[Recurrent mobile thrombus of the ascending aorta diagnosed by transesophageal echocardiography]. / Thrombus mobile récidivant de l'aorte ascendante diagnostiqué par échocardiographie transoesophagienne.

The authors report the case of a 32 year old woman with no risk factors for thromboembolism apart from a raised Lipoprotein (a) level, in whom a mobile thrombus of the ascending aorta was diagnosed only by transoesophageal echocardiography after multiple episodes of systemic embolism. After surgical excision the thrombus recurred and death ensued on the 17th postoperative day after multiple visceral embolism despite adequate anticoagulant therapy. This is a rare condition, the outcome of which seems often to be fatal, due to early recurrence irrespective of the treatment (anticoagulant or platelet antiaggregant therapy). This case illustrates the value of systematic transoesophageal echocardiography for the investigation of cerebral or peripheral ischaemic episodes without carotid artery disease and raises the problem of the best way of treating this pathology.

[Doppler echocardiography under dipyridamole after thrombolyzed early myocardial infarction. Comparison with coronarographic data]. / Echocardiographie Doppler sous dipyridamole après infarctus du myocarde inaugural thrombolysé. Comparaison aux données de la coronarographie.

The reliability and safety of Doppler echocardiography with dipyridamole (0.84 mg/kg in 10 min) were evaluated in 63 patients an average of 7 days after a thrombolysed early lateral infarct and 24 hours before follow-up coronary arteriography. The aims of the test were the detection of tight stenoses (diameter reduced by more than 75%) affecting the artery responsible for the infarct as well as the other coronary vessels, using the vasodilator action of dipyridamole. The echocardiographic manifestation of induced coronary steal consisted of transitory asynergism in the territory of the artery involved. Clinical tolerability of the test was good. The brief onset of anginal pain was nevertheless seen in 6 patients. Analysis of the zone corresponding to the necrosed area was possible in only 43 cases. Sensitivity of the test for detection of a post-infarction residual stenosis was 64% (39-89) and specificity 90% (79-100). Study of other territories was possible in 59 cases. Sensitivity of the test for the diagnosis of multiple vessel disease was 70% (42-98) and specificity 94% (88-100). In the population as a whole, Doppler study of variations in anterograde mitral flow revealed a sensitivity of 40% (27-53) and specificity of 87% (78-96). Variations in sub-aortic flow were analysed only in the final 27 patients, with a sensitivity and specificity of 100%. The specificity of dipyridamole echocardiography after infarction is good, both for the detection of residual stenosis and that of multiple vessel disease, the chief limiting factor being the impossibility of analysis of the infarcted region in the presence of initial akinesis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chronic constrictive pericarditis after heart surgery. Apropos of a case]. / Péricardite chronique constrictive post-chirurgie cardiaque. A propos d'un cas.

A case of pericarditis in a 52-year old patient following aorto-coronary shunt surgery is reported which gradually developed into chronic constrictive pericarditis. In this context, the diagnostic criteria of chronic constrictive pericarditis are recalled. The clinical criteria show little specificity; Doppler ultrasound provides good diagnostic information; CT scans and nuclear magnetic imaging can confirm the diagnostic. The post-heart surgery etiology has increased in recent years. The only real treatment is surgical and consists of pericardial decortication.

[Thrombolysis and acute venous thromboembolic disease]. / Thrombolyse et maladie veineuse thrombo-embolique aiguë.

Thrombolytic agents are widely used as first line treatment in severe acute pulmonary embolisms. While their indications are well defined, no controlled trial exists to provide definite evidence of their ultimate effectiveness in terms of mortality. Nevertheless, therapeutic advances and the good results obtained in terms of satisfactory changes in hemodynamic and angiographic parameters have led to renewed evaluation at the present time of the ways in which they are used in thrombo-embolic disease: administration of thrombolytics as repeated boluses in order to decrease the risk of hemorrhagic complications; and extension of the indications of thrombolysis to the venous component of thrombo-embolic disease.

[Value of transesophageal echography in the diagnosis of posterior ventricular septal rupture during the acute phase of myocardial infarction. Apropos of 2 cases]. / Intérêt de l'échographie transoesophagienne dans le diagnostic de rupture du septum interventriculaire postérieur au stade aigu de l'infarctus du myocarde. A propos de 2 observations.

The authors report two cases of posterior ventricular septal defects complicating acute myocardial infarction diagnosed by transesophageal echocardiography. Transesophageal echocardiography was well tolerated confirmed the diagnosis, and enabled accurate evaluation of the shunt in the transgastric view. The anatomical results guided the surgical approach and correlated well with the operative findings.

[Spontaneous idiopathic pneumopericardium in young patients. Review of the literature. Apropos of a new case]. / Le pneumopéricarde spontané idiopathique du sujet jeune. Revue de la littérature. A propos d'une nouvelle observation.

