[Detection of asymptomatic abdominal aorta in coronary disease patients having undergone coronarography]

Detection of asymptomatic abdominal aortic aneurysm (AAAA) was studied in 780 patients whose coronary disease had been evolving for less than 2 years, who had undergone coronagraphy within the framework of the French ALAC Survey (Autres Localisations de l'Athérosclérose chez le Coronarien--other locations of atherosclerosis in coronary disease) and had an interpretable abdominal aortic echography. Clinical and echographic research detected 19 AAAA cases in 15 men and 4 women aged 53 to 77 years having at coronagraphy at least one stenosis > or = 70% on one of the 3 coronary trunks or > or = 50% on the commun trunk. Among the 577 coronary disease patients with at least one significant stenosis, the prevalence of AAAA was 3.3%. Seventeen aneurysms were missed at abdominal palpation. A subgroup of 458 patients aged 50 to 79 years had significant coronary stenosis without history of aortic surgery. There was no significant difference between the 19 AAAA cases and the 439 cases of coronary disease without aortic aneurysm, as regards risk factors, especially age, high blood pressure and tobacco consumption. On the other hand, the 19 AAAA cases had more diffused and more severe atherosclerotic lesions in the lower limbs and carotid arteries. Abdominal echography is essential for the detection of AAAA in patients with coronary disease.

[Severe cardiomyopathy revealing amylopectinosis. Two cases in adolescents from the same family]

Type IV glycogen storage disease, also termed Andersen's disease or amylopectinosis, is a rare autosomic recessive hereditary disease usually caused by a deficit in glycogen branching enzyme. We report our observation of two siblings with type IV glycogen storage disease who had normal branching enzyme activity. The initial symptom was severe heart failure. A 14-year-old boy, born to consanguinous parents, was seen for severe global heart failure. Growth retardation had been diagnosed since the age of 6 and abnormal fatigability since the age of 12. Muscle and endomyocardium biopsies revealed abnormal glycogen storage with normal branching enzyme activity. The patient's condition improved after symptomatic treatment, but death occurred due to infectious complications after orthoptic heart transplantation. One year later, the proband's 12-year-old sister, with an uneventful personal medical history, was hospitalized for severe left ventricular failure. Muscle and liver biopsies demonstrated the same anomalies, again without branching enzyme deficiency in the liver. Heart failure was controlled with symptomatic care and the patient's current condition remains satisfactory. This observation demonstrates the clinical expression of familial type IV glycogen storage disease in patients with normal branching enzyme activity. Age at onset is quite variable, reported from 5 to 70 years, as is the clinical course before diagnosis.

[Coronary embolism revealing mitral valve stenosis]

We report a case of myocardial infarction with normal coronary arteriography in a 39-year-old woman presenting with tight mitral stenosis complicated by atrial extrasystoles and spontaneous atrial contrast at echocardiography. The diagnosis of coronary embolism was most probable. Coronary embolism is a rare disease, usually due to a blood clot or, less frequently, to a vegetation of endocarditis starting in a heart valve. The left network is usually involved, with typical myocardial necrosis. Coronary arteriography is sufficient to make the diagnosis. Preventive treatment is essential.

[Arrhythmia and syndrome of obstructive sleep apnea in adults]

Many nocturnal cardiac arrhythmias and conduction defects have been reported in the adult sleep apnoea syndrome. The most original is the great variability of the heart rate which is cyclical and related to the apnoeic episodes, and easily differentiated from simple respiratory sinus arrhythmia. It is characterised by an initial bradycardia followed by rebound tachycardia. The bradycardia is vagally dependent (inhibited by atropine) probably secondary to carotid chemoreceptor stimulation by the hypoxaemia. The tachycardia is mainly attributed to the cessation of vagal hypertonicity although catecholamine stimulation has been suggested. The origin of these changes is purely functional, regressing with treatment of apnoea (waking, tracheotomy), the maintenance of arterial oxygen concentrations with oxygen therapy and parasympathetic blockade (atropine). The intensity of the phenomenon is related to the degree of arterial desaturation, which is itself related to basal arterial saturation (SaO2) and the duration of the apnoeas. Prolonged systole due to paroxysmal sino-atrial or atrioventricular block may be observed at night in these patients. The influence of vagal overactivity is confirmed (suppression of vagotomy) with no organic pathology (diurnal absence, tracheotomy, normal electrophysiological testing) in favour of a relationship with apnoea. Though less common than conduction abnormalities, atrial arrhythmias (extrasystoles, flutter, fibrillation) are also possible complications of sleep apnoea. The absence of an organic substrate is indicated by their regression post-tracheotomy and the efficacy of atropine (again in favour of a vagally-induced mechanism). Finally, nocturnal ventricular hyper-excitabilty is sometimes observed, the probable mechanism being the association of severe hypoxaemias (SaO2 < 60%) and the increased sympathetic tone at the end of the apnoea.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography

BACKGROUND AND PURPOSE

An association between atrial septal aneurysm and embolic events has been suggested. Atrial septal aneurysm has been shown to be associated with patent foramen ovale and, in some reports, with mitral valve prolapse. These two latter cardiac disorders have been identified as potential risk factors for ischemic stroke. The aim of this prospective study was to assess the role of atrial septal aneurysm as an independent risk factor for stroke, especially for cryptogenic stroke.

