Clinical and echocardiographic observations in pulmonary valve endocarditis.

Clinical and echocardiographic data from 12 patients with pulmonary valve endocarditis are described. Seven patients had isolated pulmonary endocarditis and in 5 patients other valves were infected (aortic, tricuspid, mitral or all 3). Two patients were heroin addicts and 4 had underlying heart disease (congenital heart disease in 3 and aortic regurgitation in 1 patient). The organisms involved were alpha streptococci in 3 patients (all with underlying heart disease), Staphylococcus aureus in 4, Streptococcus D bovis in 1 patient and Candida guillermondii in 1. M-mode and 2-dimensional echocardiography was performed in 10 patients and revealed vegetations in 8. Pulsed Doppler echocardiography was performed in 6 patients and revealed pulmonary regurgitation in all 6. Seven patients had pulmonary emboli. Four patients underwent surgery. Four patients died, including 1 after cardiac surgery. Five patients, including the patient infected with Candida guillermondii, recovered with antibiotic treatment.

Calcified embolus of the left coronary ostia after aortic valve replacement.

A patient with a left coronary calcified embolus causing acute myocardial dysfunction immediately after aortic valve replacement is described. Prompt diagnosis by transesophageal echocardiogram was made, which led to removal of the embolus and a subsequent satisfactory course.

Coronary artery revascularisation without extracorporeal circulation. Indications and results.

OBJECTIVE: Coronary artery revascularisation without extracorporeal circulation is a technique which can be performed in selected patients in need of a coronary artery bypass graft. METHODS: Consecutive patients (210) underwent coronary artery bypass graft without extracorporeal circulation. Indications were high risk patients, or single coronary artery lesion. To predict perioperative mortality, preoperative risk factors were reviewed, and Parsonnet score was calculated. RESULTS: There were seven deaths (3.3%), and univariate analysis revealed greater age, NYHA, and poor ejection fraction to be the only predictors of early mortality. Perioperative myocardial infarction included 15 patients (7.1%), most of them seen in the multiple bypass group (10/39, 26%). Patients were divided into low risk (Parsonnet score < 15) 155 patients with two deaths (1.2%), and high risk (Parsonnet score > 15) 55 patients with five deaths (9%). Complete revascularisation was performed in the low risk group, while in the high risk only the symptomatic vessel was bypassed and other angiographic lesions treated with postoperative angioplasty (10 patients). A total of 12 patients developed early postoperative angina (5.7%), 9 presented an anastomosis dysfunction which was treated by angioplasty (5) and surgery (4), and 188 patients (85.7%) did not receive transfusions while 190 patients (90.4%) did not need postoperative inotropes. Length of stay, operating room time, and medical costs were all significantly reduced. CONCLUSIONS: Myocardial revascularisation without extracorporeal circulation can be performed with a low operative mortality, and minimal morbidity only in patients undergoing single bypass revascularisation. It can also be performed as part of a multiple revascularisation strategy in association with angioplasty in high risks patients.

Localization of the origin of systolic clicks using echo-pulsed Doppler technique.

Echo-pulsed doppler (EPD) studies were performed in 2 surgically controlled patients with systolic clicks. The recorded blood samples documented the click to be originated in the right atrium, at the site of the prolapsed anterior tricuspid leaflet in 1 case of heroin-induced tricuspid acute endocarditis. In the second patient suffering from aortic valve disease, an ejection click was recorded, and could be demonstrated by using EPD, to originate from the aortic leaflet at its time of maximal excursion. EPD apears to be a safe, noninvasive method to solve the problem of the origin of systolic clicks.

[Value of echocardiography in cardiovascular emergencies (not including congenital cardiopathies)]. / Intérêt de l'échocardiographie dans les urgences cardiovasculaires (en dehors des cardiopathies congénitales).

The principal echocardiographic features of the main cardiovascular emergencies are discussed. After setting out a method of detailed analysis for echocardiography, the changes found in the main causes of severe chest pain, systemic embolisation and sudden heart failure are described. Special emphasis is laid on the signs of aortic root dissection, pericarditis and tamponade, ruptured valve, the mechanical complications of acute myocardial infarction and, in particular, on the assessment of residual myocardial function. Finally, the authors maintain that echocardiography should be a systematic complementary investigation for patients in the coronary care unit.

