[Therapeutic education for heart failure: a necessity in 2007]

Heart failure is a severe illness, marked with a still too high morbidity and mortality. Therapeutic education, fundamental for any chronic pathology, is taking a more and more important place in heart failure. Its value has been proved, and its importance in the multidisciplinary management of heart failure patients has been confirmed in terms of improving the prescription of medical treatment and allowing a better quality of life. France was late to recognise this technique, but the successful development of the I-CARE programme should contribute to improving both the quality of care for patients and the understanding of this pathology.

[Response to drug therapy of cardiac failure according to gender]

The general profile of women with cardiac failure differs from that of the male population, especially with respect to aetiology and prognosis. Women are often older, have preserved systolic function more often and a higher incidence of risk factors such as hypertension and diabetes. Moreover, global mortality is lower in women. From the therapeutic point of view, women with symptomatic left ventricular dysfunction probably benefit from ACE inhibitors but those with asymptomatic dysfunction have no reduction in mortality with this class of drugs. In addition, treatment with ACE inhibitors is usually interrupted in women because of a higher incidence of secondary effects. The poorer tolerance could be explained by the profile of women with cardiac failure. The large scale multicentre trials with betablockers included very few women. In MERIT-HF, in which there was a large number of women (23%), the female subgroup was the only one in which a benefit in mortality was not demonstrated. However, a retrospective analysis of the data of this subgroup plus a meta-analysis of all trials with betablockers does show improved mortality with this class of drugs in women. In a retrospective study of the DIG study, there seems to be a difference in the effects of digoxin between men and women; the prescription of digoxin is associated with a higher overall mortality in women. Finally, women seem to require diuretics more often than do men. There are many explanations for the differences observed in therapeutic responses between men and women. The role of sex hormones is often evoked, although it has never been clinically proved. The treatment of heart failure in women should take clinical and biological factors specific to women into account and may explain the relative inefficacy of certain forms of treatment.

Role of manual compression time and bed rest duration on the occurrence of femoral bleeding complications after sheath retrieval following 4Fr left-sided cardiac catheterization

To shorten hospital stay or to allow ambulatory procedures, 4Fr catheters for left-sided cardiac catheterization can be used. These latter parameters may also be influenced by compression time and bed rest duration. The role of these parameters was assessed by prospectively including 130 consecutive patients who underwent 4Fr femoral diagnostic procedures. The patients were randomized into two groups: group 1 consisted of 70 patients undergoing 5-minute compression and group 2 consisted of 60 patients with 15-minute compression. In each group, a second randomization was applied to determine the bed rest duration (2-4 hours). More group 1 patients experienced immediate bleeding following manual compression than group 2 patients (12 [17%] vs 3 [5%], P < 0.03, respectively). Compared to group 2, a slight but nonsignificant increase in the total number of hematomas was observed in group 1 (31 vs 22%, NS). No difference existed in terms of local large hematomas at 24 hours (7% in each group) or in terms of benign > or = 10 cm diffuse subcutaneous ecchymosis at 7-day follow-up (13 [19%] group 1 patients vs 8 [13%] group 2 patients, NS). However, persistence of diffuse subcutaneous ecchymosis at 7-day follow-up appeared to be related to the history of immediate bleeding following manual compression in both groups (group 1: 5/13 vs 7/57 patients [P < 0.04] and group 2: 3/8 vs 0/52 patients [P < 0.002]). In conclusion, 4Fr femoral left-sided cardiac catheterization is safe and could be performed as an ambulatory procedure. However, it requires 15-minute duration of manual compression associated with 2-hour bed rest to decrease local bleeding complications.

