Preejectional left ventricular wall motion in normal subjects using Doppler tissue imaging and correlation with ejection fraction.

Relations have been demonstrated between the preejection period (PEP) and indexes of left ventricular (LV) systolic function. Doppler tissue M-mode imaging has the capability to measure wall velocities and to display as colored strips within the walls velocity reversals representing changes in direction of wall motion. To document LV preejectional wall motions, this procedure was performed on 16 normal subjects with a twofold purpose: to measure septal and posterior preejectional intramyocardial velocities and durations and to correlate preejectional parameters with LV ejection fraction (LVEF). Parasternal M-mode images of simultaneously recorded walls were digitized. Subendocardial wall velocities were measured every 3.8 ms from the Q wave to the onset of ejection. Total duration measured from Doppler tissue and flow traces was compared in 10 subjects. PEP total duration did not differ between both walls or techniques. Several adjacent velocity reversals with mirror signs in opposite walls were substantiated by 2 to 5 colored strips. Colored strips corresponding to the same sign in each wall had a progressively damped velocity amplitude (septum 19 +/- 8, -21 +/- 10, 15 +/- 7, -8 +/- 5, 4 +/- 2 mm/s; posterior wall -13 +/- 16, 11 +/- 7, -8 +/- 5, 9 +/- 6, -2 mm/s). Peak velocity values of opposite signs significantly differed between both walls (p <0.0001). Absolute values differed only for colored strips 2 and 3 (p <0.009). Strip 2 featured a simultaneous early inward motion of both walls toward the LV cavity with significantly prolonged duration (p <0.0001). The only positive correlation with LVEF was found for peak velocities of strip 2 in the posterior wall (r = 0.71, p <0.006). Thus, the posterior wall and its inward motion velocities have potential for future clinical implications.

Treatment of heart failure with celiprolol, a cardioselective beta blocker with beta-2 agonist vasodilatory properties. The CELICARD Group.

Treatment with beta blockers results in improvement in functional status, and reduces mortality in patients with heart failure. A number of differences in the results noted could be due to additional properties of the specific beta blockers studied: absence of cardioselectivity, and existence of a vasodilator effect and of an associated antioxidant effect. We studied the effects of celiprolol, a cardioselective beta blocker with a stimulant effect on beta2 receptors. One hundred thirty-two patients presenting with chronic heart failure of various etiologies, with an ejection fraction of <40% and New York Heart Association cardiac functional status grades II and III were included in a randomized, double-blind, placebo-controlled study. The maximum dose of celiprolol (100 mg) was attained after 1 month. The study lasted 1 year. The primary evaluation criterion was functional class as evaluated using the Goldman questionnaire. There was no difference in efficacy between the 2 treatment groups in terms of functional class (p = 0.56). With regard to the secondary evaluation criteria, an improvement in DiBianco functional score was seen with celiprolol (p = 0.03), as well as a significant reduction in heart rate (p = 0.01). Ejection fraction increased in both groups (p = 0.15). There was no difference regarding improvement in left ventricular volume as determined at echocardiography or in exercise capacity. The safety profile of celiprolol was excellent. There was no difference in terms of cardiovascular mortality (2 receiving celiprolol vs 4 placebo), onset of arrhythmias (2 receiving celiprolol vs 3 placebo), worsening of heart failure (26 receiving celiprolol vs 23 placebo), or noncardiovascular adverse events (9 receiving celiprolol vs 14 placebo). The absence of a significant efficacy of celiprolol, a beta blocker with vasodilator properties, but exerting stimulation of beta2 receptors, suggests an unfavorable role of this latter property in heart failure. However, the safety profile of celiprolol was excellent. This beta blocker may consequently be used for its other indications, hypertension and angina, in patients presenting with altered cardiac function.

Clinical and echocardiographic observations in pulmonary valve endocarditis.

Clinical and echocardiographic data from 12 patients with pulmonary valve endocarditis are described. Seven patients had isolated pulmonary endocarditis and in 5 patients other valves were infected (aortic, tricuspid, mitral or all 3). Two patients were heroin addicts and 4 had underlying heart disease (congenital heart disease in 3 and aortic regurgitation in 1 patient). The organisms involved were alpha streptococci in 3 patients (all with underlying heart disease), Staphylococcus aureus in 4, Streptococcus D bovis in 1 patient and Candida guillermondii in 1. M-mode and 2-dimensional echocardiography was performed in 10 patients and revealed vegetations in 8. Pulsed Doppler echocardiography was performed in 6 patients and revealed pulmonary regurgitation in all 6. Seven patients had pulmonary emboli. Four patients underwent surgery. Four patients died, including 1 after cardiac surgery. Five patients, including the patient infected with Candida guillermondii, recovered with antibiotic treatment.