METHODS

We studied the prevalence of atrial septal aneurysm, patent foramen ovale, and mitral valve prolapse in 100 consecutive patients < 55 years of age with ischemic stroke who underwent extensive etiological investigations. We compared these results with those in a control group of 50 consecutive patients. The diagnosis of atrial septal aneurysm and patent foramen ovale relied on transesophageal echocardiography with a contrast study and that of mitral valve prolapse, on two-dimensional transthoracic echocardiography.

RESULTS

Stepwise logistic regression analysis showed that atrial septal aneurysm (odds ratio, 4.3; 95% confidence interval, 1.3 to 14.6; P = .01) and patent foramen ovale (odds ratio, 3.9; 95% confidence interval, 1.5 to 10; P = .003) but not mitral valve prolapse were significantly associated with the diagnosis of cryptogenic stroke. The stroke odds of a patient with both atrial septal aneurysm and patent foramen ovale were 33.3 times (95% confidence interval, 4.1 to 270) the stroke odds of a patient with neither of these cardiac disorders. For a patient with atrial septal aneurysm of > 10-mm excursion, the stroke odds were approximately 8 times the stroke odds of a patient with atrial septal aneurysm of < 10 mm.

CONCLUSIONS

This study shows that atrial septal aneurysm and patent foramen ovale are both significantly associated with cryptogenic stroke and that their association has a marked synergistic effect. Atrial septal aneurysms of > 10-mm excursion are associated with a higher risk of stroke.

[Cardiac involvement in certain muscular diseases. Apropos of 216 cases]

Myopathy may be associated with very variable cardiac involvement, the expression of which is related to the type of neuromuscular disease and also to the individual. This retrospective study, performed between 1986 and 1991, was undertaken to determine the prevalence of cardiac involvement in myopathy. A total of 216 subjects with an average age of 34 years were reviewed by clinical examination, ECG, echocardiography and Holter ECG monitoring. Some patients also underwent complementary radionuclide (scintigraphy, angiography) and electrophysiological investigations. The results confirmed cardiac disease in over a half of patients. Although 3/4 of the patients were asymptomatic from the cardiac point of view at the time of evaluation, the severity of certain lesions led to a number of specific therapeutic interventions. This suggests that simple, non-invasive cardiac diagnostic procedures should be undertaken systematically in the early stages of myopathic disease.

[Left pulmonary artery originating from the ascending aorta in tetralogy of Fallot. Therapeutic strategy]

The authors report the rare case of a 12 year old child with an anomalous origin of the left pulmonary artery from the ascending aorta associated with Tetralogy of Fallot. This complex congenital malformation was treated surgically by a Deleval anastanosis between the right subclavian and right pulmonary arteries. The result was good with a 9 year follow-up, the patient having only Grade II effort duspnoea and cyanosis. The authors discuss the advantages and drawbacks of the different possible surgical approaches to this problem in the light of the outcome of this case and a review of the literature.

[Primary leiomyosarcoma of the pulmonary artery. Apropos of a case. Review of the literature]

A 59-year-old woman hospitalised because of dyspnea and a heart murmur in a context of pyrexia was found to have evidence of obstruction of the pulmonary arterial system, clearly defined by ultrasonography, catheterisation and angiography and Imatron scan. The particular feature of this fifth reported case of pulmonary artery leiomyosarcoma is its documentation by transesophageal ultrasonography and tumor biopsy during catheterisation. Surgery with partial excision of the tumor was followed by survival for 6 months, bearing in mind the absence of chemo- or radiosensitivity of this type of tumor. Cases from the literature are reviewed.

[Isolated atrial fibrillation. The risk of embolism and its prevention]

Whether or not atrial fibrillation is alone, if not idiopathic, is difficult to determine. The risk of embolization in lone atrial fibrillation is distinctly higher in healthy subjects over 60 years of age when the left atrium is dilated. In chronic atrial fibrillation this risk is higher than in paroxysmal fibrillation, especially within the year following the onset of the arrhythmia. In most patients anticoagulant therapy is effective in the primary or secondary prevention of embolic accidents. In subjects older than 75 aspirin given in daily doses of 325 mg seems to give similar results. The risk of antithrombosis therapy must not be underevaluated. The alternative is to maintain or restore the sinus rhythm, even at an advanced age, if the arrhythmia is recent and the left atrium is moderately dilated.

[Isosorbide dinitrate in the treatment of coronary insufficiency]

The improvement of our understanding of the pharmacology of nitrate derivatives has allowed rationalisation of their use in the treatment of coronary artery disease. The comprehension of the evolution of the sensitivity of the vessel wall to nitrate vasodilatation with time has enabled definition of a rhythm of administration which preserves therapeutic efficacy: a daily therapeutic window of 8 to 10 hours. The introduction of new galenic forms (slow release oral preparations and transdermal patches) facilitates the practical application of the "optimal" pharmacokinetic profile. A single daily dose of slow release ISDN is effective in controlled trials versus placebo in the treatment of chronic stable angina. Many clinical trials have also shown the synergy of the anti-anginal effects of ISDN and betablockers, both in single dose studies and during prolonged administration. These therapeutic windows are not adapted to the treatment of acute coronary insufficiency (unstable angina, myocardial infarction); however, it has recently been shown that the use of small, fixed doses of intravenous ISDN over a 3 day period is usually adequate for controlling acute coronary insufficiency and is not associated with the phenomenon of tolerance.

