[Cardiac decompensation after an adenectomy for primary hyperparathyroidism: hypocalcemic cardiopathy or cascade effect?]. / Décompensation cardiaque après adénectomie pour hyperparathyroïdie primaire: cardiopathie hypocalcémique ou effet de cascade?

A 42 year old woman presented with an auricular tachyarrhythmia as well as a congestive cardiac failure ascribed to a viral myocarditis, two months after an adenectomy for primary hyperparathyroidism. Serum calcium was low whereas parathormone serum was increased suggesting a "hungry bone syndrome". The left ventricular dysfunction persisted for a long period even after normalization of the serum calcium. The contributory role of hypocalcemia in unexplained or refractory heart failure is reviewed. The eventuality of a cascade effect is evoked.

Minocycline-induced pericardial effusion.

OBJECTIVE: To describe a reversible hypersensitivity reaction characterized by pericardial effusion and acute mixed liver injury in a woman treated with minocycline. CASE SUMMARY: A 39-year-old white woman developed dyspnea and chest pain with pericardial effusion on echocardiography approximately 20 days after starting minocycline treatment. Additional manifestations consisted of eosinophilia and liver injury. No lung, skin, or joint involvement was noted; antinuclear antibody testing was negative. DISCUSSION: Minocycline has been associated with rare but severe hypersensitivity reactions and autoimmune disorders, generally involving the lungs, skin, or joints. We observed a patient with an unusual minocycline-induced reaction with pericardial effusion and acute mixed liver injury. The number of spontaneously reported cases in national and international databases indicates that minocycline-induced pericardial effusion is very rare as a main clinical manifestation. CONCLUSIONS: Clinicians should be aware of the possibility of pericardial effusion without lung, skin, or joint involvement as an adverse effect of minocycline.

[Dynamic three-dimensional cardiac reconstruction by transesophageal echocardiography. A clinical experience apropos of 100 cases]. / Reconstruction tridimensionnelle dynamique du coeur par échocardiographie transoesophagienne. Expérience clinique à propos de 100 cas.

Three-Dimensional (3D) echocardiography was performed during routine transesophageal examinations in 100 patients to identify the most promising applications. The approach used was based on the integration of multiple two-dimensional images recorded with a multiplane probe to achieve 3D reconstruction. A series of 90 cardiac cycles was recorded from a fixed position during computer-controlled rotation of the transducer. The images were digitized, then reorganized according to their spatial and temporal location. The cardiac structures were then represented dynamically in three dimensions. In 100 patients referred for transesophageal echocardiography, the 3D reconstruction provided good quality images, under new angles, such as the view of the atrial aspect of the mitral valve as seen from the roof of the left atrium. This method was particularly well suited to assess mitral valve prolapse or stenosis. The spatial extent, direction and number of jets of mitral regurgitation were easily appreciated throughout systole, as were the regurgitant jets of mechanical prosthetic valves. However, the sensitivity of the 3D method was not as good as 2D echocardiography for detecting bacterial vegetations in cases of infective endocarditis. On the other hand, the determination of the precise localization of infectious, degenerative and tumoral lesions and their size were facilitated by 3D reconstruction. The authors conclude that 3D echocardiography is applicable in routine practice and the complementary information provided in certain cardiac diseases should help management of these patients.

The influence of coronary collateral flow on the assessment of myocardial perfusion by videodensitometry.

OBJECTIVES: Coronary collateral flow often mitigates the effects of coronary artery obstruction and has a significant impact on the prognosis of patients with coronary artery disease. In the presence of variable degrees of coronary collateral flow, digital radiographic assessment of myocardial blood flow has not been quantitatively validated. METHODS: A distal coronary arterial collateral path was created into the left anterior descending coronary artery (LAD) bed in 8 anesthetized pigs. Both LAD and collateral paths were pump-perfused and corresponding flows measured. A number of commonly used digital indices and parametric images of myocardial perfusion were then extracted from the sequence of images filmed before and during the injection of contrast. Data were acquired at 5 levels of total flow (LAD flow + collateral flow): 100, 85, 70, 55 and 40% of maximally vasodilated, baseline flow. At each level of total flow, data were acquired at 4 levels of collateral flow ratios (collateral flow/total flow): 0, 10, 25 and 50%. RESULTS: Regional percent segment shortening, reflecting myocardial blood flow, decreased as total flow fell, and remained unaltered when coronary collateral ratio alone was altered without change in total flow. On the other hand, linear regression between total flow and digital indices at 10, 25 and 50% coronary collateral flow ratios, compared with 0%, showed a successive and significant downward displacement, documenting an underestimation of flow by all digital indices in the presence of collateral flow. CONCLUSIONS: In the absence of a collateral pathway and during maximal coronary vasodilation with adenosine, digital radiographic indices of myocardial perfusion, based upon indicator dilution theory, show a relatively good correlation with regional transmural myocardial blood flow. However, due to underestimation of total transmural blood flow, these indices have limited utility when myocardial perfusion is provided in part by a collateral pathway. The effect is probably related to an alteration in the regional vascular volume into which iodinated contrast is injected.

