In young patients with stroke of undetermined etiology, large vessel occlusions are less frequent in the group with high-risk patent foramen ovale

INTRODUCTION

Patent foramen ovale (PFO) is present in a significant proportion of young patients with stroke of undetermined etiology, but is not always causal. Therefore, classifications (RoPE, PASCAL) have been developed to determine the probability that PFO is the stroke cause. However, the presence of an initial arterial occlusion as a prediction factor was not studied when these classifications were built. Our aim was to evaluate the presence of arterial occlusion in young patients with stroke of undetermined etiology with/without high-risk PFO.

METHODS

From a prospectively-built monocentric database, we identified patients aged≥18 to<60-years with strokes of undetermined etiology and complete etiological work-up, including transesophageal echocardiography. We divided patients in two groups: (i) with high-risk PFO [i.e. PFO with large interatrial shunt (>30 microbubbles) or associated with atrial septal aneurysm] and (ii) with low-risk/without PFO. We recorded the presence of arterial occlusion and large vessel occlusion (LVO) in the acute phase.

RESULTS

We included 96 patients; 55 (57%) had high-risk PFO. Their median age was 48 (40-52) years, and 28 (29%) were women. The percentages of patients with arterial occlusion and with LVO were lower in the high-risk PFO group than in the low-risk/without PFO group: 11 (20%) versus 19 (46%) (P=0.008), and 5 (9%) versus 15 (37%) (P=0.002), respectively. There was no difference in the median RoPE score between groups (P=0.30).

CONCLUSION

The presence of LVO could represent a "red flag" of PFO causality in stroke of undetermined etiology, and could be implemented in future PFO-related stroke classifications.

P1843Transcatheter aortic valve implantation in patients with uninterrupted vitamin k antagonist

Background

Bridging of vitamin K antagonist (VKA) with heparin is usually not promoted during interventional or surgical procedures related to increased risk of bleeding and thrombotic events but this strategy has not been evaluated during TAVI.

Purpose

The aim of this study was to evaluate the rate of major bleeding and vascular complications after TAVI performed in patients with uninterrupted VKA.

Methods

From January 2016 to October 2017, consecutive patients who underwent TAVI with uninterrupted VKA (INR between 1.5 and 3.5) were prospectively included in a monocentric registry. TAVI were performed according to current guidelines and a 50UI/kg bolus of heparin was injected at the beginning of the procedure for all patients. Vascular and bleeding complications were assessed using the Valve Academic Research Consortium 2 (VARC2) and the Bleeding Academic Research Consortium (BARC) definitions at 30 day follow-up.

Results

A total of 88 patients were included with a median age of 84 years [81.8–87], 42% being female, the median STS score was 5.1 [4.1–7.5], the median CHADS2-VASc was 5.5 [5–6] and 60.2% had a chronic kidney failure. Median INR at time of implantation was at 2.1 [1.8–2.6]. VKA were used for atrial fibrillation (89.8%), mechanic mitral prosthesis (5.7%) or venous thromboembolic disease (4.5%). Trans femoral access was used in 88.6% of the patients. Major bleeding (BARC ≥3b) occurred in 5 patients (5,7%) and major vascular complications occurred in 7 patients (8%). Peripheral arterial disease (RR = 10.95; 95% CI: 1.63 to 73.75; p=0.014) and carotid access (RR=8.56; 95% CI: 1.19 to 61.51; p=0.033) were significantly associated with major bleeding. INR >2.5 was significantly associated with vascular complications (RR=7.14; 95% CI: 1.29 to 39.63; p=0.025). In multivariate analysis, Body mass index (OR=1.26; 95% CI: 1.02 to 1.57; p=0.032) and INR >2.5 (OR=18.91; 95% CI: 1.62 to 221.26; p=0.010) were independent factor significantly associated with vascular complications or major bleeding. Mortality rate at 30 days follow-up was 2.3%, there was no myocardial infarction and stroke rate was 4.5%.

Figure 1. Study flowchart

Conclusion

TAVI with uninterrupted VKA treatment seems to be feasible and safe with low risk of bleeding and vascular complications in this first single centre experience. Particular caution is advocated in low BMI patients and to keep INR<2.5.

P1793Eight-year clinical outcome and valve durability after transcatheter aortic valve implantation

Background

With the growing indications of transcatheter aortic valve implantation (TAVI) worldwide and among lower risk patients, valve durability has become a crucial issue.