Role of the etiology of cardiomyopathies on exercise capacity and oxygen consumption in patients with severe congestive heart failure

Peak oxygen consumption is of great importance for the decision of heart transplantation in congestive heart failure. Moreover, the level of exercise capacity seems to depend on the etiology of congestive heart failure. This study compared 14 heart failure patients with idiopathic dilated cardiomyopathy (group 1) to 14 heart failure patients with cardiomyopathy due to ischemic heart disease (group 2), matched for sex (13 male, one female in each group), age +/-10 years, left ventricular ejection fraction +/-5% and pulmonary artery mean pressure +/-5 mm Hg, to assess exercise capacity and oxygen consumption independently of the age, sex and the level of left ventricular dysfunction. Right ventricular function was also assessed. No difference existed in terms of right ventricular parameters. Maximal exercise parameters were significantly higher in group 1 than in group 2. Peak oxygen consumption was statistically higher in group 1 than in group 2. In the whole population, a significant correlation was found between peak oxygen consumption and right ventricular ejection fraction (r=0. 44, P<0.02) but not between peak oxygen consumption and left ventricular ejection fraction. For similar levels of left ventricular dysfunction, exercise capacity and oxygen consumption appear to be better in idiopathic dilated cardiomyopathy than in ischemic cardiomyopathy, thereby suggesting that functional tolerance of left ventricular dysfunction might depend on the etiology of severe congestive heart failure.

[Chronic cardiac insufficiency. Treatment with angiotensin I converting enzyme inhibitors and angiotensin II receptor antagonists]

RENIN-ANGIOTENSIN SYSTEM: This system plays a major role in regulation of blood pressure. Angiotensin converting enzyme inhibitors (CEI) modify the balance between the vasocilator and diuretic properties of bradykinin and the vasoconstrictor and antidiuretic properties of angiotensin II, favoring vasodilatation and natriuresis. Angiotensin II receptor antagonists (ARAII) block AT1 receptors and stimulate AT2 receptors with favorable vasodilator and natriuretic affects. CEI: Converting enzyme inhibitors play an indispensable role in the treatment of heart failure and should be prescribed at high dosage. They have a long-term beneficial effect. ARAII: These compound could play a role in the future, but studies conducted to date comparing ARAII and CEI have been unable to demonstrate superior or equivalent effects with ARAII, and do not warrant their prescription for hypertension.

[Management of patients with symptoms on effort]

The aim of the treatment of symptomatic cardiac failure on effort (Classes II and III) is to improve symptoms and functional capacity and to decrease mortality. The management of such patients includes the investigation of causal and/or aggravating factors which require specific treatment. Hygenic-dietetic rules are important with a low salt diet and restriction of water intake. The continuation of mild physical exercise should be encouraged. Medical treatment associates diuretics to reduce congestive symptoms and angiotensin converting enzyme inhibitors to improve survival. This treatment may be completed by the association of digoxin and/or carvedilol depending on the functional outcome. When stabilised, the patient's diuretic should be reduced to the minimal required dose. If patients remain symptomatic on quadruple therapy, they probably require reevaluation in hospital.

Increased atrial vulnerability in arrhythmogenic right ventricular disease

Supraventricular tachyarrhythmias (SVTA) may occur in patients with the arrhythmogenic right ventricular dysplasia (ARVD). The purpose of the study was to evaluate the incidence of SVTA in 47 patients with ARVD proved by right ventricular angiography. Thirty-three men and 14 women, aged 21 to 72 years (mean 44 +/- 18) were admitted for nonsustained or sustained ventricular tachycardia. Eight patients had a history of spontaneous SVTA several years before ventricular tachycardia occurrence. Protocol of the study consisted of programmed atrial stimulation with one and two extrastimuli delivered during sinus rhythm and two driven rhythms (600 and 400 msec), programmed ventricular stimulation with up to three extrastimuli and was performed in the control state and after infusion of isoproterenol. The results of programmed atrial stimulation were compared with those obtained in 36 asymptomatic subjects without heart disease and with a mean age of 50 +/- 18 years (control group). Sustained SVTA (> 1 minute) was induced in seven of eight patients with spontaneous SVTA, in 27 (69%) of those with ARVD, who did not have spontaneous SVTA, and in two control subjects (5.5%) (p < 0.001). SVTA was inducible in the control state, but ventricular tachycardia induction required isoproterenol in 11 of 27 patients. Two patients without SVTA history but with inducible SVTA developed later spontaneous SVTA. ARVD was associated with a significantly higher incidence of inducible SVTA than in a control population. Supraventricular tachycardias may precede ventricular tachycardias. This association argues for a diffuse myocardial disorder in ARVD.

