[Aortic dissection at 6 months gestation in a women with Marfan's syndrome. Simultaneous Bentall intervention and cesarean section]. / Dissection aortique au 6e mois d'une grossesse chez une femme atteinte d'un syndrome de Marfan. Intervention de Bentall et césarienne simultanées.

A 31 year old woman with Marfan's syndrome had a dilatation of the aortic root (55-60 mm at the beginning of pregnancy). Pregnancy was continued with beta-blocker therapy and with regular echocardiographic follow-up. The aortic dilatation increased (62-65 mm) at the last control and, at the 34th week of pregnancy, the patient suffered a dissection of the ascending aorta. A caesarean section was performed with a Bentall procedure during the same operative session. The mother and baby girl are well two years later. The problems of pregnancy in patients with Marfan's syndrome are discussed.

[Effects of active synchronized prolonged coronary perfusion in the animal]. / Effets de la perfusion coronaire active synchronisée prolongée chez l'animal.

The efficacy of a system of active diastolic synchronised coronary perfusion was studied during prolonged balloon angioplasty in 8 sheep. In the first part of the study (group 1) including 5 animals, the aim was to study the effects of high and constant flow (48 ml/min) for 90 minutes perfusion on haemolysis, the arterial wall and the perfused myocardium. The second part of the study (group 2), including 3 animals, assessed whether flow adapted to the extent of the vascular bed perfused (24 to 40 ml/min) could protect the myocardium for an interval of 60 minutes. In group 1, after 90 minutes of perfusion (48 ml/min), there was no haemolysis, or jet lesion of the arterial wall distal to the catheter tip. On the other hand, the creatinine phosphokinase levels increased at the 60th minute (188 vs 119 i.u./l for controls) and at the 90th minute (238 vs 119 i.u./l; p < 0.05). Moreover, the perfused myocardium was the site of histological lesions. These observations showed myocardial changes due to the "overflow phenomenon". In group 2, the flow rate was adapted to each animal, increasing progressively until disappearance of electrocardiographic signs of ischaemia (ST elevation) and maintained for 60 minutes. No signs of haemolysis, jet lesions or myocardial changes were observed, with absence of creatinine phosphokinase elevation and histological abnormalities. These preliminary results show that the system investigated allowed myocardial protection after arterial occlusion for an interval of 60 minutes.

[Synchronized anterograde perfusion during percutaneous transluminal coronary angioplasty: preliminary clinical study]. / Perfusion antérograde synchronisée pendant l'angioplastie coronaire: étude clinique préliminaire.

A new circulatory system, "physiologic anteroperfusion system", has been developed and tested in 6 patients with significant proximal coronary artery stenosis. Prolonged and safe balloon inflation was possible without any ischemic signs. The system consists of an electronic cardiac synchroperfusor which, by activating a pulsatile unit, permits increased diastolic anteroperfusion of autologous blood under physiologic pressure through low-profile standard angioplasty catheters. This study reports the results obtained in 6 patients during proximal prolonged percutaneous transluminal coronary angioplasty. Four men and two women suffering from severe exertional angina pectoris, with normal resting left ventricular function, no collaterals and excellent apical two-dimensional four-chamber echocardiographic views were studied. After a 90 +/- 10 seconds of control occlusion under continuous monitoring of hemodynamics, electrocardiograms (3 to 4 leads), two-dimensional echo and chest pain grading, a second balloon inflation protected by the physiologic anteroperfusion system at a flow rate of 44 +/- 12 ml/min was performed for fifteen minutes. The ischemic signs present in the myocardium depending on the occluded artery were totally abolished during prolonged inflation protected by physiologic anteroperfusion system. All the patients were successfully dilated and were discharged from hospital the following morning without cardiac enzyme elevation or signs of central or peripheral hemolysis. Conclusion, in 6 patients with severe proximal coronary artery stenosis, safe prolonged proximal angioplasty without signs of ischemia was performed using a new simple physiologic anteroperfusion system, which allows active diastolic flow-pressure controlled autologous arterial blood perfusion, through standard low profile catheters.

Coronary venous synchronized retroperfusion during percutaneous transluminal angioplasty of left anterior descending coronary artery.

