[Coronary artery aneurysm associated with fistula: two anatomically similar cases with different clinical presentation]. / Anévrysme coronaire associé à une fistule artérielle: deux cas anatomiquement similaires malgré une présentation clinique différente.

Coronary artery fistulas are rare anomalies and their association with a coronary aneurysm even more infrequent. We report two cases which are illustrative because of their different clinical presentations. In the first case the diagnosis was made after discovering fortuitously a heart murmur. In contrast in the second case the coronary artery fistula was demonstrated during a check-up for thoracic pain. In both cases the right coronary artery gave a fistulous communication to the right atrium.

[A ventricle of all dangers: a clinical observation and evolution of a case of arrythmogenic right ventricular dysplasia]. / Un ventricule de tous les dangers: observation clinique et évolution d'un cas de dysplasie ventriculaire droite arythmogène.

Arrythmogenic right ventricular dysplasia (ARVD) is rare disease but it is a major cause of sudden death in young people and in athletes. ARVD is a cardiomyopathy characterized by structural and functional abnormalities of the right ventricle precipitating its electrical instability. This electrical instability is responsible for ventricular arrhythmias. Sudden death, by ventricular fibrillation, may be the first symptom of the disease. The diagnosis is based upon specific ventricular pathology at the histological level as well as typical electrocardiographic and diagnostic imaging features. A better understanding of the disease has increased along with the new data on genetics. Its management remains a challenge because of the wide spectrum of clinical presentation as well as its natural history. We present a case of ARVD and its evolution in order to show the difficulties of the management of this particular entity.

[Cor triatriatum in the adult]. / Coeur triatrial chez l'adulte.

A 18-year old girl suffering from effort dyspnea presented to our hospital. She had no previous medical history. The first investigations revealed a linear structure traversing the left atrium. A transoesophageal echocardiogram demonstrated a thin mobile membrane in the atrium. Many investigations were realized to describe better this structure and its contribution to the symptoms. Cor triatrium is a rare congenital disease and its discovery is rare in adulthood. So, there are no guidelines for the optimal management.

[Role of transesophageal echocardiography in infectious endocarditis]. / Rôle de l'échocardiographie transoesophagienne dans l'endocardite infectieuse.

The role of transoesophageal echocardiography in infective endocarditis is detailed after concisely restating the precautions required by this examination. The diagnosis is nowadays based on the Duke University criteria, the major echocardiographic criteria being a typical image of vegetation, of abscess or of prosthetic valve dehiscence. The assessment of the complications includes the evaluation of the extent of destruction of the valvar or intracardiac structures and its hemodynamic consequences, the occurrence of a pericarditis and the assessment of the embolic risk. The different pitfalls and limitations of the examination are considered. The indications for repeating transoesophageal echocardiography during follow-up are considered, based on recently published recommendations. The respective advantages of the transthoracic and the transoesophageal approach are discussed, with a special focus on right heart endocarditis.

[Myocarditis]. / Les myocardites.

The definition, pathogenesis and clinical picture of myocarditis are reviewed. Recent studies emphasize the importance of immune mechanisms in the genesis of the myocardial damage. Among particular forms of myocarditis, Coxsackie B viral infections, HIV infections, Lyme disease and Chagas disease are successively considered. The main measures for the treatment of myocarditis remain a restriction of physical activities along with the classical medications of heart failure. Due to the increased embolic risk, anticoagulation is often indicated.

European certification of clinical competence in adult echocardiography issued in Belgium. The Steering Committee of the Belgian Working Group on Echocardiography and Cardiac Doppler.

In accordance with the European proposals, adapted guidelines are proposed for a certification of clinical competence in adult echocardiography, with transoesophageal echocardiography as a special option. The conditions required to be candidate to the certification, the exemptions of practical training for long-term echocardiographers and the organisation of the training itself are successively considered. Standards for training, site accreditation, official logbook characteristics, minimal numbers of examinations and minimal stage duration are defined. Content of theoretical training, as well as organisation of formal and informal education and of final examination, are described.

Biplane transesophageal echocardiographic diagnosis of cor triatriatum.

A transthoracic echocardiogram disclosed a linear structure in the left atrium of an adult presenting with atypical chest pain. Biplane transesophageal echocardiography revealed a cor triatriatum. The longitudinal plane was most useful for the assessment of the membrane orifice and the Doppler flow pattern.

