Swimming-induced immersion pulmonary edema while snorkeling can be rapidly life-threatening: case reports.

It is well known that immersion pulmonary edema can be life-threatening for divers using a self-contained underwater breathing apparatus (scuba). Swimming-induced pulmonary edema in otherwise healthy individuals is not an object of dispute but its real severity is not well known and is probably underestimated. We report two cases of life-threatening acute respiratory distress while swimming and snorkeling, one of which is well documented for swimming-induced pulmonary edema. The interest of these case reports lies in the suddenness of these life-threatening events. Such accidents can mimic a loss of consciousness due to cardiac dysrhythmia and lead to drowning. In the case of swimming-induced pulmonary edema, the prognosis is far better than for a cardiac disorder, but it is also dependent on the efficiency of the supervision. Swimmers, divers, race organizers and supervising physicians should be given knowledge of this pathology and its potentially acute occurrence. Adequate organizational dispositions are mandatory to prevent swimming-induced pulmonary edema-related deaths.

[Contribution of cardiac MRI in the etiologic diagnosis of chest pain syndrome with a normal angiographic aspect of the coronary arteries]. / Apport de l'IRM cardiaque dans le diagnostic étiologique des syndromes douloureux thoraciques à réseau coronaire angiographiquement normal.

The etiologic diagnosis of chest pain with elevation of specific cardiac enzymes, repolarization abnormalities and a normal angiographic aspect of the coronary arteries is difficult. In this situation, the role of cardiac MRI is growing, frequently allowing to precise the etiology of the chest pain. We present a literature review concerning the semiology of the cardiac MRI in the three main involved etiologies: myocarditis, takotsubo syndrome, and myocardial ischemia with a normal angiographic aspect of the coronary arteries.

[Clinical and angiographic parameters affecting the quality of 16 slice spiral CT in the diagnosis of restenosis after stenting the left main coronary artery]. / Paramètres cliniques et angiographiques influant sur la qualité de l'angioscanner spiralé 16 détecteurs dans le diagnostic de resténose après stenting du tronc commun de la coronaire gauche.

The metallic component of coronary stents makes it difficult to study their lumen by angio scanner. The object of this preliminary study was to appreciate the factors influencing the diagnosis of restenosis after stenting the left main coronary artery by 16-slice spiral angio CT. This Monocentric study included 27 patients who underwent 16-slice spiral angio CT six months after stenting of the left main coronary artery. It was possible to assess the stent lumen in 21 patients (78%) and no cases of > 50% restenosis were observed. In 4 patients, hypodense zones adjacent to the stent links were observed suggesting moderate intimal hyperplasia. The tests for ischaemia were normal in 3 of these patients. Coronary angiography and endocoronary ultrasound excluded significant restenosis in the fourth patient. In univariable analysis, the facors associated with good or excellent angioscanner quality (45% of patients) were Ostial stenosis (p = 0.03), no or minimal calcification on initial coronary angiography (p = 0.0S), stent diameters > 3.5mm (p = 0.03), heart rates < 60/min (p = 0.04), absence of extrasystoles (p = 0.05) during acquisition. In multivariable analysis, the only significant factors were absent or minimal calcification and stent diameters > 3.5mm (p = 0.02). The multidetector scanner seems a very promising method of investigating patients who have undergone stenting of the left main coronary artery but this study shows that certain clinical and angiographic parameters are limiting factors of surveillance with a 16-slice angioscanner.

[Pilot study of a strategy combining coronary angioplasty with valvular and/or coronary surgery on the same day]. / Etude pilote d'une stratégie combinée associant une angioplastle coronaire a une chirurgie valvulaire et/ou coronaire le même jour.

