[Syncopal angina caused by sinus arrest; cured by transluminal coronary angioplasty and calcium inhibitor]. / Angor syncopal par arrêt sinusal; guérison par angioplastie coronaire transluminale et inhibiteur calcique.

The authors report the case of a 42 year old man who smoked and who presented with recurrent spontaneous anginal chest pain followed by syncope due to sinus arrest. The mechanism underlying these symptoms was spasm of the left circumflex artery at the site of severe stenosis of its middle segment just before the origin of the sinus node artery. Treatment with a calcium antagonist with transluminal coronary angioplasty of the narrowed segment of the circumflex artery resulted in complete regression of all symptoms with a follow-up of 15 months. Seven other reports of the same type were found in the literature concerning 6 men and 1 woman, with an average age of 49 years, presenting with the same symptoms and sinus arrest associated with the minimal coronary artery disease. The proof of coronary spasm was documented in 6 of the 7 cases by a positive ergometrine stress test or by the observation of spontaneous spasm during coronary angiography or rapid atrial pacing. The outcome was good with calcium antagonist therapy in 5 cases, and with slow release nitrate derivatives in 1 case. One patient, treated by betablockers, died. It is useful to investigate some sino-atrial blocks to diagnose the underlying ischaemic mechanism as the patients may be treated simply with calcium antagonists rather than undergo implantation of a pacemaker.

[Frequency of angiographic restenosis after 6 months and long-term outcome of coronary angioplasty]. / Fréquence des resténoses angiographiques à 6 mois et devenir à long terme après angioplastie coronaire.

Five hundred patients with a mean age of 59 years were followed up for an average of 32 months after coronary angioplasty. All patients were included in a prospective study comprising coronary angiography at 6 months for 379 patients (91% primary successes). The long-term outcome was evaluated by a questionnaire or telephone interview in all cases. The global primary success rate was 84.4% in this series. The primary failures include 1.8 fatalities, 0.6% myocardial infarction, 2% emergency coronary bypass surgery and 11.2% without immediate clinical consequences. At 6 months, there were 48% of restenoses (182/379 patients) and 28% underwent immediate repeat angioplasty (141/500 patients) with a primary success rate of 91%. After the repeat angioplasty, the restenosis rate was 43% but this varied according to the time from the first restenosis: 60% when the interval was short (under 2 months) compared with 21% when the interval was 6 months (p < 0.01). The actuarial survival rates at 4 years were 95% after successful angioplasty 96% after uncomplicated failures or medically treated restenosis and 98% after bypass surgery. The predictive factors for secondary death were age of over 70 years, previous non-thrombolized myocardial infarction and complications of angioplasty. The long-term outcome was good despite the 48% 6 months restenosis rate requiring revascularisation procedure in 73% of cases.

[Significant stenosis of the common trunk of the left coronary artery. Retrospective study of 227 cases]. / Sténose significative du tronc commun de l'artère coronaire gauche. Etude rétrospective de 227 cas.

Significant left main coronary artery disease is a separate disease entity in coronary artery disease. The prognosis is classically poor and the treatment of choice is surgical. A retrospective study of patients with left main coronary disease, diagnosed and treated at the CHRU Dupuytren, Limoges, between 1/01/80 and 15/06/91 was undertaken to determine the aetiological, clinical and therapeutic factors which influence mortality related to this condition. During this period, 8198 coronary angiographies were performed in the cardiology department. The diagnosis of significant left main coronary disease (> or = 50% stenosis) was made in 250 cases (3% of all investigations). Of these 250 cases, 227 were treated medically or surgically by our group during the study period. Twenty patients were treated in another centre and 3 underwent surgery after the 15/06/91. Seven patients died in the period immediately after coronary angiography. Of the 220 survivors of coronary angiography, 185 (85%) were referred for surgery (direct or sequential venous and/or arterial bypass or coronary endarteriectomy). Four patients died within 30 days of surgery. Thirty five patients were treated medically. The therapeutic decision was based on the absence of surgical contra-indications. The retrospective, non-randomized nature of this study with allocation of patients to surgical or medical treatment without control invalidated statistical analysis. At the date of the last follow-up appointment, arbitrarily chosen as the 1/01/93, 163 operated patients (88.1%) of which 130 (79.7%) were asymptomatic and 13 medically treated patients (37%) were alive. The prognostic factors after surgery in this study were: stage IV dyspnoea at the time of diagnosis, severe abnormalities on catheter study (end diastolic pressure over 18 mmHg after angiography), left ventricular wall abnormalities (functional score > 10) and incomplete revascularization. The risk of coronary angiography in this condition were confirmed in this study.