[Prognostic value of serial electrophysiological tests in inducible sustained ventricular tachyarrhythmias]

The authors report the results of a study evaluating serial electrophysiological tests on a series of 166 patients with inducible sustained ventricular tachyarrhythmia. The initial electrophysiological investigation was indicated because of sustained ventricular arrhythmias documented in 95 patients or suspected in 71 symptomatic patients. Serial tests allowed identification of a protective antiarrhythmic treatment (non-inducible ventricular tachycardia) in 74 responding patients (44.6%) (group R) after 1.3 +/- 0.5 therapeutic trials versus 1.8 +/- 0.8 inconclusive trials in 92 non responding patients (group NR). Multivariate analysis demonstrated the absence of any underlying ischaemic heart disease (p < 0.01) and the presence of spontaneous ventricular fibrillation (p < 0.01) as independent predictive factors of success during serial testing. A follow-up of 43 +/- 29 months was available for 151 patients (91%). kaplan-Meier survival curves showed a better long-term prognosis for group R with survival rates of 97%, 87% and 70% at 1.3 and 6 years, respectively, versus 83%, 68% and 45% for group NR. Two variables were considered on multivariate analysis to be predictive factors of survival: left ventricular ejection fraction (p < 0.001) and response to serial electrophysiological tests (p < 0.02). Therapeutic ventricular pacing therefore remains a reliable method to select patients whose prognosis is improved with antiarrhythmic treatment after induction of sustained ventricular arrhythmia.

[Long-term reproducibility of programmed atrial stimulation]

Programmed atrial stimulation is a technique increasingly used to assess different pathologies but the reproducibility of the results is totally unknown. The aim of this study was to determine its reproducibility. Two electrophysiological studies were undertaken without antiarrhythmic therapy in an interval of one to three months (average 18 months) in 48 patients. The programmed atrial stimulation used 1 and 2 extrastimuli delivered in sinus rhythm and then three paced rhythms (sinus cycle -10%, 600 ms, 400 ms). Twenty-one patients had documented atrial arrhythmias (atrial fibrillation n = 13, flutter n = 3 or tachycardia n = 5) (group 1) and the 27 other patients had no spontaneous arrhythmias (group II). In group I, clinical tachycardial was reproduced in 18 patients during the initial stimulation procedure. During the second investigation, 17 remained inducible and in the 3 in whom stimulation was negative, it remained so in 2 of the cases. The reproducibility was therefore 90%. In group II, 12 patients had inducible sustained (for over 1 minute) tachycardia during the first procedure (44%) but this only remained inducible in 6 patients. In the other 15 subjects, stimulation was negative during the first procedure but 7 of them had inducible tachycardial during the second procedure. The reproducibility of the technique was therefore only of 52%. The authors conclude that the reproducibility of programmed atrial stimulation in patients with documented spontaneous paroxysmal arrhythmias is excellent. However, the reproducibility is mediocre in subjects without spontaneous arrhythmias and the induction of tachycardial in this group of patients should be interpreted with caution given the variability of the response to programmed atrial stimulation.

Beneficial cumulative role of both nitroglycerin and dobutamine on right ventricular systolic function in congestive heart failure patients awaiting heart transplantation

End-stage idiopathic dilated cardiomyopathy or ischemic heart disease usually present with very low cardiac output and severe ventricular dysfunction which may require pharmacological support before heart transplantation. Right ventricular ejection fraction might be an important factor of functional capacity and survival in congestive heart failure. In order to test the immediate response of right ventricular hemodynamic parameters to nitroglycerin and dobutamine usually used to treat severe left ventricular dysfunction, we studied 17 congestive heart failure patients (15 men, two women; mean age 55 +/- 13 years) with end-stage idiopathic dilated cardiomyopathy (n = 10) or end-stage ischemic heart disease (n = 7), left ventricular ejection fraction < 35% (mean 22 +/- 8%), and sinus rhythm. A well validated thermodilution technique using a dedicated catheter with a fast catheter-computer response, permitting instantaneous measurements of right ventricular ejection fraction, was used. Right ventricular hemodynamic parameters were recorded at baseline, after an intravenous bolus injection of 3 mg nitroglycerin and after an intravenous infusion of dobutamine administered after nitroglycerin until normalization of cardiac index or a maximal dose of 15 micrograms/kg/min. Pulmonary artery mean pressure significantly decreased after nitroglycerin (43 +/- 9 mmHg at baseline vs. 31 +/- 10 mmHg after nitroglycerin, P < 0.0001) and did not subsequently change after dobutamine (32 +/- 10 mmHg after dobutamine, ns). Cardiac index was not affected by nitroglycerin (1.7 +/- 0. l/min/m2 at baseline vs. 2.0 +/- 0.3 l/min/m2 after nitroglycerin, ns), but dramatically increased after dobutamine (3.0 +/- 1.0 l/min/m2 after dobutamine, P < 0.0001). Concomitantly to the changes of these two parameters, right ventricular ejection fraction progressively increased (14 +/- 8% at baseline vs. 20 +/- 10% after nitroglycerin (P < 0.0006) vs. 28 +/- 13% after dobutamine (P < 0.0001)). Progressive increase of right ventricular ejection fraction after administration of nitroglycerin followed by administration of dobutamine suggests the beneficial cumulative role of both medications on right ventricular systolic function in severe congestive heart failure.

