Long-term prognosis in patients with alcoholic cardiomyopathy and severe heart failure after total abstinence.

We prospectively evaluated the long-term prognosis of 14 patients with alcoholic cardiomyopathy and severe end-stage congestive heart failure after total abstinence. Improvement was very significant after 6 months of follow-up in most patients, and continued thereafter.

Evaluation of left ventricular function and mitral regurgitation during left ventricular-based pacing in patients with heart failure.

BACKGROUND: Beneficial effects of left ventricular (LV)-based pacing on acute hemodynamic parameters were reported in several series, but only a few studies examined the long-term effects of this new pacing procedure. AIMS: To assess long-term effects of permanent LV-based pacing on LV function and mitral regurgitation (MR) in patients with refractory congestive heart failure (CHF). METHODS: A prospective evaluation of LV function and MR was performed in 23 patients with severe but stable CHF and left bundle branch block (mean QRS: 186+/-31 ms) by radionuclide and echocardiographic techniques at baseline and 6 months after implantation of a permanent LV-based (LV alone: 13 patients; biventricular: 10 patients) pacemaker programmed either in a DDD mode (sinus rhythm; n=14) or in a VVIR mode (atrial fibrillation; n=9). RESULTS: Compared to baseline, the 6 months follow-up visit demonstrated a significant increase in radionuclide derived LV ejection fraction from 23.3+/-7 to 26.2+/-7% (P<0.01) and in echocardiographic LV fractional shortening from 13+/-4 to 16+/-6% (P<0.05), without any change in cardiac index, a significant decrease in LV end-diastolic diameter (from 73.2+/-6 to 71.2+/-7 mm; P<0.05), end-systolic diameter (from 63.6+/-6 to 60.2+/-8 mm; P<0.05) and color Doppler MR jet area (from 11.5+/-6 to 6.6+/-4 cm(1); P<0.001). A comparison of patients with LV pacing alone and patients with biventricular pacing showed similar beneficial effects of pacing on MR severity in the two subgroups and a non-significant trend for a better improvement of LV function during biventricular pacing. CONCLUSION: Thus, in patients with severe CHF and left bundle branch block, permanent LV-based pacing may significantly improve LV systolic function and decrease MR.

Assessment of arterial distensibility by monitoring the timing of Korotkoff sounds.

The timing of Korotkoff sounds, blood pressure, and heart rate can now be monitored in the ambulatory patient: the QKD interval is the time between the onset of the depolarization on the electrocardiogram (Q) and detection of the last Korotkoff sound (K) at the level of brachial artery during cuff deflation, corresponding to diastolic blood pressure (D). Because this interval is inversely related to pulse wave velocity, this recently developed device enables evaluation of the influence of blood pressure on arterial rigidity, providing valuable information on the properties of the arteries. In this study, we examined the influence of hypertension and age on the above parameters and their correlations to left ventricular mass. QKD interval, blood pressure, and heart rate were monitored over a period of 24 h (four measurements/hour) in 33 normotensive and 70 untreated essential hypertensive patients. The slopes of the plots of QKD interval versus systolic and pulse pressure during the 24 h were calculated for each patient. The influence of age and hypertension on these slopes was tested by comparison of matched groups and multivariate analysis. Moreover the relationships between these parameters and echocardiographically assessed left ventricular mass were studied in 37 patients. We found a reduction in mean QKD interval with age and hypertension, reflecting the recognized higher pulse wave velocity in these patients. The slopes of the plots of QKD interval versus blood pressure were also lower in these patients, indicating the smaller influence of a change in blood pressure on pulse wave velocity in patients with stiffer arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

Postinfarction atrioventricular septal rupture.

Postinfarction communication between a left ventricular aneurysm and the right atrium is a rare acquired disease. We report a case of a 72-year-old man who recently had dyspnea on minimal exertion and was found to have left ventricle-to-right atrial shunt by two-dimensional transthoracic echocardiography. This diagnosis was confirmed with transesophageal echocardiography, cardiac catheterization, and angiography. The patient underwent successful repair but died of multisystem failure. This case shows the importance of transthoracic echocardiography for the adequate diagnosis and management of such cases.

Hypoxic contractile response in isolated rat thoracic aorta: role of endothelium, extracellular calcium and endothelin.

