BACKGROUND:Nitric oxide (NO) donors, in addition to their vasodilator effect, decrease platelet aggregation and inhibit vascular smooth muscle cell proliferation. These actions could have beneficial effects on restenosis after coronary balloon angioplasty.METHODS AND RESULTS:In a prospective multicenter, randomized trial, 700 stable coronary patients scheduled for angioplasty received direct NO donors (infusion of linsidomine followed by oral molsidomine) or oral diltiazem. Treatment was started before angioplasty and continued until 12 to 24 hours before follow-up angiography at 6 months. The primary study end point was minimal lumen diameter, assessed by quantitative coronary angiography, 6 months after balloon angioplasty. Clinical variables were well matched in both groups. However, despite intracoronary administration of isosorbide dinitrate, the reference diameter in the NO donor group was significantly greater than in the diltiazem group on the preangioplasty, postangioplasty, and follow-up angiograms. Pretreatment with an NO donor was associated with a modest improvement in the immediate angiographic result compared with pretreatment with diltiazem (minimum luminal diameter, 1.94 versus 1.81 mm; P = .001); this improvement was maintained at the 6-month angiographic follow-up (minimal lumen diameter, 1.54 versus 1.38 mm; P = .007). The extent of late luminal narrowing did not differ significantly between groups (loss index in the NO donor and diltiazam groups, 0.35 +/- 0.78 and 0.46 +/- 0.74, respectively; P = .103). Restenosis, defined as a binary variable (> or = 50% stenosis), occurred less often in the NO donor group (38.0% versus 46.5%; P = .026). Combined major clinical events (death, nonfatal myocardial infarction, and coronary revascularization) were similar in the two groups (32.2% versus 32.4%).CONCLUSIONS:Treatment with linsidomine and molsidomine was associated with a modest improvement in the long-term angiographic result after angioplasty but had no effect on clinical outcome. The improved angiographic result related predominantly to a better immediate procedural result, because late luminal loss did not differ significantly between groups.

The aim of this study was to analyse the prognostic factors of long term left ventricular function after successful delayed angioplasty of residual coronary stenosis after thrombolysis for myocardial infarction. The left ventricular function of fifty patients, aged 54 +/- 10 years, who underwent intravenous thrombolysis 2.9 +/- 1.3 hours after the onset of myocardial infarction (28 anterior, 22 inferior wall) was assessed by angiography at the 6.1 +/- 1.7th day and 6.1 +/- 2.5 months after successful angioplasty undertaken on the 8.3 +/- 5.2nd day. In cases without reocclusion (n = 44), the ejection fraction and the wall motion of the infarcted region improved significantly from 56.8 +/- 12.2% to 59.5 +/- 15.4% (p < 0.002) and from 8.4 +/- 14.8% to 18.3 +/- 24.3% (p = 0.0001), respectively. These parameters did not change in cases with reocclusion (n = 6). When the dilated artery remained patent, an improvement in motion of the infarcted region was observed in 69.5% of hypokinesis (n = 23), 50% of akinesis (n = 10) and 9.1% of dyskinesis (n = 11) (p < 0.005). The improvement in motion of the infarcted zone was negatively correlated with the delay of thrombolysis (r = 0.36; p < 0.02) and peak CPK levels (r = 0.31; p < 0.04). Over 60% restenosis on digitalised densitometry (n = 11) did not compromise the possibilities of improvement, the evolution of wall motion of the infarcted zone and volumes with respect to cases without restenosis (n = 33).(ABSTRACT TRUNCATED AT 250 WORDS)

Alternans of the ST segment is a rare phenomenon during coronary angioplasty. The authors report three cases. It is usually observed in left anterior descending arteries without collateral circulation. Alternans is not accompanied by haemodynamic changes and does not initiate malignant ventricular arrhythmias. It is a transient phenomenon. Electrical alternans is thought to be due to changes in the configuration of the transmembrane action potential and modifications of calcium exchanges.

