Tako-Tsubo syndrome after an exercise echocardiography.

The Tako-Tsubo syndrome is a clinical entity recently described that associate a chest pain occurring during a stress, an abnormal ECG and/or an increase in the troponin blood level and a transient left ventricular dysfunction with an akinesis involving generally the midsection and the apex of the heart. It has also been reported that left ventricle (LV) dysfunction may involve only the midventricle, although it seems less common. We report the case of a 66 year old woman that developed a stress-induced cardiomyopathy (Tako-Tsubo syndrome) involving the midventricle when performing an exercise echocardiography. To our knowledge, this is the first case reported in such circumstances.

Relationship between left ventricular hypertrophy, myocardial contractility, and load conditions in hemodialysis patients: an echocardiographic study.

Left ventricular hypertrophy (LVH) is common and is an independent cardiac risk factor in dialysis patients. The aim of this study was to assess hemodynamic determinants of LVH and, more particularly, the relationship between left ventricular mass, myocardial contractility, and load conditions. Eighty dialysis patients aged 51 +/- 15 years were prospectively studied by echocardiography. LVH was detected in 62 patients (78%). Left ventricular mass was significantly correlated to both end-diastolic volume (r = 0.54; P < 0.001) and end-systolic stress/end-systolic volume, an index of contractility (r = -0.66; P < 0.001), but not to systolic blood pressure or end-systolic stress, both indexes of afterload. Thus, in dialysis patients, the degree of LVH is significantly correlated with the severity of both left ventricular dilatation and contractile myocardial failure, but not with left ventricular afterload.

Detection of coronary artery disease in diabetic patients.

Coronary artery disease may be difficult to detect in diabetic patients. This study was designed to determine the specificity and sensitivity of three noninvasive tests. Accordingly, the results of 48-h ambulatory electrocardiogram (ECG) monitoring, maximal ECG exercise test, and intravenous dipyridamole myocardial thallium scintigraphy were compared in 59 middle-aged diabetic patients who were consecutively selected for suspected coronary artery disease. All patients also underwent coronary angiography, which was performed regardless of the results of the non-invasive tests. Twenty patients (34%) had significant coronary lesions, i.e. stenosis equal to or greater than 70%, and 16 of these 20 patients (80%) had double or triple vessel disease. Sensitivity and specificity were, respectively, 25% and 88% for ambulatory ECG monitoring, 75% and 77% for the exercise test and 80% and 87% for thallium myocardial scintigraphy. This observation strongly supports the use of non-invasive tests for the detection of coronary artery disease in those diabetic patients at high risk of such disease. As the exercise test is cheaper and more widely available than thallium myocardial scintigraphy it should be used as a first line examination. Dipyridamole myocardial scintigraphy may provide an alternative solution for those patients who cannot perform maximal exercise, or with atypical clinical presentation.

Cardiac valve replacement in relapsing polychondritis. A review.

Cardiac valve replacement is a rare but not exceptional eventuality in patients with relapsing polychondritis. One case requiring aortic and mitral valve replacement and its follow up is described. From the review of the literature an additional twenty patients who required cardiac valve replacement are analyzed. The mean delay between the first onset of relapsing polychondritis and operation was 6.51 years and the mean age at operation was 38.8 years. There was a preponderance of male patients (73.7%). Aortic and mitral valves were replaced in 100% and 28.5% of patients, respectively. During the four first postoperative years 23.8% of them were reoperated for periprosthetic leak or aortic aneurysm, and during the same period 52.6% died of a cardiovascular cause. Immunosuppressive agents should be employed in patients with relapsing polychondritis and cardiovascular involvement because they seem to be more effective than steroids in severe forms of the disease. Therefore, we recommend close and prolonged follow up: firstly because there can be early paravalvular prosthetic leakage due to the friability of the tissue to which it has been anchored; secondly because aortic aneurysms occur frequently in relapsing polychondritis, may be multiple, may involve all parts of the aorta and result in fatal rupture even in asymptomatic patients; and thirdly because there can be a fatal outcome due to other organ involvement, like airway obstruction, acute glomerulonephritis, or systemic vasculitis. Prophylactic composite graft replacement of the ascending aorta associated with replacement of the aortic valve and re-implantation of the coronary arteries could avoid the need for reoperation in these high risk patients.