The effects of hypoxia on isolated arteries remain controversial, depending on the species, vascular beds and protocols. The aims of the study were to characterize the response of rat thoracic aorta to hypoxia and to examine the roles of endothelium, extracellular calcium and endothelin in this response. Hypoxia was induced by bubbling Krebs solution with 95% N2 and 5% CO2 instead of 95% O2 and 5% CO2. Experiments were performed during 1 h in norepinephrine (0.01 microM) precontracted rings. Hypoxia produced a biphasic response consisting of an initial transient partial relaxation (67% at 14 min) followed by a slow but sustained contraction (27% from 40 to 60 min). After endothelium removal, relaxation appeared faster with increased magnitude (82% at 12 min) and was followed by a weak transient contraction (16% at 25 min). In endothelium-intact rings, Ca2+ free medium (EGTA, 0.1 mM) and Ca2+ channel blockers, verapamil (0.05, 0.5 and 5 microM) or nicardipine (0.1, 1 and 10 microM), had no effect on relaxation but inhibited the contraction, the effects of both calcium antagonists being concentration-dependent. Similarly, the ETA/ETB receptor antagonist, bosentan (0.1, 10 and 1,000 nM), induced a concentration-dependent decrease in the contraction. We conclude that 1) the response of rat thoracic aorta during 1 h of hypoxia is biphasic (relaxation followed by contraction); 2) the endothelium is involved in the contraction whereas its role in the relaxation remains to be elucidated; 3) extracellular calcium is involved in the contraction; and 4) endothelin may play a role in the contraction.

Endothelin, but not angiotensin II, contributes to the hypoxic contractile response of large isolated pulmonary arteries in the rat.

UNLABELLED: The aims of this study were to investigate whether angiotensin II and/or endothelin could contribute to the hypoxic contractile response of isolated rat pulmonary artery. Experiments were performed for 1 h on noradrenaline precontracted arterial rings in hypoxic conditions (95% N2 and 5% CO2). Nicardipine, lisinopril, losartan, phosphoramidon, FR139317 and bosentan were used to block Ca2+ channels, angiotensin I-converting enzyme, AT1 receptors, endothelin-converting enzyme, ETA receptors, and ETA/ETB receptors, respectively. The profile of the hypoxic contractile response was biphasic, displaying, after a short relaxation, a weak and transient contraction (from 2-4 min) and then, before complete relaxation, a slowly developed but sustained contraction (from 14-60 min). Endothelium removal abolished the transient contraction and reduced (-59%) the sustained contraction. Nicardipine did not modify the transient contraction, but concentration-dependently decreased (from -35% to -100%) the sustained contraction (P = 0.024). Lisinopril and losartan did not affect the response (P = 0.418 and P = 0.973, respectively). Bosentan did not modify the transient contraction, but concentration-dependently decreased (from -14% to -71%) the sustained contraction (P = 0.016), whereas phosphoramidon and FR139317 did not affect the response (P = 0.830 and P = 0.806, respectively). CONCLUSIONS: In rat, (i) both phases of the hypoxic contractile response are endothelium-dependent and independent of angiotensin II; (ii) the transient contraction does not depend on endothelin; (iii) the sustained contraction, which involves calcium influx, appears partly dependent on mature endothelin released from storage granules by stimulating ETB receptors.

[Mortality and morbidity in the acute phase of myocardial infarction. Comparison of 3 patient cohorts admitted to hospital over 10 years]. / Mortalité et morbidité à la phase aiguë de l'infarctus du myocarde. Comparaison de trois cohortes de patients hospitalisés espacées de 10 ans.

The management of acute myocardial infarction has been transformed over the last thirty years by a number of therapeutic innovations. The authors decide to compare the outcomes of three cohorts of unselected patients admitted to hospital at 10 year intervals, to evaluate the impact of these innovations on morbidity and mortality. Six hundred and sixty one patient admitted to the Coronary Care Unit for acute myocardial infarction were included: Group I comprised 223 patients admitted consecutively during the period 1972-1973; Group II comprised 243 patients admitted between 1982-1983 and Group III comprised 195 patients admitted between 1992-1993. The average age was comparable, about 65 years, in the 3 groups, although there were gender differences. Taking into consideration earlier hospital admission, the in-hospital mortality decreased from 25% in Group I to 21.8% in Group II and to 15.4% in Group III (p < 0.05 between the first 2 groups and the third group). This decrease in mortality is even greater in anterior wall infarction and is observed in all ages. Similarly to selected patients in large scale randomised clinical trials, the ordinary "run of the mill" patient has also benefited from therapeutic innovations over the last ten years.

[Internal atrial defibrillation after failure of attempted pharmacological and electrical cardioversion. Mid- and long-term outcome]. / Défibrillation auriculaire par voie interne après échecs des tentatives de réductions pharmacologiques et électriques par voie externe. Résultats à moyen et long terme.

