Immune response to pertussis vaccine in COPD patients.

Exacerbation triggered by respiratory infection is an important cause of morbidity and mortality in chronic obstructive pulmonary disease (COPD) patients. Strategies aiming to preventing infection may have significant public health impact. Our previous study demonstrated decreased immunological response to seasonal flu vaccination in COPD patients, questioning the efficiency of other vaccines in this group of patients. We performed a prospective, monocenter, longitudinal study that evaluated the humoral and cellular responses upon pertussis vaccination. We included 13 patients with stable COPD and 8 healthy volunteers. No difference in circulating B and T cell subsets at baseline was noted. Both groups presented similar levels of TFH, plasmablasts and pertussis specific antibodies induction after vaccination. Moreover, monitoring T cell immunity after ex-vivo peptide stimulation revealed equivalent induction of functional and specific CD4+ T cells (IFNγ, TNFα and IL-2-expressing T cells) in both groups. Our results highlight the immunological efficiency of pertussis vaccination in this particularly vulnerable population and challenge the concept that COPD patients are less responsive to all immunization strategies. Healthcare providers should stress the necessity of decennial Tdap booster vaccination in COPD patients.

Relationship between achieved personalized glycaemic targets and monitoring of clinical events in elderly diabetic patients.

AIM: Recent guidelines for the management of type 2 diabetes (T2DM) in the elderly recommend adjusting the therapeutic target (HbA1c) according to the patient's health. Our study aimed to explore the association between achieving the recommended personalized HbA1c target and the occurrence of major clinical events under real-life conditions. METHODS: The T2DM S.AGES cohort was a prospective multicentre study into which 213 general practitioners recruited 983 non-institutionalized T2DM patients aged>65 years. The recommended personalized HbA1c targets were<7%, <8% and <9% for healthy, ill and very ill patients, respectively. Major clinical events (death from any cause, major vascular events and/or hospitalization) were recorded during the 3-year follow-up. Mixed-effects logistic regression models were used for the analyses. RESULTS: Of the 747 patients analyzed at baseline, 551 (76.8%) were at their recommended personalized HbA1c target. During follow-up, 391 patients (52.3%) experienced a major clinical event. Of the patients who did not achieve their personalized HbA1c target (compared with those who did), the risk (OR) of a major clinical event was 0.95 (95% CI: 0.69-1.31; P=0.76). The risk of death, major vascular event and hospitalization were 0.88 (95% CI: 0.40-1.94; P=0.75), 1.14 (95% CI: 0.7-1.83; P=0.59) and 0.84 (95% CI: 0.60-1.18; P=0.32), respectively. CONCLUSION: Over a 3-year follow-up period, our results showed no difference in risk of a major clinical event among patients, regardless of whether or not they achieved their personalized recommended HbA1c target. These results need to be confirmed before implementing a more permissive strategy for treating T2DM in elderly patients.

Tissue Doppler imaging differentiates transmural from nontransmural acute myocardial infarction after reperfusion therapy.

BACKGROUND: The evaluation of transmural extent of necrosis after acute myocardial infarction remains a major problem in clinical practice. We sought to determine whether color M-mode tissue Doppler imaging (TDI) could differentiate transmural from nontransmural myocardial infarction. METHODS AND RESULTS: Twenty-one anesthetized open-chest dogs underwent 90 or 120 minutes of left anterior descending coronary artery occlusion followed by 180 minutes of reperfusion. The transmural extension of infarct was measured by triphenyltetrazolium chloride (TTC) staining. Segment shortening in the endocardium and epicardium of the anterior and posterior walls was assessed by sonomicrometry. Regional myocardial blood flow was measured by radioactive microspheres. TDI was obtained from an epicardial short-axis view. We calculated systolic and diastolic velocities within the endocardium and epicardium of myocardial walls and the subsequent myocardial velocity gradient (MVG). TTC staining could identify 2 groups according to the transmural extent of necrosis: 15 dogs had a nontransmural (NT) necrosis (42+/-3% of wall thickness), and 6 dogs developed a transmural (T) infarct (81+/-4% of wall thickness). In both groups, ischemia resulted in a significant and similar reduction in endocardial and epicardial velocities, with a resulting low systolic MVG in the anterior wall (0.10+/-0.07 in NT and 0.10+/-0.08 s(-1) in T). At 60 minutes of reperfusion, systolic MVG failed to change significantly in the transmural group (-0.20+/-0.09 s(-1)). In contrast, it increased significantly after reflow in the NT group compared with ischemic values (-0.99+/-0.20 versus 0.10+/-0.07 s(-1), P:<0.05). CONCLUSIONS: TDI can differentiate transmural from nontransmural myocardial infarction early after reperfusion.