A strategy combining percutaneous coronary angioplasty followed by valvular and/or coronary surgery was recently proposed as an alternative to the classical surgical only approach. The aim of this study was to assess the feasibility and the results of such a combined strategy with the two procedures performed the same day. The population comprised 34 patients including 17 with valvular disease and revascularisable coronary lesions (15 symptomatic severe aortic stenoses and two acute mitral insufficiencies) plus 17 multitrunk coronary patients without valvular disease but with an indication for revascularisation. Angioplasty was performed several hours prior to surgery and a loading dose of 300mg clopidogrel was administered immediately postoperatively; all patients were on aspirin before the procedure. The average age was 67 +/- 11 years, NYHA class 2.3 +/- 0.7, angina 73%, LVEF 58 +/- 10%. Single coronary artery disease was present in 26%, two vessel disease in 35% and three vessel disease in 39%. The success rate for angioplasty plus stent was 98%. 60 stents were active. Bypasses were exclusively arterial (left or right internal mammary arteries). We observed 4 in-hospital deaths, one of which was due to an infarct and three due to extra-cardiac causes (1 non-cardiogenic acute respiratory distress syndrome, 1 respiratory tract infection and 1 pyelonephritis). Further surgery was necessary in 4 cases: for haemorrhage and one episode of digestive tract haemorrhage. There were no additional deaths, coronary events nor haemorrhage at the end of an average follow-up of 15 +/- 6 months. The results of this combined strategy are encouraging in this population and merit further evaluation in a prospective study.

Treatment of drug-eluting stents in-stent restenosis with paclitaxel-coated balloon angioplasty: Insights from the French "real-world" prospective GARO Registry.

BACKGROUND: Data about paclitaxel-eluting balloon (PCB) angioplasty to treat drug-eluting stents (DES) in-stent restenosis (ISR) were mainly collected in selected patient populations in the setting of randomized trials. The main goal of this prospective registry was to confirm the positive findings of these studies in an unselected population in clinical practice. METHODS: Consecutive patients with DES-ISR treated by PCB angioplasty were recruited in this prospective real-world registry. The primary endpoint was clinically driven target-lesion revascularization (TLR) at 9 months. Secondary endpoints included acute technical success, in-hospital outcomes, 9-month major adverse cardiac events (MACE) a composite of death, myocardial infarction (MI) and TLR and the occurrence of target vessel revascularization. RESULTS: A total of 206 patients (67.7 ± 10.2 years, 80.6% male, 41.3% diabetics) with 210 lesions were recruited. Unstable coronary artery disease was present in 55.3% of patients. The time from DES implantation to DES-ISR was 3.0 ± 2.4 years. Quantitative analyses revealed that patterns of treated DES-ISR were focal in 55.7% and diffuse in 44.3%. The reference diameter was 2.76 ± 0.64 mm. The 9-month follow-up rate was 90.8% (187/206). At 9 months, the TLR rate was 7.0% (13/187) whereas the rates for MACE, MI and cardiac death were 10.7% (20/187), 4.8% (9/187) and 2.1% (4/187) respectively. Results were consistent in patients with paclitaxel and non-paclitaxel-eluting stents (PES) ISR. CONCLUSION: This large prospective registry demonstrated acceptable rates of TLR and MACE at 9 months after treatment of DES-ISR by PCB angioplasty. PCB angioplasty was equally effective in patients with PES-ISR and non PES-ISR.

Stent placement compared with balloon angioplasty for small coronary arteries: in-hospital and 6-month clinical and angiographic results.