Arterial patency is a good prognostic factor in terms of survival and left ventricular function after myocardial infarction. The aim of this prospective study was to evaluate the benefit of secondary angioplasty of the infarct-related artery in single vessel, left anterior descending disease, on regional and global left ventricular function. Initial coronary angiography was undertaken at the 7th +/- 2 days after the onset of infarction. Arterial patency was assessed by the TIMI criteria and by percentage stenosis on quantitative angiography. Forty consecutive patients (Group I) underwent conventional angioplasty of the left anterior descending artery at the 9th +/- 2 days. Twelve consecutive patients (Group II) did not undergo angioplasty. A repeat coronary angiographic study was performed at 3 months. The results showed no difference between the two groups of patients in base line values. A significant improvement in arterial patency was observed in Group I (TIMI Grades II or III) and in residual stenosis at 3 months (54.7 +/- 13% versus 80.6 +/- 13%, p < 0.05). In addition, a significant improvement in ejection fraction of +4.7% (p < 0.02), of left anterior descending myocardial regional wall motion of +7.6 (p < 0.02) and a reduction of induced left ventricular end systolic volume of -2.2 ml/m2 (p < 0.05) were observed in Group I. Initial segmental hypokinesia or akinesia improved in 67.5% of patients. However, 50% of patients in Group II improved their segmental wall motion abnormalities at 3 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous coronary artery dissection is rare compared with the high incidence of atheromatous coronary artery disease. Eight new clinical and angiographic cases diagnosed between 1984 and 1990 are reported. The patients were 6 men and 2 women with an average age of 44.1 +/- 10.7 years. The initial presentation is angina in half the cases, and myocardial infarction in the other half. Clinical signs and the results of non-invasive investigations are non-specific. Diagnosis is made by coronary angiography. The dissection is usually observed on a proximal segment of one of the main coronary arteries. In 5 cases, the disease was confined to a single vessel left anterior descending (3) and right coronary arteries (2). One patient had double vessel disease (left anterior descending and left retroventricular arteries); one patient had triple vessel disease (left anterior descending left circumflex and right coronary arteries), and finally, one patient had left main stem disease extending to the left anterior descending and first diagonal arteries. There was no aetiological factor in 5 cases whereas 3 had coronary atherosclerosis. After a period of 25 months all patients are alive. Five have drug therapy and 3 have undergone coronary bypass surgery. Six patients are asymptomatic and 2 have mild angina. One patient's coronary circulation has returned to normal. The extension of the indication of coronary angiography explains the diagnosis of an increasing number of spontaneous coronary artery dissection. The condition is serious but there are more and more long-term survivors as in our series.

Infectious endocarditis around indwelling pacemakers is rare (0.15% of all implantations). They have a gloomy prognosis with a global mortality rate of nearly 34% as emerges from this review of the literature concerning 58 cases of infectious endocarditis published within the past 16 years. On the basis of the 6 cases which the authors report, they stress the importance and sometimes difficulty of using ultrasound in a positive diagnosis. Cardiographic ultrasound, which can determine the size and emboligenic nature of vegetations is capital in choosing how to remove the pacemakers. Percutaneous ablation by simply pulling or by catheterization currently gives the best results, but it may be necessary to resort to surgery involving right atriotomy if emboligenic vegetations are present. By combining antibiotic treatment and ablation of the intracavitary material, a cure is obtained in 92% of cases. These figures should be compared with the lack of success of using antibiotic treatment alone which results in a high level of mortality (84%).

