[BNP and echocardiography can predict the occurrence of acute cardiac decompensation during titration of bisoprolol in chronic systolic heart failure]. / Le BNP et l'échocardiographie prédisent la survenue de décompensation cardiaque aigue au cours de la titration du bisoprolol dans l'insuffisance cardiaque chronique systolique.

OBJECTIVES: Based on the fact that NYHA class, plasma BNP level, and echocardiographic indices of left ventricular filling pressures are prognostic factors in chronic systolic heart failure, we evaluated their predictive value for acute decompensation following initiation and titration of bisoprolol in this illness. METHODS AND RESULTS: Bisoprolol was initiated and/or increased according to the ESC/ACC/AHA recommendations in 50 patients with stable chronic systolic heart failure (age: 60+/-2 years, males: 88%) in NYHA class? 2 with a left ventricular ejection fraction (LVEF)<40% and a plasma creatinine<250 micromol/l. The clinical parameters, plasma BNP levels and echocardiographic indices were measured blind on the same day, on admission and then once a week for three weeks. On admission, the NYHA was 2.9+/-0.1, mean plasma creatinine 99+/-3 micromol/l, plasma BNP 503+/-57 pg/ml, LVEF 29+/-1%, E/A ratio 1.9+/-0.2, E/Ea ratio 8.8+/-0.3, E wave deceleration time 155+/-9 ms, systolic pulmonary artery pressure 40+/-2 mmHg and the diameter of the inferior vena cava was 16+/-1 mm. Over the course of follow up, an episode of acute decompensation occurred in 16% of the patients (8/50). Using univariate analysis, age and initial (admission) values for NYHA class, blood pressure, plasma BNP level, E/A ratio, E wave deceleration time, E/Ea ratio and the systolic pulmonary arterial pressure allowed prediction of the occurrence of acute decompensation following initiation and titration of bisoprolol. The use of the initial value of NYHA class alone allowed prediction of the occurrence of acute decompensation in just 56% of the patients, and the absence of an occurrence of acute decompensation in 93% of them. Normal results for the echocardiographic indices (systolic pulmonary arterial pressure<40 mmHg or E/A ratio<1.4 or E wave deceleration time>145 ms) as recorded on admission were associated with the absence of an occurrence of acute decompensation is 100% of cases. The combined use of NYHA class>3 and either a BNP>398 pg/ml or echocardiographic indices in favour of an elevation in left ventricular filling pressures (systolic pulmonary arterial pressure>40 mmHg, E/A ratio>1.4 or E wave deceleration time<145 ms) allowed prediction of the occurrence of acute heart failure in 100% of cases CONCLUSION: The combined use of NYHA class, BNP level and echocardiographic indices for measuring left ventricular filling pressures is more pertinent than the isolated use of clinical parameters for predicting tolerance to bisoprolol in chronic heart failure with a LVEF<40%.

[Treatment of left intraventricular thrombosis with low molecular weight heparin]. / Traitement des thrombus intraventriculaires gauches par héparine de bas poids moléculaire.

UNLABELLED: Following the discovery of a left intra ventricular thrombus (LIVT), the classical approach consists of treatment with non-fractionated heparin (NFH) followed by oral anticoagulants. The use of NFH for this indication has only been evaluated in one open, non randomised study of 23 patients with no control group. Low molecular weight heparins (LMWH) have not been the object of any study although they are routinely used by certain teams. The objective of this study was to evaluate the feasibility of the use of LMWH in the treatment of left intra ventricular thrombus. This was an open, non randomised prospective study. All patients having a newly diagnosed LIVT between September 2000 and September 2002 were treated with enoxaparine (100 IU/kg twice daily) for an average duration of 13 days; replacement with fluindione was started on the fifth day. The progression of the LIVT was followed using twice weekly transthoracic echocardiography for 3 weeks. RESULTS: 19 LIVT were discovered in 2 years (13 complicating an anterior infarct and 6 with a dilated cardiomyopathy). The average area was between 2.64 +/- 0.41 cm2 and 0.43 +/- 0.21 cm2 (p < 0.0001). Thirteen out of 19 thrombi disappeared with treatment (68.5%). There was no thrombocytopenia or haemorrhage. One transient ischaemic attack was noted. CONCLUSION: This preliminary work shows that LMWH are well tolerated and effective to make a thrombus disappear or to reduce its size.

