Free-floating thrombus and embolic risk in patients with angiographically confirmed proximal deep venous thrombosis. A prospective study.

BACKGROUND: A free-floating thrombus (FFT) is often considered to be a risk factor for pulmonary embolism (PE), despite adequate anticoagulation therapy, in patients with proximal deep venous thrombosis. METHODS: Ninety-five patients underwent prospective assessment according to the presence (FFT group [n = 62]) or absence (occlusive thrombus group [n = 28]) of an FFT. On day 1, color venous duplex scanning, venography (reference method), perfusion lung scanning, and, if results of the lung scan were abnormal, pulmonary angiography were performed. On day 10 (range, days 9-11), the lung scan was repeated, as well as pulmonary angiography if the lung scan demonstrated impairment. A 3-month clinical follow-up visit was scheduled. Five patients were retrospectively excluded from analysis for uncertain diagnosis of FFT. Patients were treated with intravenous unfractionated heparin sodium adjusted for activated partial thromboplastin time (n = 1) or subcutaneous low-molecular-weight heparin (n = 89) (nadroparin calcium, 225 Institut Choay factor Xa inhibitory units per kilogram for 12 hours). Warfarin sodium therapy was initiated on day 3 (range, days 2-4). RESULTS: Both groups were well-matched according to age, sex, risk factors, and delay from onset of symptoms to treatment. Positive and negative predictive values of color venous duplex scanning for the diagnosis of an FFT were 91% and 55%, respectively. On admission, PE prevalence was 64% in the FFT group (40 of 62 patients) and 50% in the occlusive thrombus group (14 of 28 patients) (P = .19). Two patients were excluded on follow-up analysis (range, days 9-11) for preventive vena cava filtering (due to major bleeding in 1 and cholecystectomy in the other); the recurrent rate of PE was 3.3% in the FFT group (2 of 61 patients) and 3.7% in the occlusive thrombus group (1 of 27 patients). No symptomatic recurrent PE occurred between day 10 (range, days 9-11) and 3 months. Four patients died of evolutive neoplasm after hospital discharge. CONCLUSIONS: No higher risk for PE was observed in patients with free-floating proximal deep venous thrombosis; anticoagulant therapy should prevent recurrent PE in such patients.

Diagnosis of arrhythmogenic right ventricular cardiomyopathy by fourier analysis of gated blood pool single-photon emission tomography.

To evaluate the diagnostic performance of Fourier phase analysis of gated blood pool single-photon emission computed tomography (GBP SPECT) in arrhythmogenic right ventricular (RV) cardiomyopathy, 18 patients with confirmed arrhythmogenic RV cardiomyopathy underwent GBP SPECT and x-ray cineangiography. Results were compared with data obtained with GBP SPECT in 10 control subjects. This 3-dimensional method demonstrated good correlation with cineangiography for measurements of RV enlargement and extent of the disease; RV and left ventricular segments were analyzed with the same accuracy. Tomographic abnormalities were significant decreased RV ejection fraction, RV dilatation, nonsynchronized contraction of the ventricles, increased RV contraction dispersion, presence of segmental RV wall motion disorders and/or phase delays, and occasionally regional left ventricular abnormalities. RV-delayed phase areas were always present in our population. A scoring system with RV criteria was proposed to diagnose RV disease. Because Fourier analysis of GBP SPECT provides ventricular morphologic information for the right ventricle with the same accuracy as for the left ventricle, it may replace planar radionuclide studies. Therefore, this method is helpful in patients with a strong clinical suspicion of arrhythmogenic RV cardiomyopathy, and should be used as a screening method before right ventriculography.

Thrombolysis or heparin therapy in massive pulmonary embolism with right ventricular dilation: results from a 128-patient monocenter registry.

