[Long term evolution of chronic constrictive pericarditis. A study of 56 patients]. / Evolution a long terme des péricardites constrictives chroniques. A propos de 56 patients.

OBJECTIVE AND METHOD: We retrospectively analysed 56 consecutive patients with a confirmed diagnosis of chronic constrictive pericarditis over a period of 23 years. The objective was to analyse the evolution of the annual frequency of constrictive pericarditis, its aetiology and to define the prognostic factors for mortality. RESULTS: The annual frequency of constrictive pericarditis has not diminished over the 23 years of this study, remaining at 2.4 cases per year. Cases with a tuberculous origin have diminished progressively, being replaced by complications of cardiac surgery and mediastinal radiotherapy. Pericardectomy was performed in 41 patients and the average follow up was 9.5 +/- 8.6 years. By the end of the study, 34 patients had died (61.8%), 18 from a cardiovascular cause (38.3%). The independent predictive factors for overall mortality were a history of mediastinal radiotherapy, the age, and plasma sodium level. Only the presence of first degree atrio-ventricular block was an independent predictive factor for cardiovascular mortality. In the pericardectomy group, 24 patients died (60%). A history of mediastinal radiotherapy and the presence of pre-operative hyponatraemia were independent predictive factors for overall mortality. CONCLUSION: Constrictive pericarditis remains a serious pathology. Pericardectomy allows a clear functional improvement, but following pericardectomy more than 60% of patients will die within 10 years of the diagnosis being made.

[Acute coronary syndromes and myocardial perfusion. Cardiac magnetic resonance imaging and ultrafast CT]. / Syndromes coronaires aigus et perfusion myocardique. Les acquis de l'IRM cardiaque, les perspectives du scanner multibarrettes.

Imaging myocardial perfusion is essential in the management of acute coronary syndromes without ST elevation (ACS ST-) confirming the diagnosis of coronary lesions and quantifying the myocardial ischaemia, an important factor in the stratification of coronary risk. In ACS ST-, perfusion imaging allows evaluation of myocardial viability, diagnosis of residual ischaemia and also the detection of no-reflow phenomena after reperfusion procedures. Although myocardial scintigraphy is the reference method in clinical practice, it has many limitations such as its spatial resolution, its irradiation, its attenuation artefacts, and also the fact that it does not visualise the coronary arteries. This has led to the rapid development of two new non-invasive imaging techniques: cardiac MRI and ultrafast CT. The major advantage of MRI is the possibility of associating analysis of myocardial perfusion with that of cardiac muscle function by investigating right and left ventricular function at rest and during myocardial ischaemia stress tests and by analysis of myocardial viability. More recently, ultrafast CT has been clinically validated for coronary imaging. However, analysis of myocardial perfusion and ventricular function by CT scan is still only at the research stage.

[Intra-aortic balloon pumping and variations in flow in the dilated coronary artery in acute myocardial infarction]. / Contrepulsion intra-aortique et variation du flux de l'artère coronaire dilatée à la phase aiguë de l'infarctus du myocarde.

The object of this study of acute anterior myocardial infarction uncomplicated by cardiogenic shock, a context in which the role of intra-aortic balloon pumping (IABP) remains controversial, was to analyse the effects of IABP on coronary flow in the culprit artery. Twenty-one patients admitted for angioplasty in the acute phase of anterior myocardial infarction were included. The IABP was performed in 6 patients (Group 1) because of clinical signs of cardiac failure. Fifteen patients (Group 2) had no signs of cardiac failure. Coronary flow velocity was recorded by a Doppler catheter after successful angioplasty. The following parameters were analysed: average peak velocity (APV), average diastolic peak velocity (ADPV), average systolic peak velocity (ASPV), diastolic to systolic velocity ratio (DSVR) and maximum peak velocity (MPV). Intra-aortic balloon pumping was associated with an increase in the diastolic indices (APV 17.9 +/- 3.5 vs 14.9 +/- 3.6 cm/s; p < 0.05; ADPV 27.6 +/- 5.2 vs 19.7 +/- 4.7 cm/s; p < 0.05), and a decrease in the systolic index ASVP (3.8 +/- 1.3 vs 7.6 +/- 2.6 cm/s; p < 0.05). The diastolic indices recorded with IABP did not change in Group 2. The velocity spectra changed with the appearance of abnormalities usually described in the presence of microcirculatory abnormalities ("no reflex" phenomenon): decrease in anterograde systolic flow, rapid deceleration of diastolic velocities with appearance of a retrograde systolic flow. The authors conclude that IABP increases diastolic velocities of coronary flow in the acute phase of revascularised anterior myocardial infarction complicated by left ventricular failure but does not seem to be accompanied by improved myocardial perfusion.

