[Value of systematic biological markers of inflammation for the prognosis at 12 months of patients undergoing programmed coronary angioplasty]

Value of systematic dosage of biological markers of inflammation for the prognosis at 12 months of patients undergoing programmed coronary angioplasty Systematic dosage of proteins of inflammation has been suggested for assessing the prognosis of athero-thrombotic diseases. The authors undertook a study of plasma C-reactive protein (CRP) and interleukin 6 (IL-6) for evaluating the prognosis of patients undergoing programmed coronary angioplasty. A prospective monocentric study of 117 patients (65 +/- 8 years) was divided into a control group of 28 patients undergoing coronary angiography (Group 1) and 89 patients undergoing programmed coronary angioplasty (Group 2). Serum IL-6 and CRP levels were measured before arterial puncture and at H12 and H24 after coronary catheterisation. The follow-up period was 12 months. The angioplasty did not significantly increase CRP and IL-6 concentrations compared with coronary angiography. Twenty patients (Group 2) (22%) suffered a cardiovascular event in the 12 months' follow-up. These patients had significantly higher CRP levels at H0, H12 and H24 after coronary angioplasty than those who had uncomplicated outcomes. This was not observed for IL-6 concentrations because of the wide dispersion of the results obtained. Increased CRP concentrations between H0 and H24 was also a good predictive factor independently of high basal CRP levels potentially due to other causes than atheroma. Coronary angioplasty is associated with increased CRP at H0, H12 and H24. These values are correlated with the risk of future events at 6 and 12 months. This information is easily obtained and should help management of these patients.

Resistance to aspirin in vitro at rest and during exercise in patients with angiographically proven coronary artery disease

BACKGROUND

Acetylsalicylic acid, or aspirin, is widely used in secondary prevention of coronary artery diseases, but the inhibition of platelet aggregation is not uniform in all individuals.

OBJECTIVE

To investigate the prevalence of aspirin resistance at rest and during exercise in coronary artery disease patients.

MATERIALS AND METHODS

Fifty patients with stable coronary artery disease were prospectively studied. All patients received aspirin (75-300 mg/day for >1 month) and no other antiplatelet therapy. Aspirin resistance was studied, at rest and immediately after a stress test, using the standardized platelet function analyzer (PFA-100(R), Dade-Behring). Aspirin resistance was defined as a normal collagen/epinephrine closure time (<186 s).

RESULTS

Ten patients (20%) were aspirin-resistant at rest. Out of the 40 patients who were aspirin-sensitive at rest, 9 (22%) were aspirin-resistant immediately after the exercise stress test. There were no differences in aspirin sensitivity regarding gender, age, diabetes, hypertension, dyslipidemia, platelet count, medical treatment or number of the coronary arteries involved.

CONCLUSIONS

Aspirin resistance is detected, at rest, in 20% of our patients with stable coronary artery disease. Aspirin treatment does not seem to protect against exercise-induced platelet activation in 22% of such patients, despite aspirin sensitivity at rest.

Resistance to aspirin in vitro is associated with increased platelet sensitivity to adenosine diphosphate

BACKGROUND

Platelet activation plays an important role in arterial thrombosis and the widespread use of aspirin has reduced major events by 25% in the secondary prevention of cardiovascular diseases. However, it appears that aspirin antiplatelet effect is not uniform and 8-45% of the population are, in vitro, aspirin resistant, and it is well recognized that platelets can be activated by pathways that are not blocked by aspirin, such as adenosine diphosphate (ADP).

OBJECTIVES

To investigate whether aspirin-resistant patients have a modified sensitivity to ADP-induced platelet activation

MATERIALS AND METHODS

Seventy-two patients were enrolled. Platelet function was measured by the PFA-100(R) analyser; platelet GP IIb-IIIa activation by ADP 10 micro M was assessed by flow cytometry using PAC-1 MoAb.

