Valvular heart disease in patients with Parkinson's disease treated with pergolide. Course following treatment modifications

Valvular heart abnormalities have been reported in patients with Parkinson's disease (PD) treated with pergolide. However, the incidence and severity of these abnormalities vary from study to study and their course after drug withdrawal has not been systematically assessed.

OBJECTIVES

To estimate the frequency and severity of valvular heart abnormality and its possible reversibility after drug withdrawal in a case-control study.

METHODS

All PD patients in the Amiens area treated with pergolide were invited to attend a cardiologic assessment including transthoracic echocardiography. Thirty PD patients participated in the study. A second echocardiography was performed (median interval: 13 months) after pergolide withdrawal (n=10 patients). Controls were age- and sex-matched non-PD patients referred to the cardiology department.

RESULTS

Compared to controls, aortic regurgitation (OR: 3.1; 95% IC: 1.1-8.8) and mitral regurgitation (OR: 10.7; 95% IC: 2.1-53) were more frequent in PD patients (tricuspid: NS). The number of affected valves (n=2.4+/-0.7) and the sum of regurgitation grades (n=2.8+/-1.09) were higher (p=0.008 and p=0.006, respectively) in the pergolide group. Severity of regurgitation was not correlated with pergolide cumulative dose. A restrictive pattern of valvular regurgitation, suggestive of the role of pergolide, was observed in 12/30 (40%) patients including two with heart failure. Pergolide was discontinued in 10 patients with valvular heart disease, resulting in a lower regurgitation grade (p=0.01) at the second transthoracic echocardiography and the two patients with heart failure returned to nearly normal clinical examination. This study supports the high frequency of restrictive valve regurgitation in PD patients treated with pergolide and reveals that a significant improvement is usual when the treatment is converted to non-ergot dopamine agonists.

[Results of 17 months' surgical experience in the Cardiological Centre of Phnom-Penh (CCPP). The challenge of sanitation in a developing country]

The authors report the preliminary results of the first 17 months' experience at the Cardiological Centre of Phnom-Penh (CCPP), set up by the initiative of the "Chaîne de l'Espoir" organisation. The CCPP has only two operative theatres, 8 intensive care beds and 32 hospital beds. During the 17 months, 1193 patients under 30 years of age were examined. Nine hundred and five had cardiac disease. Three hundred and twenty-two patients underwent surgery for congenital and valvular heart disease. The commonest operated congenital lesions were left-to-right shunts (71%) and tetralogy of Fallot (24%). In the valvular group, 53% had mitral insufficiency, 40% had mitral stenosis and 7% had aortic insufficiency. The selection of patients and surgical strategy depended on the economic constraints specific to developing countries: --strict selection of operable patients: exclusion of severe pulmonary hypertension, left ventricular dysfunction or cachexia and neonates with complex congenital heart disease; --simple, effective and low cost surgical procedures are preferred, repair in the majority of cases, preference given to valvuloplasty over valve replacement. The quality of the results with low morbid-mortality, justifies the creation of such cardiac surgical centres; surgery must be accompanied by strict measures of prevention of endemic rheumatic fever which remains a major public health problem.

[Epidemiology and aetiology of cardiac failure in the Somme]

The epidemiology of cardiac failure (CF) is little known in France. Our work, integrated in the prospective ETICS (epidemiology and therapeutics of cardiac insufficiency in the Somme) study, was aimed at determining the incidence of hospitalisation, the epidemiological profile, the causes of CF, as well as the frequency of cardiac failure with preserved systolic function in the Somme.

METHOD

Patients hospitalised for a first attack of CF from January 1 to December 31, 2000 in one of the 11 medical establishments in the Somme were included.

RESULTS

During this period, 799 patients were included. The male/female ratio was 1.05; the mean age was 75 +/- 12 years, for males it was less than for females (72 +/- 12 and 78 +/- 11 years respectively p < 0.001); 60% of patients were > 75 years. The average length of hospitalisation was 10.8 +/- 7 days. The hospital mortality was 8.4% (N = 67). The standardised hospital incidence was 1.92 percent per thousand of inhabitants per year and varied from 0.06 percent per thousand among those under 40 years to 14.7 percent per thousand in those over 80 years. The left ventricular ejection fraction, evaluated in 82.8% of patients, was greater than 50% in 55% of cases. The 2 principal causes found were: ischaemic (40%) and hypertensive (39%).

CONCLUSION

The hospital incidence of CF in the Somme during the year 2000 was 1.92 percent per thousand. The proportions of males and females were equivalent. This disease preferentially affects the elderly. CF with preserved systolic function is common (55% of cases), particularly in elderly subjects.

[Value and indications of transesophageal echocardiography before cardioversion of atrial fibrillation]

Transoesophageal echocardiography is essential for the diagnosis of left atrial thrombosis and its precursors (dense spontaneous contrast--reduced auricular emptying velocities) and for the diagnosis of complex aortic atheroma. The sensitivity and specificity of transoesophageal echocardiography for the diagnosis of left atrial thrombus are about 100% and about 90% for that of aortic atheroma. The formal indications for transoesophageal echocardiography before cardioversion are: atrial fibrillation complicated by stroke or a recent systemic embolism: atrial fibrillation complicated by mitral valve disease as the thrombo-embolic risk is major in this context: atrial fibrillation with a high thromboembolic risk: a history of stroke, presence of cardiac failure, diabetes, permanent hypertension, a very dilated left atrium (> or = 50 mm): apparently isolated atrial fibrillation for which long term anticoagulant therapy is hoped to be avoided. On the other hand, in recent, uncomplicated, non-valvular atrial fibrillation, a common fallacy should be corrected: transoesophageal echocardiography does not improve the safety of electrical cardioversion. With similar durations of prior anticoagulant therapy. Over a 3 week period, the frequency of thromboembolic complications is the same whether or not transoesophageal echocardiography is performed before cardioversion (0.8% in both groups of the SEIDL study). With short periods of anticoagulant therapy before cardioversion, there is a higher thromboembolic complication and mortality rate (ACUTE study). The safety of cardioversion is not related to the practice of prior transoesophageal echocardiography but to strict and efficacious anticoagulation for a period of 3 weeks before cardioversion.

Plasma homocysteine and severity of thoracic aortic atherosclerosis

STUDY OBJECTIVES

Plasma homocysteine level is a risk factor for coronary events, stroke, and peripheral atherosclerotic disease. However, few data are available concerning the relationship between homocysteine level and severity of thoracic aortic atherosclerosis. We hypothesized in this multiplane transesophageal echocardiography (TEE) study that homocysteine level is a marker of the presence and severity of thoracic aortic atherosclerosis.

DESIGN

Cross-sectional study.

SETTING

University hospital.

PATIENTS

Risk factors, angiographic features, and TEE findings were analyzed prospectively in 82 valvular patients.

MEASUREMENTS AND RESULTS

The following risk factors were recorded: age, gender, hypertension, smoking, lipid parameters, diabetes, body mass index, and family history of coronary artery disease. Plasma levels of homocysteine, vitamin B(12), and folic acid were measured for each patient. By univariate analysis, age, diabetes, hypertension, smoking, family history of coronary artery disease, and levels of homocysteine, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol were significant predictors of the presence of thoracic aortic plaques. There was a positive correlation between the plasma homocysteine levels and the score of severity of thoracic atherosclerosis (r = 0.48; p = 0.0001) as well as between the homocysteine levels and the grades of severity of aortic intimal changes (p = 0.0008). Multivariate regression analysis revealed that homocysteine was an independent predictor of the presence and severity of thoracic aortic atherosclerosis.

CONCLUSION

This prospective study indicates that plasma homocysteine level is a marker of severity of thoracic atherosclerosis detected by multiplane TEE. These findings emphasize the role of homocysteine as a marker of atherosclerotic lesions in the major arterial locations.

Relation between low-density lipoprotein cholesterol and thoracic aortic atherosclerosis

This prospective study, which included 320 patients, showed that total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, total cholesterol/high-density lipoprotein cholesterol, and triglycerides correlate with thoracic aortic atherosclerosis. Low-density lipoprotein cholesterol is identified as an independent predictor of thoracic aortic plaque related to the severity of thoracic aortic atherosclerosis.

