[Partial anomalous pulmonary venous return in a 64-year-old woman]

Partial anomalous pulmonary venous return (PAPVR) represents 3 % of the congenital cardiopathies. Diagnosis in adults is challenging as clinical symptomatology is non-specific and echocardiographic signs are discrete and misleading potentially confusing with idiopathic pulmonary hypertension. We report the case of a 64-year-old woman in whom we diagnosed PAPVR associated with sinus venosus atrial septal defect. We describe medical history, clinical signs, investigations and postoperative evolution.

[Totally asymptomatic coronary left main artery critical stenosis: when non-invasive tests are falsely reassuring]

Left main coronary artery severe stenosis is frequently very symptomatic and is considered as a classical contraindication for non-invasive ischemia testing. When performed, those tests usually yield a large area of ischemia associated with a rich symptomatology. We report the case of a 69-year-old completely asymptomatic man in whom both treadmill effort testing and dobutamine stress echocardiography were falsely reassuring as they eliminated significant ischemia despite the presence of a critical stenosis of distal left main artery ultimately confirmed by angiography. Dobutamine 2D strain performed afterwards was pathological and could have corrected the initially reassuring diagnosis.

Examination of the kinetic mechanism of mitogen-activated protein kinase activated protein kinase-2

The kinetic mechanism of mitogen-activated protein kinase activated protein kinase-2 (MAPKAPK2) was investigated using a peptide (LKRSLSEM) based on the phosphorylation site found in serum response factor (SRF). Initial velocity studies yielded a family of double-reciprocal lines that appear parallel and indicative of a ping-pong mechanism. The use of dead-end inhibition studies did not provide a definitive assignment of a reaction mechanism. However, product inhibition studies suggested that MAPKAPK2 follows an ordered bi-bi kinetic mechanism, where ATP must bind to the enzyme prior to the SRF-peptide and the phosphorylated product is released first, followed by ADP. In agreement with these latter results, surface plasmon resonance measurements demonstrate that the binding of the inhibitor peptide to MAPKAPK2 requires the presence of ATP. Furthermore, competitive inhibitors of ATP, adenosine 5'-(beta,gamma-imino)triphosphate (AMPPNP) and a staurosporine analog (K252a), can inhibit this ATP-dependent binding providing further evidence that the peptide substrate binds preferably to the E:ATP complex.

[Evaluation of the efficacy and tolerance of naftidrofuryl in patients presenting with exertional angina. Multicenter double-blind versus placebo study]

Due to its vascular and platelet 5-HT2 receptor antagonist properties and its metabolic properties, naftidrofuryl specifically counteracts local ischaemic phenomena. One of its major indications is the treatment of intermittent claudication, but it is well known that peripheral arterial disease is the sign of diffuse arterial disease, associated with particularly lethal coronary disease. Recent studies increasingly implicate serotonin (5-HT) in coronary ischaemic processes. In view of the similarities between these pathophysiological data and the characteristics of this molecule, we decide to evaluate the coronary protection afforded by naftidrofuryl and its safety. This multicentre double-blind placebo-controlled study was conducted in 51 patients over a period of one month. Inclusion criteria were stable angina with an electrically positive stress test, despite antianginal treatment either by beta-blocker or by calcium channel blocker. Follow-up comprised clinical assessment and a stress test on inclusion and at 1 month. The groups were comparable on inclusion. Overall, the results showed a greater improvement with naftidrofuryl than with reference treatment for all parameters studied. Significant differences were observed in favour of the verum group for time to onset of ST depression, the maximum level reached, the number of stress tests which became negative and the patient's global assessment. No problems of interaction with concomitant treatments, particularly beta-blockers, calcium channel blockers or antiarrhythmics was observed. This study shows that naftidrofuryl allows improvement of ergometric parameters and especially elevation of the ischaemic threshold on exertion.

A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. The THESEE Study Group. Tinzaparine ou Heparine Standard: Evaluations dans l'Embolie Pulmonaire

BACKGROUND

Low-molecular-weight heparin appears to be at least as effective and safe as standard, unfractionated heparin for the treatment of deep-vein thrombosis, but only limited data are available on the use of low-molecular-weight heparin to treat acute symptomatic pulmonary embolism.

METHODS

We randomly assigned 612 patients with symptomatic pulmonary embolism who did not require thrombolytic therapy or embolectomy to either subcutaneous low-molecular-weight heparin (tinzaparin) given once daily in a fixed dose or adjusted-dose, intravenous unfractionated heparin. Oral anticoagulant therapy was begun between the first and the third day and was given for at least three months. We compared the treatments at day 8 and day 90 with respect to a combined end point of recurrent thromboembolism, major bleeding, and death.