[Late potentials and mitral valve prolapse]. / Potentiels tardifs et prolapsus valvulaire mitral.

Signal averaged electrocardiogrammes were recorded in 100 consecutive patients with echocardiographic mitral valve prolapse (MVP) and compared with 50 normal control subjects. Criteria of normality were defined in the reference population: QRS duration after averaging < 113 ms, Simson's vector of the last 40 ms (RMS40) > or = 17 microV, and duration of the terminal potential within the 40 microV range < 38 ms, using a high-pass bidirectional 40 Hz filter. Of the 100 patients with MVP, late ventricular potentials (LP) were recorded in 38 cases with at least 2 criteria of positivity, compared to only 3 out of 50 (6%) in the control group (p < 0.01). The prevalence of LP was very dependent on the appearances of the valve; when the valve was of normal thickness and only showed slight systolic bulging there were only 5/46 cases of LP (10.9%) which did not differ significantly from the control group. On the other hand, when the valve showed myxoid changes, the prevalence of LP was very high: 33/54 = 61% (p < 0.001 versus controls). Six patients had severe ventricular arrhythmias (sustained ventricular tachycardia or ventricular fibrillation): all had LP. In cases of MVP with frequent ventricular extrasystoles (VEs) the prevalence of LP was the same with normal valves (2/23 = 9% and 2/22 = 9%, NS) whereas LPs were more common in cases of VEs with myxoid valve (23/33 = 70% versus 5/16 = 31%; p = 0.01). The high prevalence of LP in MVP with myxoid valves is a convincing argument in favour of myocardial abnormality in this disease.(ABSTRACT TRUNCATED AT 250 WORDS)

[Doppler echocardiography in dysfunctions of valvular prostheses: diagnostic and quantitative significance. Apropos of 20 cases]. / L'échocardiographie Doppler dans les dysfonctions de prothèses valvulaires: intérêt diagnostique et quantitatif. A propos de 20 cas.

We present a retrospective study of 20 patients with cardiac valve prosthetic dysfunction who required reoperation and underwent pre-operative doppler echocardiography. There were 13 cases of mitral valve prosthesis (3 mechanical, 10 xenografts), 5 cases of aortic valve prosthesis (1 mechanical, 4 xenografts), 1 pulmonary valve bioprosthesis and 1 tricuspid valve mechanical prosthesis. Our purpose was to evaluate the diagnostic and quantitative value of this examination in prosthetic dysfunction by comparing doppler data with anatomical findings at surgery. The parameters measured were peak and mean pressure gradients in all cases, gradient half-decrease time and valve surface calculated therefrom in mitral and tricuspid valve prostheses. The results of doppler examination were compared with per-operative anatomical findings in 6 cases, and pre-operative haemodynamic exploration was performed in one case. The diagnosis of prosthetic stenosis was found to be correct in all patients, even in those with moderate stenosis. All leaks and their locations were diagnosed, except in a mitral valve mechanical prosthesis where leaking was detected by continuous doppler. 14 out of the 20 patients were reoperated upon without catheterization. These results suggest that doppler examination is a sensitive and specific method for evaluating cardiac valve dysfunction. However, variations in doppler results from one prosthesis to another make it necessary to perform pulsed and continuous doppler at the end of the operation to be used as reference if dysfunction is suspected subsequently.

[Aorto-septal angulation: a new cause of disorder in left ventricular ejection? (a 2-dimensional echocardiographic study apropos of 66 cases)]. / La désaxation aorto-septale: une nouvelle cause de gêne à l'éjection ventriculaire gauche? (étude échocardiographique bidimensionnelle à propos de 66 cas).

Aorto-septal angulation is defined as an acute angled connection between the anterior aortic wall and the interventricular septum. It is quite a common 2D-echo finding. Does it correspond to a simple anatomical curiosity or is it associated with certain well defined diseases? Could it be a cause of obstruction to left ventricular ejection? To try to answer these questions, 66 consecutive cases of aorto-septal angulation were analysed; the echocardiographic and clinical data were correlated. The dynamic features of angulation were studied during the cardiac cycle and the investigations were completed by a phonomecanogramme with pharmacodynamic stress tests. All patients had cardiovascular pathology: aorto-septal angulation was not observed in normal subjects. The dynamic 2D-echo study distinguished two types of angulation with respect to the cardiac cycle: predominantly diastolic angulation tending to correct itself in systole (16 patients: Group CI); the majority of these patients had severe compensated aortic regurgitation; fixed angulation with no significant change between diastole and systole (50 patients: Group C2). This group consisted of patients with ventricular deformation due to coronary artery disease and patients with hypertension associated in some cases with other pathologies. Phonomecanography with pharmacodynamic stress testing in Group C2 revealed the possibility of dynamic obstruction to left ventricular ejection (6 cases) and the apparition of an ejectional systolic murmur (2 cases). Aorto-septal angulation seems to be closely related to hypertension (57% of patients) irrespective of age. Therefore, it should not be classified exclusively as a change observed in the "aging heart" but it may be the direct consequence of an adaptation to systolic strain of the left ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)