Correlation of thoracic aortic atherosclerotic plaque detected by multiplane transesophageal echocardiography and cardiovascular risk factors

This study of 416 patients identified age, male gender, smoking, diabetes, hypertension, and hypercholesterolemia as independent predictors of thoracic aortic atherosclerotic plaque. Age, smoking, hypercholesterolemia, hypertension, and diabetes were predictors of the severity and extent of thoracic aortic atherosclerosis.

[Diagnostic value of echocardiography and thoracic spiral CT angiography in the diagnosis of acute pulmonary embolism]

The objective of this study was to define the limits of echocardiography and to evaluate thoracic spiral CT angiography (TSCTA) for the diagnosis of pulmonary embolism (PE). One hundred twelve consecutive patients, hospitalised for suspected PE, were included in this prospective study. All were investigated by pulmonary ventilation-perfusion scintigraphy (Sc) and 50 had a high probability of PE on this examination. Sc was normal in 22 patients. Forty patients were excluded because of an intermediate probability. In 50 patients with PE confirmed on Sc, transthoracic echocardiography (TTE) showed only indirect evidence of PE (intracavitary thrombus in 4% of cases). TSCTA demonstrated PE in 82% of cases and did not show any thrombus image when Sc was normal. Its negative predictive value was therefore 70% and its positive predictive value was 100%. Its sensitivity varied according to degree of perfusion defect (96% in the case of lobar lesion, 66% in the case of segmental lesion and 16% for a subsegmental lesion). Multidimensional transoesophageal echocardiography (TOE), performed in 37 of the 50 patients with PE, only revealed thrombi in the pulmonary tree in 3 patients (8%), all presenting severe PE. No thrombus was visualized on TOE in patients with non-serious PE. All thrombi observed on TOE were also demonstrated by TSCTA. In conclusion, TTE usually provides only indirect signs of PE. TOE has a poor diagnostic sensitivity for PE. TSCTA has a better sensitivity than TOE for the detection of thrombi in the pulmonary artery trunk and proximal centimetres of its two branches, but normal CT angiography cannot exclude a distal PE.

Comparative value of Doppler echocardiography and cardiac catheterization in the decision to operate on patients with aortic stenosis

With the use of Doppler echocardiography, severity of valvular stenosis, etiology and type of valve lesions, and left ventricular function can be assessed accurately in patients with aortic stenosis. The purpose of this study was to compare the value of noninvasive clinical and Doppler echocardiographic findings, with cardiac catheterization, in the management decision-making for patients with aortic stenosis. One hundred and seventy consecutive patients with aortic stenosis who underwent cardiac catheterization and Doppler echocardiography were prospectively studied. A decision to operate, not operate or remain uncertain was made independently by experienced cardiologists given clinical information in combination with either Doppler echocardiographic (group I) or cardiac catheterization (group II) data. The severity of aortic stenosis agreed between Doppler echocardiography and cardiac catheterization in 168 patients (98.8%), and disagreed in two patients. There was agreement on clinical decision to operate or not operate between Group I and Group II in 160 patients (94.1%) and a discrepant decision in only two patients (1.1%). In eight patients (4.7%) with poor echogenecity or with discordance between clinical and echocardiographic data, the decision made by group I remained uncertain. We conclude that in a large majority of patients with aortic stenosis, Doppler echocardiographic assessment provides the same management decision reached by cardiac catheterization findings.

Paradoxical embolism following acute pulmonary embolism: diagnosis and outcome

We report on ten cases of paradoxical embolism that occurred following pulmonary embolism and emphasize the echocardiographic contribution. Two patients had a thrombus trapped in a foramen ovale. An embolectomy was performed on one of those patients and the outcome was post-operative death. The other patient died suddenly prior to planned surgery. The remaining eight had inter atrial communication or foramen ovale that were highly patent upon contrast echography. Two of them who presented cardiogenic shock died rapidly despite resuscitation measures. The remaining six patients were treated medically with anticoagulants and have experienced no recurrence of embolism after a mean follow up 34+/-31 months.

Use of transesophageal echocardiography to predict significant coronary artery disease in aortic stenosis

STUDY OBJECTIVES

This study was conducted to examine if the use of multiplane transesophageal echocardiography (TEE) could predict the absence or the presence of significant coronary artery disease (CAD) in patients with aortic stenosis.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS

Clinical, angiographic features and TEE findings were prospectively analyzed in 132 consecutive patients with aortic stenosis.

MEASUREMENTS AND RESULTS

In 63 patients with significant CAD, 57 had thoracic aortic plaque on TEE studies. In contrast, aortic plaque existed in only 19 of the remaining 69 patients with normal or mildly abnormal coronary arteries. Therefore, the presence of aortic plaque on the TEE identified significant CAD with a sensitivity of 90.5%, a specificity of 72.5%, and with positive and negative predictive values of 75.0% and 89.3%, respectively. There was a significant relation between the severity of thoracic aortic atherosclerosis and the severity of CAD (p<0.0001). Multivariate logistic regression analysis revealed that aortic plaque, angina, and age were independent predictors of CAD. Aortic plaque was the most significant independent predictor.

CONCLUSION

This prospective study indicates that TEE examination of thoracic atherosclerotic plaque is a powerful predictor of absence of significant CAD in patients with aortic stenosis.

Fibrinogen is an independent marker for thoracic aortic atherosclerosis

The fibrinogen level is an independent risk factor for coronary events and stroke, but no detailed data are available concerning fibrinogen and atherosclerotic disease of the thoracic aorta. This prospective study using multiplane transesophageal echocardiography examined the relation between atherosclerotic thoracic aortic plaque and fibrinogen level. One-hundred forty-eight patients (65 +/- 11 years) with valvular heart disease underwent multiplane transesophageal echocardiography and coronary angiography. We measured plasma fibrinogen level for each patient and recorded the following cardiovascular risk factors: age, sex, systemic hypertension, history of smoking, hypercholesterolemia, diabetes mellitus, body mass index, and family history of coronary artery disease (CAD). Patients with thoracic aortic plaque had a higher level of plasma fibrinogen (p = 0.0001), were older (p = 0.0001), and had significantly more risk factors: history of smoking (p = 0.009), hypertension (p = 0.008), hypercholesterolemia (p = 0.0001), diabetes mellitus (p = 0.01), and family history of CAD (p = 0.003). Multivariate logistic regression analysis of fibrinogen level and risk factors revealed 4 independent predictors of thoracic aortic plaque: fibrinogen, age, hypercholesterolemia, and history of smoking. Fibrinogen was also an independent predictor of CAD. There was a relation between fibrinogen levels and the severity of aortic atherosclerosis (r = 0.46; p = 0.0001) and the severity of CAD (r = 0.30; p = 0.0001). This prospective study indicates that fibrinogen is an independent marker for thoracic aortic plaque related to the severity of thoracic aortic atherosclerosis and confirms that fibrinogen constitutes an independent marker for CAD related to the severity of angiographically evaluated coronary atherosclerosis.

[Transesophageal echocardiography before electric cardioversion for supraventricular arrhythmia]

OBJECTIVES

The aim of this prospective study was to assess the risks of electrical shock cardio-version in the treatment of supraventricular rhythm disorders when administered under effective-dose but short duration anticoagulation in patients with no intracavitary thrombus detectable by transesophageal echocardiography.

PATIENTS AND METHODS

One hundred nineteen patients, mean age 66 years, with permanent arrhythmia due to atrial fibrillation (n = 102), atrial flutter (n = 16) or atrial tachycardia (n = 1) and taking no long-term anticoagulant therapy were treated by electrical shock cardioversion. The patients were given heparin at an effective dose 72 hours prior to cardioversion. A transthoracic and a transesophageal echocardiography were performed less than 24 hours prior to cardioversion.

