Comparison of clinical and morphological characteristics of Staphylococcus aureus endocarditis with endocarditis caused by other pathogens.

OBJECTIVES: To analyse clinical, echocardiographic, and prognostic characteristics of Staphylococcus aureus infective endocarditis (IE) compared with endocarditis caused by other pathogens. DESIGN: Cohort study. METHODS: 194 consecutive patients with definite IE according to the Duke criteria prospectively examined by transthoracic and transoesophageal echocardiography were enrolled. Patients without identified microorganisms were excluded. The S aureus IE group (n = 61) was compared with the group with IE caused by other pathogens (n = 133). RESULTS: Compared with IE caused by other pathogens, S aureus IE was characterised by severe co-morbidity, a shorter duration of symptoms before diagnosis, and a higher prevalence of right sided IE, cutaneous portal of entry, and history of renal failure. Severe sepsis, major neurological events, and multiple organ failure were more frequent during the acute phase in S aureus IE. In-hospital mortality (34% v 10%, p < 0.001) was higher in patients with S aureus IE and the 36 month actuarial survival rate was lower in S aureus IE than in IE caused by other pathogens (47% v 68%, p = 0.002). Multivariate analyses identified S aureus infection as a predictive factor for in-hospital mortality and for overall mortality. CONCLUSIONS: S aureus IE compared with IE caused by other pathogens occurs in a more debilitated clinical setting and is characterised by a higher prevalence of severe sepsis, major neurological events, and multiple organ failure leading to higher mortality.

[Transesophageal echographic demonstration of ulcerated atheromatous plaques of the thoracic aorta responsible for cholesterol emboli]. / Mise en évidence par échographie transoesophagienne de plaques athéromateuses ulcérées de l'aorte thoracique à l'origine d'embolies de cholestérol.

The authors present of case of a 61-year-old man suffering from cholesterol emboli, in whom transoesophageal echocardiography revealed complex atheromatous lesions of the thoracic aorta. There is growing emphasis, at the present time, on the concept of triggering factors with the multiplication of endovascular radiological investigations, the more widespread availability of cardiac surgery and the use of anticoagulants and fibrinolytics. The prognosis is poor, treatment is only palliative and preventive measures are therefore essential.

[Non-bacterial thrombosing endocarditis. Apropos of 2 cases]. / Endocardite thrombosante non bactérienne. A propos de deux cas.

The diagnosis of nonbacterial thrombosing endocarditis or marasmic endocarditis must be considered in patients presenting with a combination of cancer and systemic embolism. The pathophysiological mechanisms of this entity are unclear and purely hypothetical. However, hypercoagulability appears to play an essential role in the pathogenesis of this endocarditis, which could be the cardiac expression of a coagulopathy involving the entire vascular system. The authors report two cases of marasmic endocarditis which emphasize the value of transthoracic and transoesophageal echocardiography in the difficult diagnosis of this disease.

[Malignant cardiac lymphoma. Diagnosis by echocardiography]. / Lymphome malin tumoral de localisation cardiaque. Diagnostic par échocardiographie.

The authors report a case of cardiac malignant non-Hodgkin lymphoma. The initial clinical presentation suggested recurrent angina in a patient who had undergone angioplasty of the left anterior descending artery two years previously. Echocardiography showed severe left ventricular dysfunction with apical and septal akinesia and also allowed visualisation of two oval masses in the right ventricle without dilatation of the right heart chambers. Transoesophageal echocardiography confirmed these abnormal echos which corresponded to tumour invasion of not only the right heart chambers but also the interatrial septum, the left atrial appendage and the descending thoracic aorta. Histological diagnosis of lymphoma was made from an excision biopsy of a mass in the calf muscle. The post-mortem examination confirmed the presence of a highly malignant T-cell non-Hodgkin lymphoma. The patient rapidly deteriorated and died during the first session of chemotherapy.

AREVA: multicenter randomized comparison of low-dose versus standard-dose anticoagulation in patients with mechanical prosthetic heart valves.

