Perforated aneurysm of the anterior mitral leaflet: late assessment with transesophageal echocardiography.

We present a case study of a 54-year-old patient with a perforated aneurysm of the anterior mitral valve leaflet, diagnosed 13 years after an episode of bacterial endocarditis by transesophageal echocardiography. This report illustrates the superiority of transesophageal echocardiography in the diagnosis and management of valvular endocarditis.

Nomogram for Doppler echocardiographic assessment of mitral stenosis in atrial fibrillation.

Non-invasive assessment of the stenotic mitral valve area is often difficult when the mitral stenosis is associated with atrial fibrillation. In this study, 16 patients with mitral stenosis and atrial fibrillation were evaluated by transthoracic Doppler echocardiography. The mitral valve area calculated by the pressure half-time method was 1.65 +/- 0.73 cm2. The enddiastolic mitral gradient was obtained from the enddiastolic forward mitral flow velocity by application of the simplified Bernoulli equation. For each patient there was a linear relationship between the enddiastolic mitral gradient and the corresponding RR interval. The slope and intercept of this relationship were significantly correlated with the mitral valve area. From the regression equations describing these correlations we established a nomogram ascertaining mitral valve area from enddiastolic mitral gradient and corresponding heart rate. This nomogram was helpful in the non-invasive assessment of stenotic mitral valve area in the presence of atrial fibrillation.

[Treatment of atrial fibrillation with fenoxedil hydrochloride. Apropos of 112 cases]. / Traitement de la fibrillation auriculaire par le chlorhydrate de fénoxédil. A propos de 112 observations.

One hundred and twelve patients with atrial fibrillation of different causes were treated with fenoxedil chlorhydrate. Sinus rhythm was restored in 81 cases (72.3 p. 100). The best results were obtained in the following conditions: hypertensive heart disease (77.6 p. 100), ischemic heart disease (75 p. 100), idiopathic atrial fibrillation (76.4 p. 100), senile lone fibrillation (78.2 p. 100). The results were average in valvular heart disease (57.1 p. 100) and in hyperthyroidism (40%). Age did not appear to be a deciding factor, the overall results being comparable in patients under 70 years of age (70.8 p. 100) and over 70 years of age (73.4 p. 100). Although recent atrial fibrillation was reduced more easily (83.3 p. 100), the results were satisfactory in chronic arrhythmias (over 3 years) (77.7 p. 100). The success rate was 76.3 p. 100 when the cardiothoracic index was over 0.60, and 66.6 p. 100 when less than 0.60. The antiarrhythmic effect of fenoxedil chlorhydrate is related to its electrophysiological properties as it depresses sinus node activity and atrioventricular conduction. No arrhythmic or conduction complications were observed during a short period (maximum 5 days) of close monitoring. However, lengthening of the QT and PR intervals was a common phenomenon. The advantages of fenoxedil chlorhydrate over electrical cardioversion (atraumatic, possibility of associating digitalis) and the results obtained whilst respecting the prescribing advice, justify its adoption as a method of converting atrial fibrillation.

[Myocardial infarction by complete thrombosis of the left main coronary artery: emergency treatment with angioplasty with implantation of a coronary stent and follow-up at one year: a case report]. / Infarctus par thrombose complète du tronc commun coronaire gauche: traitement en urgence par angioplastie avec pose de prothèse endocoronaire et suivi à 1 an. A propos d'un cas.

Acute occlusion of the left main coronary artery is usually responsible for cardiogenic shock, severe arrhythmias or sudden death. Despite the widespread use of emergency coronary angiography in acute myocardial infarction, occlusion of the left main coronary artery is rarely observed and its treatment remains controversial. The authors report the case of a young man with a previous history of radiotherapy for Hodgkin's disease, admitted for acute myocardial infarction due to complete thrombosis of the left main coronary artery treated as an emergency by percutaneous transluminal angioplasty and implantation of a Palmaz Schatz stent. There were no complications of the procedure and the patient was asymptomatic one year later.

[Normal coronary angiography. Survival and functional status at 6 years]. / Coronarographie normale. Pronostic vital et fonctionnel à 6 ans.

