Long-term efficacy of dynamic cardiomyoplasty. Clinical, ultrasonic and haemodynamic evidence in one case.

We report one case of successful cardiomyoplasty in a 21-year-old male and its beneficial effects as assessed by clinical examination, Doppler echocardiography, phonocardiography, haemodynamic and angiographic evaluation at 1 year. Long-term efficacy of this procedure on left ventricular function was confirmed by these techniques.

[Progression from hypertrophic obstructive cardiomyopathy to dilated cardiomyopathy. Apropos of 4 cases]. / Evolution d'une myocardiopathie hypertrophique obstructive vers une myocardiopathie dilatée. A propos de 4 cas.

Four cases of hypertrophic obstructive cardiomyopathy diagnosed on clinical, phonomechanographic, echocardiographic and haemodynamic criteria progressing to dilated cardiomyopathy are reported. This evolution was observed over a number of years (up to 20 years) and was accompanied by a clinical aggravation in all cases with 2 deaths and atrial fibrillation in 3 of the 4 cases. The signs of intraventricular obstruction [systolic murmur, bulge on the carotid pulse tracing, systolic anterior motion of the mitral valve (SAM) and intraventricular pressure gradient] disappeared as the left heart chambers dilated with a reduction in ventricular wall motion and parietal thinning but no change in myocardial mass.

Contribution of the dynamic phonocardiography to the valvular heart disease diagnosis: an expert system study.

The contribution of pharmacodynamic tests to the diagnostic accuracy of phono-mechanocardiography was tested by means of an expert system, in order to make an objective evaluation. In 198 valvular heart disease patients, the use of dynamic tests significantly improved the rate of diagnostic success, thus confirming the usefulness of dynamic phono-mechanocardiography.

[Surgical mitral valvuloplasty and dynamic left ventricular obstruction syndrome]. / Valvuloplastie mitrale chirurgicale et syndrome d'obstruction intraventriculaire gauche "dynamique".

The "dynamic" left ventricular outflow obstruction syndrome, which is found in 4.5 to 11 p. 100 of patients who underwent mitral valve repair by Carpentier's technique, seems to be due to the association of two different sets of circumstances. The first set is anatomical; the syndrome is thought to result from the implantation of a semi-rigid valve ring, from the excessive length of the mitral valve system in relation to the size of the ventricular cavity, and from excessive correction of mitral regurgitation with subsequent excessive reduction in caliber of the left ventricular outflow tract, change in the interrelation between outflow tract and ventricular filling and strongly anterior position of the mitral valve. The second set is functional; it is due to a more than 20 p. 100 reduction in caliber of the left ventricular outflow tract on the one hand, and to a more than 2.5 m/s increase in blood flow velocity on the other hand. These two phenomena may be produced by a decrease in left ventricular volume as a result of hypovolaemia, tachycardia or more rapid circulation. Treatment of the syndrome consists of correcting the associated abnormalities by prescribing a diet with a normal sodium content, together with an appropriate anti-arrhythmic agent and a beta-blocker.

[Phono-mechanographic evaluation of aortic stenoses. Contribution of the B1-maximum murmur/B1-B2 index]. / Evaluation phonomécanographique des rétrécissements aortiques. Apport de l'indice B1-maximum du souffle/B1-B2.

The diagnostic value of phonomechanography in valvular aortic stenosis was reassessed with a rarely used index, the ratio S1-maximum intensity of the systolic murmur/S1-S2, or Thiron's index, the author of which only studied the correlations with the aortic transvalvular pressure gradient. The results obtained by the author being considered inconclusive, we decided to examine its correlations with aortic valve surface area calculated with the Gorlin's formula. The study was carried out in 38 patients with pure aortic stenosis, in whom 4 phonomechanographic parameters, the corrected left ventricular ejection time (Meiners), the carotid pulse half peak time, the S1-maximum intensity of the murmur interval and Thiron's index, were compared with the transvalvular pressure gradient and the aortic valve surface area at catheterisation. The first two parameters mentioned above were of limited value (correlations with aortic valve surface area r = 0.315, p less than 0.05 and r = 0.477, p less than 0.01 respectively). On the other hand, a good correlation was obtained with Thiron's index (r = 0.624, p less than 0.001) which was better than that found with the interval between S1 and maximum intensity of the systolic murmur (r = 0.483, p less than 0.001) in a population not excluding subjects with cardiac failure. These results indicate that: when Thiron's index less than or equal to 0.45, the aortic stenosis is probably mild (aortic surface area greater than 0.8 cm2), when Thiron's index is 0.46 greater than 0.56, the aortic stenosis is likely to be moderately severe (aortic surface area 0.8 less than 0.5 cm2), when Thiron's index is greater than 0.57, the aortic stenosis is probably severe (aortic surface area less than 0.5 cm2). In our series, Thiron's index was the best phonomechanographic parameter for the assessment of pure aortic stenosis. It could not be calculated in 10 out of 48 patients; this drawback was not encountered with the corrected left ventricular ejection time or the carotid pulse half peak time.(ABSTRACT TRUNCATED AT 250 WORDS)

[Current role of phonomechanocardiographic recording in the diagnosis of heart valve diseases]. / Place actuelle des enregistrements phonomécanocardiographiques dans le diagnostic des valvulopathies.

