Noninvasive estimation of pulmonary arterial wedge pressure with Doppler transmitral flow velocity pattern in patients with known heart disease.

Pulmonary arterial wedge pressure (PAWP) is an important marker of cardiac function. Regrettably, it requires catheterization, which can occasionally result in serious complications. A noninvasive method of estimating PAWP would thus be helpful. Recent studies have indicated that the Doppler transmitral flow velocity pattern was strongly dependent on preload and could provide an estimate of PAWP. This study was therefore designed to evaluate the relation between doppler transmitral flow velocity indexes and measured PAWP in 91 patients (learning group: 73 men, mean age 57 +/- 13 years) with ischemic heart disease (n = 41), dilated (n = 29) or hypertrophic cardiomyopathy (n = 4), or aortic stenosis (n = 17). Multiple regression analysis was used to derive an equation for estimation of PAWP, which was subsequently tested in a separate group of 33 patients (testing group: 28 men, mean age 58 +/- 12 years) with similar cardiac conditions. PAWP ranged from 4 to 48 mm Hg in the learning group and from 7 to 40 mm Hg in the testing group. In the learning group, PAWP correlated with the E/A ratio (r = 0.95), atrial filling fraction (r = -0.80), peak E velocity (r = 0.79), isovolumic relaxation period (r = -0.75), and deceleration time (r = -0.61). In the learning group, PAWP was best predicted as PAWP = 18.4 + [17.1.In(E/A ratio)]. This equation allowed prediction of PAWP within 3 mm Hg of the measured value in 24 of 33 patients (73%) in the testing group. In 8 additional patients, the equation also accurately predicted the changes in PAWP induced by volume loading or intravenous nitrates (r = 0.98).(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperamylasemia with papillary serous cystadenocarcinoma of the ovary.

High levels of serum amylase and CA19.9 were noted in a patient with papillary serous cystadenocarcinoma of the ovary. Electrophoresis identified isoamylases of salivary type. Both markers decreased rapidly after removal of the ovarian tumour. These considerations argue in favor of the early detection of amylase isoenzymes in patients in whom history, objective signs, and routine diagnostic studies fail to disclose a pancreatic disease.

Dilated cardiomyopathy and the level of alcohol consumption: a planned multicentre case-control study.

The association between clinical or environmental factors and dilated cardiomyopathy (DCM) has been assessed in a planned case-control study. Patients and controls were men aged between 20 and 65 years, matched for age, profession and geographic location. DCM was defined by strict radiologic and angiographic criteria excluding multiple-vessel coronary disease. Controls were recruited from the surgical centres after excluding diseases usually linked with alcohol or tobacco consumption. Univariate and multivariate analyses were used to ensure adequate techniques for matched pairs. The prevalence of diabetes and hypertension and the exposure to toxic substances, drugs and tobacco was identical in both groups. Alcohol consumption before the onset of first symptoms was higher in patients than in controls (101 vs 64 ml day-1, P less than 0.001); the excess of consumption concerns all kinds of alcoholic beverage (wine, beer, etc.). The relative risk (RR), estimated from the odds ratio, increased only among heavy drinkers (greater than or equal to 110 ml day-1; RR: 7.6, P less than 0.001) with an independent contribution of both wine (RR: 4.7, P less than 0.001) and other alcoholic beverages (RR: 4.1, P less than 0.01). In conclusion, alcohol is a strong risk factor for DCM, but the excess of risk is limited to heavy drinkers and is independent of the type of beverage.

[Outcome of hypertrophic and obstructive myocardiopathies treated with high doses of propranolol]. / Evolution des myocardiopathies hypertrophiques et obstructives sous fortes doses de propranolol.

Twenty-five patients with hypertrophic obstructive cardiomyopathy confirmed by clinical, echocardiographic and haemodynamic investigations were treated with high dose propranolol (320 to 800 mg/day, average 420 mg/day) and assessed after an average follow-up period of 25 months. The effects of treatment were assessed by interrogation in all patients and by exercise testing before and after propranolol in 19 cases. Comparative echocardiographic (21 patients) Holter (20 patients) and catheter studies (14 patients) were also performed. The cardiovascular mortality rate during the study period was nil. All patients were symptomatic before treatment; 9 became asymptomatic and 13 patients were improved, the average functional score decreasing from 5.16 +/- 2.15 to 2.28 +/- 1.49 (p less than 0.001). The persistence of severe symptoms led to withdrawal of the beta-blocker in 2 cases. There was a parallel improvement in maximal work capacity during exercise stress testing (96 +/- 27 watts vs 117 +/- 30 watts, p less than 0.01). A resting intraventricular pressure gradient was recorded in 12 of the 14 patients undergoing repeat catheter study which decreased after propranolol from an average of 66.75 +/- 32.72 mmHg to 42.75 +/- 37.6 mmHg (p less than 0.05). Left ventricular end diastolic pressures remained unchanged. The change in pressure gradient did not correlate with the symptomatology and there were no associated echocardiographic changes. The Holter monitoring did not show any improvement of ventricular hyperexcitability under propranolol: the number of patients with complex ventricular arrhythmias remained unchanged (7 patients).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of propranolol on left ventricular relaxation in hypertrophic cardiomyopathy: an echographic study.