RESULTS

Twenty-one thrombi were evidenced in 16 patients (14.6%) including 18 in the left auricle, 1 in the left atrium and 2 in the right atrium. A spontaneous contrast was visualized in 38 patients (32%). Cardioversion was performed in 103 patients without thrombus and later in 9 of the 16 patients with thrombus after absorption under anticoagulant therapy as evidenced on the control transesophageal echocardiography. A sinus rhythm was obtained in 82% of the cases. All patients were given anti-vitamin K anticoagulants for one month. There were no clinical manifestation of ischemic vascular events during cardioversion nor during the one-month follow-up.

CONCLUSION

Early use of electrical shock cardioversion in patients with supraventricular rhythm disorders can be proposed without long-term anticoagulation therapy if the absence of thrombi is demonstrated by transesophageal echocardiography and short-term heparin is given followed by oral anticoagulants for at least 4 weeks. A large-scale randomized prospective study comparing the conventional strategy with the protocol used in this study would be required to definitively validate this approach and determine its possible advantages.

[Malignant cardiac lymphoma. Diagnosis by echocardiography]

The authors report a case of cardiac malignant non-Hodgkin lymphoma. The initial clinical presentation suggested recurrent angina in a patient who had undergone angioplasty of the left anterior descending artery two years previously. Echocardiography showed severe left ventricular dysfunction with apical and septal akinesia and also allowed visualisation of two oval masses in the right ventricle without dilatation of the right heart chambers. Transoesophageal echocardiography confirmed these abnormal echos which corresponded to tumour invasion of not only the right heart chambers but also the interatrial septum, the left atrial appendage and the descending thoracic aorta. Histological diagnosis of lymphoma was made from an excision biopsy of a mass in the calf muscle. The post-mortem examination confirmed the presence of a highly malignant T-cell non-Hodgkin lymphoma. The patient rapidly deteriorated and died during the first session of chemotherapy.

Multiplane transoesophageal echocardiographic detection of thoracic aortic plaque is a marker for coronary artery disease in women

OBJECTIVE

This study was conducted to examine if the multiplane transoesophageal echocardiographic detection of atherosclerotic plaque in the thoracic aorta could predict the absence or the presence and the severity of significant coronary artery disease in women. Its association with coronary disease is attractive and may have great influence on foregoing routine preoperative cardiac catheterization in patients with valvular heart disease but no data are available in women.

METHODS

Clinical and angiographic features and transoesophageal echocardiographic findings were prospectively analysed in 111 women.

RESULTS

In 24 women with significant coronary disease, 20 had thoracic aortic plaque on transoesophageal echocardiographic studies. In contrast, aortic plaque existed in only 12 of the remaining 87 women with normal or mildly abnormal coronary arteries. Therefore, the presence of aortic plaque had a sensitivity of 83%, a specificity of 86%, a positive and negative predictive values of 62% and 95%, respectively for the detection of significant coronary disease. There was a significant relation between the severity and the extent of atherosclerotic lesions and the angiographic coronary score (P<0.0001). Multivariate logistic regression analysis revealed that aortic plaque was the most significant independent marker of coronary disease (odds ratio=27.9; 95% confidence interval=5.5-131.6; P<0.0001).

CONCLUSIONS

This prospective study indicates that multiplane transoesophageal echocardiographic examination of thoracic atherosclerotic plaque is a marker for coronary disease in women and especially a powerful predictor of absence of significant coronary artery disease. Transoesophageal echocardiographic aortic examination might be used with risk factors and angina symptoms to discuss the need for preoperative coronary angiography in women with valvular heart disease.

Multiplane transoesophageal echocardiographic absence of thoracic aortic plaque is a powerful predictor for absence of significant coronary artery disease in valvular patients, even in the elderly. A large prospective study

AIMS

This study was conducted to examine whether detection of atherosclerotic aortic plaque by multiplane transoesophageal echocardiography could predict the absence or presence of significant coronary artery disease in young and elderly valvular patients.

METHODS AND RESULTS

Clinical and angiographic features and transoesophageal echocardiography findings were prospectively analysed in 278 consecutive valvular patients. In 93 patients with significant coronary artery disease, 85 had thoracic aortic plaque on transoesophageal echocardiography studies. In contrast, aortic plaque existed in only 33 of the remaining 185 patients with normal or mildly abnormal coronary arteries. Therefore, the presence of aortic plaque on transoesophageal echocardiography studies had a sensitivity of 91%, a specificity of 82%, and positive and negative predictive values of 72% and 95%, respectively, for significant coronary artery disease. In the 109 patients aged > or = 70 years, these sensitivity, specificity, and positive and negative predictive values were 96%, 78%, 79%, and 96%, respectively. The above high negative predictive value was the major finding of this study and indicated that the absence of thoracic plaque is a strong predictor for absence of significant coronary artery disease. There was a significant relationship between the degree of aortic intimal changes and the severity of coronary artery disease (P < 0.0001). Multivariate logistic regression analysis revealed that aortic plaque, angina, hypercholesterolaemia and age were significant predictors of coronary artery disease: aortic plaque was the most significant independent predictor, even in patients > or = to 70 years.

CONCLUSION

This large prospective study indicates that examination of thoracic atherosclerotic plaque, by multiplane transoesophageal echocardiography, is a marker for coronary artery disease, and is a particularly powerful predictor for absence of significant coronary artery disease in valvular patients, even in the elderly.

Familial incidence of late ventricular potentials and electrocardiographic abnormalities in arrhythmogenic right ventricular dysplasia

Familial forms of arrhythmogenic right ventricular dysplasia (ARVD) have been described. Signal-averaged electrocardiograms (SAECGs) and standard electrocardiograms have been used to detect ARVD. The purpose of this prospective study, for a given family member, was to evaluate the risk of having ARVD or only belonging to an affected family. To address these issues, we assessed the incidence of late ventricular potentials and electrocardiographic (ECG) abnormalities in the families of our patients with ARVD. SAECGs and electrocardiograms were recorded in 101 eligible family members and compared with those recorded in ARVD patients with sustained ventricular tachycardia (13 patients in 12 families), and in 37 control subjects with a normal electrocardiogram. The incidence of late ventricular potentials was significantly higher in family members than in control subjects (16% vs 3%, p <0.05). The incidence of ECG abnormalities was 34% in family members. When the incidence of late ventricular potentials and/or ECG abnormalities were added up, results were 38% abnormal findings in family members. Late ventricular potentials and/or ECG abnormalities were found in members of all 7 families; these abnormalities were initially thought to be sporadic forms, and thereafter were classified as familial forms. Thus, SAECGs and standard ECG recordings in ARVD family members showed 38% abnormal findings, and that all cases of ARVD could be classified as familial forms. The incidence of familial forms of ARVD was greater than was previously believed, which is highly suggestive of a genetic transmission of the disease in our geographic area.

[Transesophageal echographic demonstration of ulcerated atheromatous plaques of the thoracic aorta responsible for cholesterol emboli]

The authors present of case of a 61-year-old man suffering from cholesterol emboli, in whom transoesophageal echocardiography revealed complex atheromatous lesions of the thoracic aorta. There is growing emphasis, at the present time, on the concept of triggering factors with the multiplication of endovascular radiological investigations, the more widespread availability of cardiac surgery and the use of anticoagulants and fibrinolytics. The prognosis is poor, treatment is only palliative and preventive measures are therefore essential.

[Non-bacterial thrombosing endocarditis. Apropos of 2 cases]

The diagnosis of nonbacterial thrombosing endocarditis or marasmic endocarditis must be considered in patients presenting with a combination of cancer and systemic embolism. The pathophysiological mechanisms of this entity are unclear and purely hypothetical. However, hypercoagulability appears to play an essential role in the pathogenesis of this endocarditis, which could be the cardiac expression of a coagulopathy involving the entire vascular system. The authors report two cases of marasmic endocarditis which emphasize the value of transthoracic and transoesophageal echocardiography in the difficult diagnosis of this disease.