Synchronized coronary venous retroperfusion was applied and studied in 16 patients undergoing percutaneous transluminal coronary angioplasty (PTCA) balloon dilatation of proximal left anterior descending (LAD) coronary artery stenosis. The rationale for using retroperfusion support during the PTCA-induced coronary artery occlusions was to ameliorate or prevent myocardial ischemia and possibly facilitate extension of the PTCA balloon-inflation period. After therapeutic PTCA treatment, which successfully dilated the culprit coronary artery in all 16 patients, and a 5-minute recovery period, a single retroperfusion-treated LAD occlusion (101 +/- 36 seconds) was compared with equivalent untreated control LAD occlusions (86 +/- 24 seconds) before and after the retroperfusion-supported balloon occlusion. Observations and measurements encompassed 1) ease and time of coronary sinus catheterization, 2) incidence of anginal pain during LAD occlusion, 3) electrocardiographic signs of myocardial ischemia, and 4) two-dimensional echocardiographic indexes of global left ventricular function. The coronary sinus was successfully catheterized within 139 +/- 140 seconds, and in 12 of the 16 patients, the tip of the special autoinflatable retroperfusion balloon catheter could be placed in the desired location of the great cardiac vein. The retroperfusion protocol interfered minimally with the PTCA procedure, and application of the support system had no deleterious effects. As compared with the pain reported 23 (72%) times during the 32 control LAD occlusions, only five (31%) of the patients indicated pain or discomfort during the retroperfused occlusions. Treated occlusions exhibited delayed or significantly lower electrocardiographic ST segment elevations (sum, 10.4 +/- 7.8 mm) as compared with the controls (sum, 16.2 +/- 7.9 mm and 18.8 +/- 10.6 mm; both p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis of acute aortic dissection by echocardiography]. / Diagnostic des dissections aortiques aiguës par l'échocardiographie.

Until recently, the diagnosis of aortic dissection rested on aortography. The purpose of this study was to evaluate the diagnostic value of echocardiography in that disease and its ability to inform on the extent of the dissection and on the presence of associated lesions. Twenty-six patients (mean age 64 +/- 10 years) admitted for suspected aortic dissection were explored by echocardiography and the results were compared with those of angiography and/or anatomical findings. Echocardiography provided the diagnosis in 14 of the 16 patients with aortic dissection and excluded it in the remaining 10 patients. The sensitivity and specificity of the method were 87.5 p. 100 and 100 p. 100 respectively. The type of dissection was correctly determined in 90 p. 100 of the patients whose aorta had been totally explored by echocardiography. Aortic regurgitation and pericardial effusion were detected in 81 p. 100 and 50 p. 100 respectively of patients with aortic dissection. These results confirm the diagnostic value of echocardiography in dissection of the aorta. The extent of the lesion can only be evaluated when the whole of the aorta is visualized. The echocardiographic diagnosis is easier when the ascending aorta is involved (type I), while in type III aortic dissection there is a risk of missing a retrograde lesion of the aorta and confusing this type with type I. In this study two kinds of intimal flap motion were observed: in the first one the motion was independent of that of the aorta, while the second one resembled a division of the aortic, wall the motion of which is parallel to that of the aorta.

[Two-dimensional echocardiography in a cardiac intensive care unit]. / L'échocardiographie bidimensionnelle dans une unité de soins intensifs cardiologiques.

The increasing number of physicians competent to carry out emergency echocardiography, and the availability of high performance equipment, facilitated the development of this technique in the Coronary Care Unit (CCU). This paper reports our experience of 610 2D echocardiographic recordings performed on 319 patients admitted to the CCU. The quality of the recording was excellent or satisfactory in 67% of cases and mediocre in 30% of cases. In 11 patients (3%) the quality of the recording was too poor to obtain reliable data. In this group of patients, the apical 4-chamber and subcostal views seemed better than the apical 2-chamber and parasternal views. An echocardiographic diagnosis was made in 94% of cases. It contributed to the diagnostic process in 70% of cases. Of the patients studied, 54% were admitted for a recent myocardial infarction. Echocardiography was particularly useful in atypical forms or when the diagnosis was difficult. It was also helpful in detecting complications of recent myocardial infarction, the frequency of which was determined. With respect to other cardiovascular emergencies, echocardiography was determined. With respect to other cardiovascular emergencies, echocardiography was very useful in the diagnosis of dissection of the aorta, pericarditis and for assessing left ventricular function and the causal mechanism in cases of decompensated cardiac failure. The non invasive nature of the investigation allows repeated examination of the patient at the bedside and makes it a particularly valuable technique to monitor the evolution of acute cardiac conditions requiring admission to the Coronary Care Unit.