Many authors have shown that hypertrophic cardiomyopathy (HCM) is often associated with diastolic abnormalities. The purpose of this study was to determine the effect of propranolol on left ventricular isovolumic relaxation time (IVRT) measured by echocardiography in 20 patients with hypertrophic cardiomyopathy under basal conditions and under increasing doses of propranolol (160 mg, 320 mg, and 480 mg per day) and in two control groups, 10 patients with aortic stenosis, and 10 normal subjects. IVRT was less than 50 msec in all normal subjects, while it was always above this limit in aortic stenosis (77 msec +/- 8, p less than 0.001), and in hypertrophic cardiomyopathy (94 msec +/- 19, p less than 0.001), with also a significant difference between these two last groups (p less than 0.01). Under increasing doses of propranolol, relaxation time often shortens gradually until 50 msec or less. These results show an improvement in left ventricular relaxation dependent on the propranolol dosage and often a normalization at high dosages.

[Aortic and mitral valve bioprostheses. Normal and pathological M mode echocardiographic aspects]. / Bioprothèses valvaires aortiques et mitrales. Aspects échocardiographiques TM normaux et pathologiques.

The M mode echocardiographic recordings of 52 normal mitral bioprostheses (NMB), 7 pathological mitral bioprostheses (PMB), 30 normal aortic bioprostheses (NAB) and 10 pathological aortic bioprostheses (PAB) were reviewed. In normal bioprostheses a significant correlation was observed between the echocardiographic and the "specified" diameters, the diastolic and systolic slopes and the amplitude of anterior motion of the support. In NMB, the end-systolic diameter of the left ventricular outflow tract depended on the "specified" diameter of the bioprosthesis. Paradoxical septal motion was observed in 78 p. 100 of cases. In PMB, the velocity of anterior leaflet opening was significantly increased (p less than 0.001). The end-diastolic internal left ventricular dimension was also increased (p less than 0.01). A significant correlation was found between left ventricular fractional shortening and maximal leaflet separation (p less than 0.05). Normal septal motion was more common (p less than 0.05). In 5 cases of prosthetic valve dysfunction with mitral regurgitation the maximal leaflet separation was greater than normal (p less than 0.001), the diastolic slope of the support was increased (p less than 0.05) and diastolic vibrations of thickened irregular leaflets were observed. Systolo-diastolic vibrations with chaotic leaflet motion were characteristic of cusp tear and/or eversion. Stratified echos behind a support with reduced leaflet excursion was observed in one case of partial thrombosis: a thickened systolic echo with reduced diastolic excursion was observed in a case of degenerative stenosis. The review of 10 PAB showed a reduced amplitude of systolic excursion of the anterior support in cases of aortic regurgitation (p less than 0.05). Systolic vibrations of the cusp were not specific and were observed in normal cases. In severe valvular regurgitation mitral and/or septal diastolic fluttering was observed. Systolic excursion of the cusps was reduced in cases of relative stenosis due to an inappropriately small sized bioprosthesis. Thickening of the diastolic cusp echos was observed in cases of degenerative stenosis. Ventricular dilatation and reduced septal and free wall motion were dysfunction.

[Wolff-Parkinson-White syndrome and cardiopathies]. / Syndrome de Wolff-Parkinson-White et cardiopathies.

