[Risk profile in acute myocardial infarction: a necessary assessment for the population's comparisons]. / Le profil de risque dans l'infarctus du myocarde: une évaluation indispensable pour la comparaison des populations.

OBJECTIVE: The aim of this study is to show that differences of mortality, in acute myocardial infarction, observed between hospitals are not necessarily linked to a bad application of guidelines but can be linked to differences in the risk profile of the populations. METHODS: Two populations admitted for ST and non-ST elevation myocardial infarction in the same region in 2006 were compared: the population of Chalon-sur-Saône's hospital with a standard population from the observatoire des Infarctus de Côte d'Or (RICO). The risk profile of the two populations has been realised with the risk scores GRACE, EMMACE and the Simple Risk Index (SRI). RESULTS: The three scores are applicable for our populations according to the "C statistic". Moreover, there is a significant difference of in-hospital mortality between Chalon-sur-Saône and RICO. But, the population of Chalon-sur-Saône presents a higher risk. Finally, in-hospital rate mortality expected by the three scores is not different from the actual mortality. CONCLUSION: GRACE, EMMACE and SRI are valid scores for the comparison of risk profile of populations in acute myocardial infarction. Comparisons between hospitals are only possible after risk adjustment of the populations.

[Acute lung oedema during a tako-tsubo syndrome associated with mitral stenosis]. / Odème aigu du poumon lors d'un syndrome de tako-tsubo et rétrécissement mitral associé

The tako-tsubo syndrome is the subject of a lot of publications focusing on the different circumstances of discovery (emotion, anesthetic stress...). We report the original case of a patient of 56 years with a tight mitral stenosis, hospitalized for acute lung oedema, sinus rhythm, in which the original data and follow-up studies have identified a tako-tsubo syndrome with favorable evolution.

[Recurrent delayed pericarditis after pacemaker implantation: a post-pericardiotomy-like syndrome?]. / Une péricardite retardée récidivante après implantation de pacemaker: un équivalent de syndrome de Dressler?

INTRODUCTION: Pacemaker implantation is a usual technique in cardiology which may be followed by acute pleural effusion and delayed unusual pericarditis. CASE REPORT: We reported the case of a 67 year-old man hospitalized for faintness. Rhythmical auricular disease was diagnosed and pacemaker was implanted without immediate complication. Though pericarditis with tamponade at the day 21 will require emergency pericardiotomy surgery. A recurrent pericarditis at day 45 was treated with anti-inflammatory drugs without relapse at the end of the treatment. DISCUSSION: Repeated delayed pericarditis after pacemaker surgery may be compared to the Dressler syndrome which occurs after myocardial infarction.

[Reactivity of "white coat" type is associated with reactivity to mental stress]. / La réactivité de type "blouse blanche" est associée à la réactivité au stress mental.

This study was aimed to compare the white coat effect and the response to a mental stress. 29 subjects, referred for high blood pressure (BP) were included. Systolic BP (SBP) was recorded beat-to-beat with a Finapres device during 3 periods of at least 5 minutes: 1) rest (alone, in lying position); 2) white coat (5 measurements of BP with a standard mercury sphygmomanometer by the same physician); 3) mental stress (version for computer of the Stroop Word Color Conflict Test). A Coarse-graining spectral analysis was performed to compute the power in the low frequency band (PLF: 0-0.150 Hz) and in the high frequency band (PHF: 0.150-0.500 Hz). SBP was 142 +/- 3.7 during the rest period and increased significantly during the white coat (156.7 +/- 3.9 mmHg) and the mental stress (190.7 +/- 4.8 mmHg) periods. These rises of SBP levels were associated with a rise of PLF, significant only during mental stress (11.3 +/- 1.4, 15.7 +/- 3.7, 17.2 +/- 2.4 mmHg2/Hz, during rest, white coat and mental stress periods, respectively). Moreover, a significant correlation (r = 0.76; p < 0.0001) was found between the white coat effect (PAS "white coat"-PAS "rest") and the response to stress (PAS "stress"-PAS "rest"). This work shows that white coat effect is not a specific response but may rather represent an increased reactivity to stress. As it is associated with an increased power in the LF band like the response to stress, this white coat effect may involve an activation of the sympathetic system.

