Cryoglobulin detection from blood and peritoneal fluid smears.

Laboratory identification of cytoplasmic inclusions in leucocytes as unusual manifestation of cryoglobulinemia has been previously reported (Maitra et al., 2000 American Journal of Clinical Pathology, 113, 107-112; Fohlen-Walter et al., 2002 American Journal of Clinical Pathology, 117, 606-614.). We would like to add two observations highlighting the following: (i) the peculiar picture of cryoglobulins in neutrophils and monocytes but sparing other white blood cell (WBC) and (ii) possibility of deposit occurrence with morphological identification in body fluids.

[Pulmonary arterial hypertension in the elderly subject]. / Hypertension artérielle pulmonaire du sujet âgé. La cohorte d'un centre régional.

OBJECTIVE: To describe the features of pulmonary arterial hypertension (PAH) in elderly patients. METHODS: A single centre, descriptive study of PAH patients consecutively referred to a regional centre, from September 2002 to February, 1st, 2009. The group of patients aged 65 and above at the time of the diagnosis was compared to the younger patients. RESULTS: Sixty-six patients suffering from PAH (group 1) have been investigated by means of right heart catheterisation. There were 24 patients aged 65 and above. Mean pulmonary arterial pressure was lower in the patients aged over 65. The older patient group had more respiratory and/or cardiac co-morbidities, a lower median distance in the 6minute walk test and a higher median Pro-BNP level. Specific PAH treatments were prescribed in both groups. Fifteen patients aged 65 and above were on long-term oxygen therapy (vs four younger patients, p<0.0001). The elderly patients had a median survival of 32 months. CONCLUSION: The diagnosis of PAH in elderly patients is associated with a poor prognosis. The management of these patients needs further studies.

[Recurrent transient ischemic stroke in a young patient with papillary fibroelastoma of the mitral valve and hyperhomocysteinemia. A case report]. / Accidents vasculaires cérébraux ischémiques transitoires récurrents chez une jeune patiente secondaire à un fibroélastome papillaire de la valve mitrale et une hyperhomocystéïnémie. A propos d'une observation.

We describe a case of a young patient admitted for recurrent ischemic stroke caused by a papillary fibroelastoma of the mitral valve and a hyperhomocysteinemia. A papillary fibroelastoma is a benign cardiac tumor which can be associated with serious embolic complications. A moderate plasma level of hyperhomocysteinemia is considered as a risk factor of ischemic stroke. The authors suggest that this association increases the risk of ischemic stroke in their patient. The tumor was surgically removed to avoid new embolic events associated with a vitamin B supplementation. After surgery and acid folic supplementation, no recurrence was observed.

[Floating thrombus in an aberrant right subclavian artery: a rare cause of peripheral arterial embolic events]. / Thrombus flottant d'une artère sous-clavière droite aberrante (arteria lusoria): une cause rare d'embolies artérielles périphériques.

INTRODUCTION: Floating thrombus in an aberrant right subclavian artery is a rare cause of peripheral arterial embolic events. CASE REPORT: We report a 45-year-old woman who presented with an ischemia of the right superior limb from embolic event. The diagnosis of mobile thrombus in an aberrant right subclavian artery was obtained with transoesophageal echocardiography and computed tomography. After three weeks of oral anticoagulant therapy, there was no significant resolution of the thrombus, and a surgical treatment was performed to prevent further embolization. The surgical procedure consisted of thrombectomy and reimplantation of the aberrant right subclavian artery to the right carotid artery. Postoperative recovery was uneventful. CONCLUSION: This case report illustrates that transoesophageal echography and computed tomography are useful to detect mobile thrombus of the thoracic aorta and is warranted in any embolic event in young patients.

[Increase neuroanatomic definition of nervous central system structures by addition on slices of ferric chloride]. / Rehaussement des structures du système nerveux central par traitement des coupes anatomiques avec le chlorure ferrique.

The authors have described a new method of coloration on anatomic slices of the central nervous system realised on formolated subjects. They have presented their first results on their experiences carried out on the different levels of the brain, and this simple method of proceeding shows how interesting it could be for all practicians of Neurosciences and for the teaching of Neuroanatomy.

Short and long-term single-centre experience with an S-shaped unipolar lead for left ventricular pacing.