STUDY OBJECTIVES: To assess the potential benefit of thrombolysis in patients with massive pulmonary embolism (PE) with stable hemodynamics and right ventricular dysfunction. DESIGN: Retrospective, cohort study. SETTING: University-based, tertiary referral medical center. PATIENTS: One hundred fifty-three consecutive patients with massive PE from January 1992 to December 1997 treated with heparin or thrombolysis. MEASUREMENTS AND RESULTS: Massive PE was confirmed by perfusion lung scan or pulmonary angiography. Right ventricular dysfunction was assessed by echocardiography (right ventricular/left ventricular [RV/LV] diastolic diameter ratio > 0.6) in all patients. In order to study a homogeneous population, 64 patients treated with thrombolysis (group 1) were matched on baseline RV/LV diameter ratio to 64 patients treated with heparin (group 2). Perfusion lung scan was repeated at day 7 to day 10. Mean relative improvement in perfusion lung scans was higher in group 1 than group 2 (54% vs 42%, respectively). PE recurrences were the same in both groups (4.7%; n = 3). There were no bleeding complications and no deaths in group 2. Conversely, in group 1, 15.6% (n = 10) of patients suffered from bleeding (4.7%; n = 3 with intracranial bleeding) and 6.25% (n = 4) of them died. CONCLUSIONS: The results of this monocenter registry do not support the indication for thrombolysis in patients suffering from massive PE with stable hemodynamics and right ventricular dysfunction. Appropriate therapy in such patients still remains unknown. Further prospective randomized trials should be performed.

Localization of the ventricular preexcitation site in Wolff-Parkinson-White syndrome with Doppler tissue imaging.

PURPOSE: The objective of this study was to evaluate the ability of Doppler tissue imaging (DTI) to localize the ventricular emergence site of accessory atrioventricular pathways (Wolff-Parkinson-White syndrome). METHODS: Thirty-three patients were studied prospectively by Doppler tissue imaging (128XP and Sequoia 256 echocardiographic systems; Acuson, Mountain View, Calif) before investigation of Wolff-Parkinson-White syndrome and after radiofrequency ablation of the accessory pathways. The normal appearance of the ventricular contractions was defined in a group of 10 control subjects. The preexcitation zone was determined as a zone of maximum acceleration in "DTI acceleration mode" or as a coded contraction zone in "DTI velocity mode," at the time of the delta wave or before the onset of the QRS complex. RESULTS: The earliest ventricular activation site was correctly localized for 12 of the 15 left-sided pathways (8 anterior or anterolateral, 2 lateral or posterolateral, 2 inferior). When wall motion abnormalities were detected in the left ventricle by DTI, the left-sided localization was confirmed by electrophysiologic exploration. For the right-sided pathways, the localization was correct in only 4 of 11 cases (3 posteroseptal and 1 anterolateral). After effective ablation in all patients, the abnormalities corresponding to the electrophysiologic data disappeared totally in only 11 of 16 patients. CONCLUSION: In the presence of Wolff-Parkinson-White syndrome, DTI localizes contraction abnormalities associated with early activation of a part of the ventricle. However, the interpretation of the images remains difficult because the normal coding of the contraction of the ventricular walls depends on the incidence for which they are investigated. This noninvasive examination seems to be an effective tool for localizing the left-sided accessory pathways of the left ventricle, in particular in the anterior, anterolateral, or inferior walls.

Regional blood flow in microgravity: adaptation and deconditioning.

The objectives were to evaluate cardiac and peripheral changes induced by microgravity with and without countermeasures (CM), to assess the peripheral response to orthostatic tests (tilt, LBNP). Inflight or HDT, we used echography and Doppler to assess the left heart function and the peripheral arteries. We studied the cardiovascular system during 1) 21-d and 25-d spaceflights without CM, 2) 14.d spaceflight with "bracelets" CM, 3) 28-d HDT with and without LBNP, and 4) 30-d HDT with and without Exercise+LBNP. Similar peripheral circulation changes were noticed in both astronauts and HDT subjects without CM. There was a decrease in renal, cerebral, and femoral vascular resistances and maintenance of cerebral flow at rest, and a lack of increase in lower limb vascular resistance and abnormal flow redistribution during orthostatic tests. Conversely, with CM at rest, cerebral and renal vascular resistances stayed elevated and femoral resistance decreased, but less than without countermeasures. Lower limb vascular resistance increased normally, peripheral flows were adequately redistributed during orthostatic tests, and no orthostatic intolerance was observed. This confirms the efficiency of countermeasures (LBNP, exercise, cuffs) in preserving the vasomotor tone in most peripheral areas at rest and reducing the development of orthostatic intolerance.

