Internal right atrial cardioversion of chronic atrial fibrillation: effects of low-energy biphasic shocks.

This study evaluates the efficacy and safety of internal right atrial cardioversion of atrial fibrillation using a defibrillation right atrial catheter and 2 thoracic patches with low-energy biphasic shocks.

Intermittent left coronary occlusion caused by native aortic valve thrombosis in a patient with protein S deficiency.

A 77-year-old woman presented with chest pain and cardiogenic shock. Transesophageal echocardiography showed a mobile mass occluding intermittently the left coronary ostium. The mass was surgically resected, and histologic examination revealed an organized thrombus. Coagulation study demonstrated a protein S deficiency. This is the first case of aortic thrombosis associated with protein S deficiency, and it is the first time that transesophageal echocardiography provided definite evidence that a mass can cause intermittent left ostium coronary obstruction.

[Antithrombotic agents in acute myocardial infarction]. / Antithrombotiques dans l'infarctus myocardique aigu.

Coronary thrombosis, which is responsible for myocardial infarction, is a complex phenomenon involving the interaction of the arterial wall, the coagulation system and the platelets. Better understanding of the molecular biology of thrombosis has led to the rapid development of antithrombotic therapy. The limitations of aspirin and heparin have promoted the development of new molecules whose site of action on platelets or at different stages of coagulation are known. Some of them are the object of large scale international trials. Some results have been disappointing such as those with the direct antithrombins: others are promising and in the phase of evaluation, such as the inhibitors of glycoproteins GP IIb-IIIa.

[Internal atrial defibrillation after failure of attempted pharmacological and electrical cardioversion. Mid- and long-term outcome]. / Défibrillation auriculaire par voie interne après échecs des tentatives de réductions pharmacologiques et électriques par voie externe. Résultats à moyen et long terme.

Cardioversion of atrial fibrillation by an endocavitary electrical shock was first proposed during the 1980s. The authors studied the efficacy of this technique at short and medium term in a population of 36 patients (28 men and 8 women) in whom atrial fibrillation persisted despite attempts to reduce it by antiarrhythmic drugs and external electrical cardioversion. The immediate success rate was high : 34 out of 36 patients (94%) and, at medium term, the number with sinus rhythm was comparable to that of studies evaluating the medium-term efficacy of external electrical cardioversion; 19 out of 33 patients (57%) were in sinus rhythm at 6 months and 9 out of 27 patients (33%) at 12 months. These results seem to justify attempts at internal atrial defibrillation in patients in whom the other two techniques of cardioversion have failed. Its use as the method of first intention could be proposed if the profile of "resistant" patients to classical techniques was known, which is unfortunately not presently the case.

[Mortality and morbidity in the acute phase of myocardial infarction. Comparison of 3 patient cohorts admitted to hospital over 10 years]. / Mortalité et morbidité à la phase aiguë de l'infarctus du myocarde. Comparaison de trois cohortes de patients hospitalisés espacées de 10 ans.

The management of acute myocardial infarction has been transformed over the last thirty years by a number of therapeutic innovations. The authors decide to compare the outcomes of three cohorts of unselected patients admitted to hospital at 10 year intervals, to evaluate the impact of these innovations on morbidity and mortality. Six hundred and sixty one patient admitted to the Coronary Care Unit for acute myocardial infarction were included: Group I comprised 223 patients admitted consecutively during the period 1972-1973; Group II comprised 243 patients admitted between 1982-1983 and Group III comprised 195 patients admitted between 1992-1993. The average age was comparable, about 65 years, in the 3 groups, although there were gender differences. Taking into consideration earlier hospital admission, the in-hospital mortality decreased from 25% in Group I to 21.8% in Group II and to 15.4% in Group III (p < 0.05 between the first 2 groups and the third group). This decrease in mortality is even greater in anterior wall infarction and is observed in all ages. Similarly to selected patients in large scale randomised clinical trials, the ordinary "run of the mill" patient has also benefited from therapeutic innovations over the last ten years.

[Modeling of coronary arteries and cardiovascular risk factors]. / Modelage des artères coronaires et facteurs de risque cardiovasculaires.

