Myocardial viability assessed by dobutamine echocardiography in acute myocardial infarction after successful primary coronary angioplasty.

Dobutamine echocardiography (5 and 10 microg/kg/ min) was performed in 40 patients 4 +/- 1 days after acute myocardial infarction reperfused by primary coronary angioplasty. The left ventricle was divided into 11 segments. Reversible myocardial dysfunction was indicated by a decrease in at least 2 grades in the total segmental score. Follow-up echocardiography was performed 2 months later. Contractile reserve was documented in 18 patients with dobutamine echocardiography (45%). Sensitivity, specificity, positive, and negative predictive value of dobutamine echocardiography in predicting improvement in contractile function at follow-up were 82%, 83%, 78%, and 86%, respectively. Negative predictive value was high in all dyssynergic segments (86%). Positive predictive value was higher in hypokinetic than in akinetic segments (73% vs 21%; p <0.05). Recovery of wall motion at follow-up was statistically associated with higher left ventricular ejection fraction (p <0.04), collateral blood flow before reperfusion (p = 0.007), and dobutamine responsiveness (p = 0.0001), and was more frequently observed in hypokinetic than in akinetic segments (p <0.05). Thus, low-dose dobutamine echocardiography accurately predicts the extent of irreversibly damaged myocardium early after successful direct coronary angioplasty in acute myocardial infarction.

Combined assessment of reflow and collateral blood flow by myocardial contrast echocardiography after acute reperfused myocardial infarction.

OBJECTIVE: To evaluate the combined assessment of reflow and collateral blood flow by myocardial contrast echocardiography after myocardial infarction. DESIGN: Myocardial contrast echocardiography was performed in patients with acute myocardial infarction shortly after successful coronary reperfusion (TIMI 3 patency) by direct angioplasty. Collateral flow was assessed before coronary angioplasty, and contrast reflow was evaluated 15 minutes after reperfusion. The presence of contractile reserve was assessed by low dose dobutamine echocardiography (5 to 15 micrograms/kg/min) at (mean (SD)) 3 (2) days after myocardial infarction. Recovery of segmental function (myocardial viability) was evaluated by resting echocardiography at a two month follow up. The study was prospective. PATIENTS: 35 consecutive patients referred for acute transmural myocardial infarction. RESULTS: Contrast reflow was observed in 20 patients (57%) and collateral flow in 14 (40%). Contrast reflow and collateral contrast flow were both correlated with reversible dysfunction on initial dobutamine echocardiography and at follow up (p < 0.05). The presence of reflow or collateral flow on myocardial contrast echocardiography was a highly sensitive (100%) but weakly specific (60%) indicator of segmental dysfunction recovery. Simultaneous presence of contrast reflow and collateral flow was more specific of reversible dysfunction than reflow alone (90% v 60%). CONCLUSIONS: Combined assessment of reflow and collateral blood flow enhanced the sensitivity of myocardial contrast echocardiography in predicting myocardial viability after acute, reperfused myocardial infarction. The simultaneous presence of reflow and collateral blood flow was highly specific of recovery of segmental dysfunction.

Successful conservative surgery of acute ascending aortic dissection occurring during coronary angiography.

We reported the case of an acute aortic dissection complicating right guiding catheter manipulation during engagement in the right coronary ostium. Despite absence of hemodynamic deterioration, dissection progressed rapidly from the sinus of Valsalva to the ascending aorta along its entire length. At surgery, performed in emergency, the aorta was not dilated and the aortic wall did not appear pathologic. Therefore conservative surgery was performed, consisting of suture of the aortic tear and incollage of the false lumen, with good immediate and mid-term results.

[Carotid artery thrombosis and myocardial infarction in nephrotic syndrome]. / Thrombose carotidienne et infarctus du myocarde au cours d'un syndrome néphrotique.

