Fragmentation of a right atrial myxoma presenting as a pulmonary embolism.

We report here a tricky case of right atrial myxoma with a pulmonary localization mimicking pulmonary thromboembolism. The diagnosis on imaging investigation was delayed because of its atypical appearance. This case report emphasizes the leading role of transthoracic and transesophageal echocardiography in the management of this condition. In autopsy series, the incidence of primary tumors of the heart is evaluated at 0.0017% to 0.19%.(1) Nearly half of them are myxoma.(1, 2) Myxoma are more frequently observed in adults and are commonly localized in the left atrium. Signs and symptoms are comparable to those arising in other cardiovascular and systemic conditions, including variable cardiac murmur, uneasiness, blackout, systemic embolism, cardiac insufficiency, lasting fever, or sudden death.(3) Rare cases of pulmonary embolism have been described. We report here an atypical case of right atrial myxoma with a pulmonary localization mimicking pulmonary embolus.

[Triangular or rectangular rehabilitation after myocardial infarction. Comparative study by drawing of lots evaluating performance and respiratory gas exchange]. / Réadaptation triangulaire ou rectangulaire après infarctus du myocarde. Etude comparative par tirage au sort évaluant la performance et les échanges gazeux respiratoires.

Triangular and rectangular rehabilitation techniques were assessed by comparative exercise performance and respiratory evaluation in twenty six phase II post-myocardial infarction patients. Patients all performed a standard exercise test with measurement of VO2, before and after 40 rehabilitation sessions. Clinical, exercise and ventilatory parameters were identical in the two groups before rehabilitation (triangular--n = 13; rectangular--n = 13). Exercise capacity was increased by 18% and 19% respectively after rehabilitation. Maximum aerobic capacity nevertheless remained unchanged (27.6 +/- 7.1 before; 28.3 +/- 6.7 ml/kg/min after) in all patients. Analysis of variance failed to reveal superiority of one of the two rehabilitation techniques over the other.

[Measurement of cardiac output by CO2 rebreathing technique. A study of reproducibility in the normal subject; application to cardiac insufficiency]. / Mesure du débit cardiaque par technique du CO2 rebreathing. Etude de reproductibilité chez le sujet sain, application à l'insuffisance cardiaque.

A feasibility and reproducibility study of cardiac output measurement by CO2 rebreathing was performed in normal subjects and in patients with compensated cardiac failure. The measurements were performed at rest and at the second stage of the Bruce protocol in normal subjects (N = 12) with a good reproducibility (r = 0.81) after an interval of two days. In patients with stable cardiac failure (N = 17), the cardiac outputs were 9.4 +/- 3.9 l/min and 9.3 +/- 3.1 l/min by measuring the arterial pCO2 and end-expiratory CO2 compared with the theoretical value of 9.9 +/- 2 l/min. The non-invasive measurement of cardiac output by the CO2 rebreathing method was well tolerated by patients and is reliable and reproducible.

[Return to work after myocardial infarction: evaluation and decision]. / La reprise du travail après infarctus du myocarde: bilan et décisions.

Working capacity after myocardial infarction depends on the physical and cardiovascular status, psychological repercussions and conditions of work. The latter two are much more important than the first two factors. Cardiovascular functional status is readily assessed by the large number of available investigations which leave little unknown. Exercise stress testing during the second week is the most cost-efficient investigation, providing reliable and sufficiently quantifiable data about the possible sequellae of cardiac failure on effort, ischemia and arrhythmias: an idea of the patient's functional capacity and circulatory responses (athletic, hyperkinetic) may also be obtained allowing adjustment of treatment to improve exercise capacity which goes much further than the statistical hope of prolonging survival. However, it would be naive to think that a satisfactory exercise stress test guarantees the patients' capacity to return to work. Psychological and sociological factors are more important by far. The dominant trait of the post-infarction psychological syndrome must be identified (anxiety, depression, negation): the positive and negative influences of the family, social and professional environment must be evaluated. A good knowledge of the patient's working conditions is essential to go against a number of taboos hindering the return to work (stress, stairs, restaurant meals, etc...). Finally, the medico-legal relationship between the infarct and work should not be neglected: the management of myocardial infarction when an occupational disease must respect the legislative and judicial texts which do not always correspond with everyday clinical practice. There is a lack of structures for cardiac function testing for assessing physical aptitude: we suggest that in the context of the proposed hospital reforms, departmental heads should consider setting up such units which would have a specific task respecting the spirit of these reforms. Nevertheless, cardiologists should pay more attention to the convalescent phase of infarction. This is the time when many social catastrophes can be avoided.

[Role of physical effort in the monitoring of coronary disease: under medical treatment, after bypass, after angioplasty]. / Place de l'épreuve d'effort dans la surveillance de la maladie coronaire: sous traitement médical, après pontage, après angioplastie.

Exercise tests must be performed only in hospitals and private clinics equipped for intensive care. Electrocardiographs must be fitted with a computer-assisted system for averaging and smoothing. In all but special cases it would be preferable to interrupt or delay the anti-angina treatment, so that the degree of ischaemia can be quantified. In this way, the severity of coronary lesions, the risk of arrhythmia and the prognosis for life can be predicted with good statistical certainty. In addition, the patient's fitness for work can easily be evaluated. As years go by, the ischaemia may be found to have become worse, and it might be decided to revascularize the myocardium in due course. Following revascularisation exercise tests are used to evaluate its benefits and follow their persistence. In addition, exercise tests are a very useful means of adjusting the antianginal treatment. Finally, exercise tests create a special link between patients and their medical team since they participate, both physically and psychologically, in their own diagnosis and evaluation of treatment.

