[Influence of open chest conditions on pulse pressure variations]. / Influence de l'ouverture du thorax par sternotomie sur les variations respiratoires de la pression pulsée.

OBJECTIVES: Pulse pressure variations are used to assess fluid responsiveness in mechanically ventilated patients. The accuracy of this index in open chest conditions remained unclear. The aim of the study was to evaluate the effect of open chest conditions on pulse pressure variations. STUDY DESIGN: Non-interventional prospective study. METHODS AND PATIENTS: Twenty-eight mechanically ventilated patients scheduled for open-heart surgery were included. Pulse pressure variations, peak aortic velocity, and stroke volume were measured before and after thoracotomy with pericardotomy. Measurements were made at each step and compared. RESULTS: Neither pulse pressure variation nor peak aortic velocity and nor stroke volume variation were modified by open chest conditions (median=5% [interquartile range=6] vs 4% [6], p=NS), (20% [11] vs 17% [12], p=NS and 11% [7] vs 10% [3], p=NS) respectively. Pulse pressure variations were correlated to stroke volume before thoracotomy (r'=-0.432; p=0.02) and after thorocatomy (r'=-0.433, p=0.02). CONCLUSION: In these studied patients, preload dependancy indices were not modified by open chest conditions. Pulse pressure variations remained correlated to stroke volume even after thoracotomy.

Aortic valve replacement with the minimal extracorporeal circulation (Jostra MECC System) versus standard cardiopulmonary bypass: a randomized prospective trial.

BACKGROUND: We prospectively evaluated a newly introduced minimal extracorporeal circulation system (Jostra MECC System; Jostra AG, Hirrlingen, Germany) for aortic valve surgery. METHOD: In a prospective, randomized study, 100 patients underwent aortic valve replacement either with standard cardiopulmonary bypass (n = 50, group B) or with the MECC System (n = 50, group B). The myocardial protection and the left vent were identical for the two groups. The intrapericardial suction device was never used (only the cell salvage device was used) to reduce the air-blood contact area. RESULTS: No significant differences were noted in patient characteristics and operative data between groups. Operative mortality (<30 days) was 2% for group A and 4% for group B (difference not significant). From the preoperative period to the postoperative period, the increase in C-reactive protein was significantly higher for group B (P <.001). The postoperative troponin I level was significantly lower in group A (mean 4.65 +/- 2.9 microg/L at 24 hours) than in group B (8.2 +/- 4.4 microg/L, P <.03). On the other hand, the MECC System was associated with platelet preservation. Renal function was better preserved and the neurologic event rate was significantly lower for the MECC group (P <.02). CONCLUSION: The MECC System is safe and allows aortic valve replacement under the most favorable conditions. The system is more biocompatible than standard cardiopulmonary bypass and provides a good postoperative biologic profile and good clinical results, particularly for high-risk patients.

Intimo-intimal intussusception: a rare clinical form of aortic dissection.

A 33-year-old hypertensive man presented with epigastric pain radiating to the back. Transoesophageal echocardiography (TOE) revealed an intimal flap on the aortic arch and descending aorta. No intimal flap of the ascending aorta was detected on TOE or CT. The diagnosis was made on opening the ascending aorta: complete circumferential dissection of the ascending aorta flush with the coronary ostia, with no residual intimal flap, and intimo-intimal glove-finger intussusception of the internal channel into the descending thoracic aorta. Aortic intussusception is a very rare form of Type I dissection, and the absence of intimal tear in the ascending aorta can be misleading and delay the diagnosis.

[Ectopic atrial tachycardia complicating a congenital left atrial aneurysm: value of an electro-anatomical mapping system]. / Tachycardie atriale ectopique compliquant un anévrysme congénital de l'auricule gauche: apport d'un système de cartographie électro-anatomique.

The authors report the case of a patient with a congenital left atrial aneurysm complicated by ectopic atrial tachycardia treated successfully by surgery. Transoesophageal echocardiography and magnetic resonance imaging provided accurate measurements of the aneurysm and its anatomical relationships. Three-dimensional electro-anatomical mapping with the CARTO, system (Biosense) confirmed the shape and dimensions of the aneurysm. The system showed the electrically mute zones and the ectopic focus situated just beyond the aneurysmal neck. Surgical ablation confirmed the morphological and functional data of the imaging techniques and the patient was definitely cured.

[Dissection of the aorta complicated by aorto-pulmonary fistula]. / Dissection aortique compliquée de fistule aorto-pulmonaire.