Cardioversion of atrial fibrillation by an endocavitary electrical shock was first proposed during the 1980s. The authors studied the efficacy of this technique at short and medium term in a population of 36 patients (28 men and 8 women) in whom atrial fibrillation persisted despite attempts to reduce it by antiarrhythmic drugs and external electrical cardioversion. The immediate success rate was high : 34 out of 36 patients (94%) and, at medium term, the number with sinus rhythm was comparable to that of studies evaluating the medium-term efficacy of external electrical cardioversion; 19 out of 33 patients (57%) were in sinus rhythm at 6 months and 9 out of 27 patients (33%) at 12 months. These results seem to justify attempts at internal atrial defibrillation in patients in whom the other two techniques of cardioversion have failed. Its use as the method of first intention could be proposed if the profile of "resistant" patients to classical techniques was known, which is unfortunately not presently the case.

[Cerebral abscess disclosing tetralogy of Fallot with situs inversus in adulthood]. / Abcès cérébral révélant à l'âge adulte une tétralogie de Fallot sur situs inversus.

The authors report the case of tetralogy of Fallot (TOF) associated with situs inversus, the first description of this rare association in a previously asymptomatic adult. A 32 years old chauffeur was admitted to hospital with pyrexia and convulsions due to a left temporo-parietal cerebral abscess which had a favourable outcome. The chest X-ray and Doppler echocardiographic study showed a TOF with a high infundibular stenosis and dextrocardia. Abdominal ultrasonography confirmed a complete situs inversus. The good tolerance was attributed to the equilibrated character of the TOF. The orientation of the heart and the cono-truncal septation occur at different times during embryogenesis. However, there are genetic arguments in favour of the non-fortuitous nature of this association.

[Return to work after cardiac valvular surgery. Retrospective study of a series of 105 patients]. / La reprise du travail après chirurgie valvulaire cardiaque. Etude rétrospective d'une série de 105 patients.

This was a retrospective study realised by a mailed questionnaire of the medical and socio-professional conditions of return to work in patients with valvular heart disease aged 20 to 59 and operated in the cardiac surgery department of Rennes University Hospital in 1998. The results concern 105 patients of whom 78 were working before surgery and 27 were unemployed, and 53 were professionally active after surgery. The average age was 48 +/- 9 years and the male/female ratio was 2.38. After surgery, 78.4% of patients were NYHA Stages I or II, compared with 38.1% before surgery. Three main surgical procedures were carried out, sometimes in association: aortic valve replacement (71.4%), mitral valve replacement (21%) and mitral valvuloplasty (11.4%). Valve replacement was with a mechanical prosthesis in 83% of cases, a bioprosthesis in 11% of cases and a homograft in 6% of cases. Return to work (67.9%) after an average of 5.3 +/- 3.9 months was correlated with the following factors: age: 50 years old patients or more, were less likely to return to work (p < 0.02); postoperative NYHA stage: patients in stages III and IV were less likely to return to work (p < 0.03); the time off work before surgery: the longer the time (threshold > 6 months) the less likely the patients are to return to work (p < 0.03). Return to work was preferred to non-return (p < 0.03). This study shows the difficulties of professional rehabilitation of patients despite a satisfactory general condition. This is partially explained by the difficult economic context which favorises invalidity but also by the lack of information concerning the role of works doctors in the return to work. The realisation of a liaison file with permission of the person concerned between the general practitioner, the cardiologist and a medico-social security doctor and works doctor should remedy the difficulties in communication and sustain a policy of return to work.

[Endocoronary ultrasonography and quantitative coronary angiography. Correlations before and after transluminal coronary angioplasty]. / Echographie endocoronaire et coronarographie quantitative. Corrélations avant et après angioplastie transluminale coronaire.

A comparative study of the results of quantitative coronary angiography and endocoronary ultrasonography was performed in 37 patients undergoing percutaneous transluminal coronary angioplasty to determine the correlations between the two methods. The analyses were made before and after angioplasty at the site of stenosis and on a reference segment. A complete study before and after angioplasty using both techniques was only possible in 24 cases. The quantitative ultrasonographic analysis consisted of measurement of two orthogonal diameters, total surface area of the vessel, the endoluminal surface area and surface area of plaque. Transluminal coronary angioplasty acts mainly by forcing the plaque outwards. Ultrasonography showed a decrease in plaque area, from 10.5 +/- 6 mm2 to 9.8 +/- 5.5 mm2 and the total surface area of the vessel increased from 12.8 +/- 0.7 to 15.3 +/- 6.9 mm2 (p < 0.05). This accounted for the gain in main surface area of the stenosed lumen, from 2.28 +/- 1.28 to 5.9 +/- 2.65 mm2 (p < 0.001). The correlations between quantitative coronary angiography and ultrasonography at the site of stenosis were only significant after angioplasty both the vessel diameter (r = 0.67; p < 0.0002) and endoluminal surface area (r = 0.63; p < 0.0001). A correlation was not observed before angioplasty because of the complexity of the plaque and its excentric location. At the reference site, the correlations between ultrasonography and angiography before and after angioplasty were significant but not very close (Spearman coefficient 0.53 and 0.82 respectively, p < 0.001). Therefore, correlations between quantitative data obtained by coronary angiography and ultrasonography are modest in patients undergoing transluminal coronary angioplasty. The ultrasonographic information is more qualitative, enabling a better understanding of the mechanism of the therapeutic procedure and allowing optimal choice of the appropriate tool.