[Failure and complications of transesophageal echocardiography. Apropos of 1500 consecutive cases]. / Echecs et complications de l'échocardiographie transoesophagienne. A propos de 1,500 examens consécutifs.

Transesophageal echocardiography (TEE) requires the introduction of a flexible probe into the oesophagus and therefore cannot be strictly considered to be non-invasive. This manipulation exposes the patient to complications which are benign in the large majority of cases. The authors report their experience in a prospective study analysing the failures and complications of TEE in the first 1,500 cases performed in their laboratory between May 1988 and May 1992, in mainly adult and ambulatory patients. The probe could not be introduced in 24 patients (1.6%), including 5 cases during the initial learning period. No serious complications were observed during of after TEE. Minor incidents were noted in 28 cases (1.9%) intolerance of the probe (12 cases), nausea and/or vomiting (4 cases), dyspnea (4 cases) due to tracheal intubation in 2 patients, laryngeal in 1 patient and to cardiac failure in 1 case. Pharyngeal haemorrhage (2 cases), atrial fibrillation (3 cases), vertigo (1 case), mandibular dislocation (1 case) and salivary hypersecretion affecting the quality of the imaging (1 case), were also observed. The investigation had to be interrupted prematurely in 12 cases (0.8%) usually because of intolerance of the probe. These results show that TEE is not dangerous in trained hands. Failure to introduce the probe is usually encountered during the learning period, which reinforces the need for apprenticeship in a teaching center. The safety of this technique, plus its considerable diagnostic value in many clinical indications, justify its present role in everyday cardiological practice.

[Giant leiomyoma of the esophagus detected by echocardiography and corroborated by x-ray computed tomography and surgery]. / Léiomyome géant de l'oesophage détecté par échocardiographie et confirmé par tomodensitométrie et chirurgie.

The authors report the case of a 44 year old man with a giant leiomyoma of the lower third of the esophagus. The patient presented with chest pain and the tumour was detected by echocardiography. The diagnosis was confirmed by computerised tomography and histological examination of the surgical specimen weighing 501.5 g. The surgeon performed a large esophago-gastric resection and reestablished the continuity of the digestive track by interposing a section of colon. A good result was obtained with a follow-up of 4 years. The authors underline the potential value of a simple barium swallow during cardiological assessment.

[Barlow's disease and risk for life]. / Maladie de Barlow et risque vital.

Idiopathic mitral valve prolapse, also called Barlow's disease, has been estimated to affect 5 p. 100 of the general population. Normally a benign disease, it becomes life-threatening in only a very small number of cases. High risk subjects could be detected by simple TM-mode echocardiography, provided this examination is of good quality and reproducible, for it shows a 5 mm or more thickening of mitral leaflets. Should this be the case, according to the Mayo Clinic authors, serious complications, such as sudden death, infective endocarditis or ischaemic cerebral vascular accidents, would be expected to occur in 10 p. 100 of the patients. Sudden death, of which only 60 cases have been published, is exceptional; it mainly concerns young subjects (mean age 40 years), predominantly women, with a family history of sudden death, who have experienced one or several syncopes and present with severe per- or intercritical dysrhythmias. Such subjects must be regularly supervised clinically as well as by basal or ambulatory electrocardiography and, if necessary, by electrophysiological or even haemodynamic exploration. Treatment with appropriate beta-blockers or antiarrhythmic agents is often required as is, in refractory cases, implantation of an automatic defibrillator. Infective endocarditis is a cause of death in 10 to 20 p. 100 of the patients. It mainly threatens subjects whose mitral valve regurgitation is suspected on the presence of a holo- or end-systolic murmur and confirmed by Doppler echocardiography.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bepridil and torsades de pointes. Apropos of 11 cases]. / Bépridil et torsades de pointes. A propos de 11 observations.