Assessment of nonuniformity of transmural myocardial velocities by color-coded tissue Doppler imaging: characterization of normal, ischemic, and stunned myocardium.

BACKGROUND: Transmural myocardial contractile performance is nonuniform across the different layers of the left ventricular wall. We evaluated the accuracy of color M-mode tissue Doppler imaging (TDI) to assess the transmural distribution of myocardial velocities and to quantify the severity of dysfunction induced by acute ischemia and reperfusion in the inner and outer myocardial layers. METHODS AND RESULTS: Thirteen open-chest dogs underwent 15 minutes of left anterior descending coronary artery occlusion followed by 120 minutes of reperfusion. M-mode TDI was obtained from an epicardial short-axis view. Systolic velocities were calculated within endocardium and epicardium of the anterior and posterior walls. Regional myocardial blood flow was assessed by radioactive microspheres. Segment shortening was measured by sonomicrometry in endocardium and epicardium of both the anterior and posterior walls. At baseline, endocardial velocities were higher than epicardial velocities, resulting in an inner/outer myocardial velocity gradient. Ischemia caused a significant and comparable reduction in endocardial and epicardial systolic velocities in the anterior wall with the disappearance of the velocity gradient. Systolic velocities significantly correlated with segment shortening in both endocardium and epicardium during ischemia and reperfusion. In the first minutes after reflow, endocardial velocities showed a greater improvement than epicardial velocities, and the velocity gradient resumed although to a limited extent, indicative of stunning. CONCLUSIONS: TDI is an accurate method to assess the nonuniformity of transmural velocities and may be a promising new tool for quantifying ischemia-induced regional myocardial dysfunction.

Selective endothelin-A versus combined endothelin-A/endothelin-B receptor blockade in rat chronic heart failure.

BACKGROUND: The relative efficacy of endothelin-A (ET(A)) receptor blockade versus combined ET(A)-ET(B) receptor blockade in chronic heart failure (CHF) is still largely unknown. METHODS AND RESULTS: We compared, in a rat model of CHF (coronary ligation), the hemodynamic and structural effects of 1 month of treatment with the ET(A) antagonist ABT-627 (5 mg x kg(-1) x d(-1)), the ET(B) antagonist A-192621 (30 mg x kg(-1) x d(-1)) or a combination of the 2 drugs. Doses were chosen for their capacity to block the pressor response to ET-1 (for ET(A) blockade) or the depressor responses to sarafotoxin S6c or ET-1 (for ET(B) blockade). ET(A) and combined ET(A)-ET(B) blockade reduced systolic blood pressure to the same extent, whereas ET(B) blockade had no effect. In contrast, only combined ET(A)-ET(B) blockade significantly reduced heart rate. Both ET(A) and combined ET(A)-ET(B) blockade, but not ET(B) blockade alone, increased left ventricular (LV) fractional shortening and wall thickening and reduced LV end-diastolic pressure, as well as LV end-diastolic and end-systolic volumes. However, all treatments (including ET(B) blockade) decreased LV collagen accumulation. CONCLUSIONS: The chronic blockade of both ET(A) and ET(B) receptors improved systemic hemodynamics, as well as LV function and remodeling, to the same extent as ET(A) receptor blockade alone. However, only combined ET(A)-ET(B) receptor blockade decreased heart rate. Whether this differential effect on heart rate affects the long-term outcome after treatment with ET(A) or mixed ET(A)-ET(B) antagonists in CHF remains to be determined.

