[Aortic atheroma: not a sensitive indicators for coronary artery disease in patients with mitral valve disease]. / L'athérome aortique: indicateur peu sensible de coronaropathie dans les valvulopathies mitrales.

Aortic atheroma detected by transoesophageal echocardiography has been reported to be a good prognostic marker for coronary disease on angiography. The value of this detection in valvular heart disease would be to avoid preoperative coronary angiography in asymptomatic patients. The aim of this study was to assess the prognostic value of aortic atheroma in a population with a low prevalence of coronary artery disease in whom transoesophageal echocardiography was systematically performed. In addition, calcification of the aortic knuckle, a marker of atherosclerosis, was analysed by simple chest X-ray. One hundred and ninety two patients (103 men, 89 women; mean age: 63.1 +/- 15 years), operated for mitral valve replacement, underwent transoesophageal echocardiography, angiography, within 6 months, and chest X-ray. The cardiovascular risk factors, presence of aortic atherome, angiographic coronary artery disease and aortic calcification were studied. Aortic atheroma was observed in 72 patients (37.5%), usually in the descending thoracic aorta (73.6%). Coronary stenosis was observed in 36 patients (18.7%). On univariate analysis, aortic atherome predicted coronary stenosis with a sensitivity of 53%, specificity of 66% and positive predictive value of 26% and negative predictive value of 86%, compared with chest X-ray: 71%, 65%, 33% and 90%, respectively. In multivariate analysis, only hypercholesterolaemia, smoking and age predicted the presence of coronary artery disease. The presence of aortic atheroma was not predictive (p = 0.3). The authors conclude that aortic atheroma does not predict the presence of coronary artery disease in a patient population with mitral valve disease and a low prevalence of coronary artery disease. Simple chest X-ray has almost the same diagnostic value. The association of these two investigations does not give sufficient negative predictive values to avoid coronary angiography.

Feasibility and reliability of ankle/arm blood pressure index in preventive medicine.

Despite its potential usefulness for assessing preclinical atherosclerosis and cardiovascular risk, the ankle/arm blood pressure index (AAI) has not yet been the matter of study evaluating its feasibility and reliability by nonspecialist doctors in a general population. This study was planned for two steps. In step 1, the measurement of AAI, (ratio between Doppler systolic pressure at the ankle for each lower limb and the highest value of Doppler systolic pressure of the two upper limbs), should be performed by 50 general practitioners (GPs), 50 social security center physicians, and 50 occupational health physicians in 3,000 male smokers, 40 to 59 years, without clinical cardiovascular disease. In step 2, AAI measurement, coupled with echography-Doppler of iliofemoral arteries, should be repeated by a specialist in all subjects with decreased AAI (<0.90) and the first two subjects with normal AAI recruited in step 1 by each nonspecialist. The number of physicians and subjects participating in step 1 was lower than planned (80 physicians and 962 subjects) with the greatest defect for GPs (six physicians and 35 subjects) and the prevalence of decreased AAI was low (28 subjects). AAI measurement was repeated in step 2 in only 12 subjects with decreased AAI in step 1 and in 124 subjects with normal AAI in step 1. Five of the six subjects with decreased AAI in step 2 also had decreased AAI in step 1 and 123 of the 130 subjects with normal AAI in step 2 also had normal AAI in step 1. As regards echographic stenosis, decreased AAI had a sensitivity of 44% and a specificity of 98%. AAI seems more feasible for occupational health physicians and social security center physicians and AAI is also reliable for nonspecialists previously trained, but its predictive value as regards echographic stenosis is poor in asymptomatic subjects, which may limit its usefulness for detecting preclinical atherosclerosis.

[Double stenosing valve disease after mediastinal radiotherapy: a case report of a 31 year-old man]. / Double valvulopathie sténosante post-radiothérapie médiastinale. A propos d'un cas, chez un homme de 31 ans.

Cardiac complications of radiotherapy for cancer, especially lymphoma and breast cancer, are well documented. The three tunics of the heart can be affected. However, valvular disease is rare and, when present, is usually regurgitant. Stenosis is very rare. The authors report the case of a 31 year old man who developed double mitro-aortic valvular stenosis 20 years after mediastinal radiotherapy associated with aortic regurgitation, right coronary stenosis and inflammatory epicardo-pericarditis with effusion. Surgery was undertaken and associated double aortic and mitral valve replacement and right coronary by pass grafting.

