Echocardiographic follow-up after Ross procedure in 100 patients.

The Ross procedure could provide an ideal aortic valve replacement method in children and young adults. We evaluated midterm echocardiographic results to assess pulmonary homograft function as well as pulmonary autograft dimensions and function. In all, 105 patients (26 women and 79 men) underwent the Ross procedure; median age at implant was 29 years. All patients underwent free root replacement. Transvalvular gradients and autograft dimensions were measured at 3 levels (annulus, sinuses of Valsalva, and proximal aorta) at discharge, at 6 months, and annually thereafter. Perioperative mortality was 4.7%. The mean period for echocardiographic follow-up in 100 patients was 32.7 months (range 0.5 to 7 years), during which 4 noncardiac-related deaths occurred. Two patients underwent late reintervention. No moderate or severe regurgitation was recorded. There was 1 case of mild homograft regurgitation and 4 of mild autograft regurgitation at late follow-up. Autograft peak gradients were low and reproducible (5 +/- 2.8 mm Hg at discharge vs 5.5 +/- 3.5 mm Hg at last follow-up, p = NS). Homograft peak gradients increased significantly without severe obstruction (7.8 +/- 5.7 mm Hg at discharge vs 15.8 +/- 9.2 mm Hg at last follow-up). The diameter of the autograft annulus was stable during follow-up, whereas autograft dimensions at sinuses and proximal aorta increased significantly. One group of patients was identified with sinus diameter increases >20% (group A). The 90 remaining patients were classified into group B. The only parameter significantly different between the 2 groups was the sinus diameters measured at discharge (1.74 cm/m2 (group A) vs 1.92 cm/m2 (group B); p = 0.036). In 100 patients and with echocardiographic follow-up for up to 7 years, the Ross procedure showed excellent results. For 10% of patients, we observed a 20% dilation of sinus diameters, but in only 3 patients (3%) was this beyond the upper normal limit.

Congenital high flow coronary cameral fistula in an 81-year-old woman: management problems.

An 81-year-old woman presenting with severe congestive heart failure was found to have a congenital right coronary fistula draining into the superior vena cava. The diagnosis was suspected on transthoracic two-dimensional echo-Doppler study and confirmed with coronary angiography. Transesophageal echocardiography and magnetic resonance imaging were nondiagnostic. An attempt to close the fistula with transcatheter embolization using a detachable latex balloon was unsuccessful because of the very large size of the fistula. Follow-up showed a favorable outcome with medical therapy. Despite the advent of more recent diagnostic and therapeutic techniques, management of such large fistulae remains unresolved.

Multiple cerebral infarcts associated with an atrial septal aneurysm. Superimposed thrombus detected by transesophageal echocardiography.

The authors describe the case of a patient referred for evaluation of multiinfarct dementia. Conventional echocardiography revealed an aneurysm of the interatrial septum. A transesophageal echocardiogram demonstrated superimposed thrombus. This rare cause of systemic emboli can be diagnosed only by transesophageal echocardiography and is of major interest to avoid recurrence of ischemic strokes.

[Acute rheumatoid aortic insufficiency treated by valve replacement. Apropos of a case]. / Insuffisance aortique aiguë rhumatoïde traitée par un remplacement valvulaire. A propos d'un cas.

Rheumatoid valvular heart disease and aortic valve replacement for a rheumatoid lesion have been previously reported in the literature. The authors report the first case of emergency surgery for acute aortic regurgitation due to necrosis and rupture of a rheumatoid granuloma: the anatomopathological lesions observed were patholognomic.

[Left intraventricular gradients measured by Doppler echocardiography at rest, during exercise and during isoproterenol test in hypertrophic cardiomyopathy]. / Gradients intraventriculaires gauches, mesurés par échocardiographie Doppler au repos, à l'effort et lors d'un test à l'isoprotérénol, au cours de la cardiomyopathie hypertrophique.