RESULTS

In the first eight days of treatment, 9 of 308 patients assigned to receive unfractionated heparin (2.9 percent) reached at least one of the end points, as compared,with 9 of 304 patients assigned to low-molecular-weight heparin (3.0 percent; absolute difference, 0.1 percentage point; 95 percent confidence interval, -2.7 to 2.6). By day 90, 22 patients assigned to unfractionated heparin (7.1 percent) and 18 patients assigned to low-molecular-weight heparin (5.9 percent) had reached at least one end point (P=0.54; absolute difference, 1.2 percentage points; 95 percent confidence interval, -2.7 to 5.1). The risk of major bleeding was similar in the two treatment groups throughout the study.

CONCLUSIONS

Under the conditions of this study, initial subcutaneous therapy with the low-molecular-weight heparin tinzaparin appeared to be as effective and safe as intravenous unfractionated heparin in patients with acute pulmonary embolism.

Quantitative detection of outlet strut separations in Björk-Shiley convexo-concave mitral valves

BACKGROUND

As of January 31, 1995, 564 outlet strut fractures (OSFs) of Björk-Shiley convexo-concave (BSCC) heart valves had been reported to the Shiley Heart Valve Research Center, of which approximately two thirds resulted in the death of the patient. Previous studies indicate that one leg of the outlet strut separates (single-leg separation, SLS) from the valve before the second leg breaks, which results in complete OSF. To identify those valves at risk of complete OSF, an in vivo radiographic imaging technique is being developed to evaluate the strut leg integrity. The goal of the present study was to develop an objective postprocessing technique to evaluate outlet strut leg integrity quantitatively in these cineradiographic images.

METHODS AND RESULTS

Twenty-two sets (12 intact valves, 10 SLS valves) of cineangiographic images were obtained from individuals whose valve status was subsequently verified ex vivo. Several quantitative measures of SLS were evaluated to identify possible loss of metal or gaps in the SLS legs. Two of these measures, decrease in pixel intensity (DIPI) ratio and gap half-width, are diagnostic metrics of SLS: i.e., the maximum likelihood estimate of the area under the receiver operating characteristic curve was 0.892 (SD, 0.066) for a model based on DIPI ratio and 0.802 (SD, 0.093) for gap half-width.

CONCLUSIONS

We have developed a postprocessing technique that can be used to objectively evaluate outlet strut integrity in cineradiographic images of BSCC heart valves. At an estimated specificity of 1.0, the estimated sensitivity of the objective review was comparable to that of a subjective expert review panel.

Radiographic detection of single strut leg separations as a putative basis for prophylactic explantation of Björk-Shiley convexo-concave heart valves

Cineradiography, using higher kVp and two or more specified profiles for each outlet strut leg, was used to evaluate Björk-Shiley convexo-concave (C/C) heart valves with epidemiologically defined > 0.1% per year estimated fracture rates. Among 828 mitral valves, eight radiographs were assessed as definite single leg separations (SLS) and 23 were read as probable SLS. Explantation confirmed SLS in 24 valves; 4 probables were false positives, and 3 patients with probable SLS ratings decided against explantation. Four patients with SLS died, an operative mortality of 14%. Only 23 mitral and 6 aortic valves receiving ratings ranging from apparently normal to suspicious have become available for verification; 1 rated apparently normal was found to have a SLS. Two patients experienced fatal fractures and 1 SLS valve was explanted 3 to 15 months after apparently normal x-ray studies; it cannot be known if a SLS was or was not present at the time of these examinations. As 97% of negatively rated valves remain in situ, the sensitivity of the test is similarly not known. Only 1 SLS has been detected among 136 aortic valves. Uncertainty about test accuracy and SLS progression condition the clinical utility of radiographic SLS detection, particularly with respect to assurance from apparently normal readings. However, radiographic identification of an SLS substantially enhances epidemiologically derived risk categorization as a basis for consideration of prophylactic replacement for the approximately 12,000 valves with a > 0.1% estimated annual fracture risk, currently thought to be implanted in living patients.

A medical workstation for the display and analysis of multi-frame digital cineradiographic data

A medical workstation has been developed for the efficient display and analysis of large sets of digital cineradiographic images. Various features aid the clinician in quickly identifying and extracting the image information relevant for diagnosis: animated viewing of image frames, a digital magnifying glass for local image enlargement and enhancement, a special review queue for critical image frames, and task-oriented image processing. Double frame buffering and direct memory addressing ensure fast, artifact-free image display and transfer. Much freedom is provided for adapting the system to one's own preferences. A statistical analysis of extensive tests conducted by eight clinical expert reviewers is given.