Prosthetic valve endocarditis in the ICU. Prognostic factors of overall survival in a series of 122 cases and consequences for treatment decision.

We carried out univariate and multivariate analysis of outcome among 122 patients with prosthetic valve endocarditis (PVE) admitted to our ICU between 1978 and 1992. The predominant pathogens were Staphylococcus aureus (33%), streptococci (20%), coagulase-negative staphylococci (12%), enterococci (10%), and Gram-negative bacilli (9%). At 4 months, overall survival was 66% (42 deaths). Staphylococcus aureus was the main predictor of death (75% vs 15% with other pathogens). In S aureus PVE, multivariate analysis identified the following predictors of death: prothrombin time < 30% (relative risk [RR]: 8.3), concomitant mediastinitis (RR: 4.9), heart failure (RR: 4.4), and septic shock (RR: 2.6). In PVE due to other pathogens, prothrombin time < 30% (RR: 32.26), renal failure (RR: 7.31), and heart failure (RR: 6.07) were associated with death. In S aureus PVE, survival was higher in patients who received medical-surgical therapy than in those who received medical therapy alone (9/20 [45%] vs 0/20) (p < 0.01). In PVE due to other pathogens, there was no difference in survival between patients who underwent prosthesis replacement (89%) and those who received only medical treatment (81%). Among the 65 patients who underwent heart surgery, the mortality rate and incidence of postoperative paravalvular leakage did not correlate with positive prosthesis cultures. We conclude that non-S aureus and uncomplicated PVE may be managed without valve replacement but that prompt surgical intervention should be required in all other situations.

Colour doppler valvar and subvalvar flow diameter imaging versus echo score in mitral stenosis: comparison with type of surgery.

OBJECTIVE: To compare the value of echo score with that of Doppler subvalvar flow broadening in deciding the type of mitral stenosis surgery. PATIENTS: 30 patients, mean age 47 years, with severe stenosis undergoing surgery were divided into two groups according to type of surgery: open heart commissurotomy (group 1, n = 12), or prosthesis (group 2, n = 18). A control group of 10 patients with prosthesis served as reference, representing mild stenosis without subvalvar connection. METHODS: For echo, the score proposed by Wilkins for cross sectional imaging was used. For Doppler, the flow diameters were measured in cm by an independent examiner from the long axis view in early diastole at two levels: (1) at the level of the stenosis (origin flow diameter), and (2) 1.5 cm downstream from the stenosis in the left ventricle (subvalvar flow diameter) with calculation of a Doppler ratio relating these two measurements, expressed as a percentage of broadening. Diagnostic value was compared for both procedures. RESULTS: There was no significant difference in age, mitral valve areas, or haemodynamics for the two groups. Mean values (SD) were: echo score: group 1, 9.83 (1.26) v group 2, 10.8 (8.1), NS; Doppler ratio %: group 1, 44 (24) v group 2, 12 (21) (P < 0.001); control group: 69 (15). The per cent diagnostic value for an open heart commissurotomy of respective cut off points was: Doppler ratio > 25% (range 71% to 87%); echo score < 10 (range 50% to 75%). CONCLUSIONS: The new Doppler ratio diagnostic value agreed better with surgical management, repair or prosthesis, in this study. Thus, it appears to better reflect the subvalvar involvement and changes in kinetics than the echo score alone. This easy Doppler method might become a routine examination for follow up of patients with open heart commissurotomy, to avoid performing repeated transoesophageal echocardiography.

Right and left isovolumic ventricular relaxation time intervals compared in patients by means of a single-pulsed Doppler method.