Purpose

To assess mid and long-term evolution of different generations of percutaneous balloon-expandable prostheses, predictive factors of valve deterioration and its correlation with long-term mortality.

Methods

All consecutive patients undergoing TAVI for severe aortic stenosis with balloon-expandable prosthesis between 2009 and 2014 and with a minimum follow-up of one-year were included in this monocentric prospective study. All echocardiograms were reviewed by two independent experts. Clinical events were defined according to the Valve Academic Research Consortium criteria. Valve deterioration was defined according to the 2017 EAPCI-ESC-EACTS international consensus statement at the longest follow-up.

Results

A total of 160 patients were included with a median follow-up of 3.4 years [1.5–4.9] and a maximum of 8 years. Patients were mostly implanted with the first generation Sapien XT valve (n=138, 86.2%). Median age was 85 [79–86] years, with 42.5% of women and a median logistic Euro-SCORE of 14.2% [10.6–23.2]. Immediately after TAVI, mean aortic gradient decreased dramatically from 51±12mmHg to 9±2.6mmHg (p<0.0001) and remained overall stable with a mean gradient of 12±1mmHg at 8 years. Valve deterioration occurred in 5.6% (n=9) of patients, of which 3.7% (n=6) with severe deterioration. Moderate or severe peri-prosthetic aortic regurgitation was observed in 2.5% (n=4) of patients. The eight-year survival rate was 12.9%. During follow-up, hospitalization for acute heart failure was required for 23.7% (n=38) of patients, a myocardial infarction or a stroke occurred respectively among 1.9% (n=3) and 5% (n=8) of patients. After multivariate analysis, size or generation of valves were not independent predictive factors of valve deterioration.

Evolution of mean aortic gradient

Conclusions

After a maximal 8-year follow-up, valve deterioration after balloon-expandable TAVI is very low. In this high-risk population, TAVI seems to be a safe and durable alternative to surgery in severe aortic stenosis regardless of prosthesis generation.

Acknowledgement/Funding

Edwards Lifesciences

Prevalence of obstructive sleep apnoea in acute coronary syndrome: Routine screening in intensive coronary care units

INTRODUCTION

Increased evidence has shown that, despite the maximum care afforded to patients admitted with acute coronary syndromes (ACS), a residual risk of mortality remains, in which obstructive sleep apnoea (OSA) appears to be a largely undiagnosed factor, particularly in the intensive cardiac care unit (ICCU). The purpose of this study is to determine whether the systematic screening for sleep-disordered breathing (SDB) is feasible and may be recommended. The aims of our study are to determine: (1) The estimated prevalence of OSA in patients admitted to the ICCU for ACS determined by a validated, user-friendly portable screening device; (2) The feasibility of the screening in this context; (3) To assess any negative impact of OSA on the severity of ACS.

PATIENTS AND METHODS

This is an observational study of 101 patients admitted to the ICCU for ACS showing no clinical evidence of heart failure (HF). In the 24-72hours following admission, they underwent an overnight sleep study using a 3-channel portable screening device with automatic analysis.

RESULTS

Sixty-two out of the 101 patients proved positive to the screening test, and its feasibility was acceptable. OSA patients tended to have greater peak levels of hs-cTnT (3685±3576ng/L versus 2830±3333ng/L, P=0.08) than the non-OSA group. Compared with the non-OSA group, OSA patients presented more severe ACS, with a greater average GRACE score at admission of 112.2±26.3 (versus 98.4±19.2, P<0.001). In the OSA group, we found a statistically significant inverse correlation between the apnoea-hypopnea index (AHI) and the left ventricular ejection fraction (LVEF) in the linear regression analysis (r=-0.26; P=0.037).

CONCLUSIONS

A systematic screening of patients in the ICCU is acceptable. OSA is frequently found in the acute phase of ischaemic heart disease and its presence is associated with more severe ACS and a poorer left ventricle systolic function.

[Are patients undergoing coronary angiography well-informed? Prospective evaluation of the effectiveness of written information]

INTRODUCTION

Prior information in the realization of an invasive intervention is crucial. Indeed, the patient has to know theoretically his disease, diagnostic and therapeutic means, but also the risks of the used technique. The habits of information vary many from one center to another, in spite of the proposition of an information leaflet written by the French Society of Cardiology. Our aim was to evaluate the effectiveness of written information for patients hospitalized for coronary arteriography.