The authors report 11 cases of spikes occurring under bepridil treatment. It concerns an elderly population, predominantly female, receiving most of the time 300 mg of bepridil. The frequency of associated hypokalemic or arrhythmic medications is emphasized. The comparison of these results to those from other series in the literature, enables to propose precautions for the use of this molecule.

[Pneumopathy caused by amiodarone. An often unrecognized iatrogenic entity]. / Pneumopathie à l'amiodarone. Une entité iatrogène sovent méconnue.

Three cases of interstitial pneumopathy secondary to amiodarone are reported, in addition to almost 200 cases previously published in the literature. The main clinical, radiological, biological and evolutive characteristics are reminded in emphasizing the advantages of bronchioalveolar irrigation. Some factors seem to be predisposing, without any definite proof however. They are: high daily dosage, long term treatment, high cumulative dose, concomitant ingestion of another anti-arrhythmic medication, especially in elderly patients, and in patients who, before any treatment, presented a decreased total pulmonary capacity and a CO transfer capacity lower than 80 p. cent of the theoretical values. Discontinuation of amiodarone and administration of steroids usually produce a rapid regression of the clinical and radiological symptoms.

[Automatic quantitative analysis of myocardial tomography thallium-201 scintigraphy]. / Analyse quantitative et automatique de la tomoscintigraphie myocardique au thallium 201.

An automatic and quantitative analysis method for tomographic scintigraphy was applied to 104 patients with myocardial infarction (anterior 37, inferior 67, lateral 20, involving 2 territories in some cases). All patients underwent exercise and redistribution scintigraphy and coronary arteriography which served as reference. Two types of tomographic sections were used: 2 short axis sections exploring the left ventricle at different levels, and 1 apical section at a right angle with the first ones. A circumferential analysis program studied the isotopic activity of each section and drew an activity profile curve which was compared with those obtained in normal subjects. Exercise curves proved superior to redistribution and wash-out curves and were therefore used exclusively. Two sectoring methods for territories with infarcts were defined: conventional sectoring, which gives a 90 degrees angle to the anterior region and a 180 degrees angle to the inferior lateral region, and real sectoring established from the scintigraphic abnormalities observed in patients whose infarction was not accompanied by significant lesions in other territories. Real sectoring divides the territory into two regions (anterior and infero-lateral) and determines the extension territory and the territories specific to each necrotic region. The sensitivity and specificity of these two methods for the diagnosis of necrosis and the detection of a significant abnormality (greater than 70% stenosis, or necrosis) in a territory other than the one with infarct were compared. In the diagnosis of infarction: conventional sectoring sensitivity 92%, specificity 46% for anterior infarcts, 94% and 25% for inferior and lateral infarcts; real sectoring 94% and 63% respectively for anterior infarcts, 92% and 68% for inferior infarcts.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary angiography after the age of 70 years]. / La coronarographie après 70 ans.

100 patients over the age of 70 years underwent coronary angiography. The indications for this examination at this age were different from those in younger patients. After the age of 70 years, 58 per cent of coronary angiographies are performed as part of the haemodynamic survey of valvular disease. The risk of the examination appears to be higher, as two deaths occurred in this small series, while the mortality is estimated to be 2 per thousand in younger patients. Coronary angiography is very useful at this age in patients with valvular disease to determine the need for an associated coronary graft and also to determine contraindications for operation because of the severity of the lesions. A surgical indication was confirmed in 50 patients, but surgery was only performed in 36 of them. The follow-up of these patients demonstrates that patients operated for valvular disease had a longer survival that those considered to be inoperable or who refused operation. On the other hand, there was no difference in survival between grafted and non-operated patients over the age of 70 years.

[A case of electrically and mechanically stunned myocardium]. / Une observation de sidération électrique et mécanique du myocarde.