Spontaneous idiopathic pneumopericardium (SIPP) in young subjects is a rare disorder since, apart from the case described here, only 28 cases have been reported in the literature. It occurs mainly in young adults. The physiopathology of the disorder involves alveolar rupture, as described by Macklin. The symptoms of SIPP are dominated by chest pain, which usually develops suddenly and is combined with dyspnea. Clinical examination is not very helpful, cardiac auscultation detects either pericardial rubbing or a more suggestive metallic sound. Recovery usually occurs without treatment, but there is a risk of long-term recurrence. An unusual complication to be feared is aerial tamponade, which may be life-threatening and calls for emergency draining. The treatment of SIPP involves strict bed-rest, symptomatic treatment of the pain and clinical monitoring.

[Anaphylactic shock complicated by myocardial infarction: side effect of glaphenine?]. / Choc anaphylactique compliqué d'un infarctus du myocarde: effet indésirable de la glafénine? A propos d'un cas.

The authors report a case of anaphylactic shock complicated by coronary spasm and infarction attributed to glafenine medication in a 43-year-old male patient. The outcome was positive and coronary angiography showed healthy coronary vessels. The ergonovine maleate was negative. A review of the literature confirms the rarity of this complication of anaphylactic shock and study the ECG changes induced by this type of reaction and to analyze the mechanisms responsible for this coronary spasm in this situation. These consists basically of histamine release and prostaglandin-synthesis inhibition.

[Predictive factors of regularization and maintenance of sinus rhythm in chronic atrial fibrillation]. / Les facteurs prédictifs de la régularisation et du maintien en rythme sinusal de la fibrillation auriculaire chronique.

The aim in treating chronic atrial fibrillation, is not limited to simply achieving immediate regularization. What matters, is sustaining the sinus rhythm. The various methods of regularization, using either medical procedures or cardioversion, involve constraints and risks. Investigation of the relapse predicting factor is of great value in evaluating the benefit/risk ratio. For regularization, the absence ultrasound signs of heart disease, an undilated left atrium, recent atrial fibrillation and all forms of heart disease which are curable, albeit surgically, are indicative of success. With regard to prophylaxis, relapses occur more frequently in cases involving mitral valve disease, long-standing atrial fibrillation or a dilated left atrium.

Visualization of myocardial infarction 6 h after injection of 111In-antimyosin antibodies using a blood pool subtraction technique.

111In-antimyosin antibodies are capable of visualizing myocardial infarction (MI). Because of slow blood clearance, images are usually recorded 24 or 48 h postinjection. In this pilot study, a blood pool subtraction technique, which makes it possible to visualize MI 6 h postinjection, is validated. Twenty-five patients with proven MI (16 anterior, 9 inferior) were imaged a few minutes, 6 and 24 h after an injection of 111 MBq 111In-labelled antimyosin antibodies. Three planar views are obtained each time. Using software which performs the geometric registration, the grey level normalization and the subtraction of images, the blood pool image (obtained a few minutes postinjection) is subtracted from the 6 h image. The resulting image is the blood pool corrected 6 h image. The 24 h images and the blood pool corrected 6 h images were interpreted blindly and the number of correct, incorrect and impossible MI localizations was counted. The number of correct localizations is 19/25 for the standard 24 h images and 22/25 for the blood pool corrected 6 h images. Then, with this blood pool subtraction method, it is possible to visualize MI 6 h postinjection. This has to be taken into account when discussing the role of antimyosin scintigraphy in the management of patients with MI.

[Massive pulmonary embolism disclosing thrombocytopenia induced by low molecular weight heparin. Therapeutic success of prostacyclin]. / Embolie pulmonaire massive révélant une thrombopénie induite par héparine de bas poids moléculaire. Succès thérapeutique d'une prostacycline.

The authors report a case of massive pulmonary embolism revealing thrombocytopenia induced by a low molecular weight heparin (LMWH) initially proposed for the treatment of superficial phlebitis. The diagnosis was confirmed by in vitro aggregation tests and a fall in the platelet count when the LMWH was reintroduced. The outcome was clinically, angiographically and hematologically satisfactory in response to in situ treatment with prostaglandin, subsequently replaced by Vitamin K antagonists.

[Prognostic value of exercise angioscintigraphy in coronary disease]. / Valeur pronostique de l'angioscintigraphie d'effort dans la maladie coronaire.

