[Effects of temporary dual-chamber cardiac pacing in refractory cardiac failure]. / Effets de la stimulation cardiaque double chambre temporaire dans l'insuffisance cardiaque réfractaire.

The authors studied 18 patients (15 men, 3 women) with an average age of 67 +/- 8 years with refractory cardiac failure. In order to determine the potential of pacing to raise cardiac output in severe cardiac failure. The average ejection fraction was 26 +/- 6.5%. All patients were in sinus rhythm:resting cardiac output was 3.35 l/min. Two temporary pacing catheters were positioned in the right atrium and at the apex of the right ventricle for dual-chamber mode pacing triggered by the spontaneous P waves. Changes in cardiac output were measured by Doppler echocardiography at different values of atrioventricular delay. Patients were considered to be responders if their cardiac outputs rose by 15%. In 7 patients meeting this criterion, the average increase in cardiac output was 27% (2.99 +/- 0.7 to 3.81 +/- 0.86 l/mn; p < 0.01); all had dilated cardiomyopathies with left bundle branch block and the optimal AV delay was 103 +/- 21 ms (80-140 ms); the duration of diastolic filling increased from 212 +/- 98 to 292 +/- 116 ms (p = 0.02). In the non-responding group (11 patients with an increase of cardiac output of only 3.6 +/- 0.09 to 3.9 +/- 0.92 l/mn; p < 0.01), the underlying disease process was mainly ischaemic. Two predictive factors of efficacy of dual-chamber pacing were identified: a short ventricular filling period (29 +/- 8% of the RR interval in the responders vs 44 +/- 9% in the non-responders; p < 0.01) and the presence of 1st degree atrioventricular block. Dual-chamber pacing could be a valuable method of increasing resting cardiac outputs in a selected group of patients with severe, refractory, cardiac failure.

[Late supraventricular arrhythmia complicating Fontan or cavopulmonary type procedures. Apropos of 7 cases]. / Troubles du rythme auriculaire tardifs compliquant les opérations de type Fontan ou de type cavopulmonaire. A propos de 7 observations.

The authors report 7 cases of late arrhythmias after atriopulmonary (5 cases) or total cavopulmonary (2 cases) bypass procedures. There were 6 cases of atrial flutter and one case of atrial tachycardia. The condition presented with cardiac failure in 5 cases. In 2 patients, atrial flutter caused syncope or dizziness. The arrhythmia was reduced by atrial stimulation (3 cases) or by cardioversion (1 case). Prevention of recurrence with oral amiodarone was effective in all cases but was responsible for secondary effects in 4 cases. In one patient, recurrence of atrial flutter was complicated by right atrial thrombosis with cerebral embolism. Five patients were reoperated after cardiac catheterisation and angiography. Surgery consisted of resection of a stenosis of the anastomosis in one case, and the transformation of atriopulmonary anastomosis into a total cavopulmonary bypass because of a very dilated right atrium without stenosis in 4 patients. The immediate postoperative period was complicated by a recurrence of the arrhythmia in 3 children not treated by antiarrhythmic therapy. At long-term, one patient died 6 months after withdrawal of amiodarone therapy of recurrence of atrial flutter. Five of the 6 survivors are treated with amiodarone or a betablocker; 3 have had pacemaker implantation for severe bradycardia. Late atrial arrhythmias complicating atrio- and cavopulmonary bypass procedures carry a risk of cardiac failure and sudden death. When diagnosed, the patient should be investigated for stenosis of the anastomosis but severe dilatation of the right atrium is often the only finding. After restoration of sinus rhythm, maintenance antiarrhythmic therapy should be continued indefinitely.

[Thoracic electric bioimpedance. A non-invasive method for the measurement of cardiac output]. / Bioimpédance électrique thoracique. Une méthode non invasive de calcul du débit cardiaque.

Bioimpedance offers a simple non-invasive means of measuring systolic ejection volume and heart rate and thus cardiac output. Four pairs of electrodes are placed on precise locations on the chest and stroke volume is calculated according to the equation developed by Kubicek in 1966 and modified by Sramek in 1980. The aim of this work was to evaluate this method in patients with heart disease. In a series of 50 patients, the coefficient of correlation for cardiac index between impedance values (2.52 +/- 0.71 ml/min/m2) and thermodilution values (2.74 +/- 0.69 ml/min/m2) was 0.63 (p < 0.01). The mean difference was -0.2 l/min/m2 (confidence interval +1 l/min/m2 to -1.4 l/min/m2). There was no statistical correlation in patients with complete left bundle branch block, severe mitral or aortic regurgitation or dilatation of the aorta. In a group of 11 healthy volunteers, there was a good correlation between two measures taken at a 2 day interval (r = 0.95). The coefficient of variation ranged from 1.2 to 7% for ejection volume. Bioimpedance is reproducible and simple, authorizing its use for non-invasive monitoring of cardiac output in a given patient in various clinical situations.

