[Contribution of cardiac MRI in the initial evaluation and follow-up of myocarditis mimicking acute coronary syndrome: a series of 43 patients]. / Apport de l'IRM cardiaque dans l'évaluation initiale et le suivi des myocardites mimant un syndrome coronaire aigu : à propos d'une série de 43 patients.

AIMS: The diagnosis of acute myocarditis is complex, especially when the clinical presentation mimics an acute coronary syndrome. This condition may promote the progression to dilated cardiomyopathy and the occurrence of severe arrhythmias. A reassessment integrating a cardiac MRI at three months after the acute episode could help identify patients with a poor prognosis. PATIENTS AND RESULTS: This prospective series of 43 consecutive patients hospitalised for acute myocarditis included 36 men and seven women, with a mean age of 32 years, with no indication of heart failure. All patients presented elevated levels of troponin I. Echocardiography showed moderate left ventricular dysfunction in six cases and segmental wall motion abnormalities in 22 cases. After gadolinium injection, a subepicardial late enhancement was observed in 39 cases. Three months after the acute episode, all patients were asymptomatic. The echocardiography and laboratory tests were normal. In 23 cases, the MRI showed persistence of the late enhancement without segmental wall motion abnormality. After a mean follow-up of three years, one patient was lost to follow-up and only one suffered a heart failure revealing a dilated cardiomyopathy complicated by ventricular arrhythmias. CONCLUSION: On admission, the subepicardial localisation of late enhancement in the cardiac MRI is reliable criteria for the diagnosis of acute myocarditis, enabling to rule out an acute coronary syndrome. During follow-up, the persistence of late enhancement has no impact on prognosis. In this series, after a mean follow-up of three years, it was not associated with clinical or paraclinical abnormalities, except in one patient.

[Cardiac MRI: technical considerations]. / Les conditions techniques d'utilisation de l'IRM cardiaque.

Establishing a clinical cardiovascular magnetic resonance imaging (MRI) program needs a dedicated technical surroundings as well as a specific and expert staff. These guidelines based either on proofs or on expert consensus are stated in order to help the physicians to reach or maintain the competence required for clinical use of cardiovascular MRI. After the general safety statements, the guidelines are focused on hardware and software requirements, the MRI sequences and views, the post-acquisition analysis, and the staff. Specific safety concerns are then approached, more particularly stress testing MRI.

One-month results of coronary stenting in patients > or = 75 years of age.

Coronary artery bypass operations are associated with increased morbidity and mortality in the elderly. Similarly, it has been shown that coronary angioplasty is associated with a higher risk of complications in the elderly than in younger patients. The purpose of this study was to evaluate the 1-month outcome of elderly patients (>75 years old) who were included in the Stenting without Coumadin French Registry. From December 1992 to March 1995, 2,900 patients (mean age 61+/-11 years) were included in this registry. All patients were treated with ticlopidine (250 to 500 mg/day) for 1 month from the day of percutaneous transluminal angioplasty, aspirin (100 to 250 mg/day) for >6 months, and low-molecular-weight heparin (antiXa 0.5 to 1 IU/ml) for 1 month in phase II, 15 days in phase III, and 7 days in phase IV. No heparin was given in phase V. The study group included 233 patients (8.0%) > 75 years old (mean age 79+/-4), 44 (18%) of whom were women. All patients underwent dilatation of a native coronary vessel. One hundred seventeen had unstable angina (50.2%), 20 had postmyocardial infarction ischemia (8.6%), and 6 had acute myocardial infarction (2.6%). Indications for stenting were de novo lesion in 63 patients (27.0%), restenosis in 38 (16.3%), suboptimal result in 48 (20.6%), nonocclusive dissection in 56 (24.0%), and occlusive dissection in 28 (12.0%), respectively. Stented coronary arteries were the left anterior descending in 109 (46.8%), the right in 80 (34.3%), the left circumflex in 40 (17.2%), and the left main in 4 (1.7%). Palmaz-Schatz stents were used in 228 patients (82.0%), AVE microstents in 38 (13.7%), and other stents in 12 (4.3%). More than 1 stent was used in 48 patients (17.3%). The mean diameter of the balloon used for stenting was 3.31+/-0.38 mm and maximal inflation pressure was 12.2+/-2.9 atm. At one-month follow-up, vascular complications occurred in 5 patients, requiring surgery in 2 (1.3%), acute closure occurred in 1 (0.4%), subacute closure in 3 (1.3%), emergency or planned coronary artery bypass graft surgery in none, acute myocardial infarction in 4 (1.7%), stroke in 1 (0.4%), and death in 8 (3.4%). The composite end point of a major cardiac event was observed in 13 cases (5.6%). Coronary stenting using ticlopidine and aspirin appears to be a particularly safe approach in this high-risk subset.

