[Perspectives in cardiology: evidence of efficacy in atrial fibrillation and hopes in acute coronary syndrome]. / Perspectives en cardiologie : une efficacité démontrée dans la fibrillation atriale, des espoirs dans le syndrome coronaire aigu.

New antithrombotic drugs, antithrombin or anti Xa, will probably be very useful in cardiology. Two directions are interesting: in one hand atrial fibrillation, in which the unmet need concern drugs as effective as vitamine K antagonists but easier to use. On the other hand, in acute coronary syndrome the situation is different, there are many antithrombotic drugs available but there is still a place for innovative drugs which could provide a gain in terms of efficacy, but the hemorrhagic risk must remain acceptable. In atrial fibrillation, the RELY trial, performed in 18,113 patients has demonstrated, as compared to warfarin, a non inferiority of dabigatran at the dose of 110 mg BID and a superiority of dabigatran at 150 mg BID with a reduction of 34% of the primary endpoint, i.e.stroke and systemic embolism.

[Ventricular tachycardia revealed by a left ventricular non-compaction]. / Tachycardie ventriculaire révélant un ventricule gauche non compacté.

We report a case of a 55-year-old woman who has a non-compaction of the left ventricular myocardium diagnosed after a cardiac arrest due to a polymorphic ventricular tachycardia. The patient was implanted with a cardioverter-defibrillator. A review of literature of this recently described cardiopathy is done.

[Uterine carcinosarcoma in a teenager: report of a case macroscopically mimicking rhabdomyosarcoma]. / Le cas clinique du mois. Carcinosarcome utérin chez une adolescente: a propos d'un cas simulant macroscopiquement un rhabdomyosarcome.

Uterine carcinosarcoma (malignant mixed mullerian tumor) is uncommon. We report the case of a 17-year-old patient who complained of pelvic pain and abnormal genital bleeding, and had a voluminous hemorrhagic tumor protruding through the vaginal os. Hysterectomy was performed. The histopathologic and immunohistochemical evaluation led to the diagnosis of uterine carcinosarcoma. Adjuvant chemotherapy was given. In spite of the surgical treatment, the evolution was fatal with widespread metastases. From data of the literature, we discuss the diagnosis, histogenesis and treatment of this rare tumor.

[Ectopic atrial tachycardia complicating a congenital left atrial aneurysm: value of an electro-anatomical mapping system]. / Tachycardie atriale ectopique compliquant un anévrysme congénital de l'auricule gauche: apport d'un système de cartographie électro-anatomique.

The authors report the case of a patient with a congenital left atrial aneurysm complicated by ectopic atrial tachycardia treated successfully by surgery. Transoesophageal echocardiography and magnetic resonance imaging provided accurate measurements of the aneurysm and its anatomical relationships. Three-dimensional electro-anatomical mapping with the CARTO, system (Biosense) confirmed the shape and dimensions of the aneurysm. The system showed the electrically mute zones and the ectopic focus situated just beyond the aneurysmal neck. Surgical ablation confirmed the morphological and functional data of the imaging techniques and the patient was definitely cured.

[Dissection of the aorta complicated by aorto-pulmonary fistula]. / Dissection aortique compliquée de fistule aorto-pulmonaire.

The authors report the case of chronic dissection of the aorta presenting with congestive cardiac failure. The diagnosis was made for the first time by transoesophageal echocardiography which showed both the dissection of the aorta and its fistulalisation into the pulmonary artery. Aortography confirmed the diagnosis. The patient underwent surgery which consisted of suture of the fistula and replacement of the ascending aorta with a prosthetic tube. The outcome was favourable after 8 months follow-up.

[Validation of the measurement of cardiac output by acoustic quantification in patients with severe congestive heart failure]. / Validation de la mesure du débit cardiaque par la méthode de quantification acoustique chez le patient insuffisant cardiaque sévère.

