High prevalence of ventricular repolarization abnormalities in people carrying TGFßR2 mutations.

Mutations in the TGFßR2 gene have been associated with a life threatening risk of aortic dissection but no arrhythmic death has been previously reported. Two young females carrying a TGFßR2 mutation, initially diagnosed as Marfan syndrome or Loeys Dietz syndrome, presented sudden death with autopsy ruling out dissection. The ECGs of the 2 Sudden Cardiac Deaths revealed profound ventricular repolarization abnormalities with a sinusoidal T-U morphology associated with normal left ventricular ejection fraction. These data strongly suggest sudden cardiac arrhythmic deaths and prompted us to systematically study the repolarization pattern in the patients with TGFßR2 mutations. ECG findings from 58 mutation carriers patients (TGFßR2 group) were compared with those of 46 non-affected first degree relatives (control group). TGFßR2 mutation was associated with ventricular repolarization abnormalities in 47% of patients (p < 0.001 vs. controls), including a 19.6 ms (95%CI 8.7; 30.5) QTc interval prolongation compared to the non-affected first degree relatives (p < 0.001), higher prevalence of abnormal U waves (16% vs. 2%), and sinusoidal T-U morphology (10% vs. 0%). TGFßR2 mutations can be associated with abnormal ventricular repolarization pattern, longer QT interval than non-carrier relatives and an increased risk for sudden death.

Outcomes of renal transplantation in obese recipients.

PURPOSE: Although obesity has been shown to paradoxically increase dialysis patient survival, its impact has not been clearly defined on renal transplantation. We assessed outcomes of obesity renal transplant patients by evaluating graft and patient survivals. PATIENTS AND METHODS: A single-institution, retrospective study was performed on 202 renal transplant recipients from January 2004 to December 2008 excluding two combined kidney and liver transplantations. Recipients were classified based on body mass index (BMI) at the time of transplantation: obese (BMI ≥ 30 kg/m(2)) and nonobese recipients (BMI < 30 kg/m(2)). The comparative analysis included surgical complications, hospital stay, onset of delayed graft function (DGF), acute rejection episodes and graft patient survivals. RESULTS: Twenty-one renal transplants were performed in obese recipients versus 179 in the control group. Obese patients were older (53.3 ± 11.2 versus 46.4 ± 14.4 years old; P = .035) and more often diabetic (29% ± 0.46 versus 60% ± 0.24, P = .001), but there were no differences among other combidities of high blood pressure, arteriopathy, thrombophilia, and smoking. Obesity did not appear to be a risk factor for urinary or vascular as well as parietal complications, but did tend to augment lymphatic complications (14.3% ± 0.36 versus 4.5% ± 0.21; P = .065). DGF occurred more frequently in obese patients (38% ± 0.50 versus 14% ± 0.34; P = .004) and hospital stays were therefore longer in this group (24.9 ± 23.53 days versus 15.6 ± 13.67 days; P = .008). Graft (hazard ratio [HR] 1.22; 95% confidence interval [CI] [0.25-6.0], P = .63) and patient survivals (HR:0,81; 95% CI [0.12- 5.3], P = .83) were comparable between the groups. CONCLUSION: Obese patients seeking renal transplantation are usually older and more often diabetic compared with nonobese recipients. The higher rate of lymphatic complications and DGF lead to longer hospital stays among the group with BMI ≥ 30 kg/m(2). However, long-term results showed similar graft and patient survivals as nonobese patients. Consequently, there seemed to be no reason to avoid renal transplantation in obese recipients.

Risk factors for surgical complications after renal transplantation and impact on patient and graft survival.

PURPOSE: We report herein the incidence of and factors predisposive to surgical complications (SC) after renal transplantation. METHODS: Between 2004 and 2008, we performed 200 renal transplantation. We retrospectively studied recipient and donor characteristics, cold ischemia time, surgical revision in the month after transplantation, delayed graft function, surgical complications (vascular, urologic, wound, or bleeding), as well as graft and patient 5-year survival rates. RESULTS: Sixty-six surgical complications were reported among 49 patients with a preponderance of urologic complications. We noted 6.1% Clavien I, 1.5% Clavien II, 30.3% Clavien IIIa, 53% Clavien IIIb, and 9.1% Clavien IVa SCs. Vascular complications showed a worse prognosis. Among recipients, dialysis duration before transplantation (40.3 ± 50.8 months in SCs versus 28 ± 26.5 months in the control unaffected group, P = .032) and anti-HLA immunization (34.7 ± 48% versus 21.2 ± 41%, P = .05) appeared to be risk factor. No significant factor was identified among donors, although patients with surgical complications received older transplants than the control popuation (49.7 ± 14.5 years versus 45.5 ± 15.1 years, P = .08). A greater percentage of delayed graft function (30.6 ± 46.6% versus 11.4 ± 31.9%; P = .001) and graft rejection episodes (34.7 ± 48.1% versus 17.9 ± 38.4%, P .013) were observed among the SC compared with the control group. No significant difference in patient (89.5% versus 95.6% confidence interval, CI 95% [0.7-10.0]; P = .14) or graft survival (88.7% versus 91.8%, CI 95% [0.4-3.9] P = .63) was observed between the groups. CONCLUSION: Surgical complications, especially urologic complications appear frequently after renal transplantation. Dialysis duration and pre-transplant immunization were linked to the occurrence of a surgical complication, which did not affect graft or patient survival.