RESULTS

Using a collagen/epinephrine coated cartridge on the PFA-100(R), the prevalence of aspirin resistance was 29.2% (n=21). For aspirin-resistant patients, the collagen/ADP coated cartridge showed a closure time significantly shorter (p=0.004) compared to the sensitive and control groups. Platelets from aspirin-resistant patients bound PAC-1 significantly more (p=0.03) than the aspirin-sensitive patients and controls when activated with 10 micro M ADP.

CONCLUSIONS

Platelets from aspirin-resistant patients appear to be more sensitive and activable by ADP. This hypersensitivity could provide a possible explanation for the so-called aspirin resistance, and this could justify therapeutic improvement with alternative antiplatelet agents.

[Platelet polymorphism and coronary artery disease]

Several publications over the last ten years have addressed the problem of genetic mutation coding platelet membrane glycoproteins and thrombotic arterial disease. The principal polymorphisms studied are those of glycoproteins GPIIIa, GPIb and the GPIa-IIa complex. The relationships of each of these polymorphisms and myocardial infarction or coronary artery disease are reported and are often subject to controversy. The polymorphism PLA2 of the GPIIIa has been shown to be a risk factor for infarction in young people, especially when associated with cigarette smoking. Its role in triggering myocardial infarction or in the severity of coronary artery disease is not so clear in the general population. Two types of polymorphism concerning the GPIb and that of the GPIa-IIa complex should also predispose to early coronary thrombotic complications. In addition, the study of these platelet polymorphisms gives a better insight into individual sensitivity to platelet antiaggregant therapy.

[Is it necessary to operate quickly in patients with significant left main coronary stenosis?]

Although coronary bypass surgery is performed rapidly in the majority of cases of left main coronary stenosis to prevent cardiovascular complications, there is no reported consensus in the literature about the ideal interval between diagnostic coronary angiography and surgery. The aim of this multicenter study was to make an inventory of the serious vascular cardiovascular events which occurred between coronary angiography and surgery to determine possible predictive factors for complications and thereby identify a high risk subgroup requiring immediate revascularisation. The population comprised 283 patients with significant left main coronary disease, out of a total of 8,205 patients who underwent coronary angiography in the university hospitals of Angers, Brest, Nantes, Poitiers and Rennes. A surgical indication was retained in 216 patients. The choice of the operation date depended on clinical data in the presence of an acute coronary syndrome, patients remaining in the intensive care unit and undergoing revascularisation rapidly. Serious cardiac events (death, myocardial infarction, refractory unstable angina and left ventricular failure) occurring while waiting for surgery were rare, observed in only 6.5% of patients. Recent myocardial infarction and, to a lesser degree, unstable angina and/or left ventricular systolic dysfunction, were predictive of serious cardiac complications before surgery. The severity of the left main coronary disease and the association of right coronary disease did not increase the risk of serious cardiac events in the preoperative period. The low incidence of complications demonstrates that this strategy enables patients to wait for surgery with an acceptable risk without having to operate all patients with left main coronary disease as an emergency.

[Systemic markers of inflammation after coronary angioplasty]

THE RISK OF RESTENOSIS: Coronary angioplasty is an effective treatment of stable and instable coronary disease and its principle limitation, despite technical progress, remains restenosis. In instable angina, the physiopathologic and prognostic role of inflammation proteins is well documented. THE ROLE OF THE C-REACTIVE PROTEIN (CRP): Is a validated risk factor for patients presenting with heart failure, whether instable or stable angina and in the general population. This risk factor is distinct from tobacco abuse, hypercholesterolemia or diabetes. In all the series studied to date, the frequency of restenosis following coronary angioplasty increases when CRP values are high prior to surgery and continue to rise up to the 48th or 72nd hour.

PERSPECTIVES

New therapeutic measures widen the possibilities of mechanical strategies (angioplasty with or without stent) and treatment of inflammatory mechanisms in the atheromatous plaques (statines, brachytherapy or "covered" stents).

