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Resume L’insuffisance cardiaque chronique est un probleme majeur de sante publique : premiere cause d’hospitalisation apres 60 ans (220 000 sejours hospitaliers par an en France), 120 000 nouveaux cas par an, importante mortalite (31 % de survie a 5 ans), cout tres eleve (12 a 20 000 euros par patient par an). Ameliorer le pronostic tout en gardant le patient hors de l’hopital, lui assurant donc une meilleure qualite de vie est l’enjeu que s’est fixe Cardiauvergne, service de telesurveillance et de coordination des soins. Ce groupement de coordination sanitaire (GCS, 35 partenaires) a commence a inclure des patients en janvier 2012 : ils sont aujourd’hui 745 a beneficier de cette solution financee par l’ARS Auvergne et les collectivites locales, et developpee grâce a un partenariat avec Almerys (filiale d’Orange specialisee dans la gestion de donnees informatiques medicales). Deux principes ont concouru au dispositif : les professionnels de sante restent « maitres du jeu » et la telesurveillance doit etre simple pour qu’elle soit acceptable tant pour les patients que pour les professionnels. Ainsi, le patient n’est equipe que d’un seul capteur : une balance connectee. Les infirmieres liberales avec un smartphone renseignent l’evolution clinique (signes fonctionnels, œdemes, frequence cardiaque, pression arterielle). La surveillance biologique est inclue automatiquement dans le dossier par les laboratoires d’analyse, et le pharmacien d’officine renseigne la therapeutique a chaque delivrance de l’ordonnance. Le dossier patient informatise est consultable par son professionnel qui s’identifie avec sa carte CPS. L’ensemble des donnees est analyse par un systeme expert qui genere des alertes ou alarmes selon le niveau de gravite fixe par des bornes. Celles-ci sont gerees par la cellule de coordination dans les 3 h, 7 jours/7 (1,5 cardiologues, 2 infirmieres diplomees en education therapeutique et 1 secretaire medicale). Les alertes et alarmes motivent un appel au patient, qui recevra donc des conseils d’education therapeutique, et si l’etat du patient le justifie, un appel au medecin traitant, voire au cardiologue pour adaptation therapeutique. Une evaluation a ete faite au terme de 2 ans de fonctionnement (355 jours de suivi moyen) sur les 558 premiers patients inclus. Le taux de deces est de 12 % par an (contre 28 a 35 % selon les series avec prise en charge conventionnelle), quant aux rehospitalisations pour nouvelle poussee d’insuffisance cardiaque, elles sont reduites a 13,6 % par an (contre 26 % a 40 % dans les cohortes europeennes). Enfin l’impact economique est remarquable (economie estimee a 7000€ par patient par an). Le taux de satisfaction des patients et des professionnels est unanimement favorable.

Background An assessment of the primary school prevention program “To be and to behave, the health school” was necessary to pursue the activity and enable the development of health education at school. Methods “To be and to behave, the health school” is a health education program designed for primary school pupils in the Auvergne region in France whose targets are primary prevention of cardiovascular diseases and cancers. The program involves a three steps sequence: delivery of a teaching kit, intervention of a health bus, health olympiads. The health assessment focused on resources allocated (program content and functioning of tools created for the program), processes employed (number of schools voluntarily participating and number of pupils who effectively participated with the olympiads of the “health” bus), immediate impact (short-term knowledge acquired by pupils, by class, before the bus arrived and during the olympiads). Results The program involved the participation of 28 schools, 90 classes and 2,137 children. The tools conceived were well adapted. Knowledge scores achieved in the different domains of the program fields progressed significantly for participating classes (p Conclusion The program “To be and to behave” has enabled pupils to progress in their health knowledge. The present results are currently being considered for continuing the program.

Resume Le thrombus flottant de la crosse aortique est une cause rare et souvent meconnue d’evenements emboliques peripheriques. Nous rapportons l’observation d’une patiente presentant des manifestations emboliques peripheriques recidivantes : ischemie aigue du membre superieur gauche et accident vasculaire cerebral transitoire. Le bilan (echocardiographie transœsophagienne et angio TDM) a mis en evidence un thrombus de 12 mm de l’arche aortique. L’evolution a ete bonne sous traitement anticoagulant. Ce diagnostic ne doit pas etre meconnu dans le bilan d’une pathologie emboligene, sous peine de lourdes sequelles fonctionnelles causees par un retard diagnostique important.

