[Traumatic coronary dissection caused by deceleration. Report of a case]

Myocardial infarction is a rare complication of traumatic thoracic deceleration. The authors report the case of anterior myocardial infarction with dissection of the left anterior descending artery in a 16 year old boy who was injured in a motorbike accident without a penetrating thoracic wound. Therefore, the only pathological mechanism was deceleration. The authors review the 12 previously reported cases.

[Idiopathic aneurysm of the pulmonary artery trunk. Report of a case]

Aneurysms of the aorta are frequent and treatment is well known, correlated with a statistical risk of rupture. Pulmonary artery aneurysms are less frequent. They may occur in connection with other conditions (infection, cardiopathy, notably pulmonary artery hypertension, endovascular trauma) or much more exceptionally regarded as idiopathic. Chest x-ray, CT-scan and digitalized pulmonary angiography and echocardiography give the diagnosis and help evaluate extension and localization. We report the case of a 72-year-old woman who developed idiopathic aneurysm of the left pulmonary artery which was discovered fortuitously. Because of the stability of the lesion and the lack of any worsening factor, we decided not to operate this high-risk patient. After 3 years, no complication has been observed and the CT-scan shows no evolution. In case of proximal idiopathic aneurysm of the pulmonary artery, the indication of surgery should be discussed.

[Coronary angiography in octogenarians. Therapeutic impact and medium-term follow-up]

In the face of the general aging of the population and technical improvements, cardiologists are more commonly faced with the decision of whether to perform coronary angiography in octogenarians who are often in good general health. The morbidity and mortality of this investigation, its therapeutic impact and medium-term survival were analysed in 145 consecutive octogenarians who underwent coronary angiography between 1988 and 1996. In this study, coronary angiography was performed essentially for angina refractory to medical treatment and confirmed the severity of the lesions with stenosis of the left main stem in 7.6% of cases and multiple vessel disease in 67.5% of cases. The mortality related to the investigation was nil in this series. Revascularisation was feasible clinically and angiographically in 38% of cases (84% by angioplasty). The actuarial survival at 3 years was 65% in the group who underwent revascularisation and in the group treated medically.

[Candida albicans myocarditis or endocarditis? Echocardiographic aspects]

The authors report the case of a patient presenting with atypical features of Candida albicans cardiac infection, with unusual infectious destructive lesions. While the initial hypothesis was that of aortic endocarditis, the clinical course and operative findings showed echocardiographic features of septal micro-abscesses adjacent to the aortic orifice, which was devoid of any infectious lesions.

[3-dimensional reconstruction technic using power Doppler. In vitro use on normal and stenosed pulmonary artery bifurcations]

Power Doppler imaging is an ultrasonic technique representing circulating red cells as a colour signal independent of their direction and angle of analysis. This noninvasive technique provides a morphological representation of blood flow within a blood vessel. This in vitro study in pulsed flow enabled three-dimensional reconstruction of blood flow in the bifurcation of the pulmonary artery with automatic shifting of the ultrasound probe and an integral digital transfer of the echographic data. The software for treating the images and for volumic reconstruction of the flow is explained. This technique provides a quantitative method of assessing residual intrastenotic flow with a simple computer system.

[Physiopathology of myocardial infarction: the acute coronary occlusion]

Rupture of the atheromatous plaque, thrombosis and local vasoconstriction are involved in the genesis of acute myocardial infarction. The vulnerability of the plaque depends on its histological structure. Its fragility is related to the size of the lipid core, the thinness of the fibrous capsule and the inflammatory reaction. External aggression favourites rupture. This triggers both thrombogenesis by bringing the blood cells into contact with thrombogenic subendothelial factors and local vasoconstriction due to endothelial dysfunction. Although rupture of the plaque is an unpredictable event, there is a circadian variability the highest incidence of infarction being between 6 a.m. and midday. Comprehension of the physiopathology of myocardial infarction has opened up new therapeutic approaches which should reduce the incidence of plaque rupture. Prevention is based on stabilisation of the plaque by dietary hygiene, lipid-lowering drugs and, maybe, in the future, by local application of antisense oligonucleotides. Finally, anti-aggregant therapy (aspirin or anti-GIIb-IIIa) could prevent the formation or extension of the thrombus.

