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Impairment of muscle energy metabolism has been demonstrated in normal subjects with chronic hypoxaemia (altitude chronic respiratory failure). The purpose of this study was to verify the hypothesis that a comparable condition could develop in patients with sleep apnoea syndrome (SAS), considering that they are exposed to prolonged and repeated hypoxaemia periods. Muscle metabolism was assessed in 11 patients with SAS performing a maximal effort on cycloergometer. In comparison with normal subjects, SAS patients reached lower maximal loads [144 +/- 7 vs. 182 +/- 10 W (P < 0.005)] and lower peak oxygen uptakes [26.4 +/- 1.2 vs 33.2 +/- 1.4 ml kg-1 min-1 (P < 0.005)]. Abnormal metabolic features were found: maximal blood lactate concentration was significantly lower than in normal subjects [0.034 +/- 0.004 vs. 0.044 +/- 0.002 mmol l-1 W-1 (P < 0.05)]; and lactate elimination rate, calculated during a 30-min recovery period, was reduced [0.127 +/- 0.017 vs, 0.175 +/- 0.014 mmol l-1 min-1 (P < 0.025)]. The extent of these anomalies correlated with the severity of SAS. The patients also showed higher maximal diastolic blood pressures than normal subjects [104 +/- 5 vs. 92 +/- 4 mmHg (P < 0.05)]. These results can be interpreted as indications of an impairment of muscle energy metabolism in patients with SAS. Decrease in maximum blood lactate concentration suggests an impairment of glycolytic metabolism, while decrease in the rate of lactate elimination indicates a defect in oxidative metabolism. Since no respiratory pathology apart from SAS was found in this group of patients, it seems legitimate to link the genesis of these impairments to repeated bouts of nocturnal hypoxaemia.

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From January 1993 to January 1994, we realized at Risk Hospital 11 percutaneous mitral commissurotomies (PMC). This first Lebanese series comprised 9 women and 2 men. The mean age was 36 y (18-73 y). Ten patients were en class III of the NYHA and one in class IV (pregnant woman on the end of the 7th month). The predilatation evaluation was done by transthoracic echocardiography for the just 2 patients and by transthoracic with transesophageal multiplane echocardiography for the 9 others. The mean gradient was at 20 mmHg (10-24 mmHg) and the mean mitral area at 1 cm2 (0.65-1.5 cm2). We used the Inoue balloon for all these procedures with a stepwise technique and a color echo-doppler control between inflations. We obtain bicommissural opening in 8 patients and unicommissural opening in 3 patients. The mean gradient post dilatation was at 4 mmHg (3-8 mmHg) and the mean mitral area at 2.3 cm2 (1.5-2.8 cm2). No mitral regurgitation > 2/4 was noted. After a general review, we concluded the PMC is at present the treatment of choice of non or discrete calcified mitral stenosis and this procedure has to be taken on charge by the Ministry of Health in Lebanon.

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We report two cases of coronary artery fistula discovered accidentally during coronary-angiography. One case between the left anterior descending and the pulmonary artery and another case between the circumflex and the left ventricule. Both cases were associated with hypertrophic cardiomyopathy. There was a spontaneous closure of the fistula in the first case. A brief review of the literature is presented because this anomaly is being discovered frequently because of the possibility of diagnosis with transesophageal echocardiography.

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Fifty patients under prolonged mechanical ventilation who developed nosocomial lung infections caused by Pseudomonas aeruginosa were treated with ceftazidime. This cephalosporin was used alone in 18 cases and combined with another antibiotic (usually an aminoglycoside) in 32 cases. Favourable results were obtained in 40 cases, with regression of the clinical signs and eradication of the organism between the 5th and 10th days of treatment. Eight of the 10 failures occurred in patients with impaired ventilation due to chronic obstructive lung disease. Secondary superinfection was observed in 12 cases. Among the 257 strains of P. aeruginosa isolated in our respiratory intensive care unit over an 18-month period, 88 per cent were sensitive to ceftazidime, and this figure remained stable after the period when ceftazidime was given. These in vitro findings probably account for the remarkable results obtained in infections which up to now had mortality rates of 30 to 60 per cent, depending on the patient's underlaying condition.

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The authors report the case of a 52 year old patient with a significant stenosis of the medial portion of the left anterior descending artery (LAD) with excellent left ventricular function. Transluminal coronary angioplasty (TCA) was indicated following a positive exercise stress test. This was initially performed successfully. Fifteen minutes after the end of the procedure, a total obstruction occurred at the site of dilatation immediately eliciting significant precordial chest pain and massive elevation of the ST segment. Isosorbide dinitrate (ISDN) at a dose of 2 mg was injected into the artery 3 times without success as was an attempt to pass through the obstruction with a guide wire. Another TCA was then attempted without administration of the thrombolytic agent. The dilating catheter passed easily by the obstruction permitting several dilatations which restored rapid coronary artery flow, relieved completely the chest pain, and normalized electrocardiographic abnormalities. This procedure represents a new therapeutic approach to obstruction, an often unpredictable and serious complication of coronary angioplasty in the absence of collateral circulation, thereby preventing the development of a myocardial infarction and an emergency aortocoronary bypass operation.