Effects of full-dose heparin anticoagulation on the development of left ventricular thrombosis in acute transmural myocardial infarction.

The incidence of left ventricular thrombosis after acute transmural myocardial infarction has been evaluated with two-dimensional echocardiography. To assess the preventive action of early anticoagulation with full-dose heparin, 90 patients, admitted within 5.2 +/- 4.6 hours after the onset of symptoms of their first episode of acute myocardial infarction (46 anterior and 44 inferior), were prospectively studied. Patients were randomly assigned either to therapeutic anticoagulation with heparin or to no anticoagulant therapy. Serial two-dimensional echocardiograms were recorded on the day of admission, the next day, days 4 to 7 and days 20 to 50 to detect left ventricular thrombus and to assess global left ventricular performance. On the first echocardiogram (10.3 +/- 8.0 hours after the onset of symptoms) no thrombus was visualized. In 44 patients with inferior myocardial infarction (23 receiving heparin and 21 not receiving heparin) no further left ventricular thrombus developed. In 46 patients with anterior myocardial infarction, 21 additional thrombi developed (45.6%) within 4.3 +/- 3.0 days after the acute event. Thrombus developed in 8 (38%) of 21 patients receiving heparin, compared with 13 (52%) of 25 patients not receiving heparin. This difference in ventricular thrombosis was not statistically significant (chi-square with the Yates correction = 0.76; NS). No difference was found between the subgroups in terms of clinical variables, infarct size, hemodynamic impairment, intensity of the inflammatory process and quantitative two-dimensional echocardiographic and cineangiographic left ventricular function. It is concluded that early anticoagulation with heparin reduced by 27% the incidence of left ventricular thrombus formation in anterior acute transmural myocardial infarction, and this relative risk reduction was not statistically significant when compared with findings in the untreated group.

[Diagnosis of atrial septal defects by contrast echocardiography with sensitivity increased by coughing]. / Diagnostic des déhiscences du septum interauriculaire par l'échocardiographie de contraste sensibilisée par la toux.

The aim of this study was to assess the sensitivity of contrast echocardiography in the diagnosis of permanent (atrial septal defects, ASD) and transient (patent foramen ovale, PFO) interatrial communications under basal conditions, after Valsalva manoeuvres and coughing. Sixty-four patients suspected of having defects of the interatrial septum were studied. The results of echocardiography were compared with those of cardiac catheterisation, the classical method of reference. The sensitivity of contrast echocardiography was significantly improved in the diagnosis of PFO by the cough test (100%) compared with contrast echocardiography during spontaneous respiration (55%). Similarly, the cough test increased the sensitivity of contrast echocardiography in the diagnosis of ASD (96% compared to 83%). The specificity was good in both cases, about 90%. The cough test was a better method (98%) than Valsalva manoeuvres (59%) for the potentiation of interatrial right-to-left shunts. The results of echocardiography and catheterisation explain the mechanism of the right-to-left shunt during spontaneous respiration, Valsalva manoeuvres and coughing. The passage of the microbubbles from the right to the left atrium occurs during early systole when the atrioventricular valves are closed. The right-to-left shunt is potentiated by provocative manoeuvres. The demonstration of a right-to-left shunt by contrast echocardiography therefore indicates the presence of an interatrial communication; our results show that this non-invasive technique is a reliable method of diagnosing ASD and PFO.

Two-dimensional echocardiographic evaluation of right ventricular size and contractility in acute respiratory failure.

Right ventricular size and contractility were evaluated using two-dimensional echocardiography during the first days of respiratory support in 23 patients requiring mechanical ventilation for acute respiratory failure. Nine patients had normal echocardiographic right ventricular function, and nine other patients had a slightly enlarged right ventricle with normal systolic function. The remaining five patients had a severely enlarged right ventricle with abnormal contractile pattern. In these five patients, two-dimensional echocardiography also showed a reduction in left ventricular size suggesting detrimental ventricular interdependence. All 23 patients had normal left ventricular systolic function by two-dimensional echocardiography.