[Early clinical, electrocardiographic and biological criteria of reperfusion after intravenous fibrinolysis during the acute phase of myocardial infarction]. / Critères précoces, cliniques, électrocardiographiques, et biologiques de reperfusion après fibrinolyse intraveineuse à la phase aiguë de l'infarctus du myocarde.

Between May 1991 and February 1992, 31 consecutive patients were included in a prospective study, the aims of which were to determine the criteria of early coronary revascularisation after intravenous thrombolysis in the acute phase of myocardial infarction. The rise in serum myoglobin, the ST segment elevation, accelerated idioventricular rhythm and the evolution of chest pain were analysed. All patients underwent coronary angiography. Twenty-six were revascularized and 5 remained with coronary occlusion. Two types of serum myoglobin curves were demonstrated. Those with a sudden , decrease and a well defined peak in the first 4 hours were specific for revascularisation and easily identified (Group A: 16 patients). The graphs with a progressively rising slope to a peak after the 4th hour were observed in patients with coronary occlusion, but also in 10 patients with recanalized arteries (Group B). No significant difference was demonstrated with regards to the clinical and coronary angiographic parameters between patients in Group A and Group B. On the other hand, the time between the onset of chest pain and peak myoglobin was shorter in Group A (298 +/- 81 min) than in recanalised patients in Group B (380 +/- 54 min) (p < 0.05). The difference in the profile of the serum myoglobin could therefore reflect restoration of arterial flow in myocardial cells which had not suffered the same period of ischemia. ST segment elevation may increase, decrease of remain stable at 120 minutes in patients revascularised and those remaining occluded. In 9 patients, the ST elevation increased compared with the initial electrocardiogram .(ABSTRACT TRUNCATED AT 250 WORDS)

Post-radiotherapeutic left main coronary ostial stenosis: clinical and histological study.

Pericardial abnormalities remain the most common manifestation of radiation-induced cardiac disease, but coronary artery lesions are not rare. In this report we describe a left coronary ostial stenosis which appeared five years after mediastinal irradiation for breast carcinoma in a 50-year-old woman. The patient underwent coronary angiography. A pressure drop was observed as the left catheter tip engaged the left coronary ostium; so, only nonselective coronary opacifications were performed showing an isolated, marked narrowing of the left coronary ostia. During surgery, a circumferential aortotomy allowed the examination of the left coronary ostium which appeared severely stenosed. The coronary tree was otherwise normal. A termino-terminal saphenous vein graft was anastomosed on the left stem and its proximal part was implanted on the ascending aorta. The coronary ostium and the proximal part of the left main stem were excised and the macroscopic examination of the proximal part of the left coronary artery confirmed the diagnosis of severe ostial stenosis. Microscopic examination of the coronary ostium showed a severe intimal thickening without any evident lesion of the media. This intimal thickening consisted of fibrous tissue without extracellular lipid deposit. Microscopic examination of the aorta near the coronary ostium also demonstrated an intimal thickening without any lesion of the media. Coronary ostial stenosis appears to be a rare lesion; its incidence has varied between 0.13 and 2.7% in angiographic studies and there is co-existing disease in multiple coronary vessels in the majority of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Short-term clinical and haemodynamic assessment of balloon aortic valvuloplasty in 30 elderly patients. Discrepancy between immediate and eighth-day haemodynamic values.