Doppler echocardiography has been shown to be an accurate method of assessing left ventricular outflow obstruction in hypertrophic cardiomyopathy (HCM). One of the characteristics of this pressure gradient is its variability and, therefore, we measured this parameter during dynamic exercise testing in 33 patients. The results were compared with those recorded during isoproterenol infusion, the reference stress test for patients with HCM. Submaximal exercise in the recumbent position is usually well tolerated and resulted in a 43% increase in heart rate and a 47% increase in pressure gradient. There was a significant correlation between resting and exercise outflow obstruction (r = 0.90; p = 0.001). Moreover, exercise echo revealed obstruction in 26% of patients without resting pressure gradients (latent obstruction). The interpretation of results obtained with isoproterenol infusion is more difficult: this test resulted in an important increase in the left ventricular pressure gradient (231%) and "revealed" obstruction in 84% of cases. Therefore, we believe that exercise is more physiological and better tolerated than isoproterenol stress infusion and should be adopted as the investigation of choice in HCM even without obstruction at rest. If it is not possible to perform the exercise or no outflow tract obstruction can be demonstrated, an isoproterenol infusion may be used but this is not always well tolerated and the results should be interpreted with caution.

[Compression of the right pulmonary artery by chronic aortic dissection]. / Compression de l'artère pulmonaire droite par une dissection aortique chronique.

The authors report the case of a 56-year old woman who had presented with clinical symptoms resembling those of pulmonary embolism and due to chronic dissection of the first aortic segment compressing the right branch of the pulmonary artery. Eighteen months after the acute episode, the diagnosis was suspected at echocardiography, but the other paraclinical examinations performed (scintigraphy of the lung, angiography, computerized tomography) failed to display the aortic dissection, although they enabled the diagnosis to be approached and the physiopathology to be determined. At surgery, a type II dissection was discovered, the compression was relieved and the pulmonary artery was recanalized. The post-operative period was uneventful, with return to normal of the scintigraphic and CT images. This case is exceptional in that it is extremely rare (this is the 6 th case reported) and the lesion was well tolerated, probably due to the presence of a systemic-pulmonary circulation.

[Unilateral left agenesis of the pericardium. Contribution of cardiac imaging]. / L'agénésie unilatérale gauche du péricarde. Apport de l'imagerie cardiaque.

The authors report a case of congenital absence of the left pericardium in a pauci-symptomatic young woman. Indirect signs in favour of this diagnosis were elicited on chest X-ray (levoposition of the heart, convex left heart border). An associated congenital heart lesion was excluded by Doppler echocardiography. Computed tomography and MRI showed the right pericardium to be present but the left pericardium (not always visible in normal subjects) and the pre-aortic recess (present in all normal subjects) were absent. Abnormal presence of lung tissue between the aorta and pulmonary artery, and also between the pulmonary artery and left auricle was, however, confirmed. Nevertheless, these investigations did not enable the authors to define the exact extent of the pericardial defect. Finally, the indirect signs of levocardioposition were the main diagnostic markers of congenital absence of the left pericardium which did not require surgery in this particular case.

[Double compression of the celiac and mesenteric arteries by the arcuate ligament. An unusual cause of abdominal angina in young subjects]. / Compression coelio-mésentérique double par le ligament arqué. Une cause rare d'angor abdominal du sujet jeune.

The authors report the case of a 26 year-old woman hospitalized because of epigastric pain with onset a few years previously, occurring primarily after a heavy meal, and the recent discovery of a para-umbilical abdominal murmur with irradiation to the right iliac artery. The digital aortic angiography showed the absence of opacification of the coeliac trunk (CT) at its origin due to a very tight stenosis and a 50% narrowing of the proximal part of the superior mesenteric artery (SM). The abdominal ultrasonogram with pulsed Doppler clearly showed the very tight stenosis of the ostium of the CT and the stenosis of the S.M. Surgery confirmed the extrinsic compression of the two vessels by an aberrant fibromuscular bundle resembling an arcuate ligament. Section of this bundle completely freed the vessels. The course was favorable: the pain and murmur disappeared and there was no imprint on either vessel on the control angiography. In the discussion, the authors review the numerous atypical anatomical abnormalities which have been incriminated in the genesis of these compressions and analyze the resulting clinical syndrome. The contribution of the pulsed Doppler coupled with ultrasonography is discussed. Treatment is always surgical. This case provides an opportunity to review this exceptional entity represented by the double coeliac-mesenteric compression by the arcuate ligament. This is the first time a patient was examined by pulsed Doppler, which allows for rapid noninvasive and detailed work-up of the affection, entirely in agreement with the data obtained from the other examinations and the operative observations.