Infectious endocarditis aroung indwelling pacemakers is rare (0.15% of all implantations). They have a gloomy prognosis with a global mortality rate of nearly 34% as emerges from this review of the literature concerning 58 cases of infectious endocarditis published within the past 16 years. On the basis of the 6 cases which the authors report, they stress the importance and sometimes difficulty of using ultrasound in a positive diagnosis. Cardiographic ultrasound, which can determine the size and emboligenic nature of vegetations is capital in choosing how to remove the pacemakers. Percutaneous ablation by simply pulling or by catheterization currently gives the best results, but it may be necessary to resort to surgery involving right atriotomy if emboligenic vegetations are present. By combining antibiotic treatment and ablation of the intracavitary material, a cure is obtained in 92% of cases. These figures should be compared with the lack of success of using antibiotic treatment alone which results in a high level of mortality (84%).

Spontaneous coronary artery dissection is rare compared with the high incidence of atheromatous coronary artery disease. Eight new clinical and angiographic cases diagnosed between 1984 and 1990 are reported.The patients were 6 men and 2 women with an average age of 44.1 +/- 10.7 years. The initial presentation is angina in half the cases, and myocardial infarction in the other half. Clinical signs and the results of non-invasive investigations are non-specific. Diagnosis is made by coronary angiography. The dissection is usually observed on a proximal segment of one of the main coronary arteries. In 5 cases, the disease was confined to a single vessel left anterior descending (3) and right coronary arteries (2). One patient had double vessel disease (left anterior descending and left retroventricular arteries); one patient had triple vessel disease (left anterior descending left circumflex and right coronary arteries), and finally, one patient had left main stem disease extending to the left anterior descending and first diagonal arteries. There was no aetiological factor in 5 cases whereas 3 had coronary atherosclerosis.After a period of 25 months all patients are alive. Five have drug therapy and 3 have undergone coronary bypass surgery. Six patients are asymptomatic and 2 have mild angina. One patient's coronary circulation has returned to normal.The extension of the indication of coronary angiography explains the diagnosis of an increasing number of spontaneous coronary artery dissection. The condition is serious but there are more and more long-term survivors as in our series.

The aim of this study was to assess the value and limitations of Doppler echocardiographic measurement of aortic flow in the quantification of aortic regurgitation. Sixty-one patients were examined by Doppler echocardiography within 48 hours of cardiac catheterisation.There were 9 Grade I, 18 Grade II, 18 Grade III and 16 Grade IV angiographic aortic regurgitations. The mean aortic blood flow in angiographic Grades I and II (p < 0.01). A correlation was observed between Doppler aortic flow and the angiographic grade of regurgitation (r = 0.66, p < 0.001) and between aortic flow and regurgitant fraction (r = 0.68, p < 0.001). Aortic flow greater than 10 1/mn identified angiographic Grades III or IV regurgitation with a sensitivity and specificity of 73.5 % and 92.5 % respectively and a positive and negative predictive values of 92.5 % and 73.5 % respectively. Aortic regurgitation with a regurgitant fraction greater than 40 % was identified by a pulsed Doppler aortic blood flow greater than 10 1/mn with a sensitivity and specificity of 70 % and 93 % respectively, and positive and negative predictive values of 95 % and 61 % respectively.The sensitivity of this criterion is relatively poor as some severe aortic regurgitations have aortic flows of less than 10 1/mn : these patients have low outputs because of left ventricular dysfunction which is apparent from measurement of left ventricular fractional shortening.

The aim of this study was to assess the value and limitations of Doppler echocardiographic measurement of aortic flow in the quantification of aortic regurgitation. Sixty-one patients were examined by Doppler echocardiography within 48 hours of cardiac catheterisation. There were 9 Grade I, 18 Grade II, 18 Grade III and 16 Grade IV angiographic aortic regurgitations. The mean aortic blood flow in angiographic Grades I and II (p less than 0.01). A correlation was observed between Doppler aortic flow and the angiographic grade of regurgitation (r = 0.66, p less than 0.001) and between aortic flow and regurgitant fraction (r = 0.68, p less than 0.001). Aortic flow greater than 10 l/mn identified angiographic Grades III or IV regurgitation with a sensitivity and specificity of 73.5% and 92.5% respectively and a positive and negative predictive values of 92.5% and 73.5% respectively. Aortic regurgitation with a regurgitant fraction greater than 40% was identified by a pulsed Doppler aortic blood flow greater than 10 l/mn with a sensitivity and specificity of 70% and 93% respectively, and positive and negative predictive values of 95% and 61% respectively. The sensitivity of this criterion is relatively poor as some severe aortic regurgitations have aortic flows of less than 10 l/mn: these patients have low outputs because of left ventricular dysfunction which is apparent from measurement of left ventricular fractional shortening.