[Is it necessary to operate quickly in patients with significant left main coronary stenosis?]. / Faut-il opérer rapidement tous les patients atteints d'une sténose significative du tronc commun de la coronaire gauche?

Although coronary bypass surgery is performed rapidly in the majority of cases of left main coronary stenosis to prevent cardiovascular complications, there is no reported consensus in the literature about the ideal interval between diagnostic coronary angiography and surgery. The aim of this multicenter study was to make an inventory of the serious vascular cardiovascular events which occurred between coronary angiography and surgery to determine possible predictive factors for complications and thereby identify a high risk subgroup requiring immediate revascularisation. The population comprised 283 patients with significant left main coronary disease, out of a total of 8,205 patients who underwent coronary angiography in the university hospitals of Angers, Brest, Nantes, Poitiers and Rennes. A surgical indication was retained in 216 patients. The choice of the operation date depended on clinical data in the presence of an acute coronary syndrome, patients remaining in the intensive care unit and undergoing revascularisation rapidly. Serious cardiac events (death, myocardial infarction, refractory unstable angina and left ventricular failure) occurring while waiting for surgery were rare, observed in only 6.5% of patients. Recent myocardial infarction and, to a lesser degree, unstable angina and/or left ventricular systolic dysfunction, were predictive of serious cardiac complications before surgery. The severity of the left main coronary disease and the association of right coronary disease did not increase the risk of serious cardiac events in the preoperative period. The low incidence of complications demonstrates that this strategy enables patients to wait for surgery with an acceptable risk without having to operate all patients with left main coronary disease as an emergency.

[Very long-term outcome of 68 vena cava filters percutaneously implanted]. / Devenir à très long terme de 68 filtres caves implantés par voie percutanée.

Between January 1987 and December 1991, 68 consecutive patients aged 71.5 +/- 12.0 years underwent percutaneous implantation of a vena caval filter, mainly the LGM (N = 64). Fifty seven patients had pulmonary embolism, 61 had deep vein thrombosis of the lower limbs. The average follow-up interval was 4.9 +/- 3.3 years (7.0 +/- 2.7 years for the patients still alive). The follow-up included a telephonic enquiry to determine the date and cause of death, recurrent deep vein thrombosis and/or pulmonary embolism; surviving patients underwent clinical examination, plain abdominal X-ray with a lateral decubitus view and duplex ultrasonography of the lower limb veins to assess the patency of the filter. Fifty three per cent of the patients died. Four predictive factors for mortality were identified: a contra-indication to anticoagulant therapy, chronic post-embolic cor pulmonale, an indication of prophylactic implantation in the elderly and the presence of underlying malignant disease. There were 5.8% recurrences of pulmonary embolism, 26.1% of lower limb deep vein thrombosis and 25% of filter thrombosis. The only predictive factor of thrombosis was a proximal venous thrombus and was associated in 50% of filter thrombosis. Seventy per cent of the plain abdominal X-rays were abnormal with 9 displacements. 9 migrations and 10 closures of the filters. There was a significant correlation between closure on plain abdominal X-ray and caval thrombosis and between recurrent deep vein thrombosis and caval thrombosis. The frequency of long-term complications after implantation of a caval filter in this study suggests that interruption of the vena cava should be reserved for the only validated indications in the presence of a formal contra-indication to or failure of anticoagulant therapy. Other indications require evaluation with prospective randomised trials.