[Short and medium-term outcome after radiofrequency ablation of the atrioventricular junction]. / Evolution à court et moyen termes après ablation de la jonction auriculoventriculaire par courant de radiofréquence.

The aim of this retrospective study was to assess short and long-term mortality and morbidity after radiofrequency ablation of the atrioventricular junction in patients with supraventricular arrhythmias resistant to treatment. This cooperative series included 91 patients (47 men, mean age 68 +/- 9 years). The arrhythmia was paroxysmal in 56% of cases. The mean duration of symptoms was 67 +/- 61 months and 45 patients (49.4%) were in the NYHA Classes III and IV. An escape rhythm was present in 58 patients with a mean frequency of 39 +/- 9/min. Early complications were observed in 5 patients (venous thromboses, pulmonary embolism, mild pericardial effusion and haemothorax). The hospital mortality was 4 patients (4.4%). Death was of cardiac origin in 1 case (cardiac failure). The mean follow-up of patients was 14.5 +/- 8.6 months. Eleven patients died during this period, 8 of cardiac causes: cardiac failure (3 cases), sudden death (3 cases), thrombosis of a valve prosthesis (1 patient) and major electrolyte disturbances causing loss of stimulation in 1 case. Six patients had recurrences. Long-term morbidity was either related to cardiac pacing (3 cases) or cardiac failure (3 cases). Thirteen patients were in NYHA Classes III or IV at the end of follow-up. The authors conclude that radiofrequency ablation at the atrioventricular junction is an effective method of treating resistant supraventricular arrhythmias. Complications are not frequent but mortality appears to be high, probably due to the presence of advanced cardiac disease in the majority of cases. Sudden death seems to be rare and unrelated to pacing defects.

[Spontaneous ventilation in positive expiratory pressure in cardiogenic pulmonary edema. Prospective study]. / Ventilation spontanée en pression expiratoire positive au cours de l'oedème pulmonaire cardiogénique. Etude prospective.

New equipment facilitating the use of spontaneous ventilation with positive expiratory pressure (PEP) has become available in France since January 1996. This technique was applied in 38 patients with severe cardiogenic pulmonary oedema and persistent respiratory distress despite high flow classical oxygen therapy and standard treatment. After 1 hour of ventilation with a flow of 220 l/min of 100% oxygen with an average PEP of 7.7 cm H20, a significant improvement of clinical (heart and respiratory rate) and biological parameters (arterial gases) was observed. There were no side effects. Four patients died during the hospital period and only 1 was intubated. Spontaneous ventilation with PEP is a simple technique for coronary care units and, compared with conventional oxygen therapy, it rapidly improves arterial oxygenation, reduces respiratory work and improves conditions of cardiac load. Acute severe cardiogenic pulmonary oedema seems to be an indication of choice, especially in the elderly, where it may help avoid an often controversial intubation.

[Percutaneous dilatation of subaortic stenosis in an adult: a 3-year follow-up]. / Dilatation percutanée d'un rétrécissement aortique sous-valvulaire chez un adulte. Suivi à 3 ans.

Subaortic stenosis is usually diagnosed in the first years of life and treated surgically. The authors report the case of stenosis by a subaortic membrane diagnosed in an adult, treated by percutaneous balloon dilatation with a satisfactory outcome at 3 years.

[Torsades de pointe with spiramycine and metiquazine therapy. Apropos of a case]. / Torsades de pointes sous traitement par spiramycine et méquitazine. A propos d'un cas.

