[Acute pericarditis: results of a survey of treatment practices of cardiologists]. / Péricardite aiguë.

UNLABELLED: Benign acute pericarditis is a common disorder. Although, at first glance, its management appears well defined, the guidelines issued by professional societies with respect to optimal treatment and length of its administration remain vague. METHODS: a brief, anonymous questionnaire probing into treatment practices was sent in April 2005 to all cardiologists of Brittany. RESULTS: we collected 164 analyzable questionnaires out of 248 submitted (66%). The initial investigations in presence of acute pericarditis included an electrocardiogram in 100% of cases, an echocardiogram in 95%, and screening biochemistry in 93% of cases. Systematic hospitalisation was advised by only 24% of cardiologists. Aspirin was prescribed as first choice treatment in 92.5% of cases. Duration of treatment recommendations varied widely, from <5 days by 2.5%, between 5 and 10 days by 25.5%, 11 and 15 days by 23.0%, 16 to 21 days by 35.3%, and for >21 days by 14% of cardiologists. Hospital-based cardiologists were more likely to systematically hospitalise their patients than outpatient practice-based physicians (79.5% versus 5.1%; p<0.001) as well as to order an initial biochemical screening tests (100% versus 81.4%, p<0.01). Cardiologists <42 years of age recommended significantly fewer hospitalisations than older physicians (6.8% versus 36.4%: p<0.001). CONCLUSIONS: the management of acute, benign pericarditis was limited nearly exclusively to the prescription of aspirin. Duration of treatment varied widely. These observations are concordant with data published in the literature (where the recommended duration of treatment is systematically missing).

Response of normal and abnormal sinus node to right ventricular stimulation.

Right ventricular pacing at progressively increasing rates was performed in 25 patients with complete ventriculoatrial block, before and after autonomic blockade with intravenous propranolol and atropine. At the end of each ventricular pacing stage a right intraatrial electrogram and electrocardiographic leads were simultaneously recorded. The relation between right ventricular pacing and atrial rates was studied from the recordings obtained at each pacing stage in both group I, 8 patients with sick sinus syndrome, and group II, 17 patients with normal sinus function. Right ventricular pacing was associated with an increment in atrial rate that ws significantly smaller (probability [p] less than 0.001) in patients in group I (mean +/- standard error of the mean 8 +/- 6 beats/min) than in group II (mean 25 +/- 10 beats/min). The maximal atrial rate reached during right ventricular pacing exceeded 80 beats/min in all patients in group II but remained less than 74 beats/min in patients in group I. Because autonomic blockade did not significantly influence the preceding results, it is concluded that a mechanical effect on the sinus node may explain this phenomenon.

Evaluation of left ventricular based pacing in patients with congestive heart failure and atrial fibrillation.

Acute hemodynamic data of left ventricular based pacing were assessed in 2 groups of patients with severe cardiac failure: 11 patients with atrial fibrillation and 17 patients with sinus rhythm. Both biventricular and left ventricular pacing significantly improved acute hemodynamic findings to a similar degree in both groups, suggesting that left ventricular based pacing may be beneficial in patients with severe cardiac failure regardless of whether or not they are in sinus rhythm.

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.

Constrictive perivenous mesh prosthesis for preservation of vein integrity. Experimental results and application for coronary bypass grafting.

