Diagnosis of Coxiella burnetii pericarditis using a systematic prescription kit in case of pericardial effusion.

Coxiella burnetii, regarded as a potential agent of pericarditis, wa found to be responsible for almost 5% of the cases of idiopathic pericardial effusion reported in this series. Diagnosis was aided by use of a systematic kit described in this paper.

[Modern management of vasovagal syncope]. / Prise en charge moderne de la syncope vasovagale.

The management of vasovagal syncope is limited in the majority of cases to reassuring, explaining and advising how to perform some simple methods whose efficacy is assured. When repeated episodes of syncope significantly alter the quality of life, which is the case in about 1% of patients, the management requires medications which are proposed on the basis of as yet uncertain pathophysiological data (beta-blockers, alpha-stimulants, serotonin re-uptake inhibitors), or non-drug treatment (orthostatic training, cardiac pacing). However, none of these treatments has been proved in a randomised study. In these severe and disabling forms, the doctor has to make a choice between empirical prescibing, preferably midodrine, and a more rational strategy guided by an intercritical recording obtained with an implanted ECG monitor which allows better selection of patients who might benefit from pacemaker implantation.

[Role of antiarrhythmic drugs in reducing the number of defibrillation shocks]. / Place des anti-arythmiques dans la réduction du nombre de chocs des défibrillateurs.

There is a logical basis for the prescription of antiarrhythmic therapy (AAT) in patients with an implanted automatic defibrillator (IAD): the prevention of supraventricular and ventricular arrhythmias, slowing the rate of a ventricular arrhythmia to improve the haemodynamic tolerance and better efficacy of anti-tachycardia stimulation. Adjuvant therapy of this kind is used in 49 to 69% of cases. Forty six per cent of patients in the MADIT I trial had AAT at the last follow-up. In the AVID trial, despite recommendations to avoid the association of AAT and [AD, 18% of patients had this combination because of the large number of shocks in 64% of cases; AAT was associated with both a reduction in the number of shocks (p < 0.05) and in the delay to a recurrence of the arrhythmia (p < 0.0001). In the CASCADE trial, carried out in survivors of cardiac arrest, the prescription of amiodarone in patients with IAD significantly reduced the number of defibrillation shocks. Finally, almost 40% of patients with IAD have an "arrhythmia storm", sometimes during follow-up, usually requiring the association of AAT. Despite the frequent association of AAT and IAD, the results of this combination have rarely been studied systematically. Only one randomised trial has been published comparing D,L-sotalol and placebo in patients with IAD. The treatment reduced the probability of a first defibrillation shock, whether appropriate or not. Amiodarone has often been proposed in association with IAD in isolated cases. The OPTIC trial (Optimal Pharmacological Therapy in Implantable Cardioverter), currently under way, has three sub-groups of IAD (betablocker, amiodarone and betablocker, sotalol), with the aim of determining the preventive value of each AAT with respect to the IAD performance. In addition to the results of combined treatment, the interaction with the threshold of defibrillation is an important factor which is not clearly understood at present. Class I AAT increases the threshold of defibrillation whereas Sotalol reduced it. Amiodarone has a variable effect, neutral or deleterious. The OPTIC trial should provide valuable information via the sub-analysis of the effects of drugs on the threshold of defibrillation in each of the three arms of the trial.

[Pacemaker longevity. Replacement of the device]. / Longévité des stimulateurs cardiaques. Remplacement du boîtier de stimulateur.

Life expectancy of patients implanted with cardiac pacemakers has largely increased, so that generator replacement is becoming an important part of the activity in most of the implanting centers. In more than 70% of the cases, the indication for pacemaker replacement is normal battery depletion. Since the new devices are more and more sophisticated and smaller, longevity optimization becomes a real challenge. The main determinant of pacemaker longevity is the output programmed for the pulse generator. It mainly depends on the output voltage and duration settings. The pacing impedance and the percentage of time with pacing are other major determinants of pacemaker longevity. Each manufacturer provides specific policy but the battery voltage and internal impedance are the more accurate and easy-to-obtain battery depletion parameters. The magnet rate is still frequently used but is less valuable since it can drop abruptly at the end of battery life. The complication rate of pacemaker replacement is three-fold higher than the one of first implant. Infections, skin erosions and lead related complications are not uncommon. The replacement should be systematically preceded by the checking of several points including the patient's pacemaker dependency, the necessity to replace or extract one or several leads, the venous system status, the compatibility between the new generator and the leads and the necessity to upgrade the pacing system or to change the pacemaker pocket.

