[Lemierre's syndrome: Diagnosis, exploration, treatment]. / Syndrome de Lemierre : diagnostic, exploration, traitement.

Lemierre's syndrome is a rare and severe sepsis that can rapidly lead to a life-threatening condition in the absence of early management. This syndrome described at the beginning of the 20th century combines oropharyngeal infection complicated with septic thrombosis of the internal jugular vein and septic emboli predominantly pulmonary. Fusobacterium necrophorum, anaerobic germ, Gram negative bacillus is the main germ in this "necrobacillosis". The diagnosis is should be confirmed precociously with cervicothoracic CT-scan, reference exam, and bacteriological examinations (especially in atypical forms). Its management consists of an emergency antibiotic treatment, combining a third-generation cephalosporin or a betalactam with metronidazole, anticoagulant therapy to be reserved for high-risk situations related to thrombosis. Surgical treatment may be required.

[One center's experience of coronary angioplasty with a 5 French catheter guide by a femoral approach at the same time as coronary angiography]. / Expérience monocentrique de l'angioplastie coronaire par cathéter guide 5 French menée par voie fémorale dans le même temps que l'examen coronarographique.

The object of this study was to assess the feasibility of so-called ad hoc 5 F percutaneous transluminal coronary angioplasty (PTCA). This monocentric register included 200 consecutive procedures (233 lesions) of 5F PTCA by a femoral approach after a bolus of standard heparin (50 to 70 IU/kg). The population included 15.4% of stable angina, 29.4% of unstable angina, 11% acute phase, 13.5% post-revascularisation angina and 30.7% post-infarction cases. A successful procedure was defined as a good angiographic result without ischaemic complications. A failed 5F procedure was defined by the need to fall back on a 6F PTCA. The peripheral vascular complications were recorded. The lesions were stented in 77.4% of cases including 13.4% of direct stenting. There were 200 successful procedures (87%). The failures (N = 26) were mainly explained by the inability to cross chronic obstruction (N = 11). The ischaemic complications included 2 coronary bypasses (2 retrograde dissections of the left anterior descending artery) and 7 enzymatic increases without ECG changes. Fall back to 6F PTCA was required in 4 cases (1.7%) always because of the instability of the 5F catheter guide before the procedure. The quality of coronary contrast was estimated to be good. The vascular complication rate was low with 2% of communicating haematomas (N = 4). Therefore, 5F PTCA is feasible with failure and complication rates comparable to those reported with catheters of larger dimensions. One of its principal advantages is "ad hoc" angioplasty after 5F coronary angiography.

[Transthoracic echocardiography and diagnosis of acute pulmonary embolism. Change in the diagnostic valve with respect to thresholds of classification]. / Echocardiographie transthoracique et diagnostic d'embolie pulmonaire aiguë. Variation de la valeur diagnostique en fonction des seuils de classification.

The diagnostic value of transthoracic echocardiography in acute pulmonary embolism is not well established. Although many parameters are abnormal, the thresholds used vary according to the authors, limiting the contribution of the investigation to the diagnosis. In a prospective study of 70 patients with suspected acute pulmonary embolism without previous cardio-respiratory disease, the authors tried to determine the diagnostic thresholds using discriminating linear analysis and ROC curves. Parameters easily recorded in an emergency were analysed: end diastolic ventricular dimensions, ratio of these diameters and maximal velocity of tricuspid regurgitant flow. Thirty-one patients had pulmonary embolism quantified by the Miller index (average: 16 +/- 7, range 2 to 28). Measurements of left ventricular dimension were disappointing (sensitivity: 0.52, specificity: 0.73 for a threshold value of 45 mm). The right ventricular dimension was a better predictive parameter (sensitivity: 0.70, specificity: 0.86 for a threshold value of 25 mm). However, the ratio of right to left ventricular dimension had a better diagnostic value (sensitivity: 0.85, specificity: 0.78 for a threshold value of 0.5). The best diagnostic parameter was the maximal velocity of tricuspid regurgitation (sensitivity: 0.93, specificity: 0.82 for a threshold value of 2.5 m/s). The authors conclude that the maximal velocity of tricuspid regurgitation with a threshold of 2.5 m/s and the ratio of the ventricular dimensions with a threshold value of 0.5 are valuable diagnostic indicators for acute pulmonary embolism.

[Ventricular late potentials and sleep apnea syndromes]. / Potentiels tardifs ventriculaires et syndromes d'apnées du sommeil.