Saphenous veins undergo dramatic morphologic changes when used as coronary bypass grafts, and careful preparation of the graft alone is inadequate in preventing these changes. In this study, the use of a constrictive mesh for vein graft was evaluated. Fourteen sheep were subjected to a 5 cm resection of the carotid artery. Six sheep (Group A) received a jugular vein interposition graft, and the other eight sheep (Group B) received a jugular vein graft on which the constrictive mesh had been applied. The diameter of grafts in Group A was 14 +/- 1 mm compared with 7 +/- 0.5 mm for Group B (p = 0.05). The animals were put to death 4 months later. Scanning electron microscopy showed a disruption of the endothelial lining in Group A and a normal endothelium in Group B. Microscopy showed a statistical difference between Groups A and B regarding regularity and thickness of the intimal hyperplasia. Group B showed a moderate and regular intimal thickening and increased vasa vasorum. This indicates that distention and subsequent damage of the vein graft may be minimized by use of a constrictive mesh. Saphenous grafts surrounded by this constrictive mesh were inserted in four patients. Vein diameters were, respectively, 5, 4.3, 3.5, and 3.5 mm before meshing. After insertion in the mesh, vein diameters were 4.3, 3.5, 2.8, and 2.5 mm, respectively. Angiography performed 2 months later showed patent grafts of regular caliber.

Left ventricular-based pacing in patients with chronic heart failure: comparison of acute hemodynamic benefits according to underlying heart disease.

BACKGROUND: Acute left ventricular-based pacing has been shown to improve hemodynamics in patients with severe heart failure and left bundle branch block (LBBB). However, it is not known whether the cause of the underlying heart disease influences the potential effect of left ventricular-based pacing. OBJECTIVES: The aim of this study was to determine whether beneficial hemodynamic effects of acute left ventricular-based pacing in severe chronic heart failure are dependent on underlying heart disease. METHODS: After coronary angiography, patients with severe heart failure and LBBB were separated into two groups: dilated (25 patients; 20 male) and ischemic cardiomyopathy (21 patients; 20 male). Hemodynamic parameters were evaluated at baseline and during left ventricular-based pacing. RESULTS: Improvement in hemodynamic parameters were similar in both groups, during acute left ventricular pacing (changes expressed in percentage): pulmonary capillary wedge pressure, -16+/-15% vs. -14+/-10%; V wave amplitude, -25+/-18% vs. -21+/-17%; and biventricular pacing, -15+/-15% vs. -11+/-11% and -23+/-18% vs. -16+/-18%, respectively. CONCLUSION: Underlying heart disease does not influence the response to acute left ventricular-based pacing in patients with severe heart failure and LBBB. This finding provides support for including all patients with enlarged heart and heart failure in future studies evaluating left ventricular-based pacing.

Evaluation of left ventricular function and mitral regurgitation during left ventricular-based pacing in patients with heart failure.

BACKGROUND: Beneficial effects of left ventricular (LV)-based pacing on acute hemodynamic parameters were reported in several series, but only a few studies examined the long-term effects of this new pacing procedure. AIMS: To assess long-term effects of permanent LV-based pacing on LV function and mitral regurgitation (MR) in patients with refractory congestive heart failure (CHF). METHODS: A prospective evaluation of LV function and MR was performed in 23 patients with severe but stable CHF and left bundle branch block (mean QRS: 186+/-31 ms) by radionuclide and echocardiographic techniques at baseline and 6 months after implantation of a permanent LV-based (LV alone: 13 patients; biventricular: 10 patients) pacemaker programmed either in a DDD mode (sinus rhythm; n=14) or in a VVIR mode (atrial fibrillation; n=9). RESULTS: Compared to baseline, the 6 months follow-up visit demonstrated a significant increase in radionuclide derived LV ejection fraction from 23.3+/-7 to 26.2+/-7% (P<0.01) and in echocardiographic LV fractional shortening from 13+/-4 to 16+/-6% (P<0.05), without any change in cardiac index, a significant decrease in LV end-diastolic diameter (from 73.2+/-6 to 71.2+/-7 mm; P<0.05), end-systolic diameter (from 63.6+/-6 to 60.2+/-8 mm; P<0.05) and color Doppler MR jet area (from 11.5+/-6 to 6.6+/-4 cm(1); P<0.001). A comparison of patients with LV pacing alone and patients with biventricular pacing showed similar beneficial effects of pacing on MR severity in the two subgroups and a non-significant trend for a better improvement of LV function during biventricular pacing. CONCLUSION: Thus, in patients with severe CHF and left bundle branch block, permanent LV-based pacing may significantly improve LV systolic function and decrease MR.