BACKGROUND: Stenting has been demonstrated to be superior to balloon angioplasty in de novo focal lesions located in large native vessels. However, in small vessels, the benefit of stenting remains questionable. METHODS AND RESULTS: A total of 381 symptomatic patients with de novo focal lesion located on a small coronary segment vessel (<3 mm) were randomly assigned to either stent implantation (192 patients; 197 lesions) or standard balloon angioplasty (189 patients; 198 lesions). The primary end point was the angiographic restenosis rate at 6 months, as determined by quantitative coronary angiography. On intention-to-treat analysis, angiographic success rate and major adverse cardiac events were comparable: 97.9% and 4.6% versus 93.9% and 5.8% in the stent group and the balloon group, respectively. After the procedure, a larger acute gain was achieved with stent placement (1.35+/-0.45 versus 0.94+/-0.47 mm, P=0.0001), resulting in a larger minimal lumen diameter (2.06+/-0.42 versus 1.70+/-0.46 mm, P=0.0001). At follow-up (obtained in 91% of patients), angiographic restenosis rate was 21% in the stent group versus 47% in the balloon group (P=0.0001), a risk reduction of 55%. Repeat target lesion revascularization was less frequent in the stent group (13% versus 25%, P=0.0006). CONCLUSIONS: Elective stent placement in small coronary arteries with focal de novo lesions is safe and associated with a marked reduction in restenosis rate and subsequent target lesion revascularization rate at 6 months.

Clinical and angiographic results of stenting for long coronary arterial atherosclerotic lesions.

A prospective registry of 187 patients who underwent percutaneous coronary angioplasty with attempted long NIR stent delivery was performed. A successful stent delivery was achieved in 93% of cases with a low rate of major cardiovascular events, and 6-month follow-up showed low rates of clinical events, new revascularization procedures, and angiographic restenosis.

Aneurysms and pseudoaneurysms of saphenous vein coronary artery bypass grafts.

Aneurysms of saphenous vein grafts to coronary arteries are unusual complications of coronary artery bypass graft (CABG) surgery. Three patients (men aged 47, 62, and 68 years) are presented with spontaneous chest pains 10, 21, and 17 years after CABG surgery. In one case, the saphenous vein graft had eroded into the right atrium and had established a fistula between the graft and the right atrium. Diagnosis of saphenous vein graft aneurysms was confirmed by echocardiography, computed tomography or magnetic resonance imaging, and by arteriography. Two patients were treated surgically, the third by percutaneous coil embolisation followed by balloon angioplasty of the right coronary artery.

CARDIOMEDIA: a communicable multimedia medical record on Intranet and digital optical memory card.

As part of French health reform, French physicians were computerised by the end of 1998. A specific Intranet network will be used to communicate medical data between the health professionals. The objectives of the CARDIOMEDIA project were to develop and evaluate the feasibility of a coronary multimedia data record stored on an optical card and communicable on Intranet within the hospital. Patients treated by angioplasty at the University Hospital of Rennes participated in the experiment. In general, patients are treated in the University Hospital and are followed up by another health care provider closer to their home. The patient leaves the University Hospital with his card, which is directly available elsewhere for emergency or for consultation. This approach is assumed to reduce the number of examinations and to offer a better patient follow-up. The CARDIOMEDIA card is a specialised record including various data types: text, images, image sequences of coronarography and ECG signals. For this purpose an optical card with its large memory is very convenient. We used the DICOM format for image exchange and management. It is combined with CARDIOMEDIA specific compressing software. For the multimedia record the HTML format and web Intranet method are chosen. This provides an intuitive interface which can combine various data types and helper applications like a DICOM image viewer.

[Value of an algorithm of automatic adaptation of the atrio-ventricular delay to the instantaneous atrial rate in cardiac stimulation]. / Intérêt d'un algorithme d'adaptation automatique du délai auriculo-ventriculaire à la fréquence atriale instantanée en stimulation cardiaque DDD.