[Aneurysms of the atrial septum]. / Anévrysmes du septum interauriculaire.

Aneurysms of the atrial septum (ASA) frequently diagnosed since the introduction of transoesophageal echocardiography are implicated in the aetiology of cerebral and systemic embolic events. This update was undertaken to resume recent data on this pathology and its relationship with embolic events. The diagnostic criteria are described together with the morphological features (size, movements, thickness) and associated abnormalities (interatrial shunts, valvular prolapse). The authors summarise the data concerning possible complications of ASA, especially the different mechanisms invoked to explain embolism (paradoxical embolism. thrombosis in situ, supraventricular arrhythmias). Therapeutic options are discussed with respect to the clinical contexts (therapeutic abstention, platelet antiaggregant drugs, oral anticoagulants, interventional cardiology or surgery.

[Systemic embolism and thrombosis of the left atrium in a patient in sinus rhythm with cardiac amyloidosis]. / Embolie systémique et thrombus de l'auricule gauche, chez une patiente en rythme sinusal présentant une amylose cardiaque.

The authors report the case of a female patient admitted for complete heart failure with a diagnosis of type AL amyloidosis associated with dysglobulinaemia. While in hospital, she developed femoral embolism found to be secondary to atrial thrombosis in the absence of any supraventricular arrhythmia. The frequency and mechanism of intracardiac thrombosis and embolic accidents in cardiac amyloidosis are discussed in the light of this case.

Atrial septal aneurysm. Morphological characteristics in a large population: pathological associations. A French multicenter study on 259 patients investigated by transoesophageal echocardiography.

UNLABELLED: A strong association between interatrial septal aneurysm (IASA) and stroke has recently led many authors to consider IASA as a potential cardiac source of embolism. We studied the morphological characteristics and main associations of IASA in a large cooperative study based on transoesophageal echocardiographic examinations; 259 IASA were studied in 134 men and 125 women with a mean age of 59 +/- 15 years. Fifty-five percent of IASA were found to overlap the commonly described fossa ovalis region. IASA protruded into the right atrium in 90% of the cases. They appeared thin in 81% of the patients and highly mobile in 79%. Fifty-eight percent of patients had a history of systemic embolic events, while an atrial septal shunt was detected in 61% of the patients. In patients with an embolic event, only the mobility of IASA was significantly higher than in those with no embolic event. In nine cases a pulmonary embolism was associated with arterial embolism. Furthermore, we reported three cases of paradoxical embolism. However, the true demonstration of a thrombus within the IASA was quite rare. CONCLUSION: IASA is probably an important risk factor for stroke. In patients with IASA and a history of embolic events, IASA may enhance migration of a thrombus constituted in situ or transiting through it. Marked mobility of IASA may also increase the risk of peripheral embolus.

Predictive value of hemostatic factors for sudden death in patients with stable angina pectoris.

To assess hemostatic risk factors for sudden death in patients with stable angina, 323 consecutive patients were recruited prospectively. Patients with clinical heart failure or recent myocardial infarction were excluded. The following clinical variables were recorded: age, gender, smoking habits, hypertension, previous myocardial infarction, left ventricular hypertrophy, and severe ventricular arrhythmia. Angiographic variables included coronary extent, assessed from Jenkins' and mean atherosclerotic scores, and left ventricular ejection fraction. Lipid variables included total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and apolipoproteins A-I and B. Hemostatic factors included fibrinogen, fibrinopeptide A, antithrombin III, factor VIII antigen, factor VIII coagulant, protein C, plasminogen, alpha 2 antiplasmin, euglobulin clot lysis time, tissue plasminogen activator before and after venous occlusion, and plasminogen activator inhibitor. There were 34 deaths, 19 of which were sudden during the follow-up period (60 +/- 17 months). The association between each variable and the risk of sudden death was assessed by calculating the relative risk with the Cox univariate model. All significant predictors from the univariate analysis were then incorporated in a Cox multivariate model to select the independent predictors of sudden death. The independent predictors of sudden death were left ventricular hypertrophy (p < 0.04), lower left ventricular ejection fraction (p < 0.04), and shorter euglobulin clot lysis time after venous occlusion (p < 0.02), whereas fibrinogen (p < 0.07) and Jenkins' score (p < 0.08) were borderline. Determination of hemostatic variables, especially those pertaining to dynamic fibrinolysis, may thus be of value in assessing risk of sudden death.