The authors report the case of a 18 year old man with a chronic corticosteroid-refractory nephrotic syndrome complicated by carotid artery thrombosis and myocardial infarction. Thromboembolism is one of the most serious complications of the nephrotic syndrome. Serious clotting factor disturbances are observed: changes in platelet function (hyperaggregability) increased plasma zymogens and cofactors, increased plasma fibrinogen, abnormalities of the fibrinolytic system and acquired deficiencies of coagulation inhibitors. The respective role of each of these abnormalities have not been clearly established, but it is likely that increased platelet aggregation and antithrombin III deficiency are important factors in producing a hypercoagulable state in the nephrotic syndrome. Hyperlipidemia is also a characteristic feature of the nephrotic syndrome: these is a wide spectrum of lipoprotein patterns with increased low density lipoproteins (LDL) or very low density lipoproteins (VLDL) or both; contradictory results have been reported with respect to the high density lipoproteins (HDL): decreased, normal or even increased plasma levels have been observed. In addition, changes in the distribution and composition of LDL and VLDL subclasses have been detected. Most of these changes have an atherogenic potential but controversy still surrounds the question of the prevalence of ischaemic heart disease in the nephrotic syndrome; it is unlikely that nephrotic syndromes of short duration have any influence on the incidence of coronary events, but patients with chronic heavy protein urea and long-term exposure to abnormalities of haemostasis and lipid profiles appear to have a significant risk of developing cardiovascular disease and may require long-term anticoagulant therapy.

[Multiple congenital coronaro-left ventricular fistulas. Apropos of 7 cases]. / Les fistules congénitales multiples coronaro-ventriculaires gauches. A propos de 7 observations.

Multiple congenital coronary-left ventricular fistulae (CLVF) are rare (4.5% of all coronaro-cardiac fistulae, the same incidence as isolated CLVF); data obtained from 7 personal and 25 previously reported cases, showed that this anomaly, is diagnosed at coronary angiography performed for anginal chest pains in 2 out of 3 cases; cardiac auscultation was usually normal but the basal ECG was pathological in 3 out of 4 cases; the electrical changes suggested myocardial ischaemia in 20 out of 24 cases. However, exercise stress testing was negative in 47% of cases. Multiple CLVF usually arose from the same artery (59%); the commonest artery involved was the left anterior descending (84% of the single artery fistulae and 100% in cases of multiple CLVF arising from more than one artery). The angiographic appearances of multiple CLVF were constant: images of "intracavitary rain". Associated ventriculographic abnormalities were uncommon but coronary atherosclerosis was observed in 15% of cases. The main differential diagnosis is that of CLVF secondary to intra-left ventricular thrombosis due to the development of neovascularisation of the thrombus from the underlying endocardium. The value of non-invasive investigations (2D echocardiography alone or coupled with pulsed Doppler) has not been shown in this type of coronaro-cardiac fistulae. Surgical correction was attempted in 3 cases, 2 of which had associated cardiac pathology justifying surgery. The presence of unequivocal coronary insufficiency due to CLVF was not demonstrated despite some suggestive clinical and paraclinical indicators.

[Proximal and peripheral coronaro-pulmonary fistulae. Apropos of 10 cases]. / Fistules coronaro-pulmonaires proximales et périphériques. A propos de 10 observations.

Coronaro-pulmonary fistula (CPF) is a rare congenital malformation comprising about 17 p. 100 of coronaro-cardiac fistulae. The authors report a series of 10 cases of CPF diagnosed in over 6 000 coronary angiographic studies. This material includes 7 cases of "proximal" CPF in which the receiving vessel was the main pulmonary artery (MPA), there were two cases of fistula between the coronary and distal pulmonary arteries ("distal" fistulae), one of which had an associated proximal CPF; finally one case showed abnormal vascularisation of part of the lung by a branch of the left circumflex artery. The left coronary artery was involved in all 8 cases of proximal CPF, confirming previously published data. The communication comprised a single pedicle or a plexus arising from the initial segment of the coronary artery and draining into the MPA in all cases. Coronary angiography was performed in the 5 men and 3 women (average age 53 years) for chest pain (2 cases) acute ischaemia in the territory of the left anterior descending artery (1 case), residual post-infarction angina and assessment after infarction (2 cases), mitral valve disease (2 cases) and for a continuous murmur (1 case). The ECG was normal in 2 cases; 5 patients had ST abnormalities; left ventricular hypertrophy was observed in 2 cases but these patients had associated mitral valve disease. Radiological cardiomegaly was present in 2 cases. Finally, no significant left-to-right shunt could be detected on cardiac catheterisation. The outcome was favourable in 7 patients (resection of fistula and eventual coronary bypass surgery in 3 cases; surgical abstention in the remainder).(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiological aspect of Kearns' syndrome. Apropos of 3 cases, with histopathological study of the conduction tissue in one of them]. / Aspect cardiologique du syndrome de Kearns. A propos de 3 cas dont 1 avec étude histo-pathologique du tissu de conduction.