The 4 cases of transmural myocardial infarction by closed chest trauma reported by the authors bring the number of angiographically documented and published cases to 52. This group serves as a basis for a detailed review of coronary and myocardial anatomical lesions and their pathophysiological mechanism is suggested. Long controversial, direct traumatic coronary damage has been confirmed by coronary angiography and is the essential mechanism of transmural infarctions. Myocardial contusion, much commoner, is responsible for non transmural lesions which remain difficult to diagnose. The authors stress the twin value of coronary arteriography: pathophysiological with its medicolegal consequences, and also therapeutic since a revascularisation procedure may be particularly beneficial in situations where thrombolysis is generally contraindicated.

End diastolic flow velocity just beneath the aortic isthmus was measured within 72 hours of cardiac catheterisation by pulsed Doppler echocardiography in 30 controls and 61 patients with aortic regurgitation. The end diastolic flow velocity was determined at the peak R wave on a simultaneously recorded electrocardiogram. In all controls there was no reverse flow at the end diastole beneath the aortic isthmus. In patients with aortic regurgitation the end diastolic flow velocity correlated well with the angiographic grade of regurgitation (r = 0.81) and regurgitant fraction (r = 0.82). The mean (SD) values were 6.3 (5.2), 12.2 (4.3), 22.1 (5.7), and 34.3 (9.3) cm/s for patients with regurgitant fraction of less than 20%, between 20% and 40%, between 41% and 60%, and greater than 60%, respectively. An end diastolic flow velocity of greater than 18 cm/s predicted a regurgitant fraction of greater than or equal to 40% with a sensitivity of 88.5% and a specificity of 96%. The study suggests that the pulsed Doppler derived end diastolic flow velocity is a useful index in the routine non-invasive assessment of the severity of aortic regurgitation.

The authors report two cases of cardiac rupture during acute myocardial infarction successfully treated surgically. In the first case, rupture occurred 7 days after hospital admission for anteroseptal myocardial infarction. The patient developed sudden cardiogenic shock with signs of venous hypertension without left ventricular failure. The second patient was admitted for syncopal chest pain with transient hypotension which regressed after volume repletion and pressor amine therapy. On admission, the patient had signs of cardiac tamponade. The ECG showed recent inferolaterobasal myocardial infarction. In both cases the diagnosis was made by 2D echocardiography which showed voluminous circumferential pericardial effusions probably due to haemorrage, with an image very suggestive of a blood clot in the effusion of the second patient. The two patients underwent emergency cardiac surgery and both survived with a 4 and 1.5 month follow-up respectively.These two cases confirm the value of 2D echocardiography as an emergency bedside procedure for the diagnosis of cardiac rupture, especially when images of intrapericardial thrombosis are observed, as in our second patient. In addition, the first case raises once again the question of the role of late thrombolysis as a predisposing factor of cardiac rupture at a time when this technique is proposed up to 24 hours after the onset of symptoms.

The authors report the case of an asymptomatic 67 year old patient, in whom, 6 years after aortic valve replacement, Doppler color flow mapping showed the presence of a coronary artery--left ventricular fistula. The normality of preoperative coronary angiography suggested that this fistula was created during peroperative left ventricular purging: the implantation of a needle through the right ventricle and interventricular septum. A iatrogenic lesion of a septal branch probably caused the communication between the left anterior descending artery and the left ventricle. Postoperative normalisation of the left ventricular end diastolic dimension, the absence of dilatation of the left main coronary on 2D echocardiography, the narrowness of the Doppler color jet and the absence of a significant end diastolic Doppler signal in the aortic isthmus indicated a fistula of small size and simple Doppler echocardiographic follow-up was decided upon.