[Accuracy of prostate biopsies to evaluate tumor location in prostate cancer]. / Fiabilité des biopsies prostatiques pour l'étude de la topographie tumorale dans le cancer de prostate.

INTRODUCTION: The therapeutic approach of prostate cancer depends mainly on pathological criteria obtained through prostate biopsy. The low accuracy of prostate biopsy for Gleason grade determination is well known but its accuracy for bilateral or multifocal tumor has not been evaluated. The goal of this study was to assess the concordance between prostate biopsy and whole prostate specimen obtained after radical prostatectomy especially for bilateral and/or multifocal tumor. METHODS: We retrospectively compared the pathological results of prostate biopsy cores to the prostate specimen in patients who underwent radical prostatectomy in our department between the 01/01/1999 and the 31/12/2008. The criteria analyzed were the Gleason score, tumor bilaterality or multifocality. The impact of the number of prostate biopsy cores was also analyzed. RESULTS: Two hundred and five complete histological records were studied. Regarding the Gleason score overall concordance was 55%. In 38%, prostate biopsies downgraded the Gleason score. This concordance decreased with tumor differentiation (90.6% for Gleason 6 vs. 31% for Gleason greater than 7). For the tumor bilaterality, 78% of cancers affected both lobes at the definitive specimen analysis while only 49% were bilateral at prostate biopsies, achieving a concordance of 61%. Multifocal disease was observed in 36% at definitive pathology analysis with low concordance with prostate biopsies (36%). The number of biopsies increased the concordance for the Gleason score (60 to 81% for Gleason 7 and from 28 to 50% for Gleason greater than 7) and tumor location (44 to 70%). CONCLUSION: Pathological criteria and tumor mapping obtained from prostate biopsies were not very reliable especially when the tumor was poorly differentiated. An increased number of prostate biopsy core improved the sensitivity and specificity for the Gleason score diagnostic and of the tumor mapping.

[Muscularis mucosae invasion: prognostic factor for intravesical BCG immunotherapy failure for T1 bladder carcinoma]. / Atteinte de la Muscularis Mucosae dans les tumeurs urothéliales T1 de vessie : facteur pronostique de progression après immunothérapie par BCG.

OBJECTIVES: To study the prognostic impact of muscularis mucosae (MM) invasion for pT1 bladder cancer treated by transurethral resection (TUR) and adjuvant Bacille Calmette-Guerin (BCG) intravesical immunotherapy. METHODS: Sixty-six patients treated by BCG intravesical instillations were substaged into pT1a and pT1b, regarding Muscularis Mucosae invasion. Tumor grade, associated carcinoma in situ (CIS), multifocality, tumoral size up to 3cm, BCG maintenance were noted. With a mean follow-up of 50.5±38 months, we studied recurrence, progression, overall and specific survival. Cox's model method was used for multivariate analysis. RESULTS: Tumor recurrence was observed in 30±7% and 43±10% (P=0.29) and tumor progression in 16.3±5% and 39±10% (P=0.04) for pT1a and pT1b. The rate of progression was higher (P=0.04) and progression free survival was decreased (P=0.04) for pT1b. Specific death rates were 11±5% and 21±9% (P=0.28), median overall survival was 80.9 [1.5-92] and 48.2 [12-93] months for pT1a and pT1b. Overall and specific survival weren't different between the two populations (P=0.38; P=0.3). Cystectomy rates were 2.3±2% and 30±9% for pT1a and PT1b (P=0.0006). For pT1a patients, recurrence (P=0.8) or progression rates (P=0.64) were no different regarding BCG maintenance immunotherapy but pT1b population had a better progression free survival with BCG maintenance than without (P=0.0051). Only CIS had prognostic value in multivariate analysis. CONCLUSIONS: Tumors with Muscularis Mucosae invasion have a higher risk of progression and BCG failure. Maintenance immunotherapy should be given to improve results with these patients.

[Urinary complications of one-stitch ureteroneocystostomy in renal transplantation]. / Complications urinaires après réimplantation urétérovésicale selon la technique du "one-stitch" en transplantation rénale.