[Doppler echocardiographic evaluation of physical properties of the aorta and left ventricular geometry in normotensive hemodialyzed patients]. / Etude par échocardiographie doppler des propriétés physiques de l'aorte et de la géométrie ventriculaire gauche chez des patients hémodialysés normotendus.

Twenty-five patients undergoing hemodialysis therapy with a normal blood pressure (16 men, 9 women, age = 54 +/- 14 years) and 25 sex and age-matched healthy normotensive subjects were examined by doppler-echocardiography. Pulse wave velocity (PWV) in the thoracic descending aorta, diameter of the ascending aorta (AD), left ventricular mass (m), thickness-radius ratio (th/r), shortening fraction (SF), end systolic pressure-diameter ratio (P/D) and the ratio of late and early mitral velocity (A/E) were obtained. Pulse wave velocity, SF, P/D, were not significantly different in the 2 groups whereas AD, m, th/r, and A/E were significantly larger in dialysis patients than in controls (both, p < 0.001). These results indicate that in patients treated by hemodialysis with a normal blood pressure, a concentric left ventricular hypertrophy is associated with a normal aortic stiffness, suggesting a depressed myocardial contractility.

Management of giant coronary artery aneurysm with fistulization into the right atrium.

A giant right coronary artery aneurysm communicating with the right atrium is reported. Its diagnosis using echocardiography, computed tomography of the chest, and angiography is illustrated. The operative management of this rare cardiac pathology is described. The role of operation in such a large aneurysm is emphasized.

Determinants of stroke volume response to exercise in patients with mitral stenosis: a Doppler echocardiographic study.

OBJECTIVES: The aim of this study was to assess exercise-induced changes in stroke volume and their main determinants in mitral stenosis. BACKGROUND: The mechanisms of the stroke volume response to exercise in mitral stenosis are not clearly established. METHODS: Twenty-seven patients with mitral stenosis, aged 47 +/- 13 years, and 10 healthy control subjects, aged 46 +/- 11 years, were examined by Doppler echocardiography to obtain stroke volume, mitral velocity-time integral and calculated mitral valve area (by continuity equation) at rest and during submaximal supine bicycle exercise. Measured mitral valve area at rest and total mitral score were also obtained. RESULTS: During exercise, stroke volume increased significantly (p < 0.001) in the control subjects (+25 +/- 6%) but remained unchanged in the patients. In 10 patients (Group I), stroke volume increased by > or = 14% (+23 +/- 10%, p < 0.001); in the other 17 (Group II), it decreased or increased by < 14% (-5 +/- 14%, p = NS). Mitral velocity-time integral did not change in the three groups, whereas calculated mitral valve area increased significantly (p < 0.001) and similarly in Group I and the control group but remained unchanged in Group II. The exercise change in calculated mitral valve area correlated significantly with both measured mitral valve area at rest (r = 0.46, p < 0.05) and total mitral score (r - 0.53, p < 0.005). However, at constant mitral score, exercise change in calculated mitral valve area no longer correlated significantly with measured mitral valve area at rest. CONCLUSIONS: In mitral stenosis, the change in stroke volume during exercise depends on the change in mitral valve area, which itself depends on the degree of mitral valve damage.

Late thrombotic obstruction of an aortic bioprosthetic valve: successful treatment by oral anticoagulation.

Thrombotic obstruction of aortic bioprostheses is rare. Few cases have been reported involving the use of the Carpentier-Edwards (CE) prosthesis, the Hancock bioprosthesis, or the Medtronic Intact porcine valve. Thrombolytic therapy for mechanical valve thrombosis has been used frequently even though it is known to carry a high risk of embolism and recurrence. However, the use of this therapy was reported for the first time only recently, in a case of acute aortic thrombosis which occurred 3 1/2 months after bioprosthesis insertion. We report a case of late progressive thrombotic obstruction of a CE aortic valve 3 years after insertion. The case was successfully treated with coumadin therapy, as confirmed by serial Doppler echocardiographic examinations and a 3-year follow-up.