The authors report the case of an asymptomatic 67 year old patient, in whom, 6 years after aortic valve replacement, Doppler color flow mapping showed the presence of a coronary artery - left ventricular fistula. The normality of preoperative coronary angiography suggested that this fistula was created during peroperative left ventricular purging: the implantation of a needle through the right ventricle and interventricular septum. A iatrogenic lesion of a septal branch probably caused the communication between the left anterior descending artery and the left ventricle. Postoperative normalisation of the left ventricular end diastolic dimension, the absence of dilatation of the left main coronary on 2D echocardiography, the narrowness of the Doppler color jet and the absence of a significant end diastolic Doppler signal in the aortic isthmus indicated a fistula of small size and simple Doppler echocardiographic follow-up was decided upon.

The authors report two cases of cardiac rupture during acute myocardial infarction successfully treated surgically. In the first case, rupture occurred 7 days after hospital admission for anteroseptal myocardial infarction. The patient developed sudden cardiogenic shock with signs of venous hypertension without left ventricular failure. The second patient was admitted for syncopal chest pain with transient hypotension which regressed after volume repletion and pressor amine therapy. On admission, the patient had signs of cardiac tamponade. The ECG showed recent inferolaterobasal myocardial infarction. In both cases the diagnosis was made by 2D echocardiography which showed voluminous circumferential pericardial effusions probably due to haemorrage, with an image very suggestive of a blood clot in the effusion of the second patient. The two patients underwent emergency cardiac surgery and both survived with a 4 and 1.5 month follow-up respectively. These two cases confirm the value of 2D echocardiography as an emergency bedside procedure for the diagnosis of cardiac rupture, especially when images of intrapericardial thrombosis are observed, as in our second patient. In addition, the first case raises once again the question of the role of late thrombolysis as a predisposing factor of cardiac rupture at a time when this technique is proposed up to 24 hours after the onset of symptoms.

The 4 cases of transmural myocardial infarction by closed chest trauma reported by the authors bring the number of angiographically documented and published cases to 52. This group serves as a basis for a detailed review of coronary and myocardial anatomical lesions and their pathophysiological mechanism is suggested. Long controversial, direct traumatic coronary damage has been confirmed by coronary angiography and is the essential mechanism of transmural infarctions. Myocardial contusion, much commoner, is responsible for non transmural lesions which remain difficult to diagnose. The authors stress the twin value of coronary arteriography: pathophysiological with its medicolegal consequences, and also therapeutic since a revascularisation procedure may be particularly beneficial in situations where thrombolysis is generally contraindicated.

The aim of this study was to measure the changes in mitral and aortic blood flow induced by rate changes and different atrioventricular intervals in dual chamber pacemaker patients. Ten totally pacemaker dependant patients were studied under basal conditions, in double atrial and ventricular stimulation mode, by pulsed Doppler recordings of mitral and aortic flow, at three different pacing rates (80, 100 and 120/mn) and with three different atrioventricular intervals at each rate (short, 90 or 115 ms; medium, 165 or 190 ms; and long, 240 ms). The increase in pacing rate and prolongation of the atrioventricular interval significantly shortened the duration of mitral flow. Increasing the pacing rate induced a significant fall in stroke volume measured from the aortic flow. The optimal atrioventricular interval tended to shorten when the pacing rate was increased; a long atrioventricular interval had a deleterious effect on stroke volume compared with medium and short atrioventricular intervals; however, the difference between the short and medium atrioventricular intervals was not statistically significant even at 120 mn. These observations emphasise the hemodynamic advantages of shortening of the atrioventricular interval of dual chamber pacemakers when the pacing rate increases.