[Neisseria Sicca endocarditis disclosed by multiple organ failure syndrome]. / Endocardite à Neisseria sicca révélée par un syndrome de défaillance multiviscérale.

The authors report a case of Neisseria sicca endocarditis presenting with multiple organ failure in a 33 year old intravenous drug user. The diagnosis was confirmed by transthoracic and transoesophageal echocardiography showing vegetations on the aortic valve and three blood cultures positive for Neisseria Sicca. Massive aortic regurgitation occurred on the 4th day. The patient died of complications of intracerebral haematomas before surgical intervention. Contrary to pathogenic Neisseria gonorrhoeae and meningitides, saprophytic Neisseria, including Neisseria sicca, are commensal organisms of the upper respiratory tract. They are exceptionally rare causes of endocarditis. A review of the literature from the era of antibiotic therapy, found about thirty cases of saprophytic Neisseria endocarditis of which only five were due to Neisseria sicca. The clinical characteristics were the young age, the mainly left heart valve disease and the high incidence of cerebrovascular accidents. The originality of this case was the exceptionally rare involvement of this organism and the multiplicity of the extracardiac manifestations, especially renal and neurological.

[Cardiac manifestations of phospholipid antibody syndrome. Study of 2 cases]. / Les manifestations cardiaques du syndrome des anticorps antiphospholipides. Etude de deux observations.

Cardiac manifestations of phospholipid antibody syndrome may include mitral and/or aortic valve disease, pseudo-infectious endocarditis, thrombi of the right atrium, myocardial infection, pulmonary artery hypertension and cardiomyopathy with global or segmental left ventricular dysfunction. The authors report two patients showing evidence simultaneously of a circulating anticoagulant, dissociated syphilis serology and cardiolipin antibodies at a very high level. They had the majority of cardiac complications described in phospholipid antibody syndrome. Both also had renal involvement and one of them had recurrent venous thromboses and a cerebrovascular accident. Prolonged corticosteroid treatment, combined with anticoagulants in one patient, was accompanied by stability of lesions with follow-up of five years and ten months respectively.

[Deep venous thrombosis of the upper limb complicated by pulmonary embolism. Apropos of a case]. / Thrombose veineuse profonde du membre supérieur compliquée d'embolie pulmonaire. A propos d'un cas.

Venous thrombosis of the upper limb is classically rarely complicated by pulmonary embolism. The authors report a case of phlebitis of the upper limb in a 46-year-old woman with a thoracic outlet syndrome complicated by multiple and recurrent pulmonary emboli. Analysis of recent data from the literature would appear to bring into question the classically accepted harmless nature of this condition regarding the risk of embolic complications.

[Chronic obstructions of the left main and right coronary arteries]. / Occlusions chroniques du tronc coronaire gauche et de la coronaire droite.

The authors report a case of chronic occlusion of the left main coronary associated with occlusion of the second segment of the right coronary artery documented at coronary angiography carried out for effort angina without previous infarction. Myocardial perfusion was preserved mainly by a marginal branch of the right coronary arising immediately before the occluded second segment and by a small branch of the left main coronary artery.

[Sudden syncope and myocardial ischemia. Apropos of a case]. / Syncope à l'emporte-pièce et ischémie myocardique. A propos d'une observation.

It is unusual to carry out a systematic search for myocardial ischemia in patients who have suffered a sudden syncopy with no known history of angina. We report a case involving loss of consciousness (LC) in the context of sub-hissian atrioventricular block (AVB) which required the installation of a pacemaker, with the detection of angina pectoris immediately after its installation. Coronary artery angiography confirmed a diagnosis of severe, multitrunk coronary disease characterized by a tight stenosis of the common trunk. If consciousness is lost by a patient suffering from baseline conduction impairment with no chest pain, the first thought is 3rd degree degenerative paroxysmal AVB but the possibility of an ischemic origin of this AVB should not be overlooked.

[Renal cortex ischemia, right atrial thrombosis and coronary occlusion in anti-phospholipid antibody syndrome]. / Ischémie rénale corticale, thrombose auriculaire droite et occlusion coronaire au cours d'un syndrome des anticorps antiphospholipides.

The presence of a lupus anticoagulant (LA) is paradoxically associated with a high incidence of arterial and venous thrombosis. In a patient with a lupus-like systemic disease, having received phenindione for 11 years, LA was discovered in association with recurrent deep venous thrombosis, a right atrial thrombus, coronary occlusion, arterial hypertension, thrombopenia, and anticardiolipin antibodies without anti-DNA antibodies. Renal cortical ischemia was detected by a tomographic scan. Renal biopsy showed glomerular ischemia and diffuse interstitial fibrosis. After a one-year anticoagulant and steroid therapy, LA has disappeared despite a high level of anticardiolipin antibodies, and renal function remains normal.

