[Case report of a successful pregnancy following thrombolysis for acute myocardial infarction]. / Grossesse menée à terme malgré une thrombolyse à la sixième semaine d'aménorrhée pour infarctus du myocarde: à propos d'un cas.

A non-smoker 24-year-old woman presented to emergency department of Carhaix (France) for evaluation of acute chest pain. She is pregnant since six weeks and has no risk factors for coronary artery disease; her initial electrocardiogram was compatible with an acute posterior myocardial infarction (AMI). After thrombolysis by tenecteplase and treatment with both aspirin and heparin, she underwent coronary and left ventricular angiography that were normal, methergine test involved no coronary spasm. The mechanism of this AMI was not very clear. Nevertheless, an infant is born in good health eight months later after a pregnancy unrolled without any problems (aspirin was stopped at seven months, beta-blocker gradually stopped during second half of pregnancy).

[Acute pericarditis: results of a survey of treatment practices of cardiologists]. / Péricardite aiguë.

UNLABELLED: Benign acute pericarditis is a common disorder. Although, at first glance, its management appears well defined, the guidelines issued by professional societies with respect to optimal treatment and length of its administration remain vague. METHODS: a brief, anonymous questionnaire probing into treatment practices was sent in April 2005 to all cardiologists of Brittany. RESULTS: we collected 164 analyzable questionnaires out of 248 submitted (66%). The initial investigations in presence of acute pericarditis included an electrocardiogram in 100% of cases, an echocardiogram in 95%, and screening biochemistry in 93% of cases. Systematic hospitalisation was advised by only 24% of cardiologists. Aspirin was prescribed as first choice treatment in 92.5% of cases. Duration of treatment recommendations varied widely, from <5 days by 2.5%, between 5 and 10 days by 25.5%, 11 and 15 days by 23.0%, 16 to 21 days by 35.3%, and for >21 days by 14% of cardiologists. Hospital-based cardiologists were more likely to systematically hospitalise their patients than outpatient practice-based physicians (79.5% versus 5.1%; p<0.001) as well as to order an initial biochemical screening tests (100% versus 81.4%, p<0.01). Cardiologists <42 years of age recommended significantly fewer hospitalisations than older physicians (6.8% versus 36.4%: p<0.001). CONCLUSIONS: the management of acute, benign pericarditis was limited nearly exclusively to the prescription of aspirin. Duration of treatment varied widely. These observations are concordant with data published in the literature (where the recommended duration of treatment is systematically missing).

Long-term left ventricular pacing: assessment and comparison with biventricular pacing in patients with severe congestive heart failure.

OBJECTIVE: The purpose of this study is to report prospectively the results of six-month follow-up of permanent left ventricular (LV) based pacing in patients with severe congestive heart failure (CHF) and left bundle branch block (LBBB). BACKGROUND: Left ventricular pacing alone has been demonstrated to result in identical improvement compared to biventricular pacing (BiV) during acute hemodynamic evaluation in patients with advanced CHF and LBBB. However, to our knowledge, the clinical outcome during permanent LV pacing alone versus BiV pacing mode has not been evaluated. METHODS: Pacing configuration (LV or BiV) was selected according to the physician's preference. Patient evaluation was performed at baseline and at six months. RESULTS: Thirty-three patients with advanced CHF and LBBB were included. Baseline characteristics of LV (18 patients) and BiV (15 patients) pacing groups were similar. During the six-month follow-up period, seven patients died three BiV and four LV). In the surviving patients at 6 months, 8 of 14 patients in the LV group and 9 of 12 in the BiV group were in New York Heart Association class I or II (p = 0.39). No significant difference was observed between the two groups in terms of objective parameters except for LV end-diastolic diameter decrease (-4.4 mm in BiV group vs. -0.7 mm in LV group; p = 0.04). CONCLUSION: At six-month follow-up, a trend toward improvement was observed in objective parameters in patients with severe CHF and LBBB following LV-based pacing. The two pacing modes (LV and BiV) were associated with almost equivalent improvement of subjective and objective parameters.

Prevalence of factor V Leiden in patients with myocardial infarction and normal coronary angiography.

