Coronary artery perforation during coronary angioplasty.

In one patient percutaneous transluminal coronary angioplasty was complicated by coronary artery perforation of the left anterior descending coronary artery with light pericardial effusion. The outcome was favorable without either pericardiocentesis or emergency surgery.

Role of coronary spasm in the genesis of myocardial infarction: study of a case treated by isosorbide dinitrate in situ then by transluminal angioplasty.

We report the observation of a 62-year-old patient who was admitted for unstable angina. A prolonged chest pain (more than two hours) with a major electrocardiographic lesion in the posterior leads needed an urgent coronary arteriography in order to attempt a recanalization. Antecedents of arteriopathy of the lower limbs with aortobifemoral bypass required an axillary artery right side approach. A selective right coronary opacification showed complete occlusion at the junction of segments 1 and 2. An intracoronary injection of isosorbide dinitrate relieved a coronary spasm and allowed a complete visualization of the right coronary artery. This appeared to be very atherosclerotic with several severe narrowings, and a subocclusive lesion at the site of the initial occlusion. Percutaneous transluminal coronary angioplasties (PTCA) were performed and led to real 'restructuring' of the right coronary artery. The clinical outcome was excellent without recurrent angina pectoris. An angiographic control performed 6 months after PTCA demonstrated the persistence of the coronary recanalization and an evident improvement of the segmental contractility. This report emphasizes the role of coronary spasm in the genesis of myocardial infarction and shows that PTCA may be performed as a first approach at the acute phase of myocardial infarction; to our knowledge it is the first PTCA performed by an axillary approach at the acute stage of myocardial infarction.

[Distomatosis and cardiac disease. Apropos of 2 new cases. Trials of classification and pathogenetic hypotheses]. / Distomatose et cardiopathie. A propos de deux nouvelles observations. Essais de classification et hypothèses pathogéniques.

The authors report two new cases of cardiac disease associated with distomatosis: one case of biventricular fibroblastic parietal endocarditis affecting mainly the left side in a young female of 26 years, and one case of cardiomyopathy with atrial endocardial fibrosis, affecting especially the left ventricle in a man of 47. Bearing in mind the five cases reported in the literature, the authors propose a classification of cardiac disorders supposed to be due to distomatosis using three groups (endocardial fibrosis, cardiomyopathy, myocarditis) and relate them to a common pathogenesis based on immuno-allergic theory.

[Late supraventricular arrhythmia complicating Fontan or cavopulmonary type procedures. Apropos of 7 cases]. / Troubles du rythme auriculaire tardifs compliquant les opérations de type Fontan ou de type cavopulmonaire. A propos de 7 observations.

The authors report 7 cases of late arrhythmias after atriopulmonary (5 cases) or total cavopulmonary (2 cases) bypass procedures. There were 6 cases of atrial flutter and one case of atrial tachycardia. The condition presented with cardiac failure in 5 cases. In 2 patients, atrial flutter caused syncope or dizziness. The arrhythmia was reduced by atrial stimulation (3 cases) or by cardioversion (1 case). Prevention of recurrence with oral amiodarone was effective in all cases but was responsible for secondary effects in 4 cases. In one patient, recurrence of atrial flutter was complicated by right atrial thrombosis with cerebral embolism. Five patients were reoperated after cardiac catheterisation and angiography. Surgery consisted of resection of a stenosis of the anastomosis in one case, and the transformation of atriopulmonary anastomosis into a total cavopulmonary bypass because of a very dilated right atrium without stenosis in 4 patients. The immediate postoperative period was complicated by a recurrence of the arrhythmia in 3 children not treated by antiarrhythmic therapy. At long-term, one patient died 6 months after withdrawal of amiodarone therapy of recurrence of atrial flutter. Five of the 6 survivors are treated with amiodarone or a betablocker; 3 have had pacemaker implantation for severe bradycardia. Late atrial arrhythmias complicating atrio- and cavopulmonary bypass procedures carry a risk of cardiac failure and sudden death. When diagnosed, the patient should be investigated for stenosis of the anastomosis but severe dilatation of the right atrium is often the only finding. After restoration of sinus rhythm, maintenance antiarrhythmic therapy should be continued indefinitely.