Right and left isovolumic ventricular relaxation time intervals measurements were obtained as follows: from the peak R wave on the electrocardiogram to either the mitral or the tricuspid pulsed Doppler flow trace onset minus the R to end-ejection zero flow crossing of the subaortic (left side) or pulmonary (right side) D flow trace time interval. A ratio was calculated as a percent difference duration between both isovolumic ventricular relaxation time intervals. The aim was to compare isovolumic ventricular relaxation time interval values in 42 healthy controls and to study the changes induced by heart diseases in 27 patients with (1) controlled hypertension without left ventricular hypertrophy, (2) hypertrophic cardiomyopathy, and (3) Cor pulmonale. Mean values of isovolumic ventricular relaxation time intervals significantly differed at paired and unpaired studies, with right isovolumic ventricular relaxation time intervals shorter than those of the left side in all groups (p < 0.001) except for patients with Cor pulmonale. Isovolumic ventricular relaxation time intervals did not correlate with heart rate and moderately correlated with left ventricular mass and age. No significant difference was found between healthy controls and patients with controlled hypertension. Significant changes were found in patients with hypertrophic cardiomyopathy and Cor pulmonale versus healthy controls for both isovolumic ventricular relaxation time intervals. However, significant changes in the ratio were only found in patients with Cor pulmonale (p < 0.005) because of abnormal similar values for both isovolumic ventricular relaxation time intervals. This Doppler method enabled, for the first time, serial comparison of isovolumic ventricular relaxation time intervals with a homologous method. Both isovolumic ventricular relaxation time intervals significantly lengthened with age and with left ventricular indexed mass, but their ratio remained insignificantly changed except for patients with Cor pulmonale. The concomitant right and left isovolumic ventricular relaxation time intervals lengthening in patients with hypertrophic cardiomyopathy and Cor pulmonale suggests interdependence of both ventricles through the septum. This makes recommendable systematic comparison of both sides. The calculation of a ratio, free from the effect of factors intervening on isovolumic ventricular relaxation time intervals, may, in addition, be of diagnostic help.

Comparison of 2 myocardial velocity gradient assessment methods during dobutamine infusion with Doppler myocardial imaging.

Myocardial velocity gradient (MVG) has been shown to be the best quantitative parameter for the detection of ischemic myocardium during dobutamine infusion with the use of Doppler myocardial imaging. MVG has been previously assessed by velocity measurements across the thickness of the myocardium at the time of visually selected maximal color brightness (thickness-velocity plot method). We hypothesized that MVG could be assessed by velocity measurements throughout the cardiac cycle in the subendocardium parallel to the endocardial boundary to the left ventricular cavity and in the subepicardium parallel to the epicardial boundary (time-velocity plot method). This study was designed to compare MVG obtained from the thickness-velocity plot method and from the time-velocity plot method in quantifying dobutamine-induced changes in myocardial wall motion in 8 phases of the cardiac cycle on color M-mode Doppler myocardial imaging recordings of the left ventricular posterior wall performed in 8 conscious dogs at baseline and at steady state during dobutamine infusion (10 microg/kg per minute). For both methods, MVG was considered present if its mean value was significantly different from zero and if endocardial and epicardial velocities were significantly different. There was close agreement between the 2 methods. MVG was present during the preejection period, systole, rapid ventricular filling, and atrial contraction. Dobutamine induced a significant increase in MVG during the preejection period (from 2.64 +/- 0.83 to 4.05 +/- 0.81 seconds-1 ), systole (from 2.14 +/- 0.59 to 6.08 +/- 2.20 seconds-1 in early systole, from 1.90 +/- 1.06 to 5.31 +/- 2.95 seconds-1 in mid systole, from 1.37 +/- 0.57 to 2.44 +/- 0.53 seconds-1 in end systole), and rapid ventricular filling (from 3.06 +/- 1.12 to 7.82 +/- 2.58 seconds-1 ), related to a greater rise in endocardial than in epicardial velocities. The time-velocity plot method showed that ejection and diastole were 11% and 28% decreased during dobutamine infusion, respectively, as heart rate was 31% increased. Thus according to our quantitative criteria, both MVG assessment procedures enabled objective interpretation of dobutamine effects on left ventricular wall motion. In addition, the time-velocity plot method provided automatic detection of peak velocity, timing, and duration of wall velocity changes over time.

A double-blind study in hypertensive patients of an original new compound, indapamide.

In a double-bind crossover study in 18 patients with essential hypertension, the hypotensive activity of 5 mg. indapamide daily was compared with 40 mg. frusemide daily over a period of 4 months after an initial 15 days on placebo. The overall clinical assessment showed satisfactory blood pressure control in 72% of patients receiving indapamide compared with 57% on frusemide. The weight of patients on active therapy dropped significantly with both products, but to a greater extent with indapamide. Indapamide was well-tolerated by all 18 patients; 3 patients on frusemide developed side-effects. The results of blood chemistry investigations are discussed. Variations in potassium levels during indapamide therapy were modest and did not warrant the use of potassium supplements.

