High risk hypertensives: pre-hospital management of acute myocardial infarction--results from the French nationwide registry USIC 2000.

OBJECTIVE: To assess the use of mobile coronary care units (MCU) in hypertensive patients previously treated for cardiovascular diseases in comparison with those with no history of cardiovascular disease and to estimate the influence of the use of MCU on cardiovascular outcome in this population. PATIENTS: We used a nationwide prospective registry of all patients admitted for AMI in French intensive care units in 2000. Patients without history of hypertension or patients admitted with pulmonary oedema or cardiogenic shock were excluded. Men (N = 514) and women (N = 291) were analysed separately. RESULTS: The proportion of patients with history of myocardial infarction, peripheral artery disease and stroke was not significantly higher in subjects who used physician-staffed MCU as compared with patients with no history of myocardial infarction, peripheral artery disease or stroke. In each sex, revascularization (pre hospital fibrinolysis, in hospital fibrinolysis or coronary angioplasty) were more frequent in patients who used MCU. Also, one year cardiovascular mortality was lower in men who used MCU. CONCLUSION: Known high risk hypertensive patients did not use physician-staffed MCU more than subjects free of such condition. Education of hypertensive patients at risk during routine visits is required to increase of the use of physician-staffed MCU in case of symptoms suggestive of AMI.

Aneurysms of sinus of Valsalva: two-dimensional echocardiographic diagnosis and recognition of rupture into the right heart cavities.

The aim of this study was to evaluate the role of echocardiography in the diagnosis of sinus of Valsalva aneurysms projecting toward the right heart cavities. Three patients who had a ruptured aneurysm of a sinus of Valsalva diagnosed by echocardiography and confirmed by catheterization underwent cardiac surgery. In two patients, the aneurysm originated from the right coronary sinus and had perforated into either the inflow or outflow tract of the right ventricle. In the third patient, the aneurysm, which originated from the noncoronary sinus, ruptured into the atrium. A fourth patient was also investigated and had an unruptured aneurysm of the right coronary sinus projecting into the right ventricular outflow tract. M-mode, two-dimensional and contrast echocardiographic studies were performed before cardiac catheterization in all patients and after surgery in three patients. M-mode echocardiography was useful only when the aneurysm had an anterior projection, whether or not the aneurysm was ruptured. Conversely, two-dimensional echocardiography was always able to identify the aneurysmal sac which appeared as an abnormal circular thin-walled structure protruding into the right heart cavities. By using multiple views, it was possible to investigate the whole abnormal structure and locate the sinus from which the aneurysm originated. The use of the echo contrast technique allowed more precise definition of the aneurysmal sac and diagnosis of a left to right shunt by demonstrating a negative contrast image in the right cavities. On the other hand, no negative contrast image was recorded in the patient with an unruptured aneurysm or in the two instances of a successful surgically reconstructed aorta.

[Management of patients admitted for acute myocardial infarction in France from 1995 to 2000: time to admission dependent improvement in outcome]. / Prise en charge de l'infarctus du myocarde en France dans les études USIK 1995 et USIC 2000: amélioration pronoslique et rôle du délai d'admission.

The in-hospital management and short- and long-term outcomes was assessed in 2 registries of consecutive patients admitted for acute myocardial infarction, 5 years apart, in France. The 2000 cohort was younger and with a less frequent history of cardiac diseases, but was more often diabetic and with anterior infarcts. Time to admission was actually longer in 2000 than in 1995 (median 5.25 hours vs 4.00 hours). Overall, reperfusion therapy was used in 43% of the patients in both registries. However, the use of reperfusion therapy increased from 1995 to 2000 in patients admitted within 6 hours of symptom onset (64 vs 58%), with an increasing use of primary angioplasty (from 12 to 30%). Five-day mortality significantly improved from 7.7 to 6.1% (p < 0.03) and one-year survival was also less in the most recent period (85 vs 81%, p < 0.01). Multivariate analyses showed that the period of inclusion (2000 vs 1995) was an independent predictor of both short- and long-term mortality in patients admitted within 6 hours of symptom onset. Thus, in the real world setting, a continued decline in one-year mortality was observed in patients admitted to intensive care units for recent acute myocardial infarction, especially for patients admitted early. This goes along with a shift in reperfusion therapy towards a broader use of primary angioplasty, and with an increased use of the early prescription of recognised secondary prevention medications.