[Heart rupture by closed chest trauma]

Cardiac rupture is certainly unrecognised in the context of closed chest trauma. There have been few reports in the literature despite the fact that autopsy series show that it is the second cause of death after serious thoracic injury. The authors report three cases of traumatic rupture of the heart. The clinical presentation, apart from cardiogenic shock, differs according to whether there is an associated rupture of the pericardium. When the pericardium is intact, the diagnosis is suggested by the signs of tamponade: With earlier treatment of trauma by medical teams, this lesion should be diagnosed as soon as possible. Echocardiography has many indications in closed chest trauma. Early surgical intervention is the only treatment of these lesions.

[Cardiogenic shock due to myocardial infarction: surgical revascularization with centrifugal left ventricular assistance. Report of 2 cases treated successfully]

Cardiogenic shock in the acute phase of myocardial infarction still carries a high mortality. In young patients who cannot be revascularised by angioplasty, when medical therapy is failing, some workers recommend an energetic approach, even cardiac transplantation, often with the bridge of mechanical cardiac assistance. This is not possible everywhere, thus preventing possible myocardial salvage and resulting in fairly high mortality. The authors report two cases in which endoluminal revascularisation was not possible and so complete surgical revascularisation with left ventricular assistance was chosen. The two patients survived and one was successfully transplanted electively. This management may be proposed in young patients with multiple occlusions of large coronary arteries in post-infarction cardiogenic shock when medical management is failing despite intra-aortic balloon pumping.

Echocardiographic features of Candidaspecies endocarditis: 12 cases and a review of published reports

OBJECTIVE

To describe the specific echocardiographic features of Candidaspecies endocarditis.

DESIGN

Retrospective review of the case records of patients with confirmed candida endocarditis.

SETTING

Cases referred to three French university centres over an eight year period were studied.

DESIGN

12 patients with confirmedCandida species endocarditis infection were identified. The transthoracic (n = 12) and transoesophageal (n = 12) echocardiographic appearances were compared with the surgical findings (n = 10).

RESULTS

Large dense heterogeneous vegetations were found in 11/12 cases. A hyperechogenic heterogeneous myocardial texture, observed in seven of the 12 patients, was associated with extensive myocardial damage at surgery. While it was possible to diagnose candidal cardiac infection in all patients by transthoracic echocardiography, transoesophageal echocardiography was useful for optimal assessment of the valvar and paravalvar structures.

CONCLUSIONS

In the setting of endocarditis, the detection of myocardial involvement, which is characterised by a heterogeneous myocardial texture, is an argument in favour of Candida species endocarditis and may warrant early surgical intervention.

Echocardiographic features of Candida species endocarditis: 12 cases and a review of published reports

OBJECTIVE

To describe the specific echocardiographic features of Candida species endocarditis.

DESIGN

Retrospective review of the case records of patients with confirmed candida endocarditis.

SETTING

Cases referred to three French university centres over an eight year period were studied.

DESIGN

12 patients with confirmed Candida species endocarditis infection were identified. The transthoracic (n = 12) and transoesophageal (n = 12) echocardiographic appearances were compared with the surgical findings (n = 10).

RESULTS

Large dense heterogeneous vegetations were found in 11/12 cases. A hyperechogenic heterogeneous myocardial texture, observed in seven of the 12 patients, was associated with extensive myocardial damage at surgery. While it was possible to diagnose candidal cardiac infection in all patients by transthoracic echocardiography, transoesophageal echocardiography was useful for optimal assessment of the valvar and paravalvar structures.

CONCLUSIONS

In the setting of endocarditis, the detection of myocardial involvement, which is characterised by a heterogeneous myocardial texture, is an argument in favour of Candida species endocarditis and may warrant early surgical intervention.

Dobutamine stress echocardiography response of asymptomatic patients with diabetes

AIMS

This study investigated the role of dobutamine stress echocardiography for the silent diagnosis of myocardial ischemia in a diabetic population. Results from the stress test were compared between diabetic and nondiabetic groups.

METHODS

Forty-nine diabetics and 63 consecutive nondiabetics underwent dobutamine stress echocardiography between April and December 1999, to check for new regional wall-motion abnormalities. A single operator, using the same echograph with tissue harmonic imaging in each case, performed all the examinations, using the same techniques.

