[Color-Doppler study of the velocity profile of the left ventricular outflow tract in normal subjects and in patients with valvular aortic stenosis]. / Etude du profil de vitesse de la chambre de chasse du ventricule gauche des patients normaux et atteints de rétrécissement orificiel aortique. Etude Doppler couleur.

A better understanding of the velocity profiles in the cardiac chambers and great vessels should allow more accurate estimation of cardiac output and valve surface area by Doppler echocardiography. The velocity profile in the left ventricular outflow tract was studied by Colour Doppler in 12 patients with pure valvular aortic stenosis with normal left ventricular function and compared with a control population of 12 normal subjects. The selected recordings were digitised and stocked on a laser optic disc. Measurement of the angle of incidence of the line of colour aliasing with respect to the interventricular septum was performed manually on a colour video display unit. A program of digitised image processing allowed the tracing of the axes of reference defining the angle of incidence measured at peak systole. The average angle of incidence was 40.7 +/- 5.6 degrees in the control population and 56.8 +/- 6.8 degrees in aortic stenosis; therefore, in this condition, the angle was significantly flatter (less acute) (p less than 0.001). The correlation between the angle of incidence and the transvalvular pressure gradient was poor (r = 0.24). These results suggest that: real time ambulatory analysis of isovelocity profiles in the left ventricular outflow tract is possible by using the phenomenon of colour aliasing: the presence of an obstacle to left ventricular ejection tends to flatten the velocity profile, justifying the use of the continuity equation in patients with calcific aortic stenosis but questioning its systematic use in control populations of normal subjects used as a reference.

[Strategy for quantification of valvular regurgitations by Doppler echocardiography]. / Stratégie pour la quantification des régurgitations valvaires en échocardiographie Doppler.

Of all the diagnostic facilities offered by ultrasound in cardiology, clinicians often pause one question: how can valvular regurgitation be quantified by Doppler echocardiography? The large number of articles which have been published in the international literature indicates that there is no simple answer. The aim of this paper is two-fold: firstly, to review the different approaches and underlying "philosophies" and, secondly, to set out a practical strategy for the investigation of the two most important regurgitations, mitral and aortic. The authors conclude this technical presentation with an essential word of caution in the interpretation of the data: concordance of the different indices of severity and clinical coherence of the criteria of evaluation.

[Transesophageal, anatomic and Doppler echocardiography. Technic, indications, interpretation]. / Echocardiographie, anatomique et Doppler, transoesophagienne. Technique, indications, interprétation.

Cardiac ultrasonography completed by the Doppler technique has demonstrated his ability to visualize almost all of the anatomical pathology including description and semi-quantification of pathological blood flows within the heart. However, the physical properties of the ultrasound beam frequently limit the imaging process and Doppler flow studies. Absorption of ultrasound by the chest wall is a major determinant of quality and hence interpretation, together with the depth of the examined zone of interest. It's a common finding that echo-Doppler images are better in children than in obese adults. Moreover, strong echo-reflectors, such as calcification or prosthetic heart valves, create large acoustic shadowing effects behind which obtaining an ultrasound signal is difficult if not impossible. For this reason transesophageal echocardiography represents a new essential window into the heart. By positioning a transducer mounted on a fibroscopy sheath into the esophagus in close contact with the left atrium, images of unequaled quality are obtained. An image-resolution of the order of 1-2 mm explains the diagnostic quality in infectious aortic and mitral valve diseases for assessing small vegetations, annular abscesses, and regurgitant lesions by adding color-coded Doppler. The investigation of prosthetic valves dysfunction is completely renewed for detecting disinsertion and thromboses. Heart screening for systemic emboli includes mandatory how the visualization of left (and also right) auricles and the interatrial septum associated with contrast study. Lesions of the descending aorta (aneurysms, thromboses and especially dissections) are perfectly documented in combination with color-Doppler indicating true and false channels as well as re-entry sites. Lastly, other applications are being developed including global and segmental myocardial contractility at rest or even at stress, although this last application is still at the experimental stage. Transesophageal echocardiography therefore appears to constitute a real revolution as an added possibility to the cardiological use of ultrasound: the indication for this "window" being decided for the preferential cases described above only after having performed a standard echo examination. Very often, the indication will be raised by the echocardiographer who, after performing a conventional echo may consider that better or supplementary information could be obtained via the esophageal route. This technique performed by trained operators, is relatively simple, minimally traumatic and can be performed on an outpatient basis provided certain precautions, imposed by the preparation and the consequences of premedication received by the patient, are respected.

[Long-term prognosis of spastic angina with normal or irregular coronary arteries. Apropos of 48 cases]. / Pronostic à long terme de l'angor spastique à coronaires normales ou irrégulières. A propos de 48 cas.

