[Compression of the right pulmonary artery by a dissecting aneurysm of the ascending aorta. Apropos of a case occurring long after aortic valve replacement]. / Compression de l'artère pulmonaire droite par un anévrysme disséquant de l'aorte ascendante. A propos d'un cas survenu à distance d'un remplacement valvulaire aortique.

The authors report the case of a dissecting aneurysm of the ascending aorta compressing the right pulmonary artery in a 62 year old man, 6 years after aortic valve replacement. The clinical presentation was that of pulmonary embolism. The diagnosis was confirmed by angiopneumography and CT scanning. The ascending aorta was successfully replaced with a Dacron prosthesis. One other case was found in a review of the literature. After discussing the predisposing factors of aortic dissection during cardiac surgery, the authors underline the diagnostic value of CT scanning in cases of suspected aneurysms of the thoracic aorta.

[Complex ventricular extrasystole. Value of programmed electric stimulation for evaluating the risk of sudden death]. / Extrasystolie ventriculaire complexe. Intérêt de la stimulation électrique programmée pour évaluer le risque de mort subite.

A prospective study was carried out from May 1984 to July 1987 to determine the prognostic value of the results of programmed electrical stimulation (PES) in patients with complex ventricular ectopy. The study population comprised 118 patients, 80 with and 38 without apparent underlying cardiac disease. The PES consisted in at most 3 extrastimuli delivered to the right ventricular apex during 2 imposed basal rhythms. Two groups of patients were identified: Group I (n = 35; 29.6%) in which a significant ventricular arrhythmia was induced (sustained ventricular tachycardia (11 cases), non-sustained VT (21 cases) and ventricular fibrillation (3 cases); and Group II (n = 83; 70.3%) in which no significant arrhythmia could be induced. During follow-up (average 28.7 +/- 11.7 months, range 6 to 48 months) there were 10 cardiac deaths, 8 of which occurred suddenly. Sudden death only occurred in patients with cardiac disease and usually with LV ejection fraction of less than 0.40; the prevalence of sudden death in Group I (11.5%) was higher than in Group II (4.8%) but the difference was not statistically significant. The prognosis of patients in Group II was the same as that of the general population. The results of this study suggest that PES enables identification of a subgroup of patients with complex ventricular ectopy in which ventricular tachyarrhythmias cannot be induced and the risk of sudden death is low; the management of patients with inducible ventricular tachyarrhythmias and normal LV function has to be determined case by case.

[Wolff-Parkinson-White syndrome. Value of intravenous flecainide for detecting Kent's pathways with short refractory period]. / Syndrome de Wolff-Parkinson-White. Intérêt de la flécaïnide i.v. dans le dépistage des faisceaux de Kent à période réfractaire courte.

The aim of this study was to assess the value of a non-invasive test in detecting accessory pathways with short anterograde effective refractory periods (AERP) (less than or equal to 270 ms) in patients with the Wolff-Parkinson-White syndrome. An intravenous injection of Flecainide acetate was administered to 19 consecutive patients referred for electrophysiological investigation of a WPW syndrome with permanent pre-excitation of the surface electrocardiogram. The first 8 patients (Group I) received a dose of 1.5 mg/kg over 5 minutes and the following 11 patients (Group II) were given 2 mg/kg in 5 minutes. In Group I, preexcitation disappeared in 3 patients (37.5%) who all had accessory pathways with AERP greater than 270 ms. It persisted in the other 5 patients (62.5%) of whom 4 had AERP less than or equal to 270 ms and 1 an AERP greater than 270 ms (false negative). In Group II, preexcitation disappeared in 8 patients (72.2%) of whom 4 had AERP greater than 270 ms and 4 had AERP less than 270 ms (false positives). Preexcitation persisted in the 3 other patients (27.3%); the AERP was less than or equal to 270 ms in 2 patients and greater than 270 ms in the other patients. These results suggest that intravenous Flecainide acetate at the dose of 1.5 mg/kg could be useful in differentiating WPW syndromes with long refractory periods (greater than 270 ms) from those with short refractory periods (less than or equal to 270 ms) with a satisfactory sensitivity and specificity, and that further studies on larger numbers of patients are required to confirm this hypothesis.

[Electrophysiologic evaluation and follow-up of patients with a syncopal episode of unknown origin]. / Evaluation électrophysiologique et suivi des patients ayant présenté un épisode syncopal d'étiologie inconnue.