Technetium-99m ECD single photon emission computed tomography in brain trauma: comparison of early scintigraphic findings with long-term neuropsychological outcome.

OBJECTIVE: The aim of this study was to assess the prognostic value of early brain scintigraphy in head injury in relation to long-term neuropsychological behavior. Twenty-four patients underwent technetium-99m (Tc-99m) ethyl cysteinate dimer single photon emission computed tomography (SPECT) within 1 month of the trauma. Scintigraphic abnormalities were evaluated both visually and semiquantitatively using the brain-to-cerebellum ratio method. The clinical neuropsychological investigation was conducted to evaluate abnormalities related to motor deficit, frontal behavior, and memory and language disorders. All patients had abnormalities on SPECT scan. One year after trauma, 14 patients (58%) had neuropsychological sequelae. The brain-to-cerebellum ratios in the left basal ganglia and brain stem were significantly decreased in patients with memory disorders (P = .03 and P = .02, respectively). Moreover, SPECT visual analysis indicated that low uptake in the basal ganglia, thalamus, and brain stem was associated with subsequent motor deficit, frontal behavior, and language and memory disorders. The authors conclude that brain SPECT can be valuable in predicting the neuropsychological behavior of survivors of severe head injury.

The value of immunoscintigraphy in the detection of recurrent colorectal cancer.

The aim of this prospective study was to determine whether anti-carcinoembryonic antigen (anti-CEA) scintigraphy is a useful additional technique in the diagnosis recurrence of colorectal cancer. Forty patients with suspected recurrence of colorectal cancer, underwent immunoscintigraphy (IS) and helical computed tomography (CT) in the 2 weeks before surgery. Surgical findings were used to evaluate the performance of the imaging techniques. Suspected areas on IS and CT were systematically explored. Helical CT was found to be superior to IS for the liver, the sensitivity and specificity of CT being 100% and 90%, respectively, vs 53% and 100% for IS. However, IS was better than CT for the detection of extra-hepatic abdominal recurrence: sensitivity and specificity of IS were 100 and 82% respectively vs 33 and 82% for CT. Seven cases of peritoneal carcinomatosis were overlooked by helical CT. Our results indicate that IS improves detection of extra-hepatic abdominal recurrence of colorectal cancer. Immunoscintigraphy is valuable as a guide to the treatment strategy and operative procedures.

The contribution of nuclear medicine and ultrasounds in cardiac surgery.

The constant progress in surgical techniques during the last few years have prepared the way for important developments in the field of noninvasive cardiac exploration. Their non-traumatic character, appreciable in diagnostic and preoperative examinations, become indipensable whenever there is a need to repeat the examination in order to evaluate the effects of a treatment or to monitor progress both in the short and long term. In order that such methods be adopted in cardiac surgery it is important that not only must they be without risk but also that the results obtained be clearly presented, if possible in the form of images, and allow a quantitative interpretation. It is necessary also that the results can be justified both by clinical experience and also by comparison with other examinations. No procedure, not even radiologic, can at the same time explore the myocardium and its perfusion, the central circulation and the cardiac haemodynamics. By reason of their respective principles, radioisotopic methods and ultrasounds tackle cardiac problems in different ways and facilitate, by appropriate choice of methods, the selection of one diagnostic response from among several. This paper contains first of all, a resume of the principal nuclear and ultrasonic techniques used together with their basic principles. Next we try to show how these non-invasive techniques, most with dynamic imaging, can assist cardiac surgery. For this, we successively look at the different pathologies, working from the exterior (pericardium) towards the interior (intracardiac structures and central circulation) and covering the different aspects of the myocardial pathology. In each case the mutual contributions of physical techniques is specified as well as the preference for either isotopic or ultrasonic methods.

