Impact of chronic coronary syndromes on cardiovascular hospitalization and mortality: the ESC-EORP CICD-LT registry

Background

In Europe, global data on guideline adherence, potential geographic variations and determinants of major clinical events in chronic coronary syndromes (CCS) remain suboptimal. The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Chronic Ischemic Cardiovascular Disease Long-Term (CICD-LT) registry, a prospective European registry, was designed and conducted to describe the profile, care and outcomes of patients with CCS across the ESC countries

Purpose

We aimed to investigate clinical events at one-year follow-up from the ESC EORP CICD-LT Registry and identify the variables associated with an increased risk of clinical events.

Methods

Consecutive adults presenting with a diagnosis of CCS during a routine ambulatory visit or an elective coronary revascularisation procedure at participating centres were recruited across 154 centers from 20 countries between 1 May 2015 and 31 July 2018. Information on clinical and survival status was collected after 1 year from study inclusion. Composite events were cardio-vascular (CV) mortality and/or CV rehospitalisations, all-cause mortality and/or all cause rehospitalisation. A multivariable Cox regression analysis was performed to identify the independent predictors of each composite. Cox models were also performed with age, sex and region forced in the model. Significance levels of 0.05 were required to allow a variable to stay within the model. Co-linearity between all candidate variables (variables with p<0.05 in univariable) within the model and variables considered of relevant clinical interest were tested before proceeding to the multivariable model. Missing data were not imputed.

Results

One-year outcomes of 6655 patients from the 9174 recruited in this European registry were analyzed. Overall, 168 patients (2.5%) died, mostly from CV causes (n=97, 1.5%). Northern Europe had the lowest CV mortality rate, while southern Europe had the highest (0.5% vs 2.0%, p=0.04). Women had a higher rate of CV mortality compared with men (2.0% vs 1.3%, p=0.02). During follow-up, 1606 patients (27.1%) were hospitalised at least once, predominantly for CV indications (n=1220, 20.6%). Among the population with measured LDL-cholesterol level at one year, 1434 patients (66.5%) were above the currently recommended target. Age, history of atrial fibrillation, previous stroke, liver disease, chronic obstructive pulmonary disease or asthma, increased serum creatinine and impaired left ventricular function were each independently associated with an increased risk of CV death or hospitalization.

Conclusion

In the CICD registry, the majority of patients with CCS have uncontrolled CV risk factors. The mortality rate at one year was low, but these patients are frequently hospitalised for CV causes. Early identification of comorbidities may represent an opportunity for enhanced care and better outcomes.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The study was funded by the EORP program.

[Coronary artery spasm revealed by an out-of-hospital cardiac arrest associated with a moyamoya disease. A case report of multimodality imaging]

Moyamoya disease is a rare angiopathy characterized by a progressive distal occlusion of the internal carotid arteries and their branches. Extracerebral involvement, including coronary arteries, has been described. We report the case of a patient with moyamoya disease who suffered an out-of-hospital cardiac arrest associated with coronary spasm. We discussed the possible links between coronary spasm and moyamoya, as well as the contribution of multimodal cardiac imaging, combining conventional and intracoronary imaging, cardiac MRI, provocative tests for spasm, in the exploration of out-of-hospital cardiac arrest without obvious electrocardiographic and angiographic cause.

[Isolated right ventricular acute myocardial infarction mimicking anterior infarction]

Isolated right ventricular acute myocardial infarction is rare and its presentation can sometimes mimic an anterior ST-segment elevation myocardial infarction. We reported two cases of isolated right ventricular acute myocardial infarction presenting with a ST-elevation in anterior leads. The first case was admitted for an out-of-hospital cardiac arrest due to ventricular fibrillation. The patient died from neurologic consequences of the cardiac arrest, despite a successful prehospital thrombolysis, followed by a percutaneous angioplasty of the right coronary artery. The second case occurred after a complex percutaneous angioplasty of the right coronary artery, complicated by a total occlusion of a right marginal branch. These two cases illustrate the limits of the ECG for the diagnosis of isolated right ventricular acute infarction, and the difficulties of the differential diagnosis with anterior infarction, which may determine the treatment and the prognosis.

[Complicated transcatheter aortic-valve endocarditis with abscess and pseudoaneurysm: Value of the ECG-gated multidetector computed tomography angiography]

A 80-year-old man was admitted to catheterization room for an acute infero-lateral ST-elevation myocardial infarction (STEMI). Coronary angiography showed a thrombotic occlusion of the second left marginal branch, and normal other coronary arteries. The thrombo-embolic mechanism of the STEMI, and the infectious context in this patient who had had a transcatheter aortic valve implantation (TAVI) two months earlier, led us to suspect a bioprosthesis endocarditis. It was confirmed by transthoracic and transoesophageal echocardiography, which showed an aortic-mitral curtain abscess and aortic bioprosthesis vegetations, associated to Enterococcus faecalis bacteriemia. In order to specify the diagnosis, an ECG-gated multidetector CT angiography (MDCTA) had been performed. Additionally to echocardiographic findings, MDCTA showed a pseudo-aneurysm, sized 20 to 22mm, beginning from the outflow tract of the left ventricle to end on the antero-lateral face of the aorta. The patient was referred for emergency aortic bioprosthesis removal and replacement. Through this case, MDCTA showed its importance for the diagnosis and the prognostic evaluation of cardiac prosthesis endocarditis. MDCTA provided additional informations that echocardiography could not detect, because of artifacts caused by the prosthetic material and calcifications, frequent in elderly patients with comorbidities.