Rapid and selective induction of blood eosinophilia in guinea pigs by recombinant human interleukin 5

Interleukin 5 (IL-5) has been implicated as a causal mediator in the development of pulmonary eosinophilia and airway hyperreactivity in human asthma. Supportive evidence for a pathogenic role of IL-5 in this disease has been provided by guinea pig models in which antigen-induced lung eosinophilia and bronchial hyperresponsiveness have been specifically attenuated with a neutralizing antibody to IL-5. In the present report, we describe a rapid mechanism-based model of IL-5-induced eosinophilia in the guinea pig. Our results show that intravenous injection of human IL-5 induced a 5-10-fold increase in the percentage and number of eosinophils in blood within 1 hour. In contrast, neutrophils and mononuclear cells were not recruited during this time. The increase in eosinophils was blocked by pretreatment of animals with an anti-IL5 monoclonal antibody (TRFK5) in doses similar to those which inhibit eosinophilia in guinea pig asthma models. Furthermore, dexamethasone, a potent inhibitor of eosinophilia in guinea pig asthma, profoundly suppressed the eosinophilia induced by human IL-5. This rapid model will be useful for elucidating the eosinophil activating properties of IL-5 in vivo and may potentially facilitate the development of IL-5 receptor antagonists for the specific blockade of the eosinophilic inflammation observed in human asthma.

Radiographic detection of strut separations in Björk-Shiley convexo-concave mitral valves

BACKGROUND

The outlet struts of Björk-Shiley convexo-concave heart valves can occasionally fracture. By December 31, 1994, 564 complete strut fractures had been reported to the manufacturer, approximately two thirds of which were fatal. There are no reliable diagnostic methods to detect valves that may be at risk for strut fracture. The outlet strut has two legs, and one leg often appears to break before the other, potentially permitting detection of the single-leg separation while the valve is still functionally intact.

METHODS

We used high-resolution cineradiography and defined valve profiles to evaluate 315 patients selected on the basis of their having mitral convexo-concave valves with an estimated fracture rate of 0.46 percent or higher per year. Two examinations were scheduled six months apart, with early reimaging performed when initial ratings were indeterminate.

RESULTS

Three patients had unsatisfactory studies, the most recent examinations in 277 patients were rated as apparently normal, 23 had findings considered minimally suspicious, and 1 had findings termed suspicious. The number of false negative results in this study group is unknown. Eleven cineradiograms were rated as showing probable or definite single-leg separations. All five "definite" ratings and five of the six "probable" ratings were confirmed by removal of the valves. One valve with a "probable" rating was intact. Two complete outlet-strut fractures occurred three and seven months after apparently normal radiographic examinations. Unsuspected new positive findings were not found at six months among 288 patients who completed the examination cycle.

CONCLUSIONS

Cineradiographic imaging can detect some single-leg separations in mitral convexo-concave valves and may help the estimated 41,000 patients with these valves worldwide and their physicians decide about elective valve removal.

[Cardiac rhabdomyoma in the adult. Echocardiographic diagnosis and successful surgical treatment]

Cardiac rhabdomyoma is a rare tumour (190 cases in the literature). Since the first operation, in 1959, the tumour has been removed in about 30 patients. Our case is the first cardiac rhabdomyoma diagnosed in live adults. The patient was a 59-year old woman without any significant history. Echocardiography showed a single tumour in the right atrium. A tentative diagnosis of myxoma was made and the patient was operated upon. At pathology, the tumour turned out to be a rhabdomyoma. After a 2.5-year follow-up period, the patient remains asymptomatic. Cardiac rhabdomyoma almost exclusively occurs in children. Only six adult cases have been published, all diagnosed at autopsy. Cardiac symptoms are either those of a valve disease or arrhythmias. Treatment is surgical for single tumours. Multiple rhabdomyomas are associated with Bourneville's disease (tuberous sclerosis) in 50 p. 100 of the cases, which entails a sombre prognosis. In our patient, the presence of a single tumour at the age of 59 without any sign of tuberous sclerosis and the fact that the tumour could be entirely removed were factors of favourable prognosis.