BACKGROUND: Moderate anticoagulation may be proposed to reduce the risk of hemorrhage for certain patients with a mechanical prosthesis, but the consequences for risk of thromboembolism are debated. METHODS AND RESULTS: The purpose of the AREVA trial was to compare moderate oral anticoagulation (international normalized ratio [INR] of 2.0 to 3.0) with the usual regimen (INR of 3.0 to 4.5) after a single-valve replacement with a mechanical prosthesis, either Omnicarbon or St Jude. Patients included were between 18 and 75 years old, in sinus rhythm, and with a left atrial diameter < or = 50 mm on the time-motion echocardiogram. Patients were randomized for INR after surgery. From 1991 to 1994, 433 patients underwent valve replacement (aortic, 414; mitral, 19) with 353 St Jude and 80 Omnicarbon prostheses; 380 patients were randomized for INR: 188 for INR 2.0 to 3.0 and 192 for INR 3.0 to 4.5. Mean follow-up was 2.2 years (1 to 4 years). Analysis of 18001 INR samples showed that the mean of the median of INR was 2.74 +/- 0.35 in the 2.0 to 3.0 group and 3.21 +/- 0.33 in the 3.0 to 4.5 group (P < .0001). Thromboembolic events, as assessed from clinical data and CT brain scans, occurred in 10 patients in the 2.0 to 3.0 INR group and 9 patients in the 3.0 to 4.5 INR group (P = .78). Hemorrhagic events occurred in 34 patients in the 2.0 to 3.0 INR group and 56 patients in the 3.0 to 4.5 INR group (P < .01), with 13 and 19 major hemorrhagic events, respectively (P = .29). CONCLUSIONS: In selected patients with mechanical prostheses, moderate anticoagulation prevents thromboembolic events as effectively as conventional anticoagulation and reduces the incidence of hemorrhagic events.

[Pulmonary hypertension associated with portal hypertension. Apropos of 2 cases]. / Hypertension artérielle pulmonaire associée à une hypertension portale. A propos de 2 cas.

The authors report the cases of two patients with pulmonary hypertension associated with portal hypertension. This is a rare association with a reported prevalence ranging from 0.25 to 0.73%. The diagnosis of portal hypertension preceded that of pulmonary hypertension by several years. The physiopathological mechanism of the latter is not well known although several hypotheses have been proposed. Treatment is only symptomatic. The prognosis is usually poor, the causes of death being related to complications of liver failure and/or portal hypertension or to those of pulmonary hypertension.

[Multidimensional transesophageal echocardiography in the determination of the orificial surface of aortic stenoses in adults. Apropos of 85 cases]. / Apport de l'échocardiographie transoesophagienne multiplan dans la détermination de la surface orificielle des sténoses aortiques de l'adulte. A propos de 85 cas.

The objective of this study was to assess the validity of multidimensional transoesophageal echocardiography (TOE) in the determination of the orificial surface area of aortic stenosis (AS) in 85 patients, using as a reference the surface area calculated on transthoracic ultrasonography (TTU) by applying the continuity principle (n = 75) and/or by haemodynamic studies using Gorlin's formula (n = 40). Planimetry was able to be performed in 78 of the 85 patients (92%). Planimetry was impossible in 7 patients with massive calcification of the aortic orifice (n = 5) or posterior valve (n = 2). The mean value of the selected angle was 45 +/- 13 degrees (0 to 78 degrees). An excellent correlation was observed between aortic surface area (ASA) measured by multidimensional TOE and TTU (r = 0.94; y = 0.90x +/- 0.10; SEE = 0.10 cm2; p < 0.001). Similarly, the ASA on multidimensional TOE was also well correlated with the haemodynamic surface area (r = 0.90, y = 0.94x +/- 0.05; SEE = 0.09 cm2; p < 0.001). The correlations between multidimensional TOE and TTU measurements (n = 26; r = 0.96; y = 0.85 x +/- 0.11; SEE = 0.07 cm2; p < 0.001) and cardiac catheterization (n = 13; r = 0.92; y = 0.77 x +/- 0.7; SEE = 0.09 cm2; p < 0.001) remained satisfactory in patients with associated aortic incompetence. Multidimensional TOE identifies cases of AS with an ASA on TOE or haemodynamic studies less than or equal to 0.75 cm2 with sensitivities of 93% and 92%, respectively, and a specificity of 100%. Overall, multidimensional TOE allows a precise and reliable evaluation of ASA in the great majority of cases of AS.

[Does mitral insufficiency prevent spontaneous contrast phenomenon and formation of thrombi in the left atrium?]. / L'insuffisance mitrale prévient-elle la formation du phénomène de contraste spontané et la constitution des thrombus dans l'oreillette gauche?