Forty-eight consecutive patients (37 men, 11 women, mean age 49 +/- 8 years) were followed up regularly for a mean period of 7 years. All presented with spontaneous angina, documented coronary spasm and no stenosis greater than 50 p. 100 at coronary arteriography. The first attack of pain had taken place 3 days to 9 years previously; exertion angina was also present in 47 p. 100 of the cases and severe arrhythmia in 17 p. 100. Treatment was based on calcium antagonists in doses and combinations that varied with the course of the disease. The follow-up period lasted from 16 to 122 months (mean 85 +/- 24 months). 3 patients are now known to be alive but were lost sight of after 12 to 21 months. Major cardiac complications were 1 death (2 p. 100) and 3 cases of myocardial infarction (6.6 p. 100). None of the patients died suddenly. 70 p. 100 of the remaining 41 patients became asymptomatic; angina persisted in 15 p. 100 and 14 p. 100 had episodes of severe angina but with remissions of at least one year. No predictive factor of functional deterioration or major cardiac complications could be elicited. The long-term prognosis of vasospastic angina in patients with little or no coronary stenosis is favourable, but there is a very small risk of myocardial infarction or death.

[A new procedure for the study and treatment of myocardial infarction in the acute phase: percutaneous coronary angioscopy]. / Nouveau procédé d'investigation et de traitement de l'infarctus du myocarde à la phase aiguë: angioscopie coronarienne percutanée.

The recent development of small diameter optical fibers, which are also very flexible allows us to realise percutaneous coronary angioscopy. First of all we visualized normal dog's arteries, bifurcations, origin of small branches; then we created and visualized intimal tears, dissections and experimental thrombi. The second part of this work consisted in applying this new technic in three patients who had an evolving myocardial infarction and an occluded right coronary artery. In all three cases a clot has been visualized, occluding the lumen of the artery. This small experiment shows that percutaneous angioscopy is a feasible, quick and save procedure. Its developments will be very important according to the development of percutaneous interventional therapies.

[National survey on cardiovascular emergencies. Modalities of admission to cardiologic intensive care units (Paris excluded)]. / Enquête nationale sur les urgences cardio-vasculaires. Modalités d'admission en unité de soins intensifs cardiologiques (à l'exclusion de Paris).

In a national investigation carried out between December 10, 1985 and March 31, 1986, the modalities of admission of 19 Cardiology Intensive Care Units (Paris excluded) of 738 cardiovascular emergency patients were evaluated. Detail of the pre-medical phase duration and of the dispatching phase duration was obtained for each patient. Each of these two phases was then analyzed according to the geographical location of the Intensive Care Unit (ICU), to the symptoms experienced by the patient, to the type of medical aid initially sought (general practitioner, cardiologist, "emergency doctor") and to the medical itinerary followed. The median duration of the pre-medical phase was 1 h 45 min, that of the dispatching phase 2 h, 15 min and that of the total time elapsed before admission 5 hours, there being no clear-cut differences due to the location of the ICU. The duration of the pre-medical phase was essentially determined by the awareness of a vital risk or otherwise, or by the relation established by the patient between his symptoms and a possible heart disease. The median duration of the dispatching phase was about 2 hours when only one doctor intervened and 4 h, 35 min when a second doctor was consulted. The role of the cardiologist in the dispatching of these cardiovascular emergency cases was very limited (7 p. 100 of the patients) and not very expeditive, the median duration of admission being 6 h, 30 min when he intervened initially and 12 hours when he intervened at the request of the patient's general practitioner.(ABSTRACT TRUNCATED AT 250 WORDS)

[Median-term course of left ventricular effects in aortic insufficiency. Echocardiographic study of 90 patients]. / Evolution á moyen terme du retentissement ventriculaire gauche de l'insuffisance aortique. Etude echocardiographique de 90 patients.

It is important to know the natural evolution of the changes in left ventricular dimensions and contractility in AR if one wishes to determine the critical echocardiographic values at which LV function starts to deteriorate. This was the aim of our echocardiographic study of 90 patients with chronic pure AR in whom we analysed the changes in LV dimensions, mass and contractility for 11 to 84 months (average 34.6 months). The patients were divided into 2 groups according to the degree of ventricular dilatation (delta DD): Group A: delta DD less than 30% (58 patients), Group B: delta DD greater than 30% (32 patients). The annual mean increase in diastolic and systolic LV dimensions and myocardial mass in each group was: 1.5 mm vs 3.2 mm (p less than 0.02); 0.9 mm vs 4.1 mm (p less than 0.003), 14 g vs 24 g (p = 0.07 NS) respectively. The parameters of the systolic function were normal in Group A (EF = 68 +/- 8% and % FS = 38 +/- 6%) and decreased in Group B (EF = 58 +/- 13%, % FS = 32 +/- 9%). A significant annual decrease of the mean values of these parameters was only observed in patients of Group B (EF = 1.8% per year; % FS = -1.2% per year). These results are on average of unequal individual variations: variations of DD or EF greater than the variability due to the reproducibility of the method were only observed in 43 patients. The number of patients in whom echocardiographic changes were observed was comparable in Groups A and B.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiography in chronic aortic insufficiency. Prediction of the reversibility of left ventricular dysfunction following surgical correction]. / L'échocardiogramme de l'insuffisance aortique chronique. Prévision de la réversibilité des anomalies ventriculaires gauches après correction chirurgicale.

