[Morphological and functional characteristics of the culprit coronary artery in acute coronary syndrome]

In the catheter laboratory, faced with a patient with unstable angina, the problem is not the diagnosis of epicardial coronary artery stenosis but rather the atherothrombotic complexity of the stenosis and the identification of other less stenotic lesions on angiographically normal or nearly normal segments. The authors describe two appearances with morphological analysis of the vulnerable or unstable plaque and functional analysis of coronary artery vasomotricity. Acute coronary syndromes due to a clearly stenotic atherothrombotic plaque on angiography pose no diagnostic problems. However, an acute coronary syndrome may be more difficult to assess when angiography shows only simple irregularities of the lumen or no lesions at all. In these cases, angiography is said to be normal and the coronary arteries are considered to be possibly "healthy". Evaluation of the vessels' vasomotricity is especially valuable in this context. Using pharmacological stress tests, endovascular ultrasonography is a complementary diagnostic tool which allows identification of the unstable atheromatous process or of a partial atherothrombosis masked by positive remodelling process. These tests may also indicate the optimal treatment.

[Treatment of coronary artery vasospasm during coronary arteriography]

Coronary spasm was first demonstrated by Gensini in 1962, and the diagnostic value of spontaneous spasm during coronary angiography is now generally accepted. In its absence, provocation tests with ergonovine or its derivatives form part of routine hemodynamic investigation for confirming the spastic nature of atypical chest pain or pain suggestive of Prinzmetal angina. The coronary spasm so induced gives rise to reduced coronary flow, an increase in coronary resistance and myocardial ischemia as shown by an increased lactate extraction in coronary sinus blood; therefore, once it is documented, it must be treated in order to avoid myocardial necrosis or ventricular arrhythmias. Three groups of drugs of drugs are used to counteract spontaneous or provoked spasm: alpha-blockers, especially phentolamine, nitrate derivatives, trinitroglycerine or isosorbide dinitrate, and calcium inhibitors nifedipine or diltiazem, which have a direct antispastic effect. The hemodynamic and pharmacological actions of these three groups of drugs depend on whether they are given orally, intravenously or by intracoronary injection. Twenty six coronary spasms were observed in 23 patients out of a total of 780 coronary angiographies (3,3 per cent) performed between June 1980 and June 1981: 12 spasms were spontaneous (1,5 per cent), 6 provoked by the catheter (0,8 per cent) and 8 by methylergometrine. There were no complications. Five coronary spasms were also observed during 70 coronary angioplasties (7,1 per cent). The spasm was relieved in all cases by intravenous injection of 1,5 to 3 mg of trinitrin (Lenitral). Calcium inhibitors, especially nifedipine, have been used successfully by Hugenholtz and Bertrand who consider that nifedipine has a slower action and the coronary dilatation obtained is never as great with the nitrate derivatives. Trinitrin remains the treatment of choice for the rapid relief of provoked spasm.

[Transluminal angioplasty of the coronary vessels. Preliminary results]

Transluminal coronary angioplasty is a new therapeutic procedure perfected by Gruntzig in 1977 consisting of compressing atheromatous plaques and dilating the arterial lumen with an inflatable balloon-tipped catheter of fixed external diameter. This catheter is introduced into the coronary artery through a preformed catheter guide under radioscopic control. The authors describe their experience of 36 attempts at coronary angioplasty performed over a one year period. The stenosis was catheterised in 30 cases and a good immediate result was obtained in 28 patients (77%). The percentage narrowing was reduced from an average of 79 +/- 8% to 26 +/- 12% (p less than 0.001) and the trans stenotic gradient from 40 +/- 11 mm Hg to 4 +/- 8 mm Hg (p less than 0.001). No serious complications were observed during these procedures. The 8 other patients underwent aorto-coronary bypass surgery as an emergency (2 cases) or otherwise (5 cases). 26 patients with good immediate results are asymptomatic at medium term follow-up, 1 has improved from functional Class IV to II, and I has recurrent Class IV effort angina. 15 patients have been followed up after six months. 14 remain asymptomatic with negative maximal exercise stress testing; 1 has angina. 14/15 stenoses remain dilated, 1 stenosis has progressed (60%). 2 patients developed a new stenosis, 1 of whom underwent another angioplasty procedure (functional Class III). In the 13 remaining patient, clinical improvement was confirmed by exercise stress testing. With strict selection of patients and a prudent operative technique this method seems to be an attractive intermediate therapeutic procedure (over 60% good results at medium term) between medical and surgical management of patients with severe angina and a tight monotruncular stenosis.