Non-invasive identification of severe coronary artery disease in patients with long-standing diabetes mellitus.

OBJECTIVES: To detect severe coronary artery disease in asymptomatic middle-aged diabetic patients exposed to coronary artery disease risk factors. PATIENTS AND METHODS: Forty-four middle-aged patients (30 to 65 years of age) with a known duration of diabetes exceeding 10 years and at least one additional cardiovascular risk factor were studied. Patients were free of anginal chest pain and had a normal 12-lead ECG at rest. All patients underwent 24-hour ambulatory ECG, maximal bicycle exercise electrocardiography and intravenous dipyridamole thallium myocardial scintigraphy. If one of these 3 non-invasive tests revealed signs of myocardial ischaemia, a coronary angiography was performed. RESULTS: Non-invasive investigation yielded the diagnosis of myocardial ischaemia in 9/44 patients (20%). Six of the 9 patients had significant coronary artery stenoses (> 70% narrowing) and 5 exhibited severe triple-vessel disease. With dipyridamole thallium scintigraphy, the positive predictive value for diagnosis of coronary artery disease was optimal. CONCLUSION: In diabetic patients with additional coronary risk factors, periodical thorough clinical examination and resting ECG may fail to detect severe coronary disease. More sophisticated cardiovascular non-invasive tests should then be proposed as part of the periodical care of these patients.

[Apropos of acute changes in left ventricular filling induced by antihypertensive treatment]. / A propos des modifications aiguës du remplissage ventriculaire gauche induites par le traitement antihypertenseur.

The purpose of the study was to interpret the acute improvement in left ventricular (LV) filling induced by a new calcium channel blocker (SR 33 557) using Doppler echocardiography. Thirteen patients, 29 to 68 years old (mean 52) with mild to moderate hypertension were examined by Doppler echocardiography before and 4 hours after treatment (SR 33 557: 300 mg). The LV filling parameters, E, A, A/E, VTIM, VTIA, VTIA/VTIM, pressure half time (PHT) and isovolumic relaxation time (IRT) were measured. An index of left atrial pressure was obtained by measuring the mean pulmonary arterial pressure (PAP). The following hemodynamic parameters were also obtained: systolic blood pressure (SBP), heart rate (HR), PR interval (PR), stroke volume (SV) at aortic origin, total systemic resistances (TSR), pulse wave velocity (PWV) at thoracic descending aorta, LV end systolic stress (ESS), LV geometry (thickness/radius: th/r) and systolic function indices: mean VCF and contractility (mean VCF-ESS relationship). Following acute treatment, E and VTIM increased, A, VTIA and PHT did not change, and A/E, VTIA/VTIM ans IRT decreased, both significantly (p < 0.05). PAP did not change, HR, SBP, TSR, PWV, ESS decreased and PR increased both significantly (p < 0.05). LV geometry and systolic function did not change. No significant relationship was found between LV filling changes and changes in hemodynamic parameters. In conclusion, the acute increase in early LV filling induced by the calcium blocker treatment may be interpreted as the consequence of the improvement in LV relaxation in the absence of any change in left atrial pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Functional coupling of the left ventriculo-arterial system and aging in man]. / Couplage "fonctionnel" ventricule gauche-système artériel et vieillissement chez l'homme.