The etiology of syncope of presumed cardiac origin can be determined by clinical and electrocardiographic examination with Holter monitoring in about 50 per cent of cases. The aim of this study was to review the data of electrophysiological investigation and the outcome of the patients in whom a cardiac pacemaker was eventually implanted, in those cases in whom the initial work-up had been negative. Ninety four patients, all of whom underwent standardised electrophysiological investigation, were included. The results of the investigations enabled us to identify three groups of patients: Group I: patients in whom the criteria did not suggest a cardiac origin of syncope; Group II: with criteria possibly suggesting a cardiac origin and Group III in which the criteria were strongly suggestive of a cardiac origin. A cardiac pacemaker was implanted systematically for AV block in Group III; on the other hand, this was very rare (only 1 patient) in Group I, and the indication in Group II depended on age and the history of recurrent syncope. Ninety patients (96%) were followed up for an average of 39.3 +/- 15.3 months. There was a very low incidence of recurrent syncope irrespective of the original classification, so confirming the value of electrophysiological investigations for cardiac pacemaker implantation in this type of patients. In addition, negative electrophysiological investigations allowed identification of a group of patients with a low mortality and low risk of recurrent syncope.

[Oral propranolol in Wolff-Parkinson-White syndrome. Electrophysiological data]. / Le propranolol oral dans le syndrome de Wolff-Parkinson-White. Données électrophysiologiques.

The effects of oral propranolol were studied in 24 patients with the WPW syndrome. The average daily dose of propranolol was 130 +/- 24 mg administered in 3 doses over a period of 48 to 72 hours. Endocavitary electrophysiological study was performed 2 to 4 hours after the last dose. The effective anterograde refractory periods (EARP) of the accessory and normal pathways were measured before and after propranolol (and, in both studies, before and after isoproterenol). The EARP of the accessory pathway was not affected by the propranolol. However, in the 9 patients in whom its value was less than 270 ms, it increased significantly (p = 0.01). The EARP of the accessory pathway measured after administration of isoproterenol increased significantly in all patients with oral propranolol (p = 0.001). Sustained reciprocating tachycardia could be induced in 19 patients and non-sustained reciprocating tachycardia in 5 other patients during base line electrophysiological study. Oral propranolol prevented the induction of the tachycardias in 18 patients (75%), even after isoproterenol. The shortest R-R interval between two pre-excited complexes in atrial fibrillation increased after propranolol (283 +/- 45 to 343 +/- 95 ms). These results show that oral propranolol increases the EARP of the accessory pathway and the shortest R-R interval between two pre-excited complexes in atrial fibrillation in patients with short anterograde refractory periods of their accessory pathways, and is effective in preventing reciprocating tachycardia. Oral propranolol may be useful and can be used safely in patients with the Wolff-Parkinson-White syndrome.

[Coronary angioplasty in patients aged 70 and over. Immediate results and later outcome]. / L'angioplastie coronaire chez le sujet âgé de 70 ans et plus. Résultats immédiats et devenir à moyen terme.

One hundred and ninety one consecutive patients over 70 years of age (127 men and 64 women, average age 75.6 years) underwent percutaneous transluminal coronary angioplasty (PTCA) between January 1986 and February 1989. One hundred and sixty patients had severe angina (20 Class III and 140 Class IV), 72 patients had previous myocardial infarction, 36 of which were recent (less than 1 month), and 6 patients had previously undergone coronary bypass surgery. The coronary lesions affected one vessel in 67 patients and more than one vessel in 124 patients. The left ventricular ejection fraction was less than 50% in 15 patients. Angioplasty was attempted on 245 lesions (228 stenoses and 17 occlusions): 1 lesion in 141 patients, 2 lesions in 46 patients, 3 lesions in 4 patients, with a primary success rate of 81% in stenotic and 41% in occluded arteries. There were 9 deaths (4.7%) 6 of which occurred in patients with multivessel disease and unstable angina; there were 6 Q-wave infarctions (3.1%), 8 non Q-wave infarctions (4.2%) and 3 emergency coronary bypass operations (1.6%). The first 123 patients of this series were followed up for an average of 18.8 months (7 to 37 months). Follow-up of the 100 patients successfully dilated (4 lost to follow-up) showed that 55 remained improved (53 asymptomatic), 25 had recurrent angina after the initial improvement due to restenosis in 19, progression of coronary athero-sclerosis in 3, restenosis and an evolution of coronary atherosclerosis in 1 and a lesion which had been neglected in 2 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute occlusion of the renal artery caused by an embolism of cardiac origin. Treatment by in situ thrombolysis]. / Occlusion aiguë de l'artère rénale par une embolie d'origine cardiaque. Traitement par thrombolyse in situ.

An intra-arterial infusion of streptokinase successfully dissolved a large thrombus of the renal artery in a 54-year old male patient with old-standing mitral stenosis. This case illustrates the effectiveness of fibrinolysis in situ. This method provides complete arterial recanalization and preserves the renal function, thus enabling surgical embolectomy to be performed.

[Comparison of the efficacy of 2 delayed-action preparations of hydroquinidine and quinidine in the prevention of pacing induced ventricular tachycardia]. / Comparaison de l'efficacité de deux formes à libération prolongée d'hydroquinidine et de quinidine dans la prévention des tachycardies ventriculaires induites par stimulation.