Despite the development of non-invasive diagnostic techniques, the absence of significant coronary stenosis is observed in 10 to 30% of coronary angiographic studies. The authors report the survival and functional status at 6 years of 172 consecutive patients with symptoms of angina without significant angiographic coronary stenosis. The average age was 60.8 years with a sex ratio of 1.1 and chest pain as the indication for coronary angiography in over 90% of cases. The global mortality after an average of 75.6 months follow-up was 11%, lower in women (8.5%) than in men (13.3%) with an annual mortality of 16.3 per thousand. Sudden death was observed in 4 patients and a third of deaths was of cardiac origin. The persistence of symptoms was reported by 58% of patients, mainly atypical chest pain. Despite the result of coronary angiography, nearly half of the patients were followed up annually by a cardiologist, two thirds remained on anti-anginal therapy, 20% were treated by psychotropic agents and hospital admission to the cardiology department was required in 22% of cases during follow-up. None of the patients had myocardial infarction. Survival and myocardial function after normal coronary angiography therefore appear to be good in contrast with the functional status of these patients.

[Platelet polymorphism and coronary artery disease]. / Polymorphisme plaquettaire et coronaropathies.

Several publications over the last ten years have addressed the problem of genetic mutation coding platelet membrane glycoproteins and thrombotic arterial disease. The principal polymorphisms studied are those of glycoproteins GPIIIa, GPIb and the GPIa-IIa complex. The relationships of each of these polymorphisms and myocardial infarction or coronary artery disease are reported and are often subject to controversy. The polymorphism PLA2 of the GPIIIa has been shown to be a risk factor for infarction in young people, especially when associated with cigarette smoking. Its role in triggering myocardial infarction or in the severity of coronary artery disease is not so clear in the general population. Two types of polymorphism concerning the GPIb and that of the GPIa-IIa complex should also predispose to early coronary thrombotic complications. In addition, the study of these platelet polymorphisms gives a better insight into individual sensitivity to platelet antiaggregant therapy.

[Doppler echographic evaluation of mitral valve stenosis with atrial fibrillation. Construction of a nomogram]. / Evaluation par échocardiographie Doppler des sténoses mitrales en fibrillation auriculaire. Construction d'un nomogramme.

Doppler echocardiographic evaluation of mitral stenosis is often difficult in patients with atrial fibrillation. Sixteen patients were examined by transthoracic Doppler echocardiography and the relation between the variations in transmitral end diastolic pressure gradient and the length of the corresponding cardiac cycles was analysed. Mitral valve surface area (1.65 +/- 0.73 cm2) was determined by the pressure half-time method. The end diastolic transmitral pressure gradient was calculated from the simplified Bernouilli formula applied to end diastolic mitral flow velocity. In each patient, a linear relationship was observed between the end diastolic mitral gradient and the corresponding RR interval. The slope and intercept of the graph correlated significantly to mitral valve surface area (r = 0.72, p < 0.002 and r = 0.93, p < 0.00001, respectively). Using regression equations describing these correlations, it has been possible to construct a nomogramme indicating mitral valve surface area as a function of mitral end diastolic pressure gradient and the duration of the corresponding RR cycle. This nomogramme facilitates Doppler evaluation of mitral stenosis in atrial fibrillation.

[Value of echocardiography in the diagnosis of a complicated form of Kawasaki's disease]. / Intérêt de l'échocardiographie dans le diagnostic des formes compliquées de la maladie de Kawasaki.

Kawasaki disease affects children under 4 years of age and is characterized by fever, mucocutaneous rash and cervical lymph node enlargement. It is often complicated by coronary vasculitis and/or pericarditis, myocarditis and endocarditis. Echocardiography is indispensable to diagnose and follow up these complications. A study of the literature and of 4 personal patients showed that it is also useful for the early detection of coronary aneurysm and simple dilatation of the coronary arteries. The sensitivity and specificity of echocardiography in recognizing these complications are such that coronary angiography is exceptionally required. In the search for a cause of prolonged fever in children, the sensitivity of echocardiography makes it possible to diagnose an atypical form of Kawasaki disease.

[Ultrasonic detection of arteriosclerosis of the main arterial trunks in the coronary patient]. / Athérosclérose des gros troncs artériels chez le coronarien, dépistage ultrasonore.

