[Accentuation of myocardial ischemia during coronary recanalization in the acute phase of myocardial infarction]

Coronary recanalisation during the acute phase of myocardial infarction, especially by in situ infusion of thrombolytic agents, is accompanied in most cases by rapid regression of chest pain and a reduction in the degree of ST elevation. However, a multicentre retrospective study of 104 attempts at recanalisation, including 78 successful procedures, showed in 10 cases (12.8 p. 100), an apparently paradoxical accentuation of the chest pain with or without increased ST elevation, at the time of angiographically demonstrable recanalisation. This phenomenon may be interpreted as being the result of aggravation of the ischaemia of the border zone, the objective of therapy. Several pathogenic hypotheses, all with experimental proof, may be suggested to explain these observations (haemorrhagic infarction, non reperfusion, ischaemic contraction due to massive intracellular flow of calcium, etc.). It is usually associated with arrhythmias and may be considered to be a reliable sign of recanalisation. It may also explain certain cases of persistence of chest pain and ECG changes despite the demonstration of a permeable epicardial artery on initial coronary angiography.

[Exercise test in isolated anomalies of auriculo-ventricular conduction in children and adolescents. Value in idiopathic auriculo-ventricular blocks and ventricular pre-excitation syndromes]

Abnormal atrioventricular conduction in children and adolescents without obvious underlying cardiac disease poses the problem of long term prognosis. This study of 45 patients aged 8 to 18 years with congenital atrioventricular block (30 cases) or ventricular pre-excitation (15 cases), was undertaken to determine the value of exercise testing, a physiological adrenergic stress test, in the assessment of these patients. Our results show that exercise testing was valuable in determining the site of atrioventricular block: during exercise the degree of block increased in two patients, justifying electrophysiological investigations which showed infrahisian block in one case; when the block was stable or improved on exercise, the atropine test, performed in 21 cases, gave concordant results in 18 cases (the same change with atropine and exercise): the block was nodal in all these patients. A concordant response to exercise and atropine, improving the degree of block, indicates suprahisian block and endocavitary investigation would not seem to be necessary. On the other hand, when the degree of block increases or remains the same during exercise and/or the atropine test, the site of block cannot be predicted and endocavitary investigation and Holter monitoring may be required. In patients with ventricular pre-excitation, exercise testing provides information on the relative values of the effective refractory periods of the normal and accessory pathways: in the 10 cases in which endocavitary studies were undertaken, the exercise electrocardiogram changed in the expected manner (disappearance of the pre-excitation wave on exercise in patients with accessory pathways with longer refractory periods than the normal pathway and persistence of pre-excitation when the accessory pathway refractory period was shorter).(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronarography by percutaneous puncture of the axillary artery. Value in arteriopathies of the lower limbs]

Coronary angiography by a percutaneous femoral approach using the Judkins-Bourassa technique with special preformed catheters is widely used. This approach is potentially dangerous or impossible in patients with severe lower limb arteriosclerosis even after operation and so the investigation has to be done by Sones' technique (denudation of the humeral artery). There is, however, another upper limb approach which does not involve arterial denudation: percutaneous right or left axillary artery catheterisation. This paper reports the experience of a multicentre study of this method in 105 patients. This study is of interest as an arterial catheter introducer was used which, does not compress the artery, prevents bleeding when the catheter has to be changed and reduced the risk of thromboses or laceration of the axillary artery. 73 of the 105 patients had lower limb arteriosclerosis 5 had aortic aneurysms and 1 patient had a previous history of femoral artery embolism. There was a primary indication for this approach in 21 cases. The left axillary artery was used in 83 cases (79%) and the right axillary artery in 22 cases (21%). The coronary catheters were those usually used with the femoral approach. The left side was chosen preferentially as it avoided the brachiocephalic trunk and facilitated the catheterisation of the coronary ostia and of aorto-coronary bypass grafts. Selective catheterisation of the left coronary artery was achieved in 21 out of 22 cases (95%) and of the right coronary artery in all 22 cases (100%) by the right axillary route. Both left and right coronary arteries were selectively catheterised in all cases by the left axillary approach.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term follow up of surgically-treated congenital heart disease: interauricular communication, aortic coarctation, tetralogy of Fallot]