Factor V Leiden is associated with an increased risk of venous thrombosis and myocardial infarction in young women, but not in men in this latter case. The aim of this study was to evaluate the prevalence of this mutation in patients with myocardial infarction but normal coronary angiography. We compared 3 groups of patients: one group consisted of 107 patients with premature myocardial infarction but no significant coronary artery stenosis; another group of 244 patients with myocardial infarction and significant coronary artery stenosis; a third group of 400 healthy controls. Factor V Leiden was found in 13 patients (12.1%) who had a myocardial infarction without significant coronary artery stenosis, 11 patients (4.5%) who had a myocardial infarction with significant coronary artery stenosis (p = 0.01) and in 20 controls (5%) (p = 0.01). Odds ratio associated with factor V Leiden were respectively 2.93 (CI95: 1.18-7.31 ) and 2.63 (CI95: 1.19-5.78) when we compared myocardial infarction patients without significant coronary artery stenosis to controls or to patients with significant coronary artery stenosis. In myocardial infarction patients without significant coronary artery stenosis, prevalence of factor V Leiden is significantly higher than in controls. This new finding supports the hypothesis that thrombosis plays a key role in this selected situation.

Comparison of oral loading dose of propafenone and amiodarone for converting recent-onset atrial fibrillation. PARSIFAL Study Group.

In patients with recent-onset atrial fibrillation (AF), restoration of sinus rhythm is considered to be the first-line therapeutic option. Although this conversion might be obtained by direct-current shock or intravenous antiarrhythmic drugs, administration of an oral loading dose of class I or III antiarrhythmic drugs is more simple and convenient. This prospective, randomized, multicenter study compares the time to conversion to sinus rhythm obtained with an oral loading dose of propafenone or amiodarone. Patients with recent-onset AF (<2 weeks), without contraindications for the 2 drugs, were randomly assigned to be treated with propafenone (600 mg for the first 24 hours and if necessary a repeated dose of 300 mg for 24 hours) or amiodarone (30 mg/kg for the first 24 hours and if necessary a repeated dose of 15 mg/kg for 24 hours). Exact conversion time during the first 24 hours was determined by Holter monitoring. In each treatment group 43 patients with the same baseline characteristics were included. The median time for restoration of sinus rhythm was shorter (p = 0.05) in the propafenone (2.4 hours) than in the amiodarone (6.9 hours) group. After 24 hours (56% in the propofenone and 47% in the amiodarone group) and 48 hours, the same proportion of patients in the 2 groups recovered sinus rhythm (no serious adverse events were noticed). Thus, oral loading dose of propafenone or amiodarone was safe with a similar conversion rate of recent-onset AF. Propafenone had a faster action.

Response of normal and abnormal sinus node to right ventricular stimulation.

Right ventricular pacing at progressively increasing rates was performed in 25 patients with complete ventriculoatrial block, before and after autonomic blockade with intravenous propranolol and atropine. At the end of each ventricular pacing stage a right intraatrial electrogram and electrocardiographic leads were simultaneously recorded. The relation between right ventricular pacing and atrial rates was studied from the recordings obtained at each pacing stage in both group I, 8 patients with sick sinus syndrome, and group II, 17 patients with normal sinus function. Right ventricular pacing was associated with an increment in atrial rate that ws significantly smaller (probability [p] less than 0.001) in patients in group I (mean +/- standard error of the mean 8 +/- 6 beats/min) than in group II (mean 25 +/- 10 beats/min). The maximal atrial rate reached during right ventricular pacing exceeded 80 beats/min in all patients in group II but remained less than 74 beats/min in patients in group I. Because autonomic blockade did not significantly influence the preceding results, it is concluded that a mechanical effect on the sinus node may explain this phenomenon.

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.

Internal right atrial cardioversion of chronic atrial fibrillation: effects of low-energy biphasic shocks.

This study evaluates the efficacy and safety of internal right atrial cardioversion of atrial fibrillation using a defibrillation right atrial catheter and 2 thoracic patches with low-energy biphasic shocks.

Evaluation of left ventricular based pacing in patients with congestive heart failure and atrial fibrillation.