Comparative haemodynamic effects of dobutamine and isoproterenol in man.

Dobutamine was infused at a rate of 8 mcg/kg/min in 17 patients with or without congestive heart failure. Cardiac output increased from an average 2.92 to 4.45 1/min/m2(p less than 0.001) with no change in mean aortic pressure (93.4 to 97.8 mmHg) and only a slight increase in heart rate (78 to 87 beats/min). Left ventricular end-diastolic pressure decreased from an average 19 to 13.7 mmHg (p less than 0.01). Peak left ventricular dp/dt was doubled (1147 to 2370 mmHg/sec, p less than 0.001) and Vmax increased from 1.08 to 2.18 circ/sec (p less than 0.001). In 10 patients given equi-inotropic doses (100 per cent increase in peak dp/dt) Isoproterenol produced a greater increase in cardiac output (71 percent) than Dobutamine /51 percent). Isoproterenol caused mean aortic pressure to fall significantly (8 percent) while no change was noted with Dobutamine. Accordingly, peripheral vascular resistances were reduced to a greater extent with Isoproterenol than with Dobutamine (p less than 0.05). Mean pulmonary arterial pressure decreased significantly (25 +/- 5.9 to 22 +/- 5.7 mmHg, p less than 0.05) with Isoproterenol infusion and remained unchanged with Dobutamine infusion. Dobutamine increased both stroke work (57 percent) and minute work (83 percent). With Isoproterenol however, only minute work was significantly increased (90 percent). Dobutamine therefore is a potent inotropic drug, with mild chronotropic and peripheral vascular effect and may be valuable in the management of severe heart failure not associated with hypotension.

Intermittent left coronary occlusion caused by native aortic valve thrombosis in a patient with protein S deficiency.

A 77-year-old woman presented with chest pain and cardiogenic shock. Transesophageal echocardiography showed a mobile mass occluding intermittently the left coronary ostium. The mass was surgically resected, and histologic examination revealed an organized thrombus. Coagulation study demonstrated a protein S deficiency. This is the first case of aortic thrombosis associated with protein S deficiency, and it is the first time that transesophageal echocardiography provided definite evidence that a mass can cause intermittent left ostium coronary obstruction.

Postinfarction atrioventricular septal rupture.

Postinfarction communication between a left ventricular aneurysm and the right atrium is a rare acquired disease. We report a case of a 72-year-old man who recently had dyspnea on minimal exertion and was found to have left ventricle-to-right atrial shunt by two-dimensional transthoracic echocardiography. This diagnosis was confirmed with transesophageal echocardiography, cardiac catheterization, and angiography. The patient underwent successful repair but died of multisystem failure. This case shows the importance of transthoracic echocardiography for the adequate diagnosis and management of such cases.

Left ventricular papillary fibroelastoma: two-dimensional echocardiographic detection and surgical resection.

We report a patient with a papillary fibroelastoma arising from the left ventricular posterior wall. The tumor was detected incidentally during echocardiography undertaken to evaluate aortic stenosis. Possible complication from tumor embolization was avoided by surgical resection during aortic valve replacement.

Right ventricular function in healed myocardial infarction in man. A cineangiographic assessment.