This prospective study in 37 patients evaluated the prevalence of ventricular late potentials in sleep apnea syndrome, a condition associated with an increased risk of ventricular rhythm disorders and sudden death. A comparative analysis was conducted among a group of patients considered free of coronary heart disease and admitted for suspected sleep apnea syndrome based on clinical symptoms and simple blood gas measurements. The prevalence of ventricular late potentials was 56% in the subgroup with and 14% in the subgroup without polygraphy evidence of apnea (F < 0.01). The analysis of clinical, respiratory, and echocardiographic findings in the apneic subgroup failed to detect any factors associated with the presence of ventricular late potentials. Only long-term follow-up studies involving invasive heart rhythm testing could define the prognostic significance of ventricular late potentials in sleep apnea syndrome. However, our data demonstrate that there is an association between ventricular late potentials and sleep apnea syndrome.

[Estimation of left ventricular volumes and ejection fraction with acoustic quantification in myocardial infarction. Comparison with echocardiographic, angiographic and scintigraphic data]. / Estimation des volumes et de la fraction d'éjection ventriculaires gauches par quantification acoustique dans l'infarctus du myocarde. Comparaison aux données échographiques, angiographiques et scintigraphiques.

The object of this study was to assess the reliability of measurements of left ventricular volumes and ejection fraction by acoustic quantification by the method of summation of discs in acute myocardial infarction. Thirty-two patients with an average age of 55.9 +/- 12 years were studied prospectively on average 6 +/- 2 days after the onset of myocardial infarction. Within 48 hours, the patients underwent TM echocardiography (Teichholz's method) two-dimensional echocardiography (Simpson's method on freeze frames and acoustic quantification) before left ventricular angiography and isotopic ventriculography, considered as the reference methods for comparing left ventricular volumes and ejection fractions. The data displayed in real time by acoustic quantification correlated well with the results of left ventricular angiography (r = 0.77; p = 0.0001) and moderately underestimated (+4.1 +/- 11.9%) the ejection fraction, but were relatively disappointing for estimating volumes. When compared with isotopic ejection fraction, the correlation coefficient was r = 0.71 (p = 0.0004) and the values were overestimated. In this study, acoustic quantification was the most reliable echocardiographic method of assessing the left ventricular ejection fraction with reference to contrast angiography (Teichholz: r = 0.56; p = 0.0014; Simpson: r = 0.76; p = 0.001). The authors conclude that assessing the left ventricular ejection fraction with acoustic quantification is reliable in acute myocardial infarction. However, the method is not very accurate in measuring end systolic and end diastolic volumes.

[Value of transesophageal echocardiography in post-infarction septal ruptures]. / Intérêt de l'échographie transoesophagienne dans les ruptures septales postinfarctus.

The role of transoesophageal echocardiography in the diagnosis of ventricular septal defect in the acute stage of myocardial infarction, was evaluated in 15 consecutive patients (10 men and 5 women) with a mean age of 72 years in the period between June 1991 and April 1995. The patients had 11 anterior infarcts and 4 inferior infarcts with extension to the right ventricle. One patient was in Killips class I,7 patients in class II, 2 in class III and 5 in class IV. Only 8 of the 15 septal ruptures could be visualised directly by conventional transthoracic echocardiography, though all 15 were suspected from continuous Doppler and colour Doppler analysis. Transoesophageal echocardiography was successfully performed in 14 of the 15 patients with a monoplane probe in 11 cases and a multiplane probe in 3 cases. The average duration of the procedure was 12 minutes and clinical and haemodynamic tolerance was good. Ventricular septal defect was directly visualised in all cases in the short axis transgastric view and in 7 cases in transoesophageal views. Transoesophageal echocardiography was concordant with peroperative findings with regards to the site of ventricular septal defect (8 apical, 5 postero-basal and 1 median), their type (6 punched-out defects, 5 fissures, and 3 perforated aneurysms), their size (average 9.3 mm), their number with 5 multiple defects, and associated lesions (4 right ventricular extensions, 4 hemopericardiums and 1 free wall fissure). Transoesophageal echocardiography completes traditional transthoracic echocardiographic examination in the diagnosis of post-infarction ventricular septal defect. It is well tolerated and, in the authors' experience, allows limitation of invasive procedures to coronary angiography alone.

Use of transthoracic Doppler echocardiography combined with clinical and electrocardiographic data to predict acute pulmonary embolism.