Right ventricular volumes by thermodilution in the adult respiratory distress syndrome. A comparative study using two-dimensional echocardiography as a reference method.

Measurements of right ventricular ejection fraction and volumes were obtained at bedside by the thermodilution method performed with a fast-response balloon-tipped thermistor in a group of 18 patients undergoing respiratory therapy for the adult respiratory distress syndrome (ARDS). These measurements were compared with right ventricular dimensions simultaneously obtained with two-dimensional echocardiography. A significant correlation was found between right ventricular ejection fraction by thermodilution and two-dimensional echocardiographic fractional area contraction (r = 0.74; p less than 0.001), between right ventricular end-diastolic volume by thermodilution and two-dimensional echocardiographic end-diastolic area (r = 0.70; p less than 0.001), and between right ventricular end-systolic volume by thermodilution and two-dimensional echocardiographic end-systolic area (r = 0.78; p less than 0.001). Right ventricular end-diastolic pressure, a commonly used index of right ventricular preload, did not correlate with two-dimensional echocardiographic end-diastolic area. In conclusion, the thermodilution method allowed reliable measurements of right ventricular ejection fraction and volumes at bedside in critically ill patients. Appraisal of right ventricular end-diastolic volume by this method appeared to be a better predictor of right ventricular preload than were the measurements of pressure.

[Left-right shunt caused by anomalous implantation of the left coronary artery in the trunk of pulmonary artery. Detection by contrast echocardiography]. / Shunt gauche-droite par anomalie d'implantation de l'artère coronaire gauche dans le tronc de l'artère pulmonaire. Détection par échocardiographie de contraste.

The authors describe a case of an anomalous left coronary artery arising from the main pulmonary artery in an 11 year old child suffering from chest pain on effort and with a continuous murmur in the second left intercostal space. Two dimensional echocardiography (2D E) showed dilatations of the first segment of the right coronary artery and the anomalous origin of the left main coronary artery. A peripheral injection of microbubbles showed a left-to-right shunt between the left coronary artery and the pulmonary artery. Semi-quantitative evaluation of LV regional wall motion showed abnormal contraction of the anterolateral walls. Haemodynamic, angiographic data and the operative findings confirmed the diagnosis. The abnormal coronary ostium was closed and a bypass graft from the aorta to the left anterior descending artery was performed. Clinical and echocardiographic follow-up 7 months after surgery was completely normal.

Vasodilator synchronized retroperfusion: quantitative assessment of flow-function relation in acutely ischemic canine myocardium.

To investigate whether addition of vasodilator drugs can increase the beneficial effects on the ischemic myocardium of diastolic synchronized retroperfusion (DSR), low doses of verapamil (2 micrograms/kg/min) or nitroglycerin (0.7 microgram/kg/min) were infused through DSR in open-chest dogs undergoing 180 minutes of proximal left anterior descending coronary artery occlusion. Verapamil-DSR (n = 6), nitroglycerin-DSR (n = 6) or DSR alone (n = 8, controls) were started 10 minutes after the onset of occlusion and maintained for 170 minutes. Regional myocardial blood flow (MBF) (microspheres) and left ventricular function (endocardial ultrasonic crystals) were simultaneously assessed in nonischemic and ischemic zones in the 3 groups, before and after 10 and 180 minutes of coronary occlusion. DSR alone significantly increased ischemic regional MBF, endocardial/epicardial flow ratio and endocardial segmental length shortening. Verapamil DSR increased both nonischemic and ischemic regional MBF but reduced the endocardial/epicardial flow ratio and worsened ischemic contractile function. Nitroglycerin DSR did not modify ischemic transmural flow compared with DSR alone, but abolished the beneficial endocardial/epicardial blood flow redistribution, resulting in no additional improvement of contractile function. Thus, ischemic MBF and function are not improved by addition of small amounts of verapamil or nitroglycerin to the arterial retroperfusate in this model of acute myocardial ischemia.

[Takayasu's aortitis. Exploration of the aorta and its branches by digital angiography and cross-sectional echography]. / Aortite de Takayasu. Exploration de l'aorte et de ses branches par angiographie numérisée et échographie bidimensionnelle.