[Mechanism of cellular action of nitrate derivatives]

Nitrate derivatives have to undergo metabolic activation in the smooth muscle cell or in the plasma with a sulflydryl radical. This transformation results in the formation of nitric oxide and/or S-nitrosothiols. These products stimulate an enzyme, the soluble guanylate cyclase in the sarcoplasm of the smooth muscle cell; giving rise to the formation of intracellular cyclic GMP from GTP. The cyclic GMP activates a kinase protein which in turn activates a number of other protein enzymes involved in the recaptation of calcium by the sarcoplasmic reticulum and in the extrusion of calcium from the cell. In addition, cyclic GMP reduces the level of phosphorylation of the myosin light chain, thereby reducing the sensitivity of the contractile proteins to intracellular calcium. All these phenomena cause smooth muscle relaxation so explaining most of the vasodilator effect of nitrate derivatives.

[Evaluation of tolerance during intravenous administration of low dose of isosorbide dinitrate in the treatment of unstable angina]

The eventuality of tolerance was assessed in 19 patients with unstable angina treated by continuous intravenous infusion of 50 micrograms/min of isosorbide trinitrate (ISDN) in association with heparin and betablocker therapy. The tolerance phenomenon was evaluated by the hypotension produced by the ISDN infusion and by the amplitude of fall in blood pressure produced by an intravenous bolus of 1 mg of glyceryl trinitrate (GTN) according to the principle of crossed tolerance to the two nitrate derivatives. Under these conditions of administration, the authors observed partial attenuation of the blood pressure response to continuous ISDN infusion and absence of cross tolerance between ISDN and intravenous GTN. The co-prescription of intravenous N-acetylcysteine at a dosage of 10 g/24 hours in 10 of the 19 patients did not affect the blood pressure or the response to the GTN bolus compared with the 9 other patients who had received placebo after double-blind randomisation. The results of this study do not indicate if the maintenance of vascular sensitivity to nitrate derivatives at least for 72 hours, was related to the choice of a relatively low dose and/or the use of ISDN rather than another nitrate derivative, in particular glyceryl trinitrate. The use of intravenous ISDN at a low dose over a 3 day period in the usual conditions of prescription for unstable angina does not seem to induce a quantitatively significant phenomenon of tolerance.

[Effect of sinorphan, an endopeptidase inhibitor on severe congestive cardiac insufficiency]

Sinorphan is a powerful inhibitor of enkephalinases or endopeptidases 24-11, enzymes implicated in the degradation of the atrial natriuretic factor (ANF). In healthy volunteers, it increases plasma concentrations of endogenic ANF and increases diuresis and natriuresis. In order to study the tolerance and biological effects of pharmacological increase of plasma concentrations of endogenic ANF in severe congestive cardiac failure, 12 patients (in functional Classes III or IV of the NYHA classification) were given a single oral dose of 10, 20 or 40 mg of Sinorphan. Sinorphan was clinically well tolerated. The diastolic blood pressure decreased slightly (- 10 +/- 9 mmHg) but significantly (p less than 0.05). Systolic blood pressure and heart rate were unchanged. Despite spontaneously high plasma ANF concentrations (on average 15 times higher than normal subjects), Sinorphan induced an additional increase of 80 to 100% of plasma ANF concentration compared to the initial values (p less than 0.01) with no dose-dependent response for the dosages used. The inhibition of plasma endopeptidase activity attained 47% at the 30th minute. Urinary cyclic GMP excretion increased by 30% at the second hour (p less than 0.05). In addition, a statistically non significant tendency to increase diuresis and natriuresis was observed. These results show that Sinorphan increases plasma ANF concentrations by inhibition of its degradation in severe congestive cardiac failure and that this increase seems to be associated with potentially beneficial biological changes. The concept of endopeptidase inhibition should constitute a new therapeutic approach in cardiac failure, a situation in which the ANF seems to exert a favourable effect.(ABSTRACT TRUNCATED AT 250 WORDS)

[Demonstration of abnormalities of myocardial mitochondrial oxygenation in cardiac graft rejection]

Abnormalities of myocardial metabolism during acute rejection may be due to ischemia to primary metabolic changes related to rejection. An experimental study of heterotopic cardiac transplantation in the rat was undertaken to study myocardial mitochondrial oxidation during acute rejection. The receivers were Lewis rats and the donors Fischer (FL: allograft) or Lewis (LL: isograft) rats. The oxygen consumption of the mitochondria (VO2m) isolated from the transplanted and native hearts was measured by oxygraphy six days after transplantation. Using maleate and glutamate substrates, the VO2m of transplanted hearts was significantly lower than that of native hearts in the two groups of rats (FL, p less than 0.01; LL, p less than 0.01). In addition, the VO2m of FL allograft transplanted hearts was significantly lower than in the LL rats (30 +/- 9 vs 100 +/- 15 nanoatoms of oxygen/min.mg/prot, p less than 0.01) as was the VO2m of the native hearts (FL: 106 +/- 23 vs LL: 164 +/- 26, p less than 0.02). The respiratory control ratio (RCR) was significantly lower in the transplanted than in the native hearts in both the FL and LL groups (p less than 0.05 and p less than 0.01 respectively). The comparison of the RCR in the two groups (FL vs LL) showed no significant difference for transplanted or native hearts. Electron microscopy of transplanted (rejected or not) and native hearts showed no morphological abnormality of the mitochondria. The lower VO2m of the allograft group indicates a disturbance in the mitochondrial respiratory pathway during acute rejection.(ABSTRACT TRUNCATED AT 250 WORDS)

