Technique for tricuspid annuloplasty with a flexible linear reducer: medium-term results.

The surgical treatment for tricuspid incompetence requires a choice between reconstruction or replacement with a prosthetic valve. The conservative approach offers many advantages in functional tricuspid incompetence. Our technique for annuloplasty utilizes a flexible linear reducer (FLR) to support a selective reduction of the distended portion of the anulus. The insertion of the septal leaflet is always left free, and physiological flexibility of the tricuspid anulus is assured. The repaired valve is sturdy because of the prosthetic support, and inserting the FLR is simple and poses no risk to the His bundle. The medium-term results (mean follow-up 10 months) in 20 consecutive patients (all with a complete postoperative reinvestigation) are satisfactory. Because this procedure is simple and harmless, it frequently can be applied for direct correction of functional tricuspid incompetence during polyvalvular operation.

Visualization of myocardial infarction 6 h after injection of 111In-antimyosin antibodies using a blood pool subtraction technique.

111In-antimyosin antibodies are capable of visualizing myocardial infarction (MI). Because of slow blood clearance, images are usually recorded 24 or 48 h postinjection. In this pilot study, a blood pool subtraction technique, which makes it possible to visualize MI 6 h postinjection, is validated. Twenty-five patients with proven MI (16 anterior, 9 inferior) were imaged a few minutes, 6 and 24 h after an injection of 111 MBq 111In-labelled antimyosin antibodies. Three planar views are obtained each time. Using software which performs the geometric registration, the grey level normalization and the subtraction of images, the blood pool image (obtained a few minutes postinjection) is subtracted from the 6 h image. The resulting image is the blood pool corrected 6 h image. The 24 h images and the blood pool corrected 6 h images were interpreted blindly and the number of correct, incorrect and impossible MI localizations was counted. The number of correct localizations is 19/25 for the standard 24 h images and 22/25 for the blood pool corrected 6 h images. Then, with this blood pool subtraction method, it is possible to visualize MI 6 h postinjection. This has to be taken into account when discussing the role of antimyosin scintigraphy in the management of patients with MI.

[Cardiac manifestations of pheochromocytoma. Anatomo-clinical study]. / Les manifestations cardiaques des phéochromocytomes. Etude anatomo-clinique.

Cardiomyopathy induced by catecholamines, first demonstrated in the animal is also observed in clinical medecine either after infusion by vasopressor drugs or during the course of pheochromocytoma. The clinical presentation is varied and may often deceive: acute coronary insufficiency, arrhythmia, heart failure, and, above all, cardiogemic shock. The authors emphasise the importance of considering the diagnosis of "adrenergic myocarditis" in such situations as well as in cases of pheochromocytoma, for which the only cure is ablation of the tumour.

[Echocardiographic aspects of the atrio-ventricular canal]. / Aspects échocardiographiques du canal atrio-ventriculaire

The authors report their experience of echocardiography in cases of atrio-ventricular canal in the light of 9 cases which were studied by time-movement and 2-dimensional echography. In cases if ostium primum, the essential findings are: diastolic juxtaposition of the mitral valve to the left side of the septum, its multiple-echo appearance during systole, and the abnormal movement of the ventricular septum. In cases of complete atrio-ventricular canal, two main types are found. In the first, the echos of the atrio-ventricular valve are confused with those of the interventricular septum during diastole; in diastole, the septum disappears, one valve moves anteriorly into the right ventricle, and the other moves posteriorly into the left ventricle. In the second type, the appearances are those of a single valve which is situated within the left ventricle during systole, and which 'crosses' the interventricular septum to gain the right ventricle during diastole. The interpretation of these findings is difficult. It becomes clearer, however, when it is realised that the plane of incidence of the ultrasonic waves is not perpendicular to the plane of movement of the atrio-ventricular valve. The authors' conculsion is that echocardiography is a method of diagnosings atrio-ventricular canal defects, bud does not allow the anatomical type to be defined.

[Predictive value of the exercise test for multivessel disease after initial myocardial infarction]. / Valeur prédictive de l'épreuve d'effort vis-à-vis des lésions pluritronculaires après un premier infarctus du myocarde.

