[Course of the results observed in the 1st 100 coronary angioplasties performed in 96 patients. Experience in Lyons]

TCA is an original method of myocardial revascularisation which, when successful, enables coronary bypass surgery to be avoided. However, a certain number of failures and complications are inherent to the development of a new therapeutic technique. The object of this study is to analyse the evolution of our results with this technique to determine which factors changed as our experience increased. The methodology used was that initially described by A. Gruntzig. TCA was carried out 72 times on the left anterior descending, 20 times on the right coronary and 8 on the left circumflex coronary artery (72 single vessel, 28 multivessel disease). The primary success rate was 75% (72% for the first 50 and 78% for the second 50 procedures). Coronary bypass surgery was required within the first 24 hours of TCA in 7% of cases. Myocardial infarction (Q wave changes) was observed in 5% of cases. One patient died on the third day (occlusion of an aorto-coronary venous graft). In retrospect, taking into account the experience gained and the development of the material now available, a certain number of failures and complications could probably have been avoided. However, a certain number of complications seems to be unavoidable. TCA remains an inviting but not infallible alternative in the treatment of coronary artery disease and should be included in the medico-surgical management of this condition.

[The future of catheterization in acquired heart valve diseases]

The value of routine catheterization and angiography in the investigation of acquired valvular disease is currently under debate. In many cases, echocardiography provides enough information, even for pre-operative assessment of the heart disease. However, the pre-operative assessment of the valvular disease requires an estimation of the severity of the valvular lesion and a study of left ventricular performance. In older patients, associated coronary artery disease also has to be evaluated. Finally, in patients who have been treated surgically, the disorders related to recurrence of their valvular disease or to the dysfunction of their valvular prosthesis also have to be identified. Each of these aspects has to be considered; this requires a very thorough clinical evaluation of the symptoms and signs and a combination of investigations, consisting of echocardiography, haemodynamic studies and angiography.

[Chronic aortic insufficiency with major left ventricle failure.ion. Results of aortic valve replacement and study of prognosis]

Twenty four patients with chronic aortic incompetence and major left ventricular dysfunction underwent aortic valve replacement. Left ventricular failure was responsible for severe symptoms: NYHA Classes III and IV. It was defined by the following haemodynamic criteria: LV ejection fraction (EF) 40 p. 100 (mean 37 +/- 13 p. 100), LV end diastolic volume 250 ml/m2 (mean 254 +/- 82 ml/m2), LV end diastolic pressure 20 mmHg (mean 26 +/- 10 mmHg), AV difference 6 vol p. 100 (mean 7,07 +/- 1,77). The mean cardiac index was 2,03 +/- 0,59 l/m2. Of the 24 patients, 9 died (Group A). There were 3 perioperative deaths and 6 deaths 5 to 60 months after surgery. One patient died suddenly after improving 3 years after surgery; 3 patients died with moderate persistent cardiac failure and 2 patients died without regression of cardiac failure after surgery. Of the 15 survivors, (mean follow-up 16 months), Group B, 6 were operated within the last three months and rapidly improved. Nine patients were followed up for 8 to 55 months after surgery and had significant symptomatic improvement (NYHA: Class II). No preoperative clinical, electrocardiographic or echocardiographic prognostic criteria were found to distinguish between these two groups of patients. There were no significant differences in cardiac surface area (1,89 +/- 34 compared to 1,95 +/- 23), LVEDP (26 +/- 11 compared to 26 +/- 10 mmHg), LVEDV (257 +/- 21 compared to 252 +/- 60 ml/m2), EF (31 +/- 11 compared to 40 +/- 13) or cardiac index (2,0 +/- 0,58 compared to 2,0 +/- 0,61 l/m2).(ABSTRACT TRUNCATED AT 250 WORDS)

[Current etiology of organic mitral insufficiency in adults]

Between 1976 and 1981, 173 patients with severe symptomatic mitral incompetence were referred for preoperative assessment. The etiological diagnosis was based on echocardiography, catheterisation, angiography, and, in the 71 patients operated on, the surgical findings. Rheumatic valvular disease was demonstrated in 40 cases (23,1 p. 100), bacterial endocarditis in II cases (6,3 p. 100), myocardial disease in 30 cases (17,3 p. 100) including 19 cases of mitral incompetence during cardiomyopathy with dilatation, and II cases of mitral incompetence during hypertrophic obstructive cardiomyopathy: ischemic heart disease was the underlying cause in 27 patients (15,6 p. 100), congenital heart disease in 9 patients (5,3 p. 100); dystrophic valvular disease (mitral valve prolapse with or without chordal rupture) was detected in 56 cases (32,3 p. 100). These results show a continuing reduction in the incidence of rheumatic fever and an increase in the number of cases of dystrophic mitral valve disease in patients of 50 to 70 years of age, a condition often rapidly progressive with hemodynamic characteristics very similar to those of mitral incompetence observed in ischemic heart diseases.