METHODS

Among patients hospitalized for realization of a programmed coronarography, a questionnaire was delivered before the information leaflet. The knowledge of the patients was so tested (27 items) before and after the reading of the information sheet (not limited time). The knowledge of the patients concerning coronarography indication, modalities, benefits, possible complications or still later possibilities was informed.

RESULTS

Thirty-four patients were included: all knew hospitalization reason, 86% were men, middle-aged 65 (IC 95% 60-70). Thirty-four percent (15-54) had studied in higher education. Ninety-seven percent had had information before. Only 56% (38-74) were informed about the mode of anesthesia, 36% (19-53) duration, 69% (53-86) the injection of iodine, 44% the risk of allergy, 53% the risk of bruise, 15% of the cardiac risks, 21% the renal risks. Seventy-one percent knew the diagnostic benefits, 44% the possible coronary angioplasty, 17% the eventuality of a bypass surgery. The delivery of the information leaflet did not modify the knowledge on most of these items, in particular the modalities and the profits. The risks were known significantly better for the allergy (P=0.019), the bruise (P=0.018), the cardiac risks (0.001).

CONCLUSIONS

The population benefiting from a coronarography considers to be enough informed. However, knowledge of the modalities, profits and risks is very low. The delivery of the consensual leaflet does not allow improving the situation, except as far as concerned the complications. Better information is so indispensable, not only to obtain a better support of the patient in the treatment, but also to prevent the forensic implications. The improvement of the information must be multifactorial, but usually used means could be not sufficient.

Routinely-feasible multiple biomarkers score to predict prognosis after revascularized STEMI

INTRODUCTION

We assessed the long-term prognostic value of an easy-to-do multiple cardiac biomarkers score after a revascularized acute myocardial infarction (MI) in order to evaluate a multimarker approach to risk stratification, based on routine biomarkers.

MATERIAL AND METHODS

Blood samples from 138 patients hospitalized with acute myocardial infarction and successfully treated by primary coronary intervention (with TIMI 3 flow) were subsequently tested for creatinin level at admittance and then BNP, hsCRP, troponin I from Day 0 to day 7. The primary endpoint was a clinical evaluation comprising: new hospitalization for cardiac reasons, acute coronary events (acute coronary syndrome), and death.

RESULTS

During the median follow-up period of 11.01 months [9.44-12.59], 47 events were recorded. All the following markers were able to predict events: creatinemia on admission (p=0.0057), CRP on day 3 (p, troponin I on day 1 (p<0.001), BNP (p<0.0001) and biological multimarker score (p<0.0001). Clinical events were predicted with a hazard ratio (HR) of respectively 3.30 [2.88-12.30] in BNP Q4 as compared to the three lower quartiles (Q1-3), and 3.15 [2.75-21.00] for the Multimarker approach. The multimarker score was not significantly better than BNP on day 1 alone (p=0.77), troponin on day 1 alone (p=0.43), creatininemia on admission (p=0.19) or CRPhs on day 3 alone (p=0.054). Nevertheless, the Multimarker approach leads to the selection of a smaller, hence more manageable, high-risk population (13% versus 25%).

CONCLUSION

Among 138 subjects admitted for acute MI, and all successfully revascularized, a routinely multimarker approach with BNP, hsCRP, creatininemia, troponin I, is feasible. BNP is the most powerful marker, and this multimarker approach renders additional prognostic information helping to identify patients with high-risk to clinical events.

Can troponin elevation predict worse prognosis in patients with acute pericarditis?

INTRODUCTION

Myopericarditis are common in clinical practice: up to 15% of acute pericarditis have a significant myocardial involvement as assessed by biological markers. This prospective, bicentric study is aimed at describing a myopericarditis population, the clinical and MRI follow-up, and search for prognosis markers.

PATIENTS AND METHODS

Between May 2005 and September 2007, 103 patients hospitalised for acute pericarditis were prospectively enrolled. Physical examination, ECG, echocardiography, biological screening and cardiac MRI, in case of myopericarditis defined as acute pericarditis with troponin I elevation, were performed. Between December 2007 and July 2008, patients were contacted for new clinical and MRI evaluation.

