[Detection of thrombosis of the left atrium in mitral valve stenosis. Particular value of transesophageal echography]. / Détection des thromboses de l'oreillette gauche du rétrécissement mitral. Intérêt particulier de l'échographie transoesophagienne.

This retrospective study assessed the prevalence of left atrial thrombi in mitral stenosis and evaluated the diagnostic value ot the main means of investigation Five hundred and eighty-one patients underwent open heart surgery over a 10 year period. The prevalence of atrial thrombi was 7%, the majority (60%) being located in the left atrial appendage. The sensitivity of transthoracic echocardiography for detecting thrombi in the left atrial cavity was satisfactory (65%) but was very poor for detecting thrombi in the left atrial appendage (4%). The results of invasive investigations (atrial angiography and coronary angiography) are no better. Without any doubt, transoesophageal echocardiography, performed in 101 patients in this series, has transformed these results (sensitivity 83%, specificity 97%). False negatives in this study mainly concerned small thrombi adherent to the atrial wall. Under these conditions, it would seem reasonable to propose transoesophageal echocardiography to all patients with mitral stenosis complicated by an embolic event or for those for whom percutaneous commissurotomy is suggested.

Diagnosis of left atrial thrombi in mitral stenosis--usefulness of ultrasound techniques compared with other methods.

The purpose of this study was to evaluate various methods of diagnosis of left atrial thrombi (LAT) in patients (pts) with mitral stenosis (MS). From 1980 to 1990, 581 pts with MS have undergone open mitral commissurotomy (n = 169) or valve replacement (n = 412). All pts had transthoracic 2D echocardiography (TTE), 101 transoesophageal echocardiography (TEE), 192 a left atrial angiography (A) (from a left ventricular injection if associated mitral regurgitation grade 3 (n = 154) or from an injection in the pulmonary artery (n = 38) and 229 a coronary angiography (CA). Tomodensitometry (TD), nuclear magnetic resonance (NMR) and 111 Indium platelet imaging (IPI) were performed in some cases, 2, 8 and 5 respectively. All these examinations were carried out in the month before surgery. LAT was found by the surgeon in 43 pts (7%). The site was left atrial appendage in 26 cases (60%) and left atrial cavity in 17 cases. Sensitivity (Se), specificity (Sp) of TTE/TEE/A/CA were the following: TTE, Se% 28, Sp% 99; TEE, Se% 83, Sp% 97; A, Se% 28, Sp% 99; CA, Se% 14, Sp% 100. Specificity was high with all methods but sensitivity was high only with TEE and poor with other methods because of difficulty in detecting thrombi of the left atrial appendage. Specificity and sensitivity of TD, NMR and IPI require more information. False-negative cases are possible with NMR (1 case) and IPI (1 case) in well established LAT. We conclude: TEE is the easiest way to detect LAT, particularly when located in the left atrial appendage. It should be carried out systematically before percutaneous mitral valvuloplasty or surgery.

[Echography in surgical mitral insufficiency. Pathologic diagnosis and provision of the surgical procedure]. / L'échographie des insuffisances mitrales chirurgicales. Diagnostic lésionnel et prévision du type de chirurgie.

The aim of this study was to determine the reliability of preoperative transthoracic and transesophageal echocardiography compared with the surgical findings in pure or dominant severe mitral regurgitation with respect to: the evaluation of the lesions, mechanism and etiology; the provision of the type of surgery (valve replacement or reconstruction); One hundred and fifty patients were divided into two groups: Group I (N = 120) in which preoperative assessment included transthoracic echo-Doppler coupled with color Doppler in the last 32 patients; Group II (N = 30) operated recently who underwent both transesophageal and transthoracic echo-Doppler examination. In Group I, the sensitivity of transthoracic echo in the evaluation of the etiological was 86% overall [100% in rheumatic valve disease (N = 28), 86% in degenerative or dystrophic valves (N = 72), 44% in endocarditis (N = 9), 87% in ischaemic dysfunction (N = 8)]. The echo evaluation of the mechanism of the regurgitation was also reliable with the exception of ruptured chordae in which direct visualisation of the rupture was only possible in 19 of the 64 cases (30%). The type of surgery predicted by echo was practiced in 87% of cases.

[Value of transesophageal echocardiography. From a preliminary experience of 532 cases]. / Intérêt de l'échographie cardiaque par voie transoesophagienne. A partir d'une expérience préliminaire de 532 cas.

Transesophageal echocardiography (TEE) was introduced recently in France. The aim of this study was to review the diagnostic value of this technique after 8 months' use in our cardiology department. A total of 532 TEE studies were carried out between April and December 1988 in 396 patients (average age 54 years, range 17 to 89 years) at Tenon Hospital. The failure rate was 1.8 per cent (N = 10), over half of which occurred at the beginning of the operator's experience. TEE was particularly valuable compared with the standard transthoracic approach in the following instances: the investigation of mitral stenosis, especially before percutaneous valvuloplasty (N = 75). A left atrial thrombus was demonstrated in 5 cases by TEE vs none by standard echocardiography. There was also a much higher diagnostic sensitivity for small interatrial shunts (40 vs 6) resulting from transseptal catheterisation. In the preoperative investigation of severe mitral regurgitation (N = 29). The etiology was accurately diagnosed in 29 vs 26 cases, and the mechanism of the regurgitation was correctly classified especially in cases of ruptured chordae (15 vs 6 cases). In endocarditis (N = 26) by the visualisation of abscess of the aortic ring (7 vs 1) and vegetations (19 vs 8). In prosthetic valve dysfunction (N = 65) by the demonstration of primary degeneration of bioprostheses (7 vs 4), perivalvular leaks (10 vs 4) and non-occlusive thrombi of mechanical prostheses (3 vs 0). In cases of intracardiac tumours, dissection of the thoracic aorta and atrial septal defects.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cicletanine administered with other antihypertensive agents]. / Etude du ciclétanine administré en association avec d'autres antihypertenseurs.