[Arterial hypertension in black patients]. / L'hypertension artérielle du sujet noir.

Arterial hypertension in blacks seems to present a few peculiarities in comparison to that of caucasians, whether it is from the epidemiological point of view: greater frequency of the disease, more severe prognosis; from the physiopathological point of view with especially a definite prevalence of HBP with low renin and inflation of the plasma volume and increased tendency to sodium retention, or finally from the therapeutic point of view, since randomized studies have demonstrated that black patients respond better to diuretics than to beta-blockers. Currently, it is impossible to explain these differences in a simple fashion: is it a genetic factor or, on the contrary, environmental factors? Perhaps the response lies between those two extremes.

[Double valve replacement in a 30-year-old man with acute systemic lupus erythematosus]. / Double remplacement valvulaire chez un homme de 30 ans atteint d'un lupus érythémateux aigu disséminé.

A 30 year old man presenting with a 10 year history of delayed pressure urticaria had a secondary lupus-induced double mitral and aortic regurgitation which necessitated double valve replacement within 2 years. The anatomical appearances of the valvular lesions were very unusual and suggest a new anatomo-clinical form of the classical Libman-Sacks endocarditis. In addition to infective endocarditis, systemic lupus erythematosus may also lead to valvular lesions necessitating valve replacement. The association of S.L.E. and delayed urticaria is rare, and also merits publication.

[Aortic insufficiency in certain so-called systemic diseases]. / Insuffisance aortique au cours de certaines maladies dites systémiques.

The authors present a retrospective study of all the patient followed up for systemic disease in the rheumatology Department of Bichat hospital between 1975 and 1984 in whom aortic regurgitation developed. Only rare or previously undescribed associations were retained: two MacDuffie syndromes, one adult form of Still's disease, one Takayashu's disease, one association of rheumatoid arthritis and Takayashu's disease, one rheumatoid arthritis, one Cogan's syndrome and two cases of disseminated lupus erythematosis. The authors use these cases and a review of the literature to discuss the possible physiopathological mechanisms of the aortic regurgitation. This study confirms the value of regular clinical cardiovascular examination with echocardiography in cases with progressive symptoms. The evolution of the vascular disease seems to be more or less parallel to that of the systemic disease and in a significant number of cases it becomes sufficiently severe to become the main clinical problem. In our series, there was one sudden death, one death due to cardiogenic pulmonary oedema and three patients required aortic valve replacement.

Total and unbound cortisol-, progesterone-, oestrone- and transcortin-binding activities in sera from patients with myocardial infarction: evidence for differential responses of good and bad prognostic cases.

Day-of-admission sera from myocardial infarction patients (MI) and patients with cardiopathies other than MI (non-MI) were analysed for total and unbound cortisol (F), progesterone (P4), oestrone (E1), and corticosteroid binding activities (CBG). The MI who survived (n = 28) showed high increases of F, P4 and E1 compared to healthy controls. By contrast, the MI who died within 10 days of admission (n = 6) had unchanged F and less increased P4 and E1 than survivors. The non-MI (n = 6) had higher F and E1 than controls but normal P4. The unbound steroids were increased in all patients: however, the MI who died showed much smaller rises than survivors (P less than 0.001 for unbound F and E1 increases in survivors vs. deceased). The CBG activity was in all MI lower than in normals (P less than 0.001) but unchanged in non-MI. These results are discussed in terms of the potential significance of unbound plasma steroids as predictors of MI severity.

[Detection of anterior interventricular involvement after primary posterior wall infarct]. / Dépistage d'une atteinte de l'interventriculaire antérieure après primo-infarctus postérieur.

Forty-five patients (average age 53.3 +/- 9.4 years) underwent exercise stress testing coupled with exercise myocardial scintigraphy and right heart catheterisation on exercise during the 3rd week after primary posterior wall infarction. Coronary angiography and ventriculography were carried out 24 to 48 hours later. Significant (greater than or equal to 75%) left anterior descending disease was present in 9 patients (Group I) and absent in 36 patients (Group II). Tolerance of maximal exercise stress testing was good in all patients. The results were uninterpretable in on third of the cases because the theoretical maximal heart rate was not attained. No significant difference was noted between groups I and II with respect to: mean age, percentage of theoretical maximal heart rate attained, mean pulmonary capillary pressures at rest and during exercise, basal and exercise cardiac index, end diastolic index and angiographic left ventricular ejection fraction. The sensitivity and specificity for the detection of LAD disease were 80% and 84% for the exercise stress testing (n = 30), 44% and 75% for exercise right heart catheterisation (n = 30), 60% and 92% for exercise myocardial scintigraphy (n = 30), 100% and 75% for combined exercise stress testing and myocardial scintigraphy (n = 30) and 78% and 64% for combined exercise stress testing and myocardial scintigraphy and exercise right heart catheterisation (n = 45). These results show that in patients capable of performing maximal exercise stress tests, the best method of early detection of significant LAD disease after primary posterior infarction was combined exercise stress testing and exercise myocardial scintigraphy. These investigations are useful for the selection of candidates for coronary angiography.