In Takayasu's disease full radiological exploration of the arteries requires multiple injections of a contrast medium, and this would be difficult to achieve in the course of one single examination. In the present study, two non-invasive methods--digital angiography and cross-sectional echography--were used comparatively to evaluate arterial lesions in 13 ambulatory patients presenting with this disease. Conventional arteriography had previously been performed in 11 of them. The results obtained with digital angiography were considered satisfactory in 12 patients. All underwent aortic and pulmonary echography. Digital angiography and cross-sectional echography provide full, reliable and non-invasive exploration of the aorta and pulmonary artery. Echography shows abnormal thickness of the vascular walls, but the arterial branches can be explored only by digital angiography. The value of these two non-invasive methods is discussed.

[Acute right ventricular failure. Treatment with dobutamine]. / Défaillances ventriculaires droites aiguës. Traitement par la dobutamine.

Acute right ventricular failure is commonly observed during respiratory intensive care, particularly in patients suffering from massive pulmonary embolism, chronic obstructive pulmonary disease or adult respiratory distress syndrome. The haemodynamic effects of a continuous dobutamine infusion at the rate of 9.4 +/- 3.7 micrograms/kg/min were assessed in a group of 15 patients with acute and isolated right ventricular failure, as evidenced by haemodynamic and two dimensional echocardiographic measurements. This inotropic agent induced at 37% increase in mean cardiac index and a 25% increase in mean stroke index, with only a 10% increase in mean heart rate. Moreover, measurement of the right ventricular ejection fraction by a thermal dilution technique performed in 10 patients demonstrated that dobutamine consistently and significantly increased right ventricular systolic function and also significantly reduced right ventricular end-diastolic tension. In conclusion, it appeared that dobutamine was able to improve circulatory status in patients with acute right heart failure or various origins.

Contrast echocardiographic visualization of cough-induced right to left shunt through a patent foramen ovale.

In a series of 24 consecutive patients referred to the echocardiography laboratory because of suspected patent foramen ovale, contrast two-dimensional and M-mode echocardiographic studies were performed during normal breathing and during two provocative tests: the Valsalva maneuver and cough. A right to left shunt was visualized in 8 patients during normal breathing, in 11 patients during the Valsalva maneuver and in 17 patients during the cough test. Cardiac catheterization performed in all 24 patients and postmortem examination available in 3 patients confirmed the patency of the foramen ovale in only 15 patients. In these 15 patients, echo contrast appeared in the left heart cavities in early systole and almost simultaneously with complete right heart opacification. In contrast, for the two false positive results during the cough test, ultrasound contrast appeared at any time of the cardiac cycle when the right heart cavities had been partially cleared of contrast material. Right and left atrial pressures were simultaneously measured in four patients, and the normal interatrial pressure gradient was reversed during the Valsalva maneuver and the cough test. Echocardiography during both provocative tests showed that the interatrial septum flattened or became convex toward the left atrium. The cough test appears to be more reliable and easier to perform in critically ill patients than the Valsalva maneuver for the detection of right to left shunting through a patent foramen ovale.

Two-dimensional echocardiographic demonstration of acute myocardial depression in septic shock.

A 50-yr-old woman exhibiting streptococcal neck cellulitis developed severe septic shock with low cardiac output, which was reversed by infusion of dopamine plus dobutamine. Two-dimensional echocardiography performed at the bedside demonstrated severe myocardial failure. The patient's condition remained dependent on inotropic drug support for 2 days and ultimately improved. Two-dimensional echocardiography repeated on the fourth day corroborated the disappearance of transient myocardial failure.

Aneurysms of sinus of Valsalva: two-dimensional echocardiographic diagnosis and recognition of rupture into the right heart cavities.