[Chronic constrictive pericarditis apropos of 3 cases disclosed by refractory cardiac failure]

Chronic constrictive pericarditis is a difficult diagnosis and may present atypically. The authors report three clinical cases and review the diagnostic strategy of constrictive pericarditis. In these three patients, the diagnosis was finally made after one or more years of symptomatic disease and after several diagnostic work ups and ineffective treatments. In cardiac failure, pericardial calcification is often not observed on chest X-ray and Doppler echocardiography is usually the diagnostic investigation. Adiastole presents with dilatation of the vena cava and atria, contrasting with normal ventricles without major valvular disease. Doppler echocardiography enables distinction of constrictive pericarditis from restrictive cardiomyopathy: normal myocardium, thickened pericardium, specific septal motion, inspiratory increase in right ventricular dimensions, premature opening of the pulmonary valve, important variations in ventricular filling with respiration, expiratory diastolic reflux in the hepatic veins. Catheterisation confirms adiastole and may suggest a pericardial aetiology in characteristic cases, associated with only mild increases in pulmonary artery pressure. If need be, the pericardial thickening > 4 mm may be observed with magnetic nuclear resonance imaging and, when a doubt remains with respect to the diagnosis of cardiomyopathy, the absence of fibrosis on endomyocardial biopsy provides the diagnosis and indication for curative surgery: pericardectomy.

[Can Doppler echocardiography help to avoid cardiac catheterization in the surgical decision-making in isolated left heart valve diseases?]

The aim of this study was to assess the value of non-invasive investigation based on clinical evaluation and Doppler echography in deciding the operative indications of patients with isolated left heart valvular lesions compared. Three hundred and thirty five patients were included in a prospective study: 78 had MR, 57 had AR, 150 had AS and 50 had MS. All underwent clinical. Doppler echography and catheter studies. The therapeutic decision was taken blind by two groups of 2 cardiologists. Group I took its decision based on clinical findings and results of Doppler echography whilst Group II took its decision on the clinical and catheter data. For each patient, one of the following three choices was proposed: 1) medical treatment: 2) surgery or valvuloplasty with balloon catheter; 3) request for further information. In addition, in group I, the need for coronary angiography was left to the appreciation of two cardiologists. The quantification of the valvular disease was concordant for groups I and II in 93, 97, 98.5 and 100% for MR, AR, AS and MS respectively. These percentages were respectively 97, 95, 92 and 100% for assessment of left ventricular function. The theoretical management decision was concordant between the two groups for 97% of MR, 94.7% of AR, 95.3% of AS and 94% of MS. Complementary information requiring invasive studies was required by group I in 3.9% of cases. A discordant opinion was obtained in 0.6% of cases (2 cases of AS). Coronary angiography was requested by the cardiologists of Group I in 34% of patients, identifying all patients who underwent coronary bypass surgery. These results show that cardiac catheterisation is no longer an essential diagnostic procedure for discussing the indications of valvular surgery in the majority of patients with isolated left heart lesions.

[Outcome of cardiac valve ring abscesses after medical treatment: attempt to identify criteria of favorable prognosis]

OBJECTIVES

Identify factors predicting favorable outcome after medical management of valve ring abscesses in order to propose a surveillance schedule for conservative treatment.

METHODS

A multicentric study conducted from July 1989 to February 1996 included 28 patients (mean age 64 +/- 16 years, range 26-83) hospitalized for active endocarditis and valve ring abscesses diagnosed at transthoracic or transesophageal echography. Conservative medical therapy was given because of a decision of the medico-surgical team (n = 9), high surgical risk (n = 12), or patient refusal of surgery (n = 7). Outcome was favourable in 18 patients (Group I) and unfavorable in 10 (Group II) due to death (n = 9) or subsequent surgery (n = 1). Univariate and multivariate analysis were used to determine differences between the groups in terms of clinical and laboratory data.

RESULTS

Mean follow-up in Group I was 33 +/- 18 months and 15 +/- 10 months in Group II. Univariate analysis showed significant differences between Group I and II respectively for age (59 +/- 18 yr vs 72 +/- 10, p = 0.04), delay to apyrexia after antibiotics (4.3 +/- 2.8 vs 8.3 +/- 2.4 days, p < 0.0008), heart failure (5% vs 70%, p = 0.003), grade III or IV valvular regurgitation (5% vs 60%, p < 0.04), and mean surface area of the abscess (1.5 +/- 1.2 vs 5.4 +/- 6.4 cm2, p < 0.03). Independent factors at multivariate analysis were by decreasing order: lack of heart failure at admission, delay to apyrexia, abscess surface area, and age. Outcome was favorable (mean follow-up 33 +/- 10 months) in all patients with an abscess surface area < 1.5 cm2, no signs of heart failure, no grade III or IV valvular regurgitation, apyrexia after less than 8 days on antibiotics and no staphylococcus positive blood culture.

CONCLUSION

Medical management of valve ring abscesses may be indicated in selected patients in care units with rigorous surveillance facilities. Further studies are needed to precisely identify surveillance and treatment criteria.

[Ablation of the slow pathway in reciprocating nodal rhythms by radiofrequency]

Radiofrequency ablation is a therapeutic alternative to drug therapy in recurrent reciprocating nodal rhythms. Selective ablation of the slow pathway guided by endocavitary recordings has the advantage of being effective at the price of a very low incidence of atrioventricular block. The authors report their experience with this technique. Fifty consecutive patients with recurrent attacks which were syncopal or uncontrolled by medical therapy, underwent selective ablation of the slow pathway. Firstly, they all underwent electrophysiological investigation to confirm the nodal origin of the reciprocating rhythm before proceeding to ablation itself, guided by the search for the slow pathway potentials. After ablation, it was impossible to trigger reciprocating tachycardia. Interruption of the anterograde slow pathway was achieved in 24 patients and of the retrograde pathway in 1 patient : the other 25 patients went on having dual conduction but with a prolongation of the effective refractory period of the slow pathway (268 +/- 46 ms vs 251 +/- 41 ms : p < 0.01). There were no cases of permanent complete atrioventricular block. Interruption of the slow pathway was associated with shortening of the effective refractory period of the rapid pathway (323 +/- 71 ms vs 348 +/- 80 ms : p < 0.01), which was not observed in cases of persistent dual conduction. No recurrence of tachycardia was observed during follow-up (mean period = 19.2 months) : however, control endocavitary studies in 25 asymptomatic patients after 1 to 3 months showed recurrence in 4 cases, which led to immediate further radiofrequency ablation which was successful. The authors conclude that guided selective radiofrequency of the slow intranodal pathway is a remarkably effective and reliable method of treating poorly tolerated or resistant reciprocating nodal tachycardias. Widening of the clinical indications to patients not wishing to undergo long-term antiarrhythmic therapy is now possible.

Clinical significance of intracavitary spontaneous echo contrast in patients with dilated cardiomyopathy

To assess the occurrence rate and major determinants of spontaneous echo contrast and to examine its impact on thromboembolic events and mortality in patients with dilated cardiomyopathy, 86 hospitalized patients (73 men and 13 women, mean age 63 +/- 11 years) with dilated cardiomyopathy who underwent transthoracic and transesophageal echocardiographic examinations were followed up for a mean of 20 +/- 13 months. Spontaneous echo contrast was observed in 36 patients (42%) and was detected only with the transesophageal approach. It was seen in the left atrium in 33 patients, in both right and left atria in 1 patient, in both left atrium and left ventricle in 1 patient, and in the descending aorta in 1 patient. Spontaneous echo contrast was more frequent in the presence of atrial fibrillation (p < 0.05), left atrial enlargement (p < 0.02) and severely depressed left ventricular function (p < 0.01), but was less common in patients with moderate to severe mitral regurgitation (p < 0.05). This imaging phenomenon was the only significant independent predictor of intracardiac thrombus formation and previous and subsequent thromboembolic events. During follow-up, there were 26 deaths, and survival in patients with spontaneous echo contrast was significantly lower than in those without it (p < 0.02). A spontaneous echo contrast is commonly detected with transesophageal echocardiography in patients with dilated cardiomyopathy especially in the presence of atrial fibrillation, left atrial enlargement and severe left ventricular dysfunction. This imaging phenomenon represents an important marker for thromboembolic risk and may influence the treatment and clinical outcome of these patients.