To evaluate the frequency of right ventricular dysfunction following recovery from myocardial infarction (MI) and the relationship of segmental right ventricular (RV) wall motion abnormalities to left ventricular (LV) function or location of coronary arterial stenosis, biplane right and left ventricular cineangiograms were obtained in 100 consecutive patients (4 +/- 3 months post MI). Thirty (group A) had anterior MI and significant stenosis or obstruction of left anterior descending artery (LAD). The remaining 70 patients had inferior MI. They were divided into three groups according to the site of the main coronary stenosis or obstruction and corresponding LV akinesia: right coronary artery (RCA) proximal to the acute marginal artery (RMA), (group B: 32 patients), RCA distal to the RMA (group C: 18 patients), left circumflex artery (LCF), (group D: 18 patients). RV and LV end-diastolic volume index (EDV), end-systolic volume index (ESV), stroke volume (SV) and ejection fraction (EF) have been determined. RV segmental wall motion was assessed in RAO and LAO projection by determining the percentage of systolic shortening (+ delta R) along 11 hemiaxes. Mean axial shortening (delta R) of the RV inferior and free walls were considered. When compared with that in 10 normal subjects, RV end-diastolic volume (RVEDV), RV end-systolic volume (RVESV) were increased and RV ejection fraction (RVEF) was lower in patients with anterior or inferior MI. Inferior delta R exhibited comparable sequential changes in the three groups of inferior MI and similar LVEF alteration.(ABSTRACT TRUNCATED AT 250 WORDS)

[Carotid sinus hypersensitivity. Median-term development as a function of treatment and symptoms]. / Hypersensibilité sino-carotidienne. Evolution à moyen terme en fonction du traitement et des symptômes.

The aim of this study was to assess the incidence and natural history of carotid sinus hypersensitivity (CSH) with respect to treatment and symptoms. Between May 1976 and December 1981, 714 patients underwent carotid sinus massage (CSM) during electrophysiological investigation (271 for syncope, 163 for dizziness); 79 had a pathological response (sinus arrest for over 3 s or two successive pauses of over 2 s each). Twenty five of these patients were excluded from the study group; 23 had the sick sinus syndrome or an associated AV block, and two were lost to follow-up. The remaining 54 patients were divided into two groups: Group I, comprising 33 patients who were given no treatment, and Group II, comprising 21 patients who were treated by permanent pacing. The patients in Group I were followed up for an average of 29 +/- 16 months and those in Group II for 25 +/- 22 months. Nine of the 18 patients in Group I, hospitalised for syncope, but none of the 5 patients admitted for dizziness alone, relapsed during follow-up. Only 1 patient without syncope or dizziness at the time of investigation reported having had a syncope during follow-up. The actuarial graph of absence of syncope fell regularly in Group I (58 p. 100 at 5 years), 4 patients in Group I were then given demand pacemakers and there was no further recurrence of syncope (follow-up: 34 +/- 15 months). Only 1 patient, admitted for dizziness, out of the 21 patients in Group II (13 syncopes, 8 cases of dizziness) continued to complain of the symptoms for which he had been paced.(ABSTRACT TRUNCATED AT 250 WORDS)

[Antithrombotic agents in acute myocardial infarction]. / Antithrombotiques dans l'infarctus myocardique aigu.

Coronary thrombosis, which is responsible for myocardial infarction, is a complex phenomenon involving the interaction of the arterial wall, the coagulation system and the platelets. Better understanding of the molecular biology of thrombosis has led to the rapid development of antithrombotic therapy. The limitations of aspirin and heparin have promoted the development of new molecules whose site of action on platelets or at different stages of coagulation are known. Some of them are the object of large scale international trials. Some results have been disappointing such as those with the direct antithrombins: others are promising and in the phase of evaluation, such as the inhibitors of glycoproteins GP IIb-IIIa.

[Rheumatic involvement of the tricuspid valve. Anatomical types and possibilities of dilatation]. / Les atteintes rhumatismales de la valve tricuspide. Etude des types anatomiques et des possibilités de dilatation.

