[Radiofrequency ablation of left premature ventricular complex from the papillary muscle]. / Ablation par radiofréquence d'un foyer d'extrasystoles ventriculaires gauches du muscle papillaire.

BACKGROUND: Radiofrequency ablation for incessant and symptomatic premature ventricular complex (PVC) localized in a left papillary muscle is uncommon. 3D mapping and cardiac MRI may be useful to achieve ablation success. CLINICAL CASE: A fifty-four-years-old man was referred for palpitations. His medical history included placement of a right coronary artery stent six years before and a normal ejection fraction (EF). The Holter monitoring under beta-blocker therapy (46% PVCs) and ECG showed monomorphic PVCs with a right bundle branch block, positive concordance with V5 transition and a superior axis, with no R/T phenomenon. During two separate electrophysiologic procedures (recurrence), a 3D mapping (Velocity, ST-Jude Medical™) system was used combined with an irrigated tip catheter. The earliest site of PVC activation documented with the mapping system was near the posterior papillary muscle. Pace mapping in this area showed nearly 90% concordance. After 2126 seconds of radiofrequency applications, there were no more PVC and no inducible arrhythmia. Post procedure cardiac MRI showed scar in the inferior-lateral area of the left ventricle including a section of the posterior papillary muscle. Scar included 50% of the thickness of the wall (previous 2005 myocardial infarction and radiofrequency lesions). Residual EF was 55%. At 2 months of follow-up, the patient was asymptomatic, with only 53 PVCs on 24-hour Holter monitoring. Patient was maintained under beta-blocker therapy for his coronary artery disease. At six-month follow-up, he is still asymptomatic. CONCLUSION: This case report stresses the role of cardiac MRI and 3D cartography systems for successful treatment of papillary muscle PVCs associated with ischemic cardiomyopathy, which still represent a therapeutic challenge.

[Evaluation of management of infarction in the Franche Comté province by the use of the Franche Comté Cardiology Registry, May 2005-May 2006]. / L'évaluation des pratiques professionnelles pour la prise en charge des infarctus en Franche-Comté. Expérience d'une évaluation à l'échelle régionale par l'utilisation des données du registre franc-comtois de cardiologie, mai 2005-mai 2006.

RATIONALE: The management of acute infarction often necessitates a network of organisation between different centres, thus making it the object of an evaluation of professional practices (EPP). We report the experience in the Franche Comté province of an EPP at a regional level in the management of infarction. METHODS: All of the patients admitted to 10 of the 11 centres in the region were included in a prospective survey. Quality indicators for acute and chronic care were defined, as well as scores, on the basis of use of treatments specified in guidelines. RESULTS: Between May 2005 and May 2006, 1,170 patients were admitted. The patients' risk levels and quality scores were calculated. The rate of use of the quality indicators was higher in our survey than that observed in all of the published studies, except for the use of betablockers. The quality of care could therefore be considered as highly satisfactory. Comparison between the centres revealed some differences. Even after adjustment for the risk score on admission, the quality score for acute care was related to mortality at 1 month. CONCLUSIONS: An EPP is possible for the management of infarction, on a regional scale such as in the province of Franche Comté. The acute quality score turned out to be an independent factor for mortality. The indicators showed that the quality of care was highly satisfactory, even though more progress could be made in the prescription of betablockers.

Ventricular patch endocarditis caused by Propionibacterium acnes: advantages of gallium scanning.

Propionibacterium acnes is a weakly pathogenic commensal of the skin. When isolated from blood cultures it is often considered a contaminant. However, P. acnes may be responsible for severe infections and its role in certain cases of infectious endocarditis has now been definitely established.(1) We report a case of endocarditis due to P. acnes stemming from a ventricular patch and revealed by a gallium 67 scan.

Unusual cutaneous manifestations of miliary tuberculosis.

Cutaneous manifestations of miliary tuberculosis are extremely rare. We describe a 62-year-old woman with leukopenia who developed infiltrated dermal-hypodermal and ulcerative cutaneous lesions during the course of miliary tuberculosis. Miliary tuberculosis was diagnosed when Mycobacterium tuberculosis bacilli were isolated by cultures of the bronchoalveolar lavage fluid and blood and when acid-fast bacilli were detected on histopathologic examination of hepatic, pulmonary, and cutaneous biopsy specimens. With the increasing incidence of immunocompromised patients, unusual presentations of tuberculosis may be observed more often. Acute miliary tuberculosis of the skin is an exceptional manifestation that is due to acute hematogenous dissemination of M. tuberculosis to the skin. We describe a patient who had unusual cutaneous manifestations of miliary tuberculosis.