BACKGROUND Recombinant tissue-type plasminogen activator (rt-PA or alteplase) and anisoylated plasminogen streptokinase activator complex (APSAC or anistreplase) have been demonstrated to limit infarct size significantly and to preserve left ventricular function when injected soon after acute myocardial infarction. However, as yet, the efficacy and safety of these two thrombolytic agents have not been directly compared in one trial; this was the aim of this study. METHODS AND RESULTS One hundred eighty-three patients suffering from a first acute myocardial infarction were randomly allocated to either APSAC (30 units over 5 minutes) or single-chain rt-PA (100 mg over a 3-hour period) within 4 hours of the onset of symptoms. Global and regional left ventricular function were assessed from contrast angiography an average of 5.3 +/- 2.3 days after initial therapy. Radionuclide angiography and thallium-201 single-photon emission computerized tomography were performed before hospital discharge. Infarct size was assessed by single-photon emission computerized tomography and expressed in percentage of the total myocardial volume. Ninety patients received APSAC and 93 received rt-PA within a mean period of 172 +/- 52 minutes after the onset of symptoms. The two groups were similar in age, location of the acute myocardial infarction, Killip class, and time of randomization. The patency rate of the infarct-related artery was 72% in the APSAC group and 76% in the rt-PA group (NS). Initial and predischarge left ventricular ejection fraction as well as infarct size were similar in both therapeutic groups (0.50 +/- 0.14 versus 0.52 +/- 0.12 for initial and 0.48 +/- 0.10 versus 0.47 +/- 0.10 for predischarge ejection fraction, 11 +/- 7% versus 9 +/- 7% for infarct size, respectively, for APSAC- and rt-PA-treated patients). Bleeding complications requiring blood transfusion occurred in one APSAC patient and in two rt-PA patients. One patient in the rt-PA group died of a massive intracranial hemorrhage. At the end of the 3-week follow-up period, five APSAC patients (5.5%) and seven rt-PA patients (7.5%) had died. CONCLUSIONS The early infusion of APSAC or rt-PA in acute myocardial infarction produced a similar patency rate, limitation of infarct size, and preservation of left ventricular systolic function with an equivalent rate of bleeding complications.

A total of 231 patients suffering from a first acute myocardial infarction were randomly allocated within 4 hours following the onset of symptoms either to anistreplase or anisoylated plasminogen streptokinase activator complex (APSAC), 30 U over 5 minutes, or to conventional heparin therapy, 5000 IU in bolus injection. Heparin was reintroduced in both groups 4 h after initial therapy at a dosage of 500 IU/kg per day. A total of 112 patients received anistreplase and 119 received heparin within a mean period of 188 +/- 62 min following the onset of symptoms. Infarct size was estimated from single photon emission computerized tomography and expressed in percentage of the total myocardial volume. The patency rate of the infarct-related artery was 77% in the anistreplase group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the anistreplase group than in the heparin group (6 absolute percentage point difference). A significant 31% reduction in infarct size was found in the anistreplase group (33% for the anterior wall infarction subgroup [p less than 0.05] and 16% for the inferior wall infarction subgroup, NS). A close inverse relation was found between the values of left ventricular ejection fraction and infarct size (r = -.73, p less than 0.01). In conclusion, early infusion of anistreplase in acute myocardial infarction produced a high early patency rate, a significant limitation of infarct size, and a significant preservation of left ventricular systolic function, mainly in the anterior wall infarctions.

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.

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.

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.

In digital angiography, densitometric information inside the arterial bed are widely used to calculate spatial variations in cross-sectional areas. These measurements are influenced by the orientation of the stenotic segment with respect to the image intensifier. Here, the authors show that these discrepancies can be appreciably removed by a three-dimensional correction using two projection views and a regularization step.

Pattern recognition methods are applied to track a single coronary in its movement. The efficiency of several deformable models is tested in order to accurately locate the same vessel branch all over the digital subtraction angiography (DSA) imaging sequence by the use of a single projection view. Hereby, functional information, such as flow measurements, very helpful to coronary lesion diagnosis, could be provided. >

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.

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.

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 (stenosisor = 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.

This study sought to determine whether pravastatin affects clinical or angiographic restenosis after coronary balloon angioplasty.Experimental data and preliminary clinical studies suggest that lipid-lowering drugs might have a beneficial effect on restenosis after coronary angioplasty.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).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 (recurrence50% 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.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.