[Asymptomatic postoperative thrombosis of a Saint Jude mitral valve prosthesis. Treatment by fibrinolysis with rt-PA]. / Thrombose postopératoire asymptomatique d'une valve de Saint-Jude mitrale: traitement par fibrinolyse au rt-PA.

Routine Doppler echocardiography after cardiac surgery demonstrated stenotic dysfunction of a Saint Jude Medical mitral valve prosthesis due to blockage of one hemidisc although the patient was totally asymptomatic. Despite the precocity of this thrombosis (14th postoperative day), thrombolytic treatment was undertaken. It led to normalisation of the Doppler parameters of prosthetic valve function and mobility of the two hemidiscs. Haemopericardium occurred at the end of thrombolytic therapy and was drained easily, a benign complication of early postoperative thrombolysis.

[Quantitative analysis of ventricular volumes by digital two-dimensional echocardiography]. / Analyse quantitative des volumes ventriculaires par échocardiographie bidimensionnelle numérisée.

The purpose of this study was to assess the usefulness of digital enhancement of two-dimensional echocardiographic images by cardiac cycle-synchronized summation and digital manipulation of the resulting images. We developed a system which provides for: (1) real-time storage of end-diastolic and end-systolic cardiac cycle images irrespective of rhythm variations; (2) exclusion from summation of end-diastolic and end-systolic images altered by respiratory movements or transducer displacements; (3) performance on the resulting images of various mathematical operations (3*3 convolutions, colour scale-guided manipulation of grey shades); (4) performance of complex mathematical calculations from the extracted edges including, in particular, reconstruction of ventricular volumes by Simpson's crossed method from a transverse and an apical section or from two apical sections. This method was used to collect echocardiographic images from 32 patients who had undergone left ventricular quantitative angiography during the same week. Qualitatively, digital enhancement of two-dimensional echocardiographic images undoubtedly facilitated the identification of endocardial edges and reduced image noise, notably in patients whose ventricular edges were virtually unrecognizable by any other method. Moreover, summation improved correlations with angiography and reduced the variability of quantitative ventricular volume assessment. Finally, the ease and rapidity with which this "real-time" system can be used enables quantitative analysis of left ventricular function to be routinely carried out.

[Left atrial myxoma: a surgical emergency. Apropos of 2 cases]. / Le myxome auriculaire gauche: une urgence chirurgicale. A propos de deux observations

This study reports on two more cases of left atrial myxoma. They were two women with embolic manifestation for several years and in whom the diagnosis was not clinically considered. It was made by echocardiography. Emergency surgery was applied in both cases one of whom without hemodynamic study. The presence of a recent brain embolism did not seem to us to be a contraindication to this surgery. In both cases the tumoral pedicle was implanted on the posterior wall of the left atrium, an unusual location.

[Pulsed echo-Doppler diagnosis and evaluation of tricuspid valve, and interventricular and interatrial communication insufficiencies. Flowmeter study of shunts]. / Diagnostic et évaluation par écho-Doppler pulsé des insuffisances tricuspidiennes et des communications interventriculaires et interauriculaires. Etude vélocimétrique des shunts.