The aim of this study was to assess the influence of mitral regurgitation on the prevalence of left atrial spontaneous echo contrast and thrombosis in 2,180 consecutive patients undergoing transthoracic and transoesophageal echocardiography. Two groups of patients were defined according to the absence (group I) or presence (group II) of grades 3 or 4 mitral regurgitation quantified by transoesophageal echocardiography. Group II was associated with a statistically significant lower frequency of spontaneous echo contrast (0.6 vs 11.2%; p < 0.0001), left atrial thrombosis (0.6 vs 4.2%; p < 0.03), ischaemic cerebrovascular accidents (1.2 vs 21%; p < 0.0001), transient ischaemic attacks (0 vs 12%; p < 0.0001) and systemic embolism (0 vs 4.6%; p < 0.01). Conversely, the prevalence of atrial fibrillation was higher in group II (28 vs 19%; p < 0.01) and there were more patients with left atrial dimensions > or = 5.5 cm (16 vs 6.7%; p < 0.0001). When mitral stenosis and valve prosthesis were excluded, there were no cases of spontaneous echo contrast (8.3 vs 0%; p < 0.001) or left atrial thrombosis (2.9 vs 0%; p < 0.05) in the group with grades 3 or 4 mitral regurgitation. The phenomenon of left atrial spontaneous echo contrast and/or thrombosis is rare in patients with grade 3 or 4 in native mitral valve regurgitation and explains the low incidence of systemic embolism in these cases.

[Paradoxical embolisms after pulmonary embolism. 6 cases]. / Embolies paradoxales au décours d'une embolie pulmonaire. 6 observations.

Among a series of 6 patients who had paradoxical emboli after pulmonary embolus, thrombus was encrusted in the foramen ovale in 2 while contrast echocardiography showed a free foramen ovale in the 4 others. Surgical embolectomy was performed in 1 of the patients with a thrombus in the foramen ovale. This patient died in the post-operative period and the second patient died suddenly before the indication for surgery had been established. The 4 other patients were treated medically with anticoagulant therapy. After a follow-up of 37, 33, 32 and 3 months respectively none of these patients has developed recurrent emboli. The association of a thromboembolic disease and a systemic ischaemic event should strongly suggest the diagnosis of paradoxical embolus. Echocardiography is required to determine whether the foramen ovale is free or harbours a thrombus.

Quantitation of aortic valve area in aortic stenosis with multiplane transesophageal echocardiography: comparison with monoplane transesophageal approach.

The accuracy and reliability of two-dimensional monoplane and multiplane transesophageal echocardiography (TEE) in the quantitation of aortic valve area were compared in 54 patients with aortic stenosis. Fifty patients had aortic valve area calculated by the continuity equation and transthoracic Doppler echocardiography (TTE); 25 underwent cardiac catheterization. Two-dimensional echocardiograms adequate for quantitation of aortic valve area were obtained in 21 (39%) patients with monoplane TEE and in 51 (94%) with multiplane TEE. The mean aortic valve area determined by both TEE methods did not differ significantly from that derived from TTE and catheterization. The mean difference of aortic valve area measurements between monoplane TEE and TTE was -0.045 +/- 0.11 cm2; that between multiplane TEE and TTE was 0.001 +/- 0.11 cm2. Multiplane TEE provided a better correlation of aortic valve area measurements with either TTE (y = 0.97 x + 0.03; r = 0.96; SEE = 0.11 cm2) or catheterization (y = 0.84 x + 0.11; r = 0.90; SEE = 0.12 cm2) than the monoplane TEE (y = 0.88 x + 0.13; r = 0.83; SEE = 0.15 cm2 and y = 0.41 x + 0.42; r = 0.81; SEE = 0.15 cm2). Severe aortic stenosis with valve orifice area of < or = 0.75 cm2 during TTE examination was found by multiplane TEE with a sensitivity of 96% and a specificity of 96%. Thus aortic valve area can be directly and reliably measured by two-dimensional multiplane TEE in majority of patients with aortic stenosis.

[Doppler echocardiography of tricuspid insufficiency. Methods of quantification]. / Echocardiographie-Doppler de l'insuffisance tricuspidienne. Méthodes de quantification.