The extent of coronary artery disease after primary myocardial infarction is an important prognostic factor. The predictive value of exercise electrocardiography for multivessel disease was assessed by comparison with coronary angiography in a series of 100 patients. In the group of patients with primary anterior infarction (n = 48), 37.5% had positive exercise ECGs. Coronary angiography showed 62.5% single vessel disease. In multivessel disease, the sensitivity of exercise ECG was 78% and specificity 86%. The predictive value of a positive test was 78% and, for a negative test, 86%. In primary inferior infarction (n = 52), positive exercise ECGs were recorded in 48% of cases. Coronary angiography showed 48% multivessel disease. In multivessel disease, sensitivity of exercise ECG was 92% ans specificity 93%. The predictive value of a positive test was 92% and of a negative test, 93%. Therefore, exercise ECG gives a more precise prediction of the extent of coronary artery disease after primary inferior infarction than after primary anterior infarction. However, it is not an ideal guide for the choice of patient for coronary angiography because of its poor predictive value in cases of anterior infarction, and because of the high incidence of multivessel disease in patients with primary inferior infarcts. Nevertheless, it is of great prognostic value with regards to the eventual course of the coronary disease.

[Diagnostic and prognostic value of continuous Doppler in pulmonary embolism]. / Intérêt diagnostique et pronostique du Doppler continu dans l'embolie pulmonaire.

A prospective study of 18 patients admitted to hospital for acute pulmonary embolism confirmed the reliability of continuous wave cardiac doppler as a non-invasive method of evaluating systolic pulmonary artery pressures. These pressures were calculated by applying the simplified Bernoulli equation to the maximal velocity of regurgitant tricuspid flow and compared with the results of cardiac catheterisation and angiography, the percentage of vascular obstruction being assessed using Miller's index. The correlations between the two methods were good, r = 0.96; p less than 0.001, with a standard error of +/- 5.2 mmHg. The correlations between the velocity of tricuspid flow and the percentage of obstruction were less significant (r = 0.65; p less than 0.005) but improved when patients with pre-existing cardiopulmonary disease were excluded. This technique of non-invasive assessment of haemodynamic parameters also helps in evaluating the underlying pathology; tricuspid regurgitation with velocities greater than 3.5 m/s is associated with pre-existing chronic cor pulmonale, information of prognostic interest which would guide therapeutic management.

[Role of clinical manifestations, the exercise test and exertion angioscintigraphy in the diagnosis of coronary disease. A multivariate study]. / Place de la clinique, de l'épreuve d'effort et de l'angioscintigraphie d'effort dans le diagnostic de maladie coronaire. Une étude multivariée.

Data of clinical examination, exercise electrocardiography and stress radionuclide angiography in 102 patients referred for assessment of chest pain was included in a logistic regression to optimise the diagnosis of coronary artery disease with coronary angiography as the reference investigation. None of the patients had other cardiac problems nor previous myocardial infarction. In the absence of symptoms exercise testing was continued until at least 80 p. 100 of the theoretical maximal heart rate was attained. Each patient was characterised by the value of the logistic function or probability of coronary artery disease. A threshold value corresponding to 80 p. 100 sensitivity was determined by the technique of ROC graphs. The significant variables were: a clinical variable--the type of chest pain as assessed by the clinical history; two radionuclide angiographic variables--the ejection fraction at peak effort and the corrected variation of ejection fraction between rest and stress, that is not taking into account possible decreases at the last increment of exercise. Coronary patients can be identified with an 80 p. 100 sensitivity and 77 p. 100 specificity on these criteria. This specificity is greater than that obtained by clinical examination and exercise electrocardiography alone (65 p. 100). Stress radionuclide angiography may therefore reduce the number of unnecessary coronary angiographies.

[Validation of a method for measuring the area of aortic stenosis using only continuous Doppler. Value for the surveillance of transluminal aortic valvuloplasties]. / Validation d'une méthode de mesure de la surface des sténoses aortiques utilisant uniquement le doppler continu. Intérêt pour la surveillance des valvuloplasties aortiques transluminales.