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.

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.

Two hundred and seventy patients under 71 years of age with myocardial infarction less than 4 hours old, defined by clinical and electrocardiographic criteria, were included in this trial and followed up for 1 year: two groups of 89 and 92 patients were randomised to receive APSAC (30 mg i.v. over 5 minutes) or rt-PA (10 mg bolus + 5000 IU of heparin as a bolus, followed by 90 mg rt-PA over 3 hours) and compared with a control series of 89 consecutive patients treated with streptokinase (1.5 MU in 1 hour). Heparin and aspirin (250 mg/day) were prescribed systematically. A score of efficacy was established from the following 4 parameters: patency of the infarct-related artery on coronary angiography at day 6 +/- 2 (N = 252), dyssynergic score on radiological ventriculography, infarct size on resting Thallium myocardial scintigraphy performed between day 15 and 21 (N = 242) and radionuclide ejection fraction performed at the same time. This score (0-24) was respectively 17.8 +/- 6.4 for rt-PA, 17.7 +/- 6.0 for APSAC and 18.1 +/- 6.0 for streptokinase (NS). The costs of hospital treatment were assessed by including: the cost of thrombolytic therapy (ranging from 1.7% of total cost for streptokinase to 16% for rt-PA), the cost of other treatments and biological investigations (10% of total cost); the cost of followed coronary angiography, in 33% of patients, by an angioplasty (21% of total cost), the cost of hospital stay averaging 17 days (49% of total cost in the rt-PA and APSAC groups and 56% in the streptokinase group NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Two hundred and seventy patients, under 71 years of age and suffering from a less than 4 h infarction diagnosed according to clinical and electrocardiographic criteria, were included: two 90-patient groups were randomized and then treated with either anistreplase (30 mg iv over 5 min) or alteplase (10 mg bolus injection + 5000 IU heparin bolus injection, followed by 90 mg alteplase over 3 h), and compared with a consecutive control series of 90 patients treated with streptokinase (1.5 million U over 1 h). Intravenous heparin and aspirin (250 mg day-1) were then prescribed routinely. The three groups were comparable as regards age (55.2 +/- 10 years), male/female ratio (10.4), the site of the infarction (42% anterior, 55% inferior) and initial clinical seriousness (Killip I = 90%, II = 8%, III = 2%). The patients were thrombolysed in 17 community hospitals, and then referred to a university hospital with catheterization facilities. An efficacy score was determined, based on four parameters: two obtained from coronary angiography and left ventriculography performed on day 6 +/- 2 (N = 252) (asynergic score and patency of the infarct-related artery), one from Tl-tomography performed at rest (infarct size) and one from radionuclide angiography (global left ventricular ejection fraction) performed between day 15 and day 21 (N = 242). The score (range: 0-24 per patient) was 17.8 +/- 6.4 for alteplase, 17.7 +/- 6.0 for anistreplase and 18.1 +/- 6.0 for streptokinase respectively (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

A hundred and eighty three patients with a primary myocardial infarction less than 4 hours old were included in a double blind trial versus placebo comparing an isolated plasminogen streptokinase activator complex (APSAC: 30 mu in 5 mn) and tissue type plasminogen activator (rt PA: 10 mg bolus followed by 90 mg in 130 mn). Clinical evolution, side effects, patency of the artery responsible for infarction, left ventricular contractile function (contrast angiography on the 7th day and angioscintigraphy on the 21st day) and infarct size were studied. The two groups were comparable in age (54 +/- 11 years), delay in randomisation (170 +/- 50 mn), infarct site and severity of cardiac failure. There was no significant difference in hospital mortality (7 in the rt PA group and 5 in the APSAC group) or in adverse effects (haemorrhage: rt PA: 9 patients, APSAC: 11 patients). The patency was 72% in the APSAC and 76% in the rt PA group. Left ventricular function and infarct size were comparable in the two groups: angiographic EF (0.50 +/- 0.1 in the APSAC and 0.52 +/- 0.1 in the rt PA group: NS); asynergic score (11.3 +/- 1.7 in the APSAC and 10.5 +/- 1.8 in the rt PA group: NS); infarct size (10.9 +/- 8.0 in the APSAC and 9.4 +/- 7.2 in the rt PA group: NS). This trial shows that these two thrombolytic agents have the same efficacy. The authors recommend adaptation of the dosage of rt PA to body weight.

