Pregnancy in women with bicuspid aortic valve

Background

Aortic dissection during pregnancy is uncommon, however, the risk of aortic dissection is increased if there is underlying aortopathy. Bicuspid aortic valve (BAV) is common in the general population and is associated with the presence of an aortic aneurysm, but this condition is mostly asymptomatic and ignored in women of childbearing age. Data on pregnancy in patients with BAV are scarce, and guidelines on this topic are based on the consensus opinion of experts. The risk of occurrence of aortic dissection as a function of aortic diameter during pregnancy remains poorly known in women with BAV.

Purpose

To investigate demographic and echocardiographic characteristics and aortic events associated with pregnancy in women with BAV and to estimate ascending aortic diameter at the time of pregnancy.

Methods

We performed a retrospective study using data from our tertiary centre. All women seen at our centre between 1996 and 2020 with BAV, at least 1 pregnancy, and no genetic syndrome were included. We have collected data from echocardiograms performed in and out of our centre and aortic events.

Assuming from the literature an annual aortic dilation rate of 0.2 mm at the sinus of Valsalva and 0.4 mm at the tubular ascending aorta, we estimated ascending aortic size and Z-score at the time of pregnancy.

Results

We identified 47 women with BAV with occurrence of 103 pregnancies. The median age of BAV diagnosis was 43 years. The aorta was measured at a median of 13.3 years since the last delivery. At BAV diagnosis, the median largest ascending aortic diameter was 44mm, and the median Z-score was +4.3. Ascending aortic diameter was ≥40mm in 37/47 (79%) and Z-score ≥2 in 44/47 (94%).

No aortic dissection was observed during pregnancy and postpartum in all 103 pregnancies.

At the time of pregnancy, the estimated median diameter of the ascending aorta was 37mm and the estimated median Z-score was +3.3. The largest aortic diameter during pregnancy was estimated to be ≥40mm in 36/103 pregnancies, ≥45mm in 13/103, and ≥50mm in 1/103; Z-score was estimated to be ≥2 in 81/103 and ≥4 in 40/103.

Type A aortic dissection occurred in 1 woman, 13 years after pregnancy, and type B aortic dissection in 1 woman, 14 years after pregnancy. Planned surgery was performed in 8 women at a median of 17.5 years after the last pregnancy: 1 isolated aortic valve replacement and 7 prophylactic aortic surgeries associated with aortic valve surgery.

Conclusions

In our population of women with BAV, pregnancy is not associated with the occurrence of aortic dissection even though, when estimating aortic diameter at the time of pregnancy, the rate of aortic dilation was high (Z-score ≥2 in 81/103 pregnancies). Prospective studies of a large population of women with BAV are needed to assess the risk of aortic complication during pregnancy according to aortic diameter.

Funding Acknowledgement

Type of funding sources: None.

Electrocardiographic and echocardiographic abnormalities associated with mitral valve prolapse in patients with Marfan syndrome

Introduction

Marfan syndrome (MFS) is responsible for cardiovascular disorders such as aortic aneurism and mitral valve prolapse (MVP).

A malignant MVP phenotype combining clinical, electrical and morphological features has been described in symptomatic patients who have experienced sudden cardiac death or complex ventricular arrhythmias.

We have taken advantage of the high prevalence of MVP in MFS patient to study the clinical, electrical and echocardiographic abnormalities associated with MVP.

Purpose

The aim of this study is to describe the clinical, electrical and morphological cardiac abnormalities associated with MVP in a cohort of MFS patients with FBN1 mutations with a high prevalence of MVP and who did not suffer from severe ventricular arrhythmias.

Methods

All consecutive patients coming to the National Reference Center for Marfan syndrome were evaluated prospectively i.e. clinical examination, 12-lead electrocardiogram, standard transthoracic echocardiography study and molecular genetic screening.

Results

352 consecutive patients were included from April 2015 to October 2016 [250 FBN1 mutation carriers (MFS) and 102 healthy relatives (HR)]. None of the patients had a history of sudden cardiac death or complex ventricular arrhythmia.

MFS vs HR: MFS patients were younger (33 vs 41yo p<0.001) and 2/3 were women in both groups. In the MFS group, abnormal T waves repolarization in lateral leads were more common [172 MFS (70.2%) vs. 87 HR (86.14%) p<0,0012], as was MVP [38.37% vs 1.96%; p<0,0001], and diastolic hypertrophy of the basal segment of the inferolateral wall (thickness >11mm) [22.31% vs. 9.18%; p<0.0001].

In MFS, MVP affected either one valve (21.22%), or both (17.14%), and was not associated with electric abnormalities. However, diastolic basal inferolateral wall hypertrophy was associated with mitral valve prolapse (p<0,0001), QTc interval prolongation (p<0.0229), abnormal T waves repolarization in the inferior leads (p=0.004), and higher aortic Z-Score (p=0.274).

Conclusion

In MFS patients, the prevalence of MVP is high and no significant association between MVP and electrical abnormalities was found. In contrast, basal inferolateral wall hypertrophy is associated with MVP and repolarization disorders in inferior leads and QTc interval prolongation, i.e, electrocardiographic abnormalities described in malignant MVP.

QTc and basal inferolateral hypertrophy

Funding Acknowledgement

Type of funding source: None

Ear Workshop on Education in Radiology in Europe, Held in Berlin/GDR on

The workshop on Education in Radiology in Europe was held in Berlin on October 21st 1988, organized by the Commission of Education of the European Association of Radiology (EAR).

Thirty-three representatives from 20 countries took part in this workshop, as well as 23 GDR university teachers and one radiologist from China as guests.