[Oxygen requirements of the myocardium]

Myocardial oxygen consumption (MVO2) is defined by the equation: MVO2 = coronary blood flow x arteriovenous difference in O2 content. The average value for a heart of 300 g is 30 to 35 ml/min. In the absence of physiological variations in the arteriovenous difference in O2 content, MVO2 is related to coronary blood flow and the typical anti-anginal agent is one which prevents or reduces increases in MVO2. MVO2 depends on several factors: 1. intraparietal tension, which depends on intraventricular pressure and volume and in which the oxygen demands of pressure overload are much higher than those of volume overload; 2. contractility or myocardial inotropism: 50 per cent increase in the velocity of left ventricular contraction increases MVO2 by 40 per cent; 3. heart rate; 4. external cardiac work--the work accomplished during the ejection phase; this represents about 15 per cent of the MVO2; 5. the energy of electrical activation; this represents about 0,5 per cent of the MVO2; 6. the oxygen requirements of basal myocardial metabolism which represent about 20 per cent of the MVO2; 7. ventricular relaxation: is a factor to be added to those described above; this consumes about 15 per cent of the total energy of a cardiac beat; it may be increased with Isoproterenol or decreased by increasing the calcium concentration. This mechanism may explain the physiopathological impact of calcium inhibitors in effort angina or angina due to increased MVO2.

[Analysis of interobserver variations in the estimation of myocardial volume, thickness and mass in right anterior oblique monoplanar angiocardiography]

The parameter derived from right anterior oblique angiocardiography (end diastolic and end systolic volumes, stroke volume, ejection fraction, wall thickness and myocardial mass) are used to decide the most appropriate management of cardiac disease. It is important to assess their reliability especially as other clinical data may be underestimated and the objective results may play a prominent role in the decision. Therefore, good quality cinefilms of 31 patients were reinterpreted by three observers (A, B and C); the contours were traced on a Vanguard console with an electromagnetic pet and the data treated automatically by the SNIASS SYSCOMORAN program (Simpson's method, assimilating the left ventricle to an ellipsoid divided into n identical cylinders). The interobserver variability (A and B; A and C; B and C) was good in the assessment of end diastolic volume (R = 0,96; 0,98; 0,99), end systolic volume (R = 0,96; 0,96; 0,98). On the other hand, it was poor in the measurement of wall thickness (R = 0,63; 0,73; 0,69) and myocardial mass (R = 0,85; 0,83; 0,89). In addition, the ejection fraction and end systolic volume were perfectly reproducible from one observer to another whether or not the left ventricle was dilated. End diastolic volumes seemed to be more reproducible in dilated cavities (EDV greater than 104 ml/m2). These results confirm that monoplane RAO cineangiography remains a good method of assessing left ventricular performance.

[Prognosis of asymptomatic or slightly symptomatic chronic aortic insufficiency. Apropos of 54 patients followed for an average of 36 months]

A series of 54 patients with chronic aortic insufficiency with little (38) or no symptoms (16) were studied. All had severe regurgitation leading to discussion of aortic valve replacement. All patients (44 male and 10 female) underwent clinical, radiological, electrocardiographic, hemodynamic and angiographic investigation with assessment of left ventricular volume by monoplane 30 degrees cineangiography on entry to the study. They were then followed-up for an average of 36 months and the data assessed in a prospective study. At the end of the 36 months period, 4 patients had been lost to follow-up but were still alive, 31 patients were unchanged (Group A) and 19 patients had deteriorated (Group B). The parameters characterising Group B (P less than 0.001) were: corrected cardiac surface area of 1,72 +/- 0,13, a Sokolow index of 60,1 +/- 18,8 mm an ejection fraction of 56.2 +/- 14 % and a left ventricular end diastolic value of 225,3 ml/m2. Therefore, in chronic asymptomatic aortic incompetence, the parameters of cardiac dilatation, cardiac surface area greater than 1,70 and left ventricular end diastolic volume greater than 170 ml/m2, would appear to be good indications for aortic valve replacement. However, the values are nor formal criteria because a discrepancy between symptoms and the volumetric measurements may be observed in some cases, and also large variations in these measurements may be observed in patients in the same functional class.