Hemodynamic comparison of Medtronic intact bioprostheses and bileaflet mechanical prostheses in aortic position.

Hemodynamic properties of both bioprostheses and mechanical valves have improved over the years, however, direct comparison between second-generation porcine and bileaflet valves is rare. Therefore, by the mean of Doppler echocardiography, we determined hemodynamic performances in 45 patients with Medtronic Intact bioprostheses in the aortic position and in 67 patients with bileaflet mechanical valves. Differences in pressure gradients between the two groups were essentially attributable to differences in annulus size. Indeed when the transvalvular gradient was stratified according to annulus size, mean values were no longer significantly different between Medtronic Intact porcine valves and bileaflet mechanical valves for each annulus size. In conclusion, Medtronic Intact bioprostheses in the aortic position exhibit similar hemodynamic characteristics compared to bileaflet mechanical valves.

[Diagnosis and treatment of cerebrovascular accidents of cardioembolic origin]. / Investigations et traitement des AVC d'origine cardio-embolique.

Compared to the normal population, patients with atrial fibrillation are at a significantly enhanced risk for cerebrovascular insults, in particular when the fibrillation is of recent occurrence, chronic rather than paroxysmal, and when it is associated with cardiopathy. Several studies have documented the efficacy of anticoagulation in prevention of cerebrovascular insults. Aspirin may be a valid alternative in young patients without cardiopathy; however, anticoagulation is more effective in patients which have experienced thromboembolism. In elderly patients (over 75 years) the situation is unclear, because the favorable effects of anticoagulation are offset by an increased risk for intracerebral hemorrhage. The treatment must thus be individualized by assessment of a risk/benefit ratio.

[Physical exercise and its effects on the cardiovascular system in elderly subjects]. / L'exercice physique et ses effets sur le système cardiovasculaire chez le sujet âgé.

Physical capacity and exercise tolerance decrease in the elderly because of derangements of the cardiovascular and musculoskeletal systems. It is increasingly apparent that many of these alterations are not necessarily connected to ageing but rather to physical inactivity. Rehabilitation programs adapted to the individual capacities of each patient permit prevention and even reversal of organic and functional deficits of the two systems, which are sometimes at the onset of serious invalidity. The recognition of the usefulness of such programs should lead the practitioner to persuade his elderly patients to sustain a physical activity adapted to their state of health.

Intravascular ultrasound imaging of coarctation of the aorta: animal and human studies.

Although the use of balloon dilation for treatment of native and recurrent coarctation of the aorta (coA) has become widespread, the optimal balloon size and postdilation vessel wall changes remain undetermined. Intravascular ultrasound (IVUS) imaging has emerged as a an important adjunct in the treatment and follow-up of patients with coronary artery and peripheral vascular lesions, and has been used for evaluation in a limited number of patients with CoA. We used a combination of balloon dilation/ultrasound imaging catheter in animals with experimentally-induced CoA. We used a combination balloon dilation/ultrasound imaging catheter in animals with experimentally-induced CoA . This technique provided real-time data regarding aortic wall morphology and luminal diameter during balloon angioplasty of the CoA. In humans, we used IVUS to study CoA before and after both transcatheter and surgical therapy. IVUS was more sensitive than angiography in the detection of intimal tears post-balloon dilation and in the evaluation of vessel wall changes and remodelling observed at follow-up after relief of CoA. IVUS may provide valuable information regarding vascular wall changes that predict aneurysm format ion, restenosis, or a successful result after balloon dilation.

Coronary angiography in octogenarians: results and implications for revascularization.

PURPOSE: To determine the risks and the consequences of coronary angiography performed on octogenarians with symptomatic coronary artery disease. PATIENTS AND METHODS: In order to define angiographic findings, procedural complications, and therapeutic consequences, a retrospective evaluation was made of 115 consecutive patients with angina, aged 80 or above, who underwent coronary angiography in our institution between 1988 and 1992. RESULTS: In all, 115 patients (68 men) aged 82 +/- 2 years, 70% with unstable angina, underwent coronary angiography corresponding to 1.4% of all the procedures performed between 1988 and 1992. Three-vessel or left main coronary artery disease, or both, was found in 42% of cases, but this proportion decreased over the years. Revascularization by means of percutaneous transluminal angioplasty (PTCA) or bypass grafting followed angiography in 54% of cases. Use of revascularization has markedly increased, from 33% in 1988 to 64% in 1992 (P < 0.05), and now tends to be performed more often by PTCA. Eight patients (7%) suffered minor periprocedural complications and 8 patients (7%) died in the hospital, but none of the deaths was directly related to the diagnostic procedure itself. At follow-up (28 +/- 16 months), 68% and 44% of the survivors were free of angina after revascularization and medical treatment, respectively (P < 0.05), and there was a nonsignificant trend for better survival after revascularization. Of the survivors, 80% were able to pursue an independent life. CONCLUSIONS: Coronary angiography may be done in symptomatic octogenarians with an acceptably low complication rate. Following diagnostic evaluation, revascularization procedures are performed in an increasing proportion of patients, and despite a relatively high procedural complication rate, they result in definite symptomatic improvement.