Dobutamine stress echocardiography in orthotopic heart transplant recipients. VACOMED Research Group.

OBJECTIVES: This study sought to determine whether dobutamine stress echocardiography could accurately identify coronary artery disease after heart transplantation. BACKGROUND: After heart transplantation, coronary artery disease is related to either diffuse concentric intimal thickening or focal stenosis and may be underdiagnosed by coronary angiography. METHODS: We enrolled 41 patients, a mean (+/- SD) of 40 +/- 20 months after heart transplantation, at the time of their routine control coronary angiogram. Three patients were excluded because of poor echogenicity on the angiogram and one because of ventricular premature beats. Standard echocardiographic views were acquired at baseline and at incremental dobutamine infusion levels (from 5 to a maximal dose of 40 micrograms/kg body weight per min at 3-min intervals). Regional wall motion score was calculated from a 16-segment model, and each segment was graded from 1 (normal) to 4 (dyskinesia). Coronary angiography was performed 24 h after dobutamine stress echocardiography, and angiograms were analyzed in blinded manner. RESULTS: Twenty-three (62%) of 37 patients had normal coronary angiographic findings. Dobutamine stress echocardiography showed abnormalities in only 2 of 23 patients. Fourteen patients (38%) had abnormal angiographic findings, seven of whom had stenoses > 50%. Dobutamine stress echocardiography correctly identified the corresponding hypoperfused segments in these seven patients. More of interest were the other seven patients, of whom three had angiographic nonsignificant stenoses (< 50%), and four had minor diffuse coronary irregularities. Dobutamine stress echocardiography showed hypokinesia in five of these seven patients despite nonsignificant lesions at coronary angiography. The respective overall sensitivity and specificity of dobutamine stress echocardiography were 86% and 91%. At follow-up, 2 of the 37 patients had an acute myocardial infarction. Both had abnormal findings on dobutamine stress echocardiography: One had normal coronary angiographic results, and one had significant coronary lesions. CONCLUSIONS: Dobutamine stress echocardiography is a useful technique for the diagnosis of coronary artery disease after heart transplantation. These preliminary results indicate that dobutamine stress echocardiography may have a predictive value for further ischemic events in heart transplant recipients.

Echocardiography predicts embolic events in infective endocarditis.

OBJECTIVES: The aim of our study was to assess the value of transesophageal echocardiography (TEE) in predicting embolic events (EEs) in a large group of patients with definite endocarditis according to the Duke criteria, including silent embolism. BACKGROUND: The value of echocardiography in predicting embolism in patients with endocarditis remains controversial. Some studies reported an increased risk of embolism in patients with large and mobile vegetations, whereas other studies failed to demonstrate such a relationship. METHODS: Multiplane transesophageal echocardiograms of 178 consecutive patients with definite infective endocarditis (IE) were analyzed. The incidence of embolism was compared with the echocardiographic characteristics (localization, size and mobility) of the vegetations. To detect silent embolism, cerebral and thoraco-abdominal scans were performed in 95% of patients. RESULTS: Among 178 patients, 66 (37%) had one or more EEs. There was no difference between patients with and without embolism in terms of age, gender and left valve involved. On univariate analysis, Staphylococcus infection, right-side valve endocarditis and vegetation length and mobility were significantly related to EEs. A significant higher incidence of embolism was present in patients with vegetation length >10 mm (60%, p < 0.001) and in patients with mobile vegetations (62%, p < 0.001). Embolism was particularly frequent among 30 patients with both severely mobile and large vegetations (> 15 mm) (83%, p < 0.001). On multivariate analysis, the only predictors of embolism were vegetation length (p = 0.03) and mobility (p = 0.01). CONCLUSIONS: Our study shows that the presence of vegetations on TEE is predictive of embolism and that the morphologic characteristics of vegetations are helpful in predicting EEs in both mitral and aortic valve IE. It also suggests that early operation may be recommended in patients with vegetations > 15 mm and high mobility, irrespective of the degree of valve destruction, heart failure and response to antibiotic therapy.

Value and limitations of the Duke criteria for the diagnosis of infective endocarditis.