The authors report the case of chronic dissection of the aorta presenting with congestive cardiac failure. The diagnosis was made for the first time by transoesophageal echocardiography which showed both the dissection of the aorta and its fistulalisation into the pulmonary artery. Aortography confirmed the diagnosis. The patient underwent surgery which consisted of suture of the fistula and replacement of the ascending aorta with a prosthetic tube. The outcome was favourable after 8 months follow-up.

Plasma homocysteine and severity of thoracic aortic atherosclerosis.

STUDY OBJECTIVES: Plasma homocysteine level is a risk factor for coronary events, stroke, and peripheral atherosclerotic disease. However, few data are available concerning the relationship between homocysteine level and severity of thoracic aortic atherosclerosis. We hypothesized in this multiplane transesophageal echocardiography (TEE) study that homocysteine level is a marker of the presence and severity of thoracic aortic atherosclerosis. DESIGN: Cross-sectional study. SETTING: University hospital. PATIENTS: Risk factors, angiographic features, and TEE findings were analyzed prospectively in 82 valvular patients. MEASUREMENTS AND RESULTS: The following risk factors were recorded: age, gender, hypertension, smoking, lipid parameters, diabetes, body mass index, and family history of coronary artery disease. Plasma levels of homocysteine, vitamin B(12), and folic acid were measured for each patient. By univariate analysis, age, diabetes, hypertension, smoking, family history of coronary artery disease, and levels of homocysteine, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol were significant predictors of the presence of thoracic aortic plaques. There was a positive correlation between the plasma homocysteine levels and the score of severity of thoracic atherosclerosis (r = 0.48; p = 0.0001) as well as between the homocysteine levels and the grades of severity of aortic intimal changes (p = 0.0008). Multivariate regression analysis revealed that homocysteine was an independent predictor of the presence and severity of thoracic aortic atherosclerosis. CONCLUSION: This prospective study indicates that plasma homocysteine level is a marker of severity of thoracic atherosclerosis detected by multiplane TEE. These findings emphasize the role of homocysteine as a marker of atherosclerotic lesions in the major arterial locations.

Hemodynamic and echocardiographic effects of hemofiltration performed during cardiopulmonary bypass.

OBJECTIVE: To evaluate the effects of hemofiltration performed during rewarming before emergence from cardiopulmonary bypass on hemodynamic and echocardiographic parameters. DESIGN: Prospective randomized study; blind analysis of echocardiographic parameters and hemodynamic parameters. SETTING: Single-center study performed in a university hospital. PARTICIPANTS: Two groups of 13 adult patients undergoing coronary artery bypass graft surgery. INTERVENTION: Patients were randomized to conventional procedure or hemofiltration performed with a polysulfone hemofilter. Hemofiltration, started at the time of rewarming on cardiopulmonary bypass, was performed with a flow rate adjusted to achieve an ultrafiltrate volume of 15 mL/kg on completion of rewarming. MEASUREMENTS AND MAIN RESULTS: Hemodynamic (systemic mean arterial pressure, right atrial pressure, heart rate) and echocardiographic parameters (shortening fraction, segmental kinetic score, cardiac output, systemic vascular resistance) were measured before and after hemofiltration and on arrival in the intensive care unit. Heart rate and cardiac index were increased significantly in both groups during the postoperative period. In the control group, systemic vascular resistance was decreased significantly, and cardiac index was increased during the postoperative period, together with significant alterations of segmental kinetic score and shortening fraction. In the hemofiltration group, systemic vascular resistance remained unchanged, associated with a significantly improved segmental kinetic score compared with the control group. CONCLUSIONS: Hemofiltration performed during rewarming before emergence from cardiopulmonary bypass is associated with stability of hemodynamic parameters and improved segmental myocardial kinetics.

[Transesophageal echocardiography before electric cardioversion for supraventricular arrhythmia]. / Echocardiographie transoesophagienne avant cardioversion électrique pour trouble du rythme supra-ventriculaire.