[Contribution of two-dimensional echography in predicting spontaneous closure of interventricular defects in infants]. / Apport de l'échographie bidimensionnelle dans la prédiction de fermeture spontanée des communications interventriculaires du nourrisson.

The aim of this study was to assess the evolution of ventricular septal defects (VSD) with respect to their initial echocardiographic appearances: size and site. One hundred consecutive neonates under 3 months of age with a typical VSD murmur, were included in a prospective study. Malformation syndromes and associated cardiac disease were criteria of exclusion. Disappearance of the murmur was indicative of closure of the VSD. The VSDs were classified as: small (diameter less than or equal to 3 mm), medium (3 to 6 mm) and large (greater than 6 mm). Twelve children were lost to follow-up; the remainder were followed up for an average of 35 months. The VSDs were muscular (39%), membranous (37%), infundibular (2%) or unlocalised (22%). Of the muscular VSDs, 85% were small and 15% were medium-sized; 48% of membranous VSDs were small, 43% were medium and 9% large-sized. Spontaneous closure was observed in 64% of cases but this figure varied with the size and site of the VSD. The prognosis of unlocalised VSDs was excellent (100% spontaneous closures at 1 year), as was that of small muscular VSDs (89% spontaneous closures at 1 year). The prognosis of medium size muscular and small membranous VSDs was less favourable: 40% closures at 1 year, 50% closures at 2 years respectively. The closure of medium-sized membranous VSDs was slower: 7% at 2 years. It was essentially in this group and that of large-sized membranous VSDs that the surgical indications were mostly to be found. No spontaneous closures were observed in the large membranous or the infundibular VSDs.

[Echocardiographic Doppler study of left ventricular filling in the diagnosis of minimal or moderate rejection in cardiac transplantation]. / Etude du remplissage ventriculaire gauche par écho-Doppler cardiaque pour le diagnostic de rejet aigu minime ou modéré dans les transplantations cardiaques.

The study of left ventricular filling by Doppler echocardiography may be a non-invasive diagnostic method of detection of acute rejection of cardiac transplants. The aim of this study was to assess the value of the method for diagnosis of minimal to moderate rejection (grades 1 to 3 of the Billingham classification). A total of 466 Doppler echocardiographic studies were performed in 23 cardiac transplantation patients (21 men, mean age 49.3 +/- 10 years) with endomyocardial biopsy as the reference method for the diagnosis of rejection. Over a follow-up period of 18.5 +/- 10 months, 22.7% of biopsies showed minimal or moderate rejection. The Doppler measurements of the isovolumic relaxation period and peak early diastolic (E) velocity with respect to the mitral velocity-time integral were no different in cases of acute rejection. The only difference observed was in the mitral half-pressure time which was much shorter in cases of rejection. However, after drawing a ROC graph, the accuracy of this parameter was insufficient for diagnosing rejection irrespective of the threshold of variation considered (23% sensitivity for a 20% shortening and 36% sensitivity for a 10% shortening). The authors conclude that Doppler echocardiographic study of left ventricular filling is of limited value for the diagnosis of acute minimal or moderate rejection in cardiac transplant patients. The half-pressure time may be a useful complement to endomyocardial biopsy or when biopsy investigations are performed less frequently.

[Comparative efficacy and risks of low molecular weight heparins and thrombolysis in massive pulmonary embolism without cardiogenic shock]. / Efficacité et risques comparés des héparines de bas poids moléculaire et de la thrombolyse dans l'embolie pulmonaire massive sans état de choc. A propos de 62 patients.

The aim of this retrospective study was to assess pulmonary reperfusion by scintigraphy, the risks of recurrent embolism and of bleeding complications at the 7th day and 3rd month in 2 groups of patients admitted to hospital for massive pulmonary embolism without cardiogenic shock treated by intravenous thrombolysis (Group I) and by subcutaneous low molecular weight heparin (Group II) paired by Miller's index. The basal characteristics of the two groups, each comprising 31 patients, were comparable with respect to the severity of the pulmonary embolism with an average global scintigraphic defect of 40.6 +/- 13.5% in Group I and 39 +/- 13.7% in Group II. The scintigraphic changes at the 7th day were comparable with a relative improvement of 55 and 51% respectively and at 3 months of 74% in both groups. There was no significant difference in terms of recurrence of embolism (3 versus 0% at the 7th day and 3% in each group at 3 months) or of bleeding complications (13 and 10% at the 7th day and 10 and 6% at 3 months respectively). Low molecular weight heparin seems to be as effective as intravenous thrombolysis for the treatment of massive pulmonary embolism without shock. This result requires confirmation by a large scale prospective randomised trial.