OBJECTIVES: The purpose of this study was to assess the value and limitations of Duke criteria for the diagnosis of infective endocarditis (IE). BACKGROUND: Duke criteria have been shown to be more sensitive in diagnosing IE than the von Reyn criteria, but the diagnosis of IE remains difficult in some patients. METHODS: Both classifications were applied in 93 consecutive patients with pathologically proven IE. Blood cultures, and transthoracic and transesophageal echocardiography were performed in all patients. RESULTS: Sensitivities for the diagnosis of IE were 56% and 76% for von Reyn and Duke criteria, respectively. Fifty-two patients were correctly classified as "probable IE" by von Reyn and "definite IE" by Duke criteria (group 1). However, discrepancies were observed in 41 patients. Eleven patients (group 2) were misclassified as "rejected" by von Reyn, but were "definite IE" by Duke criteria; this difference could be explained by negative blood cultures and positive echocardiogram in all patients. In eight patients (group 3), the diagnosis of IE was "possible" by von Reyn but "definite" by Duke criteria. This difference was essentially explained by the failure of the von Reyn classification to consider echocardiographic abnormalities as major criteria. Twenty-two patients (group 4) were misclassified as possible IE using Duke criteria, being false negative of this classification. Echocardiographic major criteria were present in 19 patients, but blood cultures were negative in 21 patients. The cause of negative blood cultures was prior antibiotic therapy in 11 patients and Q-fever endocarditis diagnosed by positive serology in three cases. CONCLUSIONS: Twenty-four percent of patients with proved IE remain misclassified as "possible IE" despite the use of Duke criteria, especially in cases of culture-negative and Q-fever IE. Increasing the diagnostic value of echographic criteria in patients with prior antibiotic therapy and typical echocardiographic findings and considering the serologic diagnosis of Q fever as a major criterion would further improve the clinical diagnosis of IE.

Selective ETA receptor blockade prevents left ventricular remodeling and deterioration of cardiac function in experimental heart failure.

BACKGROUND: Left ventricular (LV) dilation, which is a predictor of survival in humans with chronic heart failure (CHF), is limited by a mixed endothelin ETA-ETB antagonist. Whether selective ETA receptor blockade influences LV dilation is unknown. We determined, in a rat model of CHF, the effects of the ETA receptor blocker LU 135,252 on LV remodeling. METHODS AND RESULTS: Rats were subjected to coronary artery ligation and treated for ten weeks with placebo or LU 135,252 (LU), at a dose of 10 or 30 mg kg-1 day-1. Systolic blood pressure and heart rate (plethysmography) were determined in conscious animals before and after four and ten weeks of treatment. At these time points, cardiac output and LV dimensions were measured in anesthetized rats by transthoracic echocardiography. LV hemodynamics were determined in anesthetized rats after ten weeks. Pressor responses to ET-1 (1 nmol/kg, i.v.) and sarafotoxin S6c (0.3 ng/kg, i.v.) were measured, to assess the efficacy of ET receptor antagonism and the lack of blockade of ETB receptor blockade, respectively. The pressor response to ET-1 was significantly reduced by LU (% change in systolic blood pressure: sham: 9 +/- 1; CHF: 5 +/- 1; CHF LU: 0 +/- 3 and -4 +/- 2% for the low and high dose, respectively). LU did not affect the response to sarafotoxin (CHF: -37 +/- 3; CHF LU: -29 +/- 3 and -28 +/- 2% for the low and high dose, respectively). Both doses of LU decreased systolic blood pressure, but only the high dose of LU reduced heart rate. Furthermore, LU restored cardiac output dose-dependently throughout the study. Both doses of LU limited LV dilatation and deterioration of LV fractional shortening to the same extent. After ten weeks, LU normalized LV end-diastolic- and central venous pressures, but did not affect LV dP/dtmax or dP/dtmin. LU did not prevent the development of cardiac hypertrophy, but reduced LV collagen density. CONCLUSIONS: In this rat model, the selective ETA receptor blocker LU, at the dose of 30 mg kg-1 day-1, reduced blood pressure and heart rate, limited progressive left ventricular remodeling and improved cardiac hemodynamics and function. These effects of LU might have important clinical relevance in the treatment of heart failure.

