[The potential of magnetic resonance imaging for the surveillance of septal alcohol ablation in hypertrophic obstructive cardiomyopathy. A case report]. / Potentialité de l'imagerie par résonance magnétique pour la surveillance du traitement par alcoolisation septale de la cardiopathie hypertrophique obstructive. A propos d'un cas.

We describe here the MRI surveillance of septal alcohol ablation in a case of symptomatic obstructive cardiomyopathy. MRI examinations were performed before, 15 days and 2 months after alcohol ablation using an identical protocol to study the function, regional perfusion and the equilibrium perfusion in order to directly visualize the infarction. MRI seems to be an excellent investigation in the surveillance of such patients, allowing precise quantification of the infarcted zone. The various stages of cellular necrosis in the induced infarct were demonstrated, and the role of remodelling in increasing the functional area of the systolic ejection pathway.

[Long-term results of aorto-bifemoral prostheses in the surgery for atheromatous stenosis of the aortic bifurcation]. / Résultats à long terme des prothèses aorto-bifémorales dans la chirurgie des sténoses athéromateuses du carrefour aortique. 700 malades suivis pendant 20 ans.

Seven hundred patients operated consecutively by the same surgical team for atheromatous stenosis of the aortic bifurcation were followed up for 20 years with only 5 patients lost to follow-up. There were 94.5% of men with a mean age of 58 years. The operative mortality was 2.7% with few deaths due to true cardiovascular causes (0.7% of patients). The secondary mortality was very high with two main causes: cancer (39% of patients) and cardiovascular diseases (37%). Other causes were responsible for only 24% of deaths. The principal complications of the prostheses were: infection (0.6% of operated patients), thrombosis (6.7%), pseudo-aneurysm of the aorta (1.57%) and pseudo-aneurysm of Scarpa's triangle (4%). The benefits of surgery are unquestionable both on terms of survival, as amputation, bed confinement and invalidity are avoided, and in terms of function, as amputation was avoided in 84% of the 32% of patients in Stages III or IV before surgery. Only 5% of patients were amputed during the observation period. Moreover, 79% of survivors had a good functional result at 15 years. Improvement of results depends on better hygienic measures, systematic screening for high risk cancers and a better management of the arterial disease with early treatment of other arterial diseases (coronary, carotid) in order to reduce postoperative and mostly medium- and long-term cardiovascular mortality.

[Postoperative transparietal Doppler ultrasonographic study of the internal mammary artery graft flow with respect to quality of the underlying myocardium]. / Etude en écho-doppler transpariétal postopératoire du flux du greffon mammaire interne en fonction de la qualité du myocarde sous-jacent.

The authors studied flow in the internal mammary artery by Doppler ultrasonography after bypass surgery of the left anterior descending artery to determine the correlation between the flow pattern and the quality of the distal run off. A pulsed Doppler was used to record flow from the right and left internal mammary arteries in the first, second and third intercostal spaces and the supraclavicular fossa. Only the best quality recordings with the highest amplitudes were retained for analysis. Forty-nine patients (average age 61 +/- 10 years), 43 men and 6 women, were included and were examined between the 10th and 15th postoperative days. All had stenosis of the left anterior descending on coronary angiography: three subgroups were identified ad the time of evaluation: (I) revascularisation of an infarcted zone with important angiographic and echographic sequellae. (II) revascularised zones with slight wall motion abnormalities. (IIIa) revascularisation of myocardium with no abnormality (including a subgroup of 5 patients (IIIb) characterised by a postoperative low output state and echocardiographic changes not present before surgery). Significant changes were observed in the flow patterns of the different groups. (I) an exclusively systolic flow (diastolic velocity time integral = 2.85 cm), (II) systolodiastolic flow (diastolic velocity time interval = 9 cm) similar to that in group IIIb, and IIIa predominantly diastolic flow (diastolic velocity time integral = 15.2 cm). The amplitude of diastolic flow in the mammary artery graft was therefore related to previous ischaemia of the revascularised myocardium; detection of stenosis by Doppler ultrasonography should therefore take into account the previous history of the patient.

[Syncopal angina caused by sinus arrest; cured by transluminal coronary angioplasty and calcium inhibitor]. / Angor syncopal par arrêt sinusal; guérison par angioplastie coronaire transluminale et inhibiteur calcique.

The authors report the case of a 42 year old man who smoked and who presented with recurrent spontaneous anginal chest pain followed by syncope due to sinus arrest. The mechanism underlying these symptoms was spasm of the left circumflex artery at the site of severe stenosis of its middle segment just before the origin of the sinus node artery. Treatment with a calcium antagonist with transluminal coronary angioplasty of the narrowed segment of the circumflex artery resulted in complete regression of all symptoms with a follow-up of 15 months. Seven other reports of the same type were found in the literature concerning 6 men and 1 woman, with an average age of 49 years, presenting with the same symptoms and sinus arrest associated with the minimal coronary artery disease. The proof of coronary spasm was documented in 6 of the 7 cases by a positive ergometrine stress test or by the observation of spontaneous spasm during coronary angiography or rapid atrial pacing. The outcome was good with calcium antagonist therapy in 5 cases, and with slow release nitrate derivatives in 1 case. One patient, treated by betablockers, died. It is useful to investigate some sino-atrial blocks to diagnose the underlying ischaemic mechanism as the patients may be treated simply with calcium antagonists rather than undergo implantation of a pacemaker.

[Frequency of angiographic restenosis after 6 months and long-term outcome of coronary angioplasty]. / Fréquence des resténoses angiographiques à 6 mois et devenir à long terme après angioplastie coronaire.