[Myocardial bridge: description, significance, treatment]. / Pont myocardique description, signification, traitement.

The myocardial bridge is a well known anomalous trajectory of the coronary arteries, the significance of which has been discussed for a long time. It now appears that some myocardial bridges may cause myocardial ischaemia with clinical electrocardiographic, scintigraphic or metabolic signs--even myocardial infarction or sudden death. In these symptomatic cases, treatment is usually medical and rarely surgical. In the last few years, angioplasty and stenting have been used more frequently in cases resistant to medical therapy and appear to be an effective alternative to surgery.

[Occlusion of a coronary endoprosthesis after a negative stress test]. / Occlusion d'endoprothèse coronaire au décours d'une épreuve d'effort négative.

The frequency of early occlusion of coronary stents has fallen with the use of a powerful association of platelet antiaggregants (ticlopidine and aspirin) in the first month. The authors report the case of coronary stent occlusion after a negative exercise stress test, 11 days after implantation in a centre of cardiac rehabilitation. According to the literature, this type of complication would appear to be rare and related to the small size of the stent and the conditions of implantation (acute phase). It would be useful to compile a registry of complications related to coronary angioplasty during rehabilitation to determine their prevalence and, if necessary, change the protocols of physical training of these patients.

[Iatrogenic acute renal failure caused by overdosage of flecainide acetate]. / Insuffisance rénale aiguë iatrogène à l'origine d'un surdosage en acétate de flécaïnide.

BACKGROUND: Rapid degradation of renal function may occur in patients given drug regimens combining a converting enzyme inhibitor, a diuretic and a nonsteroidal anti-inflammatory drug. CASE REPORT: A patient given flecainide and an enalapril /hydrochlorothiazide combination in a well-tolerated long-term regimen suddenly developed acute renal failure when a nonsteroidal anti-inflammatory drug was introduced leading to an overdose of the anti-arrhythmic drug. DISCUSSION: A poor understanding of the elimination routes for anti-arrhythmic drugs and the risks involved when combined with nonsteroidal anti-inflammatory drugs modifying glomerular hemodynamics can lead to dangerous prescriptions and life-threatening situations in patients on multiple drug regimens.

[Hormone replacement therapy in postmenopausal women and cardiovascular risk]. / Hormonothérapie substitutive chez la femme ménopausée et risque cardiovasculaire.

Although the cardiovascular effects of hormone replacement therapy of menopause have been controversial for a long time, the benefit of this treatment currently appears to be well established, despite the methodological problems of most studies and the absence of definitive demonstration by a prospective randomized study. The mechanism of this favourable action appears to be multifactorial with, in particular, an improvement of the lipid profile. In the absence of any gynaecological contraindication, the combination of a natural oestrogen and a progestogen devoid of any androgenic effect therefore appears to be the preferable treatment in postmenopausal women, especially as its cardiological value is added to other important and clearly documented actions.

[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.

[Prognostic factors in dilated cardiomyopathies]. / Facteurs pronostiques des cardiomyopathies dilatées.

One hundred and sixteen patients (mean age 46 years) with dilated cardiomyopathy documented by haemodynamic investigations and angiography with normal coronary arteriography were followed up for a mean period of 29 +/- 19 months. During that period, 36% of the patients died after a follow-up of 30 +/- 20 months. The actuarial death rates were 15% at 2 years, 45% at 6 years and 60% at 10 years. The main factors predictive of survival at 10 years were the clinical and haemodynamic markers of left heart failure. The death rate was multiplied by 1.6 in patients in stages III or IV of the NYHA classification (83% vs 51%, p less than 0.01), by 2.6 in patients with left ventricular end-diastolic pressure above 15 mmHg (73% vs 29%, p less than 0.01), by 2.2 when the indexed end-diastolic volume rose above 200 ml/m2 (75% vs 35%, p less than 0.01), by 2.2 when the left ventricular ejection fraction was below 40% (75% vs 35%, p less than 0.05) and by 2.6 when angiographic mitral valve regurgitation was present (75% vs 34%, p less than 0.01). The death rate at 9 years was 2.3 times higher in patients with left bundle branch block (72% vs 36%, p less than 0.05). A cardiothoracic index over 0.60 proved to be of poor prognosis at one year (death rate: 19%). While alcoholism played no part in the prognosis, the death rate in smokers was consistently higher than in non smokers (56% vs 32% at 6 years, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Intermediate-term trial treatment of arrhythmia in hypertrophic myocardiopathy with sotalol]. / Essai de traitement à moyen terme des troubles du rythme de la myocardiopathie hypertrophique par le sotalol.