Comparative value of Doppler echocardiography and cardiac catheterization for management decision-making in patients with left-sided valvular regurgitation

OBJECTIVE

The purpose of this study was to examine the value of non-invasive clinical and Doppler echocardiographic findings, compared to cardiac catheterization, in management decision-making for patients with left-sided valvular regurgitation.

METHODS

One hundred and thirty-five consecutive patients with left-sided valvular regurgitation who underwent cardiac catheterization and detailed Doppler echocardiography were prospectively studied. Two independent groups of experienced cardiologists, given clinical information combined with either Doppler echocardiographic or cardiac catheterization data, decided to operate, not to operate, or remained uncertain.

RESULTS

In 63 (81%) of 78 patients with mitral regurgitation, there was agreement on the decision for valve surgery or medical treatment between Doppler echocardiography and cardiac catheterization. Valve repair was performed in 22 patients, which agreed with the echocardiographic decision. In the remaining 15 patients, although the severity and type of mitral valve lesions and left ventricular functional status were confirmed by Doppler echocardiography, the clinical decision was uncertain; additional information concerning coronary anatomy (13 patients) and pulmonary artery pressure (one patient) or both (one patient) was required. In 47 of 57 patients (82%) with aortic regurgitation, there was agreement on their management as a result of Doppler echocardiography and cardiac catheterization findings. In 10 patients, the clinical decision reached with the help of Doppler echocardiography alone was uncertain and coronary (seven patients), left ventricular (two patients) angiography or aortography (one patient) were requested. Overall, there were no conflicting clinical decisions made by the two methods in patients with either mitral or aortic regurgitation.

CONCLUSIONS

In every patient in whom it was considered that a decision could be reached by echocardiography alone (more than 80% of patients) there was 100% agreement from the cardiac catheterization assessment group on the management decision. Therefore, in patients with significant mitral or aortic regurgitation where echocardiographic data is adequate, cardiac catheterization can be safely omitted from the investigative process for surgery. Where echocardiographic indices are conflicting, or significant coronary artery disease is suspected, cardiac catheterization is required.

[Cardiac involvement in amyloidosis. Apropos of a case of hereditary amyloidosis of neurologic expression]

The authors report a case of hereditary amyloidosis in a 54-year old patient with an essentially neurological clinical expression. The cardiovascular assessment, consisting of echocardiography performed systematically while the patient was free of any cardiac symptoms, revealed typical amyloid infiltration with a hyperechoic, shiny appearance of the myocardium and significant parietal hypertrophy. Systolic function was preserved, in contrast with impairment of diastolic function, revealed by the presence of Appleton type I mitral blood and decreased propagation velocity of the transmitral flow on colour TM. The authors stress the importance of ultrasonographic examination in all patients with suspected cardiac amyloidosis, even in the absence of clinical or electrical signs.

[The main indications for transesophageal echocardiography]

Transoesophageal echocardiography is one of the major technological advances over the last ten years; it allows imaging of unequalled quality for two main reasons: the proximity of the structures studied without interposition of pulmonary or parietal structures and the high resolution of the transducers used. Aortic dissection is the first main indication: the presence of an intimal flap confirms the diagnosis with a sensitivity and specificity of approximately 95% and 99%. This examination should be performed immediately whenever this diagnosis is suspected. Increasingly, the surgeon acts exclusively on the basis of these data. Acute endocarditis is another preferential indication: TOE is essential whenever the transthoracic image is imperfect, when fever persists or when valvular damage deteriorates despite well conducted antibiotic treatment, i.e. whenever an abscess is suspected. Thromboembolic accidents constitute a third indication for TOE. Three direct causes can be demonstrated:--thrombus in the left atrium or auricular appendage,--valve vegetation or tumour,--"intra-aortic debris", a recently identified cause. Abnormalities of the interatrial septum (aneurysm, PFO) raise difficult problems of causality and management. Valvular heart disease constitutes a fourth indication: in aortic stenosis, when transthoracic echocardiography is insufficient, TOE is able to obtain the valvular surface by direct planimetry in approximately 85% of cases. In the field of mitral incompetence, TOE is irreplaceable to define the mechanism of regurgitation and in the assessment of its severity. In mitral stenosis, however, its only value is to allow precise assessment mitral incompetence and detection of a thrombus. Suspension of dysfunction of a prosthetic valve constitutes another preferential indication for TOE: it allows much better visualization of thrombi, vegetations and the precise origin of periprosthetic leaks than transthoracic echocardiography. Finally, TOE is increasingly used intraoperatively and in intensive care.

[Pulmonary hypertension associated with portal hypertension. Apropos of 2 cases]

The authors report the cases of two patients with pulmonary hypertension associated with portal hypertension. This is a rare association with a reported prevalence ranging from 0.25 to 0.73%. The diagnosis of portal hypertension preceded that of pulmonary hypertension by several years. The physiopathological mechanism of the latter is not well known although several hypotheses have been proposed. Treatment is only symptomatic. The prognosis is usually poor, the causes of death being related to complications of liver failure and/or portal hypertension or to those of pulmonary hypertension.

[Multidimensional transesophageal echocardiography in the determination of the orificial surface of aortic stenoses in adults. Apropos of 85 cases]

The objective of this study was to assess the validity of multidimensional transoesophageal echocardiography (TOE) in the determination of the orificial surface area of aortic stenosis (AS) in 85 patients, using as a reference the surface area calculated on transthoracic ultrasonography (TTU) by applying the continuity principle (n = 75) and/or by haemodynamic studies using Gorlin's formula (n = 40). Planimetry was able to be performed in 78 of the 85 patients (92%). Planimetry was impossible in 7 patients with massive calcification of the aortic orifice (n = 5) or posterior valve (n = 2). The mean value of the selected angle was 45 +/- 13 degrees (0 to 78 degrees). An excellent correlation was observed between aortic surface area (ASA) measured by multidimensional TOE and TTU (r = 0.94; y = 0.90x +/- 0.10; SEE = 0.10 cm2; p < 0.001). Similarly, the ASA on multidimensional TOE was also well correlated with the haemodynamic surface area (r = 0.90, y = 0.94x +/- 0.05; SEE = 0.09 cm2; p < 0.001). The correlations between multidimensional TOE and TTU measurements (n = 26; r = 0.96; y = 0.85 x +/- 0.11; SEE = 0.07 cm2; p < 0.001) and cardiac catheterization (n = 13; r = 0.92; y = 0.77 x +/- 0.7; SEE = 0.09 cm2; p < 0.001) remained satisfactory in patients with associated aortic incompetence. Multidimensional TOE identifies cases of AS with an ASA on TOE or haemodynamic studies less than or equal to 0.75 cm2 with sensitivities of 93% and 92%, respectively, and a specificity of 100%. Overall, multidimensional TOE allows a precise and reliable evaluation of ASA in the great majority of cases of AS.

[Recording of pulmonary venous flow with Doppler echocardiography; normal and pathological aspects]

The appearances of pulmonary venous flow Doppler echocardiography have been the subject of many reports. The recording is obtained by transthoracic or transoesophageal pulsed Doppler examination. The value of this parameter in the study of left ventricular diastolic function has been clearly established. The transoesophageal approach is mainly useful for quantifying mitral regurgitation and for monitoring left atrial pressure during surgery. This review of the literature describes the methods of recording and the normal appearances of pulmonary venous flow, and then discusses the different variations encountered in pathological conditions.

[Does mitral insufficiency prevent spontaneous contrast phenomenon and formation of thrombi in the left atrium?]