This workshop was preceded by an inquiry among all EAR member countries on the following subjects, and the results of this inquiry were included in the report and the discussion.

Outcomes of renal transplantation in obese recipients

PURPOSE

Although obesity has been shown to paradoxically increase dialysis patient survival, its impact has not been clearly defined on renal transplantation. We assessed outcomes of obesity renal transplant patients by evaluating graft and patient survivals.

PATIENTS AND METHODS

A single-institution, retrospective study was performed on 202 renal transplant recipients from January 2004 to December 2008 excluding two combined kidney and liver transplantations. Recipients were classified based on body mass index (BMI) at the time of transplantation: obese (BMI ≥ 30 kg/m(2)) and nonobese recipients (BMI < 30 kg/m(2)). The comparative analysis included surgical complications, hospital stay, onset of delayed graft function (DGF), acute rejection episodes and graft patient survivals.

RESULTS

Twenty-one renal transplants were performed in obese recipients versus 179 in the control group. Obese patients were older (53.3 ± 11.2 versus 46.4 ± 14.4 years old; P = .035) and more often diabetic (29% ± 0.46 versus 60% ± 0.24, P = .001), but there were no differences among other combidities of high blood pressure, arteriopathy, thrombophilia, and smoking. Obesity did not appear to be a risk factor for urinary or vascular as well as parietal complications, but did tend to augment lymphatic complications (14.3% ± 0.36 versus 4.5% ± 0.21; P = .065). DGF occurred more frequently in obese patients (38% ± 0.50 versus 14% ± 0.34; P = .004) and hospital stays were therefore longer in this group (24.9 ± 23.53 days versus 15.6 ± 13.67 days; P = .008). Graft (hazard ratio [HR] 1.22; 95% confidence interval [CI] [0.25-6.0], P = .63) and patient survivals (HR:0,81; 95% CI [0.12- 5.3], P = .83) were comparable between the groups.

CONCLUSION

Obese patients seeking renal transplantation are usually older and more often diabetic compared with nonobese recipients. The higher rate of lymphatic complications and DGF lead to longer hospital stays among the group with BMI ≥ 30 kg/m(2). However, long-term results showed similar graft and patient survivals as nonobese patients. Consequently, there seemed to be no reason to avoid renal transplantation in obese recipients.

[Accuracy of prostate biopsies to evaluate tumor location in prostate cancer]

INTRODUCTION

The therapeutic approach of prostate cancer depends mainly on pathological criteria obtained through prostate biopsy. The low accuracy of prostate biopsy for Gleason grade determination is well known but its accuracy for bilateral or multifocal tumor has not been evaluated. The goal of this study was to assess the concordance between prostate biopsy and whole prostate specimen obtained after radical prostatectomy especially for bilateral and/or multifocal tumor.

METHODS

We retrospectively compared the pathological results of prostate biopsy cores to the prostate specimen in patients who underwent radical prostatectomy in our department between the 01/01/1999 and the 31/12/2008. The criteria analyzed were the Gleason score, tumor bilaterality or multifocality. The impact of the number of prostate biopsy cores was also analyzed.

RESULTS

Two hundred and five complete histological records were studied. Regarding the Gleason score overall concordance was 55%. In 38%, prostate biopsies downgraded the Gleason score. This concordance decreased with tumor differentiation (90.6% for Gleason 6 vs. 31% for Gleason greater than 7). For the tumor bilaterality, 78% of cancers affected both lobes at the definitive specimen analysis while only 49% were bilateral at prostate biopsies, achieving a concordance of 61%. Multifocal disease was observed in 36% at definitive pathology analysis with low concordance with prostate biopsies (36%). The number of biopsies increased the concordance for the Gleason score (60 to 81% for Gleason 7 and from 28 to 50% for Gleason greater than 7) and tumor location (44 to 70%).

CONCLUSION

Pathological criteria and tumor mapping obtained from prostate biopsies were not very reliable especially when the tumor was poorly differentiated. An increased number of prostate biopsy core improved the sensitivity and specificity for the Gleason score diagnostic and of the tumor mapping.

[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.

Decreased glycolytic metabolism contributes to but is not the inducer of apoptosis following IL-3-starvation

IL-3 regulates the glycolytic pathway. In Baf-3 cells IL-3 starvation leads to a decrease in glucose uptake and in lactate production. To determine if there is a link between the decreased metabolism induced by growth factor-starvation and the induction of cell death, we have compared the cell death characteristics and the metabolic modifications induced by IL-3-deprivation or glucose-deprivation in Baf-3 cells. We show that in both conditions cells die by an apoptotic process which involves the activation of similar Caspases. Different metabolic parameters (i.e. intracellular ATP levels and lactate accumulation in the culture medium) were measured. We show that IL-3 deprivation leads to a partial decrease in lactate production in contrast to glucose deprivation that completely inhibits lactate production. Similarly following IL-3-starvation a significant drop in the intracellular ATP levels in live cells is observed only after 16 h when a large fraction, more than 50 per cent of cells, is already apoptotic. On the contrary, glucose deprivation is followed by an abrupt decrease in ATP levels in the first 2 h of treatment. However, in the presence of IL-3, cells are able to survive for an extended time in these conditions since 70% of cells survived with low ATP levels for up to 16 h. This was not due to partial inhibition of the apoptotic process by the low level of ATP as glucose-deprivation in the absence of IL-3 led to faster death kinetics of Baf-3 cells compared with IL-3 starvation only. These results indicate that the drop in ATP levels and the triggering of apoptosis can be dissociated in time and that when the glycolytic pathway is strongly inhibited, cells are able to survive with relatively low ATP levels if IL-3 is present. Finally we show that induction of bcl-x by IL-3 protects cells from glucose-deprivation induced cell death.