[Contribution of transesophageal echocardiography to the diagnosis of pulmonary embolism]. / Apport de l'échocardiographie transoesophagienne au diagnostic de l'embolie pulmonaire.

Between September 1992 and August 1993 transoesophageal echocardiography was undertaken in 30 patients with clinical and scintigraphic signs of pulmonary embolism. The diagnosis was confirmed by pulmonary angiography (1 patient had failure of venous puncture; 1 patient refused the investigation). The aim of this study was to assess the tolerance and to determine the diagnostic value of transoesophageal echocardiography in patients with suspected pulmonary embolism (PE). Two groups of patients were identified: Group 1: presence of thrombus in the pulmonary artery on transoesophageal echocardiography and group 2: absence of visible thrombus. The produce was well tolerated in all patients. In 21 cases (group 1) 21 thrombi were observed in the right pulmonary artery and 4 thrombi in the left pulmonary artery. The appearances were those of a mobile venous thrombosis in 20 cases (91%) and of clearcut amputation of the proximal segment of the right pulmonary artery in 1 case. No thrombus was detected in 9 patients (group 2). In group 1, the first clinical signs occurred 12 +/- 12 days and the latest signs 2 +/- 3 days before the investigation. One patient had a history of chronic bronchitis. Two patients had a history of PE but with no sign of chronic post-embolic cor pulmonale. Twenty patients underwent pulmonary angiography. Miller's index was 71 +/- 9% and obstruction of proximal pulmonary arteries was observed in 20 patients. In group 2, the PE was confirmed at angiography in 8 cases. The first clinical signs dated from 27 +/- 54 days and the latest signs were observed 6 +/- 4 days before investigation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Angiography of right ventricular volume after surgical repair of tetralogy of Fallot]. / Etude angiographique des volumes du ventricule droit après correction chirurgicale de la tétralogie de Fallot.

Right ventricular volume and ejection fraction were measured in children who had undergone surgical repair for tetralogy of Fallot with excellent results. Fourteen children who had been operated upon at the age of 3 +/- 2.6 years had cardiac catheterization and cineangiography of the right ventricle at the age of 4.6 +/- 2.7 years. Right ventricular volumes were determined from single-plane cineangiography in right anterior oblique projection (Ferlinz method). Eleven children with a normal right ventricle served as controls. Dual projection cineangiography of the pulmonary artery enabled the pulmonary insufficiency to be divided into 4 grades. Echocardiography with colour-coded doppler velocimetry was also performed, showing the absence of residual shunt and of tricuspid, mitral and aortic valve abnormalities. The extension of pulmonary regurgitation flow to the right ventricle was analysed and divided into 4 grades. Pulmonary insufficiency was present in all patients; it was graded 1 or 2 by the two methods in 8 cases (group A) and 3 or 4 by one or the other of the two methods in 6 cases (group B). In 7 patients of group A the operation had included the insertion of a small patch to widen the pulmonary channels (infundibulum alone in 3 cases, transvalvular in 4 cases); in 5 patients of group B a large infundibulo-pulmonary transvalvular patch had been installed. The right ventricular systolic pressure was always below 50 mmHg (mean: 40.9 +/- 6.7 mmHg) and the systolic gradient between right ventricle and pulmonary artery never exceeded 30 mmHg (mean: 14.9 +/- 6.2 mmHg).(ABSTRACT TRUNCATED AT 250 WORDS)

[Evolution of ventricular septal defects. Relation to echocardiographic anatomy]. / Evolution des communications interventriculaires membraneuses. Relation avec l'anatomie échocardiographique.