[Abnormalities of the skeletal muscle in hypertrophic cardiomyopathy. Spectroscopy using phosphorus-31 nuclear magnetic resonance]

There have been several reports of electromyographic and histological changes of striated skeletal muscle, especially of the type I oxidative fibres, in hypertrophic cardiomyopathy. In order to determine whether these anomalies also cause metabolic changes, a P-31 magnetic resonance spectroscopic study was undertaken at rest and on exercise in 5 pauci-symptomatic patients and 10 control subjects. The 5 patients had primary hypertrophic cardiomyopathy without alteration of systolic function or signs of congestive cardiac failure (Stages I or II). There were no clinical signs of myopathy. None of the patients were receiving betablocker therapy at the time of investigation. No significant difference was observed at rest. Intracellular acidosis was particularly pronounced in 2 of the 5 patients at the peak of exercise. In addition, the phosphocreatine recovery time (T1/2) was longer in the patient group (3.4 +/- 1.7 vs 1.6 +/- 0.9 mn; p less than 0.01) suggesting a mitochondrial metabolic oxidation abnormality. These results suggest that some patients with primary hypertrophic cardiomyopathy have abnormalities of mitochondrial oxidation in their striated skeletal muscle which can be demonstrated by P-31 magnetic resonance spectroscopy. This would suggest a global abnormality of striated muscle which, at a more advanced stage of the disease, could account for decreased effort tolerance in these patients.

The effect of nifedipine on myocardial perfusion and metabolism in systemic sclerosis. A positron emission tomographic study

We assessed the effect of nifedipine on myocardial perfusion and metabolism in 9 patients with systemic sclerosis, using positron emission tomography with a perfusion tracer (potassium-38) and a metabolic tracer (18F-fluorodeoxyglucose [18FDG]). Nifedipine, 20 mg 3 times daily for 1 week, induced a significant increase in 38K myocardial uptake, a significant decrease in 18FDG myocardial uptake, and a significant increase in the myocardial 38K: 18FDG ratio. These results indicate that the increase in myocardial perfusion is associated with modifications in myocardial energy metabolism, which probably result from a beneficial anti-ischemic effect of nifedipine in patients with systemic sclerosis.

[Adrenergic betareceptors and cardiac insufficiency]

Noradrenergic sympathetic tone is always increased in chronic left ventricular failure of which it is one of the main compensatory mechanisms. Beta-1-adrenergic stimulation increases the heart rate and left ventricular contractility. However, the efficacy of this "compensatory" mechanism is limited on the one hand by the energetic cost of inotropic stimulation and, on the other hand, by the phenomenon of desensitisation and down-regulation of myocardial beta-1-receptors during intense and prolonged noradrenergic stimulation as observed in chronic cardiac failure. These physiopathological concepts raise the question of the indications of drugs affecting betareceptors in cardiac failure. Positive inotropic beta-mimetics can only be used during short periods of acute decompensation: low dose betablocker therapy protects the betareceptors from the phenomenon of desensitisation and seem to exert a beneficial action in this way in some cases of cardiac failure; these preliminary results require confirmation by large scale controlled therapeutic trials. Finally, a new pharmacological class of drugs, the beta-1 adrenergic partial agonists, seems to be useful in the management of moderate degrees of cardiac failure due to ischemic heart disease.

[Dilated cardiomyopathy with deep, completely reversible dysfunction of the left heart in alcoholic patients. Report of 2 cases]

Two cases of dilated, hypokinetic cardiomyopathy complicated by cardiac failure, are reported in a 29 year old woman and a 55 year old man, with no etiological factors other than chronic major alcoholism (consumption of over 100 ml of alcohol per day for over 5 years). This was completely reversed 10 and 14 months after cessation of alcohol consumption. The isotopic left ventricular ejection fraction increased from 22 to 70 p. 100 and from 12 to 73% respectively. These cases are are and are evidence in favour of an alcoholic cardiomyopathy rather than alcohol being an aggravating factor in patients with cardiomyopathy.

[The function of beta receptors in chronic left ventricular insufficiency]

Hyperactivity of the noradrenergic sympathetic system is one of the essential "compensatory"mechanisms in chronic left ventricular failure. The ensuing stimulation of myocardial beta-adrenergic receptors results in an increase of heart rate and contractility which, to some extent, counterbalances the alteration of left ventricular function, but rapidly reaches its limits: the excessive shortening of diastoles and, mostly, the increase of myocardial oxygen demand neutralize the beneficial haemodynamic effect of beta-adrenergic stimulation, especially when ischaemia is the cause of the heart failure; the chronic exposure of adrenergic receptors to noradrenaline in high concentrations leads to desensitization, to a "down regulation" which primarily affects the beta 1 receptors and spares, at least partly, the myocardial beta 2 receptors which seem to play a quantitatively important inotropic role, particularly in chronic heart failure. These new data on the physiology of the cardiac noradrenergic system have major therapeutic consequences: in practice, the positively inotropic beta-stimulants can only be used for a short period in acute episodes of heart failure; - the use of beta-blockers in low doses is now considered in the treatment of some forms of heart failure; the mechanism of their therapeutic action remains controverted, and their long-term effectiveness in a large patient population is under study; - a new pharmacological class, beta-adrenoceptor partial agonists, seems to give satisfactory clinical and haemodynamic results in mode-rate heart failure, A wider clinical evaluation is needed to determine the therapeutic role of theses new pharmacodynamic agents.

