[Jean-Paul Cachera. 1930-1993].
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Cardiac Surgical Procedures↗
Biomedical subjects
A Vacheron
Publications and source records attributed to A Vacheron.
[Current ethical problems in cardiology].
The multiplication of therapeutic protocols and increasingly complex procedures, together with the development of invasive methods and interventional cardiology, mean that ethical considerations are becoming more and more numerous. They intervene in routine cardiology, where the practitioner must give the patient the best possible care without relying too heavily on technology. They are also important from an economic point of view: cardiology is one of the most costly specialties, yet economic considerations mus not prevent the individual patient from receiving the necessary care. This calls for rational use of resources, by means of a thorough evaluation of diagnostic and therapeutic tools, as well as rationalization of prescriptions and therapeutic decisions. Ethical considerations serve as both a decision-making tool and a "buffer". They involve striking a balance between provision of the best possible care and the interests of society as a whole.
Cardiology↗
[Value of linsidomine (SIN 1) in the evaluation of myocardial viability by 201-Tl scintigraphy after exertion].
201Tl scintigraphy can be used to determine exercise-induced ischemia and the viability of the hypoperfused myocardium as a function of radiotracer redistribution. Redistribution is calculated by differential analysis of the normalized circumferential curves of activity. Intravenous injection of linsidomine (SIN 1) a patent coronary vasodilatator, gives more reliable results than conventional imaging at the 4th h, and compares favourably with the results obtained at the 24th h after reinjection of 201 Tl. Linsidomine provides images in 60 to 90 min, in stable clinical conditions.
Adult↗
[Evaluation of a new commercial kit for emergency determination of serum myoglobin].
The usefulness of a nephelometric-based serum myoglobin assay kit in the early diagnosis of acute myocardial infarction was assessed in 92 consecutive patients admitted within 24 hours of the onset of spontaneous chest pain lasting > or = 20 minutes. The discharge diagnosis was acute myocardial infarction in 37 patients (40.2%), myocardial infarction lasting > or = 6 hours in 10, and no myocardial infarction in 45 (48.9%). The characteristic curve showed that the best differential diagnostic value was a serum myoglobin > or = 130 micrograms/l (sensitivity, 75.6%; specificity, 91.7%; positive-predictive value, 88%; negative-predictive value, 82%). The initial diagnosis was doubtful in 33 patients (36%) because of an inconclusive electrocardiogram. A serum myoglobin value of > or = 130 micrograms/l would have identified 9 of the 13 patients with acute myocardial infarction and all of the 20 patients without myocardial infarction, giving an accuracy of 84.8%. These results suggest that this new rapid, quantitative serum myoglobin assay would be useful in the evaluation of suspected myocardial infarction, especially in patients with an inconclusive electrocardiogram.
Aged↗
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)
Adult↗
Percutaneous coronary angioplasty in patients over 75 years old: immediate and mid-term results.
Ninety-five patients 75 years or older (range 75-90, mean 79) underwent PTCA from 1987 to 1991. Forty-two patients were 80 years or older. Forty-four had prior MI, 5% had prior coronary bypass surgery (CBS), 13% had a prior history of recent cardiac failure, and 81% (77/95) presented with unstable angina, refractory to intravenous treatment in 31 cases. The mean left ventricular ejection fraction was 62% (range 34%-80%). Thirty-nine percent had single vessel disease, 41% had two vessel disease, and 20% had three vessel disease. Coronary calcifications were present in 28%. A single vessel was dilated in 81 patients, two vessels in 14 patients; complete revascularization was achieved in 41%. The clinical angiographic primary success rate was 79% (75/95). There were five procedural deaths, five MI, five CBS and, ten hematomas. Follow-up data were obtained in 100% cases, with a mean follow-up duration of 12 months (ranging from 1-36). There were four deaths, one MI, and two CBS. Twenty percent (15/74) of patients had a second PTCA with a 73% success rate. Finally, 70% of the initial population was asymptomatic after first or second PTCA at mid-term follow-up. We conclude that PTCA is safe and effective in elderly patients, with 70% clinical success rate at mid-term follow-up in spite of frequent incomplete revascularization limited to the culprit lesion.
Aged↗
[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).
4-Hydroxycoumarins↗
[Third angioplasty, and after that?].