Lisinopril versus slow-release nifedipine in the treatment of mild to moderate hypertension: a multicentre study. The Cooperative Study Group.

The antihypertensive effects of lisinopril 20 mg once daily and slow-release nifedipine 20 mg twice daily were compared in a double-blind, parallel group, 10-week study involving 274 patients with mild to moderate hypertension. During the first 6 weeks of treatment, slow-release nifedipine and lisinopril produced similar reductions in lying and standing blood pressure (BP), except for lying systolic BP (SBP) which was reduced to a greater extent by lisinopril. After 6 weeks of double-blind treatment, hydrochlorothiazide 25 mg once daily was added if BP remained uncontrolled (lying DBP greater than or equal to 95 mmHg); a significantly greater proportion of patients in the nifedipine group than in the lisinopril group required additional diuretic treatment (29% versus 14%, respectively; P = 0.005). Moreover, after a further 4 weeks of treatment BP was adequately controlled (lying DBP less than 95 mmHg) in significantly more lisinopril-treated patients than in the nifedipine group (91.4% versus 78.3%, respectively; P = 0.006). Lisinopril was better tolerated than slow-release nifedipine. The frequency of drug-related events was significantly lower (threefold) for lisinopril than for nifedipine (P = 0.001) and the number of withdrawals from treatment with nifedipine was more than three times that in the lisinopril treatment group (P = 0.009). Lisinopril appears to provide an effective once-daily antihypertensive treatment which is at least as effective as, and better tolerated than, slow-release nifedipine.

Pre-ejectional left ventricular wall motions studied on conscious dogs using Doppler myocardial imaging: relationships with indices of left ventricular function.

Duration of the pre-ejection period is a sensitive index of myocardial function. Our purpose was to document normal pre-ejectional left ventricular (LV) wall motions at rest and under dobutamine using Doppler myocardial imaging (DMI), and to correlate posterior wall velocities with indices of LV systolic function. M-mode recordings of both walls were imaged on eight conscious dogs chronically instrumented. Subendocardial pre-ejectional velocities were digitized and measured every 3.8 ms. DMI analysis consisted of sign recognition, velocity measurement, duration and timing from the Q wave of the electrocardiogram. Isovolumic contraction time (Ict) was represented by the time interval from onset to peak of the first derivative of LV pressure. Conventional Doppler labelling of velocity signs, positive toward and negative away from the transducer, was applied to the direction of encoded wall motions. For physiological understanding, wall motions of both walls were also labelled inward and outward with respect to the left ventricular cavity center. In each wall, PEP was shown as several colored strips, each strip representing the period of time that the wall was moving in one direction. Changes in velocity sign corresponding to changes in direction of motion were opposed in each wall (p < 0.001), featuring successive inward and outward wall motions. There was a markedly sustained inward motion during Ict. Its velocity amplitude increased with dobutamine. There was a positive correlation between velocities of the inward motion contemporaneous of Ict and ejection fraction (r = 0.72, p < 0.003). Values of Ict respectively drawn from DMI and from hemodynamics were also significantly correlated (r = 0.85, p < 0.007). Thus, the inward motion evidenced by DMI during Ict appears promising to assess myocardial function and effect of drugs.

[Evaluation of rhythm tolerance of cicletanine using continuous electrocardiographic recording]. / Evaluation de la tolérance rythmologique du ciclétanine par enregistrement électrocardiographique continu.

The effectiveness of cicletanine against hypertension, as well as its clinical, biochemical and electrocardiographic safety, were studied in 52 patients (24 women, 28 men, mean age 60.3 +/- 8.6 years) presenting with permanent, moderate to severe arterial hypertension without severe cardiovascular complications. After three months of treatment, blood pressure had fallen from 182.2/116.8 mmHg, with a mean daily dose of 181 mg of cicletanine at the end of the study. Mean falls of 34 mmHg for the systolic arterial pressure and 25 mmHg for the diastolic arterial pressure normalized BP in 55.8% of the patients treated and significantly reduced the functional symptoms of hypertension. Continuous 24-hour ECG recording (Holter system), performed on days 0, 30 and 90, demonstrated a considerable reduction (about 70%) of ventricular and supraventricular extrasystoles during treatment. No undesirable side-effect, even minor, was reported. There was little change in biochemical parameters: the moderate decrease of natraemia and kalaemia observed was due to the natriuretic effect of cicletanine in doses of 200 mg/day. Plasma creatinine and uric levels remained stable, and an improvement in glucose and lipid metabolism was noted.