[Transluminal dilatation of occluded coronary arteries. Value of retrograde opacification of the occluded vessel by the contralateral artery]. / Dilatation endoluminale d'artères coronaires occluses. Intérêt de l'opacification rétrograde du vaisseau occlus par l'artère controlatérale.

The authors report the results of 8 cases of percutaneous transluminal coronary angioplasty of occluded arteries: the artery concerned was the proximal segment of the left anterior descending artery in 5 cases and the proximal segment of the right coronary artery in 3 cases. All patients had unstable angina with a very positive exercise stress test. The conservation of viable myocardium was the result of an excellent collateral circulation from the controlateral vessel in all patients. In 7 out of the 8 cases, the guide wire and dilating balloon were correctly positioned by opacifying the distal segments of the occluded artery by injection of contrast into the controlateral artery. Almost simultaneous injection of the occluded and controlateral vessels allowed evaluation of the length of the occlusion. Controlateral opacification disappeared immediately after adequate recanalisation to reappear during inflation of the balloon. These cases show that in patients with chronic coronary occlusion, opacification of its distal segments by injection of contrast into the controlateral vessel seems to be helpful and without risk to the patient.

[Cardiac tumors with neonatal disclosure. Apropos of a case with spontaneously favorable development]. / Tumeurs cardiaques à révélation néonatale. A propos d'un cas d'évolution spontanément favorable.

The authors report the case of a cardiac tumour documented by 2 D echocardiography, presenting in the newborn with cardiac arrest. The echocardiographic features of multiple nodules disseminated in the ventricular walls suggested a diagnosis of rhabdomyoma. The initial course was complicated by poorly tolerated attacks of tachycardia which were rapidly brought under control with amiodarone. The long term outcome was clinically favourable with a rapid regression of the number and size of the tumours on echocardiography, and a tendency to normalisation of the electrocardiogramme. The possibility of regression, which has already been reported by many investigators, suggests that these cardiac tumours may have a better prognosis than previously thought.

[Tumoral vascularization in a case of asymptomatic myxoma]. / Vascularisation tumorale dans un cas de myxome asymptomatique.

A 67 year old woman was admitted for assessment of asymptomatic aortic stenosis. A large left atrial myxoma was demonstrated by 2D and M mode echocardiography. Coronary angiography was performed as part of the investigation of the aortic stenosis and showed that the tumour depended on the right coronary artery for its blood supply. Careful frame-by-frame study showed the presence of a true right coronary-left coronary fistula through the tumour. The authors discuss the different clinical presentations of left atrial myxomas and their vascularisation in the rare cases in which it has been described.

[Abnormal origin of the left coronary artery from the pulmonary artery, fortuitously discovered in an adult]. / Naissance anormale de la coronaire gauche à partir de l'artère pulmonaire, découverte fortuitement chez un adulte.

The authors report a case of an anomalous left coronary artery discovered by chance in a totally asymptomatic 39 year old man. Appearances of anterior myocardial infarction were observed on routine preoperative ECG in a man with multiple injuries. Coronary angiography showed an anomalous left coronary artery arising from the main pulmonary artery. Left ventricular function was poor with associated mitral regurgitation. Surgical correction consisted in an end-to-end venous graft between the ostium of the coronary artery detached from the pulmonary artery and the right anterior border of the ascending aorta. Left ventricular function did not improve four months after surgical correction. The irreversibility of the myocardial lesions argues in favour of an early correction of this malformation.

[Early clinical, electrocardiographic and biological criteria of reperfusion after intravenous fibrinolysis during the acute phase of myocardial infarction]. / Critères précoces, cliniques, électrocardiographiques, et biologiques de reperfusion après fibrinolyse intraveineuse à la phase aiguë de l'infarctus du myocarde.

