[Comparison of apical and infundabular pacing in patients with primary dilated or ischemic cardiomyopathy]. / Comparaison de la stimulation apicale et infundibulaire chez les patients atteints d'une cardiomyopathie dilatée primitive ou ischémique.

Dual chamber pacing has been proposed as an alternative treatment to patients with cardiac failure refractory to optimal medical therapy. The influence of the site of ventricular pacing was studied in 15 patients with an average age of 68.7 +/- 8.7 years with dilated cardiomyopathies and an average left ventricular ejection fraction of 22.3 +/- 6.8%. Three temporary USCI electrodes were positioned in the right atrium, the right ventricular outflow tract (RVOT) and the right ventricular apex. The average duration of the QRS complexes and the haemodynamic parameters (PAP, PCP and cardiac index) were measured in sinus rhythm and during DDD apical, RVOT and simultaneous apical and RVOT pacing. The RVOT and simultaneous pacing significantly reduced the QRS duration (135 +/- 14 ms and 137 +/- 17 ms, p < 0.0001 respectively) compared with apical pacing (150 +/- 19 ms). The mean PAP and mean PCP remained unchanged in the different modes of pacing but the cardiac index increased significantly during RVOT pacing (2.99 +/- 0.67 l/min/m2) and simultaneous pacing (3 +/- 0.77 l/min/m2) compared with apical pacing (2.66 +/- 0.62 l/min/m2) (p < 0.001 and p < 0.01 respectively) and compared with sinus rhythm (2.62 +/- 0.7 l/min/m2) (p < 0.001 and p < 0.005 respectively). This study suggests that better results may be obtained with RVOT screw in lead than with the traditional right ventricular apical electrode.

[Infections on permanent endocavitary pacemaker leads: value of transesophageal echocardiography]. / Infections sur sonde de stimulation endocavitaire permanente: intérêt de l'échocardiographie transoesophagienne.

The prevalence of infection of permanent pacing material ranges from 0.13 to 19.9% of patients according to published series. The seriousness of this condition requires early diagnosis and treatment. Transesophageal echocardiography visualised vegetations on the intracardiac pacing lead in all of 11 patients studied, whereas transthoracic echocardiography and polynuclear leucocyte scintigraphy only provided positive diagnoses in 4 cases for each investigation. Three types of vegetation were visualised; no cases of tricuspid valve endocarditis were observed. Treatment was based on explantation of all implanted material by endovascular traction in 7 cases and by surgery in the other 4 cases according to the results of transesophageal echocardiography. There were no deaths or recurrence of infection. Transesophageal echocardiography is the investigation of choice for imaging a vegetation on an endocavitary pacing lead. Complete explanation is essential for a complete recovery of this infection.

[Indications of partial interruption of the inferior vena cava in pulmonary embolism]. / Indications d'interruption partielle de la veine cave inférieure dans l'embolie pulmonaire.

Forty years after the first implantation of caval filters, there is still no indication for implantation validated by a controlled clinical trial. This fact may be explained by our poor understanding of the evolution of thromboembolic disease, especially in certain groups of patients. The absolute contra-indications to heparin therapy would seem to be a logical indication for a caval filter. In cases of a relative contra-indication to anticoagulants, the physician has to rely on his clinical judgement and the decision will be taken case by case. In patients with suspected pulmonary embolism under anticoagulant therapy, it is also logical to check that anticoagulation is effective, and to request proof of embolism, to assess its risk and that due to thrombosis before considering a caval filter. The prophylactic implantation of a caval filter is a very controversial indication whether the thrombus is proximal in the ilio-caval region, extensive, not uncommon despite treatment, or floating. For groups said to be at high risk of thromboembolism (elderly, malignant disease or multiple injuries), there is no consensus because of the discordant results in the literature. The implantation of a filter would seem to be justified in patients with chronic cor pulmonale after pulmonary embolectomy. The value of a temporary caval filter during thrombolysis has not been demonstrated; there are hopes that temporary filters "of long duration" will provide filtration of the vena cava during vulnerable periods. The results of the first controlled trial (PREPIC) are eagerly awaited and should rationalise the indications of inferior vena cava filters.

Hemodynamic importance of preserving the normal sequence of ventricular activation in permanent cardiac pacing.

