[Cardiac incidentaloma]. / Incidentalome cardiaque.

We describe a case of lipomatous hypertrophy of the atrial septum mimicking a tumor of the right atrium. The association of echocardiography and radiology for the detection of this disease is illustrated in this report.

Double orifice mitral valve with flail leaflet: a transoesophageal echocardiographic examination.

We describe a case of double orifice mitral valve and a flail leaflet in a 54-year-old man. This rare congenital abnormality was disclosed through the discovery of a murmur. The transoesophageal approach clearly showed two approximately equal orifices with multiple papillary muscles. Colour Doppler echocardiography showed a moderate mitral regurgitation due to the prolapse of the posterior leaflet of the anteromedial orifice. No other abnormality was associated. Transoesophageal echocardiography is useful to analyse as well the anatomy as the functional aspect of the mitral apparatus in this particular case of congenital disease.

Doppler-derived left ventricular rate of pressure rise determination in presence of severe acute mitral regurgitation in pigs.

Doppler-derived left ventricular (LV) rate of pressure rise (Dop LV DeltaP/Deltat) is described as an index of LV performance in the presence of mitral regurgitation (MR). This study was designed to define more accurately the accuracy of the method in the presence of severe MR. Ten pigs were anesthetized and monitored. MR was gradually created. At each grade of MR, preload was manipulated with the intent of modifying LV end-diastolic area value within a range of +/-20%. Concurrently, the mean left atrial pressure (LAP) was recorded, MR was quantified by the mitral to aortic velocity-time integral ratio (mitroaortic VTI ratio), Dop LV DeltaP/Deltat was calculated, and peak LV dP/dt was derived from LV catheterism data. During the procedure Dop LV DeltaP/Deltat gradually underestimated peak LV dP/dt. This difference was correlated to the mean LAP (P < 10(-5)) and mitroaortic VTI ratio (P < 10(-5)) and became clinically significant when the mean LAP was superior to 21 mm Hg.

Successful Cox-maze III procedure combined with mitral valve replacement in a massively thrombosed left atrium.

A case is reported of chronic atrial fibrillation resulting from long-standing rheumatic mitral stenosis complicated by a massively thrombosed left atrium. In this patient, restoration of sinus rhythm and atrial transport function was performed using a Cox-maze III procedure with mitral valve replacement.

Adaptive mechanisms of arterial and venous coronary bypass grafts to an increase in flow demand.

OBJECTIVE: To compare the mechanisms by which arterial and venous grafts increase their flow during pacing induced tachycardia, early and later after coronary bypass surgery. DESIGN: 43 grafts (13 epigastric artery, 15 mammary artery, 15 saphenous vein) evaluated early (9 (3) days (mean (SD)) after bypass surgery were compared with 41 other grafts (15 epigastric, 11 mammary, 15 saphenous vein) evaluated later after surgery (mean 23 months, range 6 to 168 months) by quantitative angiography and intravascular Doppler velocity analysis during atrial pacing. Controls were 17 normal coronary arteries. RESULTS: Baseline graft flow tended to be lower later after surgery than early (41 (16) v 45 (21) ml/min, NS). Blood flow increased during pacing by 30 (16)% early after surgery, less than later after surgery (+46 (18)%, p < 0.001) and less than in normal coronary arteries (+54 (27)%, p < 0.001 v early grafts; NS v late grafts). There was no difference between venous and arterial grafts. No significant vasodilatation was observed during pacing early after surgery in arterial and venous grafts. Later after surgery, significant vasodilatation was observed only in arterial grafts (mammary and epigastric grafts), from 2.41 (0.37) to 2.53 (0. 41) mm (+5.1% v basal, p < 0.001). Early after surgery and in venous grafts later after surgery, the increase in flow was entirely due to an increase in velocity. In later arterial grafts, the relative contribution of the increase in velocity to the increase in flow during pacing was lower in arterial grafts (70 (22)%) than in venous grafts (102 (11)%, p < 0.001) and similar to normal coronary arteries (68 (28)%). CONCLUSIONS: Early and later after surgery, arterial grafts and venous grafts both increase their flow similarly during pacing. Early arterial grafts and venous grafts increase their flow only through an increase in velocity. Later after surgery, arterial grafts act as more physiological conduits and increase their flow in the same way as normal coronary arteries, through an increase in velocity and calibre mediated by the endothelium.

Noninvasive functional assessment of left internal mammary artery grafts by transcutaneous Doppler echocardiography.

A noninvasive method to assess left internal mammary artery (LIMA) patency and function would be useful because this vessel is frequently used for revascularization of the left anterior descending coronary artery. The purpose of this study was to assess the feasibility of measuring changes in LIMA velocities by transcutaneous Doppler during dipyridamole-induced vasodilation. Twenty-five patients with a LIMA graft anastomosed to the left anterior descending coronary artery were studied at least 1 month after surgery by the use of a 5 MHz transducer placed in the left supraclavicular fossa. Doppler velocity parameters were measured at baseline and after intravenous administration of dipyridamole. Dipyridamole increased mean velocity by 127% +/- 54% (p < 0.001), systolodiastolic velocity time integral by 89% +/- 31% (p < 0.001), and diastolic-to-systolic peak velocity ratio from 0.7 +/- 0.3 to 1.2 +/- 0.4 (p < 0.001). The dipyridamole-to-baseline mean velocity ratio was 2.3 +/- 0.5. We conclude that it is possible to measure dipyridamole-induced changes in LIMA flow velocities and thus obtain an index of LIMA blood velocity reserve by transcutaneous Doppler echocardiography.