[Dystrophic aortic insufficiency]

Dystrophic aortic regurgitation is the result of 2 diseases: (1) aortic regurgitation, consequence of (2) aortic dilatation due to decreased aortic wall resistance. Marfan syndrome, which is a genetic disease, should be looked for systematically, with the help of an ophthalmologist and a rheumatologist. Aortic dilation is responsible for the increased mortality because of aortic dissection. Diagnosis is often made when the aorta is dilated wheras the aortic regurgitation is minimal or moderate; when the patient is asymptomatic. This has 2 consequences: siblings of Marfan patient should be examined by echocardiography; surgical replacement of the ascending aorta is often performed because of the aortic dilation, not because of the aortic regurgitation.

[Aortic dissection at 6 months gestation in a women with Marfan's syndrome. Simultaneous Bentall intervention and cesarean section]

A 31 year old woman with Marfan's syndrome had a dilatation of the aortic root (55-60 mm at the beginning of pregnancy). Pregnancy was continued with beta-blocker therapy and with regular echocardiographic follow-up. The aortic dilatation increased (62-65 mm) at the last control and, at the 34th week of pregnancy, the patient suffered a dissection of the ascending aorta. A caesarean section was performed with a Bentall procedure during the same operative session. The mother and baby girl are well two years later. The problems of pregnancy in patients with Marfan's syndrome are discussed.

Oral enoximone as a substitute for intravenous catecholamine support in end-stage congestive heart failure

We performed a double-blind, placebo-controlled study to determine whether oral enoximone would aid weaning dobutamine-dependent patients. Twenty-four patients 64 +/- 10 years, with an echocardiographic ejection fraction of 0.20 +/- 0.06, and receiving maximal therapy were studied. After failure of dobutamine weaning, a dobutamine infusion was set up at 10 micrograms.kg-1.min-1 for 48 h. Oral enoximone (100 mg t.i.d.) or placebo was added from D0 for the next 28 days, while the dobutamine dosage was progressively decreased after D4 and eventually stopped at D7. The patients were then followed-up for 21 days (i.e. until enoximone administration had continued for 28 days). In the placebo group, two patients suffered a relapse of congestive heart failure (CHF) before D4, six patients withdrew during dobutamine tapering (five with a relapse of CHF and one with septic shock) and two during follow-up (one with a relapse of CHF and one with sustained ventricular tachycardia). In the enoximone group, three patients withdrew during dobutamine tapering (two with a relapse of CHF, one with a cutaneous rash). Four patients on placebo and nine receiving enoximone could be weaned from dobutamine, P < 0.05. Echocardiographic LV ejection fraction significantly increased and Doppler-derived indexes of systolic function tended to increase when enoximone but not placebo was associated with dobutamine. Oral enoximone might be helpful in weaning patients with end-stage congestive heart failure from i.v. dobutamine.

[Simultaneous measurement of systolic pulmonary artery pressure by catheterization and contrast enhancement doppler echocardiography]

The aim of this study was to assess the value of echocardiographic contrast in measuring systolic pulmonary artery pressures. Thirty-four patients with an average age of 61 +/- 15 years undergoing right heart catheterisation had a simultaneous measurement of systolic pulmonary artery pressures by catheter and colour-coded Doppler echocardiography under basal conditions and after injection of 5% dextrose agitated with 1 cm3 of air to form microcavitations. The Doppler echocardiographic measurements were performed after withdrawal of the catheter into the inferior vena cava before and after injection of contrast. Patients were divided into two groups according to the pulmonary artery pressures at catheterisation: Group I, comprising 11 patients with systolic pulmonary artery pressures of less than 35 mmHg; Group II, comprising 23 patients with systolic pulmonary artery pressures of over 35 mmHg; The injection of contrast significantly increased the number of patients in whom systolic pulmonary artery pressures could be calculated from the Doppler signal of tricuspid regurgitation (TR) in Group I (control: 18%; contrast: 100%, p < 0.01) and Group II (control: 65%; contrast: 96%, p < 0.05). There was a close correlation between the catheter and Doppler measurements of the trans-tricuspid valve pressure gradients before and after injection of contrast in Group I (n = 11, r = 0.85, p = 0.001, with an estimated standard error (ESE) = 3.8 mmHg) and in Group II (control: n = 15, r = 0.89, p = 0.001, ESE = 10.5 mmHg, and after contrast: n = 22, .r = 0.90, p = 0.001, ESE = 7.95 mmHg) with the catheter in the right ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)

Autosomal dominant Marfan-like connective-tissue disorder with aortic dilation and skeletal anomalies not linked to the fibrillin genes

We describe a large family with a connective-tissue disorder that exhibits some of the skeletal and cardiovascular features seen in Marfan syndrome. However, none of the 19 affected individuals displayed ocular abnormalities and therefore did not comply with recognized criteria for this disease. These patients could alternatively be diagnosed as MASS (mitral valve, aorta, skeleton, and skin) phenotype patients or represent a distinct clinical entity, i.e., a new autosomal dominant connective-tissue disorder. The fibrillin genes located on chromosomes 15 and 5 are clearly involved in the classic form of Marfan syndrome and a clinically related disorder (congenital contractural arachnodactyly), respectively. To test whether one of these genes was also implicated in this French family, we performed genetic analyses. Blood samples were obtained for 56 family members, and four polymorphic fibrillin gene markers, located on chromosomes 15 (Fib15) and 5 (Fib5), respectively, were tested. Linkage between the disease allele and the markers of these two genes was excluded with lod scores of -11.39 (for Fib15) and -13.34 (for Fib5), at theta = .001, indicating that the mutation is at a different locus. This phenotype thus represents a new connective-tissue disorder, overlapping but different from classic Marfan syndrome.