Between May 1991 and February 1992, 31 consecutive patients were included in a prospective study, the aims of which were to determine the criteria of early coronary revascularisation after intravenous thrombolysis in the acute phase of myocardial infarction. The rise in serum myoglobin, the ST segment elevation, accelerated idioventricular rhythm and the evolution of chest pain were analysed. All patients underwent coronary angiography. Twenty-six were revascularized and 5 remained with coronary occlusion. Two types of serum myoglobin curves were demonstrated. Those with a sudden , decrease and a well defined peak in the first 4 hours were specific for revascularisation and easily identified (Group A: 16 patients). The graphs with a progressively rising slope to a peak after the 4th hour were observed in patients with coronary occlusion, but also in 10 patients with recanalized arteries (Group B). No significant difference was demonstrated with regards to the clinical and coronary angiographic parameters between patients in Group A and Group B. On the other hand, the time between the onset of chest pain and peak myoglobin was shorter in Group A (298 +/- 81 min) than in recanalised patients in Group B (380 +/- 54 min) (p < 0.05). The difference in the profile of the serum myoglobin could therefore reflect restoration of arterial flow in myocardial cells which had not suffered the same period of ischemia. ST segment elevation may increase, decrease of remain stable at 120 minutes in patients revascularised and those remaining occluded. In 9 patients, the ST elevation increased compared with the initial electrocardiogram .(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral valve insufficiency secondary to endocardial fibrosis associated with distomatosis]. / Insuffisance mitrale secondaire à fibrose endocardique associée à une distomatose.

A new case of assumed parasitic cardiac disease is reported once more; a 67 year old woman with a trematode injection presenting with mitral incompetence and left ventricular failure. Biventricular endomyocardial fibrosis predominating at the apex was diagnosed at angiography and confirmed at surgery. Mitral incompetence was related to retraction of the papillary muscles which were surrounded by fibrosis, the rest of the mitral apparatus being normal. There was no indication for endocardectomy and so, mitral valve replacement alone was performed. There are few previous reports of parasitic cardiac disease: one case of left ventricular endomyocardial fibrosis, one case of biventricular fibroplastic parietal endocarditis and one case of cardiomyopathy. This report emphasises the need for cardiac examination in patients with parasitic diseases.

[Rare mechanical complications of right ventricle infarction. Value of two-dimensional echocardiography]. / Complications mécaniques rares de l'infarctus du ventricule droit. Intérêt de l'échocardiographie bidimensionnelle.

Two rare mechanical complications of right ventricular infarction are reported: myocardial dissection and rupture of the RV free wall. The diagnosis was made by 2D echocardiography in both cases. Myocardial dissection resulted in the formation of an oblong, expansive, intraparietal space. The rupture of the RV free wall was visualised as a breach of the continuity of the ventricular wall. These cases underline the importance of 2D echocardiography in the acute phase of myocardial infarction for the diagnosis of these complications.

[Effects of temporary dual-chamber cardiac pacing in refractory cardiac failure]. / Effets de la stimulation cardiaque double chambre temporaire dans l'insuffisance cardiaque réfractaire.

