[Acute type-B aortic dissection associated with isthmic coarctation in adult]. / Dissection de l'aorte descendante révélant une coarctation méconnue chez l'adulte.

The authors report a case of acute type-B aortic dissection in association with an unknown isthmic coarctation in a 30-year-old adult. Successful surgical repair was performed 6 months later without cardiopulmonary bypass. Physiopathological aspects and surgical strategy are discussed. Acute aortic dissection distal to isthmic coarctation is extremely rare and has been reported in only 5 other cases. Present case is the first, to our knowledge, to be operated without cardiopulmonary bypass.

[Secondary prevention after acute coronary syndrome: therapeutic goals achievement in relation with changes in guidelines]. / Prévention secondaire après syndrome coronarien aigu: évolution des recommandations et niveaux d'atteinte des objectifs.

BACKGROUND: Secondary prevention is a key strategy for reducing levels of coronary heart disease, but a gap between guidelines and practice remains. OBJECTIVES: The aim of this double-part survey was to evaluate the improvement in secondary prevention one year after acute coronary syndrome (ACS) in real life, between 1999 and 2005, with respect to the change in guidelines. METHODS: Two surveys of almost similar design were performed in 1999 and 2005-2006. In each survey, unselected consecutive patients suffering from ACS (n=112 hospitalized in 1998, and n=110 in 2004) were evaluated at admission, and one year after hospitalization, for the risk factors, lifestyle, and achievement of therapeutic goals recommended by the most recent guidelines. Follow-up (FU) data were obtained by mail and phone contact with patient, general practitioner and cardiologist, and medical laboratory when appropriate. RESULTS: At 1-year FU (n=192 survivors with FU), smoking cessation (87% in 1999 versus 89% in 2005) and obesity (13% versus 19%, respectively) did not vary significantly. Blood pressure was controlled (< 140/90 mmHg, excepted in diabetics in 2005 with less than 130/80 mmHg) in 65% versus 80% (p<0.03). The rate of patients with no or controlled diabetes mellitus decreased from 1999 to 2005 (90% versus 76%), despite more intensive treatment (insulin in 1% versus 20%).The goals for LDL cholesterol were achieved in 47% of patients in 1999 (< 3.4 mmol/L) and in 76% in 2005 (< 2.6 mmol/L) (p<0.0001). Goals for triglycerides were achieved in 86% in 1999 (< 2g/L), and in 80% in 2005 (< 1.5 g/L) (NS). Besides, 63% of patients received an hypolipemic drug in 1999 (a statin in 59%) and 91% in 2005 (a statin in 88%). Mean number of controlled risk factors was 3.96+/-1.52 in 1999 versus 4.94+/-1.83 in 2005, and prevalence of pts with more than five controlled risk factors at one year FU increased from 15 to 44% (p<0.0001). CONCLUSIONS: These results, drawn from unselected consecutive patients managed in real life, demonstrate an improvement in secondary prevention one year after ACS, between 1999 and 2005, despite strengthened guidelines for blood pressure, triglycerides and LDL cholesterol levels. Control of obesity and diabetes remains unoptimal.

Time course of troponin I, myoglobulin, and cardiac enzyme release after electrical cardioversion.

The results of this study, conducted in 25 patients without myocardial infarction, showed that all the biologic markers of myocardial infarction, except the highly cardiospecific cardiac troponin I, increased in some patients after electrical cardioversion. These results allow us to conclude that electrical cardioversion, even preceded by a mechanical resuscitation of short duration, does not result in myocardial damage, and that cardiac troponin I is more accurate than creatine kinase-MB activity and creatine kinase-MB mass determination for the diagnosis of myocardial damage in patients who have undergone electrical cardioversion.

Radiographic features of cauda equina syndrome complicating ankylosing spondylitis.

Cauda equina syndrome is an uncommon complication of ankylosing spondylitis. The characteristics of this disease, as shown by plain radiography, computed tomography and magnetic resonance imaging (MRI) in a 56-year-old man, are described. The MRI features are pathognomonic, allowing accurate noninvasive diagnosis of the disorder.

Thoracic splenosis after blunt trauma: frequency and imaging findings.