A group of 44 patients with a total of 48 cardiac lesions ( 22 tricuspid incompetence - TI - , 12 ventricular septal defect - VSD - and 14 atrial septal defect - ASD - , and two control groups of 20 normals and 23 patients with other cardiac disease , were studied by pulsed Doppler echocardiography ( PDE ) . The flow patterns recorded in the normal right heart were identical to those recorded previously during catheterisation . TI was diagnosed by the presence of an abnormal negative systolic wave usually associated with widening of the time interval histogram with a specificity of 82 % and a sensitivity of 86 % . An acceptable semi-quantative assessment of the severity of regurgitation was obtained in 83 % by comparing the amplitude of the negative systolic wave with that of the positive diastolic wave . Shunts were diagnosed by detecting septal or tricuspid turbulence with a sensitivity of 83 % and a specificity of 90 % . A satisfactory assessment of the size of the shunt was obtained in 90 % of diagnosed cases by assessing the pulmonary and infundibular flow patterns . A systolic wave starting with isometric contractions , followed by positive early and late diastolic waves and some intermediary negative oscillations of variable amplitude were recorded along the right side of the interventricular septum in 75 % of VSDs . In 78 % cases of ASD a large late systolic - early diastolic wave overriding the second heart sound , followed by positive mid and late diastolic waves of variable size , according to the heart rate , were recorded in the right atrium . In conclusion , PDE recording of blood flow patterns and turbulence in the right heart is a useful non-invasive method of diagnosis and assessment of these three cardiac lesions . It provides a valuable contribution towards the physiopathological study of shunt patterns in atrial and ventricular septal defects .

[Incidence and development of aortic stenosis in chronic hemodialysis. An ultrasonographic and biological study of 112 patients]. / Incidence et évolutivité des rétrécissements aortiques chez l'hémodialysé chronique. Une étude échographique et biologique sur une population de 112 patients.

Valvular calcification in chronic haemodialysis patients has already been reported in the literature, particularly the abnormally high incidence of aortic stenosis. In this study, 112 haemodialysis patients were followed up by Doppler echocardiography for a period of 36 months. Sixteen patients developed aortic valvular calcification with aortic stenosis over an 18.7 +/- 7.5 months period. The indexed aortic valve surface area decreased from 1.24 +/- 0.9 cm2/m2 to 0.66 +/- 0.21 cm2/m2 with abnormally rapid progression. Eight patients with aortic stenosis died during the 3 year study period. These results reflect the abnormal extra-skeletal calcification of chronic haemodialysis patients. Several predisposing factors were demonstrated: age (68.5 +/- 11.1 years versus 57.1 +/- 16.3 years in patients without calcifications), male gender, a longer period of dialysis than the patients without aortic stenosis (8.1 +/- 5.3 versus 5.9 +/- 5.7 years), abnormalities of calcium and phosphate metabolism, increased of the phosphocalcic product by hyperphosphoraemia and not by hypercalcaemia, hypoparathyroidism in 62% and hyperparathyroidism in 38% an increase in vitamin D 3 (19.7 +/- 14 ng/ml versus 9.6 +/- 6.3 ng/ml) biological signs of adynamic osteodystrophy. Calcific aortic stenosis is a commonly observed valvular lesion in haemodialysis patients: its progression may be very rapid, associated with a poor prognosis. Old age, male gender, duration of haemodialysis, hyperphosphataemia associated with hypoparathyroidism and raised Vitamin D3 are predisposing factors.

[Echocardiographic findings in the papyraceous right ventricle syndrome]. / Données échocardiographiques dans le syndrome du ventricule droit papyracé.

The echocardiographic findings in a young man with a "paper-thin right ventricle" or Uhl's anomaly are reported. The usual signs of right ventricular diastolic overload with slight delay in tricuspid valve closure were observed. The discordance between the normal clinical examination and the pathological appearances on echocardiography led to cardiac catheterisation which established the diagnosis.

[Echocardiographic diagnosis of 4 cases of tricuspid valve endocarditis]. / Diagnostic échocardiographique des endocarditis tricuspidiennes. A propos de 4 cas.

Four tricuspid endocarditis cases are reported. Echocardiography found, four times, large vegetations on the tricuspid leaflets leading to the diagnosis. The degree of tricuspid insuffisancy was appreciated by the RV/LV ratio. Successive echos have permitted to survey the evolution and specially to establish a clear decrease of abnormal tricuspid echoes succeeding to pulmonary embolisms. In the four cases, surgery confirmed the diagnosis.

[Traumatic rupture of the aortic valve. Echocardiographic aspects. Apropos of a case]. / Rupture traumatique de la valve aortique. Aspect échocardiographique. A propos d'un cas.