Forty patients with aortic valve stenosis underwent continuous wave doppler-echocardiographic exploration followed by catheterization within 24 hours on average. Three methods of aortic functional area calculation, based on the continuity equation principle, were tried and compared with the haemodynamic data. The results of the reference equation (continuity through the whole systole) gave a correlation coefficient r = 0.77 with a standard error (SE) of 0.17 cm2. The continuity equation using only maximum velocity values was less satisfactory: r = 0.69; SE = 0.19 cm2. The simplified equation with an arbitrary 2 cm subaortic diameter and a subaortic velocity obtained by continuous wave doppler recording yielded results that were very similar to those of the reference equation: r = 0.78; SE = 0.16 cm2. It is suggested that this third equation should be used in the follow-up of transluminal aortic valvuloplasties, since its calculation is based only on aortic velocity, which reflects the degree of stenosis, and subaortic velocity, which indirectly reflects left ventricular function.

[Evaluation of pulmonary systolic arterial pressures by continuous Doppler in tricuspid regurgitation in adults. Apropos of 43 cases]. / Estimation des pressions artérielles pulmonaires systoliques par le Doppler continu en présence d'une fuite tricuspide chez l'adulte. A propos de 43 cas.

Forty-three hospital patients with tricuspid regurgitation were prospectively explored by continuous wave Doppler ultrasound to determine their pulmonary systolic arterial pressure. In the absence of pathology of the pulmonary orifice this value corresponds to the sum of the right atrioventricular systolic gradient calculated by Bernoulli's equation DP = 4V2 from the tricuspid regurgitation and the right atrial pressure evaluated by clinical examination. The values obtained are compared with the results of right heart catheterization. Our study showed good correlation (r = 0.90) with a standard error of 8.2 mmHg, the main source of effort being the clinical quantification of right atrial pressure. These results confirm that pulmonary systolic arterial pressure can reliably be measured by this method in the presence of tricuspid regurgitation. The method is of considerable interest in permanent pulmonary hypertension or in emergencies.

[Subvalvular aortic stenosis discovered after surgical repair of an atrioventricular canal in the adult. Apropos of a case]. / Rétrécissement aortique sous-valvulaire découvert après correction d'un canal atrio-ventriculaire chez l'adulte. A propos d'une observation.

The case of an adult female patient in whom subaortic stenosis was discovered 9 months after surgical correction of a partial atrioventricular canal is reported. The authors describe the difficulties encountered in the pre-operative diagnosis of this uncommon association and the paraclinical methods now available, notably echocardiography, that may help overcome these difficulties.

[Treatment of functional tricuspid insufficiency by a valvuloplasty with a flexible linear reducer]. / Traitement de l'insuffisance tricuspidienne fonctionnelle par plastie type réducteur linéaire souple.

Valvuloplasty with preservation of the valvular apparatus is the treatment of choice in functional tricuspid incompetence (FTI). A new method of valvuloplasty has been developed using a flexible linear reducer (FLR); its insertion is simple and without risk to the Bundle of His. It is made of sections of elastomere covering a dacron core. The principle of the FLR is reduction of the tricuspid annulus leaving the septal leaflet free. It is a simple method which allows individual variations in the zone reduced (usually involving the anterior and inferior leaflets) and in the size of the reduction at each point. The excellent results at medium term in 20 patients with tricuspid FLR lead us to recommend widening the surgical indications for correction of FTI especially in cases where signs of right ventricular failure have been observed.

[Acute dysfunction of mitral bioprosthesis: Doppler expression of a musical holosystolic murmur. Apropos of 2 cases]. / Dysfonctionnement aigu de bioprothèse mitrale: traduction doppler d'un souffle musical holosystolique. A propos de 2 observations.