[The value of recording the pulmonary insufficiency flow by continuous Doppler for the evaluation of systolic pulmonary artery pressure]

Systolic, diastolic and mean pulmonary artery pressures can be evaluated by Doppler recordings of the maximal velocity of tricuspid regurgitation and early and late diastolic pulmonary regurgitant flow. The aim of this study was to assess the reliability of the calculation of systolic pulmonary artery pressure from pulmonary regurgitant flow by comparing the values with those obtained from the tricuspid regurgitant flow in the same patient. With this objective in mind, we investigated 70 patients with an average age of 45 +/- 34 years, in sinus rhythm, all of whom had tricuspid and pulmonary regurgitant jets which could be recorded with continuous wave Doppler. Systolic pulmonary artery pressure was calculated as follows: from tricuspid regurgitation: maximum pressure gradient + 10 mmHg; from pulmonary regurgitation: 3 x early diastolic gradient - 2 x late diastolic gradient + 10 mmHg. The systolic pulmonary artery pressures calculated from tricuspid and pulmonary regurgitation were: 42 +/- 16 mmHg and 43 +/- 17 mmHg respectively (r = 0.97) with an estimated standard error of 4.7 mmHg. These results show that the recording of pulmonary regurgitation by continuous wave Doppler allows accurate estimation of pulmonary artery pressures. The calculation by the two methods using tricuspid and pulmonary regurgitant jets increases the reliability of the results and provides a means of internal validation of the Doppler technique.

Pharmacodynamic effect of nicardipine on left ventricular function in systemic sclerosis

Left ventricular dysfunction in systemic sclerosis may be due in part to myocardial ischemia caused by a disturbance in coronary microcirculation. We evaluated the pharmacodynamic effect of the calcium channel blocker nicardipine on left ventricular function assessed by radionuclide ventriculography in 20 patients with systemic sclerosis. Resting gated, blood-pool images were obtained at baseline and 90 min after 40 mg of oral nicardipine. The mean (+/- SEM) left ventricular ejection fraction significantly increased from 65.4 +/- 2.3% at baseline to 71.3 +/- 2.3% after nicardipine (p less than 0.005). The mean global defect score significantly decreased from 2.90 +/- 0.73 without nicardipine to 1.50 +/- 0.52 with nicardipine (p less than 0.01). The mean number of left ventricular sectors with severe hypokinesis significantly decreased from 0.80 +/- 0.24 at baseline to 0.20 +/- 0.09 after nicardipine (p less than 0.05). No significant side effects were observed with nicardipine. These results demonstrate short-term improvement in left ventricular function with nicardipine in patients with systemic sclerosis.

Change in human cardiac rhythm induced by a 2-T static magnetic field

The influence of a 2-T static magnetic field on the cardiac rhythm was studied with 24-hour electrocardiographic monitoring in 12 healthy volunteers for 1 hour before exposure, 1 hour during exposure, and 22 hours after exposure. Four other subjects were exposed to 1 T, and nine control subjects were exposed to 0 T. In the 2-T group, the mean cardiac cycle length (CCL) was 912 msec +/- 83 before exposure. A significant 17% increase in CCL was observed after 10 minutes of exposure. No further significant variation was observed during exposure, and the CCL was back to preexposure values 10 minutes after exposure. No other arrhythmogenic effect was noted during the 24-hour monitoring. No statistically significant change was observed at either 0 or 1 T. The magnetically induced blood-flow potentials superimposed on the T wave were observed. The CCL increase during exposure could reflect a direct or indirect effect of magnetic fields on the sinus node, which is probably harmless in healthy subjects. However, its safety in dysrhythmic patients remains to be determined.

[The value of NMR spectroscopy in the study of myocardial ischemia and in cardiovascular pharmacology]

Nuclear magnetic resonance spectroscopy is a non-destructive method used to investigate the intracellular repercussions of experimental myocardial ischaemia. The effectiveness of drugs or cardioplegic agents in preserving myocardial metabolism during and immediately after ischaemia can be tested on various models. The results obtained in different experiments and the metabolic studies conducted in patients treated with cardiotropic drugs illustrate the value of this method in cardiovascular pharmacology.

[Incomplete spontaneous rupture of the supravalvular aorta complicated by pericarditis and aortic insufficiency]

The natural history of an incomplete spontaneous rupture of the ascending aorta over a 4-year period is reported. The initial presentation was subacute pericarditis which regressed spontaneously. Aortic regurgitation developed on the 100th day of the disease and was perfectly well tolerated haemodynamically for 4 years. This favourable course was interrupted by type I aortic dissection. The post-mortem examination provided an explanation for the peculiar development and course of the aortic regurgitation: it was due not to the usual prolapse of the cups but to displacement of the left posterior commissure by the retractile fibrosis arising from the lower lip of the spontaneous rupture.