Intracardiac hemodynamics in man during short periods of head-down and head-up tilt.

The intracardiac hemodynamic responses to short periods of 70 degrees head-down and head-up tilts were studied in 12 normal male subjects, ages 19-24 years. Echo-Doppler techniques were used to measure the transmitral and transaortic flow velocities as well as cardiac index, and to evaluate the peripheral impedance. Head-down tilt (HDT) rapidly induced an increase (9.7%, p < 0.05) in the early passive filling of the left ventricle (ME peak of the transmitral flow velocity curve) and in transaortic flow velocity (8%, p < 0.05), as well as in cardiac output (6%, p < 0.05). In spite of a peripheral vasodilation, the blood pressure increased (7%, p < 0.05 for the systolic; 15%, p < 0.01 for the diastolic) and remained at a high level for the 5 min of the experiment. Head-up tilt (HUT) induced inverse responses; i.e., a large initial decrease in the transmitral (-15%, p < 0.05) and transaortic (-16%, p < 0.001) flows. The shape of the arterial peripheral flow indicated an increased vascular impedance. After a short drop, the blood pressure rapidly recovered a level statistically close to that of the pretest. In both cases, tachycardia occurred. We conclude that, in man, the cardiac responses to the changes in posture appear to be related more to the passive changes in ventricular filling due to the blood shift than to the nervous regulation by the arterial baroreflexes, whereas these reflexes mainly act in the control of the vascular impedance.

[Cardiac complications in adult onset Still disease: from pericarditis to tamponade as manifestations]. / Complications cardiaques de la maladie de Still de l'adulte: de la péricardite à la tamponade parfois révélatrice.

Pericarditis is a common manifestation of adult still's diseases (ASD), observed in 20% to 3% cases. Pericardial tamponade is more seldom, less than ten cases have been reported in the literature. We reported two observations of patients with ASD and pericardial tamponade above a series of 18 patients with ASD, in one case revealed the disease. The first patient was a 32-year-old women and had fever, arthritis, high white blood cell count and developed pericardial tamponade. The evolution was favourable with bolus of methylprednisolone. In the second case, cardiac tamponade occurred several years after the onset of the disease. Surgical drainage was first required (800 ml) because of inefficacity of oral prednisone. A dramatic improvement was observed after bolus of methylprednisolone. In conclusion pericardial tamponade is a seldom but sometimes the first manifestation of ASD and may required in first intention bolus of methylprednisolone.

[Pulmonary hypertension screening in systemic scleroderma: a cohort study of 67 patients]. / Dépistage de l'hypertension artérielle pulmonaire au cours de la sclérodermie systémique: étude d'une cohorte de 67 patients.

