[Chronic occlusion of the left coronary artery]. / Occlusion chronique du tronc coronaire gauche.

Chronic occlusion of the left main coronary artery is rare with less than 100 reported cases. the treatment is essentially surgical but medical management has been proposed. This case report illustrates the prognostic benefit of surgical management in view of the risk of secondary occlusion of the proximal right coronary artery.

[Flecainide exercise induced left bundle branch with chest pain]. / Bloc de branche gauche douloureux d'effort induit par flécaïnide.

Ischaemia has been the suggested mechanism of simultaneous left bundle branch block and chest pain on effort with normal coronary angiography. This hypothesis is very controversial and was not the mechanism in the two new cases of this syndrome. The two patients in whom effort pain and left bundle branch block were observed had been treated for paroxysmal supraventricular tachycardia with flecaine. Withdrawal of the anti-arrhtymic resulted in the disappearance of this syndrome. In these cases, the ischaemic mechanism could be excluded without ambiguity. The flecaine was the only cause of rate-related LBBB by slowing conduction in the left bundle branch with no effects on coronary reserve. It would seem that LBBB alone was the cause of chest pain. The absence of coronary artery disease was confirmed in the first patient and the diagnosis was highly improbable in the second.

[Contribution of myocardial biopsy and immunohistochemistry to the prognostic evaluation of cardiac amyloidosis]. / Apport de la biopsie myocardique et de l'étude immunohistochimique à l'évaluation pronostique des amyloses cardiaques.

The authors report four cases of cardiac amyloidosis, the diagnosis of which was confirmed by endomyocardial biopsy. They underline the value of immuno-histological studies with labelling of the biopsy fragments with anti-transthyretin and anti-light chain immunoglobulin antibodies. This approach provides a more precise typing of amyloidosis and a more accurate evaluation of the prognosis.

[A new case of pericardial thymic cyst]. / Un nouveau cas de kyste thymique paracardiaque.

The thymic cysts are benign tumours of the thymo-pharyngeal canal, usually located in the cervico-mediastinal region. The authors report the case of a large thymic cyst with an ectopic right paracardiac location compressing the right heart chambers. It was a chance finding on chest X-ray of an asymptomatic 21 year old man. Though suggestive of a pericardial cyst in view of its position, curative surgical ablation allowed confirmation of the diagnosis at anatomo-pathological examination.

[Aorto-coronary dysplasia and pseudoxanthoma elastica]. / Dysplasie aorto-coronaire et pseudoxanthome élastique. A propos d'un cas.

The authors report the case of a 50 year old man with pseudowanthoma elastica with a history of myocardial infarction and severe aortic regurgitation. Angiography showed multiple coronary artery aneurysms and aneurysmal dilatation of the aortic annulus. The outcome after triple coronary bypass surgery with aortic valve replacement in a valved Bentall conduit was favourable. Pseudoxanthoma elastica is a rare condition in which the prognosis depends on the degree of vascular involvement. In this context, coronary artery aneurysms and aneurysmal dilatation of the aorta are rare complications.

[Heart rate variability and vagal syncope in the young adult]. / Variabilité sinusale et syncope vagale chez l'adulte jeune.

Heart rate variability is a sign of sympathetic activity. The authors compared two study populations of young males aged 19 to 30 years: population T comprised 15 healthy volunteers who had two negative tilt tests, one under basal conditions and the other after a bolus of isoproterenol; population S comprised 12 patients without cardiac or other disease, who were followed up for malaise and in whom the basal tilt test was positive, confirming the vagal origin of syncope. Temporal and spectral (total power, low frequency 0.04-0.15 Hz, hight frequency 0.16-0.40 Hz) data was obtained concerning heart rate variability from 24 hour Holter monitoring. The main difference between the two study populations was in the temporal data over 24 hours especially with respect to the heart rate (T = 73.5 +/- 6.9; S = 65.4 +/- 6.2/min; p = 0.004) and the percentage of successive R-R intervals varying by more than 50 ms (PNN 50) (T = 20.2 +/- 8.3%; S = 30.7 +/- 10.2%; p = 0.024). At night, the lowest SDANN/5 (standard deviation of RR intervals over periods of 5 minutes) were observed in group S (67.2 +/- 16.7 ms vs 87.3 +/- 24.4 ms; p = 0.026). No statistically significant differences between the two groups was observed in the spectral data. The temporal data of heart rate variability on Holter ECG monitoring over 24 hours could therefore have a good predictive value of the vagal origin of syncope in young adults.

