Contribution of the dynamic phonocardiography to the valvular heart disease diagnosis: an expert system study.

The contribution of pharmacodynamic tests to the diagnostic accuracy of phono-mechanocardiography was tested by means of an expert system, in order to make an objective evaluation. In 198 valvular heart disease patients, the use of dynamic tests significantly improved the rate of diagnostic success, thus confirming the usefulness of dynamic phono-mechanocardiography.

[Surgical mitral valvuloplasty and dynamic left ventricular obstruction syndrome]. / Valvuloplastie mitrale chirurgicale et syndrome d'obstruction intraventriculaire gauche "dynamique".

The "dynamic" left ventricular outflow obstruction syndrome, which is found in 4.5 to 11 p. 100 of patients who underwent mitral valve repair by Carpentier's technique, seems to be due to the association of two different sets of circumstances. The first set is anatomical; the syndrome is thought to result from the implantation of a semi-rigid valve ring, from the excessive length of the mitral valve system in relation to the size of the ventricular cavity, and from excessive correction of mitral regurgitation with subsequent excessive reduction in caliber of the left ventricular outflow tract, change in the interrelation between outflow tract and ventricular filling and strongly anterior position of the mitral valve. The second set is functional; it is due to a more than 20 p. 100 reduction in caliber of the left ventricular outflow tract on the one hand, and to a more than 2.5 m/s increase in blood flow velocity on the other hand. These two phenomena may be produced by a decrease in left ventricular volume as a result of hypovolaemia, tachycardia or more rapid circulation. Treatment of the syndrome consists of correcting the associated abnormalities by prescribing a diet with a normal sodium content, together with an appropriate anti-arrhythmic agent and a beta-blocker.

[Correlation between the angiographic appearance and the left intraventricular gradient in obstructive myocardiopathy. Apropos of 42 cases]. / Corrélations entre l'aspect angiographique et le gradient intraventriculaire gauche au cours des myocardiopathies obstructives. A propos de 42 observations

42 patients who were given the diagnosis of obstructive cardiomyopathy (OCM) on the basis of a basal left intraventricular systolic gradient equal to or in excess of 20 mmHg were divided into two groups, according to the angiocardiographic appearances (in the right anterior oblique projection) of the left ventricular cavity during systole. In 20 cases the appearances were those of a typical obstructive cardiomyopathy. In the other 22, despite the presence of a fairly large left intraventricular gradient, the appearances on angiocardiography were closest to those described for the non-obstructive cardiomyopathies with diffuse myocardial hypertrophy. These two groups were compared in the quest for a difference between the clinical, radiological, electrocardiographic, phonomechanographic, and haemodynamic picture on the one hand, and the appearances at angiography on the other. These two groups can only be separated by the mean value of the left intraventricular systolic gradient established under basal conditions; this is greater when the angiographic picture is less characteristic. However, the value of this gradient is shown by the positive correlation between the figure for the gradient and that for the left ventricular ejection time, as determined from external phonomecanographic measurements and from the catheter on the left side. This determination confirms the existance of obstruction to the outflow and the diagnosis of obstructive cardiomyopathy, even when the angiographic appearances are not typical.

[Long term results of surgical treatment of obstructive myocardiopathy by intervention on the interventricular septum]. / Résultats à long terme du traitement chirurgical de la myocardiopathie obstructive par intervention sur le septum interventriculaire

An analysis of the results of septal myotomy or myectomy in 26 adults with obstructive cardiomyopathy (OCM) with a mean follow-up period of more than 5 years lead to the conclusion that this treatment brings about, at the price of a mortality rate of about 10%, a sustained improvement in function, a reliable correction of the left ventricular gradient, and an improved long term survival rate by comparison with the rate among patients treated medically.

[Spontaneous development of obstructive myocardiopathies]. / Evolution spontanée des myocardiopathies obstructives

49 cases of obstructive cardiomyopathy (37 of the sporadic type, 12 of the familial type), confirmed by phonomechanocardiographic, haemodynamic and/or angiographic investigation and followed up for more than 5 years (mean 7.5 years) without surgical intervention, form the basis of a study on the natural history of this condition. There were 19 deaths (39%), of which 7 were of the familial type (58%) and 12 of the sporadic type (32%). The actuarial survival curves, which were commenced at the time or the first clinical symptom or the date of the first hospitalisation, show that approximately one patient in two dies at or about the age of 40. In 6 cases, death occurred in patients who were greatly improved by medical treatment to the extent of remaining symptomfree up to the time of death. No factors could be found in the initial investigation (phonomechanocardiographic electrocardiographic, radiographic, haemodynamic and angiographic examination (phonomechanocardiographic, electrocardiographic, between the patients still alive and those who had died; each paramater studies had mean values which overlapped in the two groups. Only the age at which the first clinical feature appeared separated the two groups: those patients who died had their first symptom or sign of disordered function at a much younger average age (15.9 years) than the survivors (25 years). This study has confirmed the very serious nature of obstructive cardiomyopathy, especially the familial types, and those with a low age of onset. It emphasises the extreme difficulty in arriving at a prognosis in this condition.