PURPOSE: Pulmonary hypertension is a severe complication of systemic sclerosis and has emerged as a major cause of morbidity and mortality in this condition. Treatment is all the more efficient as pulmonary hypertension is early diagnosed. A good knowledge of the clinical, biological and functional features of pulmonary hypertension in systemic sclerosis is therefore necessary to suspect and to diagnose pulmonary hypertension as early as possible. METHODS: Sixty seven patients with systemic sclerosis were retrospectively studied. We compared clinical, immunological, functional (spirometry) and morphological (pulmonary fibrosis) features according to the presence (n = 25) and the characteristic of pulmonary hypertension (isolated or secondary) or the absence (n = 42) of pulmonary hypertension, assessed by Doppler echocardiography. RESULTS: CREST syndrome (calcinosis, Raynaud's phenomenon, oesophageal involvement, sclerodactyly and telangiectasia) was more frequent in patients with isolated pulmonary hypertension than in patients without PH (72.7% vs 28.5%, P < 0.05; odds-ratio [OR] = 6.6) and dyspnea was more severe (P < 0.001; OR = 11.4). The age at time of pulmonary hypertension diagnosis was higher in patients with secondary pulmonary hypertension than in patients with isolated from (median: 62.5 years (range: 32-35) vs 53 years (range: 37-85), P < 0.05). Patients with isolated pulmonary hypertension had anticardiolipin antibodies more frequently than patients without pulmonary hypertension (72.7% vs 35.7%, P < 0.05). Isolated reduction of diffusing capacity was preferentially observed among patients with isolated pulmonary hypertension than among those without pulmonary hypertension. A linear relation between systolic pulmonary artery pressure values and diffusing capacity values (r = 0.72, P < 0.01) was found. Isolated reduction of diffusing capacity was more frequent in patients with isolated pulmonary hypertension than in patients without pulmonary hypertension (63.6% vs 14.3%, P < 0.001; OR = 10.5). CONCLUSION: The severity of pulmonary hypertension in systemic sclerosis justifies a systematic screening by Doppler echocardiography and diffusing capacity measurement. Our results allow us to better define the characteristics of sclerodermic patients with isolated or secondary pulmonary hypertension. The search for pulmonary hypertension should be repeated with time and clinicians should be particularly vigilant in the case of a patient presenting these characteristics.

[Primary Aspergillus endocarditis. Apropos of a case and review of the international literature]. / Les endocardites aspergillaires primitives. A propos d'un cas et revue de la littérature mondiale.

The authors report a case of primary aspergillus endocarditis with endophthalmitis and vertebral osteomyelitis. No underlying disease and no predisposing factors were found. Valve replacement plus combined antifungal chemotherapy proved to be effective as the patient is asymptomatic 18 months after the first symptoms. 48 cases of aspergillus endocarditis, without prior cardiac surgery have been reported in the literature. Aspergillus endocarditis was valvular or mural. Extracardiac dissemination was common but endophthalmitis and osteomyelitis were infrequent. In 11 cases, the diagnosis was made by histologic examination of embolectomy or ocular, skin biopsy tissue. All patients were febrile. Blood cultures showed no Aspergillus species. Clinical manifestations of endocarditis were described in less than fifty per cent of cases. Echocardiographic visualization of vegetations was obtained in 5 cases. Many patients experienced embolic phenomena. Mortality from Aspergillus endocarditis is extremely high (96%). Surgery is the main treatment, consisting of valve replacement. Antifungal chemotherapy should be combined. The proper duration and dosage and the combination of antifungal drugs have not been clearly defined.

[Isolated tricuspid endocarditis. Apropos of a case caused by Streptococcus D bovis and faecalis occurring after coloscopy]. / Les endocardites tricuspidiennes isolées. A propos d'un cas à Streptococcus D bovis et faecalis survenu après coloscopie.

A 59-year-old chronic alcoholic male, with no cardiac past history, was hospitalised with septicemia 5 months after the endoscopic removal of 2 benign intestinal polyps. The diagnosis of tricuspid endocarditis was possible only 2 months later on the basis of echocardiography requested because of the onset of a tricuspid systolic murmur. Blood cultures revealed the presence in succession of streptococcus D fecalis then bovis. Antibiotics, changed several times because of the onset of complications (allergy, agranulocytosis), failed to deal with the problem of infection as shown by the development of several septic pulmonary emboli which finally resulted in total tricuspidectomy with neither immediate nor secondary valve replacement. The authors use this clinical case to review the characteristics of tricuspid endocarditis, the incidence of which is on the increase in certain etiological contexts (staphylococcal endocarditis in drug addicts or secondary to central vascular lines). They stress that the clinical picture is often confusing since the murmur of tricuspid incompetence is absent in 2/3 of cases. Echocardiography must therefore be requested routinely in all septicemias, thus enabling earlier diagnosis and assessment of the risk of pulmonary embolism (risk if vegetation greater than 10 mm). The nature of the organism responsible may be suggestive of certain etiologies. Thus malignant disease of the colon should be sought if the bacterium is a streptococcus D bovis. Apart from antibiotics, treatment must include effective anticoagulation to decrease the risk of embolic recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

[Post-embolic chronic pulmonary heart disease: a case report]. / Coeur pulmonaire chronique post-embolique: à propos d'une observation.