Recently, percutaneous aortic valvuloplasty has been considered as a possible palliative procedure in elderly patients with critical valvular stenosis in whom valve replacement is deferred or contra-indicated because of high operative risk. However, the demonstration of the efficacy of such a procedure is based on immediate post dilatation haemodynamic data and clinical improvement. The purpose of this study was to evaluate the haemodynamic consequences of this procedure on the eighth day after a post procedure haemodynamic control. Thirty consecutive patients (mean age 75 +/- 8.4 years) with long-standing aortic stenosis were treated at the time of cardiac catheterization with balloon dilatation. Of these 30 patients, 24 (mean age 76 +/- 8) underwent haemodynamic evaluation eight days after the procedure. Prevalvuloplasty examination revealed a mean aortic valve gradient (MAVG) of 82 +/- 19.9 mmHg, a mean thermodilution calculated cardiac output (CO) of 3.6 +/- 0.9 l min-1 and a mean aortic valve area (VA) of 0.37 +/- 0.14 cm2. Immediate postvalvuloplasty control showed a fall in MAVG to 44.5 +/- 16.7 mmHg (P less than or equal to 0.001), a decrease in CO to 3.3 +/- 1.4 l min-1 (NS) and an increase in VA to 0.60 +/- 0.35 cm2 (P less than or equal to 0.01). Eighth-day haemodynamic control revealed an increase in MAVG to 71 +/- 18.8 mmHg (P less than or equal to 0.001), an increase in CO to 4.1 +/- 1.3 l min-1 (P less than or equal to 0.001) and a decrease in VA down to 0.47 +/- 0.10 cm2 (P less than or equal to 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous balloon dilatation of calcific aortic valve stenosis: anatomical and haemodynamic evaluation.

Two groups of elderly patients with calcified aortic stenosis were treated by balloon dilatation. In group 1, the valve was dilated just before surgical replacement of the valve. The valvar and annular changes occurring during dilatation were examined visually. In 20 of the 26 patients in this group there was no change. In the six remaining patients mobilisation of friable calcific deposits (1 case), slight tearing of the commissure (4 cases), or tearing of the aortic ring (1 case) were seen. Dilatation did not appear to alter valvar rigidity. In 14 patients (group 2) the haemodynamic gradient across the aortic valve was measured before and immediately after dilatation and one week after the procedure. Dilatation produced an immediate significant decrease of the aortic mean gradient and a significant increase of the aortic valve area. Eight days later the mean gradient had increased and the aortic valve area had decreased. Nevertheless there was a significant difference between the initial gradient and the gradient eight days after dilatation. The initial aortic valve area was also significantly larger than the area eight days after dilatation. The aortic valve gradient rose significantly in the eight days after dilatation and at follow up the gradients were those of severe aortic stenosis.

Angioplasty of chronic totally occluded coronary arteries: usefulness of retrograde opacification of the distal part of the occluded vessel via the contralateral coronary artery.

Eighteen patients with chronic totally occluded coronary arteries underwent percutaneous coronary angioplasty. Eleven of these patients had a proximal occlusion of the left anterior descending artery and seven had occlusion of either the proximal or middle right coronary artery. All patients had severe angina pectoris with clearly positive results of stress treadmill testing. Preservation of a viable myocardium despite an occluded artery was, in each instance, the result of excellent collateral flow arising from the contralateral coronary artery. The guide wire and the dilatation balloon were properly positioned by opacifying the distal segment of the occluded artery by injection of contrast into the contralateral artery in 15 of 18 patients. Almost simultaneous injection, first into the contralateral vessel and then into the occluded artery, allowed evaluation of the true length of the occlusion. Contralateral opacification disappeared immediately after adequate recanalization and reappeared during inflation of the balloon. These examples show that in patients with chronic coronary occlusion, opacification of the distal segment by injection of contrast into the contralateral vessel seems to be helpful and without risk to the patient.

[Isolated ostial stenosis: a peculiar anatomic form of coronary insufficiency in women]. / Les sténoses ostiales isolées: une forme anatomique particulière d'insuffisance coronaire de la femme.

We report 5 cases of isolated ostial stenosis of the left main coronary vessel. Isolated ostial stenosis occurs preferentially in young or middle aged women for whom coronary insufficiency is usually not a serious threat. Patients with this type of lesion have characteristically severe angina of relatively recent onset. The condition may be difficult to diagnose at angiography, but a fall in pressure when the tip of the catheter enters the coronary lumen beyond the stenosis, a lack of reflux of the contrast medium into the sinus of Valsalva during intracoronary injection and its persistence in the coronary vessel should alert the investigator. A pathological study of 3 cases revealed typical atheromatous lesions in 2 patients (with extension of an aortic plaque to the left coronary ostium in one, and atheroma localized on the ostium in the other) and a purely fibrous lesions in a patient who had undergone thoracic radiotherapy 5 years previously. Although relatively rare, stenosis must be diagnosed in view of its sombre spontaneous prognosis (one patient died 3 days after coronary arteriography), of the risk of underestimating its frequency, and of the hazards of selective coronary catheterization in such patients (one of our patients died 15 minutes after coronary exploration).