[Myocardial infarction by complete thrombosis of the left main coronary artery: emergency treatment with angioplasty with implantation of a coronary stent and follow-up at one year: a case report]

Acute occlusion of the left main coronary artery is usually responsible for cardiogenic shock, severe arrhythmias or sudden death. Despite the widespread use of emergency coronary angiography in acute myocardial infarction, occlusion of the left main coronary artery is rarely observed and its treatment remains controversial. The authors report the case of a young man with a previous history of radiotherapy for Hodgkin's disease, admitted for acute myocardial infarction due to complete thrombosis of the left main coronary artery treated as an emergency by percutaneous transluminal angioplasty and implantation of a Palmaz Schatz stent. There were no complications of the procedure and the patient was asymptomatic one year later.

[Cardiac lymphoma disclosed by tamponade and complete atrioventricular block: apropos of a surgically treated case. Heart and lymphoma]

Cardiac lymphoma is becoming increasingly frequent, especially in the context of acquired immune deficiency syndrome, and due to progress in imaging, particularly echocardiography. The authors report the case of a 49-year-old patient in whom the diagnosis of cardiac lymphoma was established in the presence of complete atrioventricular block, tamponade and right atrial tumour. The authors review the various electrocardiographic and echocardiographic features of cardiac lymphoma.

[Reproducibility of measurements of blood gas exchange during exercise in mild cardiac failure: need for a preliminary test?]

The reproducibility of blood gas exchange measurements on exercise in chronic cardiac failure has already been established in patients familiar with this technique. The aim of this prospective study was to evaluate the reproducibility of cardiopulmonary parameters on exercise in a population of patients who had never undergone this type of investigation. Twenty patients with chronic cardiac failure in classes I to III of the NYHA classification, with a mean age of 55 +/- 11.5 years and a mean LV ejection fraction of 31.2 +/- 9%, underwent two cardiopulmonary exercise tests (CPX Medgraphic) performed on a bicycle ergometer. Patients underwent maximal exercise stress testing attaining 89% of the theoretical maximal heart rate and 1.14 of the respiratory quotient during the first test. There was no significant change in peak VO2 (22.5 ml/min/kg vs 22.6 ml/min/kg) or in ventilatory anaerobic threshold (12.8 ml/min/kg vs 12.7 ml/min/kg) between the two tests. The ventilatory anaerobic threshold could not be measured in one patient and seemed less reproducible than peak VO2 with a standard deviation of relative differences (T2-T1/T1) of 10.4 versus 7.8%. There was a significant increase in the duration of exercise (7.4 +/- 9.2%; p < 0.002) and a ventilatory flow (4.5 +/-, p = 0.03). This study shows that peak VO2 is a reproducible measurement in mild to moderate chronic cardiac failure, even in the absence of a preliminary test to familiarize the patient with the equipment. The reproducibility of the ventricular anaerobic threshold is less satisfactory than that of peak VO2. The increase in the duration of exercise is more dependent on motivation and should not be taken into account alone in the functional evaluation of chronic cardiac failure.

Thrombus in a normal sinus of Valsalva: angiographic, multiplane transoesophageal echocardiographic, and surgical findings

A large intraluminal thrombus within an otherwise normal sinus of Valsalva was diagnosed in a 41 year old man who was investigated for myocardial infarction. The thrombus was suspected by aortic root injection, confirmed by transoesophageal echocardiography, and treated surgically.

[Isolated left superior vena cava: value of intraoperative echocardiography for implantation of a cardiac pacemaker]

The authors report the case of a patient presenting with isolated left superior vena cava, for which intracardiac implantation of a cardiac pacemaker was facilitated by intraoperative transthoracic ultrasonographic detection of the course of the ventricular catheter. Transoesophageal ultrasonography confirmed the diagnosis and eliminated a possible associated malformation.

[Mammary bypass dysfunction caused by proximal stenosis of the homolateral subclavian artery: treatment by percutaneous angioplasty. Apropos of a case]

Proper function of a coronary bypass using the internal mammary artery obviously depends upon the quality of the mammary artery used and of the distal coronary system, but also the absence of any significant stenosis of the first centimetres of the homolateral subclavian artery. The authors report the case of a patient in whom angina was destabilized by dysfunction of a bypass between the left internal mammary artery and the left anterior descending coronary artery. This mammary bypass dysfunction was related not to stenosis of the bypass but to stenosis of the proximal part of the left subclavian artery. Angioplasty of this stenosis led to disappearance of anterior myocardial circulatory impairment and of angina attacks.