In 194 cases of rheumatic cardiac valve diseases (41 men, 153 women), macroscopic examination singled out 21 lesions of the tricuspid valve (11 p. 100). These lesions were found exclusively in women and were always associated with a mitral valve disease (18 cases) or a mitral and aortic valve disease (3 cases). The fairly uncommon tricuspid valve lesions were of two different types, the incidence of which did not seem to be influenced by age. There were 7 cases of moderately tight (n = 5) or tight (n = 2) stenosis (TS) and 14 cases of tricuspid valve disease (TD), where a moderately tight stenosis coexisted with a varying degree of regurgitation (TR). In subjects with pure TS the three commissures were regularly fused by fibrosis, whereas the only lesion of the tricuspid leaflets was thickening of their free border. In TD the commissural fusions were less extensive, but the fibrous thickening was retractile and invaded the entire leaflet. The other anatomical data (perimeter of the tricuspid annulus, condition of the right cardiac cavities, heart weight, etc.) were approximately the same in both types. On anatomical specimens, percutaneous dilatation seemed possible only in pure TS; TD did not lend itself to this of treatment. In most cases two-dimensional echocardiography combined with doppler ultrasound can provide an accurate evaluation of the lesions from which can be deduced roughly the possibilities of percutaneous valvuloplasty limited to pure TS.

[Tight calcified aortic valve stenosis in adults aged from 50 to 69. Anatomical study of 50 cases]. / Les sténoses aortiques orificielles serrées et calcifiées de l'adulte de 50 à 69 ans. Etude anatomique de 50 observations.

The results of anatomical examination in fifty patients aged from 50 to 69 years presenting with calcified and tight aortic stenosis are reported. The calcifications were located mostly on the aortic side of the valves, and the aortic orifice area was less than 1 cm2. The macroscopic features of the aortic valve system fell into three categories: bicuspid valve in 28 patients (21 men, 7 women), trivalve orifice with commissural adhesion (calcified in every case) in 21 patients (18 men, 3 women), and trivalve orifice without commissural adhesion in 1 patient (a 68-year old man). Male predominance was obvious (40/50; 80 p. cent). From an analysis of the various anatomical data recorded three differences emerged: the aortic annulus was wider in cases with bicuspid valve (P less than 0.01); the calcifications did not involve the free border of the valves in cases with bicuspid valve or trivalve orifice without commissural adhesion, but they involved this free border in 1 out of 2 cases with trivalve orifice and commissural adhesion; the aortic stenosis was minimal to moderate in all cases with trivalve orifice and commissural adhesion. In patients of that age group, the main cause of stenosis was bicuspid valve which seemed to be congenital in all cases. Dilatation with the finger through the left ventricle - which cannot by any means be assimilated to inflation of a balloon passed into the aortic orifice - resulted in significant opening of the aortic orifice by compression and/or disruption of the calcareous formations in patients with bicuspid valve.(ABSTRACT TRUNCATED AT 250 WORDS)

[Narrow and calcified aortic valve stenosis in subjects in their 8th and 9th decades. An anatomic study of 64 cases]. / Les sténoses aortiques orificielles serrées et calcifiées des sujets des 8e et 9e décennies. Etude anatomique de 64 observations.

Anatomical data obtained from 64 patients aged from 70 to 86 years with calcified and tight aortic orifice stenosis (functional area less than 1 cm2) were divided into three types according to the macroscopic appearance of the aortic valve: (1) tricuspid valve without commissural fusion: 44 cases (18 men, 26 women, mean age 76 years); (2) tricuspid valve with commissural fusion: 12 cases (8 men, 4 women, mean age 72 years); (3) calcified congenital bicuspid valve: 8 cases (6 men, 2 women, mean age 73 years). Thus, the distribution of patients by sex became the same starting from the eighth decade of life. Calcified aortic orifice stenosis (CAOS) of degenerative origin was the most common lesion (69 p. 100), with a strong female predominance. There were several differences between degenerative CAOS and bicuspid valve stenosis on the one hand and aortic orifice stenosis with commissural fusion on the other hand. In the first group, calcification did not involve the free edge of the aortic cusps, large calcifications of the mitral ring were extremely frequent, and there was little or no aortic regurgitation. Moreover, the aortic ring clearly was wider in cases with bicuspid valve. In patients with degenerative CAOS and bicuspid valve, attempts at digital dilatation by the left ventricular route succeeded in most cases in obtaining a fairly important widening of the aortic orifice by compression and/or disruption of the valvular calcium deposits, without causing significant regurgitation of injuring the valve; the cusps recovered some mobility.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tricuspid insufficiency in posterior infarction caused by occlusion of the right coronary artery. Anatomical study]. / L'insuffisance tricuspidienne dans les infarctus postérieurs par occlusion de l'artère coronaire droite. Etude anatomique.

