The everolimus eluting Synergy MegatronTM drug-eluting stent platform: Early outcomes from the European Synergy MegatronTM Implanters' Registry

BACKGROUND

The Synergy MegatronTM is an everolimus-drug eluting stent that may offer advantages in the treatment of aorto-ostial disease and large proximal vessels.

AIMS

To report the short- to medium-term clinical outcomes from the European Synergy MegatronTM Implanters' Registry.

METHODS

This registry was an investigator-initiated study conducted at 14 European centers. The primary outcome was target lesion failure (TLF), defined as the composite of cardiovascular death, target vessel myocardial infarction (MI), and target lesion revascularisation.

RESULTS

Five hundred seventy-five patients underwent PCI with MegatronTM between 2019 and 2021. Patients were 69 ± 12 years old, 26% had diabetes mellitus, 24% had moderate-severe left ventricular impairment and 59% presented with an acute coronary syndrome. 15% were deemed prohibitively high risk for surgical revascularisation. The target vessel involved the left main stem in 55%, the ostium of the RCA in 13% and was a true bifurcation (Medina 1,1,1) in 50%.  At 1 year, TLF was observed in 40 patients, with 26 (65%) occurring within the first 30 days. The cumulative incidence of TLF was 4.5% at 30 days and 8.6% (95% CI 6.3-11.7) at 1 year. The incidence of stent thrombosis was 0.5% with no late stent thromboses. By multivariate analysis, the strongest independent predictors of TLF were severe left ventricular impairment (HR 3.43, 95% CI: 1.67-6.76, p < 0.001) and a target vessel involving the left main (HR 4.00 95% CI 1.81-10.15 p = 0.001).

CONCLUSIONS

Use of the Synergy MegatronTM everolimus eluting stent in a 'real-world' setting shows favorable outcomes at 30 days and 1 year.

The ability of computed tomography angiography to predict 5-year mortality in the SYNTAX III REVOLUTION trial

BACKGROUND

The feasibility of using coronary computed tomography angiography (CCTA) for long-term prediction of vital prognosis post-revascularization remains unknown.

OBJECTIVES

To compare the prognostic value of the SYNTAX score II 2020 (SS-2020) derived from invasive coronary angiography (ICA) or CCTA in patients with three-vessel disease and/or left main coronary artery disease undergoing percutaneous or surgical revascularization.

METHODS

In the SYNTAX III REVOLUTION trial, the probability of death at five years was retrospectively assessed by calculating the SS-2020 using ICA and CCTA. High- and low-risk patients for mortality were categorized according to the median percentages of predicted mortality based on both modalities. The discriminative abilities of the SS-2020 were assessed using Harrell's C statistic.

RESULTS

The vital status at five years of the 215 patients revascularized percutaneously (64 patients, 29.8%) or surgically (151 patients, 70.2%) was established through national registries. In patients undergoing revascularization, the SS-2020 was possibly helpful in discriminating vital prognosis at 5 years, with similar results seen with ICA and CCTA (C-index with ICA ​= ​0.75, intercept ​= ​-0.19, slope ​= ​0.92 and C-index with CCTA ​= ​0.75, intercept ​= ​-0.22, slope ​= ​0.99). In high- and low-risk patients, Kaplan-Meier estimates showed significant, and almost identical relative differences in observed mortality, irrespective of imaging modality (ICA: 93.8% vs 78.7%, log-lank P ​< ​0.001; CCTA: 93.7% vs 78.5%, log-lank P ​< ​0.001).

CONCLUSIONS

The predictive ability of the SS-2020 for five-year all-cause mortality derived from ICA and CCTA was comparable, and could helpfully discriminate vital prognosis in high- and low-risk patients.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Case report: takotsubo cardiomyopathy after transcatheter aortic valve-in-valve replacement

Background 

Transcatheter aortic valve implantation (TAVI) has become a first-line therapeutic option in patients with severe, symptomatic aortic stenosis at increased surgical risk. Despite its success, the TAVI procedure has been associated with acute life-threatening complications as myocardial infarction secondary to periprocedural coronary occlusion, annular rupture, or vascular injury.