Evaluation of tricuspid incompetence has benefitted considerably from the development of Doppler ultrasound. In addition to direct analysis of the valves, which provides information about the mechanism involved, this method is able to provide an accurate evaluation, mainly through use of the Doppler mode. In addition to new criteria being evaluated (mainly the convergence zone of the regurgitant jet), some indices are recognised as good quantitative parameters: extension of the regurgitant jet into the right atrium, anterograde tricuspid flow, laminar nature of the regurgitant flow, analysis of the flow in the supra-hepatic veins, this is only semi-quantitative, since the calculation of the regurgitation fraction from the pulsed Doppler does not seem to be reliable; This accurate semi-quantitative evaluation is made possible by careful and consistent use of all the criteria available. The authors set out to discuss the value of the various evaluation criteria mentioned in the literature and try to define a practical approach.

[Contribution of transesophageal ultrasonography in the etiologic evaluation of a systemic embolic accident. Apropos of 451 patients]. / Apport de l'échographie transoesophagienne dans le bilan étiologique d'un accident systémique embolique. A propos de 451 patients.

In order to compare the respective values of transoesophageal and transthoracic echocardiography in the investigation of systemic embolic events, 451 consecutive patients (average age 60 +/- 15 years) presenting either with a cerebral ischaemic event (n = 401) or a peripheral arterial embolism (n = 50), were examined. One hundred and ninety eight patients had documented cardiac disease and/or atrial fibrillation; 253 patients had no previous cardiovascular history. Transoesophageal echocardiography revealed a possible cardiac embolic lesion in 37% of patients compared with 11% by transthoracic echocardiography (p < 0.001). In those patients with previous cardiac disease, transoesophageal echocardiography was contributory in 50% of cases compared with 27% of cases in patients with no previous cardiac disease (p < 0.001), whereas transthoracic echocardiography was only contributory in 12% and 9.8% of cases, respectively. Transoesophageal echocardiography was more sensitive for the diagnosis of intracavitary thrombus (7.5% vs 2.2%, p < 0.001), prosthetic valve thrombosis (2.4% vs 0.6%, p < 0.01), spontaneous contrast in the left atrium (10.8% vs 0%, p < 0.001), interatrial septal aneurysm (6.4% vs 1.9%, p < 0.001), mitral valve prolapse (5.3% vs 2.8%, p < 0.01). Moreover, irregular atheromatous plaques in the thoracic aorta could only be visualised by transoesophageal echocardiography (9% of cases). This study underlines the superiority of transoesophageal echocardiography over transthoracic echocardiography in the investigation of systemic embolic events. Transoesophageal echocardiography is even more contributory in patients with a history of cardiac disease.

[Contribution of transesophageal and transthoracic echography in the evaluation of the mechanism and quantification of regurgitation in mitral and aortic bioprosthetic valves]. / Apport de l'échographie transoesophagienne et transthoracique dans l'évaluation du mécanisme et la quantification des régurgitations sur bioprothèses mitrales et aortiques.

The respective values of transoesophageal (TOE) and transthoracic echocardiography (TTE) in the evaluation of the mechanism and the quantification of pathological regurgitation of bioprosthetic heart valves were analysed in 23 patients (14 mitral, 9 aortic; duration of implantation 108 +/- 43.2 months). Surgical or pathological correlations were available in all cases and catheter data in 18 of the 23 patients. With regards to mitral bioprostheses, the TOE evaluations of the mechanism and site of regurgitation corresponded in all cases with the operative or pathological findings and quantification of mitral regurgitation concorded with angiography. There was an underestimation of the severity of mitral regurgitation in 30% of cases by TTE compared with angiography; prolapse was diagnosed in 7 of the 10 cases with cusp tears. It was not possible to accurately determine the intra or perivalvular site of regurgitation by TEE. With regards to aortic bioprostheses, TOE and TTE were equally useful in determining the mechanism of regurgitation, showing cusp prolapse in 6 of the 9 cases with cusp tears. However, TTE quantified regurgitation accurately in all cases with respect to angiography, whereas TOE was only contributive in 50% of cases. These results show that single plane TOE is superior to TTE in the quantification and determination of the mechanism of regurgitation in mitral bioprostheses, but that TTE remains better for the quantification of regurgitation of aortic bioprostheses.

[Value and limits of single-plane transesophageal echocardiography in dysfunctions of aortic valve prosthesis]. / Intérêts et limites de l'échographie transoesophagienne monoplan dans l'étude des dysfonctions de prothèses valvulaires aortiques.