[Study of myocardial metabolism of NADH by laser fluorimetry during cardiac catheterization]

Laser fluorimetry of reduced nicotinamide-adenine-dinucleotide (NADH) p6 a new technique used for in situ and real-time study of myocardial metabolism. We have evaluated its applicability to clinical situations in 5 patients undergoing haemodynamic exploration. An optic fibre was inserted in a catheter the end of which was positioned in the postero-diaphragmatic part of the left ventricle. The optic fibre was connected to a Cilas-Alcatel fluorimeter. Variations in fluorescence were studied during variations in left ventricular end-diastolic pressure (LVEDP) and during coronary arteriography. An increase in LVEDP resulted in a slight increase in NADH, but when the LVEDP was reduced by a nitroglycerin infusion, NADH fell significantly below baseline values in patients with coronary disease. This effect was most probably due to redistribution of the coronary blood flow from healthy territories to ischaemic territories. In patients without significant coronary stenosis, NADH was not modified by an injection of 10 ml of contrast medium into the right coronary artery. In contrast, in patients with severe stenosis NADH fluorescence significantly increased during the injection, reflecting the ischaemia or myocardial anoxia induced by the contrast medium. NADH laser fluorimetry therefore seems to be promising as a means of exploring myocardial metabolism during cardiac catheterization.

Nicardipine in the treatment of Raynaud's phenomenon: a randomized double-blind trial

The efficacy of the calcium-channel blocker nicardipine in the treatment of Raynaud's phenomenon was assessed in a prospective, double-blind, randomized, crossover trial in 20 patients. Each patient received nicardipine 20 mg or placebo three times a day for two weeks and then was crossed over for two weeks. Nicardipine significantly decreased the frequency and severity of Raynaud's phenomenon as compared with placebo. The authors conclude that nicardipine is effective in the treatment of Raynaud's phenomenon.

Left ventricular ultrastructure in pulmonary stenosis and in tetralogy of Fallot

Twelve patients underwent haemodynamic studies and myocardial biopsies: 7 with pulmonary stenosis (PS) and 5 with tetralogy of Fallot (TOF). Their ages ranged between 2 and 43 years. Right ventricular pressure was 128 +/- 43 mmHg in PS and 98 +/- 8 mmHg in TOF. Aortic blood oxygen saturation was 97.0% +/- 1.4% in PS, and 88.4% +/- 6.3% in TOF. Left ventricular (LV) weight was normal in TOF while it was increased in PS: 140.7 +/- 74.3 vs 74.0 +/- 8.7 g/m2 (P less than 0.001). Contractility was altered in both PS and TOF: ejection fractions were 56% +/- 7% vs 65% +/- 6% (P less than 0.001). Light microscopy showed abnormal transverse diameter of left ventricular myocytes in both PS and TOF: 18.6 micron +/- 4.0 micron vs 19.4 micron +/- 4.9 micron. The percentage of interstitium was normal: 29.6% +/- 3.9% vs 26.2 +/- 5.1%. Transmission electron microscopic examination revealed hypertrophic changes in all patients and degeneration in 7 of them. Hyperfunctional alterations of the myocytes were characterized by the increased number and reduced size of mitochondria, the enlarged Golgi complex, the increased number of ribosomes, the marked folding and convolutions of the nuclear membrane, the dilatation and tortuosity of T tubules. Myofibrillar lysis was the major degenerative change, which was also observed in the right ventricle (RV) of the same patients. No correlation was observed between these alterations and the patient ages, RV pressures, aortic blood oxygen saturations and ejection fractions. These findings led us to conclude that: (1) suprasystemic pressure overload of the RV induces macroscopic LV hypertrophy; (2) mild and suprasystemic pressure overload of the RV induces hyperfunctional changes in the LV; (3) myocardial degeneration is not related to hypertrophy nor to hypoxia, but is part of a more widespread cardiovascular fetopathy.

Nifedipine and thallium-201 myocardial perfusion in progressive systemic sclerosis

Heart disease in patients with progressive systemic sclerosis may be due in part to myocardial ischemia caused by a disturbance of the coronary microcirculation. To determine whether abnormalities of myocardial perfusion in this disorder are potentially reversible, we evaluated the effect of the coronary vasodilator nifedipine on myocardial perfusion assessed by thallium-201 scanning in 20 patients. Thallium-201 single-photon-emission computerized tomography was performed under control conditions and 90 minutes after 20 mg of oral nifedipine. The mean (+/- SD) number of left ventricular segments with perfusion defects decreased from 5.3 +/- 2.0 to 3.3 +/- 2.2 after nifedipine (P = 0.0003). Perfusion abnormalities were quantified by a perfusion score (0 to 2.0) assigned to each left ventricular segment and by a global perfusion score (0 to 18) for the entire left ventricle. The mean perfusion score in segments with resting defects increased from 0.97 +/- 0.24 to 1.26 +/- 0.44 after nifedipine (P less than 0.00001). The mean global perfusion score increased from 11.2 +/- 1.7 to 12.8 +/- 2.4 after nifedipine (P = 0.003). The global perfusion score increased by at least 2.0 in 10 patients and decreased by at least 2.0 in only 1. These observations reveal short-term improvement in thallium-201 myocardial perfusion with nifedipine in patients with progressive systemic sclerosis. The results are consistent with a potentially reversible abnormality of coronary vasomotion in this disorder, but the long-term therapeutic effects of nifedipine remain to be determined.