The effects of two antiarrhythmic agents, hydroquinidine and quinidine on the prevention of pacing induced sustained ventricular tachycardia (VT) were studied in 14 patients. The underlying cardiac disease was old myocardial infarction (12 patients) or dilated cardiomyopathy (2 patients). Sustained monomorphic VT was induced in 14 patients during the initial electrophysiological study performed at least 48 hours after withdrawal of all antiarrhythmic therapy. The same stimulation protocol including 3 extrastimuli (S2 S3 S4) and 2 paced cycles (600 ms and 400 ms) was repeated at least 48 hours after the administration of 600 mg (2 gelules) per 24 hours of hydroquinidine or 1100 mg of quinidine arabogalactane sulphate, 3 to 4 hours after the last dose. This was an open, randomised, crossed over trial. Irrespective of the result observed with the first antiarrhythmic, used in an order attributed by a randomised table, the other antiarrhythmic was tested. Plasma concentrations were measured during the programmed stimulation test for both drugs. Induced VT was prevented by the two antiarrhythmics in 4 patients (28%). In one patient, VT was prevented by hydroquinidine but not by the quinidine compound, resulting in a prevention rate of 35% for the hydroquinidine. On the other hand, the quinidine compound was a total success in one patient in whom only a partial success was observed with hydroquinidine. VT remained inducible with both antiarrhythmics in 9 patients (64%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of systematic preventive antibiotherapy in cardiac pacemaker implantation]. / Intérêt de l'antibiothérapie prophylactique systématique lors de l'implantation d'un stimulateur cardiaque.

The aim of this study was to assess the usefulness of prophylactic antibiotics during insertion of a cardiac pacemaker, in order to avoid infection of exteriorisation of infectious origin. The study involved two groups. One hundred and eight patients made up group I, a control group without the use of prophylactic antibiotics. Group II consisted of 101 patients who were given an intravenous injection of 1 or 2 g of oxacillin before surgery, followed up by four days of oral oxacillin (3 g per day). Serum oxacillin levels at the end of the procedure were 0.37 +/- 0.09 mcg/ml, falling within the range of minimum inhibitory concentrations of methicillin-sensitive staphylococci. In the patients of the control group, followed up for 1 to 36 months (mean 12 +/- 11 months), during the first 2 months there were 2 infections, 4 exteriorisations and one cutaneous erosion over the pacemaker. In addition, one exteriorisation and one infection occurred at 17 and 29 months respectively. In patients with exteriorisation of their pacemaker device, there was nothing to suggest an infection and bacteriological specimens were sterile. No obvious infections nor any cutaneous complications occurred in the patients of group II, with prophylactic antibiotics, followed up for 1 to 21 months (mean 6 +/- 5 months). In conclusion, anti-staphylococcal antibiotic treatment appears not only to be capable of avoiding cardiac pacemaker infections but also of preventing exteriorisation of the pacemaker device, which may be linked to hidden infections. A randomised study is nevertheless necessary to confirm this hypothesis.

A randomized comparison of external and internal cardioversion of chronic atrial fibrillation.

BACKGROUND: Delivery of shocks within the right atrium has been reported to be more effective than conventional external shocks in converting atrial fibrillation (AF), but these two cardioversion techniques have never been compared prospectively. The purpose of this study was to compare the efficacies of external and internal cardioversion in patients with chronic AF unresponsive to prior attempts at electrical and/or pharmacological cardioversion. Low-dose amiodarone was used in all patients after cardioversion to suppress recurrences of AF. METHODS AND RESULTS: One hundred twelve patients with AF of at least 1 month in duration were randomly assigned to undergo external cardioversion with 300-360-J shocks or internal cardioversion with 200-300-J shocks delivered through a standard electrode catheter within the right atrium. The patients were treated with amiodarone (200 mg/day 5-7 days/week) for 1 month before electrical cardioversion and afterward if the cardioversion was successful. The patients were evaluated at regular intervals during 1 year of follow-up. The efficacy of internal cardioversion was significantly greater than that of external cardioversion (91% versus 67%, p = 0.002). The only variable that was associated with the outcome of cardioversion was body weight. Among patients in whom sinus rhythm was restored, AF recurred as often after internal and external cardioversion; at 1 year of follow-up, 37% of patients in whom external or internal cardioversion had been effective were still in sinus rhythm. Patients who had undergone an attempt at electrical cardioversion before entry into this study were less likely to remain in sinus rhythm after cardioversion. The only complications of cardioversion were one instance of cerebral thromboembolism after external cardioversion and one instance of transient pulmonary edema after internal cardioversion. Therapy with amiodarone was discontinued because of an adverse drug effect in only three patients. CONCLUSIONS: Internal cardioversion is more effective than external cardioversion in restoring sinus rhythm and is as safe as external cardioversion in patients with chronic AF. The recurrence rate of AF is the same after both types of cardioversion. If conventional electrical cardioversion is ineffective, internal cardioversion should be attempted. The combination of low-dose amiodarone and external or internal cardioversion may result in maintaining sinus rhythm long-term in patients with refractory AF.