[Operative risk of heart valve surgery after 80 years]. / Le risque opératoire de la chirurgie valvulaire après 80 ans.

The continuous prolongation of life expectancy in developed nations and the progress made in the surgical treatment of valvulopathy have substantially increased the number of octogenarians undergoing heart valve surgery with extracorporeal circulation. Most of them have calcified aortic stenosis and the valve is replaced with a bioprosthesis. At these ages, mitral valve disease--usually insufficiency--is predominantly treated by repair rather than valve replacement. In both cases, the etiology is primarily degenerative. In addition, an ever-increasing percentage of these patients require replacement of deteriorated bioprostheses. These octogenarians are exposed to surgical risk estimated to be about 9-10%, i.e. 2-3 times higher than that of patients under 70 years of age, and even higher when surgery is a reintervention. Furthermore, morbidity affecting approximately an additional third of those undergoing surgery must be added to this mortality. Therefore, only half of the patients have uncomplicated surgical outcomes. Age is not the only factor enhancing the risk, which is also linked to comorbidities, preoperative functional class, stage of the evolving valvulopathy, and association of coronary artery disease. Predictive scores (Parsonnet, EuroScore) have been devised to evaluate the surgical risk to which these patients are subjected. Rigorous selection of patients with severe valvulopathy should enable potential candidates, willing to undergo an intervention, to be provided with indications for surgery sufficiently early so as to not enhance the risk by intervening too late.

[Clinical and therapeutic specificities of myocardial infarction in patients with peripheral arterial disease: the USIC 2000 registry]. / Particularités cliniques et thérapeutiques de l'infarctus du myocarde chez l'artéritique: etude à partir du registre USIC 2000.

OBJECTIVE: Several studies underlined the worse prognosis of myocardial infarction (MI) among patients with peripheral arterial disease (PAD). We sought to describe the presentation and management modalities of a cohort of PAD patients presenting an acute MI, compared to those without PAD. MATERIALS AND METHODS: The USIC 2000 registry, a nationwide database on all patients admitted to a CCU for an acute MI < 48 hours in France in November 2000 was used for this study. RESULTS: Among the 2311 patients included, PAD was reported in 215 subjects (9.3%). In multivariate analysis, the following factors were positively related to the presence of PAD (P < or = 0.05): age >75 y (OR = 2.3), diabetes (OR = 2.0), hypertension (OR = 1.4), active smoking (OR = 4.6), renal failure (OR =3.1), and treatments with antiplatelets (OR = 3.9), anti-vitamin K (OR = 1.9), statins (OR = 1.7) and low molecular weight heparins (OR = 6.8). By introducing the data concerning the arrival in CCUs in the model, the following factors were also significantly more frequent among PAD patients: male sex (OR = 1.6), past history of coronary artery disease (OR = 2.2), left bundle branch block (OR = 1.8) and late management >6 hours (OR = 1.4). Conversely, ST-segment elevation was less frequent (OR = 0.7). When the CCU stay data were introduced in the model, a lower rate of coronary stenting (OR = 0.7) and betablockers use within 48 hours of admission (OR = 0.6) were noted. CONCLUSION: Beyond the presence of PAD per se, several particularities do exist, especially the coexistence of a high number of pejorative factors and an under-utilization of treatments presenting prognostic benefits.

Management and short-term outcome of diabetic patients hospitalized for acute myocardial infarction: results of a nationwide French survey.