[Paraganglioma associated with renal artery stenosis: unusual cause of secondary arterial hypertension. A case report and review of the literature]. / Paragangliome associé à une sténose de l'artère rénale: une cause rare d'hypertension artérielle secondaire. A propos d'un cas et revue de la littérature.

Secreting paraganglioma is a rare cause of secondary HT and corresponds to an extra-adrenal phaeochromocytoma. This case reports the consecutive coexistence, with a free interval of 10 years, of dysplastic renovascular HT and abdominal paranganglioma in the organ of Zuckerkandl. This is a rare association which requires investigation of a common genetic predisposition (neural crest disease) and emphasizes the importance of long-term surveillance of these patients.

[Isolated primary streptococcal tricuspid endocarditis. A case report]. / Une endocardite tricuspide primitive isolée à streptocoque. A propos d'un cas.

The authors report a new case of primitive isolated endocarditis of the tricuspid valve. The microorganism responsible, Streptococcus sanguis, is unusual in its localization and in this environment. The uncomplicated evolution poses the problem of deciding what action should be taken vis-à-vis the persistence of an important isolated vegetation after effective antibiotic treatment. Therapeutic abstention was chosen rather than surgical intervention in light of the literature. A spontaneous pulmonary embolic migration of the vegetation was effectuated 3 weeks after termination of the antibiotic treatment without pulmonary or hemodynamic complications.

[Esophageal approach in rythmology. Diagnostic and therapeutic applications]. / La Voie oesophagienne en rythmologie. Applications diagnostiques et thérapeutiques.

The oesophageal route is a simple technique, which is easy to perform. It allows precise assessment of supraventricular arrhythmias without using the endocavitary route. There is a perfect correlation between the two methods for the study of sinus function and the Wenckebach point. This technique makes a considerable contribution to the diagnosis of junctional tachycardia and the evaluation of Wolff-Parkinson-White syndrome. It can reduce approximately 65% of flutters and 50% of atrial tachyarrythmias. It can also be used to monitor antiarrhythmic treatment or in the assessment of radiofrequency resection, especially in nodal tachycardias and left atrioventricular accessory pathways. Its limitations concern the sometimes painful nature of the investigation and the impossibility of recording the electrical activity of the His bundle.

[Arrhythmogenic right ventricular dysplasia disclosed by ventricular extrasystole]. / Dysplasie ventriculaire droite arythmogène révélée par une extrasystolie ventriculaire.

Arrhythmogenic right ventricular dysplasia is one of the principal causes of sudden cardiac death in young subjects. In the absence of ventricular tachycardia, the disease can be revealed by simple ventricular extrasystole. In the light of such a case, the authors discuss the value of various complementary investigations for the diagnosis of these clinical forms with little or no symptoms. Detailed examination of the electrocardiogram followed by a search for late ventricular potentials are decisive steps before proceeding to invasive investigations which often remain essential to confirm the diagnosis. The prognosis remains uncertain, and is always dominated by the risk of sudden death, even in these apparently minor forms of the disease. This point further emphasizes the need for detection, which should be facilitated by the recent establishment of a list of diagnostic criteria.

[Alcohol and salt consumption. Two closely related variables]. / Consommation d'alcool et consommation de sel. Deux variables étroitement liées.

In a transverse epidemiological study, 3,329 male firm-employees were questioned on their daily alcohol consumption and on their use of salt during meals, which divided them into four categories: those who virtually never added salt to their food; those who salted their food according to its taste; those who salted systematically, and those who added salt to a salt-free family cooking necessitated by the health of another member of that family. This questioning showed that as the alcohol consumption increased the proportion of subjects who salted their food without tasting or because of salt-free familial meals was greater (P = 0.0018) and, conversely, the proportion of subjects who virtually never added salt to their food decreased (P = 0.0001). There is, therefore, a highly significant correlation between the alcohol consumption level and the type of salt consumption. Whether there is a relationship between the amount of salt consumed and the level of alcohol consumption remains, for the time being, an open question.

