Increased risk for heart valve disease associated with antiphospholipid antibodies in patients with systemic lupus erythematosus: meta-analysis of echocardiographic studies.

BACKGROUND: Heart valve disease (HVD) is frequent in patients with systemic lupus erythematosus (SLE), and the role of antiphospholipid antibodies (aPL) is controversial. Thus, our objective was to estimate the risk of HVD, including Libman-Sacks endocarditis, associated with aPL in patients with SLE. METHODS AND RESULTS: Studies were selected if they investigated the association between aPL and HVD in SLE patients and if aPL-negative patients were included for comparison. Data sources were MEDLINE, Embase, Cochrane Library, hand search, contact with investigators, and reference lists of studies, without language restrictions. Data on study and patient characteristics, risk estimates, and study quality were independently extracted by 2 investigators. Pooled effect estimates were obtained by using the DerSimonian-Laird method. Of 234 identified abstracts, 23 primary studies (15 cross-sectional, 7 cohort, 1 case-control) met inclusion criteria, including 1656 SLE patients and 508 cases of HVD. Compared with SLE patients without aPL (n=988), the overall pooled odds ratios for HVD and Libman-Sacks endocarditis in aPL-positive patients (n=668) were 3.13 (95% confidence interval, 2.31 to 4.24) and 3.51 (95% confidence interval, 1.93 to 6.38), respectively. The risk of HVD depending on aPL subtypes was the highest for lupus anticoagulant at 5.88 (95% confidence interval, 2.92 to 11.84) and IgG anticardiolipin antibodies at 5.63 (95% confidence interval, 3.53 to 8.97). CONCLUSIONS: Overall, the presence of aPL in SLE patients is significantly associated with an increased risk for HVD including Libman-Sacks endocarditis. The risk conferred by IgG anticardiolipin antibodies is as strong as by lupus anticoagulant. Systematic echocardiographic examinations in SLE patients with aPL should be performed.

[Prevalence of sudden cardiac death during sports activities]. / Prévalence de la mort subite au cours du sport.

Sudden death during sport is a rare and unexpected event. It essentially affects young males, and a cardiomyopathy that had not been diagnosed during medical examinations is present in the majority of cases. In young subjects, there is generally hypertrophic cardiomyopathy or arhythmogenic right ventricular dysplasia. This is revealed during sporting activity, and sudden death is often the first symptom of the disease. Competitive sport increases the relative risk of sudden death to 2.5 compared to the risk in a non-sporting subject. The prevalence of sudden death during competitive sport is poorly understood. From the rare studies available, it could be estimated at 2.3/100,000 athletes per year. In Europe, it essentially occurs during football matches. However, the prevalence of sudden death during so-called 'recreational' sports is not precisely known. It could be much higher because these activities involve a larger number of people, and take place without supervision and usually without a medical examination beforehand. The participants are older, and coronary pathology is usually implicated.

Haemorheological abnormalities in arterial hypertension and their relation to cardiac hypertrophy.

Haemorheological characteristics were measured in a group of 52 patients with essential arterial hypertension (HT), and were compared with those of a group of normotensive subjects. The relationships between the arterial blood pressure (BP), the echocardiographic indices of left ventricular hypertrophy (LVH), and the haemorheological measurements, were studied. The group of hypertensive patients was found to have a hyperviscosity syndrome with significant elevations of blood viscosity at all shear rates (for gamma = 0.20/s, 29.6 +/- 0.6 versus 28.0 +/- 0.3 mPa.s, P less than 0.01: for gamma = 128/s, 4.2 +/- 0.05 versus 4.1 +/- 0.02 mPa.s, P less than 0.02, of plasma viscosity (1.29 +/- 0.01 versus 1.22 +/- 0.06 cSt, P less than 0.001); of erythrocyte aggregation index (17.8 +/- 0.06 versus 14.6 +/- 0.4, P less than 0.001); of erythrocyte filterability index (13.3 +/- 0.5 versus 8.8 +/- 0.2, P less than 0.001) and plasma fibrinogen level (3.4 +/- 0.9 versus 2.8 +/- 0.6 g/l, P less than 0.02). The haematocrit did not differ from that of normotensive subjects (43.3 +/- 0.6 versus 44.7 +/- 0.5%, NS). The left ventricular mass was increased and was positively correlated with the blood viscosity at a high shear rate (r = 0.38, P less than 0.01) and with the erythrocyte aggregation index (r = 0.47, P less than 0.01). Systolic, diastolic, and mean arterial blood pressures were positively correlated with the left ventricular mass (r = 0.34-0.47, P less than 0.05) and with the erythrocyte aggregation index (r = 0.42-0.46, P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Noninvasive assessment of coronary flow dynamics before and after coronary angioplasty using transesophageal Doppler.