OBJECTIVES: To compare management and short-term outcome of diabetic and non-diabetic patients hospitalized for acute myocardial infarction. METHODS: This was a prospective epidemiological survey. All patients admitted in coronary care units in France in November 2000 for confirmed acute myocardial infarction were eligible to enter the study. RESULTS: Of the 2320 patients recruited from 369 centers, 487 were diabetic (21%). Compared to non-diabetic patients, diabetic patients were 5 years older, more often female, obese and hypertensive; they had more often a history of cardiovascular disease; they had a lower ejection fraction and worse Killip class. Reperfusion therapy was less frequent among diabetic patients (39% versus 51%; p=0.0001), as was the use of beta-blockers (61% versus 72%; p=0.0001), aspirin (83% versus 89%; p=0.0001) and statins (52% versus 60%; p=0.001) during hospitalization. Conversely, the use of ACE-inhibitors was more frequent (54% versus 44%; p=0.0001). 58% of diabetic patients received insulin during hospitalization. Twenty-eight-day mortality was 13.1% in diabetic patients and 7.0% in non-diabetic patients (risk ratio: 1.87; p=0.001). Diabetes remained associated with increased mortality after adjustment for relevant risk factors including age and ejection fraction (risk ratio: 1.51; p=0.07). In patients treated with antidiabetic drugs (chiefly sulfonylureas) before admission, 28-day mortality was 10.4% compared with 19.9% in diabetic patients on diet alone or untreated (p=0.005). CONCLUSION: Despite higher cardiovascular risk and worse prognosis, in-hospital management of diabetic patients with acute myocardial infarction remains sub-optimal. Patients previously treated with antidiabetic drugs including sulfonylureas had a better prognosis than untreated diabetic patients.

Incremental cost-effectiveness ratio of alteplase in patients with acute myocardial infarction in the French setting.

On the basis of data collected from general hospital centres in France on 704 patients initially presenting with acute myocardial infarction, the mean 1-year cost of treatment was calculated to be 52,160 French francs (F) per patient (1994 values). This was independent of whether the patient received thrombolysis, and included all costs associated with initial hospitalisation including a stay in intensive care, cardiology or medical units, as well as rehospitalisations, revascularisation procedures and any drugs prescribed. When only those patients who survived the initial hospitalisation were considered, the mean cost of treatment was F58,184 per patient. Among patients who received thrombolysis during their initial hospitalisation, the respective mean 1-year costs were F74,684 per patient for those treated with alteplase and F64,866 per patient for those treated with streptokinase (p = 0.09). This nonsignificant difference can be explained by the higher cost of alteplase relative to that of streptokinase, the lower mortality rate associated with alteplase during the initial hospitalisation period (9.2% versus 10.6%) and the difference in the percentage of additional revascularisations required in the 2 treatment groups (32.8% versus 42.3%). Combining the pharmacoeconomic data collected in the French general hospital setting with incremental patient survival data stemming from the Global Utilisation of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial showed that the incremental cost-effectiveness ratio of alteplase versus streptokinase amounted to F70128 per life-year saved for the total group, and F52035 per life-year saved for those patients who survived the initial period of hospitalisation.

[Anticoagulant therapy during pregnancy in patients with mechanical valvular prostheses]. / Conduite du traitement anticoagulant pendant la grossesse chez les patientes ayant une prothèse mécanique.

Anticoagulant therapy (heparin or oral anticoagulants) during pregnancy in patients with mechanical valvular prostheses should take into consideration the respective risks of the usage of these two products: thromboembolic for the mother, congenital malformations for the children and haemorrhagic for them both. Basically, heparin therapy is useful by limiting the risk of foetal complication, but it increases maternal risk, especially related to thromboembolism. The risks of oral anticoagulants are concentrated in the second half of the first trimester (coumarin-related embryopathies) and in the peri-partum period (maternal and foetal haemorrhage). There is general agreement to use oral anticoagulants outside these periods, during the second trimester and most of the third. During the first trimester, the European and North American Recommendations make provision for parental consultation. Some authors recommend oral anticoagulants even during the first trimester because of the scarcity of coumarin-related embryopathies. In fact, the incidence greatly increases when the dosage required is over 5 mg of coumarin per day. Others continue anticoagulation until the end of pregnancy, stopping 48 hours before delivery, either vaginal or by caesarean section. These attempts to avoid heparin therapy are related to difficulties of obtaining stable anticoagulation with non-fractionated heparin which increases the risk of thromboembolism, especially prosthetic valve thrombosis. Low molecular weight heparin, which is widely used in venous and arterial thromboembolic disease, including during pregnancy, is not yet recommended for usage in pregnant women with mechanical valvular prostheses because there are not results from large series concerning their efficacy and safety in this particular indication. In the absence of randomised studies in pregnancy, the renewal of small series in specialised centres will probably open up the field for their usage in the years to come.

[The best in 2000 on valve diseases]. / L'essentiel de 2000 dans les valvulopathies.

