[Cardioverter-defibrillator implantation and follow-up in a non-university hospital]. / Suivi des défibrillateurs automatiques implantables en centre hospitalier général.

Implantable cardioverter-defibrillators (ICD) have emerged as a major treatment for life threatening ventricular arrhythmias. This technique is available in France in all the university hospitals and, with the favor of the new regulation, in some qualified private centers. However, ICD implantation and follow-up in a non-university hospital is infrequent. This study reports long-term results following ICD implantation in 152 patients (age 61+/-13 years). The vast majority (49%) of the patients were implanted for post-infarction ventricular tachycardia and 17% in primary prevention for left ventricular dysfunction. An appropriate therapy was delivered in 83 patients including 68 (81%) treated by antitachycardia pacing without the need for a cardioversion shock. An inappropriate shock was observed in 13 patients (9%). Because of iterative shocks, catheter radiofrequency ablation was proposed among 9 patients, with a success in 8. In conclusion, the technique of the implantable defibrillator can be performed in a non-university hospital with acceptable results. The increase in the ICD number in France implies that there is a need for collaboration between non-university and university hospitals in managing routine and emergency follow-up.

[Iatrogenic syncopes and malaises]. / Syncopes et lipothymies d'origine iatrogène.

Syncope or presyncope related to adverse drug reactions are well-known. On the other hand, little is known about the specific role of different drugs. Over one six year period, 1611 patients were referred in our hospital for syncope or presyncope, including 688 in the cardiology department. Among these patients, 420 were 70 years old or more. The search for an adverse drug reaction was systematic, with the help of the French method for causality of adverse drug reaction: knowledge of "extrinsic" criteria (bibliographical data relating to the drug involved); moreover, score on the basis of "intrinsic", chronological and symptomatic criteria. Seventy five patients (11% of the group with syncope leading to admission in cardiology department) were thus retained: score = I2, "possible adverse drug reaction", for 28 patients (37%); score = I3, "probable adverse drug reaction", for 47 patients (63%). Score I4, "definite adverse drug reaction" was not used since it required the readministration of the drug to prove the iatrogenic effect. Average age was 78 years, with a female majority of 69%. Seventy two patients (96%) had previous cardiovascular disease, 37 (50%) previously experienced syncope or presyncope. In addition to the basic assessment, a Holter recording was performed among 56 patients, finding a drug-induced arrhythmia in three cases. In the majority of the patients (59 patients, 79%), the adverse drug reaction consisted of hypotension, clinically obvious in 49 cases. In ten cases, vasovagal syndrome facilitated by the drugs was diagnosed by a tilt-test. The other side effects were eight rhythm disorders and eight severe metabolic disorders. The treatments were always multiple. The involved drug was a cardiovascular therapy in 66% of the cases. The other drug classes were primarily represented by uroselective alpha 1-adrenergic blocking drugs (12%) and psychotropic ones (22%). Among the cardiovascular treatments, ACE inhibitors and diuretics, generally in association, were involved (59%). This study confirms the role for antihypertensive drugs in iatrogenic syncope, its great frequency in elderly patients but also the responsibility of another drug class less often reported, the uroselective alpha 1-adrenergic blocking drugs.

Unilateral pulmonary oedema complicating mitral regurgitation: diagnosis and demonstration by transoesophageal echocardiography.

One aetiology of unilateral pulmonary oedema is mitral valve disease. We report three cases of right pulmonary oedema caused by acute mitral regurgitation. These reports underline the diagnostic value of transoesophageal echocardiography, which rapidly visualised severe mitral regurgitation with retrograde jet directed toward the right pulmonary veins. Two patients underwent prompt cardiac surgery.

Resumption of right atrial isthmus conduction following atrial flutter radiofrequency ablation.

