Right ventricular outflow obstruction after radiation therapy.

A unique case of radiation-induced heart disease associated with acquired right ventricular outflow obstruction is presented. Surgical management of this case is described.

Percutaneous transluminal coronary angioplasty by high-volume and low-volume operators.

We retrospectively compared the results of percutaneous transluminal coronary angioplasty (PTCA) of three low-volume operators (1.3 PTCAs/month) to those of a relatively high-volume operator (14.9 PTCAs/month) in 396 consecutive procedures (358 patients). PTCA for multiple vessels, total occlusions, or evolving acute myocardial infarction had been excluded. For low-volume operators experienced assistance was considered present when the high-volume operator participated as second operator. The three low-volume operators performed 42, 38, and 24 PTCAs, respectively. Success rates per procedure for these operators were 88%, 84%, and 83%, and the complications rates 5%, 3%, and 13%, respectively. The success rates for assisted vs. nonassisted procedures were 89% vs. 88%, 100% vs. 78%, and 90% vs. 71%, and the complications rates were 6% vs. 4%, and 0% vs. 21%, respectively. The high-volume operator performed 292 PTCAs, with a success rate of 93%, and a complication rate of 5%. The cumulated success rate of the three low-volume operators of 85% was significantly (p less than 0.05) lower than the 93% success rate of the high-volume operator, while the complication rates of 6% and 5%, respectively, were not significantly different. Low-volume operators in an experienced center can perform PTCA safely even without assistance by a high-volume operator. However, their success rate is lower.

[Triggering of paroxysmal auricular fibrillation. Study using continuous electrocardiographic recording (Holter system)]. / Déclenchement de la fibrillation auriculaire paroxystique. Etude par l'enregistrement électrocardiographique continu (système de Holter).

Recent studies of the mode of initiation of atrial fibrillation (AF) have emphasises the role of the autonomic nervous system, vagal and sympathetic, in the development of this arrhythmia. Continuous 24 hour electrocardiographic recording (Holter monitoring) is a good method of studying arrhythmias. The role of vagal or sympathetic stimulation was evaluated by retrospective analysis of 3 000 Holter recordings performed in our department. Three groups of patients were identified: Group I, patients with bradycardia at the time of onset of AF (sinus rhythm less than 60/min); Group II, patients with sinus rhythms greater than or equal to 60/min at the time of onset of AF. Some of the rapid atrial arrhythmias encountered in the sick sinus syndrome may be confused with AF on Holter monitorings; patients with signs of sinus node dysfunction were therefore set apart (Group III). The following features were studied in all patients: the morphology of the sinus P wane, the duration of the PR interval, the permeability of the atrioventricular node at the start of AF, the presence of arrhythmias before AF and the time of day of the episodes of AF. The highest incidence of prolongation and abnormalities of the P wave and increased AV conduction at the beginning of AF was observed in Group I. There was also a marked prevalence of supraventricular beginning before AF and most episodes of AF were observed during the night. In groups II and III no attacks of AF were observed at sinus rhythm greater than 94/min. The extrasystole initiating AF had the same average coupling interval in all three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiographic discoveries in 102 patients with vascular cerebral accidents]. / Découvertes échocardiographiques chez 102 patients atteints d'accident vasculaire.

The causes of vascular ischaemic accidents are numerous, and when the brain is involved management is limited to the prevention of similar events. Since cardiac sources of embolism potentially curable, we have prospectively analyzed the results of cardiovascular examinations (including ECG and radiography of the chest) and of echocardiography in 102 patients with cerebral or peripheral vascular ischaemic event in order to determine the impact of echocardiography and the influence of different diagnoses on the need for anticoagulant therapy. Intracardiac thrombi, mitral stenosis, dilated cardiomyopathy, severe left ventricular dysfunction with or without aneurysm and cardiac valve vegetations were regarded as diseases carrying a high risk of embolism, the low risk diseases being mitral valve prolapse, mitral annulus calcification and isolated left atrial dilatation. Atrial fibrillation was treated separately, as it may be associated with several of the diseases listed above. We found 14 diseases with a high risk of embolism (14 p. 100) and 35 diseases with a low risk of embolism (34 p. 100). 10/91 patients with cerebral vascular accident (11 p. 100) and 4/11 patients with peripheral vascular accident presented with a heart disease carrying a high risk of embolism. The most common heart disease with a high risk of embolism (10/14, 71 p. 100) was severe left ventricular dysfunction secondary to a coronary disease or a dilated cardiomyopathy. We did not find more cases of mitral valve prolapse or mitral annulus calcification than in the normal population. 20/29 patients with normal cardiac examination had a normal echocardiogram. The anticoagulant treatment was modified after echocardiography in only one case.(ABSTRACT TRUNCATED AT 250 WORDS)

Thermodilution determination of right ventricular volume and ejection fraction: a comparison with biplane angiography.

In 13 patients without tricuspid incompetence, we compared the values of right ventricular ejection fraction (RVEF) and right ventricular end-diastolic volume (RVEDV) obtained with biplane angiography and thermodilution at end-inspiration. A modification of Simpson's rule was used to measure angiographic volumes, and a new pulmonary artery catheter equipped with a rapid response thermistor was used to measure the ejection fraction by the Holt plateau method. The correlation between the two methods was acceptable (r = 0.83 for RVEF, r = 0.71 for RVEDV) despite the limitations of both angiography and thermodilution. Thermodilution underestimated RVEF and overestimated RVEDV when compared to angiography. The variation coefficient with thermodilution for five measurements of the RVEF per patient was 12 +/- 5%. In addition to pressure and cardiac output measurements, monitoring of RVEF and RVEDV in the ICU should be possible with such a catheter. Further work is needed to assess the clinical relevance of these added data and their use for optimizing the therapy of right ventricular failure in acutely ill patients.

