[Does Doppler analysis of hepatic venous flow predict increased right atrial pressure and right ventricular dysfunction?]. / L'analyse doppler du flux des veines sus-hépatiques permet-elle de prédire le niveau de pression auriculaire droite au cours de l'infarctus du ventricule droit?

The aim of this study was to test the hypothesis that Doppler study of hepatic venous flow, reflecting right atrial pressures and right ventricular dysfunction, allows prediction of increased right atrial pressure and right ventricular dysfunction in patients with right ventricular infarction. The authors studied 30 patients (27 men, mean age 54 +/- 12 years) in sinus rhythm with acute inferior myocardial infarction who underwent right heart catheterisation and Doppler echocardiography including recording of regurgitant and hepatic vein flow within 48 hours of hospital admission. Hepatic venous flow was used to measure peak velocity and velocity time integrals (VTI) of the systolic (S), diastolic (D) and atrial (a) contraction waves. The fraction of systolic filling was calculated: VTI S/VTI S + VTI D. The pressure half-time of pulmonary regurgitant flow (PHT IP) was also measured. Using haemodynamic criteria (non-compliant right atrial pressure wave form or right ventricular end diastolic pressure/pulmonary capillary pressure > or = 0.8), patients were divided into two groups: Group 1: right ventricular infarction (VD+, N = 22). Group 2: no right ventricular infarction (VD-, N = 8). No correlation was observed between Doppler parameters of hepatic venous flow and haemodynamic data, in particular right atrial pressure and pressure wave form. Moreover, no statistically significant difference was observed between the two groups with respect to the Doppler parameters derived from hepatic venous flow. On the other hand, the results confirmed good diagnostic performance of Doppler analysis of pulmonary regurgitant flow: sensitivity 80%, specificity 83%, positive predictive value 94%, negative predictive value 55%. The authors conclude that, in patients with acute inferior wall infarction, Doppler analysis of hepatic venous flow does not allow assessment of right atrial pressure or of ischaemic right ventricular dysfunction.

[Comparative incidence of protrusive atheromatous plaques of the thoracic artery in patients with atrial fluter and atrial fibrillation]. / Fréquence comparée des plaques athéromateuses protrusives de l'aorte thoracique chez les patients en flutter et en fibrillation auriculaire.

Although it has been demonstrated recently that in patients with atrial fibrillation, protrusive atheromatous plaques of the thoracic aorta (thickness 4 mm) and left atrial abnormalities such as thrombosis, spontaneous contrast and low atrial blood flow velocities carry an additional embolic risk, this has not yet been studied in atrial flutter. Out of 2493 patients undergoing transoesophageal echocardiography between September 1993 and December 1997, 271 consecutive patients in atrial flutter (N = 41) or fibrillation (N = 230) for over 48 hours, underwent transoesophageal echocardiography before cardioversion. Patients with atrial flutter were compared with those with atrial fibrillation. Their characteristics were comparable with respect to age (68 +/- 13 and 67 +/- 12 years respectively, p = 0.628), sex ratio (men 66 and 54% respectively, p = 0.212), previous thromboembolic disease (5 and 15% respectively, p = 0.126). The incidence of protrusive aortic atheroma (12 and 11% respectively, p = 0.919), of spontaneous contrast in the thoracic aorta (15 and 14% respectively, p = 0.847) were identical in both groups. The left atrium was significantly smaller (3.1 +/- 0.7 and 6 +/- 3 cm2 respectively, p = 0.001), spontaneous atrial contrast less frequent (17 and 37% respectively, p = 0.024) and the velocities of atrial emptying higher (47 +/- 10 and 30 +/- 10 cm/s respectively, p = 0.030) in patients with flutter compared with atrial fibrillation. There was no difference in left ventricular fractional shortening (30 +/- 10 and 33 +/- 13% respectively, p = 0.630), the presence of rheumatic valvular disease (5 and 12%, p = 0.301), left atrial diameter (43 +/- 7 and 45 +/- 8, p = 0.134), right atrial surface area (16 +/- 4 and 17 +/- 6 cm2, p = 0.384) or in intraatrial thrombosis (2 and 3%, p = 0.888) respectively. These results show a high prevalence of protrusive atheroma of the thoracic aorta both in atrial flutter and in atrial fibrillation, and fewer left atrial abnormalities in patients with flutter.

Comparison of echocardiographic markers of embolism in atrial flutter and fibrillation: frequency of protruding atherosclerotic plaques in the thoracic aorta.