Echocardiographic assessment of the interventricular delay of activation and correlation to the QRS width in dilated cardiomyopathy.

The aim of the study was to define criteria for left ventricular pacing in dilated cardiomyopathy (DCM) using an echocardiographic evaluation of interventricular electromechanical delay (IMD) and a correlation of IMD to QRS duration. Standard 12-lead ECG and echocardiography with pulsed Doppler tissue imaging (DTI) were recorded in 35 DCM patients (mean age 58 +/- 11 years) with QRS duration from narrow (80 ms) to broad (222 ms) patterns. The timefor left ventricular activation was evaluated from the onset of QRS to the onset of aortic flow (Q-Ao) by standard pulsed Doppler (SP) or to the onset of mitral annulus systolic wave (Q-Mit) (DTI). The time for right ventricular activation was determinedfrom the onset of QRS to the onset of pulmonary flow (Q-Pulm) (SP) or to the onset of tricuspid annulus systolic wave (Q-Tri) (DTI). (Q-Ao)-(Q-Pulm) and (Q-Mit)-(Q-Tri) determined IMD for each method, respectively. QRS width and IMD showed correlation coefficients of r = 0.86 ([Q-Ao]-[Q-Pulm]) and r = 0.82 ([Q-Mit]-[Q-Tri]) (P < or = 0.001 ). Mean IMD of 77 +/- 15 ms (SP) and 88 +/- 26 ms (DTI) were noted for QRS width above 150 ms. Left ventricle delayed activation was positively correlated to QRS widening with both methods, (r = 0.90, [Q-Ao]), (r = 0.83, [Q-Mit]) (P < or = 0.001). In conclusion, QRS duration is a good marker of an interventricular mechanical asynchrony. According to IMD correction, left ventricular pacing may be mainly proposed to symptomatic DCM patients with QRS duration > 150 ms.

Randomised comparison of coronary stenting with and without balloon predilatation in selected patients.

BACKGROUND: The SWIBAP (stent without balloon predilatation) prospective randomised trial was designed to compare direct coronary stenting with stenting preceded by lesion predilatation with an angioplasty balloon. OBJECTIVE: To determine the feasibility and safety of direct stenting in non-complex coronary lesions in a prospective study. PATIENTS AND DESIGN: All patients < 76 years of age scheduled to undergo angioplasty of a non-complex, non-calcified lesion in a coronary artery of > 3.0 mm, who granted their informed consent, were randomised into the trial. In group I, the stent was placed without balloon predilatation, while in group II stent implantation was preceded by balloon predilatation. The primary end point was the angiographic result according to procedure assigned by randomisation. An intravascular ultrasound substudy was performed in 60 patients. RESULTS: Stent implantation was successful without predilatation in 192 of the 197 group I patients (97.5%), and with predilatation in 197 of the 199 group II patients (99%) (NS). No in-hospital stent thrombosis or death occurred. Overall procedural times, fluoroscopy times, and volumes of contrast agent given (mean (SD)) in group I v group II were 23.50 (13.54) min v 27.96 (15.23) min (p = 0.002), 6.04 (4.13) min v 6.67 (3.65) min (NS), and 135 (65) ml v 157 (62) ml (p < 0.001), respectively. No major adverse cardiovascular events had occurred by 30 days. CONCLUSIONS: The feasibility and safety of direct stenting of selected and non-complex coronary lesions is confirmed. This technique was as successful as the conventional approach and was associated with a minor reduction in fluoroscopic exposure and procedure time and the administration of less contrast agent.

[Loffler's fibroblastic endocarditis. A report of a case complicating toxocarosis]. / Endocardite fibroblastique de Löffler. A propos d'un cas compliquant une toxocarose.