Ilio-psoas hematoma in the intensive care unit: a multicentric study

Background

Clinical features and outcomes of patients with spontaneous ilio-psoas hematoma (IPH) in intensive care units (ICUs) are poorly documented. The objectives of this study were to determine epidemiological, clinical, biological and management characteristics of ICU patients with IPH.

Methods

We conducted a retrospective multicentric study in three French ICUs from January 2006 to December 2014. We included IPH diagnosed both at admission and during ICU stay. Surgery and embolization were available 24 h a day for each center, and therapeutic decisions were undertaken after pluridisciplinary discussion. All IPHs were diagnosed using CT scan.

Results

During this period, we identified 3.01 cases/1000 admissions. The mortality rate of the 77 included patients was 30 %. In multivariate analysis, we observed that mortality was independently associated with SAPS II (OR 1.1, 95 % CI [1.013–1.195], p = 0.02) and with the presence of hemorrhagic shock (OR 67.1, 95 % CI [2.6–1691], p = 0.01). We found IPH was related to anticoagulation therapy in 56 cases (72 %), with guideline-concordant reversal performed in 33 % of patients. We did not found any association between anticoagulant therapy type and outcome.

Conclusion

We found IPH is an infrequent disease, with a high mortality rate of 30 %, mostly related to anticoagulation therapy and usually affecting the elderly. Management of anticoagulation-related IPH includes a high rate of no reversal of 38 %.

Establishment of diagnostic reference levels in cardiac CT in France: a need for patient dose optimisation

The objective of this study was to propose diagnostic reference levels (DRLs) for coronary computed tomography angiography (CCTA), in the context of a large variability in patient radiation dose, and the lack of European recommendations. Volume Computed Tomography Dose Index (CTDIvol) and dose-length product (DLP) were collected from 460 CCTAs performed over a 3-month period at eight French hospitals. CCTAs (∼50 per centre) were performed using the routine protocols of the centres, and 64- to 320-detector CT scanners. ECG gating was prospective (n = 199) or retrospective (n = 261). The large gap in dose between these two modes required to propose specific DRLs: 26 and 44 mGy for CTDIvol, and 370 and 970 mGy cm for DLP, respectively. This study confirms the large variability in patient doses during CCTA and underlines the need for the optimisation of cardiac acquisition protocols. Availability of national DRLs should be mandatory in this setting.

[Undifferentiated sarcoma: usefulness of multimodality cardiac imaging in characterizing a rare intracardiac mass]

We report the case of a man presenting with a Pierre Marie-Bamberger syndrome. This paraneoplastic syndrome revealed an undifferentiated intracardiac sarcoma. This case emphasizes the need for multimodality imaging to characterize intracardiac tumor.

[Variations of radiation dosage delivered to patients undergoing interventional cardiological procedures. A monocentric study 2002-05]

X-ray exposure of patient during coronary angiography (CA) and percutaneous transluminal coronary angioplasty (PTCA) may have some deleterious effects. The dose area product (DAP), related to the effective dose, is a measure of stochastic risk and a potential quality indicator. The aim of our study was to assess radiation exposure of patients in a large series of "real life" interventional cardiac procedures. We evaluated DAP and Fluoroscopy time (t) during CA and/or PTCA in 3600 consecutive patients from 2002 to 2005. Procedures were performed by five experienced physicians, using successively femoral and radial techniques. DAP and t significantly correlated (r = 0.73; p < 0.0001). Median [25th-75th percentiles] values for DAP and for t were 63 [40-101] Gy.cm2 and 6.3 [4-10] min for CA, 100 [62-178] Gy.cm2 and 14.0 [9-22] min for elective PTCA, and 141 [90-219] Gy.cm2 and 15.7 [11-23] min for CA immediately followed by ad hoc PTCA, respectively. Differences between operators ranged from 50% (CA) to 70% (PTCA) for both DAP and t (p < 0.001). Moving from the femoral to the radial approach resulted in a 1.5 to 2-fold increase in DAP in 2002 (p < 0.001). DAP and t then decreased toward the european DIMOND reference values (in 2005: 53.4 Gy.cm2 and 5.5 min for CA, 104.64 Gy.cm2 and 13.1 min for elective PTCA, 128.4 Gy.cm2 and 13.6 min for ad hoc PTCA). In conclusion, radiation exposure to patients and staff are strongly dependent on operators, time course, and the arterial access, due in part to the learning curve for radial approach. The enhanced knowledge of radiation dose is the first step of a radiation dose-reduction program, likely to minimize patient and operator radiation hazards in interventional cardiology. Definition of national reference values for DAP and fluoroscopy time would be helpful for appropriate comparisons.