The potential additional embolic risk of protruding aortic plaques > or = 4 mm and left atrial abnormalities such as thrombus, spontaneous echocardiographic contrast (SEC), low left atrial appendage velocity, recently has been shown in patients with atrial fibrillation (AF). However, the presence and potential role of transesophageal echocardiographic (TEE)-detected protruding aortic plaques > or = 4 mm have not been systematically evaluated in patients with atrial flutter. Among 2493 patients evaluated by TEE, 271 consecutive patients with atrial flutter (n = 41) and AF (n = 230) > or = 2 days duration were included in the study. Clinical and echocardiographic characteristics in consecutive patients with atrial flutter were compared to those in patients with AF, especially atrial morphology and function and atherosclerotic disease of the thoracic aorta. Clinical characteristics of patients with atrial flutter and AF were similar with regard to age (68 +/- 13 and 67 +/- 12, P = 0.628), sex ratio (men, 66% and 54%, P = 0.212), and previous embolic events (5% and 15%, P = 0.126), respectively. The frequency of protruding atherosclerotic plaques > or = 4 mm (12% and 11%, P = 0.919) and SEC (15% and 14%, P = 0.847) in the thoracic aorta was similar in patients with atrial flutter and AF. Left atrial appendage area was smaller (3.1 +/- 0.7 and 6.0 +/- 3.0 cm(2), P = 0.001), left atrial appendage SEC was less frequent (17% and 37%, P = 0.024), and left atrial appendage emptying velocity was higher (47 +/- 10 and 30 +/- 10 cm/s, P = 0.030) in patients with atrial flutter as compared to those with AF. There was no difference between the two groups regarding left ventricular fractional shortening (30 +/- 10% and 33 +/- 13%, P = 0.630), rheumatic valvular disease (5% and 12%, P = 0. 301), left atrial diameter (43 +/- 7 and 45 +/- 8 mm, P = 0.134), right atrial area (16 +/- 4 and 17 +/- 6 cm(2), P = 0.384), left atrial SEC (39% and 53%, P = 0.124), or atrial thrombus ( 2% and 3%, P = 0.888) respectively. Our results point to the high prevalence of protruding atherosclerotic plaques in the thoracic aorta in patients with atrial flutter.

[Cardiac ultrasonography in the diagnosis and monitoring of infectious endocarditis]. / Echographie cardiaque dans le diagnostic et la surveillance des endocardites infectieuses.

Transthoracic and transoesophageal doppler echocardiography has become an essential tool for the diagnosis of infective endocarditis. It detects valvular vegetations and destructions, evaluates regurgitations, and appreciates haemodynamic tolerance. Recognition of endocarditis, early identification of high-risk patients, and detection of mechanical complications are the most accurate informations derived from this technique. Transoesophageal echocardiography has the potential to avoid the difficulties encountered using the transthoracic approach, and it must be used particularly in the presence of non diagnostic transthoracic examination when clinical suspicion is high.

Usefulness of pulmonary regurgitation Doppler tracings in predicting in-hospital and long-term outcome in patients with inferior wall acute myocardial infarction.

Right ventricular (RV) involvement is frequent during inferior wall acute myocardial infarction (AMI) and has been reported as a risk factor for in-hospital morbidity and mortality. The objectives of the present study were: (1) to evaluate in-hospital events in patients with and without RV involvement as diagnosed by abnormal flow characteristics derived from pulmonary regurgitation (PR) analysis (pressure half-time of PR, PHT(PR) < or = 150 ms and the lowest mid-diastolic to peak early diastolic velocity ratio, Vmin/Vmax < or = 0.5); and (2) to determine the influence of RV involvement in complications at long-term follow-up. Among 126 consecutively admitted patients with inferior wall AMI (mean age, 58 +/- 13 years), 101 had PR. We determined the prognostic significance of in-hospital and long-term events for the following variables: age > or = 65 years, ST-segment elevation > or = 1 mm in lead V4R, RV dilation, PHT of PR < or = 150 ms and Vmin/Vmax < or = 0.5, thrombolytic therapy, 3-vessel disease, and diabetes mellitus. We found that the PR derived Doppler index (PHT of PR < or = 150 ms and Vmin/Vmax < or = 0.5) was the only predictor of overall in-hospital clinical events (hazards ratio, 2.7, 95% confidence interval, 1.2 to 6.1, p = 0.016). At long-term follow-up (mean: 20 +/- 12 months, range 12 to 69), event-free survival analysis showed that age > or = 65 years was the only predictor of any event (relative risk, 3.7, 95% confidence interval, 2.1 to 6.3, p < 0.0001). Thus, RV involvement diagnosed with the use of PR flow-derived variables is an accurate and independent predictor of in-hospital complications. However, RV involvement does not influence long-term prognosis.

[Dobutamine stress echocardiography; a monocentric experience on 600 consecutive patients. Effect of age]. / Echocardiographie sous dobutamine; expérience monocentrique portant sur 600 patients consécutifs. Influence de l'âge.

The increasing indications of dobutamine stress echo in the investigation of myocardial ischaemia, viability and evaluation of the prognosis of coronary artery disease has made this technique a tool of everyday clinical practice. The authors reviewed the results of 600 investigations in consecutive unselected including patients aged over 75. No significant difference was observed with respect to the causes of interruption of the test between patients aged less than 75 (521 patients) and those older than 75 (79 patients). Attaining the target theoretical maximal heart rate was the commonest reason for stopping the test (47 and 48% respectively). Ventricular arrhythmias were not more common (12 and 10% respectively). Twelve cases of ventricular tachycardia were observed, 8 of which were non-sustained; 9 led to interruption of the test. No cases of ventricular fibrillation were observed. A previous history of cardiac arrhythmias was not associated with a higher frequency of arrhythmia during the test (8% in those with a previous history, 4% in those patients without). Supraventricular arrhythmias were significantly more common in patients over 75 years of age (15 versus 8%, p = 0.046). Dobutamine stress echocardiography' is feasible in a population of unselected patients, including those over 75. Therefore, age does not represent a limitation to the extension of this investigation.