OBJECTIVES: The aim of this prospective study was to assess the risks of electrical shock cardio-version in the treatment of supraventricular rhythm disorders when administered under effective-dose but short duration anticoagulation in patients with no intracavitary thrombus detectable by transesophageal echocardiography. PATIENTS AND METHODS: One hundred nineteen patients, mean age 66 years, with permanent arrhythmia due to atrial fibrillation (n = 102), atrial flutter (n = 16) or atrial tachycardia (n = 1) and taking no long-term anticoagulant therapy were treated by electrical shock cardioversion. The patients were given heparin at an effective dose 72 hours prior to cardioversion. A transthoracic and a transesophageal echocardiography were performed less than 24 hours prior to cardioversion. RESULTS: Twenty-one thrombi were evidenced in 16 patients (14.6%) including 18 in the left auricle, 1 in the left atrium and 2 in the right atrium. A spontaneous contrast was visualized in 38 patients (32%). Cardioversion was performed in 103 patients without thrombus and later in 9 of the 16 patients with thrombus after absorption under anticoagulant therapy as evidenced on the control transesophageal echocardiography. A sinus rhythm was obtained in 82% of the cases. All patients were given anti-vitamin K anticoagulants for one month. There were no clinical manifestation of ischemic vascular events during cardioversion nor during the one-month follow-up. CONCLUSION: Early use of electrical shock cardioversion in patients with supraventricular rhythm disorders can be proposed without long-term anticoagulation therapy if the absence of thrombi is demonstrated by transesophageal echocardiography and short-term heparin is given followed by oral anticoagulants for at least 4 weeks. A large-scale randomized prospective study comparing the conventional strategy with the protocol used in this study would be required to definitively validate this approach and determine its possible advantages.

[Diagnostic value of echocardiography and thoracic spiral CT angiography in the diagnosis of acute pulmonary embolism]. / Valeur diagnostique de l'échographie cardiaque et de l'angioscanner thoracique hélicoïdal pour le diagnostic de l'embolie pulmonaire aiguë.

The objective of this study was to define the limits of echocardiography and to evaluate thoracic spiral CT angiography (TSCTA) for the diagnosis of pulmonary embolism (PE). One hundred twelve consecutive patients, hospitalised for suspected PE, were included in this prospective study. All were investigated by pulmonary ventilation-perfusion scintigraphy (Sc) and 50 had a high probability of PE on this examination. Sc was normal in 22 patients. Forty patients were excluded because of an intermediate probability. In 50 patients with PE confirmed on Sc, transthoracic echocardiography (TTE) showed only indirect evidence of PE (intracavitary thrombus in 4% of cases). TSCTA demonstrated PE in 82% of cases and did not show any thrombus image when Sc was normal. Its negative predictive value was therefore 70% and its positive predictive value was 100%. Its sensitivity varied according to degree of perfusion defect (96% in the case of lobar lesion, 66% in the case of segmental lesion and 16% for a subsegmental lesion). Multidimensional transoesophageal echocardiography (TOE), performed in 37 of the 50 patients with PE, only revealed thrombi in the pulmonary tree in 3 patients (8%), all presenting severe PE. No thrombus was visualized on TOE in patients with non-serious PE. All thrombi observed on TOE were also demonstrated by TSCTA. In conclusion, TTE usually provides only indirect signs of PE. TOE has a poor diagnostic sensitivity for PE. TSCTA has a better sensitivity than TOE for the detection of thrombi in the pulmonary artery trunk and proximal centimetres of its two branches, but normal CT angiography cannot exclude a distal PE.

[Non-bacterial thrombosing endocarditis. Apropos of 2 cases]. / Endocardite thrombosante non bactérienne. A propos de deux cas.

The diagnosis of nonbacterial thrombosing endocarditis or marasmic endocarditis must be considered in patients presenting with a combination of cancer and systemic embolism. The pathophysiological mechanisms of this entity are unclear and purely hypothetical. However, hypercoagulability appears to play an essential role in the pathogenesis of this endocarditis, which could be the cardiac expression of a coagulopathy involving the entire vascular system. The authors report two cases of marasmic endocarditis which emphasize the value of transthoracic and transoesophageal echocardiography in the difficult diagnosis of this disease.

[Can Doppler echocardiography help to avoid cardiac catheterization in the surgical decision-making in isolated left heart valve diseases?]. / L'échocardiographie Doppler peut-elle éviter le cathétérisme cardiaque dans l'indication opératoire des valvulopathies isolées du coeur gauche?