Case summary 

A 79-year-old woman with a dysfunctional bioprosthetic valve following previous surgical valve replacement was hospitalized in our institution to perform a Valve-in-Valve Transcatheter Aortic Valve Replacement (ViV TAVR). Shortly after the implantation of an Evolut R valve (without complication), left ventricle dysfunction with apical akinesia and basal hyperkinesia was identified during bedside transthoracic echocardiography, in spite of a good prosthesis implantation and function. A concomitant Troponin elevation was noted, and the day-after resting electrocardiogram showed a lateral T-wave inversion. Coronary computed tomography angiography showed no coronary stenosis or occlusion, cardiac magnetic resonance imaging showed no necrosis or fibrosis, and no argument for myocarditis. The patient remained asymptomatic during her hospital stay, and the aforementioned anomalies spontaneously regressed after an in-hospital 2-week surveillance. In the presence of these transient anomalies and after ruling out myocardial infarction and myocarditis, post-procedural stress cardiomyopathy (takotsubo) was diagnosed.

Discussion 

Post-TAVR stress-related cardiomyopathy seems to be an extremely rare entity. To our knowledge, this is the first case of a takotsubo cardiomyopathy after ViV TAVR. Though the association between the two seems likely to be causal, no clear physiopathological explanation can be formulated.

Treatment with a dedicated bifurcation sirolimus-eluting cobalt-chromium stent for distal left main coronary artery disease: rationale and design of the POLBOS LM study

AIMS

The aim of this study is to demonstrate the non-inferiority of the BiOSS LIM C sirolimus-eluting cobalt-chromium bifurcation dedicated stent against the XIENCE stent regarding the patient-oriented composite endpoint (POCE) at 12 months among patients with left main coronary artery disease (LMCA).

METHODS AND RESULTS

The POLBOS LM study is a single-arm, prospective, multicentre study enrolling 260 patients (SYNTAX score ≤32) with a pre-specified performance goal based on the results of the EXCEL trial with contemporary percutaneous coronary intervention (PCI) for LMCA disease. Patient enrolment will comply with objective inclusion criteria of diameter stenosis ≥50% in the LMCA based on off-line quantitative coronary angiography (QCA) analysed by an independent core laboratory using dedicated bifurcation QCA software. The BiOSS LIM C is used for the treatment of LMCA disease with the same specific technical classification as for the BiOSS LIM (modified MADS classification) and the stent implantation is optimised by using pre-specified intravascular ultrasound criteria. The primary endpoint is POCE (a composite of all-cause death, stroke, any myocardial infarction, and any revascularisation) at 12 months.

CONCLUSIONS

The POLBOS LM study will indicate the efficacy of the BiOSS LIM C stent with contemporary PCI for distal left main bifurcation lesions in comparison with the XIENCE stent from the recent EXCEL trial, as a performance index.

Outcomes of transfemoral balloon expandable transcatheter aortic valve implantation: Comparison of two subsequent valve generations

BACKGROUND

The SAPIEN 3 (S3) addresses several limitations of the SAPIEN XT (SXT) for the performance of transfemoral (TF-) balloon expandable transcatheter aortic valve implantation (TAVI).

OBJECTIVES

We aimed to determine whether their altered features translate into improved outcomes in a real-world TF-TAVI patient population.

METHODS

Data for 3,314 patients were extracted from the European registries SOURCE-XT and SOURCE-3. Patients were propensity-score (PS) matched (n = 1,169/group).