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Coronary angiography by the percutaneous femoral approach is widely used. This technique is potentially dangerous or impossible in patients with advanced arterial disease of the lower limbs, whether or not surgically treated. In these cases, percutaneous left or right axillary approach is an alternative to brachial approach. In this article, we report our multicenter experience involving 120 patients. The left axillary artery was used in 94 cases (78%) and the right in 26 cases (22%). We used performed coronary catheters usually associated with the femoral approach. The left axillary artery was used preferentially since this avoids catheterization of the innominated trunk and allows easier catheterization of the coronary ostia and aortic ends of aorto-coronary bypass grafts. The routine use of a sheath (arterial introducer) avoided arterial compression during catheterization, prevented hemorrhagic suffusion when the catheters were exchanged, and reduced the risk of thrombosis or laceration of the axillary artery. There were no failures in the catheterization of the axillary artery and no complication was observed during or after the procedure. Axillary percutaneous technique appears to have the following advantages over the brachial arteriotomy: 1) Investigation time is equivalent to the time needed for the femoral percutaneous approach. 2) There is the possibility of lateral and simultaneous bi-plane angiograms. 3) Arterial puncture is preferable to arteriotomy. The axillary approach could also be used for percutaneous transluminal coronary angioplasty.

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Coronary angiography by a percutaneous femoral approach using the Judkins-Bourassa technique with special preformed catheters is widely used. This approach is potentially dangerous or impossible in patients with severe lower limb arteriosclerosis even after operation and so the investigation has to be done by Sones' technique (denudation of the humeral artery). There is, however, another upper limb approach which does not involve arterial denudation: percutaneous right or left axillary artery catheterisation. This paper reports the experience of a multicentre study of this method in 105 patients. This study is of interest as an arterial catheter introducer was used which, does not compress the artery, prevents bleeding when the catheter has to be changed and reduced the risk of thromboses or laceration of the axillary artery. 73 of the 105 patients had lower limb arteriosclerosis 5 had aortic aneurysms and 1 patient had a previous history of femoral artery embolism. There was a primary indication for this approach in 21 cases. The left axillary artery was used in 83 cases (79%) and the right axillary artery in 22 cases (21%). The coronary catheters were those usually used with the femoral approach. The left side was chosen preferentially as it avoided the brachiocephalic trunk and facilitated the catheterisation of the coronary ostia and of aorto-coronary bypass grafts. Selective catheterisation of the left coronary artery was achieved in 21 out of 22 cases (95%) and of the right coronary artery in all 22 cases (100%) by the right axillary route. Both left and right coronary arteries were selectively catheterised in all cases by the left axillary approach.(ABSTRACT TRUNCATED AT 250 WORDS)

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A case of hemopericardium after coronary recanalisation with streptokinase during the acute phase of myocardial infarction is reported, emphasising the value of routine daily echocardiography in all cases of intracoronary thrombolysis. The patient was a 48 year old man with a primary antero-lateral infarct in whom coronary angiography was performed at the 4th hour, showing total proximal obstruction of the left anterior descending artery. The streptokinase protocol of intracoronary thrombolysis was performed, resulting in recanalisation of the left anterior descending artery at the 30th minute. Improved left ventricular function and persistance of coronary patency were confirmed 14 hours after recanalisation. In the following days the patient showed signs of right ventricular failure with successive echocardiogrammes demonstrating an increasing pericardial effusion. On the 4th day, 600 ml of blood were drained surgically and aorto-coronary bypass carried out on the left anterior descending artery. This procedure maintained coronary patency and the improvement in left ventricular function. Several studies have shown that the hemorrhage of reperfusion only occurs in the zones of necrosis, and thrombolytics, especially streptokinase, may aggravate this condition.