Interleukin-6 gene polymorphisms and susceptibility to myocardial infarction: the ECTIM study. Etude Cas-Témoin de l'Infarctus du Myocarde

There is growing evidence that interleukin (IL) 6 plays an important role in the atherosclerotic process because of its role in mediating immune and inflammatory responses and inducing cell proliferation. The present study examined whether molecular variations at the IL-6 locus are involved in the predisposition to myocardial infarction. The entire coding region, 1,158 bp of the 5' flanking region and 237 bp of the 3' flanking region of the IL-6 gene were screened. We detected three nucleotide substitutions in the 5' region at positions -174 (G/C), -572 (G/C), and -596 (G/A) from the transcription start site, and one insertion/deletion in the 3' region at position +528 after the Stop codon. These polymorphisms were genotyped in the Etude Cas-Témoin de l'Infarctus du Myocarde study comparing male patients (n=640) and age-matched controls (n=719) from Northern Ireland and France. The IL-6/G-174C and IL-6/G-596A polymorphisms were in nearly complete association. Carriers of the IL-6/-174 C allele were more frequent in patients than in controls. The population-adjusted odds ratio for myocardial infarction associated with genotype CC+CG vs. GG was estimated as 1.34. In French patients the number of coronary arteries with greater than 50% stenosis was assessed by angiography. The IL-6/-174 C allele was more frequent in patients with two or fewer stenosed vessels than in patients with three-vessel lesions. These results suggest that genetic variation at the IL-6 locus is associated with susceptibility to myocardial infarction, especially events occurring on less extended lesions. These findings would be compatible with a lower IL-6 secretion associated with the IL-6/-174 C allele, itself or in combination with other promoter polymorphisms, leading to more unstable plaques.

New polymorphisms in the interleukin-10 gene--relationships to myocardial infarction

BACKGROUND

Interleukin-10 (IL-10) is a cytokine with anti-inflammatory and B-cell-stimulating activity. IL-10 is expressed in human atherosclerotic plaques and recent studies have shown the involvement of IL-10 in the atherosclerotic process. Therefore, we hypothesized that polymorphisms in the IL-10 gene might be associated with a predisposition to coronary heart disease.

MATERIALS AND METHODS

To identify new polymorphisms in the human IL-10 gene, the entire coding sequence and the 3' flanking sequence of the gene were screened by polymerase chain reaction-single strand conformation polymorphism (PCR-SSCR) followed by sequencing. The polymorphisms identified, and three others which have been previously described in the promoter region of the IL-10 gene (G-1082A, C-819T, C-592A), were then investigated in the ECTIM Study, a large population-based case-control study of myocardial infarction.

RESULTS

Four new polymorphisms were identified: one in exon 1 (G+78/ex1A), which predicts a Glycine to Arginine change at position 15 in the putative signal peptide of the protein, two in the intron 3 (C+19/in3T, T+953/in3C) and one in the 3' flanking region (C+117T). All the IL-10 polymorphisms were in complete or nearly complete pairwise linkage disequilibrium. No case-control difference was found in genotype or allele frequencies for any of the polymorphisms.

CONCLUSIONS

Our results suggest that IL-10 polymorphisms are not associated with an increased risk of myocardial infarction.

Late results with bioprosthetic valves in the elderly

AIM

We report the long-term outcome of aortic and mitral bioprostheses in patients over 65 years of age at the time of implantation. The aim was to determine actuarial patient survival, causes of death, and the rate of documented primary structural deterioration.

METHODS

One hundred ten patients > or = 65 years of age (mean, 73.4; range, 65-82) underwent successful bioprosthetic valve replacement (aortic, n = 71; mitral, n = 32; both, n = 7) from 1979 to 1985. The valve was pericardial in 39 cases and porcine in 78. The mean follow-up was 8.5 years (101.9 months-total; 934 patient-years; range, 2 months to 15 years).

RESULTS

Actuarial patient survival was 79.6% (71-86) at 5 years and 62.4% (52-71) at 10 years. Forty-four patients died, 21 from valve-related causes and 23 from other causes. Thirteen patients (11.8%) had reoperation for valve-related complications: 10 structural deteriorations, 2 paravalvular leaks, and 1 case of endocarditis. One surgical death occurred (7.7%). Twenty-six percent of the patients were receiving anticoagulants because of atrial fibrillation, and 6.4% developed severe bleeding (2.9% patient-years).

CONCLUSIONS

Long-term follow-up of these patients > 65 years of age, undergoing bioprosthetic value replacement surgery revealed a low rate of documented primary structural deterioration (0.95% per patient-year), a low mortality rate on reoperation (7.7%), and a high mortality rate due to non-value-related causes (52.3%).

New polymorphisms of the angiotensin II type 1 receptor gene and their associations with myocardial infarction and blood pressure: the ECTIM study. Etude Cas-Témoin de l'Infarctus du Myocarde

OBJECTIVE

In an earlier report, we suggested that a polymorphism located in the 3' untranslated region of the angiotensin II type 1 receptor gene (AT1R+1166 A/C) might interact with the angiotensin I converting enzyme (ACE) insertion/deletion (I/D) polymorphism to increase the risk of myocardial infarction. Since the AT1R+1166 A/C polymorphism does not appear to be functional, we postulated that it might be in linkage disequilibrium with an unidentified functional variant which would affect the regulation of the gene in response to angiotensin II. The present study was conducted to identify new polymorphisms of the AT1R gene that might be responsible for this interaction.