[Which coronary investigation should be performed in patients with peripheral arterial diseases?]. / Quel bilan coronarien faut-il faire chez un patient présentant une artériopathie périphérique?

In the context of peripheral vascular disease, the clinical history provides a means of evaluating coronary risk. The key features are: age, previous myocardial infarction especially when recent (under 6 months), anginal pain, smoking, diabetes and ventricular arrhythmias. Treadmill testing, often limited by symptoms of claudication, may reveal severe coronary ischemia and thereby the patients at very high risk. Upper limb exercise stress testing gives results similar to standard protocols of non-atherosclerotic patients when correctly performed and a reliable detection and evaluation of coronary lesions. Thallium dipyridamol myocardial scintigraphy is a very useful diagnostic method but requires special radionuclide facilities. This technique demonstrates the site of ischemia. Coronary angiography should be reserved for special cases because the risks of the procedure are always greater in patients with peripheral vascular disease.

[Treatment of cardiac insufficiency in ischemic heart disease]. / Traitement de l'insuffisance cardiaque des cardiopathies ischémiques.

Over 30 per cent of coronary patients die of cardiac failure excluding the acute phase of myocardial infarction. With the exception of preexisting hypertension, there is no compensatory hypertrophy in ischemic heart disease. However, hypertrophy is a costly adaptation in terms of myocardial oxygen demand and, therefore, coronary flow. Fibrous zones are unresponsive to inotropic drugs and so the treatment of cardiac failure due to ischemic heart disease consists in limiting or preventing episodes of ischemia. Each mechanism of ischemia has an appropriate treatment: the preload is reduced by trinitrin and its derivatives and by molsidomine; the after-load by calcium antagonists and angiotensin converting enzyme inhibitors; tachycardia and hypercontractile states by betablockers. The risk of arrhythmia, aggravated by many inotropic therapies, constitutes the major danger to ischemic heart failure; amiodarone, betablockers and preventive nitrate therapy are the most effective and least dangerous antiarrhythmics. Revascularisation is effective for permanently ischemic segments or for ischemia on effort but does not improve large plaques of fibrosis which sometimes require surgical ablation or plastic procedures. But these measures are incomplete if all aspects of the disease are not taken in consideration: loss of excessive body weight, exercise rehabilitation by modern techniques, limitation of bed rest at the ultimate stage of the disease allowing patients with ischemic cardiac failure a better quality of life without aggravating the prognosis.

Risk factors for myocardial infarction during coronary artery bypass graft surgery.

Patients with a particular thrombotic profile may be at greater risk of myocardial infarction during coronary artery bypass graft surgery. The thrombotic profile of 50 patients admitted to hospital with stable angina pectoris was determined prior to haemodynamic investigation. ECG results and determination of cardiac enzymes showed that 12 patients had suffered a perioperative myocardial infarction. These patients had a higher mean atherosclerotic score (42.1 +/- 10.5 vs 32.9 +/- 13, P less than 0.02), a longer aortic cross clamp time (59 +/- 15.2 vs 45.7 +/- 16.3 min, P less than 0.05), lower serum levels of protein C (101.2 +/- 26 vs 124.7 +/- 31.4%, P less than 0.05) and tissue plasminogen activator (322 +/- 580 vs 2307 +/- 2830 IU ml-1, P less than 0.01). There were no differences between the two groups in Jenkin's coronary score, the number and type of grafts, ejection fraction, left ventricular end-diastolic pressure, lipid profile or levels of markers of platelet release. In addition to a more severe distal coronary atheroma and a longer aortic cross-clamp time, patients with impaired endothelial fibrinolytic activity appeared to be at greater risk of myocardial infarction during coronary artery bypass graft surgery.

Validation of a digitized Holter monitoring system by comparison with the Marquette case system.

Detection of silent myocardial ischaemia must be accurate and reliable. With the new digitized Holter monitoring systems these qualities are feasible. We tested one of these devices (Monitor One, Q Med) by comparison with a digitized and averaged ECG signal provided by the Marquette Case system during exercise tests in 30 patients with angiographically documented coronary artery disease. Detection and quantitation of ST segment depression episodes by the Holter system were excellent. Furthermore, indirect ECG criteria of ischaemia as R-wave amplitude variations were easily recognized. Thus digital monitors may be used to detect ischaemic events in prospective and multicentre studies for the diagnosis and prognosis of silent myocardial ischaemia.

[Protease inhibitors and ectasia in coronary atherosclerosis]. / Inhibiteurs protéasiques et ectasie dans l'athérosclérose coronarienne.

The possibility of elastase contributing to degradation of the arterial wall in atherosclerosis and to the formation of ectasia has prompted us to assay the main protease inhibitors, alpha 1-antitrypsin and alpha 2-macroglobulin, in patients with angiographic coronary disease with and without coronary ectasia. Serum concentrations of these two proteins were measured by immunonephelometry in 203 patients admitted for coronary arteriography. The results obtained were analyzed according to the presence of atheromatous lesions and their severity and to the presence or absence of ectasia. There was no correlation between the values observed and the presence or severity of coronary atherosclerosis, but the concentration of alpha 1-antitrypsin was significantly higher in patients with coronary ectasia (247.2 +/- 40.5 mg/ml) than in patients without ectasia (213.5 +/- 36.6 mg/100 ml; p less than 0.001). This study shows that coronary ectasia is associated with disturbances in the protease-antiprotease system, which may be consecutive to initial changes in elastase activity. Our results support the theory that elastase and protease inhibitors play a specific role in some atheromatous processes.