[Vagal syncope in young adults: specificity of the tilt-table test]. / Syncope vagale de l'adulte jeune: spécificité du test d'inclinaison.

OBJECTIVE: The head-up tilt test has been used for more than 10 years to reproduce vagal lipothymia. The criteria for a positive test and specificity are however still lacking. METHOD: Thirty male volunteers, age 18 to 35 years, with no past history of lipothymia nor any signs of hypervagotonicity at physical examination, on fasting blood samples or on exercise tests with sudden interruption and Holter recording were selected for the study. Two head-up tilt tests at 60 degrees for 45 minutes were conducted, one with no presensitivisation and the other with a bolus of isoproterenol (2, 4, 6 and 8 micrograms) starting 30 minutes after the beginning of the test. Blood pressure was measured throughout the test. RESULTS: The systolic blood pressure curves showed drops of more than 30 mmHg accompanied by spontaneously resolving clinical signs in 6 of the 30 subjects during the non-sensitized tests and in 14 out of 30 during the sensitized tests. A symptomatic drop in systolic blood pressure of more than 30 mmHg compared to the moment before the malaise accompanied by clinical signs which did not resolve within 1 minute and required returning to the supine position occurred in one volunteer during a non-sensibilized test. This same type of reaction was observed in 4 volunteers during sensitized tests, three times after an isoproterenol bolus. CONCLUSION: Taking this later manifestation as the criteria for a positive head-up tilt test, the specificity of the non-sensitized and isoproterenol-sensitized tests in the young adult are 96.7 and 86.7% respectively. These findings must be considered with caution since there is no proof that these young men with no past history of hypervagotonicity but a positive head-up tilt test may be one day confronted with a situation generating a vagal reaction.

[Acute necrotizing eosinophilic myocarditis. Favorable clinical course after heart transplantation]. / Myocardite aiguë nécrosante à éosinophiles. Evolution clinique favorable après transplantation cardiaque.

A case of acute eosinophilic myocarditis without hypereosinophilia, presenting as hypokinetic dilated cardiomyopathy in a 24-year old man is reported. Sudden worsening of subacute cardiac failure required heart transplantation 3 months after the onset of the disease. Only pathological examination provided the diagnosis of acute necrotizing eosinophilic myocarditis of undetermined origin. Two years after transplantation, the patient had no clinical or histological sign of recurrence. Seldom described in the literature, acute eosinophilic myocarditis is a dangerous form of eosinophilic heart disease which often follows a fulminant course beyond all therapeutic resources. This case, which is particular in its clinical presentation, in the lack of hypereosinophilia and above all in its cure after heart transplantation, enables the authors to discuss the mechanisms and various manifestations of the cardiotoxicity of eosinophils.

[Increase of troponin I during acute pericarditis. 69 cases at an emergency service]. / Elévation de troponine i lors d'une péricardite aiguë. 69 observations en service d'urgence.

OBJECTIVE: The purpose of this study was to determine the incidence and significance of troponin i (tni) elevation in acute pericarditis. PATIENTS AND METHODS: We retrospectively included 69 patients with acute idiopathic pericarditis. We analyzed ECG recordings, echocardiography findings and tni level. Thirty-four patients (49%) had detectable tni (> 0.5 ng/ml), 15 (22%) had a significantly elevated level (> 1.5 ng/ml). There was a significant correlation between elevated tni level and ST elevation. All patients were well at one year. CONCLUSIONS: A rise in tni is frequently observed during acute idiopathic pericarditis. According to the correlation with ST segment elevation, a rise in tni is apparently indicative of superficial myocardial damage. The prognostic value remains unknown.