[Percutaneous extraction of a silicone catheter 5 years after its migration in the pulmonary artery]. / Extraction percutanée d'un cathéter siliconé 5 ans après sa migration dans l'artère pulmonaire.

The authors describe a case of percutaneous extraction of a piece of silicone-coated catheter, 5 years after its embolisation in the pulmonary artery and the results of electronic microscopic study of the specimen. The discussion provides the factors indicating extraction which is relatively easy with this technique irrespective of the chronicity of embolisation, in order to avoid infectious complications.

[Spontaneous dissection of the common trunk and principal branches of the left coronary arterial system. Apropos of a case]. / Dissection spontanée du tronc commun et des principales branches du réseau coronaire gauche. A propos d'un cas.

The authors report the case of a 45 year old woman presenting with inaugural anterior myocardial infarction due to spontaneous dissection of the left main and principal branches of the left coronary arterial system. Two attempts of thrombolysis at a one hour interval were made within 6 hours of the onset of symptoms with signs of reperfusion but the ECG and echocardiography showed anterolateral myocardial infarction. A recurrence of chest pain on the fifth day led to emergency coronary angiography. The extent and severity of the observed lesions led to emergency surgical revascularisation with no post-operative complications. Skin biopsy showed signs of dystrophy of the elastic tissues. Angiographic control ten months after surgery showed complete regression of the lesions, especially those of the left main coronary with, however, occlusion of the second segment of the left anterior descending artery and sequellae of anterior myocardial infarction. Treatment of this type of disease is difficult as the outcome is unpredictable and has to be decided case by case.

[Trans-septal catheterization. Technic and indications]. / Cateterismo transettale. Tecnica e indicazioni.

We report our experience with transseptal catheterization of the left side of the heart via the right femoral vein. This technique was attempted in 50 patients undergoing left heart catheterization for hemodynamic evaluation of aortic valve stenosis (15 patients) and prosthetic valves (35 patients). The importance of some manoeuvres, especially within the right atrium, to avoid some of the most usual complications, like cardiac or aortic perforations, intramyocardial injection of contrast medium, and embolization of left atrial masses, is underlined.

[Sequential double demand programmable stimulation in the treatment of resistant supraventricular tachycardia. Long-term results]. / La stimulation séquentielle double-demande programmable dans le traitement des tachycardies supraventriculaires rebelles. Résultats à long terme.

Asynchronous pacing at a rhythm slower than that of the tachycardia (underdrive) is an established procedure for the reduction of supraventricular tachycardia. Simultaneous or sequential stimulation depolarising two parts of the circuit (atrium and ventricle) has a greater chance of reducing the tachycardia than stimulation of a single chamber. Five patients with supraventricular tachycardia resistant to antiarrhythmic therapy were treated by sequential pacing in the underdrive mode. Electrophysiological investigations showed a bundle of Kent to be responsible for the ECG appearances of Wolff-Parkinson-White (3 cases) with retrograde conduction only (concealed WPW) in 2 cases. One patient was able to put a stop to his attacks by the application of a magnet over the pulse generator. In four patients, a newly designed pulse generator, based on this concept, was implanted with the property of automatic detection of tachycardia (defined as a heart rate faster than 150/min) triggering almost simultaneous pacing of the coronary sinus and right ventricle (sequential interval of 65 ms) in the asynchronous mode at 77 bpm. The results were reviewed with a follow up of 6 to 36 months. This pulse generator was shown to be effective in both the reduction and prevention of episodes of supraventricular tachycardia. Sequential double demand pacing is a valuable and useful method of treating reentrant tachycardias associated with the WPW syndrome or concealed Kent bundles. It provides an alternative to surgery when the effective refractory period of the Kent bundle is long. Present advances in the field of cardiac pacing will probably result in a widening of the indications for this mode of therapy.

[Calculation of the ejection fraction from simultaneously recorded systolic intervals and angiography. Comparative study]. / Le calcul de la fraction d'éjection d'après les intervalles systoliques et l'angiographie simultanément enregistrés. Etude comparative.