It has been suggested that an algorithm of automatic adaptation of the AV delay to the instantaneous atrial rate be introduced into the program of DDD pacemakers to reproduce the physiological adaptation of the PR interval to effort, characterised by progressive shortening inversely linearly related to the heart rate. In order to evaluate the potential benefits in conditions of "standard" programming (basal AV delay the same for all patients: maximal frequency of 1/1 AV synchronisation uniformly limited to 120 bpm), a haemodynamic study was undertaken in 10 patients who had permanent DDD pacemakers implanted for advanced AV block. Measurements were taken during two standardized exercise stress tests (20 W/2 mn steps from an initial load of 20 W) performed in a random order, one with a fixed AV delay of 156 ms and the other with an "automatic AV delay" allowing linear reduction from a maximum value of 156 ms at rest to a minimum value of 84 ms at the maximum heart rate of 120 bpm. At the peak of exercise the "automatic AV delay" significantly affected 4 parameters: the paced ventricular rate (p = 0.008) and rate-pressure product (p = 0.005) which increased, pulmonary capillary pressure (p = 0.03) and cycle-to-cycle variability of systolic and diastolic blood pressures (p = 0.02 < p < 0.0001) which decreased. There was a tendency (NS) to slowing of the spontaneous atrial rate and to increase in cardiac output. This increase was significant in some patients and seemed to be due to a good relationship between the individual optimal value of the value basal AV delay measured by Doppler echocardiography and the value programmed in this study (156 ms).(ABSTRACT TRUNCATED AT 250 WORDS)

[Indications of partial interruption of the inferior vena cava in pulmonary embolism]. / Indications d'interruption partielle de la veine cave inférieure dans l'embolie pulmonaire.

Forty years after the first implantation of caval filters, there is still no indication for implantation validated by a controlled clinical trial. This fact may be explained by our poor understanding of the evolution of thromboembolic disease, especially in certain groups of patients. The absolute contra-indications to heparin therapy would seem to be a logical indication for a caval filter. In cases of a relative contra-indication to anticoagulants, the physician has to rely on his clinical judgement and the decision will be taken case by case. In patients with suspected pulmonary embolism under anticoagulant therapy, it is also logical to check that anticoagulation is effective, and to request proof of embolism, to assess its risk and that due to thrombosis before considering a caval filter. The prophylactic implantation of a caval filter is a very controversial indication whether the thrombus is proximal in the ilio-caval region, extensive, not uncommon despite treatment, or floating. For groups said to be at high risk of thromboembolism (elderly, malignant disease or multiple injuries), there is no consensus because of the discordant results in the literature. The implantation of a filter would seem to be justified in patients with chronic cor pulmonale after pulmonary embolectomy. The value of a temporary caval filter during thrombolysis has not been demonstrated; there are hopes that temporary filters "of long duration" will provide filtration of the vena cava during vulnerable periods. The results of the first controlled trial (PREPIC) are eagerly awaited and should rationalise the indications of inferior vena cava filters.

[Results of coronary-angiographic evaluation after endocavitary fulguration of the accessory pathways]. / Résultats d'un bilan angio-coronarographique de principe après fulguration endocavitaire des voies accessoires.

Left ventricular aid coronary angiography was performed systematically in 32 consecutive patients (average age 34 +/- 16 years) to assess the potential risk of coronary and myocardial lesions after high energy catheter ablation of an accessory pathway. The control was performed 2 to 6 months after the procedure in 30 patients and as an emergency immediately after the procedure in 2 patients because of prolonged ST segment elevation in 1 and an echocardiographic abnormality in the other. The catheter ablation was performed by a right heart approach in 19 patients and by retrograde catheterisation of the left heart in the other 13. The average number of shocks delivered was 3.6 +/- 2.4 in 1.8 +/- 1.2 session with an average energy of 632 +/- 220 joules. The global success rate was 88%, 70% complete successes and 18% clinical successes. The left ventricular and coronary angiographies were normal in 31 patients, including the 2 patients investigated as an emergency. On the other hand, one totally asymptomatic patient in whom a left lateral bundle of Kent had been ablated 2 months previously by a retrograde transaortic approach, had a large pseudo-aneurysm of the left ventricular posterior wall and coronary angiography showed a fistula between the first lateral branch of the circumflex artery and the left ventricle. At surgery, a localised rupture of the mitral annulus was confirmed. Two factors may at least partially explain this complication: the quantity of energy delivered (1,000 joules) in a single session to a limited area, and the site of ablation on the ventricular side of the mitral annulus.(ABSTRACT TRUNCATED AT 250 WORDS)

[Influence of exercise on the permeability of accessory pathways and supraventricular arrhythmia in Wolff-Parkinson-White syndrome]. / Influence de l'effort sur la perméabilité des voies accessoires et le comportement des arythmies supraventriculaires dans le syndrome de Wolff-Parkinson-White.