Since its introduction in cardiovascular therapeutics, thrombolysis has established itself as an effective procedure of coronary reperfusion during the acute phase of myocardial infarction. Large scale clinical trials have demonstrated a clear cut reduction in mortality providing that the treatment is administered sufficiently early after the onset of symptoms. This reduced mortality is probably related to the limitation of infarct size and the conservation of ventricular function even though this relationship is not always analysed. Studies of infarct size and left ventricular function are difficult to perform and this is reflected in the number of different methods proposed. Apart from coronary reperfusion and its timing, other factors influence the definite size of the infarct, such as the development of a collateral circulation, the existence of cellular reperfusion lesions and the occurrence of reocclusion. The infarct size may be assessed by a number of methods, some simple (enzymes, electrocardiogram) but relatively inaccurate, others more promising but difficult to perform and more costly. Thallium 201 scintigraphy seems to be the best available method and our experience is based on these results. The reference method for the evaluation of left ventricular function is angiography but angioscintigraphy also provides information on global and regional function, the regional study being particularly valuable in the analysis of thrombolytic drug efficacy. A review of the literature shows that thrombolysis is associated with a reduction in infarct size compared with conventional therapy and with conservation of left ventricular function whichever thrombolytic agent is used.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report the histological discovery of a case of Takayasu syndrome affecting the ascending aorta. This involvement appearing to concern only the aorta, with no symptomatic complaints nor any laboratory abnormalities indicative of an inflammatory syndrome, corticosteroids were not prescribed. Management consisted of biennial monitoring by transthoracic and transesophageal ultrasonography of the aorta and the supra-aortic main vessels together with monitoring of laboratory parameters.

Two cases of angina pectoris, induced by methylergometrine (Methergin) and by an association of ergotamine tartrate (Gynergene) and methysergide (Desernil) respectively, are reported. In both patients, angiography revealed spontaneous spasm in a coronary system free from any significant atheromatous stenosis. In the second case, a test administration of i.v. Methergin, administered during calcium-channel antagonist treatment a few days after the "guilty" drugs had been stopped was found to be negative. The outcome was favorable in both cases: the angina disappeared and the base-line and exercise ECG returned to normal. The hypothesis of coronary spasm induced by the treatment was adopted in both cases. In this context, the major iatrogenic etiologies of vasospastic angina are recalled, together with the prophylactic and therapeutic measures they call for.

The distributions of 201Tl and 99Tcm-MIBI on stress images were quantitatively measured in a series of 15 patients presenting with documented coronary artery disease. Following two sequential, one-week apart, peak-exercise injections of either 74 MBq of 201Tl or 370 MBq of 99Tcm-MIBI, tomographic views of the myocardium were reconstructed and two thick, central short-axis sections were divided into nine sectors. A sector was considered as showing a defect if its relative activity was lower than 30, 40, 50 or 60% of the highest level of activity in the 18 sectors. Results demonstrate that there were more defects with 201Tl than with 99Tcm-MIBI. However, the difference disappeared if the inferior wall was not included. These results suggest that depth attenuation could be, at least partly, responsible for the higher rate of positive results observed in single photon emission computed tomography with 201Tl than with 99Tcm-MIBI.

Pericarditis is one of the possible complications of mediastinal teratoma. Bronchogenic cysts are the commonest mediastinal cysts and may be observed at any age. We report our diagnosis of a bronchogenic cyst by transoesophageal echocardiography. It was successfully excised surgically. This is the eleventh case published in the world literature.

Single photon emission computed tomography (SPECT) is superior to conventional radionuclide scintigraphy. The most widely used marker is thallium-201, despite the fact that it is not exclusively flow-dependent. Thallium-201 SPECT can be performed in patients at rest, during exercise followed by a redistribution study, under dipyridamole or nitrate infusion, or combined with spasm provocation test. When performed at rest, it is helpful to diagnose and, above all, quantify a myocardial infarction. Under nitrate infusion, it delineates the viable muscle remaining around the infarct. During exercise or under dipyridamole infusion, it is more effective than any other non-invasive method in detecting myocardial ischaemia (sensitivity 95%, specificity 90%). Following surgical revascularization, a normal exercise SPECT indicates a functional aorto-coronary bypass in 80% of the cases. It is a good method to detect post-angioplasty restenosis (sensitivity 82%, specificity 86%, negative predictive value 93%). Like all paraclinical examinations, SPECT has its limitations: left bundle branch block, reverse redistribution, non-ischaemic (i.e. dilated or hypertrophic) cardiopathies.