Based on data from the literature and their own experience, the authors study the long-term clinical course of patients with interatrial communications (IAC), coarctation of the aorta (CAo) and tetralogy of Fallot (TF) who have been operated. According to data from the literature and 50 cases which were reviewed an average of 11 years after the operation, operated cases of IAC are at risk of developing arrhythmias or conduction disturbances, especially if the operation was performed after the age of 20, in cases with cardiomegaly, with a mean pulmonary artery pressure of more than 20 mmHg and a pulmonary flow/systemic flow ratio due to the shunt greater than 1.5. Surgery for CAo carries a risk of long-term residual hypertension (HT). According to the majority of authors and a study of 55 cases. HT is present in 3 to 6% of cases operated between the ages of 1 and 10 years. This percentage is much higher for the older age groups. The increase in blood pressure on effort and the demonstration of a gradient between the upper limb and the lower limb are the methods of detecting post-operative hypertension and residual stenosis. Cardiac failure and coronary occlusion can occur in the cases which were operated late. Following complete correction of TF, severe ventricular arrhythmias can arise in the long term. From a study of 59 patients at least 3 years after the operation, the authors outline the elements which favour the development of these arrhythmias. The cases at highest risk are those which were operated after the age of 2 years with significant residual lesions, cardiomegaly and ventricular extrasystoles on the resting trace.(ABSTRACT TRUNCATED AT 250 WORDS)

[Relations between the site of significant monotruncular coronary stenosis and left ventricular function. Therapeutic implications]

The indications of coronary bypass surgery in single vessel disease remain controversial. Therefore, we carried out a retrospective study of the coronary angiogrammes and left ventriculography of 93 patients with single vessel disease (greater than 70 p. 100 stenosis) involving the left anterior descending (LAD) or dominant right coronary arteries (RCA) to evaluate the quantity of myocardium at risk. Five angio-hemodynamic parameters were compared: the ejection fraction (EF), the ratio of end systolic left ventricular pressure to volume (LVESP/LVESV), the velocity of circumferential fibre shortening (VCF), end diastolic volume (EDV) and end systolic volume (ESV). Six subgroups were defined: 28 proximal LAD stenosis (16 without and 12 with myocardial infarction (MI], 37 mid LAD stenosis (20 without and 17 with MI), and 28 RCA stenosis (8 without and 20 with MI). In all, there were 44 single vessel stenoses without MI and 49 with previous necrosis. Left ventricular function was normal in the absence of MI but deteriorated progressively in cases with MI and LAD disease. In cases of proximal LAD stenosis without and with MI, the hemodynamics showed: EF (p. 100) = 67,12 +/- 2,07 leads to 43,83 +/- 4,7 (p less than 0,001); LVESP/LVESV = 3,24 +/- 0,34 leads to 1,92 +/- 0,50 (p less than 0,05); VCF (s-1) = 1,28 +/- 0,05 leads to 0,74 +/- 0,06 (p less than 0,001); in cases of mid LAD stenosis without and with MI: EF = 69,1 +/- 2,08 leads to 45,11 +/- 3,42 (p less than 0,001); LVESP/LVESV = 3,64 +/- 0,39 leads to 1,46 +/- 0,12 (p less than 0,001); VCF = 1,32 +/- 0,008 leads to 0,74 +/- 0,06 (p less than 0,001). In contrast the change in LV function was minimal in patients with necrosis and RCA stenosis: EF = 70,37 +/- 3,85 leads to 56,4 +/- 3,19 (p less than 0,05); LVESP/LVESV = 5,20 +/- 1,83 leads to 2,56 +/- 0,36 (p less than 0,05); VCF less than 1,42 +/- 0,17 leads to 1,03 +/- 0,08 (p less than 0,05).(ABSTRACT TRUNCATED AT 400 WORDS)

[Hemopericardium after coronary recanalization with streptokinase in the acute phase of myocardial infarction. Drainage and early aortocoronary bypass on the 4th day]

A case of hemopericardium after coronary recanalisation with streptokinase during the acute phase of myocardial infarction is reported, emphasising the value of routine daily echocardiography in all cases of intracoronary thrombolysis. The patient was a 48 year old man with a primary antero-lateral infarct in whom coronary angiography was performed at the 4th hour, showing total proximal obstruction of the left anterior descending artery. The streptokinase protocol of intracoronary thrombolysis was performed, resulting in recanalisation of the left anterior descending artery at the 30th minute. Improved left ventricular function and persistance of coronary patency were confirmed 14 hours after recanalisation. In the following days the patient showed signs of right ventricular failure with successive echocardiogrammes demonstrating an increasing pericardial effusion. On the 4th day, 600 ml of blood were drained surgically and aorto-coronary bypass carried out on the left anterior descending artery. This procedure maintained coronary patency and the improvement in left ventricular function. Several studies have shown that the hemorrhage of reperfusion only occurs in the zones of necrosis, and thrombolytics, especially streptokinase, may aggravate this condition.

[Unstable angina and single vessel stenosis of the anterior interventricular artery. Evaluation of the threatened myocardium. Therapeutic implications]

The authors report a special cases of precise evaluation of threatened myocardium during coronaro-ventriculography. Two elements provided this evaluation: 1) spasm in the tight stenosis of the middle part of the anterior interventricular artery with immediate left ventricular dyskinesia (EF: 37%, EDP/EVD: 1.74; EDV: 98 cc/m2). 2) Complete instantaneous recovery after injection of 2 mg of trinitrine into the left ventricle (EF: 69%, EDP/EVD: 4.33; EDV: 28 cc/m2). This loss, in the order of 50%, in the left ventricular function led us to perform an angioplasty (ACT) with success. A further clinical and angiographic stenosis, three months later, in this 72 years old patient with arteritis, led us to perform an aorto-coronary graft, rather than another ACT.