[Ventricular extrasystole and arrhythmogenic right ventricular dysplasia. Critical analysis of the diagnostic value of non-invasive tests]. / Extrasystolie ventriculaire et dysplasie ventriculaire droite arythmogène. Analyse critique de la valeur diagnostique des examens non invasifs.

Asymptomatic ventricular extrasystoles were discovered in 2 active sportsmen (32 and 33 years). The cardiology work-up rapidly led to the diagnosis of arrhythmogenic right ventricular dysplasia in one. In the other, the clinical presentation was similar and the initial diagnosis was ventricular extrasystole with a healthy heart. Four years later however, the subject was still asymptomatic but a second evaluation revealed arrhythmogenic right ventricular dysplasia. This delayed diagnosis emphasizes the importance of renewed noninvasive evaluation of patients with asymptomatic ventricular extrasystoles.

[Cardiovascular risk for the traveler]. / Le risque cardio-vasculaire pour le voyageur.

The incidence of cardiovascular events during travel is rising with the age of the population and number of traveling seniors. Cardiovascular events are the second most frequent reason for medical evacuation and the cause of 50% of deaths recorded during commercial air travel. In most cases the underlying disorder is coronary artery disease which is readily destabilized by stress and fatigue associated with travel. Inflight conditions that can cause problems include altitude-related hypoxia, pressurization, and cramped seating in most sections of the plane. Upon arrival the traveler is exposed to a variety of climatic, food, and environmental factors that can trigger manifestations of latent heart disease. Prophylactic drugs for tropical infectious disease (especially antimalarials of the quinidine group) should be used with caution due to possible adverse interaction with medications used to treat heart disease. A pre-travel examination is necessary to ascertain cardiovascular status and define simple preventive precautions.

[Round pulmonary lesions after returning from French Guyana. Six cases of american pulmonary histoplasmosis]. / Image ronde pulmonaire au retour de Guyane française. A propos de six cas d'histoplasmose américaine pulmonaire.

From 1989 to 1994, 71 patients were hospitalized for diagnosis of round lung lesions including 49 servicemen under the age of 45 years who had been stationed in tropical areas. In 6 of these servicemen, the diagnosis was pulmonary histoplasmosis at the tertiary stage of histoplasmoma. All had done duty in French Guyana and were negative for human immunodeficiency virus. The subpleural lung opacity was the only lesion in 5 out of 6 patients and was calcified in 4 out of 6 patients. Since skin tests with histoplasmin and serologic testing for histoplasmosis failed to achieve definitive diagnosis, surgical biopsy was performed by conventional thoracotomy in 2 cases and video-assisted thoracic surgery in 4 cases. The specimens obtained confirmed diagnosis of histoplasmosis on mycologic criteria in 3 cases and on a combination of findings including compatible histologic evidence in 3 cases. Treatment consisted in surgical excision of the nodules, for which video-assisted thoracoscopic surgery proved to be an excellent technique because of its simplicity and rapidity.

[Ventricular arrhythmia in the athlete: practical management]. / Arythmie ventriculaire chez le sportif: conduite pratique.

The aim of athletic competition is to exceed ones present limits, which exposes the athlete to increased risk is helshe has a cardiac disorder. Ventricular excitability is not part of the athletic heart syndrome, and only the presence of resting ventricular extrasystoles that are monomorphic, ungrouped and disappear with exercise can be considered physiological. Significant ventricular arrhythmia can reflect a cardiac disorder that should be routinely sought in order to determine if there is a potential risk of sudden death favoured by physical effort. The confirmation of arrhythmia and seeking a cardiac disorder require a rigorous approach based on history-taking, clinical examination and initial performance of non-invasive, orienting examinations. Invasive examinations, based on the case, are often required if a disorder is suspected or if there is a question concerning the severity of the arrhythmia. Decisions concerning aptitude for competition are decided case by case, according to the disorder, with reference to the 26th Bethesda Conference. If the ventricular arrhythmia is shown to be benign and no underlying cardiac disorder exists, athletic competition may be pursued without restrictions. In case of contrary findings, physical activity will be limited and the authorized level will be precisely determined according to the context and the results of exertion tests made during treatment.