[Treatment of ischemic myocardiopathy]

Ischaemic myocardiopathy mandates the control of coronary risk factors and the administration of antiplatelet therapy. If myocardial ischaemia exists, an antianginal treatment will be prescribed. In case of heart failure, the association of an angiotensin-converting enzyme inhibitor and diuretics is required. A beta-blocker, especially at low dose, should be discussed according to the symptoms. When ischaemic cardiomyopathy is asymptomatic, an angiotensin-converting enzyme inhibitors is also likely to benefit the patient. Coronary revascularization may be indicated according to the importance of both residual ischaemia and resistance to medical therapy.

[Is percutaneous transluminal coronary angioplasty in chronic total coronary occlusion justified? Long term results in a series of 201 patients]

Percutaneous transluminal coronary angioplasty of chronic total coronary occlusions has a low primary success rate and is associated with a high percentage of restenosis. The aim of this retrospective study was to assess the long-term benefits of these procedures. In a series of 201 patients with 203 chronic total occlusions, the technical success rate was 51%, the clinical success rate was 46% with 3% of major complications. The only factor associated with a favourable outcome was the presumed duration of the occlusion. The clinical follow-up period was established at 6 years. The result of the initial procedure was used to establish two groups of patients: group I, clinical success, and group II, clinical failure. Patients in group I had a probability of survival greater than that of those in group II (97 vs 92%; p < 0.05); survival without coronary bypass surgery was also significantly better (89 vs 74%; p < 0.003). On the other hand, the probability without angioplasty was less in group I (70 vs 77%; p < 0.01), the result of a high restenosis rate (48%). A Cox analysis identified clinical success of angioplasty as a good prognostic factor for survival. Moreover, the clinical status at long-term was significantly better in patients in group I. These results indicate that in patients with chronic total coronary occlusions, the success of angioplasty has a favourable effect on long-term outcome both in terms of survival and in quality of life. They must be interpreted in the light of the limitations inherent in a retrospective study and should be confirmed by prospective trials.

Isolated myocardial bridges with angiographic milking of the left anterior descending coronary artery: a long-term follow-up study

Among 7467 consecutive coronary angiograms performed during an 8-year period, 61 patients had a myocardial bridge of the left anterior descending coronary artery. The overall prevalence of myocardial bridges was 0.82% (from 0.41% to 1.16% per year). Among these patients, 26 had coronary artery disease, 4 had valvular heart disease, and 3 had cardiomyopathy. We studied the long-term outcome (11 +/- 3 years) of the other 28 patients with isolated milking at baseline. Two groups were constituted according to the percentage of systolic reduction of the left anterior descending coronary artery lumen: group A, < 50% (15 patients) and group B, > or = 50% (13 patients). During follow-up, 1 group A patient (cancer) and 2 group B patients (1 cancer and 1 suicide) died. Moreover, 1 group B patient was lost to follow-up. None of the patients sustained a myocardial infarction during follow-up. In group A patients, 71% felt very well or well and 50% had clinical symptoms; 64% took antianginal medications. In group B patients, 50% felt well and 70% had clinical symptoms; 50% took antianginal drugs. The long-term prognosis of isolated myocardial bridges of the left anterior descending coronary artery is good and is independent of the severity of systolic narrowing of internal lumen diameter.