Three cases of Kearns syndrome are reported. The neuro-ophthalmological signs were comparable with ophthalmoplegia, pigmentary retinal degeneration and polymorphic neuro-muscular and sensory deficits. The electrocardiological signs were observed 2-4 years after the onset of the condition; the cause of death in each case was related to complete heart block. The post-mortem findings in one of the cases were spongial degeneration of the central nervous system and a seemingly primitive degeneration of the Bundle of His and its branches.

[Embryological duplications of the node-bundle of His : its pathological rôle]. / Dualité embryologique des voies nodo-hisiennes : son rôle en pathologie

A histological study by the method of seriated sections in one case of "double-outlet left ventricle" made it possible to confirm and to describe the embryology of the nodal-His junction: not only the atrio-ventricular node (AV N) but also the His bundle (H) have a double origin, atrial and ventricular. Fusion of these two buds, inexistant in the "lone ventricle" is certainly imperfect. Two macroscopically normal hearts provided examples of nodal buds in one case, of a persisting cleft between the two His buds in the other.

[Floating thrombus in the right atrium and severe pulmonary embolism. Value of intravenous thrombolysis]. / Thrombus flottant de l'oreillette droite et embolie pulmonaire grave. Intérêt de la thrombolyse intraveineuse.

Mobile right atrial thrombi carry a high risk of pulmonary embolism which may be massive and are a medical emergency. Although surgery is commonly indicated, treatment with intravenous thrombolytics is an alternative and was successful in 4 out of 6 cases reported by the authors. Six patients, admitted for severe pulmonary embolism confirmed by pulmonary scintigraphy (6 cases) and by angiography (2 cases), underwent echocardiography which demonstrated a mobile right atrial thrombus. One patient was operated as an emergency and died immediately afterwards. Another, treated with heparin because of contraindications to surgery and thrombolysis had a recurrent fatal pulmonary embolism. In the other four cases, intravenous thrombolytic therapy was started immediately after echocardiography with 250,000 IU of streptokinase in 30 minutes, followed by 100,000 IU per hour for 48 to 72 hours associated with heparin 300 to 500 IU/kg/day. The biological efficacy of the treatment was confirmed in all cases (fibrinogen < 1 milligram; TCA > 60 s). A clinical improvement with improved blood gases was rapidly obtained in all 4 cases. The thrombus had totally disappeared at control echocardiography 8 to 12 hours after the initial examination. There were no complications, in particular no haemorrhages. After 6 months' follow-up, the outcome was good with oral anticoagulants (4 cases) associated with implantation of a caval filter in 1 case. Thrombolysis seems to be an effective alternative to surgery as there four cases demonstrate.

[Abnormalities of the renal arteries in arterial hypertension in adults]. / Les anomalies des artères rénales dans l'hypertension artérielle de l'adulte

Results of arterial surveys on the basis of renal arteriograms in 100 consecutive unselected and hospitalized cases of lone arterial hypertension of the adult. Abnormal polar arteries with direct branching from the aorta were observed in 52 cases, combined with a stenosing or parnechymatous arterial anomaly in 7, quite isolated in 45 cases (61.8 percent of 73 cases). The very great incidence of abnormal polar arteries is a fundamental epidemiological datum of lone arterial hypertension of the adult.

[Kidney parenchymatous hypoplasia and arterial dysplasia in adult arterial hypertension. Data of selective renal arteriography]. / Les hypoplasies parenchymateuses et les dysplasies artérielles des reins dans l'hypertension artérielle de l'adulte. Données de l'artériographie rénale sélective

Analysis of a further series of 125 consecutive unselected adults who were admitted to hospital with hypertension has advanced the study of arterial abnormalities and parenchymal hypoplasia, as demonstrated by selective renal arteriography, further in the direction of the parenchyma. An index of arterioparenchymal thinning is described. The authors list the features and incidence of polar arteries arising from the aorta (46%), polar arteries of non-aortic origin (31%), stenosing dysplasia (26%) and other arterial malformations, as well as biapical hypoplasia (67%), monofocal hypoplasia (37%), and the main types of renal dysgenesis (30%) which they found. The incidence of these abnormalities confirms the previous study of polar arteries arising from the aorta, and gives much more extensive information on the topic of parenchymal hypoplasia in so-called essential hypertension in the adult.

[Lesions of immature renal parenchyma in the region of an abnormal aortic polar artery during arterial hypertension in the young adult. anatomo-clinical example]. / Lésions du parenchyme rénal immature dans le territoire d'une artère polaire aortique anormale au cours de l'hypertension artérielle de l'adulte jeune. Exemple anatomo-clinique

A female patient of 22 with major hypertension was operated upon for a dyspalastic diaphragm stenosis of the right renal artery; she had otherwise a left lower polar aortic artery. The histological study was under-taken on four comparative biopsy specimens. In the aortic polar artery territory, the signs of atrophic dysgenesis were demonstrated: rarefaction and sclerosis of the glomeruli, sclerosing intretitial infiltration. They reproduce exactly the lesions of immature kidneys described by Marshall.