[Prognostic value of exercise gamma-angiography in coronary insufficiency]. / Valeur pronostique de la gamma-angiographie d'effort dans l'insuffisance coronarienne.

The predictive value for cardiac events in stable coronary artery disease was analysed with resting and exercise radionuclide angiography and conventional exercise stress testing under medical therapy. The population comprised 93 men and 12 women, followed up for 1 to 8 years (mean 51 months). The patients were divided into two groups. Group I without cardiac events; Group II including spontaneous complications and myocardial revascularisations. The analysis was performed at 2 years and at the end of follow-up. At 2 years, 30 events (15 spontaneous complications, 15 revascularisations) were observed, and at the end of follow-up, there were 61 uncomplicated outcomes and 44 cardiac events (22 spontaneous complications, 22 revascularisations). Two independent prognostic factors distinguishing patients in Group I from those in Group II were identified at 2 years and at the end of the study: exercise EF and occurrence of exercise (on: chest pain on exercise) chest pain. Four parameters were significantly different between the two groups at 2 years: exercise EF, resting EF, difference between exercise-resting EF (all p < 0.005) and duration of exercise testing (p = 0.04). The 3 radionuclide parameters remained different between the 2 groups as well as chest pain on exercise stress testing (p = 0.03) throughout the study. The predictive value of these parameters depended on the type of cardiac event. The exercise EF was the best predictive factor of cardiac death. Pain and ST depression on exercise ECG were the best predictive factors for myocardial revascularisation. In 12 patients undergoing myocardial revascularisation, the clearest improvement was observed in exercise EF (p = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Prognostic value of the normalization of the exercise test under medical treatment in coronary insufficiency]. / Valeur pronostique de la normalisation de l'épreuve d'effort sous traitement médical dans l'insuffisance coronarienne.

The prognostic value of exercise testing was studied in 118 patients with angiographically proven chronic coronary disease, positive ET and/or a history of myocardial infarction (MI) who were followed up for 698 years (mean 5.9 years). Medical treatment was instituted step by step and controlled by repeated ET's. ET remained positive (ST depression 1 mm) in 58 cases (group I), was alternately positive and negative in 22 cases (group II) and became normal in 38 cases (group III). The mean duration of follow-up in these three groups was 5.0, 7.6 and 6.4 years respectively. Eight patients were lost sight of. Ergometric data and outcome were similar in groups II and III, but there were differences between group I (58 patients) and groups II + III (60 patients) as regards: (a) ergometric data: total workload (22,077 +/- 9,860 vs 34,856 +/- 15,552 joules), workload causing a 1 mm ST depression (13,892 +/- 9,253 vs 31,555 +/- 15,811 joules) and maximal ST depression (2.5 +/- 0.9 vs 0.9 +/- 0.8 mm); (b) outcome: cardiac deaths (12 vs 3), myocardial revascularization (19 vs 6); but there was no significant difference as regards MI (4 vs 5), heart failure (11 vs 5) and extracardiac deaths (3 vs 4). It is concluded that the persistence of a positive ET under optimal medical treatment is a major argument in favour of myocardial revascularization.

[Randomized ergometric study of vasodilators combined with betablockaders]. / Etude ergométrique randomisée des vasodilatateurs associés aux bêtabloqueurs.

The ergometric effects of different vasodilator drugs in 5 series of 10 patients with stable angina and persistent effort ischaemia despite beta-offckade, were compared two by two in a random, single blind cross-over study under basal conditions on betablocker therapy and at the peak of their action, the second measurement being performed after a 2 to 7 day interval. The principal criteria of assessment were the work required to induce 1 mm ST depression (WST1), and the maximum ST depression (ST max) at comparable work loads. Molsidomine (2 mg), Risordan 20 mg) and Nifedipine (10 mg) significantly improved both parameters (p less than 0.001). Lenitral (7.5 mg), Langoran (40 mg), Trinitrin skin patch (10 mg) did not produce a significant improvement. Corditrine improved WST1 (p less than 0.05) and slow release Trinitrin (2.5 and 5 mg) improved WST1 at 3 hours (p less than 0.05) and ST max at 15 minutes (p less than 0.001) and 3 hours (p less than 0.05). The fall in resting blood pressure was parallel to the ergometric changes. These results suggest that Molsidomine, Nifedipine, Risordan and slow release Trinitrin (2.5 mg) are the most effective vasodilators when used in association with betablockers.