Transthoracic echocardiography and continuous wave Doppler were prospectively performed in 132 out-patients with suspicion of pulmonary embolism, and who had no previous history of severe cardiac or pulmonary disease. Bedside echocardiography determined diagnosis other than pulmonary embolism in 55 patients. Further study was completed in 70 patients; pulmonary embolism was found in 31 and excluded in 39. Significant differences were found as regards right ventricular diameter (27 +/- 8 vs 22 +/- 5 mm, P < 0.001), left ventricular diameter (41 +/- 9 vs 49 +/- 7 mm, P < 0.001), right over left ventricular diameter ratio (0.67 +/- 0.23 vs 0.43 +/- 0.15, P < 0.0001), tricuspid regurgitant flow peak velocity (2.9 +/- 0.4 vs 2.4 +/- 0.7 m.s-1, P < 0.0001), and abnormal septum motion (12 vs 4, P < 0.01). Multivariate analysis of echocardiographic data included a tricuspid regurgitant flow peak velocity greater than 2.5 m.s-1 and a right over left ventricular diameter ratio greater than 0.5 in a logistic model (sensitivity 93%, specificity 81%). The combination of echocardiographic and non-echocardiographic data included the two previous echocardiographic variables, together with signs of deep vein thrombosis, a deep S wave in lead D1, and a Q wave in lead D3 on the electrocardiogram in a logistic model (sensitivity 96%, specificity 83%). It can be concluded that emergency echocardiography, alone or combined with clinical examination and electrocardiogram, satisfactorily predicts acute pulmonary embolism.

Floating right heart thrombi and pulmonary embolism: diagnosis, outcome and therapeutic management.

The aim of this study was to analyze clinical and echographic findings and to assess therapeutic management in 14 floating right atrial thrombi diagnosed with systematic echocardiography in 200 consecutive patients with proven pulmonary embolism. Auscultatory findings were abnormal in 7 cases, 4 of them showing signs of tricuspid obstruction. Echocardiography displayed a mobile ovoid, polycyclic or worm-like right atrial mass, always associated with signs of cor pulmonale. Four patients (29%) died, 2 of them before any treatment could be started. Regarding the remaining 10 patients with favorable outcome, surgical embolectomy was carried out in 7. Our data suggest that echocardiographic examination is necessary in all suspected pulmonary embolisms and has to be done quickly for emergency treatment in patients with floating right atrial thrombus.

[Pulmonary embolism and thrombi of the right heart]. / Embolie pulmonaire et thrombus des cavités droites.

In general, there are two types of right heart thrombi diagnosed by echocardiography: mobile and non-mobile thrombi, more often located in the atrium than in the ventricle and a potential source of pulmonary embolism. However, they differ in several points: clinical context, clinical and echocardiographic presentations, embolic potential, prognosis and treatment. The result of peripheral venous thrombosis, mobile thrombus it is usually diagnosed during echocardiographic investigation of pulmonary embolism. The appearances are often that of serpentine thrombus floating in the right heart chambers associated with signs of acute cor pulmonale. It is a marker of imminent and often fatal embolism as it completes a previous and usually severe pulmonary embolism; the mortality is over 40%. It is a contra-indication for pulmonary angiography because of the risk of embolism and a therapeutic emergency. Some groups advocate surgical embolectomy and others thrombolysis. Its precise frequency in the acute stage of pulmonary embolism and its treatment remain to be determined by a prospective, multicentre clinical trial. The adherent non-mobile thrombus is usually implanted on the free wall of the right atrium or the interatrial septum. Its formation, in situ, is due to stasis secondary to decompensated congenital or acquired cardiac disease or to the presence of an intracardiac foreign body such as a pacing wire. It is less likely to cause pulmonary embolism. It decreases or disappears with anticoagulant therapy and the outcome is usually good. The differential diagnosis between a mobile thrombus and a Chiari network, or between an adherent thrombus and a vegetation on a intracardiac pacing wire may be difficult and requires transoesophageal echocardiography. The investigation of pulmonary embolism requires systematic echocardiography, one of the objectives of which is to search for right sided thrombi.

[Evaluation of the systematic use of wide lumen 6 French guiding catheters in conventional coronary angioplasty]. / Evaluation de l'utilisation systématique de cathéter-guide 6 French à large lumière en angioplastie coronaire conventionnelle.