Phonocardiography (and auscultation) provide many accurate diagnoses of valvular heart diseases, when they are fully developed and give rise to a typical murmur. Echocardiography displays its mechanism, in most cases (leaflet thickening, ruptured chordae tendinae, vegetations, prolapse). Assessment of their severity is based on analysis of the systolic time intervals on the one hand, and on echocardiographic measurements on the other, i.e., internal dimensions of the heart chambers, wall thickenesses and motions. When necessary, acute pharmacologic interventions permit the diagnosis (positive and differential) of the various types of ventricular outflow tract obstructions (mild or severe), of mild, atypical or "masquerading" regurgitations and of the "innocent" murmurs. They are easier to carry out and to interpret on the basis of phonocardiographic than echocardiographic recordings. Hence the advisability of using both diagnostic methods, as each provides specific data which often support, and always complete one another.

Effect of propranolol on left ventricular relaxation in hypertrophic cardiomyopathy: an echographic study.

Many authors have shown that hypertrophic cardiomyopathy (HCM) is often associated with diastolic abnormalities. The purpose of this study was to determine the effect of propranolol on left ventricular isovolumic relaxation time (IVRT) measured by echocardiography in 20 patients with hypertrophic cardiomyopathy under basal conditions and under increasing doses of propranolol (160 mg, 320 mg, and 480 mg per day) and in two control groups, 10 patients with aortic stenosis, and 10 normal subjects. IVRT was less than 50 msec in all normal subjects, while it was always above this limit in aortic stenosis (77 msec +/- 8, p less than 0.001), and in hypertrophic cardiomyopathy (94 msec +/- 19, p less than 0.001), with also a significant difference between these two last groups (p less than 0.01). Under increasing doses of propranolol, relaxation time often shortens gradually until 50 msec or less. These results show an improvement in left ventricular relaxation dependent on the propranolol dosage and often a normalization at high dosages.

[Aortic and mitral valve bioprostheses. Normal and pathological M mode echocardiographic aspects]. / Bioprothèses valvaires aortiques et mitrales. Aspects échocardiographiques TM normaux et pathologiques.

The M mode echocardiographic recordings of 52 normal mitral bioprostheses (NMB), 7 pathological mitral bioprostheses (PMB), 30 normal aortic bioprostheses (NAB) and 10 pathological aortic bioprostheses (PAB) were reviewed. In normal bioprostheses a significant correlation was observed between the echocardiographic and the "specified" diameters, the diastolic and systolic slopes and the amplitude of anterior motion of the support. In NMB, the end-systolic diameter of the left ventricular outflow tract depended on the "specified" diameter of the bioprosthesis. Paradoxical septal motion was observed in 78 p. 100 of cases. In PMB, the velocity of anterior leaflet opening was significantly increased (p less than 0.001). The end-diastolic internal left ventricular dimension was also increased (p less than 0.01). A significant correlation was found between left ventricular fractional shortening and maximal leaflet separation (p less than 0.05). Normal septal motion was more common (p less than 0.05). In 5 cases of prosthetic valve dysfunction with mitral regurgitation the maximal leaflet separation was greater than normal (p less than 0.001), the diastolic slope of the support was increased (p less than 0.05) and diastolic vibrations of thickened irregular leaflets were observed. Systolo-diastolic vibrations with chaotic leaflet motion were characteristic of cusp tear and/or eversion. Stratified echos behind a support with reduced leaflet excursion was observed in one case of partial thrombosis: a thickened systolic echo with reduced diastolic excursion was observed in a case of degenerative stenosis. The review of 10 PAB showed a reduced amplitude of systolic excursion of the anterior support in cases of aortic regurgitation (p less than 0.05). Systolic vibrations of the cusp were not specific and were observed in normal cases. In severe valvular regurgitation mitral and/or septal diastolic fluttering was observed. Systolic excursion of the cusps was reduced in cases of relative stenosis due to an inappropriately small sized bioprosthesis. Thickening of the diastolic cusp echos was observed in cases of degenerative stenosis. Ventricular dilatation and reduced septal and free wall motion were dysfunction.

Contribution of pharmacologic tests to the diagnosis of left ventricular regurgitations and obstructions: a phono-echocardiographic confrontation.

Pharmacologic interventions--procedures akin to exercise tests--facilitate, and sometimes permit, the diagnosis of left ventricular regurgitations and obstructions. Particularly when, at rest, the resulting murmur a) is soft or atypical (or absent) and, b) reflects a disease combining both mechanisms (obstruction and regurgitation) during systole. In these circumstances, the echocardiogram may be nondiscriminating or incomplete, and the pharmacologic tests difficult to carry out and to interpret with this technique. Hence the necessity to combine both diagnostic procedures, phonocardiography with pharmacologic intervention, on the one hand; echocardiography, on the other. Each method provides specific and complementary information.