The authors reviewed retrospectively the results of transoesophageal and transthoracic echocardiography in 26 patients with prosthetic aortic valve dysfunction in order to study the value and limitations of monoplane transoesophageal echocardiography in this condition. Surgical data was available in 14 of these cases. The diagnosis of abscess of the aortic ring was made on 7 occasions by transoesophageal echocardiography and on 3 occasions by transthoracic echocardiography Bacterial vegetations were visualised in 5 cases by transoesophageal echocardiography and in 1 case by transthoracic echocardiography. The diagnosis of thrombosis was made in 1 case by transoesophageal echocardiography and missed by transthoracic echocardiography; fibrous pannus (n = 1) was not recognised on transoesophageal and transthoracic echocardiography. In the latter two conditions, transthoracic Doppler showed signs of obstruction. The diagnosis of a stenotic bioprosthesis due to fibrocalcific degeneration was made in 1 case by transoesophageal and in 1 case by transthoracic echocardiography. Prolapse of cusp was diagnosed in 6 cases by transthoracic echocardiography. An intraprosthetic valve leak was visualised in 7 cases by transoesophageal echocardiography and in 9 cases by transthoracic echocardiography; periprosthetic leaks were diagnosed in 9 cases by transoesophageal and in 12 cases by transthoracic echocardiography. These results indicate that transoesophageal echocardiography is a major advance in the diagnosis of abscess of the aortic ring, bacterial vegetations and prosthetic valve thrombosis. On the other hand, transthoracic echocardiography remains superior for the quantification or regurgitation and enables evaluation of transprosthetic gradients of obstructive prostheses with continuous mode Doppler. Therefore, the two methods are complementary.

[Echocardiographic diagnosis of a thrombus trapped in a patent foramen ovale. Apropos of a case]. / Diagnostic par échographie d'un thrombus enclavé dans un foramen ovale perméable. A propos d'un cas.

The authors report the case of a patient presenting with pulmonary embolism in which transthoracic echocardiography showed the presence of an intracardiac thrombus trapped in a patent foramen ovale; this was confirmed at surgery. It is rare to see this type of thrombus (which usually gives rise to paradoxical embolism) by transthoracic echocardiography. Previously, this used to be a postmortem diagnosis but the condition is often suspected nowadays when deep venous thrombosis and/or pulmonary embolism, an unexplained systemic embolism and a right-to-left interatrial shunt, are associated. However, the diagnosis can only be confirmed by the visualisation of the thrombus crossing the interatrial septum.

[Contribution of transesophageal echocardiography in the diagnosis of intra- and para-cardiac masses]. / Apport de l'échocardiographie transoesophagienne dans le diagnostic des masses intra- et paracardiaques.

The authors detected 59 thrombi and 7 intra- or paracardiac tumors in 58 patients in a series of 1,100 transesophageal echocardiography. Twenty-six of the 51 patients with a thrombus were in sinus rhythm; 25 had atrial fibrillation. In 44 cases, the thrombus was single and in 7 cases there were multiple thrombi. A phenomenon of spontaneous contrast in the left atrium was observed in 24 patients (47%). In 31 cases (53%) the thrombi were located in the left auricle, in 21 cases (36%) in the left atrium, in 4 cases in the left ventricle and in 3 cases in the right atrium. Transthoracic echocardiography only detected 25% of these thrombi. The superiority of transesophageal echocardiography was particularly evident for the detection of thrombi in the left auricle (31 by transesophageal echocardiography versus 2 by transthoracic echocardiography) and in the left atrium (13 by transesophageal echocardiography versus 7 by transthoracic echocardiography). Five myxomas were diagnosed by transesophageal echocardiography and 4 of them were identified by transthoracic echocardiography. The site of implantation of the tumor was located in all 5 cases by transesophageal echocardiography. Two right paracardiac tumours were only visible by transesophageal echocardiography. Transesophageal echocardiography is therefore very useful in the diagnosis of thrombi in the left atrium and auricle, of rare hypodense myxomas and paracardiac tumors. In addition, it enables precise localisation of the site of implantation of nearly all intracardiac tumors.

[Aneurysm of the interatrial septum. Contribution of transesophageal echography. Relation with systemic embolic complications]. / Anévrysmes du septum interauriculaire. Apport de l'échographie transoesophagienne. Relation avec les accidents systémiques emboliques.