OBJECTIVE: Thoracic splenosis is an uncommon sequela of simultaneous splenic and diaphragmatic injury. The aim of this prospective study was to evaluate the prevalence of thoracic splenosis in 17 subjects who had sustained splenic and diaphragmatic injury and to describe the CT and MR features of thoracic splenosis. SUBJECTS AND METHODS: All patients had 99mTc-RBC scintigraphy. Subjects with radionuclide uptake in the thorax were further examined with radiography, CT, and MR imaging of the chest. RESULTS: Three subjects (18%) had evidence of ectopic splenic activity in the left side of the thorax. The CT features consisted of one pleural nodule and two pleural masses. The MR appearance of the ectopic splenic tissue was similar to that of normal spleen. CONCLUSION: Thoracic splenosis occurs with moderate frequency after combined splenic and diaphragmatic injury. The CT appearance is that of pleural masses or nodules. The MR appearance is relatively similar to that of normal spleen.

Ultrasonographic features of abdominal ectopic splenic tissue.

Ectopic splenic tissue may be congenital (an accessory spleen) or a result of traumatic autotransplantation (splenosis). The purpose of this study was to identify the features of ectopic splenic tissue in ultrasonography (US) scans. Selective spleen scintigraphy (with heat-denatured erythrocytes labelled with technetium 99m) was performed on 33 patients who had undergone splenectomy after trauma; the 25 (76%) for whom the results were positive subsequently underwent US. Of the 25 patients, 23 (92%) had one to five foci of ectopic splenic tissue; 62 of the 68 foci (91%) were in the left upper quadrant. US identified splenic tissue in 17 of the 25 patients (68%). All 44 foci visible with US were hypoechoic, and 33 of them (75%) exhibited acoustic enhancement or an incomplete hyperechoic rim or both. Nineteen of the foci revealed by US (43%) were smaller than 1 cm2. No criteria were found to permit differentiation of accessory spleens from splenosis. In three of every four patients who undergo splenectomy after trauma, ectopic splenic tissue eventually develops. Radiologists should be aware of this condition to avoid incorrectly diagnosing this ectopic tissue as metastasis, adenopathy or another solid tumour. US, in combination with selective spleen scintigraphy, permits a specific diagnosis without invasive procedures.

Ultrasonographic appearance of appendiceal endometrioma.

Endometriosis may involve the gastrointestinal tract, but only rarely is the appendix affected. The authors report the ultrasonographic appearance of appendicular endometriosis, which was unexpectedly discovered in a 31-year-old woman. The lesion was also demonstrated by computed tomography and an upper gastrointestinal tract radiographic series after barium ingestion. The diagnosis was confirmed by surgery. The authors believe this to be the first description of the ultrasonographic appearance of appendicular endometriosis.

Life-threatening thyrotoxicosis induced by amiodarone in patients with benign heart disease.

We report four cases of life-threatening amiodarone iodine-induced thyrotoxicosis. Two patients died of a thyroid storm, and the other two patients developed severe thyrocardiac disease unresponsive to 6 months intensive antithyroid and steroid therapy. One of these latter patients died 1 month after thyroidectomy. Euthyroidism was achieved in the last patient by treatment with potassium perchlorate. The course could not be explained by the prior thyroid or cardiac status in any of the four cases.

Valvular replacement for aortic stenosis in patients over 70 years: immediate risk and long-term results (from a consecutive series of 355 patients).

From 1971 to 1985, 355 patients over 70 years of age (mean age 73.7) underwent isolated aortic valve replacement, most of them for pure calcified stenosis (78.6%). Mechanical valves (group A) were used in 112 cases (109 Bjork-Shiley; 3 SJM) and bioprostheses (group B) exclusively implanted since 1981 (192 Edwards-Carpentier; 51 Ionescu-Shiley). Thirty-six patients died post-operatively (10.1%). 36% of the deaths were related to cardiac causes, and 14% to cerebral damage. The follow-up involved 100% of the 319 survivors and spanned 12 years (1 month to 11.8 years), with an average of 3.2 years. The follow-up was almost equally distributed between groups A and B: 474 and 453 patient-years, respectively. Sixty late deaths (18.8%) occurred: 26.7% of them related to cardiac causes, and 20% to cerebral accidents. Twenty-nine cases were in group A (6.1% patient-years), and 31 in group B (5.7% patient-years). Acturial analysis shows that, at five years, 94.1% of patients in group A and 96% in group B were free of valve-related complications, and that 88.9% in group A and 89% in group B were free of valve-related non-lethal complications. Actuarial calculation of survival rates shows that, at five years, the probability of survival was 70.8% for the entire series, including the operative deaths. This curve of survival is similar to that of the normal population of the same age. Moreover, the functional status is dramatically improved by surgery: 99.6% of patients are in the NYHA classes I or II.

[Light chain disease with terminal myocardiopathy]. / Maladie des chaînes légères avec myocardopathie terminale.