The authors report the case of a 72 year old patient with ECG changes of anterior myocardial infarction complicated by left ventricular failure and shock which has a favourable outcome with regression of the pathological Q waves on the 7th day. Radionuclide investigation and coronary angiography showed no myocardial sequellae and the coronary arteries appeared normal. This case, an example of stunned myocardium, confirms that severe myocardial ischaemia, even of short duration, may induce reversible but prolonged metabolic disturbances. The practical implications of this concept are discussed.

[Outcome of patients with inoperable multivessel coronary disease]. / Evolution des coronariens pluritronculaires impontables.

The authors studied the clinical course of 100 patients with two or three vessel coronary artery disease who were unsuitable for surgery because of the poor quality of the distal vascular bed or excessively depressed left ventricular function. The 6 year actuarial survival was 58 per cent; 43 of the 100 patients did not present any serious cardiac events causing death or requiring further admission to hospital, over this follow-up period. The severity of the clinical course in women and the presence of heart failure prior to coronary angiography were considered to be among the most important clinical prognostic factors. On the basis of the haemodynamic survey, the probability of survival or the risk of a further coronary accident appears to depend more on the extent of the left ventricular kinetic abnormalities than on the ejection fraction or the severity of the coronary lesions.

[Iatrogenic internal mammary arteriovenous fistula. Apropos of 2 cases]. / Les fistules artério-veineuses mammaires internes iatrogènes. A propos de deux cas.

Two fairly similar cases of internal mammary arterio-venous fistula were observed in two patients involved in serious road accidents, following which a catheter was inserted into the subclavian vein for the purposes of resuscitation. The clinical diagnosis was made in both cases on routine examination, which revealed a continuous right subclavian bruit with extensive radiation three years after the accident. There were no functional implications. Further investigations revealed a fistula located between the internal mammary artery and the right brachiocephalic venous trunk and demonstrated the haemodynamic consequences: normal intra-cardiac pressures, but a pulmonary blood flow which was twice that of the systemic blood flow. Both cases were treated by means of surgical cure via thoracotomy, which confirmed the nature of the arterio-venous fistula and which defined the relations with the phrenic nerve, which is the most exposed element. The results of this operation were excellent in both cases.

[Late chronic constrictive pericarditis following aortic valve replacement]. / Péricardite chronique constrictive tardive après remplacement valvulaire aortique.

The authors report a case of chronic constrictive pericarditis in a 54 year old patient who had undergone aortic valve replacement 6 years previously. The valve was replaced with a Starr-Edwards prosthesis because of aortic regurgitation due to infective endocarditis. The outcome after pericardectomy was favourable with a 3 year follow-up. This complication of cardiac surgery, of which there are now 45 reported cases, should not be overlooked because it can be cured surgically. The diagnosis is based on phonomechanographic, echocardiographic and, above all, haemodynamic investigations to distinguish the condition from irreversible myocardial dysfunction.

[Hyperthyroidism and mitral valve prolapse: comparative two-dimensional echocardiography study of a hyperthyroid and a control population totalling 104 patients]. / Hyperthyroïdie et prolapsus valvulaire mitral: Etude comparative par échocardiographie bidimensionnelle d'une population hyperthyroïdienne et d'une population témoin réunissant 104 patients.

Recent studies seem to demonstrate a higher incidence of mitral valve prolapse in hyperthyroid patients. A complete cardiological check-up including 2D echocardiography was performed in 52 hyperthyroid patients and 52 control subjects. In the hyperthyroid population, mitral valve prolapse was diagnosed 3 times, 5,8 p. 100 of cases. These 3 subjects were female; hyperthyroidism was nodular in 2 cases: Grave's disease was only present in 1 case. Hyperthyroidism was very active at the time of the echocardiographic study in those 3 patients. In the control group, mitral valve prolapse was observed in 4 cases (7.7 p. 100). These 4 patients were all female. The results of this study do not show a higher incidence of mitral valve prolapse in the hyperthyroid population than in the control group. Grave's disease was not more prevalent in hyperthyroid patients with mitral valve prolapse. On the other hand, there were significantly more female patients with MVP in both the hyperthyroid and control populations.