The aim of this study was to evaluate the results of systematic use of 6 French guiding catheters in conventional balloon coronary angioplasty without any restriction of indications apart from coronary lesions necessitating other techniques such as atherectomy. Therefore, after a learning period, 200 consecutive procedures performed between November 1993 and June 1994 for the treatment of 234 lesions were analysed prospectively. Fifty-one patients had stable and 70 unstable angina. In 79 cases, the angioplasty was performed on the culprit lesion of a myocardial infarction. An angiographic success was obtained for 206 lesions or 88% of cases which increased to 95% after exclusion of attempted recanalisation. There were 3 cases of damage to the ostium and 7 patients underwent implantation of a stent with the same catheter for occlusive or threatening dissection. There were 10 ischaemic complications (5%) (7 non-Q wave infarctions, 2 Q wave infarctions, 1 aorto-coronary bypass, no deaths) and 8 local complications at the site of arterial catheterisation during the hospital period. These results demonstrate the feasibility of coronary angioplasty with wide lumen 6 French guiding catheters and show that they amy be used in first intention for all conventional balloon angioplasty procedures.

Coronary angioplasty of bifurcational lesions with the protecting branch technique using 6 French guiding catheter.

The use of 6 French guiding catheters is still usually limited to elective percutaneous transluminal coronary angioplasty. We describe our preliminary experience with this guiding size to perform a double guide wire procedure for angioplasty or coronary bifurcation lesions, to protect (n = 5) and/or to sequentially dilate (n = 9) a major side branch. Technical success was 12/14 (86%), angiographic success 13/14 (93%), and in-hospital outcome was event free in all patients. Thus, 6 French guiding size is both safe and effective for the majority of coronary bifurcation angioplasty.

[Transesophageal echocardiographic diagnosis of left ventricular parietal rupture, a complication of myocardial infarction]. / Diagnostic par échographie transoesophagienne d'une rupture pariétale du ventricule gauche sur infarctus du myocarde.

The authors report the case of postero-lateral myocardial infarction complicated by free wall rupture at the 48th hour. The diagnosis was suspected clinically and transoesophageal echocardiography showed the appearance of pericardial effusion in a patient difficult to examine by conventional echocardiography. Transoesophageal echocardiography was performed and well tolerated. The transgastric view showed a thrombus adjacent to a thinned and lacerated postero-lateral wall. The clinical outcome was favourable after surgical repair.

Diagnostic accuracy of echocardiography-Doppler in acute pulmonary embolism.

We studied prospective recording of clinical, electrocardiographic, Doppler and echographic parameters in 32 patients with proven pulmonary embolism, matched with 32 patients with clinically suspected pulmonary embolism and normal perfusion scan or angiography. Thirty-seven per cent of cases and 16% of control subjects had clinical signs of right ventricular overload; S1-Q3-T3 ECG pattern was found in 11 cases and one control. Other clinical and ECG parameters did not reach significant difference. Echographic septum motion was abnormal in 42% of cases and 9% of controls (P < 0.05), end-diastolic right ventricular diameter was > 25 mm in 67% of cases and 11% of controls, ratio of end-diastolic right over left ventricular diameters increased over 0.6 in 67% of cases and 11% of controls, while Doppler examination found tricuspid regurgitant peak flow velocity > 2.5 m/s in 84% of cases vs. 10% of controls. According to these parameters, Doppler-echocardiography was normal in 6% of cases and 87% of control subjects (P < 0.001 for each). In suspected pulmonary embolism, our study shows that Doppler-echocardiography may be both sensitive and specific in emergency conditions and help the decision making for further invasive investigations.

Prevalence of valvular involvement in systemic lupus erythematosus and association with antiphospholipid syndrome: a matched echocardiographic study.

Antiphospholipid antibodies in patients with systemic lupus erythematosus (SLE) are often associated with thrombosis, recurrent abortions and thrombocytopenia. The purpose of this study was to evaluate the prevalence of cardiac valvular abnormalities in patients with SLE and to establish the relationship between the echographic findings and the presence of an antiphospholipid syndrome. A total of 52 consecutive patients with SLE and 52 healthy sex- and age-matched controls were therefore evaluated in a cross-sectional study. All underwent M-mode and two-dimensional echocardiography, color-flow imaging, pulsed and continuous-wave Doppler. In the SLE group, subjects exposed to antiphospholipid syndrome (n = 20) were compared to controls. Patients with SLE had significantly more mitral (p = 0.032; RR 2.48; 1.25-5.6) and tricuspid regurgitations (p = 0.0016; RR 2.41; 1.58-8.85). There was no significant difference between either group for mitral valve thickness (p = 0.66). The antiphospholipid syndrome was significantly associated with increased relative risk for tricuspid.