Pacing the right ventricle in the apex profoundly modifies the sequence of activation and thus the sequence of contraction and relaxation of the left ventricle. To evaluate the relative importance of preserving normal ventricular activation sequence and optimal atrioventricular (AV) synchrony in permanent pacing, we compared the effects of three pacing modes: AAI, preserving both normal AV synchrony and normal activation sequence; DDD, with complete ventricular capture that preserves only AV synchrony; and VVI, disrupting both, at rest and during exercise. Hemodynamic and radionuclide studies were performed in 11 patients who had normal intrinsic conduction and who were implanted on a long-term basis with a DDDR pacemaker for isolated sinus node dysfunction. AAI versus DDD and VVI significantly increased cardiac output at rest (6.6 +/- 1.3 L/min vs 6 +/- 0.9 L/min vs 5 +/- 1 L/min; p < 0.01) and during exercise (13.5 +/- 2 L/min vs 12.1 +/- 2.2 L/min vs 14.4 +/- 2.1 L/min; p < 0.01). Pulmonary capillary wedge pressure was lowest with AAI (15.4 +/- 4.5 mm Hg), with an average reduction of 17% compared with DDD (19.6 +/- 5 mm Hg; p < 0.01) and of 30% compared with VVI (25.8 +/- 7 mm Hg; p < 0.01) during exercise. Identical benefits were observed for all other hemodynamic parameters: right atrial pressure, pulmonary artery pressure, left ventricular (LV) stroke work index, and systemic vascular resistances. LV ejection fraction was significantly higher in AAI than in DDD at rest (61% vs 58%, respectively; p < 0.05) and during exercise (65% vs 60%, respectively; p < 0.05). This improvement in LV systolic function resulted principally from the increase in septal ejection fraction. LV filling also was improved in AAI as demonstrated by a significant increase in peak filling rate at rest and during exercise. These data show the importance of preserving, whenever possible, not only normal AV synchrony but also normal ventricular activation sequence in permanent cardiac pacing.

[Long-term follow-up of a rare complication of vena cava filters: complete and spontaneous rupture of the filter]. / Suivi a long terme d'une complication rare des filtres cave: la rupture complète et spontanée du filtre.

Complete spontaneous rupture of a percutaneous caval filter produced two equal parts. Long-term follow-up showed that the filter then remained stable with no complications. This case emphasizes the importance of long-term follow-up of patients with caval filters.

Short-term follow-up of inferior vena caval filters: comparison of imaging techniques.

OBJECTIVE: The aim of this prospective study was to assess the advantages and limitations of various imaging techniques in identifying problems associated with percutaneous placement of filters in the inferior vena cava. SUBJECTS AND METHODS: One hundred four vena caval filters (65 Filcard, 39 Cardial) were placed in 100 patients (four patients received two filters). Venacavograms, duplex sonograms of the abdomen, abdominal radiographs, perfusion scans of the lung, and impedance plethysmograms were obtained in all patients within 1-2 days and 3 months after filter placement. CT scans of the filter were obtained in 55 patients. RESULTS: In five patients, thrombosis of the inferior vena cava, with retraction of the filter struts in four patients, was noted on venacavograms, CT scans, duplex sonograms, and impedance plethysmograms. Perforation of the inferior vena cava was noted in 36 patients after comparison of findings on venacavograms and CT scans, with an increase in the filter span in 29 patients (apparent on duplex sonograms in only two patients). Four filter tiltings (> 30 degrees) and 25 migrations (> 5 mm) were noted on abdominal radiographs. Trapped thrombi in the filter were shown on venacavograms in nine cases, but on duplex sonograms and unenhanced CT scans in only two cases. CONCLUSION: Our study shows that the major complications of inferior vena caval filters can be detected by noninvasive examinations. Only venacavograms consistently show small trapped thrombi that do not extend above the filter, but the importance of such thrombi is unknown.

[Left intraventricular dynamic gradients in the follow-up of aortic valve replacement: an echo-Doppler study]. / Gradients dynamiques intraventriculaires gauches dans les suites de remplacement valvulaire aortique: étude écho-Doppler.