[Low-dose dobutamine echocardiographic assessment of reversible contractile dysfunction (myocardial stunning) after myocardial infarction]. / Evaluation par l'échocardiographie dobutamine à faible dose de la dysfonction contractile réversible (sidération myocardique) après infarctus du myocarde.

Low dose (5 to 10 micrograms/min) dobutamine echocardiography was used to predict the presence of reversible contractile dysfunction (myocardial stunning) after myocardial infarction successfully revascularised in the acute phase of primary angioplasty. The investigation was undertaken in 40 patients, 4 +/- 1 days after inaugural myocardial infarction. The left ventricle was divided into 16 segments. Viable myocardium was diagnosed when the initial regional wall motion score decreased by at least 2. Resting echocardiography was performed at 2 months to evaluate the effective recovery of regional wall motion (myocardial viability). The presence of contractile reserve was documented by dobutamine echocardiography in 18 patients (45%). The sensitivity, specificity and positive and negative predictive values of dobutamine echocardiography for the diagnosis of myocardial viability were 82, 83, 78 and 86% respectively. The negative predictive value was high in all dysnergic segments (86%). The positive predictive value of the investigation was however higher in hypokinetic than in akinetic segments (73 vs 21%; p < 0.05). The recovery of regional wall motion during follow-up was statistically related to higher initial left ventricular ejection fraction (p < 0.04), the presence of angiographically documented collateral circulation before revascularisation (p = 0.007), the contractile response to dobutamine (p = 0.0001) and was observed more frequently in hypokinetic than in akinetic segments (p < 0.05). These results show that low-dose dobutamine echocardiography is a sensitive and specific investigation for predicting irreversible myocardial damage after successful primary angioplasty in acute myocardial infarction. However, even in the absence of residual coronary stenosis, the presence of viable myocardium is only identified specifically in hypokinetic segments.

[Traumatic tricuspid insufficiency. Apropos of 2 cases]. / Insuffisance tricuspide traumatique. A propos de 2 observations.

The authors report two cases of tricuspid regurgitation by a ruptured anterior papillary muscle secondary to non-penetrating thoracic trauma. In the presence of suggestive clinical and electrocardiographic abnormalities (systolic murmur, right heart failure, right bundle branch block), echocardiography confirmed the tricuspid regurgitation, showed its mechanism and excluded any other intracardiac lesions. Tricuspid annuloplasty was performed in both cases because of the persistence of failure or degradation of the patient's clinical condition. Peroperative echocardiography was used to judge the quality of the surgical repair in both cases. Traumatic tricuspid regurgitation is a rare condition and the diagnosis is often delayed. Echocardiography is the investigation of choice and guides treatment which is essentially valvular repair in symptomatic patients.

[Hemorrhage of the brain after therapeutic fibrinolysis. 11 cases]. / Hémorragies du système nerveux central après fibrinolyse thérapeutique. 11 Cas.

Ten cases of cerebral hemorrhage and one of intraspinal subdural hematoma after thrombolytic therapy are reported. Six patients were treated with streptokinase, four with rt-PA and one with a combination of both drugs. The incidence was 0.5 to 2% and was higher in case of rt-PA therapy (3.7%). In all cases, CT scan showed primary hemorrhage rather than hemorrhagic infarction. Four patients died of stroke. Among the survivors, residual disability was severe in one and mild in five. Only one patient recovered completely. In patients treated with streptokinase, the hemorrhage was probably due to a more than 80% decrease in plasma fibrinogen. In those receiving rt-PA, either excessive dosage (2 cases in our series) or lysis of cerebral microthrombi are thought to be responsible for the hemorrhagic complications. Treatment consists of infection of aprotinin (an anti-fibrinolytic drug), cryoprecipitates with factors V and VIII and protamine sulfate.

[Aneurysm of a saphenous vein aortocoronary graft. Apropos of a case presenting with a presternal mass and review of the literature]. / Anévrysme d'un pontage veineux aorto-coronarien. A propos d'un cas révélé par une masse pré-sternale et revue de la littérature.