[Coronary angioplasty immediately after coronary recanalization in the acute phase of myocardial infarct]

The author report the case of a 48 years old patient, admitted to hospital 3 hours and a half after an anterior myocardial infarct which was well tolerated. Coronary recanalization with urokinase-plasminogen removed the obstruction of the middle part of the anterior interventricular artery 1 hour and a half after the patient's arrival. Selective left coronary angiography demonstrated a narrow stenosis, in the order of 98%, in the proximal part of the AIV artery. Angioplasty was attempted immediately, in view of the ease with which the guide wire was passed through the initial thrombosis and the good haemodynamic tolerance. The residual stenosis was estimated to be 20% after the angioplasty and at the examination 48 hours later. The ECG on discharge from hospital showed a QS appearance in V1 to V3 with R in V4. An improvement in the ejection fraction (EF) and in the end-diastolic volumes was found: EF: 48% compared to 38%, EDV (cc/m2): 79 compared to 120. The clinical course at two months is very satisfactory, with no residual angina and a negative stress test. This special procedure, combining a double therapeutic catheterization, lasted 1 hour 50 minutes and allowed the progression of the myocardial infarction to be halted and also avoided a subsequent aorto-coronary graft operation.

[Sequential double demand programmable stimulation in the treatment of resistant supraventricular tachycardia. Long-term results]

Asynchronous pacing at a rhythm slower than that of the tachycardia (underdrive) is an established procedure for the reduction of supraventricular tachycardia. Simultaneous or sequential stimulation depolarising two parts of the circuit (atrium and ventricle) has a greater chance of reducing the tachycardia than stimulation of a single chamber. Five patients with supraventricular tachycardia resistant to antiarrhythmic therapy were treated by sequential pacing in the underdrive mode. Electrophysiological investigations showed a bundle of Kent to be responsible for the ECG appearances of Wolff-Parkinson-White (3 cases) with retrograde conduction only (concealed WPW) in 2 cases. One patient was able to put a stop to his attacks by the application of a magnet over the pulse generator. In four patients, a newly designed pulse generator, based on this concept, was implanted with the property of automatic detection of tachycardia (defined as a heart rate faster than 150/min) triggering almost simultaneous pacing of the coronary sinus and right ventricle (sequential interval of 65 ms) in the asynchronous mode at 77 bpm. The results were reviewed with a follow up of 6 to 36 months. This pulse generator was shown to be effective in both the reduction and prevention of episodes of supraventricular tachycardia. Sequential double demand pacing is a valuable and useful method of treating reentrant tachycardias associated with the WPW syndrome or concealed Kent bundles. It provides an alternative to surgery when the effective refractory period of the Kent bundle is long. Present advances in the field of cardiac pacing will probably result in a widening of the indications for this mode of therapy.

Retrograde (ventriculoatrial) conduction

Interest in retrograde VA conduction has been renewed with the advent of tachycardias induced by physiologic pacemakers with atrial sensing capabilities. Accurate representation of ventriculoatrial conduction requires detailed electrophysiologic analysis during sinus rhythm, during tachycardias whether or not associated with accessory pathways, and during ventricular pacing studies. Retrograde conduction should be assessed in patients considered for implantation of atrial sensing and tracking pacemakers (VAT, VDD, DDD), until technologic advances overcome the problems of endless loop tachycardias.

[Calculation of the ejection fraction from simultaneously recorded systolic intervals and angiography. Comparative study]

Garrard, Weissler and Dodge have reported a close correlation (r = -0,90) between angiographic ejection fractions (EF) and the ratio of left ventricular preejection and ejection periods (PEP/LVET) in patients with left ventricular disease without simultaneous recording equation Y" = 1,25 - 1,25 x where x is the PEP/LVET ratio and Y" the ejection fraction. Using this formula a theoretical EF may be calculated when the PEP/LVET ratio is known. A number of precautions must be taken in measuring systolic time intervals (synchronous recordings, rapid and constant recording speeds of at least 100 mm/s, good quality tracings). Respecting these conditions, close correlations between the theoretical and angiographic EF were obtained. However, discrepancies were observed in some cases and so the relationship was examined with and without simultaneous recordings in 28 patients (19 with coronary artery disease). The equations obtained were Y = 1,2 - 1,51 x and Y = 1,04 - 1,04 x respectively. The correlations in the whole group and in the coronary subgroup were not as good when the recording was not simultaneous (r = -0,78, compared to r = -0,85). The theoretic EF appeared to be "optimised" under these conditions. The "optimisation" increased with increasing values of the PEP/LVET ratio. A downward correction had to be made for abnormally high values (for example for a PEP/LVET of 0,38, the EF had to be corrected by -3,1% and for a value of 0,50 by -10,5%). This was also applicable in the patients with coronary artery disease. Curiously, the equation relating simultaneous EF and PEP/LVET was very close to that obtained by Garrard (Ya = 1, 12 - 1,27 x, ra = -0,80). The theoretical EF calculated from this equation was very close to the angiographic value. However, it was slightly higher or lower in coronary patients with or without myocardial infarction. Garrard's equation would appear to be useful for repeated studies of the ejection fraction in these patients.