Echocardiography and pulmonary scintigraphy demonstrated post-embolic chronic cor pulmonale in a six-year-old woman presenting with dyspnoea. The patient's symptoms deteriorated during subsequent thromboembolic episodes, despite treatment consisting of oral anticoagulants and diuretics. After discussing the pathophysiology and diagnostic methods, the authors emphasize the limits of medical treatment of post-embolic chronic cor pulmonale and the value of two surgical treatments: thromboendarterectomy and lung transplantation. They also recall the precise selection criteria for lung transplantation.

[Constrictive pericarditis: study by Doppler echography of blood flow in the supra-hepatic veins]. / Péricardite constrictive: étude par échographie Doppler du flux sanguin dans les veines sus-hépatiques.

The blood flow rate in the supra-hepatic veins has been measured by Doppler ultrasound in 11 subjects suffering from more or less advanced constrictive pericarditis; the results were compared to those obtained with normal subjects. In all the pathological cases, the flow rate curve shows the following modifications: a slight decrease in the X peak, which is related to the blood "demand" caused by the decrease in the ventricular volume during the ejection, and a correlative increase in the Y peak, contemporaneous of the ventricular filling up. In the patients in which the pericarditis has not reached a marked stage of constriction, the intra-thoracic ventilatory pressure variations still exert a certain influence on the supra-hepatic blood flow rate; on the other hand, this influence is suppressed when the constriction is complete. These phenomena are parallel to the pressure modifications observed by catheterism and to those of the mitral and tricuspid transvalvular flow. The advantage of measuring the blood flow rate in the supra-hepatic veins lies in the fact that the access, for ultrasound analysis, to these vessels is quicker and more constant than to the heart valves. This method seems therefore to be an interesting one to assess the stage of development of the constricting pericarditis.

[Asymptomatic carotid stenoses. A cardiologist's viewpoint]. / Sténoses carotidiennes asymptomatiques.

Cardiologist work is undergoing profound changes. He is in charge of the prevention and treatment of atherothrombotic disease. Preoperative evaluation of global cardiovascular risk is of paramount importance to choose between medical, surgical or interventional treatment. Furthermore, because the cardiologist has extensive experience with coronary angioplasty, he will have an essential role in carotid angioplasty.

[The risk of cerebrovascular complications in the combination of pregnancy and mitral valve prolapse]. / Le risque d'accidents vasculaires cérébraux au cours de l'association grossesse et prolapsus valvulaire mitral.

A case of left intraventricular thrombus, developed from a myxoid mitral valve and revealed by embolic cerebral vascular accidents at the end of a pregnancy, is reported. The links between a mitral valve prolapse and cerebral vascular accidents of embolic origin are studied during pre- and post-partum periods, where coagulation alterations are reviewed. It appears that, in pregnant women with a mitral valve prolapse, there is a maximum risk of developing an intra-cardiac thrombus in the last four weeks of pregnancy or immediately after delivery; this justifies, during that time, a thorough sonocardiographic monitoring.

[Evaluation of embolic cerebrovascular complication: contribution of transesophageal echography]. / Le bilan d'un accident vasculaire cérébral embolique: apport de l'échographie transoesophagienne.