METHODS

The first four exons, which are untranslated, and 2.2 kb in the 5' flanking region of the AT1R gene were explored by polymerase chain reaction/single-strand conformation polymorphism. Seven polymorphisms were detected in the 5' region at positions -1424, -810, -713, -521, -214, -213 and -153 upstream from the start of transcription. The genotypes of the -810, -713, -214, -213 and -153 polymorphisms were completely concordant. One substitution was detected at the 55th nucleotide of exon 4. These polymorphisms, together with the +1166 A/C polymorphism and a previously described T/C substitution at the 573th nucleotide of exon 5, were genotyped in the Etude Cas-Témoin de l'Infarctus du Myocarde (ECTIM) study, a multicentre study comparing 651 patients who had survived a myocardial infarction and 728 controls from Belfast (United Kingdom) and Lille, Strasbourg and Toulouse (France).

RESULTS

The newly identified polymorphisms were not in linkage disequilibrium with the +1166 A/C polymorphism and therefore could not explain the interaction observed with ACE I/D. None of the polymorphisms was associated with blood pressure levels in control subjects. In the four populations, the A allele of the -810 polymorphism was associated with a lower risk of myocardial infarction (population-adjusted odds ratio of 0.80, confidence interval 0.65-0.97, P< 0.05).

CONCLUSIONS

None of the newly identified polymorphisms could account for the previously described interaction between the AT1R+1166 A/C and the ACE I/D polymorphisms affecting the risk of myocardial infarction. However, the present study suggests that AT1R-810 T/A, or other polymorphisms which are in complete association with it, might be associated with the risk of myocardial infarction. Further studies are required to confirm this finding and to identify the functional variants.

Time course of troponin I, myoglobulin, and cardiac enzyme release after electrical cardioversion

The results of this study, conducted in 25 patients without myocardial infarction, showed that all the biologic markers of myocardial infarction, except the highly cardiospecific cardiac troponin I, increased in some patients after electrical cardioversion. These results allow us to conclude that electrical cardioversion, even preceded by a mechanical resuscitation of short duration, does not result in myocardial damage, and that cardiac troponin I is more accurate than creatine kinase-MB activity and creatine kinase-MB mass determination for the diagnosis of myocardial damage in patients who have undergone electrical cardioversion.

[Tolerance of amlodipine in left ventricular dysfunction of ischemic origin]

The aim of this study was to assess the effects of amlodipine on left ventricular function at rest and on effort, at least 30 days after myocardial infarction. The 30 patients included in the study had resting isotopic ejection fractions of 40 to 60%. At inclusion and after 15 days treatment with 10 mg of amlodipine, the patients underwent exercise stress testing with a standard Bruce protocol and resting and exercise isotopic left ventricular ejection fractions were measured. The association of betablockers was allowed but vasodilator therapy was prohibited. During the second exercise stress test, the duration of exercise increased (437 +/- 167 to 518 +/- 154 s; p < 0.002) and the work level rose from 140 +/- 56 to 169 +/- 60 Watts; p < 0.04. The number of electrically positive tests did not change significantly (33 vs 26.7%; NS). The resting ejection fraction did not increase after 15 days treatment with amlodipine (47.4 +/- 6.7 vs 48.3 +/- 8.9%; NS). Similar results were observed with respect to the exercise ejection fraction (51.4 +/- 10.4 vs 52.6 +/- 8.6%; NS). These patients may however be divided into two subgroups. In the first subgroup of 10 patients, the resting ejection fraction rose by more than 5% with amlodipine whereas the exercise ejection fraction remained unchanged (54.4 +/- 7.7% vs 54.5 +/- 7.5% with amlodipine). In the second subgroup of 20 patients, the resting ejection fraction decreased slightly with amlodipine (48 +/- 6.9% vs 45.3 +/- 8%; p = 0.04) but increased significantly on exercise (45.3 +/- 8% vs 51.7 +/- 9.1%; p < 0.0002). Therefore, amlodipine, a new generation calcium antagonist, does not induce any deleterious effect after myocardial infarction with mild left ventricular dysfunction.

[Treatment of refractory unstable angina by transluminal coronary angioplasty]

The aim of this retrospective study was to assess the value of percutaneous transluminal coronary angioplasty (PTCA) in unstable angina refractory to maximal medical therapy. The results of this procedure in these patients were compared with the results in unstable angina controlled by medication before angioplasty. Between january 1987 and january 1993, 30 patients underwent emergency PTCA for refractory unstable angina (group I). The clinical and angiographic features were compared with these of 30 patients with medically controlled unstable angina, paired for age and dilated artery (group II). The left ventricular ejection fraction was compared in the two groups (58 and 57%). The morphology of the coronary lesions according to the Ambrose classification, TIMI grading, number of lesions, degree of stenosis and severity of coronary calcification were comparable in the two groups. However, in group I, there was a significantly higher number of filling defects (30% compared with 10%, p = 0.05) and a greater number of per-PTCA complications, especially acute occlusions (23 compared with 13%, NS) with 3 deaths and 2 myocardial infarctions (compared with 1 death and 2 myocardial infarctions in group II). At long term, the restenosis, myocardial infarction and secondary death rates were comparable in the two groups with an average follow-up of 27 +/- 18 months. The poor prognosis of refractory unstable angina is therefore related to morbidity in the hospital period. These results confirm the physiopathological importance of the thrombotic process in unstable angina; the presence of "filling defect" is a poor prognostic factor associated with resistance to medical therapy. Coronary angioplasty is a valuable technique in this context but carries a higher risk of acute complications which can be reduced by an optimal platelet antiaggregant and anticoagulant therapy and in future by the use of new antithrombotic agents.