The technique of acoustic quantification (AQ), because of its automatic detection of the contours, enables left ventricular volumes to be calculated in real time using the technique of disk summation. The objective of the study was to evaluate the reliability of cardiac output (CO) measurements obtained with AQ based on left ventricle volumes in patients with severe congestive heart failure. Seventeen patients, mean age 68 +/- 11 years, NYHA stage IV, in sinus rhythm and without significant valve regurgitation were enrolled prospectively. CO, measured simultaneously by 2-dimensional echocardiography (2DE), pulsed Doppler echocardiography (DOP) and AQ, was compared to the thermodilution technique (TD) data. CO, measured by AQ, was highly correlated with TD (r = 0.875; p < 0.001) with a small bias (-0.05 l/min). DOP and 2DE were also well correlated with TD (r = 0.835 and r = 0.701, respectively). Concerning ventricular volume measurement, AQ was well correlated with 2DE (for telediastolic, r = 0.892, and telesystolic volumes, r = 0.874). However, telesystolic (bias, +36.6 +/- 35 ml) and telediastolic volumes (bias, +35.6 +/- 35 ml) were overestimated. We conclude that AQ is a reliable technique, able to estimate CO precisely in patients with severe congestive heart failure. On the other hand, both telesystolic and telediastolic volumes were overestimated.

Assessment of left ventricular regional wall motion by color kinesis technique: comparison with angiographic findings.

The analysis of segmental wall motion using two-dimensional (2-D) echocardiography is subjective with high interobserver variability. Color kinesis is a new technique providing a color-encoded map of endocardial motion. We evaluated the accuracy of color kinesis and 2-D for assessment of regional asynergy compared with left ventricular angiography as a reference method. Fifteen patients admitted for myocardial infarction were studied by echocardiography the day before left ventricular angiography. The left ventricle was divided into seven segments. Each segment was classified by two independent observers as normal or abnormal in 2-D and color kinesis. Accuracy of color kinesis and 2-D was evaluated and compared to left ventricular angiography. Color kinesis is significantly superior to 2-D for all seven segments (mean 0.80/0.68, P = 0.05), except for the septum (0.67/0.60, P = NS). Interobserver variability studied by chi-square statistic is lower with color kinesis (0.70) than with 2-D (0.57). We conclude that these data suggest that color kinesis is a useful method for assessing systolic wall motion in all segments, except the septum and for improving the accuracy of segmental ventricular function and interobserver variability.

[Left ventricular kinetics studied by the color kinesis method. Comparison of bidimensional echographic and angiographic data]. / Etude de la cinétique ventriculaire gauche par la technique du color kinesis. Comparaison aux données échographiques bidimensionnelles et angiographiques.

The object of this study was to assess the value of CK in the evaluation of left ventricular wall motion. Fifteen coronary patients aged 56 +/- 12 years were included: 8 patients were examined after acute myocardial infarction and 7 after unstable angina with a history of myocardial information. The left ventricle was divided into 7 segments after a modified Heger model, excluding the basal septal and basal lateral segments not seen on angiography. The left ventricular wall motion was assessed in two-dimensional echocardiography (2DE) and colour kinesis (CK) by two observers and compared with the results of left ventriculography, considered the reference method. Over all the 105 segments studied (7 segments for each of the 15 patients), CK was significantly better than 2DE (80% of segments correctly evaluated by CK vs 68% by 2DE, p < 0.05). Colour kinesis significantly improved the study of all segments except the interventricular septum (67% vs 60%, p = NS). The inter-observer variability in 2DE and CK evaluated over 135 segments (9 per patient) by the kappa was improved by colour kinesis (0.57 in 2DE, 0.7 in CK). The authors conclude that CK enables evaluation of left ventricular wall motion with greater precision and less inter-observer variability.

Comparative value of Doppler echocardiography and cardiac catheterization in the decision to operate on patients with aortic stenosis.

With the use of Doppler echocardiography, severity of valvular stenosis, etiology and type of valve lesions, and left ventricular function can be assessed accurately in patients with aortic stenosis. The purpose of this study was to compare the value of noninvasive clinical and Doppler echocardiographic findings, with cardiac catheterization, in the management decision-making for patients with aortic stenosis. One hundred and seventy consecutive patients with aortic stenosis who underwent cardiac catheterization and Doppler echocardiography were prospectively studied. A decision to operate, not operate or remain uncertain was made independently by experienced cardiologists given clinical information in combination with either Doppler echocardiographic (group I) or cardiac catheterization (group II) data. The severity of aortic stenosis agreed between Doppler echocardiography and cardiac catheterization in 168 patients (98.8%), and disagreed in two patients. There was agreement on clinical decision to operate or not operate between Group I and Group II in 160 patients (94.1%) and a discrepant decision in only two patients (1.1%). In eight patients (4.7%) with poor echogenecity or with discordance between clinical and echocardiographic data, the decision made by group I remained uncertain. We conclude that in a large majority of patients with aortic stenosis, Doppler echocardiographic assessment provides the same management decision reached by cardiac catheterization findings.