Two women who had been fitted with a porcine mitral valve seven years previously suddenly developed acute dysfunction of the bioprosthesis with regurgitation. In both patients physical examination revealed an intense, vibrating, musical holosystolic murmur sounding like a "goose cry" and located at the apex. Pulsed doppler showed major, jet-like, central orothetic mitral regurgitation. A harmonic graph was recorded when the doppler window was positioned upstream of the porcine valve leaflets. The finding of such a doppler signal in this clinical context suggests tearing or perforation of one cuspid and rules out the possibility of bioprosthesis degeneration.

[Postoperative hemopericardium compressing the left atrium. Apropos of a case]. / Hémopéricarde postopératoire comprimant l'oreillete gauche. A propos d'un cas.

We report a case of tamponade due to an effusion of blood which had occurred two weeks after an aorto-coronary bypass and was unusually located behind the left atrium. The effusion, with severe clinical symptoms, was diagnosed by echocardiography and computerized tomography of the chest. These examinations provided an accurate anatomical diagnosis on which the approach route of the emergency operation was based.

[Recurrent mobile thrombus of the ascending aorta diagnosed by transesophageal echocardiography]. / Thrombus mobile récidivant de l'aorte ascendante diagnostiqué par échocardiographie transoesophagienne.

The authors report the case of a 32 year old woman with no risk factors for thromboembolism apart from a raised Lipoprotein (a) level, in whom a mobile thrombus of the ascending aorta was diagnosed only by transoesophageal echocardiography after multiple episodes of systemic embolism. After surgical excision the thrombus recurred and death ensued on the 17th postoperative day after multiple visceral embolism despite adequate anticoagulant therapy. This is a rare condition, the outcome of which seems often to be fatal, due to early recurrence irrespective of the treatment (anticoagulant or platelet antiaggregant therapy). This case illustrates the value of systematic transoesophageal echocardiography for the investigation of cerebral or peripheral ischaemic episodes without carotid artery disease and raises the problem of the best way of treating this pathology.

[Value of transesophageal echography in the diagnosis of posterior ventricular septal rupture during the acute phase of myocardial infarction. Apropos of 2 cases]. / Intérêt de l'échographie transoesophagienne dans le diagnostic de rupture du septum interventriculaire postérieur au stade aigu de l'infarctus du myocarde. A propos de 2 observations.

The authors report two cases of posterior ventricular septal defects complicating acute myocardial infarction diagnosed by transesophageal echocardiography. Transesophageal echocardiography was well tolerated confirmed the diagnosis, and enabled accurate evaluation of the shunt in the transgastric view. The anatomical results guided the surgical approach and correlated well with the operative findings.

[Malignant histiocytofibroma of the heart simulating myxoma of the left atrium]. / Histiocytofibrome malin du coeur simulant un myxome de l'oreillette gauche.

The authors report a case of malignant fibrous histiocytoma of the left atrium which was excised but rapidly recurred in a 47-year-old woman. Clinical examination, echocardiography and the absence of biochemical abnormalities were in favour of the diagnosis of left atrial myxoma. This report illustrates the clinical similarity between myxoma and sarcoma of the left atrium. Very careful anatomopathological examination of multiple sections of the tumour are necessary to distinguish it from benign tumours, especially myxomas.

[Spontaneous pneumopericardium. Review of the literature apropos of 2 cases in the young adult]. / Les pneumopéricardes spontanés--revue de la littérature. A propos de deux observations chez l'adulte jeune.

Pneumopericardium is defined as the presence of air in the pericardial cavity. It is a rare condition in adults, usually due to trauma; it is commoner in the more exposed neonate and usually iatrogenic. The clinical presentation of chest pain and shortness of breath is associated with the pathognomonic auscultatory sign described by Bricheteau: a water-mill bruit. The diagnosis is confirmed by chest X-ray which shows the air-gap sign surrounding the cardiac silhouette. The principal differential diagnosis is a pneumomediastinum. The prognosis of pneumopericardium depends on the cause and complications of which tamponade and infection are the most serious and potentially life-threatening. The treatment of pneumopericardium is bed rest and surveillance when uncomplicated: evacuation of the air becomes necessary when complications set in.