Family study of lipoprotein lipase gene polymorphisms and plasma triglyceride levels

To better characterize the role of the lipoprotein lipase (LPL) gene in the determination of triglyceride levels in healthy subjects, a study was performed in 193 nuclear families (384 parents, means age = 42.0 +/- 5.2 years; 399 offspring, mean age = 14.6 +/- 4.3 years) volunteering to have a free health checkup examination. The pattern of familial resemblance was compatible with a zero correlation between spouses, a weak father-offspring correlation (0.099 +/- 0.054; P < 0.07), and significant mother-offspring (0.235 +/- 0.053; P < 10(-4)) and sib-sib (0.294 +/- 0.064; P < 10(-4)) correlations. Associations of triglyceride levels with the LPL HindIII and PvuII polymorphisms were investigated by a familial measured genotype analysis, specifying sex- and age-dependent polymorphism effects. The effects associated with both polymorphisms were significant only in fathers, the H+ and P+ alleles being associated with raised triglyceride levels. The HindIII and PvuII polymorphisms explained 3.5% and 3%, respectively, of the variability of triglycerides in fathers. The relationship was weakened after prior adjustment on body mass index, but remained significant for PvuII. Because of the lack of effect in mothers and offspring, the polymorphisms did not contribute to the covariance of triglyceride levels in relatives. In conclusion, this family study showed a weak relationship of the HindIII and PvuII polymorphisms to plasma triglyceride levels in young healthy male subjects. The effects detectable only in fathers suggest a possible modulation of the LPL expression by hormonal or lifestyle factors.

Bioprosthetic valve replacement in the elderly

One hundred and ten patients aged more than 65 years (mean, 73.4; range, 65-82) underwent successful bioprosthetic valve replacement (aortic, n = 71; mitral, n = 32; both, n = 7) from 1979 to 1985. The valve was pericardial in 39 cases and porcine in 78. The mean follow-up was 75 months (total, 688 patient-years; range, 2 months to 12 years). Actuarial patient survival was 79.4% at 5 years and 55.2% at 10 years. Thirty-seven patients died: 18 from valve-related causes and 19 from other causes. Eight patients have been reoperated on for valve-related complications (1.17% per patient-year): five primary deteriorations, two paravalvular leaks and one case of endocarditis. One surgical death occurred (12.5%). Twenty-five percent of the patients were receiving anticoagulants because of atrial fibrillation, and 5.4% developed severe bleeding (3.8% patient-year). Mid-term follow-up of these patients aged more than 65 years and undergoing bioprosthetic valve replacement surgery revealed a low rate of documented primary structural deterioration (0.9% per patient-year), a low mortality rate on reoperation (12.5%) and a high mortality rate due to non valve-related causes (51.4%).

[Favorable outcome of orbital nasal sinus mucormycosis complicating the induction treatment of acute lymphoblastic leukemia]

BACKGROUND

Most cases of mucormycosis occur in immunosuppressed children. Intracranial extension is lethal and must be prevented with early specific treatment.

CASE REPORT

A 42 month-old boy was admitted suffering from acute lymphoblastic leukemia. Edema of the left eyelid developed on the sixth day of induction chemotherapy. Mucormycosis was suspected because of gradual extension of infection to nasal ala and periorbital area with fever, edema of nasal turbinates and nasal black secretions. Chemotherapy was discontinued and the patient was given intravenous amphotericin B (1.0 mg/kg/day) and heparin associated with G.CSF. Improvement was only temporary and scan examination performed on day 17 showed involvement of the orbit, eye and wall of the maxillary sinus; cultures of secretions were positive for staphylococcus and Absidia corymbifera. Remission of leukemia was obtained a few days later permitting surgical resection of involved tissues on day 30. A relapse of mucormycosis was observed six weeks later despite prolonged administration of amphotericin B requiring extended resection of necrotic areas and replacement of amphotericin B by its liposomal form (Ambisome). Bone marrow relapse of leukemia required further chemotherapy. The patient is in good condition 30 months after the initial symptoms.

CONCLUSION

Our patient seems to be the first with prolonged remission of facial mucormycosis and acute leukemia despite relapse of both diseases. This favorable outcome could be due to the use of Ambisome.

Usefulness of radionuclide ventriculography during transesophageal atrial pacing in the diagnosis of coronary artery disease