The possibility of an intraventricular pressure gradient in patients with aortic stenosis is well known: this entity is associated with a high risk of postoperative complications. The authors carried out a Doppler echocardiographic study of flow in the left ventricle in 51 patients who had recently undergone valve replacement for severe aortic stenosis (valve area < 0.75 cm2). Before surgery, only one patient had significant acceleration of intraventricular systolic flow attaining 3.8 m/s (maximum pressure gradient of 60 mmHg). After surgery, maximum intraventricular systolic velocities of over 2.5 m/s with a typical end systolic peak were observed in 8 patients under basal conditions (gradients of 30 to 115 mmHg), and in 7 others after inhalation of amyl nitrite. Pulsed spectral and color Doppler flow mapping showed that the highest velocities were located at the mitral papillary muscle level. In addition, these patients had significant reduction in cavity size. Only one patient had systolic anterior motion of the anterior mitral leaflet with septal contact. Left ventricular dimensions were measured by TM echocardiography. High intraventricular velocities seemed to be significantly related to the smallest ventricular dimensions, the thickest ventricular walls and the smallest preoperative aortic valve surface area. The highest intraventricular pressure gradients-disappeared with betablocker therapy (4 cases), after correction of hypovolemia (1 case), after drainage of large pericardial effusions (2 cases) or spontaneously (1 case). This study confirms the relatively high prevalence of dynamic intraventricular gradients after surgical cure of aortic stenosis and the value of Doppler echocardiography for the avoidance of certain drugs (inotropic agents, vasodilators, diuretics), which could aggravate the hemodynamic abnormality.(ABSTRACT TRUNCATED AT 250 WORDS)

[Efficacy and tolerance of 2 new percutaneous vena cava filters. A prospective study in 80 patients]. / Efficacité et tolérance de deux nouveaux filtres cave percutanés. Etude prospective chez 80 patients.

Eighty consecutive patients with an average age of 66.5 +/- 16 years were reviewed 3 and 9 months after implantation of two new percutaneous vena caval filters (Filcard, Cardial) in order to evaluate their efficacy and tolerance. The indications were: a contra-indication to anticoagulants in 19 cases, recurrent pulmonary embolism under anticoagulant therapy in 22 patients, chronic cor pulmonale in 4 patients; finally, in 35 cases, the filter was implanted prophylactically for a "floating" or extensive ilio-caval thrombosis under anticoagulant therapy or in high risk patients: severe cardio-pulmonary failure, malignant disease, massive pulmonary embolism with a contra-indication to fibrinolytic therapy. All implantations were performed by the jugular approach with no local or general complications apart from one pericaval haematoma with a favourable outcome. Cavography and opacification of the renal veins was carried out systematically during implantation. All patients underwent clinical examination, antero-posterior and lateral X rays of the filter, pulmonary scintigraphy, antero-posterior and lateral cavography, a CT scan of the filter, Doppler ultrasonography and rheoplethysmography of the legs 3 months after implantation. At 9 months, clinical examination, abdominal X rays and rheoplethysmography were repeated. There was 100% follow-up at 3 and 9 months. The complications observed at 3 and 9 months were: 5 cases of malposition (6%), 3 recurrent pulmonary emboli (4%), 9 recurrent venous thromboses (13%), 4 vena caval thromboses (5.7%), 7 thrombi caught in the filter (10%), 27 perforations of the vena cava (38%), 3 over 30 degrees tilts of the filter (4%) and 22 migrations (31%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Right atrial thrombosis and severe pulmonary embolism]. / Thrombose auriculaire droite et embolie pulmonaire grave.

Two cases of severe pulmonary embolism associated with right atrial thrombosis are reported. In the first case, fibrinolytic therapy was administered and was thought to be a causative factor in the death of the patient due to massive pulmonary embolism. In the second case, the patient was referred for surgery and two enormous thrombi were extracted. Unfortunately, the outcome was fatal. These two cases were confronted with the results of the literature. They strongly suggest that echocardiography should be a first-line investigation in severe pulmonary embolism. The detection of right atrial thrombosis modifies the clinical strategy and orientates treatment towards surgical referral when the patient's condition allows it.

[Myocardial infarction in young women: apropos of 22 cases. Pathogenic and prognostic approach]. / L'infarctus du myocarde chez la femme jeune: à propos de vingt-deux cas. Approche pathogénique et pronostique.