A 61 year old man was admitted with a pulsatile pre-sternal swelling ten years after saphenous vein coronary-artery bypass grafting. The precise diagnosis of this vascular tumor was not established despite various investigations. At reoperation, an aneurysm of the saphenous vein graft, eroding the sternum, was found. This rare complication of saphenous vein coronary artery bypass grafting is described and a review of the literature is presented. Reoperation is mandatory for this uncommon alteration of the saphenous vein graft.

[Validation of the therapeutic role of amlodipine in 31,946 French hypertensive patients]. / Validation de l'intérêt thérapeutique de l'amlodipine dans une population française de 31,946 patients hypertendus traités en pratique de ville.

Amlodipine, a dihydropyridine calcium channel blocker (CCB), with a long duration of action, has been the subject of numerous controlled studies which showed its effectiveness and good tolerance in arterial hypertension in once-daily doses. We report the results of a large, multicentric, French, prospective phase IV study which evaluated the effectiveness and tolerance of amlodipine administered at a rate of 5 to 10 mg in only one daily dose. We also assess the evolution of the quality of life after 12 weeks of treatment among 31,946 hypertensive patients followed up to the ambulatory stage by general practitioners. The response rate--defined as the patients having had a reduction of 10 mmHg or more diastolic blood pressure--was 88%. The blood pressure standardization--defined by a diastolic blood pressure lower than 90 mmHg--was achieved for 70% of the patients. Amlodipine was administered in stand-alone therapy in 78% of the cases. The occurrence of an undesirable event was noted in the course of treatment in 12% of the patients and justified interruption of the treatment for 3.7% of the total population. The index average of quality of life was improved by the end of the 12-week treatment. This study carried out on a significant number of hypertensive patients (n = 31,946) under real prescription conditions confirms the efficacy and good tolerance of amlodipine, as has already been demonstrated in the preliminary developmental studies.

[Post-radiation coronary diseases. Presentation of 7 cases and review of the literature]. / Les coronaropathies post-radiques. Présentation de 7 cas et revue de la littérature.

Coronary lesions are one of the complications of mediastinal radiotherapy; they are more uncommon, at least in their clinical expression, than the involvement of the pericardium, but they are interesting by their gravity and occurrence in young patients (35 years old, in an average). We are reporting 7 cases in addition to the 53 already recorded in the literature. The neoplasm which led to the radiation treatment is, in 85 p. cent of the cases Hodgkin's disease and in 10 per cent of the cases a breast cancer. The time of occurrence of the clinical signs is of 5 years, in an average. The revealing symptom is an initial necrosis or an angor, most often unstable (45 p. cent of the cases, for each of them), more exceptionnally it is a sudden death or a pericarditis. The coronary risk factors have been determined in 37 patients; 45 p. cent had none. In half of the cases, the coronary involvement is monotruncular and frequently proximal (the anterior interventricular trunk is affected twice as often as the right coronary); in the other half, there is an equal distribution between bi-troncular and tri-truncular involvement. There are various pathological lesions: typical with isolated fibrosis of the intima and aventitia, pure atherosclerotic lesions or association of the two. The prognosis of these coronary lesions is severe (43 p. cent of deaths), but the patients who underwent revascularization procedures (by-pass or more seldom transluminal angioplasty) have in 80 p. cent of the cases a favorable evolution.(ABSTRACT TRUNCATED AT 250 WORDS)

[Auricular flutter after cardiothoracic surgery. Treatment by auricular stimulation using the esophageal approach]. / Flutter auriculaire après chirurgie cardio-thoracique. Traitement par stimulation auriculaire par voie oesophagienne.

Transoesophageal atrial pacing was used in 10 patients to interrupt post-operative atrial flutter after cardio-thoracic surgery. The method was successful in all cases. The arrhythmia was converted directly into sinus rhythm in 8 patients and into atrial fibrillation followed by spontaneous reversion to sinus rhythm in 2 patients. The results differed according to the underlying disease. Return to sinus rhythm was the rule in all patients who underwent coronary artery bypass grafting and pneumonectomy, whereas transient atrial fibrillation seemed to be more frequent (and should be considered a satisfactory result) in patients with heart valve surgery. Relapses of arrhythmias seemed to be more resistant to transoesophageal stimulation irrespective of the operation performed. The method is non-invasive, easy to carry out and safe in patients receiving digitalis. The risk of ventricular pacing is very low. The burning sensation and chest pain experienced during stimulation are well tolerated. Transoesophageal pacing is as effective as epicardial atrial stimulation and more effective in such patients than temporary transvenous atrial pacing.