The appearance of a diastolic murmur in a pyrexial patient 15 days after trauma was suggestive of infectious endocarditis. This diagnosis was excluded, especially by echocardiography, and the aortic incompetence was attributed to the trauma. The value of echocardiography and the features of other reported cases are discussed with referrence to this case.

[Contribution of multiplane transesophageal echocardiography in the study of mitral valve prostheses]. / Apport de l'échographie transoesophagienne multiplan dans l'étude des prothèses mitrales.

Many reports have confirmed the value of transoesophageal echocardiography in the diagnosis of mechanical mitral valve prosthesis dysfunction: new biplane and multiplane probes seem to provide additional information in the assessment of cardiac disease. The aim of this study was to quantify the additional value of these new probes in the assessment of mitral valve prostheses. Seventy-five mitral valve prostheses were assessed with the multiplane probe, 45 normal bileaflet prostheses, 17 with regurgitant dysfunction and 12 with non obstructive thrombi and/or strands, and one with a blocked leaflet. In order to compare the respective values of monoplane, biplane and multiplane probes, the recordings were performed at 0 degrees, 90 degrees and from 0 degrees to 180 degrees in continuous sweep mode through the scanning plane. Globally, with the monoplane assessment, it was only possible to visualise both leaflets simultaneously in 13% of cases. The majority of prostheses was correctly analysed between 60 and 100 degrees. This was of paramount importance for the diagnosis of blockage of one leaflet. With respect to para-prosthetic valve regurgitation, the transverse view allowed visualisation of the lateral and paraseptal annular regions. The addition of a longitudinal view allowed visualisation of anterior and posterior regurgitant jets: the supplementary views provided by the multiplane probe allowed detection of small regurgitant jets in the diagonal planes between the longitudinal and transverse views. The multiplane probe offers the possibility of identifying the precise origin of the jet and helps quantification and peroperative localisation of its position. Small, non-obstructive thrombi and strands are better seen using a multiplane probe, especially when of small size. Therefore, multiplane transoesophageal echocardiography improves the assessment of mitral valve prostheses, the majority of diagnoses being, however, accessible with biplane probes.

[Ventricular arrhythmias and mitral valve prolapse. A study of 35 cases]. / Troubles du rythme ventriculaires et prolapsus mitral. A propos de 35 observations.

35 patients with mitral valve prolapse (MVP) underwent investigation by Holter monitoring with computerised analysis. Ventricular arrhythmias were observed in 70% patients with MVP. There does not seem to be a close correlation between the severity of the arrhythmia and the degree of prolapse. The mechanisms of the ventricular arrhythmia are variable: two patients had the necessary criteria for ventricular reentry, at least six had parasystolic foci, protected or not from the sinus rhythm. The most severe ventricular arrhythmias are characterised by their variable morphology (but usually showing right bundle branch block), a clear diurnal rhythm, the inducing role of exercise or emotion and a greater diurnal variation of the sinus rhythm suggesting increased sympathetic tone. The results of beta blockade are better in the patients with the most marked diurnal rhythms.

[Visualization by bidimensional echocardiography of the trunk of the left coronary artery. Affirmation of its integrity before coronary angiography]. / Visualisation par échocardiographie bidimensionnelle du tronc de la coronaire gauche. Affirmation de son intégrité avant coronarographie.

The aim of this study was to visualise and analyse the status of the main left coronary artery by 2D echocardiography before coronary angiography. Fifty two patients were studied. The recordings were performed from the left parasternal position on video cassettes and played back frame by frame for each patient, to analyse the left main coronary artery and its bifurcation. The patients had known stenosis of this vessel; there were echocardiographic abnormalities in all 10 cases; the stenosis was visualised directly in 5 patients and the vessel was considered to be abnormal in the other 5 patients. Forty two patients underwent 2D echo before coronary angiography. The echo of the left main coronary artery was considered to be abnormal in 8 patients: these results were compared with those of coronary angiography. In 33 cases there were no echocardiographic abnormalities and there were no angiographic lesions. The false positive results were due to the inability to record the bifurcation (proximal stenosis of the LAD interpreted as stenosis of the left main coronary) or to the direction of the left main coronary which is curved and thus cannot be analysed in the plane of the transducer. False negative results corresponded to slight stenosis (less than 50 p. 100). The bifurcation can be visualised in 60 p. 100 of patients with normal left main coronary arteries. It is only in these cases that the absence of significant lesions can be confirmed before coronary angiography.