[Ergometric study of a new vasodilator agent in angina: molsidomine. Value of combination with beta-blockaders]. / Etude ergométrique dans l'angor d'un nouveau vasodilatateir : la molsidomine. Intérêt de l'association aux bêta-bloqueurs.

Molsidomine, a new venous vasodilator, was studied in 40 cases of stable angina by ergometric stress testing. 1. In 10 patients, one hour after 2 mg molsidomine sublingually, the work inducing a 1 mm ST depression (WST 1) increased by 94% (p less than 0,05), the total work by 52% (p less than 0,005) and the maximum ST depression (ST max) fell by 45% (p less than 0,01). Resting heart rate was unchanged. There was a mild fall in systemic blood pressure. 2. Molsidomine had a significant synergic effect in 3 groups of 10 patients on betablocker therapy but with ischaemic changes on exercise: a) Molsidomine 1 mg sublingually increased WST 1 by 36% (p less than 0,05); at a 2 mg dosage, by 55% (p less than 0,001). ST max decreased from 2,4 +/- 0,4 mm to 1,3 +/- 0,3 (p less than 0,005) and 1,2 +/- 0,33 (p less than 0,001) respectively. The maximal effect was obtained with 1 mg in 5 out of 10 patients. b) One and three hours after 2 mg Molsidomine sublingually or orally: WST 1 increased from 97% to 110% (p less than 0,005): ST max decreased in similar proportions (p less than 0,005). c) 2 mg Molsidomine and 230 mg isosorbide dinitrate orally were compared after two hours: WST 1 increased by 130% after Molsidomine (p less than 0,005) and by 112% after isosorbide (p less than 0,005). ST max decreased in similar proportions (p less than 0,005). The blood pressure fell less with molsidomine. Molsidomine appeared to be better tolerated than isosorbide. (5 cases of mild headache in 40 patients compared to 4 cases out of 10 patients). The results of a preliminary clinical trial are reported. The association of molsidomine (2 mg per os three times daily) reduced the number of anginal attacks by over 50% in 16 out of 17 patients inadequately controlled by betablockade alone. 3 patients complained of headache at the onset of therapy. The efficacity was comparable and the tolerance better than in 28 patients with isosorbide dinitrate and betablockade, and in 10 patients with nifedipine and betablockade. In conclusion, molsidomine is a venous vasodilator with useful pharmacokinetic properties. It seems to be effective and well tolerated in the treatment of angina whether used alone or in association with betablockers.

[Acute bacterial endocarditis]. / Les endocardites bactériennes aiguës

Acute endocarditides, defined by the intensity of the infectious syndrome, increase rapidly in incidence, both in absolute number and in relation with classical subacute endocarditides. 60 cases were studied out of a lot of 130 cases of bacterial endocarditides. They are characterized by the nature of the portals of entry, particularly in hospital, the nature of the causal germs (staphylococci and gram-negative germs essentially), their habitually primary character, the importance of embolic manifestations. Cardiac failure through valvular mutilation is common, but surgical valve replacement is not always possible in view of the visceral or infectious context. Their overall prognosis is a very bad one: lethality 67 percent as against 15 percent for subacute endocarditides. An important part of prevention lies in a better hospital hygiene.

[Outcome of prognostic factors of infectious endocarditis over a 16 year period. Apropos of 471 cases]. / Evolution des facteurs pronostiques de l'endocardite infectieuse sur une période de 16 ans. A propos de 471 observations.