[Conservative surgery of the mitral valve. Immediate and late results]

A consecutive series of 130 cases of pure or predominant mitral regurgitation underwent conservative mitral valve surgery between January 1975 and January 1982. The mean age of the patients was 30 +/- 17 years; 25 patients were under 15 years of age. The most common aetiology was rheumatic fever (112/130). Fifty nine patients had associated valvular lesions requiring surgical correction. The patients were divided into 4 groups, according to the surgical technique: Group I: valvular mobilisation (35 cases); Group II: reduction of the amplitude of valvular excursion (48 cases); Group III: mixed valvular mobilisation and reduction of amplitude of excursion (45 cases); Group IV: isolated annuloplasty (2 cases). Hospital mortality was 2.3% (3 patients). Five patients (3.8%) were lost to follow-up. The mean follow-up period was 38 +/- 27 months for the 122 patients followed-up. Seven patients needed reoperation. The long term mortality was 3.1% (4 patients). Four late thromboembolic episodes were observed; they were all transient and regressive in patients with atrial fibrillation. The 7 year actuarial survival rate for the whole series, including hospital mortality, was 92% (1.0 +/- 0.5 patients/year). It was 93.7 +/- 4.9% at 7 years for isolated mitral valvuloplasty and 89.9% +/- 5.6% at 5 years for combined mitro-tricuspid procedures. The actuarial percentage of patients without thromboembolic complications was 91.2% at 7 years with a thromboembolic risk of 1.0 +/- 0.5% patients/year. Eighty eight per cent of patients were not reoperated at 7 years and the reoperation rate was 1.7 +/- 0.7% patients/year.(ABSTRACT TRUNCATED AT 250 WORDS)

[Subvalvular aortic stenosis in adults. Apropos of 31 cases]

The aim of this cooperative study was to analyse the clinical profile of subvalvular aortic stenosis (SVAS) in adults. Thirty one cases were collected : patients aged 17 to 60 years (average 34 years). The diagnosis was confirmed in all patients either at surgery (30 cases) or at autopsy (1 case). The overall incidence of SVAS in patients with fixed obstruction to left ventricular ejection operated in the same period was 3.5%. Associated congenital malformations were detected in 15% of cases but intracardiac shunts were rare. Adult SVAS is a purer malformation than in children, probably because of spontaneous and surgical selection. The anatomical type of stenosing lesion in this series was a subaortic ring or membrane; 45% of patients, usually over 40 years of age (7 out of 9) had localised septal hypertrophy at the level of the diaphragmatic obstruction. The clinical presentation was that of mixed aortic disease with associated stenosis and regurgitation. Over 80% of patients had aortic incompetence diagnosed clinically (26 out of 31 cases) or on aortography (24 out of 25 cases); the regurgitant flow was assessed as mild in 15 cases, moderate in 6 cases and severe in 3 cases. There were obvious valvular lesions at surgery in 19 cases, especially in patients over 40 years of age (8 out of 9 cases). The mechanism was variable : non-specific (8 cases), destructive (6 cases), rheumatic (2 cases) or congenital (3 cases). Bacterial endocarditis was particularly common (26% of cases). Adult SVAS is a particularly difficult clinical diagnosis : the electrocardiogram and chest X-ray are not very informative.(ABSTRACT TRUNCATED AT 250 WORDS)

[Molsidomine prevention of coronary artery spasm caused by alkalosis]

A test provocation of coronary artery spasm by alkalosis was used to evaluate a possible anti-coronary artery spasm effect of molsidomine. The rapid infusion of an alkaline buffer followed by maximal voluntary hyperventilation in 10 patients with angina at rest led to the appearance of angina pain and significant, transient ischaemic changes of the ST segment, due to alkalosis induced coronary spasm. A second provocation test was performed under the same conditions, 24 hours later, after the prior administration of 4 mg of molsidomine. Molsidomine prevented the development of coronary artery spasm in 8 of the 10 patients in the study group. These preliminary results justify further clinical evaluation of molsidomine in the treatment of vasospastic angina.

[Aortic rheumatoid insufficiency. 3 cases and review of the literature]

The authors report on three cases of rheumatoid aortic valve insufficiency. The three patients had classic sero-positive rheumatoid arthritis. In one patient aortic valve insufficiency and pericarditis occurred simultaneously; aortic valve insufficiency appeared in two patients less than two years and in the third patient 17 years after the beginning of arthritis. In the first two cases, the aortic regurgitation evaluated by echocardiography and angiography was not severe enough to require valvular replacement. In the third patient, rheumatoid granuloma of the aortic valve caused fatal aortic insufficiency.