Forty-nine cases of Wolff-Parkinson-White syndrome (WPW) were diagnosed out of 10 750 patients with cardiac disease (0.45 p. 100), 24 cases out of 3 761 congenital malformations and 25 cases in the 6 989 patients with acquired heart disease. Right ventricular pre-excitation was recorded in 31 cases; 13 in the lateral zone, 12 in the posterior paraseptal zone and 6 in the anterior paraseptal zone. Left ventricular pre-excitation was recorded in 18 cases: 8 in the lateral zone, 5 in the anterior paraseptal and 5 in the posterior paraseptal zones. WPW and congenital heart disease: Out of 20 cases of Ebstein's anomaly, 5 cases of WPW were observed: 4 right posterior and 1 right lateral pre-excitations. Out of 218 cases of hypertrophic obstructive cardiomyopathy, 7 cases of WPW were observed, 4 of which were congenital. Three cases of WPW were recorded in 699 patients with ventricular septal defects. Out of 1 348 cases of atrial septal defect, 5 cases of pre-excitation were recorded, including 3 right posterior pre-excitations associated with an ostium primum defect. Pre-excitation was also observed in isolated cases of corrected transposition of the great arteries, supravalvular aortic stenosis, aortic incompetence and patent ductus arteriosus. Pre-excitation and acquired heart disease: Five cases of pre-excitation were recorded out of 305 cases of dilated cardiomyopathy (1.62 p. 100). Eleven cases of pre-excitation were recorded in a total of 3 471 cases of valvular heart disease (0.31 p. 100): 9 in rheumatic valve disease and 2 in mitral valve prolapse. Nine cases of pre-excitation were observed in 2 850 cases of coronary artery disease. Intermittent Wolff-Parkinson-White syndrome: Ventricular pre-excitation masks the ECG changes of complete right bundle branch block in Ebstein's anomaly, complete left bundle branch block in aortic incompetence and dilated cardiomyopathy, and the in-complete right bundle branch block often seen in mitral valve prolapse. The characteristic appearances of WPW depend on the zone of pre-excitation. Right ventricular hypertrophy observed in ventricular septal defect with pulmonary stenosis and mitral stenosis may be masked by right lateral pre-excitation. Changes of inferior wall myocardial infarction may be masked by left anterior wall pre-excitation. On the other hand, the effects of WPW on left ventricular hypertrophy are variable, high amplitudes of the resultant forces seeming to depend on late and isolated activation of one of the left ventricular walls.

[Myocardial infarction in young subjects]. / Infarctus myocardique du sujet jeune.

The annual incidence of myocardial infarction (MI) before 40 years of age is 10 times less frequent than that in patients of all ages, and 10 times less frequent in women than men. The severity and extensiveness of lesions demonstrated by coronary arteriography are significantly less in a young patient with an infarction than an elderly patient. Significant isolated coronary artery stenosis is encountered 10 times more frequently before age 35 than after age 50; 15 percent of young patients have no significant stenosis and 8 to 14 percent have entirely normal coronary artery circulation, depending on the study. There appears, then, to be two pathogenetically distinct varieties of MI in the young patient: approximately one-half of cases exhibit multiple sclerosis seen with typical coronary artery atherosclerotic disease; the remainder, which are almost specific for young patients, represent a single obstruction due most often to the rapid development of a thrombosis on an otherwise normal vascular tree. Coronary artery spasm resulting in complete arterial occlusion is certainly involved, nevertheless its frequency must be further defined.

[Coexistence of left branch block and ectopic rhythm simulating alternating block]. / Coexistence dans la branche gauche d'un bloc et d'un rythme ectopique simulant un bloc alternant.

During the acute phase of diaphragmatic myocardial infarction with septal extension, the ECG of a patient with a chronic left bundle branch block changed in a period of seconds from complete left bundle branch block to incomplete right bundle branch block then to narrow QRS complexes followed by incomplete and then complete left bundle branch block: the same QRS changes then occurred in reverse order; the atrial rhythm was absolutely stable during the recording. These appearances are explained by fusion of sinus and of an ectopic rhythm arising distal to the zone of block, the rate of which (sometimes faster and sometimes slower than the sinus rhythm) could have been influenced by an electrotonic effect after retrograde activation of the right bundle and concealed conduction in the left bundle. Appearances of bundle branch block may be recorded when the ventricle is partially activated from the point of breakthrough of the blocked branch.

[Time of occurrence of primary ventricular tachycardia in the acute phase of myocardial infarction]. / Horaire de survenue des tachycardies ventriculaires primaires de la phase aiguë de l'infarctus du myocarde.