[Late discovery of inferior vena cava draining into the left atrium after surgical closure of atrial septal defect]. / Découverte tardive d'une dérivation de la veine cave inférieure dans l'oreillette gauche après fermeture chirurgicale d'une communication interauriculaire.

Drainage of the inferior vena cava into the left atrium during surgery for closure of an atrial septal defect is a rare complication. More common in low situated defects, it was more frequent when this type of surgery was performed without cardiopulmonary bypass. This diagnosis was made in a 45 year old woman with cyanosis operated 28 years previously. The right-to-left shunt was demonstrated by the hyperoxia test and confirmed by perfusion pulmonary scintigraphy and contrast echocardiography but only when the contrast was injected in the inferior vena cava territory, and by angiography. The surgeon confirmed the abnormality, closed the interatrial septum and reconnected the inferior vena cava to the right atrium.

Mechanical cardiac valve thrombosis in patients in critical hemodynamic compromise.

BACKGROUND: Valve obstruction is a life threatening complication of mechanical valve prosthesis. METHODS: From 1985 to 1993, 29 consecutive patients were hospitalized in our intensive care unit for mechanical prosthetic valve thrombosis (PVT). There were 12 men and 17 women aged 25-75 years (57 +/- 12). Prosthetic valve location was mitral in 14 patients, aortic in 6, aortic and mitral in 9. PVT occurred from 15 days to 174 months (67 +/- 52 months) after surgery. Delay from first symptoms to hospitalization ranged from 1 to 45 days (11 +/- 11). RESULTS: First clinical symptoms were progressive left heart failure in 17 patients, stroke in 6, and chest pain in 6. Furthermore, acute myocardial infarction was later documented in 3. Left heart failure NYHA III-IV was present in 26 patients (90%) on admission and 10 of those were in cardiogenic shock. Anticoagulation regimen was inadequate in 13 cases (45%). It has been recently stopped in 8 patients and incorrectly conducted in 5. Total hospital mortality was 41.3% (12). It was independent of type and position of the valve prosthesis. Diagnosis of PVT was only made at autopsy in 3 patients who died of recurrent myocardial infarction (2) or cardiogenic shock (1). Five further patients died before any surgery could be attempted (cardiac arrest: 2, cardiogenic shock: 3). Valve replacement could be done in 21 cases, 7 of whom were in cardiogenic shock and 9 had severe pulmonary edema. Four patients died after surgery, the operative mortality was 19%. CONCLUSION: PVT remains a serious complication of mechanical heart valve prostheses. Overall mortality rate is high, related to difficulty to diagnosis, delay to hospitalization and severe clinical condition at admission. In our study, operative risk remained acceptable even when the clinical presentation was severe.

[Risk assessment of hypertension: from population to individual]. / Evaluation du risque de l'hypertension: de la population à l'individu.

Epidemiological studies have contributed to our understanding of several aspects of hypertension which could not have been remarked upon by clinical medicine alone: 1) the continuous nature of the relationship between the level of hypertension and cardiovascular risk has shown that the clinical definition by criteria based on numbers is arbitrary and should be adjusted according to the context and therapeutic management; 2) the risk of high blood pressure is strongly dependent on the presence or absence of other risk factors (smoking, diabetes, serum lipids, left ventricular hypertrophy), a factor which is not sufficiently taken into account in clinical practice; 3) assessment of the absolute risk of an individual on the basis of the respective roles of the principal risk factors is a useful guide to treatment. Moreover, population studies have shown that mild increases in blood pressure, associated with a long individual risk, are responsible for a large number of cardiovascular events because of the many people affected. Preventive action on the whole population is necessary in addition to individual therapeutic intervention in the clinical setting.

[Apical hypertrophic cardiomyopathy]. / Myocardiopathie hypertrophique apicale.

Apical hypertrophic cardiomyopathy was defined initially by three electrocardiographic and angiographic criteria: the presence of giant (over 10 mm) inverted T waves in leads V4 and V5 of the resting ECG; an "ace of spades" appearance of left ventricular angiography in end diastole in the right anterior oblique projection; the electrocardiographic sum RV5 + SV1 greater than 35 mm. There after, authentic cases of apical hypertrophy have been demonstrated by imaging techniques or observed anatomically without the presence of these three criteria. The authors review the epidemiological, clinical and paraclinical features of this particular form of hypertrophic cardiomyopathy.