The authors report a case of Löffler's fibroblastic endocarditis complicating a toxocarosis infection. Parasitic infestation with toxocara canis is usually asymptomatic, but this was a very rare observation of cerebral involvement associated with symptomatic Löffler's endocarditis. This is an unusual form of restrictive cardiac disease constantly accompanied by prolonged hypereosinophilia. In addition to the classical signs of cardiac failure, an acute febrile illness imitating a connective tissue disease may be observed. Echocardiography helps diagnosis by showing endomyocardial fibrosis and adherent thrombosis at one or both ventricular apices. The management of cardiac failure should include, whenever possible, radical treatment of the hypereosinophilia. At an advanced stage, surgical endocardial decortication is the only means of improving symptoms and the prognosis of these patients.

[Apropos of a case of Streptococcus pneumoniae salpingitis, epidemiology of female genital pneumococcal infections]. / A propos d'un cas de salpingite à Streptococcus pneumoniae, épidemiologie des infections génitales de la femme à pneumocoque.

BACKGROUND: Pneumoccocci were sometimes isolated from female genital tract specimens, usually without any clinical signification. However few cases of female pneumococcal genital infections were previously reported. CASE REPORT: We describe an additional report of salpingitis, occurring in a 35-years old female early after installation of an intra-uterine device. DISCUSSION: Data collected by the National Reference Center for Pneumococci show that 0.9% of the strains documented in the past five years (1992 to 1996) were isolated from the female genitals tract. Most of these infections are caused by S. pneumoniae belonging to the serotypes 1 or 3. About 20% of the strains displayed a reduced sensitivity to penicillin. Although genital infections caused by S. pneumoniae and the neonatal colonisation with the maternal strain are rare, their potential occurrence should not be neglected. Thus, in order to limit the risks of such infections, an antibiotic treatment should immediately started following the detection of a pneumococcal genital carriage.

Discovery of a parachute mitral valve complex (Shone's anomaly) in an adult.

Parachute mitral valve complex is an unusual congenital anomaly described by Shone et al. It is characterized by a parachute deformity of the mitral valve associated with additional forms of left heart anomalies, such as aortic valvular stenosis and coarctation of the aorta. Fewer than 50 cases of Shone's complex have been reported in the literature, and it has only been observed in children. We report the case of a 33-year-old man who was referred to our department because of atrial fibrillation. Echocardiographic evaluation and aortogram evidenced a Shone's complex, including a parachute mitral valve anomaly, an aortic bicuspid valvular anomaly, and a coarctation of the aorta.

[Incidence and timing of thyroid dysfunction with long-term amiodarone therapy]. / Incidence et délai d'apparition des dysthyroïdies sous traitement chronique par amiodarone.

The aim of this retrospective study was to assess the incidence, timing and classical presentations of thyroid dysfunction in patients treated long-term with amiodarone. Ninety patients (sex ratio M/W 67/33, mean age 71 years) were followed up for 48 months. The daily dose of amiodarone was 200 mg after loading doses during the hospital stay for atrial fibrillation. The average treatment period was 33 +/- 19 months. Hypothyroidism, observed in 5.5% of cases, occurred at variable intervals with few clinical manifestations. Hyperthyroidism was more common (12.2%), occurred increasingly with time, and was clinically symptomatic with recurrent supraventricular arrhythmias in 36% of cases. Long-term amiodarone therapy causes undesirable thyroid side-effects for nearly 1 out of 5 patients. Hyperthyroidism is more common than hypothyroidism and may be explained by increased iodine intake. The increasing incidence of hyperthyroidism with time suggests a cumulated dose relationship, a situation which is not observed with hypothyroidism.

Clonal relationships among penicillin-susceptible, multiresistant serotype 6B Streptococcus pneumoniae isolates recovered in Greece and France.

In January 1996 the emergence of penicillin-susceptible, multiresistant serotype 6B Streptococcus pneumoniae isolates resistant to chloramphenicol, tetracycline, erythromycin, clindamycin and trimethoprim-sulfamethoxazole was observed in young carriers in the city of Patras, located in the southwestern region of Greece. Later, a significant spread of pneumococci with this unusual phenotype was noted in carriers living in various other areas of the country. Using restriction fragment length polymorphism of the ribosomal RNA genes, clonal relationships were found between these Greek strains and serotype 6B penicillin-susceptible, multiresistant pneumococci isolated in France between January 1992 and September 1996. The French and Greek isolates appear to have a common ancestry.