Methergin testing with angiographically normal coronary arteries.

To evaluate the incidence of spasm in patients with angiographically normal coronary arteries or with stenosis less than or equal to 50%, methergin testing was done consecutively in 1,200 patients (742 men and 458 women). The methergin test was performed 850 times during coronary angiography and 350 times after it. The test was globally positive in 11% (127 of 1,200 patients), positive in 7% among 921 patients presenting with atypical chest pain, 13% of 31 patients with effort angina, 54% of 54 with angina at rest, 57% of 53 with Prinzmetal's angina, 3% of 59 with acute myocardial infarction and 1% of 82 miscellaneous patients without chest pain. Another test was done in 291 patients after blockade of the cardiac autonomous nervous system with 0.04 mg/kg of atropine and 2 mg/kg of labetolol. The frequency of positive results in the methergin test increased after blockade from 8 to 19% (p less than 0.01). The increase of positive results was especially obvious among patients with atypical chest pain (from 6 to 14%). Thus, frequency of spasm in these patients with normal coronary arteries or without significative lesions was 11%. This incidence was influenced by the composition of the patient population and increased with blockade of the cardiac autonomous nervous system.

Prolonged QT interval and altered QT/RR relation early after radiofrequency ablation of the atrioventricular junction.

This study evaluated the paced QT interval in the days after radiofrequency ablation of the atrioventricular junction in patients with chronic rapid atrial fibrillation. There is an abnormality in the dynamics of the paced QT interval until the second day after ablation, resulting in an increased duration when the paced heart rate is <75 beats/min.

Right- and left-sided interatrial septal aneurysm mimicking atrial tumor and stroke.

We report the cases of two patients with cerebral embolization and interatrial septal aneurysm. Transesophageal echocardiography required for stroke showed right-sided interatrial septal aneurysm in the first patient and left-sided interatrial septal aneurysm in the second. In the two patients, interatrial septal aneurysm was mimicking atrial cystic tumor or abscess. Significant internal carotid artery stenosis was found in the first patient and aortic arch atheroma with mobile components but no patent foramen ovale in the second patient. In the two patients, interatrial septal aneurysm appears to be only an incidental finding and not the true cause of stroke. Furthermore, we discuss the differential diagnoses of atrial masses.

Embolic thrombus on mitral anulus calcification.

Embolic thrombus on mitral anulus calcification (MAC) was demonstrated in an 83-year-old woman with retinal embolism. Mitral anulus calcification has been associated with a significant increase of stroke in elderly people. Atrial fibrillation and calcific emboli have been reported, and embolic thrombus by MAC may be another potential cause.

Clinical electrophysiologic effects of a single high oral dose of amiodarone.

Several recent reports have described the antiarrhythmic effects of a single high oral dose of amiodarone but clinical electrophysiologic effects have not been reported. The present study was performed to assess electrophysiologic effects in 12 patients. After baseline electrophysiologic studies (EPS) patients were administered a single oral dose of 30 mg/kg of amiodarone. EPS was repeated 7.5 +/- 0.5 hours later. Plasma levels of amiodarone and its metabolite desethylamiodarone were determined at the time of the second EPS, Holter monitoring was performed for 24 hours after amiodarone administration. Amiodarone significantly increased the following parameters: corrected QT interval (+4.5%), functional refractory period of the right atrium (+7%); AH interval (+12.3%), effective refractory period of the atrioventricular node (+18.5%), and cycle length of Wenckebach block (+8.4%). These effects were not correlated with plasma levels of amiodarone and desethylamiodarone. Holter monitoring detected no significant bradycardia or arrhythmia. These findings indicate that the effects of a single high oral dose of amiodarone are the same as those known to be induced by acute intravenous administration.

Treatment of venous thrombosis and pulmonary embolism by streptokinase.