Multivariate survival analysis (MSA) was applied to 97 patients with coronary disease using the Cox model and a stepwise regression procedure. Seventeen variables including data based upon clinical examination, exercise testing (ET), and exercise angioscintigraphy (EAS) as well as coronary arteriography were studied in each patient. During the monitoring period (interval: 1-57 months), 38 patients sustained a cardiac event (recurrence of coronary disease or death). Neither resting left ventricular ejection fraction, nor coronary anatomy were significant prognostic variables. The only two variables identified by MSA were a variable of EAS: corrected ejection fraction at maximum exercise (p less than 0.008), and a variable of ET: maximum heart rate during exercise (p less than 0.03). This study shows that the prognosis of a coronary disease patient can best be assessed by two variables which are both exercise parameters.

[Comparative study of 4 ultrasonic methods for evaluating the severity of mitral valve narrowing. Apropos of 36 cases]. / Etude comparative de quatre méthodes ultrasonores d'évaluation de la sévérité des rétrécissements mitraux. A propos de 36 cas.

Four ultrasound methods of estimating the severity of mitral narrowing (MN) were investigated in a prospective manner in 36 patients who underwent ultrasound-Doppler and catheterization (KT) within a space of 24 hours. The correlation of the mean Doppler and KT gradients was poor: r = 0.56 (n = 36, p less than 0.001). The mitral surface areas (MA), calculated from Gorlin's equation (mean A = 0.98 +/- 0.26 cm2) were successively compared with those obtained using the Hatle equation (A = 220/PHT) and by a planimetric determination. The coefficients of correlation were as follows: r = 0.80 (n = 36) and r = 0.70 (n = 32) (p less than 0.001). There was good correlation between the Hatle equation and the planimetric determination: r = 0.80 (n = 32, p less than 0.001). The continuity equation was carried out 15 times; the second measurement site was aortic in 8 cases and pulmonary in 7 cases. Correlations with the Gorlin equation were scored 0.70 and 0.80 respectively (p less than 0.05). The MA was best estimated by the Hatle equation, which was always technically feasible and not influenced by the presence of atrial fibrillation, mitral valve incompetence of previous commissurotomy. Planimetric determination, which is hampered in the presence of considerable calcification, remains valid after commissurotomy. The ultrasound estimation of the MA was very reliable when the planimetric and Hatle estimations concurred. The results obtained from the continuity equation were reliable; however, this method is slow, unreliable in a context of atrial fibrillation and inapplicable in a context of mitral valve incompetence.(ABSTRACT TRUNCATED AT 250 WORDS)

[Postoperative hemopericardium compressing the left atrium. Apropos of 8 cases]. / Hémopéricardes post-opératoires comprimant l'oreillette gauche. A propos de huit cas.

The authors report 8 cases of hemopericardium compressing the left atrium occurring at varying intervals after cardiac surgery. This is an unusual anatomical and classically rare site of pericardial effusion. This type of tamponnade has special clinical features, leading to a picture of subacute left ventricular failure, by interference with filling and typical echocardiographic appearances, with special features in two-dimensional mode and, in TM mode, an abnormal anterior movement of the posterior wall of the left atrium, which is studied. CT scan of the thorax, when performed, confirms this highly specific topographic situation. This type of effusion must be managed surgically as quickly as possible, with an anterior approach, either by left thoracotomy or by midline sternotomy.

[Doppler echocardiographic evaluation of the efficacy of fibrinolytic treatment of pulmonary embolism]. / Evaluation de l'efficacité du traitement fibrinolytique de l'embolie pulmonaire par échocardiographie Doppler.

The efficacy of the fibrinolytic therapy in pulmonary embolism was studied by Doppler echocardiography: the evolution of the cardiac and angiographic changes could be studied in parallel. Thirty patients with severe pulmonary embolism and vascular obstruction greater than 40% (67.2 +/- 9.9%) were examined prospectively by Doppler echocardiography before and after thrombolysis. The following parameters were studied: systolic pulmonary artery pressure calculated from the jet of tricuspid regurgitation and left and right ventricular diameters for the calculation of the ratio of the ventricular dimensions. All patients underwent Doppler echocardiography and pulmonary angiography immediately after thrombolysis. The average improvement of the percentage vascular obstruction was 37%. The hemodynamic and echocardiographic changes were globally favourable. The pulmonary artery systolic pressure fell from 51 +/- 10 to 33 +/- 6.7 to 25.3 +/- 6.3 mm and the ratio of ventricular dimension from 0.87 +/- 0.3 to 0.60 +/- 0.16 (p less than 0.001). Only 4 patients had pulmonary artery systolic pressures over 40 mmHg after therapy compared with 26 before therapy. However, the hemodynamic and angiographic correlations were poor (r = 0.37; p less than 0.001). In the 6 patients in whom treatment was ineffective according to angiographic criteria (less than 20% improvement of vascular obstruction), the echocardiographic changes were small or absent, the improvement in the ratio of ventricular dimensions being less than 20%. However, a satisfactory correlation was observed between the percentage improvement of the ratio of ventricular dimensions and that of vascular obstruction (r = 0.59; p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Therapeutic value of esophageal stimulation. Factors influencing the results in flutter and atrial tachysystole]. / Intérêt thérapeutique de la stimulation oesophagienne. Facteurs influençant les résultats pour le flutter et la tachysystolie auriculaire.

