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OBJECTIVES We sought to evaluate whether cellular mass changes (including apoptosis and proliferation) after arterial injury could interact with restenosis and arterial remodeling. BACKGROUND The mechanisms controlling arterial remodeling after angioplasty remain poorly understood. Apoptosis and cell proliferation have been previously described after balloon angioplasty. However, their importance in the occurrence of arterial remodeling and restenosis is unknown. METHODS Atherosclerosis was induced in 48 femoral arteries of New Zealand White rabbits by air-desiccation and a high-cholesterol diet. One month later, angioplasty was performed in 40 arteries. Apoptosis, cell proliferation, residual stenosis and arterial remodeling were evaluated at 2 h and 3, 7, 14, 21 and 28 days after angioplasty. RESULTS Cell proliferation and apoptosis profiles were similar, but the peak in cell proliferation occurred approximately four days earlier than the peak in apoptosis in the neointima and media. Apoptosis density was positively correlated with arterial remodeling in the neointima and media (r = 0.69, p = 0.005 and r = 0.50, p = 0.05, respectively). Moreover, residual stenosis was inversely correlated with apoptosis density in the neointima and media (r = -0.62, p = 0.008 and r = -0.52, p = 0.04, respectively). In contrast, cell proliferation was independent of restenosis and arterial remodeling. CONCLUSIONS In this model, cell proliferation preceded apoptosis throughout the four weeks after angioplasty. Apoptosis was inversely correlated with restenosis. Interestingly, apoptosis was also related to enlargement remodeling after balloon angioplasty.

Aims Idiopathic atrial fibrillation describes atrial fibrillation of unknown origin occurring without heart disease. Mortality is considered unaVected by idiopathic atrial fibrillation. We used the long follow-up period (23 years on average) of the Paris Prospective Study I to assess the mortality of idiopathic atrial fibrillation subjects in middle-aged men. Methods 7746 working Frenchmen, aged 43‐52 in 1967‐ 72, underwent a physical examination plus ECG, answered questionnaires, and provided blood samples. Strict exclusion criteria were used to select idiopathic atrial fibrillation only, and men with known cardiac disease were further excluded from analysis. At 1 January 1994, vital status was unknown for 4·6% of the subjects. The analysis was conducted on the 6722 remaining subjects. Results Twenty-five subjects had idiopathic atrial fibrillation at inclusion. The relative risk (and 95% confidence interval) associated with idiopathic atrial fibrillation was 4·22 [2·10‐8·47] for cardiovascular mortality (P=0·0001) and 1·97 [1·14‐3·40] for total mortality (P=0·01). When age, systolic blood pressure, cholesterol, body mass index and tobacco consumption were entered into a Cox model, idiopathic atrial fibrillation remained an independent risk factor for cardiovascular (P=0·0008) and total death (P=0·04). Conclusion With a long follow-up period, idiopathic atrial fibrillation was associated with higher mortality in middle aged Frenchmen. (Eur Heart J 1999; 20: 896‐899)

A randomized pilot study was performed comparing conventional balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA] group) and rotational atherectomy (RA) with a medium size burr (50% to 70% burr/artery ratio) with systematic adjunctive balloon angioplasty (RA group) in type B2 stenosis. A total of 64 patients were included. Primary success was 93.7% in the RA group and 87.5% in the PTCA group (p = NS). Technical failure with no complication occurred once in each group. Acute complications occurred in three patients in the PTCA group and in one in the RA group. Angiographic restenosis rates were similar (RA group: 39%, PTCA group: 42%, p = NS) with a follow-up rate of 93%. In type B2 lesions, when compared with conventional angioplasty, RA with systematic balloon angioplasty does not seem to increase procedural success, and the restenosis rate remains comparable. However, these results must be confirmed in a larger series of patients.

We report one case of successful cardiomyoplasty in a 21-year-old male and its beneficial effects as assessed by clinical examination, Doppler echocardiography, phonocardiography, haemodynamic and angiographic evaluation at 1 year. Long-term efficacy of this procedure on left ventricular function was confirmed by these techniques.

Scientific progress has modified the meaning of medical liability: Total recovery is considered the standard result, and side effects or harm are considered to be malpractice. When medical experts find no errors, liability may be based on legal technicalities despite the absence of any ethically wrong behavior. The increase in lawsuits may well lead to the practice of defensive medicine, despite the negative effects for patients of this approach. The substantial improvements in public health are due to ever better drugs, diagnostic methods, and treatments, but this increasing effectiveness is associated with an increased risk of side effects or unpredictable complications. Indemnification for unforeseeable complications should reduce the number of lawsuits if applied generally and separated from the concept of liability. Civil and criminal procedures would remain available for cases of real malpractice.