RESULTS

Among the initial population of 103 patients admitted for acute pericarditis, 14 myopericarditis and 38 pericarditis were included. Compared with pericarditis, the myopericarditis group was associated with the following features: younger age (34.9 years [95% CI 28.3-41.2]; p=0.01), ST-segment elevation (nine patients between 14; p=0.03), higher troponin I (7.3 microg/L [95% CI 4.4-10.2]; p<10(-4)) and lower systemic inflammation (CRP peak 38.1mg/L [95% CI 7-69.2]; p=0.01). In the case of myopericarditis, infectious etiologies were predominant (12 patients among 14; p=0.002) and patients stayed longer in hospital (5.8 days [95% CI 4.7-6.8]; p=0.01). Follow-up showed no difference in terms of functional status (p=0.3) and global complications (p=0.9) between paired myopericarditis and pericarditis. Nevertheless, cardiac mortality was higher for myopericarditis (p=0.04). MRI follow-up showed myocardial sequelae without clinical impact.

CONCLUSION

Myopericarditis significantly distinguished from pericarditis. Three years follow-up showed no difference in terms of global complications but a higher cardiac mortality for myopericarditis. MRI myocardial lesions did not develop into symptomatic sequelae.

[Daily management of acute pericarditis: clinical and paraclinical outcomes, etiological diagnosis]

INTRODUCTION

Acute pericarditis is a frequent hospitalization cause. A prospective, bicentric study aimed at different goals: population description, aetiologies screening, and evaluation of the interest of a coordinated and combined management between cardiologists and internists.

PATIENTS AND METHODS

Between May 2005 and September 2007, all patients admitted for acute pericarditis were prospectively enrolled. Physical examination, ECG, echocardiography, biological screening were performed. Patients were asked to consult both cardiologist and internist, one month later.

RESULTS

Hundred and three patients were enrolled (mean age 43 years). Clinical outcome was classical in 60% of cases. ECG was typical in 59%. Troponin elevation was noted in 30% of patients. CRP was normal at diagnosis in 27% of patients, and increased significantly at first day (P=0.002). Possible cause was identified in 44 patients. In 26 patients (24.3%), precise diagnosis was performed: six cancers, one hemopathy, three connectivities, one EBV and one parvovirus B19 seroconversions, two untreated HIV patients, four inflammatory diseases, three endocrinology troubles, one oesophagitis, one dental sepsis, one amyloidosis, one acute pancreatitis, one declined dialysis indication. Eighteen de novo diagnoses (16.5%) were performed, out of them at least 12 benefited from specific management.

CONCLUSION

Population of patients admitted for acute pericarditis are very heterogeneous. Our co-management between internists and cardiologists aims to diagnose earlier and easier curable diseases. Long-term follow-up remains of great interest, in order to diagnose later other disorders, which remained hidden, and to follow evolution of the population.

[Intra-cardiac lymphoma with right heart failure: a therapeutic emergency in two patients]

We report the cases of two patients admitted to the Emergency Department with a clinical picture of right heart failure. An emergency echocardiograph suggested an intra-cardiac tumor which turned out to be a primary intra-cardiac lymphoma in one case, and a diffuse lymphoma principally localised in the heart in the other. Echocardiographic, CT and MRI investigations clarified the sites, as well as anatomical relations and extensions. Histology confirmed the diagnosis, and allowed classification of the lymphoma in order to decide on treatment. A PET scan performed in one patient illustrated the response to treatment. The respective significance of each of these investigations is discussed, in addition to the management. While transthoracic echocardiography remains the key element in the acute management, MRI and PET scans are being used more and more often for determining the character of these lesions, as well as for assisting with therapeutic decisions and for follow-up.

Long-term follow-up of biventricular pacing using a totally endocardial approach in patients with end-stage cardiac failure

BACKGROUND

Besides standard left ventricular (LV) stimulation via the coronary sinus, a transseptal approach allows left ventricular endocardial stimulation. We report our long-term observations with biventricular stimulation, using a strictly endocardial system for patients presenting with severe congestive heart failure.

METHODS

Six patients with nonischemic cardiomyopathy (mean age = 60 +/- 9.6 years, women) in New York Heart Association (NYHA) functional class III (n = 5) or IV, despite optimal drug therapy, and a mean LV ejection fraction of 24 +/- 3%, underwent implantation of biventricular stimulation systems between April 1998 and March 1999. All presented with left bundle branch block and an increased LV end-diastolic diameter (mean = 66 +/- 5 mm). In all patients, a bipolar pacing lead was implanted in the lateral LV wall using a direct transseptal approach. After implantation, all patients received oral anticoagulation.