The hour of day of primary ventricular tachycardia (VT) in the acute phase of myocardial infarction was studied in 63 consecutive patients without cardiac failure or antiarrhythmic therapy, admitted to hospital less than 6 hours after the onset of chest pain. There were 19 women and 44 men, with an average age of 63 years. The site of infarction was anterior in 23 cases, posterior in 34 cases and circumferential in 6 cases. The cardiac rhythm was analysed from the 6th hour following the onset of chest pain for 4 days, using a HP 98220 A computerised analyser CPK levels were measured daily. Ventricular tachycardia occurred in 73% of cases with no significant difference between daytime (18 patients) and night time (28 patients). The patients developing VT did not differ from the remainder with respect to age, sex, or site of ECG changes, but peak CPK levels were significantly higher than in patients without VT. The risk of VT decreased slowly as the interval from the onset of chest pain increased and fell practically to zero after the 40th hour. Diurnal and nocturnal VT were independent of age, sex or site of infarct. However, nocturnal VT correlated independently of the time of onset of chest pain to high values of CPK. There was no difference with respect to age, sex, location of infarct or incidence of ventricular tachycardia between infarcts with pain starting during the day, and infarcts with pain starting at night. However, when the pain started during the day, the peak CPK was significantly higher and there were significantly more attacks of nocturnal ventricular tachycardia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Rare complication of extracorporeal circulation: diffuse coronary fibrosis; giant cell myocarditis]. / Complication surprenante de la circulation extra-corporelle : fibrose coronaire diffuse; myocardite à cellules géantes.

A 38 year old woman developed severe coronary stenosis several months after double valve replacement. Aorto-coronary bypass surgery was performed but the patient died of a peroperative myocardial infarction. Histological studies showed not only fibrous thickening of the intima of the whole coronary arterial tree, but also variable medial changes with inflammatory infiltration. In addition, inflammatory granulomata with giant cells were found in the myocardium. These coronary lesions and their association with a giant cell myocarditis cannot be satisfactorily explained by known pathological conditions. The usual mechanisms of coronary disease were not operative in this case. There remains the hypothesis of a primary change of the coronary wall related to either cannulation, anoxic arrest or perfusion fluid, or a combination of these factors. The coronary lesions could have developed by an immunological process which would also explain the giant cell myocarditis.

[Sustained ventricular tachycardia 7 years after complete correction of tetralogy of Fallot]. / Tachycardie ventriculaire soutenue 7 ans après correction complète d'une tétralogie de Fallot.

The authors report a case of sustained ventricular tachycardia which occurred seven years after complete surgical correction of Fallot's tetralogy in a 13 year old girl. This arrhythmia was well tolerated haemodynamically, showed right-sided delay and was associated with mitral valve prolapse. After reviewing the literature, several physiopathological mechanisms are discussed: --the role of residual intraventricular conduction defects in sustaining the tachycardia; --the role of the ventriculotomy scar or of other associated lesions (mitral valve prolapse in this case) in the genesis of ventricular extrasystoles; --the postoperative haemodynamic status in the tolerance of the arrhythmias. This is a rare complication with an incidence of less than 2% of survivors followed-up over long periods. There is a risk of sudden death in 38% of these patients with ventricular arrhythmias which justifies Holter monitoring and ECG stress testing for their detection.

[Mexiletine therapy of ventricular extrasystoles in the acute phase of myocardial infarction]. / Traitement par la mexilétine des extrasystoles ventriculaires de la phase aiguë de l'infarctus du myocarde.

25 patients with recent myocardial infarction and ventricular extrasystole occurring either frequently or in bursts were treated by intravenous and then oral mexiletine. Side-effects occurred during the loading dose in 6 patients, then disappeared without sequel, even while treatment was continued in 2 of these patients, or after it was stopped in the remaining 4 (on account of the severity of the side-effects). Rhythm disorders disappeared under mexiletine in 14 patients as soon as the loading dose was administered; its effectiveness was maintained during intravenous perfusion and after the switch to oral administration. Failure occurred in cases of extensive infarction and/or cardiac insufficiency. Mortality, which was zero in those cases in which mexiletine was effective, reached 45% in the failure group. In cases in which mexiletine proved a failure, lidocaine was also ineffective. In one case in which mexiletine was effective, but was stopped because of side-effects, lidocaine proved ineffective. The efficacy of mexiletine is therefore at least equal to that of lidocaine and is maintained after the switch to oral administration.

[Significance of repetitive ventricular extrasystoles in the acute phase of myocardial infarction]. / Signification des extrasystoles ventriculaires répétitives de la phase aiguë de l'infarctus du myocarde.