The aim of this study was to assess the impact of cardiovascular risk factors on the modelling of atherosclerotic coronary arteries. One hundred consecutive patients who underwent coronary angioplasty were studied by endocoronary ultrasonography at the site of dilatation. At the site of the treated stenosis of the dilated arteries there was either compensatory widening or positive modelling (PM), or focal contraction or negative modelling (NM) if the total surface area (TSA) of the artery at the site of dilatation was greater or smaller than the total surface area of the proximal or distal reference segments. PM was observed in 53 cases (53%) and NM in 47 cases (47%). Lesions with NM had smaller TSA (13.7 +/- 5.8 versus 20.8 +/- 6.4 mm2, p < 0.0001) and a smaller atheromatous plaque (11.8 +/- 5.6 versus 19.1 +/- 6.5 mm2, p < 0.0001) than lesions with PM. Cardiovascular risk factors such as hypercholesterolaemia, smoking and hypertension were not predictive of either form of arterial modelling and there was no relationship between the cardiovascular risk factors and the qualitative appearances of the plaque studied.

[Percutaneous dilatation of subaortic stenosis in an adult: a 3-year follow-up]. / Dilatation percutanée d'un rétrécissement aortique sous-valvulaire chez un adulte. Suivi à 3 ans.

Subaortic stenosis is usually diagnosed in the first years of life and treated surgically. The authors report the case of stenosis by a subaortic membrane diagnosed in an adult, treated by percutaneous balloon dilatation with a satisfactory outcome at 3 years.

[Endocoronary ultrasonography and quantitative coronary angiography. Correlations before and after transluminal coronary angioplasty]. / Echographie endocoronaire et coronarographie quantitative. Corrélations avant et après angioplastie transluminale coronaire.

A comparative study of the results of quantitative coronary angiography and endocoronary ultrasonography was performed in 37 patients undergoing percutaneous transluminal coronary angioplasty to determine the correlations between the two methods. The analyses were made before and after angioplasty at the site of stenosis and on a reference segment. A complete study before and after angioplasty using both techniques was only possible in 24 cases. The quantitative ultrasonographic analysis consisted of measurement of two orthogonal diameters, total surface area of the vessel, the endoluminal surface area and surface area of plaque. Transluminal coronary angioplasty acts mainly by forcing the plaque outwards. Ultrasonography showed a decrease in plaque area, from 10.5 +/- 6 mm2 to 9.8 +/- 5.5 mm2 and the total surface area of the vessel increased from 12.8 +/- 0.7 to 15.3 +/- 6.9 mm2 (p < 0.05). This accounted for the gain in main surface area of the stenosed lumen, from 2.28 +/- 1.28 to 5.9 +/- 2.65 mm2 (p < 0.001). The correlations between quantitative coronary angiography and ultrasonography at the site of stenosis were only significant after angioplasty both the vessel diameter (r = 0.67; p < 0.0002) and endoluminal surface area (r = 0.63; p < 0.0001). A correlation was not observed before angioplasty because of the complexity of the plaque and its excentric location. At the reference site, the correlations between ultrasonography and angiography before and after angioplasty were significant but not very close (Spearman coefficient 0.53 and 0.82 respectively, p < 0.001). Therefore, correlations between quantitative data obtained by coronary angiography and ultrasonography are modest in patients undergoing transluminal coronary angioplasty. The ultrasonographic information is more qualitative, enabling a better understanding of the mechanism of the therapeutic procedure and allowing optimal choice of the appropriate tool.

[Myocardial infarction caused by acute left main coronary artery occlusion. Apropos of 4 cases and review of the literature]. / Infarctus du myocarde par occlusion aiguë du tronc commun gauche. A propos de 4 cas et revue de la littérature.

Between 1979 and 1996, 4 acute occlusions of the left main coronary artery (LMC) were treated by primary transluminal coronary angioplasty. They were 4 men with a mean age of 43 +/- 5 years, admitted to hospital less than 8 hours after the clinical onset of symptoms of anterior myocardial infarction in Killip class 4 with complete right bundle branch block on the initial electrocardiogramme. All cases had a previous history of unstable angina over 2 to 15 days. Angioplasty was undertaken immediately in view of the haemodynamic instability. The coronary circulation was of a dominant right coronary type in the 4 cases: significant stenoses were discovered after recanalisation, on the left anterior descending artery (LAD) in 2 cases and the circumflex or marginal arteries in 3 cases. The right coronary artery was atheromatous in all cases but without significant stenosis. Angioplasty was completed by implantation of a stent in 3 cases (LAD : 1 case, LMC : 2 cases). The outcome was rapidly fatal in 3 cases. Only one patient survived 6 months in functional class 3. These results show that myocardial infarction due to occlusion of the left main coronary artery is a very severe condition which justifies rapid recanalisation. Primary angioplasty with stent implantation in an immediate therapeutic option which enables the patient to survive the acute stage, though only in a limited number of cases.