Ultrasonic investigations of the peripheral vessels (continuous Doppler with spectral analysis, echotomography) were performed to evaluate atherosclerosis of the main arteries (abdominal aorta, cervical arteries, lower limb arteries) in 50 coronary patients and 40 control subjects. In the main, our results support those of previously published series (epidemiological and autopsy studies): Atherosclerosis of the main arterial vessels is significantly more common (p less than 0.01) in coronary patients than in control subjects: carotid lesions: 70% (including 10% with severe stenosis) compared to 32% (no severe stenosis); aortic lesions: 50% (including 20% with severe stenosis) compared to 17.5% (7.5% severe stenosis); lower limb arteries: 58% (including 16% severe stenosis) compared to 12.5% (no severe stenosis). The difference of incidences of associations of atherosclerosed vessels between the two groups was significant (p less than 0.01): no peripheral vascular disease was detected in 57.5% of controls compared to only 12% of coronary patients; more than one territory diseased in 15% of controls compared to 58% of coronary patients. The severity of these lesions correlated with the presence of the three major cardiovascular risk factors which were studied (hypertension, smoking, hypercholesterolaemia) and was significantly higher (p less than 0.01) in coronary patients (38% had more than one major risk factor and only 10% had none) than in controls (47% had no risk factors and 6% had more than one). In addition, the preferential sites of atherosclerosis were also confirmed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Spontaneous course of myxoma of the left atrium]. / Evolution spontanée du myxome de l'oreillette gauche.

Little is known about the natural history of left intra-atrial myxomas. We report 3 cases of that disease where successive echocardiographic examinations provided figures of 11, 12 and 14 months respectively for the formation of the tumour in the left atrium. Echocardiography is perfectly reliable for the diagnosis of myxoma. False-negative results are rare and usually due to very small myxomas being beyond the resolution potential of the instrument; this seems to have been the case in 2 of our 3 patients. Two data, however, remain unknown: the beginning of formation and the rapidity of tumoral growth. These 3 cases raise the problem of repeat echocardiography some time after a cerebral accident of suspected embolic origin, when the initial examination is negative.

[Development at 5 years of chronic branchial blocks in 164 patients fitted with pacemakers without documented spontaneous atrioventricular block. Study of predictive criteria]. / Evolution à 5 ans des blocs de branches chroniques chez 164 patients appareillés par stimulateur sans bloc auriculo-ventriculaire spontané documenté. Etude des critères prédictifs.

When no complete atrioventricular block (CAVB), paroxysmal and spontaneous, is recorded, implanting a pacemaker in patients with chronic bundle branch block (CBB) has an arbitrary aspect which must be reduced as much as possible. In order to determine more precisely the criteria predicting an evolution towards CAVB, we studied the electrocardiographic changes observed in 164 patients with various types of CBB. 110 patients had a right bundle branch block which was isolated (RBB) in 16 cases, associated with a left anterior hemiblock (RBB + LAH) in 74 cases and associated with a left posterior hemiblock (RBB + LPH) in 20 cases; 54 patients had a left bundle branch block with a normal axis in 26 cases (LBB - NA) and with a strongly left axis in 28 cases (LBB - LA). All patients had been fitted with a pacemaker. Patients were followed up for a mean period of 5 years (59.1 +/- 25.3 months), the minimum being 2 years. 49.4 p. 100 of them had experienced one ore serveral syncopes. The basal HV interval, studied in 90.2 p. 100 of the patients, was 60 ms or more in 64.9 p. 100 of those who were explored. An ajmaline test, performed in 60 of the 85 patients whose basal HV was less than 70 ms, demonstrated at least a 100 ms or more prolongation of HV in 41 cases (68.3 p. 100).(ABSTRACT TRUNCATED AT 250 WORDS)

[Reproducibility of measurements of blood gas exchange during exercise in mild cardiac failure: need for a preliminary test?]. / Reproductibilité de la mesure des échanges gazeux a l'effort chez l'insuffisant cardiaque modéré: nécessité d'une épreuve préliminaire?

The reproducibility of blood gas exchange measurements on exercise in chronic cardiac failure has already been established in patients familiar with this technique. The aim of this prospective study was to evaluate the reproducibility of cardiopulmonary parameters on exercise in a population of patients who had never undergone this type of investigation. Twenty patients with chronic cardiac failure in classes I to III of the NYHA classification, with a mean age of 55 +/- 11.5 years and a mean LV ejection fraction of 31.2 +/- 9%, underwent two cardiopulmonary exercise tests (CPX Medgraphic) performed on a bicycle ergometer. Patients underwent maximal exercise stress testing attaining 89% of the theoretical maximal heart rate and 1.14 of the respiratory quotient during the first test. There was no significant change in peak VO2 (22.5 ml/min/kg vs 22.6 ml/min/kg) or in ventilatory anaerobic threshold (12.8 ml/min/kg vs 12.7 ml/min/kg) between the two tests. The ventilatory anaerobic threshold could not be measured in one patient and seemed less reproducible than peak VO2 with a standard deviation of relative differences (T2-T1/T1) of 10.4 versus 7.8%. There was a significant increase in the duration of exercise (7.4 +/- 9.2%; p < 0.002) and a ventilatory flow (4.5 +/-, p = 0.03). This study shows that peak VO2 is a reproducible measurement in mild to moderate chronic cardiac failure, even in the absence of a preliminary test to familiarize the patient with the equipment. The reproducibility of the ventricular anaerobic threshold is less satisfactory than that of peak VO2. The increase in the duration of exercise is more dependent on motivation and should not be taken into account alone in the functional evaluation of chronic cardiac failure.