RESULTS

In the PS matched comparison, device success was higher in the S3 (99.2%) compared to the SXT group (98.2%; p = .04). S3 patients experienced a lower rate of procedural death (0.7 vs. 2.6%; p = .0004), moderate/severe paravalvular leakage (PVL; 1.4 vs. 5.5%; p < .0001), and procedure-related stroke (1.2 vs. 2.4%; p = .04) while higher rates of mean aortic valve gradients ≥20 mmHg, and new permanent pacemaker implantations were seen. At 30 days a lower rate of all-cause mortality was seen (2.1% vs. 4.3%; p = .003), which was preserved after 1 year (10.7% vs. 14.9%; p = .002). A Cox regression predicting 1-year mortality resulted in a hazard ratio of 0.684 in favor of S3 (p = .0026). The same was true of stroke (2.8% vs. 5.7%; p = .0007), and moderate/severe PVL (2.7 vs. 7.3%; p = .0002) at 1 year. The rate of new pacemaker implantations (13.6% vs. 9.5%; p = .001) and NYHA III/IV (12.8 vs. 8.6%; p = .004) was higher with the S3.

CONCLUSIONS

The improved features of the S3 appear to translate into improved survival and reduced rates of adverse complications, with the exception of a higher rate of new pacemaker implantations.

[Management of non-rhythmic complications of TAVI procedures]

Transcatheter aortic valve (TAVI) is the treatment of choice in patients with severe symptomatic aortic stenosis at high surgical risk. Recent data have also shown favorable results in patients considered to have an intermediate operative risk, which broadens the application of this new technology. Despite its success, the TAVI procedure has been associated with life-threatening complications. Advances in preoperative screening and patient selection have reduced the incidence of these complications. When these complications occur, early recognition and rapid management are essential. The purpose of this review is to describe non-rhythmic mechanical complications attributable to TAVI procedures with their predictive factors, how to prevent and manage them.

[Optimization of systolic heart failure treatment by general practitioners after hospital discharge: Are guidelines applied?]

Heart failure is a common and serious disease, with constantly increasing incidence. General practitioners have an essential role in its management.

AIM OF THE STUDY

Describe general practitioner's practice in optimizing heart failure treatment after hospital discharge.

PATIENTS AND METHOD

All patients admitted for heart failure with altered ejection fraction in Nanterre's hospital cardiology department between February 2014 and January 2015 and having a general practitioner were included. Demographic, clinical, biological, ultrasound data and treatments were collected. A questionnaire was submitted to general practitioners two months after discharge.

RESULTS

A total of 82 patients (age 76±12years, left ventricular ejection fraction 36±8%) were included. The target dose of angiotensin-converting-enzyme inhibitors and beta-blockers was reached for 18% of patients during hospitalization. Forty-two general practitioners answered the questionnaire, which concerned 60% of patients (n=49). None of them modified angiotensin-converting-enzyme inhibitors nor beta-blockers. The reasons were the lack of patient consultation (43%), the good tolerance (43%), the absence of habit (24%), and the attribution of this role to the cardiologist (41%). Possible improvements are: more precise hospitalization reports, alternating consultations and educational sessions.

CONCLUSION

Patients with heart failure are under-treated at discharge and general practitioners do not optimize the treatment after hospital discharge. The main axis of improvement is to establish a better defined care pathway.

Characteristics and outcomes of patients ≤ 75 years who underwent transcatheter aortic valve implantation: insights from the SOURCE 3 Registry

BACKGROUND

Current trials and registries of transcatheter valve implantation (TAVI) mostly include patients older than 75 years. Little is known about younger patients who undergo this treatment. We investigated comorbidities among patients < 75 years old who underwent TAVI in the SAPIEN 3™ European post-approval SOURCE 3 Registry, and analysed outcomes at 30 days and 1 year.