Lack of effects of trimetazidine on systemic hemodynamics in patients with coronary artery disease: a placebo-controlled study

Trimetazidine has been shown to improve anginal symptoms and exercise tolerance in patients with coronary artery disease (CAD). To determine the hemodynamic effects of trimetazidine, systemic hemodynamics were studied in 15 patients suffering from CAD (12 male, 3 female, mean age +/- SEM = 58.6 +/- 1.8 years). Cardiac index was determined by thermodilution method. Left ventricular and aortic pressures were measured using micromanometers (Miller Instruments). After basal measurements, patients were randomly given either placebo (n = 5) or one of two therapeutic doses of trimetazidine 1 mg.kg-1 (n = 5) or trimetazidine 1.5 mg.kg-1 (n = 5) in a double-blind procedure. Data were recorded 5, 10 and 20 min after intravenous drug bolus. Throughout the procedure, the evolution of systemic hemodynamic parameters was not statistically different between the three groups, in particular heart rate, cardiac index, systolic, diastolic and mean aortic pressures, end-diastolic ventricular pressure, mean capillary wedge pressure, pulmonary artery pressures or systemic vascular resistances. We conclude that, unlike other antianginal drugs (particularly beta-blockers, nitrates and calcium-channel inhibitors), trimetazidine does not modify systemic hemodynamics in patients with CAD. These results are consistent with a direct effect of trimetazidine on the ischemic myocardial cell previously reported.

Nomogram for Doppler echocardiographic assessment of mitral stenosis in atrial fibrillation

Non-invasive assessment of the stenotic mitral valve area is often difficult when the mitral stenosis is associated with atrial fibrillation. In this study, 16 patients with mitral stenosis and atrial fibrillation were evaluated by transthoracic Doppler echocardiography. The mitral valve area calculated by the pressure half-time method was 1.65 +/- 0.73 cm2. The enddiastolic mitral gradient was obtained from the enddiastolic forward mitral flow velocity by application of the simplified Bernoulli equation. For each patient there was a linear relationship between the enddiastolic mitral gradient and the corresponding RR interval. The slope and intercept of this relationship were significantly correlated with the mitral valve area. From the regression equations describing these correlations we established a nomogram ascertaining mitral valve area from enddiastolic mitral gradient and corresponding heart rate. This nomogram was helpful in the non-invasive assessment of stenotic mitral valve area in the presence of atrial fibrillation.

Perforated aneurysm of the anterior mitral leaflet: late assessment with transesophageal echocardiography

We present a case study of a 54-year-old patient with a perforated aneurysm of the anterior mitral valve leaflet, diagnosed 13 years after an episode of bacterial endocarditis by transesophageal echocardiography. This report illustrates the superiority of transesophageal echocardiography in the diagnosis and management of valvular endocarditis.

[Doppler echographic evaluation of mitral valve stenosis with atrial fibrillation. Construction of a nomogram]

Doppler echocardiographic evaluation of mitral stenosis is often difficult in patients with atrial fibrillation. Sixteen patients were examined by transthoracic Doppler echocardiography and the relation between the variations in transmitral end diastolic pressure gradient and the length of the corresponding cardiac cycles was analysed. Mitral valve surface area (1.65 +/- 0.73 cm2) was determined by the pressure half-time method. The end diastolic transmitral pressure gradient was calculated from the simplified Bernouilli formula applied to end diastolic mitral flow velocity. In each patient, a linear relationship was observed between the end diastolic mitral gradient and the corresponding RR interval. The slope and intercept of the graph correlated significantly to mitral valve surface area (r = 0.72, p < 0.002 and r = 0.93, p < 0.00001, respectively). Using regression equations describing these correlations, it has been possible to construct a nomogramme indicating mitral valve surface area as a function of mitral end diastolic pressure gradient and the duration of the corresponding RR cycle. This nomogramme facilitates Doppler evaluation of mitral stenosis in atrial fibrillation.