[Idiopathic aneurysm of the left ventricle. Apropos of 4 cases operated on with success]

Over a period of 3 years, 4 cases of idiopathic left ventricular aneurysm, 3 white females and one coloured male aged 34, 53, 29 and 47 years respectively, were observed. All presented with paroxysmal ventricular or supraventricular tachycardia, which, in one case, was severe enough in itself to justify surgery. On angiography, large left ventricular aneurysms bordering the mitral annulus and responsible for moderate mitral regurgitation in two patients were demonstrated. Aneurysmectomy was only possible in 2 cases, the other two having pericardial adhesions with a risk of uncontrollable haemorrhage during dissection being managed by suture of the neck of the aneurysm. The surgical results were very satisfactory, especially with respect to the arrhythmias with a follow-up of 48, 24, 15 and 9 months respectively. In a review of the literature, 93 cases of idiopathic left ventricular aneurysm were analysed, less than 20 of which have been managed surgically. Left ventricular aneurysms seem to be large fibrotic structures located at the border of the mitral, or, less commonly, below the aortic annulus. It is important to differentiate them from congenital left ventricular diverticuli which are usually located at the apex, have muscular walls and are therefore contractile. The aetiology of these aneurysms is unknown: the possible role of myocardial infarction may be excluded as the coronary arteries are always normal on angiography and at autopsy. The relatively young age of the patients is also an argument against this hypothesis. Other suggested causes such as syphilis, tuberculosis, Chagas' disease, non-specific myocarditis, sarcoidosis and thoracic trauma may also be excluded. Surgery seems to be indicated in cases complicated by resistant arrhythmias, peripheral embolism or when the aneurysm increases rapidly in size.

[Value and limitations of sequential technetium 99m angiocardiography in the detection, localization and quantification of left-right intracardiac shunts apropos of 110 cases]

A comparative study of the diagnosis of intracardiac left-to-right shunts by isotope radiography on the one hand and oxymetry, abnormal catheter trajectory and angiocardiography on the other, was performed on a series of 110 patients, comprising 12 normals, 46 valvulopathies or cardiomyopathies without shunts, 23 ASDs, 22 VSDs, and 7 other shunts. Intravenous injection of Technetium 99 m with scintigraphic imagery and interpretation of time-activity curves detected even small left-to-right shunts and appeared to be more sensitive than oxumetry. The estimation of the size of the shunt correlated well with oxymetry for VSDs but not for ASDs. The localisation of the shunt was more difficult. The atrial level of the defect was detected in some but not the majority of cases. The isotopic technique appeared unreliable in the presence of severe haemodynamic disturbances. The isotopic method is a quick means of detecting left-to-right shunts without measurable risk, particularly useful in the investigation of children and young adults thought to have left-to-right shunts.

[Long-term results of palliative operations and complete cure of tetralogy of Fallot]

714 cases of Fallot's tetralogy have been encountered over the last thirty years. A closed heart operation was undertaken in 472 patients. The mean age at operation was 5,1 years. In 87% of cases, a Blalock-Taussig anastomosis was carried out. The operative mortality was of the order of 3%. The operative risk was almost three times as large before the age of two years as after. The patients benefit by a demonstrable improvement of function after this operation, but it does not protect them from the complications of the condition (cervica abscess, Osler's disease, cerebro-vascular accidents) or from death. Open heart surgery was carried out in 403 patients. 161 as a primary procedure, and 242 after an initial palliative operation. The mean age at operation was 13.3 years. The operative mortality was 15%. The functional improvement was striking, and the patients appeared to be protected from the usual sequelae of the condition. On the other hand they cannot always be considered as cured: 16 died some time after the operation; 37% had pulmonary incompetence; 15% had a residual BSD; 8% had a block of both bundles, and 3% had a definitive atrio-ventricular block.

[Hypoplasia of the right ventricle with inter-atrial communication and without any other abnormality. Apropos of a case treated surgically by closure of the inter-atrial communication]

A case is reported of hypoplasie of the right ventricle with a wide atrial septal defect in a child of 10. The presence of cyanosis with right atrial and left ventricular preponderance led us to suspect tricuspid atresia, but this was excluded by catheterisation and angiocardiography. There was definitely and atrial septal defect with a two-directional shunt, but the tricuspid valve could be negotiated, and the right-sided opacity provided the essential diagnostic criterion, namely hypoplasia of the sinus portion of the right ventricle with a normal infundibulum. 17 other published cases of hypoplasia of the right ventricle with atrial septal defect are reviewed. The current indications for surgery are discussed in the light of the nature of the disordered physiology. Simple closure of the atrial septal defect, which was carried out successfully in 3 cases, appears to be of great value in the larger child, when there is a wide defect.

Natural history of ventricular septal defect. A study involving 790 cases

The development of 790 untreated patients affected by ventricular septal defect (VSD) has been the object of a 25-year study. Of these patients, 72% had had at least one catheterization; 13% had several. The mean observation interval is six years, and the average age at the latest data is 19.5 years. This study covers 4717 patient-years. For the entire population, the incidence rate or aortic regurgitation is 6.3% (4.3 for 1000 patient-years) and that of bacterial endocarditis is 3.7% (2.4 for 1000 patient-years). Twenty-five patients died, 15 of them between the ages of one and 39. Of the 499 cases with several clinical examinations, 71% remained stable. In 21%, changes suggesting some level of closure developed; in 7%, infundibular stenosis began to evolve and in 1% pulmonary vascular disease began to appear or became accentuated. These different rates are studied and discussed in relation to patients' age, VSD type, and various follow-up characteristics.