[Treatment of recurrent pericarditis: case report and review of literature]. / Le traitement de la péricardite récidivante: à propos d'un cas et revue de la littérature.

Benign acute pericarditis is a common disorder. Recurrence is probably the most troublesome complication, characterized by a return of pericardial pain after recovery from an episode of typical acute pericarditis. Treatment of recurrence is often difficult and the guidelines issued by scientific societies remain vague. A number of investigators published enthusiastic reports on the efficacy of colchicine as adjuvant treatment of recurrent pericarditis and other authors suggested that colchicine should also be used as part of the treatment regimen of acute pericarditis. Colchicine is effective and safe and may be proposed as treatment of choice, especially in the idiopathic form. Treatment with corticosteroids exacerbates and extends the course of recurrent pericarditis and attenuates the efficacy of colchicine.

[New therapeutic guidelines in cardiology]. / Actualités thérapeutiques en cardiologie.

Cardiovascular diseases are the leading cause of mortality in the so-called industrial countries. An appropriate management is mandatory and its modalities should be known and applied by physicians. European and American recommendations are regularly published and updated. They are available on the web sites of the European Society of Cardiology (www.escardio.org), the American Heart Association (www.aha.org) and the American College of Cardiology (www.acc.org This article describes the recent therapeutic options of some cardiovascular diseases, especially coronary artery disease, valvular diseases, atrial fibrillation and implantable defibrillator, but is far to be exhaustive.

[Arrhythmogenic right ventricular dysplasia]. / Dysplasie arythmogène du ventricule droit.

Arrhythmogenic right ventricular dysplasia is an unfrequent disease that associates ventricular tachycardia with left bundle branch block morphology and right ventricular fibro-fatty degeneration. The etiology, pathogenesis, criteria for diagnosis and treatment are discussed.

Incidence, pathophysiology and prognosis of exercise-induced sustained ventricular tachycardia associated with healed myocardial infarction.

Of 150 consecutive patients with sustained monomorphic ventricular tachycardia (VT) (n = 116) or ventricular fibrillation (VF) (n = 34) late after acute myocardial infarction, 17 had reproduction of their sustained monomorphic VT during exercise testing. Data from these patients (group I) were compared with data from patients without exercise-induced VT (group II). No statistical difference was found between groups I and II with relation to age, sex, number of vessels with greater than 70% stenosis, left ventricular ejection fraction, number of previous myocardial infarctions, inducibility during programmed stimulation and total mortality during follow-up. In group I, only 1 patient (6%) developed ST depression during exercise compared with 47 patients (35%) in group II (p less than 0.01). After a 34-month mean follow-up, 6 patients in group I (35%) and 18 patients in group II (13%) died suddenly (p = 0.02). It is concluded that sustained monomorphic VT is reproduced during exercise in only 11% of patients with spontaneous late sustained monomorphic VT or VF. Electrocardiographic findings do not support ischemia as a triggering mechanism of exercise-induced sustained monomorphic VT. Patients with exercise-induced sustained monomorphic VT have a high incidence of sudden death.

The efficacy of intravenous mexiletine on ventricular ectopic activity.

Twelve patients with severe ventricular dysrhythmias were treated by one single dose of 250 mg of mexiletine injected intravenously over a 15 min. period. All patients showed some antiarrhythmic response. In 9 cases, the ventricular premature beats were totally or almost totally abolished up to 20 to 100 min. after the end of the infection. In most patients (5/7), there existed a correlation between the plasma concentration of the drug and the antiarrhymic action. However, the drug levels were not different in the good responders as compared to the poor responders or in those who manifested a prolonged antiarrhythmic activity as compared to the others. Side-effect appeared in three cases and consisted of vomiting, tremor, and episodes of sinus arrest.

The efficacy of intravenous moxaprindine on ventricular ectopic activity.

Moxaprindine, a new derivative of aprindine, has been showed to possess strong antiarrhythmic properties in the dog. It is significantly less toxic than aprindine on hematopoietic cells in culture. This drug was given intravenously (2 mg/kg given over a 30 min period), to 10 patients with severe, refractory and symptomatic ventricular arrhythmias. In 8 of them, all ventricular ectopic activity was suppressed for at least 90 min following the end of perfusion. In 7, no ventricular ectopic beats recurred before the end of the experimentation (150 min). There were two non-responders: one of them developed a torsade de pointes phenomenon under the influence of the drug. The mean drug concentration which was reached at the end of perfusion was 4.83 +/- 2.46 gamma/ml. It progressively fell to a value of 1.11 +/- 0.35 gamma/ml, 150 min later. The drug prolongs the PR interval, QRS duration and QT interval. Moxaprindine is a powerful antiarrhythmic agent which deserves further assessment in long term studies.

Antegrade conduction over a concealed accessory pathway after His bundle catheter ablation.

The existence of unidirectional retrograde preexcitation or concealed bypass fibers and their role in paroxysmal supraventricular tachycardia have been known for a long time. However, the exact anatomic and physiological nature of this retrograde limb remains unclear. We report here on a patient who had a concealed accessory pathway (AP) with circus movement tachycardia. After His bundle catheter ablation the AP had the property to conduct in the antegrade direction. The absence of antegrade conduction over the AP before ablation is likely due to its decremental properties of conduction and to repetitive retrograde concealed conduction from the normal pathway.

Clinical aspects during long-term follow-up after DC shock ablation of the atrioventricular junction. A Belgian experience.