Ventricular extrasystoles were analysed by a computerised monitor in 144 patients during the first three days of myocardial infarction. The patients had been hospitalised within 6 hours (77% of cases) and within 12 hours (92% of cases) of onset of symptoms. The patients were divided into 4 groups: Group A (46 cases) without repetitive ventricular extrasystoles; Group B (37 cases) with repetitive ventricular extrasystoles but without frequent isolated extrasystoles; Group C (25 patients) with repetitive ventricular extrasystoles and frequent isolated extrasystoles but without polymorphism or R on T phenomenon; and Group D (36 patients) with repetitive extrasystoles, frequent isolated polymorphic extrasystoles and/or R on T phenomenon. The size of infarction, as judged by peak CPK values, was smaller in Group A than in the other groups but was not significantly different in Groups B, C and D. The incidence of cardiac failure was comparable in Groups A and B and in Groups C and D, and was higher in the latter two groups than in A and B. The cardiothoracic ratio on admission was increased more often in Group D than in the other groups. Therefore, repetitive ventricular extrasystoles are the result of large infarcts. Their association with frequent isolated ventricular extrasystoles is a sign of insufficiency of the remaining myocardium. Patients with pre-existing poor myocardial function develop polymorphism and R on T phenomenon, signs which are associated with a particularly poor prognosis (hospital mortality: 42%). On the other hand, patients in Group B appeared to have satisfactory myocardial function despite the size of their infarcts, and the mortality, nil in this group, was less than in patients without arrhythmias.

[Myocardial infarction in the young subject: a medium-term clinical and coronary angiographic study in 40 patients under 36 years of age. Comparison with coronary angiographic data of myocardial infarction in patients after 50 years of age]. / L'infarctus myocardique du sujet jeune: étude clinique et coronarographique à moyen terme de 40 patients de moins de 36 ans. Comparaison avec les données coronarographiques de l'infarctus myocardique après 50 ans.

A series of 40 myocardial infarctions, occurring in patients under 36 years of age was studied retrospectively (Group I: mean age 31.3 years). The medium term results of coronary angiography in this group were compared with those of 60 myocardial infarctions after 50 years of age (Group II: mean age 56.6 years). Group I had a clear male predominance (92.5%), a high incidence of smoking (69%), hypercholesterolaemia (69%); myocardial infarction was the first manifestation of their disease in 54% and it was often extensive (42%). A comparative angiographic study between the two groups showed: 1) Less widespread lesions in Group I, as assessed by the number of main arteries stenosed (p less than 0.001), the coronary index (p less than 0.01) and the mean coronary score using Friesinger's method (p less than 0.01). 2) A higher incidence of subnormal coronary angiogrammes in Group I (absence of 50% stenosis) (15%) and of single vessel disease (40%): compared with Group II in which multivessel disease was observed in 86.5% of cases. 3) Collateral circulation was less common in Group I (p less than 0.01). On the other hand, a comparative study of regional and global left ventricular function showed no difference between the two groups. Two subgroups were distinguished in Group I: in one subgroup, multiple lesions similar to those found in Group II, suggestive of premature coronary atherosclerosis (52.5%); the other group (47.5%) presented unilocular lesions i.e. focal mono-arterial lesions compatible with other causes of infarction (thrombosis and/or spasm). These patients were younger (p less than 0.05) and had significantly fewer cardiovascular risk factors (p less than 0.01). Despite the fact that the coronary lesions were limited, the myocardial damage was comparable with the other groups as the collateral circulation was much less developed (p less than 0.02). These appearances were only observed in 3.5% of patients in Group II. The study of the angiographic outcomes of these two types of lesions should show a difference and could contribute to the understanding of their mechanisms.

[Lengthening of the direct sinoatrial conduction time: a criterion of sinus node dysfunction]. / L'allongement du temps de conduction sino-auriculaire direct: un critère de dysfonction sinusale.

In order to determine the significance of prolongation of the direct sinoatrial conduction time (DSACT), an attempt was made to record the sinus node potential in 110 patients which was successful in 84 cases. The DSACT was normal in 45 cases (Group A) and prolonged (over 130 ms) in 39 cases (Group B). The symptomatology, standard ECG and the results of investigation of sinus node function by atrial stimulation of the two groups were compared. The DSACT was prolonged in all 13 patients with paroxysmal sinoatrial block or the sick sinus syndrome, in 71% of 15 patients with permanent sinus bradycardia, in 88% of 22 patients with a corrected sinus node recovery time of over 525 ms, in 82% of 38 patients with a sinoatrial conduction time estimated by the extrastimulus method of over 130 ms or an abnormal zone II, in 80% of 39 patients with sinoatrial conduction times estimated by Narula's method of over 130 ms; therefore, 87% of the 35 patients with probable sinus node dysfunction had long DSACT. On the other hand only 2 out of 35 patients (6%) with apparently normal sinus node function had prolonged DSACT. These results indicate that prolongation of the DSACT is a sensitive and specific criterion of sinus node dysfunction. In cases of sinus node dysfunction dizziness and/or syncope without any known cause were common complaints in patients in Group B but absent in patients in Group A. A prolonged DSACT could be of prognostic significance in sinus node dysfunction.