We applied the standard treatment with streptokinase to 52 cases of deep venous thrombosis and 35 cases pulmonary embolism. Angiography demonstrated total lysis of the clot 22 times, partial lysis 42 times, and no lysis 23 times. The absence of lysis was more frequent in venous clots than in pulmonary clots. Early treatment was more effective, achieving complete lysis in 21 of 22 cases. Nevertheless, in deep venous thrombosis, late treatment can result in partial lysis and set an important venous junction free. With the standard treatment, the biologic controls showed good lysis in 75% of the cases, insufficient lysis in 15%, and no lysis in 10%. The extent of the thrombosis is an important point. The clot was totally lysed in 9 of 10 cases of localized deep venous thrombosis. In patients with pulmonary embolism, about 30% of the obstructed surface is cleared. Nevertheless, in such cases we must take into consideration not only the nonperfused pulmonary area, but also the venous starting point of the clot.

[The best of cardiac pacing in 2002]. / L'essentiel de 2002 en stimulation cardiaque.

The year 2002 was marked by the publication of several studies for which the results have above all brought confirmation but also disappointment. One of them has even revealed a new therapeutic approach. In patients affected by sinus dysfunction the MOST study has shown the absence of superiority of DDD stimulation over VVI stimulation in respect of death and cerebral vascular accidents. However, double chamber stimulation reduces the risk of atrial fibrillation, the signs of cardiac insufficiency and slightly improves the quality of life. In the field of multisite stimulation, the MIRACLE study has in patients with moderate to severe cardiac insufficiency confirmed the results of the MUSTIC study with a significant improvement relating to the 6 minute walking test, the NYHA class, the quality of life, and the ejection fraction. The 12 and 24 month follow up of patients included in the MUSTIC study has shown the persistence of the observed short term benefit. Hopes for prevention of atrial fibrillation by atrial stimulation piloted by special algorithms have not been confirmed by the results of the PIPAF study except for patients with predominantly spontaneous AV conduction. The significance of stimulation in disabling vaso-vagal syncope has been questioned by the publication of the results of the VPS 2 study. Cardiac stimulation could in the future constitute a new treatment for sleep apnoea syndrome because it has been reported that atrial overdrive significantly reduces the amount of central or obstructive apnoea.

[Protection systems of dual-chamber pacemakers against atrial arrhythmia]. / Les systèmes de protection des stimulateurs double chambre contre les arythmies atriales.

The incidence of atrial arrhythmias may be as high as 10% in patients paced in the DDD mode carrying the risk of tracking of rapid atrial rates leading to non-physiological rapid ventricular paced responses. The unquestioned benefits of DDD pacing in terms of mortality and morbidity has led to the conservation of this mode in such situations, but with various systems of protection. Initially, limitation of the maximum frequency and programming a long atrial refractory period were proposed, but these measures were contrary to the physiological vocation of DDD pacing. Similarly, DDI and DDIR pacing, which do not ensure synchronisation on spontaneous P waves, were suggested, but in some cases there was loss of atrio-ventricular synchronism in sinus rhythm. Therefore, the manufactures developed "fallback systems" allowing programming of physiological pacing in patients with paroxysmal atrial arrhythmias. The aims of these systems are: 1) to detect atrial arrhythmias; 2) to change the pacing mode when the arrhythmias is detected for ventricular pacing not synchronised on the P wave (VVIR or DDIR modes); 3) to revert to the initial mode of pacing when the arrhythmia is over. This paper describes the different specialised algorhythms currently available, with their advantages and draw-backs, their main indications and possible future developments.

[Left anterior hemiblock induced by exertion, caused by diagonal arterial stenosis: apropos of a case]. / Hémibloc gauche antérieur à l'effort par sténose d'une artère diagonale: à propos d'un cas.

The authors report the case of a patient who developed left anterior hemiblock and ST segment depression during exercise testing which regressed during the recovery period. Coronary angiography showed severe stenosis of the diagonal artery. This conduction defect did not recur after effective angioplasty of the stenosed artery, reflecting the ischaemic nature of this abnormality.

[Thrombolysis in the pre-hospitalization phase of myocardial infarction]. / La thrombolyse à la phase préhospitalière de l'infarctus du myocarde.