[Coronary bypass surgery. Results after 5 years : mortality - morbidity]

The improvement in the expectation and quality of life of patients undergoing coronary bypass surgery has been studied in the short term but there are relatively few studies with follow-up periods of over five years. The results in 239 patients operated on between 1970 and 1976 are presented. The preoperative data was obtained from a computerised filing system; studies were made at 3 months, at an average of 60 months, and in 78 patients with follow-up exceeding 5 years. Actuarial survival rates were calculated. The operative mortality was 9 patients (3,7%); late mortality was 21 patients (9,2%). Most deaths were due to cardiac causes. The following factors did not appear to be associated with a poor prognosis: sex, the number of cardiovascular risk factors, the number of bypass grafts; however, age and poor left ventricular function as identified by ECG (p less than 0,01), the presence of clinical cardiac failure (p less than 0,001) and by angiography (p less than 0,001) were associated with a poor prognosis. The long-term functional results were interesting: 67% patients followed up to 5 years and 56% patients followed up for over 5 years had no angina. Myocardial infarction occurred in 16,7% of patients at 5 years. Preexisting left ventricular failure which affected the operative and immediate postoperative results was also found secondarily in 9% of patients at 5 years. In the long term, the annual mortality rate seemed to be less in patients with triple vessel disease after myocardial revascularisation. The annual mortality rate of patients with left anterior descending disease alone did not seem to be improved when compared with medically treated patients until after the third year. Once again, the extent of myocardial disease was shown to be the essential prognostic factor whatever the coronary profile of the patient. In this study patients with severe angina or unstable angina who had been treated medically before surgery had the same results as those treated surgically by first intention; this fact is an argument in favour of initial medical management in all forms of angina.

[The risk of coronary angiography in unstable angina. Survey by the working group of "Functional cardiovascular tests" of the French Society of Cardiology]

Coronary angiography has become a current cardiological investigation in acute coronary insufficiency. A multicentre study was performed by the French Cardiac Society's work group (Pierre Calazel) to define the risk of this investigation. The investigation was performed on 581 patients with unstable angina and the following complications were observed at coronary angiography or during the 48 hours which followed: --16 myocardial infarcts (2,75%); --8 deaths (1,37%), 2 by severe arrhythmias and 6 complicating acute myocardial infarction considered as induced by the coronary angiography. The risk of coronary angiography is higher in unstable angina than in stable angina. The highest risk group are patients with unstable angina after recent infarction. The incidence seems to be related to the severity of the coronary lesions especially those on the main left coronary artery. On the other hand, other factors, such as the period between the onset of pain and coronary angiography and the function of the left ventricle, do not seem to play an important part.

[Assessment of ejection fraction and left ventricular and diastolic volume by non-invasive methods: echocardiography and isotopic technics. Comparison with angiography in 30 patients]

Three methods of measuring the ejection and the left ventricular end-diastolic volume were compared in 30 consecutive patients (all adults, 3 normal, 3 congestive cardiomyopathy, 6 mixed aortic valve disease, 9 pure aortic stenosis and 9 pure aortic incompetence). The haemodynamic and angiographical data was compared to the results of M-mode echocardiography and gammaangiocardiography. The global results of the ejection fractions were compared: angiography gave the lowest values (0,58 +/- 18). The non-invasive methods gave very similar results (0,67 +/- 15 for the echo and gammaangio). A better correlation was obtained in the group with pure aortic incompetence; the results in pure aortic stenosis were not reliable. The global results of end-diastolic volume showed constant underestimation by the non-invasive methods compared to angiography. The choice of method in each technique may influence the results obtained; each laboratory should determine its normal values; results should not be accepted without a critical assessment. Standardisation of techniques would be desirable.

[Vegetating endocarditis on a Hancock valve. Diagnostic value of echocardiography (author's transl)]

Vegetations of endocarditis are frequently seen at echocardiography performed in patients with infective endocarditis. The presence of such vegetations was demonstrated on a Hancock porcine heterograft inserted two years' previously. These vegetations were responsible for quite severe stenosis and had produced systemic emboli on two occasions. Histological examination after valve replacement confirmed the echographic findings.

Effects of amiodarone on cardiac and coronary hemodynamics and on myocardial metabolism in patients with coronary artery disease

While the antiarrhythmic effects of amiodarone are well-documented, its hemodynamic effects are not. We injected 5 mg/kg amiodarone i.v. in 16 patients undergoing coronary arteriography. Heart rate did not change. Aortic (systolic, diastolic and mean) and left ventricular (systolic and end-diastolic) pressures decreased significantly (p less than 0.01) at 5 and 15 minutes; systemic vascular resistance also fell significantly (p less than 0.05), while cardiac index increased slightly but significantly (p less than 0.05). Coronary vascular resistance decreased significantly (p less than 0.01) and coronary sinus blood flow rose in most patients, from a mean of 138 ml/min to 153 ml/min at 5 minutes (p less than 0.02); it then returned toward the control value at 15 minutes (mean 145 ml/min). Myocardial metabolism of O2 was normal and unchanged. Metabolism of lactate improved in five patients, remained unchanged in seven and deteriorated transiently in four. No undesirable hemodynamic and clinical side effects occurred when the drug was administered slowly. We conclude that amiodarone is a powerful systemic and coronary vasodilator. In addition to its present indications in the treatment of angina pectoris and arrhythmias, the drug might be very useful as an afterload-reducing agent.