[Long-term fate of 103 patients with auricular fibrillation lasting for over 15 days treated with cardioversion and preventive therapy]. / Devenir à long terme de 103 patients ayant une fibrillation auriculaire datant de plus de 15 jours traités par cardioversion et traitement préventif.

103 patients with atrial fibrillation lasting more than 15 days were treated by cardioversion, with a return to normal sinus rhythm in 92 per cent of cases. If the atrial fibrillation recurred during the first six months, a further electric shock was given and the treated was changed or better adapted to the patient. The sinus rhythm was maintained in 85.7 per cent of patients at one year, 84.4 per cent at 2 years, 80.1 per cent at 3 years and 76.1 per cent at 4 years. The factors which predict a good result are: sex, the presence of mitral valve disease, especially when it has been operated, good tolerance of the arrhythmia and good haemodynamic status prior to the shock. The treatment used were quinidine arabogalactane sulfate (QAGS) and amiodarone. QAGS was better tolerated, while amiodarone proved to be more effective.

[Septicemia on endocavitary sounds for cardiac stimulation]. / Septicémies sur sondes endocavitaires de stimulation cardiaque.

Two cases of septicaemia on endocavitary cardiac pacemaker probes lead the authors to discuss the aetiological and therapeutic aspects of this type of infection. In both cases, the pacemaker had been in situ for a long time and had been replaced on several occasions, there was infection in the site of implantation and an attempt at removal of all of the pacemaker material failed, leaving a probe incarcerated in the right ventricle by one of its extremities with the other extremity floating free. The endocarditis associated with this septicaemia can, theoretically, be due to two mechanisms: metastatic implantation of infection form a distant site which must be detected or infection developing in contact with the pacemaker and propagated along the probe. The treatment of this type of septicaemia consists of appropriate antibiotics, which are only rarely sufficient to sterilize the infection. In most cases, all of the pacemaker material must be removed, which is easily achieved in the majority of cases. After cleansing of the site, the pacemaker has been successfully replaced. Sometimes, the probe is buried in the myocardium: surgical removal by cardiotomy, with or without extracorporeal circulation, seems to be preferable to the techniques of continuous traction which carry certain risks (tricuspid and myocardial lesions). Persistent floating probes must be removed surgically.

[Results of singular valve replacement with a mechanical prosthesis or bioprosthesis in valve diseases with advanced myocardial failure]. / Résultats du remplacement monovalvulaire par prothèse mécanique ou bioprothèse dans les valvulopathies en défaillance myocardique avancée.

Surgery may prolong survival in some patients in advanced cardiac failure due to valvular heart disease refractory to digitalo-diuretic and vasodilator therapy. The operative risk is high and myocardial dysfunction after surgery is also a problem. However, in some cases, surprising improvement is observed. An analysis of the principal publications in the literature on the natural history of valvular heart disease and the results of surgery in the last ten years show that: In chronic aortic valve disease complicated by congestive heart failure, the natural prognosis does not exceed 2 to 3 years in either aortic stenosis or regurgitation. On the other hand, prosthetic valve replacement is associated with a 57% 4 years survival in aortic regurgitation, and a 70% 5 years survival in aortic stenosis, but with an operative mortality of 20 to 27%. Surgery is even more valuable in acute aortic regurgitation due to endocarditis, leading to a 60% 2 years survival compared to only 6% with medical therapy alone. In chronic mitral valve disease with advanced cardiac failure, the natural prognosis does not exceed 4.5 years in mitral regurgitation, 8 years in mitral stenosis and an intermediate period in mixed mitral valve disease. On the other hand, prosthetic valve replacement with an operative risk of 21 to 26% is associated with a life expectancy of 56 to 60% at 5 years, and 46% at 10 years, operative mortality included. The surgical results depend on good myocardial protection and intensive pre-, per- and post-operative care using positive inotropic agents, vasodilators and, when necessary, intra aortic balloon pumping.(ABSTRACT TRUNCATED AT 250 WORDS)