RESULTS

QRS duration decreased from 184 +/- 22 ms to 108 +/- 11 ms. NYHA functional class decreased to II in all patients within 1 month. Over a 85 +/- 5 month follow-up, two patients underwent cardiac transplantation, 2 and 4 years after device implantation, respectively; two patients died of end-stage heart failure 4 years after system implantation; and two patients were alive in functional class II. One patient, who experienced syncope due to fast ventricular, underwent implantation of an ICD. One transient ischemic attack occurred in a patient whose anticoagulation was temporarily interrupted.

CONCLUSIONS

Long-term endocardial biventricular stimulation via a transseptal approach was safe and effective in this small population. This approach needs to be further compared with conventional epicardial pacing via the coronary sinus.

[Ventricular tachycardia due to branch to branch re-entry]

Ventricular tachycardia due to branch to branch re-entry constitutes a rare clinical entity. This circuit is remarkable by the fact that it is made up of the branches or hemi-branches of the bundle of His bifurcation. They occur under specific conditions, with a combination of left ventricular dilatation and atrioventricular or intraventricular conduction defects. They are also very often found in Steinert's disease. A positive diagnosis can sometimes be difficult and relies on a variety of factors. Recording of the His potential shows His activity preceding each ventriculogram, and variations in spontaneous cycles between 2 ventriculograms preceded by variations between the 2 His potentials. Atrial capture without modification of the QRS is possible, but fusion excludes the diagnosis. Drug therapy is only slightly effective, and the best treatment is ablation of the right branch of the bundle of His, which stops the tachycardia definitively.

[The electrocardiogram of atrioventricular blocks]

Atrioventricular block (AVB) is defined as delay or absence of transmission of one or more atrial excitations to the ventricle. Physiological functional block protects the ventricle against very rapid atrial rhythms. Organic blocks may be transient, due to an acute regressive condition, or chronic, in which case they fall into two groups--permanent blocks or paroxysmal and generally rate-dependant blocks. The blocks are classified in three categories according to whether the atrial activation is delayed, conducted intermittently or not at all. The site of AVB may be determined by His bundle recordings but it may also be deduced from the surface ECG recording. Fundamental studies have questioned the reality of Rosenbaum's phase 3 and 4 blocks and suggest abnormalities of excitability in pathological zones.

[Right atrial thrombus--a complication of central venous catheters]

We describe the development, in three days, of a pediculate mass hanging on the right atrial lateral wall in a 39-year-old woman with a subclavian venous catheterization. She was a current smoker and alcoholic but without drug addict. The hypothesis of a non valvular right atrial infective endocarditis was considered at first, but subsequent events directed the diagnosis towards a thrombus, which was resorbed by heparin. We discuss the incidence, the complications, the treatment and the differential diagnosis of thrombus caused by a central venous catheter. The prevention of right atrial thrombus caused by a central venous catheter depends on the position of the central venous catheter tip, either in the superior vena cava or at the superior vena cava-right atrium junction. A more distal position is a frequent source of thrombotic and embolic complications.

[Concealed phenomena in electrocardiography]

Concealed phenomena in electrocardiography are events which, having no direct effect on the electrocardiogramme, nevertheless change the following sequences giving rise to very unusual appearances. They are diagnosed by deduction. First of all, there is concealed anterograde or retrograde conduction in the AV node, the consequences of which are either a block or the suppression of an escape rhythm or even facilitation of the transmission of activation. Concealed conduction is also possible in the Bundle of His and its branches, explaining the frequency of dependent blocks and aberrant conduction. There is also concealed conduction in accessory pathways. The second form is concealed rhythms: hisian extrasystoles giving rise to pseudo A-V block, and concealed extrasystoles and parasystoles. With temporary pacing of tachycardia, it has finally been possible to describe "visible" concealed phenomena, not on the surface but on the endocavitary electrogramme.

[Diagnosis of narrow QRS complex tachycardias]

Tachycardias with normal QRS complexes (less than 0.12 seconds) may have multiple origins which may be classified in 4 groups: sinusal, atrioventricular nodal, atrioventricular junctional and finally, some ventricular tachycardias arising from near the conduction pathways. The electrocardiographic diagnosis requires analysis of the QRS complexes to detect an eventual irregularity which would suggest atrial fibrillation. When the tachycardia is regular, analysis of the P waves is fundamental (position in the ventricular cycle and morphology). The relationship of the P waves and the QRS complexes enables identification of those forms independent of the AV node and some rare types of tachycardia. Finally, the response to vagal stimulation is essential whether the tachycardia stops, slows down or persists unchanged.