Percutaneous mitral valvotomy in rheumatic mitral stenosis: a new approach.

Three patients with rheumatic mitral stenosis were treated with percutaneous mitral valvotomy. A Brockenbrough catheter was advanced transseptally into the left atrium and then into the left ventricle over a long guide wire. An angle wire loop retriever was advanced through a 10 Fr straight catheter via the femoral artery into the left ventricle. The retriever was used to catch the flexible end of the long guide wire. This end of the long guide wire was then drawn out of the right femoral artery by the retriever through the straight catheter. The straight catheter was left in the descending aorta; the Brockenbrough catheter was removed and a 7 Fr balloon catheter was introduced percutaneously over the long guide wire through the femoral vein. This balloon catheter was used for interatrial septal dilatation and right femoral venous dilatation. In two patients this catheter was replaced over the long guide wire with a 9 Fr Schneider-Medintag Grüntzig catheter (3 X 12 mm diameter when inflated) and in the other by a Mansfield (18 mm diameter when inflated). The procedure was well tolerated in these three patients and there were no complications. Haemodynamic function improved, there was appreciable decrease in dyspnoea, and exercise tolerance was increased. This procedure has several advantages: the balloon is more easily positioned through the mitral valve; the stability of the balloon during inflation is improved by traction at both ends of the long guide wire; and there is the option of rapidly exchanging one balloon for a larger one over the long guide wire. This technique seems to be less arrhythmogenic and results in less blood loss because manual compression of the femoral vessels after the procedure is easier.

[Cardiac involvement in 2 cases of malignant non-Hodgkin's lymphoma. Course of cardiac involvement under chemotherapy]. / Atteinte cardiaque dans deux cas de lymphomes malins non hodgkiniens. Evolution de l'atteinte cardiaque sous chimiothérapie.

In a recently published post-mortem series the incidence of cardiac lesions in malignant lymphoma was estimated at about 8.7%. These lesions rarely produce specific cardiac symptoms; they usually are late manifestations of a disease with multiple secondary lesions or are discovered at autopsy. In most patients the lesions are not limited to the heart but represent the extension to that organ of a malignant lymphoma. We observed two cases of cardiac lesions secondary to malignant non-Hodgkin lymphoma and we were able to evaluate their response to chemotherapy. In the first patient the cardiac symptoms revealed the lymphoma; in the second patient the cardiac involvement was discovered 4 years after the lymphoma was diagnosed. In both cases the cardiac lesions were detected by two-dimensional echocardiography. They presented as polypoid masses filling the right atrium and associated with periaortic thickening in the first case, and as a large heterogeneous mass including a tricuspid valve leaflet and extending to the free wall of the right ventricle in the second case. Pericardial effusion was present in the two patients. These echocardiographic findings were confirmed computerized tomography and catheterization. In the first case, followed up for one year, the echocardiographic images reverted to normality after chemotherapy. The second patient, unfortunately, did not respond to chemotherapy and deteriorated rapidly.

Anterograde percutaneous transseptal valvuloplasty in a case of severe calcific aortic stenosis.

The retrograde catheterization and percutaneous dilatation of calcific stenotic aortic valves is not always possible in elderly patients. We report the case of a 76-year old woman admitted with severe aortic stenosis in whom it was impossible to reach the left ventricle retrogradely. This led us to attempt percutaneous aortic valvuloplasty using a transseptal anterograde approach. The Mullins transseptal sheath catheter was advanced into the left ventricle and a 7 F catheter containing a long guide wire (400 cm) passed through the sheath. The flexible end of the guide wire was advanced through the aortic valve anterogradely and an angled wireloop retriever used to catch the flexible end of the guide wire and to draw it out of the body through the left femoral artery. A 7 F balloon catheter was introduced percutaneously over the long guide wire and allowed dilatation of the interatrial septum and femoral vein. A 8 F Schneider-Grüntzig catheter (80 mm) length, 19 mm diameter when inflated) was inserted anterogradely through the aortic valve over the guide wire without difficulty and the balloon catheter was inflated to a pressure of 6 atmospheres with a 30 seconds inflation-deflation cycle. Before the procedure the mean aortic valvular gradient was 114 mmHg and the aortic valve area was 0.30 cm2. After the procedure the mean aortic gradient had fallen to 60 mm Hg and the valve area had risen to 0.90 cm2. These results are comparable to those expected using the more usual retrograde balloon dilatation of the aortic valve.