Management of Coronary Restenosis via the Radial Artery: An Elegant Approach to the AchillesÕ Heel of PTCA.

In spite of many efforts, the most effective treatment for restenosis after coronary angioplasty remains repeat angioplasty. Although the second procedure is known to be at lower risk, it is usually performed by the same technique, thus requiring hospitalization. In such a group of patients, the feasibility of using the radial route for repeat coronary angiography and angioplasty when needed and the safety of early discharge were evaluated prospectively. Coronary angiography via the radial artery was attempted in 51 patients referred within 6 months of initial coronary angioplasty with the clinical suspicion of restenosis. Successful cannulation of the radial artery was possible in 48 (94%). Following placement of a 4 Fr arterial sheath, coronary angiography was completed successfully in all but one patient. Restenosis was confirmed angiographically in 25 patients (one via the femoral route) and a new lesion was observed in 3. Repeat angioplasty was attempted via the radial route (25 patients) or via the femoral route (one patient) using a fixed-wire balloon catheter through the 4 Fr diagnostic catheter (n=22). Angioplasty via the radial route including elective stent implantation (5 patients) was a technical success in 92% of the patients. Immediate arterial sheath withdrawal and mechanical compression of the radial artery provided satisfactory hemostasis after 186 +/- 126 minutes. The radial pulse was absent post-procedure without clinical consequence in 3 patients (6%). Of the 46 patients without a femoral artery puncture, 39 (85%) were discharged the same day without any cardiac or local complications. Thus, early discharge after repeat coronary angiography and angioplasty for restenosis is feasible and safe using the transradial route in the majority of patients.

New device for compression of the radial artery after diagnostic and interventional cardiac procedures.

Recently the transradial route has emerged as a valuable alternative to the femoral approach for coronary angiography and angioplasty. However, sheath and catheter size and their immediate removal after the procedure, combined with aggressive antiplatelet and anticoagulant therapies, have favored mechanical compression of the radial artery to achieve satisfactory hemostasis. We report on our initial clinical experience with a new device specially designed for prolonged controlled mechanical compression of the radial artery (the RadiStop radial compression system, RADI Medical Systems AB, Uppsala, Sweden). A total of 159 consecutive patients (mean age 60 +/- 11 yr, 130 males) who required either coronary angiography (group 1, 103 patients) or ad hoc or elective coronary angioplasty (group 2, 56 patients) via the right radial route had local hemostasis with the RadiStop system. In group 1, 4F and 5F sheaths and catheters were used, whereas in group 2, 6F systems were inserted in the radial artery. Hemostasis was achieved with the device in all patients but was considered difficult to obtain in 4 patients (2.5%). Twenty-eight patients (18%) considered the device uncomfortable or painful, but no release of pressure was necessary. The mean compression time was 151 +/- 82 min (114 +/- 64 min in group 1, and 223 +/- 64 min in group 2; P = 0.0001). There were 23 local complications (15%). In 7 patients (4.4%), the radial pulse was absent after compression and at discharge, without major clinical consequences. In one patient, recurrent bleeding occurred 2 hr after compression, requiring a new compression session. In 15 patients, a small local hematoma was observed. Neither heparin dosage nor the use of a 6F sheath affected the rate of radial artery patency in this survey. We conclude that the use of this device for mechanical compression of the radial artery after coronary angiography and angioplasty is efficient, and that its use is related to an acceptable rate of local complications.

[Early percutaneous coronary angioplasty in unstable angina]. / Angioplastie coronaire percutanée précoce dans l'angor instable.

The risks of complications of percutaneous transluminal coronary angioplasty (PTCA) are increased in unstable angina. Medical treatment for a few days before PTCA is widely adopted to reduce the risk of thrombosis or occlusive dissection during and after the procedure. Over the last few years, the authors have adopted a strategy of early coronary angiography completed by immediate angioplasty when possible, without waiting for the eventual benefit of aspirin or heparin therapy. Their experience from 1988 to 1995 of 853 patients treated by PTCA (151/853 or 17.7%, with implantation of a stent) for unstable angina, was reviewed. Group I comprised 402 patients treated on the day of or the day after admission. Group II comprised 451 patients treated 2 days or more after admission. Patients in Group I were younger (62 +/- 11 vs 64 +/- 12, p < 0.001), and had single vessel disease more often (61 vs 52%, p < 0.005). The success rate of PTCA was similar in the 2 groups (85.3 vs 88.2%, NS), as was the rate of complications (death, infarction or coronary bypass surgery, 9.9 vs 7.3%, NS). The length of hospital stay was significantly shorter in Group I (6.1 +/- 5.6 vs 8.7 +/- 6.9 days, p < 0.0001). With the limitations inherent to all retrospective studies, these data suggest that an early interventional approach in unstable angina has a similar success rate with no more complications than angioplasty. This approach is associated with a deferred significant decrease in the duration of hospital stay.