Unlike amiodarone, beta-blockers have proved ineffective in the treatment of severe ventricular rhythm disorders encountered in hypertrophic myocardiopathy. We tried to evaluate the efficacy of sotalol, a betablocker with anti-arhythmic properties, like amiodarone, on the supraventricular and ventricular rhythm disorders of this disease. 13 patients (6 men and 7 women, mean age 53.5 +/- 26.5 years) were evaluated with a 48 hours electrocardiographic recording, before and 8 and 120 days after a sotalol treatment at a mean dose of 290 mg/day (160 to 640 mg). The diagnosis of hypertrophic myocardiopathy was established on standard clinical, phonomecanographic (13 cases), sonocardiographic (13 cases) and haemodynamic (9 cases) criteria. Five patients presented bursts of supraventricular tachycardia on DO. Their number decreased to 4 on D8 and to 3 to D120. Six patients presented Lown's class III or IV ventricular rhythm disorders on DO. Their number went from 2 on D8 to 4 on D120. Therefore, in this short series, sotalol has shown a non-negligible efficacy on the rhythm disorders encountered in hypertrophic myocardiopathy.

[Hemodynamic effects on intravenous propafenone in hypertrophic myocardiopathy]. / Effets hémodynamiques de la propafénone intraveineuse dans la myocardiopathie hypertrophique.

None of the medical treatments of hypertrophic cardiomyopathy is perfect. In the present study conducted on 11 patients with hypertrophic cardiomyopathy in whom the usual treatments were either ineffective or badly tolerated, the haemodynamic effects of propafenone administered intravenously were investigated. The drug was injected centrally in doses of 2 mg/kg over 10 minutes, then by continuous intravenous infusion of 1.5 mg/min during 30 minutes. Various parameters were recorded before and after propafenone treatment by right and left cardiac catheterization. This anti-arrhythmic drug, which has beta-blocking and amiodarone-like properties, reduced left intraventricular obstruction but had no beneficial effect on diastolic function. The baseline and induced left intraventricular gradients were reduced from 30.4 to 17.7 mmHg and from 74 to 43 mmHg respectively. Diastolic function values showed a fall in dp/dt min from 1470 to 1307 mm/sec and an increase in T value from 0.066 to 0.084. The use of propafenone in hypertrophic cardiomyopathy must be accurately determined by long-term oral studies.

[Outcome of hypertrophic and obstructive myocardiopathies treated with high doses of propranolol]. / Evolution des myocardiopathies hypertrophiques et obstructives sous fortes doses de propranolol.

Twenty-five patients with hypertrophic obstructive cardiomyopathy confirmed by clinical, echocardiographic and haemodynamic investigations were treated with high dose propranolol (320 to 800 mg/day, average 420 mg/day) and assessed after an average follow-up period of 25 months. The effects of treatment were assessed by interrogation in all patients and by exercise testing before and after propranolol in 19 cases. Comparative echocardiographic (21 patients) Holter (20 patients) and catheter studies (14 patients) were also performed. The cardiovascular mortality rate during the study period was nil. All patients were symptomatic before treatment; 9 became asymptomatic and 13 patients were improved, the average functional score decreasing from 5.16 +/- 2.15 to 2.28 +/- 1.49 (p less than 0.001). The persistence of severe symptoms led to withdrawal of the beta-blocker in 2 cases. There was a parallel improvement in maximal work capacity during exercise stress testing (96 +/- 27 watts vs 117 +/- 30 watts, p less than 0.01). A resting intraventricular pressure gradient was recorded in 12 of the 14 patients undergoing repeat catheter study which decreased after propranolol from an average of 66.75 +/- 32.72 mmHg to 42.75 +/- 37.6 mmHg (p less than 0.05). Left ventricular end diastolic pressures remained unchanged. The change in pressure gradient did not correlate with the symptomatology and there were no associated echocardiographic changes. The Holter monitoring did not show any improvement of ventricular hyperexcitability under propranolol: the number of patients with complex ventricular arrhythmias remained unchanged (7 patients).(ABSTRACT TRUNCATED AT 250 WORDS)

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.