The aim of this study was to analyse the outcome of membranous ventricular septal defects (VSD) with respect to the echocardiographic data obtained during the first year of life. This retrospective series included patients born between January 1st 1986 and December 31st 1995, in the Indre et Loire department, with membranous ventricular septal defects alone or associated with minor abnormalities. The initial echocardiography, an echocardiography performed 2 to 6 months later, one a year later and the final echocardiography were compared. Three groups of VSD were constituted according to their diameter: group I (< or = 3 mm), group II (3-6 mm), and group III (> 6 mm). Depending on the outcome, the patients were classified as spontaneous closure (group A), surgical closure (group B) or persistent VSD (group C). The population comprised 84 children. There were 6 spontaneous deaths, three of which were unexplained, and 7 children were lost to follow-up. After the initial echocardiography, the VSD were classified as group I (38%), group II (26.2%) and group III (35.7%). After the second echocardiogram, 24 VSD changed group (31.5%), by increase (N = 10) or decrease (N = 14) in diameter. Aneurysms of the membranous septum were observed during the first two echocardiographies in 31.2% and 79.3% of VSDs of group I, 31.8% and 70% of VSDs of group II and 6.6% and 3.3% of VSDs of group III (p < 0.01). The average follow-up was 3.1 years (range 1 month-10 years). In group A (N = 22), the mean age of closure of the VSD was 26 months (3 months-7 years). In group B (N = 28), surgery was undertaken at an average age of 10 months (range 3 months-5 years). In group C (N = 21), the VSDs were classified as group I (N = 19) or group II (N = 2) at the last echocardiography. The frequency of aneurysms of the membranous septum in groups A, B and C were respectively 100%, 7.1% and 66.6% (p < 0.01). At the second echocardiographic examination, a significant relationship (p < 0.001) was observed between the diameter of the VSDs and their outcome. The VSDs of group A were associated with aneurysms of the membranous septum more often than those of group C (p < 0.005). The authors conclude that surgery is required in about one third of membranous VSD. At medium term, the others either close spontaneously or become smaller in comparable numbers. The outcome is directly related to the diameter of the VSD and the development of an aneurysm of the membranous septum. During the first 6 months, the dimensions of membranous VSDs change in about 30% of cases with an increase in frequency of aneurysms of the membranous septum.

[Isotopic study of myocardial perfusion and innervation in 28 patients with primary hypertrophic cardiomyopathy: relation to ventricular arrhythmia]. / Etude isotopique de la perfusion et de l'innervation myocardique chez 28 patients atteints de cardiomyopathie hypertrophique primitive: relation avec les troubles du rythme ventriculaire.

Ventricular arrhythmias are frequent, sometimes complex and severe, in primary hypertrophic cardiomyopathy. They carry a poor prognosis. Some workers have reported that these arrhythmias are more common in patients with abnormal myocardial perfusion. Other groups have underlined the important role of the sympathetic nervous system in the development of ventricular hypertrophy and the genesis of ventricular arrhythmias. Therefore, a population of 28 patients with primary hypertrophic cardiomyopathy (PHCM) were studied by thallium 201 myocardial scintigraphy and sympathetic innervation was assessed using a structural analogue of noradrenaline, meta-iodobenzyl-guanidine (MIBG). Then, perfusion and innervation were correlated with ventricular arrhythmias observed on 24 hours holter monitoring electrocardiogram. Perfusion abnormalities were observed in 60% of patients: stable in mild left ventricular hypertrophy, labile in severe left ventricular hypertrophy. They were not related to the presence of muscular bridges and systolic compression of septal arteries demonstrated by coronary angiography. These perfusion abnormalities were closely correlated to ventricular extrasystoles observed on Holter monitoring. In this series, and compared to controls, the fixation of MIBG as determined by the Heart/Mediastinum (H/M) ratio was significantly decreased (2.27 +/- 0.31 versus 2.57 +/- 0.33 in controls). Uniform myocardial uptake of MIBG with no defect or significant global hypofixation was observed in 32% of PHCM. Regional and occasionally global hypofixation was observed in 68% of patients. In moderate hypertrophy, reduced uptake was not uniform, the lateral wall and apex being the most abnormal. Uptake of MIBG was significantly correlated to septal wall thickness and to left ventricular mass index. These defects were related to abnormal neuronal uptake of MIBG.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of tomoscintigraphy with Fourier analysis in the diagnosis of arrhythmogenic right ventricular cardiomyopathy]. / Intérêt de la tomoscintigraphie cavitaire avec analyse de Fourier dans le diagnostic de cardiomyopathie arythmogène du ventricule droit.