Therapeutic management in ambulatory elderly patients with atrial fibrillation: the S.AGES cohort.

UNLABELLED: Few epidemiologic studies have specifically focused on very old community dwelling population with atrial fibrillation (AF). The objectives of the AF-S.AGES cohort were to describe real-life therapeutic management of non-institutionalized elderly patients with AF according to age groups, i.e., 65-79 and ≥ 80 and to determine the main factors associated with anticoagulant treatment in both groups. METHODS: Observational study (N=1072) aged ≥ 65 years old, recruited by general practitioners. Characteristics of the sample were first evaluated in the overall sample and according to age (< 80 or ≥ 80 years) and to use of anticoagulant treatment at inclusion. Logistic models were used to analyze the determinants of anticoagulant prescription among age groups. RESULTS: Mean age was 78.0 (SD=6.5) years and 42% were ≥ 80 years. Nineteen percent had paroxysmal AF, 15% persistent, 56% permanent and 10% unknown type, 77% were treated with vitamin K antagonists (VKA), 17% with antiplatelet therapy with no differences between age groups. Rate-control drugs were more frequently used than rhythm-control drugs (55% vs. 37%, p < 0.001). VKA use was associated with permanent AF, younger age and cancer in patients ≥ 80 years old and with permanent AF and preserved functional autonomy in patients < 80 years old. Hemorrhagic scores were independently associated with non-use of VKA whereas thromboembolic scores were not associated with VKA use. CONCLUSIONS: In this elderly AF outpatient population, use of anticoagulant therapy was higher even after 80 years than in previous studies suggesting that recent international guidelines are better implemented in the elderly population.

Assessment of the progression of cardiac allograft vasculopathy by dobutamine stress echocardiography.

BACKGROUND: After heart transplantation, accelerated coronary vasculopathy is a major factor that limits long-term survival and is usually detected by serial coronary angiography. The aim of this study was to determine whether dobutamine stress echocardiography could accurately identify the progression of cardiac allograft vasculopathy. METHODS: Two sequential controls by dobutamine stress echocardiography were performed at an 18-month interval in 37 heart transplant recipients at the time of their routine coronary angiography. The first control (control 1) occurred 37+/-20 months after transplantation, and the second control (control 2) occurred after 56+/-21 months. Standard echocardiographic views were acquired at baseline and at incremental dobutamine infusion levels. Regional wall motion score was calculated in a 16-segment model, and each segment was graded from 1 (normal) to 4 (dyskinesia). Visual and quantitative coronary angiographic analysis were used to assess the severity of the coronary vasculopathy. RESULTS: The incidence of coronary vasculopathy increased from 46% (17/37 patients, four of whom had stenoses > 50%) at control 1 fo 70% (26/37 patients, six of whom had stenoses > 50%) at control 2. Progression of coronary vasculopathy was diagnosed by coronary angiography in 25 patients (new abnormalities in 19 and worsening of previous abnormalities in 6). Dobutamine stress echocardiography correctly identified the progression of vasculopathy in 21 of these 25 patients (84%) with new abnormalities in 17 and worsening in four. In the four remaining patients with evidence of progression of vasculopathy on coronary angiography, the result of dobutamine stress echocardiography was abnormal in three patients and normal in only one. Therefore dobutamine stress echocardiography results were abnormal in 12 patients at control 1 (sensitivity: 65%, specificity: 95%) and in 27 at control 2 (92% sensitivity, 73% specificity). CONCLUSION: Dobutamine stress echocardiography is a sensitive, noninvasive method to diagnose the progression of allograft vasculopathy, and a negative test result is a strong predictor of absence of allograft coronary vasculopathy. Therefore serial routine coronary angiography may be deferred when dobutamine stress echocardiography results are normal.

Can power motion imaging mode combined with contrast agent assess myocardial contraction and perfusion? In vitro and in vivo studies.