[Transluminal dilatation of occluded coronary arteries. Value of retrograde opacification of the occluded vessel by the contralateral artery]. / Dilatation endoluminale d'artères coronaires occluses. Intérêt de l'opacification rétrograde du vaisseau occlus par l'artère controlatérale.

The authors report the results of 8 cases of percutaneous transluminal coronary angioplasty of occluded arteries: the artery concerned was the proximal segment of the left anterior descending artery in 5 cases and the proximal segment of the right coronary artery in 3 cases. All patients had unstable angina with a very positive exercise stress test. The conservation of viable myocardium was the result of an excellent collateral circulation from the controlateral vessel in all patients. In 7 out of the 8 cases, the guide wire and dilating balloon were correctly positioned by opacifying the distal segments of the occluded artery by injection of contrast into the controlateral artery. Almost simultaneous injection of the occluded and controlateral vessels allowed evaluation of the length of the occlusion. Controlateral opacification disappeared immediately after adequate recanalisation to reappear during inflation of the balloon. These cases show that in patients with chronic coronary occlusion, opacification of its distal segments by injection of contrast into the controlateral vessel seems to be helpful and without risk to the patient.

[Acute mitral endocarditis in a 4-month-old infant]. / Endocardite aiguë mitrale chez un nourrisson de 4 mois.

The authors report a case of bacterial endocarditis from unidentified bacteria, responsible for a rupture of chordae of the mitral valve in a 4 month-old infant with a previously normal heart. Bidimensional echocardiography led to diagnosis. The importance of the mitral loss thus created made a mitral plasty necessary with cardiopulmonary by-pass at age 2 years. Ultrasonographic data were then confirmed. Postoperative result was excellent. The features of acute bacterial endocarditis in infancy are reviewed.

Coronary artery perforation during coronary angioplasty.

In one patient percutaneous transluminal coronary angioplasty was complicated by coronary artery perforation of the left anterior descending coronary artery with light pericardial effusion. The outcome was favorable without either pericardiocentesis or emergency surgery.

Role of coronary spasm in the genesis of myocardial infarction: study of a case treated by isosorbide dinitrate in situ then by transluminal angioplasty.

We report the observation of a 62-year-old patient who was admitted for unstable angina. A prolonged chest pain (more than two hours) with a major electrocardiographic lesion in the posterior leads needed an urgent coronary arteriography in order to attempt a recanalization. Antecedents of arteriopathy of the lower limbs with aortobifemoral bypass required an axillary artery right side approach. A selective right coronary opacification showed complete occlusion at the junction of segments 1 and 2. An intracoronary injection of isosorbide dinitrate relieved a coronary spasm and allowed a complete visualization of the right coronary artery. This appeared to be very atherosclerotic with several severe narrowings, and a subocclusive lesion at the site of the initial occlusion. Percutaneous transluminal coronary angioplasties (PTCA) were performed and led to real 'restructuring' of the right coronary artery. The clinical outcome was excellent without recurrent angina pectoris. An angiographic control performed 6 months after PTCA demonstrated the persistence of the coronary recanalization and an evident improvement of the segmental contractility. This report emphasizes the role of coronary spasm in the genesis of myocardial infarction and shows that PTCA may be performed as a first approach at the acute phase of myocardial infarction; to our knowledge it is the first PTCA performed by an axillary approach at the acute stage of myocardial infarction.

[Rare mechanical complications of right ventricle infarction. Value of two-dimensional echocardiography]. / Complications mécaniques rares de l'infarctus du ventricule droit. Intérêt de l'échocardiographie bidimensionnelle.

Two rare mechanical complications of right ventricular infarction are reported: myocardial dissection and rupture of the RV free wall. The diagnosis was made by 2D echocardiography in both cases. Myocardial dissection resulted in the formation of an oblong, expansive, intraparietal space. The rupture of the RV free wall was visualised as a breach of the continuity of the ventricular wall. These cases underline the importance of 2D echocardiography in the acute phase of myocardial infarction for the diagnosis of these complications.

[Ectasia of coronary arteries. Review of the literature. Apropos of 5 cases]. / Ectasies des artères coronaires. Revue de la littérature. A propos de 5 observations.

The authors present 5 cases of coronary artery ectasia discovered on coronary angiography and review the literature on the subject. The aetiology of these coronary aneurysms is discussed: coronary atherosclerosis seems to be the most common cause of this condition which some authors consider to be a variant of coronary atheroma. The therapeutic management is controversial. The indications for surgery are rare and should be carefully considered. Long term anticoagulant therapy, however, appears to be essential.