Background —Constrictive remodeling plays a prominent role in restenosis after balloon angioplasty, but its regulation remains unclear. Because endothelial dysfunction and changes in extracellular matrix have been reported after angioplasty, this study was designed to simultaneously evaluate endothelial function and collagen and elastin changes after restenosis and arterial remodeling. Methods and Results —Atherosclerosis was induced in femoral arteries of 22 New Zealand White rabbits by air-desiccation and a high-cholesterol diet. One month later, angioplasty was performed. Histomorphometry and in vitro assessment of endothelial function were performed 4 weeks after angioplasty. Restenosis correlated with constrictive remodeling ( r =0.60, P =0.01) but not with neointimal growth ( r =−0.06, P =0.79). Restenosis correlated with an impaired relaxation to acetylcholine (ACh; r =0.61, P =0.02) but not with the response to the endothelium-independent vasodilator sodium nitroprusside ( r =−0.25, P =0.40). Restenosis correlated positively with collagen accumulation ( r =0.69, P =0.004) and inversely with elastin density ( r =−0.48, P =0.05). Relaxations to ACh were significantly more decreased in arteries with constrictive remodeling than in those with enlargement remodeling (3.7±7.9% versus 35.5±15.0%, P =0.04). Neointimal collagen density was significantly higher in arteries with constrictive remodeling than in those with enlargement remodeling (34.5±4.5% versus 18.2±4.7%, P =0.03). Endothelial function and collagen and elastin density were independent predictors of restenosis in the study. Conclusions —These results demonstrate that the severity of restenosis after angioplasty correlated with both defective endothelium-dependent relaxation and increased collagen density.

Background —Sudden death was found to share the same set of usual risk factors as coronary events and therefore could not be specifically predicted in the population. It appears, however, that parental history of sudden death has not been investigated yet as a risk factor for sudden death. Therefore, we assessed risk factors, including parental sudden death, associated with the occurrence of sudden death in a long-term cohort study. Methods and Results —We included 7746 men employed by the city of Paris who were 43 to 52 years of age in 1967 to 1972 in the Paris Prospective Study I. Each subject underwent a physical examination and an ECG, provided blood for laboratory tests, and answered questionnaires administered by trained interviewers who paid particular attention to family medical history. Men with known ischemic cardiac disease were further excluded from analysis. For 95.5% of the men, vital status was obtained from specific inquiries until retirement, then by death certificates. Resting heart rate, systolic or diastolic blood pressure, tobacco consumption, body mass index, diabetes status, serum cholesterol, and parental history of sudden death were independent factors associated with sudden death during follow-up (23 years on average). When adjusted for confounding variables, including parental history of myocardial infarction, relative risk of sudden death associated with parental sudden death was 1.80 (95% CI, 1.11 to 2.88). Conclusions —Parental sudden death is an independent risk factor for sudden death in middle-aged men. The existence of familial risk factors for sudden death may help provide better identification of subjects at high risk of and early prevention of sudden death.

Background Beneficial hemodynamic effects after dynamic cardiomyoplasty have been inconsistently demonstrated, and the effects seen may be due to the wrap itself, to flap stimulation, or both. The aim of this study was to determine whether flap stimulation per se acts as a systolic active process after cardiomyoplasty. Methods and Results Catheterizations were performed in 13 patients 14.4±7 months after cardiomyoplasty. New York Heart Association functional class decreased from 3.3 to 2.1 after the procedure ( P =.0005). Hemodynamic evaluations were first performed with the stimulator on in the 2:1 mode and then after the stimulator had been off for at least 24 hours. Left ventricular (LV) ejection fraction increased from 25.1±6% before surgery to 28.2±6.7% with the stimulator on after cardiomyoplasty ( P =.04). When stimulation was stopped, there was no change ( P >.05) in indexes of systolic or diastolic LV function (peak systolic LV pressure, LV ejection fraction, peak positive dP/dt, peak negative dP/dt, or τ). Pulmonary capillary wedge pressure and cardiac index were unchanged when stimulated and nonstimulated settings were compared ( P >.05). However, a remarkable heterogeneity of individual responses was observed. Ejection fraction and cardiac index decreased with the stimulator off in 3 patients, but peak positive dP/dt decreased in 6 patients; diastolic function deteriorated in 2 patients, but a slight improvement was noted in 3 patients. Cardiothoracic ratio, echocardiographic LV end-diastolic dimension, and fractional shortening remained unchanged between immediate ( Conclusions In the majority of our patients, there was no short-term hemodynamic benefit of flap stimulation; therefore, we conclude that the efficacy of cardiomyoplasty may be a consequence of a passive “girdling effect,” which limits the progression of ventricular enlargement and further deterioration of ejection fraction.