Power motion imaging (PMI) is a new Doppler imaging technology that can enhance contrast agent visualization. We hypothesized that PMI combined with Albunex injection (CPMI) could provide new insights into myocardial contractility and perfusion. In a first step, PMI signal was studied with an in vitro phantom. In a second step, PMI signal was studied in 10 rabbits at different workloads. In a third step, 10 rabbits were studied before and after ischemia produced by coronary ligation and finally during reperfusion. During the latter protocol, epicardial echocardiography analyzed by PMI and fundamental mode was performed before and after Albunex injection. PMI signal was well correlated with phantom velocity. PMI signal and myocardial wall thickening were well correlated, particularly in the septal area. On the coronary occlusion model, ischemia was associated with a significant decrease in PMI and CPMI signals, whereas reperfusion was associated with a significant decrease in PMI signals only, indicating stunning. We conclude that PMI combined with CPMI is a powerful tool to assess myocardial contractility and perfusion.

Comparison of regional myocardial velocities assessed by quantitative 2-dimensional and M-mode color Doppler tissue imaging: influence of the signal-to-noise ratio of color Doppler myocardial images on velocity estimators of the Doppler tissue imaging system.

M-mode color Doppler imaging of the myocardium affords a greater sampling rate and signal-to-noise (S/N) ratio than 2-dimensional (2D) imaging. In this study, we compared myocardial velocities assessed by 2D and M-mode Doppler tissue imaging (DTI) at the same site and evaluated the influence of the S/N ratio on velocity estimates of the currently used DTI systems. In patients with and without impaired regional left ventricular function, myocardial velocities assessed by 2D DTI were lower than those obtained with M-mode DTI. The difference between regional velocities derived from both imaging techniques was positively correlated with the extent of the "black zone," which could be considered as indirectly reflecting the S/N ratio for each frame. Thus in the clinical setting and on currently used echocardiographs, 2D DTI may provide underestimated regional myocardial velocities when compared with M-mode, mainly because of the influence of the lower sampling rate and S/N ratio on velocity estimators of the imaging system.

Conventional and total orthotopic cardiac transplantation: a comparative clinical and echocardiographical study.

OBJECTIVE: Clinical interest has recently emerged in a new technique of heart transplantation with bicaval and pulmonary venous anastomosis. This technique is thought to improve left heart function and reduce thromboembolism. We have used this technique systematically since 1993. We compared the patients transplanted before September 1993 with the standard technique and the patients transplanted with the new technique. METHODS: A total of 135 patients were transplanted at our institution from 1987 to 1995, 100 with the standard technique and 35 with the new technique. of these, 95 survivors were studied by transthoracic and transesophageal echocardiography; 65 were transplanted with the standard technique ('standard' group) and 30 with the new technique ('total heart' group). All patients were free from rejection and in sinus rhythm when studied. RESULTS: Boths groups were similar in pretransplant characteristics. Operative data were similar with a limited increase in the ischemic time with the total heart technique (210 +/- 73 min for 'total heart' vs. 196 +/- 84 min for 'standard'). Right heart catheterization showed comparable cardiac output and pulmonary pressures. Peripheral embolic events occured in 9 patients in the 'standard' group and none in the 'total heart' group. The left atrium was larger in the 'standard' group (58 +/- 6 vs. 42 +/- 4 mm, P = 0.0006). Left atrial spontaneous echo contrast was present in 32 patients in group 'standard' and none in 'total heart' group (P < 0.0001), and left atrial thrombi were detected in 17 patients in group 'standard' vs. none in group 'total heart' (P = 0.01). All patients with a history of embolism had left atrial thrombus and spontaneous echo contrast. CONCLUSION: This study showed a high incidence of left atrial spontaneous echo contrast and thrombi when using the standard technique, which was absent when using the total heart technique. Total heart transplantation with bicaval and pulmonary venous anastomosis should be preferred for heart transplantation.

Aortic valve replacement after aortic valvuloplasty for calcified aortic stenosis.