Electrophysiologic effects of bepridil in the anesthetized dog studied by endocardiac electrodes

The electrophysiologic effects of bepridil in the anesthetized closed-chest dog were studied with intracardiac electrodes using the extrastimulus technique to measure the refractory periods of atria, atrioventricular (AV) junction and ventricles. Intravenous administration of 5 mg/kg of bepridil caused a reduction in sinus node rate and prolonged the sinus node recovery time. Refractory periods in the atrium, especially the effective refractory period, increased. Anterograde AV nodal conduction was slowed and refractoriness increased, often resulting in AV nodal Wenckebach periods, during atrial pacing, and retrograde conduction was always completely abolished. Refractory periods of the AV junction were altered in a comparable fashion to conduction through the AV node. No significant actions on conduction or the refractory period were noticed in the His-Purkinje system or the ventricle. The mechanism of action of bepridil seems to be correlated to its membrane effects, namely, inhibition of pathways responsible for the slow inward current, which explains its selective action on myocardial sites where this current is particularly involved.

Cardiac electrophysiological effects of cibenzoline by acute and chronic administration in the anesthetized dog

The electrophysiological effects of cibenzoline on the myocardium of the anesthetized dog were studied by the endocavitary catheter method. Plasma cibenzoline levels were measured throughout. The cibenzoline effects on the sinus rate were negligible. The corrected sinus recovery time was significantly prolonged only following chronic oral administration. Atrial refractory periods were significantly increased only at the fifth minute following acute intravenous administration and after chronic oral treatment. The intranodal conduction time (AH) and the refractory periods in atrio-ventricular node were slightly modified or not at all. On the other hand, intraventricular and His-Purkinje (HV) conduction times, ventricular refractory periods and QRS duration were strongly increased following acute or chronic administration. This would imply a principal effect on the rapid kinetics sodium entry current. Nevertheless, the very marked effect upon this current could, under the experimental conditions adopted, have masked a lesser action upon other membrane permeabilities, involved in other myocardial structures.

[Role of gamma cineangiography in the evaluation of chronic cerebral arteriopathies]

Gamma scintigraphy plays an important role in the topographic diagnosis of focalized cerebrovascular insufficiency. Furthermore, sequential imaging allows a comparative study of arterial distribution while studying the "transit time" of the radioactive tracer. In this work, the authors attempted to quantify transit time in patients with chronic cerebrovascular insufficiency while comparing the radioactivity in the hemispheres with that of the various arterial territories. The study of the arca and slope of the various arterial territories. The study of the area and slope of the tracer profile indirectly gives information about the cerebro-correlation between cerebrovascular resistance and the clinical state, there was, however, an interesting relation during vasodilator treatment (ifenprodil tartrate) in which promising clinical results were preceded by an increase in the arterial inflow component of the radioactivity curve.

Internal deletion in a collagen gene in a perinatal lethal form of osteogenesis imperfecta

Cloned probes specific for unique genes have proven to be powerful tools in defining the nature of genetic diseases such as the thalassaemias and growth hormone deficiencies. A similar approach should be useful in defining heritable diseases of type I collagen, the heterotrimer of two alpha 1(I) chains and one alpha 2(I) chain, which is the most abundant member of the collagen family of proteins. Recently, cloned cDNAs and genomic DNAs for the two polypeptide chains of the type I collagen have become available and have been used to elucidate the chromosomal location of the corresponding genes. Here, we have used several of these cloned DNAs to demonstrate the presence of an internal deletion of about 0.5 kilobases (kb) in one allele for the pro alpha 1(I) chain in a patient with osteogenesis imperfecta (OI), a group of heritable disorders which are characterized by brittle bones but which are highly heterogeneous both phenotypically and biochemically.

Electrophysiological properties of butoprozine studied by multiple intracardiac recordings on the anaesthetized dog

Electrophysiological effects of butoprozine (L 9394 Labaz) were investigated on the anaesthetized dog by programmed electrical stimulation of the heart and simultaneous recording of the His bundle electrogram and monophasic action potentials from the auricular and ventricular endocardial wall. Butoprozine injected intravenously depressed sino-atrial node function, lengthened A-V nodal conduction time and the A-V nodal refractory period, and prolonged the atrial refractory period. Thus butoprozine acted preferentially on parts of the myocardial tissue where the slow inward current seems to be particularly involved. In this respect, butoprozine was more active than amiodarone, but in contrast to this drug, butoprozine did neither prolong the ventricular monophasic action potential duration nor the ventricular refractory period. In the anaesthetized dog both drugs have practically analogous actions except at the ventricular level, which suggests that their effect on ionic currents at this level may be different.