Five hundred patients with a mean age of 59 years were followed up for an average of 32 months after coronary angioplasty. All patients were included in a prospective study comprising coronary angiography at 6 months for 379 patients (91% primary successes). The long-term outcome was evaluated by a questionnaire or telephone interview in all cases. The global primary success rate was 84.4% in this series. The primary failures include 1.8 fatalities, 0.6% myocardial infarction, 2% emergency coronary bypass surgery and 11.2% without immediate clinical consequences. At 6 months, there were 48% of restenoses (182/379 patients) and 28% underwent immediate repeat angioplasty (141/500 patients) with a primary success rate of 91%. After the repeat angioplasty, the restenosis rate was 43% but this varied according to the time from the first restenosis: 60% when the interval was short (under 2 months) compared with 21% when the interval was 6 months (p < 0.01). The actuarial survival rates at 4 years were 95% after successful angioplasty 96% after uncomplicated failures or medically treated restenosis and 98% after bypass surgery. The predictive factors for secondary death were age of over 70 years, previous non-thrombolized myocardial infarction and complications of angioplasty. The long-term outcome was good despite the 48% 6 months restenosis rate requiring revascularisation procedure in 73% of cases.

[Failure and complications of transesophageal echocardiography. Apropos of 1500 consecutive cases]. / Echecs et complications de l'échocardiographie transoesophagienne. A propos de 1,500 examens consécutifs.

Transesophageal echocardiography (TEE) requires the introduction of a flexible probe into the oesophagus and therefore cannot be strictly considered to be non-invasive. This manipulation exposes the patient to complications which are benign in the large majority of cases. The authors report their experience in a prospective study analysing the failures and complications of TEE in the first 1,500 cases performed in their laboratory between May 1988 and May 1992, in mainly adult and ambulatory patients. The probe could not be introduced in 24 patients (1.6%), including 5 cases during the initial learning period. No serious complications were observed during of after TEE. Minor incidents were noted in 28 cases (1.9%) intolerance of the probe (12 cases), nausea and/or vomiting (4 cases), dyspnea (4 cases) due to tracheal intubation in 2 patients, laryngeal in 1 patient and to cardiac failure in 1 case. Pharyngeal haemorrhage (2 cases), atrial fibrillation (3 cases), vertigo (1 case), mandibular dislocation (1 case) and salivary hypersecretion affecting the quality of the imaging (1 case), were also observed. The investigation had to be interrupted prematurely in 12 cases (0.8%) usually because of intolerance of the probe. These results show that TEE is not dangerous in trained hands. Failure to introduce the probe is usually encountered during the learning period, which reinforces the need for apprenticeship in a teaching center. The safety of this technique, plus its considerable diagnostic value in many clinical indications, justify its present role in everyday cardiological practice.

[Exercise echocardiography in coronary disease]. / L'échocardiographie d'effort dans la maladie coronaire.

Exercise echocardiography is a new method used in the investigation of coronary disease. It evaluates the repercussions on regional contractile function of the increase in oxygen consumption induced by physical exercise. It makes it possible to analyse in real time not only the amplitude of endocardial displacement, but also that of parietal thickening and thereby seems to be more precise than conventional ergonomic tests in the diagnosis of myocardial ischaemia. Its recent development owes much to the advent of digital technologies which make it easier and more accurate to interpret the changes observed in left ventricular regional kinetics by comparing the data at rest with those recorded at peak physical effort. When associated with an equally non-invasive ergometric test it is well accepted by the patients. Another of its advantages is its moderate cost. Echocardiographists must devote as much time as necessary to training. Training is indispensable to rapidly capture the images, particularly during efforts, and to reliably interpret the variations observed in left ventricular wall contraction. Exercise echocardiography is still under evaluation. Experience is lacking for the cardiologist to choose, only on its results, the most appropriate treatment for each individual patient, but its help will be appreciated in some difficult therapeutic decisions. Behind this phase of training for, and evaluating this technique several of its main clinical indications can already be outlined.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiography by the transesophageal route. Technique and the main clinical indications]. / L'échocardiographie par voie transoesophagienne. Technique et principales indications cliniques.

Transoesophageal Doppler-echocardiography is a new heart imaging technique avoiding many of the problems which sometimes limit standard transthoracic exploration. The transducer, mounted on a fibroscope sheath, is introduced into the oesophagus and therefore lies in the immediate vicinity of the atrial complex, the mitral valve, the aortic valve and the different segments of the thoracic aorta. The examination can be carried out on ambulatory patients in the echocardiography laboratory. The main clinical indications of this technique are: studies of prosthetic valves (notably the mitral valve); detection of vegetations or annular abscesses in infective endocarditis; determination of an emboligenic focus after arterial embolism; study of the causative mechanism in mitral valve regurgitation; pathology of the thoracic aorta and, in particular, of aortic dissection. The usual lack of difficulty in skilled hands, the quality of the images obtained and the diagnostic value of information collected by this route explain why this relatively new technique has very rapidly progressed from evaluation to routine use in most echocardiography laboratories.

[Doppler echocardiography in myocardial infarction and its complications]. / L'exploration échographique Doppler de l'infarctus du myocarde cicatrisé et de ses complications.

Echocardiography has established an important role in the surveillance of patients with myocardial infarction. Segmental wall motion abnormalities are easily identified and their extension reflects the size of the infarct. Global left ventricular function may be assessed and left ventricular dilatation documented. This information is useful in evaluating the long-term prognosis. In addition, Doppler echocardiography is valuable for detecting complications persisting or occurring after the acute phase such as pericardial effusion, mural thrombus, aneurysm or mitral regurgitation. The indications of Doppler echocardiography should be guided by the symptomatology and the results of clinical examination.