The aim of this study was to evaluate the contribution of transesophageal echocardiography to the diagnosis of aneurysms of the interatrial septum and to identify the role played by this condition in unexplained systemic embolic accidents. Thirty two aneurysms of the interatrial septum were discovered in a consecutive series of 751 transesophageal echocardiograms, i.e. an incidence of 4.2 per cent. The diagnosis was possible by transthoracic echocardiography in only 9 cases (28%). Search for a patent foramen ovale by a contrast test was positive in 87 per cent of cases of aneurysm of the interatrial septum as compared with 45 per cent for patients without an aneurysm (p < 0.01). In patients in whom transesophageal echocardiography was requested for etiological evaluation of an ischemic vascular accident of embolic origin (n = 191), an aneurysm of the interatrial septum was found in 8.3 per cent of cases. In patients with no history of a systemic embolic accident (n = 560), the incidence of septums of the interatrial septum was 2.8 per cent (p < 0.01). Furthermore, 50 per cent of patients with an aneurysm of the interatrial septum had a history of systemic embolism. Transesophageal echocardiography thus appears to be superior to transthoracic echocardiography in the positive diagnosis of aneurysms of the interatrial septum and our study is suggestive of their emboligenic nature.

[Value and limits of the determination of aortic output by Doppler echocardiography in the quantification of aortic valve insufficiencies]. / Intérêt et limites de la détermination du débit aortique par échographie Doppler dans la quantification des insuffisances aortiques.

The aim of this study was to assess the value and limitations of Doppler echocardiographic measurement of aortic flow in the quantification of aortic regurgitation. Sixty-one patients were examined by Doppler echocardiography within 48 hours of cardiac catheterisation. There were 9 Grade I, 18 Grade II, 18 Grade III and 16 Grade IV angiographic aortic regurgitations. The mean aortic blood flow in angiographic Grades I and II (p less than 0.01). A correlation was observed between Doppler aortic flow and the angiographic grade of regurgitation (r = 0.66, p less than 0.001) and between aortic flow and regurgitant fraction (r = 0.68, p less than 0.001). Aortic flow greater than 10 l/mn identified angiographic Grades III or IV regurgitation with a sensitivity and specificity of 73.5% and 92.5% respectively and a positive and negative predictive values of 92.5% and 73.5% respectively. Aortic regurgitation with a regurgitant fraction greater than 40% was identified by a pulsed Doppler aortic blood flow greater than 10 l/mn with a sensitivity and specificity of 70% and 93% respectively, and positive and negative predictive values of 95% and 61% respectively. The sensitivity of this criterion is relatively poor as some severe aortic regurgitations have aortic flows of less than 10 l/mn: these patients have low outputs because of left ventricular dysfunction which is apparent from measurement of left ventricular fractional shortening.

Left ventricular aneurysm and prognosis in patients with first acute transmural anterior myocardial infarction and isolated left anterior descending artery disease.

To determine the clinical and angiographic factors responsible for left ventricular aneurysm formation and the prognosis of patients with aneurysm, 79 patients with a first acute transmural anterior myocardial infarction and angiographically documented isolated left anterior descending artery disease were retrospectively evaluated. Presence of large infarct size and left ventricular volumes, reduced left ventricular function, and evidence of clinical functional impairment were more common in patients with aneurysm (n = 31) than in those without (n = 48). Patients with aneurysm often had total occlusion of the proximal left anterior descending artery without collateral vessels on angiography. During a mean follow-up of 53 months, 10 patients with and three without aneurysm died (P less than 0.01). Compared to survivors with or without aneurysm, the nonsurvivors were older, had significantly larger infarct size and left ventricular volumes and poor systolic function. The incidence of total occlusion of the left anterior descending artery without collaterals was higher in nonsurvivors. In patients with aneurysm, stepwise multivariate analysis revealed that left ventricular ejection fraction and the status of left anterior descending artery obstruction and collaterals were independent predictors of mortality. The study indicates that in patients with a first acute transmural anterior myocardial infarction and isolated anterior descending artery disease, left ventricular aneurysm often results from a large infarct caused by total occlusion of the proximal left anterior descending artery without collateral supply to the infarct region. The reduced survival rate for patients with aneurysm is primarily related to severe global left ventricular dysfunction which may be determined by assessing the residual flow to the infarct region.