Frédéric Mouquet

Metabolic syndrome and collateral vessel formation in patients with documented occluded coronary arteries: association with hyperglycaemia, insulin-resistance, adiponectin and plasminogen activator inhibitor-1

Aims The metabolic syndrome (MS) is associated with an increased cardiovascular risk. Patients with the MS have endothelial dysfunction, decreased circulating adiponectin, and a high expression of angiogenic inhibitors such as plasminogen activator inhibitor-1 (PAI-1). We hypothesized that such patients, in the event of a coronary occlusion, might exhibit a less developed collateral circulation. Methods and results Three hundred and eighty-seven consecutive patients with at least one coronary occlusion of a major coronary vessel at diagnostic angiography were prospectively enrolled. Collateral development was graded with validated angiographic methods. The MS was defined according to the ATP-III definition. Fasting glucose, adiponectin, insulin concentrations, and PAI-1 were measured at the time of angiography. MS was associated with less developed collateral vessels (P = 0.005). In multivariable analysis adjusting for potential confounding factors including the duration of coronary occlusion (P = 0.0001), fasting glycaemia (P = 0.0007), low adiponectin concentration (P = 0.01), insulin-resistance (HOMA-IR; P = 0.01), high circulating PAI-1 concentration (P = 0.01), and hypertension (P = 0.008) were independently associated with poor coronary collateral vessel development. Conclusion This study shows that in patients with coronary occlusion, collateral circulation is impaired in patients with the MS. This association is partly related to fasting glycaemia and to key parameters linked to insulin resistance.

Exercise does not enhance the prognostic value of Doppler echocardiography in patients with left ventricular systolic dysfunction and functional mitral regurgitation at rest.

BACKGROUND Functional mitral regurgitation (MR) is a powerful predictor of poor prognosis in patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (LVSD). However, severity of MR varies with dynamic exercise. Accordingly, we sought to assess the prognostic value of exercise-induced changes in functional MR in patients with LVSD and functional MR at rest. METHODS One hundred four patients with chronic heart failure due to LVSD (ejection fraction [EF] < 45%) and functional MR at rest underwent conventional continuous 2-dimensional Doppler echocardiography at rest and during maximal symptom-limited exercise. The primary end point of the study was all-cause mortality. The median follow-up period was 20 months. RESULTS Fifty-six patients (54%) had ischemic cardiomyopathy. When feasible, all 56 patients with ischemic cardiomyopathy had undergone revascularization procedures before enrollment into the study. In the whole patient cohort, resting LV end-diastolic volume was 205 +/- 76 mL and EF was 26% +/- 9%. Univariate predictors of death were functional class (New York Heart Association), LV EF, LV end-diastolic volume, resting mitral effective regurgitant orifice, mitral E deceleration time, tricuspid annular plane systolic excursion < or = 14 mm, systolic blood pressure, LV EF, and trans-tricuspid pressure gradient response to exercise. Exercise-induced change in mitral effective regurgitant orifice did not predict survival (HR 0.99, 95% CI 0.94-1.04, P = .63). By Cox multivariate analysis, resting LV end-diastolic volume and tricuspid annular plane systolic excursion < or = 14 mm were the independent predictors of death. CONCLUSIONS Exercise Doppler echocardiography does not refine the predictive value of resting Doppler echocardiography in patients with LVSD and functional MR at rest.

Pivotal Role of Bedside Doppler Echocardiography in the Assessment of Patients with Acute Heart Failure and Mitral Regurgitation

Patients presenting with mitral regurgitation and acute heart failure remain a challenge for the clinicians. Bedside echocardiography ascertains the functional or primary nature of mitral regurgitation, thereby allowing to focus therapy on the left ventricle and mitral valve apparatus in patients with functional mitral regurgitation and to hasten mitral valve repair or replacement when acute heart failure results from primary mitral regurgitation. This short article reviews the evaluation by bedside echocardiography to guide management of these patients.

No gender survival difference in a population of patients with chronic heart failure related to left ventricular systolic dysfunction and receiving optimal medical therapy

INTRODUCTION Controversial results have been published concerning a possible gender survival difference in patients with chronic heart failure (CHF). METHODS We analysed data from consecutive patients with stable CHF admitted to our department for prognostic evaluation. Patients underwent coronary angiography, echo-cardiography, radionuclide angiography and a cardiopulmonary exercise test. RESULTS We included 613 consecutive patients of whom 115 (19%) were women. The major difference in clinical characteristics was a higher proportion of ischaemic cardiomyopathy in men compared to women (51% vs 28%, p<0.0001) and a lower left ventricular ejection fraction (35+/-9 vs 38+/-9%, p=0.001). Therapeutic management was similar in men and women. A total of 140 cardiovascular-related deaths and 4 urgent transplantations occurred during a median follow-up of 1.234 days. There was no gender difference in cardiac survival. Cardiovascular mortality rates at 2 years were 11% in men and 13% in women. CONCLUSIONS Despite a lower percentage of ischaemic cardiopathy in women, no gender survival benefit was found in our population of CHF patients receiving optimal medical therapy.

Thérapie cellulaire et insuffisance cardiaque

Resume Introduction. – L’insuffisance cardiaque resulte frequemment d’une alteration de la fonction systolique ventriculaire gauche dans les suites d’un infarctus du myocarde. Malgre toutes les recentes avancees therapeutiques, le pronostic des stades evolues reste plus pejoratif que celui de certains cancers, avec un taux de survie de 30 % a 5 ans. Exegese. – Les traitements actuellement disponibles ne peuvent que retarder l’evolution vers le stade terminal de l’insuffisance cardiaque. Au stade terminal, la seule issue therapeutique est la mise en place d’un systeme d’assistance ventriculaire gauche dans l’attente d’une greffe cardiaque. Or, la greffe cardiaque ne permet de prendre en charge qu’un nombre minime de patients. Dans le contexte particulier du post-infarctus, la therapie cellulaire apparait comme une technique d’avenir innovante pouvant corriger la perte aigue des cardiomyocytes ; cette solution est en outre applicable a une majorite de patients et potentiellement peu invasive. Conclusion. – Apres des resultats experimentaux prometteurs, une etude de phase I en France a montre la faisabilite d’une greffe intracardiaque de myoblastes autologues. D’autres equipes, en Europe et aux Etats-Unis, etudient d’autres types cellulaires et des voies d’administration differentes. Enfin, la premiere etude de phase II a debute en France.