RESULTS

Significant coronary artery disease was detected in 9% of asymptomatic diabetics. Dynamic left ventricular obstruction was observed in 59% of the diabetic population and only 22% in the nondiabetic population. One patient suffered an adverse event (fast atrial fibrillation) during the stress test. Cardiac frequency at the beginning and end of the stress test differed significantly between the two populations.

CONCLUSION

Dobutamine stress echocardiography allows for detection of silent myocardial ischemia. In the diabetic population, we describe, for the first time under dobutamine infusion, a great number of dynamic left ventricular obstructions.

Normal coronary angiogram and dobutamine-induced left ventricular obstruction during stress echocardiography: a higher hemodynamic responsiveness to dobutamine

This study assessed the clinical or echographic factors predisposing to dynamic left ventricular obstruction (LVO) during dobutamine echocardiography (DE) in patients with angina-like chest pain but without coronary artery disease (CAD). DE is an effective technique for the noninvasive diagnosis of underlying CAD. During DE, an LVO is not unusual in ischemic patients.

METHODS

DE (5-40 microg/kg/min) was performed in 52 consecutive patients with angina-like chest pain and normal coronary angiogram. Mean (standard deviation) age was 61 +/- 10 years (27 men, 25 women). Dobutamine-induced LVO was defined as a new intracavitary flow acceleration of at least 3 msec in the left ventricle.

RESULTS

Dynamic LVO was observed during DE in 20 (38%) of the 52 patients and was not related to clinical or baseline echocardiographic parameters. The chronotropic response and the systolic blood pressure during DE were higher in the group with LVO (P < 0.03 and P < 0.05, respectively). Appearance of chest pain during the test was also more frequent when LVO occurred (P < 0.02).

CONCLUSION

Dynamic LVO is common during DE in a population of patients with angina-like chest pain without epicardial CAD and is associated with a higher hemodynamic responsiveness to dobutamine.

[Normal coronary angiography. Survival and functional status at 6 years]

Despite the development of non-invasive diagnostic techniques, the absence of significant coronary stenosis is observed in 10 to 30% of coronary angiographic studies. The authors report the survival and functional status at 6 years of 172 consecutive patients with symptoms of angina without significant angiographic coronary stenosis. The average age was 60.8 years with a sex ratio of 1.1 and chest pain as the indication for coronary angiography in over 90% of cases. The global mortality after an average of 75.6 months follow-up was 11%, lower in women (8.5%) than in men (13.3%) with an annual mortality of 16.3 per thousand. Sudden death was observed in 4 patients and a third of deaths was of cardiac origin. The persistence of symptoms was reported by 58% of patients, mainly atypical chest pain. Despite the result of coronary angiography, nearly half of the patients were followed up annually by a cardiologist, two thirds remained on anti-anginal therapy, 20% were treated by psychotropic agents and hospital admission to the cardiology department was required in 22% of cases during follow-up. None of the patients had myocardial infarction. Survival and myocardial function after normal coronary angiography therefore appear to be good in contrast with the functional status of these patients.

[Comparison of tissue harmonic imaging and standard imaging in echocardiography based on 4 different emission frequencies]

Harmonic imaging is an innovative technique which is now available in most of the echographic equipment currently on the market. The use of echographic contrast agents led to the introduction of this particular technology, which has largely superseded the former method. In everyday medical practice, it seems to provide a better definition of endocardial contours. In this article, the authors have described a prospective study including 32 patients with an average age of 64 years (+/- 5 years). The aim was to compare imaging quality obtained by 2 acquisition frequencies for standard imaging with that procured by harmonic imaging (emission and reception frequency, 2.5 and 3.3 MHz respectively for the former technique; emission and reception frequency, 1.7 and 2.2 MHz respectively for the latter). The overall scores given by 2 different examiners for emission and reception frequency were as follows: 3.28 and 3.15 for 2.5 MHz, 2.84 and 2.56 for 3.3 MHz regarding the standard technique; 2.56 and 3.031 for 1.7 MHz and 2.56 and 2.063 for 2.2 MHz for the harmonic imaging technique. The superior performance of tissue harmonic imaging has been confirmed in the endocardial study of the left ventricular segments and in the analysis of the mitral valve. This study shows that harmonic imaging, a technique which was easy to use in the present study, provides a means of obtaining an average level of ultrasound imaging that facilitates the interpretation of the clinical picture.