[Does recanalisation of chronic right coronary occlusion improve long-term quality of life and the return to work?]

Between 1985 and 1990, right coronary artery recanalisation was attempted in 60 consecutive patients. In order to evaluate the long-term benefits, 2 groups were compared: group A (27 patients: 26 men, 1 woman) with an initial success; 1 patient was lost to follow-up (3.7%); group B (33 patients, 31 men, 2 women) with an initial failure; no patients were lost to follow-up and 1 patient died after secondary coronary artery surgery. After a follow-up of at least 1 year, the patients assessed their health and compared it with their pre-angioplasty state with the aid of a questionnaire. Age, initial left ventricular ejection fraction, the percentage of multiple vessel disease and the number of patients at work before angioplasty were the same in the two groups. After a mean follow-up period of two and a half years, 7.6% of patients had undergone coronary bypass surgery in group A compared with 18.2% in group B (NS); 69% of patients in group A claimed to be improved compared with only 24% in group B (p = 0.07); a bi or triple anti-anginal therapy was used in 58% of patients in group B and 42% of patients in group A (NS); however, 59% of patients returned to work in group B compared with 44% in group A (NS). Initial successful recanalisation of chronic right coronary occlusion improves the quality of life at long-term but does not increase the chances of returning to work.(ABSTRACT TRUNCATED AT 250 WORDS)

[Permanent atrial resynchronization by synchronous bi-atrial pacing in the preventive treatment of atrial flutter associated with high degree interatrial block]

Interatrial conduction block results in a very delayed and retrograde activation of the left atrium and is associated with a high incidence of atrial tachyarrhythmias, especially a particular (and specific) form of atypical atrial flutter. Electrophysiologic studies have suggested that these arrhythmias were usually due to reentry and could be directly related to the conduction disturbances in the atrium. If so, we can expect reasonably that permanent atrial resynchronization resulting from simultaneous pacing in different target sites in the atria, may not only correct for interatrial dysynchrony, but also may significantly contribute to prevent arrhythmia recurrences. Twenty-eight patients, mean age 68 years, were included. The mean P wave duration in spontaneous sinus rhythm was 181 +/- 28 ms. In all patients, many recurrences of atrial tachyarrhythmia were documented, especially a specific form of atypical atrial flutter. Medical therapy was constantly ineffective. Three different pacing modes were used: 6 patients, with normal A-V conduction were implanted with a SSI device, programmed in AAT mode and connected, using a Y bifurcated connector, to two atrial leads, one positioned in the right atrium, the second one into the coronary sinus-in 14 patients, with A-V conduction defects, a conventional DDDR unit was implanted and connected to a composite biatrial electrode and a ventricular lead. In that configuration atrial resynchronization was only effective on paced atrial cycles -a specific DDD Chorus ELA Medical device with a special algorithm loaded into the RAM memory was implanted in 14 patients (8 new indications, and 6 patients first implanted with a DDDR unit).

RESULTS

during sinus rhythm atrial resynchronization induced a reduction of the P wave duration from 181 +/- 28 ms to 116 +/- 12 ms. During permanent pacing the mean value decreased from 209 +/- 38 ms to 108 +/- 13 ms. During follow-up (34 +/- 15 months) arrhythmia prevention was assessed by history, by monthly surface ECG's and by bimonthly 24 hours Holters recordings and telemetric interrogation of the pacemaker statistics. Twenty-one patients did not experienced any recurrence of arrhythmia. One to three recurrences occurred in the other seven patients, including six patients implanted with a conventional DDDR unit. These preliminary results seem validate the new concept of atrial resynchronization for prevention of atrial arrhythmia associated with interatrial conduction block.

