for myocardial revascularization were randomized to either rotational or conventional angioplasty if the occlusion morphology was judged suitable for either technique. All baseline variables were evenly distributed among the 2 groups. The primary success rate in the rotational angioplasty groupø was 66% (33 of 50) compared with 52% (26 of 50) in the conventional angioplasty group before crossover to the rotational technique (p=NS). According to lesion morphology, the respective primary success rates were 77% (10 of 13) versus 92% (11 of 12) for tapered occlusions (p=NS), and 61% (22 of 36) versus 38% (14 of 37) for "stump-like" occlusions (p < 0.05). After taking into account the crossovers after failed conventional angioplasty, there was no benefit in performing rotational angioplasty first versus conventional angioplasty first (primary success rates 66% vs 60%, p=NS). Thus, in chronic coronary occlusions of tapered morphology, rotational angioplasty is not superior to conventional angioplasty. In stump-like occlusions, the primary success rate is higher with the rotational angioplasty technique; however ther is a disadvantage in using rotational angioplasty as a second-line device if the conventional technique is unsuccessful.

Radionuclide angiography at rest or on effort is one of the most valuable diagnostic and prognostic non-invasive methods for investigating left ventricular function. This procedure provides perfectly reproducible quantitative information; However, its usefulness in detecting myocardial ischaemia is debatable: on the other hand, its prognostic value is uncontested and its role in therapeutic assessment, especially in myocardial infarction, is growing.