[Ultrasonic myocardial characterization. Application of an original method of acoustic quantification to analysis of healthy and hypertrophic interventricular septal myocardium]

Echocardiography does not provide objective tissue characterisation of sonified tissues. A recent advance has been the introduction of the radiofrequency signal. At present, its exploitation remains a research tool. The required material for quantification is still insufficiently robust and discriminative. The indices derived from histograms of grey scales are calculated by the majority of workers for regions of interest manually positioned in the image. This statistical method allows analysis of the average grey level but not of the architecture of the tissue examined. Tissue characterisation is, therefore, only a potential feature of echocardiography. The authors' approach consists in developing software applied to digital signal provided by the echograph and not directly by the transducer, as in the research based on the use of radiofrequency signals. This software allows characterisation of the texture by two statistical methods applied to signal processing: the histograms of the grey scales, the matrix of co-occurrence (assessing the make-up of the different grey scales in the region of interest). This tool of tissue characterisation is presented here in the studies of the interventricular septum in the parasternal long axis view. Two populations, one with healthy myocardium and the other with myocardial hypertrophy, have been studied. These two populations are differentiated in a significant manner by their respective values of parameters of myocardial texture characterisation in early diastole. Despite a number of methodological problems, this study confirms the hopes that it will be possible in the near future to obtain a quantitative "histological" definition of tissues by echocardiography.

[Tissue characterization by study of myocardial response to ultrasound. Review of the literature and perspectives]

Echocardiography is a routine daily cardiological investigation. Recent technological developments suggest that it may become possible to quantify myocardial texture and thereby achieve histological and functional definitions of cardiac diseases. Two approaches are under evaluation: "videodensitometry" uses tools of statistical quantification from the echocardiographic image; more recently, analysis of the radiofrequency signal has been proposed. This is based on direct exploitation of a continuous signal at the transducer head of wide dynamic range containing all the information received by the piezo-electric crystals. These two approaches have given encouraging preliminary results in the recognition of different myocardial hypertrophic reactions, in diabetic cardiac disease and in the identification of myocardial viability. Despite the many remaining problems, the perspectives are promising and a new field of echocardiography should see the light of day.

[Valvular tumor: diagnostic trap. Report of a case of marastic endocarditis]

Marastic endocarditis is a rare clinical condition described in cases of cancer or other severe inflammatory diseases. The authors report the case of a young patient in good general condition, admitted after a cerebro-vascular accident. Investigations showed an isolated mitral valvular mass on transoesophageal echocardiography which, after unsuccessful medical therapy, was operated. It was, in fact, a case of marastic endocarditis, and a pulmonary tumour was discovered one month after surgery. The bronchopulmonary adenocarcinoma had remained infraclinical beforehand. The advances in echocardiographic imaging will probably lead to an increase in such cases of early diagnosed thrombotic non-bacterial endocarditis (ETNB. This case suggests that it is justified to carry out an aetiological investigation of thrombotic non-bacterial endocarditis in all cases of isolated mitral valve masses.

[Myocardial infarction caused by septic embolism during mitral endocarditis]

Embolic infarction is a rare complication of mitral valve endocarditis. The authors present the case of a patient with a linear vegetation of the anterior mitral leaflet measuring over 15 mm and entering the aortic valve orifice at each systole. This valvular infarction was the cause of an extensive anterior wall infarct treated by primary angioplasty because of haemodynamic instability. The outcome at 3 months was very favourable with regards to the mitral valve. However, a large mycotic coronary aneurysm developed at the site of angioplasty and there were sequellae of a large anterior wall infarction.

[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)