The aim of this study was to evaluate the role of echocardiography in the diagnosis of sinus of Valsalva aneurysms projecting toward the right heart cavities. Three patients who had a ruptured aneurysm of a sinus of Valsalva diagnosed by echocardiography and confirmed by catheterization underwent cardiac surgery. In two patients, the aneurysm originated from the right coronary sinus and had perforated into either the inflow or outflow tract of the right ventricle. In the third patient, the aneurysm, which originated from the noncoronary sinus, ruptured into the atrium. A fourth patient was also investigated and had an unruptured aneurysm of the right coronary sinus projecting into the right ventricular outflow tract. M-mode, two-dimensional and contrast echocardiographic studies were performed before cardiac catheterization in all patients and after surgery in three patients. M-mode echocardiography was useful only when the aneurysm had an anterior projection, whether or not the aneurysm was ruptured. Conversely, two-dimensional echocardiography was always able to identify the aneurysmal sac which appeared as an abnormal circular thin-walled structure protruding into the right heart cavities. By using multiple views, it was possible to investigate the whole abnormal structure and locate the sinus from which the aneurysm originated. The use of the echo contrast technique allowed more precise definition of the aneurysmal sac and diagnosis of a left to right shunt by demonstrating a negative contrast image in the right cavities. On the other hand, no negative contrast image was recorded in the patient with an unruptured aneurysm or in the two instances of a successful surgically reconstructed aorta.

Echocardiographic evaluation of ventricles during continuous positive airway pressure breathing.

Using M-mode and two-dimensional echocardiography, we have compared left and right ventricular dimensions at expiration and inspiration in a group of 12 healthy young volunteers during the following two distinct periods: 1) a control period with atmospheric pressure breathing, and 2) a continuous positive airway pressure (CPAP) period with 15 cmH2O end-expiratory pressure breathing. In 6 of the 12 subjects we also evaluated inferior vena caval size, using the same technique. Inspiratory decrease in left ventricular short-axis area (A), length (L), calculated volumes (V = 5/6 AL), and inspiratory increase in right ventricular short-axis diameter and long-axis area were evident at both control and CPAP periods. CPAP also produced a marked decrease in left and an increase in right ventricular dimensions during both expiration and inspiration and a significant decrease in calculated stroke output. An increase in vena caval size during CPAP breathing indirectly suggested a decrease in venous return, but the finding of an unchanged percent of inspiratory change of this vessel during CPAP indicated that the inspiratory augmentation of venous return was still present. On the other hand, the finding of an increased right ventricular size indicated that the right ventricle was afterloaded by CPAP; this probably could explain the observed reduction in calculated stroke output.

Circulatory failure in acute pulmonary embolism.

Circulatory failure occurs in about 10% of patients with pulmonary embolism, resulting from a massive obstruction of the pulmonary arterial bed. Hemodynamic and respiratory features are well established; they involve precapillary pulmonary hypertension, low cardiac output state, elevated filling pressure for the right ventricle, and venous admixture. More recently, two-dimensional echocardiography permitted the visualization of pulmonary artery and right heart enlargement, reduced right ventricular ejection fraction, and tricuspid regurgitation. Evaluated by this latter means, left ventricular systolic function appeared unchanged, but diastolic function might be reduced by septal bulging.

Two-dimensional echocardiographic assessment of left ventricular function in chronic obstructive pulmonary disease.

In 10 patients undergoing therapy for a mild exacerbation of their chronic obstructive pulmonary disease (COPD), a quantitative two-dimensional echocardiographic (2DE) study was performed together with hemodynamics to assess left ventricular (LV) function. From the 2DE examination, which was made up of parasternal, subcostal, and apical views, measurements of LV short axis end-diastolic and end-systolic areas (A) at the high papillary muscle level and long axis end-diastolic and end-systolic length (L) permitted us to calculate LV end-systolic and end-diastolic volumes (V) using the formula V = 5/6 AL. Compared with the same measurements obtained in a group of 12 normal volunteers, patients with COPD exhibited a markedly reduced LV cavity (LVES, 28.9 +/- 14.6 ml/m2 versus 51.5 +/- 11.0 ml/m2; LVEDV, 67.7 +/- 24.6 ml/m2 versus 103.2 +/- 19.9 ml/m2). An increased thickness of both left ventricular free wall and interventricular septum was also evidenced in patients with COPD. Left ventricular systolic function, assessed using both peak systolic blood pressure/end-systolic volume ratio and calculated left ventricular ejection fraction, was found to be clearly enhanced in patients with COPD. The influence of right ventricular enlargement on left ventricular diastolic function was also investigated in patients with COPD using progressive volume loading and 2DE right ventricular measurements. After a given threshold of volume loading, reduction in stroke index, opposite variations in right and left ventricular size and septal flattening, suggested the occurrence of ventricular interaction.