Five patients were studied 5-13 months after dynamic cardiomyoplasty for refractory heart failure. In two, muscle flap stimulation caused a pronounced increase in cardiac index (mean 55%) and ejection fraction (mean 75%); no patient showed improvement in cardiac filling pressure. 2 years after surgery, one of the patients with haemodynamic improvement died from ventricular fibrillation, and histochemistry of the stimulated muscle flap revealed predominantly fatigue-resistant type I fibres, without evidence of fibrosis. In selected cases, dynamic cardiomyopathy could be of long-term benefit.

A rapid up and down motion (“crochetage”) of the R ware in at least one inferior lead — involving the initial 30 to 70 msec of the QRS - is usually observed in pts with ostium secundum (OS) ASD, but its diagnostic value was not previously studied. Thus, we retrospectively tested the presence of a “crochetage” in 2 groups (Gr) of pts: Gr 1 (568 pts with OS ASD and QRS duration lesser than 120 msec); Gr 2 (459 pts with normal heart, matched for age with Gr 1). In Gr 1, an incomplete right bundle branch block (RBBB) was present in 522 pts, mean pulmonary artery pressure (PAP) and shunt severity (Qp/Qs) were assessed in all pts, and surgery was performed in 484 pts.Results(1) In Gr 1, a “crochetage” was absent in 143 pts (Gr A, 27%), present in one inferior lead in 80 pts (Gr B, 15%) and in 2 to 3 leads in 309 pts (Gr C, 58%); (2) Sensitivity, specificity, accuracy and positive predictive value (PPV) of a “crochetage” pattern for an OS ASO reached 73%, 93%, 92% and 94%; comparatively, they reached 98%, 89%, 94% and 91% for a RBBB pattern; when associated to an incomplete RBBB, the PPV of a “crochetage” pattern reaches 96% if limited to one lead and 99.5% if present in 2 to 3 inferior leads; (2) In Gr 1, age and PAP were not different between Gr A, B or C; means Qp/Qs were 2.8 in Gr A, 3.6 in Gr Band 3.8 in Gr C (p 30mmHgl. this pattern was present in 213 leads in 29% of cases if Qp/Qs < 1.5 vs 67% if Qp/Qs > 1.5 (p

Day-of-admission sera from myocardial infarction patients (MI) and patients with cardiopathies other than MI (non-MI) were analysed for total and unbound cortisol (F), progesterone (P4), oestrone (E1), and corticosteroid binding activities (CBG). The MI who survived (n = 28) showed high increases of F, P4 and E1 compared to healthy controls. By contrast, the MI who died within 10 days of admission (n = 6) had unchanged F and less increased P4 and E1 than survivors. The non-MI (n = 6) had higher F and E1 than controls but normal P4. The unbound steroids were increased in all patients: however, the MI who died showed much smaller rises than survivors (P less than 0.001 for unbound F and E1 increases in survivors vs. deceased). The CBG activity was in all MI lower than in normals (P less than 0.001) but unchanged in non-MI. These results are discussed in terms of the potential significance of unbound plasma steroids as predictors of MI severity.

Objectives. This study sought to determine the clinical significance of a “crochetage” pattern—a notch near the apex of the R wave in electrocardiographic (ECG) inferior limb leads—in secundum atrial septal defect.Background. Atrial septal defect is often overdiagnosed on the basis of classical clinical features. Thus, more specific signs on the ECG for screening are needed.Methods. We searched for a crochetage pattern in 1,560 older children and adults: 532 with secundum atrial septal defect, 266 with ventricular septal defect, 146 with pulmonary stenosis, 110 with mitral stenosis, 47 with cor pulmonale and 459 normal subjects.Results. This pattern was observed respectively in 73.1%, 35.7%, 23.3%, 6.4%, 10.6% and 7.4% of these groups (p < 0.001). In atrial septal defect, its incidence increased with larger anatomic defect (p < 0.0001) or greater left-to-right shunt (p < 0.0001), even in the presence of pulmonary hypertension. By multiple regression analysis, only shunt size (p < 0.0006) and defect location (p < 0.0001) were the determinants of its presence. In all groups, the specificity of this sign for the diagnosis was remarkably high when present in all three inferior limb leads (≥92%), even when comparison was limited to patients with an incomplete right bundle branch block (≥95.2%). Early disappearance of this pattern was observed in 35.1% of the operated-on patients although the right bundle branch block pattern persisted.Conclusions. A crochetage pattern of the R wave in inferior limb leads is frequent in patients with atrial septal defect, correlates with shunt severity and is independent of the right bundle branch block pattern. Sensitivity and specificity of this sign are remarkably high when it is associated with an incomplete right bundle branch block or present in all inferior limb leads.