UNLABELLED: Left ventricular-based pacing is an established method for treatment of congestive heart failure in patients with ventricular dyssynchrony. The transvenous epicardial approach is the method of choice to pace the left ventricle. AIMS: To evaluate short and long-term stability and pacing and sensing performance of an S-shaped non-steroid unipolar lead. METHODS: Forty-eight procedures were performed in 43 consecutive patients (mean age: 70+/-8 years, 32 males) with severe congestive heart failure. The left ventricular lead was placed into a coronary sinus tributary. Pacing and sensing thresholds and pacing impedance were measured at implant, 1 and 6 months. RESULTS: The mean procedure time was 90.0+/-35.5 min. Pacing thresholds at implant, 1 and 6 months were 1.1+/-0.8 V, 1.9+/-1.3 V and 1.9+/-1.5 V respectively. In 7 patients, lead implantation was unsuccessful. One of them had a successful second attempt. Lead revision was performed in 5 patients for loss of capture. CONCLUSION: The S-shaped unipolar lead evaluated in this study provides stable long-term position and pacing thresholds. Recent improvement of this S-shaped lead model will hopefully reduce the rate of implantation failures and acute dislodgements.

Stent implantation for the treatment of superior vena cava syndrome related to pacemaker leads.

This is a case-report of two patients with superior vena cava syndrome related to pacemaker leads. Both patients were treated successfully using intravenous stenting.

Long-term left ventricular pacing: assessment and comparison with biventricular pacing in patients with severe congestive heart failure.

OBJECTIVE: The purpose of this study is to report prospectively the results of six-month follow-up of permanent left ventricular (LV) based pacing in patients with severe congestive heart failure (CHF) and left bundle branch block (LBBB). BACKGROUND: Left ventricular pacing alone has been demonstrated to result in identical improvement compared to biventricular pacing (BiV) during acute hemodynamic evaluation in patients with advanced CHF and LBBB. However, to our knowledge, the clinical outcome during permanent LV pacing alone versus BiV pacing mode has not been evaluated. METHODS: Pacing configuration (LV or BiV) was selected according to the physician's preference. Patient evaluation was performed at baseline and at six months. RESULTS: Thirty-three patients with advanced CHF and LBBB were included. Baseline characteristics of LV (18 patients) and BiV (15 patients) pacing groups were similar. During the six-month follow-up period, seven patients died three BiV and four LV). In the surviving patients at 6 months, 8 of 14 patients in the LV group and 9 of 12 in the BiV group were in New York Heart Association class I or II (p = 0.39). No significant difference was observed between the two groups in terms of objective parameters except for LV end-diastolic diameter decrease (-4.4 mm in BiV group vs. -0.7 mm in LV group; p = 0.04). CONCLUSION: At six-month follow-up, a trend toward improvement was observed in objective parameters in patients with severe CHF and LBBB following LV-based pacing. The two pacing modes (LV and BiV) were associated with almost equivalent improvement of subjective and objective parameters.

Evaluation of left ventricular function and mitral regurgitation during left ventricular-based pacing in patients with heart failure.

BACKGROUND: Beneficial effects of left ventricular (LV)-based pacing on acute hemodynamic parameters were reported in several series, but only a few studies examined the long-term effects of this new pacing procedure. AIMS: To assess long-term effects of permanent LV-based pacing on LV function and mitral regurgitation (MR) in patients with refractory congestive heart failure (CHF). METHODS: A prospective evaluation of LV function and MR was performed in 23 patients with severe but stable CHF and left bundle branch block (mean QRS: 186+/-31 ms) by radionuclide and echocardiographic techniques at baseline and 6 months after implantation of a permanent LV-based (LV alone: 13 patients; biventricular: 10 patients) pacemaker programmed either in a DDD mode (sinus rhythm; n=14) or in a VVIR mode (atrial fibrillation; n=9). RESULTS: Compared to baseline, the 6 months follow-up visit demonstrated a significant increase in radionuclide derived LV ejection fraction from 23.3+/-7 to 26.2+/-7% (P<0.01) and in echocardiographic LV fractional shortening from 13+/-4 to 16+/-6% (P<0.05), without any change in cardiac index, a significant decrease in LV end-diastolic diameter (from 73.2+/-6 to 71.2+/-7 mm; P<0.05), end-systolic diameter (from 63.6+/-6 to 60.2+/-8 mm; P<0.05) and color Doppler MR jet area (from 11.5+/-6 to 6.6+/-4 cm(1); P<0.001). A comparison of patients with LV pacing alone and patients with biventricular pacing showed similar beneficial effects of pacing on MR severity in the two subgroups and a non-significant trend for a better improvement of LV function during biventricular pacing. CONCLUSION: Thus, in patients with severe CHF and left bundle branch block, permanent LV-based pacing may significantly improve LV systolic function and decrease MR.