[Enoximone in the hemodynamic evaluation before heart transplantation. A new test]

A better selection of patients referred for cardiac transplantation should lead to better surgical results. The presence of severe and irreversible pulmonary hypertension is an important factor and its pretransplantation assessment requires pharmacodynamic testing with vasodilators and dobutamine. The aim of this study of 10 patients in congestive cardiac failure referred for cardiac transplantation was to evaluate enoximone in this indication by comparing it with sodium nitroprussiate (3 micrograms/kg/mn). Intravenous enoximone (total dose of 1.5 mg/kg) increased the cardiac index (+49%; p less than 0.01), slightly reduced the mean systemic blood pressure (-8%; p less than 0.05) whilst inducing a greater reduction in systemic arterial resistances (-36%; p less than 0.01); the fall in mean blood pressure was less than with sodium nitroprussiate (-23%; p less than 0.01). Myocardial oxygen consumption (rate-pressure product) did not increase in contrast to the effect of dobutamine (+21%; p less than 0.01). There was a significant reduction in pulmonary arteriolar resistances (p less than 0.01) with all three drugs but the interpretation of this response and its prognostic significance in patients with a low cardiac output and persistent pulmonary hypertension are discutable even when pulmonary arteriolar resistances are less than 6 Wood units. The value of using an inotropic agent such as Dobutamine or Enoximone is to unmask fixed pulmonary hypertension which may be missed in patients with low cardiac output even with vasodilator drugs, and also to mimic the haemodynamic result of transplantation. In this indication Enoximone may be used like Dobutamine but with the advantage of not increasing myocardial oxygen consumption and being probably less arrhythmogenic.

[Contribution of two-dimensional echocardiography to the diagnosis of abnormalities of the left coronary artery originating in the trunk of the pulmonary artery]

The abnormal origin of the left coronary artery from the trunk of the pulmonary artery is rarely encountered, difficult to diagnose and has a severe prognosis because of the major risk of sudden death. The authors report the case of a 63 year-old male patient, presenting this anomaly which creates a true left-to-right shunt with myocardial ischemia secondary to the steal of coronary blood toward the pulmonary artery. The diagnosis is evoked by bidimensional cardiac sonography, pulsated and color Doppler, which permit to confirm the left-to-right shunt while this is confirmed by coronary angiography. The treatment is essentially surgical.

[Value of echocardiography in the diagnosis of a complicated form of Kawasaki's disease]

Kawasaki disease affects children under 4 years of age and is characterized by fever, mucocutaneous rash and cervical lymph node enlargement. It is often complicated by coronary vasculitis and/or pericarditis, myocarditis and endocarditis. Echocardiography is indispensable to diagnose and follow up these complications. A study of the literature and of 4 personal patients showed that it is also useful for the early detection of coronary aneurysm and simple dilatation of the coronary arteries. The sensitivity and specificity of echocardiography in recognizing these complications are such that coronary angiography is exceptionally required. In the search for a cause of prolonged fever in children, the sensitivity of echocardiography makes it possible to diagnose an atypical form of Kawasaki disease.

[Rhythm complications of radiotherapy. Apropos of a case]

We are reporting a case of complete atrio-ventricular block following radiotherapy; this diagnosis was made after ruling out other etiologies. In relation with this case, we are discussing the different rhythm complications of radiotherapy. Therefore, we are presenting tissue involvements, revealed either by minimal electrocardiographic alterations, or by rhythm or conduction disorders, insisting on atrio-ventricular blocks. Finally, we are insisting on a recent disease, cardiac pacemaker dysfunctions, induced by radiotherapy, from in vitro studies and clinical cases.

[Development at 5 years of chronic branchial blocks in 164 patients fitted with pacemakers without documented spontaneous atrioventricular block. Study of predictive criteria]

When no complete atrioventricular block (CAVB), paroxysmal and spontaneous, is recorded, implanting a pacemaker in patients with chronic bundle branch block (CBB) has an arbitrary aspect which must be reduced as much as possible. In order to determine more precisely the criteria predicting an evolution towards CAVB, we studied the electrocardiographic changes observed in 164 patients with various types of CBB. 110 patients had a right bundle branch block which was isolated (RBB) in 16 cases, associated with a left anterior hemiblock (RBB + LAH) in 74 cases and associated with a left posterior hemiblock (RBB + LPH) in 20 cases; 54 patients had a left bundle branch block with a normal axis in 26 cases (LBB - NA) and with a strongly left axis in 28 cases (LBB - LA). All patients had been fitted with a pacemaker. Patients were followed up for a mean period of 5 years (59.1 +/- 25.3 months), the minimum being 2 years. 49.4 p. 100 of them had experienced one ore serveral syncopes. The basal HV interval, studied in 90.2 p. 100 of the patients, was 60 ms or more in 64.9 p. 100 of those who were explored. An ajmaline test, performed in 60 of the 85 patients whose basal HV was less than 70 ms, demonstrated at least a 100 ms or more prolongation of HV in 41 cases (68.3 p. 100).(ABSTRACT TRUNCATED AT 250 WORDS)