The authors studied retrospectively a series of 39 patients with a documented second restenosis after coronary angioplasty between January 1987 and November 1992, 33 of whom (31 men, 2 women) underwent a third procedure. The artery dilated was the left anterior descending (n = 17 including 9 proximal stenoses), the right coronary (n = 10), the left circumflex or its branches (n = 5) and the left main stem (n = 1). The lesions were confirmed to one vessel in 25 cases (75%) and affected two vessels in 8 cases (25%). The third angioplasty procedure was performed on a single artery in all cases. The average left ventricular ejection fraction was 60% (43%-75%). The diameter of the dilated artery was over 3.25 mm in 24% of cases (8/33). The primary success rate was 100% without any complications. The average period between the first and second angioplasties was 16 +/- 10 weeks, and between the second and third angioplasties 19 +/- 12 weeks. Angioplastic controls of the 3rd angioplasty were performed in 25 cases (75%). A third restenosis (n = 7) was treated by surgical bypass (n = 1), repeat angioplasty (n = 4), endocoronary stenting (n = 1) or medically (n = 1), with a global follow-up of 22 months (2-56 months), 2 patients underwent coronary bypass grafting, 2 have residual angina (contralateral lesion which could not be dilated), 1 had an infarct in the territory of an undilated artery, and 28 (85%) were asymptomatic. The restenosis rate after the third angioplasty procedure was 28% (7/25).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Robert de Vernejoul (1890-1992)].
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France↗
[Short- and mid-term results of percutaneous mitral valve commissurotomy for restenosis after surgical commissurotomy].
Fifty nine of the 280 percutaneous mitral valvuloplasties (21%) performed between March 1987 and December 1991 at the Montreal Heart Institute were carried out for symptomatic mitral restenosis 15 +/- 6 years after surgical commissurotomy. The patients were selected according to echocardiographic criteria. The mitral valve disease was comparable to that of patients without previous surgical commissurotomy. Patients with good hemodynamic result had undergone surgical commissurotomy more recently and had less severe valvular damage than patients with an incomplete (n = 10) or poor result (n = 7). One patient died of a cerebral embolism during the procedure, two patients underwent emergency surgery for a mitral valve rupture and 4 patients had an atrial septal defect with Qp/Qs ratio greater than 1.5 by oximetry. The numbers of successes and complications were comparable to those observed in patients without previous surgical commissurotomy. The patients who had undergone previous surgical commissurotomy were followed up for 1 year. At 12 months, 4 remained in Class II of the NYHA classification, 44 (74%) were improved by at least 1 functional class and 10 (17%) had required a mitral valve replacement. Percutaneous mitral valvuloplasty is therefore a useful procedure in patients with moderate degrees of valvular disease who develop restenosis after surgical commissurotomy. A functional improvement can be expected in 3/4 of patients Complications related to the procedure are rare and acceptable compared with the risks of a second thoracotomy. Failure of percutaneous mitral valvuloplasty is generally due to the degree of valvular disease which contraindicated surgical commissurotomy and required mitral valve replacement.
Adult↗
["White-coat" effect in 35 consecutive patients with hypertension. Quantification method, role of physician-patient dialogue].
The "white coat" effect, an alarm reaction to the presence of a doctor, is an important cause of blood pressure variability, the frequency, amplitude and mechanisms of which are only partially understood. In order to evaluate these factors, a prospective study was undertaken in 35 consecutive patients referred for assessment of clinical hypertension. The alarm reaction was investigated during the consultation, at the time of interrogation, in periods of silence, in the sitting and upright positions. Twenty-four to forty-eight measurements (average 36.8) of the blood pressure and heart rate were performed in each patient with a Diasys 200 R monitor. The ambulatory period of 3 to 5 hours after the consultation provided 12 to 24 measurements (average 20.7) which were considered to be the reference for comparison with the consultation period. A total of 2,038 measurement were made and analysed. Analysis of variance (GLM) for each patient and for the whole group gave an assessment of the alarm reaction during the patient-doctor dialogue and periods of silence with reference to the ambulatory period. During the ambulatory period, the average and standard deviation for systolic pressure were 134 +/- 0.7 mmHg, and for diastolic pressure 93.1 +/- 0.6 mmHg. These pressures were significantly lower than during the two periods of consultation, with and without dialogue (p < 0.0001). During the consultation, the systolic and diastolic blood pressure values were significantly higher during the dialogue than during the periods of silence (p < 0.0001). During the dialogue, the systolic pressure attained 153.7 +/- 0.7 mmHg and the diastolic pressure: 107.2 +/- 0.6 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)
Ambulatory Care↗
[A rare course of spastic angina with normal coronary arteries].
The authors report the case of a 65-year-old woman smoker monitored for spastic angina. A first coronary arteriogram in 1986 failed to reveal any significant coronary lesion and was complicated by reversible occlusive spasm of the anterior interventricular artery. A second coronary arteriogram 6 years later because of recurrence of angina revealed the development of 70% stenosis of the coronary segment affected by the spasm. Such an outcome is rarely reported in the literature and raise the question of a possible link between spasm and the progression of atheroma.
Aged↗
[Reperfusion-induced arrhythmia and oxidative stress].