[Double-blind clinical and echocardiographic study of oral enoximone versus placebo in severe cardiac insufficiency]

The effect of enoximone was assessed by a randomised double blind trial versus placebo. The clinical status of the patients was evaluated by the NYHA classification and quality of life score. Inotropic state was estimated from the maximum acceleration of aortic and pulmonary blood flow recorded by Doppler echocardiography. Thirty patients with severe cardiac failure, aged 66.4 +/- 14 years, symptomatic despite maximal therapy associating diuretics, digitalis, nitrate derivatives and angiotensin converting enzyme inhibitors, were included. Fifteen patients were given enoximone 100 mg three times a day orally (Group E) and the other 15 were given a placebo (Group P). The NYHA class and quality of life scores were assessed at D0, D4 and D31. Doppler echocardiography and Holter recordings were performed on D0 and D31. The two groups were comparable at D0. Ten patients abandoned the trial, 3 from Group E (including 1 death) and 7 from Group P (including 3 deaths). At D4, 13 patients from Group E and 8 from Group P were clinically improved (p < 0.05). At D31, the clinical state was stable or improved in 10 of the 12 patients in Group E and 6 of the 8 patients in Group P (NS). No secondary effects were severe enough to warrant the withdrawal of treatment: the frequency of ventricular extrasystoles was comparable in the two groups at D0 and D31. At D31 the maximal aortic acceleration had increased by 20% compared with D0 (p < 0.05) and the maximal pulmonary acceleration by 31% (p < 0.05) in Group E. The same parameters showed no significant change in Group P (-6% and +5% respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

[Doppler echocardiographic evaluation of vasodilator treatments in patients with cardiac insufficiency. Contribution to the combination of isosorbide dinitrate and captopril]

Hemodynamic evaluation of a vasodilator drug is a difficult exercise in which Doppler echocardiography can be a useful tool. We studied the hemodynamic effect of isosorbide dinitrate (ISDN) by Doppler echocardiography in 7 patients with severe cardiac failure despite prolonged therapy with usually effective doses of captopril. The patients were evaluated before (H0) and 24 hours after treatment by ISDN (120 mg/24 hr) (H24) and 10 minutes after sublingual 0.75 mg of trinitrin (H24 + T). M mode echocardiography did not show any significant changes in chamber dimension as reported after vasodilator therapy in patients without cardiac dilation: in patients with severe left ventricular dilatation a reduction in LV filling pressures causes little if any changes in fractional shortening and ventricular dimensions. Two-dimensional echocardiography showed a reduction in end systolic volume and an increase in ejection fraction, emphasizing the superiority of this technique in cases of abnormal left ventricular function and the sensitivity of indices of systolic function to changes in afterload in these patients. Cardiac output measured by Doppler increased during the study. The maximal acceleration did not change significantly and pulmonary artery pressures were stable after administration of nitrates. ISDN caused a marked change in diastolic mitral flow patterns for which there are several explanations: an effect of ISDN on relaxation or LV compliance or on the conditions of LV filling or on both factors together. The presence of mitral regurgitation and/or atrial arrhythmia prevents the use of Doppler indices for analysis of diastolic LV function.(ABSTRACT TRUNCATED AT 250 WORDS)

[Correlations between plasma concentrations of atrial natriuretic factor and right ventricular function in patients with severe cardiac failure]

The atrial natriuretic factor (ANF) is secreted by the atria in mild and moderate cardiac failure but, during the evolution of the cardiac failure, the ventricles are also recruited and secrete ANF. In order to investigate the relation between plasma ANF and Doppler echocardiographic parameters of severe cardiac failure, the concentrations were measured simultaneously in 20 patients with NYHA Class III and IV cardiac failure (10 due to ischaemic and 10 due to primary dilated cardiomyopathy) despite optimal medical treatment including an angiotensin converting enzyme inhibitor. Overall, there was a weak negative correlation between the plasma ANF concentrations and the decrease in right ventricular surface area (r = -0.58, p less than 0.005, n = 20 patients). This relation was highly significant in ischaemic cardiomyopathy (r = -0.81, p less than 0.002, n = 10 patients) and not significant in primary dilated cardiomyopathy (r = -0.29, NS, n = 10 patients). No relationship was observed between plasma ANF and other echocardiographic parameters (atrial surface area, right and left ventricular dimensions, left ventricular ejection fraction and mass) or with Doppler aortic indices (acceleration, maximum and mean velocities, aortic velocity-time integrals). However, plasma ANF was related to the velocity of mitral regurgitant jets (r = -0.70, p less than 0.01) which is dependent on left ventricular pump function. These results show that plasma ANF concentrations are only related to right ventricular systolic function and the velocity of mitral regurgitation in patients with severe cardiac failure.

[Quantitative two-dimensional echocardiography in acute pulmonary embolism]

Emergency two-dimensional echocardiography was carried out in 61 patients admitted to an intensive care unit for suspected pulmonary embolism, in order to find out whether signs of acute cor pulmonale (ACP) were present or absent. Pulmonary angiography was subsequently performed to confirm or infirm the diagnosis of pulmonary embolism. Only 7 out of 13 patients with normal echocardiography had no pulmonary embolism. All other patients who showed echocardiographic signs of ACP had pulmonary embolism. Thus, the finding of normal echocardiographic results does not necessarily exclude a diagnosis of pulmonary embolism. Conversely, the presence of echocardiographic signs of ACP in a suggestive context provides a near-certain diagnosis of pulmonary embolism.