ECG gated blood pool tomography has been performed in sixteen patients with right ventricular arrhythmias in whom the diagnosis of arrhythmogenic right ventricular cardiomyopathy was made based on the finding of abnormalities on contrast angiography. They were compared both to control subjects and to patients with primary dilated cardiomyopathy. Thick slices of ventricles were obtained throughout the cardiac cycle in three orthogonal planes: horizontal long axis and short axis thick slices for analysis of right and left ventricular regional wall motion abnormalities and analysis of the spread of the contraction by means of Fourier phase imaging, vertical long axis slices (one for each ventricle) for ejection fractions, because of easy and reproducible determination of valvular planes and analysis of all right ventricular segments, especially the pulmonary infundibulum. Five typical right ventricular abnormalities were seen: decreased ejection fraction (32 +/- 15% vs 55 +/- 3% in control; p < 0.001), increased diameter (ratio of right to left diameters = 1.2 +/- 0.3 vs 0.9 +/- 0.1; p < 0.01), global delayed contraction versus that of the left ventricle (22 +/- 20 degrees vs -2 +/- 6%; p < 0.01), increased dispersion of contraction (32 +/- 16 degrees vs 13 +/- 4 degrees; p < 0.01) and presence of segments with decreased and/or delayed contraction. Right ventricular disease was observed in all the patients: localized form (56%), diffused form (44%). This method provides accurate functional data for diagnosis and follow-up of patients. In future, this wall motion evaluation method may replace planar nuclear angiography as myocardial SPECT have replaced myocardial planar scintigraphy.

Results of a 4-week head-down tilt with and without LBNP countermeasure: II. Cardiac and peripheral hemodynamics--comparison with a 25-day spaceflight.

Cardiovascular hemodynamics were assessed by ultrasound echography and Doppler during a 28-d head-down tilt "CNES HDT: 87-88," and during the 25-d French-Soviet spaceflight "Aragatz 88." For both studies we used the same ultrasound methodology. The main hemodynamic parameters of the left heart function and of the peripheral arterial system (cerebral, renal, femoral arteries) were measured four times during the HDT (day 7, 14, 21, 28) and twice post-HDT. The same measurements were performed six times during the flight (day 4, 5, 15, 18, 20, 24) and five times postflight. During the HDT, two groups were studied: six subjects no countermeasures and six subjects with repeated lower body negative pressure (LBNP). In the first group the cardiac volumes and the cardiac output were significantly decreased, whereas in the group with LBNP these parameters were superior to the basal value. In the group without LBNP the cerebral flow was maintained because of a decrease of the brain vascular resistance. In this group the renal vascular resistance was decreased as inflight. In the lower limbs we observed a loss of the vasomotor control. The vascular resistance was decreased after the end of the HDT and the subjects suffered orthostatic intolerance. In the population with LBNP, we did not observe the same decrease of vascular resistance during the HDT, and after the HDT no sign of orthostatic intolerance was observed. During the flight, the left ventricular volume was significantly decreased. The carotid flow was maintained owing to a decrease of the cerebral vascular resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transesophageal echography and systemic ischemic incidences: 235 cases]. / Echographie transoesophagienne et accident ischémique systémique: 235 cas.

