[Management of comorbidities in heart failure]. / Prise en charge des comorbidités de l'insuffisance cardiaque.

We will review some diseases that interfere most with management of heart failure : anemia, chronic renal failure, chronic pulmonary diseases, diabetes, atrial fibrillation/flutter, sleep apnea, angina, systemic arterial hypertension, rheumatic disease, depression and anticancer chemotherapy. We will retain principally their therapeutic implications. Anemia can be partially corrected by administration of intravenous iron or erythropoietin. Chronic renal failure requires adaptation of the treatment, in particular for drugs of the renin-angiotensin-aldosterone system. Chronic pulmonary diseases complicate diagnosis of heart failure and may lead to sub prescription of beta-blockers. Diabetes does not alter the usual recommendations for the treatment of heart failure but some hypoglycemic medications should be prescribed with caution. In the presence of atrial fibrillation or flutter, the main purpose of the treatment is to improve the quality of live and to diminish the thromboembolic risk ; it may be obtained by rhythm or rate control. Therapeutic approach of sleep apnea is based on optimal treatment of heart failure and weight loss. In the presence of angina, systemic arterial hypertension, rheumatic disease or depression, certain drugs usually prescribed are contraindicated or must be prescribed with caution. Finally, chemotherapy can be cardiotoxic and require careful monitoring of cardiac function.

[Management of atrial fibrillation in 2011]. / Prise en charge de la fibrillation auriculaire en 2011.

Some new guidelines have been published by European (2010) and American (2011) Societies of Cardiology regarding to the management of atrial fibrillation, the most frequent arrhythmia affecting from 1 to 2% of the global population. In this article we summarize and analyse the new aspects of these guidelines in which the different types of atrial fibrillation are redefined, as well as new criterias for the indication of oral anticoagulation and bleeding risk. New antiarrhythmic and anticoagulant molecules also appear in these guidelines, and there is growing evidence for the use of catheter ablation.

[Particular aspects of heart failure in elderly patients]. / Aspects particuliers de l'insuffisance cardiaque du patient agé.

The prognosis of heart failure in elderly patients is poor. The knowledge of the particular aspects of this pathology could certainly increase the prevention and the therapeutic approach of this disease. The presence of many precipitating factors and comorbidities is typical of this pathology. The clinical diagnosis is particularly difficult, especially because the signs and symptoms are similar to those of frequent disorders in elderly patients. Moreover, cognition and sensory impairments and the spontaneous reduction of the physical activity, masking symptoms, may also disturb the diagnosis. Diastolic heart failure, frequent in old patients, contributes sometimes to perturb the diagnosis. The treatment of heart failure in elderly people is based in first line on the control of the precipitating factors. The pharmacotherapy is not fundamentally different from the younger patient and must follow the recommendations of the literature (Evidence Based Medicine). The underutilization of proven therapy must indeed be avoided. However, the careful beginning, at very low doses, and a careful titration to obtain the recommended doses, is essential. Moreover, the susceptibility to side effects and the frequent contra-indications in the elderly require meticulous precautions in the prescription of the drugs. Diuretics remain the cornerstone to promptly control the pulmonary congestion and the edema. The angiotensin-converting-enzyme inhibitors, the antagonists of the angiotensin-receptors and the beta-blockers must be prescribed as in the younger patients. Digoxin plays also a role in several precise indications. Coronary angioplasty, heart surgery and technique of resynchronization have indications in certain cases. Multidisciplinary approach and vigilant follow-up are essential to improve the prognostic of heart failure in elderly patients.

Clinical usefulness of biplane transesophageal echocardiography.

The clinical usefulness of biplane color Doppler transesophageal echocardiography is illustrated by the results obtained in 300 successive examinations. The additional contribution of the newer longitudinal plane was judged significant or major in 64% of the cases. The method was useful mainly for intraoperative examinations, assessment of native valvular disease, prosthetic valve evaluation, search for tumors, and assessment of endocarditis, congenital heart disease, and aortic disease. In contrast, the longitudinal plane option was not contributory in 68% of the cases of thromboembolism. Typically, the technique aided in the evaluation of mitral valve insufficiency and the detection of paraprosthetic leaks. Lesions located at the level of the ascending aorta, the left and right ventricular outflow tracts, and the interatrial septum were also visualized best. The limitations of the method were negligible and the duration of the examination was not significantly increased in comparison to the monoplane method. When available, biplane transesophageal echocardiography seems to be preferred in most clinical settings.