OBJECTIVE: This study concerns patients who underwent one or several aortic balloon valvuloplasties at our institution and subsequently required cardiac surgery, either on an emergency basis after aortic valvuloplasty or due to the development of aortic stenosis. METHODS: Between February 1987 and December 1993, 137 patients (73 male, 64 female, mean age 72 +/- 9 years) underwent aortic valve replacement for calcified aortic stenosis after several percutaneous balloon aortic valvuloplasties. Thirty-one patients were in NYHA stage II, 70 in stage III and 36 in stage IV. Seventy patients had angina (23 stage I or II, 47 stage III or IV) and 24 patients presented syncope or lipothymia. Twenty-three percent had at least two of these three symptoms. The indications for balloon dilatation were non-definitive surgical contraindication or high surgical risk (73), personal choice (49), refusal of surgery (9) and emergency (5:2 massive aortic regurgitation, 1 left ventricle perforation, 1 cardiogenic shock, 1 endocarditis in cardiogenic shock). Seven patients received preoperative aortic valvuloplasty due to a very high operative risk. The average time between dilatation and surgery was 472 days and there was clinical improvement for an average period of 261 days. The aortic valve replacements consisted of 58 mechanical prostheses and 79 xenografts with 22 concomitant procedures. RESULTS: Operative mortality was eight patients (5.8%). During the follow-up (17.4 +/- 9.2 months), four patients died (3.6%), 91.2% of the patients were in class I and II and 95% were without angina. The actuarial survival rate was 90.5 +/- 6.6% including hospital mortality. CONCLUSIONS: Both our experience and the literature show that balloon aortic valvuloplasty is followed by an immediate improvement in hemodynamic status with a decrease in valve gradient and an increase in valve area. However, the hemodynamic benefit is typically short-lived with a very high restenosis rate. Balloon aortic valvuloplasty is not an alternative to aortic valve replacement, which remains the best treatment for calcified aortic stenosis; the benefits and long-term results of aortic valve replacement are well established, even in the elderly.

[What indicators for tissue Doppler?]. / Quels indices utiliser en Doppler tissulaire?

The analysis and quantification of regional myocardial function are necessary in numerous pathologies, of which ischaemic cardiomyopathy figures above all. Several ultrasound techniques have been developed with the objective of quantifying regional function. Among these methods, myocardial tissular Doppler is well placed, analysing the radial and longitudinal components of the myocardial fibres with different indices: movement indices (myocardial velocity and displacement) deformation indices (speed of deformation which is just the myocardial velocity gradient multiplied by the relative myocardial distance and deformation). The measurement of speeds, particularly at the level of the mitral ring, is a now well validated tool for the analysis of left ventricular filling. However, other indices (deformation in particular) are still being evaluated.

[Alterations of left ventricular mechanics after anterior myocardial infarction. Quantitative analysis by tissue doppler echocardiography]. / Altérations de la mécanique ventriculaire gauche après infarctus du myocarde antérieur. Etude quantitative par échocardiographie doppler tissulaire.

Myocardial ischemia is usually responsible for alterations of regional left ventricular function which are not quantified by routine echocardiography. We used tissue Doppler echocardiography to quantitate the three main components (radial, longitudinal and angular) of left ventricular function, and their alterations after acute anterior myocardial infarction. Radial function was assessed by the myocardial velocity gradient derived from M-mode color tissue Doppler echocardiography, and longitudinal function by the pulsed wave tissue Doppler echocardiography, in 26 patients who experienced a first acute anterior myocardial infarction and in 11 matched healthy subjects. We describe a new tissue Doppler method for the measurement of septal angular deformation during cardiac contraction. In healthy subjects, our results showed heterogeneous regional myocardial contraction. Septal angular deformation occurred in the same direction and was of the same order as predicted by previous MRI studies. After anterior infarction, systolic and diastolic myocardial velocity gradients were dramatically decreased in the anterior wall when compared with controls (p < 0.01), whereas the systolic velocity gradient was significantly higher in the opposite wall (p < 0.05). Pulsed wave tissue Doppler echocardiography revealed significant alterations of longitudinal left ventricular function. Septal angular deformation was decreased after anterior infarct, and a good correlation was found between the angle of rotation and the left ventricular ejection fraction by cineangiography. These results indicate that tissue Doppler echocardiography has the potential for measuring the three main components of regional left ventricular function, and for quantitatively assessing their functional alterations induced by acute myocardial ischemia.

