Scintigraphic images of myocardial iodine 123-labeled metaiodobenzylguanidine (MIBG) reflect the relative distribution of adrenergic neurodensity and function in the myocardium. In patients with hypertrophic cardiomyopathy or after infarction, MIBG uptake in hypertrophied myocardium and the infarct-related myocardium was found to be decreased in comparison to blood flow distribution, delineated with thallium 201. Most intriguingly, semiquantitative measurements in patients with congestive heart failure demonstrated reduced myocardial MIBG uptake. This reduction correlated directly with indexes of left ventricular function. Decreases in neuronal density, dysfunction of adrenergic neurons, or chronically elevated circulating norepinephrine levels may account for this diminished myocardial uptake, which, as demonstrated in a pilot study of 90 patients with congestive heart failure, was found to be of predictive value for survival.

3-Iodobenzylguanidine↗

PubMedDate not supplied

Improved patient selection for TAH implantation.

Patient selection and optimal timing for implantation are unsettled issues in candidates for a bridge to cardiac transplantation. A prospective evaluation of a strategy based on enoximone (E) given IV, in addition to sympathomimetic drugs, permitting to buy time, and delay by hours or days the decisions, has been performed from 1985 to 1988. Thirty-four patients in cardiogenic shock with hemodynamical criteria for TAH implantation have been included: Cl was 1.8 +/- 0.2 L/min/m2 PCWP 29 +/- 7 mmHg, diuresis less than 20 ml/hr. The protocol permitted to postpone decisions of implantation in 30 cases. The 4 unresponsive patients were implanted immediately with TAH (3) or VAD (1). Three were transplanted, two successfully. For 30, time given permitted discovery of hidden contraindications to transplantation in 17 patients. In 13, indication for transplantation was confirmed and performed in 11 within 6 hrs to 8 days (survival 64%). In two, sudden deterioration led to an unsuccessful TAH implantation. Multifactorial analysis showed that a 50% rise in Cl together with a 50% drop in PCWP, a 50% drop in PVR 30 min after IV E has a high predictive value of survival. These data suggest that enoximone IV bolus given in addition to maximal sympathomimetics to patients in cardiogenic shock reduces by 88% the need for TAH or VAD. It also permits a better selection of the candidates.

Adult↗

PubMedDate not supplied

[The place of a new drug in the therapeutic strategy].

A therapeutic strategy is a hierarchical set of appropriate measures to provide an answer to a pathological state. A drug is a part of this set (together with the diagnosis, the environment and the other medicinal interventions or not). A new drug's place in a therapeutic strategy can be evaluated according to one or several referential(s) when it (or they) exist, referentials which express the state of knowledge before launch of the new drug. The drug's profile (indication or contraindication, etc.), at the point when the marketing authorization is given, is purely theoretical. One must evaluate the real place of the drug under its real conditions of use (pragmatic trials, observable surveys). A new drugs' place in a therapeutic strategy can only be evaluated in the course of time unless a therapeutic revolution occurs.

Case Management↗

PubMedDate not supplied

[Cardiac transplantation in an extreme emergency].

Urgent cardiac transplantation in very unstable patients, kept alive in intensive care unit, is a significant (34 percent) part of the Henri-Mondor's transplantation program. Nineteen patients received a donor graft from january 1986 to october 1988. Sixteen were bridged pharmacologically as 5 received a mechanical bridge. Time on waiting list ranged from 12 to 21 days. Six patients died in the first post-operative month. Death was due to uncontrolled preoperative problems in 5, donor graft failure in one. The survival rate at one year was 52 percent, to be opposed to 76 percent in stable patients. These figures must be considered when selecting the priority of the transplantation candidates.

Adult↗

PubMedDate not supplied

[Resumption of work after myocardial infarct].

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Age Factors↗

PubMedDate not supplied

Myocardial high-energy phosphate depletion in allograft rejection after orthotopic human heart transplantation.

The present study was designed to assess whether acute rejection affects myocardial energy content of the human orthotopically transplanted heart. Adenosine triphosphate content was measured in one tissue sample obtained during 46 routine right ventricular endomyocardial biopsies 6 to 455 days (98 +/- 110) after transplantation in 19 cyclosporine-treated transplant recipients. Tissue samples were immediately frozen in liquid nitrogen within 10 seconds after excision. Adenosine triphosphate analysis was performed with high performance liquid chromatography. Three groups of biopsy specimens were classified according to the standardized cardiac biopsy grading system. Group 1: Eight biopsy specimens without rejection; group 2: 24 biopsy specimens with mild rejection; group 3: 14 biopsy specimens with moderate or severe rejection. Graft systolic function evaluated by echocardiographic fractional shortening was in the normal range the day of biopsy. All patients had normal coronary angiograms within 1 month of the study. In the presence of mild rejection (grade 1A or 1B), adenosine triphosphate content was not significantly different from that of nonrejecting hearts (26.15 +/- 7.1 and 28.57 +/- 8.23 nmol/mg protein, respectively). By contrast, a significant decrease in adenosine triphosphate content was observed when moderate or severe rejection with focal or diffuse aggressive infiltrates were present (10.46 +/- 4.11 nmol/mg protein; p < 0.01 versus two other groups). In seven cases, sequential analysis showed a significant increase in adenosine triphosphate content after rejection therapy concomittant with histologic improvement: 10.19 +/- 2.9 before and 30.13 +/- 7.0 nmol/mg protein after treatment (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Adenosine Triphosphate↗

PubMedDate not supplied

[Importance of meta-analysis in cardiology].

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Cardiology↗

PubMedDate not supplied

[Clinical evaluation: from intermediate to surrogate criteria].

The development and evaluation of new drugs often rely on surrogacy. An intermediate outcome becomes a surrogate outcome if it fulfils certain criteria, it should be easier to measure compared with the clinical outcome, a statistical relationship should exist between the clinical outcome and the surrogate outcome, a relation should exist allowing prediction of the degree of clinical effect based on the measured effect on the surrogate outcome. Development and authorization of drugs today often rely on so-called surrogate outcomes. Is this use sound? The validity of such outcomes has been reviewed in different therapeutic areas: hypertension, venous thromboembolism, AIDS, osteoporosis, hepatitis C. Based on this review, a pragmatic strategy is proposed which allows for the validation and proper use of surrogate outcomes.

Acquired Immunodeficiency Syndrome↗

PubMedDate not supplied

[Renin-angiotensin-aldosterone system and heart failure: therapeutic aspects].

Renin, angiotensin II and aldosterone levels are elevated in congestive heart failure, especially when diuretics are introduced. This activation is clearly deleterious by elevating myocardial workload and is related to prognosis of heart failure. The link between hormonal activation and prognosis is causal, as hormonal inhibition by converting enzyme inhibitors improves heart failure prognosis. Angiotensin II and aldosterone appears to be toxic for the myocardium. The results of the trial conducted with angiotensin II antagonist losartan confirm data derived from converting-enzyme-inhibitors trials. The exact role of aldosterone is currently being evaluated in the RALES programme.

Heart Failure↗