Hypertrophic cardiomyopathy (HCM) is currently considered to be a condition characterised by abnormal diastolic function, sometimes associated with left ventricular outflow obstruction which appears to be a secondary phenomenon. It is important to avoid overlooking this diagnosis especially in young subjects, because of the risk of sudden death, but conversely, false positive diagnosis can result in a serious social and psychological handicap. Echocardiography has assumed a major role in the diagnosis and follow-up of HCM over the last decade. It allows analysis of the localisation, extension and severity of the septal hypertrophy and of the mechanism of systolic anterior motion of the mitral valve. Cardiac doppler completes the non-invasive assessment of this condition by demonstrating the presence or absence of outflow tract obstruction, evaluating diastolic dysfunction, and documenting mitral and occasionally aortic valve regurgitation. Only severely symptomatic patients who do not respond to high dose medical therapy and for whom surgery might be an option need cardiac catheterization. Strenuous physical activity and sport are not recommended in asymptomatic forms. It is vital to identify those patients at high risk of sudden death (family history of sudden death, 48 to 72 hour Holter monitoring). In the absence of silent arrhythmias, preventive therapy should be more general in patients under 30 years of age. Despite a better understanding of the disease, the indications of medical and surgical treatment remain controversial and poorly defined. Treatment is mainly medical with Propranolol as the drug of choice. The dosage has to be tailored for each individual patient.(ABSTRACT TRUNCATED AT 250 WORDS)

The failing heart is unable to provide some organs, notably the brain and the myocardium, with the amount of blood flow they require. To this myocardial inadequacy and resulting "circulatory insufficient" the body reacts by setting in action compensatory mechanisms which are "intracardiac" first (Starling's heterometric regulation, ventricular hypertrophy), then neurohormonal, with the activation of vasoconstrictor systems (noradrenergic system, renin-angiotensin-aldosterone system, arginine-vasopressin system) counterbalanced by the activation of vasodilator systems (vasodilator prostaglandins, atrial natriuretic factor and kinins). However, the vasoconstrictor systems outweigh the vasodilator systems. They create an excessive arterial and venous vasoconstriction, together with water-and-salt retention, which leads to an increase of left ventricular work during both systole and diastole and to a gradual worsening of the heart failure. The present-day treatment of heart failure aims at reducing the water-and-salt retention and at restoring the balance between the vasoconstrictor and vasodilator systems.

The authors report two cases of acquired post-nephrectomy arteriovenous fistula. The large shunt was responsible for cardiac failure. The first case was treated by percutaneous embolisation and the second by reoperation. The clinical results were excellent. These two cases illustrate the value of different imaging techniques and therapeutic approaches: direct surgery or embolisation.

Eleven of 17 case histories recensed after an inquiry addressed to all the French university hospital cardiological departments were attributed to peripartum cardiomyopathy. Three patients (27%) needed cardiac transplantation. Predisposing factors were multiparity and twin pregnancies. Forty five per cent of patients were under 25 years of age. Hypoproteinemia was present in all serious forms of the condition. Hypoproteinemia, a cardio-thoracic ratio of over 0.60, echocardiographic left ventricular fractional shortening of under 15 per cent and presistance of symptoms after one month of medical treatment were poor prognostic factors. The relatively high incidence of myocarditis (1 out of 11 cases) justifies endomyocardial biopsy.

Eighteen patients with pure aortic stenosis without coronary artery disease underwent equilibrium radionuclide angiography to evaluate the adaptation of their left ventricular function to exercise. The left ventricular ejection fraction, peak left ventricular ejection, and fillings, and their timing were calculated from time-activity curves and their first derivatives at rest and at the maximum of exercise. There were no clinical complications. The ST segment and T wave changes of 14 patients were accentuated and 3 patients developed anginal pain. The ejection fraction was normal at rest and did not change significantly during exercise. The peak ejection did not vary but peak left ventricular filling was prolonged by exercise. There was a correlation between peak ventricular ejection at rest and the aortic valve surface area at catheterisation. This isotopic parameter was inversely correlated with LVEDP. There was a close correlation between age and peak ventricular filling on exercise. The variation between resting and exercise values of this parameter was inversely correlated with age. This study shows that exercise stress testing can be undertaken without risk in patients with aortic stenosis. The results of radionuclide angiography show that peak left ventricular ejection is a valuable parameter. The interpretation of the diastolic parameters is however more difficult because they are age-related.