[Vasovagal syncope: the value of tilt-table testing in the evaluation of loss of consciousness]. / La syncope vaso-vagale: intérêt du test d'inclinaison dans l'évaluation des pertes de connaissance.

Syncope, an eminently frequent syndrome, has multiple and varied causes. Its diagnosis is important in view of the poor prognosis of cardiac syncopes and also of the morbidity and discomfort associated with the other etiologies. Unfortunately, the cause eludes us in half the patients so that a clear prognosis and effective therapy can be given to only a few patients. Tilt-table testing, alone or with isoproterenol, is now considered as a noninvasive, sensitive and specific method for identifying patients predisposed to vaso-vagal syncope, a major cause of syncope of unknown origin. Tilt-table testing also helps in tracking many pathologies contributing to syncopes. In the absence of a universal treatment of vasovagal syncope, tilt-table testing has revealed itself as a contributory guide to the best possible treatment.

Membranous subvalvular pulmonary stenosis in complete transposition of the great arteries: usefulness of serial exercise testing.

A 22-year-old male who had Mustard repair for complete transposition presented with progressive exercise intolerance, documented by a gradual decrease in exercise capacity on cycle ergometer. Cardiac catheterization and angiography demonstrated subvalvular pulmonary stenosis. After surgical relief of the obstruction, exercise capacity returned to previous level.

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.

Membranous subvalvar pulmonary stenosis in complete transposition; advantage of biplane transoesophageal echocardiography for the diagnosis in a young adult.

A young adult who had previously undergone a Mustard repair for complete transposition developed symptomatic left ventricular outflow tract obstruction. Biplane transoesophageal echocardiography allowed an optimal preoperative assessment. In the longitudinal plane, a discrete calcified membrane was imaged. Consequently, a pulmonary arteriotomy was chosen for the relief of the malformation.

Evaluation of membranous subaortic stenosis using biplane transesophageal echocardiography. Report of two cases.

A biplane transesophageal echocardiography was performed in two young adult patients with discrete subvalvular aortic stenosis. The combined information obtained in the transverse and in the longitudinal plane allows in these instances an accurate diagnosis and the choice of an optimal approach.

[Localization of the accessory pathway and surgical treatment in Wolf-Parkinson White syndrome]. / Localisation de la voie accessoire et traitement chirurgical dans le syndrome de Wolf-Parkinson-White.

The accessory bypass tracts are responsible for many episodes of supraventricular arrhythmias in man. The Wolff-Parkinson-White syndrome is the best example. These arrhythmias can be refractory to the medical treatment and are sometimes lethal. Different techniques can be used to destroy these pathways. The surgical dissection is the most widely accepted technique. The accessory pathways are made of working muscle and are neither visible, nor palpable by the surgeon. The electrical properties of these pathways are used to localize them. These techniques are either non-invasive or invasive. The non-invasive techniques consist of the careful analysis of the surface electrocardiogram in sinus rhythm and during tachycardia. The invasive techniques consist of a pre-operative electrophysiological study and intra-operative mapping. The electrophysiological study consists of the introduction of multiples catheters inside the heart through peripheral veins. The intra-operative mapping consists of measurements done on the surface or inside the heart after the chest has been open. After precise localization of the areas of insertion of these abnormal tracts the surgeon proceeds with the dissection, starting either on the epicardial or on the endocardial side of the heart. The surgical results are excellent and there are only few complications. These techniques were used to operate six patients presenting with the Wolff-Parkinson-White syndrome.

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.

Left atrial myxoma associated with systemic AA amyloidosis.

A 76-year-old woman presenting with generalized amyloidosis of the AA-type protein was found to have a left atrial myxoma. Retrospective estimation of the concentration of SAA protein, a serum precursor of AA amyloid, before and after surgical removal of the myxoma, showed that the SAA protein had disappeared after the operation. A common manifestation of myxoma is the development of a severe inflammatory syndrome that sometimes simulates rheumatic fever or bacterial endocarditis. However, to our knowledge, it has never been described in association with amyloidosis. We suggest that atrial myxoma should be added the list of neoplastic and inflammatory diseases predisposing to AA amyloidosis.

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.