[Modeling of coronary arteries and cardiovascular risk factors]. / Modelage des artères coronaires et facteurs de risque cardiovasculaires.

The aim of this study was to assess the impact of cardiovascular risk factors on the modelling of atherosclerotic coronary arteries. One hundred consecutive patients who underwent coronary angioplasty were studied by endocoronary ultrasonography at the site of dilatation. At the site of the treated stenosis of the dilated arteries there was either compensatory widening or positive modelling (PM), or focal contraction or negative modelling (NM) if the total surface area (TSA) of the artery at the site of dilatation was greater or smaller than the total surface area of the proximal or distal reference segments. PM was observed in 53 cases (53%) and NM in 47 cases (47%). Lesions with NM had smaller TSA (13.7 +/- 5.8 versus 20.8 +/- 6.4 mm2, p < 0.0001) and a smaller atheromatous plaque (11.8 +/- 5.6 versus 19.1 +/- 6.5 mm2, p < 0.0001) than lesions with PM. Cardiovascular risk factors such as hypercholesterolaemia, smoking and hypertension were not predictive of either form of arterial modelling and there was no relationship between the cardiovascular risk factors and the qualitative appearances of the plaque studied.

[Coronary prosthesis implantation. Immediate and mid-term results]. / Implantation de prothèses endocoronaires. Résultats immédiats et à moyen terme.

The aim of this study was to evaluate the clinical events occurring after coronary stenting in a series of 318 consecutive patients treated in 1997. Hospital follow-up was by gathering all the data in the hospital record and medium-term follow-up was performed by questionnaire filled with the help of the patient, the attending physician and the referring cardiologist. The primary clinical success rate was 95.6% and the clinical follow-up rate was 98.7%. The follow-up period was at least 16 months (mean 22 +/- 6 months). The restenosis rate was 15% in the remaining population (318-7 deaths and 4 lost to follow-up) and 47% in the population undergoing control coronary angiography. No major clinical cardiac events (death, myocardial infarction or revascularisation) were observed in 80.5% at 1 year and 79% at 22 months. Twenty per cent of the remaining population had no non-invasive paraclinical investigations for myocardial ischaemia after coronary stenting. These results are comparable to those of the literature, indicating excellent feasibility of this technique and the fact that, programmed or not, coronary stenting is a safe procedure confirming its value in what has become everyday practice. Nevertheless, this experience did highlight certain lapses in medical follow-up and patient information.

Adverse events with transvenous left ventricular pacing in patients with severe heart failure: early experience from a single centre.

AIMS: Assessment of complications following implantation of transvenous ventricular electrodes to pace the left ventricle. METHODS AND RESULTS: Twenty-eight patients with severe cardiac failure and left bundle branch block were prospectively followed for adverse effects of implantation of a left ventricular transvenous pacing system. Immediate follow-up was associated with loss of left ventricular pacing in nine patients (32%). This was due to lead dislodgement in four cases (corrected by re-operation in three of these cases), and due to increased threshold in five cases (corrected by programming a higher pacing amplitude in all five cases, but with intermittent diaphragmatic contraction in one case). After 1 month, one patient died, one patient with severe coronary heart disease suffered a myocardial infarction, and left ventricular pacing was lost in two patients. Pericardial effusion, new significant ventricular arrhythmias or other adverse effects were not observed. After a mean follow-up of 16 +/- 9.2 months, pacing leads remained stable and no late complications related to the transvenous left ventricular epicardial pacing were observed. CONCLUSION: Placement of a permanent lead in a tributary of the coronary sinus is feasible without serious adverse effects during the first month. The only frequent adverse event was lead dislodgement; a finding which emphasizes the need for development of specially designed leads for this application.

[Left ventricular stimulation in treatment of heart failure]. / La stimulation ventriculaire gauche dans le traitement de l'insuffisance cardiaque.