METHODS AND RESULTS

Three age groups of patients were analysed for outcomes and characteristics: < 75 (n = 235), 75-80 (n = 391) and ≥ 80 years (n = 1320). Overall, the mean age was 81.6 ± 6.7 years; transfemoral access was used in 87.1% of patients treated with SAPIEN 3 transcatheter heart valves. The mean logistic EuroSCORE increased according to age group (12.6%, 17.3% and 19.7%, respectively, p < 0.001). Younger patients had a higher incidence of comorbidities, particularly those not included in surgical risk score assessment tools, e.g., severe liver disease, previous radiation therapy, and porcelain aorta. Mortality rates were similar between age groups at 30 days (1.7%, 2.0% and 2.3%, respectively, p = 0.79) and 1 year (14.2%, 9.3% and 13.3%, respectively, p = 0.08). However, sudden cardiac death rates were higher in the < 75 years age group compared with the ≥ 85 years age group (20.7% vs. 4.8%, p = 0.010).

CONCLUSIONS

In current TAVI practice, patients younger than 75 years are a minority (12%). Despite younger age and lower surgical risk scores, this cohort was characterized by comorbidities not accounted for by traditional surgical risk scores. More data are needed for this age group to guide the appropriate decision between surgery and TAVI. CLINICALTRIAL.

GOV NUMBER

NCT02698956.

Comparative assessment of "plaque/media" change on three modalities of IVUS immediately after implantation of either everolimus-eluting bioresorbable vascular scaffold or everolimus-eluting metallic stent in Absorb II study

The purpose of the study to assess the comparability of immediate changes in plaque/media volume (PV) on three modalities of intravascular ultrasound (IVUS) after implantation of either bioresorbable vascular scaffold (BVS) or everolimus-eluting metallic stent (EES) in Absorb II Study. The two devices have different device volume and ultrasound backscattering that may interfere with the “plaque/media” assessed by three modalities on IVUS: grayscale, backscattering of radiofrequency and brightness function. In a multicenter randomized controlled trial, 501 patients with stable or unstable angina underwent documentary IVUS pre- and post- implantation. The change in plaque/media volume (PV) was categorized into three groups according to the relative PV change in device segment: PV “increased” >+5% (PVI), PV unchanged ±5% (PVU), and PV decreased <−5% (PVD). The change in PV was re-evaluated three times: after subtraction of theoretical device volume, after analysis of echogenicity based on brightness function. In 449 patients, 483 lesions were analyzed pre- and post-implantation. “PVI” was more frequently observed in BVS (53.8%) than EES group (39.4%), p = 0.006. After subtraction of the theoretical device volume, the frequency of “PVI” decreased in both BVS (36.2%) and EES (32.1%) groups and became comparable (p = 0.581). In addition, the percentage of “PVI” was further reduced in both device groups after correction for either radiofrequency backscattering (BVS 34.4% vs. EES 22.6%) or echogenicity (BVS 25.2% vs. EES 9.7%). PV change in device segment was differently affected by BVS and EES devices implantation due to their differences in device volume and ultrasound backscattering. It implies that the lumen volume was also artifactually affected by the type of device implanted. Comparative IVUS assessment of lumen and plaque/media volume changes following implantation of BVS and EES requires specific methodological adjustment.

Prevalence, clinical characteristics and outcomes of high-risk patients treated for severe aortic stenosis prior to and after transcatheter aortic valve implantation availability

OBJECTIVES

Transcatheter aortic valve implantation (TAVI) has emerged as an effective treatment for high-risk patients with severe aortic stenosis (AS). The aim of our study was to compare the prevalence, characteristics and outcomes of high-risk patients treated prior to and after the availability of TAVI in our high-volume surgical institution.

METHODS

Among 879 consecutive patients treated 2 years before ('pre-TAVI era') and after ('modern era') the availability of TAVI in our institution, 83 patients were at high risk [defined by logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) >20%].