UNLABELLED: The long term outcome of patients undergoing aortic valve replacement (AVR) for chronic aortic regurgitation (AR) is mainly determined by the reversibility or permanence of left ventricular dysfunction. We analysed the echocardiogram of 49 patients before and after surgery to identify the patients whose left ventricular dysfunction regressed completely after AVR. The patients were divided into 2 groups according to the results of the last postoperative echocardiogram: Group I: 25 patients whose left ventricular dimensions and wall motion reverted to normal; Group II: 24 patients with dilated and/or hypokinetic left ventricles. The two groups of patients were comparable for sex (Group I: 19 men, 6 women; Group II: 20 men, 4 women), age (Group I: 50,8 years, Group II: 53,9 years) and length of postoperative follow-up (Group I: 32 months, Group II: 34 months). The following parameters were measured and compared: diastolic and systolic left ventricular dimensions, myocardial mass and ventricular wall motion. RESULTS: Patients in Group I had less left ventricular dilatation than those in Group II (+35% vs +60%, p less than 0,001) and left ventricular contraction was better (FE: 62% vs 45%, p less than 0,001; %FS: 35% vs 23%, p less than 0,001). This study establishes that patients with chronic AR and % delta Dd less than 60%, an EF greater than 50% or %FS greater than 25%, have about a 90% probability of normalisation of LV function after AVR. If one of the indices exceeds these threshold values, the probability of permanent LV dilatation and/or hypokinesia after AVR is also about 90%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary insufficiency caused by spasm with arteries injured slightly or not at all (31 cases)]. / L'insuffisance coronaire par spasme avec artères peu ou pas lésées (31 cas).

An epidemiological and clinical study was carried out on 31 patients with spasm of normal coronary arteries. The series comprised 24 males and 7 females aged 30 to 68 years (mean age: 48 years) with isolated resting chest pain (61 p. 100) or with resting and effort chest pains (39 p. 100). Their cardiovascular risk factors were compared to 735 unselected patients with coronary insufficiency undergoing coronary coronary angiography. Abnormalities of lipid metabolism (45 p. 100) and obesity (14 p. 100) were less common but there was a higher incidence of smoking (74 p. 100 compared to 48 p. 100). Sixteen patients had a psychological test: repressed aggressivity and severe anxiety were found in all patients, a state of separation coincided wtih the onset of the illness in 10 of the 16 patients. On admission, 13 patients presented with attacks of Prinzmetal variant angina, with myocardial infarction in 2 cases. Eighteen patients had non-invalidating angina with sporadic attacks. Coronary angiography was normal in 8 patients and showed lesions with less than 50 p. 100 narrowing in the other 23 patients. Mitral valve prolapse was found on left ventriculography in four patients. Exercise electrocardiography was positive in 7 out of 20 patients, and notably in those who had not had effort angina. All patients were treated with calcium antagonist drugs (25 Nifedipine, 6 Diltiazem), the efficacity of which was tested in 20 patients with a control ergometrine test. Thirty patients were followed up for 6 to 46 months (mean: 15 months). The exercise stress tests were repeated in the 7 patients with positive results before treatment and the results were negative in all cases. Twenty three patients were completely pain free or significantly improved, although 25 p. 100 of control tests remained positive (4/16). Six patients continued to have as much chest pain, and three had positive control tests. One patient with a negative control test developed acute myocardial infarction six months later in the territory of the spasm: during hospitalisation the ergometrine test became positive again.

[Study of the mechanism of an atrial pause using endocavitary recording of the sinus node potential in man]. / Etude du mécanisme de la pause auriculaire par l'enregistrement endocavitaire du potentiel sinusal chez l'homme.