SEARCH FOR AN ALTERNATIVE TREATMENT: The concept of stimulating the ventricle to improve heart function in patients with severe heart failure is an old one, but the first published series was reported about 10 years ago and provided encouraging results that lead to numerous other studies. A PROMISING TECHNIQUE: Excepting a few patients with a long PR, stimulation of the right ventricle is ineffective or even deleterious. Stimulation of the lateral region of the left ventricle has produced some undeniably favorable and sometimes even spectacular improvement in hemodynamic performances. Permanent stimulation of both ventricles or the left ventricle produces an overall clinical improvement in patients with severe heart failure (NYHA III or IV) and major left intraventricular conduction disorders (QRS > 140 ms). These results have been recently confirmed in a prospective randomized trial. CAREFUL OPEN QUESTIONS: There is no fully satisfactory explanation for the improvement which, it is important to note, does not occur in all patients. A more homogeneous contraction of the left ventricle certainly plays a fundamental role. Resynchronization of the two ventricles with dual stimulation is more complex and costly and remains to be evaluated. One crucial question is currently being examined: what is the effect of stimulation on the high mortality in these patients?

Left ventricular-based pacing in patients with chronic heart failure: comparison of acute hemodynamic benefits according to underlying heart disease.

BACKGROUND: Acute left ventricular-based pacing has been shown to improve hemodynamics in patients with severe heart failure and left bundle branch block (LBBB). However, it is not known whether the cause of the underlying heart disease influences the potential effect of left ventricular-based pacing. OBJECTIVES: The aim of this study was to determine whether beneficial hemodynamic effects of acute left ventricular-based pacing in severe chronic heart failure are dependent on underlying heart disease. METHODS: After coronary angiography, patients with severe heart failure and LBBB were separated into two groups: dilated (25 patients; 20 male) and ischemic cardiomyopathy (21 patients; 20 male). Hemodynamic parameters were evaluated at baseline and during left ventricular-based pacing. RESULTS: Improvement in hemodynamic parameters were similar in both groups, during acute left ventricular pacing (changes expressed in percentage): pulmonary capillary wedge pressure, -16+/-15% vs. -14+/-10%; V wave amplitude, -25+/-18% vs. -21+/-17%; and biventricular pacing, -15+/-15% vs. -11+/-11% and -23+/-18% vs. -16+/-18%, respectively. CONCLUSION: Underlying heart disease does not influence the response to acute left ventricular-based pacing in patients with severe heart failure and LBBB. This finding provides support for including all patients with enlarged heart and heart failure in future studies evaluating left ventricular-based pacing.

Use of left ventricular pacing in heart failure: evaluation by gated blood pool imaging.

BACKGROUND: Left ventricular (LV) pacing has been suggested to complement other forms of therapy in patients with heart failure. METHODS AND RESULTS: We investigated 17 patients (15 men, 2 women, aged 68 +/- 6 years, 10 ischemic and 7 primary dilated cardiomyopathy) with heart failure (13 were in New York Heart Association class IV and 4 in class III). One month after LV pacer implantation, 12 patients reported clinical improvement (mean class 3.7 before pacing vs 2.6 with LV pacing; P = .001). We report the results of 3 equilibrium-gated blood pool studies performed in each patient, 1 before pacing and 2 after pacer implantation (1 with pacing on, and 1 after turning off the pacer). LV pacing did not modify LV ejection fraction. Phase analysis demonstrated a significant decrease of the interventricular phase shift (delta(pi)) with LV pacing (no pacing, delta(pi) = 8.99 degrees +/- 19.05 degrees; delta7n= -0.97 degrees +/- 27.85 degrees with LV pacing). Clinical improvement was observed in patients with an initial positive delta(pi) that decreased with pacing and/or an initial LV phase standard deviation >50 degrees that decreased with pacing. CONCLUSION: LV pacing induces interventricular and intraventricular synchronization. A decrease of the interventricular phase shift seems to be the most important predictor of functional recovery for paced patients with heart failure.

Evaluation of left ventricular based pacing in patients with congestive heart failure and atrial fibrillation.

Acute hemodynamic data of left ventricular based pacing were assessed in 2 groups of patients with severe cardiac failure: 11 patients with atrial fibrillation and 17 patients with sinus rhythm. Both biventricular and left ventricular pacing significantly improved acute hemodynamic findings to a similar degree in both groups, suggesting that left ventricular based pacing may be beneficial in patients with severe cardiac failure regardless of whether or not they are in sinus rhythm.

Angiographic anatomy of the coronary sinus and its tributaries.