RESULTS

Among all patients treated for severe AS, the prevalence of high-risk patients was higher in the modern era (12.7 vs 4.9%, P < 0.0001). In the modern era, high-risk patients were treated by TAVI in 89% of cases. Despite similar logistic EuroSCORE (34.9 vs 34%, P = 0.96), the clinical characteristics of these patients have evolved: high-risk patients in the modern era were older (85.3 ± 5.9 vs 78.5 ± 6.5 years, P = 0.0005) and presented more frequently with New York Heart Association class III-IV (92.3 vs 61.1%, P = 0.003), while high-risk patients treated by surgical aortic valve replacement in the pre-TAVI era presented more frequently with a critical preoperative status (33.3 vs 7.7%, P = 0.01), lower left ventricular ejection fraction (41 ± 14 vs 49 ± 15%, P = 0.05) and a history of recent myocardial infarction (27.8 vs 6.1%, P = 0.02). The overall 1-year survival was not different for high-risk patients treated in the pre-TAVI era or in the modern era (61 ± 11 vs 68 ± 6%, P = 0.52).

CONCLUSIONS

The availability of TAVI has increased the prevalence of high-risk patients treated for severe AS and changed the clinical features of this kind of patients who were rarely surgically treated before. The 1-year survival was similar between pre-TAVI and modern eras.

Prevalence of coronary artery spasm during dobutamine stress echocardiography

The aim of this study was to assess the prevalence of coronary artery spasm during dobutamine stress echocardiography (DSE). Over a 9-year period (from November 2001 to October 2010) we reviewed all patients (n = 2,224) referred for DSE. Criteria for selection included patients > 18 years old who underwent DSE. We systematically analyzed all electrocardiograms obtained during DSE to detect ST-segment elevation during the examination. All patients with ST-segment elevation underwent coronary angiography. DSE was performed in 2,179 patients. ST-segment elevation was observed in 21 patients, all of whom underwent emergency coronary angiography. In 13 of these 21 patients (62%) significant coronary stenosis was observed: 6 patients with critical coronary stenosis and 7 patients with chronic coronary occlusion. The remaining 8 patients (38% of patients presenting with ST-segment elevation during DSE, 7 men, mean age 67 ± 11 years) had no significant coronary stenosis. Prevalence of coronary artery spasm during DSE was 0.4%. In conclusion, physicians should be aware that, although rare, coronary artery spasm may occur during DSE.

Prevalence and characteristics of left ventricular outflow tract obstruction in Tako-Tsubo syndrome

BACKGROUND AND OBJECTIVE

Tako-Tsubo syndrome is a clinical entity mimicking acute coronary syndrome (ACS). Left ventricular outflow tract (LVOT) obstruction may occur in Tako-Tsubo syndrome. The aim of this study was to determine the prevalence and features of LVOT obstruction in Tako-Tsubo syndrome in a population presenting with ACS.

METHODS

This study included consecutive patients admitted to 2 catheterization laboratories for suspected ACS. All patients underwent echocardiography, coronary arteriography, and left ventricular angiography if no significant coronary lesions were found.

RESULTS

Among 10,366 patients referred for coronary angiography, the study population consisted of 3,909 patients with suspected ACS. Thirty-two patients (mean age 71 +/- 13 years old) presented with Tako-Tsubo syndrome, resulting in a prevalence of 0.8% in our population of ACS and 5% of patients without significant coronary lesions. Eight women (mean age 81 +/- 4 years old, P = .01) exhibited LVOT obstruction, a prevalence of 25% among Tako-Tsubo syndrome cases. All patients with intraventricular pressure gradient had systolic anterior motion of the mitral valve and septal bulge. Prevalence of septal bulge was 100% in patients with Tako-Tsubo syndrome and LVOT obstruction versus 29% in patients without LVOT obstruction (P = .002). Mean degree of mitral regurgitation was 2.1 +/- 0.7 in cases of LVOT obstruction versus 0.9 +/- 0.7 in patients without LVOT (P = .0003) and significantly decreased during follow-up (1 +/- 0.8, P = .002). Recovery of left ventricular ejection fraction was similar in patients with and without LVOT obstruction (P = .58).