Two hundred and thirty-one patients admitted to hospital within 5 hours of the onset of symptoms of a primary myocardial infarction were randomised into 2 groups: one received thrombolytic therapy [anisoylated plasminogen streptokinase activator complex (APSAC): 30 IU in 5 minutes] and the other was given conventional heparin therapy (5,000 IU). Heparin was given to both groups 4 hours later (500 IU/kg/day); the APSAC (N = 119) was identical with respect to age, location of infarct, Killip classification, delay before randomisation (188 +/- 62 minutes). Coronary angiography and ventriculography were performed after 3.4 +/- 1.2 days, and angioscintigraphy and myocardial scintigraphy after 19 +/- 2.5 days to determine the size of the infarct and the quality of left ventricular function. Coronary patency was much higher in the APSAC group (77%) than the heparin group (37%) (p less than 0.001). The angiographic ejection fraction was significantly greater in the thrombolytic group than in the heparin group (53 +/- 13% vs 47 +/- 12%, p less than 0.002), the difference being statistically significant in the anterior and inferior infarct subgroups. At the third week, the difference remained significant in the anterior infarct subgroup: a 31 per cent reduction in necrosed myocardial mass was observed in the APSAC group (33% in anterior infarcts: p less than 0.05 and 16% in inferior infarcts: NS). The limitation of infarct size explained the smaller reduction in left ventricular systolic function (r = 0.73; p less than 0.01). The hospital and one year mortality was comparable in the two groups which was not surprising given the small number of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The early intravenous administration of thrombolytic agents in the acute phase of myocardial infarction induces reperfusion of the artery responsible for the necrosis, thereby limiting the size of the infarct and preserving the left ventricular systolic function with consequent reduction of short- or long-term mortality. With the exception of urokinase, these effects have been demonstrated with all thrombolytic agents used so far, including streptokinase, plasminogen tissue activator and anistreplase. Owing to its special pharmacokinetic properties, the latest thrombolytic agent, formerly known as APSAC (anisoylated plasminogen streptokinase activator complex), provides a high arterial reperfusion rate with a low percentage of reocclusion. As a result, the mean size of the infarct is reduced by 31 per cent (36% in the case of anterior infarct), and the left ventricular systolic function is highly significantly preserved.

Introduction et but de l’etude L’insuffisance cardiaque evolue dans 16% des cas vers un etat de denutrition caracterise par une perte importante du muscle squelettique, appelee cachexie cardiaque. La cachexie cardiaque pourrait faire intervenir de profondes modifications du metabolisme proteique, ainsi que des perturbations des fonctions mitochondriales au sein du muscle. Notre but etait donc d’etudier la proteosynthese et les fonctions mitochondriales de differents types musculaires (squelettiques types 1 et 2, cardiaque) durant la cachexie cardiaque chez le rat. Materiel et methodes Un infarctus du myocarde (IDM) a ete realise chez 7 rats LEWIS de 3 mois par ligature chirurgicale de l’IVA. La dysfonction ventriculaire gauche etait confirmee par echocardiographie. Un animal ayant maigri de plus de 7,5% etait considere comme cachectique cardiaque (CC) et etait alors sacrifie simultanement a un rat temoin sain (TS). Apres l’injection d’un traceur isotopique ([13C]valine), le sang, les muscles (soleus, gastrocnemius, tibialis anterior), le coeur, le foie et le tissu adipeux intra-abdominal etaient preleves. Le taux de synthese (FSR) des proteines mitochondriales etait calcule a partir de l’enrichissement en [13C]valine des proteines mesure par spectrometrie de masse. Les activites enzymatiques mitochondriales de la citrate synthase (CS) et de la cytochrome c oxydase (COX) etaient mesurees par spectrophotometrie. L’analyse statistique utilisait un test non parametrique de Mann-Withney. Resultats 6 rats sur les 7 ayant subi l’IDM sont devenus cachectiques, en moyenne en 85 jours. Le poids du foie etait statistiquement superieur dans le groupe CC par rapport aux TS (11,4±2,4 g vs 8,6±1,3 g, P Conclusions Cette etude confirme que la CC est associee a de profondes alterations de la fonction mitochondriale musculaire dans les muscles squelettiques de type oxydatif (soleus), associees a une augmentation de la vitesse de synthese des proteines de cet organite. Ce dernier phenomene pourrait etre lie a des mecanismes de compensation tentant de limiter les perturbations fonctionnelles.