Acute hemodynamic data of left ventricular based pacing were assessed in 2 groups of patients with severe cardiac failure: 11 patients with atrial fibrillation and 17 patients with sinus rhythm. Both biventricular and left ventricular pacing significantly improved acute hemodynamic findings to a similar degree in both groups, suggesting that left ventricular based pacing may be beneficial in patients with severe cardiac failure regardless of whether or not they are in sinus rhythm.

Constrictive perivenous mesh prosthesis for preservation of vein integrity. Experimental results and application for coronary bypass grafting.

Saphenous veins undergo dramatic morphologic changes when used as coronary bypass grafts, and careful preparation of the graft alone is inadequate in preventing these changes. In this study, the use of a constrictive mesh for vein graft was evaluated. Fourteen sheep were subjected to a 5 cm resection of the carotid artery. Six sheep (Group A) received a jugular vein interposition graft, and the other eight sheep (Group B) received a jugular vein graft on which the constrictive mesh had been applied. The diameter of grafts in Group A was 14 +/- 1 mm compared with 7 +/- 0.5 mm for Group B (p = 0.05). The animals were put to death 4 months later. Scanning electron microscopy showed a disruption of the endothelial lining in Group A and a normal endothelium in Group B. Microscopy showed a statistical difference between Groups A and B regarding regularity and thickness of the intimal hyperplasia. Group B showed a moderate and regular intimal thickening and increased vasa vasorum. This indicates that distention and subsequent damage of the vein graft may be minimized by use of a constrictive mesh. Saphenous grafts surrounded by this constrictive mesh were inserted in four patients. Vein diameters were, respectively, 5, 4.3, 3.5, and 3.5 mm before meshing. After insertion in the mesh, vein diameters were 4.3, 3.5, 2.8, and 2.5 mm, respectively. Angiography performed 2 months later showed patent grafts of regular caliber.

Left ventricular-based pacing in patients with chronic heart failure: comparison of acute hemodynamic benefits according to underlying heart disease.

BACKGROUND: Acute left ventricular-based pacing has been shown to improve hemodynamics in patients with severe heart failure and left bundle branch block (LBBB). However, it is not known whether the cause of the underlying heart disease influences the potential effect of left ventricular-based pacing. OBJECTIVES: The aim of this study was to determine whether beneficial hemodynamic effects of acute left ventricular-based pacing in severe chronic heart failure are dependent on underlying heart disease. METHODS: After coronary angiography, patients with severe heart failure and LBBB were separated into two groups: dilated (25 patients; 20 male) and ischemic cardiomyopathy (21 patients; 20 male). Hemodynamic parameters were evaluated at baseline and during left ventricular-based pacing. RESULTS: Improvement in hemodynamic parameters were similar in both groups, during acute left ventricular pacing (changes expressed in percentage): pulmonary capillary wedge pressure, -16+/-15% vs. -14+/-10%; V wave amplitude, -25+/-18% vs. -21+/-17%; and biventricular pacing, -15+/-15% vs. -11+/-11% and -23+/-18% vs. -16+/-18%, respectively. CONCLUSION: Underlying heart disease does not influence the response to acute left ventricular-based pacing in patients with severe heart failure and LBBB. This finding provides support for including all patients with enlarged heart and heart failure in future studies evaluating left ventricular-based pacing.

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.

Intermittent left coronary occlusion caused by native aortic valve thrombosis in a patient with protein S deficiency.

A 77-year-old woman presented with chest pain and cardiogenic shock. Transesophageal echocardiography showed a mobile mass occluding intermittently the left coronary ostium. The mass was surgically resected, and histologic examination revealed an organized thrombus. Coagulation study demonstrated a protein S deficiency. This is the first case of aortic thrombosis associated with protein S deficiency, and it is the first time that transesophageal echocardiography provided definite evidence that a mass can cause intermittent left ostium coronary obstruction.

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.

Myocardial infarction with normal coronary arteries complicated by rupture of the left ventricular free wall.

We report the case of a 73-year-old woman successfully treated for a subacute rupture of the ventricular free wall which occurred on the fourth day after a postero-lateral myocardial infarction. Angiography performed prior to surgical repair revealed the presence of normal coronary arteries. The pathogenetic mechanism of such a happening remains uncertain, but the role of abrupt recanalization must be considered.