The authors report 22 cases of myocardial infarction documented by selective left ventriculography and coronary angiography in women under 45 years of age. The average age in this series was 36 +/- 6.8 years. Two patient groups were identified: Group I (n = 16) with the cardiovascular risk factor of oral contraception (mean age 33.9 +/- 5 years); and Group II (n = 6) comprising older patients (43.8 +/- 1.8 years) with a high prevalence of other risk factors (hyperlipidaemia, hypertension, diabetes). Myocardial infarction tended to be the inaugural event in Group I (9 out of 16 cases, 56.2%) whereas symptoms of effort angina were commonly observed in Group II (5 out of 6 cases, 83.3%). Coronary angiography showed more severe coronary lesions in Group II (score 1.5) than in Group I (score 0.75) in which isolated, single vessel disease mainly affecting the left anterior descending artery or normal coronary angiography was observed. Thrombolytic therapy was performed in 8 patients: percutaneous transluminal angioplasty was performed in 4 patients in the first month with a primary success in 3 cases. Coronary bypass surgery was performed in 1 case. The outcome during follow-up lasting 44.5 +/- 4.2 months was mainly favourable as 15 of the 20 patients had no secondary complications. Nevertheless, 2 patients died in the hospital period (1 from cardiogenic shock and 1 from complications of transluminal coronary angioplasty), 2 patients died less than 1 year after acute myocardial infarction (1 sudden death, 1 cardiogenic shock). Although oral contraception was withdrawn in all cases, many women continued to smoke.(ABSTRACT TRUNCATED AT 250 WORDS)

Systolic intra-cavitary gradients following aortic valve replacement: an echo-Doppler study.

Systolic left ventricular flow was studied by pulsed and continuous wave Doppler in 41 patients following aortic valve replacement for severe stenosis (mean valvular area: 0.58 cm2; range 0.3-0.75 cm2). Maximal left ventricular velocities by continuous wave Doppler study, were higher than 2.5 m.s-1 with a sharp peak at end-systole in five patients in basal condition and in four others after amyl nitrite inhalation. Pulsed Doppler study showed that the high velocities started from the apex or mitral papillary muscle level with a marked chamber narrowing at two-dimensional echography. Only one patient had a systolic anterior motion (SAM) of the anterior mitral leaflet with mitral-septal contact. The left ventricular dimensions, as measured by M-mode echography were compared in the various patient groups. High velocities seemed statistically associated with the smaller systolic and diastolic diameters of the left ventricle and outflow tract and the larger relative thickness of the posterior wall. The highest pressure gradients disappeared after correction of hypovolaemia (one patient), clearance of pericardial effusion (one patient), or beta-blocker treatment (three patients). The present study confirms that left intra-ventricular dynamic gradients can occur after clearance of fixed outflow obstruction, for which Doppler examination is a reliable and innocuous diagnostic means. Haemodynamically, this syndrome resembles hypertrophic obstructive cardiomyopathy, but the scarcity of the systolic anterior motion of the mitral leaflets is suggestive of a different mechanism that could be cavity obliteration or mid-ventricular obstruction.

[Diagnosis of coronary artery disease by thallium 201 myocardial scintigraphy during atrial pacing]. / Diagnostic de l'insuffisance coronaire par tomoscintigraphie myocardique au thallium 201 sous stimulation auriculaire.