[Left atrial free floating thrombus without mitral valve disease. Review of the literature apropos of a case]. / Thrombus libre intra-auriculaire gauche en l'absence de pathologie valvulaire mitrale. Revue de la littérature à propos d'un cas.

Free ball thrombi of the left atrium are usually observed with mitral valve disease. The authors report the unusual case of this condition without mitral valve disease. A number of classical echocardiographic criteria suggested the precise nature of this left atrial mass before surgical excision. The diagnosis of a free ball thrombus of the left atrium should lead to urgent surgery because of the high risk of haemodynamic and embolic complications.

[Radiofrequency ablation of intranodal tachycardia]. / Traitement par radiofréquence des tachycardies intranodales.

The first radical approach to the treatment of atrioventricular nodal reentrant tachycardia was surgical dissection of the perinodal region. This technique has been replaced by the delivery of radiofrequency energy by an ablation catheter to the region of the atrioventricular node. The aim of this report is to describe the authors' experience of atrioventricular nodal application of radiofrequency current. The study comprised 53 cases (32 women and 21 men, mean age 46 +/- 17 years) with frequent attacks of reciprocating tachycardia. Endocavitary electrophysiological investigation confirmed the intranodal reentrant mechanism. The region of application of the radiofrequency current was located radiologically and then the precise site determined by the recording of nodal electrical activity. The appearance of junctional rhythm during the procedure was also used as a means of identification of the zone of ablation. Dual conduction persisted after ablation in 35 patients. However, no episode of tachycardia could be induced after the procedure. The AH interval increased during application of radiofrequency current in 3 cases but this abnormality regressed in the 2 months following the procedure. Recurrences of nodal reentrant tachycardia were observed in 14 cases (26%), 24 hours to 2 months after ablation. The rate of recurrence was significantly higher in patients who did not have a junctional rhythm during application of the radiofrequency current (62% vs 4%, p < 0.05). The number of recurrences was also greater in the group of patients with persistence of slow intranodal conduction after the radiofrequency ablation (p < 0.04). A second session of radiofrequency ablation was undertaken in 14 patients and a third session was required for 2 of them.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term course after electric ablation of the bundle of His in the treatment of supraventricular tachycardia]. / Evolution à long terme après ablation électrique du faisceau de His dans le traitement des tachycardies supraventriculaires.

The authors report the long term results of His bundle ablation for supraventricular tachycardia in a series of 49 patients. This retrospective study was based on a patient population of 27 men and 22 women with an average age of 59 at the time of ablation, between 1984 and 1993. The indication for His bundle ablation was invalidating supraventricular tachycardia resistant to antiarrhythmic therapy in all cases. One group of patients (Group I, n = 31 patients) underwent high energy electrical shock and the second group (Group II, n = 18 patients) recruited after 1991, underwent radiofrequency catheter ablation. Complete atrioventricular block was obtained in the first group in 1 to 4 sessions whereas 17 patients of Group II were treated in a single session. During a follow-up period of an average of 40 months, 2 patients were lost to follow-up and 6 died, 3 of cardiac failure, 1 of a cerebrovascular accident, 1 of pulmonary carcinoma and 1 of unknown cause. In Group I, atrioventricular conduction persisted in 1 patient (primary failure) and reappeared in one other patient, but, in Group II, complete atrioventricular block persisted even in the patient in whom the interruption was not obtained with a single session of radiofrequency ablation. The patients were generally physically improved and satisfied not to have any palpitations. A decrease in exercise capacity estimated by the NYHA classification was observed in 38% of patients without apparent cardiac disease who developed dyspnea. On the other hand, 43% of patients with cardiac disease and in NYHA class > or = 2 were improved.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hemomediastinum caused by spontaneous rupture of the thoracic aorta]. / Hémomédiastin par rupture spontanée de l'isthme aortique.

The authors report the rare case of spontaneous rupture of the aortic isthmus in the absence of preexisting aortic aneurysm or dissection in a hypertensive woman presenting with chest pain and haemomediastinum. The history of trauma 30 years previously, could have been a predisposing factor. The diagnosis of this condition remains difficult and is often missed. The physiopathological, aetiological, clinical and diagnostic features are reviewed. Transoesophageal echocardiography showing an intraparietal haematoma confirmed the aortic origin of the haemomediastinum. Conventional angiography was of no value in the reported case because of the absence of rupture of continuity or of an intimal tear.