PURPOSE: To assess urinary complications related to the "one-stitch" technique extravesical ureteroneocystostomy in renal transplantation, and evaluate the impact of such complications on kidney graft and patient survival. PATIENTS AND METHODS: A single-institution, retrospective study was performed on 202 renal transplant recipients, from January 2004 to December 2008. Two combined kidney and liver transplantations were excluded. The "one-stitch" extravesical ureteroneocystostomy technique, fast and easy to perform, was systematically used. The evaluated urinary complications were urinary fistula, ureteral stenosis, symptomatic ureteral reflux, stone formation and complicated hematuria. We tried to point out factors impacting urinary complications occurrence and studied grafts and patients survival according to the existence of urinary complications. RESULTS: Fifty-five patients presented urinary complications (27.5%). The most frequent urinary complications were complicated hematuria (36 over 200, 18%), ureteral stenosis (15 over 200, 7.5%). Few cases of stone disease (one over 200, 0.5%), urinary fistula (two over 200, 1%) and symptomatic ureteral reflux (one over 200, 0.5%) were noted. Male gender (100 vs 34, P=0.95), age (46.78 ± 14.17 vs 48.06 ± 14.19 years, P=0.58), Body mass index (24.14 ± 5.04 vs 24.28 ± 4.83, P=0.86) and past history of renal transplantations (16 ± 3% vs 10 ± 3%, P=0.27) as well as cold ischemia time (17.08 ± 7.07 vs 16.9 ± 8.95 hours, P=0.71) were not significantly different in the urinary complications group and the non-urinary complications group. Median hospitalization time was similar in both groups (14 vs 12 days, P=0.37). The existence of urinary complications didn't affect the 5 years kidney graft survival (91.9% vs 89.9%, HR 1.21, CI 95% [0.37-3.3], P=0.83) neither the 5 years patient survival (94.8% vs 92.15%, HR 0.52 CI 95% [0.13-2.07], P=0.85). CONCLUSION: If benign urinary complications in "one-stitch" ureteroneocystostomy were frequent in our study (17% grade II Clavien Dindo), kidney graft and patients survivals were not affected.

[Marfan syndrome]. / Syndrome de Marfan.

Marfan's syndrome is a monogenetic disease with an autosomal dominant transmission generally accompanied by type I fibrillin abnormality. This widely-distributed molecule participates in the structure of connective tissues so that any aberration may result in disease of many systems: skeletal morphology, dislocation of the lens, neurological or cutaneous signs and dilatation of the aorta predisposing to dissection, mitral valve prolapse being a common association. The diagnosis, clinical because of the size of the culprit gene and the multiplicity of the possible mutations, is sometimes difficult, and diagnostic criteria have been proposed. It is important to make the diagnosis because treatment is based on the restriction of violent exercise, betablocker therapy and regular echocardiographic monitoring of the ascending aorta, the region at highest risk of dilatation and dissection. A family enquiry is essential to make the diagnosis before the onset of complications in pauci-symptomatic patients (great intra-familial variability). Pregnancy poses special problems in these patients.

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

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

[Dystrophic aortic insufficiency]. / Insuffisance aortique dystrophique.

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

[Aortic dissection at 6 months gestation in a women with Marfan's syndrome. Simultaneous Bentall intervention and cesarean section]. / Dissection aortique au 6e mois d'une grossesse chez une femme atteinte d'un syndrome de Marfan. Intervention de Bentall et césarienne simultanées.

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

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

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

[Simultaneous measurement of systolic pulmonary artery pressure by catheterization and contrast enhancement doppler echocardiography]. / Mesure simultanée de la pression artérielle pulmonaire systolique par cathétérisme et échocardiographie doppler avec contraste.

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

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

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

[Double-blind clinical and echocardiographic study of oral enoximone versus placebo in severe cardiac insufficiency]. / Etude clinique et échocardiographique en double insu de l'enoximone oral contre placebo dans l'insuffisance cardiaque sévère.

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

[Doppler echocardiographic evaluation of vasodilator treatments in patients with cardiac insufficiency. Contribution to the combination of isosorbide dinitrate and captopril]. / Evaluation par l'échocardiographie-doppler des traitements vasodilatateurs chez l'insuffisant cardiaque. Application à l'association dinitrate d'isosorbide/captopril.

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

[Correlations between plasma concentrations of atrial natriuretic factor and right ventricular function in patients with severe cardiac failure]. / Corrélation entre les concentrations plasmatiques de facteur atrial natriurétique et la fonction ventriculaire droite chez des patients en insuffisance cardiaque sévère.

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

[Quantitative two-dimensional echocardiography in acute pulmonary embolism]. / Echocardiographie bidimensionnelle quantitative au cours de l'embolie pulmonaire aiguë.

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

[Cardiac toxicity of 5-fluorouracil. Two cases]. / Cardiotoxicité du 5-fluorouracile. Deux observations.

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

[Anti-angina effect of amiodarone versus delayed-action propranolol. A double-blind randomized study]. / Effet anti-angineux de l'amiodarone. Etude randomisée en double aveugle contre le propranolol retard.

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

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

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