The aim of this study was to assess the value of non-invasive investigation based on clinical evaluation and Doppler echography in deciding the operative indications of patients with isolated left heart valvular lesions compared. Three hundred and thirty five patients were included in a prospective study: 78 had MR, 57 had AR, 150 had AS and 50 had MS. All underwent clinical. Doppler echography and catheter studies. The therapeutic decision was taken blind by two groups of 2 cardiologists. Group I took its decision based on clinical findings and results of Doppler echography whilst Group II took its decision on the clinical and catheter data. For each patient, one of the following three choices was proposed: 1) medical treatment: 2) surgery or valvuloplasty with balloon catheter; 3) request for further information. In addition, in group I, the need for coronary angiography was left to the appreciation of two cardiologists. The quantification of the valvular disease was concordant for groups I and II in 93, 97, 98.5 and 100% for MR, AR, AS and MS respectively. These percentages were respectively 97, 95, 92 and 100% for assessment of left ventricular function. The theoretical management decision was concordant between the two groups for 97% of MR, 94.7% of AR, 95.3% of AS and 94% of MS. Complementary information requiring invasive studies was required by group I in 3.9% of cases. A discordant opinion was obtained in 0.6% of cases (2 cases of AS). Coronary angiography was requested by the cardiologists of Group I in 34% of patients, identifying all patients who underwent coronary bypass surgery. These results show that cardiac catheterisation is no longer an essential diagnostic procedure for discussing the indications of valvular surgery in the majority of patients with isolated left heart lesions.

Comparative value of Doppler echocardiography and cardiac catheterization for management decision-making in patients with left-sided valvular regurgitation.

OBJECTIVE: The purpose of this study was to examine the value of non-invasive clinical and Doppler echocardiographic findings, compared to cardiac catheterization, in management decision-making for patients with left-sided valvular regurgitation. METHODS: One hundred and thirty-five consecutive patients with left-sided valvular regurgitation who underwent cardiac catheterization and detailed Doppler echocardiography were prospectively studied. Two independent groups of experienced cardiologists, given clinical information combined with either Doppler echocardiographic or cardiac catheterization data, decided to operate, not to operate, or remained uncertain. RESULTS: In 63 (81%) of 78 patients with mitral regurgitation, there was agreement on the decision for valve surgery or medical treatment between Doppler echocardiography and cardiac catheterization. Valve repair was performed in 22 patients, which agreed with the echocardiographic decision. In the remaining 15 patients, although the severity and type of mitral valve lesions and left ventricular functional status were confirmed by Doppler echocardiography, the clinical decision was uncertain; additional information concerning coronary anatomy (13 patients) and pulmonary artery pressure (one patient) or both (one patient) was required. In 47 of 57 patients (82%) with aortic regurgitation, there was agreement on their management as a result of Doppler echocardiography and cardiac catheterization findings. In 10 patients, the clinical decision reached with the help of Doppler echocardiography alone was uncertain and coronary (seven patients), left ventricular (two patients) angiography or aortography (one patient) were requested. Overall, there were no conflicting clinical decisions made by the two methods in patients with either mitral or aortic regurgitation. CONCLUSIONS: In every patient in whom it was considered that a decision could be reached by echocardiography alone (more than 80% of patients) there was 100% agreement from the cardiac catheterization assessment group on the management decision. Therefore, in patients with significant mitral or aortic regurgitation where echocardiographic data is adequate, cardiac catheterization can be safely omitted from the investigative process for surgery. Where echocardiographic indices are conflicting, or significant coronary artery disease is suspected, cardiac catheterization is required.

[Cardiac involvement in amyloidosis. Apropos of a case of hereditary amyloidosis of neurologic expression]. / Atteinte cardiaque dans l'amylose. A propos d'un cas d'amylose héréditaire à expression neurologique.

The authors report a case of hereditary amyloidosis in a 54-year old patient with an essentially neurological clinical expression. The cardiovascular assessment, consisting of echocardiography performed systematically while the patient was free of any cardiac symptoms, revealed typical amyloid infiltration with a hyperechoic, shiny appearance of the myocardium and significant parietal hypertrophy. Systolic function was preserved, in contrast with impairment of diastolic function, revealed by the presence of Appleton type I mitral blood and decreased propagation velocity of the transmitral flow on colour TM. The authors stress the importance of ultrasonographic examination in all patients with suspected cardiac amyloidosis, even in the absence of clinical or electrical signs.

[Pulmonary hypertension associated with portal hypertension. Apropos of 2 cases]. / Hypertension artérielle pulmonaire associée à une hypertension portale. A propos de 2 cas.

The authors report the cases of two patients with pulmonary hypertension associated with portal hypertension. This is a rare association with a reported prevalence ranging from 0.25 to 0.73%. The diagnosis of portal hypertension preceded that of pulmonary hypertension by several years. The physiopathological mechanism of the latter is not well known although several hypotheses have been proposed. Treatment is only symptomatic. The prognosis is usually poor, the causes of death being related to complications of liver failure and/or portal hypertension or to those of pulmonary hypertension.

[Multidimensional transesophageal echocardiography in the determination of the orificial surface of aortic stenoses in adults. Apropos of 85 cases]. / Apport de l'échocardiographie transoesophagienne multiplan dans la détermination de la surface orificielle des sténoses aortiques de l'adulte. A propos de 85 cas.