Recent invasive studies using intracoronary Doppler catheters or guide wires reported improved coronary flow dynamics after successful percutaneous transluminal coronary angioplasty. Transesophageal Doppler enables the measurement of coronary flow velocities within the left anterior descending artery. The present study was designed to test: (1) whether transesophageal Doppler may detect coronary flow velocity changes in patients undergoing angioplasty for left anterior descending artery stenosis, and (2) whether this technique may help to evaluate non-invasively the results of the procedure. Twenty-three patients undergoing angioplasty of the left anterior descending artery were studied by transesophageal Doppler before and < or = 24 hours after the interventional procedure. Coronary flow velocities were measured in the proximal part of the left anterior descending artery with the use of pulsed Doppler guided by color flow imaging. The degree of stenosis was measured by computerized quantitative coronary arteriography. Coronary flow velocity signals were successfully obtained in 19 of 23 patients (83%). In 16 successful angioplasty procedures, peak diastolic velocity increased from 37 +/- 14 cm/s before angioplasty to 51 +/- 16 cm/s after (p = 0.0001). In the 3 patients in whom angioplasty was unsuccessful, transesophageal Doppler showed no significant increase in peak diastolic coronary flow velocity. In a total of 19 angioplasty procedures, a good linear relation was found between the percent changes in coronary flow diastolic velocity and the reduction in the degree of stenosis (r = 0.85; p = 0.0001). All patients with > 20% increase in peak diastolic velocity had > 40% stenosis reduction.(ABSTRACT TRUNCATED AT 250 WORDS)

[Esophageal M mode echocardiography]. / L'échocardiographie TM par voie oesophagienne.

M mode echocardiography may be difficult or even impossible from the standard transducer positions (parasternal or subcostal) in obese, broncho-emphysematous patients and subjects with thoracic malformations. For this reason, the authors used the oesophageal route. A 2.25 MHz unfocused 11 mm diameter transducer was attached to a wire enabling it to be orientated. The patients were asked to swallow this probe after local anaesthesia. The aortic ring served as a landmark for other cardiac structures. The technique was well tolerated and no complications ensued. Fifty seven patients were examined: echocardiography from the standard positions was of mediocre quality in 55%. Excellent recordings were obtained by the oesophageal route, of the aortic ring (Ao, 100% of cases), of the aortic cusp opening (ACO, 92% of cases) and of the anterior mitral leaflet (AML, 96.5% of cases); the recording of the left ventricle was more difficult (LV, 45.5% of cases). Exceptionally good recording were obtained of the right heart. Correlations between the measurements made from the oesophageal and standard positions were excellent with respect to the aortic structures (Ao: r = 0.92; ACO: r = 0.92) and LV dimensions (systolic: r = 0.82; diastolic: r = 0.87). The correlations between the measurements of DE mitral valve amplitude, EF slope and left atrial dimension were mediocre (r = 0.63, r = 0.72 and r = 0.69, respectively). In 6 cases, this recording technique enabled a precise diagnosis to be made. Oesophageal echocardiography is simple and well tolerated and should effectively complete the arsenal of cardiological ultrasonic techniques.

[Bidirectional ventricular tachycardia (arguments in favor of reentry)]. / Tachycardie ventriculaire bidirectionnelle (arguments en faveur d'une reentrée).