[Pump and muscle functions and the index of perfusion of the subendocardium in severe aortic stenosis in adults]

47 patients with severe aortic stenosis (AS) (valve area less than 0.7 cm2) and normal coronary angiography were divided into three groups, according to their functional class (NYHA classification): - Group 1 (n = 21): Classes 1 and 2 - Group 2 (n = 18): Class 3 - Group 3 (n = 8): Class 4. Haemodynamic and angiographic parameters and the index of subendocardial perfusion (ISEP) defined by Buckberg's method were compared with a control group (n = 14). In group 1, pump function was normal without end diastolic dilatation. Moderate hypertrophy was compensatory and isofunctional (SW/mass = normal). Despite normal EF and VCF, contractile function was reduce (dp/dt/p, % shortening, % thickening and velocity of systolic thickening were lower than the control group (p less than 0.05)), and there was chronic subendocardial ischaemia (ISEP = 0.58 +/- 0.2, p less than 0.01). In groups 2 and 3, pump function was depressed (Group 2: CI = 2.5 +/- 0.5 1/min/m2 (p less than 0.05)) (Group 3: CI =2.0 +/- 0.6 1/min/m2, p less than 0.01)) despite an increased preload (LVEDP and EDV increased), and a greater degree of hypertrophy (Mass Index, Group 1 = 130 +/- 30 g/m2, Group 2 = 190 +/- 30 g/m2 (p less than 0.01), Group 3 = 210- +/- 30 g/m2 (p less than 0.01)). (SW/mass decreased, p less than 0.01). EF and VCF and all other indices of contractility were depressed and subendocardial ischaemia was the same (0.5 +/- 0.2). The complete lack of adaptation of the preload, non-compensatory hypertrophy, decreased contractility and chronic subendocardial ischaemia, all affect the operative prognosis and the long-term result after valve replacement. This data is in favour of early surgical correction of severe AS before the appearance of signs of cardiac failure.

[Outcome of myocardial infarctions complicated by heart conduction disorders in the acute phase]

Of 945 patients hospitalised for myocardial infarction between January 1st 1972 and December 31st 1975, 40 with anterior myocardial infarction (Group I-A) and 53 with posterior myocardial infarction (Group II-A) were complicated by atrioventricular and/or intraventricular arrhythmias. The average follow up period is now of 48 months (range 24 to 78 months). Their outcome was compared to two control groups of 50 anterior myocardial infarctions (Group I-B) and 50 posterior myocardial infarctions (Group II-B) uncomplicated by arrhythmias in the acute phase. The immediate (10%) and secondary (30%) mortality was identical in the two groups II-A and II-B with posterior wall necrosis. The immediate (32%) and secondary (40%) mortality in Group I-A was much higher than in Group I-B (22% and 28% respectively). Sudden death was the most frequent form of demise in all groups (I-A, II-A, II-B) except Group I-B in which heart failure predominated. Death occured earlier in Group I-A than in the control Group II-B. These results pose the problem of the indication of prophylactic permanent pacing to decrease the incidence of sudden death.