The aim of this clinical study was to determine the electrophysiological mechanism of spontaneous atrial standstill, defined as a sudden lengthening of the trial cycle to over 10 p. 100 of its basal value, by recording the sinus node potential by endocavitary electrocardiological techniques. Satisfactory recordings of the sinus potential were obtained for the study of 65 atrial pauses recorded in 31 patients (18 without sinus node dysfunction and 13 with sinus node disease). It was shown that atrial pauses, shorter than two basal atrial cycles correspond to a moderate slowing of the sinus rhythm and to a sometimes very significant lengthening of the sinoatrial conduction time when sinus rhythm resumed. Pauses longer than two basal atrial cycles were always due to sinoatrial block which sometimes occured in patients with clearly individualised sinus activity, and sometimes with a slow continuous sinus activity. The sinus period did not change during these long pauses and sinoatrial conduction was normal when sinus rhythm resumed. The increased duration of the sinus potential, a constant finding during these pauses, is related to an intrasinusal conduction defect. This suggest that the primum movens of sinoatrial block is intrasinusal block which prevents rapid recruitment of a sufficient number of elemental sinus potentials so that the resultant potential becomes subliminal and therefore incapable of passing the sinoatrial junction. Short-lasting atrial pauses with a normal response to extrastimulus or atrial stimulation and characterised electrophysiologically by an increased sinoatrial conduction time without block of the sinus potential may be opposed to long atrial pauses with the pathological response of sinus node dysfunction characterised electrophysiologically by block of the sinus impulse. In practice the ability to induce a long pause by atrial stimulation (sinoatrial block) revealing latent disease of intrasinusal or sinoatrial conduction, may constitute an essential physiological sign of sinus node dysfunction.

[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.

[Methyl-ergometrin maleate test during coronary arteriography in spontaneous chest pain]. / Le test au maléate de méthyl-ergométrine au cours de la coronarographie dans les douleurs thoraciques spontanées.

This coronary spasm provocation test with methyl-ergometrine maleate was carried out during coronary arteriography in 47 patients presenting with spontaneous chest pain. Coronary spasm was triggered in 16 cases, reproducing the chest pain in 11 patients, and accompanied by electrical changes in 15 cases, 12 subepicardial ischaemias and 3 subendocardial ischaemias. This test is not without danger to the patient as arrhythmias and conduction defects were recorded in 6 cases although the spasm was readily reversible on injection of intravenous glyceryl trinitrate. Of 7 patients with Prinzmetal variant angina, the test was positive 6 times, in three of which on pre existing severe organic lesions, so confirming the mechanism of this syndrome and the reliability of the test. Of 40 patients presenting with spontaneous chest pain, 10 had a positive test. In 2 of these cases the chest pain was subsequently observed with subepicardial ischaemic electrical changes, so confirming the screening value of this test. In the 7 cases where coronary spasm gave rise to electrical changes with or without pain, the logical diagnosis would appear to be spastic angina. In the 30 cases where the test was negative the subsequent outcome did not provide any proof in favour of a coronary origin of the chest pain.

[Myocardial infarct before the age of 36: 20 cases]. / L'infarctus du myocarde avant 36 ans. A propos de 20 cas.

Twenty cases of myocardial infarction in 16 males and 4 females and less than 36 are reported. The number of heavy smokers was greater than in other age groups (86%), and an association between tobacco consumption and lipid abnormalities was found in 3/4 of cases. All the females were on contraceptive treatment, one recurring during pregnancy. The clinical features of the infarctions were an onset which was usually unexpected (n=14), ar attack which was sometimes precipitated by exercise (n=3), and the infrequency of residual angina. The exercise test (n=16) showed up an associated abnormality in only one case out of four, but the fact that the rate-pressure product was normal suggests that the coronary artery networks were in a satisfactory state of function. Ventriculography (n=14) was normal in 35% of cases. Coronary arteriography (n=18) showed significant lesions in 12 cases, one trunk being affected in 6, two trunks in 5, and 3 trunks in one; the lesion index was 1.6. In 6 cases there were few changes in the coronary arteries, and the probable mechanism of the infarct is discussed: besides the possibility of a recanalised thrombus, which appears to be the likely one in two of our patients, spasm played a possible role even though the ergonovine provocation test was negative. The mortality during the first month was zero; as a secondary event over a follow-up period of 38 months, there were two deaths and four recurrences, one of which occurred in a healthy coronary vascular tree.

[Identification of the sino-atrial potential in the dog by epicardial electrocardiography]. / Identification du potentiel sinusal chez le chien par électrocardiographie épicardique.

The electrical activity of the sino-atrial node has been recorded in the dog through a thoracotomy and using both unipolar and bipolar electrodes. Amiodarone was used to establish that the pre-artial potential which was registered was indeed originating in the sinus, as it allowed us to produce various degrees of sino-atrial block in a reliable and reproducable manner. The fact that the sinus potential can be recorded in the presence of intermittent abnormalities of the surface P wave suggests that the abnormalities may be associated with intra-sinus displacement of the pacemaker and not with ectopic depolarisation of the atrium.