CONCLUSIONS

The present study demonstrates that the prevalence of LVOT obstruction in Tako-Tsubo syndrome is high, with specific characteristics as compared with patients without LVOT obstruction. Echocardiography should be systematically performed for all patients presenting with Tako-Tsubo syndrome for the detection of LVOT obstruction.

Tako-Tsubo syndrome after an exercise echocardiography

The Tako-Tsubo syndrome is a clinical entity recently described that associate a chest pain occurring during a stress, an abnormal ECG and/or an increase in the troponin blood level and a transient left ventricular dysfunction with an akinesis involving generally the midsection and the apex of the heart. It has also been reported that left ventricle (LV) dysfunction may involve only the midventricle, although it seems less common. We report the case of a 66 year old woman that developed a stress-induced cardiomyopathy (Tako-Tsubo syndrome) involving the midventricle when performing an exercise echocardiography. To our knowledge, this is the first case reported in such circumstances.

Reliability of echocardiography for hemodynamic assessment of end-stage heart failure

The management of patients with end-stage heart failure is difficult and may require the monitoring of intracardiac pressures. The aim of this prospective study was to assess the reliability of echocardiography in patients with end-stage HF. Twenty consecutive patients presenting with severe left ventricular dysfunction in end-stage heart failure were prospectively studied. All patients underwent right-sided cardiac catheterization and transthoracic echocardiography. Right atrial pressure, estimated using a new echocardiographic parameter, was significantly improved. There was good agreement between systemic and pulmonary vascular resistance, determined by catheterization and echocardiography. All patients with echocardiographic pulmonary vascular resistance<6 Wood units also had invasive pulmonary vascular resistance<6 Wood units. Only echocardiographic mean right atrial pressure was related to the use of saline infusion or bolus infusion of furosemide. All patients requiring intravenous furosemide had pulmonary capillary wedge pressures persistently>or=15 mm Hg despite adequate medication. In conclusion, this study indicates that echocardiography may be a reliable tool for the management of patients with end-stage heart failure.

[Very late intrastent thrombosis--at 27 months!]

Interrupting platelet antiaggregant therapy in coronary patients treated by stenting exposes them to the risk of cardiac complications. The risk of acute thrombosis of the stent is well known but late intrastent thrombosis is less common and mainly observed with drug eluting stents. The authors report the case of a 54 year old man who had thrombosis of an ordinary stent implanted 27 months previously which occurred in the immediate post-operative period after repair of an inguinal hernia. The interruption of platelet antiaggregant therapy was relayed by flurbiprofen in accordance with recommendations of scientific societies. After a review of the literature, the authors discuss late stent thrombosis and interruption of platelet aggregant therapy in coronary patients before non-cardiac surgery.

Prevalence of tako-tsubo syndrome in a large urban agglomeration

Among 4,551 patients referred to the investigators' catheterization laboratory, 1,613 presented with acute coronary syndrome, and 12 had confirmed Tako-Tsubo syndrome (prevalence 0.7%). In conclusion, the present study emphasizes the underestimation of this new heart disease.

Echocardiographic automated cardiac output measurement of pulmonary output and quantification of intracardiac shunt

BACKGROUND

The quantification of intracardiac shunt (ICS) with echocardiographic pulsed-wave Doppler (PWD) method using pulmonary-to-systemic flow ratio (QP/QS ratio) remains difficult and may induce false quantification of pulmonary output. We sought to validate the recent echocardiographic automated cardiac output measurement (ACM) for the calculation of pulmonary output and the quantification of ICS in adults.

METHODS

One hundred and twenty consecutive patients were divided in 1) 40 patients who underwent echocardiographic and invasive explorations (group I) with groups IA (quantification of ICS using ACM, PWD and invasive oximetric methods in 20 patients) and IB (calculation of pulmonary output with ACM, PWD and thermodilution methods in 20 patients); 2) 80 patients underwent calculation of aortic and pulmonary outputs using echocardiographic ACM and PWD methods (group II).