[Cardiac toxicity of 5-fluorouracil. Two cases]

Major ventricular repolarization disorders without evidence of myocardial infarction developed in 2 patients during the first course of a 5-fluorouracil (5-FU) treatment in doses of 1,000 mg/m2/day. Anginal pain was present in one patient but not in the other. The electrical abnormalities persisted for more than 6 weeks in one case. Explorations carried out 2 and 6 weeks later respectively under calcium inhibitors showed absence of coronary artery stenosis, negative methyl ergonovine test (even after 5-FU infusion in one patient) and normal left ventricular kinetics. The mechanism of cardiac toxicity is discussed on the basis of these data: some elements support a coronary spasm and others direct myocardial toxicity.

[Anti-angina effect of amiodarone versus delayed-action propranolol. A double-blind randomized study]

Long-acting Propranolol (160 mg/day) and Amiodarone (200 mg/day after impregnation) were compared in chronic stable angina pectoris. Forty-three patients with stable angina of effort were included in a randomised double blind trial (19 in the amiodarone and 24 in the propranolol group). The duration of the study was 8 weeks; the placebo phase (2 weeks) was followed by 6 weeks of active treatment. An exercise stress test was performed before and after the treatment period. The number of episodes of angina and the consumption of glyceryl trinitrate decreased significantly (p less than 0.001) in the same proportion with both drugs with respect to the placebo period. The time to the appearance of criteria of positivity of the exercise stress test increased from 6.82 +/- 0.50 mn to 8.35 +/- 0.50 mn with amiodarone, and from 7.15 +/- 0.47 mn to 9.50 +/- 0.52 with the propranolol preparation. This improvement was very significant compared with the placebo phase (p less than 0.001) but the difference between the two drugs was not statistically significant (p = 0.39). The other parameters which were studied (time to onset of angina, total duration of exercise, maximum heart rate, double product, maximum ST depression) changed in a parallel fashion significantly versus placebo. There were no differences between the two treatment groups with the exception of the resting heart rate which decreased more in patients on propranolol (80.94 +/- 3.92 to 62.47 +/- 1.97) than in patients on amiodarone (84.87 +/- 2.63 to 73.41 +/- 2.01; p less than 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

Placebo-controlled trial of oral enoximone in end-stage congestive heart failure refractory to optimal treatment

A double-blind, randomized, concurrent trial of enoximone vs placebo was undertaken to assess the efficacy and safety of enoximone, 100 mg t.d.s. added to optimal therapy in 30 patients (mean age, 66.4 +/- 14 years) with severe congestive heart failure. Before inclusion, all patients remained markedly symptomatic despite treatment with diuretics, digitalis, vasodilators and angiotensin converting enzyme inhibitors. Symptoms and quality of life were evaluated at inclusion, and at days 4 and 31; 24-hour electrocardiography and Doppler echocardiography were performed at inclusion and at day 31. Clinical and echocardiographic baseline characteristics were similar in the two groups. During the study, 10 patients dropped out: 3 in the enoximone group (1 death) and 7 in the placebo group (3 deaths). At day 4, symptoms were improved in 13 enoximone-treated patients and in 8 patients on placebo (P less than 0.05). At day 31, symptoms were still improving in 10 of 12 patients on enoximone and in 6 of 8 patients on placebo (NS). No serious clinical side-effects were reported, and no statistically significant difference in the frequency of premature ventricular contractions between the two groups was apparent on Holter monitoring. Peak acceleration of ascending aortic blood flow at entry was 17 +/- 6 m/second2 in the enoximone group and 18 +/- 5 m/second2 in the placebo group (NS). At day 31, the change in peak acceleration was +20% in the enoximone group vs -6% in the placebo group (P less than 0.05). Cardiac index increased by 18% in the enoximone group (from 2.17 +/- 0.7 litres/minute/m2 to 2.4 +/- 1.0 litres/minute/m2 (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Reevaluation of hemodynamic consequences of positive pressure ventilation: emphasis on cyclic right ventricular afterloading by mechanical lung inflation

To examine the cyclic changes in right ventricular (RV) function induced by controlled ventilation, right heart catheterization and two-dimensional echocardiography were combined in a group of 20 patients requiring respiratory support for an episode of acute respiratory failure. Simultaneous measurements of RV pressure (using a modified pulmonary artery catheter), RV stroke output (thermodilution), and RV dimensions (two-dimensional echocardiography), permitted a beat to beat evaluation of RV function throughout the mechanical respiratory cycle. When compared with expiration, lung inflation produced an increase in RV systolic pressure and volume, an increase in RV diastolic volume with an unchanged RV diastolic pressure, and a marked decrease in RV ejection fraction. It is concluded that controlled ventilation altered RV function primarily by increasing RV afterload during the lung inflation period.

[Hypertrophic cardiomyopathy. Data from Doppler echocardiography]

Hypertrophic cardiomyopathy (HCM) often involves the interventricular septum in the absence of any other cardiac or systemic abnormality capable of explaining this hypertrophy. M mode echocardiography shows septal hypertrophy and a posterior left ventricular wall of normal thickness. Two-dimensional echocardiography gives a better idea of the spatial distribution of the hypertrophy, especially in the short axis parasternal views. Obstruction to left ventricular ejection is another feature of this condition but presence of the obstruction remains a subject of controversy. Doppler studies give easy access to the changes in intraventricular hemodynamics and thereby contribute to fueling the controversy between supporters of intraventricular obstruction and those who prone the theory of hypercontractility. Color coded Doppler enables visualisation of the acceleration of blood flow in the left ventricular outflow tract and the demonstration of mitral regurgitation, which is always present in HCM with obstruction. The echocardiographic evaluation has been facilitated by the recent introduction of transesophageal probes. Doppler studies of mitral blood flow also enable evaluation of left ventricular diastolic function. The evaluation of left ventricular relaxation is often difficult and inaccurate in patients with supraventricular arrhythmias, intraventricular conduction defects or mitral regurgitation. Nevertheless, Doppler echocardiography remains the most reliable and useful method of evaluating HCM.