Bidirectional ventricular tachycardia, defined as the rapid alternation of the QRS complexes with successive opposing axial deviation, is a rare arrhythmia. In the rare cases which have undergone endocavitary investigations, an infrahisian origin has generally been proved. However, the mechanism of these tachycardias remains poorly understood and is discussed with respect to a new case. Bidirectional tachycardia occurred in a 79 year old woman with previous diaphragmatic and anterior wall infarction. It was a wide QRS tachycardia at 180/min with a succession of ventriculogrammes of opposing axis in the frontal plane and permanent right bundle branch block over the right precordium. The two types of tachycardia were observed, monomorphic type A or Type B or a combination of the two realising an A-B bidirectional tachycardia. The origin of these episodes, which occurred on a background of atrial tachycardia at about 100/min, was ventricular as shown by the absence of a His potential before the ventricular complexes in tachycardia. The presence of ventricular extrasystoles with relatively fixed coupling intervals, and the results of endocavitary investigation were suggestive of a reentry phenomenon ventricular extrastimuli were capable of transforming the bidirectional into monomorphic tachycardia and vice versa; this suggests that A was at times the origin of a reentry B, but protected by A, tachycardia B could be sustained. In the light of previously reported cases with documented endocavitary investigation and this new case, it seems possible to talk in terms of true "bidirectional ventricular tachycardia", a tachycardia whose mechanism is obscure but certainly not univocal.

[Blood hyperviscosity syndrome in essential arterial hypertension. Characterization and clinical effects]. / Le syndrome d'hyperviscosité sanguine dans l'hypertension artérielle essentielle. Caractérisation et incidences cliniques.

Blood viscosity (BV) is one determinant of total arterial resistance (TAR) which is usually increased in hypertension. This increase is mainly related to vasoconstriction. In this study, we investigated the blood rheological properties in hypertension and their relation to blood pressure (BP) and left ventricular hypertrophy (LVH) since the latter could be related to increased TAR. BP and echocardiographic measurement of left ventricular mass (LVM) according to Devereux were measured and blood samples obtained from 22 untreated hypertensives aged 31 to 62 (13 men, 9 women) Control group consisted of 30 age-matched, normotensive blood donors. Results are shown in table I. (Formula: see text). A positive significant correlation was found between LVM and BV (r = 0.50; p less than 0.05) red cell filterability (r = 0.53; p less than 0.05) and red cell aggregability (r = 0.57; p less than 0.02). These results suggest that erythrocyte abnormalities are one of the determinants of the hyperviscosity syndrome in hypertension. Some variables of this syndrome were related to LVM and could therefore be among the determinants or a consequence of LVH in hypertensives.

[Vectorcardiography in inferior infarction associated with left bundle-branch block]. / Le vectocardiogramme dans l'infarctus inférieur associé au bloc de branche gauche.

The authors report a series of 13 patients, 8 men and 5 women, with an average age of 68 years (range 39 to 87 years) presenting with documented inferior infarction with anteroseptal extension in 2 cases. These patients developed LBBB (complete in 9 cases, incomplete in 4 cases). This complications occurred in the acute phase in 8 cases and 4 months to 9 years later (average 4,5 years) in the other 5 cases. The block was intermittent in 4 patients and became permanent in all cases. The diagnosis of inferior infarction with LBBB was made by vectorcardiography (VCG) in 5 out of the 13 patients (38,4 p. 100) on the criteria suggested by Starr. 3 of the 8 false negative results were directly related to the block which masked the ECG and VCG signs of inferior infarction. The VCG signs observed were an upwards displacement of the QRS loop with preservation of the superior orientation of the initial forces (5 cases). Atypical appearances of LBBB were observed in 2 cases with a posterior and right-sided shift of the efferent loop following the anterior and left-sided orientations of the initial forces. The sensitivity of the VCG and ECG is mediocre in inferior infarction with LBBB because the block may mask the electrical signs of inferior infarction. The specificity of the VCG could not be assessed because of the mode of selection of the patients and the small number of cases.

[Influence of gender and size on parameters measured by signal-averaged electrocardiography in healthy subjects: preliminary study]. / Influence du sexe et de la taille sur les paramètres mesurés par électrocardiographie haute amplification chez les sujets sains; étude préliminaire.

