[Postoperative hemopericardium compressing the left atrium. Apropos of a case]

We report a case of tamponade due to an effusion of blood which had occurred two weeks after an aorto-coronary bypass and was unusually located behind the left atrium. The effusion, with severe clinical symptoms, was diagnosed by echocardiography and computerized tomography of the chest. These examinations provided an accurate anatomical diagnosis on which the approach route of the emergency operation was based.

[Comparative study of pulsed and continuous Doppler in the quantification of aortic insufficiency]

31 patients whose mean age was 61 +/- 29 yrs. presenting with aortic regurgitation (AR) benefited from cardiac catheterization which was preceded by Doppler ultrasound examination in a prospective study to compare the diagnostic contributions made by continuous vs pulsed wave techniques respectively in the quantitative assessment of AR, with reference to semi-quantitative angiographic evaluation. Pulsed Doppler analysis involves mapping of the left ventricle in two projections as well as the investigation of blood flow in the aortic isthmus using a suprasternal approach. Collection of continuous wave signals from the cardiac apex makes it possible to measure circulatory deceleration and the half-time of decrease in signal velocity and the protodiastolic pressure gradient. Our results corroborate the reliability of data obtained using continuous-wave Doppler technique in finding significant correlations for each parameter respectively: r' = 0.88 (p less than 0.001); r' = -0.81 (p less than 0.001); r' = -0.75 (p less than 0.001). Values determined by pulsed wave Doppler mapping of the left ventricle appear to be less satisfactory but are significant: r' = 0.68 (p less than 0.001) while measurement of end-diastolic blood flow recorded in the isthmus of the aorta is more highly correlated: r' = 0.84 (p less than 0.01), with the main disadvantage being its limited applicability to a small number of our patients (48%). We thus concluded that continuous-wave Doppler ultrasound is a better technique in the quantitative evaluation of AR, while recalling the essential additional value of pulsed-wave Doppler technique to localize the leakage and of ultrasound to assess its impact on the left ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)

[Validation of a method for measuring the area of aortic stenosis using only continuous Doppler. Value for the surveillance of transluminal aortic valvuloplasties]

Forty patients with aortic valve stenosis underwent continuous wave doppler-echocardiographic exploration followed by catheterization within 24 hours on average. Three methods of aortic functional area calculation, based on the continuity equation principle, were tried and compared with the haemodynamic data. The results of the reference equation (continuity through the whole systole) gave a correlation coefficient r = 0.77 with a standard error (SE) of 0.17 cm2. The continuity equation using only maximum velocity values was less satisfactory: r = 0.69; SE = 0.19 cm2. The simplified equation with an arbitrary 2 cm subaortic diameter and a subaortic velocity obtained by continuous wave doppler recording yielded results that were very similar to those of the reference equation: r = 0.78; SE = 0.16 cm2. It is suggested that this third equation should be used in the follow-up of transluminal aortic valvuloplasties, since its calculation is based only on aortic velocity, which reflects the degree of stenosis, and subaortic velocity, which indirectly reflects left ventricular function.

[Diagnostic and prognostic value of continuous Doppler in pulmonary embolism]

A prospective study of 18 patients admitted to hospital for acute pulmonary embolism confirmed the reliability of continuous wave cardiac doppler as a non-invasive method of evaluating systolic pulmonary artery pressures. These pressures were calculated by applying the simplified Bernoulli equation to the maximal velocity of regurgitant tricuspid flow and compared with the results of cardiac catheterisation and angiography, the percentage of vascular obstruction being assessed using Miller's index. The correlations between the two methods were good, r = 0.96; p less than 0.001, with a standard error of +/- 5.2 mmHg. The correlations between the velocity of tricuspid flow and the percentage of obstruction were less significant (r = 0.65; p less than 0.005) but improved when patients with pre-existing cardiopulmonary disease were excluded. This technique of non-invasive assessment of haemodynamic parameters also helps in evaluating the underlying pathology; tricuspid regurgitation with velocities greater than 3.5 m/s is associated with pre-existing chronic cor pulmonale, information of prognostic interest which would guide therapeutic management.