[Value of transesophageal echography in the detection of left intraventricular masses. Apropos of a case of apical thrombus]. / Intérêt de l'échographie transoesophagienne biplan dans la détection des masses intra-ventriculaires gauches. A propos d'une observation de thrombus apical.

The authors report a case of left intraventricular thrombus investigated by two-dimensional transesophageal echocardiography (TEE). Three longitudinal views obtained by rotation, left lateral inclination and by advancing the probe, enabled the precise evaluation of a mass situated at the apex of the left ventricle, together with ventricular morphology and kinetics. Two-dimensional TEE is electively indicated for confirmation of the diagnosis of left intraventricular apical masses, in particular in hypoechogenic patients and to guide possible surgery. The two-plane probe provides a certain number of sections which remain relatively limited but this problem is resolved with the development of multidimensional probes.

[Mobile thrombus of the right heart and pulmonary embolism: diagnostic and therapeutic problems. Apropos of 12 cases]. / Thrombus mobile du coeur droit et embolie pulmonaire: problèmes diagnostique et thérapeutique. A propos de 12 cas.

The objectives of this report were to analyse clinical presentation, echocardiographic features and diagnostic and therapeutic problems posed by an unusual form of thrombo-embolic disease: mobile right heart thrombosis. Systematic echocardiography in 170 cases of severe pulmonary embolism identified mobile right thrombi in 12 cases. The auscultatory findings were abnormal in 6 cases, 3 showing signs of tricuspid obstruction. Two-dimensional echocardiography showed an extremely mobile right atrial mass, sometimes prolapsing across the tricuspid valve, which was variously spheric, ovoid or worm-like; dilatation of the right heart chambers and echocardiographic signs of cor pulmonale were observed in all cases. The differential diagnosis with other embolic masses of the right atrium and, above all, with well-developed Chiari networks, may be difficult and requires transoesophageal echocardiography. Pulmonary angiography is contra-indicated because of the risk of embolism. Embolectomy under cardiopulmonary bypass was carried out in 8 patients, immediately after echocardiography in 6 cases. The thrombus was recovered from the right atrium in 6 cases and from the pulmonary artery in 2 cases: there was one operative death. Medical treatment was administered to 3 inoperable patients. The clinical and echocardiographic outcome was good in 2 of these but the third patient died; autopsy revealed thrombi in the right atrium and pulmonary artery. One patient died before any treatment could be given and autopsy showed the thrombus in the pulmonary artery. These results confirm the extreme instability of this type of thrombus and the risk of death due to its embolism.(ABSTRACT TRUNCATED AT 250 WORDS)

[Late complication of blunt injuries of the thorax: acute pericarditis. Apropos of a case]. / Une complication tardive des traumatismes fermés du thorax: la péricardite aiguë. A propos d'un cas.

The authors report a case of closed trauma of the thorax, complicated after a symptom-free period by acute pericarditis, combined with pleural effusion. The clinical outcome was favorable and the pericardial effusion, which was considerable at the first ultrasound scan, spontaneously recovered fully. The incidence of this delayed complication of closed trauma of the thorax is unknown. Its mechanism, related to that of the Dresler syndrome and post-pericardiotomy syndrome differs from that of initial hemopericardium which is of mechanical origin. This case highlights the capital importance of ultrasound in the diagnosis and assessment of cardiac complications of thoracic trauma.

[Thrombolysis and acute venous thromboembolic disease]. / Thrombolyse et maladie veineuse thrombo-embolique aiguë.

Thrombolytic agents are widely used as first line treatment in severe acute pulmonary embolisms. While their indications are well defined, no controlled trial exists to provide definite evidence of their ultimate effectiveness in terms of mortality. Nevertheless, therapeutic advances and the good results obtained in terms of satisfactory changes in hemodynamic and angiographic parameters have led to renewed evaluation at the present time of the ways in which they are used in thrombo-embolic disease: administration of thrombolytics as repeated boluses in order to decrease the risk of hemorrhagic complications; and extension of the indications of thrombolysis to the venous component of thrombo-embolic disease.