Mechanisms of macrolide resistance in clinical pneumococcal isolates in France.

The genetic basis of macrolide resistance was investigated in a collection of 48 genotypically unrelated clinical isolates of Streptococcus pneumoniae obtained between 1987 and 1997 in France. All strains were resistant to erythromycin, clindamycin, and streptogramin B, exhibiting a macrolide-lincosamide-streptogramin B resistance phenotype, and harbored the erm(B) gene. None of the strains carried the mef(A) or erm(A) subclass erm(TR) gene.

Molecular epidemiology survey of penicillin-susceptible and -resistant Streptococcus pneumoniae recovered from patients with meningitis in France.

The genetic diversity of Streptococcus pneumoniae isolates (n=291) recovered from cerebrospinal fluid of patients with meningitis in France was investigated by restriction fragment length polymorphism analysis of the ribosomal RNA gene regions and of the pbp2b and 2x genes. Statistical analysis of the data by factorial analysis of correspondence established the following: penicillin-susceptible isolates had a high level of genetic diversity, especially those belonging to serogroups frequently associated with carriage; capsular serotype switches could occur among penicillin-susceptible and -resistant isolates; and the mechanisms of acquired penicillin resistance were clearly distinct in isolates with penicillin minimum inhibitory concentration (MIC) values <1 mg/L and isolates with penicillin MIC values >/=1 mg/L. Thus, an increase in the penicillin MIC for a given strain, from intermediate to high-level resistance would be a rare event.

Carriage of antibiotic-resistant Streptococcus pneumoniae in Greek infants and toddlers.

The prevalence, resistance patterns and serotypes of antibiotic-resistant Streptococcus pneumoniae strains recovered from Greek carriers under 24 months of age were studied. From February 1997 to April 1998, nasopharyngeal cultures were performed in 1,269 children (ages 2-23 months, median 11 months) living in various areas of central and southern Greece. Resistance (including both intermediate and resistant isolates) to one or more antimicrobial agents was found in 132 of the 421 (31%) Streptococcus pneumoniae isolates, as follows: penicillin, 9% intermediate, 7.6% resistant; cefotaxime, 5.2% intermediate, 0.5% resistant; erythromycin, 0.7% intermediate, 18.1% resistant; clindamycin, 0.2% intermediate, 12.4% resistant; tetracycline, 0.7% intermediate, 16.4% resistant; chloramphenicol, 12.4% resistant; and trimethoprim-sulfamethoxazole, 3.8% intermediate, 14.3% resistant. The MICs of penicillin for 66% of the penicillin-nonsusceptible pneumococci were 1-4 microg/ml. Multidrug resistance was found in 64% of penicillin-nonsusceptible and 37% of penicillin-susceptible strains. Sixty-two percent of the penicillin-susceptible, multidrug-resistant strains belonged to serotype 6B and were resistant to all five non-beta-lactam agents tested. This notable serotype 6B resistance pattern was described for the first time in a previous study performed from December 1995 to February 1996 in the city of Patras, southwestern Greece. Seventy-two percent of antibiotic-resistant isolates belonged to serotypes 6B, 9V, 14, 18C, 19F and 23F. These results document the spread of resistant pneumococcal strains in central and southern Greece, many of which are multidrug resistant.

[Plasma homocysteine is not a predictive factor of restenosis after coronary angioplasty]. / Le dosage plasmatique de l'homocystéine n'est pas un facteur prédictif de resténose après angioplastie coronaire.

Hyper-homocysteinaemia is a cardiovascular risk factor. In parallel, anatomopathological studies of post-angioplasty coronary restenosis show histological appearances similar to those observed in patients with severe hyper-homocysteinaemia. Based on these histological observations, the authors tried to assess the predictive value of raised plasma homocysteine levels for coronary restenosis after angioplasty. Two hundred and twenty-two patients treated by coronary angioplasty were followed up clinically for 6 months. Thallium 201 myocardial scintigraphy was performed in 179 patients and coronary angiography in 74 patients. Seventy-nine patients had coronary restenosis diagnosed by coronary angiography in 55 cases, by myocardial scintigraphy in 23 cases and strongly suspected clinically in only one patient. No significant differences in homocysteine levels were observed between patients with multiple restenosis or requiring revascularisation, and those without restenosis and not requiring revascularisation. Plasma homocysteine does not therefore seem to be a predictive factor of post-angioplasty coronary restenosis.