[Role of clinical manifestations, the exercise test and exertion angioscintigraphy in the diagnosis of coronary disease. A multivariate study]

Data of clinical examination, exercise electrocardiography and stress radionuclide angiography in 102 patients referred for assessment of chest pain was included in a logistic regression to optimise the diagnosis of coronary artery disease with coronary angiography as the reference investigation. None of the patients had other cardiac problems nor previous myocardial infarction. In the absence of symptoms exercise testing was continued until at least 80 p. 100 of the theoretical maximal heart rate was attained. Each patient was characterised by the value of the logistic function or probability of coronary artery disease. A threshold value corresponding to 80 p. 100 sensitivity was determined by the technique of ROC graphs. The significant variables were: a clinical variable--the type of chest pain as assessed by the clinical history; two radionuclide angiographic variables--the ejection fraction at peak effort and the corrected variation of ejection fraction between rest and stress, that is not taking into account possible decreases at the last increment of exercise. Coronary patients can be identified with an 80 p. 100 sensitivity and 77 p. 100 specificity on these criteria. This specificity is greater than that obtained by clinical examination and exercise electrocardiography alone (65 p. 100). Stress radionuclide angiography may therefore reduce the number of unnecessary coronary angiographies.

[Floating thrombus of the right atrium in acute pulmonary embolism. Clinical, echocardiographic aspects and therapeutic sequelae]

The performance of a systematic sonocardiography in all our patients hospitalized since January 1985 for pulmonary embolism, has enabled to discover five cases of floating thrombus of the right atrium. Three patients presented an abnormal auscultation, with one of them presenting a tricuspid wedge syndrome. On the sonogram, the aspect of the thrombus, "coil or ball-shaped", floating in the atrial cavity, sometimes prolapsed through the tricuspid valve, associated with the signs of a pulmonary heart, enables to rule out other right intraatrial masses. Pulmonary angiography seems contra-indicated because of the risk of embolus of this thrombus, the migration of which may be fatal. Embolectomy, under extra-corporeal circulation (heart-lung pump) with examination of the right cavities appears to be the treatment of choice.

[Quantification of chronic aortic insufficiency. Comparison between Doppler ultrasonic diagnosis and the radiocardiogram]

The objective of this study is to quantify aortic insufficiency by comparing pulsated Doppler ultrasonography and radiocardiography used as reference test. Since february 1986, 23 patients were tested with both techniques within 15 days. The Doppler ultrasonography enabled to quantify aortic insufficiency in 4 stages by semi-quantitative mapping of the regurgitation flow of the left ventricle (LV). Radiocardiography (RCG) has enabled the determination of the regurgitation fraction (RF), for each patient. A mean RF was calculated on RCG, for each Doppler stage. The FR difference between each Doppler stage is significant, especially between minimal and severe aortic insufficiency. RCG is the first stage of an isotopic examination, at rest and during stress; it may be followed by Doppler ultrasonography in monitoring patients with aortic insufficiency.

[Subvalvular aortic stenosis discovered after surgical repair of an atrioventricular canal in the adult. Apropos of a case]

The case of an adult female patient in whom subaortic stenosis was discovered 9 months after surgical correction of a partial atrioventricular canal is reported. The authors describe the difficulties encountered in the pre-operative diagnosis of this uncommon association and the paraclinical methods now available, notably echocardiography, that may help overcome these difficulties.

Diagnostic value of stress radionuclide angiography in coronary artery disease: a comparison of different interpretation criteria

In order to compare different criteria in the interpretation of stress radionuclide angiography (SRNA) 96 patients with suspected coronary artery disease (CAD) were investigated by both SRNA and coronary arteriography. The result of coronary arteriography was taken as the gold standard for the diagnosis of CAD. Left ventricular ejection fraction (LVEF) was measured at each step of the stress study using the equilibrium radionuclide technique. The diagnostic value of eight interpretation criteria based on the evolution of global LVEF during stress were compared with each other, using the ROC technique. The best diagnostic criterion proved to be the normalized increase of LVEF proposed by Goris. The most commonly used criteria, LVEF increase and LVEF measured at maximal exercise, were not optimal. In the whole population of patients, the best criterion had a sensitivity of 85% for a specificity of 80% and a specificity of 83% for a sensitivity of 80%. In the population, following exclusion of patients with preceding myocardial infarction, the specificity was 74% for a sensitivity of 80% and a sensitivity of 74% for a specificity of 80%. Thus, the choice of interpretation criteria is very important in order to optimize the sensitivity and specificity of this diagnostic test.