Ischemic cerebrovascular accidents are classically attributed to an embolism of cardiac origin in 15% of cases. This longstanding concept is questioned by trans-esophageal echocardiography (TEE). The incidence of anomalies which could be the origin of a cerebral embolism involves more than 50% of cases in certain series. The superiority of TEE over trans-thoracic echocardiography (TTE) emerges in particular when certain abnormalities such as an intra-atrial thrombus, spontaneous atrial contrast, an intra-aortic atherosclerotic plaque, a patent foramen ovale or an aneurysm of the inter-atrial septum are sought. The high incidence of such abnormalities in a population having sustained an ischemic cerebrovascular accident is not sufficient to establish a cause-and-effect relationship between the abnormality and the cerebral event. Certain abnormalities are commonly associated with each other or with emboligenic arrhythmias (atrial fibrillation). Studies hence remain required to determine the respective responsibilities of these various abnormalities and stratify their embolic risk by defining certain risk factors. While awaiting the result of such studies, it would seem valid to suggest the more routine use of TEE in the investigation of ischemic cerebrovascular accidents in young patients free of clinically obvious heart disease, and this regardless of the result of TTE.

[Efficacy and acceptability of lercanidipine are not age dependent in patients with essential hypertension: the AGATE study]. / Efficacité et la tolérance de la lercanidipine ne sont pas liées à l'âge des patients hypertendus: étude AGATE.

UNLABELLED: Calcium channel blockers (CCB) are known to be more efficacious and better tolerated in elderly patients. Lercanidipine is a highly lipophilic CCB with a specific safety profile linked to its pharmacokinetics. OBJECTIVES: To evaluate and compare the efficacy and safety of lercanidipine according to age. METHODS: Two groups of hypertensive patients (G1: aged < 65, G2: aged > or = 65) entered an open study conducted over 56 days. All received lercanidipine 10 mg/d (monotherapy or add-on), titrated to 20 mg/d if blood pressure (BP) was not controlled at D28. BP was measured using a semi-automatic device at doctor's office (three measurements at 1-min intervals) and at home by the patient himself (three measurements in the morning and in the evening at 1-min intervals over the 7 days before D0 and D56). RESULTS: Seven hundred and fifty-six patients entered the study. Thirty-eight patients dropped out prematurely and 30 were excluded because they were normotensive; 691 patients (G1 n = 375, G2 n = 316) were kept for analysis. At the end of the study, 507 patients were treated with lercanidipine alone (10 mg/d n = 221, 20 mg/d n = 286) and 184 with a combination including lercanidipine (10 mg/d n = 91, 20 mg/d n = 93). Efficacy was not different between the groups excepted home pulse pressure which decreased more in G2. In the office, SBP decreased by 17 and 21 mmHg, respectively, for G1 and G2, and DBP by 9 and 10 mmHg. The prevalence of leg edema was not different between G1 and G2 and was particularly low in both groups (3%). CONCLUSION: Lercanidipine was as efficacious and well tolerated in younger patients as in elderly patients.

[Doppler effect in cardiology. Continuous Doppler, pulsed Doppler, Doppler color]. / L'effet Doppler en cardiologie. Doppler continu, Doppler pulsé, Doppler-couleurs.

Echocardiography has contributed to the exploration of the heart by providing much information, and it has even given rise to new semiological concepts. However, abnormalities of intracardial blood flow, notably shunts and regurgitations, could only be diagnosed indirectly from their effects on cardiac cavities. A new step forward was the advent of pulsed and continuous doppler ultrasound, since from that moment it has been possible to demonstrate abnormal blood flows, to measure their velocity and to determine, albeit with some reservation, such crucial values as pressure gradients. Yet even when these two techniques were combined in the doppler-echotomography systems blind areas persisted, and a blood flow of strongly abnormal direction could in fact escape doppler velocimetry. This is where another development came to the rescue, for it enabled both normal and abnormal flows to be visualized in colours. Owing to this visualization, and provided all possible projections are used, it has become exceptional to "miss" an abnormal blood flow. The diagnosis is now easier and more accurate, and in a second stage the flow can be quantified by pulsed or continuous doppler ultrasound. The colour-coded doppler technique therefore has not superseded the previous one: one may say that it has merely increased diagnostic reliability, but is this not a decisive improvement?