[Acute myocarditis: from chest pain to cardiogenic shock]. / Les myocardites aiguës: de la douleur thoracique au choc cardiogénique--a propos de trois cas.

We report the observations of three patients with myocarditis. The first one with chest pain, the second one with a pseudo-infarct presentation and the third one with a cardiogenic shock. We discuss the different anatomo-clinical presentations of myocarditis, the diagnosis, the indications of endomyocardial biopsies and the prognosis of this pathology.

[Angiotensin-converting enzyme inhibitors and/or angiotensin II receptors antagonists in the treatment of arterial hypertension]. / Inhibiteurs de l'enzyme de conversion de l'angiotensine et/ou antagonistes des récepteurs de l'angiotensine II dans le traitement de l'hypertension artérielle.

The renin-angiotensin system (RAS) plays an important role in the development of cardiovascular diseases. The favorable effects of inhibitors of this system are mainly due to a decrease of the production of angiotensin II. Usual association between angiotensin II receptor antagonists (AIIA) and angiotensin-converting enzyme (ACE) inhibitors results of a mutual action on the RAS, but important differences exist. ACE inhibitors demonstrated major benefits in heart failure and in post-infarction. In diabetic patients, ACE inhibitor treatment is associated with nephroprotective effects. In four main studies ACE inhibitors didn't demonstrated superior effect on primary outcome compare to standard antihypertensive treatment (diuretics or beta-blockers). However, in HOPE and PROGRESS studies, ACE inhibitors decrease myocardial infarction incidence, even after arterial pressure adjustment. Can we expect the same effects with the AIIA? Of course a direct comparison would be preferable, but some differences emerge. In a main study, AIIA treatment was compared to a standard antihypertensive treatment. The LIFE trial demonstrated superior benefits with losartan than with beta-blocker atenolol for the same degree of blood pressure reduction in hypertensive patients with left ventricular hypertrophy. Losartan had particularly strong effect on risk for stroke and prevented new-onset diabetes. So we have some data to emit the hypothesis that ACE inhibitors decrease the incidence of myocardial infarction and AIIA the incidence of stroke.

Echocardiographic diagnosis of right and left sinus of Valsalva aneurysms dissecting into the ventricular septum.

We report a case of dissection of the ventricular septum by two aneurysms of the right and left coronary sinuses of Valsalva. Transthoracic and transesophageal echocardiography allowed accurate preoperative assessment and postoperative evaluation.

Early hemodynamic course of septic shock.

OBJECTIVE: To assess the relative contributions of changes in vascular tone and changes in cardiac function to hemodynamic recovery from septic shock. DESIGN: Case series, observational study. SETTING: Multidisciplinary department of intensive care in an academic hospital. PATIENTS: Sixty-seven patients with septic shock (prolonged hypotension, signs of tissue hypoperfusion, signs of sepsis, suspected source of infection, or documented bacteremia). In addition to the antibiotic therapy and the removal of the source of sepsis whenever possible, each patient received intravenous fluids and vasoactive agents (dopamine, norepinephrine, and dobutamine). Each patient was also treated with mechanical ventilation. Twenty-four (36%) patients survived their intensive care unit course. INTERVENTIONS: Hemodynamic measurements were obtained at baseline, after initial resuscitation (as soon as apparent hemodynamic stability was achieved), after 12 hrs, and after 24 hrs. MEASUREMENTS AND MAIN RESULTS: There were no significant differences in hemodynamic or oxygen-derived variables at baseline between the survivors and the nonsurvivors. During the initial resuscitation period, only the survivors demonstrated a significant increase in mean arterial pressure (from 69 +/- 17 to 82 +/- 18 mm Hg; p < .02) and left ventricular stroke work index (from 25.2 +/- 11.0 to 35.5 +/- 19.4 g.m/m2; p < .05). The increases in cardiac index and systemic vascular resistance were greater in the survivors than in the non-survivors, but the differences did not reach statistical significance. Study of the left ventricular function curves indicated an improvement of left ventricular function in the survivors but not in the nonsurvivors. CONCLUSION: An early improvement in left ventricular function is a hallmark of the survivors from septic shock.

Ruptured aortic dissection into the left atrium which presented as congestive heart failure and was diagnosed by transoesophageal echocardiography.