The aim of this study was to determine the influence of electrocardiographic and biomorphometric factors on the parameters measured by signal averaged electrocardiography (SA-ECG) in normal subjects. The study population comprised 40 Caucasian students (20 men, 20 women). The SA-ECG measured 6 parameters: total duration of the averaged QRS, the root mean square of the voltage of the last 40 ms of the QRS (RMS 40) and the length duration of the terminal signal of under 40 microV (LAS), each parameter being measured with a band pass filter of 25 and 40 Hz. The echocardiographic recording included measurement of 12 parameters including left ventricular mass and ventricular volumes. Five morphological parameters were measured, including height, weight and body surface area. The duration of QRS measured with a 25 Hz band pass filter was significantly longer by 9.7 ms in men than in women (102.9 +/- 8.5 ms versus 93.2 +/- 8.1 ms; p < 0.001). Similarly, QRS duration measured with the 40 Hz band pass filter was longer in men by 11.4 ms than in women (102.1 +/- 9.6 ms versus 90.7 +/- 7.5 ms; p < 0.001). Multiple linear regression analyses showed that in both men and women, the duration of the QRS measured with either a 25 or 40 Hz band pass filter was correlated to size: the taller the subject, the longer the QRS duration. A negative correlation was observed between size and RMS 40 measured with both 25 and 40 Hz band pass filters: the taller the subject, the smaller the value of RMS 40.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of permanent cardiac pacing in hypertrophic and obstructive cardiomyopathies resistant to medical treatment]. / Intérêts de la stimulation cardiaque permanente dans les myocardiopathies hypertrophiques et obstructives rebelles au traitement médical.

The authors report their experience of long-term dual-chamber pacing in the treatment of hypertrophic and obstructive cardiomyopathy. Between August 1990 and March 1993, 16 patients (8 men, average age 53.5 +/- 18.9 years, range 21 and 79 years) with symptomatic hypertrophic obstructive cardiomyopathy resistant to medical therapy underwent electrophysiological investigation to assess atrioventricular conduction and the effects of temporary atrioventricular pacing on the intraventricular pressure gradient before implantation of a dual-chamber pacing system. The decision to implant was taken if the endocavitary studies showed severe atrioventricular conduction defects and/or if temporary pacing reduced the systolic pressure gradient by more than 30%. Temporary dual-chamber pacing led to a decrease of 48% of the systolic pressure gradient from 78.6 +/- 21.3 to 40.1 +/- 23.6 mmHg (p < 0.0005), a regression observed in 15 of the 16 patients. After an average follow-up period of 18.7 +/- 9.5 months (range 6 and 37 months), all 15 patients who received a dual-chamber pacing system were alive and were clinically improved. The systolic pressure gradient continued to decrease during the follow-up period (24.4 +/- 17.2 mmHg at the 6th month compared with 36.5 +/- 18.6 mmHg at the time of implantation; p = 0.014). The clinical improvement was dependent on careful adjustment of the atrioventricular delay which was programmed at relatively short values (65.6 +/- 14 ms, range 47 and 75 ms) to obtain permanent right ventricular capture. The authors conclude that dual-chamber pacing is an effective means of treating symptomatic hypertrophic obstructive cardiomyopathy resistant to medical therapy, even in the absence of preexisting conduction defects.

[Hemolytic anemia and cardiac heterografts. Apropos of 2 cases]. / Anémie hémolytique et hétérogreffes cardiaques. A propos de deux observations.

Two cases of severe haemolytic anaemia developed after heterograft valve replacement are reported. In one case haemolysis was caused by prosthetic degeneration; in the other case the heterograft was not altered, but a ventricular septal defect had created a high turbulence around the valve which was in pulmonary position. In both cases anaemia subsided after surgical correction of the abnormalities responsible for periprosthetic turbulence. Haemodialysis can only develop in patients with heterograft valve replacement if a change in blood flow rate occurs around the valve, due to its alteration or to an associated cardiac disease.

[Semiquantitative evaluation of mitral insufficiency by pulsed Doppler technic. Value of a simple index of left auricular cartography (apropos of a series of 63 patients)]. / Appréciation semi-quantitative de l'insuffisance mitrale par la technique doppler pulsé. Valeur d'un index simple de cartographie auriculaire gauche (a propos d'une série de 63 patients).