[Evaluation of pulmonary systolic arterial pressures by continuous Doppler in tricuspid regurgitation in adults. Apropos of 43 cases]

Forty-three hospital patients with tricuspid regurgitation were prospectively explored by continuous wave Doppler ultrasound to determine their pulmonary systolic arterial pressure. In the absence of pathology of the pulmonary orifice this value corresponds to the sum of the right atrioventricular systolic gradient calculated by Bernoulli's equation DP = 4V2 from the tricuspid regurgitation and the right atrial pressure evaluated by clinical examination. The values obtained are compared with the results of right heart catheterization. Our study showed good correlation (r = 0.90) with a standard error of 8.2 mmHg, the main source of effort being the clinical quantification of right atrial pressure. These results confirm that pulmonary systolic arterial pressure can reliably be measured by this method in the presence of tricuspid regurgitation. The method is of considerable interest in permanent pulmonary hypertension or in emergencies.

[Comparison of the effects of bepridil and diltiazem in Prinzmetal's angina. Crossed, randomized, double-blind study. Apropos of 14 cases]

The efficacy of bepridil was compared with that of diltiazem in treatment of Prinzmetal's angina, in a crossed, randomized double-blind study of 14 observations using repeated Holter recordings (a total of 9 for each patient). Clinical and electrical monitoring showed that the efficacy of bepridil is comparable to that of diltiazem in treatment of spastic angina.

A new method for objective evaluation of cardiac parametric images

A new method for analyzing cardiac parametric images is introduced. Its original feature is the representation of local heart motion in a polar coordinate plane which makes the integration of the information contained in three parametric images possible. These images are calculated using first harmonic Fourier filtering and are the maximum volume image, the local ejection fraction image, and the phase image. The last two parametric images are considered as the complex ejection fraction parametric image which is described by a 2D distribution in the complex plane. This method is a generalized 2D version of the well-known phase histogram method. By segmenting the complex plane in which this representation is made, four indexes are defined called the index of hypokinesia, the index of asynergy, the mean phase shift in asynergic regions, and the mean ejection fraction in asynergic regions. The values of those indexes are used to assess the degree and extent of regional wall motion abnormalities. An automated classification as normal, hypokinetic, akinetic, slightly dyskinetic, and strongly dyskinetic made on the basis of the values of those indexes has been compared with a visual classification made by three observers in 219 studies. ROC curves show a good agreement between the automated and visual methods. This new method provides an efficient means of automatically classifying cardiac studies.

[Study of thesaurismosis induced by perhexiline maleate. Confirmation of experimental data]

Perhexiline maleate is an amphiphilic molecule. Along with many other drugs it is responsible for experimental and, in some instances, clinical lipidoses. Sphingomyelinase deficiency has been evidenced in cell cultures incubated with perhexiline maleate. We describe the occurrence of a similar defect in a patient. The disturbances in the phospholipid turnover which are responsible for the thesaurismosis may originate in the sphingomyelinase deficiency.

[Predictive value of the exercise test for multivessel disease after initial myocardial infarction]

The extent of coronary artery disease after primary myocardial infarction is an important prognostic factor. The predictive value of exercise electrocardiography for multivessel disease was assessed by comparison with coronary angiography in a series of 100 patients. In the group of patients with primary anterior infarction (n = 48), 37.5% had positive exercise ECGs. Coronary angiography showed 62.5% single vessel disease. In multivessel disease, the sensitivity of exercise ECG was 78% and specificity 86%. The predictive value of a positive test was 78% and, for a negative test, 86%. In primary inferior infarction (n = 52), positive exercise ECGs were recorded in 48% of cases. Coronary angiography showed 48% multivessel disease. In multivessel disease, sensitivity of exercise ECG was 92% ans specificity 93%. The predictive value of a positive test was 92% and of a negative test, 93%. Therefore, exercise ECG gives a more precise prediction of the extent of coronary artery disease after primary inferior infarction than after primary anterior infarction. However, it is not an ideal guide for the choice of patient for coronary angiography because of its poor predictive value in cases of anterior infarction, and because of the high incidence of multivessel disease in patients with primary inferior infarcts. Nevertheless, it is of great prognostic value with regards to the eventual course of the coronary disease.