Four hundred and seventy one cases of infective endocarditis (IE) were reviewed: 338 native valve IE and 133 prosthetic valve IE (42 early and 91 late IE). Two periods were compared: 1973-1980 (250 cases) and 1981-1988 (221 cases). There was a decrease in native valve IE (78% to 64%) and an increase in late prosthetic valve IE (13% to 27%), little change with respect to age, causal cardiac disease, delay in diagnosis (except in native valve IE, 39 to 29 days), or frequency of complications, especially cardiac (50% and 51%). However, global mortality decreased from 41% to 27% (p < 0.001). The evolution of the frequency of cardiac complications, cardiac surgery and mortality for the two periods was: for native valve IE respectively 53% to 42%, 41% to 37%, 37% to 20% (p < 0.005); for early prosthetic valve IE respectively, 45% to 55%, 41% to 55%, and 82% to 50% (p < 0.05); for late prosthetic IE, respectively 34% to 69%, 34% to 69% and 37% to 36%. The frequency of surgery had therefore little influence on prognosis except in early prosthetic valve IE. The percentage of infections which could not be controlled medically decreased from 17% to 11%. The mortality of unoperated patients decreased from 46% to 28% (p < 0.01), suggesting more effective antibiotherapy, and the mortality of operated patients fell from 34% to 26%. Global surgical mortality was 35% in the acute phase (positive valve culture), 14% after sterilisation (p < 0.001) and the corresponding frequencies of paravalvular leaks was 17% and 4% (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Prognostic factors of prosthetic valve endocarditis. Apropos of 122 cases]. / Facteurs pronostiques des endocardites sur prothèse valvulaire. A propos de 122 observations.

The prognostic factors of 122 patients suffering from prosthetic valve endocarditis between 1978 and 1992 were studied by univariate and multivariate analysis. The principal causative organisms were Staphylococcus aureus (33%), streptococci (20%), coagular-negative staphylococci (12%), enterococci (10%) and gram-negative bacilli (9%). The 4 month survival rate was 66% (42 deaths). The main predictive factor for death was infection with S. aureus (75% vs 15% with other organisms). In S. aureus infection, multivariate analysis identified the following predictive factors for death: a prothrombin ratio less than 30% (RR = 8.3), mediastinitis (RR = 4.9), cardiac failure (RR = 4.4) and septic shock (RR = 2.6). In cases of infection with other organisms, the following factors were predictive of death: a prothrombin ratio of less than 30% (RR = 32.26), renal failure (RR = 7.31) and cardiac failure (RR = 6.07). In patients with S. aureus infection, survival was better after than without surgery: 9/20 (45%) versus 0/20 (p < 0.001). In infection with other organisms, there was no difference in a survival after surgical (89%) or medical therapy (81%). Chronic endocarditis relapses over 1 to 5 years was observed in 9 cases. All patients were reoperated a total number of 18 times with 5 deaths. Very prolonged antibiotic therapy is recommended in these patients. The authors conclude that endocarditis not due to S. aureus and without complications may be treated medically. Rapid reoperation is necessary in all other cases.

[Treatment of obstructive cardiomyopathy using myotomy in a 67-year-old patient. Pharmacological and angiographical studies]. / Traitement d'une cardiomyopathie obstructive par myotomie chez un sujet de 67 ans. Etudes pharmacologique et angiographique

The case is reported of a 67 year old man with obstructive cardiomyopathy treated by an extended myotomy. Serial phonomechanographic tracings and the pre- and post-operative angiograms show the steady progress of the disease towards a major disturbance of left ventricular compliance which became resistant to propranolol, and was partially reversed by myotomy.

[Staphylococcus aureus endocarditis]. / Les endocardites à Staphylococcus aureus.

Among 409 cases of bacterial endocarditis (BE) observed from 1972 to 1985, 142 were caused by Staphylococcus aureus. Of these 142 cases, 59 affected native valves of the left heart (left BE), 47 affected native valves of the right heart (right BE) (including 36 drug-addicts), and 36 involved prosthetic valves (BEP) and were associated with mediastinitis in 11 cases. Symptoms were acute in 122 cases and subacute in 2 cases. 91 of the BE on native valves were primary (86%). Cutaneous manifestations were present in 38 cases (27%). Of the 67 patients who died (47%), 28/59 had left BE (47%), 7/47 had right BE (15%) (including 2 drug addicts) and 32/36 had BEP (86%); all differences were statistically significant. Complications consisted of: heart failure in 78 cases (55%), including 40 cases of left BE, 8 cases of right BE and 30 cases of BEP; systemic peripheral embolism in 29 cases (left BE 17, BEP 12) and neurological accidents in 58 cases (left BE 34, right BE 24). Thirty of these accidents occurred before the 4th day (left BE 13, BEP 17). Documented neurological accidents included cerebral haemorrhage (13 cases), cerebral infarction (14 cases) and cerebral abscess (4 cases); 4 of the 12 patients who underwent arteriography were found to have one or several aneurysms. Thirty-nine of these 58 patients died, death being directly due to a neurological cause in 20 cases (left BE 10, right BE 10).(ABSTRACT TRUNCATED AT 250 WORDS)