The authors advocate a semiquantitative evaluation of mitral regurgitation (MR), based on the extent of the left intra-atrial systolic jet. Their study was performed in a series of 63 consecutive patients explored by: (1) catheterization with left ventriculography on two planes for either ischaemic heart disease (24 cases) or cardiac valve disease (39 cases including 2 with mitral valve prosthesis), and (2) pulsed Doppler ultrasound combined with two-dimensional echocardiography for evaluation of MR carried out 24 or 48 hours prior to catheterization. Five grades of MR (0 to IV) were determined by ventriculography according to the time and degree of left atrial opacification. Similarly, five grades of MR (0 to IV) were determined by Doppler ultrasound, considering only the maximum distance from the mitral annulus plane. This distance was evaluated on at least 3 projections: apical for the 4 and 2 cavities, parasternal for the greater axis. The Doppler method correlated fairly well with the angiography, whether or not grade 0 was included (r = 0.87 and r = 0.72 respectively). However, some major MR may be underestimated; thus, out of 13 RM of angiographic grade III or IV, three (23 p. 100) were graded II by the Doppler technique. Conversely, some minute or moderate MR may be overestimated: out of 33 MR of angiographic grade I or II, four (12 p. 100) were graded III or IV by the Doppler technique.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echographic rediscovery of an anatomical structure: the Chiari network. Apropos of 16 cases]. / Redécouverte grâce à l'échographie d'une structure anatomique: le "réseau de Chiari". A propos de 16 cas.

In 1897, the anatomist Chiari described a structure in the right atrium connected to the Eustachian valve identified as the embryological vestige of the right valve of the sinus venosus. This structure was then forgotten. Recently, Werner described the echocardiographic appearances. During 1981, 1 600 consecutive patients underwent 2D echocardiography and the right atrium (RA) was visualised in several incidences. Abnormal RA echos fulfilling the echocardiographic criteria of the Chiari network were detected in 16 cases. The 2D echo appearances were as follows: a fine, mobile echo crossing the RA at right angles to its long antero posterior axis; arising from the anterior border of the orifice of the inferior vena cava, variably attached to the RA walls (lateral, superior, interatrial septum). The recordings were made from the transverse parasternal and apical or subcostal 4 chamber views. An M mode recording of this structure usually guided by the sector scan was made in 13 patients. This showed a fine curvilinear echo animated by antero-posterior vibrations during the cardiac cycle situated behind the anterior tricuspid leaflet. The pathological associations of the 16 patients in whom the Chiari network was demonstrated were as follows: 5 congenital cardiopathies including 3 ASDs, 1 isolated abnormal pulmonary venous drainage, 1 complex case comprising 1 ASD and 5 acquired lesions: aortic endocarditis; chronic cor pulmonale, idiopathic atrial fibrillation, pericarditis and coronary artery disease. Six patients did not appear to have cardiac disease. This structure was confirmed at surgery in 2 cases: the operative findings were a fine network of filaments stretching from the orifice of the inferior vena cava (Eustachian valve) to the RA walls.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary lesions due to aortic valve disease. I -- Occurrence and clinical prognosis]. / Les lésions coronaires des valvulopathies aortiques opérées. I -- Fréquence et éléments cliniques de prévision.

A multicentre retrospective study of 467 cases of operated aortic valve disease was undertaken to define the indications of coronary arteriography in the pre-operative work-up. Significant coronary artery disease was present in 15% of all cases or, more precisely, in 17% of cases with angina and in 8% when investigation was only routine. Coronary artery disease was more frequent in males, in patients with clinical or electrical evidence of previous myocardial infarction, in patients with ST-T wave changes, and when angina was severe (more than one attack per day). None of these factors was specific. It is therefore difficult to limit coronary arteriography to these patients or there would be a risk of missing significant lesions in a small number of cases. It is important to give the surgeon all the necessary information before aortic valve replacement and so coronary arteriography should be widely practiced in this context. However exceptions may be made for young patients and also those in congestive cardiac failure in whom coronary arteriography represents an unnecessary risk before surgery.

[Prognostic value of bidimensional echography in the acute stage of myocardial infarction]. / Valeur prognostique de l'échographie bidimensionnelle au stade aigu de l'infarctus du myocarde.

