[The esophagus in patients with coronary disease. A sensitive area not to be neglected]. / L'oesophage chez le coronarien. Une épine irritative à ne pas négliger.

The authors report the case of a 35 year-old man, suffering from Prinzmetal's angor and stress angor associated to a complicated esophago-gastric reflux. Coronary angiography demonstrates a capillary network well dilated under Trinitrin. The Methergin test is explosive. After failure of calcium inhibitors, the sole treatment of the reflux alleviates the spontaneous pain. From this report, the place of esophageal pathology in coronary patients, the means to recognize it, the role of the reflux in the definition of myocardial ischemia, are discussed.

[Left intraventricular and right auricular double thrombus. Apropos of a case with favorable development under medical treatment]. / Double thrombus intraventriculaire gauche et auriculaire droit. A propos d'un cas d'évolution favorable sous traitement médical.

The authors report a case of right auricular and left intraventricular double thrombus involving the tricuspid valve, diagnosed by two-dimensional echocardiography. This double thrombus developed in a male of 54 years presenting dilated cardiomyopathy with heart failure who was admitted as an emergency case due to cerebral embolism. Surgery and fibrinolytic agents were contraindicated and heparin treatment was initiated. The right auricular mass subsided in 24 hours without symptomatology. Only venous pulmonary digitalized angiography showed a moderate defect. Bearing in mind literature reports, the present observation is particularly interesting on three counts: simultaneous double localization, the fortuitous detection of a right auricular clot before development of pulmonary embolism and the rapid subsidence of the thrombus under heparin treatment as wall as the satisfactory progress without symptomatology of pulmonary embolism.

[Torsades de pointe. Apropos of 60 cases]. / Les torsades de pointe. A propos de 60 observations.

The authors report a personal series of 60 cases of "torsade de pointe" (the largest series published to date) seen in the Cardiology department of Amiens Hospital over a period of 11 years. They review the essential features of this arrhythmia, which was well described by F. Dessertenne in 1966, but which is still sometimes confused with certain forms of ventricular tachycardia. "Torsade de pointe" is still a topical issue, as 25% of the cases in this series were seen over the last two years. These cases were classified into three groups according to their aetiology: severe bradycardia (21 cases), potassium depletion (16 cases), drug causes (23 cases). This arrhythmia was essentially associated with iatrogenic factors, in particular potassium depletion (41.6% of cases). The classical notion of predisposed patients was confirmed: elderly patients (mean age of 68 years), with cardiovascular disease in 70% of cases (i.e. heart failure or coronary insufficiency, hypertension) and with a marked female predominance (70% women). The ECG between episodes of "torsade de pointe" always revealed a prolonged QT interval which, in relation to the heart rate, was more marked in the patients with potassium depletion. During an attack, the average ventricular rate was 210/min (range: 170 to 290/min). 20% of cases subsequently developed ventricular fibrillation. The overall mortality was 16.6% (10 out of 60 cases), but there have been no deaths since 1977 due to the better understanding of this arrhythmia.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortoseptal approach for optimal resection of diffuse subvalvular aortic stenosis.

The results of conventional operative resection of diffuse subaortic stenosis (tunnel subaortic stenosis and diffuse idiopathic hypertrophic subaortic stenosis) have been less than satisfactory. A new approach using the concept of aortoventriculoplasty was designed to allow adequate surgical resection of a diffuse subvalvular aortic stenosis. The aorta, the right ventricle, and the septum are incised in the same way as during aortoventriculoplasty , with the aortic anulus being divided carefully across the commissure between the left and right aortic cusps. The septotomy is extended beyond the limits of the stenosis, and fibrous and/or muscular tissue is removed from each edge of the septal incision. After adequate widening of the subvalvular area, the various incisions are closed and the aortic valve is reconstructed. This aortoseptal approach was studied experimentally in the dog and then carried out on two patients, both of whom had excellent hemodynamic and functional results. The aortoseptal approach may be the procedure of choice in the treatment of diffuse stenoses limited to the subvalvular area, whereas other procedures ( aortoventriculoplasty , and apico-aortic valved conduit) should be used when the valvular and/or supravalvular levels are involved.

[Diagnostic and prognostic value of ST segment depression greater than or equal to 3 mm during exercise testing]. / Valeur diagnostique et pronostique du sous-décalage du segment ST supérieur ou égal à 3 mm au cours de l'épreuve d'effort.

This study was undertaken to assess the diagnostic and prognostic value of ST depression equal to or more than 3 mm during exercise stress testing (EST). Out of 4050 EST performed over an 8 year period, 128 patients (3,2%) had this degree of ST depression. These changes were observed in leads V4 V6 in 92% of cases. Coronary angiography was performed in 56 patients: all had significant coronary artery disease (greater than 50% stenoses) with 50% three vessel, 30% two vessel and only 20% single vessel disease; all patients had at least one severe stenosis (greater than 75%) of a main coronary artery. The predictive value of EST was therefore 100% in the 56 patients undergoing coronary angiography. Angina or ventricular extrasystoles during EST or greater than 5 mm ST depression were predictive of multiple vessel disease. The following correlations were observed between EST and the extent of coronary artery disease: maximal heart rate and systolic pressure were lower, ischemic changes appeared sooner (less than 2 min) and lasted longer during the recovery phase (greater than 7 min) in patients with multiple vessel disease. The 5 year prognosis was studied in 58 patients; it was poor (death or infarction) in 31 cases (53%). The following factors were associated with a poor prognosis: low maximal heart rate and systolic blood pressure, early ischemic changes and frequent ventricular extrasystoles on EST; on the other hand, the development of anginal pain during EST was not of significant prognostic value in this series. ST depression greater than 3 mm on EST is rare.(ABSTRACT TRUNCATED AT 250 WORDS)

[Propranolol-nifedipine combination in the treatment of exercise-induced asthma]. / Association propranolol-nifédipine dans le traitement de l'angor d'effort.