[Doppler echocardiographic evaluation of the efficacy of fibrinolytic treatment of pulmonary embolism]. / Evaluation de l'efficacité du traitement fibrinolytique de l'embolie pulmonaire par échocardiographie Doppler.

The efficacy of the fibrinolytic therapy in pulmonary embolism was studied by Doppler echocardiography: the evolution of the cardiac and angiographic changes could be studied in parallel. Thirty patients with severe pulmonary embolism and vascular obstruction greater than 40% (67.2 +/- 9.9%) were examined prospectively by Doppler echocardiography before and after thrombolysis. The following parameters were studied: systolic pulmonary artery pressure calculated from the jet of tricuspid regurgitation and left and right ventricular diameters for the calculation of the ratio of the ventricular dimensions. All patients underwent Doppler echocardiography and pulmonary angiography immediately after thrombolysis. The average improvement of the percentage vascular obstruction was 37%. The hemodynamic and echocardiographic changes were globally favourable. The pulmonary artery systolic pressure fell from 51 +/- 10 to 33 +/- 6.7 to 25.3 +/- 6.3 mm and the ratio of ventricular dimension from 0.87 +/- 0.3 to 0.60 +/- 0.16 (p less than 0.001). Only 4 patients had pulmonary artery systolic pressures over 40 mmHg after therapy compared with 26 before therapy. However, the hemodynamic and angiographic correlations were poor (r = 0.37; p less than 0.001). In the 6 patients in whom treatment was ineffective according to angiographic criteria (less than 20% improvement of vascular obstruction), the echocardiographic changes were small or absent, the improvement in the ratio of ventricular dimensions being less than 20%. However, a satisfactory correlation was observed between the percentage improvement of the ratio of ventricular dimensions and that of vascular obstruction (r = 0.59; p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparative study of 4 ultrasonic methods for evaluating the severity of mitral valve narrowing. Apropos of 36 cases]. / Etude comparative de quatre méthodes ultrasonores d'évaluation de la sévérité des rétrécissements mitraux. A propos de 36 cas.

Four ultrasound methods of estimating the severity of mitral narrowing (MN) were investigated in a prospective manner in 36 patients who underwent ultrasound-Doppler and catheterization (KT) within a space of 24 hours. The correlation of the mean Doppler and KT gradients was poor: r = 0.56 (n = 36, p less than 0.001). The mitral surface areas (MA), calculated from Gorlin's equation (mean A = 0.98 +/- 0.26 cm2) were successively compared with those obtained using the Hatle equation (A = 220/PHT) and by a planimetric determination. The coefficients of correlation were as follows: r = 0.80 (n = 36) and r = 0.70 (n = 32) (p less than 0.001). There was good correlation between the Hatle equation and the planimetric determination: r = 0.80 (n = 32, p less than 0.001). The continuity equation was carried out 15 times; the second measurement site was aortic in 8 cases and pulmonary in 7 cases. Correlations with the Gorlin equation were scored 0.70 and 0.80 respectively (p less than 0.05). The MA was best estimated by the Hatle equation, which was always technically feasible and not influenced by the presence of atrial fibrillation, mitral valve incompetence of previous commissurotomy. Planimetric determination, which is hampered in the presence of considerable calcification, remains valid after commissurotomy. The ultrasound estimation of the MA was very reliable when the planimetric and Hatle estimations concurred. The results obtained from the continuity equation were reliable; however, this method is slow, unreliable in a context of atrial fibrillation and inapplicable in a context of mitral valve incompetence.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chronic constrictive pericarditis after heart surgery. Apropos of a case]. / Péricardite chronique constrictive post-chirurgie cardiaque. A propos d'un cas.

A case of pericarditis in a 52-year old patient following aorto-coronary shunt surgery is reported which gradually developed into chronic constrictive pericarditis. In this context, the diagnostic criteria of chronic constrictive pericarditis are recalled. The clinical criteria show little specificity; Doppler ultrasound provides good diagnostic information; CT scans and nuclear magnetic imaging can confirm the diagnostic. The post-heart surgery etiology has increased in recent years. The only real treatment is surgical and consists of pericardial decortication.