During the year 2000, publications on valvular heart disease have concerned all aspects of this field of cardiology at a time when old and dated therapeutic procedures are being reassessed. The ageing population of the developed world has led to aortic stenosis playing a large part, and the study of its natural history has provided two keynote publications. Aortic valve replacement, increasingly involving older patients, led to the evaluation of this surgery in this age group in which bioprostheses are often associated with coronary bypass surgery. Conversely, in younger patients, there is a regain in interest in autograft (Ross' procedure) or homograft valve replacement which requires a rigorous infrastructure of supply. In mitral valve disease, the indications of conservative surgery of mitral incompetence, ideal in degenerative forms of the posterior leaflet, have been progressively extended to include bacterial endocarditis in many cases and ischaemic mitral regurgitation according to some authors. Rheumatic lesions are not commonly treated by this technique although some encouraging results have been reported. Percutaneous mitral commissurotomy has attained maturity in the treatment of mitral stenosis, even in the less favourable forms such as restenosis after an initial percutaneous procedure or even after surgical commissurotomy. Valve replacement surgery by prosthetic valves is forty year old and many long-term retrospective and prospective evaluations of the results on large patient population either with one type of prosthesis or comparing different bioprostheses or bioprostheses with mechanical valves have been performed. The ideal age for implanting bioprostheses remains uncertain, between 60 and 70, depending on the authors. Finally, problems of anticoagulation in patients with prosthetic valves were the object of three interesting publications about the use of low molecular weight heparin, aspirin and the risks during pregnancy. 2000 was a year of steady and regular progress in the study of valvular heart disease without any major revolutionary contributions.

[The best of 2001. Valve diseases]. / L'essentiel de 2001 en valvulopathies.

The publications in 2001 regarding valvulopathies have concerned all sectors of this pathology. Aortic valvulopathies are the object of new work supporting the relationship between aortic sclerosis or stenosis and cardiovascular risk factors. They confirm the analogy between lesions of inflammatory origin observed on calcified valves and atherosclerotic plaques (Mohlner). They find higher rates of serum lipids in the case of valvular replacement for stenosis than for aortic insufficiency albeit in an older population (Novaro). Monin shows the possibility of a better pre-operative prognostic approach for advanced aortic stenoses at low transvalvular gradient with left ventricular dysfunction, for which the post-operative results are better when low dose stress echocardiography has shown the existence of a contractile reserve. For the results of aortic surgery with biological prostheses it is widely reported that they behave as homografts (O'Brien), stented heterografts (Puvimanasinghe) or stent-less (Hubaut). A controversy exists on the subject of the degenerative mechanism of bioprostheses between the supporters of the immunological hypothesis (Human) and those of the purely degenerative hypothesis (Mitchell). This controversy is far from being insignificant because the infectious or other risks run by patients with bioprostheses are conceivable with the addition of an immuno-suppressant treatment. Among the mitral valvulopathies, insufficiencies with an ischaemic origin have a harmful effect on the long term prognosis even for medium leaks (Grignoni). As for the method of repairing these ischaemic leaks, consensus has not been reached between the proponents of exclusive revascularisation, plasty or replacement (Mickleborough, Otsuji). The quality of the very long term results for mitral plasty by Carpentier's technique for rheumatic mitral insufficiency (Chauvaud) or non-rheumatic (Braunberger, Mohty) is confirmed, especially for the latter. Its feasibility by a minimally invasive approach is reported (Schroeyers). Anticoagulation for prostheses remains one of the challenges for valvular surgery. The addition of a platelet anti-aggregant is not accepted by all, due to the increased haemorrhagic risk. A meta-analysis of 2,199 operations seems in favour of this addition if the dose is weak (Massel). It's a question of an attitude having become normal practice across the Atlantic, but not in Europe (Englberger).

[The best of valvular heart disease in 2002]. / L'essentiel de 2002 des valvulopathies.