UNLABELLED: Permanent left ventricular pacing has been shown to improve the hemodynamic and clinical status of patients with severe heart failure. To pace the left ventricle, the electrode is implanted in tributaries of the coronary sinus (CS). However, the anatomy of cardiac veins with this purpose in mind has not been described in detail. METHODS: One hundred consecutive patients admitted for coronary angiography had a simultaneous coronary venography performed after the injection of 8 to 10 mL of contrast material into the left coronary artery. Cardiac veins were analyzed in antero-posterior, left anterior oblique 60 degrees, and right anterior oblique 30 degrees views by three different observers. The number, dimension, angulation, and position of the coronary sinus and of its tributaries were studied. RESULTS: Two veins are consistently present: the middle cardiac vein (mean diameter 2.62 +/- 1.26 mm) and the great cardiac vein (mean diameter 3.55 +/- 1.24 mm). The left posterior vein(s) (LPV) (mean diameter 2.25 +/- 1.2 mm) is (are) variable in number (ranging from 0 to 3), size, and angulation. The absence of LPV limits the ability to pace the left ventricle endovenously. The diameter of the vein (< 2 mm) and its angulation may also complicate the insertion of the lead. CONCLUSION: Angiographic analysis of dimensions, tortuosity, number, and angulation of venous tributaries of the CS seems to allow the insertion of commercially available pacing leads in approximately 85% of cases. An increase in this percentage hinges on the development of new, dedicated leads.

A method for permanent transvenous left ventricular pacing.

LV-based pacing has recently been reported to be of benefit in patients with severe cardiac failure and left bundle branch block. LV permanent pacing has been reported using epicardial leads but the surgical mortality is excessive. A transvenous approach is now favored. In this regard, cannulation of the coronary sinus and of one of its tributaries using only the permanent electrode is feasible but technically challenging. We describe a "long guiding sheath" method using catheterization, and a long radiopaque and peelable sheath. Once the coronary sinus is cannulated with the electrophysiological catheter, the long sheath is advanced to the mid-part of the coronary sinus. The permanent pacing electrode is then placed through the sheath and into a tributary of the coronary sinus. This method has been attempted in 10 patients and was successful in 8, with an average lead insertion time of 21 +/- 5.5 minutes and an average fluoroscopic time of 11 +/- 5.5 minutes. In conclusion, although transvenous left ventricular pacing remains a challenge, the "long guiding sheath" approach appears to facilitate this procedure with both a high success rate and an acceptable procedure time.

Evaluation of different ventricular pacing sites in patients with severe heart failure: results of an acute hemodynamic study.

BACKGROUND: Multisite ventricular pacing has recently been proposed as an additional treatment for patients with severe congestive heart failure. To further assess the potential value of this technique, we compared the acute hemodynamic changes associated with pacing the right ventricular apex (RVA) or outflow tract (RVOT) alone, the left ventricle (LV) alone, or biventricular (BIV) pacing of the RVA and LV together. METHODS AND RESULTS: Acute hemodynamic findings were measured in 27 patients with severe heart failure despite optimal therapy and either first-degree AV block and/or an intraventricular conduction defect. In the 23 patients with a high pulmonary capillary wedge pressure (PCWP) (>15 mm Hg), data were collected after transvenous pacing at different ventricular sites in either the VDD mode (AV delay=100 ms) or the VVI mode in patients with atrial fibrillation (n=6). The mean baseline cardiac index was 1.82 L x min(-1) x m(-2). Mean+/-SD baseline systolic blood pressure (SBP) (118.5+/-15.2 mm Hg), PCWP (26.4+/-6.6 mm Hg), and V-wave amplitude (39.1+/-14.6 mm Hg) were similar before and after either RVA or RVOT pacing. In contrast, LV-based pacing (either LV alone or BIV pacing) resulted in higher SBP (P<.03) and lower PCWP (P<.01) and V-wave amplitude (P<.001) than either baseline or RV pacing measurements. With LV pacing alone, SBP, PCWP, and V waves were 126.5+/-15.1, 20.7+/-5.9, and 25.5+/-8.1 mm Hg, respectively. The results with LV pacing alone were similar to those obtained with BIV pacing. CONCLUSIONS: In patients with severe congestive heart failure, both LV pacing alone and BIV pacing resulted in a similar and significant acute improvement in SBP, PCWP, and V-wave amplitude compared with baseline measurements and RV pacing alone. These results provide a strong basis for initiating long-term studies examining the chronic effects of LV-based pacing in patients with medically refractory congestive heart failure.