The aim of this study was to assess the influence of mitral regurgitation on the prevalence of left atrial spontaneous echo contrast and thrombosis in 2,180 consecutive patients undergoing transthoracic and transoesophageal echocardiography. Two groups of patients were defined according to the absence (group I) or presence (group II) of grades 3 or 4 mitral regurgitation quantified by transoesophageal echocardiography. Group II was associated with a statistically significant lower frequency of spontaneous echo contrast (0.6 vs 11.2%; p < 0.0001), left atrial thrombosis (0.6 vs 4.2%; p < 0.03), ischaemic cerebrovascular accidents (1.2 vs 21%; p < 0.0001), transient ischaemic attacks (0 vs 12%; p < 0.0001) and systemic embolism (0 vs 4.6%; p < 0.01). Conversely, the prevalence of atrial fibrillation was higher in group II (28 vs 19%; p < 0.01) and there were more patients with left atrial dimensions > or = 5.5 cm (16 vs 6.7%; p < 0.0001). When mitral stenosis and valve prosthesis were excluded, there were no cases of spontaneous echo contrast (8.3 vs 0%; p < 0.001) or left atrial thrombosis (2.9 vs 0%; p < 0.05) in the group with grades 3 or 4 mitral regurgitation. The phenomenon of left atrial spontaneous echo contrast and/or thrombosis is rare in patients with grade 3 or 4 in native mitral valve regurgitation and explains the low incidence of systemic embolism in these cases.

[Paradoxical embolisms after pulmonary embolism. 6 cases]

Among a series of 6 patients who had paradoxical emboli after pulmonary embolus, thrombus was encrusted in the foramen ovale in 2 while contrast echocardiography showed a free foramen ovale in the 4 others. Surgical embolectomy was performed in 1 of the patients with a thrombus in the foramen ovale. This patient died in the post-operative period and the second patient died suddenly before the indication for surgery had been established. The 4 other patients were treated medically with anticoagulant therapy. After a follow-up of 37, 33, 32 and 3 months respectively none of these patients has developed recurrent emboli. The association of a thromboembolic disease and a systemic ischaemic event should strongly suggest the diagnosis of paradoxical embolus. Echocardiography is required to determine whether the foramen ovale is free or harbours a thrombus.

[Valve ring abscesses: apropos of 59 cases. A multicenter study]

The authors report the results of a multicenter study which recensed 59 cases (46 men, 13 women, average age 59.8 +/- 14 years) of valve ring abscesses defined by echocardiographic criteria alone (20 cases) or by echocardiographic and/or operative criteria (39 cases). The site of abscess was aortic (53 cases), mitral (5 cases) and tricuspid (1 case). The abscess complicated a prosthetic valve in 34 cases, occurred with a non-pathological valve in 11 cases or a pathological valve in 14 cases. Taking the 39 operated patients as a reference, the diagnostic sensitivity of transthoracic echocardiography was 25% and that of transoesophageal echocardiography: 88%. Bacterial vegetations were diagnosed with a sensitivity of 55% for transthoracic and 88% for transoesophageal echocardiography. The mediocre results of transthoracic echocardiography make transoesophageal echocardiography mandatory when there is a clinical suspicion of abscess: transoesophageal echocardiography should be systematic in prosthetic valve endocarditis and widely employed in native aortic valve endocarditis. The clinical outcome of these cases was: 39 cases were operated: global mortality of 23%, and 18 cases were treated medically, surgery having been declined for various reasons: old age (2 patients), operative risk (1 patient), patient refusal (4 patients), general condition considered to be too good to justify surgery (11 cases, including 6 sterilised abscesses diagnosed some time after the acute infectious phase). The outcome of these 18 patients, who form the biggest non-operated series of valve ring abscesses to date, was studied in detail: 4 died (18% mortality), 1 was operated secondarily for progressive valve dehiscence and 13 had a favourable outcome with an average follow-up period of 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)

[A rapidly growing heart valve disease: degenerative aortic stenosis; diagnostic and therapeutic aspects]

Ostial aortic stenosis is clearly the commonest form of valvular heart disease in adults at the present time, as it represents 26% of all forms of valvular heart disease and 2% of all forms of heart disease. It is a disease middle and old-age, which appears to becoming increasingly frequent due to ageing of the population. It affects men twice as often as women and sometimes has a misleading clinical presentation at the stage of heart failure due to disappearance of the usual systolic murmur. The patient may simply present with signs of refractory left ventricular failure or complete heart failure. The diagnosis and follow-up have been radically transformed by the development of Doppler ultrasonography which allows the positive diagnosis as well as a very precise assessment of the severity, avoiding the need for cardiac catheterization, but unfortunately coronary angiography still remains essential in view of the age of these patients. In terms of treatment, percutaneous valvuloplasty according to the method developed by Cribier has unfortunately not lived up to expectations and tight aortic stenosis remains a surgical disease whose results are among the most spectacular: the patient's dramatic functional and objective transformation following insertion of a valvular prosthesis (mechanical before the age of 75 years, bioprosthesis after this age), at the cost of a reasonable operative mortality of approximately 5 to 8% in the 71 to 80 year age-group, must be stressed.

[Doppler echocardiographic evaluation of left ventricular wall stress in aortic stenosis]

The measurement of wall stress allows study of morphological adaptation of the left ventricle, especially in conditions associated with symmetric hypertrophy (hypertension, aortic stenosis). The calculation is performed in hypertensive heart disease but not in aortic stenosis because of the ventriculo-aortic pressure gradient. In a preliminary study, the authors validated the peak systolic left ventricular pressure calculated by adding the systolic brachial artery pressure to the maximal transvalvular pressure gradient by comparing the value with that obtained by catheterization in 21 patients with aortic stenosis. The second phase of the study was to measure meridian and circumferential wall stress prospectively in 35 patients with aortic stenosis (29 symptomatic, 6 asymptomatic) and to compare the results with those observed in 21 normal subjects. In the latter group, the values were 151 +/- 22 and 311 +/- 37 10(3) dynes/cm2 respectively, whereas in asymptomatic aortic stenosis the stresses were 136 +/- 28 and 303 +/- 41 10(3) dynes/cm2 respectively (NS) and in symptomatic aortic stenosis 210 +/- 55 and 437 +/- 94 10(3) dynes/cm2 respectively (p < 0.0001). None of the cases of asymptomatic aortic stenosis had raised wall stress values whereas only 6 symptomatic aortic stenosis patients had normal wall stress. The values of wall stress obtained using the method proposed were comparable to those reported by other authors with invasive investigations. Non-invasive measurement of wall stress by Doppler echocardiography may be proposed as a method of evaluation of left ventricular adaptation, especially in severe stenosis and in patients with a patent geometric abnormality (abnormal dilatation or even an inadequately hypertrophied wall).

[When should transesophageal echography be ordered?]

The exceptional quality of cardiac imaging, access to otherwise inaccessible anatomic areas and optimal alignment on anatomic structures make transoesophageal echography an exceptional high performance imaging technique. But when should it be ordered? Suspected aortic dissection is a major indication for transoesophageal echography. Diagnosis can be confirmed with sensitivity and specificity of 95 to 99%. The performance of the transoesophageal route is also better than that of the transthoracic route in case of suspected infectious endocarditis and should be ordered when the transthoracic image is insufficient, a perivalvular abscess is suspected, fever persists, infection on a prosthesis is suspected, blood cultures are negative or heart failure compromises cardiac performance. It should be remembered however, that a normal transoesophageal echography cannot eliminate the diagnosis of infectious endocarditis. The method is however extremely useful for close follow-up of endocarditis. Thrombo-embolic events with neurological or peripheral expression are also frequent indications for transoesophageal echography. Three direct causes can be detected: thrombus in the left atrium, contrast in the left atrium corresponding to micro-platelet aggregation due to prolonged stasis and intra-aortic debris. Septal anomalies may indicate an indirect cause. Aortic or mitral valvulopathies are another area of importance because transoesophageal echography results are well correlated with haemodynamic performance. Patients with a poorly tolerated mitral regurgitation with or without criteria of gravity could benefit from transoesophageal echography. Valve prostheses, especially mitral prosthesis, are also important indications. Per-operative examinations are particularly important for evaluating valve replacement quality after cardiac circulation has been reestablished. In addition, the high quality of transoesophageal images is particularly useful in investigating congenital cardiopathies and in certain intensive care patients.