[Parasystole]

Parasystole is usually an extrasystolic rhythm which can occur at every level, but particularly in the ventricle. It is admitted that the parasystolic focus is protected from the environing myocardium by an entry block but can manifest itself. Actually, a pure unidirectional block does not exist and the environing myocardium affects the parasystolic rhythm by an electrotonic current which modulates the output. A non-parasystolic complex which occurs prematurely in the parasystolic cycle delays it. Conversely it accelerates the cycle when it occurs late. By this fact, a parasystole pacing is possible and can lead to a fixed coupling. This arrhythmia is frequently unknown and can be experimentally, reproduced by a sucrose gap preparation.

Transcranial Doppler detection of cerebral microemboli during left heart catheterization

The role of transcranial Doppler ultrasonography (TCD) in individual risk assessment of embolic complications and the development of prevention strategies during coronary angiography remains to be determined. The purpose of this study was to assess the prevalence, time of occurrence and potential significance of microembolic signals (MES) detected with TCD during femoral left heart catheterization. TCD monitoring of the right and left middle cerebral artery was performed in 51 consecutive patients (36 men, 15 women) who were referred for coronary angiography. Percutaneous coronary angioplasty was performed during the same procedure in 16 patients. MES were counted manually during and after (off-line analysis) the procedure. Two patients were excluded from analysis because of the absence of an adequate acoustic temporal window. No neurological event occurred within 24 h in the 49 included patients. MES were detected in all except 2 patients (mean number 17.1 +/- 12.8 per patient), mainly during left ventriculography (38%) and contrast media injection into the coronary arteries (55%), suggesting their gaseous origin. There was no statistically significant association between the number of MES and patient age, cardiovascular history and risk factors, or catheterization results. The presence of coronary artery disease was inversely related to the number of MES (15.8 +/- 0.3 compared to 21.8 +/- 0.2 per patient when a normal angiogram was present; p < 0.05). In conclusion, although asymptomatic microemboli commonly occur during left heart catheterization, the majority of them are probably of gaseous origin, since they occurred predominantly during contrast media injection in this study, and were not related to cardiovascular history or to atheroma risk factors. Because air embolism has been reported to be harmful, attempts to reduce its occurrence during catheter-based procedures could be pertinent.

[Bouveret's tachycardia]

In 1889, in an age preceding the invention of the electrocardiogram, a physician working in the hospitals of Lyon published a remarkable paper on essential paroxysmal tachycardia, of which Bristowe in England and Huppert in Germany had already spoken. The study described 12 cases (including 3 personal cases) of essential paroxysmal tachycardia and 6 secondary tachycardias. They were not all benign, there being 4 deaths out of the 12 cases. From this period on, the term "Bouveret's tachycardia" has been used in France and, with the advances in rhythmology, some have assimilated it to paroxysmal nodal tachycardia. In fact, many forms of paroxysmal essential tachycardia have been recognised at atrial (nodal tachycardia, accessory pathway tachycardia, idiopathic atrial flutter and fibrillation) and ventricular levels (benign or ventricular Bouveret's tachycardia). This is an occasion to review the variety of clinical medicine in the accuracy of a rhythmological diagnosis without forgetting that the electrocardiogram is essential when the recordings are analysable. The term of Bouveret's tachycardia should be retained but, before electrocardiographic analysis, it englobes all paroxysmal tachycardia occurring in healthy hearts, and not only paroxysmal nodal tachycardia.

Aspergillus flavus mitral valve endocarditis after lung abscess

A 16-year-old male with bone marrow failure due to chemotherapy for recurrent acute lymphoblastic leukemia developed an abscess in the lower lobe of the left lung draining through a bronchogastric fistula, as well as mitral valve endocarditis with large vegetations. After a course of antifungal therapy, the left lobe was removed and the fistula closed. The mitral valve was then replaced, after a failed attempt at valve repair, by a mechanical, double-leaflet prosthesis. Microscopy of the lung and heart specimens disclosed hyphae. Cultures of both specimens on Sabouraud's medium recovered a fungus, which was identified by culturing on Czapek's medium as Aspergillus flavus. Despite further antifungal therapy, fatal embolism developed. The emboli contained the same A. flavus as the valve and lung specimens. This case confirms the grim prognosis of primary Aspergillus endocarditis in immunocompromised patients, and suggests that delayed surgical treatment and the presence of another focus of Aspergillus infection may increase the risk of death.