Continuous noninvasive measurement of aortic blood flow in critically ill patients with a new esophageal echo-Doppler system.

PURPOSE: Determination of aortic blood flow (ABF) using esophageal Doppler has been proposed as a low invasive hemodynamic monitoring method. The esophageal echo-Doppler Dynemo 3000 (Sometec Inc., Paris, France) system, recently available on the market, is an original device measuring simultaneously, and at the same anatomic level, aortic diameter, and blood flow velocity. Until now, this material has been used exclusively for peroperative monitoring. The objectives of the study were to assess the feasibility and reliability of use for continuous measurements of ABF in hemodynamically compromised intensive care unit patients; and to compare ABF values and its change induced by preload manipulation with the cardiac output (CO) values measured simultaneously by the standard thermodilution method. MATERIALS AND METHODS: Sixty simultaneous measurements of ABF and CO were performed in 22 intensive care unit patients. In 16 hypovolemic patients, Doppler and thermodilution measurements were repeated after fluid replacement. RESULTS: Applicability of the method was 84.6% (failure of the echo-Doppler method in 4 of 26 eligible patients). Coefficient of variation of echo-Doppler-derived ABF was 3.25 +/- 2.26%. Interobserver variability was 3.3 +/- 1.6%. Close linear relationship was found between ABF and CO (r = 0.92). Average ABF/CO ratio was 73 +/- 10%, but significant variation was observed after fluid replacement. CONCLUSIONS: The echo-Doppler Dynemo 3000 system allows reliable continuous measurements of ABF in intensive care unit patients, both easily and safely.

[Malaria attacks after returning from endemic areas. Failure or inadequate chemoprophylaxis?]. / Accès palustre au retour de zone d'endémie. Echec ou inadéquation de la chimioprophylaxie?

OBJECTIVE: Determine the causes of malaria attacks in subjects who have returned from endemic areas by assessing prescriptions for chemical prophylaxis and compliance. PATIENTS AND METHODS: All patients who developed a paroxysmal episode of malaria diagnosed at the University of Nice hospital in 1995 answered specific questions concerning their anti-malaria prophylaxis. RESULTS: Thirty-three patients were hospitalized for paroxysmal episodes of malaria in 1995. In 32 cases (97%) the attack resulted from either the lack of any prophylaxis (17 cases, 52%), inadequate prescription (11 cases, 12%) or poor compliance (4 cases, 12%). The prescribed chemical prophylaxis was not adapted to the chloroquinone-resistant area in 8 cases (24%) and medical recommendations concerning administration rules were inadequate in 3 cases (9%). Only one patient developed a paroxysmal episode despite correct compliance to a chloroquine-resistant zone-adapted well-conducted prescription. The cost of poor prophylaxis in terms of human suffering and financial cost was high for this preventable disease. Four patients had to be hospitalized in the intensive care unit and one died during hospitalization. The cumulative cost of hospitalization for these 33 cases was evaluated at 660,000 FF. CONCLUSION: Preventive measures for malaria must include better information for physicians on changing recommendations for chemical prophylaxis as well as better information for travelers provided by all those involved in organizing travel to endemic areas.

Lesser curve shortening in gastric ulceration.

Benign or malignant gastric ulcers may influence the contour of the lesser curve. A normally acute incisura angularis (angulus) may become blunted or obliterated by an ulcer because of oedema, fibrosis or infiltration. At a later stage the fibrosis resulting from a chronic ulcer may cause scarring and lesser curve shortening, with displacement of the pylorus towards the fundus. Marked deformities may arise, causing gastric stasis. The radiological demonstration of an abnormal angulus of a shortened lesser curve may occasionally provide the first clue to the presence of a gastric ulcer or other lesion.

Traumatic renal artery occlusion: 21 cases.

Sixteen cases of unilateral and 5 cases of bilateral traumatic renal artery occlusion caused by avulsion or thrombosis are presented. The injury typically follows automobile-pedestrian accidents to young male subjects. Associated extrarenal injuries are usual but non-pedicle renal injury is infrequent. Suspicion of the unilateral injury depends upon recognition of absence of visible excretion at urography. The clue to bilateral occlusion is anuria. Diagnosis is confirmed by urgent arteriography. Hematuria was absent in 24 per cent and the injury was missed at laparotomy in 29 per cent of the initial explorations. Renal function was salvaged by arterial reconstruction in 2 cases, 12 hours and 5 months after injury respectively. Hypertension developed in 50 per cent of the cases and was generally mild.