Mitral to aortic velocity-time integral ratio. A non-geometric pulsed-Doppler regurgitant index in isolated pure mitral regurgitation

To determine the clinical value of a simple and non-geometric pulsed Doppler regurgitant index, namely the mitral to aortic velocity-time integral (VTI) ratio in the semiquantitative assessment of severity of isolated pure mitral regurgitation (MR), 109 patients with isolated pure MR and sinus rhythm prospectively underwent Doppler echocardiography within 48 h of cardiac catheterization. The eccentricity of regurgitant jets was assessed by Doppler colour flow imaging and the mitral and aortic VTI and its ratio were derived from the pulsed Doppler method. Angiographic grade of MR was evaluated in all patients with MR, but haemodynamic regurgitant fraction was determined in only 91 patients. Fifty patients in sinus rhythm and without valvular disease served as controls. In the control group, the mitral VTI (16.2 +/- 2.5 cm) was lower than the aortic VTI (20.6 +/- 2.8 cm) (P < 0.001), resulting in a mitral to aortic VTI ratio of 0.79 +/- 0.08. In patients with MR, the mitral VTI was significantly greater than the aortic VTI (23.1 +/- 6.8 vs 16.9 +/- 4.7 cm, P < 0.001). There was a close relationship between the mitral to aortic VTI ratio and the angiographic grading of MR (n = 109, r = 0.74, P < 0.001). A ratio > or = 1.3 classified patients with severe MR (grade III or IV) with a sensitivity of 87%, a specificity of 91%, and positive and negative predictive values of 93% and 84%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitation of aortic valve area in aortic stenosis with multiplane transesophageal echocardiography: comparison with monoplane transesophageal approach

The accuracy and reliability of two-dimensional monoplane and multiplane transesophageal echocardiography (TEE) in the quantitation of aortic valve area were compared in 54 patients with aortic stenosis. Fifty patients had aortic valve area calculated by the continuity equation and transthoracic Doppler echocardiography (TTE); 25 underwent cardiac catheterization. Two-dimensional echocardiograms adequate for quantitation of aortic valve area were obtained in 21 (39%) patients with monoplane TEE and in 51 (94%) with multiplane TEE. The mean aortic valve area determined by both TEE methods did not differ significantly from that derived from TTE and catheterization. The mean difference of aortic valve area measurements between monoplane TEE and TTE was -0.045 +/- 0.11 cm2; that between multiplane TEE and TTE was 0.001 +/- 0.11 cm2. Multiplane TEE provided a better correlation of aortic valve area measurements with either TTE (y = 0.97 x + 0.03; r = 0.96; SEE = 0.11 cm2) or catheterization (y = 0.84 x + 0.11; r = 0.90; SEE = 0.12 cm2) than the monoplane TEE (y = 0.88 x + 0.13; r = 0.83; SEE = 0.15 cm2 and y = 0.41 x + 0.42; r = 0.81; SEE = 0.15 cm2). Severe aortic stenosis with valve orifice area of < or = 0.75 cm2 during TTE examination was found by multiplane TEE with a sensitivity of 96% and a specificity of 96%. Thus aortic valve area can be directly and reliably measured by two-dimensional multiplane TEE in majority of patients with aortic stenosis.

Noninvasive prediction of coronary artery disease by transesophageal echocardiographic detection of thoracic aortic plaque in valvular heart disease

Clinical and angiographic features and transesophageal echocardiographic (TEE) findings were retrospectively analyzed in 105 consecutive patients with valvular heart disease to assess the value of TEE detection of thoracic aortic plaque for predicting coronary artery disease. In 19 patients with significant coronary artery stenosis (> or = 70% narrowing of the luminal diameter in the left anterior descending, left circumflex, or right coronary arteries, or > or = 50% stenosis of the left main coronary artery), 18 had thoracic aortic plaque on TEE study. In contrast, aortic plaque existed in only 10 of the remaining 86 patients with normal coronary arteries or mildly atherosclerotic coronary lesions. The presence of aortic plaque on TEE study had a sensitivity of 95% and a specificity study had a sensitivity of 95% and a specificity of 88% for significant coronary stenosis at angiography. The positive and negative predictive values were 64% and 99%, respectively. There was a close relation between the degree of aortic intimal changes and the severity of coronary artery disease (r = 0.65; p < 0.001). Multivariate stepwise regression analysis of patient age, sex, risk factors of cardiovascular disease, angina, and TEE findings revealed that atherosclerotic aortic plaque was the most significant independent predictor of coronary artery disease. This study indicates that TEE detection of atherosclerotic plaque in the thoracic aorta is useful in the noninvasive prediction of the presence and severity of coronary artery disease in patients with valvular heart disease.

[Surgical treatment of leiomyosarcoma of the left atrium Report of a case and review of the literature]

The authors report a case of left atrial leiomyosarcoma presenting with systemic disturbances and retinal emboli diagnosed by echocardiography and surgery in a 59 year old woman. Surgical ablation was completed by a course of chemotherapy. Histopathological examination confirmed the diagnosis of sarcoma; although the patient remained generally well, severe mitral regurgitation appeared 21 months after surgery. Transoesophageal echocardiography revealed an abnormal, hyper-mobile, intra-atrial echo suggesting a ruptured chordae tendinae and the mitral valves appeared very thickened and retracted. The patient was reoperated and the mitral valve replaced with a bioprosthesis. After a total follow-up of 29 months, the patients is still alive and asymptomatic. The authors underline the importance of echocardiography in the diagnosis of intra-cardiac tumours in general and, in particular, of intra-cardiac sarcomas.

[Doppler echocardiography of tricuspid insufficiency. Methods of quantification]

Evaluation of tricuspid incompetence has benefitted considerably from the development of Doppler ultrasound. In addition to direct analysis of the valves, which provides information about the mechanism involved, this method is able to provide an accurate evaluation, mainly through use of the Doppler mode. In addition to new criteria being evaluated (mainly the convergence zone of the regurgitant jet), some indices are recognised as good quantitative parameters: extension of the regurgitant jet into the right atrium, anterograde tricuspid flow, laminar nature of the regurgitant flow, analysis of the flow in the supra-hepatic veins, this is only semi-quantitative, since the calculation of the regurgitation fraction from the pulsed Doppler does not seem to be reliable; This accurate semi-quantitative evaluation is made possible by careful and consistent use of all the criteria available. The authors set out to discuss the value of the various evaluation criteria mentioned in the literature and try to define a practical approach.

[Contribution of transesophageal ultrasonography in the etiologic evaluation of a systemic embolic accident. Apropos of 451 patients]

In order to compare the respective values of transoesophageal and transthoracic echocardiography in the investigation of systemic embolic events, 451 consecutive patients (average age 60 +/- 15 years) presenting either with a cerebral ischaemic event (n = 401) or a peripheral arterial embolism (n = 50), were examined. One hundred and ninety eight patients had documented cardiac disease and/or atrial fibrillation; 253 patients had no previous cardiovascular history. Transoesophageal echocardiography revealed a possible cardiac embolic lesion in 37% of patients compared with 11% by transthoracic echocardiography (p < 0.001). In those patients with previous cardiac disease, transoesophageal echocardiography was contributory in 50% of cases compared with 27% of cases in patients with no previous cardiac disease (p < 0.001), whereas transthoracic echocardiography was only contributory in 12% and 9.8% of cases, respectively. Transoesophageal echocardiography was more sensitive for the diagnosis of intracavitary thrombus (7.5% vs 2.2%, p < 0.001), prosthetic valve thrombosis (2.4% vs 0.6%, p < 0.01), spontaneous contrast in the left atrium (10.8% vs 0%, p < 0.001), interatrial septal aneurysm (6.4% vs 1.9%, p < 0.001), mitral valve prolapse (5.3% vs 2.8%, p < 0.01). Moreover, irregular atheromatous plaques in the thoracic aorta could only be visualised by transoesophageal echocardiography (9% of cases). This study underlines the superiority of transoesophageal echocardiography over transthoracic echocardiography in the investigation of systemic embolic events. Transoesophageal echocardiography is even more contributory in patients with a history of cardiac disease.