The authors report a case of a 35 year old man with of congestive cardiac failure. Echocardiography showed diffuse hypokinetic wall motion with moderate parietal hypertrophy without dilatation. Post-mortem examination showed intramyocardial deposits of light chains identical to those observed in "in vivo" renal and liver biopsies. This rarely described disease has a poor prognosis. It is characterised by polyvisceral infiltrations of light chain monoclonal immunoglobulins. Renal disease is usually the main problem progressing rapidly to renal failure. Of the extra renal localisations, cardiac involvement would appear to be common and preoccupying in itself. Monoclonal plasmocytic proliferation is observed in all cases, the majority but not all being malignant (myeloma). The incidence of this condition is probably underestimated and may pass undetected if immunofluorescent techniques are not used. Myelomatous light chain cardiac disease could therefore be more common than amyloidosis with which it presents a number of common features.

[Average steady-state plasma levels with slow release quinidine preparations]. / Concentrations plasmatiques moyennes à l'état d'équilibre avec des préparations de quinidine à libération progressive.

Arabogalactane sulphate of quinidine (AGSQ) is a slow release preparation of quinidine. The aim of this study was to compare the plasma levels of quinidine obtained by different preparations of AGSQ (AGSQ I, II and III) and to determine which was best suited to therapeutics. The "in vitro" study showed different amounts of quinidine liberated in 6 hours, 34% with AGSQ I, 58% with AGSQ II and 100% with AGSQ III. The plasma quinidine levels were studied after administration of a dose corresponding to 330 mg quinidine base, morning and evening for 7 consecutive days to 27 hospitalised patients; 7 received AGSQ I, 11 received AGSQ II 5, received AGSQ III and 4 quinidine sulphate. The delay in reaching a steady state was 24 hours for the quinidine sulphate 36 hours for AGSQ I, 48 hours for AGSQ II and 60 hours for AGSQ III. The average plasma level on the 7th day (Cee) was 2.74 +/- 0.71 microgram/ml, 2.62 +/- 0.74 microgram/ml and 3.29 +/- 0.72 microgram/ml respectively. The plasma quinidine levels were maintained between toxic and therapeutic levels (3,5 and 1,7 microgram/ml) only with AGSQ II by suppressing the peak observed 1 hour administration of quinidine sulphate. An excellent correlation (r = 0,984) was observed between the plasma quinidine 6 hours after ingestion and the Cee. A blood test during the steady state, 6 hours after ingestion of the drug, is useful in adjusting the dosage. These results suggest that AGSQ II is the preparation best suited for therapeutic usage although it does not give the best relative bioavailability of the drug.

Comparative efficacy of short-acting and long-acting quinidine for maintenance of sinus rhythm after electrical conversion of atrial fibrillation.

Forty patients with chronic atrial fibrillation, apparently unrelated to any overt heart disease, were randomly allocated to two groups after restoration of sinus rhythm by direct current shock. The patients in group A were given 4 daily doses of quinidine polygalacturonate, while those in group B were given 2 daily doses of a long-acting quinidine preparation, quinidine arabogalactan sulphate. The percentage of early relapses (within the first month following DC shock) was not significantly different in the two groups: 44-4% in group A and 35% in group B (P greater than 0-50). On the other hand, there were fewer late relapses with long-acting quinidine. After 18 months of treatment, 27-8% of patient in group A remained in sinus rhythm, compared with 61% in group B (P less than 0-05). The average amount of quinidine actually ingested by the patients in group A was smaller than that in group B. However, this could not entirely account for the difference observed in the incidence of relapse since with short-acting quinidine the proportion of patients remaining in sinu rhythm was similar whether the dose was decreased or not. The incidence of gastrointestinal side-effects was the same in the two groups and there were no seriou complications that could be attributed to treatment. It is concluded that long-acting quinidine preparations are more effective than conventional quinidine in preventing late relapses of atrial fibrillation.

[Prolonged anuria during bacterial endocarditis]. / Anurie prolongée au cours d'une endocardite bactérienne

The authors report a case of anuria which lasted 3 months in a patient with sub-acute streptoccocal endocarditis. The investigations led to the discovery, at the level of the kidneys, of arterial aneurysms, renal infarction and diffuse endo-capillary proliferative glomerulonephritis, with deposits of complement and immunoglobulin and finally, interstitial nephritis, perhaps of metastatic origin, which was probably the lesion responsible for the renal failure. Renal function progressively improved and hemodialysis was stopped at the 6th month after correction of the mitral and aortic valve disease.