RESULTS

The feasibility of ACM and conventional PWD methods for the calculation of pulmonary output was respectively 93.3% and 90%. Correlations between ACM and invasive pulmonary output were strong (r2=0.92 vs. r2=0.80 for PWD). The best correlation and agreement between invasive and echocardiographic QP/QS ratio were observed with ACM (r=0.96 vs. r=0.82 for PWD). Intracardiac shunts were best-classified with ACM, as compared to PWD (respectively 94% and 72%); sensitivities and specificities for evaluation of significant ICS were 92.3% and 100% with ACM (85% and 40% with PWD).

CONCLUSIONS

This study shows that ACM is a reliable and accurate echocardiographic method for calculating pulmonary output and quantifying ICS in adults and may be routinely performed in clinical practice.

[Marfan syndrome]

Marfan's syndrome is a monogenetic disease with an autosomal dominant transmission generally accompanied by type I fibrillin abnormality. This widely-distributed molecule participates in the structure of connective tissues so that any aberration may result in disease of many systems: skeletal morphology, dislocation of the lens, neurological or cutaneous signs and dilatation of the aorta predisposing to dissection, mitral valve prolapse being a common association. The diagnosis, clinical because of the size of the culprit gene and the multiplicity of the possible mutations, is sometimes difficult, and diagnostic criteria have been proposed. It is important to make the diagnosis because treatment is based on the restriction of violent exercise, betablocker therapy and regular echocardiographic monitoring of the ascending aorta, the region at highest risk of dilatation and dissection. A family enquiry is essential to make the diagnosis before the onset of complications in pauci-symptomatic patients (great intra-familial variability). Pregnancy poses special problems in these patients.

[Isolated and asymptomatic Brugada syndrome. A case report]

The case report of a 32-year-old man with a Brugada syndrome is presented. He was asymptomatic and without familial history of sudden death or syncope. Diagnosis criteria for Brugada syndrome were 1--a pattern of right bundle branch block and ST-segment elevation in leads V1 and V2 on the ECG, 2--no cardiac structural anomalies. Symptomatic patients with this electrical anomaly are at high risk of sudden death and need an automatic implantable defibrillator. The outcome and the treatment of asymptomatic patients are a matter of debate and are discussed in this report.

[Incidence of acute cor pulmonale and deep venous thrombosis in acute pulmonary embolism]

OBJECTIVE

Ultrasounds are a useful tool when looking for indirect evidence in favor of pulmonary embolism. The aim of this study was to determine the incidence of acute cor pulmonale and deep venous thrombosis revealed by ultrasonographic techniques in a population of patients presenting with pulmonary embolism.

METHODS

96 consecutive patients with a mean (+/- SD) age of 65 +/- 15 years, admitted to our hospital for pulmonary embolism were included in this study. The diagnosis of pulmonary embolism was made either by spiral computed tomography or selective pulmonary angiography. Each patient subsequently underwent both trans-thoracic echocardiography and venous ultrasonography. The diagnostic criterion used for defining acute cor pulmonale by echocardiography was the right to left ventricular end-diastolic area ratio over (or equal to) 0.6. Diagnosis of deep venous thrombosis was supported by the visualization of thrombi or vein incompressibility and/or the absence of venous flow or loss of flow variability by venous ultrasonography.

RESULTS

Using ultrasounds, an acute cor pulmonale was found in 63% of our patients while 79% were found to have deep venous thrombosis and 92% of the patients had either acute cor pulmonale or deep venous thrombosis or both. All of the patients with proximal pulmonary embolism had acute cor pulmonale and/or deep venous thrombosis. The presence of acute cor pulmonale on echocardiography was significantly higher in patients with proximal pulmonary embolism (p < 0.0001).

CONCLUSION

This study emphasizes the potential value of ultrasonographic techniques in the diagnosis of acute pulmonary embolism.