[Electrophysiological study of a Portuguese case of amyloidosis with conduction disorders]. / Etude électrophysiologique d'un cas d'amyloïdose portugaise avec troubles de la conduction.

Cardiac involvement in the course of familial Portuguese amyloidosis, as apart from the other primary amyloidosis, is characterised by the early and wide-spread intracardiac conduction disorders, and the contrasting late presentation of the clinical signs. A case is presented of Portuguese amyloidosis which was typical from the viewpoint of the neurological disorders, the familial characteristics, and the positive biopsy; the main conduction defects found in primitive amyloidoses are also recalled. The patient described had for many years suffered from first degree heart block, and then presented with lipid changes with syncopal attacks which led to electrophysiological investigation of the conduction defect, no similar example of which has been found in the literature. The severity and widespread nature of the disorders which were found, together with the localisation of a sub-His block led us to implant the pacemaker. We have only found two other patients who had implants for disorders of conduction secondary to cardiac amyloidosis. Emphasis has been laid on the importance of this investigation which, when it leads to the positioning of a pacemaker, should avoid the onset of syncopal attacks and sudden death which together constitute one of the primary causes of mortality in primary amyloidosis. The length of follow-up in our case has been 14 months (April 1977).

[Determination of the optimal dose of captopril in the treatment of severe cardiac failure by hourly hemodynamic monitoring]. / Recherche de la posologie optimale de captopril dans le traitement de l'insuffisance cardiaque sévère par la surveillance hémodynamique horaire.

The optimal dose of Captopril was evaluated by hourly haemodynamic monitoring in 10 patients with chronic congestive cardiac failure (Stage IV of the NYHA Classification) after administration of 25 mg, 50 mg, and 100 mg of Captopril. A similar improvement was observed in all the parameters considered with all three dosages. At its peak effect (90 minutes) 25 mg of Captopril caused a fall in pulmonary capillary, and mean pulmonary artery pressures, and a fall in systemic resistance of 40%, 20% and 30% respectively; with 50 mg of Captopril, the effect was a fall of 36%, 24% and 35% respectively. The cardiac index rose by 17% with 25 mg of Captopril, 28% with 50 mg and 12% with 100 mg of Captopril. Although the fall in pulmonary capillary pressure remained significant up to the 6th hour, the improvement in cardiac index was not significant after the 3rd hour. After 8 days' treatment, plasma renin activity increased from 7.01 +/- 4.68 to 23.6 +/- 18.3 ng/ml/hour (p less than 0.02) and serum aldosterone fell from 1.175 +/- 386 p. moles/l to 497 +/- 277 p. moles/l (p less than 0.001). There was no correlation between basal plasma renin activity and pre- or post-therapeutic systemic resistances. The clinical and haemodynamic improvement was sustained after 2 months' treatment in 5 of these patients without side effects. Increasing the dosage of Captopril does not reinforce or prolong its action; moderate doses (25 mg) are as effective as high doses (100 mg). Captopril, which acts by inhibiting the renin- angiotensin-aldosterone system is the current treatment of choice in severe refractory cardiac failure.

[Aneurysm of the azygos vein]. / Les anévrysmes de la veine azygos.

A case of azygos vein aneurysm is described. It is a very rare condition, this being the tenth reported case. The patient presented with superior vena cava obstruction and underwent successful surgical cure. This congenital malformation is practically always latent. The aneurysm is usually diagnosed after the discovery of a mediastinal mass on routine chest X ray. Although its variations in size with position and respiration are characteristic, angiography would seem to be essential to confirm its aneurysmal nature and the anatomical relationships. Surgery is usually simple and should be proposed even to asymptomatic patients because of the risk of thromboembolism.

[Myocardial infarction caused by septic embolism during mitral endocarditis]. / Infarctus du myocarde par embole septique au cours d'une endocardite mitrale.