In myocardial infarction (MI), the sooner thrombolysis is performed, the greater the chances of it being effective. We report a 19-month experience (July 1, 1986 to December 31, 1987) of thrombolysis performed at home prior to hospitalization by an organization called SOS Myocardial Infarction (SOS MI). Method. Throughout 24 hours, any patient may call by telephone a doctor attached to SAMU 13. If the doctor suspects a coronary emergency, he sends to the patient's home the SOS MI team (1 doctor and 1 nurse) in a medically-equipped ambulance. The diagnosis of MI is made on the finding of a nitroglycerin-resistant chest pain of more than 30 minutes duration associated with a more than 2 mm elevation of the ST segment on at least two electrocardiographic leads. Patients aged under 70 and in whom thrombolytic drugs are not contra-indicated are then treated intravenously with either streptokinase (1.5 million units over 30 min) or the tissue plasmogen activator (10 mg followed by a 90 mg infusion over 90 min). Results. During the 19-month period, 648 coronary emergencies were suspected from data given by telephone. The diagnosis made by the SOS MI doctor was non-coronary chest pain in 119 cases (18.4 p. 100), angina pectoris in 211 cases (32.6 p. 100).(ABSTRACT TRUNCATED AT 250 WORDS)

[Ergometrine test in 1200 consecutive patients presenting with normal coronary vessels]. / Le test à l'ergométrine chez 1,200 malades consécutifs présentant des coronaires normales.

An ergonovine test (ET) was performed in 1,200 patients-742 men, 458 women aged from 34 to 73 years (mean: 49.5 years)-either during (850 cases) or after (350 cases) coronary arteriography. Another ET made more sensitive by blocking the cardiac autonomous nervous system (CANS) with labetalol 0.04 and 2 mg/kg was performed in 291 of these patients. The ET test was positive in 10.7 p. 100 (127) of all patients and in 11.2 p. 100 (127/1125) of patients presenting with retrosternal pain. In the group where spontaneous angina could be confirmed by ECG recordings during the attack, the percentage of positive responses rose significantly to 53.7 p. 100 patients with ST depression and 56.6 p. 100 of patients with ST elevation. When the anginal nature of the retrosternal pain was not confirmed before the test, the proportion of positive responses was 6.6 p. 100. In patients who had the sensitized test the positive response rate increased in all groups and globally rose significantly from 7.9 p. 100 to 18.6 p. 100 (p less than 0.01). Thus, the usually low frequency of positive ergonovine tests differs according to the population selected and increases after CANS blockade.

[Pure coronary spasm: autonomic disease or form of onset of atheroma? Contribution of repeat coronarography in 23 patients]. / Angor spastique pur: maladie autonome ou forme de début de l'athérome? Apport de la coronarographie répétée chez 23 malades.

Coronary spasm has often been blamed for facilitating the development of atheroma, but some authors regard it as a separate disease. In order to form an opinion on these two theories, we performed repeat coronary arteriography at an interval of 4 years on average in 23 patients: 19 men and 4 women aged from 38 to 62 years (mean: 49,4 years). At the initial examination the coronary vessels were normal in 11 patients and showed irregular arterial walls without significant stenosis in 12 patients. Coronary spasm was demonstrated directly in 17 cases (6 spontaneous spasms during arteriography and 11 induced spasms) and indirectly in 6 cases (ECG signs of ischaemia during the anginal attack). At the second coronary arteriography we found that the spasms persisted, with positive response to a challenge test in 17 out of the 19 patients tested. The challenge test was not performed in 4 patients who had developed significant lesions. The vessels themselves were altered in 6 patients, with images of occlusion (2 cases), stenosis (2 cases), parietal irregularities (1 case) and aneurysm (1 case) appearing on spastic arteries, and images of stenosis in 2 patients with apparently non-spastic arteries. There was no difference in age, sex, risk factors, initial coronary status and time interval between arteriographies between these 6 patients and the 17 patients whose coronary arteries had remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of continous electrocardiography (Holter monitoring) in mitral valve prolapse]. / Intérêt de l'enregistrement continu de l'électrocardiogramme (procédé Holter) dans le prolapsus de la valve mitrale.

Twenty three patients with mitral valve prolapse underwent ambulatory 20 to 24 hour electrocardiography to study the incidence and severity of ventricular arrhythmias. These arrhythmias were found in 20 cases (87 p. 100). Ventricular extrasystoles were usually grouped (14 cases) causing doublets in 8 cases and bursts of ventricular tachycardia in the 6 others. The importance of the information obtained by Holter monitoring should not detract from the value of the standard resting electrocardiogramme. In fact, there appears to be a good correlation between the severity of the ventricular arrhythmia and the presence of ST changes over the postero-inferior zones. These abnormalities were never present in patients without ventricular extrasystoles but on the other hand they were observed in 5 of the 6 patients with ventricular tachycardia. From a practical point of view this may represent a simple means of identifying patients at high risk of dangerous arrhythmias.