Technique for tricuspid annuloplasty with a flexible linear reducer: medium-term results

The surgical treatment for tricuspid incompetence requires a choice between reconstruction or replacement with a prosthetic valve. The conservative approach offers many advantages in functional tricuspid incompetence. Our technique for annuloplasty utilizes a flexible linear reducer (FLR) to support a selective reduction of the distended portion of the anulus. The insertion of the septal leaflet is always left free, and physiological flexibility of the tricuspid anulus is assured. The repaired valve is sturdy because of the prosthetic support, and inserting the FLR is simple and poses no risk to the His bundle. The medium-term results (mean follow-up 10 months) in 20 consecutive patients (all with a complete postoperative reinvestigation) are satisfactory. Because this procedure is simple and harmless, it frequently can be applied for direct correction of functional tricuspid incompetence during polyvalvular operation.

[Cardiac manifestations of pheochromocytoma. Anatomo-clinical study]

Cardiomyopathy induced by catecholamines, first demonstrated in the animal is also observed in clinical medecine either after infusion by vasopressor drugs or during the course of pheochromocytoma. The clinical presentation is varied and may often deceive: acute coronary insufficiency, arrhythmia, heart failure, and, above all, cardiogemic shock. The authors emphasise the importance of considering the diagnosis of "adrenergic myocarditis" in such situations as well as in cases of pheochromocytoma, for which the only cure is ablation of the tumour.

[Treatment of functional tricuspid insufficiency by a valvuloplasty with a flexible linear reducer]

Valvuloplasty with preservation of the valvular apparatus is the treatment of choice in functional tricuspid incompetence (FTI). A new method of valvuloplasty has been developed using a flexible linear reducer (FLR); its insertion is simple and without risk to the Bundle of His. It is made of sections of elastomere covering a dacron core. The principle of the FLR is reduction of the tricuspid annulus leaving the septal leaflet free. It is a simple method which allows individual variations in the zone reduced (usually involving the anterior and inferior leaflets) and in the size of the reduction at each point. The excellent results at medium term in 20 patients with tricuspid FLR lead us to recommend widening the surgical indications for correction of FTI especially in cases where signs of right ventricular failure have been observed.

[Echocardiographic aspects of the atrio-ventricular canal]

The authors report their experience of echocardiography in cases of atrio-ventricular canal in the light of 9 cases which were studied by time-movement and 2-dimensional echography. In cases if ostium primum, the essential findings are: diastolic juxtaposition of the mitral valve to the left side of the septum, its multiple-echo appearance during systole, and the abnormal movement of the ventricular septum. In cases of complete atrio-ventricular canal, two main types are found. In the first, the echos of the atrio-ventricular valve are confused with those of the interventricular septum during diastole; in diastole, the septum disappears, one valve moves anteriorly into the right ventricle, and the other moves posteriorly into the left ventricle. In the second type, the appearances are those of a single valve which is situated within the left ventricle during systole, and which 'crosses' the interventricular septum to gain the right ventricle during diastole. The interpretation of these findings is difficult. It becomes clearer, however, when it is realised that the plane of incidence of the ultrasonic waves is not perpendicular to the plane of movement of the atrio-ventricular valve. The authors' conculsion is that echocardiography is a method of diagnosings atrio-ventricular canal defects, bud does not allow the anatomical type to be defined.

[Femoral nerve paralysis complicating anticoagulant treatments. A propos of 3 cases]

The authors report 3 new cases of femoral nerve paralysis complicating anticoagulant treatment. The first sign was pain, the neurological signs occurred later and the patient usually recovered but recovery was sometimes incomplete. The pathogenesis is not clear : a muscle hematoma, ischemia of the nerve trunk, and intraneural hemorrhage are the commonest theories.