[Percutaneous mitral commissurotomy by metallic dilator. Multicenter experience with 500 patients]. / Commissurotomie mitrale percutanée par dilatateur métallique. Expérience multicentrique sur 500 patients.

A clinical investigation has been conducted since January 1996 with a new valve dilator for percutaneous treatment of mitral stenosis: metallic commissurotome. This new technique is based on the principle of surgical commissurotome but, in its mechanism of action, differs from the usual techniques with balloon catheters. It also offers the unique possibility for multiple utilizations of the same device after resterilization. This article reports a multicenter international investigation involving 500 patients, mean age of 34 +/- 13 years, with a isolated mitral stenosis and an echography score of 7.7 +/- 1.9. Our technique has been feasible in 489 cases (98%) with a success rate (mitral area > 1.5 cm2 without MR > grade 2) of 93%. The transmitral gradient has diminished from 20 +/- 8 mmHg to 4 +/- 3 mm Hg and the mitral area (assessed by planimetry at 24 hrs) has increased from 0.91 +/- 0.20 to 2.12 +/- 0.34 cm2. Complications were uncommon (13 patients: 2.6%) and consisted in 6 tamponades, 5 mitral insufficiencies (one patient required an emergency valve replacement) and 2 neurological transient accidents. The outcomes of this clinical investigation appear most encouraging and at least comparable to those being reported with the commonly used techniques. The most serious complications appear to be closely related to the level of experience with this technique. Considering the possibility to reutilize the metal segments of the apparatus, this technique notably reduces the cost of the procedure per patient and it represents a significant benefit in countries with limited resources.

[Extensive isolated aneurysm of the right coronary vessel developing within 4 years]. / Volumineux anévrisme isolé de la coronaire droite apparu en 4 ans.

The authors report the case of a 64 year old man on chronic haemodialysis therapy in whom coronary angiography showed a right coronary artery aneurysm. This patient had undergone coronary angiography 4 years previously and no aneurysm had been found on that occasion. The aneurysm occurred in the context of coronary atherosclerosis, coronary angiography showing typical appearances of double vessel disease. There were several special features of this aneurysm which contribute to the originality of the case: its rapid development within 4 years, its large size and the fact that it was an isolated finding on the right coronary artery. Several aetiologies are discussed but none can be formally confirmed.

[Contribution of the continuity equation for the assessment of mitral valve area in mitral stenosis]. / Apport de l'équation de continuité dans l'évaluation de la surface mitrale des rétrécissements mitraux.

The aim of this study was to evaluate the continuity equation in the quantification of mitral valve area in mitral stenosis, the area being considered as the product of the area of the left ventricular outflow tract multiplied by the ratio of the velocity time integrals of the aortic or pulmonary flow to that mitral flow. The continuity equation was compared to two other echocardiographic methods, planimetry and Hatle's method, and to the results obtained at catheterization using the Gorlin formula in a population of 44 patients with mitral stenosis. All were in sinus rhythm; twelve had Grade I mitral regurgitation and 9 patients had Grade I aortic regurgitation. Excellent correlation were observed between the values obtained by the continuity equation and planimetry (r = 0.91; SEE = 0.19 cm2; p less than 0.001) and Hatle's method (r = 0.87; SEE = 0.20 cm2, p less than 0.001). The correlation with the catheter values were also excellent (r = 0.83; SD = 0.22 cm2, p less than 0.001), better than those observed with Hatle's method (r = 0.73; SEE = 0.27 cm2, p less than 0.001) and very similar to those obtained with planimetry (r = 0.87; SEE = 0.23 cm2, p less than 0.001). The sensibility and specificity of the continuity equation for the diagnosis of severe mitral stenosis (surface less than 1.5 cm2) were 90% and 100% respectively, when those of Hatle's method were 88% and 91% respectively. The continuity equation in the evaluation of mitral valve area in mitral stenosis seems to be reliable and accurate compared with catheter data, and superior to Hatle's method.