[Disappearance of coronary collateral circulation during a crisis of spontaneous angina. The role of spasm]. / Disparition de la circulation collatérale coronarienne au cours d'une crise d'angor spontané. Rôle du spasme.

Disappearance of the collateral coronary circulation was observed during an attack of spontaneous angina. During coronary angiography, the patient developed precordial pain, ST depression in Leads I, II, III, AVL, AVF, and V2 to V6. The two coronary arteries were opacified: there was no change in the left coronary tree but the collateral circulation arising from the right coronary artery and revascularising the obstructed left anterior descending artery the ECG reverted to its previous state and the collateral circulation reappeared. This case suggests that coronary artery spasm may lead to disappearance of the collateral circulation. It raises problems of methodology in the demonstration of spastic phenomena and emphasises the role of the collateral circulation in the genesis of ischaemia. It is another illustration of coronary artery spasm accompanied by ST depression.

[Block of the autonomic nervous system in the study of sinus function]. / Blocage du système nerveux autonome dans l'exploration de la fonction sinusale.

Blockade of the autonomic nervous system by injection of propranolol (0,2 mg/Kg) and atropine (0,04 mg/Kg) was carried out in a series of 48 patients classified in 3 groups:--Group I:sinus bradycardia (22 cases)--Group II:suspected tachycardia-bradycardia syndrome (14 cases)--Group III:suspected sinus node dysfunction (12 cases). Two parameters were studied after autonomic blockade: observed intrinsic sinus node frequency (OIF) and corrected "adjusted" sinus node recovery time (CASRT). The results were compared with those obtained during basal electrophysiological investigation. The OIF was abnormal in 26 cases (54%) and junctional rhythm was observed 9 times (19%). Prolongation of the post-stimulation pause occurred in 32 cases (67%), transformation from a normal to a pathological pause in 15 cases and normalisation of a pathological pause in 4 cases (8%). Sinus node recovery time did not change significantly in the other cases. There was a good correlation between OIF and CASRT when the OIF was abnormal and mediocre (48%), when the OIF was normal. The following conclusions were made:--CASRT improves diagnosis of organic sinus node dysfunction which may escape detection by basal electrophysiological investigation and excludes functional abnormalities.--OIF is of good diagnostic value when pathological. However, the integrity of sinus node function cannot be affirmed when this parameter is normal.

[Chemical blockade of the cardiac autonomic nervous system. Effects on the coronary arterial vasomotor activity]. / Blocage chimique du systéme nerveux autonome cardiaque. Effets sur la vasomotricité artérielle coronaire.

The results of cardiac plexectomy in spastic angina are controversial. This study was undertaken to evaluate the effects of blocking the cardiac autonomic nervous system (CANS) in this syndrome in 61 patients presenting with chest pain and angiographically normal coronary arteries. All patients underwent a methyl-ergometrine provocation test with a sequential protocol. They were then divided into two groups: Group 1 (13 patients): positive response to ergometrine. Group 2 (48 patients): negative response to ergometrine. Three sub-groups were identified: 2: 1: 9 patients with coronary spasm demonstrated by another method: 2: 2: 6 patients with myocardial infarction: 2: 3: 33 patients with chest pain alone. The results of these tests were compared with those obtained after blocking the CANS by intravenous injection over 3 minutes of an alpha and beta-blocker (labetalol 2 mg/kg) and a parasympathetic blocker (Atropine. 0.04 mg/kg). The CANS blockade was confirmed by two facts: the basal heart rate of 66.38 +/- 9.91 rose to ots intrinsic rate of 89.76 +/- 10.5 (p less than 0.01) and remained at that rate after ergometrine and trinitrate administration and myocardial ischaemia; changes in blood pressure were greater after CANS blockade: + 30.62 +/- 16.13 mmHg instead of + 8.62 +/- 0.33 mmHg after ergometrine (p less than 0.01) and -43.16 +/- 16.32 mmHg instead of -25.16 +/- 3.64 mmHg after trinitrate (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)