Rapid atrial pacing may reveal myocardial ischemia but the sensitivity for the diagnosis of coronary artery disease is not high enough for routine use. Therefore, the value of atrial pacing coupled with Thallium 201 scintigraphy was evaluated. Sixty-two patients (53 men and 9 women) referred for investigation of angina or chest pain were divided into two groups: a control group of 13 patients (9 men and 4 women, average age: 57.1 years) with insignificant coronary lesions (less than 50%) (N = 5) or normal coronary angiography (N = 8), and a group of 49 patients (44 men and 5 women, average age: 55.5 years) 27 of whom had a history of myocardial infarction (17 posterior, 10 anterior). Coronary angiography showed single vessel disease in 44.9% of cases, double vessel disease in 34.7% and triple vessel disease in 18.4% of cases, and 1 patient with left main stem disease. All 62 patients underwent the same study protocol which comprised: incremental atrial pacing (to the calculated maximal heart rate), Thallium 201 myocardial scintigraphy immediately after pacing and during the redistribution phase, and coronary angiography. The sensitivities of anginal pain (36.7%) and ECG changes during atrial pacing (57.1%) were too low for the diagnosis of myocardial ischemia. On the other hand, Thallium 201 scintigraphy with atrial pacing was more sensitive (87.8%) and specific (84.6%) for coronary artery disease. Stenosis of the left anterior descending artery was diagnosed with a sensitivity of 96.4% and that of the right coronary artery with a sensitivity of 90.9%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Aneurysm of the sinistro-anterior sinus of Valsalva causing coronary insufficiency. Apropos of a case]. / Anévrysme du sinus de Valsalva antéro-gauche responsable d'une insuffisance coronaire. A propos d'un cas.

The aneurysm of the sinistro-anterior sinus of Valsalva (ASASV) can very rarely be disclosed by symptoms of coronary insufficiency. The authors report the case of a 73 old man suffering from unstable angina pectoris, in whom the diagnosis of ASASV was evoked by two-dimensional echocardiography and confirmed by aortography. Coronary angiography revealed an external compression of IVA by the ASASV and allowed to exclude the presence of associated autonomous coronaropathy. The interest of this observation lies in the fact that the preoperative diagnosis was made after the two-dimensional echocardiography allowing the evaluation of the importance and volume of the ASASV. Aortography and coronary angiography are indispensable procedures in the presence of chest pain suspect of coronary insufficiency. These investigations will guide the surgical treatment which should always associate a closure of the aneurysmal neck, an aortic valvular replacement and a bypass of the compressed coronary artery.

[Evaluation of aortocoronary bypass using exercise myocardial thallium 201 scintigraphy]. / Evaluation des pontages aorto-coronaires par scintigraphie myocardique au thallium 201 à l'effort.

The surveillance of aortocoronary bypass grafts is a difficult problem. Clinical examination and exercise testing are unable to give a complete evaluation of the operative results and cardiac catheterisation with radiological opacification of the grafts are not without risk and cannot be repeated periodically. Therefore, radioisotopic methods have been proposed as a means of assessing aortocoronary bypass grafts. The aim of this study was to evaluate postoperative myocardial perfusion by Thallium 201 scintigraphy. The authors compared pre and postoperative scintigraphies in 37 patients undergoing aortocoronary bypass surgery (36 men and 1 woman, average age: 53.9 years). Preoperative coronary angiography showed 9 cases of single vessel disease, 11 cases of double vessel diseases and 17 cases of triple vessel disease. Seventy one bypass grafts were performed (average 1.92 grafts/patient): 37 on the LAD, 15 on the circumflex, 10 on the diagonal and 9 on the right coronary. All patients were submitted to the same protocol before surgery and during the third postoperative month; Clinical examination, ECG, exercise stress testing and Thallium 201 myocardial scintigraphy. The results confirm the improvement in myocardial perfusion after coronary bypass surgery. The percentage of pathological scintigraphic segments fell from 42 per cent before surgery to 27 per cent after surgery (p less than 0.01). The total Thallium perfusion index improved significantly after surgery from 9.3 +/- 2 to 7.7 +/- 1.9 (p less than 0.01). Thallium 201 scintigraphy was superior to clinical examination and exercise testing in the assessment of graft patency, identifying 2 postoperative infarctions inapparent on clinical examination, excluding postoperative non-anginal chest pain and evaluating myocardial perfusion in patients who had sub maximal postoperative exercise stress tests. The relatively non traumatic character of Thallium 201 scintigraphy makes it the best non-invasive method of assessing aortocoronary bypass graft patency.

Loss of efficacy of flecainide in the Wolff-Parkinson-White syndrome after isoproterenol administration.

Although anterograde conduction through a Kent bundle with a short refractory period was suppressed by 300 mg of flecainide acetate, the infusion of small amounts of isoproterenol caused the reappearance of WPW and permitted the induction of an atrial tachycardia with 1/1 conduction through the accessory pathway at a rate of 260 beats min-1. This case shows that the effect of isoproterenol may be maintained after apparently successful flecainide therapy.