[Telesystolic mitral insufficiency with systolic click, mitral valve prolapse, and hypertrophic obstructive myocardiopathy]. / Insuffisance mitrale télésystolique avec clic systolique, prolapsus valvaire mitral et myocardiopathie hypertrophique obstructive

There are several causes of the syndrome of "Late systolic murmur and mid-systolic click" due to mitral incompetence with ballooning of the valve, and, as numerous recent publications have shown, amongst them must be included abnormalities of left ventricular contraction. Seven cases have been studied by phonomechanocardiographic, cineangiographic, and haemodynamic methods, and analysis of the findings has shown that the abnormalities of contraction may be due to a cardiomyopathy, with a variable degree of left ventricular hypertrophy which is usually of patchy distribution, and leads to a certain degree of left intraventricular obstruction.

[Progression from hypertrophic obstructive cardiomyopathy to dilated cardiomyopathy. Apropos of 4 cases]. / Evolution d'une myocardiopathie hypertrophique obstructive vers une myocardiopathie dilatée. A propos de 4 cas.

Four cases of hypertrophic obstructive cardiomyopathy diagnosed on clinical, phonomechanographic, echocardiographic and haemodynamic criteria progressing to dilated cardiomyopathy are reported. This evolution was observed over a number of years (up to 20 years) and was accompanied by a clinical aggravation in all cases with 2 deaths and atrial fibrillation in 3 of the 4 cases. The signs of intraventricular obstruction [systolic murmur, bulge on the carotid pulse tracing, systolic anterior motion of the mitral valve (SAM) and intraventricular pressure gradient] disappeared as the left heart chambers dilated with a reduction in ventricular wall motion and parietal thinning but no change in myocardial mass.

[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.

[Phono-mechanographic evaluation of aortic stenoses. Contribution of the B1-maximum murmur/B1-B2 index]. / Evaluation phonomécanographique des rétrécissements aortiques. Apport de l'indice B1-maximum du souffle/B1-B2.

The diagnostic value of phonomechanography in valvular aortic stenosis was reassessed with a rarely used index, the ratio S1-maximum intensity of the systolic murmur/S1-S2, or Thiron's index, the author of which only studied the correlations with the aortic transvalvular pressure gradient. The results obtained by the author being considered inconclusive, we decided to examine its correlations with aortic valve surface area calculated with the Gorlin's formula. The study was carried out in 38 patients with pure aortic stenosis, in whom 4 phonomechanographic parameters, the corrected left ventricular ejection time (Meiners), the carotid pulse half peak time, the S1-maximum intensity of the murmur interval and Thiron's index, were compared with the transvalvular pressure gradient and the aortic valve surface area at catheterisation. The first two parameters mentioned above were of limited value (correlations with aortic valve surface area r = 0.315, p less than 0.05 and r = 0.477, p less than 0.01 respectively). On the other hand, a good correlation was obtained with Thiron's index (r = 0.624, p less than 0.001) which was better than that found with the interval between S1 and maximum intensity of the systolic murmur (r = 0.483, p less than 0.001) in a population not excluding subjects with cardiac failure. These results indicate that: when Thiron's index less than or equal to 0.45, the aortic stenosis is probably mild (aortic surface area greater than 0.8 cm2), when Thiron's index is 0.46 greater than 0.56, the aortic stenosis is likely to be moderately severe (aortic surface area 0.8 less than 0.5 cm2), when Thiron's index is greater than 0.57, the aortic stenosis is probably severe (aortic surface area less than 0.5 cm2). In our series, Thiron's index was the best phonomechanographic parameter for the assessment of pure aortic stenosis. It could not be calculated in 10 out of 48 patients; this drawback was not encountered with the corrected left ventricular ejection time or the carotid pulse half peak time.(ABSTRACT TRUNCATED AT 250 WORDS)

[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.

[Current role of phonomechanocardiographic recording in the diagnosis of heart valve diseases]. / Place actuelle des enregistrements phonomécanocardiographiques dans le diagnostic des valvulopathies.

Phonocardiography (and auscultation) provide many accurate diagnoses of valvular heart diseases, when they are fully developed and give rise to a typical murmur. Echocardiography displays its mechanism, in most cases (leaflet thickening, ruptured chordae tendinae, vegetations, prolapse). Assessment of their severity is based on analysis of the systolic time intervals on the one hand, and on echocardiographic measurements on the other, i.e., internal dimensions of the heart chambers, wall thickenesses and motions. When necessary, acute pharmacologic interventions permit the diagnosis (positive and differential) of the various types of ventricular outflow tract obstructions (mild or severe), of mild, atypical or "masquerading" regurgitations and of the "innocent" murmurs. They are easier to carry out and to interpret on the basis of phonocardiographic than echocardiographic recordings. Hence the advisability of using both diagnostic methods, as each provides specific data which often support, and always complete one another.