The therapeutic effects of the association of propranolol (P) and nifedipine (N) were compared with those of propranolol alone in the treatment of effort angina. Ten patients under 65 years of age with stable effort angina confirmed by stress testing and coronary arteriography were studied. The criterion of selection was inadequate improvement of symptoms with the betablocker alone, prescribed in first intention. The patients were divided into two groups (A and B) at random: --Phase I (2 weeks) : group A : P 80 mg/day + N 30 mg/day, group B : P 80 mg/day + Placebo 3 tablets/day; --Phase II (2 weeks) : group A : P 80 mg/day + Placebo 3 tablets/day, group B : P 80/day. The results of this cross-over trial were assessed blind. The association N + P compared to P alone led to a clinical improvement in 7 out of 10 patients, a clear cut increase in maximal exercise capacity (44%), a reduction in ST depression of 0.8 mm and to the disappearance of effort angina in half the patients. The haemodynamic tolerance of this drug association was good. These statistically significant differences between the P + N and P + placebo treatment periods demonstrate that this drug association is beneficial in patients with effort angina who are inadequately relieved by betablocker therapy alone.

[Asymptomatic coronaro-cardiac fistula. Apropos of a case]. / Fistule coronaro-cardiaque asymptomatique. A propos d'un cas.

The case of a 20 year old woman with a right coronary-right atrial fistula is reported. The diagnosis was made during investigation of a continuous murmur and the tolerance was excellent. Aortic root angiography demonstrated a fistula between the initial part of the right coronary artery and a right heart cavity. Selective coronary angiography visualised pseudo-aneurysmal dilatation of the first segment of the right coronary artery, the calibre and trajectory of which was then normal. The medical literature suggests surgical correction even in asymptomatic cases because of the risk of spontaneous complications (cardiac failure 15 p. 100, endocarditis 7 p. 100, infection 4 p. 100). Since 1968, there has been no operative mortality in 145 subjects with isolated coronaro-cardiac fistulae without cardiac failure. In the case presented, the fistula was successfully closed under cardiopulmonary bypass and endoaneurysmorrhaphy was performed to remodel the lumen of the right coronary artery.

[Tricuspid insufficiency and right traumatic ventricular aneurysm. Apropos of a case]. / Insuffisance tricuspidienne et anévrysme ventriculaire droit traumatique. A propos d'un cas.

Tricuspid incompetence associated with a right ventricular aneurysm wa discovered after a non-penetrating thoracic injury. The severity of the tricuspid lesion was confirmed by phonomechanography, catheterisation and angiography. The mechanism was demonstrated by two-dimensional echocardiography: the right ventricular aneurysm was located in the right ventricular outflow tract. As the hemodynamic tolerance was good, surgery was not performed. A review of the literature found 41 other reports of traumatic tricuspid incompetence, and 4 cases of right ventricular aneurysm, only one of which was associated with tricuspid regurgitation. The points of interest of ths case: the rarity of the association, the good hemodynamic tolerance and the value of two-dimensional echocardiography for the diagnosis of ruptured chordae in the absence of surgical observations.

Isovolumic contraction time of right ventricle in d-transposition of great arteries.

The pre-ejection period of the right ventricle in d-transposition of the great arteries is known to be prolonged, compared with the same interval of the left ventricle of normal subjects. In the present study, the echocardiographic measurement of the components of the pre-ejection period of the right ventricle of 14 patients with d-transposition of the great arteries shows that the isometric contraction time of the right ventricle in d-transposition of the great arteries is similar to the same interval calculated on the left ventricle of 76 normal children of comparable age. On the other hand, the electromechanical delay was significantly greater for the right ventricle of d-transposition of the great arteries than for the left ventricle of the normal subjects. It is concluded that the prolonged pre-ejection period of the right ventricle in d-transposition of the great arteries is not the result of right ventricular dysfunction but solely of a longer electromechanical delay.

[Artefacts during continuous electrocardiography by the Holter method]. / Les artéfacts au cours de l'enregistrement électrocardiographique continu par la méthode de Holter.

Continuous ECG by the Holter method provides valuable information on the electrical activity of the heart but the interpretation of the playback may be made difficult by the presence of artefacts. The principal artefacts which may mimic arrhythmias or blocks, disturb QRS detection or deform the ventricular depolarisation are described. The majority are caused by incomplete preparation of the patient or the electrodes, but others may arise from a mechanical or electrical fault. Artefacts interfere with the automatic analysis of the tape, which is one reason for knowing the limitations of these systems of automatic analysis, and therefore control visual reinterpretation is necessary in cases where there is the slightest doubt. The presence of these artefacts is a limitation of the Holter method, the practice of which demands a certain amount of experience to avoid incorrect diagnoses which could lead to inappropriate or injustified therapy.

Anti-hypertensive effect of acebutolol: its relation to sympathetic nervous system responsiveness and to plasma renin and dopamine-beta-hydroxylase activities.

1. Acebutolol, a beta1-receptor blocker, has, at a daily dose of 800 mg, a mild but significant anti-hypertensive effect in moderate sustained essential hypertension with normal or low plasma renin activity. 2. Prediction of its anti-hypertensive effect is better based on the evaluation of the sympathetic nervous system responsiveness to head-up tilt than on the evaluation of plasma renin activity or dopamine-beta-hydroxylase. 3. The anti-hypertensive effect of acebutolol is better explained on the basis of inhibition of the sympathetic nervous system activity than on the basis of suppression of plasma renin activity. 4. A positive correlation between plasma renin activity and dopamine-beta-hydroxylase in patients on diuretics suggests the common dependence of these two variables on sympathetic overactivity.