[Surgical treatment of infectious aneurysm of the popliteal artery. Description of a case caused by Campylobacter jejuni and a review of the literature]

The authors describe a case of mycotic aneurysm of the popliteal artery secondary to Campylobacter jejuni-derived infectious endocarditis treated by excision and in situ femoro tibial venous bypass, and take the opportunity to review 14 literature cases of infectious aneurysm of popliteal artery. This diagnosis is most frequently evoked by the development in an infectious setting of a throbbing inflammatory mass in the popliteal fossa. Management is aimed at controlling the infection and insuring proper distal vascularization. Eradication of the infection rests with the excision of the aneurysm and adequate antibiotherapy for at least 6 weeks. Distal vascularization is best provided (2 cases) by extra-anatomical bypass. However, in situ bypassing (9) is possible provided apyrexia and negative blood cultures have been obtained by preoperative antibiotherapy. The material used must be a venous autograft, whenever possible.

Linkage analysis of five fibrillar collagen loci in a large French Marfan syndrome family

Marfan syndrome consists of a group of dominantly inherited disorders of connective tissue with wide clinical variability. Using the candidate gene approach, we have attempted to map the gene defect in a large French Marfan syndrome family with no ocular manifestations. We performed linkage studies with polymorphic probes for five structural procollagen genes. The data obtained exclude linkage of Marfan syndrome to the two major fibrillar collagen (COL1A1, COL1A2, and COL2A1) genes. These results confirm previously published data obtained from smaller pedigrees. A small positive lod score (Z = 0.99, theta = 0.00) was obtained for the COL3A1-COL5A2 gene cluster located on chromosome 2.

Variability and reproducibility of quantitative left ventricular angiography

To evaluate the reproducibility of left ventricular angiography for the assessment of left ventricular (LV) function and regional wall motion, two ventriculographies were performed in the 30 degrees right anterior oblique (RAO) projection, at 15-minute intervals, in 19 patients undergoing coronary angiography. Heart rate, left ventricular systolic pressure, and end-diastolic pressure were measured 15 minutes after the first angiography returned to the baseline values (71.0 +/- 14.1 vs. 72.2 +/- 15.5 beats/minute, 153.6 +/- 18.0 vs. 152.8 +/- 19.9 mm Hg, 21.7 +/- 8.6 vs. 20.9 +/- 7.3 mm Hg, respectively). Global and regional LV performance was analyzed by two observers with a computer-assisted technique. Intraobserver mean variation of end-diastolic volume and ejection fraction was less than 3% of the control value. Interobserver mean variations for the same parameters were less than 4% of control values. For both observers, there was no significant variation of LV end-diastolic volume and ejection fraction from one study to the other. Under stable hemodynamic conditions, the mean observed variations were, depending on the observer, 5-6% of the control value for LV end-diastolic volume and 5% for ejection fraction. Analysis of segmental wall motion was also highly reproducible. The mean intraobserver variation (% of control value) of wall motion ranged from 4.4% to 9.2%, depending on the sectors studied. The mean interobserver variation, whatever the sector, ranged from 6.9% to 13.5%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Dose-response relation of intravenous enoximone in congestive cardiac insufficiency]

Enoximone (MDL 17043) is a new generation inotropic drug which acts by inhibiting phosphodiesterase and is endowed with both inotropic and vasodilator properties. The purpose of this study, which involved 23 patients aged from 18 to 75 years in NYHA class III or IV and with evidence of severe haemodynamic disturbances (cardiac index below 2.5 1/mn/m2, pulmonary wedge pressure above 15 mmHg), was to evaluate the acute haemodynamic responses to doses of enoximone that ranged from 0.25 to 2.50 mg/kg administered by bolus intravenous injection. Heart failure was either of ischaemic origin (6 cases) or idiopathic (10 cases) or due to various causes (7 cases). Group A patients (n = 11) received the drug in low doses (less than or equal to 1 mg/kg) as opposed to group B patients (n = 12) who were given high doses (greater than 1 mg/kg). Results were evaluated from the amplitude and duration of the haemodynamic response at maximum effect time (30 min). The following parameters were measured: cardiac index, pulmonary wedge pressure, systemic vascular resistance, mean arterial pressure and heart rate. Cardiac index and pulmonary wedge pressure were significantly improved in both groups (P less than 0.005): cardiac index +39 p. 100 in group A, +55 p. 100 in group B; pulmonary wedge pressure -36 p. 100 in group A, -48 p. 100 in group B; systemic vascular resistance -46 p. 100 in group B. Heart rate and arterial pressure were not significantly altered. The duration of response was 1 to 3 hours in group A patients and 4 to 8 hours in group B patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Serum sickness after fibrinolysis using intravenous streptokinase in myocardial infarction]

A case of serum sickness was observed 7 days after administration of intravenous streptokinase in the acute phase of myocardial infarction. The clinical presentation was the sudden development of fever, a papuloerythematous skin rash, myalgia and polyarthritis accompanied by a severe biological inflammatory syndrome without any signs of bacterial or viral infection. Spontaneous regression was observed within 72 hours. Although this complication of streptokinase fibrinolysis seems to be rare, clinicians should be aware of it and not confuse the allergic reaction with that of another drug, the withdrawal of which could be prejudicial for the patient.