Although recognized and reproduced in numerous animal models, reperfusion arrhythmias were not studied extensively in humans until the advent of methods of coronary reperfusion during the acute phase of myocardial infarction. Usually of ventricular origin, these arrhythmias are polymorphic and constitute imperfect but useful markers of coronary reperfusion. Their electrophysiologic mechanisms are complex and their molecular mechanisms unelucidated. Predisposing conditions are the duration and severity of the ischemia, biochemical modifications such as heterogeneous uptake of extracellular potassium, magnesium deficit, intracellular calcium overload and release of arrhythmogenic lipid metabolites or prostaglandins. The autonomic nervous system also plays a part by an increase in the number and response of alpha-adrenoceptors. Furthermore, experimental studies provide theoretical and pharmacologic arguments for the participation of free oxygen radicals (superoxide anion (02.-, hydroxyl radical OH.) in reperfusion arrhythmias in the animal. By its complexity, human myocardial infarction differs markedly from the animal models studied; it probably involves, apart from the free oxygen radicals, multiple thrombotic, humoral and nervous factors whose respective role in the production of reperfusion arrhythmias remains to be established. Some enlightenment should be obtained by analysis of rhythmic events during proposed controlled studies using anti-free radical agents to prevent these post-myocardial infarct acute events.
Arrhythmias, Cardiac↗
[Silent myocardial ischemia].
The frequency of silent myocardial ischemia (SMI) is 2 to 5% in an asymptomatic population, 25 to 30% after a myocardial infarction and 40% in stable angina. Although the prognosis of coronary insufficiency is related to the number of stenosed vessels and to left ventricular function, the presence of a silent ischemia constitutes an additive risk factor. The beneficial effect bypass surgery in terms of survival has been demonstrated in high risk patients (main coronary artery stenosis, three branch lesions with left ventricular insufficiency), while in the absence of symptoms those of medical treatment, and coronary angioplasty, have still to be demonstrated.
Humans↗
[Efficacy of intravenous milrinone in the treatment of acute congestive cardiac failure. Results of a French multicenter study].
The hemodynamic effects and safety of milrinone, a phosphodiesterase inhibitor, were studied in 57 patients in the acute phase of cardiac failure. The drug was given intravenously as an initial push dose of 50 micrograms/kg in 10 min followed by a 24 hour infusion at the dose of 0.5 micrograms/kg/min. Maximal response was obtained after 15 min and persisted throughout the infusion. Cardiac index rose by 40%, while pulmonary capillary pressure fell from 25 mmHg to 17 mmHg (-30%) by the fifth minute of treatment. Mean pulmonary artery pressure fell by 20% by the 15th minute. Systemic resistance decreased by 26% and pulmonary vascular resistance by 22%. All these variations were significant. Heart rate and systemic blood pressure remained stable. Study of three sub-groups: digoxin vs non-digoxin, sinus rhythm vs atrial fibrillation, and coronary patients vs non-coronary patients, revealed no significant difference. Safety of the drug was good, no extra-cardiac actions having required interruption of the infusion. Stoppage was made necessary by two instances of ventricular tachycardia. Improved hemodynamic effects and the good safety/acceptability of the drug indicate that milrinone is a treatment of choice in cardiac failure.
Acute Disease↗
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.
Acute Disease↗
Comparison of thallium myocardial scintigraphy after exercise and transoesophageal atrial pacing in the diagnosis of coronary artery disease.
Forty-nine patients admitted for assessment of chest pain underwent coronary angiography, planar Thallium 201 myocardial scintigraphy after submaximal exercise (TE) and transoesophageal atrial pacing (TAP). Early hypofixation with redistribution after 4 h indicated ischaemia. The criterion for a myocardial infarction (MI) was a fixed perfusion defect. Coronary angiography was carried out in all patients. Sixteen patients (group 1) had no MI and over 50% narrowing of at least one main coronary vessel. Ischaemia was noted in 10 of the 16 patients during exercise, and in 14 of the 16 patients during atrial pacing. The sensitivity for the prediction of coronary stenosis was 62% for TE and 87% for TAP. Nineteen patients (group 2) had had a previous MI. Reversible ischaemia was noted in 10 of the 19 patients during exercise, and in 11 of the 19 patients during TAP. Four of 14 patients with normal coronary arteries (group 3) had a reversible ischaemia with TE, and three of these same patients developed a positive scan with TAP. The respective specificities were 71% and 78%. Comparison of segmental hypoperfusion after TE and TAP gave identical results in 72 of the 80 segments studied in group I (90%), and in 88 of the 95 segments studied in group 2 (92%). The localizing value of TAP was good in left anterior descending (12 out of 18) and right coronary disease (16 out of 19), but poor in left circumflex stenosis (3 out of 9) misclassified as right coronary disease in four patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[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.
Aged↗