For AS, besides a very thorough update by Carabello on their management, new experimental work confirms that the pathophysiology of the condition is closer to atherosclerotic and inflammatory processes than pure degeneration. Moreover this year brings a batch of long term post-operative results, one of which is an important series relating to 2194 bioprostheses followed up for 15 years. The choice of valvular substitute between 60 and 70 years old is the subject for several studies. A series of 259 re-operations for bioprosthesis deterioration allows quantification of the operative risk to which those with this substitute are subjected in case of degeneration. Finally, the strategy to adopt in a patient with an indication for aortocoronary bypass but also with a not-tight AS is discussed (abstention, decalcification, or "preventive" valvular replacement?). For aortic insufficiency (AI) some new results for the Ross operation have been published and the first publications reporting on the attempts of experimental positioning of bioprostheses via the percutaneous route in animals are appearing. As for mitral valvulopathies, MI has carved a privileged place. Much work this year relates amongst other things to functional MI in dilated cardiomyopathies with dilatation of the ring, to the natural history of mitral valvular prolapse detailed in an important series of 833 patients, and to the evolutive risk of atrial fibrillation (AF) with MI and its treatment during plasty or mitral valvular replacement procedures. Anticoagulant treatment for mechanical prostheses is the subject of much work drawn from a large German prospective study (GELIA) confirming the general tendency for alleviation of intensity in aortic especially but also mitral valvulopathies, stressing the advantages of autocontrol. Finally, the Valvulopathy Working Group of the European Society of Cardiology publishes its recommendations for asymptomatic valvulopathies, recalling the echographic criteria of dilatation and left ventricular function to be retained for operative indications, emphasising furthermore the significance of the stress test in the follow up of asymptomatic AS.

[Prosthetic valve endocarditis: current problems]. / L'endocardite infectieuse sur prothèse valvulaire: problèmes actuels.

Prosthetic valve endocarditis is a rare complication of valve replacement surgery but carries a grim prognosis. The physiopathology of this condition allows identification of two clinically distinct forms based on their bacteriological profiles and outcome: early endocarditis, diagnosed in the first year following valve replacement is observed in 0.7 to 3% of cases: staphylococci are the predominant organism as contamination usually occurs at operation. The prognosis is poor due to the high incidence of complications and the mortality rate is about 60 to 70%; late endocarditis: diagnosed after the second year, it is observed in 0.5 to 1% of cases per year. Contamination is due to bacteraemia and the commonest organisms are the streptococci. The mortality rate is over 20%. The diagnosis is particularly difficult in chronic forms and those with negative blood cultures. Cardiac imaging in prosthetic valve endocarditis is mainly dependent on Doppler echocardiography especially using the transoesophageal approach which allows evaluation of lesion such as abscesses, vegetations and perivalvular leaks, and enables planning of treatment. Management is medico-surgical. Apart from symptomatic treatment of complications, antibiotic therapy using synergistic drugs at bactericidal dosages intravenously is essential as soon as bacteriological specimens have been sent for culture. Surgery is essential in early forms but may be avoided in uncomplicated late forms. The timing of surgery (the objectives of which are to excise the infected material, to repair destructive lesions and to implant a new valve) is a decisive factor in reducing the morbidity and mortality of this condition. Prophylactic measures have a particularly important role to play: they are based on pre- per- and postoperative guide lines.

[Silent mitral insufficiency caused by partial dislocation of a Starr-Edwards valve. Apropos of 2 cases with 1 being successfully re-operated]. / Insuffisance mitrale muette par désinsertion partielle de valve de Starr-Edwards. A propos de deux cas dont un réopéré avec succès

Silent mitral incompetence due to partial dislocation of the Starr-Edwards valve, leading to an apparently unexplained cardiac failure, has been observed in two patients, one two months and the other 35 months postoperatively. There was a fatal outcome in the first patient, no operation being carried out. Cardiac catheterisation with arteriography of the left anterior descending artery established the diagnosis, and led to a successful reoperation in the second case. It is therefore essential to carry out a haemodynamic and angiocardiographic investigation of any case who, after an initial trouble-free interval post-operatively, develops a deterioration of function which cannot be explained.

[Nodoventricular Mahaim fibres. 2 cases confirmed by electrophysiological study]. / Fibres de Mahaim nodo-ventriculaires. Deux cas mis en évidence à l'exploration électrophysiologique.