Garrard, Weissler and Dodge have reported a close correlation (r = -0,90) between angiographic ejection fractions (EF) and the ratio of left ventricular preejection and ejection periods (PEP/LVET) in patients with left ventricular disease without simultaneous recording equation Y" = 1,25 - 1,25 x where x is the PEP/LVET ratio and Y" the ejection fraction. Using this formula a theoretical EF may be calculated when the PEP/LVET ratio is known. A number of precautions must be taken in measuring systolic time intervals (synchronous recordings, rapid and constant recording speeds of at least 100 mm/s, good quality tracings). Respecting these conditions, close correlations between the theoretical and angiographic EF were obtained. However, discrepancies were observed in some cases and so the relationship was examined with and without simultaneous recordings in 28 patients (19 with coronary artery disease). The equations obtained were Y = 1,2 - 1,51 x and Y = 1,04 - 1,04 x respectively. The correlations in the whole group and in the coronary subgroup were not as good when the recording was not simultaneous (r = -0,78, compared to r = -0,85). The theoretic EF appeared to be "optimised" under these conditions. The "optimisation" increased with increasing values of the PEP/LVET ratio. A downward correction had to be made for abnormally high values (for example for a PEP/LVET of 0,38, the EF had to be corrected by -3,1% and for a value of 0,50 by -10,5%). This was also applicable in the patients with coronary artery disease. Curiously, the equation relating simultaneous EF and PEP/LVET was very close to that obtained by Garrard (Ya = 1, 12 - 1,27 x, ra = -0,80). The theoretical EF calculated from this equation was very close to the angiographic value. However, it was slightly higher or lower in coronary patients with or without myocardial infarction. Garrard's equation would appear to be useful for repeated studies of the ejection fraction in these patients.

[Effects of medullary pyramidal stimulation on myocardial contractility in anesthetized dogs]. / Effets de la stimulation des pyramides bulbaires sur la contractilité myocardique chez le chien narcosé.

In anaesthetized dogs, medullary pyramid stimulation produces a decrease of myocardial contractility. The peak of the first derivative of the left ventricular pressure (dP/dt max) was used to assess myocardial contractility; this index is independent of afterload. Medullary pyramid stimulation produces a decrease of dP/dt max and of the maximal left ventricular pressure (L.V.P. max) also, after bilateral vagotomy. But the same stimulation induces only a decrease of L.V.P. max after inhibiting beta-adrenergic efferences and bilateral vagotomy. Just as corticopyramidal fibres inhibiting alpha-adrenergic vascular tone, one does consider the existence of corticopyramidal fibres inhibiting beta-adrenergic efferences to myocardium.

[Assessment of cardiac output by a non-invasive method. Estimation of partial pressure of CO2 by rebreathing of expired gas. Comparison with thermodilution]. / Mesure du débit cardiaque par une méthode non agressive. Estimation de la pression partielle de CO2 par réinhalation du gaz expiré. Comparaison avec la thermodilution.

The cardiac output was measured in 65 patients by the FICK principle after estimation of the pp CO2 in mixed venous blood by rebreathing. This technique has been used mainly during exercise, and recently in intensive care units. We used it in resting patients hospitalised for diagnosis and treatment of a range of cardiac diseases, and in patients referred to our Physiological Laboratory. The reproductibility of our results using the rebreathing method was good: the variation of the individual results averaged 8.9%. The values of the cardiac output by rebreathing were compared to those obtained by thermodilution in 30 patients. A high coefficient of correlation was found: r = 0,897 (2p less than 0,001). This non-invasive technique is simple, rapid, and easily repeatible. Its use for serial estimations of the cardiac output should be retained.

[Mitral valve prolapse and spasmophilia in the adult]. / Prolapsus valvulaire mitral et spasmophilie chez l'adulte.

75 cases of mitral valve prolapse (MVP) for which no cause was found underwent electromyography (EMG). In 64 cases (85.3%) EMG showed changes suggestive of spasmophilia. The symptoms observed were those already described in this condition. The specific clinical signs of spasmophilia were often elicited with a positive Chvostek sign in 20 out of 30 cases (73.3%). Radiological, echocardiographical and haemodynamic studies underlined the hyperkinetic state of the left ventricle. Biochemical investigations showed a high incidence of low erythrocytic magnesium levels. Chest pain suggestive of angina pectoris, mitral valve prolapse and spasmophilia are frequently associated. The role of the low erythrocyte magnesium on left ventricular hyperkinesis and the production of MVP is discussed.

Effect of atenolol, a new cardioselective beta-blocker, on plasma renin activity in treatment of hypertension.

Atenolol, a cardioselective beta-blocking drug, was prescribed in doses of 100 mg b.i.d. in 23 patients with essential hypertension. At the end of the first month of treatment with Atenolol we found a significant fall in blood pressure, heart rate and plasma renin activity (P.R.A.). Besides, there existed a relationship between changes in diastolic blood pressure, in mean arterial pressure and initial plasma renin activity, and a relationship between changes in blood pressure and changes in P.R.A. It results from this finding that pretreatment P.R.A. is of predictive value of short-term efficacy of the beta-blocker. This correlation was borderline in 21 patients after a mean of 7 month treatment and could no be found for 12 cases after a mean of 10 month-treatment while the fall in P.R.A. was still significant. It therefore appears that--with reserve of the representativeness of the sample--quantitative relations between the antihypertensive effect of Atenonol and P.R.A. are no longer significant on long-term treatment.