[Influence of the severity of coronary stenosis on the course of left ventricular function in case of subsequent coronary occlusion. Longitudinal coronarographic study]

In order to evaluate the consequences concerning left ventricular function of the spontaneous occlusion of coronary stenoses, the authors studied the clinical and angiographic characteristics of 30 consecutive patients (25 men, 5 women, mean age: 54) undergoing successive coronary arteriograms showing progression to complete occlusion of the anterior interventricular or right coronary between the two investigations. Two groups of patients were identified: Group I (n = 19) with occlusion of a previously moderate (< or = 50%) stenosis; Group II (n = 11) with occlusion of an initially tight stenosis (> 50%). At the time of the first angiogram, left ventricular ejection fraction (LVEF) was 60 +/- 13% in Group I and 58 +/- 9% in Group II (NS). Times between the two investigations were similar in the two groups (58 +/- 43 months and 54 +/- 57 months, NS). Between the two coronary arteriograms, 7 patients of Group I sustained an infarction as against 3 in Group II (NS). Impairment of LVEF developed in 16 patients of Group I (84%) as against 5 of Group II (45%) (p < 0.005). Global LVEF varied on average by -10.4 +/- 13.3% (p < 0.005) in Group I and -0.1 +/- 9.5% (NS) in Group II. This difference in variation in LVEF between the two groups was significant (p < 0.04). Spontaneous occlusion of moderate coronary stenoses results in certain cases in greater impairment of left ventricular function than the occlusion of tight stenoses. The development of a collateral circulation probably plays a protective role in the second group.

Comparison of right ventricular systolic function in idiopathic dilated cardiomyopathy and healed anterior wall myocardial infarction associated with atherosclerotic coronary artery disease

A case-controlled study assessed right ventricular (RV) systolic function in 10 patients with idiopathic dilated cardiomyopathy (IDC) and in 10 with healed anterior wall myocardial infarction associated with atherosclerotic coronary artery disease (CAD). Each patient was matched for sex, left ventricular ejection fraction +/- 5% and pulmonary artery mean pressure +/- 5 mm Hg. All patients had sinus rhythm and a left ventricular ejection fraction < 45%. A new, well-validated thermodilution technique was used to assess RV ejection fraction and volumes. RV ejection fraction was lower in the IDC than in the CAD group (25 +/- 14% vs 36 +/- 11%; p < 0.02). Linear correlations between RV parameters and pulmonary artery pressure were significantly present in both groups. However, the slopes of the equations were not statistically different. In comparison with healed anterior wall myocardial infarction with CAD and for similar levels of left ventricular dysfunction, RV systolic function appeared to be more altered in IDC.

[Diagnostic and therapeutic strategy in coronary insufficiency in the elderly. Apropos of 65 cases]

As people live longer, so cardiologists are having to manage coronary artery disease in progressively older patients with more severe coronary lesions. The authors tried to determine the feasibility and results of coronary angiography in a retrospective study of 65 patients (44 men and 21 women) over 75 years of age (range 75 to 84 years) with coronary artery disease (excluding valvular heart disease). The study period was 22 months. The commonest indication was unstable or invalidating angina resistant to medical therapy (42 of the 65 cases). Twenty-two patients underwent coronary angiography in the context of myocardial infarction complicated in 3 cases by septal rupture. With the exception of these 3 patients, two of whom underwent surgery, 39 of the 62 remaining patients were judged to be candidates for myocardial revascularisation (63%); 37 underwent a revascularisation procedure (60%), 20 by percutaneous transluminal coronary angioplasty and 17 by coronary bypass surgery. The primary success rate of angioplasty was 90% (18 out of 20). There were no deaths in this group. Two patients who were referred for surgery died, an operative mortality of 12% (2 out of 17). All patients were followed up: 56 out of the 65 were still alive at the time of enquiry, after an average period of 18 months. All surviving patients who were successfully revascularised (by angioplasty or surgery) were pauci- or asymptomatic. Although there is an increased mortality related to revascularisation of elderly patients, this would seem to be acceptable given the quality of the medium term clinical results.

[Radiofrequency catheter ablation of accessory atrioventricular pathways: initial experience in 33 patients]