The aim of this prospective study was to identify factors predicting the efficacy of atrial stimulation by esophageal route in 57 nonselected patients between 37 and 88 years of age and admitted for intensive care due to flutter or atrial tachycardia. It was impossible to perform the procedure correctly in 4 patients. The restoration of sinus rhythm was achieved in 28.3% of cases at the end of the procedure and in 47.2% of cases after 24 hours. These results were influenced by the duration of the arrhythmia, the underlying cardiopathy and the diameter of the left atrial, but were not affected by the stimulation parameters.

[Spontaneous pneumopericardium. Review of the literature apropos of 2 cases in the young adult]. / Les pneumopéricardes spontanés--revue de la littérature. A propos de deux observations chez l'adulte jeune.

Pneumopericardium is defined as the presence of air in the pericardial cavity. It is a rare condition in adults, usually due to trauma; it is commoner in the more exposed neonate and usually iatrogenic. The clinical presentation of chest pain and shortness of breath is associated with the pathognomonic auscultatory sign described by Bricheteau: a water-mill bruit. The diagnosis is confirmed by chest X-ray which shows the air-gap sign surrounding the cardiac silhouette. The principal differential diagnosis is a pneumomediastinum. The prognosis of pneumopericardium depends on the cause and complications of which tamponade and infection are the most serious and potentially life-threatening. The treatment of pneumopericardium is bed rest and surveillance when uncomplicated: evacuation of the air becomes necessary when complications set in.

[Diagnosis and evaluation of mitral endocarditis complicating obstructive cardiomyopathy using cardiac echo-Doppler]. / Diagnostic et bilan d'une endocardite mitrale compliquant une cardiomyopathie obstructive par écho-Doppler cardiaque.

The authors report a case of mitral endocarditis diagnosed by cardiac echo-Doppler and complicating an obstructive cardiomyopathy (OCM) in a 37-year-old woman. Despite the high degree of sub-aortic obstruction and the existence of an apparently severe mitral leak by Doppler analysis, the patient remained totally asymptomatic and the outcome was favourable with appropriate antibiotics. A review of the literature revealed 11 cases of endocarditis in a context of OCM, documented by echocardiography. Echo-Doppler enables precise evaluation of this grave and often poorly tolerated complication of OCM.

[Iatrogenic arteriovenous fistula between the internal mammary artery and the innominate venous trunk. Contribution of digital arteriography in the positive and anatomic diagnosis]. / Fistule artérioveineuse iatrogène entre artère mammaire interne et tronc veineux innominé. Apport de l'artériographie digitalisée dans le diagnostic positif et anatomique.

The authors report the case of an arterio-venous fistula between the internal mammary artery and the trunk of the innominate vein following puncture of the internal jugular. The clinical signs of this unusual complication led the authors to list the differential diagnoses which should be considered and to draw attention to the importance of digitalized angiography in anatomical diagnosis.

[Malignant histiocytofibroma of the heart simulating myxoma of the left atrium]. / Histiocytofibrome malin du coeur simulant un myxome de l'oreillette gauche.

The authors report a case of malignant fibrous histiocytoma of the left atrium which was excised but rapidly recurred in a 47-year-old woman. Clinical examination, echocardiography and the absence of biochemical abnormalities were in favour of the diagnosis of left atrial myxoma. This report illustrates the clinical similarity between myxoma and sarcoma of the left atrium. Very careful anatomopathological examination of multiple sections of the tumour are necessary to distinguish it from benign tumours, especially myxomas.

[Differential analysis of mitral and tricuspid regurgitation by continuous Doppler]. / Analyse différentielle des fuites mitrales et tricuspides par le Doppler continu.

The following parameters have been measured by continuous Doppler in 40 patients with both mitral failure (MF) and tricuspid failure (TF): effusion time (ET), peak time (PT), maximum effusion speed (S. max), maximum anterograde speed (S. ant), taking into account the cardiac rate and the ejection fraction. Only the S. max. and the S. ant. are significantly different and enable the determination of the effusion origin with a percentage error of about 4%. When a straight line is drawn to joint 3.7 m/s on the ordinate (S. ant) and 5 m/s on the abcissa (S. max), the TF lie below the line and the MF above it. The selection of the sub-groups with low ejection fraction (less or equal to 30%) or with arterial pulmonary hypertension (S. max MF higher or equal to 3 m/s) does not modify the precision of the discrimination. The graph suggested seems therefore to be a rapid and reliable means of characterizing TF in order to assess the arterial pulmonary hypertension of dilated hypokinetic cardiomyopathies.