The authors studied 18 patients (15 men, 3 women) with an average age of 67 +/- 8 years with refractory cardiac failure. In order to determine the potential of pacing to raise cardiac output in severe cardiac failure. The average ejection fraction was 26 +/- 6.5%. All patients were in sinus rhythm:resting cardiac output was 3.35 l/min. Two temporary pacing catheters were positioned in the right atrium and at the apex of the right ventricle for dual-chamber mode pacing triggered by the spontaneous P waves. Changes in cardiac output were measured by Doppler echocardiography at different values of atrioventricular delay. Patients were considered to be responders if their cardiac outputs rose by 15%. In 7 patients meeting this criterion, the average increase in cardiac output was 27% (2.99 +/- 0.7 to 3.81 +/- 0.86 l/mn; p < 0.01); all had dilated cardiomyopathies with left bundle branch block and the optimal AV delay was 103 +/- 21 ms (80-140 ms); the duration of diastolic filling increased from 212 +/- 98 to 292 +/- 116 ms (p = 0.02). In the non-responding group (11 patients with an increase of cardiac output of only 3.6 +/- 0.09 to 3.9 +/- 0.92 l/mn; p < 0.01), the underlying disease process was mainly ischaemic. Two predictive factors of efficacy of dual-chamber pacing were identified: a short ventricular filling period (29 +/- 8% of the RR interval in the responders vs 44 +/- 9% in the non-responders; p < 0.01) and the presence of 1st degree atrioventricular block. Dual-chamber pacing could be a valuable method of increasing resting cardiac outputs in a selected group of patients with severe, refractory, cardiac failure.

[Pulmonary atresia with major hypoplasia of the pulmonary branches. A radical 2-stage correction]. / Atrésie pulmonaire avec hypoplasie majeure des branches pulmonaires. Cure radicale en deux temps.

Pulmonary atresia with ventricular septal defect (VSD) and severe hypoplasia of the pulmonary branches is a serious malformation and reputedly inoperable. The surgical restoration of a pulmonary outflow tract may nevertheless dilate the pulmonary arterial branches in the long term. The probable mechanism of this effect is related to high right ventricular and pulmonary pulse pressures due to the absence of the pulmonary valve. The right to left shunt, initially, reverses after a few weeks so authorizing closure of the VSD. Two patients, an adult and a child, were successfully treated by this technique.

[Isolated ostial stenosis: a peculiar anatomic form of coronary insufficiency in women]. / Les sténoses ostiales isolées: une forme anatomique particulière d'insuffisance coronaire de la femme.

We report 5 cases of isolated ostial stenosis of the left main coronary vessel. Isolated ostial stenosis occurs preferentially in young or middle aged women for whom coronary insufficiency is usually not a serious threat. Patients with this type of lesion have characteristically severe angina of relatively recent onset. The condition may be difficult to diagnose at angiography, but a fall in pressure when the tip of the catheter enters the coronary lumen beyond the stenosis, a lack of reflux of the contrast medium into the sinus of Valsalva during intracoronary injection and its persistence in the coronary vessel should alert the investigator. A pathological study of 3 cases revealed typical atheromatous lesions in 2 patients (with extension of an aortic plaque to the left coronary ostium in one, and atheroma localized on the ostium in the other) and a purely fibrous lesions in a patient who had undergone thoracic radiotherapy 5 years previously. Although relatively rare, stenosis must be diagnosed in view of its sombre spontaneous prognosis (one patient died 3 days after coronary arteriography), of the risk of underestimating its frequency, and of the hazards of selective coronary catheterization in such patients (one of our patients died 15 minutes after coronary exploration).

[Cardiac involvement in 2 cases of malignant non-Hodgkin's lymphoma. Course of cardiac involvement under chemotherapy]. / Atteinte cardiaque dans deux cas de lymphomes malins non hodgkiniens. Evolution de l'atteinte cardiaque sous chimiothérapie.

In a recently published post-mortem series the incidence of cardiac lesions in malignant lymphoma was estimated at about 8.7%. These lesions rarely produce specific cardiac symptoms; they usually are late manifestations of a disease with multiple secondary lesions or are discovered at autopsy. In most patients the lesions are not limited to the heart but represent the extension to that organ of a malignant lymphoma. We observed two cases of cardiac lesions secondary to malignant non-Hodgkin lymphoma and we were able to evaluate their response to chemotherapy. In the first patient the cardiac symptoms revealed the lymphoma; in the second patient the cardiac involvement was discovered 4 years after the lymphoma was diagnosed. In both cases the cardiac lesions were detected by two-dimensional echocardiography. They presented as polypoid masses filling the right atrium and associated with periaortic thickening in the first case, and as a large heterogeneous mass including a tricuspid valve leaflet and extending to the free wall of the right ventricle in the second case. Pericardial effusion was present in the two patients. These echocardiographic findings were confirmed computerized tomography and catheterization. In the first case, followed up for one year, the echocardiographic images reverted to normality after chemotherapy. The second patient, unfortunately, did not respond to chemotherapy and deteriorated rapidly.