[Systemic embolism in a renal transplant patient. Echocardiographic demonstration of bronchial carcinoma with intracardiac invasion]. / Embolie artérielle chez une greffée rénale. Découverte échocardiographique d'un cancer bronchique à extension intracardiaque.

A 45 year old female renal transplant patient was admitted for subacute ischaemia of a lower limb. Echocardiography was performed and showed the presence of bronchial carcinoma with intracardiac invasion. The tumour was confirmed by thoracic computerised tomography and by bronchoscopy. Histological investigation of bronchial biopsies and of the arterial embolism extracted at surgery showed large cell malignant disease. The tumour partially responded to chemotherapy and the patient survived for 5 months. Extension of a bronchial carcinoma to the left atrium is a classical complication in autopsy reports but rarely a source of systemic embolism. Echocardiographic diagnosis of this condition is very rare. The incidence of malignant diseases is higher in renal transplant patients than in the general population but this has not been verified for bronchial carcinoma. Echocardiography played an essential role in this case, detecting the tumour and its extension, indicating a poor prognosis and guiding treatment.

Safety of high energy internal cardioversion for atrial fibrillation.

High energy internal cardioversion has been proposed as an alternative method to cardiovert drug refractory or external cardioversion refractory atrial fibrillation. However, the safety of this technique has not been clearly evaluated. We reviewed findings in 53 patients who underwent 55 sessions of high energy internal cardioversion (2 patients underwent 2 sessions) for termination of longstanding atrial fibrillation. Shocks energy varied from 70-270 J. Three patients had 3 shocks during the same session, 5 had 2, and 47 only 1. Success rate was 89% (success was defined as immediate conversion to normal sinus rhythm). Low cardiac output occurred in two patients, and resulted in the death of one of these individuals, a patient with significant hypertrophic cardiomyopathy and heart failure. The other patient recovered completely. In 11% of the cases, shock induced transient atrioventricular block, necessitating ventricular pacing until sinus rhythm was restored. In three patients, a moderate but asymptomatic and uncomplicated pericardial effusion was diagnosed on echocardiogram. Finally, four patients had side effects related to venous puncture, which resolved spontaneously. These results suggest that high energy internal cardioversion is effective for conversion of atrial fibrillation. However, the technique may not be optimal in patients with advanced hypertrophic cardiomyopathy and in such cases the technique should be used carefully and only in the case of failure of external cardioversion; no more than two shocks should be delivered during the same procedure. Temporary ventricular pacing should be provided in all patients and an echocardiogram should be performed before patients are being discharged.

Angiographic anatomy of the coronary sinus and its tributaries.

UNLABELLED: Permanent left ventricular pacing has been shown to improve the hemodynamic and clinical status of patients with severe heart failure. To pace the left ventricle, the electrode is implanted in tributaries of the coronary sinus (CS). However, the anatomy of cardiac veins with this purpose in mind has not been described in detail. METHODS: One hundred consecutive patients admitted for coronary angiography had a simultaneous coronary venography performed after the injection of 8 to 10 mL of contrast material into the left coronary artery. Cardiac veins were analyzed in antero-posterior, left anterior oblique 60 degrees, and right anterior oblique 30 degrees views by three different observers. The number, dimension, angulation, and position of the coronary sinus and of its tributaries were studied. RESULTS: Two veins are consistently present: the middle cardiac vein (mean diameter 2.62 +/- 1.26 mm) and the great cardiac vein (mean diameter 3.55 +/- 1.24 mm). The left posterior vein(s) (LPV) (mean diameter 2.25 +/- 1.2 mm) is (are) variable in number (ranging from 0 to 3), size, and angulation. The absence of LPV limits the ability to pace the left ventricle endovenously. The diameter of the vein (< 2 mm) and its angulation may also complicate the insertion of the lead. CONCLUSION: Angiographic analysis of dimensions, tortuosity, number, and angulation of venous tributaries of the CS seems to allow the insertion of commercially available pacing leads in approximately 85% of cases. An increase in this percentage hinges on the development of new, dedicated leads.