[Brugada's syndrome]

Sudden death by ventricular fibrillation is a possible complication of most cardiac diseases but there are some cases of ventricular fibrillation assumed to be idiopathic, in which the most complete aetiological investigations remain negative. Syncope and sudden death by torsades de pointe then ventricular fibrillation of long QT syndromes without cardiac disease are well known: they are purely electric abnormalities, the ionic and genetic bases of which are becoming progressively better known. In 1991, a new syndrome was described by Pedro and Joseph Brugada with particular electrocardiographic appearances (right bundle branch block with ST elevation in leads V1-V3) and episodes of ventricular fibrillation occurring in patients without apparent heart disease. This syndrome, clinically similar to the unexpected cases of sudden death during their sleep of young men from South East Asia or living there, has aroused much interest. Similarly to the congenital long QT syndrome, the concept of a purely arrhythmic abnormality seems apparent and our understanding of the sequence leading from the electrocardiographic changes to the underlying ionic abnormalities initiating them and the genetic disorders which program them, have made great strides.

Successful conservative surgery of acute ascending aortic dissection occurring during coronary angiography

We reported the case of an acute aortic dissection complicating right guiding catheter manipulation during engagement in the right coronary ostium. Despite absence of hemodynamic deterioration, dissection progressed rapidly from the sinus of Valsalva to the ascending aorta along its entire length. At surgery, performed in emergency, the aorta was not dilated and the aortic wall did not appear pathologic. Therefore conservative surgery was performed, consisting of suture of the aortic tear and incollage of the false lumen, with good immediate and mid-term results.

Left ventricular lead insertion using a modified transseptal catheterization technique: A totally endocardial approach for permanent biventricular pacing in end-stage heart failure

This article describes a new technique of LV lead insertion, using transseptal catheterization performed through the right internal jugular vein, to obtain a totally endocardial biventricular chronic pacing in end-stage heart failure. Three patients with QRS widening (> 180 ms) linked to complete left bundle branch block (n = 2) or right ventricular pacing (n = 1) were included in this preliminary study. Catheterization was performed under fluoroscopy and transesophageal echocardiography guidance. Transseptal catheterization was achieved by puncture of the right internal jugular vein at the base of the neck and by using a Brockenbrough needle, the tip curve of which was more curved than the standard model. A flexible long sheath was advanced in the left atrium through the interatrial septum and then a unipolar electrode was placed easily in the LV. The proximal tip of the LV lead was tunneled from the neck to the subclavian area and connected to the ventricular channel of a dual (n = 1) or simple (n = 2) chamber pacemaker. Efficient acute sensing (V wave amplitude = 13 +/- 3 m V) and pacing (acute pacing threshold = 0. 7 +/- 0.4 V) were obtained in the three patients. Early loss of capture occurred in two patients requiring lead replacement. Functional status dramatically improved in all three patients. At 6-month follow-up, biventricular pacing was maintained in all patients (mean threshold 1.4 V) who were free of clinical embolic event with oral anticoagulation therapy. This modified technique of jugular transseptal catheterization appears promising for the development of left heart pacing.

[Patterns of left ventricular adaptation to arterial hypertension]

The level of arterial pressure is not the sole determinant of cardiac adaptation to hypertension. In order to identify other factors (such as preload as well as neuro-humoral factors) we categorized by M-mode echocardiography, 192 never treated patients with mild to moderate hypertension of short duration, according to values of end-diastolic relative wall thickness (RWT) and left ventricular mass index (LVMI). Mitral regurgitation was excluded in all patients by Doppler echocardiography. Among hypertensive patients, LVMI and RWT were normal in 43% (group 1), whereas 20% had increase RWT with normal LVMI "concentric remodeling" (group 2), 24% had concentric hypertrophy (increase both LVMI and RWT) (group 3) and 13% had increased LVMI with normal RWT (eccentric hypertrophy) (group 4). Results presented as means +/- SD. [table: see text] In addition the acute response after ACE-inhibition (captopril 50 mg) of mean arterial pressure was significantly attenuated in group 4 when compared with group 1. These results suggest that the effect of arterial pressure on the heart may be modulated by volume overload (low PRA and high CI) in hypertensive patients with eccentric LV hypertrophy with normal LV function.