[Transitory appearance of collateral circulation during coronary spasm]. / Apparition transitoire d'un réseau collatéral lors d'un spasme coronaire.

The authors report the case of a patient with coronary spasm characterised on exercise stress testing by an initial depression of the ST segment followed by ST elevation at the 3rd minute of recovery. Coronary angiography showed an important, transient collateral system arising from the left coronary artery, probably minimising the effects of complete occlusion of a dominant right coronary artery. The authors discuss effort-induced spasm and collateral circulation.

[A possible application of percutaneous transluminal angioplasty: remodelling of an occluded aortocoronary bypass]. / Une application possible de l'angioplastie transluminale percutanée: le "remodelage" d'un pontage aorto-coronaire occlus.

The authors report the case of a 53 year old patient who had undergone triple coronary bypass surgery for unstable angina. Recurrence of chest pain 4 months after surgery led to control coronary angiography which showed severe stenosis of the proximal and distal parts of the aorto-right coronary graft. Endoluminal dilatation was performed a few days later but, during angiography, complete occlusion of the graft was observed. This was repermeabilised without difficulty and a "remodelling" of the graft was carried out. The outcome was favourable with the complete regression of symptoms. The following alternatives to surgery are discussed: in cases of thrombosis which usually occur in the month following surgery, fibrinolysis may be attempted with a high success rate but a significant risk of haemo-pericardium: in cases of fibrous proliferation of the intima leading to stenosis or occlusion, endoluminal dilatation seems to be the procedure of choice, but this must always be carried out under surgical cover.

[Ectasia of coronary arteries. Review of the literature. Apropos of 5 cases]. / Ectasies des artères coronaires. Revue de la littérature. A propos de 5 observations.

The authors present 5 cases of coronary artery ectasia discovered on coronary angiography and review the literature on the subject. The aetiology of these coronary aneurysms is discussed: coronary atherosclerosis seems to be the most common cause of this condition which some authors consider to be a variant of coronary atheroma. The therapeutic management is controversial. The indications for surgery are rare and should be carefully considered. Long term anticoagulant therapy, however, appears to be essential.

[A possible alternative in failure of percutaneous intracoronary fibrinolysis: percutaneous endoluminal dilatation]. / Une alternative possible à l'échec de la fibrinolyse intracoronarienne par voie percutanée: la dilatation endoluminale percutanée.

The authors report three cases of myocardial infarction in which an attempt at intra-coronary fibrinolysis in the acute phase was either transiently effective or totally ineffective. In these three cases, percutaneous endoluminal dilatation was possible allowing restoration of correct coronary flow. The place of percutaneous angioplasty is therefore discussed either immediately after fibrinolysis, when the risk of re-thrombosis appears to be greatest or perhaps in the absence of an attempt at clot lysis, when fibrinolytic treatment is contra-indicated.

[Angiosarcoma localized in the right cardiac cavities. Apropos of a case]. / Angiosarcome localisé au niveau des cavités cardiaques droites. A propos d'un cas.

The authors report the case of a young 26 years old man admitted for abundant fluid pericarditis which was rapidly recurrent, requiring two perocardial punctures and a surgical drainage. The two dimensional echocardiogram demonstrated a large right atrio-ventricular tumour with infiltration of the right ventricular wall, suggesting its malignant nature. After confirmation by right angiography and in view of the rapid cardiovascular deterioration, it was decided to operate. The surgery was only exploratory; not even palliative surgery was possible for this tumour mass invading the right atrium, the right ventricle and the pericardium. Histology revealed it to be an angiosarcoma.