[Current status of transluminal coronary angioplasty]. / Bilan actuel de l'angioplastie coronaire endoluminale.

The morphological and clinical indications of coronary angioplasty have been widely extended. This technique occupies now a place of choice in the treatment of ischemic heart disease. The high success rate is obtained with a minimal rate of complications and death. New technical approaches are now proposed in order to reduce the incidence of the restenosis, which remains the major problem limiting the long-term efficacy of the procedure.

Assay of serum cardiac myosin heavy chain fragments in patients with acute myocardial infarction: determination of infarct size and long-term follow-up.

To evaluate the correlation between myosin heavy chain release and the necrosis mass, serum levels of myosin heavy chain fragments were determined serially in 55 patients with acute myocardial infarction. Eight of these patients were successfully treated with thrombolytic agents: the others were not treated. The same myosin titration was applied to the sera of 25 dogs with an experimental myocardial infarction. Six of the dogs were successfully treated with thrombolytic agents. The time courses of the myosin concentrations are typical and monophasic for all patients with a noncomplex myocardial infarction. The values for the kinetic parameters of myosin release are comparable to those previously reported. We have now determined that cumulative myosin release significantly correlates with cumulative creatine kinase (CK), CK-MB, and lactate dehydrogenase release, as well as with thallium-201 distribution, as determined for different patient groups. Thrombolytic treatment does not seem to qualitatively upset myosin kinetics. The results obtained in dogs with or without thrombolysis conclusively indicate that myosin release is a quantitative index of the necrosis mass. From a practical point of view, a few serial determinations of serum levels of myosin heavy chains are enough to estimate the necrosed mass in patients with acute myocardial infarction. More generally, serum myosin titration could be useful in detecting any cardiac disturbance involving myocardial injury resulting in membrane leakage of cardiac cells.

The spectrum of mitral regurgitation in idiopathic mitral valve prolapse: a color Doppler study.

To characterize the spectrum of mitral regurgitation in mitral valve prolapse, one hundred patients were studied by color Doppler flow mapping. The findings were correlated with the clinical presentation and with the possible complications. Mitral regurgitation was absent in 46 patients, mild in 26 patients, moderate in 18 patients and severe in 10 patients. The jet orientation was central in 15 patients, antero-medial in 13 patients and postero-lateral in 26 patients. The regurgitation was early systolic in 7 patients, late systolic in 20 patients and holosystolic in 27 patients. A good agreement was observed between the color flow patterns and the presence, timing and radiation of a murmur. Systolic clicks were not predictors of the presence or the severity of regurgitation. The grade of mitral regurgitation was positively correlated with, age, left heart enlargement and valvular redundancy. No sex difference was observed. The prevalence of serious arrhythmias or cerebral ischemic events was not significantly increased when a regurgitation was present.

Transaortic saphenous patch angioplasty for left main coronary artery stenosis. An alternative to coronary artery bypass.

We present two cases of isolated proximal left main coronary artery stenosis treated by direct transaortic angioplasty. In selected patients this technique offers a valuable alternative to CAB graft with the advantage of restoring unobstructed antegrade flow.

Predictors of the variation of the ejection fraction during exercise in patients with and without coronary heart disease.

The aim of this study was to determine the factors influencing the different response of the ejection fraction (EF) of the left ventricle at exercise observed in patients with and without significant coronary heart disease. We have studied 98 patients referred for coronary angiography (82 men, 16 women), of whom 49 patients had a previous myocardial infarction and 71 patients had significant coronary heart disease. Exercise testing was performed and combined with a cardiac blood pool imaging at equilibrium. The variation of the EF between rest and peak exercise (delta EF) was measured. Twelve clinical, exercise-related, isotopic, and coronary arteriographic variables were examined in a linear univariate and statistical analysis. In the univariate regression, seven variables were significant regressors on the delta EF. In the multivariate regression, only four variables were significant regressors on the delta EF. Three independent predictors were found: the rate-pressure product, the ST depression, and the occurrence of a previous myocardial infarction. These three independent predictors reflect the myocardial functional reserve.