Objectifs Le Doppler endocoronaire peut completer l’angiographie pour evaluer les stenoses coronaires avant et apres angioplastie, mais il majore cout et duree d’examen, et requiert une certaine experience. Nous avons etudie dans cette indication une autre methode de mesure de flux. Materiels et methodes Quinze coronaires etaient explorees par angiographie, Doppler et videodensitometrie issue de l’analyse de scenes angiographiques acquises en biplan, les variations temporospatiales de densite permettant une estimation des vitesses de flux. Resultats Le Doppler distinguait 6 lesions non serrees de 5 serrees (4 reevaluees apres angioplastie). Les indices videodensitometriques : pourcentage de stenose par equation de continuite (St) et ratio de vitesses proximal / distal (P/D) avaient une bonne valeur pronostique. Les lesions serrees, avec St = 60,2 % et P/D = 1,62 (versus St = 28,3 %, P/D = 0,8 pour non serrees), voyaient leurs indices ameliores apres angioplastie (St = 17 %, P/D = 1,15). Des limites d’analyse densitometrique persistent toutefois, liees aux superpositions coronaires et opacites extra-vasculaires. Conclusion Ces resultats doivent etre prolonges par une simplification du recueil et traitement des scenes angiographiques, et l’adaptation des techniques d’hyperhemie provoquee, afin de proposer une alternative au Doppler endocoronaire.

Hypereosinophilic syndrom (HES) with cardiac involvement and anticardiolipin antibodies (ACL). Report of 4 cases. The relation between ACL and HES is discussed.

A procedure for gated single-photon emission transaxial tomography of the cardiac blood pool using a commercially available rotating camera and a computer is described. During image acquisition, the end-diastolic and end-systolic frames are retained after each of the 16 angular steps of the rotation of the camera around the anterior side of the patient's chest. Complete acquisition takes 25 minutes; 10 more minutes are required for the reconstruction and processing of the sections. One set of images is oriented transaxially; the other set includes vertical sections obtained by rotation around a vertical axis passing through the center of the left ventricular cavity. Results from the planar and tomographic examinations were in good agreement for most of the 18 patients who underwent both studies, although more inferior abnormalities were detected with tomography.

Isosorbide dinitrate (ISDN) was used by intravenous infusion in 7 patients with acute cardiac failure consecutive to acute (5) or chronic (1) myocardial infarction or to non-obstructive cardiomyopathy (1). Pulmonary artery pressure (PAP), pulmonary capillary pressure (PCP), right atrial pressure (RAP) and cardiac output were measured (PCP), right atrial pressure (RAP) and cardiac output were measured by intracardiac catheterization. The initial dosage of 2.5 mg/hour was increased until PCP was reduced to 15 mmHg or less or until troublesome side-effects developed. Control was achieved in 3 patients with doses of 2.5 to 7 mg/hour and, to a lesser extent, in one patient with up to 20 mg/hour. Three patients failed to respond even to higher doses and needed furosemide i.v. or furosemide + dobutamine. One patient died of cardiogenic shock. No changes in cardiac output, heart rate and blood pressure and no clinical side-effects were recorded. Thus, in acute cardiac failure ISDN may be effective in doses slightly superior to those of nitroglycerin, but increasing the dosage above 7 or 8 mg/hour does not bring additional benefits. The drug is remarkably well tolerated.

Myocardial thallium 201 tomography was performed in 112 patients admitted to hospital in the acute stage of a first myocardial infarction. Our quantification method for the myocardial lacuna, validated by animal studies, is described. The necrotic mass evaluated is compared with enzymatic (CPK) (r = 0.89) and angiographic (r = 0.78) quantitative assessments. Thallium 201 tomographic quantification has an unquestionable prognostic value. Thus, among patients whose infarcted mass represented more than 25% of the total myocardial mass, 71% died or developed severe heart failure. Conversely, 93% of patients with a small infarct (less than 20% of total myocardial mass) were asymptomatic on a 24-month follow-up. Myocardial thallium 201 tomography provides a reasonable quantification of the infarct. Its prognostic value seems to be satisfactory.