[Remodeling of the left ventricle following myocardial infarction: physiopathology and prevention]. / Le "remodeling" du ventricule gauche après infarctus du myocarde: physiopathologie et prévention.

The degree of left ventricular dilatation occurring after myocardial infarction is a major prognostic factor. Left ventricular remodeling is characterized by early expansion of the infarcted region and predominantly excentric hypertrophy of the noninfarcted myocardium, resulting in left ventricular cavity dilatation. Remodeling is most pronounced in large anterior infarctions. Recent evidence indicates that remodeling is amenable to treatment. Several randomized studies have demonstrated that long-term administration of converting enzyme inhibitors not only reduces left ventricular enlargement but also lowers morbidity and mortality after myocardial infarction.

[Hypersensitivity myocarditis. A case of myocarditis following drug administration]. / Hypersensitivitätsmyokarditis. Ein Fall von Myokarditis nach Medikamenteneinnahme.

Based upon the findings of eosinophilia and concomitant ECG changes, hypersensitivity myocarditis was diagnosed in a patient who had been given longstanding antibiotic therapy. With cessation of drug treatment the disease resolved spontaneously.

[Role of transesophageal echocardiography in the diagnosis of cardiac disorders]. / Apport de l'échocardiographie transoesophagienne dans le diagnostic des affections cardiaques.

Transesophageal echocardiography provides a new window for ultrasound examination of the heart. The approach allows ultrasonic access to the heart in patients with transthoracic images of inadequate quality. Furthermore, transesophageal examination may provide information additional to that from the conventional transthoracic approach in the search for lesions including complications of endocarditis, mitral prosthesis dysfunction, aortic dissection, embolism of cardiac origin and selected cardiac malformations.

[Role of echocardiography in the diagnosis of aortic dissection]. / Place de l'échocardiographie dans le diagnostic de la dissection aortique.

Since the introduction of transesophageal transducers, Doppler echocardiography allows to detect aortic dissection with high sensitivity. The extent of the dissection can be determined accurately and the possibility of conducting the examination at bedside is particularly advantageous. Caution is advisable in interpreting doubtful observations in the distal part of the ascending aorta, which often ist incompletely visualized.

Outcome after acute myocardial infarction in patients with prior coronary artery bypass surgery.

Little is known concerning the influence of remote prior coronary artery bypass grafting (CABG) on the outcome of patients with acute myocardial infarction (AMI). Therefore, this study evaluated 2,494 patients with AMI of whom 219 (8.8%) had a history of CABG a mean of 7.1 +/- 3.7 years before the index AMI. Compared with all other patients, those with a history of CABG had an increased prevalence of a history of prior AMI (153 [70%] vs 547 [24%]), congestive heart failure (48 [22%] vs 236 [10%]), and angina pectoris (165 [75%] vs 787 [35%]), all p < 0.001. There was no difference in age, but patients with prior CABG were more often men (192 [88%] vs 1,702 [75%], p < 0.001). During the hospitalization for AMI, patients with prior CABG had more recurrent ischemic pain (100 [46%] vs 732 [32%, p < 0.001]), and more frequently developed non-Q-wave AMI (72 [33%] vs 514 [23%], p < 0.01). In-hospital mortality did not differ among patients with or without prior CABG (15 [7%] vs 195 [9%]). At hospital discharge, more patients with prior CABG had complex ventricular ectopic activity on 24-hour ambulatory electrocardiographic monitoring (48 of 74 [65%] vs 327 of 797 [41%], p < 0.0001), and radionuclide ejection fraction < 0.45 (53 of 99 [54%] vs 430 of 1,024 [42%], p < 0.01). Among patients undergoing coronary angiography during the first 2 months, multivessel coronary artery disease was more prevalent among patients with prior CABG (78 of 107 [73%] vs 508 of 959 [53%], p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Assessment of blood flow in hart and large vessels using Doppler color flow mapping]. / La cartographie du flux sanguin dans le coeur et les gros vaisseaux par Doppler couleur.