[Prognostic value of bidimensional echocardiography in the acute phase of myocardial infarct]. / Valeur pronostique de l'échocardiographie bidimensionnelle au stade aigu de l'infarctus du myocarde.

To evaluate the prognostic value of two-dimensional echocardiography we have studied 43 consecutive patients during the acute stage of myocardial infarction. Recording of sufficient quality where obtained in 74% of the patients. The extent of myocardial damage was estimated by a left ventricular wall motion index (SFR). Regional dyssynergy was found in all patients. Echocardiographic and electrocardiographic infarct localization were in agreement in 93%. Four patients died during hospitalization. The mean SFR in these patients (2.04 +/- 0.46) was significantly higher than in surviving patients (1.16 +/- 0.12; p less than 0.025). The SFR was higher than 2 in three of the four patients who died. All surviving patients had an SFR of 2 or less. In conclusion, two-dimensional echocardiography performed during the first hours of acute myocardial infarction serves to localize the infarct and estimate the extent of myocardial damage. In addition, this technique seems to offer an appropriate means of identifying high risk patients.

Comparative effects of acute O2 breathing and terbutaline in patients with chronic obstructive pulmonary disease. A combined hemodynamic and radionuclide study.

The acute effects of terbutaline (T) and breathing 100% O2 (O2) on gas exchange, pulmonary hemodynamics and radionuclide angiography were evaluated in 15 patients with severe chronic obstructive pulmonary disease (COPD). O2 breathing resulted in a decrease in mean pulmonary artery pressure (PAP) and cardiac index (CI) without changing pulmonary vascular resistance index (PVRI) or right and left ventricular ejection fractions (RVEF, LVEF). On the other hand, T administration was followed by a decrease in PVRI, an increase in CI, RVEF and LVEF. These effects of T were maintained during exercise. Although RVEF was inversely correlated with basal levels of PAP or PVRI, acute changes in pulmonary hemodynamics were not correlated with significant changes in RVEF. These results suggest that T may be useful in the treatment of patients with COPD prone to develop cor pulmonale. However, the long-term benefit of this treatment remains to be established.

Doppler assessment of left ventricular diastolic filling during brief coronary occlusion.

To assess left ventricular diastolic filling in patients with single-vessel coronary artery disease, Doppler-derived transmitral velocity was studied in 22 normal subjects and in 15 patients with isolated proximal stenosis of the left anterior descending coronary artery (LAD) and normal systolic function of the left ventricle. Transmitral velocity was recorded before and after balloon inflation during coronary angioplasty. At baseline the transmitral velocity pattern in patients with LAD stenosis differed from that of normal subjects with a significant (p at least less than 0.05) decrease in the early diastolic filling phase (E area 0.094 +/- 0.022 m in normal subjects vs 0.078 +/- 0.008 m in patients) and an increase in the late diastolic filling phase (A area 0.034 +/- 0.007 m vs 0.042 +/- 0.008 m). Correspondingly the ratio E area/A area decreased (2.7 +/- 0.51 vs 1.9 +/- 0.4) and the ratio A area/total area increased (0.28 +/- 0.04 vs 0.35 +/- 0.05). During coronary occlusion the E area and the ratio E area/A area decreased further, whereas the A area and the ratio A area/total area increased. The results suggest that patients with single-vessel disease and normal systolic function often exhibit an altered pattern of transmitral velocity even in the absence of overt ischemia, and that during acute regional ischemia early diastolic filling is further compromised with compensatory enhancement of the late diastolic filling phase.

Acute hemodynamic effects of intravenous tiapamil in patients with coronary artery disease.

The acute hemodynamic effects of intravenous tiapamil were studied during heart catheterization in 19 patients with coronary artery disease (age range 41-66 years, mean 52.4 years). 10 subjects received an initial intravenous loading dose of 1 mg/kg followed by intravenous infusion of 50 micrograms/kg/min for 15 min. The other 9 patients received an initial intravenous dose of 1.5 mg/kg which was followed by an intravenous infusion of 75 micrograms/kg/min for 15 min. Tiapamil had little effect on heart rate, intracardiac pressures and left ventricular dp/dtmax. The ejection fraction increased, but not significantly. The most striking findings were an increase in cardiac output and a decrease in systemic vascular resistance. The overall results are consistent with the drug's propensity to produce peripheral vasodilatation which outweighs its intrinsic negative inotropic property due to calcium antagonism in myocardial tissues.

Surgery in primary leiomyosarcoma of the heart.

Primary leiomyosarcoma of the heart is uncommon and we were able to find only 15 cases reported in the literature. Few of these cases were discovered during life and, as a result, even fewer have been treated surgically. We report a case of a right atrial leiomyosarcoma which was proven pathologically (histologically, immunohistochemically and ultrastructurally) after surgical resection. The clinical presentation, morphological, appearances and outcome are compared with those reported in the literature.