The influence of adrenergic stimulation on the effective anterograde refractory period of the accessory pathways and on supraventricular arrhythmias, was studied in 20 patients (average age 38 +/- 16 years) with an untreated permanent Wolff-Parkinson-White syndrome and a resting anterograde refractory period < or = 400ms. Repeated electrophysiological studies with a single endocavity catheter positioned near the atrial pole of the accessory pathway were performed under basal conditions and during a standardised exercise test on a bicycle ergometer. The effective anterograde refractory period of the accessory pathway, the length of the tachycardia cycle during reciprocating orthodromic tachycardia, the average heart rate, the percentage of preexcited QRS complexes during induced atrial fibrillation, were measured in all patients under basal conditions and at the peak of exercise. Exercise significantly reduced the anterograde refractory period of the accessory pathway (287 +/- 49 ms at rest versus 238 +/- 24 ms on exercise: p < 0.001), the cycle of orthodromic tachycardia (302 +/- 32 vs 260 +/- 22 ms p < 0.001), the minimal R-R interval (270 +/- 65 vs 227 +/- 46 ms: p < 0.05) and % of preexcited QRS complexes (75 +/- 33 vs 51 +/- 39: p < 0.05) in atrial fibrillation whilst increasing the average heart rate (165 +/- 42 vs 202 +/- 39 bpm: p < 0.02). Adrenergic stimulation significantly improves anterograde conduction in the accessory pathway. The reduction in the % of preexcited QRS complexes in atrial fibrillation could indicate a preferential action of catecholamines on the nodo-hisian pathway.(ABSTRACT TRUNCATED AT 250 WORDS)

[Myocardial infarction in young women: apropos of 22 cases. Pathogenic and prognostic approach]. / L'infarctus du myocarde chez la femme jeune: à propos de vingt-deux cas. Approche pathogénique et pronostique.

The authors report 22 cases of myocardial infarction documented by selective left ventriculography and coronary angiography in women under 45 years of age. The average age in this series was 36 +/- 6.8 years. Two patient groups were identified: Group I (n = 16) with the cardiovascular risk factor of oral contraception (mean age 33.9 +/- 5 years); and Group II (n = 6) comprising older patients (43.8 +/- 1.8 years) with a high prevalence of other risk factors (hyperlipidaemia, hypertension, diabetes). Myocardial infarction tended to be the inaugural event in Group I (9 out of 16 cases, 56.2%) whereas symptoms of effort angina were commonly observed in Group II (5 out of 6 cases, 83.3%). Coronary angiography showed more severe coronary lesions in Group II (score 1.5) than in Group I (score 0.75) in which isolated, single vessel disease mainly affecting the left anterior descending artery or normal coronary angiography was observed. Thrombolytic therapy was performed in 8 patients: percutaneous transluminal angioplasty was performed in 4 patients in the first month with a primary success in 3 cases. Coronary bypass surgery was performed in 1 case. The outcome during follow-up lasting 44.5 +/- 4.2 months was mainly favourable as 15 of the 20 patients had no secondary complications. Nevertheless, 2 patients died in the hospital period (1 from cardiogenic shock and 1 from complications of transluminal coronary angioplasty), 2 patients died less than 1 year after acute myocardial infarction (1 sudden death, 1 cardiogenic shock). Although oral contraception was withdrawn in all cases, many women continued to smoke.(ABSTRACT TRUNCATED AT 250 WORDS)

[Left intraventricular dynamic gradients in the follow-up of aortic valve replacement: an echo-Doppler study]. / Gradients dynamiques intraventriculaires gauches dans les suites de remplacement valvulaire aortique: étude écho-Doppler.