Radionuclide ventriculography before, during, and after atrial transesophageal pacing was carried out in 15 patients with suspected coronary artery disease (CAD) and without myocardial infarction. All patients underwent coronary angiography. Ten patients (group 1) had a coronary lesion > 50% on at least one of the main coronary arteries. Five patients (group 2) had normal coronary arteries. Radionuclide left ventricular ejection fraction (LVEF) before pacing was 56 +/- 3% in group 1 and 59 +/- 3% in group 2 (NS). Radionuclide ventriculography during pacing was 45 +/- 4% in group 1 (P < 0.0001 vs basal in group 1) and 45 +/- 6% in group 2 (P < 0.01 vs basal in group 2, NS vs group 1 during pacing). Immediate postpacing ejection fraction did not differ in the two groups and was identical to the prepacing value. A quantitative regional wall motion analysis was performed in 105 segments. Regional radionuclide ventriculography was calculated in each segment as follows: end-diastolic counts-end-systolic counts/end-diastolic counts. The relative decrease in regional LVEF during pacing was more important in the 39 segments related to a narrowed vessel than in the 66 segments related to normal coronary artery (32 +/- 13% vs 13 +/- 10%, P < 0.0001). A more than 20% relative decrease in at least one segment during pacing occurred in 10 patients in group 1 (sensitivity 100%) and in 2 patients in group 2 (specificity 60%). In conclusion, global radionuclide ventriculography during transesophageal atrial pacing decreases in patients with and without CAD.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary angioplasty in patients 75 years and older; comparison with coronary bypass surgery

From November 1988 to May 1992, 108 patients (79 men, 29 women) 75 years or older (mean 78 +/- 3, range 75-90 years) underwent coronary angioplasty (group I: n = 62) or coronary bypass surgery (group II: n = 46). Group II patients were younger (76 +/- 2 vs 79 +/- 4, P = 0.002) and had a higher proportion of multivessel disease. The two groups were comparable with regard to the presence of unstable angina, left ventricular ejection fraction and Q wave infarction. In-hospital mortality was similar in the two groups (6.4% vs 4.3%). Complete revascularization (72% vs 47%, P < 0.05) and left anterior descending artery revascularization (100% vs 45%, P < 0.01) were more frequent in group II. Two-year infarction-free survival was similar (group I: 76 +/- 6%; group II: 79 +/- 6%) but recurrent class III or IV angina (36% vs 9%, P < 0.05) and repeat procedures (26% vs 0%, P < 0.05) were more frequent in group I.

[Mid-term results of bioprosthesis in patients over 65 years]

Between 1979 and 1985, 79 patients over 65 years of age (mean 70.8; range 65-82 years) underwent valvular replacement with a bioprosthesis (aortic: 48, mitral: 26, aortic and mitral: 5). Of the 84 valves implanted, 56 were porcine and 28 were pericardial bioprostheses. The average follow-up was 66 months (total: 434 patient-years; range: 2 months-12 years). Twenty-three patients (29%) died; 13 of these deaths were related to the prosthesis and 10 were not formally related to the bioprosthesis. Of the latter 10 deaths, 7 were caused by malignant disease. Seven patients were reoperated for a complication due to the prosthesis (1.6% per patient-year): 5 primary tissue failure, 1 endocarditis, 1 perivalvular leak. Sixteen patients (20.3%) received oral anti-coagulants for atrial fibrillation; 6 of them (7.6%) had severe haemorrhagic complications (3 deaths). The actuarial survival was 76.2% at 5 years and 53.4% at 10 years. Actuarial survival without reoperation was 76% at 5 years and 42% at 10 years. Analysis of survival with respect to the type of bioprosthesis (porcine of pericardial), the valve orifice (mitral or aortic) and age (under or over 70 years) did not show any significant differences. Follow-up of patients over 65 years of age showed a high rate of haemorrhagic complications related to oral anticoagulant therapy for atrial fibrillation (6.8% per patient-year), a low rate of primary tissue failure (1.1% per patient-year) and a low reoperative mortality (1 death for 7 reoperations).

Prognostic value of thallium-201 myocardial scintigraphy after atrial transoesophageal pacing in patients with suspected coronary artery disease

Fifty-five patients with suspected coronary artery disease underwent planar thallium-201 myocardial scintigraphy after atrial transoesophageal pacing. Coronary angiography was carried out in all patients. Eighteen patients had no myocardial infarction, but a greater than 50% narrowing of at least one main vessel: initial hypoperfusion with redistribution at 4 h occurred in 16 patients (sensitivity 89%). Twenty-one patients had had a previous myocardial infarction: a reversible thallium defect was observed in 12 patients and an irreversible defect in the nine remaining patients. Sixteen patients had normal coronary arteries: a reversible thallium defect was observed in three patients (specificity 81%). After a mean follow-up of 22 +/- 13 months (range 6 to 40), 23 cardiac events occurred: cardiac death in one patient, unstable angina in three, and revascularization procedures for recurrent angina despite medical therapy in 19 (coronary artery bypass surgery in 7 and coronary angioplasty in 12). By univariate analysis, the predictors of future cardiac events were a history of previous myocardial infarction (odds ratio 5.5, P < 0.02), multivessel coronary artery disease (odds ratio 9.6, P < 0.0002), angina during atrial pacing (odds ratio 5.1, P < 0.05), abnormal scintigraphy (odds ratio 17.1, P < 0.001) and reversible perfusion defect after pacing (odds ratio 7.9, P < 0.002). By multivariate analysis, multivessel disease (P < 0.004) and reversible perfusion defect after pacing (P < 0.02) were the only independent predictors of future cardiac events.(ABSTRACT TRUNCATED AT 250 WORDS)

[Can patients with severe left ventricular dysfunction be treated by coronary artery bypass surgery?]