Right atrial isthmus block is currently accepted as a success criterion of atrial flutter ablation. An electrophysiological study performed days after the ablation procedure may show recovery of conduction across the isthmus in some patients, followed by arrhythmia recurrence. However, few data are available on the time course of this recovery and on the monitoring of isthmus conduction at the end of the ablation procedure as a means of increasing the success rate of the procedure. Radiofrequency (RF) catheter ablation was performed in 28 men and 7 women (mean age = 65 +/- 11 years) presenting with common or clockwise atrial flutter (AFL) resistant to 2.9 +/- 1.8 antiarrhythmic drugs. Underlying heart disease was present in 13 patients. The ablation procedure was performed with an 8-mm-tip catheter, by several 45-second applications at a target temperature of 65 degrees C, directed to the isthmus between tricuspid annulus and inferior vena cava. Bidirectional isthmus block (BDB) was created with 4-24 RF applications in all but one patient. Special attention was paid to exclude incomplete block by meticulous mapping during pacing at the coronary sinus os and at the low lateral right atrium every 5 minutes for 20 minutes thereafter. Conduction recovered across the isthmus in 5 patients at 10, 10, 12, 15, and 16 minutes, respectively, and further RF applications were needed to obtain stable block. At a follow-up of 17 +/- 10 months, AFL occurred in the patient without, and in one patient with BDB. Thirty-three of the 34 patients (97%) with persistent BDB remained free of arrhythmia recurrence. This study showed that conduction resumed across the isthmus within 20 minutes, after AFL ablation in 15% of the patients. The long-term results of the procedure can be optimized by ascertaining the persistence of BDB during that period of time.

[Left intra-atrial membrane without pulmonary vein obstruction: benign condition of progressive evolution? Apropos of 7 cases]. / Membrane intra-auriculaire gauche sans obstruction veineuse pulmonaire: pathologie bénigne ou évolutive? A propos de 7 observations.

Left triatrial heart is defined as division of the left atrium into two chambers, proximal and distal, by a variably perforated membrane. The data of appearance of symptoms, often in early childhood, is related to the degree of obstruction and the presence or not of an inter-atrial shunt. Widescale usage of echocardiography, the investigation of choice for this diagnosis, has led to the detection of this abnormality in older patients, sometimes asymptomatic, without pulmonary hypertension. Three adults were referred for transthoracic and transoesophageal echocardiography to investigate systemic embolic disease (2 cerebral, 1 mesenteric). Two other adults underwent the same investigations for diagnosis of the aetiology of atrial fibrillation with mitral regurgitation. Two cases were asymptomatic children, one with a clinically benign murmur and the other with ventricular extrasystoles with no malignant features. In these seven cases, transthoracic (n = 5) and/or transoesophageal (n = 7) echocardiography demonstrated a left atrial membrane corresponding to the classical description of cor triatrium. The Doppler study showed no obstruction in 6 cases and minimal obstruction in 1 case. In our series, as in similar cases reported in the literature, the diagnosis of a left atrial membrane did not lead to surgery. Although we do not know the long-term outcome of this abnormality in asymptomatic children, the observations of complications in the adult suggest a potential of evolution which poses the question of optimal management.

[Spontaneous rupture of the ascending aorta: a diagnostic and therapeutic emergency. Report of 2 cases]. / Rupture spontanée de l'aorte ascendante: une urgence diagnostique et thérapeutique. A propos de 2 cas.

The authors report two cases of spontaneous rupture of the ascending aorta complicating atheromatous disease but without traumatic or infectious factors. The clinical presentation is very similar to that of dissection of the aorta. The diagnosis is based on non-invasive and invasive investigations showing localised abnormalities of the aortic wall suggestive of localised dissection and haemopericardium. Surgery shows transverse tearing of the aortic wall without dissection of the media. It is a surgical emergency, the deceptive presentation of which should not be missed.

[Influence of the patency of the artery responsible for myocardial infarction on the prevalence of late potentials. Apropos of a study of 80 patients]. / Influence de la perméabilité de l'artère responsable de l'infarctus du myocarde sur la prévalence des potentiels tardifs. A propos d'une étude de 80 malades.

The pejorative prognostic significance of late potentials (LP) has been clearly demonstrated over recent years. The objective of this study was to assess the influence of revascularization of the artery responsible for infarction (ARI) on the prevalence of LP. We studied 80 patients admitted to hospital for a first infarction. All patients underwent cardiac catheterization (on D8, on average) and high amplification ECG (on D9, on average). The prevalence of LP in the group with an occluded ARI (TIMI grade 0 or 1) was 54% versus 19% in the patent ARI group (TIMI grade 2 or 3) (p > 0.01). It is concluded that revascularization of the ARI (either by thrombolysis or physiological fibrinolysis) is accompanied by a lower incidence of late potentials after myocardial infarction.