[Early interruption of antiarrhythmia treatment in the acute phase of infarction complicated by ventricular arrhythmia]. / Interruption précoce du traitement antiarythmique à la phase aiguë des infarctus compliqués de troubles du rythme ventriculaire.

18 patients with myocardial infarction complicated by severe ventricular arrhythmias (polymorphic VEBs or bigeminy = 5; VT = 11; VF = 2) were treated with antiarrhythmics which were stopped after 24 hours (intravenous infusion of mexiletine 0.5 mg/kg/hr after a loading dose). This treatment resulted in one failure (recurrent VF) and 17 successes, after increasing the dose in 3 cases of VT. After stopping treatment, 72% of patients had no further arrhythmia. 5 cases had recurrent VT within 72 hours, which was controlled by oral mexiletine in 4 cases. The ejection fraction was significantly decreased in the group with recurrent VT. Plasma assays were of little help. Stopping the antiarrhythmic treatment after 24 hours does not therefore present any particular risks and can be proposed even in cases with severe arrhythmias.

[Right intraventricular tumors. Apropos of a case]. / Tumeurs intraventriculaires droites. A propos d'une observation.

The authors report a case of right ventricular tumour in a 16 year old girl who presented with dyspnoea on effort, chest pain on exertion and loss of consciousness. The diagnosis was made on the basis of abnormal right intraventricular echoes on two dimensional echocardiography and was confirmed by angiography. The patient was operated with success. Histology revealed a mesenchymoma, a benign tumour, but whose infiltrating nature calls for a reserved prognosis. The echocardiogram can be used for regular post-operative surveillance. The young patient is well after 18 months' follow-up.

[Clinical study of the action of dobutamine in acute cardiac insufficiency]. / Etude clinique de l'action de la dobutamine dans l'insuffisance cardiaque aiguë.

78 patients were treated with dobutamine for a severe episode of heart failure at a mean dose of 9.51 micrograms . kg-1 . min-1 for an average of 5 days. 59 of these patients had ischaemic heart disease, including 34 with recent infarcts. The monitoring of treatment was essentially clinical, consisting of repeated measurement of the heart rate, the systolic and diastolic blood pressure and the diuresis. A haemodynamic survey was performed in only 25 cases. 48 patients were improved. 24 of these patients had no clinical or radiological signs of heart failure at the end of the treatment. Dobutamine significantly increases the blood pressure (97.7 +/- 24.9 to 105.8 +/- 21 mm Hg), the diuresis and the cardiac index (2.02 +/- 0.51 to 2.52 +/- 0.54 l . min-1 . m-2) and it significantly decreases the mean capillary pressure (25.36 +/- 6.20 to 21.03 +/- 6.94 mm Hg). The tolerance was very satisfactory, particularly in terms of the heart rate, ventricular excitability and the progression of the coronary disease. This clinical study confirms the value of dobutamine in the treatment of severe heart failure, either alone or in combination with vasodilators. The authors do not believe tha haemodynamic monitoring is essential at the doses used, which means that dobutamine could be used more widely in these indications.

[Treatment with intracoronary streptokinase in the acute phase of myocardial infarct. Preliminary results apropos of 20 cases]. / Traitement par streptokinase intra-coronarienne à la phase aiguë de l'infarctus du myocarde. Résultats préliminaires à propos de 20 cas.

Twenty patients with primary myocardial infarction (mean age 55 years +/- 6) were treated with intracoronary streptokinase in the acute phase. The mean interval between the onset of chest pain and treatment was 4 hours 30 minutes (extremes, 30 minutes and 6 hours). The total quantity of streptokinase required to obtain coronary revascularisation varied from patient to patient and with the technique used, but it was less than 350,000 units in all cases. The immediate results were favourable in 80 p. 100 of cases with respect to the coronary obstruction, in 50 p. 100 of cases with respect to relief of pain and in 35 p. 100 of cases with respect to ST elevation. It is not possible to confirm the efficacy of this therapy in left ventricular function from the results of this preliminary study. The authors observed, however, that the best results as assessed by 2D echocardiography, left ventricular angiography, and Thallium 201 myocardial scintigraphy were obtained in patients treated early (before the 3rd hour). They emphasise the need to check the level of antistreptokinase antibodies before starting treatment to assess the optimal total dosage for each individual patient, in order to obtain a local effect without disturbing the overall coagulation mechanism.