The antihypertensive effectiveness and the clinical and biochemical safety of cicletanine were evaluated in 84 patients (28 women, 56 men) presenting with permanent essential hypertension without severe cardiovascular complications. The hypertension was insufficiently controlled by a beta-blocker, a centrally acting antihypertensive drug or nifedipine. After 3 months of treatment during which cicletanine was added to each of these three classes of drugs, there was a significant fall of systolic arterial pressure (-18 mmHg with beta-blockers, -17 mmHg with central agents and -26 mmHg with nifedipine) and diastolic arterial pressure (-22, -21 and -28 mmHg respectively), resulting in normalization of blood pressure (less than 160/95 mmHg) in 63%, 43% and 50% respectively of patients in each therapeutic group. The fall of blood pressure was accompanied by a significant decrease of functional symptoms (headache, palpitations, dizziness); in the nifedipine group, the addition of cicletanine resulted in complete regression of anginal attacks. The therapeutic combinations were well tolerated; only two patients were excluded from the study for undesirable effects unascribable to cicletanine. Otherwise, the side-effects observed were minor. The biochemical values measured did not significantly vary, and the variations noted were of small amplitude.

[Transesophageal echography. Value of the technic apropos of a preliminary experiment in 320 patients (385 examinations)]. / L'échographie par voie oesophagienne. Intérêt de la technique à propos d'une expérience préliminaire concernant 320 patients (385 examens)

The authors discuss the clinical utility and feasibility of trans-esophageal echocardiography. Between April and October 1988, 385 examinations were performed in 320 patients (mean age: 54 yr, range: 17-89). In 9 patients (2.4 p. 100), the transesophageal transducer could not be introduced. The only complication was one case of bacteremia without sequela, that occurred early in our use of this technique. Transesophageal echocardiography proved to be useful in the following indications: mitral stenosis (n = 50), mainly by detecting thromboses of the left atrium (n = 5); infectious endocarditis (n = 21), especially for diagnosing aortic ring abscesses (n = 3); severe mitral insufficiency (n = 26), to assess the mechanism of regurgitation and to visualize chordal rupture (n = 13). We conclude from this preliminary study that transesophageal echocardiography is particularly useful in the pathologies described above as a complementary procedure to conventional echocardiography.

[Echocardiography in the diagnosis of mitral valve insufficiency due to valve mutilations or chordal ruptures. 41 cases with anatomical findings]. / Apport de l'échocardiographie dans les insuffisances mitrales par mutilations valvulaires ou ruptures de cordages. A propos de 41 cas avec corrélations anatomiques.

This study analyses the echocardiographic findings in 41 cases of severe mitral regurgitation due to chordal rupture (33 cases), elongation of chordae (4 cases) or valve trauma (4 cases). The operative findings are given. It was possible to make the diagnosis of chordal rupture in 60% of cases by recording one or more of the following signs:--For the anterior cusp: amplitude of motion equal to or greater than 38 mm; co-existence of chaotic diastolic fluttering and multiple systolic echoes; recording of several diastolic wave forms of the anterior cusp, out of phase and crossing each other;--For the posterior cusp: paradoxical movement of the cusp in systole and diastole; presence of an echo in the left atrium in systole. The group studied was compared with a group of 40 normal subjects and 48 cases of other types of mitral regurgitation which were severe and received surgery. The various signs had good specificity. The sensitivity of the different signs varied from 33 to 50% of cases. It was greater when the number of chordal ruptures was greater. Whichever cusp was affected, it was sometimes the site of high frequency and large amplitude systolic vibrations, which were found in a quarter of the patients. The specificity of this sign is discussed. The diagnosis of rupture of chordae is possible in a large proportion of cases and the causes of error are analysed.

[Contribution of echocardiography to the study of stenotic mitral valve diseases in adults]. / Apport de l'échocardiographie dans l'étude des valvulopathies mitrales sténosantes de l'adulte.

The "time motion" echocardiographic findings in 133 patients, with stenotic mitral valve defects were compared with the anatomical and haemodynamic findings. The information was derived either by monosound, or after a multiscan survey, selecting the lines in two perpendicular planes. A morphological analysis of VMA has allowed us to define a statistical profile according to the type of valve defect: a single diastolic slope in the pure uncalcified stenoses, 2 slopes with the first being more rapid than the second, in other mitral conditions. The cinetics of VMP were related to the presence of associated regurgitation and to the type of fusion. In cases with multiple diastolic slopes, the degree of stenosis was correlated only with the first slope, whilst the second was fairly closely related to the left ventricular end-diastolic pressure. The degree of valvular involvement can be predicted on the coexistence of a thick contour with multiple images, or in their absence on the diminution of amplitude of opening (less than 12 mm) and on the maximum speed of opening (less than 250 mm/s). By contrast, the sub-valvular lesions are underestimated whichever technique is used.

[Importance of echocardiography in aortic valve disorders]. / Intérêt de l'échocardiographie dans les valvulopathies aortiques

It would seem that, despite certain limitations, echocardiography may be considered to be an important method of investigation in the diagnosis and prognosis of aortic valve disease. Quantitative measurements may possible study of the progression of the lesions. Nevertheless, echocardiography only appears to be a simple technique and emphasis should be placed on the importance of a complete investigation as well as the quality of the recordings to be studied.