[Rare complication of extracorporeal circulation: diffuse coronary fibrosis; giant cell myocarditis]. / Complication surprenante de la circulation extra-corporelle : fibrose coronaire diffuse; myocardite à cellules géantes.

A 38 year old woman developed severe coronary stenosis several months after double valve replacement. Aorto-coronary bypass surgery was performed but the patient died of a peroperative myocardial infarction. Histological studies showed not only fibrous thickening of the intima of the whole coronary arterial tree, but also variable medial changes with inflammatory infiltration. In addition, inflammatory granulomata with giant cells were found in the myocardium. These coronary lesions and their association with a giant cell myocarditis cannot be satisfactorily explained by known pathological conditions. The usual mechanisms of coronary disease were not operative in this case. There remains the hypothesis of a primary change of the coronary wall related to either cannulation, anoxic arrest or perfusion fluid, or a combination of these factors. The coronary lesions could have developed by an immunological process which would also explain the giant cell myocarditis.

[Ventricular arrhythmias in obstructive hypertrophic cardiomyopathy. Continuous electrocardiographic study]. / Arythmies ventriculaires de la myocardiopathie hypertrophique obstructive. Etude par enregistrement électrocardiographique continu.

Ventricular arrhythmias are thought to be responsible for the high incidence of sudden death among patients with hypertrophic obstructive cardiomyopathy (HOC). 24-h ECG recording was applied to 27 HOC patients before any treatment and repeated under beta-blockade with propranolol in doses not lower than 320 mg/day (mean dose : 354 mg/day). ECG tracings showed that 26/27 patients (96%) had ventricular arrhythmia; the arrhythmia was repetitive in 15 patients (55%), 3 of whom (11%) had bouts of ventricular tachycardia. These figures are very different from those found in normal subjects, i.e. : 40-50% ventricular arrhythmia and less than 5% repetitive arrhythmia. The most severe forms of ventricular arrhythmia (categories IVA and IVB in the Ryan, Lown and Horn classification) were exclusively seen in patients who had one or several syncopes. Statistically, the only positive correlations of arrhythmias were with age and left ventricular end-diastolic pressure on the one hand, and age and left ventricular systolic pressure gradient on the other hand. Propranolol had no effect on arrhythmia, which seems to contradict studies suggesting that high doses of propranolol play a substantial role in the prevention of sudden death among patients with HOC. Beta-blockers might act by preventing the transformation of arrhythmia into ventricular fibrillation.

[Coronary arteriovenous fistula. Apropos of a case with thallium myocardial scintigraphy and study of pre- and postoperative myocardial metabolism]. / Fistule artérioveineuse coronaire. A propos d'un cas avec scintigraphie myocardique au thallium et étude du métabolisme myocardique pré et post-opératoires.

Coronary angiography performed in a 62 year old man with spontaneous chest pain revealed a congenital fistula in the form of a vascular network arising from the proximal part of the left anterior descending artery and draining into the main pulmonary artery. A single severe atheromatous stenosis of the right coronary artery was observed. Thallium 201 myocardial scintigraphy at rest showed a large area of hypofixation in the artero-septo-apical zone. Myocardial and aorto-right coronary bypass, myocardial scintigraphy became almost normal, leaving a small antero-septal and apical deficit: myocardial metabolism returned to normal. The fact that lactate metabolism is a particularly sensitive index of myocardial hypoxia in the territory of the left coronary artery suggests a probable coronary steal syndrome induced by the fistula; this is probably also the cause of the isotopic hypofixation in the territory of the left anterior descending artery which emphasizes the value of Thallium myocardial scintigraphy in the study of congenital malformations of the coronary artery.