From the first of June 90 to the thirty first of January 94, transesophageal echocardiography was performed in 235 consecutive patients (mean age 56+/-16 years), presenting either with cerebral ischemic event (n = 202) or a peripheral arterial embolism (n = 33). All patients had normal echocardiographic and Doppler examinations of the carotid arteries, and transthoracic echocardiography did not show any possible cardiac origin for stroke. Ninety seven patients (41.2%) had documented cardiac disease and/or atrial fibrillation (group 1); 138 patients (58.8%) had no previous cardiovascular history (group 2). Transesophageal echocardiography revealed a possible embolic source in 65.9% of cases (group 1) compared with 29.7% of cases in group 2 (p < 0.001). Intracavitary thrombus and spontaneous contrast in the left atrium were detected only in group 1 (21.6% vs 0%, p < 0.001 and 24.7% vs 0%, p < 0.001 respectively). Patent foramen ovale was more frequent in group 2: 14.5% of cases vs 4.1% of cases, p < 0.01. There was no significant difference between atheromatous aortic plaques and interatrial septam aneurysm incidence in the two groups. Patent foramen ovale and interatrial septal aneurysm were more frequent in group 2: 85% of cases vs 10% of cases in group 1. Transesophageal echocardiography contributes more in patients with a history of cardiac disease. In patients without cardiac disease, patient with foramen ovale and interatrial septal aneurysm were mainly detected: their association represented a risk factor of cerebral ischemic event. Therefore transesophageal echocardiography should be performed in young patients or in case of recurrent event.

[Scintigraphic detection of gastrointestinal hemorrhage. Value and limitations]. / Localisation scintigraphique des saignements digestifs. Intérêts et limites.

A technetium-99m labelled red blood cell scintigraphy was performed in 51 patients with an unexplained gastro intestinal bleeding. Static images were acquired on the injection day then at 24 hours. Forty one patients had a positive scintigraphy. In 13 patients with a positive scintigraphy, on the injection day (5 cases) and later (8 cases), no intestinal bleeding was identified in spite of further investigations guided by scintigraphy. In 24 patients, with a positive scintigraphy on the injection day (20 cases) and later (4 cases), an intestinal lesion was identified and treated; data were confirmed in 19 cases: there were 15 colon lesions, localized on caecum in 10 cases and 4 small bowel lesions. Clinical value and limitations of the investigation are discussed. The scintigraphic localization is usually accurate if the abnormal focus activity is noticed on the injection day. It helps to guide further investigations of the bleeding site. This non invasive method should be performed more quickly to help to localize intestinal bleeding which poses a diagnostic problem.

[Diagnostic value of physical examination and electrocardiogram in the initial evaluation of heart murmurs in children]. / Valeur diagnostique de l'examen clinique et de l'électrocardiogramme dans l'évaluation initiale d'un souffle cardiaque de l'enfant.

OBJECTIVE: To investigate the diagnostic value of the physical examination and electrocardiogram in the evaluation of heart murmur in new patients referred to the pediatric cardiologist. METHOD: From 1 April to 30 September 1998, all consecutive patients referred to the pediatric cardiology clinic for evaluation of heart murmur were included. They were prospectively categorized with no heart disease, possible heart disease or definite heart disease based on history and physical examination. They then underwent electrocardiogram with which the diagnosis was reevaluated by the pediatric cardiologist. Lastly, a doppler-echocardiography was systematically performed. RESULTS: In 120 children aged four days to 14 years (median: ten months), 72 (60%) showed abnormalities on doppler-echocardiography and 48 (40%) no heart disease. After physical examination, 52 patients were categorized with no heart disease: 45 patients had a normal doppler-echocardiography; in three of them, the diagnosis was incorrectly modified to possible heart disease on the basis of the electrocardiogram. In the other seven children, the electrocardiogram was normal and the doppler-echocardiography revealed minor (n = 5) or moderate (n = 2) heart defects. Nineteen patients were suspected of having possible heart disease, no diagnosis was modified after analysis of the electrocardiogram and six had normal doppler-echocardiography; 49 patients were correctly diagnosed as having definite heart disease. The sensibility of the physical examination was 90.3%, the specificity was 93.8%, the positive predictive value 95.6% and the negative predictive value 86.5%. CONCLUSION: The electrocardiogram is of no help in the discrimination between heart disease and no heart disease in children referred to the pediatric cardiologist for a cardiac murmur. The physical examination is able to differentiate children with or without heart disease in most of the cases.