[Unstable angina with threatening coronary lesions turned down for surgery. Outcome and prognostic factors]

The aim of this study based on a series of 200 patients, was to define the outcome and the prognostic factors of patients presenting with unstable angina, according to Bertolazi's criteria [3] and at least one stenosis greater than 80% on a proximal segment of a main coronary trunc, and to determine which factors should eventually be taken into consideration in the discussion of surgical indications. 70 out of 200 patients (35%) were turned down for direct revascularisation surgery because of an ejection fraction less than 0,35 and/or a poor arterial run off. Coronary arteriography showed 30% patients with a menacing stenosis (greater than 80%) on all three vessels, 36% on two vessels and 22% on a single vessel. The distribution and the extent of the lesions was about the same as in the operated patients. 20% patients had an ejection fraction less than 0,35, 24% between 0,34 and 0,50, and 56% greater than 0,50. At patient, the follow up period ranges from 22 to 66 months (average 32 months). In this group, the hospital mortality was 2,9%, the secondary cardiac deaths 16% and the global mortality 19% compared to 12,6% for the operated patients in the same period. The incidence of secondary non-fatal infarction was low (9%). 52% of survivors have persistent angina, 39% severe (Class II or III). Two prognostic factors were detected from this study: the type of angina: the intermediary syndrome had a bad prognosis, 38,5% mortality compared to 13% for aggravated chronic angina; and the ventriculography: patients with ejection fractions less than 0,35 had 64% mortality compared to 7,3% for those with ejection fractions greater than 0,40. The number of menacing lesions, the extent of the lesions of the artery involved did not affect the prognosis when severe abnormalities of left ventricular function were absent.

[Severe coronary insufficiency in a young woman after mediastinal radiotherapy]

Three years after radiotherapy to the mediastinum for Hodgkin's disease, a 28 year old female presented with incapacititating angina. The presence of severe disease in the proximal arteries on coronary arteriography, with obliteration of the anterior descending artery and, of the right coronary artery, together with an unstable collateral circulation, constituted an indication for a double aorto-coronary bypass graft. A review of the literature suggests that early development of atherosclerosis may be produced by the synergistic action of radiotherapy and lipid disorders. Fifteen similar cases have been described, eight of them in patients of less than 40 years of age; three were discovered at post-mortem examination in patients aged under 21.

[Are stenoses of the common trunk of the left coronary artery at the root of unstable angina?]

In a series of 200 cases of unstable angina who have had coronary arteriography carried out, a stenosis of more than 60% of the trunk of the left coronary artery was noted in 40 cases (20%). This sinister site of arteriosclerosis may be suspected in patients presenting with long-standing angina (mean for the group 44 months), an angina which has recently become worse, one which is not responding rapidly to rest and beta-blockers, and in particular one where there has been a previous infarction (50% of cases). Coronary arteriography shows that the lesions were more diffuse and more severe in the group with stenosis of the main trunk. Surgical prognosis becomes worse (31% mortality) because of the risk of vascular complications. Treatment by large doses of Propranolol improves the classically gloomy prognosis of these patients when treated medically.

[Exercise electrocardiogram coupled with right cardiac microcatheterization after myocardial infarct. Correlations with ventriculo-coronarography]

This work is based on the results of a systematic scheme of investigation consisting of an exercise test on the bicycle ergometer with analysis of the ECG and of the pulmonary arterial pressure measured by cardiac micro-catheterisation, and of ventricular and coronary arteriography; 60 patients were investigated in this way after the third month following a myocardial infarction. After an anterior infarction, there is no significant correlation between the ECG changes and the coronary arteriogram. An elevation of the tracing is often (but not always) indicative of akinesia or dykinesia of the ventricle. After a posterior infarction, depression of the trace in leads which were initially normal indicates extension of the coronary lesions in 9 cases out of 10. It, is, however, possible for a tight stenosis on the anterior descending artery to exist with no changes on the ECG. A highly significant (p less than 0.001) and strong (r=0.83) correlation between an index of haemodynamic severity as defined by variations in the pulmonary arterial pressure on exercise and by the score on coronary arteriography, allows us to define certain indications for coronary arteriography and ventriculography after infarction.