Embolic infarction is a rare complication of mitral valve endocarditis. The authors present the case of a patient with a linear vegetation of the anterior mitral leaflet measuring over 15 mm and entering the aortic valve orifice at each systole. This valvular infarction was the cause of an extensive anterior wall infarct treated by primary angioplasty because of haemodynamic instability. The outcome at 3 months was very favourable with regards to the mitral valve. However, a large mycotic coronary aneurysm developed at the site of angioplasty and there were sequellae of a large anterior wall infarction.

[3-dimensional reconstruction technic using power Doppler. In vitro use on normal and stenosed pulmonary artery bifurcations]. / Technique de reconstruction tridimensionnelle en doppler puissance. Application in vitro sur une bifurcation artérielle pulmonaire normale et sténosée.

Power Doppler imaging is an ultrasonic technique representing circulating red cells as a colour signal independent of their direction and angle of analysis. This noninvasive technique provides a morphological representation of blood flow within a blood vessel. This in vitro study in pulsed flow enabled three-dimensional reconstruction of blood flow in the bifurcation of the pulmonary artery with automatic shifting of the ultrasound probe and an integral digital transfer of the echographic data. The software for treating the images and for volumic reconstruction of the flow is explained. This technique provides a quantitative method of assessing residual intrastenotic flow with a simple computer system.

[Coronary angiography in octogenarians. Therapeutic impact and medium-term follow-up]. / Coronarographie chez l'octogénaire. Impact thérapeutique et suivi à moyen terme.

In the face of the general aging of the population and technical improvements, cardiologists are more commonly faced with the decision of whether to perform coronary angiography in octogenarians who are often in good general health. The morbidity and mortality of this investigation, its therapeutic impact and medium-term survival were analysed in 145 consecutive octogenarians who underwent coronary angiography between 1988 and 1996. In this study, coronary angiography was performed essentially for angina refractory to medical treatment and confirmed the severity of the lesions with stenosis of the left main stem in 7.6% of cases and multiple vessel disease in 67.5% of cases. The mortality related to the investigation was nil in this series. Revascularisation was feasible clinically and angiographically in 38% of cases (84% by angioplasty). The actuarial survival at 3 years was 65% in the group who underwent revascularisation and in the group treated medically.

[Relations between antihypertensive and vascular effects of nitrendipine]. / Relations entre les effets antihypertenseurs et vasculaires de la nitrendipine.

We have realized an unicentric prospective study to assess the effects of Nitrendipine on carotid circulation and arterial blood pressure (BP) in essential, permanent, uncomplicated arterial hypertension. This randomized, double blind versus placebo trial concerned 21 mild to moderate hypertensive patients (pts) (WHO advices) aged from 35 to 65 years. After a 15 days washout, the pts were randomized in two groups: 11 pts received a 20 mg Nitrendipine tablet once a day and 10 pts received a placebo. BP control and ultrasonic carotid flowmetry were performed at J0 and J30. At J30, BP was normalized for 55% of pts under NT (versus 30% for placebo). This result correspond to a very significative decrease for systolic and diastolic BP and differential BP (Dif BP) without reflex tachycardia, under Nitrendipine, opposite to placebo. Ultrasonic carotid flowmetry variations are not significative excepting common carotid vasodilation under Nitrendipine. Under Nitrendipine, at J30, 5 pts show a decrease of a least 15% of the cerebral vascular resistances (responding patients); and 6 pts do not show any significative decrease of cerebral vascular resistances. For the responding pts, arteriolar vasodilation is then correlated to the decrease of BP and Dif BP, to the increase of carotid blood flow and to the arterial vasodilation; while there is no significative decrease of BP for non responding pts. It suggests an improvement of arterial compliance by a direct action on the arterial wall. Furthermore, inspite of a drop in diastolic parietal tension, there is not any group showing reflex tachycardia. Thus, antihypertensive efficacy of Nitrendipine seem to be principally subordinated to the improvement of arterial compliance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Traumatic coronary dissection caused by deceleration. Report of a case]. / Dissection coronaire traumatique par décélération. A propos d'un cas.

Myocardial infarction is a rare complication of traumatic thoracic deceleration. The authors report the case of anterior myocardial infarction with dissection of the left anterior descending artery in a 16 year old boy who was injured in a motorbike accident without a penetrating thoracic wound. Therefore, the only pathological mechanism was deceleration. The authors review the 12 previously reported cases.