The authors report the case of a 21 year old woman with a congenital long Q7 syndrome who had several syncopal attacks at least one of which was caused by torsades de pointe. This sudden complication was attributed to the simultaneous prescription of Spiramycine and Mequitazine over a 48 hour period. These two drugs are not considered to be predisposing factors for torsades de pointe despite the fact that they belong to two families of drugs which can trigger this type of arrhythmia. The withdrawal of this treatment led to the complete regression of the syncopal episodes with a follow-up of two years and a significant shortening of the initial QTc interval which remained, nevertheless, longer than normal. This case underlines the potential risks of drug associations of these two families of drugs, especially in patients with the congenital long Qt syndrome.

[Systemic embolism in a renal transplant patient. Echocardiographic demonstration of bronchial carcinoma with intracardiac invasion]. / Embolie artérielle chez une greffée rénale. Découverte échocardiographique d'un cancer bronchique à extension intracardiaque.

A 45 year old female renal transplant patient was admitted for subacute ischaemia of a lower limb. Echocardiography was performed and showed the presence of bronchial carcinoma with intracardiac invasion. The tumour was confirmed by thoracic computerised tomography and by bronchoscopy. Histological investigation of bronchial biopsies and of the arterial embolism extracted at surgery showed large cell malignant disease. The tumour partially responded to chemotherapy and the patient survived for 5 months. Extension of a bronchial carcinoma to the left atrium is a classical complication in autopsy reports but rarely a source of systemic embolism. Echocardiographic diagnosis of this condition is very rare. The incidence of malignant diseases is higher in renal transplant patients than in the general population but this has not been verified for bronchial carcinoma. Echocardiography played an essential role in this case, detecting the tumour and its extension, indicating a poor prognosis and guiding treatment.

[Myocardial infarction caused by acute left main coronary artery occlusion. Apropos of 4 cases and review of the literature]. / Infarctus du myocarde par occlusion aiguë du tronc commun gauche. A propos de 4 cas et revue de la littérature.

Between 1979 and 1996, 4 acute occlusions of the left main coronary artery (LMC) were treated by primary transluminal coronary angioplasty. They were 4 men with a mean age of 43 +/- 5 years, admitted to hospital less than 8 hours after the clinical onset of symptoms of anterior myocardial infarction in Killip class 4 with complete right bundle branch block on the initial electrocardiogramme. All cases had a previous history of unstable angina over 2 to 15 days. Angioplasty was undertaken immediately in view of the haemodynamic instability. The coronary circulation was of a dominant right coronary type in the 4 cases: significant stenoses were discovered after recanalisation, on the left anterior descending artery (LAD) in 2 cases and the circumflex or marginal arteries in 3 cases. The right coronary artery was atheromatous in all cases but without significant stenosis. Angioplasty was completed by implantation of a stent in 3 cases (LAD : 1 case, LMC : 2 cases). The outcome was rapidly fatal in 3 cases. Only one patient survived 6 months in functional class 3. These results show that myocardial infarction due to occlusion of the left main coronary artery is a very severe condition which justifies rapid recanalisation. Primary angioplasty with stent implantation in an immediate therapeutic option which enables the patient to survive the acute stage, though only in a limited number of cases.

[Angiographic course over 10 years of giant aneurysm of the circumflex artery]. / Evolution angiographique sur 10 ans d'un anévrisme géant de la circonflexe.

Pathological dilatations of the coronary arteries are not exceptional and are called megadolichoartery, aneurysm or ectasia. Cases of marked arterial dilatation, although much rarer, are regularly reported following their discovery due to the impressive angiographic, echocardiographic or autopsy findings. However, their course, particularly in the long term, remains unclear. The authors report the case of a patient with a very large spindle-shaped aneurysm of the circumflex artery whose course was able to be followed over a period of ten years on three successive angiographic assessments performed for clinical coronary events. This follow-up was dominated by thrombosis of the aneurysm, extension of the aneurysmal disease and severe deterioration of left ventricular function.

[Are non blood pressure effects of converting enzyme inhibitors important in arterial hypertension?]. / Les effets non tensionnels des inhibiteurs de l'enzyme de conversion sont-ils importants dans l'hypertension artérielle?

Lowering blood pressure by medical treatment is not enough for correct prevention of the cardiovascular complications of high blood pressure. In this respect, we would like to emphasize the potential value of the non-antihypertensive effects of angiotensin-converting enzyme (ACE) inhibitors which may be summarized as follows. In the heart, ACE inhibitors significantly reduce left ventricular hypertrophy. They have no noticeable anti-ischaemic activity and are devoid of antiarrhythmic effects. On the kidneys, ACE inhibitors seem to have a protective effect, still to be determined, in certain cases of diabetes or renal impairment. ACE inhibitors have no deleterious metabolic effects. Other antihypertensive agents share the same properties. Long-term comparative trials are necessary to find out whether some of these drugs are more effective in this field than the others.