Killing activities of trovafloxacin alone and in combination with beta-lactam agents, rifampin, or vancomycin against Streptococcus pneumoniae isolates with various susceptibilities to extended-spectrum cephalosporins at concentrations clinically achievable in cerebrospinal fluid.

The killing activities of trovafloxacin alone and in combination with beta-lactam agents (extended-spectrum cephalosporins, meropenem), rifampin, or vancomycin were evaluated against 20 genotypically characterized Streptococcus pneumoniae isolates for which amoxicillin MICs were >/=4 microg/ml (cefotaxime MICs, >/=4 microg/ml for six strains) at concentrations clinically achievable in cerebrospinal fluid. At 6 h the mean killing activity of trovafloxacin alone (range, 2.6 to 2.9 log(10) CFU/ml) did not vary significantly according to the susceptibility of the strains to beta-lactam agents. The activities of trovafloxacin or vancomycin added to the beta-lactam agents and the combination trovafloxacin-vancomycin were additive or indifferent. Against the ceftriaxone-resistant isolates, the killing activity of the combination of a beta-lactam agent and trovafloxacin did not differ significantly from that of a beta-lactam agent and vancomycin.

[MRI quantification of regional variations of left ventricular parietal stress in normal subjects]. / Quantification par imagerie par résonance magnétique des variations régionales de la contrainte pariétale du ventricule gauche chez le sujet normal.

The object of this study was to analyse regional variations in end systolic left ventricular wall stress in normal subjects using three-dimensional magnetic resonance imaging (MRI) with excellent spatial resolution. Eight to 12 contiguous short axis sections of the left ventricle were acquired from the apex to the base in apnoea with a rapid echo-gradient sequence in 15 healthy volunteers. The end systolic wall stress was calculated by three methods: Grossman's formula (CR) using the wall thickness and radius of curvature, Janz's formula (CS) using the surfaces, and a three-dimensional approach (C3D) providing a precise calculation of the radius of curvature. The values of wall stress obtained by CS and CR were lower (p < 0.001) at the apex (3.2 and 3.3 10(3) newton/m2 respectively) than at the base (6.9 and 7.1 10(3) newton/m2). There was no difference between the base and apex with the C3D method (8.0 and 9.0 10(3) newton/m2 respectively, NS). The same results were observed at the inferior, lateral, anterior and septal segments with an increase at the base using the CS and CR formulae, the C3D remaining homogeneous in the left ventricle except for the interventricular septum. The lateral wall stress was significantly lower with respect to the interventricular septum in all sections from the apex to the base, irrespective of the method of calculation used. The differences in regional wall stress from the base to the apex reported in healthy subjects seem to be related to an underestimation of left ventricular wall thickness and an underestimation of the radius of curvature rather than to a physiological phenomenon.

Regional assessment of wall curvature and wall stress in left ventricle with magnetic resonance imaging.

Left ventricular functional abnormalities are associated with regional increases of wall stress and modifications of wall curvature. This study describes the integration of the short-axis and long-axis wall curvatures for determining peak systolic wall stress. Quantification was realized with cine magnetic resonance imaging (MRI) from the location of the endocardial and epicardial borders of the left ventricle on pairs of consecutive short-axis sections. Fifteen normal volunteers were subjected to cine MRI, and different methods of calculating peak systolic wall stress were compared. A short-axis analysis showed a 55 +/- 13% increase of the circumferential mean of the peak systolic wall stress between apical and basal sections. Regarding the curvature, no significant increase of wall stress was observed except on the septal wall (31 +/- 18%). Short-axis studies proved to be insufficient for determining the regional variations of left ventricular wall stress and for providing normal reference values for the location of abnormal regions in patients.