Two adolescents with no obvious cardiac were investigated for paroxysmal tachycardia at a rate of about 200/mn with wide QRS complexes showing left bundle branch block, reduced by vagal manoeuvres. Atrial pacing showed shortening of the HV interval associated with widening of the QRS complex to appearances identical to those of the tachycardia, suggesting right ventricular preexcitation masked in sinus rhythm. The progressive prolongation of the atrio-ventricular conduction time with increasing prematurity of the extrastimulus and atrioventricular block after intravenous injection of ATP were more in favour of right nodo-ventricular Mahaim fibres (NV) than a Kent bundle. These properties of the NV pathway and the recording of a "gap" phenomenon during the measurement of the refractory period of the accessory pathway are explained by the proximal part of the AV node not being short-circuited. Paroxysmal tachycardia was easily induced by atrial and ventricular stimulation; the tachycardia QRS complexes always showed appearances of left bundle branch block with a His potential at the onset of the ventricular complex. The NV pathway therefore always depolarised in the anterograde direction in tachycardia; the retrograde pathway is discussed: His, latent Kent bundle or purely intranodal reentry.

[Pregnancy in patients with heart valve prosthesis. A French retrospective cooperative study (155 cases)]. / Grossesses chez les porteuses de prothèses valvulaires. Etude coopérative rétrospective française (155 cas).

A French cooperative study of 155 pregnancies in 103 women with valvular prosthesis (95 mechanical, 60 bioprostheses including 27 bivalvular prostheses) is reported. Therefore, a total of 182 prostheses (108 mechanical and 74 bioprostheses) were exposed to the risk of pregnancy. The maternal outcome in the group of 108 mechanical prostheses was complicated by 16 thromboembolic events (TE) including 10 prosthetic valve thromboses which required emergency valve replacement in 4 cases, 6 systemic TE in 13 mitral, 2 aortic and 1 pulmonary mechanical prostheses. The TE were four times more frequent in patients on heparin than in those on oral anticoagulants. There were 4 deaths, 3 among the 10 prosthetic valve thromboses (one reoperation, two sudden deaths). Seven of the 74 bioprostheses were reoperated for degeneration on average 5.9 years after the initial operation but there were no deaths or TE. The outcome of pregnancy was 99 children (63%), 49 of which were born to mothers with mechanical prostheses (53%) and 50 to mothers with bioprostheses (80%) (p < 0.001). Seven of the children were born prematurely, all mothers being on anticoagulant therapy. The birth weight was over 400 grams heavier (3 kg versus 2.6 kg) in the bioprosthesis group (p < 0.05). The 20 spontaneous abortions (13%) were more common in patients on anticoagulants (17%) than in those without (2%) (p < 0.02). Congenital defects due to oral anticoagulants were rare (one certain case). There was one case of phocomelia, an abnormality which has never been described in this context. The 36 remaining pregnancies were still deaths (N = 5), abortion due to maternal death (N = 4), maternal complications (N = 8), therapeutic (N = 9) or voluntary abortions (N = 10) (28 mechanical and 8 bioprostheses).(ABSTRACT TRUNCATED AT 250 WORDS)

[Complex cardiac lesion diagnosed more than 20 years after the causal injury]. / Lésion cardique complexe diagnostiquée plus de 20 ans après. Le traumatisme causal.

Penetrating wounds of the heart, when not immediately fatal, may give rise to complex lesions associating valvular regurgitations and fistulous connections. The authors report the case of a patient with mitral and aortic regurgitation associated with an aorto-left atrial fistula of traumatic origin and causing invalidating cardiac failure. The interest of this particular case lies in the duration of the interval between the causal trauma and the appearance of symptoms (over 20 years). Complete surgical repair of the lesions provided a good functional result. The authors discuss the different types of lesions which may be caused by wounds of the heart and their modes of presentation.

[Registry of heart failure patients hospitalized in 2000. Data from the National College of Cardiology and General Hospital]. / Registre des insufisants cardiaques hospitalisés en 2000. Données du Collége national des cardiologues des hôpitaux généraux (CNCHG).