The possibility of an intraventricular pressure gradient in patients with aortic stenosis is well known: this entity is associated with a high risk of postoperative complications. The authors carried out a Doppler echocardiographic study of flow in the left ventricle in 51 patients who had recently undergone valve replacement for severe aortic stenosis (valve area < 0.75 cm2). Before surgery, only one patient had significant acceleration of intraventricular systolic flow attaining 3.8 m/s (maximum pressure gradient of 60 mmHg). After surgery, maximum intraventricular systolic velocities of over 2.5 m/s with a typical end systolic peak were observed in 8 patients under basal conditions (gradients of 30 to 115 mmHg), and in 7 others after inhalation of amyl nitrite. Pulsed spectral and color Doppler flow mapping showed that the highest velocities were located at the mitral papillary muscle level. In addition, these patients had significant reduction in cavity size. Only one patient had systolic anterior motion of the anterior mitral leaflet with septal contact. Left ventricular dimensions were measured by TM echocardiography. High intraventricular velocities seemed to be significantly related to the smallest ventricular dimensions, the thickest ventricular walls and the smallest preoperative aortic valve surface area. The highest intraventricular pressure gradients-disappeared with betablocker therapy (4 cases), after correction of hypovolemia (1 case), after drainage of large pericardial effusions (2 cases) or spontaneously (1 case). This study confirms the relatively high prevalence of dynamic intraventricular gradients after surgical cure of aortic stenosis and the value of Doppler echocardiography for the avoidance of certain drugs (inotropic agents, vasodilators, diuretics), which could aggravate the hemodynamic abnormality.(ABSTRACT TRUNCATED AT 250 WORDS)

[Patient information and coronary angiography: experience of the Rennes group]. / Information du patient et coronarographie: l'expérience rennaise.

The object of this study was to assess the degree of patient information of subjects referred for coronary angiography and their reaction to a detailed protocol of information. The enquiry was performed in 3 stages: an oral evaluation of the degree of information with a standardised questionnaire; the giving of written documents from the French Federation and Society of Cardiology mentioning the risks of the procedure; the continuation of the interview with evaluation of the degree of satisfactions with the information provided. Two hundred and thirty one patients referred by cardiologists for non-urgent coronary angiography were interrogated (175 men, 56 women; mean age 63 years, range: 27-83 years). In the 164 subjects who had never had this investigation: 56 (34.1%) did not appreciate the invasive nature of the procedure 111 (67.6%) totally ignored the risks of the procedure 70 (42.6%) were not informed of the possibility of a surgical procedure or of an angioplasty as a result of the procedure. 89% were satisfied with the information concerning the risks of the investigation. In a second group of 100 patients, the comprehension of the information was checked by the same questionnaire used a posteriori. These results show that patient information is very often incomplete. Despite some reticence, the new procedures seem to be globally well accepted but would be more effective if used before hospital admission.

[Diagnosis of coronary artery disease by thallium 201 myocardial scintigraphy during atrial pacing]. / Diagnostic de l'insuffisance coronaire par tomoscintigraphie myocardique au thallium 201 sous stimulation auriculaire.

Rapid atrial pacing may reveal myocardial ischemia but the sensitivity for the diagnosis of coronary artery disease is not high enough for routine use. Therefore, the value of atrial pacing coupled with Thallium 201 scintigraphy was evaluated. Sixty-two patients (53 men and 9 women) referred for investigation of angina or chest pain were divided into two groups: a control group of 13 patients (9 men and 4 women, average age: 57.1 years) with insignificant coronary lesions (less than 50%) (N = 5) or normal coronary angiography (N = 8), and a group of 49 patients (44 men and 5 women, average age: 55.5 years) 27 of whom had a history of myocardial infarction (17 posterior, 10 anterior). Coronary angiography showed single vessel disease in 44.9% of cases, double vessel disease in 34.7% and triple vessel disease in 18.4% of cases, and 1 patient with left main stem disease. All 62 patients underwent the same study protocol which comprised: incremental atrial pacing (to the calculated maximal heart rate), Thallium 201 myocardial scintigraphy immediately after pacing and during the redistribution phase, and coronary angiography. The sensitivities of anginal pain (36.7%) and ECG changes during atrial pacing (57.1%) were too low for the diagnosis of myocardial ischemia. On the other hand, Thallium 201 scintigraphy with atrial pacing was more sensitive (87.8%) and specific (84.6%) for coronary artery disease. Stenosis of the left anterior descending artery was diagnosed with a sensitivity of 96.4% and that of the right coronary artery with a sensitivity of 90.9%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Loss of a stent in the left main coronary artery and secondary migration into the left circumflex artery needing surgical extraction. Apropos of a case]. / Perte dans le tronc commun de la coronaire gauche d'une endoprothèse et migration secondaire dans l'artère circonflexe ayant conduit à une extraction chirurgicale. A propos d'un cas.