Two-dimensional echocardiography allows the noninvasive assessment of the morphology and the movement of cardiac structures, including valves and ventricular walls. Color Doppler flow imaging presents a spatial visualization of blood flow, superimposed on two-dimensional echocardiographic images. The color indicates the direction of flow. Turbulent flow is readily identified by the 'mosaic pattern' of the color flow signal. The method facilitates the detection and localization of obstruction to flow, valvular regurgitation or a shunt.

Evaluation of inotropic effect of endothelin-1 in vivo.

The vasoconstrictive peptide endothelin-1 (ET-1) has been reported to exert a very important positive inotropic effect in vitro. To assess the effect of ET-1 on myocardial contractility in vivo, we compared the effect of intracoronary infusion of 10(-8) M ET-1 (constant coronary blood flow) to that of 10(-8) M dobutamine in 8 swine. ET infusion did not produce changes in segmental shortening (control vs. drug, mean +/- SD): 33.8 +/- 14.3 vs. 30.8 +/- 12.1%, shortening velocity: 10.3 +/- 4.3 vs. 10.7 +/- 4.5 mm/s, or maximum +dP/dt: 1,691 +/- 701 vs. 1,772 +/- 773 mm Hg/s, whereas dobutamine infusion induced an important increase in these measurements; segmental shortening: 36.9 +/- 14 vs. 48.4 +/- 18.8%, shortening velocity: 10.1 +/- 2.6 vs. 14.7 +/- 4.5 mm/s, and maximum +dP/dt: 2,041 +/- 567 vs. 2,389 +/- 765 mm Hg/s (all p less than 0.05). Mean myocardial blood flow assessed by microspheres was unchanged by ET-1 despite a marked increase in coronary artery pressure (88.6 +/- 12.9 vs. 157 +/- 8.8 mm Hg, p less than 0.001). Regional infusion of ET-1 at a dose provoking extensive coronary vasoconstriction does not induce any change in regional or global myocardial function in swine.

Intraluminal ultrasound imaging through a balloon dilation catheter in an animal model of coarctation of the aorta.

BACKGROUND: Controversy still exists over the optimal balloon size, extent of vascular disruption, and long-term results of balloon dilation therapy for coarctation of the aorta. Intravascular ultrasound imaging has been used in patients with coronary artery disease to provide further insight into the anatomy of atherosclerotic lesions and the results of angioplasty and atherectomy. Initial observations of the results of balloon dilation of coarctations with intravascular ultrasound imaging have shown prominent dissections of the inner vascular layers that are often not detected by angiography. The purpose of this study was to test a new transballoon catheter ultrasonic imaging system capable of on-line direct visualization of lumen diameter and vessel wall structure for imaging before, during, and after dilation in an acute animal model of aortic coarctation. METHODS AND RESULTS: Abdominal aortic coarctations were created surgically in three 14-19-kg mongrel dogs by using Teflon gauze ties. The 6.8F ultrasound balloon catheter was placed percutaneously in the right femoral artery through a 9F sheath. Ultrasound imaging allowed measurement of the coarctation diameter, characterization of the vessel wall structure, localization of the stenosis, and placement of the midportion of the balloon at the narrowest area. Imaging through the balloon was performed through several dilations (five to eight per animal), and after balloon deflation, it provided information on postdilation diameter, intimal tears, long-segment dissections, and intramural thrombi, findings that were confirmed at postmortem examination. CONCLUSIONS: The results of this study demonstrate that imaging with a new intraballoon ultrasound device is feasible during inflation to therapeutic dilation pressures; it allows visualization of the changes in diameter and vascular wall structure after serial dilations without having to recross the obstructed area. Adaptation to larger balloon sizes and lower frequencies should make this system applicable to interventional catheterizations in patients with congenital cardiac and vascular lesions.

Abnormal left ventricular filling pattern in patients with single vessel coronary artery disease: effect of angioplasty.

To study the effect of coronary angioplasty (PTCA) on left ventricular (LV) diastolic filling, mitral Doppler flow tracings of 15 patients with isolated stenosis of the left anterior descending coronary artery (LAD) and normal systolic LV function were recorded before PTCA as well as 24 h and 3 months after successful PTCA. Compared to control subjects, patients with LAD stenosis exhibited an abnormal LV filling velocity pattern before PTCA. The day following PTCA, the ratios of the early peak diastolic velocity to the peak late diastolic velocity and of the time velocity integral of the early diastolic filling phase to the time velocity integral of the late diastolic filling phase were unchanged. Despite the absence of clinical evidence of restenosis, LV filling remained abnormal 3 months after PTCA. The results suggest that abnormalities of the LV filling velocity in patients with isolated LAD stenosis and normal systolic function may persist as long as 3 months after PTCA.