Ninety-three patients, who underwent DC shock ablation were reviewed over a mean follow-up period of 54 months (range 3 to 84 months). These patients (46 male and 47 female, mean age: 58 years) had failed an average of 3 drugs, and the duration of symptoms was more than 2 years. Paroxysmal atrial fibrillation or flutter was treated in 75 patients (80.6%); the remainder had supraventricular tachycardia or reciprocating tachycardia using an accessory pathway. One shock of 200 J was effective in producing third degree AV block in 40 patients (43%), while 2 or more shocks were used in another 53 patients (57%). Chronic complete heart block (CHB) was obtained in 85 patients (91%), modification of conduction was seen in 2 patients (2.1%), and failure to achieve an improvement in 6 patients (6.4). All the patients of the last group had received more than 4 shocks (200 to 400 J). However no significant difference between the amplitude of atrial and His electrograms could be shown between the CHB patients and those in whom conduction persisted. Over a mean follow-up of 54 months, 66 patients (72%) with successful ablation during the first 48 hours after the procedure remained in CHB. In 18 patients AV conduction resumed but they were all asymptomatic: 10 patients (10.8%) without antiarrhythmic therapy and 8 patients (8.6%) with medication. In conclusion, ablation of the AV junction is effective in more than 82% of patients. Most of the time long-term success can be predicted within 48 hours. However, due to the invasive character of DC shocks, this technique has been supplanted by the less aggressive radiofrequency method.

[Treatment of refractory tachycardias using an implantable cardiac stimulator]. / Traitement des tachycardies rebelles par stimulateurs cardiaques implantables.

Treatment of tachycardia by permanent cardiac stimulation involves the application of techniques developed in laboratories of clinical cardiac electrophysiology. Clinicians using such treatment must possess detailed knowledge of the physiopathology of arrhythmias and of pacemaker technology, which is essential in the correct selection of patients. We report therapeutic (and not prophylactic) stimulation techniques for treatment of tachycardia, and discuss the possibilities of existing pacemakers and their clinical performance in the light of our own experience and literature data. The results are very promising and suggest that this is a treatment of the future for certain refractory supraventricular tachycardias, and particularly for rapid ventricular tachyarrhythmias. The efficacy and long-term value of this costly treatment in such cases must be evaluated by further studies.

[Utilization of implantable ventricular defibrillators (with an analysis of the value of antiarrhythmics in the treatment of potentially fatal ventricular arrhythmias]. / Utilisation des défibrillateurs ventriculaires implantables (avec une analyse de la valeur des antiarythmiques dans le traitement des arythmies ventriculaires potentiellement létales).

During the past 15 years, the efficacy of antiarrhythmic drugs has been investigated for reducing sudden cardiac death in patients at high risk of arrhythmia. Whereas the benefits of beta-blocker therapy are well established, a reduction in mortality with other antiarrhythmic drugs remains unproved and in some cases, there is evidence of increased mortality with class I and some class III agents. At the same time, the development of the automatic implantable cardioverter-defibrillator has been one of the spectacular achievements in cardiology. It has altered the therapeutic landscape for patients with symptomatic ventricular tachycardia or cardiac arrest. In these patients, the automatic implantable defibrillator is clearly first line therapy, as recognized by the international scientific cardiac societies guidelines.

[Ventricular arrhythmias]. / Les arythmies ventriculaires.

Tachycardias arise from an arrhythmogenic substrate triggered by a random factor (generally an extrasystole) and modulated by the autonomic nervous system. The three components are interactive, but their intensity and conjunction vary continuously. During the last decade, major achievements have been made to clarify definition and classification of data reported in the literature, helping our understanding of the mechanisms of ventricular arrhythmias. Nowadays, the pathophysiology of cardiac arrhythmias is well-known at the cellular and molecular ion channel activity. The progress of epidemiology and molecular genetics have allowed a better knowledge of the genotype-phenotype correlation in young patients presenting syncopes due to torsades de pointes or polymorphic ventricular tachychardia episodes which may degenerate into ventricular fibrillation and cause sudden death. The data of numerous large prospective randomised studies have led to more rational treatments with the progressive withdrawal of class I antiarrhythmics and their replacement by betablocking agents. The surgical approach of ventricular tachycardia has been overcome by the automatic implantable defibrillator and in some well-defined clinical situations, catheter ablation is used.

[Syncope]. / La syncope.

Syncope remains a clinical challenge. Accurate history taking, physical examination and EKG are mainstays of the diagnosis work up. The most important parameter for prognosis and requiring aggressive management is a structural heart disease. Patient without cardiopathy presenting multiple episodes may be candidate for tilt testing and loop EKG recorder.

[The Brugada syndrome]. / Le syndrome de Brugada.

The Brugada syndrome, a genetically transmitted disease according to an autosomal mode with a variable penetrance, is responsible for sudden death secondary to polymorphic ventricular tachycardia. The diagnosis is based on a typical electrocardiographical paturn that combines a right bundle branch block with ST elevation in the right precordial leads. In high risk patients, the automatic implantable defibrillator has the unique capability to protect against the occurrence of ventricular arrhythmias.

[Paroxysmal atrial fibrillation]. / La fibrillation auriculaire paroxystique.

Paroxysmal atrial fibrillation is one of the most common disorders of cardiac rhythm. It is often a step toward permanent arhythmia, specially if associated with cardiac disease. The management objectives of intermittent arhythmia may be different, as maintenance of sinus rhythm. However, risks of stroke and thrombo-embolism are similar to those for sustained atrial fibrillation and must be carefully assessed. In this article we review the epidemiology, pathophysiology, clinical aspects and current guidelines for treatment and management of paroxysmal atrial fibrillation.

[Left ventricular aneurysms: principles of surgical treatment]. / Les anévrysmes ventriculaires: principes de leur traitement chirurgical.

After reviewing the historical background, the morphology and physiopathology of left ventricular aneurysms, the authors review the physiology, the technical aspects, and the current surgical indications of aneurysmectomy, with a particular emphasis on the concept of endoventriculoplasty of Jatène & Dor.