The French epidemiological data on cardiac insufficiency in the hospital environment are scarce. A register collecting 1772 patients was produced by the services of the National College of General Hospital Cardiologists (C.N.C.H.G.) during two periods: autumn 1999 (November) and spring 2000 (June). It involved completing a form for each of the first 20 patients with cardiac failure hospitalized over a month. 1011 and 761 observations from 59 and 47 centres (that is 17 and 16 observations per centre) were collected during the autumn and spring periods respectively. In France, in the general hospital centres (CHG) cardiology services during the year 2000, the characteristics and the medical treatment of hospitalized patients with cardiac failure are very similar to those presented in 1998 by A. Cohen-Solal in the name of the working group "Cardiomyopathy and Cardiac Insuficiency of the French Society of Cardiology". The hospitalized patient with cardiac failure is very old, usually male, has an ischaemic cardiopathy in one in two cases, and is at stage II and III on the New York Heart Association (NYHA) scale in 83% of cases. There is practically always an electrocardiographic anomaly. Loop diuretics are prescribed nine times out of ten, digitalis one in three, anagiotensin converting enzyme inhibitors are underused being prescribed two out of three times, but an increase in the prescription of anti-aldosterone and betablockers is found. The majority of patients improve during their stay, 7.8% dying and this mortality is influenced by age, ejection fraction (FE), functional NYHA class, causal cardiopathy, and the existence of severe renal failure. The data collected by the cardiology services of the C.N.C.H.G. are representative of the profile of the population affected and are important to know in order to improve the management of these patients.

[Cardiology in general hospitals. A cooperative survey on medical teams, technical means and activity]. / La cardiologie en hôpital général. Enquête coopérative sur les équipes médicales, les moyens techniques et l'activité.

A national enquiry carried out in 1990 in the departments of cardiology of general and private non-profit making hospitals established the status of these departments and the evolution of their personnel and equipment since their creation. The enquiry involved two thirds of the cardiology departments of the general hospitals (119/180) and showed that most (66%) were established between 1974 and 1988. Implanted in fairly important cities with catchment areas of 100,000 to 400,000 people, they have an average of 32 beds (range 11 to 100) and 7.25 coronary care beds (range 4 to 19); 347 doctors work full (211) or part time (136) in these departments. These two types of work are allowed in the majority of these units (64/119). Specialist certified cardiologists practice in 62 departments (56%). The usual technical equipment is available in 80% of the units (Doppler echocardiography, exercise stress testing, Holter monitoring, right heart catheterisation). Permanent pacing is performed in 65% of these hospitals, more so in the provinces than in the Paris region. Coronary angiography is only available in 21%, radioisotopic investigations in 15% and coronary angioplasty in 12% of these centres. A prospective study performed in 1990 concerning 110 hospitals recruited 1,030 myocardial infarctions, which enabled the total number of infarcts hospitalised in the coronary care units of the general hospitals to be estimated at about 21,000 (60% of French myocardial infarctions).

[Echocardiographic-Doppler study of a case of subacute and incomplete parietal rupture after myocardial infarction]. / Etude échocardiographique-doppler d'un cas de rupture pariétale incomplète et subaiguë après infarctus du myocarde.

The authors report the case of a 55 year old man who suffered a silent, laterobasal myocardial infarction which was complicated by a subacute pseudo-false aneurysm of the lateral wall of the left ventricle. They underline: The importance of two-dimensional echocardiography in the diagnosis of a neo-para left ventricular cavity showing systolic expansion and communicating with the left ventricle by a narrow neck indicating rupture of the free ventricular wall; The value of two-dimensional color coded Doppler which enables the operator to distinguish the active nature of the neo-left ventricular cavity before surgery and its inactivity after surgery. The surgical indication for emergency resection of the pseudo aneurysm was based on these preoperative non-invasive observations. This case confirms the value of cardiac two-dimensional echo-Doppler studies in the investigation of ischaemic heart disease.

[Early postoperative thrombolysis of Saint-Jude aortic valve prosthesis]. / Thrombolyse postopératoire précoce d'une valve de Saint-Jude aortique.

The authors report a case of thrombolytic therapy with streptokinase in the early postoperative period after aortic valve replacement with a Saint Jude medical prosthesis. After good initial progress, the patient had to be reoperated on the 12th postoperative day for sternal disunion. Reoperation was followed rapidly by progressive thrombosis of the aortic prosthesis demonstrated by repeated Doppler echocardiographic examination. The impossibility of eliminating mediastinitis led to medical thrombolysis. The outcome was favourable after a regressive cerebral embolic event. This case illustrates the value of Doppler echocardiographic examination in the postoperative period. Thrombolysis may constitute an alternative to reoperation when the operative risk is high. The risk of thrombolysis may not be as great as some believe.