A 72 year old man was admitted with severe dyspnoea. Ten days before he had had intense thoracic pain with loss of consciousness that was followed by increased dyspnoea. A continuous murmur was heard in the precordial and the left infrascapular regions. Lung auscultation showed stasis over the lower half of both lungs. Transthoracic echocardiography showed a bicuspid aortic valve and a dissection of the proximal aorta, which was considerably enlarged. Transoesophageal echocardiography confirmed dissection of the proximal aorta and showed a communication from the false lumen of the aortic dissection to the left atrium; and colour flow Doppler showed a continuous shunt to the left atrium. After transoesophageal echocardiography the patient had emergency surgical repair, which was successful. He had no complications in the post-operative period.

The relation between cardiac index and oxygen extraction in acutely ill patients.

The relation between cardiac index and oxygen extraction (O2ER) can represent a useful basis for the interpretation of hemodynamic parameters in the acutely ill patient. We prospectively collected cardiac index and paired arterial and mixed venous blood gas values in 79 acutely ill patients who were successively monitored invasively during their ICU course. For each patient, the degree of cardiac failure score and sepsis was scored at time of each measurement. A total of 122 observations were reported on a cardiac index/O2ER diagram, on which, based on physiologic data obtained during physical exercise, a line of reference was included representing equal increases in cardiac index and O2ER from normal values at rest. Patients with established heart failure fell below the line of reference. However, patients without cardiac failure or with compensated cardiac failure during adrenergic therapy fell close to the line of reference. Sepsis was associated with elevated oxygen delivery (Do2) and oxygen consumption (Vo2). Although O2ER was lower in the presence than in the absence of septic shock, patients with sepsis fell close to the line of reference. Among these patients with sepsis, O2ER was greater in patients with established heart failure than without heart failure (37.6 +/- 11.7 percent vs 21.5 +/- 4.4 percent, p < 0.01). The relationship between cardiac index and O2ER is much simpler than the relationship between Vo2 and Do2 and it avoids problems of mathematical coupling. It also allows us to refer to physiologic adaptation to changes in oxygen demand. This diagram may be useful at the bedside to facilitate the interpretation of cardiac index and to guide therapy.

Oxygen extraction in patients with sepsis and heart failure: another look at clinical studies.

We collected all complete sets of measurements of cardiac index and oxygen-derived variables available in the recent literature (1975-1991; computerised Medline search) on critically ill patients with sepsis (n=21 studies), septic shock (n=20 studies) or severe heart failure (n=13 studies). For each study, the mean value for cardiac index, oxygen delivery (DO 2), oxygen uptake (VO 2), oxygen extraction ratio (O 2ER) and lactate concentration (when available) were analysed together with mortality rates. There was a significant relationship between VO 2 and DO 2 for the studies on patients with severe heart failure (r=0.79, p less than 0.001) or septic shock (r=0.55, p less than 0.01), but not in patients with sepsis (r=0.3, p=NS). As expected, O 2ER was higher in the studies in heart failure (31 to 50%) than in septic shock (25 to 45%) or sepsis (19 to 40%). When compared to the studies on patients with sepsis, the studies in septic shock included patients with lower DO 2 (481+/-89 vs 539+/-79 ml/min.M 2, p=0.032) and higher O 2ER (32.5+/-5.2 vs 27.8+/-5.0%, p less than 0.01) but similar VO 2 (143+/-29 vs 143+/-19 ml/min.M 2, p=NS). In a cardiac index/O 2ER diagram where a line of reference represents proportional changes in cardiac index and O 2ER from normal values at rest, all studies in heart failure fell below the line of reference. The majority of studies in sepsis (18/21) fell above the line of reference. Interestingly, only nine of the 20 studies in septic shock fell above this line. The review of the 14 studies in septic shock, in which O 2ER and blood lactate were reported, showed a direct relationship between these two variables (r=0.68, p less than 0.01), but no relationship between cardiac index and blood lactate (r=0.37, p=NS). This analysis suggests that patients with septic shock tend to have a lower cardiac index and higher O 2ER than septic patients who are haemodynamically stable. Furthermore, the positive relationship between O 2ER and lactate suggests that, despite the alterations in oxygen extraction capabilities in severe sepsis, mean O 2ER may be higher in the most severe cases of septic shock. This could reflect an attempt to maintain VO 2 when DO 2 is insufficient. The prevailing opinion that 0 2ER is a meaningless variable in septic shock needs to be reassessed.