[Diagnosis of acute aortic dissection by echocardiography]

Until recently, the diagnosis of aortic dissection rested on aortography. The purpose of this study was to evaluate the diagnostic value of echocardiography in that disease and its ability to inform on the extent of the dissection and on the presence of associated lesions. Twenty-six patients (mean age 64 +/- 10 years) admitted for suspected aortic dissection were explored by echocardiography and the results were compared with those of angiography and/or anatomical findings. Echocardiography provided the diagnosis in 14 of the 16 patients with aortic dissection and excluded it in the remaining 10 patients. The sensitivity and specificity of the method were 87.5 p. 100 and 100 p. 100 respectively. The type of dissection was correctly determined in 90 p. 100 of the patients whose aorta had been totally explored by echocardiography. Aortic regurgitation and pericardial effusion were detected in 81 p. 100 and 50 p. 100 respectively of patients with aortic dissection. These results confirm the diagnostic value of echocardiography in dissection of the aorta. The extent of the lesion can only be evaluated when the whole of the aorta is visualized. The echocardiographic diagnosis is easier when the ascending aorta is involved (type I), while in type III aortic dissection there is a risk of missing a retrograde lesion of the aorta and confusing this type with type I. In this study two kinds of intimal flap motion were observed: in the first one the motion was independent of that of the aorta, while the second one resembled a division of the aortic, wall the motion of which is parallel to that of the aorta.

Quantitative two-dimensional echocardiography in massive pulmonary embolism: emphasis on ventricular interdependence and leftward septal displacement

In 14 patients requiring aggressive therapy for circulatory failure resulting from massive pulmonary embolism, hemodynamic and two-dimensional echocardiographic data were obtained at bedside (acute phase) and again after circulatory improvement (intermediate phase) and during recovery. The acute stage was characterized by a low cardiac output state despite inotropic support (cardiac index 1.9 +/- 0.6 liters/min per m2) associated with increased right atrial pressure (12.4 +/- 4.2 mm Hg), increased right ventricular end-systolic and end-diastolic area (12.4 +/- 3.4 and 15.4 +/- 4.1 cm2/m2, respectively) and reduced right ventricular fractional area contraction (20.1 +/- 8.6%). Two-dimensional echocardiography also revealed interventricular septal flattening at both end-systole and end-diastole and markedly decreased left ventricular end-diastolic dimensions. Left ventricular fractional area contraction remained normal. Hemodynamic improvement occurred during the intermediate phase as shown by restoration of cardiac index (3.3 +/- 0.6 liters/min per m2), decrease in right atrial pressure (8.3 +/- 4.8 mm Hg), reduction in right ventricular end-systolic area (9.0 +/- 3.6 cm2/m2 at the intermediate stage and 6.1 +/- 1.8 cm2/m2 at recovery) and end-diastolic area (10.5 +/- 3.6 cm2/m2 at the intermediate stage and 8.9 +/- 2.9 cm2/m2 at recovery) and improvement in right ventricular fractional area contraction (31.5 +/- 16.4%). The interventricular septum progressively returned to a more normal configuration at both end-systole and end-diastole, and left ventricular diastolic dimension steadily increased. It is concluded that circulatory failure secondary to massive pulmonary embolism was mediated through a profound decrease in left ventricular preload, resulting from both pulmonary outflow obstruction and reduced left ventricular diastolic compliance.(ABSTRACT TRUNCATED AT 250 WORDS)

A dose-response study of intravenous enoximone in congestive heart failure

Previous clinical studies with intravenous enoximone have used cumulative dosing to quantify enoximone's hemodynamic effects. The magnitude and duration of the hemodynamic effects of single intravenous doses of enoximone were evaluated in patients with congestive heart failure. Sixty patients, who were in New York Heart Association functional classes III and IV, received single intravenous doses of enoximone, either 0.25 (12 patients), 0.5 (13 patients), 1 (14 patients), 1.5 (10 patients) or 2 mg/kg (11 patients). Cardiac index was increased by 20% with the 0.25 mg/kg dose and by 48% and 42% with the 1.5 and 2 mg/kg doses, respectively. These increases were statistically significant (Student's paired t test with Bonferroni's correction, p less than 0.007) for 1 hour after 0.25 and 0.5 mg/kg, for 2 hours after 1 mg/kg and for 4 hours after 1.5 and 2 mg/kg. Enoximone also reduced pulmonary artery diastolic pressure by 19% with 0.25 mg/kg and by 29% with 2 mg/kg. The duration of effect varied from 1 hour with 0.25 mg/kg to 4 hours with 2 mg/kg. Enoximone produced no consistent or dose-related effects on heart rate or blood pressure. Eighteen adverse reactions were reported by 15 patients, of which 11 were minor and transient (vein pain, flushes, nausea). In 5 patients ventricular or supraventricular arrhythmias were observed, including nonsustained ventricular tachycardia and extrasystoles; 3 of these patients had evidence of arrhythmias before enoximone. Laboratory studies before and after treatment showed no drug-related effects. Dose-related effects on the magnitude and duration of hemodynamic responses to intravenous enoximone were evident within the dose range of 0.25 to 2 mg/kg.(ABSTRACT TRUNCATED AT 250 WORDS)

[Two-dimensional echocardiography in a cardiac intensive care unit]