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The indications of coronary bypass surgery in single vessel disease remain controversial. Therefore, we carried out a retrospective study of the coronary angiogrammes and left ventriculography of 93 patients with single vessel disease (greater than 70 p. 100 stenosis) involving the left anterior descending (LAD) or dominant right coronary arteries (RCA) to evaluate the quantity of myocardium at risk. Five angio-hemodynamic parameters were compared: the ejection fraction (EF), the ratio of end systolic left ventricular pressure to volume (LVESP/LVESV), the velocity of circumferential fibre shortening (VCF), end diastolic volume (EDV) and end systolic volume (ESV). Six subgroups were defined: 28 proximal LAD stenosis (16 without and 12 with myocardial infarction (MI], 37 mid LAD stenosis (20 without and 17 with MI), and 28 RCA stenosis (8 without and 20 with MI). In all, there were 44 single vessel stenoses without MI and 49 with previous necrosis. Left ventricular function was normal in the absence of MI but deteriorated progressively in cases with MI and LAD disease. In cases of proximal LAD stenosis without and with MI, the hemodynamics showed: EF (p. 100) = 67,12 +/- 2,07 leads to 43,83 +/- 4,7 (p less than 0,001); LVESP/LVESV = 3,24 +/- 0,34 leads to 1,92 +/- 0,50 (p less than 0,05); VCF (s-1) = 1,28 +/- 0,05 leads to 0,74 +/- 0,06 (p less than 0,001); in cases of mid LAD stenosis without and with MI: EF = 69,1 +/- 2,08 leads to 45,11 +/- 3,42 (p less than 0,001); LVESP/LVESV = 3,64 +/- 0,39 leads to 1,46 +/- 0,12 (p less than 0,001); VCF = 1,32 +/- 0,008 leads to 0,74 +/- 0,06 (p less than 0,001). In contrast the change in LV function was minimal in patients with necrosis and RCA stenosis: EF = 70,37 +/- 3,85 leads to 56,4 +/- 3,19 (p less than 0,05); LVESP/LVESV = 5,20 +/- 1,83 leads to 2,56 +/- 0,36 (p less than 0,05); VCF less than 1,42 +/- 0,17 leads to 1,03 +/- 0,08 (p less than 0,05).(ABSTRACT TRUNCATED AT 400 WORDS)

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The authors report a special cases of precise evaluation of threatened myocardium during coronaro-ventriculography. Two elements provided this evaluation: 1) spasm in the tight stenosis of the middle part of the anterior interventricular artery with immediate left ventricular dyskinesia (EF: 37%, EDP/EVD: 1.74; EDV: 98 cc/m2). 2) Complete instantaneous recovery after injection of 2 mg of trinitrine into the left ventricle (EF: 69%, EDP/EVD: 4.33; EDV: 28 cc/m2). This loss, in the order of 50%, in the left ventricular function led us to perform an angioplasty (ACT) with success. A further clinical and angiographic stenosis, three months later, in this 72 years old patient with arteritis, led us to perform an aorto-coronary graft, rather than another ACT.

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The author report the case of a 48 years old patient, admitted to hospital 3 hours and a half after an anterior myocardial infarct which was well tolerated. Coronary recanalization with urokinase-plasminogen removed the obstruction of the middle part of the anterior interventricular artery 1 hour and a half after the patient's arrival. Selective left coronary angiography demonstrated a narrow stenosis, in the order of 98%, in the proximal part of the AIV artery. Angioplasty was attempted immediately, in view of the ease with which the guide wire was passed through the initial thrombosis and the good haemodynamic tolerance. The residual stenosis was estimated to be 20% after the angioplasty and at the examination 48 hours later. The ECG on discharge from hospital showed a QS appearance in V1 to V3 with R in V4. An improvement in the ejection fraction (EF) and in the end-diastolic volumes was found: EF: 48% compared to 38%, EDV (cc/m2): 79 compared to 120. The clinical course at two months is very satisfactory, with no residual angina and a negative stress test. This special procedure, combining a double therapeutic catheterization, lasted 1 hour 50 minutes and allowed the progression of the myocardial infarction to be halted and also avoided a subsequent aorto-coronary graft operation.

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After seeing 9 cases of digitalis intoxication in patients with acute respiratory decompensation of chronic respiratory failure in one year in an intensive care unit, the authors decided to review the literature on the subject. They set out to: --determine the clinical, laboratory and electrical features of digitalis intoxication in patients with chronic respiratory failure, accounting for the frequency of supraventricular arrhythmias; --evaluate the frequency of this intoxication (20% in this study), introducing a definite risk factor, given the poor haemodynamic effectiveness of digitaloids in this indication; --establish a therapeutic management based on the use of anti-arrhythmics and especially on the prevention of predisposing factors (hypoxaemia--functional renal failure and abuse of diuretics).

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Coagulation factors were measured in 50 patients presenting with acute renal failure on the day of their admission (D1) and seven days later (D7). A number of changes were observed, particularly in those patients with a poor prognosis (decreased platelet counts and plasminogen concentrations and increased factor VIII related antigen concentrations). In the majority of cases it would appear that disseminated intravascular coagulation remains sub-clinical.

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