[Myocardial infarction in the young subject: a medium-term clinical and coronary angiographic study in 40 patients under 36 years of age. Comparison with coronary angiographic data of myocardial infarction in patients after 50 years of age]. / L'infarctus myocardique du sujet jeune: étude clinique et coronarographique à moyen terme de 40 patients de moins de 36 ans. Comparaison avec les données coronarographiques de l'infarctus myocardique après 50 ans.

A series of 40 myocardial infarctions, occurring in patients under 36 years of age was studied retrospectively (Group I: mean age 31.3 years). The medium term results of coronary angiography in this group were compared with those of 60 myocardial infarctions after 50 years of age (Group II: mean age 56.6 years). Group I had a clear male predominance (92.5%), a high incidence of smoking (69%), hypercholesterolaemia (69%); myocardial infarction was the first manifestation of their disease in 54% and it was often extensive (42%). A comparative angiographic study between the two groups showed: 1) Less widespread lesions in Group I, as assessed by the number of main arteries stenosed (p less than 0.001), the coronary index (p less than 0.01) and the mean coronary score using Friesinger's method (p less than 0.01). 2) A higher incidence of subnormal coronary angiogrammes in Group I (absence of 50% stenosis) (15%) and of single vessel disease (40%): compared with Group II in which multivessel disease was observed in 86.5% of cases. 3) Collateral circulation was less common in Group I (p less than 0.01). On the other hand, a comparative study of regional and global left ventricular function showed no difference between the two groups. Two subgroups were distinguished in Group I: in one subgroup, multiple lesions similar to those found in Group II, suggestive of premature coronary atherosclerosis (52.5%); the other group (47.5%) presented unilocular lesions i.e. focal mono-arterial lesions compatible with other causes of infarction (thrombosis and/or spasm). These patients were younger (p less than 0.05) and had significantly fewer cardiovascular risk factors (p less than 0.01). Despite the fact that the coronary lesions were limited, the myocardial damage was comparable with the other groups as the collateral circulation was much less developed (p less than 0.02). These appearances were only observed in 3.5% of patients in Group II. The study of the angiographic outcomes of these two types of lesions should show a difference and could contribute to the understanding of their mechanisms.

[Obstructive hypertrophic myocardiopathy and Osler's endocarditis]. / Myocardiopathie hypertrophique obstructive et endocardite d'Osler.

Four cases of bacterial endocarditis (BE) complicating hypertrophic obstructive cardiomyopathy (HOCM) were observed between 1978 and 1980. The causal organism was a streptococcus in all cases and the portal of entry, dental. The mitral regurgitation (MR) observed in HOCM as an epiphenomenon of the obstruction became autonomous in 2 patients as shown by phonocardiography with methoxamine. In one case, the MR became severe and justified mitral valve replacement; at surgery, the chordal rupture suspected on echocardiography was confirmed. Antibiotic therapy was effective on the infectious process in all cases. However, 2 of the 4 patients died, one of thrombosis of the mitral prosthesis on the 15th postoperative day, and the other of a cerebrovascular accident. None of the patients had a detectable aortic or septal infectious lesion. Eight of 27 reported cases (30 p 100) of HOCM complicated by BE were operated; 10 (37 p. 100) died as a result of the endocarditis. These cases underline the incidence of BE in HOCM (5 p. 100) its gravity and the necessity for systematic antibiotic prophylaxis, especially before dental treatment.

[Comparative evaluation of phonocardiogram and echocardiogram in mitral valve prolapse diagnosis (author's transl)]. / Valutazione comparative del fonocardiogramma e dell'ecocardiogramma nella diagnostica del prolasso mitralico.

In order to determine the correlation between echocardiography (ECHO) and phonocardiography (PHONO) in the evaluation of the Mitral Prolapse Syndrome (PM), 87 subjects with echo or phono criteria of PM were studied using both techniques. The phonocardiographic criteria used for PM diagnosis were the presence of a telesystolic click and/or a telesystolic murmur. The echocardiographic criteria were a telesystolic or holosystolic posterior movement of a mitral leaflet continuously seen through systole or of both mitral leaflets seen in part of systole. In the 63 patients with ECHO indicative of PM, the PHONO was positive in 55 cases (87%). Methoxamin administration, in 5 cases whose basal PHONO was normal, allowed the observation of 3 telesystolic murmurs and 2 clicks. The drug also diminished the number of clicks and increased tfhe telesystolic murmurs. In 79 subjects with PHONO indicative of PM, the ECHO was positive in 57 cases (72%): this technique was of particular value in patients with olosystolic murmur; valuable also to evaluate the diastolic diameter of the left ventricle and the left atrium and other signs having a possible use for a more accurate physiopatologic definition of the PM syndrome.