[Wolff-Parkinson-White syndrome after 50 yars of age. Clinical and electrophysiological data]

The Wolff-Parkinson-White syndrome is usually observed in young people and is much rarer in patients over 50 years old. This fact may be explained by the demise of a certain number of patients before the age of 50 and/or a change in the clinical features of the syndrome with age and/or of the electrophysiological properties of the normal and accessory conduction pathways. To test the latter hypothesis, the clinical and electrophysiological data of 15 patients over 50 years old with the Wolff-Parkinson-White syndrome (Group I) were compared with that of 10 patients under 30 years old with the same syndrome (Group II). The same protocol of electrophysiological investigation was used in both groups of patients. The results showed a significant difference (p < 0.001) between the two groups in the incidence of associated cardiac disease. This was more common in Group I (1 4 out of 15 patients) than in Group II (2 out of 10 patients). The cardiothoracic ratio was significantly higher in Group I (p < 0.01). The two groups also differed in the age at which tachycardia first occured. 9 out of 11 patients in Group I only had symptoms after thirty years. On the other hand, there was no significant difference in the types of tachycardia and the frequency of attacks. There was no significant difference in QRS, PR, AH, HV intervals, in the ventriculo-atrial conduction time and the effective refractory periods of the atrium, right ventricle or atrio-ventricular node. There was no significant difference in the anterograde and retrograde refractory periods of the accessory pathways between the two groups. Reciprocating tachycardia, initiated by electrical stimulation in 7 patients in Group I and 6 patients in Group II, was conducted anterogradely to the ventricles through the normal pathway and retrogradely to the atria through the the accessory pathway. This study suggest that age-related changes in the electrophysiological properties of the accessory are not an important prognostic factor in the Wolff-Parkinson-White syndrome.

[Assessment of cardiac output by a non-invasive method. Estimation of partial pressure of CO2 by rebreathing of expired gas. Comparison with thermodilution]

The cardiac output was measured in 65 patients by the FICK principle after estimation of the pp CO2 in mixed venous blood by rebreathing. This technique has been used mainly during exercise, and recently in intensive care units. We used it in resting patients hospitalised for diagnosis and treatment of a range of cardiac diseases, and in patients referred to our Physiological Laboratory. The reproductibility of our results using the rebreathing method was good: the variation of the individual results averaged 8.9%. The values of the cardiac output by rebreathing were compared to those obtained by thermodilution in 30 patients. A high coefficient of correlation was found: r = 0,897 (2p less than 0,001). This non-invasive technique is simple, rapid, and easily repeatible. Its use for serial estimations of the cardiac output should be retained.

[Mitral valve prolapse and spasmophilia in the adult]

75 cases of mitral valve prolapse (MVP) for which no cause was found underwent electromyography (EMG). In 64 cases (85.3%) EMG showed changes suggestive of spasmophilia. The symptoms observed were those already described in this condition. The specific clinical signs of spasmophilia were often elicited with a positive Chvostek sign in 20 out of 30 cases (73.3%). Radiological, echocardiographical and haemodynamic studies underlined the hyperkinetic state of the left ventricle. Biochemical investigations showed a high incidence of low erythrocytic magnesium levels. Chest pain suggestive of angina pectoris, mitral valve prolapse and spasmophilia are frequently associated. The role of the low erythrocyte magnesium on left ventricular hyperkinesis and the production of MVP is discussed.

[Mitral valve prolapse and spasmophilia in children and adolescents]

71 cases of mitral valve prolapse (MVP) in the child and adolescent with an age range of 3 to 20 years were reviewed. The clinical symptoms, electrocardiography and catheter and angiographic data of this mitral abnormality were analysed. A systematic study of the electrocardiogram showed a tendency to spasmophilia in 68% of cases. The serum calcium, phosphate and magnesium levels were normal in 90 to 95% of patients. A reduced erythrocytic magnesium level seems to have been found in some patients. It is interesting to observe the similarity between the clinical signs in MVP and in spasmophilia. These clinical, biochemical and electrocardiographical results justify the systematic investigation of children and adolescents with MVP, with a view to the diagnosis of spasmophilia.