Forty three men and 3 women, with an average age of 59 years (13 to 78 years) underwent aorto-coronary bypass surgery despite severe left ventricular dysfunction (ejection fraction < 35%); 96% of the patients had previous infarction; 60% (N = 28) had unstable angina, 52% (N = 24) had had pulmonary oedema or an episode of congestive cardiac failure. The average ejection fraction was 29 +/- 4%, range 17 to 35%. Thirteen patients had ventricular aneurysms, 4 had grade 3 or 4 mitral regurgitation. The coronary lesions were usually multivessel left main coronary (6), triple vessel disease (27), double vessel disease (12), single vessel disease (1). The average number of bypass grafts per patient was 2.3. The average aorting clamping time was 63 minutes (range 26 to 133 minutes). There were 4 mitral valve replacements, 4 resections of ventricular aneurysms and 1 double procedure (aneurysmectomy and valve replacement). The operative mortality was 2.1% (1 death). During an average follow-up period of 27 months (range 3 to 90 months), there were: 2 recurrent infarctions, 13 episodes of cardiac failure and 8 cardiac deaths (cardiac failure: 5, sudden death: 2, recurrent infarction: 1). Two patients underwent cardiac transplantation. The regression of angina (90% of operated patients were asymptomatic) and the low operative risk, justify aortocoronary bypass surgery despite left ventricular dysfunction in patients with severe symptoms (unstable angina, chronic, invalidating angina). The medium-term results indicate a high risk of cardiac failure which is partially responsible for the secondary mortality rate of 17% at 2 years.

[Tamponade without cardiac rupture after repetitive thrombolysis in acute myocardial infarction]

The authors report the case of tamponade without cardiac rupture 48 hours after a second course of intravenous thrombolytic therapy undertaken for unstable angina in laterobasal infarction in a 72 year old woman. The outcome after ultrasonic guided pericardiocentesis and surgical drainage (700 cc) was favourable. This is a rare complication of thrombolytic therapy (10 cases) and usually observed after anterior myocardial infarction.

Treatment of severe mitral regurgitation caused by ischemic papillary muscle dysfunction: indications for coronary angioplasty

The aim of this study was to evaluate the prognosis and functional outcome of mitral regurgitation caused by ischemic papillary muscle dysfunction with respect to treatment, and to determine the role of coronary angioplasty in this context. Thirty patients with severe ischemic mitral regurgitation were followed up for 33 +/- 3 months. Thirteen patients were treated medically (group I) and 17 patients underwent surgery or angioplasty (group II). The 3-year survival was 59.5% (45.6% in group I and 70.2% in group II). Angioplasty was only used in paroxysmal mitral regurgitation caused by papillary muscle ischemia. This technique resulted in spectacular immediate results in three patients with pulmonary edema caused by mitral regurgitation during myocardial ischemia. Surgical correction of mitral regurgitation should be considered without delay if angioplasty is not feasible or if the regurgitation is permanent or severe. Widening the indications of surgery or angioplasty should result in an improvement of the prognosis of these high-risk patients.

[Doppler parameters of systolic function and heart rate]

This prospective study had two aims, to study the Doppler parameters of left ventricular systolic function with respect to heart rate, and to determine the influence of ischaemic heart disease on these variations. The Doppler indices (velocity time integral, maximum velocity and average acceleration of systolic flow in the left ventricular outflow tract) were measured and averaged over 3 beats after digitization: the measurements were repeated in 30 patients under basal conditions and after 2 minutes transoesophageal atrial pacing at 150 beats/min. These 30 patients were divided into 3 groups: group 1 control subjects with normal coronary arteries, n = 13, EF = 71 +/- 8.9%; group 2 coronary patients without myocardial infarction (greater than 70% stenosis on coronary angiography), n = 9, EF = 64.3 +/- 10.3%; group 3, coronary patients with previous infarction, n = 8, EF = 51.8 +/- 10.9% (p less than 0.0006). Variance analysis for repeated measurements showed significant decreases in velocity time integrals and maximum velocities after pacing (11.8% +/- 2.2 and 0.86 +/- 0.1 versus 18.3 +/- 2.2 and 0.91 +/- 0.1, p less than 0.0001 and p less than 0.05 respectively). This decrease was identical in the three groups. The variations observed were therefore related to the increase in heart rate and not to coronary status or left ventricular function.

Life-threatening thyrotoxicosis induced by amiodarone in patients with benign heart disease

We report four cases of life-threatening amiodarone iodine-induced thyrotoxicosis. Two patients died of a thyroid storm, and the other two patients developed severe thyrocardiac disease unresponsive to 6 months intensive antithyroid and steroid therapy. One of these latter patients died 1 month after thyroidectomy. Euthyroidism was achieved in the last patient by treatment with potassium perchlorate. The course could not be explained by the prior thyroid or cardiac status in any of the four cases.

[A rare cause of right cardiac insufficiency after pneumonectomy]

The authors report the case of a 55-year old patient, hospitalized for assessment of progressive right heart failure after left pneumonectomy due to bronchial epidermoid cancer. Right catheterization showed a dip-shaped right ventricular plateau and equal diastolic pressures (DOP 21 mmHg, diastolic pressure of the right ventricle 25 mmHg, capillary pressure 25 mmHg). A chest scan ruled out the possibility of pericardial invasion. Pericardial decortication was carried out on October 3, 1989. Six months later, the clinical signs of right heart failure had regressed. Chronic constrictive pericarditis (CCP) has been reported after cardiac surgery, but not cases have been reported after pulmonary surgery. In the absence of radiotherapy or metastatic invasion, this case leads to a discussion of the possibility of either pericardial trauma during surgery or, more probably, a fortuitous association with tubercular CCP.