Thirty-one autopsy cases of patients (20 men, 11 women) who died within 5 days of the onset of primary posterior wall myocardial infarction due to occlusion of the right coronary artery (RCA) were divided into two groups: Group A (19 cases) with associated right ventricular infarction and Group B 812 cases) without right ventricular extension of the infarct. The causes of death were practically identical in the two groups except for cardiac rupture which was always septal and more common in Group A. In Group A, the complete occlusion of the RCA was always proximal to (18 cases) or at the site of origin (1 case) of the right marginal artery. Twelve cases (63 p. 100) of tricuspid regurgitation were detected in Group A but there were no such cases in Group B. Tricuspid regurgitation was associated with a significantly poorer short term prognosis. It was not related to a greater degree of dilatation of the tricuspid ring but to more severe septal and right ventricular infarction causing prolapse of the septal and posterior septal leaflets into the right atrium. A second group of autopsy cases comprised 40 patients dying in the long term (1 to 14 years later) after primary posterior wall infarction. In 15 cases (Group A) the post-mortem study showed chronic right ventricular infarction, an extension of a chronic left ventricular infarct. These findings were absent in the other 25 cases (Group B). The mean survival times (Group A : 6.1 years, Group B : 5.9 years) were comparable.(ABSTRACT TRUNCATED AT 250 WORDS)

[Calcifications of the trunk of the left coronary artery in coronary disease. Anatomical study]. / Les calcifications du tronc de l'artère coronaire gauche dans la maladie coronarienne. Etude anatomique.

Calcification of the left main coronary artery (LCA) was found, with an equal sex distribution, in 30 out of 145 patients (21%) at autopsy. A series comprising 68 males and 77 females in whom death resulted from myocardial infarction (111 cases) or ischaemic heart disease (34 cases). The condition is rare before the sixth decade but becomes more frequent after the seventh decade of life. The incidence was the same in lethal anterior and posterior infarction (15% and 16% respectively). It was more common in ischaemic heart disease (38%, p less than 0,005). Significant narrowing of the LCA was found in 26 cases (87%) but this was only less than 70% in 11 cases. When the total number of LCA stenoses (calcified and non calcified: 39 cases) was considered, only two thirds had associated calcification. This was, therefore, only a moderately sensitive index of LCA stenosis. Calcification, nearly always circumferential, was usually situated on the second portion of the LCA. Its division was involved in all cases, the calcification extending to the initial segments of the left anterior descending artery (LAD) and left circumflex artery (CX). Calcification of the LCA was always associated with calcification of the LAD, 78% of which had stenotic lesions. Calcification of the CX and right coronary arteries was practically constant, the average percentages of occlusion being 72% and 68% respectively. On anatomical criteria, myocardial revascularisation surgery could only have been proposed in about 20% cases, and this would only rarely have been total. It is concluded that calcification of the LCA usually corresponds at least anatomically, to severe, diffuse multivessel coronary artery disease.

[Coronary disease in homozygous twins. Respective roles of heredity and environment]. / Coronaropathie chez les jumeaux homozygotes. Rôles respectifs de l'hérédité et de l'environnement.

Two 44 year old female homozygote twins presented with cardiac ischaemia due to coronary atheroma, at 39 years of age and 43 years of age, respectively. The coronary risk factors (hypertension, cigarette smoking, hypercholesterolaemia, obesity, oral contraception) were comparable in both cases. Although presenting at different times, the electrocardiographic changes were in the same territory and coronary angiography showed a similar anatomical and lesional distribution. The literature is reviewed with respect to these cases to try to determine the respective roles of heredity and the environment in the initiation and progression of coronary atheroma.