The authors report their experience in endocavitary radio-frequency ablation of 37 secondary pathways carried out in 33 consecutive patients. The indications for radical treatment were based solely on clinical arguments in 15 patients, on a combination of disabling signs and threatening electrophysiological signs in 17 patients and on high retrograde permeability in 1 asymptomatic patient. Endocavitary exploration revealed 26 left lateral sites, 7 posterior paraseptal sites and 4 right lateral sites. The procedure was successful in 88% of cases. Electrophysiological follow-up, carried out routinely in all the patients 2 months after the procedure, revealed a single recurrence (3%) which was treated by radio-frequency again, this time with a successful outcome. There was only one complication, a complete AVBBB following ablation of a left posterior paraseptal Kent's bundle, which required a permanent pacemaker. These results were similar to those reported in the literature and clearly demonstrate the efficacy of radio-frequency treatment of the secondary pathways, with a moderate risk of complication. These results were similar to those reported in the literature and clearly demonstrate the efficacy of radio-frequency treatment of the secondary pathways, with a moderate risk of complication. Recent advances in the field of endocavitary ablation have made it possible to change the method of handling symptomatic Wolff-Parkinson White syndromes, by enlarging the indications for radical treatment in order to enhance the comfort and quality of life of the patient.

Retrieval of a lost coronary stent from the descending aorta using a PTCA balloon and biopsy forceps

We report a case of unsuccessful stenting of a right coronary artery after acute dissection during percutaneous transluminal coronary angioplasty (PTCA). The stent was lost in the descending aorta and we used an original technique to remove it from the arterial bed by using both a very low profile balloon and a 6F bioptome.

[Successive decrease of left ventricular segmental kinetic disorders after transluminal coronary angioplasties in the same patient]

The authors report the case of a patient developing two successive left ventricular kinetic abnormalities secondary to acute or chronic ischemia, and reversible after transluminal coronary angioplasty. The concept of myocardial hibernation is suggested as a possible mechanism.

[Relationship between right ventricular ejection fraction and pulmonary pressure in man]

This clinical study analysed the changes in right ventricular ejection fraction induced by changes in right ventricular afterload using a new thermodilution catheter linked to a rapid response computer which allowed instantaneous measurements of the right ventricular ejection fraction. The first group comprised 16 patients referred for coronary angioplasty with single vessel disease (isolated proximal stenosis of one of the two main branches of the left coronary artery) and a normal left ventricular ejection fraction (> or = 55%) and mean pulmonary artery pressure of < 25 mmHg: right ventricular ejection fraction and mean pulmonary artery pressure were measured under basal conditions and after 60 seconds' coronary occlusion with the balloon catheter in order to assess the effects of the reactional increase in afterload on the right ventricular ejection fraction. The second group comprised 11 patients with dilated primary cardiomyopathy with decreased left ventricular ejection fraction (< 50%) and mean pulmonary artery pressure > or = 25 mmHg: the right ventricular ejection fraction and mean pulmonary artery pressure were measured under basal conditions and after intravenous trinitrin (performed to evaluate the pulmonary reaction to vasodilators) in order to analyse the effects of the reduction of afterload on right ventricular ejection fraction. Negative linear correlations were observed between the right ventricular ejection fraction and mean pulmonary artery pressure under basal conditions (r = -0.72; p < 0.005) and between the right ventricular ejection fraction and mean pulmonary artery pressure after changing the conditions of afterload (r = -0.82; p < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

[Doppler echocardiography and double chamber pacing]

Doppler-echocardiography is playing an increasing role in cardiac pacing: 1) Before implantation, to determine any cardiac disease possibly accompanying the conduction disturbance, and the quality of atrial function in order to identify the appropriate indications for the type of pacing which will restore normal AV synchronism. Alongside morphometric data (size of atria, etc.), this analysis is based above all on the evaluation of LV filling flows and ejection, if necessary during provisional pacing in DRV mode. It is important to be aware of and prevent certain problems: 1st degree AV block with very long PR, high degree interatrial conduction disturbances, etc. 2) To evaluate the possible benefits of pacing in certain new indications, e.g. obstructive hypertrophic cardiomyopathy (measurement of intra-LV gradient in sinus rhythm and with DRV pacing with total ventricular capture). 3) After implantation, to optimise the programming of double-chamber pacemakers and in particular AV intervals (base-line AV interval with paced atrial cycle, AV interval with detected atrial cycle, hysteresis of AV interval corresponding to the difference between the two previous values, slope of automatic variation in AV interval during exercise, etc.). Individual programming of these parameters based upon analysis of transmitral and ejection flow rates, at rest and, if necessary, during exercise, enables the optimisation of cardiac function (which is above all useful in the presence of concomitant organic heart disease) while at the same time improving the electrophysiological behaviour of the pacemaker at high frequencies.