[Postinfarction segmental asynergy: correction after angioplasty. Predictive value of exercise thallium scintigraphy]

The aim of this study was twofold: to evaluate the frequency of reversibility of segmental post-subendocardial infarction asynergy after coronary angioplasty, and to test the predictive value of the redistribution phenomenon during stress Thallium scintigraphy with respect to the reversibility of segmental asynergy. The inclusion criteria for this study were: previous postsubendocardial myocardial ischaemia with residual resting or effort ischaemia documented with or without the Thallium test, segmented asynergy documented by quantitative analysis of the ventriculography, complete correction of coronary angioplasty of stenotic single or double vessel disease, a balanced coronary distribution or dominant left coronary in cases of lesion of the circumflex artery. Out of 254 consecutive angioplasty procedures 39 patients met these inclusion criteria. The location of the subendocardial infarct (SEI) was anterior in 17 cases and inferior in 22 cases. The study protocol included a Thallium scintigraphy from the 10th day after SEI, ventriculography 24 hours later, angioplasty and control ventriculography 24 hours after angioplasty. Comparison of the two ventriculographies opposed Group A (reversible asynergy) and Group B (irreversible asynergy) according to criteria defined in 15 normal subjects whose average regional ejection fraction (REF) was 0.53 +/- 0.11. This result enables definition of normal segmental motion if the REF greater than 0.30 (mean--2 SD); hypokinetic if the REF greater than 0.30 or akinetic if the REF less than 0.10 (mean--4 SD). An increase of REF of 0.15 (50% of the minimal normal value) allowed definition of reversibility of asynergy. By these criteria, 19 patients (48.7%) had reversible asynergy after PTCA; 20 had definitive asynergy (51.3%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Prognosis of ischemic mitral valve insufficiency]

Seventy-nine patients with ischemic mitral regurgitation were followed up for a period of 20 +/- 8 months. The risk of death increased with age and cardiac failure at the time of inclusion. The risk of cardiac events increased with these factors and also with raised serum creatinine and decreased echocardiographic fractional shortening. The global 2 year survival was 72.8% and survival without a further cardiac event was 48.7%. Surgery and angioplasty increased global survival and freedom from cardiac events of patients with severe regurgitation (74.9% and 68.8% versus 59.4% and 46.1% for medical therapy alone). The functional improvement was also greater in patients undergoing surgery or angioplasty (80% of patients in NYHA Stage I versus 53.8% in the medical group). Angioplasty was only performed in cases of paroxysmal mitral regurgitation by reversible papillary muscle ischemia. Surgery (coronary bypass usually associated with mitral valve replacement) was associated with better results than medical therapy alone in permanent mitral regurgitation by papillary muscle dysfunction or rupture. Despite a high immediate mortality, this option should be considered rapidly in cases of severe ischemic mitral regurgitation with pulmonary oedema.

[Is the prognosis of non-thrombolysed inferior infarction benign?]

Between 1978 and 1983, 2,970 coronary angiographies were performed at the Cardiology Clinic of Necker Hospital; 220 survivors of an initial Q-wave inferior infarction who had not received thrombolytic therapy were selected. The ejection fraction was 55 +/- 11 per cent, and the indexed end diastolic left ventricular volume was 108 +/- 29 ml/m2. The left anterior descending artery was diseased in 57 per cent of cases. The incidence of multivessel disease was 67 per cent. Two hundred and eleven patients (96%) were followed up for 79 +/- 22 months. The prevalence of cardiovascular events was: cardiac deaths: 22 (10%), recurrent infarction: 20 (9%), angina requiring coronary bypass surgery: 60 (28%), cardiac failure: 22 (10%). The 10 year actuarial survival was significantly lower in patients with an ejection fraction less than 45 per cent (46% vs 91%) and in patients with triple vessel disease (62% vs 92% and 88%). The survival was not lower in patients with stenosis of the left anterior descending artery.

[Listeria rhombencephalitis caused by Listeria monocytogenes with a cerebrospinal fluid initially normal]

A case of rhombencephalitis due to Listeria monocytogenes in a non immunocompromised patient, with initially normal cerebrospinal fluid, was marked by potentially fatal neurovegetative disorders and severe neurological sequelae partly due to delay in diagnosis and treatment. The possibility of Listeria infection should be considered in patients with fever and cranial nerves deficits, in order to initiate an appropriate antibiotic therapy and to keep the subject under close monitoring in an intensive care unit.

[Persistence of the perioptic ring of the ophthalmic artery. Anatomical and embryological observations]

At the foetal age, there is an arterial ring around the optic nerve inside the orbit. This ring, partially supplied by the ophthalmic artery, is transitory. A persistence at the adult age is absolutely exceptional. The case described in this paper is the second to be published. It has been found during a microdissection of the arteries of the orbit muscles. The authors discuss the variations of the origin and the course of the ophthalmic artery, according to the three embryologic origins of the orbital arterial vascularization: dorsal and ventral ophthalmic arteries, hyoïd artery. This multiple origin explains the formation of the ring and its persistence.