Right ventricular function in healed myocardial infarction in man. A cineangiographic assessment.

To evaluate the frequency of right ventricular dysfunction following recovery from myocardial infarction (MI) and the relationship of segmental right ventricular (RV) wall motion abnormalities to left ventricular (LV) function or location of coronary arterial stenosis, biplane right and left ventricular cineangiograms were obtained in 100 consecutive patients (4 +/- 3 months post MI). Thirty (group A) had anterior MI and significant stenosis or obstruction of left anterior descending artery (LAD). The remaining 70 patients had inferior MI. They were divided into three groups according to the site of the main coronary stenosis or obstruction and corresponding LV akinesia: right coronary artery (RCA) proximal to the acute marginal artery (RMA), (group B: 32 patients), RCA distal to the RMA (group C: 18 patients), left circumflex artery (LCF), (group D: 18 patients). RV and LV end-diastolic volume index (EDV), end-systolic volume index (ESV), stroke volume (SV) and ejection fraction (EF) have been determined. RV segmental wall motion was assessed in RAO and LAO projection by determining the percentage of systolic shortening (+ delta R) along 11 hemiaxes. Mean axial shortening (delta R) of the RV inferior and free walls were considered. When compared with that in 10 normal subjects, RV end-diastolic volume (RVEDV), RV end-systolic volume (RVESV) were increased and RV ejection fraction (RVEF) was lower in patients with anterior or inferior MI. Inferior delta R exhibited comparable sequential changes in the three groups of inferior MI and similar LVEF alteration.(ABSTRACT TRUNCATED AT 250 WORDS)

Automatic P-wave analysis of patients prone to atrial fibrillation.

A method is presented for automatic analysis of the P-wave, based on lead II of a 12-lead standard ECG, in resting conditions during a routine examination for the detection of patients prone to atrial fibrillation (AF), one of the most prevalent arrhythmias. First, the P-wave was delineated, and this was achieved in two steps: the detection of the QRS complexes for ECG segmentation, using a wavelet analysis method, and a hidden Markov model to represent one beat of the signal for P-wave isolation. Then, a set of parameters to detect patients prone to AF was calculated from the P-wave. The detection efficiency was validated on an ECG database of 145 patients, including a control group of 63 people and a study group of 82 patients with documented AF. A discriminant analysis was applied, and the results obtained showed a specificity and a sensitivity between 65% and 70%.

[New developments in the management of syncope]. / Nouveautés dans la prise en charge des syncopes.

The management of patients presenting with syncope has without doubt evolved in a spectacular manner over recent years. This evolution is the result of intense clinical research activity led jointly by several teams in the world, mainly in Europe. It has materialised with the publication, at the European Cardiology Society's instigation, of recommendations which have highlighted our current knowledge and ignorance. This article does not presume to review every published development in recent years, but simply to alert or remind the reader in the limited space available about the innovations which seem the most important, starting with the unanimously accepted definition of syncope, without which any discussion of this symptom is futile.

[Vasovagal syncope, from diagnosis to treatment]. / La syncope vasovagale, du diagnostic au traitement.

The concept of vasovagal syncope has changed over the last 10 years. The clinical presentation has changed since the observation of syncopes of vasovagal origin resembling the sudden syncope of the Stokes-Adams syndrome. The physiopathology has been considerably improved but none of the hypotheses proposed is universally accepted. The results of research already performed and of that underway, prompted by these hypotheses, will be determinant for the elucidation of the relations of the cardiovascular and autonomic nervous systems. This revolution is largely due to the introduction of the tilt test in the 1980s as a clinical means of investigation of the autonomic nervous system. Its protocol and results remain to be confirmed but it has already become a reference examination with the same value as Holter monitoring and electrophysiological studies in the evaluation of unexplained syncope after classical investigations. Therapy has improved after these diagnostic improvements and recent physiopathological hypotheses; their number and absence of strictly performed controlled studies are only reflections of this rapidly evolving subject. Only time and randomised trials, with double-blind protocols when possible, will enable effective treatment and a greater precision in the clinical indications.