Single-lead VDD pacing: long-term experience with four different systems.

BACKGROUND: Previous multicenter studies have shown that single-lead VDD pacing systems provide satisfactory atrial-triggered ventricular pacing at middle term for treatment of atrioventricular block without sinus dysfunction. However, we lack data on long-term results obtained with different VDD systems implanted in a large number of patients from a single center. METHODS: One hundred fifty patients (76 +/- 11 years) with second- or third-degree atrioventricular block (n = 147) or symptomatic hypertrophic cardiomyopathy (n = 3) without sinus dysfunction were paced with four different VDD pacing systems able to sense the atrium and to pace the ventricle. Atrioventricular synchronization was assessed during follow-up by ECG and Holter monitoring. RESULTS: Mean value of the atrial electrogram during implantation was 2.01 +/- 0.94 mV without any differences among the four systems. With a mean follow-up of 24 +/- 11 months, 95% of patients remain paced in VDD mode, whereas 5% have been reprogrammed in VVI or VVIR mode for permanent atrial fibrillation or loss of atrial sensing; 96% of patients with sinus atrium have atrioventricular synchronization >90% and 94% of patients have >95%, without significant difference between the four systems used. CONCLUSIONS: These different single-lead VDD systems can provide satisfactory long-term atrioventricular synchronization; results are comparable to those obtained with conventional DDD pacing systems with two leads.

[Diagnostic value of echocardiography and thoracic spiral CT angiography in the diagnosis of acute pulmonary embolism]. / Valeur diagnostique de l'échographie cardiaque et de l'angioscanner thoracique hélicoïdal pour le diagnostic de l'embolie pulmonaire aiguë.

The objective of this study was to define the limits of echocardiography and to evaluate thoracic spiral CT angiography (TSCTA) for the diagnosis of pulmonary embolism (PE). One hundred twelve consecutive patients, hospitalised for suspected PE, were included in this prospective study. All were investigated by pulmonary ventilation-perfusion scintigraphy (Sc) and 50 had a high probability of PE on this examination. Sc was normal in 22 patients. Forty patients were excluded because of an intermediate probability. In 50 patients with PE confirmed on Sc, transthoracic echocardiography (TTE) showed only indirect evidence of PE (intracavitary thrombus in 4% of cases). TSCTA demonstrated PE in 82% of cases and did not show any thrombus image when Sc was normal. Its negative predictive value was therefore 70% and its positive predictive value was 100%. Its sensitivity varied according to degree of perfusion defect (96% in the case of lobar lesion, 66% in the case of segmental lesion and 16% for a subsegmental lesion). Multidimensional transoesophageal echocardiography (TOE), performed in 37 of the 50 patients with PE, only revealed thrombi in the pulmonary tree in 3 patients (8%), all presenting severe PE. No thrombus was visualized on TOE in patients with non-serious PE. All thrombi observed on TOE were also demonstrated by TSCTA. In conclusion, TTE usually provides only indirect signs of PE. TOE has a poor diagnostic sensitivity for PE. TSCTA has a better sensitivity than TOE for the detection of thrombi in the pulmonary artery trunk and proximal centimetres of its two branches, but normal CT angiography cannot exclude a distal PE.

[Pulmonary embolism and thrombus trapped in a patent foramen ovale. Cure by heparin therapy]. / Embolie pulmonaire et thrombus enclavé dans un foramen ovale perméable. Guérison sous héparinothérapie.

The authors report the case of a 84-year old patient admitted to hospital for pulmonary embolism. The diagnosis was made by ventilation and perfusion pulmonary scintigraphy. Transthoracic echocardiography was performed routinely and showed a thrombus wedged across a patient foramen ovale, confirmed at transoesophageal echocardiography. Spiral thoracic computerised tomography showed thrombus in the two main pulmonary arteries and the inferior vena cava. Thrombolysis or thrombectomy under cardiopulmonary bypass, was thought to carry an excessive risk at that age and with the left-sided position of the thrombus. The alternative was therefore anticoagulation which led to dissolution of the thrombus without recurrence of pulmonary embolism or cerebrovascular accident.