We report the case of a 36-year old male patient who was admitted for subacute endocarditis on an aortic prosthetic valve implanted 14 years previously for endocarditic valve regurgitation; no pathogen had been isolated at that time. Nine blood cultures were positive for Brucella abortus. The conventional antibiotic therapy did not prevent the formation of an abscess below the aortic annulus. A third antibiotic combination (quinolone and rifampicin) resulted in pyrexia prior to surgery. An atrioventricular block initially noted raised the problem of an associated myocarditis. The risk of Brucella infection existed before the first operation, and five serological tests were positive for that organism between the two episodes, which makes reinfection highly probable. This is the third case of Brucella endocarditis on a prosthetic valve. Its originality lies in its mechanism.

We have compared emission tomography and conventional scintigraphy with thallium-201 in a series including 15 normal subjects and 64 patients showing transmural myocardial necrosis in various locations, fully documented by clinical, electrocardiographic, and enzymatic evidence. The reconstruction was derived from 32 projection images collected around the left side of the patient's chest by a rotating scintillation camera. The conventional views and the transverse, frontal, and sagittal sections were interpreted independently by two observers. The final calculated sensitivity was 89% with conventional scintigraphy and 98% with emission tomography, and the specificity was 93% in the two cases. Thus, emission tomography provides a better sensitivity and also a better interobserver agreement than conventional scintigraphy in the detection of transmural myocardial necrosis with thallium-201.

One hundred and twenty seven patients (pts) suffering from a first acute myocardial infarction (AMI) were included in a multicenter trial involving three University Hospitals and 22 community Hospitals without catheterization facilities. Patientswere randomly allocated within 5 hours following the onset of symptoms either to acyl plasminogen streptokinase (APSAC) 30 IU within 5 min followed 4 hours later by heparin at a dose of 500 IU/kg/day or to conventional Heparin (H) therapy 500 IU/kg/day. 63 pts received APSAC and 64 received H. Both APSAC and H groups were similar in age, location of AMI, Killip class and time of randomization. After initial therapy Pts were referred to the University Hospitals and submitted between Day 1 and Day 7 to a selective coronary angiography and immediate percutaneous transluminal angioplasty (PTCA) of the infarct-related artery if suitable for the procedure.4 APSAC pts and 2 H pts died during the hospital course (NS).The arterial patency rate determined on average 3.4 ± 1.2 days after the onset of symptoms was 88% in APSAC and 42% in H (POn Day 14, pts were submitted to Ti 201 scan and to radionuclide angiography (RNA). Results are not yet available.Our results showed that early infusion of APSAC in AMI produced a high short term patency-rate of the IRA with a tendancy toward improvement of the left ventricular systolic function which failed to reach statistical significance because of the relatively small size of the cohort.

After a successful coronary angioplasty (less than 50 p. 100 residual stenosis and no complication), can restenosis be detected by a non-invasive method? We tested the value of stress thallium 201 myocardial scintigraphy by comparing this method with clinical angina and the conventional exercise-induced angina test. The study was prospective and involved 85 patients (74 men, 11 women; mean age 54.7 years, range 33-78 years). Sixty patients were suffering from angina, 13 had post-infarction angina and 12 had mild necrosis. Angioplasty had been performed on a single vessel (LAD in 57 cases, right in 18 cases and CX in 10 cases). After 6.4 +/- 1.8 months, all patients were re-evaluated under treatment, undergoing successively an exercise test, a stress and recovery myocardial scintigraphy and a coronary angiography. Restenosis was defined as a more than 50 p. 100 reduction of diameter on two orthogonal planes and was observed in 22 cases (26 p. 100). 19 patients were suffering from angina, 12 had restenosis, 10 were asymptomatic but had restenosis. Eighteen exercise tests were pathological; 10 corresponded to restenosis and 12 were normal in spite of restenosis. Myocardial scintigraphy was regarded as positive when, outside a necrotic territory, a lack of uptake at stress was reversible or became worse at redistribution. 27 tests were positive, 18 corresponded to restenosis, 4 were normal in spite of restenosis. The diagnostic values of the three methods were compared: (Table: see text).(1) stress myocardial scintigraphy has the best sensitivity and specificity; (2) if it is negative, restenosis is very unlikely; (3) coronary angiography may be performed only in case of symptoms and/or of positive stress scintigraphy.