In a haemodynamic and angiographic study at rest conducted in 25 men aged from 22 to 68 years who had no more than another risk factor for arterial disease and showed no evidence of cardiac or arterial disease several parameters were measured or calculated. Firstly, a global index of arterial system function (Ea) and its various factors: Ea = ESP/SV [ESP: left ventricular end-systolic pressure; SV: systolic volume]; Ea = (HR x TSR)+Ea' [HR: heart rate/min; TSR: total systemic resistance] where Ea' = (ESP - AoP/SV) [AoP: mean aortic pressure]. Secondly, the parameters concerning the left ventricle were the mass (m) and the m/EDV ratio [EDV: end-diastolic volume] and indices of the left ventricular systolic and diastolic functions, such as ELV = ESP/ESV [ESV: end-systolic volume], kp: the volumic distensibility module of the left ventricular chamber; relations EF - o ES [EF: ejection fraction; o ES: end-systolic constraint], and kp - m/EDV as indice of left ventricular muscle distensibility. In parallel with the subjects' age, Ea increased by joint augmentation of TSR and Ea' while m, m/EDV, ELV and kp also significantly increased. The inotropic quality of the left ventricular muscle and its intrinsic distensibility were found to be decreased in a few subjects aged over 45. Ea/ELV (reverse of ejection fraction -1) tended to increase (ELV relatively less than Ea), but this increase was not significant (P = 0.10). These results show that in the ageing man the improvement observed in the ejection fraction of the left ventricular pump corresponds roughly to the degradation of the arterial system transfer function, and the arterial system-left ventricle coupling, evaluated by the Ea/ELV ratio, is maintained (better in fact than in arterial hypertension and heart failure). This improvement is achieved by increases of m and, chiefly, m/EDV which compensate for both the increase of Ea and the relative decline of left ventricular muscle contractile quality. There is a disorder of the left ventricular pump diastolic function which is due to geometric changes in the chamber and to changes in the intrinsic distensibility of the left ventricular muscle.

[Sudden death in heart failure. Analysis and prevention]. / Mort subite dans l'insuffisance cardiaque. Analyse et prévention.

Sudden death is a frequent complication of heart failure occurring in 35 to 45 per cent of the cases. This multifactorial event may be of haemodynamic origin (acute heart failure, electro-mechanical dissociation) or, more often, of rhythmic origin (torsade de pointe, sustained ventricular tachycardia, ventricular fibrillation, bradycardia, asystole). Numerous structural, haemodynamic, metabolic, ionic, neurohormonal and iatrogenic factors facilitate ventricular hyperexcitability. The main predictive factors of sudden death in heart failure are the presence of coronary heart disease and of reduced left ventricular ejection fraction; the prognostic value of ventricular rhythm disorders is controverted. Prevention of sudden death begins with correcting those factors which facilitate disturbances in rhythm and conduction. Beta-blockers are effective in the post-infarction period, but there is no evidence that other drugs are useful. Identifying patients at high risk and determining the therapeutic approach that reduces this risk are still incompletely resolved problems.

[Do antihypertensive agents change the incidence of cardiovascular complications of hypertension?]. / Les traitements anti-hypertenseurs modifient-ils l'incidence des complications cardiovasculaires de l'hypertension artérielle?

The main aim of the treatment of hypertension is to reduce the incidence and severity of its complications. Despite some bias affecting the major clinical trials of diuretics and/or beta blockers, the results of the meta-analysis taking them into account demonstrate the effectiveness of the prevention of cerebrovascular complications and the less effective prevention of coronary complications. Progress can be hoped for as a result of new therapeutic categories (converting enzyme inhibitors, calcium channel inhibitors ...) and to a greater extent from new treatment strategies, involving better identification of "genuinely high risk" subjects.

[Left ventricular remodeling and ischemic heart diseases. Therapeutic possibilities]. / Remodelage ventriculaire gauche et cardiopathies ischémiques. Possibilités thérapeutiques.

Left ventricular modeling after myocardial infarction may be modified in three ways: firstly, by limiting the infarct size; secondly, by administering ACE inhibitors: these drugs limit infarct expansion and ventricular dilatation. They reduce the prevalence of secondary left ventricular failure and, in the animal, improve the prognosis. Glyceryl trinitrate also appears to be effective. The third therapeutic option is maintaining the patency of the artery responsible for the infarction, which has a beneficial effect on ventricular remodeling. The respective therapeutic indications of these three options are still a matter of discussion.

[Properties of arteries, cardiac function and structure in chronic hypertension]. / Propriétés du système artériel, fonction et structure cardiaques dans l'hypertension artérielle permanente.