The increasing number of physicians competent to carry out emergency echocardiography, and the availability of high performance equipment, facilitated the development of this technique in the Coronary Care Unit (CCU). This paper reports our experience of 610 2D echocardiographic recordings performed on 319 patients admitted to the CCU. The quality of the recording was excellent or satisfactory in 67% of cases and mediocre in 30% of cases. In 11 patients (3%) the quality of the recording was too poor to obtain reliable data. In this group of patients, the apical 4-chamber and subcostal views seemed better than the apical 2-chamber and parasternal views. An echocardiographic diagnosis was made in 94% of cases. It contributed to the diagnostic process in 70% of cases. Of the patients studied, 54% were admitted for a recent myocardial infarction. Echocardiography was particularly useful in atypical forms or when the diagnosis was difficult. It was also helpful in detecting complications of recent myocardial infarction, the frequency of which was determined. With respect to other cardiovascular emergencies, echocardiography was determined. With respect to other cardiovascular emergencies, echocardiography was very useful in the diagnosis of dissection of the aorta, pericarditis and for assessing left ventricular function and the causal mechanism in cases of decompensated cardiac failure. The non invasive nature of the investigation allows repeated examination of the patient at the bedside and makes it a particularly valuable technique to monitor the evolution of acute cardiac conditions requiring admission to the Coronary Care Unit.

[Cardiac risks of adriamycin. Early detection of high-risk patients by isotopic cardiac function study]

Adriamycin is known to be effective in the treatment of breast cancer. Serial radionuclide determinations of the left ejection fraction can provide advanced warning of adriamycin cardiotoxicity, prior to clinical signs of the left ventricular dysfunction. Patients at high risk of congestive heart failure can be detected. Depending on the results of the second course of chemotherapy, guidelines and criteria can be laid down to predict the appropriate time for drug discontinuation.

An approach to the functional anatomy of the sacroiliac joints in vivo

This first part of this paper is a review of the literature on the functional anatomy of the sacroiliac joint followed by a preliminary biomechanical study of the fresh post mortem pelvis. The latter was done in order to determine the coefficients of the screw matrix and the position of the instantaneous centers of rotation during the symmetrical movements of nutation and contranutation simulated in the biomechanics laboratory. The main part of this work deals with the spatial analysis in vivo of the relative displacements of the iliac bones with respect to the sacrum in the course of dissymmetrical movements of the pelvis. In the different phases of movement, the roentgenographic observation of the position of the bony components with respect to a three-dimensional orthonormal reference system required the use of material based on the principles of photogrammetry. This technique was used to achieve spatial reconstruction of the data recovered from a series of orthogonal x-ray films of the sacroiliac joints. Data retrieval was carried out on a digital table linked to a computer with a graphic terminal so that the information could be displayed in the form of rectangular coordinates of defined points on the bone. Owing to the limited amplitude of articular displacement, a statistical study was required to retrieve the coordinates from the projection of these points on the X-ray film with an estimated threshold of significance of 0.1 and an error of +/- 0.1 mm.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bone metastases in cancer of the breast. Diagnostic and predictive value of quantified bone scintigraphy]

Distant metastases from carcinoma of the breast are most commonly located in the skeleton. Although it has been clearly shown that bone radionuclide scanning is more sensitive than X-rays in detecting such metastases, diverging opinions have recently been voiced concerning its sensitivity and specificity. The authors have quantitatively analyzed 1631 focal alterations, taking the uptake index value as yardstick. They found that quantitative scanning increases the sensitivity of the method and makes it possible to differentiate between malignant and benign bone lesions.

Indications for ultrasonography in parotid pathologies

In connection with 141 cases of parotid tumours, 21 adenopathies of the parotid region and 22 cases of parotitis, the authors define the role of ultrasonography in the exploration of the salivary glands. Use of simple criteria permits differentiation of benign from malignant tumours with a good degree of sensitivity (79.8% in our series). This score allows ultrasonography to be offered as the first complementary examination when dealing with a tumefaction of the parotid region. When ultrasonographic findings evoke a malignant lesion, a CT scan seems necessary to evaluate any extension in depth. In contrast, ultrasonography does not appear justified in cases of parotitis or lithiasic pathologies.

[Fetal echocardiography during the 2nd half of pregnancy. Biometry and functional approach]

Fetal cardiac biometry was conducted in the TM mode, after real time anatomical outlining of the plane of the four cardiac cavities, on 48 recordings of supposedly normal pregnancies of 23 to 39 weeks of amenorrhoea. Ten measurements were made for each patient, in an immediately subvalvular plane perpendicular to the septum (dimensions of the two ventricular cavities, of the wall of the two ventricles, and of the septum, in diastole and systole respectively). Functional results derived from this data showed that the difference between diastolic and systolic values for ventricular diameters increased with term, the ratio of the diastolic diameter of the right ventricle (RV) to that of the left ventricle (LV) was a constant: 1.23 +/- 0.12, and the size of the RV was always superior to that of the LV (+ + +). Alson noted was that percentage shortening of the LV was superior to that of the RV, and mean percentage thickenings of the RV and septum were inferior to that of the LV. A further observation was that interpretation of the kinetic of the septum requires precise knowledge of the plane of the section in relation to "the pivot point".

[Congenital esophagotracheal fistulas in adults. Apropos of 2 cases]

Repeated bronchopneumopathies are the principal manifestation of congenital esophagotracheal fistulae detected at a late stage. Diagnosis is suggested by air distention of the esophagus on the thoracic image. Esophageal barium swallow examination in the standing position is usually negative: esophageal transit is too rapid, the diameter of the fistula is too small, and its ascending pathway does not allow filling by the contrast medium. Examinations should be conducted in precubitus, after the passage of an esophageal sound, employing barium sulphate as the contrast medium, and with a horizontal beam and profile projection. Kinetic exploration, employing ampliphotography is necessary. The fistula pathway is seen as a thin opaque line, oblique from above forwards, and pushing from the anterior surface of the esophagus to the posterior surface of the trachea. There is associated filling of the tracheobronchial tract.