[Contribution of transesophageal and transthoracic echography in the evaluation of the mechanism and quantification of regurgitation in mitral and aortic bioprosthetic valves]

The respective values of transoesophageal (TOE) and transthoracic echocardiography (TTE) in the evaluation of the mechanism and the quantification of pathological regurgitation of bioprosthetic heart valves were analysed in 23 patients (14 mitral, 9 aortic; duration of implantation 108 +/- 43.2 months). Surgical or pathological correlations were available in all cases and catheter data in 18 of the 23 patients. With regards to mitral bioprostheses, the TOE evaluations of the mechanism and site of regurgitation corresponded in all cases with the operative or pathological findings and quantification of mitral regurgitation concorded with angiography. There was an underestimation of the severity of mitral regurgitation in 30% of cases by TTE compared with angiography; prolapse was diagnosed in 7 of the 10 cases with cusp tears. It was not possible to accurately determine the intra or perivalvular site of regurgitation by TEE. With regards to aortic bioprostheses, TOE and TTE were equally useful in determining the mechanism of regurgitation, showing cusp prolapse in 6 of the 9 cases with cusp tears. However, TTE quantified regurgitation accurately in all cases with respect to angiography, whereas TOE was only contributive in 50% of cases. These results show that single plane TOE is superior to TTE in the quantification and determination of the mechanism of regurgitation in mitral bioprostheses, but that TTE remains better for the quantification of regurgitation of aortic bioprostheses.

Diagnosis of heart tumours by transoesophageal echocardiography: a multicentre study in 154 patients. European Cooperative Study Group

In a retrospective multicentre study, the diagnostic potential of transoesophageal 2D-echocardiography (TEE) as compared to precordial 2D-echocardiography (TTE) was determined in 154 patients with primary or secondary tumours of the heart. Additionally, the value of standard diagnostic parameters, such as symptoms, X-ray of the chest and electrocardiogram were evaluated. In 84 patients (24 male, 60 female; age 20-85, mean 56.6 years) intracardial tumours were present, and 70 patients (37 male, 33 female; age 18-79, mean 44.3 years) presented with peri- or paracardial tumours. The main symptoms of patients with intracardial tumours were dyspnoea (60.7%), vena cava syndrome (22.2%) and chest pain (20.2%). Embolization was found in 11.9%. Left or right atrial enlargement was observed on chest X-ray in 23 patients, and echocardiographic abnormalities in 17 cases. The patients with peri- or paracardial tumours presented with dyspnoea in 51.4% of cases, loss in body weight in 20.0% and with vena cava syndrome and chest pain in 17.1%. The chest X-ray was abnormal in 56 patients. Unspecific ST segment changes in the electrocardiogram were observed in five, and arrhythmias in seven cases. Diagnosis of atrial myxomas was achieved by TTE in 95.2%, by TEE in 100%, by angiography in 78.4%, by computed tomography (CT) or magnetic resonance tomography (NMR) in 70%. Identification of the attachment point was made by angiography in 8.1%, by TTE in 64.5% and by TEE in 95.2%. In 22 patients with intracardial tumours (myxomas excepted) diagnosis was achieved by TTE in 90.9%, by TEE in 100%, by CT or NMR in 88.9% and by angiography in 50%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value and limits of single-plane transesophageal echocardiography in dysfunctions of aortic valve prosthesis]

The authors reviewed retrospectively the results of transoesophageal and transthoracic echocardiography in 26 patients with prosthetic aortic valve dysfunction in order to study the value and limitations of monoplane transoesophageal echocardiography in this condition. Surgical data was available in 14 of these cases. The diagnosis of abscess of the aortic ring was made on 7 occasions by transoesophageal echocardiography and on 3 occasions by transthoracic echocardiography Bacterial vegetations were visualised in 5 cases by transoesophageal echocardiography and in 1 case by transthoracic echocardiography. The diagnosis of thrombosis was made in 1 case by transoesophageal echocardiography and missed by transthoracic echocardiography; fibrous pannus (n = 1) was not recognised on transoesophageal and transthoracic echocardiography. In the latter two conditions, transthoracic Doppler showed signs of obstruction. The diagnosis of a stenotic bioprosthesis due to fibrocalcific degeneration was made in 1 case by transoesophageal and in 1 case by transthoracic echocardiography. Prolapse of cusp was diagnosed in 6 cases by transthoracic echocardiography. An intraprosthetic valve leak was visualised in 7 cases by transoesophageal echocardiography and in 9 cases by transthoracic echocardiography; periprosthetic leaks were diagnosed in 9 cases by transoesophageal and in 12 cases by transthoracic echocardiography. These results indicate that transoesophageal echocardiography is a major advance in the diagnosis of abscess of the aortic ring, bacterial vegetations and prosthetic valve thrombosis. On the other hand, transthoracic echocardiography remains superior for the quantification or regurgitation and enables evaluation of transprosthetic gradients of obstructive prostheses with continuous mode Doppler. Therefore, the two methods are complementary.

[Echocardiographic diagnosis of a thrombus trapped in a patent foramen ovale. Apropos of a case]

The authors report the case of a patient presenting with pulmonary embolism in which transthoracic echocardiography showed the presence of an intracardiac thrombus trapped in a patent foramen ovale; this was confirmed at surgery. It is rare to see this type of thrombus (which usually gives rise to paradoxical embolism) by transthoracic echocardiography. Previously, this used to be a postmortem diagnosis but the condition is often suspected nowadays when deep venous thrombosis and/or pulmonary embolism, an unexplained systemic embolism and a right-to-left interatrial shunt, are associated. However, the diagnosis can only be confirmed by the visualisation of the thrombus crossing the interatrial septum.

Prognostic importance of left ventricular diastolic filling velocity profiles in dilated cardiomyopathy

To determine the prognostic importance of pulsed Doppler-derived left ventricular diastolic filling velocity profiles and the relationship between Doppler variables and clinical functional status, the follow-up outcome of 58 patients with dilated cardiomyopathy and symptoms of left ventricular dysfunction was analysed. During a mean follow-up period of 31.2 +/- 12.8 months, 23 died of either progressive pump failure or sudden death. Peak early filling velocity (E) was higher and late atrial filling velocity (A) lower in nonsurvivors than in survivors. The E/A ratio was higher and the deceleration time (DT) of early diastole shorter in nonsurvivors. The mortality was significantly higher in patients with an E/A ratio > 2 or a DT < 150 ms than in those without. Repeated Doppler echocardiographic examinations in 31 of 35 survivors after intense treatment showed decreased E, increased A, reduced E/A ratio and prolonged DT in 18 patients with clinical functional improvement, whereas these measurements were unaltered in the remaining 13 patients whose functional status was unchanged or deteriorated. This study suggests that pulsed Doppler-derived left ventricular diastolic filling variables may be important predictors of outcome in dilated cardiomyopathy and provide useful measures in observing the effects of therapy during long-term follow-up of the patients.

[Contribution of transesophageal echocardiography in the diagnosis of intra- and para-cardiac masses]

The authors detected 59 thrombi and 7 intra- or paracardiac tumors in 58 patients in a series of 1,100 transesophageal echocardiography. Twenty-six of the 51 patients with a thrombus were in sinus rhythm; 25 had atrial fibrillation. In 44 cases, the thrombus was single and in 7 cases there were multiple thrombi. A phenomenon of spontaneous contrast in the left atrium was observed in 24 patients (47%). In 31 cases (53%) the thrombi were located in the left auricle, in 21 cases (36%) in the left atrium, in 4 cases in the left ventricle and in 3 cases in the right atrium. Transthoracic echocardiography only detected 25% of these thrombi. The superiority of transesophageal echocardiography was particularly evident for the detection of thrombi in the left auricle (31 by transesophageal echocardiography versus 2 by transthoracic echocardiography) and in the left atrium (13 by transesophageal echocardiography versus 7 by transthoracic echocardiography). Five myxomas were diagnosed by transesophageal echocardiography and 4 of them were identified by transthoracic echocardiography. The site of implantation of the tumor was located in all 5 cases by transesophageal echocardiography. Two right paracardiac tumours were only visible by transesophageal echocardiography. Transesophageal echocardiography is therefore very useful in the diagnosis of thrombi in the left atrium and auricle, of rare hypodense myxomas and paracardiac tumors. In addition, it enables precise localisation of the site of implantation of nearly all intracardiac tumors.