The authors report a case of accidental loss of a coronary stent in the coronary arteries and its migration into the circumflex artery. This complication occurred during revascularisation of the left anterior descending artery. In view of a dissection at the site of angioplasty and the migration of the stent, emergency surgery was undertaken comprising bypass grafting of the left anterior descending and arteriology of the left circumflex arteries to recover the stent. This is a rare complication, the frequency is probably underestimated. The authors discuss the factors predisposing to failure of implantation and the means of recovering the stents. The consequences of loss of a stent in the coronary or systemic circulations are also commented.

[Efficacy and tolerance of 2 new percutaneous vena cava filters. A prospective study in 80 patients]. / Efficacité et tolérance de deux nouveaux filtres cave percutanés. Etude prospective chez 80 patients.

Eighty consecutive patients with an average age of 66.5 +/- 16 years were reviewed 3 and 9 months after implantation of two new percutaneous vena caval filters (Filcard, Cardial) in order to evaluate their efficacy and tolerance. The indications were: a contra-indication to anticoagulants in 19 cases, recurrent pulmonary embolism under anticoagulant therapy in 22 patients, chronic cor pulmonale in 4 patients; finally, in 35 cases, the filter was implanted prophylactically for a "floating" or extensive ilio-caval thrombosis under anticoagulant therapy or in high risk patients: severe cardio-pulmonary failure, malignant disease, massive pulmonary embolism with a contra-indication to fibrinolytic therapy. All implantations were performed by the jugular approach with no local or general complications apart from one pericaval haematoma with a favourable outcome. Cavography and opacification of the renal veins was carried out systematically during implantation. All patients underwent clinical examination, antero-posterior and lateral X rays of the filter, pulmonary scintigraphy, antero-posterior and lateral cavography, a CT scan of the filter, Doppler ultrasonography and rheoplethysmography of the legs 3 months after implantation. At 9 months, clinical examination, abdominal X rays and rheoplethysmography were repeated. There was 100% follow-up at 3 and 9 months. The complications observed at 3 and 9 months were: 5 cases of malposition (6%), 3 recurrent pulmonary emboli (4%), 9 recurrent venous thromboses (13%), 4 vena caval thromboses (5.7%), 7 thrombi caught in the filter (10%), 27 perforations of the vena cava (38%), 3 over 30 degrees tilts of the filter (4%) and 22 migrations (31%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Right atrial thrombosis and severe pulmonary embolism]. / Thrombose auriculaire droite et embolie pulmonaire grave.

Two cases of severe pulmonary embolism associated with right atrial thrombosis are reported. In the first case, fibrinolytic therapy was administered and was thought to be a causative factor in the death of the patient due to massive pulmonary embolism. In the second case, the patient was referred for surgery and two enormous thrombi were extracted. Unfortunately, the outcome was fatal. These two cases were confronted with the results of the literature. They strongly suggest that echocardiography should be a first-line investigation in severe pulmonary embolism. The detection of right atrial thrombosis modifies the clinical strategy and orientates treatment towards surgical referral when the patient's condition allows it.