Segmental asynergy is almost always demonstrated (in more than 90.5 per cent of cases) by means of two-dimensional ultrasonography in the acute phase of myocardial infarction. However, the value of 2D ultrasonography is not limited to this very high level of diagnostic sensitivity. In fact, the degree of asynergy, evaluated by the semi-quantitative method of ventricular scores, provides a sensitive and specific index in the prediction of intra-hospital complications (shock, death, severe arrhythmias), even before the haemodynamic data. Furthermore the asynergy of the segments situated at a distance from the infarction also constitute a valuable pejorative prognostic index in the prediction of intra- and extra-hospital complications. The excellent prognostic value of two-dimensional ultrasonography, together with its diagnostic value, justifies its routine use in coronary intensive care units.

[Vectorcardiography in infarction of the right ventricle]. / Le vectocardiogramme au cours de l'infarctus du ventricule droit.

A vectorcardiogram (VCG) was recorded in 22 patients in the acute phase of a right ventricular infarct in order to investigate any characteristic signs of this diagnosis. The RV infarct had been proven by at least two investigations: 2D echo, isotopes and right ventricular catheterisation. 17 patients had ST depression in V4R. The QRS complex presented two features: there was a reduced refractory period in every case, associated with septal extension in 3 cases and true posterior infarction in 11 cases, and, in the frontal plane, the QRS which was in clockwise rotation had showed an abnormal left axial lead in 18 cases with a maximal vectorial axis of between - 10 degrees and - 60 degrees. These modifications are similar to those seen in experimental infarcts of the RV. In conclusion, repeated VCGs in the acute phase of inferior infarction should suggest the diagnosis of right ventricular extension if it shows the appearance of more marked left axis deviation than that seen with isolated inferior infarcts. However, this sign is no constant and is not specific.

[Value of bidimensional echocardiography in the diagnosis of early mechanical complications of myocardial infarction]. / Intérêt de l'échocardiographie bidimensionnelle dans le diagnostic des complications mécaniques précoces de l'infarctus du myocarde.

Thirteen patients with myocardial infarction were investigated with two-dimensional echocardiography because of the appearance of signs of cardio-circulatory failure associated with a systolic murmur during the first 15 days following the infarct. The precise diagnosis was obtained by surgical or autopsy examination in 11 cases and by haemodynamic investigations in 2 cases. These mechanical complications were: 8 septal ruptures and 5 cases of acute mitral incompetence, due to papillary rupture in 2 cases and to papillary dysfunction in 3 cases. The 8 cases of septal rupture, complicating 6 cases of anterior infarct and 2 cases of diaphragmatic infarct, were diagnosed by 2-D echocardiography, which revealed 3 apical perforations (one of which was only visible via a sub-costal approach), 3 superior perforations or lacerations, 2 inferior perforations in the middle or the base of the septum; all visible in an apical view of the 4 cavities. The injection of ultrasonic contrast in 4 patients demonstrated negative lavage, which confirmed the diagnosis, in one case, even before the perforation could be visualised. The 2 cases of ruptured papillary muscles were visualised directly on the 2-D echocardiography. However, only one of the three cases of papillary muscle dysfunction was diagnosed by echocardiography. 2-D echocardiography has an important place in the investigation of complicated myocardial infarction, not only as a means of diagnosing ruptures of the septum or papillary muscles, but also to evaluate the deterioration in left ventricular contractile function, which enabled surgical repair without left haemodynamic investigations, in two cases.

[Isotopic exercise tests and selection of cases of inferior infarction requiring coronarography]. / Epreuves d'effort isotopiques et sélection des infarctus inférieurs nécessitant une coronarographie.

Exercise tests involving isotopes were evaluated in 38 subjects presenting inferior myocardial necrosis. Cardiographic data were used to calculate sensitivity and specificity of the method in detection of subjects requiring surgical treatment. Sensitivity was 90% and specificity 62% when three criteria were employed: ECG of positive exertion, reversible diminished accumulation of thallium 201 outside the necrotic site or decrease in the fraction of ejection force. Examination of the fraction of ejection force improved the results of myocardial scanning using thallium and increased detection of subjects requiring surgery from 61% to 90%.