Hypertension is a condition which demonstrates the relationship between the properties of the left ventricle and arterial system. The spectrum of aortic impedence expresses the principal factors which oppose LV ejection into the initial aorta: 1) capacitive forces related to the viscoelastic properties of the arterial wall, directly proportional to its rigidity, 2) forces of inertia which increase with the acceleration of the blood and which are inversely proportional to the aortic cross sectional area, 3) reflection. With respect to a stroke volume which is usually normal, hypertension is characterised by: 1) an increase in mean aortic pressure (MAP), 2) with respect to the increase in MAP, an increase in systolic, late systolic and differential pressures. These changes in the level and morphology of aortic pressure are due to: a) the increase in systemic arterial resistances, a continuous expression of the spectrum of the module, b) an increase in the elastic forces (increased rigidity of the aorta related to increased pressure and structural wall changes) usually insufficiently compensated by a decrease in the inertial forces (aortic dilatation), c) an earlier return of the reflected pulse wave, well before the end of the anterograde wave. Overall, there is a relationship between the mass, the geometry (concentric hypertrophy) and pump function of the left ventricle and the properties of the arterial system expressed in terms of pulse wave velocity, characteristic impedence or the late systolic pressure/stroke volume ratio. The relationship is much closer than that of the properties of the LV and aortic pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Ventilatory threshold during exercise in patients with mild to moderate chronic heart failure: determination, relation with lactate threshold and reproducibility.

Detection of the ventilatory threshold during exercise has been proposed in order to assess exercise tolerance in patients with chronic heart failure. The relation between the different methods of detecting the ventilatory threshold and the lactate threshold, however, and their reproducibility, have not really been assessed. Forty-three patients with chronic heart failure underwent an exercise test with respiratory gas analysis. A lactate threshold could be determined in 36 patients and a ventilatory threshold in 27 to 38 patients, depending on the method of determination of the ventilatory threshold. The greatest number of determinations (38) and the best correlation coefficient with the lactate threshold (r = 0.87 and 0.88, respectively) were obtained with the method of the ventilatory equivalent for oxygen and by averaging the different methods of determination. Reproducibility of the ventilatory threshold was only moderately good (r = 0.83) and less satisfactory than that of the peak oxygen uptake (r = 0.97). We conclude that unless the way of detecting the ventilatory threshold is improved in patients with chronic heart failure, the peak oxygen uptake will remain more reproducible.

Doppler echocardiographic study of the consequences of aging and hypertension on the left ventricle and aorta.

The aims of the study were (1) to describe the consequences of aging and hypertension on left ventricular geometry and physical properties of the aorta, (2) to study interactions between some physical properties of the aorta and left ventricular geometry in normal (NT) and hypertensive patients (HT) using Doppler echocardiography. Forty-five healthy normotensive subjects (age range 21 to 84 years) and 20 untreated sustained hypertensive patients (age range 20 to 70 years) were studied. We measured (1) resting arterial blood pressure with a Dinamap, (2) left ventricular radius (r), thickness (th), mass (LVM), th/r ratio and aortic diameter (AD) by M-mode echocardiography with 2D control, and (3) pulse wave velocity (PWV) in the descending thoracic aorta from aortic velocity tracings recorded by pulsed wave Doppler in the isthmus and near the diaphragm. The PWV/AD ratio was derived. In hypertensive patients, blood pressure, PWV, AD, PWV/AD, th, th/r and LVM were significantly increased compared with normal subjects at a similar age. In normal subjects, PWV, AD, PWV/AD, th, r, th/r and LVM correlated significantly to age. In both groups, th/r ratio was significantly related to PWV and PWV/AD. The Doppler echocardiographic method of PWV measurement is feasible, reproducible and gives similar results to other methods, especially the invasive haemodynamic method. Doppler echocardiography is an adequate method to study left ventricular geometry and some physical properties of the aorta. It can be used to assess the consequences of aging and hypertension on both left ventricle (concentric hypertrophy) and aorta (increase of aortic stiffness).