The objective of this study was to assess the validity of multidimensional transoesophageal echocardiography (TOE) in the determination of the orificial surface area of aortic stenosis (AS) in 85 patients, using as a reference the surface area calculated on transthoracic ultrasonography (TTU) by applying the continuity principle (n = 75) and/or by haemodynamic studies using Gorlin's formula (n = 40). Planimetry was able to be performed in 78 of the 85 patients (92%). Planimetry was impossible in 7 patients with massive calcification of the aortic orifice (n = 5) or posterior valve (n = 2). The mean value of the selected angle was 45 +/- 13 degrees (0 to 78 degrees). An excellent correlation was observed between aortic surface area (ASA) measured by multidimensional TOE and TTU (r = 0.94; y = 0.90x +/- 0.10; SEE = 0.10 cm2; p < 0.001). Similarly, the ASA on multidimensional TOE was also well correlated with the haemodynamic surface area (r = 0.90, y = 0.94x +/- 0.05; SEE = 0.09 cm2; p < 0.001). The correlations between multidimensional TOE and TTU measurements (n = 26; r = 0.96; y = 0.85 x +/- 0.11; SEE = 0.07 cm2; p < 0.001) and cardiac catheterization (n = 13; r = 0.92; y = 0.77 x +/- 0.7; SEE = 0.09 cm2; p < 0.001) remained satisfactory in patients with associated aortic incompetence. Multidimensional TOE identifies cases of AS with an ASA on TOE or haemodynamic studies less than or equal to 0.75 cm2 with sensitivities of 93% and 92%, respectively, and a specificity of 100%. Overall, multidimensional TOE allows a precise and reliable evaluation of ASA in the great majority of cases of AS.

[Does mitral insufficiency prevent spontaneous contrast phenomenon and formation of thrombi in the left atrium?]. / L'insuffisance mitrale prévient-elle la formation du phénomène de contraste spontané et la constitution des thrombus dans l'oreillette gauche?

The aim of this study was to assess the influence of mitral regurgitation on the prevalence of left atrial spontaneous echo contrast and thrombosis in 2,180 consecutive patients undergoing transthoracic and transoesophageal echocardiography. Two groups of patients were defined according to the absence (group I) or presence (group II) of grades 3 or 4 mitral regurgitation quantified by transoesophageal echocardiography. Group II was associated with a statistically significant lower frequency of spontaneous echo contrast (0.6 vs 11.2%; p < 0.0001), left atrial thrombosis (0.6 vs 4.2%; p < 0.03), ischaemic cerebrovascular accidents (1.2 vs 21%; p < 0.0001), transient ischaemic attacks (0 vs 12%; p < 0.0001) and systemic embolism (0 vs 4.6%; p < 0.01). Conversely, the prevalence of atrial fibrillation was higher in group II (28 vs 19%; p < 0.01) and there were more patients with left atrial dimensions > or = 5.5 cm (16 vs 6.7%; p < 0.0001). When mitral stenosis and valve prosthesis were excluded, there were no cases of spontaneous echo contrast (8.3 vs 0%; p < 0.001) or left atrial thrombosis (2.9 vs 0%; p < 0.05) in the group with grades 3 or 4 mitral regurgitation. The phenomenon of left atrial spontaneous echo contrast and/or thrombosis is rare in patients with grade 3 or 4 in native mitral valve regurgitation and explains the low incidence of systemic embolism in these cases.

[Doppler echocardiography of tricuspid insufficiency. Methods of quantification]. / Echocardiographie-Doppler de l'insuffisance tricuspidienne. Méthodes de quantification.

Evaluation of tricuspid incompetence has benefitted considerably from the development of Doppler ultrasound. In addition to direct analysis of the valves, which provides information about the mechanism involved, this method is able to provide an accurate evaluation, mainly through use of the Doppler mode. In addition to new criteria being evaluated (mainly the convergence zone of the regurgitant jet), some indices are recognised as good quantitative parameters: extension of the regurgitant jet into the right atrium, anterograde tricuspid flow, laminar nature of the regurgitant flow, analysis of the flow in the supra-hepatic veins, this is only semi-quantitative, since the calculation of the regurgitation fraction from the pulsed Doppler does not seem to be reliable; This accurate semi-quantitative evaluation is made possible by careful and consistent use of all the criteria available. The authors set out to discuss the value of the various evaluation criteria mentioned in the literature and try to define a practical approach.